| HOME | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|---|
| ||||||||||||||||||||||||||||||||
RESEARCH ARTICLE |
a Nuffield Community Care Studies Unit, University of Leicester, United Kingdom
b Department of Epidemiology and Public Health, University of Leicester, United Kingdom
c School of Nursing, Faculty of Medicine and Health Sciences, University of Nottingham, United Kingdom
Ruth Hancock, Nuffield Community Care Studies Unit, Department of Epidemiology and Public Health, University of Leicester, 22-28 Princess Road West, Leicester, LE1 6TP, United Kingdom E-mail: rmh5{at}le.ac.uk.
Decision Editor: Fredric D. Wolinksy, PhD
 |
Abstract |
|---|
 TOP Abstract MethodsResultsDiscussionReferences |
|---|
Methods. In 1988, income, home ownership, and health data were collected for 1,425 people aged 75+. Participants received up to five subsequent health assessments before the study endpoint (1999), in which care home entry was also recorded. Care home entry was identified from death certificates for those who died. Using proportional hazards regression, the effect of home ownership and income on the risk of care home entry was estimated, controlling for predisposing, enabling, and need factors, and health service utilization.
Results. Age, living alone, activities of daily living restriction, cognitive impairment, poor/fair self-perceived health, and contact with services increased the risk of care home entry. Home ownership decreased it. Gender was not a significant predictor of care home entry once other factors were controlled for, and no significant effect was found for income.
Discussion. UK public authorities can require older home owners to use the value of their homes to pay for institutional but not community-based care, thus producing a financial incentive to place home owners in institutional settings. However, we find that home ownership reduces the likelihood of care home entry, suggesting that other factors dominate the decision process.
Although the financing of long-term care for older people is a global issue, in the United Kingdom (UK), the intensity of the debate has increased over the last decade with the publication of a Royal Commission report (Royal Commission on Long-term Care 1999
) and the subsequent response by the British Government (Department of Health 2000). In the UK, means testing remains at the heart of policies that determine who pays for the provision of institutional care for older people. Therefore, the need for care is unlikely to be the only factor determining entry into care homes, and economic resources are also likely to play a part in deciding the nature, extent, and place of care in late life.
With a few exceptions (Kliebsch, Sturmer, Siebert, and Brenner 1998; Woo, Ho, Yu, and Lau 2000), most of the longitudinal studies looking at risk factors for entry into care homes have been conducted in the United States (e.g., Coughlin, McBride, and Liu 1990; Freedman 1996; Greene and Ondrich 1990; Salive, Collins, Foley, and George 1993; Steinbach 1992; Wolinsky, Fitzgerald, and Johnson 1992) and Canada (e.g., Mustard, Finlayson, Derksen, and Berthelot 1999; Tomiak, Berthelot, Guimond, and Mustard 2000). Many of these studies (Greene and Ondrich 1990; Tomiak et al. 2000; Wolinsky et al. 1992) have used Anderson's framework of access to medical care (Anderson, McCutcheon, Aday, Chiu, and Bell 1983) to distinguish between predisposing, enabling, and need characteristics. Although the way individual factors are grouped under these headings sometimes varies, predisposing characteristics typically include demographic factors and living circumstances; enabling characteristics include socioeconomic factors, such as income, home ownership, and formal and informal support; and need characteristics include health factors that are likely to indicate the need for care.
Among predisposing characteristics, greater age remains consistently associated with increased risk of admission to care homes (Greene and Ondrich 1990; Kliebsch et al. 1998; Mustard et al. 1999; Salive et al. 1993; Steinbach 1992; Tomiak et al. 2000; Wolinsky et al. 1992; Woo et al. 2000). Other predisposing factors consistently predictive of care home entry include living alone (Coughlin et al. 1990; Greene and Ondrich 1990; Steinbach 1992; Wolinsky et al. 1992) or not currently being married (Breeze, Sloggett, and Fletcher 1999; Grundy and Glaser 1997; Salive et al. 1993; Wolinsky et al. 1992); race, with older White people more likely to enter a care home (Coughlin et al. 1990; Freedman 1996; Greene and Ondrich 1990; Salive et al. 1993; Wolinsky et al. 1992); and urban living (Kliebsch et al. 1998; Salive et al. 1993). There is conflicting evidence as to whether women (Breeze et al. 1999; Grundy and Glaser 1997; Kliebsch et al. 1998) or men (Mustard et al. 1999) are more likely to be admitted to care homes when other factors are accounted for. Cognitive impairment and decreased physical functioning, usually measured by restriction in activities of daily living (ADLs), are the most commonly observed need characteristics, and both are strongly associated with care home entry (Coughlin et al. 1990; Freedman 1996; Salive et al. 1993).
Mustard and colleagues 1999 found lower household income to be associated with higher risk of nursing home admission, although other studies have found no association between income and care home entry when other factors are controlled for (Coughlin et al. 1990; Freedman 1996; Greene and Ondrich 1990; Salive et al. 1993; Steinbach 1992; Tomiak et al. 2000). In North America, home ownership is associated with a decreased risk of care home entry (Coughlin et al. 1990; Freedman 1996; Greene and Ondrich 1990; Salive et al. 1993; Tomiak et al. 2000). In a recent analysis of the UK's only national source of longitudinal general population data on risk factors for care home entry, Breeze and colleagues 1999 found home owners and those with access to a motor vehicle were at reduced risk of entering institutional residence, although the unavailability of health information meant need factors could not be included.
In the UK, most long-term care falls outside the tax-financed main provider of health care, the National Health Service. People receiving long-term care provided in care homes have to meet user charges that depend on their financial means. Those who have assets, including the value of their homes, above a relevant limit (currently £18,500) are required to meet the care home's fees in full. Those with assets below the limit make a copayment that is usually less than the full fees. For those with the lowest income and assets, this payment may be met from Income Support, the UK's means-tested welfare benefit. Virtually all older people who own their homes would be required to meet care home fees in full. Means testing dates back to 1948, and the manner in which income and assets affect payment has changed little for many years. However, as growing numbers of people survive to the older ages and increasing proportions of them own their homes, the effect of the means test is being felt more widely.
For older people who are judged to need care and who require the state to help with its cost, local public authorities are responsible for arranging their care, whether in a care home or in people's own homes. The state's share of the cost is met from authorities' cash-limited budgets. For care services delivered at home, the value of an older person's home is disregarded in determining how much he or she contributes. An older home owner is therefore likely to incur considerably more—and the public budget correspondingly less—of the cost of care in a residential setting than of equivalent cost care at home (Hancock 2000). The result is a financial incentive for public authorities to arrange for a home owner's care to be provided in an institution rather than in the person's own home. This is seen as a perverse incentive, contrary to stated policy (Department of Health 1989) that favors community over institutional care, in common with other countries (Glendinning 1998; Royal Commission on Long-term Care 1999). The financial incentive works in the opposite direction for older home owners themselves. Whether the likelihood of entry to a care home is increased or decreased by the level of an individual's economic resources would seem to depend on whether individual choice or the policy of the local public authority dominates.
The UK Government rejected the main recommendation of the recent Royal Commission on Long-term Care (1999) that the nursing and personal care components of the fees of care homes be met by the state, without a means test and financed out of general taxation. In making this recommendation, the Commission was taking into account evidence of the unpopularity of the inclusion of housing wealth in the capital test for residential care, and the resulting perverse incentive to place older home owners in care homes. The present government argued that the recommendation would not target public resources effectively (Department of Health 2000). It has decided that the nursing element of care home fees will be met by the state and that the value of the home will be disregarded for up to 3 months after entry into a care home. Thereafter, the means test will apply to personal care and accommodation elements of care homes' fees. So there will remain a potential for income and wealth to influence care home entry, and the intensity of the debate on the funding of long-term care is unlikely to diminish. Indeed, the Scottish parliament has voted to implement the Royal Commission recommendations in Scotland, ensuring continued pressure for reform in the rest of the UK.
Public authorities' assessments of the need for care generally depend on the care needs of the older person and the availability of family care. The individual's preferences should also be taken into account, but an authority's decision to offer institutional care rather than community-based care may also be influenced by the extent to which they can recoup the cost through charges. Individuals with greater economic resources may therefore be at more risk of being placed by public authorities in a care home than those with lower resources. Alternatively, they may choose to avoid care home entry, even where that could be the appropriate form of care to conserve their income and wealth. In the UK context, to label economic resources as enabling factors is to oversimplify their role.
The aim of this study was to examine whether older individuals with high levels of economic resources face a greater or lower risk of care home entry than those with lower economic resources, given that both are consistent with theoretical considerations.
|
Methods |
|---|
|
TOPAbstractMethodsResultsDiscussionReferences |
|---|
) provided baseline data. Second, as part of the requirement of general practitioners in the UK to offer annual health assessments to patients aged 75 years and over (Department of Health and the Welsh Office 1989), data are available from five rounds of health assessments conducted between 1990 and 1999. Third, details from death certificates were obtained by linking participants with the deaths register held by the Office for National Statistics.
1988 Baseline Survey
All those registered with the practice, who were aged 75 years or over on December 31, 1987, were asked to take part in a survey of older people's health needs. Interviews were conducted by trained field workers in the older person's usual place of residence. Where the older person was unable to answer questions because of severe physical or mental illness, a relative or care provider supplied relevant information.
Demographic details were collected on age, sex, place of residence (including home ownership, whether accommodation was sheltered, and, if so, warden availability), and household composition. Participants were asked to whom they would turn for help with each of six common problems and crises. The social class of men was measured by determining their last (or usual) occupation. For women, social class was based on their husband's job, if married, their own if single, or their father's if single and never employed.
Participants were asked if they were willing to respond to questions about their incomes and financial circumstances. If so, a question followed concerning total income (of self and spouse, if any), and a card was presented for the participant to respond according to weekly income bands. For this study, respondents were recategorized into one of four weekly income groups reflecting prevailing levels of the basic state pension (£39.50 for single people and £63.25 for married couples): married with under £61 or not married with under £41/married with between £61 and £70 or not married with between £41 and £50/married with between £71 and £100 or not married with between £50 and £90/married with more than £100 or not married with more than £90. Rather than restrict the analysis to those who provided income details, a fifth nonresponse category was created. Participants were also asked about sources of income, including means-tested welfare benefits and whether they had difficulty managing financially.
Need characteristics included physical functioning, measured by ability to perform (independently or with help) a series of ADLs covering dressing, feeding, getting to and from the toilet, getting in and out of a chair, and getting in and out of bed. Participants were asked about instrumental ADLs, such as shopping and light housework, what help they received with these tasks, and whether they needed more help. Cognitive function was measured by the Information/Orientation subtest of the Clifton Assessment Procedures for the Elderly (Pattie and Gilleard 1979), with a score of 8 or less used as evidence of cognitive impairment (Clarke et al. 1991). Self-perceived health was measured by asking participants to rate their general health as good, fair, or poor for someone of their age. Problems with hearing and vision were used to indicate sensory impairment. Participants were considered to have urinary incontinence if they reported difficulty in controlling their water once a week or more. A checklist was used to establish the frequency and type of contact the respondent had with various services (including community nursing services and home help).
Health Assessments
The first round of health assessments commenced in October 1990 and took 17 months to complete; the fifth was completed in February 1999. In the present analysis, data from the health assessments were used only for those who had taken part in the original 1988 survey. All participants in the original survey were eligible for every health assessment unless they were known to have died (the vast majority of ineligibles) or were no longer registered with the practice. Self-perceived health, the ability to perform ADLs, cognitive functioning, sensory impairment, urinary incontinence, and contact with services were measured at each health assessment as in the 1988 baseline survey. The health assessments also established whether participants were living alone and their housing type. The latter distinguished between own home, a relative's home, sheltered housing, or an institution. For this study, it was assumed that home owners at baseline who were living in their own homes at subsequent health assessments continued to be home owners, whereas those who changed to living in a relative's home or to sheltered housing ceased to be home owners.
Death Certificate Data
All those individuals eligible for the 1988 survey were routinely linked to the Office of National Statistics death certificate data that provided date of death and whether the older person's usual place of residence at the time of death was a care home.
Combining the Data Sources
For the present analysis, participants in the 1988 survey were included if they were "observed" at least once after that. This could be either during one or more of the five health assessments (in which case demographic details, place of residence, and indicators of health care need are known for that date); or if, despite declining the offer of a health assessment, their usual place of residence at that time was known from practice records; or at death, in which case date and usual place of residence at death were known. A cutoff point of August 6, 1999, was imposed, and all deaths up to that date were recorded. For those still alive, a final check on place of residence was made from practice records. So, in all but a few nontraceable cases, it was known whether the usual place of residence at date of death, or on August 6, 1999, was a care home.
Statistical Analysis
The statistical analysis was restricted to study participants who were not already living in a care home at the time of the 1988 survey. Survival analysis techniques were used to model time to care home entry in preference to discrete time techniques for modeling transitions between states. This was because, in our study, the time between observations is not identical and not independent of destination states, being truncated by death (where exact date is known). Survival analysis deals explicitly with censoring caused by death, but in its standard form assumes that the timing of the event of interest is known exactly. The exact dates of care home entry were not known in our study, only that entry occurred sometime between first observing residence in a care home and the most recent date of observation before that. A common approach to dealing with such interval-censored data (see, e.g., Lindsey and Ryan 1998; Samuelson and Kongerud 1994) is to assume an exact timing of the event, given that it occurred within a known time interval, for example, the beginning, middle, or end of the interval (Lindsey and Ryan 1998). Available survival analysis routines that allow for interval censoring do not accommodate updated measurement of covariates. A strength of our data is the availability of such "time-updated" covariates (Altman and De Stavola 1994). We therefore chose to estimate Cox's proportional hazards models, with time-updated variables, making the alternative assumptions that care home entry occurred at the beginning, middle, or end of the known interval. Study participants who were not observed to enter a care home and who died within the study period or were alive at the end of it were treated as censored.
Wherever possible, we chose covariates that could be updated through the period of study, our reasoning being that it would be important to have measures (e.g., of health status) taken as close as possible to care home entry points. At each point that a care home entry occurred within the sample, time-updated covariates were assigned their most recent known value.
It was anticipated that age at baseline would be a strong predictor of care home entry. To identify other predictors, separate Cox's proportional hazards models were first estimated, one for each covariate (or linked subgroup of covariates; e.g., income groups) adjusted only for age at baseline (measured as years beyond 75 and including a quadratic term). Likelihood ratio tests were used to test whether each covariate was a significant predictor of care home entry. All covariates found in these separate models to be significant, for one or more of the assumptions on timing of care home entry, were then entered together in a single model. This model was refined through a backward elimination procedure in which covariates were eliminated in turn on the basis of likelihood ratio tests. The final estimation stage tested for significant effects from interactions between the retained covariates and age, gender, and home ownership.
|
Results |
|---|
|
TOPAbstractMethodsResultsDiscussionReferences |
|---|
|
12 = 13.07, p < .001). For those who did answer the income question, there was an association between income level and owner-occupation (72=106.73, p < .001) with owner-occupiers tending to have higher incomes than those who did not own their homes. This suggests that income nonresponse may be related to higher levels of income. There was also an association between nonresponse to the income question and cognitive impairment: Nonresponders were more likely to be cognitively impaired (12= 4.69, p < .03) than responders. About half of the sample received a means-tested welfare benefit, and 81% said they had financial difficulties. Self-perceived health was fair or poor for 48% of the sample. The most common ADL restriction was difficulty getting to and from the toilet (21%). A similar proportion had hearing problems. Difficulty with bed and chair transfers, dressing, vision, and urinary incontinence were each experienced by 10%–12% of the sample at baseline, and 8% said they needed more help than they received with instrumental ADLs. Five percent of the sample was cognitively impaired at baseline.
A total of 341 (24%) of the included sample were known to have entered a care home at some point during the study period (approximately 11.5 years), 834 (59%) died without being observed to enter a care home, and 250 (18%) were alive at the end of the study and had not entered a care home (see Table 2 ). Thus, 341 experienced the event of interest and 1,084 were censored.
|
62 = 94.66, p < .001).
|
Columns (c) and (d) of Table 3 present the results of the final proportional hazards model, again assuming that care home entry occurred at the midpoint of the relevant interval. All covariates not eliminated in the backward elimination process are included in this model. Before testing for interaction terms, the covariates included in the final model were unchanged if entry was assumed to be at the end of the interval; when it was assumed to be at the beginning, contact with a community nurse or home help was eliminated from the model, but hearing impairment was retained. In both cases, home ownership reduced the risk of care home entry by about the same proportion as under the central assumption.
Age and living alone remained strong predictors of care home entry. An 80-year-old faced a risk of care home entry 3.84 times that of a 75-year-old (95% CI: 2.42–6.11). Home owners faced a lower risk of care home entry than non-home owners (relative risk: 0.75, 95% CI: 0.60–0.95). Income group was not statistically significant with other factors included. In the final model, need factors are captured by difficulty with chair transfers, cognitive impairment, and less than good self-perceived health, all of which increase the risk of care home entry with the largest and most statistically significant effect being cognitive impairment. Health service utilization also increased the risk of care home entry separately from need variables.
Interactions between gender or home ownership and other covariates were not statistically significant. Significant interactions with age were found for cognitive impairment and service use, such that the relative risk of care home entry associated with the combination of an increase in age and the onset of cognitive impairment or service use is less than the product of their separate effects on risk. For example, the relative risk resulting from an extra 5 years of age and the onset of cognitive impairment is 17.20 (95% CI: 10.0–29.5), compared with 3.84 (95% CI: 2.41–61.11) for five extra years with no cognitive impairment and 6.41 (95% CI: 3.75–10.9) for cognitive impairment with no increase in age.
|
Discussion |
|---|
|
TOPAbstractMethodsResultsDiscussionReferences |
|---|
; Coughlin et al. 1990; Freedman 1996; Mustard et al. 1999; Wolinsky et al. 1992), we find that increasing age, living alone, functional restriction, cognitive impairment, less than good self-reported health, and contact with health services increase the likelihood of care home entry. Gender was not a significant influence on care home entry once other factors were taken into account. This finding is consistent with some (Coughlin et al. 1990; Freedman 1996; Greene and Ondrich 1990; Wolinsky et al. 1992), but not other (Breeze et al. 1999; Kliebsch et al. 1998; Mustard et al. 1999) studies.
Our results indicate that being a home owner reduces the likelihood of care home entry, even taking account of predisposing, need, and other enabling factors. This finding is consistent with North American studies (e.g., Coughlin et al. 1990; Freedman 1996; Greene and Ondrich 1990; Tomiak et al. 2000) and robust to alternative assumptions on the exact timing of care home entry. The increased risk of care home entry associated with service use is open to different interpretations. Service use may be an indirect indicator of need—as perceived by older people or service providers—or it might indicate a predisposition toward service use that may make a care home a more likely choice for the individual concerned. It could also indicate that use of community services is the natural precedent to care home entry.
The strengths of this study lie in the high initial response rate, the length of the follow-up period, and the frequency of observations during follow-up. The baseline survey had a high response rate (94%) and what is known of the small group of nonresponders (e.g., gender and age) did not suggest differences from those that took part in the survey. The follow-up period of nearly 12 years (1988–1999) of an age group where the likelihood of entry to a care home increases sharply is a key strength of the study, reflected in the relatively high proportion of participants who experienced the event of interest. The Canadian study by Tomiak and colleagues 2000, for example, was similar to ours but followed up a younger age group (65 and over) for a shorter period of time (5 years). Our follow-up period included up to five interim observations before death or study endpoint, allowing for the values of covariates closer to the event to be used. Seventy-one percent of the 1,425 cases used in the study participated in every health assessment for which they were eligible, yielding values for time-updated covariates as close to the event as the study design permitted. A further 19% took part in all but one health assessment. Only 11 cases (0.8%) failed to participate in any health assessment for which they were eligible. The high response rate to the health assessments means that the effect of any response bias on the availability of updated covariates values should be small.
Evidence of entry into a care home, or community living at study endpoint or death, was obtained for 1,425 of the sample, leaving only 75 where outcome could not be determined. The latter include some who moved from the area. It is unclear how this will have affected our results, although it is possible that migration out of the area may be associated with care home entry.
It is important to be aware of the limitations of the data and study design. The study was restricted to the population of one town and surrounding area, and therefore raises the issue of generalizability. Melton Mowbray is a rural town with a predominantly White population, so we could not examine whether, as in other studies, rural living (Kliebsch et al. 1998; Salive et al. 1993) or ethnicity (Coughlin et al. 1990; Freedman 1996; Greene and Ondrich 1990; Salive et al. 1993; Wolinsky et al. 1992) was associated with care home entry. Entry to care homes is not only determined by demand, but by the supply and nature of care homes. We have no data to indicate whether Melton Mowbray is typical in this respect. However, by restricting the study to patients of one general practice, loss to follow-up was small and the availability of primary care services was similar for all study participants during the study period. There is no reason to think that the general practitioners' preferences for care settings differ from those of other practitioners.
Home ownership was associated with unwillingness to answer income questions and higher income, the latter being in line with what has been found for the UK as a whole (Hancock 1998). The small response bias with respect to owner-occupation may therefore imply an underrepresentation of those with higher incomes. This and the association between nonresponse to the income questions and cognitive impairment might explain why the effect of income on care home entry was not significant. Income was measured at baseline, but not updated throughout the study period because the interim observations were collected as part of a fairly specific health assessment. Home ownership was updated, but not perfectly. Our indicators of social support were not comprehensive, and this could confound the observed relationship between home ownership and care home entry.
A minority of interviews were conducted by proxy. Of the 1,425 participants, 27 (2%) of the baseline interviews were full proxy interviews and 101 (7%) were partial proxies. Not surprisingly, interviews with people with activity restriction and sensory or cognitive impairment were more likely to be conducted by proxy, and there was more nonresponse to the income question among proxy interviews. There was no association between proxy interviews and home ownership.
Exact time of entry into a care home was not known, but results were robust to whether entry was assumed to be at the beginning, middle, or end of the interval within which it was known to have occurred. Because intervals were truncated by death, those where entry to residential care was first identified at death had survival times that were more accurate, but biased downward compared with their surviving counterparts. However, there were no significant differences in key covariates (home ownership and income) between these two categories of care home entrants.
If a person entered and left a care home between observation points, this event would not have been captured. Where this happened, care home entry is likely to have been only temporary (e.g., for respite care), whereas our interest is in long-term care home residence. UK care homes are used relatively little for rehabilitation, although that may change in the future as a result of current policy initiatives (Department of Health 2001). Within our study, only eight participants appeared to have left care homes on a long-term basis (i.e., they were not subsequently observed in a care home).
Care home entry is the result of choices made by older people themselves, by their families, and by public authorities. Although separate decision processes of these three groups could not be distinguished directly, we were able to construct indicators of the likely influences on those decisions. The price an individual faces for institutional care is not observed, but is determined partly by his or her income and assets, so the roles of price and economic resources could not be separated. But, by including income and home ownership (as an indicator of assets) as covariates, we were able to investigate whether income and assets decreased or increased the risk of care home entry, taking account of other relevant factors.
Home ownership may reduce the likelihood of entering a care home because home owners are reluctant to sell their homes and use the proceeds to pay for their care. To avoid this, and the affect it has on their children's inheritance, they may be more resistant to institutional care than those who do not own their homes, or more persistent in their attempts to arrange home care. Clearly, public authorities cannot "force" older people into one form of care or another, but decisions to enter a care home are often made at traumatic times in older people's lives when they may be less able to exercise their own preferences. So, some potential for the authorities to influence these decisions exists. Nonetheless, home owners are likely to enjoy more choice over their care in later life than those with few assets, who are wholly dependent on the state for meeting the costs of their care.
If the UK payment rules for care homes are deterring older home owners from appropriate care home entry when their own housing is old and ill adapted to their needs, then this is arguably more important than the supposed perverse incentive for public authorities to place them in institutional care unnecessarily. One can only speculate about the effects of increasing levels of home ownership among future cohorts of older people, but our findings suggest that demand for community-based services may increase at a greater rate than for care homes. Both public and private sectors will need to be able to deliver complex packages of care to people living in the community. Future generations of older people may be less concerned to preserve their assets for their children, so that for those who will require some form of care home, increased affluence may mean that providers of these facilities will have to respond to heightened expectations of the quality of care that is provided in institutional settings.
|
Acknowledgments |
|---|
Received for publication July 3, 2001. Accepted for publication November 12, 2001.
|
References |
|---|
|
TOPAbstractMethodsResultsDiscussionReferences |
|---|
This article has been cited by other articles:
 |
|
 |
|
  E. Grundy and M. Jitlal Socio-demographic variations in moves to institutional care 1991 2001: a record linkage study from England and Wales Age Ageing, July 1, 2007; 36(4): 424 - 430. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||
| HOME | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|---|
