Factors determining VCT efficacy as a preventative public health tool and precursor to behavioral change vis--vis the HIV/AIDS pandemic in Malawi and other selected sub-Saharan African countries: A systematic review of literature.


BY


MARISEN MWALE: PH FELLOW- COM/CDC/MACRO

LECTURER

DEPARTMENT OF EDUCATION AND TEACHING STUDIES

E-mail: marisen.mwale@yahoo.co.uk

Mailing address: Mzuzu University
Private Bag 201
Luwinga
Mzuzu 2
Malawi



Abstract

According to UNAIDS, 42 million people in the world have HIV infection. Sub-Saharan Africa remains the region most heavily affected by HIV, accounting for 67% of all people living with HIV and for 75% of AIDS deaths in 2007 [UNAIDS, 2008]. Notably, the majority of new infections in the region are preventable and are spread through unsafe sex. It is only recently that VCT services have been considered important as an entry point for prevention and care interventions for HIV/AIDS not only in Malawi but in sub-Saharan Africa as a whole. As empirical findings rightly document, VCT can however lead to the practice of safe sexual behaviors and increased condom use thus preventing further spread of the disease [Vidanapathirana et al, 2007]. Systematic review on impact of VCT on risk behavior in developing countries shows increased condom use following voluntary screening and VCT is also useful in targeting persons at high risk because risky behaviors are positively associated with the decision to uptake the HIV test [Miller, 1996]. It is upon this background that the current systematic review focuses on VCT with the thesis that perceived susceptibility to contracting HIV acts as a strong predictor of the health promotive screening action, which in turn acts as a potential precursor to Behavioural change relative to the HIV/AIDS pandemic.



Key words: VCT; Home-based service; Preventative health device; Diagnostic tool







Introduction


Malawi is among the ten countries with the highest HIV prevalence in the world, estimated at 12% of adults aged 15-49 years by the National HIV Prevention Strategy
(2009), and pegged at 11.9% by the Joint United Nations Programme on HIV/AIDS -other countries with the highest global prevalence being; Swaziland- 26.1%, Lesotho- 23.2%, Botswana- 23.1%, South Africa- 18.1%, Zimbabwe- 15.3%, Namibia- 15.3%, Zambia- 15.2%, Mozambique- 12.2%, and Kenya- high but not documented; in such descending order(UNAIDS/WHO, 2008). Although trends in HIV prevalence from sentinel surveillance indicate a slight decline, overall the downward trend in prevalence appears relatively shallow. In addition, some behavior indicators are stagnating or even worsening. The proportion of male youth aged 15-24 years having sex with more than one non-regular partner is high and condom use with non-regular partners is low. Further, three-quarters of the infection is in adults 20-40 years of age encompassing the most productive segment of the population with gross repercussions on the country in all sectors of development. According to the Biological and Behavioural Surveillance Survey (NAC, 2006) the proportion of respondents expressing an interest in getting tested for HIV amongst targeted high risk groups [Male vendors, Male primary-school teachers, Female primary school teachers, Male secondary school teachers, Female secondary school teachers, Male police officers, Female police officers, Long-distance truck drivers, Male estate workers, Female estate workers, Female boarder traders, Fishermen, Female sex workers (FSW)] was consistently lower than those who had ever tested for HIV indicating an unmet need in terms of HIV counseling and testing. The
same survey also documents that efforts to reach target population groups with messages regarding HIV and AIDS need to be continued through a diverse set of channels to reach those with little access to mass media such as television. It is thus unequivocal that HIV/AIDS is not only a public health, social, economic, and development issue challenging the individual and collective well-being and security of people in Malawi. Rather, the challenge of HIV/AIDS demands a high level of commitment, strong multisectoral collaboration and sustained action among all key stakeholders and the entire populace. Routine testing in hospitals and other health care facilities, for example, significantly increases uptake and case finding among the attendees of these facilities, but cost and convenience issues often limit the use of health care facilities among most risk group strata in sub-Saharan countries. Although community-based approaches- like mobile Voluntary Counseling and Testing [VCT] units or home-based VCT provision- have been shown to dramatically increase the uptake of testing services, the rates of patronage still remain insignificant derailing the goals to attain universal HIV testing and counseling [HTC] and underscoring the need for such stringent measures as door to door testing in Malawi. In the Action Plan for the National HIV Prevention Strategy- 2009-2013 [NAC, 2009], the strategic approach for among others Prevention of Mother to Child HIV transmission [PMCT] in Malawi provides for Universal HTC [including provider initiated testing and counseling] for women and their partners, and adolescents in child bearing age. The broad activities for the strategic action emphasizes on scaling up access to VCT in all districts, including early infant diagnosis at all PMCT sites; training of health workers to provide both pediatric and adult HTC services as well as psychological support- especially for children; production of Information Education and Communication [IEC] materials on HTC; the conducting of advocacy sessions in VCT; and the provision of VCT services including couple counseling through door to door, outreach, and mobile services. The strategic plan also emphasizes the involvement of Ministry of Health [MOH] partners in the provision of HTC services and general implementation of the plan. It is upon this background that the systematic review focuses on VCT with the thesis that perceived susceptibility to contracting HIV acts as a strong predictor of the health promotive action which in turn acts as a potential precursor to Behavioural change relative to the HIV/AIDS pandemic.







Problem analysis


According to UNAIDS, 42 million people in the world have HIV infection. Sub-Saharan Africa remains the region most heavily affected by HIV, accounting for 67% of all people living with HIV and for 75% of AIDS deaths in 2007 [UNAIDS, 2008]. Notably, the majority of new infections in the region are preventable and are spread through unsafe sex. It is only recently that VCT services have been considered important as an entry point for prevention and care interventions for HIV/AIDS. Research has shown that VCT can lead to the practice of safe sexual behaviors and increased condom use, thus preventing further spread of the disease [Vidanapathirana et al, 2007]. Systematic review on impact of VCT on risk behavior in developing countries shows increased condom use. VCT is also useful in targeting persons at high risk because risky behaviors are positively associated with the decision to take the HIV test [Miller, 1996]. VCT strengthens prevention efforts through risk-reduction strategies for HIV infected people and above all else provides evidence-based approaches to specific recommendations for prevention and control of HIV/AIDS [CDC, 2001] as well as being one of the monitoring and evaluating indicators of a second-generation HIV surveillance system [UNAIDS/WHO, 2002]. Access to VCT services nevertheless, remains limited and demand is often low in many high prevalence countries of sub-Saharan Africa. Furthermore, the quality and benefits of VCT, in particular with regard to confidentiality, counseling and access to clinical and social support, vary enormously.

The crux of the problem however emanates from adverse concern with the limited success of various programmes of Public Health in initiating Behavioural change relative to the HIV/AIDS pandemic not only in Malawi but sub-Saharan Africa in general. The issue in perspective being the failure of large numbers of eligible adults to participate in HIV screening VCT- programmes provided at no charge in centers conveniently located in various neighborhoods. The current systematic review therefore aims at exploiting those factors facilitating or inhibiting such positive responses to the health promotive action relative to the HIV/AIDS pandemic thus militating against Behavioral change.
VCT efficacy review

HIV testing is the process by which blood or body fluids are analyzed for the presence of antibodies or antigens produced in response to HIV infection [WHO, 2003]. Through VCT, an individual undergoes counseling, enabling him or her to make an informed choice about being tested for HIV. This decision must be entirely the choice of the individual, and he or she must be assured that the process will be confidential [UNAIDS, 2000]. It is usually combined with pre- and- post-test counseling. The pre-test counseling prepares the client by explaining and discussing the HIV test process, myths and misinformation about HIV/AIDS, implications of testing, risk assessment, risk prevention, and coping strategies. The main aim of post-test counseling is to help clients understand their test results and initial adaptation to their seropositive or seronegative status with referral as required. VCT is one of the key tools in HIV/AIDS prevention, and it includes benefits at the individual, community, and national levels.

Poor accessibility of health facilities, fatalism, HIV-related stigma, and confidentiality are however the main barriers to use of VCT services in sub-Saharan African countries. Although several strategies to increase the uptake of VCT among sub-Saharan populations have been suggested, factors that act as motivators for and barriers to uptake of VCT are rather elusive and difficult to delineate. It is estimated that up to 90% of HIV-positive individuals in low-income countries do not know their HIV status and may be unsuspectingly spreading the disease [UNICEF, 2006]. This according to the World Health Organization [2006] and UNAIDS [2008] underscores an urgent public health priority to immediately scale up HIV testing, treatment, and counseling in most sub-Saharan African countries which command the status of being epicenter to and bear a disproportionate brunt of the global pandemic. More so for Malawi, as in other high HIV- prevalent countries of sub-Saharan Africa, residents of rural areas often lack opportunities to be tested for HIV and to learn their status [Kimchi, 2005]. While VCT has been available in various facilities in Malawi for years, most testing centers are located in major urban areas. The dearth and paucity of evaluative studies on the efficacy, impact and effectiveness of VCT programs in Malawi in particular justifies the need to conduct such studies if further progress is to be made. That however does not militate against the fact that tangible work on the ground is being done in that field.

In a study conducted on Likoma island in Malawi [Helleringer, et al, 2009] aimed at measuring the uptake of home-based VCT and estimate HIV prevalence among members of the poorest households in a sub-Saharan population, it was observed that despite the fact that less than a quarter of the study population had previously participated in facility based VCT, the home-based provision of VCT was very well accepted in the study population. Specifically when present at home at the time of the VCT teams visit, more than 75% of respondents accepted to be tested and immediately retrieved their HIV test results. Uptake was even higher among the poorest, suggesting a strong unmet need for VCT in the most disadvantaged subgroups of the population. The finding is interesting and insightful in the sense that it highlights an unmet gap of accessibility to VCT services especially in rural Malawi begging the question as to whether the majority of people are really not motivated to uptake VCT or rather that the service itself is not readily publicized through IEC and not readily accessible to the targeted masses. Empirical findings in fact demonstrate that social marketing of VCT through criteria as IEC is one of several identified strategies for scaling up VCT services [WHO/UNAIDS, 2001]. These include innovative methods of communication and community mobilization campaigns.

The analyses presented in the Likoma study also confirmed earlier findings in other studies reflecting large socioeconomic disparities in uptake of VCT at health facilities [e.g., hospitals, health centers] in general. Through informal field diary recordings and observations- complaints of ill-treatment and negligence by health practitioners as well as lack of respect for the underprivileged has been noted to be rife in Malawian health facilities in general- [a factor that has created psychological fatalism, disdain, apathy or otherwise for the public facilities per se in some quarters of the population as reflected for instance in problematic vaccination campaigns and preferred patronage of alternative traditional sources of medicine]. It might therefore as well not be an overstatement to attribute the low uptake of VCT to such other extraneous variables. In fact an analysis of reactions to VCT in rural Malawi in 2004, using testing with delayed results, revealed that there is an overall acceptance and enthusiasm for VCT in rural Malawian communities with only eight percent of individuals approached for testing refusing testing [Thornton et al, 2005].

In a similar study that occurred parallel to a larger MDICP project funded by the National Institute of Child Health and Human Development [NICHD] and specifically hypothesized that rural Malawians would respond more enthusiastically to, and favor, rapid testing in other settings rather than routine health facilities as well as over testing with delayed results, it was found out that most respondents favored VCT and the dissemination of results within their homes over other areas such as hospitals with many reasons being given for this preference [Kimchi, 2005]. According to the study results, one of the most prominent justifications for the home-based service preference was that the home protected their privacy and the confidentiality of the test results in a way that getting tested in a hospital or other service center could not. This specifically highlights the pertinent need for an opportunity to come together, to discuss serostatus results in a safe setting, and to negotiate a risk-reduction plan a strategy that could be considered in all studies of serodiscordant couples, and may have potential to reduce the high rate of transmission among such couples in developing countries.


The Likoma and MDICP studies therefore document the implication that home-based provision of VCT services has a potential of not only increasing the uptake of VCT among the general population who may not have contact with routine health services or who are reluctant to visit them due to other extraneous variables as highlighted in the foregoing. This also promises to substantially reduce the socioeconomic gradient in VCT utilization observed in several African countries with substantive ramifications in the fight against the pandemic. Above all else home-based VCT has the potential to promote couples-oriented testing with empirical data depicting current strong self-selection among couples in the use of VCT [Glick, 2005]. This also has implications for scaling down and mitigating an emerging threat in exponential prevalence rates in the name of discordant coupling. In particular, relative to discordancy a study of VCT carried out among a cohort of Rwandan women showed that HIV-seroconversion rates decreased in seronegative women whose partners were tested, but not in women whose partners were not tested [Allen, et al 1992]. The question however, still remains as to whether VCT has the efficacy to change behaviour relative to the HIV/AIDS pandemic.


The most common study design in measuring VCT efficacy is the one-group pretest and posttest design. Self-reported behaviors of VCT clients are recorded prior to and at some interval after the intervention, and any change in behavior is attributed to the intervention. Few evaluations attempt to identify appropriate comparison groups, and only one study used a control group in the context of a randomized trial. In this unique study which is documented by Coates et al [2000], and was conducted in Tanzania and Kenya (as well as in Trinidad), individuals or couples who had been recruited were randomized into VCT and basic health information arms. Overall, this research provided evidence of some reduction in self-reported risk behaviors following HIV testing or VCT. Two main patterns emerged. The first was that risk-reducing behavior change tended to be larger among individuals who tested positive than among those who tested negative [Allen, Serufilira, et al. 1992; VCT Efficacy Study Group 2000a; van der Straten et al. 1995; Lutalo, Kidugavu, and Wawer 2000]. This conforms to a general pattern observed for VCT elsewhere, including in the United States [Weinhardt et al. 1999; Wolitski et al. 1997]. One contrasting finding comes from reviews of data from Ugandas AIDS Information Center VCT program [UNAIDS 1999], which showed that at 6-month follow-up, reported condom use had risen strongly for both HIV-positive and HIV-negative clients. However, the share of HIV-negative clients who were sexually active also increased.

Another interesting empirically documented finding is that counseling of couples and/or partner testing appears to be effective at altering risk behavior as well as more effective than individual testing and counseling when the two are compared [Kamenga et al. 1991]. In some cases, individual testers also report risk reduction. Overall in the three sites of the multicountry VCT efficacy study [VCT Efficacy Study Group 2000a]- the percentage of individual testers reporting unprotected intercourse with nonprimary partners declined significantly from baseline and significantly more for the VCT group than for the health information arm [35% vs. 13% reduction for men, 39% vs. 17% for women]. Although offering less reason for optimism about those who test negative the foregoing findings present an important implication vis--vis the efficacy of VCT in promoting Behavioural change relative to the HIV/AIDS pandemic. However factors that potentiate uptake of testing whatever strategy may be utilized need to be delved into since they are fundamental for VCT Policy implementation and evaluation and as well significant for an overall public health impact. The need to address this prevailing gap hinges upon the backdrop that VCT will have significant impact on the epidemic only if it is able to attract large numbers of HIV-positive individuals, particularly those who are not yet ill, are asymptomatic, are unaware of their serostatus, are still sexually active and hence posit an exponential probability of further transmitting and spreading the virus.


In that realm, in a study conducted in Botswana (Rajaraman and Surender, 2004) and sought to determine perceptions of personal risk between respondents who had tested for HIV and those who had not, it was reported that those who had not currently tested did not generally consider themselves to be at risk of HIV infection [ sometimes incorrectly given their other information about sexual relationships or exposure- could be a function of cognitive processes such as optimism of personal precautions taken or motivational processes such as wishful thinking] this finding was considered significant because it suggests that testing is still primarily treated as a diagnostic tool rather than a preventative health device, where people seek to find out their HIV status not only to access treatment if tested positive, but also to protect themselves from future infection if tested negative. According to the findings, while this was encouraging to those who had expressed hope that the incentive of treatment would indirectly contribute to HIV prevention by increasing uptake of testing (WHO/UNAIDS, 2005; Merson, Quinn, Richman, Vella and Weiss, 2001) the findings from this study also entail some sobering information.

The findings unveil the increased attention being paid to the role of HIV testing as being typically based on a two-fold Public Health Rationale. First, that apart from the benefits of antiretroviral treatment, informing HIV positive people of their serostatus is crucial if they are to limit further transmission of the virus. Second, that it is hoped those who find out they are HIV negative will take steps to protect themselves from infection in the future. However, as the study documented, emphasis on treatment on its own may further encourage primarily those who suspect that they have symptoms of HIV to be the only to uptake testing. As such, asymptomatic HIV positive people may continue to transmit the virus unknowingly while efforts at increasing knowledge of HIV status among those who are HIV negative may be less effective. The design and implementation of programmes to promote preventive testing amongst those equally likely to be HIV negative should therefore be a priority in efforts to control the spread of HIV/AIDS.


Another finding from the study was that although knowledge and awareness of HIV appeared high in Botswana, it was clear from the study that information alone was not a sufficient catalyst for behavioral change. These results support other accounts of the limitations of conventional health education approaches which tend to rely on information giving alone as the basis for behavioural change. The findings of the study suggest that to some degree beliefs and attitudes do predict behaviour with the relationship between both perceived susceptibility and perceived benefits or barriers and behaviour being evident. It is also apparent that the social and structural circumstances in which respondents live enable or constrain their health related behaviour. Thus health care seeking behaviour is consequently a function of some complex interaction between various social environmental and structural factors.






Conclusion


My most important methodological conclusion is that demand for VCT services may increase both as a diagnostic and public health preventative tool in the medical management of people infected with HIV in Malawi in particular and other high prevalent countries of sub-Saharan Africa in general. The systematic review highlights among other factors the need to reinforce the significance of confidentiality and trust between clients and counselors. Above all else the analysis unravels the unequivocal need to emphasize on home based service provision which may guarantee not only confidentiality but help abate and mitigate the pandemic by targeting a new wave to the crisis vis--vis HIV/AIDS relative to sub-Saharan high prevalent countries in the name of serodiscordant coupling. Also unveiled in relation to home based provision of VCT is an important element that the service innovation may also tap on that exponentially higher poor rural-populace who may not have contact with routine health services or are often reluctant to patronize such service centers in generic hospitals or other facilities due to extraneous variables documented in passing within the review. As the review further postulates, home based VCT service provision also promises to substantially reduce the socioeconomic gradient in VCT utilization observed in several sub-Saharan
African countries with substantive implications in the fight against the pandemic. Notwithstanding, with an efficacious vaccine and cure for HIV and AIDS still elusive, focusing on stringent mitigative strategies such as VCT remains the window of hope in our desperate war against the HIV/AIDS pandemic not only in Malawi but sub-Saharan Africa in general.







Bibliography


Allen, S; Tice, J; Van De Perre, P (1992) Effect of serotesting with counseling
on condom use and seroconversion among HIV discordant couples in
Africa. BMJ, 304: 1605-09.

Allen, S; Serufilira, A; Bogaerts, J; Van de Perre, P; Nsengumuremyi, F; Lindan,
C; Carael, M; Wolf, W; Coates, T; Hulley, S (1992) Confidential HIV testing
and condom promotion in Africa: Impact on HIV and gonorrhea rates. Journal
of the American Medical Association 268 (23): 3338-43.


Bandura, A (1989) Perceived self-efficacy in the exercise of control over
AIDS infection. In V. M. Mayes, G. W. Albee and S. F. Schneider
(Eds.), Primary Prevention of AIDS: Psychological Approaches
(pp. 128-141). London: Sage Publications.

Becker, M; Rosenstock, I (1974) Social Learning theory and the Health-
Belief Model, Health Education Quarterly, 15: 175-183.

CDC (2001) Revised Guidelines for HIV counseling, testing and Referral and Revised
Recommendations for HIV Screening of Pregnant women. Morbidity and
Mortality Weekly Report, 50 [RR-19].


Coates, TJ; Grinstead, O; Gregorich, S (2000) Efficacy of voluntary HIV-1 counseling
and testing in individuals and couples in Kenya, Tanzania, and Trinidad:
a randomized trial. The Lancet, vol 356: 103-112.


Glick, H (2005) Scaling up HIV Voluntary Counseling and Testing in Africa: What can
Evaluation studies tell us about potential prevention impacts? Evaluation Review,
vol, 29 No. 4, August 2005, 331-357.


Helleringer, S; Kohler, HP; Frimpong J; Mkandawire, J [2009] Increasing Uptake of HIV
Testing and Counseling among the poorest in sub-Saharan countries through
home-based service provision, Journal of AIDS; 51: 185-193.

Kamenga, M; Ryder, R; Jingu, M; Mbuyi, N; Mbu, L; Behets, F; Brown, C; Heyward, W
(1991) Evidence of marked sexual behavior change associated with low HIV-1
seroconversion in 149 married couples with discordant HIV-1 serostatus: Experience
at an HIV counseling center in Zaire. AIDS 5: 61-67.

Kimchi (2005) Reactions to At-Home Voluntary Counseling and Rapid HIV Testing
in Rural Malawi. Student Summer Fellowship report. PARC, Pennsylvania.


Lutalo, T; Kidugavu, M; Wawer, M (2000) Contraceptive use and HIV counseling
and testing in rural Rakai district, SW Uganda. Abstract C246. Paper presented
at the 13th International Conference on HIV/AIDS, Durban, South Africa.

Miller (1996) Behavioral risk for HIV infection associated with HIV-testing decisions
AIDS Education and Prevention, 8[5]: 394-402.

NAC (1999) Malawi National HIV/AIDS Strategic Framework [2000-2004].

NAC (2003) National HIV/AIDS Policy- A call to renewed action [SUMMARY].

NAC (2006) Biological and Behavioral Surveillance Survey 2006 and Comparative
Analysis of 2004 BSS and 2006 BBSS.
NAC (2009) National HIV Prevention Strategy [2009-2013].

Rajaraman, D; Surender, R (2009) HIV testing in Botswana: Lessons for
Policy and Practice. htm

Rosenstock, I; Strecher, V; and Becker, M (1994) The Health Belief Model
and HIV risk behaviour change. In R. J. DiClemente, and J.L.
Peterson (Eds.), Preventing AIDS: Theories and Methods of
Behavioural Interventions (pp. 5-24). New York: Plenum Press.

Rosenstock, I; Strecher, V (1984) The Health Belief Model. In Baum. A,
Newman. S, Weinman. J, West. R, and McManus. C (Eds.)
Cambridge Handbook of Psychology, Health and Medicine
(pp. 113-116). Cambridge: Cambridge University Press.

Thornton, R; Bula, A; Chavula, K; Bignami-Van Assche, S; Witkins SC (2005)
Reactions to Voluntary Counseling and Testing in Rural Malawi. Submitted
for publication. PARC.


UNAIDS (1999) Knowledge is power: Voluntary HIV counseling and testing
in Uganda. UNAIDS Best Practice Collection. http://www.unaids.org/
EN/other/functionalities/Search.asp.


UNAIDS (2000) Voluntary Counseling and Testing. UNAIDS Technical update.


UNAIDS (2000) Tools for Evaluating HIV Voluntary Counseling and Testing. Joint
United Nations Programme on HIV/AIDS. Geneva, Switzerland.

UNAIDS/WHO (2002) Initiating second generation HIV surveillance systems:
Practical guidelines. Geneva, Switzerland.


UNAIDS (2008) Report on the global AIDS epidemic, Geneva.


UNICEF (2006) How does HIV affect young people? http://www.unicef.org


Van der Straten, A; King, A; Grinstead, A; Selufilira, A; Allen, S (1995) Couple
Communication, sexual coercion and HIV risk reduction in Kigali, Rwanda.
AIDS 9 (8): 935-44.


Vidanapathirana, J; Abramson MJ; Forbes, A; Fairley, C (2007) Mass media
interventions for promoting HIV testing [Review], The Cochrane Collaboration,
Issue 3, Wiley


Voluntary HIV-1 Counseling and Testing Efficacy Study Group. 2000a. Efficacy of
Voluntary HIV-1 counseling and testing in individuals and couples in Kenya,
The United Republic of Tanzania and Trinidad: A randomized trial. Lancet
356: 103-12


Weinhardt, L; Carey, M; Jonson, B; Bickham, N (1999) Effects of HIV counseling
and testing on sexual risk behavior: A meta-analytic review of
published research, 1985-1997. American Journal of Public Health 89(9):
1397-405.

WHO/UNAIDS (2001) Models for implementation and strategies for scaling up
of VCT services. WHO/UNAIDS Technical consultation on voluntary
HIV Counseling and Testing. Harare, Zimbabwe: 3-6 July 2001.

WHO (2003 Testing and Counseling.
http://www.who.int/hiv/topics/vct/testing/en/print.html


WHO (2004) Guidance on Ethics and Equitable Access to HIV Treatment and Care
http://www.who.int/hiv/pub/advocacy/en/guidanceethics en.pdf


Wolitski, R; MacGowan, D; Higgins, D, Jorgensen, C (1997) The effects of HIV
Counseling and testing on risk-related practices and help-seeking behavior.
AIDS Education and Prevention 9 (Suppl. B): 52-67.