Management approach of patients with violent and aggressive behaviour in a district hospital setting in South Africa
- Authors: Adeniyi, Oladele Vincent , Puzi, Ntandazo
- Date: 2021
- Subjects: mental health Emergency medical services violennce Article
- Language: English
- Type: text , article
- Identifier: http://hdl.handle.net/11260/7284 , vital:53108 , xlink:href="https://doi.org/10.4102/safp.v63i1.5393"
- Description: Background: Given the physical and mental health consequences of tobacco use amongst individuals with mental illness, it was imperative to assess the burden of tobacco use in this population. Aim: This study examined the patterns and factors associated with tobacco use in individuals attending the outpatient unit. Setting: Cecilia Makiwane Hospital Mental Health Department in Eastern Cape province, South Africa. Methods: Lifetime (ever use) use and current use of any tobacco products were examined in a cross-sectional study of 390 individuals between March and June 2020. A logistic regression was fitted to determine the correlates of lifetime and current use of any tobacco products. Results: The rates of ever use and current use of tobacco products were 59.4% and 44.6%, respectively. Of the participants interviewed, lifetime tobacco use was more prevalent amongst individuals with schizophrenia (67.9%) and cannabis-induced disorders (97.3%) and lower in those with major depressive disorders (36.1%) and bipolar and related disorders (43.5%). Men were six times more likely to have ever used or currently use tobacco products in comparison to women. Also, those who had a salaried job or owned a business were over three times more likely to have ever used or currently use tobacco products compared with those receiving government social grants. Conclusions: The prevalence of tobacco use in this study was significantly higher than the general population in the Eastern Cape. Therefore, smoking prevention and cessation interventions targeted at the general population should target this often neglected sub-population in the region. Keywords: aggressive and violent behaviour; assisted user; emergency centres; involuntary user; Mental Health Care Act.
- Full Text:
- Date Issued: 2021
Prevalence and determinants of tobacco use amongst South African adults with mental illness in the Eastern Cape
- Authors: Tindimwebwa, Linda K , Ajayi, Anthony I , Adeniyi, Oladele Vincent
- Date: 2021
- Subjects: mental health mental illiness tobacco use Article
- Language: English
- Type: text , article
- Identifier: http://hdl.handle.net/11260/7278 , vital:53109 , xlink:href="https://doi.org/10.4102/sajpsychiatry.v27i0.1637"
- Description: Background: Given the physical and mental health consequences of tobacco use amongst individuals with mental illness, it was imperative to assess the burden of tobacco use in this population. Aim: This study examined the patterns and factors associated with tobacco use in individuals attending the outpatient unit. Setting: Cecilia Makiwane Hospital Mental Health Department in Eastern Cape province, South Africa. Methods: Lifetime (ever use) use and current use of any tobacco products were examined in a cross-sectional study of 390 individuals between March and June 2020. A logistic regression was fitted to determine the correlates of lifetime and current use of any tobacco products. Results: The rates of ever use and current use of tobacco products were 59.4% and 44.6%, respectively. Of the participants interviewed, lifetime tobacco use was more prevalent amongst individuals with schizophrenia (67.9%) and cannabis-induced disorders (97.3%) and lower in those with major depressive disorders (36.1%) and bipolar and related disorders (43.5%). Men were six times more likely to have ever used or currently use tobacco products in comparison to women. Also, those who had a salaried job or owned a business were over three times more likely to have ever used or currently use tobacco products compared with those receiving government social grants. Conclusions: The prevalence of tobacco use in this study was significantly higher than the general population in the Eastern Cape. Therefore, smoking prevention and cessation interventions targeted at the general population should target this often neglected sub-population in the region. Keywords: Eastern Cape province; mental health users; mental illness; South Africa; tobacco use.
- Full Text:
- Date Issued: 2021
Prevalence and factors associated with suicidal ideation amongst college students in the Nelson Mandela Bay Municipality, South Africa
- Authors: Alabi, Adeyinka A , Oladimeji, Olawumi K , Adeniyi, Oladele Vincent
- Date: 2021
- Subjects: Suicidal behaviour Education (Higher) Students Article
- Language: English
- Type: text , article
- Identifier: http://hdl.handle.net/11260/7235 , vital:53093 , xlink:href="https://doi.org/10.4102/safp.v63i1.5195"
- Description: Background: Suicidal behaviour amongst college students constitutes a significant social and public health problem globally. This study determined the prevalence and associated factors of suicidal ideation amongst students of higher education in the Nelson Mandela Bay Municipality (NMBM), South Africa. Methods: In this institution-based cross-sectional study, a multistage cluster sampling of 826 participants, drawn from a college in NMBM, was conducted from January to March 2020. Data were collected with a standardised self-administered questionnaire. Multivariable logistic regression analysis was used to identify the factors associated with suicidal ideation. Results: Participants’ ages ranged from 18 to 24 years, with a mean age of 20.49 years (standard deviation, 1.88 years). The lifetime prevalence of suicidal ideation and plans in the preceding 12 months were 24.5% and 9.6%, respectively. The odds of suicidal ideation were higher in students who experienced bullying (adjusted odds ratio [AOR], 1.89; 95% confidence interval [CI], 1.35–2.65), mental illness (AOR, 1.89; 95% CI, 1.35–2.65), a history of sexual assault (AOR, 2.50; 95% CI, 1.20–5.21) and experience of sexual assault by or to a close family member (AOR, 1.69; 95% CI, 1.01–2.82). Underlying chronic illness was associated with a twofold risk for suicidal ideation in both sexes. Conclusion: About a quarter of the students sampled at the college had experienced suicidal ideation and some had had suicidal plans in the preceding 12 months. Screening for the identified risk factors amongst the student population coupled with prompt interventions would mitigate the risk of suicide in the study population. Keywords: suicidal behaviour; suicidal plans; higher education; students; South Africa.
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- Date Issued: 2021
Skills for communicating severe acute respiratory syndrome-coronavirus-2 result to patients and/or relatives
- Authors: Adeniyi, Oladele Vincent , Kayembe, Dominique K
- Date: 2021
- Subjects: COVID-19 Structured model Medical consultation Article
- Language: English
- Type: text , article
- Identifier: http://hdl.handle.net/11260/7236 , vital:53095 , xlink:href="https://doi.org/10.4102/safp.v63i1.5221"
- Description: Clinicians notify positive results of the severe acute respiratory syndrome coronavirus-2 polymerase chain reaction to patients and/or relatives, whilst short message service (SMS) has been adopted as a means of disseminating negative results. Therefore, clinicians should be adequately equipped to provide telephonic consultation whilst delivering a positive test result to patients. The news of the coronavirus disease 2019 (COVID-19) test result often invokes fear of impending death in patients, especially the elderlies and those with comorbidities. In addition, several survivors have reported persistent symptoms and COVID-19-related stigma, which precludes them from immediate re-integration into their workplaces. Consequently, COVID-19 results are perceived as bad news by the members of the public. This article justifies why COVID-19 test results are bad news and also discusses the notification steps to follow when delivering COVID-19 results, whilst also addressing patients’ immediate concerns. The article concludes by highlighting an important safety net for COVID-19 patients and the attending clinician.
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- Date Issued: 2021
Cross-sectional study of prevalence and determinants of uncontrolled hypertension among South African adult residents of Mkhondo municipality
- Authors: Masilela, Charity , Pearce, Brendon , Ongole, Joven Jebio , Adeniyi, Oladele Vincent , Benjeddou, Mongi
- Date: 2020
- Subjects: Blood pressure control , Dyslipidaemia , Uncontrolled hypertension
- Language: English
- Type: article , text
- Identifier: http://hdl.handle.net/11260/4481 , vital:44124 , https://doi.org/10.1186/s12889-020-09174-7
- Description: Achieving the blood pressure treatment target in individuals with hypertension is a serious global health challenge. Furthermore, the actual burden of uncontrolled hypertension is poorly understood, especially in the developing countries. Therefore, this study comprehensively examined the prevalence and factors associated with uncontrolled hypertension in individuals receiving care at the primary healthcare facilities in the rural areas of Mkhondo Municipality in the Mpumalanga Province, South Africa. Methods: In this cross-sectional study, 329 individuals attending care for hypertension were recruited from January 2019 to June 2019 at three primary healthcare centres, namely, Piet Retief hospital, Mkhondo town clinic and Thandukukhanya community health centre. Uncontrolled hypertension was defined as systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg in accordance with the South African Hypertension Society guideline (2014). Multiple logistic regression (Forward LR method) analysis was used to identify the significant determinants of uncontrolled hypertension. Results: The majority of the participants were 55 years old and above (69.0%), Zulus (81.2%), non-smokers (84.19%) and had been diagnosed with hypertension for more than a year prior to the study (72.64%). The overall prevalence of uncontrolled hypertension was 56.83% (n = 187) with no significant difference between sexes, 57.38% male versus 56.88% female, respectively. In the multiple logistic regression model analysis after adjusting for confounding variables, obesity (AOR = 2.90; 95% CI 1.66–5.05), physical activity (AOR = 4.79; 95% CI 2.15–10.65) and HDL-C (AOR = 5.66; 95% CI 3.33–9.60) were the significant and independent determinants of uncontrolled hypertension in the cohort. Conclusion: The high prevalence of uncontrolled hypertension in the study setting can be largely attributed to obesity, physical activity and dyslipidaemia. Treatment will require the collaborative efforts of individuals, clinicians and health authorities. All these determinants should be addressed decisively so as to achieve the treatment blood pressure targets in the study population.
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- Date Issued: 2020
Genetic diversity, resistance profile of hiv and risk assessment of mother-to-child transmission in pregnant women on antiretroviral therapy in the Eastern Cape, South Africa
- Authors: Adeniyi, Oladele Vincent
- Date: 2019
- Subjects: Antiretroviral agents , HIV infections -- Treatment -- South Africa
- Language: English
- Type: Thesis , Doctoral , PhD
- Identifier: http://hdl.handle.net/10353/15120 , vital:40183
- Description: Despite the initiation of life-long ART in HIV-infected pregnant women, the rate and determinants of infant HIV transmission are not known, especially in the poor resource settings of the Eastern Cape, South Africa. Maternal anti-retroviral therapy (ART) is crucial for elimination of mother-to-child transmission (MTCT) of HIV. However, the inevitable risks of emergence of HIV drug resistance poses significant threat to achieving this goal of HIV-free generation and keeping mothers alive. Also, it is unclear if women with high viral load at delivery have acquired clinically relevant mutations, which could confer resistance to the ART, thus, further increasing the risks of motherto-child transmission of HIV-drug resistance strains. In addition to the gaps identified in the prevention of mother-to-child transmission (PMTCT) context, the understanding of regional epidemics is crucial to the broader epidemiological profiling of HIV infections in the country. Despite the rapid influx of foreign nationals to South African and Eastern Cape Province, there has not been any molecular epidemiological studies profiling the HIV diversity in the Eastern Cape.
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- Date Issued: 2019
On-site evaluation of smoking, alcohol consumption and physical inactivity among commercial taxi drivers in Buffalo City Metropolitan Municipality, South Africa
- Authors: Adedokun, Aanuoluwa Odunayo , Ter Goon, Daniel , Owolabi, Eyitayo Omolara , Adeniyi, Oladele Vincent , Ajayi, Anthony Idowu
- Date: 2019
- Subjects: Alcohol use , Substance use , Commercial drivers
- Language: English
- Type: article , text
- Identifier: http://hdl.handle.net/11260/5086 , vital:44345 , https://doi.org/10.5539/gjhs.v11n2p110
- Description: Commercial drivers have been identified as eliciting behaviours that promote non- communicable diseases and road traffic accidents. The aim of the study is to determine the prevalence and pattern of alcohol use, smoking and physical inactivity among commercial taxi drivers in Buffalo City Metropolitan Municipality, South Africa. A cross-sectional study was conducted among 403 commercial drivers using the face-to-face interviews method. The WHO STEPwise questionnaire was used to obtain the demographic data, self-reported rate of alcohol consumption, tobacco use and physical inactivity. The participants’ mean age was 43.3 ± 12.5 years. About 30% of the participants were daily smokers, 37% consumed alcohol regularly and only 18% were physically active, whilst 82% were physically inactive. The prevalence of alcohol use, smoking and physical inactivity is high among commercial drivers in East London. Workplace health education on the health effects of these lifestyles’ risky behaviours on individuals and the general public should be given to the drivers.
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- Date Issued: 2019
Genetic diversity, resistance profile of HIV and risk assessment of mother-to-child transmission in pregnant women on anti-retroviral therapy in the Eastern Cape, South Africa
- Authors: Adeniyi, Oladele Vincent
- Date: 2018-12
- Subjects: Antiretroviral agents , AIDS (Disease) in infants
- Language: English
- Type: Doctoral theses , text
- Identifier: http://hdl.handle.net/10353/19817 , vital:43254
- Description: Despite the initiation of life-long ART in HIV-infected pregnant women, the rate and determinants of infant HIV transmission are not known, especially in the poor resource settings of the Eastern Cape, South Africa. Maternal anti-retroviral therapy (ART) is crucial for elimination of mother-to-child transmission (MTCT) of HIV. However, the inevitable risks of emergence of HIV drug resistance poses significant threat to achieving this goal of HIV-free generation and keeping mothers alive. Also, it is unclear if women with high viral load at delivery have acquired clinically relevant mutations, which could confer resistance to the ART, thus, further increasing the risks of motherto- child transmission of HIV-drug resistance strains. In addition to the gaps identified in the prevention of mother-to-child transmission (PMTCT) context, the understanding of regional epidemics is crucial to the broader epidemiological profiling of HIV infections in the country. Despite the rapid influx of foreign nationals to South African and Eastern Cape Province, there has not been any molecular epidemiological studies profiling the HIV diversity in the Eastern Cape. , Thesis (PhD) (Microbiology) -- University of Fort Hare, 2018
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- Date Issued: 2018-12
Adult binge drinking: rate, frequency and intensity in Buffalo City Metropolitan Municipality, South Africa
- Authors: Owolabi, Eyitayo Omolara , Goona, Daniel Ter , Adeniyi, Oladele Vincent , Seekoea, Eunice
- Date: 2018
- Language: English
- Type: text , article
- Identifier: http://hdl.handle.net/11260/4944 , vital:44305 , https://doi.org/10.1080/20786190.2017.1382970
- Description: This study was conducted to explore views about the execution of powers and functions of the police in the light of related challenges. This study made use of data from a total of 83 adult participants (a survey involving 73 individuals, and 10 in-depth interviews), including males and females of diverse occupational backgrounds from Bindura and Mount Darwin policing districts in Zimbabwe. A closed-ended, mostly Likert-scale-based questionnaire was used to collect data about the prevalent forms of police abuse of powers and functions, while an in-depth interview guide was provided to harvest information qualitatively. Findings reveal that police officers abuse their powers through unlawful arrests, arbitrary search and seizure, excessive use of force, unlawful methods of investigation, and ill treatment of detainees. Though not as prevalent as other forms of abuse, malicious criminal prosecution and partisan policing were also cited.K EYWOR DS: powers, abuse, function, police, Zimbabwe
- Full Text:
- Date Issued: 2018
Factors affecting adherence to antiretroviral therapy among pregnant women in theEastern Cape, South Africa
- Authors: Adeola, H A , Adeniyi, Oladele Vincent , Ajayi, Anthony Idowu , Goon, Daniel Ter , Owolabi, Eyitayo Omolara , Eboh, Alfred , Lambert, John
- Date: 2018
- Language: English
- Type: text , article
- Identifier: http://hdl.handle.net/11260/5272 , vital:44427 , https://neuro.unboundmedicine.com/medline/citation/29653510/Factors_affecting_adherence_to_antiretroviral_therapy_among_pregnant_women_in_the_Eastern_Cape_South_Africa_
- Description: Background:Context-specific factors influence adherence to antiretroviral therapy (ART) among pregnant womenliving with HIV. Gaps exist in the understanding of the reasons for the variable outcomes of the prevention ofmother-to-child transmission (PMTCT) programme at the health facility level in South Africa. This study examinedadherence levels and reasons for non-adherence during pregnancy in a cohort of parturient women enrolled in thePMTCT programme in the Eastern Cape, South Africa.Methods:This was a mixed-methods study involving 1709 parturient women in the Eastern Cape, South Africa. Weconducted a multi-centre retrospective analysis of the mother-infant pair in the PMTCT electronic database in 2016.Semi-structured interviews of purposively selected parturient women with self-reported poor adherence (n= 177)were conducted to gain understanding of the main barriers to adherence. Binary logistic regression was used todetermine the independent predictors of ART non-adherence.Results:A high proportion (69.0%) of women reported perfect adherence. In the logistic regression analysis, afteradjusting for confounding factors, marital status, cigarette smoking, alcohol use and non-disclosure to a family memberwere the independent predictors of non-adherence. Analysis of the qualitative data revealed that drug-related side-effects, being away from home, forgetfulness, non-disclosure, stigma and work-related demand were among the mainreasons for non-adherence to ART.Conclusions:Non-adherence to the antiretroviral therapy among pregnant women in this setting is associated withlifestyle behaviours, HIV-related stigma and ART side-effects. In order to eliminate mother-to-child transmission of HIV,clinicians need to screen for these factors at every antenatal clinic visit.Keywords:Adherence, Non-adherence, HIV, Antiretroviral therapy, Elimination of mother-to-child transmission,Prevention of mother-to-child transmission, Stigma, South Africa
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- Date Issued: 2018
Beyond health care providers’recommendations: understandinginfluences on infant feeding choices ofwomen with HIV in the Eastern Cape,South Africa
- Authors: Adeniyi, Oladele Vincent , Ajayi, Anthony Idowu , Issah, Moshood , Owolabi, Eyitayo Omolara , Ter Goon, Daniel , Avramovic, Gordana , Lambert, John
- Date: 2017
- Subjects: Africa Infant Feeding Sub-sahara
- Language: English
- Type: text , article
- Identifier: http://hdl.handle.net/11260/6063 , vital:45109 , https://doi.org/10.1186/s13006-019-0201-5
- Description: Background: Despite the array of studies on infant feeding practices of HIV-infected women, gaps still exist in the understanding of the underlying reasons for their infant feeding choices. Potential for behavioural change exists, especially in the light of the 2016 updated World Health Organization guideline on HIV and infant feeding. The aim of this paper is to determine the rate of adoption of exclusive breastfeeding in this cohort, examine the determinants of infant feeding choices of HIV-infected women and assess the underlying reasons for these choices. Methods: This was a mixed methods study conducted between September 2015 and May 2016. It analyses the quantitative and qualitative data of 1662 peripartum women enrolled in the East London Prospective Cohort Study across three large maternity services in the Eastern Cape. Women with HIV reported their preferred choices of infant feeding. In addition, participants explained the underlying reasons for their choices. Descriptive and inferential statistics summarised the quantitative data, while thematic content analysis was performed on qualitative data. Results: Of the 1662 women with complete responses, 80.3% opted to exclusively breastfeed their babies. In the adjusted model, up to grade 12 education level (AOR: 1.81; 95% CI: 1.14, 2.86), rural/peri-urban residence (AOR:1.44; 95% CI: 1.05, 1.96), alcohol use (AOR: 1.65; 95% CI: 1.25, 2.18), negative or unknown HIV status at booking (AOR:1.85; 95% CI:1.27, 2.70), currently married (AOR:1.43; 95% CI:1.01, 2.02) and WHO Clinical Stage 2–4 (AOR:1.77; 95% CI: 1.15, 2.72) were significantly associated with the decision to exclusively breastfeed. Health care providers’ recommendations, perceived benefits of breastfeeding, unaffordability of formula feeding, and coercion were the underlying reasons for wanting to breastfeed; while work/school-related demands, breast-related issues, and fear of infecting the baby influenced their decision to formula feed. Conclusion: The majority of HIV-infected women chose to breastfeed their babies in the Eastern Cape. Following up on these women to ensure they breastfeed exclusively, while also addressing their possible concerns, could be an important policy intervention. Future studies should focus on how early infant feeding decisions change over time, as well as the health outcomes for mother and child. Keywords: Exclusive breastfeeding, Infant feeding practice, infant formula feeding, HIV-infected peripartum women, South Africa, WHO guideline
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- Date Issued: 2017
Central obesity and normal-weight central obesity among adults attending healthcare facilities in Buffalo City Metropolitan Municipality, South Africa: a cross-sectional study
- Authors: Owolabi, Eyitayo Omolara , Ter Goon, Daniel , Adeniyi, Oladele Vincent
- Date: 2017
- Subjects: Buffalo City Metropolitan Municipality, South Africa Obesity Central obesity, Overall obesity, Waist circumference, Waist-to-hip ratio, Waist-to-height ratio, NICE BMI-WC composite index, Health risk, Abdominal obesity Computer File
- Language: English
- Type: text , article
- Identifier: http://hdl.handle.net/11260/5887 , vital:44664 , https://DOI10.1186/s41043-017-0133-x
- Description: Background Central obesity (CO) confers a significant threat on the cardio-metabolic health of individuals, independently of overall obesity. Disparities in the measures of fat distribution lead to misclassification of individuals who are at risk of cardio-metabolic diseases. This study sought to determine the prevalence and correlates of central obesity and normal-weight central obesity among adults attending selected healthcare facilities in Buffalo City Metropolitan Municipality (BCMM), South Africa, assess their health risk and examine the association between central obesity and cardio-metabolic diseases among adults with normal weight, measured by body mass index (BMI). Methods A cross-sectional survey of 998 adults was carried out at the three largest outpatient clinics in BCMM. Overall and central obesity were assessed using BMI, waist circumference (WC), waist-to-hip ratio (WHR) and waist-to-height ratio (WHTR). The WHO STEPwise questionnaire was used for data collection. Blood pressure and blood glucose were measured. Normal-weight central obesity was defined as CO among individuals with normal weight, as assessed by BMI. Health risk levels were assessed using the National Institute for Health and Clinical Excellence (NICE) BMI-WC composite index. Bivariate and multivariate analyses were used to determine the prevalence of CO, normal-weight central obesity and the predictors of CO. Results The mean age of participants was 42.6 (± 16.5) years. The prevalence of CO was 67.0, 58.0 and 71.0% by WC, WHR and WHTR, respectively. The prevalence of normal-weight central obesity was 26.9, 36.9 and 29.5% by WC, WHR and WHTR, respectively. About 41% of the participants had a very high health risk, 13% had increased risk or high risk and 33% had no health risk. Central obesity was significantly associated with hypertension but not associated with diabetes among those with normal weight (by BMI). Female sex, age over 30 years, marriage, secondary or tertiary level of education, non-smoking status, diabetes and hypertension significantly predicted central obesity among the study participants. Conclusion The prevalence of central obesity among the study participants is high, irrespective of the defining criteria. One in three adults of normal weight had central obesity. Body mass index should therefore not be used alone for clinical assessment by healthcare workers in the study setting.
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- Date Issued: 2017
Prevalence and factors associated with tobacco use among adults attending selected healthcare facilities in Buffalo City Metropolitan Municipality, South Africa
- Authors: Owolabia, E O , Goona, D T , Adeniyi, Oladele Vincent , Seekoea, E , Adedokun, A O
- Date: 2017
- Subjects: South Africa Tobacco 2078-6204 Computer File
- Language: English
- Type: text , article
- Identifier: http://hdl.handle.net/11260/6127 , vital:45127 , https://doi.org/10.1080/20786190.2017.1340251
- Description: Tobacco use increases the risk of cardiovascular disease, premature death and certain cancers. This study investigated the prevalence and determinants of tobacco use among adults in Buffalo City Metropolitan Municipality (BCMM), South Africa. Methods: This study forms part of the cardio-metabolic risk survey carried out at the three largest outpatient clinics in BCMM. This multi-centre cross-sectional survey utilised the relevant items of the WHO STEPwise questionnaire to obtain information on demographic and behavioural characteristics of 1 107 participants. A total of 109 participants were excluded as a result of incomplete data. Thus, 998 participants (male = 327; female = 671) were included in the analysis. Self-reported, current use of any tobacco product was defined as tobacco use while secondary smoking was defined as exposure of non-smokers to environmental tobacco smoke, either at home or in the workplace. Results: Of all the study participants, 150 (15%) were current tobacco users and 335 (39.5%) of the non-smoking participants were exposed to secondary smoking. The majority of the tobacco users were males (70.7%) compared with females (29.3%). The commonest form of tobacco use was the manufactured cigarette. The mean age at initiation of smoking was 18.3 ± 5.1 and 22.6 ± 8.0 years for men and women, respectively. Only male sex (p = 0.000), single status (p = 0.003), no formal education (p = 0.007) and self-employment (p = 0.043) were significantly associated with tobacco use. Conclusion: High prevalence of tobacco use, especially cigarette smoking, in BCMM is worrisome given its strong association with cardiovascular events and cancers. The district health authorities should prioritise smoking cessation measures at the primary health care level.
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- Date Issued: 2017