Accepted Manuscript Quality of Life, Self-care Knowledge Access, and Self-care Needs in Patients with Colon stomas One Month after Surgery in a Chinese Tumor Hospital Lingyun Ran, RN, MD, Lecturer, Xiaodong Jiang, MD, Professor, Erzhuang Qian, RN, Hongqian Kong, MD, Master student, Xiaolan Wang, MD, Associate Professor, Qin Liu, MD, Head Nurse PII:
S2352-0132(16)30006-0
DOI:
10.1016/j.ijnss.2016.07.004
Reference:
IJNSS 191
To appear in:
International Journal of Nursing Sciences
Received Date: 12 January 2016 Revised Date:
30 April 2016
Accepted Date: 20 July 2016
Please cite this article as: L. Ran, X. Jiang, E. Qian, H. Kong, X. Wang, Q. Liu, Quality of Life, Self-care Knowledge Access, and Self-care Needs in Patients with Colon stomas One Month after Surgery in a Chinese Tumor Hospital, International Journal of Nursing Sciences (2016), doi: 10.1016/ j.ijnss.2016.07.004. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Quality of Life, Self-care Knowledge Access, and Self-care Needs in Patients with Colon stomas One Month after Surgery in a Chinese Tumor Hospital Lingyun Ran,RN,MD1, Xiaodong Jiang, MD3, Erzhuang Qian, RN2, Hongqian Kong,MD3, Xiaolan Wang, MD1, Qin Liu, MD4, Nursing School of Kunming Medical University, Kunming, Yunnan Province, China
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Department of Public Foundation, Chongqing Three Gorges Medical College
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Children’s Hospital of Fudan University, Shanghai, China 201100
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Public Health School of Kunming Medical University, Kunming, Yunnan Province, China Department of Abdominal Surgery, Tumor Hospital of Yunnan Province (The Third
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Affiliated Hospital of Kunming Medical University), Kunming, China Authors:
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First author and 1st corresponding author: Lingyun Ran, RN, Lecturer, MD, Nursing School of Kunming Medical University, Kunming, Yunnan Province, China No.1168, Chunrong West Road, Yuhua Street, Chenggong District, Kunming, Yunnan, China Post Code: 650500. e-mail:
[email protected];
[email protected] Telphone: +86187167462413 Second author: Xiaodong Jiang, Professor, MD, Department of Public Foundation, Chongqing Three Gorges Medical College E-mail:
[email protected]
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Third author: Erzhuang Qian, RN, Children’s Hospital of Fudan University, Shanghai, China 201100 e-mail:
[email protected]
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Fourth author: Hongqian Kong, Master student, Public Health School of Kunming Medical University, Kunming, China e-mail:
[email protected] Fifth author: Xiaolan Wang, MD, Associate Professor, Nursing School of Kunming Medical University, Kunming, Yunnan Province, China e-mail:
[email protected] Correspondence to: Qin Liu, RN, Head Nurse, MD, Department of Abdominal Surgery, Tumor Hospital of Yunnan Province (The Third Affiliated Hospital of Kunming Medical University), Kunming, China e-mail:
[email protected] 1
ACCEPTED MANUSCRIPT Quality of Life, Self-care Knowledge Access, and Self-care Needs in Patients with Colon stomas One Month after Surgery in a Chinese Tumor Hospital
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[Abstract] Objective This descriptive cross-sectional study was utilized to investigate the quality of life (QoL), self-care knowledge access, and self-care needs of colorectal cancer patients after colostomy. Methods A convenience sample of 142 colorectal cancer patients in the Tumor Hospital of Yunnan Province was invited to this survey one month after colostomy surgery. The QoL of the participants was assessed using the Chinese version of the World Health Organization Quality of Life Instrument (WHOQOL-BREF), and another self-prepared questionnaire was used to explore the sources of self-care knowledge and self-care needs of this population. Results The response mean scores of the four domains of WHOQOL-BREF: physical health, psychological health, social relations, and environmental health are 53.49, 57.95, 65.78 and 50.75, respectively. There are no significant differences between gender, age, education level, and occupation type in quality of life scale through u test and ANOVA (p 0.05). But the female colostomates had higher grades in physical area of quality of life than male patients did; the participants who were willing to attend the self-care courses got higher scores in social area than who were not. Conclusion The QoL of this population was not good. Self-care program can be developed in accordance with their needs and education background. [Key Words]quality of life; self-care; colostomates; colorectal cancer
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1 Introduction
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Colorectal cancer (CRC) is the second and third most common malignancy worldwide in women and men, respectively. It accounts for 10% of all cancers globally, while responsible for 8% of all cancer mortalities in the world, and is the fourth commonest cause of cancer death[1].
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In China, the incidence of CRC was 71,733 cases during the 4-year period from 2003 to 2007, and the morbidity of CRC was approximately 28.08 per 10,000, which accounted for 10.56% in all malignant tumors. Meanwhile, there were 34,249 people who died of CRC and the mortality of CRC was about 13.41 per 10,000, which was the 5th leading cause of death in malignant cancers. The morbidity and mortality rates in male is higher than those of female, with the ratio 1.17:1 of men to women in morbidity[2]. Surgery is the primary treatment method for colorectal cancer[3], so there are an increasing number of colorectal cancer patients with temporary or permanent colostomy. It has been estimated that one hundred thousand people would undergo colostomy every year from 2005 and on. The total number of colostomy patients would be beyond one million by 2015 and it will continue to increase according to some statistical study[4]. Within the context of medical and healthcare research, Quality of Life (QoL) is the patient’s subjective perception of the impact of his/her disease and its treatments
ACCEPTED MANUSCRIPT on his/her physical, psychological, and social functioning as well as general well-being[5].It is known that health-related quality of life is negatively influenced by a stoma. Previous studies revealed that the presence of a stoma result in significant impairment of patient’s physical, social, cognitive and emotional functioning, then leading to a negative effect on their quality of life[6-7].
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The quality of life of colostomates might be impaired by various symptoms including leakage, skin irritation, fluid and electrolyte imbalance, etc[8-9]. Stoma self-care includes that patients learn how to manage their stomas independently[10]. Wilson et al. did a survey on the QoL of colostomates who were discharged from hospital 6 weeks after surgery. They found that younger patients and patients with diarrhea had a poorer QoL than other participants[9]. Smith-Gagen et al. performed a study on colostomates nine month after colostomy surgery and revealed that female participants were more satisfied with their social relationship than in QoL[11]. Ramsey et al. reported that patients who were at the lower socioeconomic status and the more advanced cancer stage were less satisfied with their QoL[12].A Chinese research examined the QoL and self-care needs of colostomates after surgery and found that the QoL of these patients were poor and the patients had a lot of self-care needs in life adaption skills, and diseases related knowledge[13] .The research by Lu et al. in China (2011) indicated that the QoL of colorectal cancer patients was below the average level[14], but the QoL of colostomates and the self-care related issues have been scarcely investigated in China.
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To better understand the QoL and self-care needs of this population, the Kunming Medical University (KMU) undertook a research project in the Tumor Hospital of Yunnan Province, also known as the Third Affiliated Hospital of KMU. The Colorectal Cancer Therapy Center in the Tumor Hospital of Yunnan Province is a professional department in colorectal surgery as well as colostomy nursing. Moreover, the hospital owns the first colon stoma clinic in Yunnan Province, providing colostomates with the check-up and follow-up services after the colostomy surgery.
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2 METHODS 2.1 Study Design In this study, 142 colostomates were interviewed face-to-face one month after their colostomy surgery, using printed WHOQOL- BREF scale. In addition, a self-prepared questionnaire was used to investigate the sources of self-care knowledge and self-care needs of this population. 2.2 Setting and Samples All the participants in this study were face-to-face interviewed by trained research nurses in the hospital using printed questionnaires. The inclusion criteria of sampling method were age 18 years and above, one month after temporary or permanent colostomy surgery and the mental ability to answer the interview questions. The
ACCEPTED MANUSCRIPT exclusion criteria included colostomates with cognitive disorders, severe co-morbid conditions, such as cancer metastasis, serious cardiovascular diseases.
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2.3 Ethical Considerations Written informed consents were obtained from all participants before the survey, and the protocol of this research has been approved by The Tumor Hospital of Yunnan Province since the planning phase of this project. All the personal information of the participants was assured to be kept confidentially.
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2.4 Instruments The QoL of the colostomy patients were assessed by the Chinese version of the World Health Organization Quality of Life Instrument (WHOQOL-BREF). This instrument , a generic QoL instrument developed by WHO, is composed of 26 items and available in different languages for both developed and developing countries[15-16]. The response options, ranging from 1 (very dissatisfied/very poor) to 5 (very satisfied/very good), emphasize the patients’ subjective feelings for their past four weeks rather than the objective life conditions. The questionnaire includes four domains: physical health, psychological health, social relations, and environment health. The scores of this scale ranged from 0 to 100, with 0 being the least favorable and 100 being the most favorable[17]. The higher the score is, the better the quality of life. The Cronbach alpha value that measures content consistency was 0.849.
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Another questionnaire included in this survey is a self-administered questionnaire which was developed by the research group. It contains questions on socio-demographics (e.g. gender, age, height, education background, medical insurance, ethnicity, and marital status). Furthermore, this questionnaire also includes questions on the peristomal skin status, daily stoma pouch care, the comprehensiveness of self-care knowledge from hospital, the available ways of attaining self-care knowledge and skills, preference of self-care knowledge.
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2.5 Data collection The research members contacted the nursing department and the ostomy specialist in Colorectal Cancer Therapy Center in the Tumor Hospital of Yunnan Province after the formal approval. The purpose and methods of this study were explained directly to the head nurse and ostomy specialist of this medical center. Between 2013 and 2014, 142 Chinese colorectal cancer patients after their colostomy in the Tumor Hospital of Yunnan Province were enrolled in this study. The patients answered the questions read by the interviewer or completed the questionnaire by themselves. 2.6 Data Analysis Data analysis was performed using the Statistical Package for Social Sciences (SPSS 17.0). Descriptive statistics such as frequencies, means and standard deviations were first obtained to explore the demographic and colostomy-related characteristics of the samples. U-test was used to study the effects of patient’s gender, educational
ACCEPTED MANUSCRIPT level, and occupation on the QoL. One-way ANOVA variance analysis was utilized to compare the effect of different age groups on the QoL. Significance was defined as p < 0.05.
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2.7 Data Quality A total of 142 print surveys were distributed and 142 returned; the return rate is 100%. The response rate to each item of the WHOQOL-BREF was fairly evenly distributed across the full range of the scale (Table 1). Distribution of WHOQOL-BREF responses with colostomates Very Poor Average Good poor Q1 General QOL 0.7 10.6 67.6 15.5 Q2 General health 3.5 30.3 48.6 16.2 D1:Physical health Pain and discomfort 2.8 25.4 50.7 14.1 Medication 7.7 22.5 35.9 30.3 Dependence Energy and fatigue 4.9 21.8 59.2 11.3 Mobility 4.2 16.2 47.9 27.5 Sleep and rest 8.5 17.6 27.5 40.8 Activities of daily living 2.8 14.1 32.4 45.8 Working capacity 0.7 12.7 33.1 48.6 D2:Psychological health Positive feelings 2.8 14.8 62.0 18.3 Spirituality 0.0 4.2 57.7 35.9 Concentration 1.4 9.2 49.3 33.8 Body image 2.1 40.8 47.2 7.7 Self esteem 1.4 7.0 26.8 62.0 Negative feelings 26.8 50.0 15.5 5.6 D3: Social relations Personal relations 0.7 3.5 26.1 63.4 Sex 2.8 14.1 27.5 52.8 Practical social support 0.0 4.3 19.9 68.1 D4: Environment Safety 2.1 14.9 43.3 36.2 Home environment 4.9 8.5 64.1 21.1 Financial resources 19.0 54.2 12.0 12.7 Information 6.3 36.6 50.7 6.3 Reaction and leisure 4.2 25.4 34.5 33.8 Physical environment 4.9 7.0 21.8 64.1 Access to health care 7.1 11.3 24.1 56.0 Transport 8.5 9.9 26.1 54.9 Family friction 12.0 41.5 36.6 8.5
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Table 1 Items
(n=142) Very good 5.6 1.4 7.0 3.5 2.8 4.2 5.6 4.9 4.9
2.1 2.1 6.3 2.1 2.8 2.1 6.3 2.8 7.8 3.5 1.4 2.1 0.0 2.1 2.1 1.4 0.7 1.4
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3.5
12.8
46.1
28.4
9.2
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3 RESULTS The result of this study described in the following four areas: the socio-demographic characteristics of the patients, the Scores of four domains of WHOQOL-BREF, analysis of Socio-demographic factors of QOL in each domain, and the access of self-care knowledge and self-care needs for the patients.
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3.1 Socio-demographic Characteristics of the Population Participants were from different areas of Yunnan, a southwestern province of China. The sample was composed of 103 male patients (72.53%) and 39 female patients (27.47%). The vast majority, 95.77% of participants were married, and the average age was 54.62±13.83. The socio-demographic characteristics of all participants were described in Table 2.
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Table 2 Socio-demographic characteristics of colostomates in this study (n=142) Variables Number (%) Gender Male 103 (72.53) Female 39 (27.47) Marital Status Married 136 (95.77) Divorced 2 (1.41) Widow 3 (2.11) Single 1 (0.71) Health Insurance Yes 137 (96.48) No 5 (3.52) Education Level Primary school or under 53(45.6) Secondary school or above 89(54.4) Family History of Colorectal Cancer Yes 11(7.74) No 131(92.26) 3.2 The Scores of Four Domains of WHOQOL-BREF Patients’ responses in each domain are described below. The highest domain score was social relations in QoL, which had an average 65.78 with a standard deviation of 14.14. This score indicated a moderate level of social support of the patients. The second highest one is psychological health domain (57.95±11.64) in quality of life, followed by physical health domain (53.49±15.05) and environmental health domain (50.75±13.62) (see Table 3). The higher score indicates the better quality of life. These three scores are a little lower than the average level of the chronic illnesses
ACCEPTED MANUSCRIPT patients, which means that the psychological health, physical health, and environmental health is not good in this population.
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Table 3 Summary Statistics for the WHOQoL-BREF Score in Each Domain Variables Mean Median Std. deviation Range (min.-max.) QOL (physical) 53.49 57.14 15.05 78 (14-92) QOL 57.95 58.33 11.64 62 (20-83) (psychological) QOL (social 65.78 75.00 14.14 68 (25-100) relations) QOL (environment) 50.75 53.12 13.62 68 (9-78)
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3.3 Analysis of Socio-demographic Factor of QOL in Each of the Four Domains Patients’ responses on quality of life were analyzed by using u test and one-way ANOVA to determine whether there was any significant difference between the socio-demographic variables and the scores on the scale (Table 4). The statistical results showed no significant difference between gender, age, education level, occupation in quality of life scale (P 0.05). Table 4 Analysis of Socio-demographic Factors of QoL in Each Domain QOL
QOL (physical)
Gender Male (n=103)
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SD
QOL
(social relations) M
SD
(environment) M
SD
52.25
12.62
50.12
9.22
64.89
13.94
49.88
14.41
55.86
10.41
51.21
8.44
68.20
14.61
53.04
11.21
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Female (n=39)
SD
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(psychological)
Variables
QOL
Age (year)
40 ( n=31)
54.49
12.34
52.69
7.57
66.94
15.44
51.01
12.43
41-60 (n=56)
54.91
10.27
49.48
9.73
65.18
15.42
50.97
13.87
50.84
13.50
49.39
8.80
65.74
12.08
50.41
14.26
54.65
11.44
50.47
8.90
65.41
12.16
50.77
12.85
60 (n=55) Education Level Primary school and below (n=53 )
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52.41
12.51
49.95
9.07
66.00
15.28
50.75
14.15
Farmer (n=78 )
54.03
12.24
50.85
9.43
66.24
14.83
50.45
14.56
Worker and
52.29
12.01
49.28
8.38
65.21
school and above (n=89 )
others (n=64 )
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Occupation
13.35
51.14
Note: u-test for comparing the difference between the QoL in male and female group, primary school and below versus junior high school and above group, farmer versus worker and others group. The one-way ANOVA was the QoL in different age group. P>0.05.
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utilized to explore the differences among
3.4 Access of self-care knowledge and self-care needs
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All of the participants had colostomy surgery a month before the survey and responded to the second questionnaire with their sources of self-care knowledge and self-care needs after the colostomy (see Table 5). Table 5 Findings of self-care resources and self-care needs (n=142)
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Items Peristomal skin Good Erythema Erythema and ulcer Multiple problems happened Help of stoma pouch care Did not need Needed sometimes Needed most of time Needed always Self-care knowledge from hospital Comprehensive knowledge Incomprehensive knowledge Knowledge disconnected from daily life Useless information Ways to acquire self-care knowledge Internet and relative ways Doctors and nurses Exchange knowledge with peer colostomates No way Willingness to attend the training of self-care Yes
Response Number (%)
80 (56.3) 53 (37.3) 6 (4.2) 3(2.1) 27 (19.0) 74 (52.1) 36 (25.4) 4 (2.8) 35 (24.6) 100 (70.4) 1 (0.7) 6 (4.2) 29 (20.4) 68 (47.9) 40 (28.2) 27 (19.0) 71 (50.0)
12.50
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14 (9.9) 23 (16.2) 64 (45.1) 88 (62.0) 63 (44.4) 95 (66.9) 54 (38.0) 110 (77.5)
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No Preference of the ways to acquire self-care knowledge Home visit Lecture Communication with peer colostomates Written materials Preference of knowledge on self-care Stoma care Life adaptation after colostomy Psychological adaptation General information about colorectal cancer
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3.5 Multiple linear regression results
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Multiple linear regression was used to examine the associations between two questionnaires. The statistical assumption for multiple were examined and met. The independent variables contain age, gender, education background, family history, willingness to attend the self-care training, and the scores of each domain of QoL are the covariates. This research found that female colostomates had higher grades in physical area of quality of life than male patients did. Moreover, the participants who were willing to attend the self-care courses got higher scores in social area than who were not. (see Table 6 and Table 7) Table 6 Multiple linear regression results on impact factors of physical domain of QoL (n=142) standardized regression coefficient
constant
47.278
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gender
4.650
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unstandardized regression coefficient
0.171
t value
p value
15.218
0.000
2.023
0.045
Table 7 Multiple linear regression results on impact factors of social domain of QoL (n=142) unstandardized regression coefficient
standardized regression coefficient
t value
p value
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14.885
0.000
Willingness to attend self-care training
7.101
-
3.016
0.003
4 Discussion 4.1 The indications of QoL analysis
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constant
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The present study found that the mean scores of the physical health, psychological health, social relations, and environmental health domains, as defined in WHOQOL-BREF, were 53.75, 57.95, 65.78 and 50.75, respectively. These scores are a little bit lower than that of quality of life of Chinese urban community residents[18]. Xia et al. found that the urban community residents with chronic illnesses got 60.73, 58.91, 61.13, 52.54 in the above-mentioned four domains, respectively. The low standard QoL of these patients is congruent with the finding in other Chinese research[13]. The previous researches of quality of life on this population in China utilized EORTC scale (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire), so the present study cannot compare the findings with those researches. Further, in this study social relations scored highest with an average of 65.78, which indicates the patients were supported well by their families and significant others. This result is congruent with Pan and Tsai (2012) on the QoL in colorectal cancer patients with diarrhea after surgery. Their study identified that social relationship ranked highest during the period from one week to two months after the colostomy surgery. The extra care, sympathy, and support from family and friends can lead to more satisfaction with social relationship during this time[19]. Leyk et al. also reported a high level of satisfaction of support from family and friends in colostomates in Poland. They also found that social support descended as time since colostomy surgery increased [20]. This study also found that there was no significant variance of QoL in the patients’ socio-demographic characteristics, such as gender, age, education background, and occupations. This finding differs from the study by Pan and Tsai where the result indicated that age and gender have a significant impact in QoL[19]. 4.2 Self-care knowledge access and self-care needs The findings on the self-care knowledge access and self-care needs of colostomates showed that this population had difficulties in self-care. Major areas of the greatest concern included:(1) Dealing with the ostomy and pouching system, (2) Complications, (3) Healthcare barriers, quality, and service resources, (4) Coping philosophies and adaptations, (5) Self-care education [21].
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In this study, there were 45.6% patients with primary school or lower education level, while 54.4% with second school or above, among them four finished the college or university education. Most of them cannot utilize the modern communication such as internet to acquire self-care knowledge or skills that enable them to deal with above challenges. Leykin and colleagues suggested that eHealth eduation is the easy access from home and has 24-h accessibility for the ostomy patients [22]. So the education background of these participants can be an important barrier to carry out self-care practices.
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From this study, only half of the participants were willing to attend self-care trainings, whereas a majority of the other half thought they didn’t have time to attend trainings even though they were aware of their self-care problems and needs. This could explain why most of the participants preferred reading materials on how to acquire self-care knowledge. Moreover, home visit was the least favored way. Chinese people are not as open-minded as western people to talk about unfortunate situations such as death, cancer, etc. Moreover, Chinese people would like to cover the changes of their bodies intentionally; they even feel uncomfortable when questioned by others about these situations. The patients also worry about the situation that the fecal leakage or odor will be despised by people around them. So they cannot accept home visits easily [23].
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Furthermore, 77.5% colostomates in this study responded that they hope to be educated in general knowledge about colorectal cancer. The ostomy nurse in the Colorectal Cancer Therapy Center did teach them how to care for their stomas postoperatively, but the information and knowledge of colorectal cancer might be overlooked by the doctors and nurses. Moreover, the colostomates need feedback and retraining to follow up to what extent they understand and grasp the knowledge and the self-care skills on their illnesses. The patients still had the needs to be taught on life adaptation skills, stoma care, and psychological adaptation. Atschuler et al. reported in their study that social support was fundamental to the psychosocial adaptation to an ostomy [24]. These findings indicated that the colostomates should be educated preoperatively and postoperatively on a periodic basis in the hospital setting. 4.3 Impact factors on scores of domains of Quality of Life Female patients got higher scores in physical domain of QoL than male patients did in this study. Goldzweig also found that women and married patients can deal better with colorectal cancer than men and unmarried patients [25]. The patients who desired to attend the self-care training courses had higher grades in social domain of QoL that who did not. Self-care training courses are the resources of social support which involves information support, instrumental support, material support, emotional support. Other studies also reported that colostomates with lower of social support experienced greater difficulty adapting to life with a stoma, whereas the colostomates receives higher level of social support reported a better quality of life [26-24].
ACCEPTED MANUSCRIPT Health education has been validated to improve quality of life of this population . For the self-care practice training and education in this population, the study by Grant et al. developed a chronic care ostomy self-management program to help them to learn the best way to carry out self-management. The program involves ostomates, their caregivers/partners, and peer ostomates. Essential elements of this program include (1) the community-resources and policies, (2) the health system-organization of care, in order to keep patients as healthy as possible through strategies, (3) cultural component of self-management support, (4) delivery system design (such as group classes, reactive care, training, etc.), (5) decision support, (6) clinical information system (clinical care pathways, standing orders, and referral) [28]. Their research developed an evidence-based self-care program involving above items from the changes in the four dimensions (physical well-being, psychological well-beding, social well-being, spiritual well-being) of health-related quality of life for patients with ostomies. This program could serve as a guideline to teach colostomates how to improve their self-management in this population. And the hospital can set up their self-care program according to the patients’ concerns and needs from this study and related researches.
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[27]
STUDY LIMITATIONS
CONCLUSION
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The design of this study had two limitations. First, the study had been carried out in one medical center which may not be the case in general. Second, the sample was a convenience sample consisting of patients who received colostomy surgery in the same hospital one month before the survey, which may not represent the whole population.
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In this paper, we assessed the quality of life of colostomates and explored their self-care needs after colostomy surgery. The study results of QoL with WHOQOL-BREF, indicated the performance was not good for colostomates in mainland China.
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This study identified a series of self-care problems and needs of the post-colostomy patients. The main concerns of their daily self-care activities include the care of peristomal skin, pouch care, the ways to acquire self-care knowledge and other issues. They also needed general information on colorectal cancer, life adaptation and psychological adaptation after colostomy. But they were facing a lot of barriers such as education background, healthcare services etc. The healthcare team can develop appropriate self-care program to meet their needs in accordance with their situation and socio-demographic background. It is hoped that this paper can be used as a reference for hospitals that wish to develop a self-care program for the patients in both preoperative and postoperative phases. CONFLICT OF INTEREST
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REFERENCES
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The authors acknowledge and thank Qingxi Wang who is an Ostomy Specialist of The Tumor Hospital of Yunnan Province for her active guidance and support, as well as Professor James Shi for writing guidance.
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