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Canadian Journal of Occupational

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 DOI: 10.1177/000841749506200307

1995 62: 154Canadian Journal of Occupational TherapyStanley Paul

Culture and its Influence on Occupational Therapy Evaluation  

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• STANLEY PAUL

CJOT * VOLUME 62 * NO 3

KEY WORDS

Assessment process, occupational therapy

Culture

Cultural characteristics

Stanley Paul, MS, OTR/L, is a Doc-

toral Candidate in the Occupational

Therapy Departrnent, Nevv York Univer-

sity, New York.

Mailing Address: 653 Mace Avenue,

New York, NY 10467

Culture and its influence on occupational therapy evaluation

ABSTRACT In the increasingly multicultural society of north Arnerica,

occupational therapists have a responsibility to develop awareness and

knowledge concerning different cultural groups. 13y accepting and understand-

ing clients' customs, values and beliefs, clinicians have a better chance of

assessing and producing more effective outcomes. Since occupational therapy

has incorporated western naiddle-class values into its theory and practice, many

evaluation tools used are based on norrns developed for a white middle-class

population. Using these evaluations with minority groups brings the danger of

improper interpretation of test results. Consequently, increasing emphasis is

being placed on the importance of culture fairness and the development of

culture-fair evaluation tools for usage across different cultural groups. This

paper will present a discussion concerning the importance, advantages and

disadvantages of both culture-fair and culture-specific tests and evaluation

tools.

RÉSUMÉ Dans la société nord-américaine de plus en plus

multiculturelle, les ergothérapeutes ont la responsabilité de favoriser la prise

de conscience et la connaissance en rapport avec les différents groupes

culturels. En acceptant et en comprenant les coutumes, les valeurs et les

croyances de leurs clients, les cliniciens augmentent leurs chances de mieux les

évaluer et de susciter de meilleurs résultats de traitement. L'ergothérapie ayant

adopté les valeurs occidentales de la classe moyenne dans ses fondements

théoriques et pratiques, plusieurs outils d'évaluation sont basés sur les normes

mises au point pour une population blanche, de classe moyenne. Le fait

d'utiliser ces évaluations auprès des minorités risque de fausser l'interprétation

des résultats des tests. Il en résulte qu'une emphase de plus en plus grande est

mise sur l'impartialité culturelle et le développement d'outils d'évaluation

équitables pour les différents groupes culturels. Cet exposé fera état d'une

discussion sur l'importance, les avantages et les désavantages de tests et d'outils

d'évaluation qui respectent l'équité et la spécificité culturelles.

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Emphasizing the importance of developing culture-fair tests has been an issue in psychology and education from the mid-fifties. Occupational therapy is beginning to consider the irnplications of cultural differences in evaluation, treatment planning and implementation (Dyck, 1993; Evans & Salirn, 1992; Levine, 1984; Meyers, 1992; Spadone, 1992). Evaluation is a process of collecting relevant information in order to plan and implement effective occupational therapy treatment programmes. Our primary emphasis for intervention is on improving people's ability to function in their daily occupations. Accurate rneasurements and evaluation tools are necessary in order to measure change and evaluate function of our clients.

Evaluation is the cornerstone of occupational therapy service provision. Occupational therapists recognize multiple methods for gathering inforrnation such as criterion referenced and norm referenced tests, inter-views and skilled observations. We gather information from a variety of sources: from clients, caregivers, peers, the physical and social environment, and client records. We are also skilled in direct observation of functional performance and in constructing compre-hensive task analysis. Regardless of the methods used for evaluative purposes, the culture of the clients plays a very important role in the interpretation of the data.

Lately researchers such as Fisher & Short-Degraff (1993), Christiansen (1993), Trombly(1993) and Law et al (1990) have all emphasized the need for improving the existing functional assessment tools in occupa-tional therapy and the need for newer accurate mea-surement tools. Researchers are atternpting to develop unifying occupational therapy intake assessment tool(s) which can be used across different cultural groups and different occupational therapy specialty areas. An example of such a possibility is the ongoing develop-ment of the Canadian Occupational Performance Mea-sure (COPM) (Law et al., 1990).

Many of the evaluation and functional assessment tools used in occupational therapy including motor, developmental and sensory integrative tests, are based largely on the sociocultural norms of a w hite middle-class population (Skawski, 1987). This has resulted from occupational therapy's incorporation of western middle-class values into its theory and practice. These norms may not stand true for minority groups and may in turn affect occupational therapy management based on such interpretation.

In order for evaluation tools to be used across different cultural populations, they need to be free of cultural bias. However, since altering the past sociocul-tural conditions is irnpossible researchers agree that cultural bias may be minimized but never eliminated altogether. The terms culture-fair and culture-free are often used interchangeably in the literature. Assess-ment tools, tests, and evaluation tools are terrns used

interchangeably in the occupational therapy literature. A culture-fair test reveals the true inherent abilities of the individual devoid of his/her cultural veneer (Van de Vijver & Poortinga, 1991). According to Kline (1986), culture-fair tests supposedly contain test items which are common to all different cultures and the rationale behind "culture-fair" test items is to include only those tasks which reflect the experiences, knowl-edge, and skills common to all different cultures. Culture-specificity is the opposite of culture-fairness. Culture- specific tests contain items relevant to a spe-cific cultural group and such tests are exclusively devised for usage with such specific groups. Some examples of evaluation tools standardized for the North American white middle-class are, the Functional Independence Measure (FIM) (Granger, Hamilton, & Sherwin, 1988), Klein-Bell ADL Scale (Klein & Bell, 1988), Barthel Index (Mahoney & Barthel, 1965), and the Classroom Environment Scale (Trickett & Moos, 1973).

This paper discusses the importance, advantages, and disadvantages of both culture-fair and culture-specific tests and evaluation tools. Mainstream North American community is referred to in this paper as white middle-class North Americans of European ori-gin. Cultural minority refers to Canadians and Ameri-cans of African descend, native North Americans, and other groups including non-European immigrants. Non-European immigrants mostly refers but is not limited to, Asians, Latin Americans, and people of the Caribbean and Pacific islands which are the largest immigrant groups in the past five years.

Culture and its role in Occupational Therapy Culture is a process of behaviour and communication that has been learned by persons in the context of their past experience (Krefting & Krefting, 1991). One's culture determines one's way of thinking, feeling and behaving. Mosey (1980 describes culture as a set of understandings shared by members of a group about how things should be done and what is desirable and good. Culture has a pervasive influence on a client's values, goals, interests, roles, habits, and performance and it can be seen as a filter through which clients determine their direction and degree of involvement in self care, work and leisure activities (Levine, 1984). Areas of cross cultural difference include beliefs about the inherent nature of the person, language, work, leisure, food, and historical heritage (Mosey, 1986). Ogbu, in cultural difference theory, argued that the skills and attitudes of people of various cultures differ because each culture has distinct values and goals (Patton, 1985).

Consideration of the role of culture in occupational therapy practice is vital in an increasingly multi-cultural population. Occupational therapists face new

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challenges in assessment and treatment planning with clients vvho do not share with a therapist a common language, differ in health-related beliefs and values, and have different understandings of the nature of work, leisure, and self-care (Skawski, 1987). Sanchez (1964) was among the first in the literature to call attention to the white middle-class bias of the health professions. He proposed that occupational therapy should incorporate the patients' cultural background into treatment in order for therapy to be effective. Klavins (1972) posed a general question to the profes-sion of occupational therapy, asking how much we know about the cultural beliefs and values of a great variety of people we work with and its influence on their therapeutic process. This question is yet to be fully answered.

There have been calls for changes in the norms and values underpinning occupational therapy evaluation, treatment planning and implementation. Many occu-pational therapy educators and researchers found the norms and values of our profession to create obstacles to cross-cultural care (Kinebanian & Stomp, 1992; Krefting, 1992; Miller, 1992; Weiringa & McColl, 1987). Mann and Klyczek (1988) called for revision and refinement of the existing occupational therapy mea-surement instruments and evaluation tools if they are to be used for the purpose of meaningful comparison between groups. Some researchers have tested stan-dardized assessment tools in order to evaluate their usage across different cultural populations (Fisher, Liu, Velozo, & Pan, 1992; Jungersen, 1992).

Culture-fair tests: A critical analysis Although the idea of developing a true culture-fair test had great intuitive appeal, to date it has proven to be a practical impossibility. The label "cultural minority" is used to designate individuals who belong to a recognized ethnic group and whose values, customs, patterns of thought, or language are significantly different from those of the majority of the society in which they live. Attempts to produce educational measures and intelligence tests in which people from cultural minority populations perform as well as those from white middle-class have been largely unsuccess-ful. A test developed by Mercer (1977) proposed a System of Multicultural Pluralistic Assessment (SOMPA) that in effect, used two sets of norms in assessing each examinee: the national norm group and a comparison group similar to the examinee in social and cultural background. Samuda (1982) concluded that SOMPA had all the weaknesses of the previous tests, plus a host of new weaknesses, not the least of which was the absence of any construct validity. Later results with other tests have been similar (Aiken, 1991). The Davis-Eells Test of General Intelligence, an intended culture-fair intelligence test which contained a series of group

tests for elementary school age levels, failed to mea-sure the IQ scores as predicted by the developers. A clear socioeconomic status difference in response to the test items persisted on virtually all items, regardless of their form (Van de Vijver & Poortinga, 1991).

Developing evaluation tools is a complex process. There are many variables which can make it impos-sible to devise a culture-fair test. For example, devel-oping culture-fair test items is not an easy task even within the mainstream white middle-class North Ameri-can society because test users do not constitute a homogeneous group. Studies done on social classes in American communities indicated that cultural patterns among various social classes of the North American community are very diverse. Even though some of these cultural patterns were shared and sirnilar, the differences in their values, beliefs, customs, and reli-gious practices were sufficiently divergent to warrant regarding them as sub-populations within the main-stream North American society (Gregory, 1992; Silva, 1993). When there are many sub-populations even within mainstream North American society, develop-ing culture-fair test items to evaluate diverse cultural populations including other than North American and European cultures will be impossible. Whenever some-one wants to develop a cross-cultural evaluation to be used across different cultural groups they should consider the values, beliefs, language, historical heri-tage, work, leisure and even food habits of the cultural groups in mind. Test performance can be influenced by any or all of these factors. So, developing culture-fair evaluation tools is very much desirable but hardly possible.

Making a test culture-fair involves a procedure of removing culturally biased items from existing evalu-ation tools. For example, in order to utilize a North American developed IADL scale with a recent immi-grant from Nepal, certain items from the laundry sub-section may be omitted from the scale (e.g. washer and dryer are extremely rare in a Nepali household as they wash their clothes with their hands). While omitting a few items from an already existing evaluation tool may be easier to do, it is important to investigate the differences between the Nepali culture and the norm group of the IADL scale. When a test is developed for a specific population the items and materials are the reflection of that population. This is called culture-relevancy of test items. Van de Vijver and Poortinga (1991) concluded that test performance depends upon the experience the individuals bring with them and upon psychological factors in the testing situation itself. Just removing some so called culturally-biased items from a test does not necessarily eliminate cultural differences in behaviour. In fact, tampering with the test items only compromises the validity of the test.

Another method of constructing a culture-fair test

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involves combining test items representing different cultural groups. One procedure long in use for making tests bi-cultural (for use with only two distinct cultural groups) is by adding items of a certain kind which favour an otherwise unfavoured group. For example, in an effort to make an ADL evaluation tool usable for both North Arnerican mainstream society and Chinese immigrants, certain items appropriate to Chinese cul-ture may be added to the test. In this way, the composite performance score is adjusted until it is "fair" to each group. The inherent danger is that combining different cultural items can only affect the meaningful interpretation of data and ultimately, it may not truly reflect any one of those groups. Even if a test could be developed with such items it would be extremely difficult to devise criteria against which the test could be validated. This method also reduces the constructive and predictive validity of the evaluation tools (Reynolds, 1982; Silva, 1993). Anastasi (1988) commented that the criteria against which tests are validated are themselves culturally loaded and any test is operationally meaningless unless defined in terms of such criteria. All tests and evaluation tools, to a greater or lesser degree, reflect the majority of the population in which they were devised and will be used. In places like Canada and the United States there are many different minority groups. It would be expected that members of minority groups would score lower in those tests because of their unfamiliarity with the test items and test environrnents. Other factors such as the rater bias which is caused by the cultural background of the raters may also influence the scores.

There can be little doubt that among groups vast differences exist in values and beliefs. But there is no virtue in developing instruments so blunted that they decrease the amount of information. Any standardized evaluation tool may not be accurate when used to evaluate people of a distinct cultural group (Gregory, 1992). Tests are designed to show what an individual can do at a given point in time. They cannot tell us why they perform as they do. To answer that question, we need to investigate their background, motivations, and other pertinent circumstances. Nor can tests tell us how able culturally or educationally disadvantaged people might have been if they had been reared in a more favourable environment. Moreover, tests cannot com-pensate for cultural deprivation by eliminating its effect from their scores. On the contrary, tests should reveal such effects, so that appropriate remedial steps can be taken. Test scores of ethnic minorities are useful indices of immediate or present functioning. Tests provide valuable information about their strengths and weaknesses. Doing away with tests will only deprive clinicians and educators of vital inforrnation needed to assist these individuals. To conceal the effects of cultural disadvantages or differences by rejecting tests

or by trying to devise tests that, are insensitive to such effects can only retard progress toward a genuine solution of social problems. However small the scope may be, as long as a test or evaluation tool measures whatever it proposes to measure in an accurate man-ner, its purpose is served.

By emphasizing culture-fairness we should not undermine the development of effective culture-spe-cific evaluation tools. Frustrated by their seeming inability to develop culture-fair equivalents of tradi-tional educational and psychological measures, some test developers atternpted to develop tests that were culture specific; the assumption here being that a test developed exclusively for members of the minority groups might yield a more valid measure (Anastasi, 1988).

Culture-specific evaluation tools: How useful are they?

Evans and Salim (1992) in a study conducted to find out the cross-cultural usefulness of occupational therapy assessments with clients with schizophrenia in Tanza-nia, Africa, concluded that the most effective way to measure performance dysfunction was through the use of culture-specific tests. In their study, they used a daily activity, work, and leisure activity interview based on the Model of Human Occupation (Kielhofner, 1985) and the Schroeder, Block, Campbell Adult Psychiatric Integration Evaluation(SBC) (Schroeder, Block, Trottier, & Campbell, 1978). But both of these tools were found to show their North American bias in the form of test itern inappropriateness. I3ut the cul-ture-specific Zanzibar functional activity test (Evans & Salim,1992) designed for the Tanzanian population was found to be more valuable in the form of its consistency with their material culture and sex-role expectations.

A study by Spadone (1992) which examined ethnic group differences with the use of the Model of Human Occupation (Kielhofner, 1985) between first genera-tion immigrants from Thailand & Cambodia and white Americans has brought mixed results. The study com-pared internal and external control and temporal orientation among southeast Asians and white Ameri-cans. No differences could be established for locus of control between any of these groups but differences in temporal beliefs were found between Thai and white Americans. Miller (1992) from her experience in work-ing with Cambodian orphan children pointed out that she was unable to use standardized tests such as Birth to Three, and the Peabody Test for Motor Develop-ment with Cambodian children. The Cambodian or-phan children were physically and environmentally deprived. These children did not meet the motor development norms standardized on the North Ameri-can children. They were unfarniliar with typical toys

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used in paediatrics in North Arnerica (balls, blocks, markers, Rubik's cube, stacking toys, and puzzles). Miller developed an alternative questionnaire and format in order to fit their needs (Orphan checklist, Miller 1992). Evans and Salim (1992) warn that even qualitative methods, such interviewing, should not be scored according to assumptions about human adaptations to time, self-will, and control that are not universal. They encourage investigators, theorists and therapists to design evaluation and treatment strategies that are congruent with specific populations. Consid-ering the experiences of these researchers it may be appropriate for occupational therapists to develop culture-specific tests and evaluation tools rather than developing culture fairness in tests and evaluation tools.

Can we use standardized tests and evaluation tools with different populations?

With respect to the application of tests, it has been argued that tests are often useless as predictors of behaviour, that they are unfair to minority groups, that the results are frequently misinterpreted and misused, and that they promote a narrow and rigid classification of people according to supposedly static characteris-tics (Aiken, 1991). Much of the concern centres on the differences in the test scores brought about by various cultural conditions of minority group members. How-ever, some of the proposed solutions for this problem reflect misunderstandings about the nature and func-tion of evaluation tools. Differences in the experiential backgrounds of groups of individuals are inevitably manifested in test perfortnance. Every evaluation tool measures a behaviour (performance) sample. In so far as culture affects behaviour, its influence will and should be detected by evaluation tools. If all cultural differentials from an evaluation tool are ruled out its validity as a measure of the behaviour domain it was designed to assess tnay be lowered. In that case, the evaluation tool will fail to provide the kind of informa-tion needed to correct the very condition that impaired performance. When combined with information about experiential background, test scores should facilitate effective planning for the optimal development of the individual.

Tests and evaluation tools are not necessarily en-emies of minority groups. Tests assessing discrete sensorirnotor component skills such as range of mo-tion and muscle strength evaluations may 1De used across cultures. l3ut we should keep in mincl that evaluation tools measuring such discrete component skills can also produce inaccurate data. For example, a grip strength evaluation using the JAMAR hand dynamometer which is standardized on a North Atneri-can sample may not hold true for an East Asian immigrant. If tools measuring such discrete sensorimo-

tor components can produce inaccurate data, more complex ADL, IADL, and other functional performance evaluations developed for the mainstrearn North Ameri-can population add questions of credibility if tised with diverse cultural populations. Society in Canada and the United States is diverse. Because of the diversity involved, one suggested method is to use the tools normed on the dominant culture but apply them very cautiously since the client may not match the expecta-tions of the testing tool. Anastasi (1988, p.66) com-mented that, "To conceal the effects of cultural differ-ences by rejecting tests or by trying to devise tests that are insensitive to such effects can only retard progress toward a genuine solution of social problems". The fact that undernourished children weigh less than those who are well fed hardly builds a case for banning scales. In the same vein, Clifford, an African-American educator, stated that "To disparage tests for revealing inequalities is as erroneous as for the residents of Bismarck, North Dakota, to condemn the use of thermometers as biased because when it was -11 degrees there, it was 73 degrees in Miami, Florida" (Clifford & Fishman, 1963, p.87). Tests can provide a safeguard against decisions informed by social stereo-types and prejudice. Tests should be used as an aid to understanding clients. Therapists choosing to use a standardized evaluation tool on a different population need to take an individual's sociocultural background into consideration in interpreting its score. For ex-arnple if a therapist uses a North American devised kitchen evaluation in order to measure a cooking task with an Indo-Canadian woman, the therapist should take into consideration the client's cooking habits, familiarity with different North American dishes, famil-iarity with North Arnerican kitchen set up, and various kitchen appliances. If not, the therapist runs the risk of misinterpreting her cooking skills. If the client is not familiar with North American kitchen set up and North American style cooking, a simple orientation to North American kitchen set up, utensils and appliances could minimize the misinterpretation of her skill level. On the other hand, simply asking her to cook a traditional Indian dish could assess her cooking skills more effectively.

One possible reason for difficulties encountered by therapists in using tools normed on the dorninant culture is problems with following the instructions and cautionary notes. Those who use tests are cautioned to interpret test scores in the light of a variety of factors, such as sex, age, race, language, and socio-economic status. Inevitably some users treated test scores as absolute determinations about individuals or groups (Gregory, 1992). Examiners from different cultural backgrounds use different social and cultural norms and expectations while assessing individuals. The definition of functional independence and appropriate

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behaviour may vary in different cultural groups. For example, a husband with spinal cord injury expecting his wife to attend to all his ADL needs, may be considered normal in eastern cultures whereas it may be considered as over-dependence in western cul-tures. Van de Vijver and Poortinga (1991) pointed out that the bias in various evaluation tools and tests resides not in thern but in those who interpret the scores regarding them as an absolute determination of whatever it is that they are measuring. Such costly mistakes can be greatly redt iced by gaining knowledge about, awareness of and exposure to different cultural minority groups within the North American society.

Occupational therapy and cultural awareness

The holistic nature of occupational therapy encour-ages therapists to respond to all the needs of a client including sociocultural traits that may affect evaluation and treatment (Skawski, 1987). As a society becomes multicultural, its various minority populations demand recognition. They demand cultural cornpetence in health professionals. Recognizing the urgency of this situation our leaders such as Mirkopoulos & Evert (1994) and Dyck (1989) both from Canada and the United States encourage all therapists to explore multicultural values and strive to enhance awareness and sensitivity toward other cultures. Cultural compe-tence is defined as an awareness of, sensitivity to, and knowledge of the rneaning of culture, and the differ-ences between different cultural groups (Dillard, et al., 1992). Terms such as culturally disadvantaged, or culturally deprived have to be used very cautiously since they have value implications. No one has the right to degrade a subculture that does not conform to the patterns of the majority group. Certain behaviours in minority groups may be both healthy and justified, because life conditions of these groups differ remarkedly from those of the dominant culture (Silva, 1993). We also should not view culture as a fixed, static, or natural phenomenon. Cultural characteristics such as colour, national origin, or ethnic identification are not static or stereotypical. In fact, culture is dynamic and ever changing. For example, the second generation immi-grants of various cultural groups identify themselves as part of the main stream North American society.

Occupational therapists have a responsibility to develop an awareness by being open to inspection of their own culture and developing an interest and knowledge base about other cultures. Education about different cultural groups in the curricula of profes-sional schools is needed to enhance the multicultural knowledge of future therapists. Multicultural knowl-edge is gained by a thorough understanding about values, beliefs and customs of different cultural minori-ties (Fitzgerald, 1992). Studying the self-reported

multicultural competency of a group of occupational therapy clinicians, Pope-Davis, Prieto, Whitaker, & Pope-Davis (1993) found a significant positive correla-tion between their multicultural competencies and participation in multicultural seminars and workshops, percentage of minority clients with whom they worked, and multicultural course work. Other suggestions include: multidisciplinary case conferences with atten-tion to the client's culture, consultation with staff from other cultures, staff education on specific issues, and an active consideration of all clients' sociocultural background both during the assessment and treatment planning process. 13y accepting and understanding clients' customs and values clinicians have a better chance of assessing and producing more effective outcomes. Evaluation tools can indeed be misused in testing cultural minorities. When properly used, how-ever, they serve an important function in preventing irrelevant and unfair discrimination. A realistic way of reducing culturally biased interpretations of standard-ized tests is to use them with sufficient knowledge of the clients' cultural background. Even qualitative mea-surernent tools such as, the Quality of Life Interview (Lehman, 1988) and the Play History (Behnke & Fetkovich, 1984) can be reliably used if the examiners possess adequate knowledge about different cultures. Perhaps a thorough appreciation of the cultural differ-ences of the clientele in places like Toronto and New York or for that matter any major North American city, should lead to the production of enough information to rninimize bias in interpretation of standardized occupational therapy evaluation tools.

Summary Occupational therapy has incorporated western middle-class values into its theory and practice. Most of our evaluation tools and assessment procedures are based on the sociocultural norms of a white middle-class population. In recent years there has been an influx of immigrant groups moving to Canada and the United States. Therapists of different ethnic and racial back-grounds are also increasing in number. However the majority of occupational therapists currently practicing in North America continue to be white and middle-class. It is likely that most of these occupational therapists will encounter clients from cultures with value orientations that challenge or reject the type of therapy routinely offered in Canada and the United States.

In response to the growing demands of a multicultural population, various branches of health professions have begun reassessing the needs of culturally distinct clients. Accurate evaluation is the first step to effective treatment provision. However the relationship of cul-tural background to occupational therapy evaluation procedure and treatment planning are not well

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articulated in occupafional therapy literature. Recog-nizing this situation many occupational therapy educa-tors and researchers have called for revision of existing occupational therapy evaluation tools and measure-ment methods and the need for new evaluation tools for usage across different cultural populations. But

continued effort to develop culture-fair evaluation tools has proven to be largely unsuccessful due to many sociocultural variables. Recognizing the com-plexities involved in developing culture-fair tests some researchers opted for the choice of developing culture-specific evaluation tools as opposed to misinterpreting the evaluation results with culturally distinct clients.

In the process of providing holistic treatment, occupational therapists may eniploy various presently available evaluation tools and assessment methods normed on the dominant culture with various different populations. Lack of awareness about distinct cultures may lead to possible misinterpretation of evaluation results which may further lead to incongruity between the client and therapist in goal setting and treatment. A sufficient knowledge about the clients' culture can reduce the possibility of such misinterpretations. Con-sidering the complexities involved in developing evalu-ation tools perhaps a realistic way of utilizing presently avaliable occupational therapy evaluation tools is to continue to use them with culturally distinct clients while taking their sociocultural background into con-sideration. In cases where it is impossible to use standardized evaluation tools, it is advisable to de-velop more culture-specific evaluation tools rather than misinterpreting the culture of the clients.

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