Abstract Hypertension is a major global health problem associated with severe complications and increased healthcare costs. Medication adherence is essential for controlling blood pressure and preventing adverse outcomes. This study aimed to examine the relationship between health belief model constructs (perceived susceptibility, perceived severity, perceived benefits, perceived barriers) and self-efficacy with medication adherence among persons with hypertension in Nepal. A cross-sectional correlational study was conducted with 212 hypertensive patients attending the Outpatient Department of AMDA Hospital, Nepal, from February to April 2023. Data were collected using validated instruments: the Medication Adherence Report Scale (MARS-5), the Health Belief for Hypertensive Patient Scale (HBHS), and the Medication Adherence Self-Efficacy Scale-Revised (MASES-R). Data analysis included descriptive statistics, Spearman's correlation, and multiple linear regression. The mean medication adherence score was 20.12 (SD = 3.31), with 72.64% classified as non-adherent. Perceived severity (r = 0.16, P = 0.02), perceived barriers (r = 0.19, P = 0.01), and self-efficacy (r = 0.23, P < 0.001) showed weak positive correlations with medication adherence. In the regression analysis, only self-efficacy was significantly associated with medication adherence (β = 0.26, t = 3.614, P < 0.001). In conclusion, self-efficacy was the only variable that demonstrated a significant association with medication adherence among persons with hypertension in this study. Interventions to improve adherence should focus on enhancing patients’ confidence in their ability to manage medication. These findings highlight the potential role of self-efficacy–based strategies in promoting better hypertension management in Nepal.

Keywords: Self-efficacy, Medication adherence, Hypertension, Predictive study, Health Belief Model, Nepal

Funding: The authors are grateful for the research funding provided by the Presidential Scholarship, Chiang Mai University, Chiang Mai, Thailand and Faculty of Nursing, Chiang Mai University, Chiang Mai, Thailand.

Citation:  Acharya, S., Tachaudomdach, C., and Udomkhwamsuk, W. 2025. Self-efficacy and medication adherence among persons with hypertension in Nepal: A cross-sectional study. Natural and Life Sciences Communications. 24(4): e2025075.

INTRODUCTION

Hypertension (HT) is a major global public health issue and a leading cause of morbidity and mortality worldwide (Benjamin et al., 2019). More than one billion individuals are affected by hypertension globally, and this number continues to rise (Centers for Disease Control and Prevention, 2021). This suggests that non-adherence contributes significantly to uncontrolled hypertension and its associated complications. According to the World Health Organization (WHO, 2023), the countries with the highest prevalence of hypertension include China (256.7 million cases) and India (188.3 million cases), while lower numbers are reported in countries such as Australia (4.8 million) and France (14.1 million). In Nepal, approximately 3.9 million people are living with hypertension (WHO, 2023). In addition, an alarming 26% of the general population in Nepal had hypertension (Denekew et al., 2022). Hypertension is a major risk factor for cardiovascular diseases (CVDs), kidney disease, and premature death (Wang et al., 2020). Therefore, effective management of blood pressure is critical to reducing the burden of these complications.

Medication adherence is a cornerstone in the management of hypertension. Numerous studies have confirmed that high adherence to antihypertensive medications significantly improves blood pressure control, reduces the risk of stroke and cardiovascular events, enhances renal outcomes, lowers mortality, and decreases healthcare costs (Bramley et al., 2006; Ettehad et al., 2016; Hamdidouche et al., 2017; Xu et al., 2017; Liu et al., 2021). However, adherence remains suboptimal globally. For instance, the prevalence of medication adherence among hypertensive patients was found to be 59.5% in Ghana (Chauke et al., 2022) and 33% in Iran (Oori et al., 2019). In Nepal, a study reported that 72% of hypertensive patients had low adherence to antihypertensive medications (Roka and Ghimire, 2020). A recent meta-analysis found that the pooled global prevalence of non-adherence to antihypertensive medication was 49% (Pan et al., 2021). Non-adherence contributes significantly to uncontrolled hypertension and its associated complications.

According to the World Health Organization (WHO, 2003), medication adherence is defined as the extent to which a person's behavior—taking medication, following a diet, and/or executing lifestyle changes—corresponds with agreed recommendations from a healthcare provider. Several factors influencing adherence among patients with hypertension have been identified in previous studies. These include sociodemographic and psychosocial factors such as female gender (Tibebu et al., 2017), low literacy levels (Bhandari et al., 2015; Berisa and Dedefo, 2018), low income (Chauke et al., 2022), comorbid conditions (Asgedom et al., 2018), unavailability of medications (Abdisa et al., 2022), side effects (Akhtar et al., 2022), forgetfulness (Khadka et al., 2021), and lack of social support (Olowookere et al., 2015). However, the results have been inconsistent across settings and populations due to differences in study design, tools, and theoretical frameworks.

To bridge this gap, this study adopts the Health Belief Model (HBM) as a theoretical framework to explore psychosocial predictors of medication adherence. The HBM, originally developed by Hochbaum and Rosenstock and later expanded by others (Hochbaum, 1958; Rosenstock, 1974; Glanz et al., 2008), proposes that health behaviors are shaped by an individual’s perceptions of susceptibility, severity, benefits, and barriers. In its later development, the construct of self-efficacy was incorporated into the model, making it a central component of HBM rather than an external addition. Accordingly, this study applies the HBM framework, including self-efficacy, to examine factors associated with medication adherence. In this model, perceived susceptibility refers to an individual's beliefs about the likelihood of developing a health condition; perceived severity reflects beliefs about the seriousness of the condition and its consequences; perceived benefits refer to beliefs in the efficacy of the advised action to reduce risk; perceived barriers are the obstacles perceived in taking the advised action; and self-efficacy is the confidence in one’s ability to perform the behavior successfully (Bandura, 1999).

Previous research has underutilized the full HBM in examining medication adherence in hypertensive populations, particularly in Nepal. Moreover, studies examining the relationships between HBM constructs and medication adherence have yielded conflicting results and often neglected the role of self-efficacy, despite its recognized importance. In the Nepalese context, limited studies have applied the HBM to explore behavioral adherence to antihypertensive medication, and even fewer have included self-efficacy as a potential predictor. Given the nurse’s critical role in patient education and behavioral change, understanding how these psychological constructs relate to adherence is essential for developing effective interventions.

This study, therefore, aims to examine the associations of five HBM constructs—perceived susceptibility, perceived severity, perceived benefits, perceived barriers, and self-efficacy with medication adherence among persons with hypertension in Nepal. The study particularly emphasizes exploring the role of self-efficacy, which has been theorized as an important factor related to adherence behavior. Given that hypertension often presents with few or no symptoms, making patients less likely to perceive the need for regular medication, this study seeks to expand the body of knowledge and provide practical implications for improving hypertension management in clinical and community settings in Nepal.

OBJECTIVES

This study aimed to examine the relationship between health belief model constructs (perceived susceptibility, perceived severity, perceived benefits, perceived barriers) and self-efficacy with medication adherence among persons with hypertension in Nepal.

MATERIAL AND METHODS

Study design

This study employed a cross-sectional correlational design to examine the associations between constructs of the Health Belief Model (HBM), particularly self-efficacy, and medication adherence among individuals with hypertension in Nepal.

Participants and setting

The study was conducted at the Outpatient Department (OPD) of AMDA Hospital (Association of Medical Doctors of Asia-Nepal) in Damak, Nepal. Eligible participants were adults aged 20 years or older, diagnosed with hypertension and receiving antihypertensive treatment for at least one year, with or without comorbid conditions. Additional inclusion criteria included the ability to read and write in Nepali, effective communication skills, and willingness to participate voluntarily.

Based on patient flow records in the Nepali calendar year 2079 BS, an average of 5 hypertensive patients visited the OPD daily, excluding Saturdays and public holidays. From a population estimate of 450 hypertensive OPD patients over three months, the required sample size was calculated using Yamane’s (1967) formula, with a 95% confidence level and a 0.05 margin of error, resulting in a target sample of 212 participants.

Instruments

Four instruments were used for data collection.

Demographic questionnaire

Developed by the researcher, this tool collected data on participants’ gender, age, marital status, religion, education level, employment status, duration of hypertension diagnosis, duration of medication use, number of medications taken daily, and presence of comorbid conditions.

Medication adherence report scale (MARS-5)

Developed by Alreshidi, M.S. (2023), the MARS-5 assesses medication adherence through five items on a 5-point Likert scale (1= always, 5 = never). Higher scores indicate greater adherence (range: 5-25). A score of 23-25 indicates adherence, and 5-22 indicates non-adherence (Norberg et al., 2022). The Nepali version was prepared using Brislin’s (1970) back-translation method. Cronbach’s alpha for the translated tool was 0.82.

The health belief for hypertensive patients scale (HBHS)

Adapted by the PI from a questionnaire developed by Pinprapapan et al. (2013), the HBHS consists of 25 items assessing four constructs: perceived susceptibility (7 items), perceived severity (5 items), perceived benefits (6 items), and perceived barriers (7 items). Items are rated on a 4-point scale. Items with positive meanings are rated from 1 (strongly disagree) to 4 (strongly agree), while negatively phrased items (barriers) are reverse coded. The tool was translated into Nepali using Brislin’s method. Internal consistency was high, with a Cronbach’s alpha of 0.96. Content validity was confirmed by a panel of six experts, resulting in a CVI of 0.93.

Medication adherence self-efficacy scale–revised (MASES-R)

Developed by Fernandez et al. (2008), the MASES-R contains 13 items that assess patients’ confidence in adhering to antihypertensive medication in various scenarios. Responses are rated on a 4-point scale (1 = not at all sure, 4 = extremely sure), with total scores ranging from 13 to 52. Higher scores reflect higher self-efficacy. The tool was translated into Nepali using the Brislin method. Internal consistency reliability was high, with a Cronbach’s alpha of 0.97.

Data collection procedure

Data was collected over three months, from February to April 2023. The PI prepared data collection packages consisting of an information sheet, a consent form, and the four questionnaires. Participants were approached in the OPD waiting area between Sunday and Friday. After obtaining informed consent, participants were asked to complete the questionnaires in a private space before their physician consultation. The researcher explained the study, ensured confidentiality, and answered any queries. Each participant completed the questionnaire in approximately 20–30 minutes and submitted it in a sealed drop box provided in the waiting area.

Data analysis

Descriptive statistics including frequency, percentage, mean, and standard deviation were used to describe demographic characteristics and variable distributions. The Kolmogorov Smirnov test confirmed that the data were not normally distributed. Therefore, Spearman’s rank-order correlation was used to assess relationships between medication adherence and the HBM constructs. Multiple linear regression analysis was employed to identify significant predictors of medication adherence, with an alpha level set at 0.05.

Ethical considerations

This study was approved by the Research Ethics Committee of the Faculty of Nursing, Chiang Mai University (Approval No. 2023-EXP100), and by the Nepal Health Research Council (NHRC) (Ref. No. 1181). Further permission was granted by the Medical Superintendent of AMDA Hospital. Informed consent was obtained from each participant after a clear explanation of the study's purpose, procedures, risks, benefits, confidentiality safeguards, and the right to withdraw at any point without consequence.

RESULTS

Demographic characteristics of the participants

The study sample consisted of 212 participants, including 108 males (50.94%) and 104 females (49.06%). Participants’ ages ranged from below 35 to over 75 years. The majority of participants were married (94.34%) and identified as Hindu (82.55%). Regarding educational attainment, nearly half (45.28%) had completed elementary to middle school, while 35.38% had completed the School Leaving Certificate (SLC). A smaller proportion (16.51%) had obtained a bachelor’s degree or higher. In terms of employment status, 40.56% of the participants were self-employed, 32.08% were unemployed, and 7.07% were retired. Most participants had been diagnosed with hypertension for 1 to 10 years (78.77%), and a similar proportion (79.25%) had been taking antihypertensive medication for the same duration. The majority (84.90%) reported taking one to three pills daily. Participants also reported a variety of comorbid conditions, including diabetes mellitus, kidney disease, cardiovascular disease, thyroid disorders, hyperlipidemia, chronic obstructive pulmonary disease (COPD), gout, and prostate enlargement. As presented in Table 1.

Table 1. Frequency and percentage of demographic characteristics of the participants (n = 212).

Medication adherence among persons with hypertension

Among the 212 participants, 154 individuals (72.6%) were classified as non-adherent, while 58 individuals (27.4%) were classified as adherent. The Medication Adherence Report Scale (MARS-5) scores ranged from 10 to 25, with a mean score of 20.12 (SD = 3.31), indicating an overall trend toward non-adherence. As presented in Table 2.

Table 2. Medication adherence level (adherence and non-adherence score) (n = 212).

The perceived susceptibility, perceived severity, perceived benefits, perceived barriers, and self-efficacy among persons with hypertension

The overall perceived susceptibility score was high, ranging from 7 to 28, with a mean of 23.49 (SD = 4.98). The perceived severity scores ranged from 5 to 20, with a mean of 16.80 (SD = 3.30), indicating a moderate level. Perceived benefits ranged from 6 to 24, with a mean score of 19.38 (SD = 4.18), also reflecting a high level. The perceived barriers score ranged from 7 to 28, with a mean of 16.50 (SD = 6.19), which was classified as a moderate level. Lastly, self-efficacy scores ranged from 21 to 52, with a mean of 37.65 (SD = 8.23), indicating a high level of self-efficacy among the participants. As presented in Table 3.

Table 3. The perceived susceptibility, perceived severity, perceived benefits, perceived barriers, and self-efficacy among persons with hypertension (n = 212).

Relationship between medication adherence and perceived susceptibility, perceived severity, perceived benefits, perceived barriers and self-efficacy

The result indicated no significant relationship between perceived susceptibility and medication adherence (r = 0.07, P = 0.32). Perceived severity demonstrated a weak positive correlation with medication adherence (r = 0.16, P = 0.02). Similarly, no significant correlation was found between perceived benefits and adherence (r = 0.10, P = 0.13). Perceived barriers were weakly and positively correlated with adherence (r = 0.19, P = 0.01). Notably, self-efficacy showed a weak but statistically significant positive correlation with medication adherence (r = 0.23, P < 0.001). As presented in Table 4.

Table 4. Relationship between medication adherence and perceived susceptibility, perceived severity, perceived benefits, perceived barriers, and self-efficacy (n = 212).

Note. **Spearman’s rank order correlation test, P < 0.01; *Spearman’s rank order correlation test, P < 0.05.

Factors associated with medication adherence: The role of perceived susceptibility, perceived severity, perceived benefits, perceived barriers, and self-efficacy

A multiple linear regression analysis was conducted to determine whether perceived susceptibility, perceived severity, perceived benefits, perceived barriers, and self-efficacy could significantly predict medication adherence among individuals with hypertension. The model revealed that self-efficacy was the only significant predictor of medication adherence (β = 0.260, t = 3.614, P = 0.001). This suggests that higher levels of self-efficacy were associated with better medication adherence. In contrast, perceived susceptibility (β = 0.035, t = 0.357, P = 0.722), perceived severity (β = 0.131, t = 1.287, P = 0.200), perceived benefits (β = -0.123, t = -1.400, P = 00.163), and perceived barriers (β = 0.107, t = 1.492, P = 0.137) were not statistically significant predictors of adherence in this study. The regression model had a constant value of 14.713 (SE = 1.538), with a significant t-value of 9.564 (P = 0.001), indicating the baseline level of medication adherence when all predictors are held constant. These findings highlight the critical role of self-efficacy in influencing adherence behavior among hypertensive patients, while other Health Belief Model constructs did not show predictive power in this context. As presented in Table 5.

Table 5. Factor related to Medication adherence behavior.

DISCUSSION

Medication adherence level (adherence and non-adherence scores) – In the Nepalese context

This study found that 72.6% of hypertensive patients in Nepal were non-adherent to their medication regimen, as measured by the MARS-5 scale (mean = 20.12). This level of non-adherence is alarmingly high and consistent with previous studies in underdeveloped or low-resource settings such as Ethiopia and Iran (Abdisa et al., 2022; Sharma et al., 2024). In Nepal, several systemic and socioeconomic factors likely contribute to this problem. First, out-of-pocket (OOP) health spending dominates the healthcare system, accounting for more than 50% of total health expenditure (Rajan et al., 2020). This results in financial burdens for patients who must regularly purchase antihypertensive medications. Second, geographical barriers with rural populations living far from healthcare centers complicate regular follow-up and refill visits. The health workforce shortage is another barrier. Nepal has only 1 doctor per 850 people in urban areas, with far worse ratios in rural districts (Dumka et al., 2024). Long queues, poor counseling time, and follow-up delays significantly hinder adherence. Furthermore, limited health literacy, especially among populations with lower education levels, may lead patients to misunderstand the importance of taking medications daily, even when asymptomatic. According to the World Health Organization (WHO, 2003), non-adherence can result from multiple factors, including patient-related, therapy-related, condition-related, health system-related, and socioeconomic factors. In hypertension, a common challenge identified in previous studies is that patients often omit medication when they feel well or asymptomatic, which can undermine long-term blood pressure control (Vrijens et al., 2017; Burnier and Egan, 2019). Thus, while non-adherence is a global issue, it is particularly critical in Nepal due to the intersection of poverty, fragile healthcare systems, and cultural factors that influence self-care behaviors. Understanding these multidimensional factors is essential for developing effective interventions to improve adherence in the Nepalese context.

Health belief constructs: Perceptions and self-efficacy among persons with hypertension in Nepal

The results of this study showed that participants had high perceived susceptibility and perceived benefits, moderate perceived severity and perceived barriers, and high self-efficacy. In the context of Nepal, high perceived susceptibility may reflect growing awareness of hypertension risk, possibly due to recent public health efforts (GON, 2014). However, this awareness is often surface-level and not behavior-changing, due to inadequate education and community-based follow-ups (Karmacharya et al., 2017; Neupane et al., 2017; Mehata et al., 2018; Dhungana et al., 2021, 2022; Shrestha et al., 2021). Perceived severity being moderate suggests that while people are aware of hypertension, they may not fully grasp its life-threatening consequences, especially in rural communities where stroke and renal failure are underreported or normalized as "aging problems." Perceived barriers were moderate, reflecting challenges such as long distances to hospitals, the cost of medications, and lack of family support, issues common in many Nepalese households. Unemployment and low income (noted in 32.08% of participants being unemployed) compound the issue, as individuals must often choose between food and medication. The high level of self-efficacy in this study (Mean = 37.65) may appear surprising. However, this might be due to social desirability bias in responses or the belief that taking medicine is simple even if not consistently practiced. In Nepal, especially among men, cultural notions of self-reliance and resilience may influence participants to rate their confidence in taking medication higher than their actual behavior reflects.

Relationship between medication adherence and health belief constructs in the Nepalese context

This study found no significant correlation between perceived susceptibility (r = 0.07, P = 0.32) and medication adherence, no significant correlation between perceived benefits (r = 0.10, P = 0.13) and adherence, a weak but significant relationship between perceived severity (r = 0.16, P = 0.02) and adherence, a weak positive correlation between perceived barriers (r = 0.19, P = 0.01) and adherence, and a weak but significant positive correlation between self-efficacy (r = 0.23, P < 0.001) and adherence. These results are consistent with findings from Tanzania (Edward et al., 2021) and China (Li et al., 2006; Yue et al., 2015; Yang et al., 2016; Yu et al., 2022; Zhou et al., 2024) but must be interpreted in Nepal’s specific cultural and systemic context. For example, the lack of correlation with perceived susceptibility and benefits may result from a disconnect between knowledge and behavior. Nepalese patients may recognize that hypertension is a serious issue but still do not take medication seriously, often resorting to home remedies, religious beliefs, or irregular clinic visits. The weak relationship between perceived barriers and adherence suggests that despite facing obstacles, some patients still attempt to follow their regimen. However, if barriers like cost, access, and lack of counseling are not addressed, they eventually become overwhelming. A study in Kathmandu found that patients who received free medicines from local clinics adhered better than those who had to buy them (Sharma et al., 2024). The most promising finding is the correlation with self-efficacy, which aligns with research from China and Indonesia (Shen et al., 2020; Wilandika et al., 2023). Even in low-resource contexts, patients who believe in their ability to manage medications are more likely to adhere, suggesting that psychological empowerment is a key pathway to behavior change.

Factors associated with medication adherence in Nepal: The dominant role of self-efficacy

The multiple linear regression results revealed that self-efficacy was the only significant predictor of medication adherence (β = 0.260, t = 3.614, P = 0.001). Other factors such as perceived susceptibility, severity, benefits, and barriers were not significant predictors. This finding reinforces the idea that in the Nepalese setting, belief alone is not enough to change behavior unless accompanied by confidence and skill. With limited counseling sessions and overburdened nurses and doctors, most patients in Nepal receive little guidance on managing chronic illness. Low provider interaction can reduce patients’ self-efficacy (Ghayth et al., 2023). In Nepal, enhancing self-efficacy may be a cost-effective and scalable intervention, especially in areas where access to health facilities is limited. Strategies might include community-based education, family involvement, and training health volunteers to provide support for medication reminders and lifestyle coaching. Furthermore, the predictive power of self-efficacy in this context indicates that internal motivation may override external barriers in some cases. Empowering patients through goal setting, positive reinforcement, and role modeling could improve outcomes even when structural challenges persist (Shen et al., 2020; Wilandika et al., 2023).

LIMITATIONS

This study has several limitations. Firstly, the research was conducted at a single healthcare facility, AMDA Hospital in Koshi Province, Eastern Nepal, and the findings may not be generalizable to the entire hypertensive population in other regions of Nepal, especially considering geographic, cultural, and healthcare system differences. Secondly, all participants were capable of independently taking their medications; therefore, the results may not reflect adherence behaviors among individuals who rely on caregivers or have cognitive or physical limitations. Thirdly, the study employed a cross-sectional design, which precludes establishing causation or prediction. In addition, all data were self-reported and collected from a single source, which may introduce reporting bias. These limitations should be considered when interpreting the findings.

IMPLICATIONS FOR NURSING PRACTICE

The findings of this predictive study provide valuable insights for nursing practice in Nepal and similar low-resource settings. Importantly, the study identified self-efficacy as the only significant predictor of medication adherence among hypertensive patients (β = 0.260, P = 0.001). This highlights the critical role of psychological and behavioral confidence in shaping patients’ adherence behavior. Firstly, nurses should prioritize education and counseling that strengthens patients' belief in their ability to manage antihypertensive medications under different circumstances. Targeted interventions can include role play, motivational interviewing, and peer support groups to enhance self-efficacy. Secondly, nurses and healthcare providers should address modifiable factors identified in this study, such as perceived barriers (e.g., cost, transportation, forgetfulness) and perceived severity, even though they were not statistically significant predictors. These elements may still influence behavior and can be integrated into health education strategies. Thirdly, community-based nurses and health volunteers can play an active role in monitoring medication adherence, reinforcing self-efficacy, and following up with high-risk patients. Special focus should be placed on populations with low health literacy, financial difficulties, and limited access to care. Lastly, the study findings provide a foundation for developing predictive tools and targeted intervention programs. Future nursing research should focus on intervention studies that aim to improve self-efficacy and assess its direct impact on long-term medication adherence and blood pressure control. By incorporating these insights, nurses in Nepal can develop patient-centered, cost-effective strategies to enhance hypertension management and improve health outcomes across diverse communities.

FUTURE RESEARCH

For future research on medication adherence, it may be useful to consider the Perceptions and Practicalities Approach (PaPA) as an alternative framework. Additionally, given some limitations of the Health Belief Model (HBM) in fully explaining adherence behavior, Horne’s more comprehensive model could be highlighted in the discussion as a potentially more robust approach for understanding medication adherence.

CONCLUSION

This study highlights that in the Nepalese context, self-efficacy is a key factor associated with medication adherence among patients with hypertension. While other health belief factors were present, only self-efficacy showed a significant association in the multivariate analysis. It should be noted that the study’s cross-sectional design does not allow for establishing causation or prediction. Addressing the structural, economic, and cultural challenges in Nepal will require systemic reform; simultaneously, building patients’ confidence and self-management skills can offer an immediate and impactful solution.

ACKNOWLEDGMENTS

I would like to express my sincere gratitude to Chiang Mai University for awarding me the Presidential Scholarship, which provided invaluable financial support throughout my master's study. I am also deeply thankful to the Faculty of Nursing, Chiang Mai University, for granting me the opportunity to study in this esteemed institution and for the continuous academic and administrative support I received during my program. Their generous assistance and encouragement have been fundamental to the completion of my study. I feel truly honored and privileged to have been a part of this academic community.

AUTHOR CONTRIBUTIONS

Shova Acharya assisted in conducting the research, performed the statistical analysis and data visualization and wrote the manuscript. Chiraporn Tachaudomdach designed, performed statistical analysis and wrote the manuscript. Warawan Udomkhwamsuk designed and wrote the manuscript. All authors have read and approved of the final manuscript.

CONFLICT OF INTEREST

The authors declare that they hold no competing interests.

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