scholarly journals Nonadherence to Self-Care Practices, Antihypertensive Medications, and Associated Factors among Hypertensive Patients in a Follow-up Clinic at Asella Referral and Teaching Hospital, Ethiopia: A Cross-Sectional Study

2021 ◽  
Vol 2021 ◽  
pp. 1-10
Author(s):  
Addisu Dabi Wake ◽  
Techane Sisay Tuji ◽  
Addisu Tadesse Sime ◽  
Mekuria Tesfaye Mekonnin ◽  
Taju Mohamed Taji ◽  
...  
Keyword(s):  
Teaching Hospital ◽  
Associated Factors ◽  
Formal Education ◽  
Self Care ◽  
Multivariable Logistic Regression Analysis ◽  
Antihypertensive Medications ◽  
Cross Sectional ◽  
Hypertensive Patients ◽  
Care Practices

Background. Hypertension is one of the most common noncommunicable diseases affecting several individuals globally. However, the level of nonadherence to self-care practices, antihypertensive medications, and associated factors among hypertensive patients in a follow-up clinic at Asella Referral and Teaching Hospital is unknown. Objective. To assess the level of nonadherence to self-care practices, antihypertensive medications, and associated factors among hypertensive patients in a follow-up clinic at Asella Referral and Teaching Hospital, Arsi Zone, Oromia Regional State, Ethiopia, in 2020. Methods. An institution-based cross-sectional survey was conducted on 115 hypertensive patients who visited the follow-up clinic at Asella Referral and Teaching Hospital from December 24, 2020, to January 15, 2021. Data were entered into EpiData version 4.2.0.0 and exported to SPSS version 21.0 for statistical analysis. Binary and multivariable logistic regression analysis was used to assess the presence of statistical association between dependent and independent variables. Results. A total of 115 hypertensive patients were enrolled into the study, giving a response rate of 98.29%. The mean age of the study participants was 55.17 years (SD = 17.986). More than half of them (59 (51.3%)) were females. More than half of them (58 (50.4%)) were married. Nearly two-thirds of them (79 (68.7%)) had formal education. The level of nonadherence to self-care practices was 67.0% (n = 77, 95% CI: 60.0, 75.7). Meanwhile, the patient’s level of nonadherence to antihypertensive medications was 16.5% (n = 19, 95% CI: 10.4, 24.3). The multivariable logistic regression analysis showed that age >45 years (AOR = 2.89, 95% CI: 1.16, 7.18), having no formal education (AOR = 1.67, 95% CI: 1.32, 3.74), and having ≤5 years’ duration since diagnoses of hypertension (AOR = 1.56, 95% CI: 1.07, 3.25) were factors significantly associated with nonadherence to self-care practices. Being male (AOR = 2.09, 95% CI: 1.93, 9.59), being married (AOR = 4.22, 95% CI: 1.29, 13.76), and having an average monthly income of ≤2500 ETB (AOR = 1.58, 95% CI: 1.09, 7.08) were factors significantly associated with nonadherence to medications. Conclusion. In the present study, the level of both nonadherence to self-care practices and antihypertensive medications was relatively high. There is a need to initiate programs that could create awareness about adherence to self-care practices and antihypertensive medications among hypertensive patients to improve their level of adherence.

scholarly journals Perceptions, Attitudes and Self-care Practices on Management of Hypertension Among Hypertensive Patients at Teaching Hospital, Batticaloa District, Sri Lanka

2018 ◽  
Vol 10 (1) ◽  
pp. 1-7 ◽  
Author(s):  
G Kisokanth ◽  
Ilankoon IMPS ◽  
Arulanandem K ◽  
Sundaresan KT ◽  
Goonewardena CSE ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Sri Lanka ◽  
Teaching Hospital ◽  
Self Care ◽  
Developed Countries ◽  
Independent Effect ◽  
Systematic Sampling ◽  
Cross Sectional ◽  
Hypertensive Patients ◽  
Care Practices

Objective: Hypertension is an important public health challenge in both developing and developed countries. It is one of the commonest causes of death in Sri Lanka. The patients’ perception, beliefs and attitudes about management of hypertension have an independent effect on patients’ compliance in adapting their lifestyle behaviors. Thus, the purpose of this study was to describe the adapting self-care practices, attitudes among patients with hypertension. Methods: The cross sectional descriptive study was carried out among 424 hypertensive patients attending medical clinics, Teaching Hospital, Batticaloa, Sri Lanka. Systematic sampling technique was used to select participants. Interviewer administered questionnaire was used to collect the information and descriptive statistics was applied using SPSS software. Ethical clearance was obtained. Results: Majority was females (59%) and the mean age of the participants was 60.4 years (SD± 9.6) with 1-5 years duration. More than 65% of patients agreed that ‘Doctors listen and concern their problems’. More than half of the participants also agreed that ‘Doctors clearly explain their condition’ while majority agreed that ‘I can manage my disease’. About 92.0% have reported that they have not checked their blood pressure at home. Majority of participants (88%) agreed that ‘Avoidance of extra salt in their diet is good’. About 33.0% disagreed that ‘Regular physical exercise is essential to control blood pressure’. About 24.0% of participants disagreed that it is ‘Good to have fruits than deserts and sweets’ while less than 40.0% participants disagreed that ‘high blood pressure affects kidney functions, vision, blood vessels, and lead to stroke and ischemic heart disease’. Conclusion: Majority of the hypertensive patients believe that Doctors understand and concern about their disease and have also developed confidence in self-care. Though, creating a short clinic appointment with adequate knowledge need to be encouraged for their adapting self-practices on factors related to patients and physicians .

scholarly journals Knowledge, attitudes and self-care practices of patients with glaucoma in uThungulu in KwaZulu-Natal

2018 ◽  
Vol 77 (1) ◽  
Author(s):  
Aita V. Aghedo ◽  
Boikhutso Tlou ◽  
Saajida Mahomed
Keyword(s):  
Self Care ◽  
Cross Sectional Study ◽  
Good Knowledge ◽  
Cross Sectional ◽  
Glaucoma Diagnosis ◽  
Kwazulu Natal ◽  
Strict Compliance ◽  
Males And Females ◽  
Care Practices

Background: Glaucoma remains one of the leading causes of blindness in South Africa. Early detection, effective treatment and strict compliance with treatment are instrumental to prevent further damage to the optic nerve and thus preserve vision.Aim: The purpose of this study was to assess the knowledge, attitude and self-care practices of patients with glaucoma in KwaZulu-Natal.Setting: The study was conducted in the ophthalmology outpatient department of a public hospital and a private ophthalmology practice in the uThungulu district.Methods: This was an observational, analytic, cross-sectional study. Structured questionnaires assessing knowledge, attitudes and self-care practices were administered to patients presenting for follow-up glaucoma management.Results: The median age of the 384 patients in this study was 60 (interquartile range [IQR] 48.5–69.5) and 59 years (IQR 49.0–66.5) for males and females, respectively (p > 0.05). Two hundred and thirty-eight (62.0%) patients had good knowledge of glaucoma. Age, gender and duration of glaucoma diagnosis were significantly associated with good knowledge of glaucoma. Three hundred and forty-four (89.6%) patients reported having good self-care practices. Patients over the age of 65 years were significantly less likely to have good self-care practices compared to patients aged 26–45 years (odds ratio [OR]: 0.2, confidence interval [CI]: 0.1–0.6, p = 0.01). Good knowledge of glaucoma was significantly associated with good self-care practices of glaucoma (p < 0.001).Conclusion: Elderly patients do not have sufficient knowledge of glaucoma and have poor self-care glaucoma practices. It is important to involve family members of these patients in the education and counselling of glaucoma to facilitate improved disease management.

Management Outcome of Uterine Rupture and Associated Factors in Yirgalem General and Teaching Hospital, Southern Ethiopia: A Cross-Sectional Study

2019 ◽  
Author(s):  
Achamyelesh Tekle ◽  
Hailemichael Hagos ◽  
Kebede Tefera
Keyword(s):  
Teaching Hospital ◽  
Uterine Rupture ◽  
Associated Factors ◽  
Cross Sectional Study ◽  
Southern Ethiopia ◽  
Sectional Study ◽  
Cross Sectional ◽  
Prolonged Duration ◽  
Poor Management

Abstract Background Uterine rupture is dropped significantly in the developed world. However, it is still a major public health problem in developing countries including Ethiopia. The aim of this study was to assess management outcome of uterine rupture and its associated factors in Yirgalem General and teaching Hospital of southern Ethiopia. Methods An institution based cross-sectional study was conducted. All records of uterine rupture managed in Yirgalem general and teaching hospital between January 1, 2012, and December 30, 2017, were reviewed. Data were collected using a checklist. Descriptive statistics and logistic regression analyses were done. Results A total of 331 cases of mothers who managed for uterine rupture were included in the study. 235 (71%) of them had a poor management outcome. Wound site infection 131 (39.6%) and anemia 129 (39%) where the common post-operative complications. There were 13 (4%) maternal death and 320 (96.7%) neonatal death. Lack of antenatal care follow up (adjusted odds ratio (AOR) =2.2, 95% CI: 1.1-4.5), prolonged duration of labor more than 24hr (AOR=3.6; 95% CI: 1.7-7.4), patients presented with sepsis (AOR=2.9; 95% CI: 1.4-6.1), mothers who did not transfuse for blood during the case scenario (AOR=4; 95% CI: 2.1-7.9) and prolonged intra operative time (AOR=5.5; 95% CI: 2.8-10.8) were factors associated with poor management outcome of uterine rupture. Conclusion Poor management outcome of uterine rupture was high in the study area as compared to other studies. Lack of ANC follow up, longer duration of the surgical procedure, prolonged duration of labor, lack of blood transfusion and pre and postoperative complications are associated with poor management outcome. Therefore, proper ANC and early identification of the high-risk groups can prevent and decline the occurrence of uterine rupture and that enhance good outcome.

scholarly journals Self-care practice and associated factors among hypertensive patients in public health facilities in Harar Town, Eastern Ethiopia: A cross-sectional study

2020 ◽  
Vol 8 ◽  
pp. 205031212097414
Author(s):  
Feysal Mohammed Hussen ◽  
Hassen Abdi Adem ◽  
Hirbo Shore Roba ◽  
Bezatu Mengistie ◽  
Nega Assefa
Keyword(s):  
Confidence Interval ◽  
Odds Ratio ◽  
Formal Education ◽  
Adjusted Odds Ratio ◽  
Self Care ◽  
Care Practice ◽  
Cross Sectional ◽  
Eastern Ethiopia ◽  
Hypertensive Patients ◽  
Management Protocol

Background: Self-care practice is the activity that a hypertensive patient undertakes intending to improve their health. Poor self-care practice leads to uncontrolled hypertension. Therefore, strategies designed to prevent and control hypertension-related death, disability, and morbidity should consider the level of the patient’s self-care practice and risk factors. This study assessed self-care practice and associated factors among hypertensive patients in public health facilities of Harar Town in eastern Ethiopia. Method: An institution-based cross-sectional study was conducted among 398 randomly selected hypertensive patients from 25 March 2019 to 16 April 2019. Pretested structured questionnaires adapted from validated tools were used to collect data from participants using electronic Open Data Kit software through face-to-face exit interview. Data were analyzed by SPSS version 24. Bivariable and multivariable logistic regression analyses were conducted to identify factors associated with self-care practice. Adjusted odds ratio with 95% confidence interval was used to report association and the significance was declared at p-value < 0.05. Results: Level of good self-care practice was 29.9% (95% confidence interval: 25.3% and 34.7%). Age ⩾ 60 years (adjusted odds ratio = 3.4, 95% confidence interval: 1.2 and 9.3), formal education (adjusted odds ratio = 2.3, 95% confidence interval: 1.3 and 4.2), absence of comorbidities (adjusted odds ratio = 1.8, 95% confidence interval: 1.1 and 3.1), adequate knowledge about hypertension (adjusted odds ratio = 4.7, 95% confidence interval: 2.5 and 8.8), good social support (adjusted odds ratio = 2.7, 95% confidence interval: 1.6 and 4.7), and being khat abstainer (adjusted odds ratio = 1.9, 95% confidence interval: 1.1 and 3.5) were significantly associated with good self-care practice. Conclusion: The prevalence of good self-care practice was low. In this study, good self-care practice was significantly associated with age, formal education, comorbidities, knowledge about hypertension, social support, and current khat chewing condition. Regular check-up and follow-up of patients’ compliance with self-management protocol, and more emphasis should be given to identify factors that potentially impeding patients’ adherence to hypertension self-management protocol.

scholarly journals Awareness of disease and self care among hypertensive patients attending Tribhuvan University Teaching Hospital, Kathmandu, Nepal

2012 ◽  
Vol 1 (2) ◽  
pp. 29-35 ◽  
Author(s):  
Buna Bhandari ◽  
Mahesh Bhattarai ◽  
Manjul Bhandari ◽  
Nilambar Jha
Keyword(s):  
Teaching Hospital ◽  
Self Care ◽  
Study Finding ◽  
Cross Sectional Study ◽  
University Teaching ◽  
Renal Diseases ◽  
Cross Sectional ◽  
Hypertensive Patients ◽  
Treatment And Prevention ◽  
Prevention Of Hypertension

Background: Hypertension (HTN) is a major risk factor for cardiovascular and renal diseases. The prevalence of hypertension has substantially increased during the past four decades. Information on prevalence as well as awareness regarding treatment and prevention of hypertension is scarce particularly in rural settings. The levels of awareness, treatment, and control of HTN vary between different countries and population groups. Objectives: The objective of this study was to find out the awareness of hypertensive patients about their own disease and self care. Methodology: Descriptive cross sectional study was conducted among 50 hypertensive patients who were admitted to Tribhuvan University Teaching Hospital (TUTH) and attended to medical OPD. Data was collected by using interview schedule by face to face interview method. Results: Among 50 hypertensive patients, 56% were aware about meaning of hypertension, 68% symptoms, 34% cause, 62% prognosis, and 62% complication of HTN. Likewise regarding self care, 70% were doing regular follow up, 92% using regular medication, most of them (80%) were not smoker and 84% were non alcoholic, and 74% taking low fat and low salt diet. Conclusion: Study finding reflects many of them (56%) had more than 50% of knowledge about the hypertension and more than half (54%) were giving more than 50% emphasis about their own self care.DOI: http://dx.doi.org/10.3126/jonmc.v1i2.7296 Journal of Nobel Medical College (2012), Vol.1 No.2 p.29-35

scholarly journals Self-care Practice and Associated Factors Among Hypertensive Follow Up Patients at East Gojam Zone Public Hospitals, North West Ethiopia, 2021

2021 ◽  
Author(s):  
Haymanot Mitiku Zeleke ◽  
Birtuka Assefa ◽  
Teshager Sergo ◽  
Nakachew Mekonnen
Keyword(s):  
Social Support ◽  
Associated Factors ◽  
Self Care ◽  
Public Hospitals ◽  
Care Practice ◽  
Co Morbidity ◽  
Poor Social Support ◽  
Care Practices ◽  
Unfavorable Attitude

Abstract Background: Self-care practice is crucial for the prevention and management of Hypertension. Poorly controlled hypertension leads to cardiovascular complication as well as organ damage. Despite the availability of several effective pharmacologic and non-pharmacologic therapies, hypertension control remains suboptimal. Self-care practices allow hypertensive patients to have improved quality of life by avoiding complication and decrease health care expenditure. Objective: we assessed self-care practice and its associated factors among Hypertensive Follow up patients at East Gojjam Zone public hospitals, Northwest Ethiopia, 2020.Methods: Institution based cross sectional study was conducted by both quantitative and qualitative methods from October 1-30, 2020. Epi data version 3.1 and SPSS version 25.0 were used for data entry and for analysis respectively. Descriptive statistics and binary logistic regression analysis was employed. Adjusted odds ratios were used to ascertain effect sizes for any association between the dependent and associated variables while significance level at p value of 0.05 was determined using 95% confidence intervals. Result: Out of 480 patients included in the study 51% have Poor self-care practices. About 44.6%, 92.5%, 82.8%, 62.5% of respondents were poor adherent to antihypertensive medications, low diet quality, poor practiced to physical activity, poor practice to weight management respectively. Some of the respondents 3.3%, 9.8% were smokers and were alcohol drinkers respectively. Educational status who cannot read and write (AOR=3.153, 95% CI: 1.674-5.939), no co morbidity (AOR = 0.418, 95% CI: 0.263-0.663), uncontrolled blood pressure status (AOR = 2.141, 95% CI: 1.271- 3.609), poor social support status (AOR = 2.587, 95% CI: 1.544-4.334) and unfavorable attitude (AOR= 3.193, 95% CI: 1.951-5.225) showed significant statistical association with poor self-care practice.Conclusion: The level of hypertension self-care practices found to be low. Therefore, education towards hypertension self-care practices should be strengthened for patients living with hypertension. Special attention should be given to patients with low educational level that cannot read and write, patients with co morbidity, uncontrolled state of hypertension, poor social support and those with unfavorable attitude towards hypertension management modalities.

scholarly journals Assessment of drug therapy problem and associated factors among adult hypertensive patients at Ayder comprehensive specialized hospital, Northern Ethiopia

2019 ◽  
Vol 19 (3) ◽  
pp. 2571-2579
Author(s):  
Asgedom Solomon Weldegebreal ◽  
Fekadu Tezeta ◽  
Atey Tesfay Mehari ◽  
Wubetu Gashaw ◽  
Kassa Tesfaye Dessale ◽  
...  
Keyword(s):  
Substance Use ◽  
Drug Therapy ◽  
Associated Factors ◽  
Cross Sectional Study ◽  
Northern Ethiopia ◽  
Antihypertensive Medications ◽  
Cross Sectional ◽  
Hypertensive Patients ◽  
Drug Therapy Problem ◽  
Drug Therapy Problems

Background: Drug-therapy problems(DTPs) among hypertensive patients can result in patient’s morbidity and mortality. The main aim of this study was to assess drug therapy problem and associated factors among <="" span="" style="font-family: hypertensive patients.Methods: A hospital based cross sectional study was conducted. The data was collected from patients’ medical charts and through interview. Drug therapy problem was categorized according to Cipolle methods of DTP classification. Thedata was analyzed using the Statistical Package for the Social Sciences (SPSS), version 21.Results: A total of 241 patients were studied. The mean number of antihypertensive medications prescribed were 1.41±0.53. A total of 357 drug therapy problems(DTPs) were identified. From the patients studied,134(55.6%) had at least one evidence of drug therapy problem. Non adherence was the most commonly identified drug therapy problem occurred in (143(59.3%)) patients. Substance use (AOR=0.445, 95% CI= 0.227-0.870, p=0.018) and comorbidity (AOR= 2.099, 95% CI= 1.192-3.694, p=0.010) werethe predictors of DTP.Conclusion: More than half of the participants had evidence of onset drug therapy problem. Thus efforts that could boost antihypertensive compliance and minimizes substance use should be adopted to reduce patients’s drug therapy problems.Keywords: assessment, drug, therapy, problem, Ethiopia.

scholarly journals Missed Opportunity for Routine Immunization and Its Associated Factors in Gozamen District Health Centers, Northwestern Ethiopia

2020 ◽  
Vol 7 ◽  
pp. 2333794X2098130
Author(s):  
Fetelework Muluneh ◽  
Muluken Wubetu ◽  
Abebe Abate
Keyword(s):  
Associated Factors ◽  
Formal Education ◽  
Health Centers ◽  
Routine Immunization ◽  
World Health ◽  
Multivariable Logistic Regression Analysis ◽  
District Health ◽  
Cross Sectional ◽  
Missed Opportunities ◽  
Missed Opportunity

Background. Vaccine- preventable diseases constitute a major cause of morbidity and mortality in children under-5 years of age in Ethiopia and other developing countries. There are limited studies conducted on this aspect in Ethiopia especially in Gozamen district. Objectives. To assess missed opportunity for routine immunization and its associated factors among children aged <24 months in Gozamen district health centers. Methods. Institutional based cross-sectional study exit interview was conducted on 422 mothers with under 2 years old children. Data was collected using the standard World Health Organization’s missed opportunity tool. Vaccines examined in this study were BCG, OPV0, OPV1, PCV1, rota 1, penta valant 1, OPV2, PCV2, rota2, pentavalant 2, OPV3, PCV3, IPV, pentavalant 3, and measles vaccine. The vaccination status of the children was assessed by a structured questionnaire based on vaccination cards or mothers/caregiver verbal responses. Binary and multivariable logistic regression analysis were used to identify factors associated with missed opportunities for routine immunization among children aged <24 months. Result. The prevalence of missed opportunity for this study was 74.9% ; major vaccines with high missed opportunity were OPV0 (67.8), BCG (17.3%), and Measles (14%). Home delivery, lack of vaccination center near the village, unable to attend formal education and younger age (0-12 months) were independently associated with missed opportunity for routine immunization. Conclusion. The prevalence of missed opportunities for routine immunization in Gozamen district health centers was high. Health centers should give routine immunization services regularly.

scholarly journals Non-Adherence Related Factors to Antihypertensive Medications Among Hypertensive Patients on Follow up at Nedjo General Hospital in West Ethiopia

2018 ◽  
Vol 11 (1) ◽  
pp. 62-71 ◽  
Author(s):  
Habtamu Dame Berisa ◽  
Mohammed Gebre Dedefo
Keyword(s):  
General Hospital ◽  
Patient Adherence ◽  
Antihypertensive Medications ◽  
Related Factors ◽  
Cross Sectional ◽  
Hypertensive Patients ◽  
Income Status ◽  
Cardiovascular Morbidity And Mortality ◽  
Study Participants

Background:Hypertension is an overwhelming global challenge. Increasing awareness and diagnosis of hypertension, and improving control of blood pressure with appropriate treatment are considered critical public health initiatives to reduce cardiovascular morbidity and mortality.Objective:To assess non-adherence-related factors to antihypertensive medications among hypertensive patients on follow up at Nedjo General Hospital.Methods:A cross-sectional study was conducted among hypertensive patients on follow up at Nedjo General Hospital from March 15 to May 5, 2015. A total of 172 hypertensive patients who were available during study period were included in the study. To identify the independent non-adherence-related factors, backward logistic regression analysis was used.Results:Only 54 (31.4%) of the study participants were adherent to their treatment. On multivariable logistic analysis non-adherence was more likely to occur among those with age of>55 years (Adjusted odds ratio (AOR) = 0.10, 95% CI = 0.01-0.85, p=0.035), illiteracy (AOR = 6.76, 95% CI = 1.01-45.08, p=0.049), income status of <500 Ethiopian birr (AOR = 18.51, 95% CI = 1.95-176.06, p=0.011), duration of treatments of>5 years (AOR = 5.41, 95% CI = 1.08-27.22, p=0.041), physical inactivity (AOR = 34.51, 95% CI = 4.66-255.89, p=0.001) and knowledge deficit about hypertension and its treatment (AOR = 7.67, 95% CI = 2.48-23.73, p<0.001).Conclusion:A finding of this study revealed that an adherence status of study participants was low. Thus, greater effort is needed to improve patient adherence to antihypertensive medications.

scholarly journals Knowledge, Attitude and Self-Care Practice towards Control of Hypertension among Hypertensive Patients on Follow-up at St. Paul’s Hospital, Addis Ababa

1970 ◽  
Vol 29 (4) ◽  
Author(s):  
Dawit Bacha ◽  
Hailu Abera
Keyword(s):  
Risk Factor ◽  
Formal Education ◽  
Addis Ababa ◽  
Good Practice ◽  
Self Care ◽  
Basic Knowledge ◽  
Care Practice ◽  
Hypertensive Patients ◽  
Inadequate Knowledge

BACKGROUND: Hypertension is the number one cardiovascular risk factor and the leading cause of mortality worldwide. It’s the driver of the cardiovascular disease epidemic in Africa where it is a major, independent risk factor for heart failure, stroke and renal failure. There is no study to assess the level of knowledge of hypertension among hypertensive patients in our setup. The objective of this study was to assess knowledge, attitude and selfcare practice towards control of hypertension among hypertensive patients on follow up at our hospital.METHODS: A total of 385 hypertensive patients who were on follow up at our hospital were randomly selected for interview. The Sociodemographic and relevant clinical data were extracted using a structured questionnaire. Operational definitions and Likert scale was used to compare the variables.RESULTS: Only 48.6% of hypertensive patients participated in this study have good basic knowledge of hypertension, 47.8% of them have good attitude and only 39.5% of the study participants have good practice towards control of hypertension. Male sex, formal education and being urban resident are associated with better knowledge, attitude and self-care practice of hypertensive patients at our hospital.Conclusion:The result states that there is an inadequate knowledge about hypertension; as well attitude and self-care practice towards control of hypertension among our hypertensive patients is generally poor. Responsible bodies should focus on addressing such limitations of hypertensive patients. Attention should be given to hypertensive patients who are females, low educational level and those coming from rural.

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