RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES4 th Block, Jayanagar, Bangalore-41,Karnataka

PROFORMA SYNOPSIS FOR REGISTRATION OF SUBJECT

FOR DISSERTATION

1.Name and address of the candidate (In block letters)

MERLIN MARGARETD/O. K.S. THOMAS, # 100, ESTHER ILLAM, 3rd MAIN,3rd CROSS,BEHIND SARAVATHY FACTORY,UDAYANAGAR,DOORVANINAGAR P.O.,BANGALORE – 560 016.

2.Name of the Institute ACHARYA COLLEGE OF NURSING

3. Course of study and subjects

1ST YEAR MSC NURSING (PEDIATRIC)

4.Date of Admission 30/06/2008

5. Title of the TopicA DESCRIPTIVE STUDY TO ASSESS THE LEVEL OF STRESS AND ITS ASSOCIATION WITH THE QUALITY OF LIFE OF PARENTS HAVING CHILDREN WITH MAJOR CONGENITAL ANOMALIES AT INDIRA GANDHI INSTITUTE OF CHILD HEALTH, IN BANGALORE.

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6. BRIEF RESUME OF INTENDED WORK

INTRODUCTIONA new baby is like the beginning of all things – wonder, hope and dreams. Becoming a parent is one of life’s greatest blessings. It is a joyous moment every parent eagerly waits for. Parenting is a life long process with ever evolving changes in the family. The birth of the child changes the actions and even the life style of the parents.

All parents dream of giving birth to the perfect child. Birth of a child with a congenital anomaly challenges those dreams. This forces families to deal with a crisis for which they may be completely unprepared. It may bring many new additional problems for parents. Discovering one’s child has a disability causes major stress, this can disrupt the total family functioning. Bringing up such a child by parents affects their quality of life.

Birth defects are often found within the first year of life. Their effects can range from milder to severe. Cardiac and circulatory congenital anomalies account for 33.5 percent, digestive congenital anomalies account for 18.5 percent, congenital genitourinary and nervous system anomalies account for 9.3 percent and 5.0 percent respectively. All remaining birth defects account for about 3.8 percent.1

The burden of congenital anomalies is high in all countries. Each year, birth defects affect one out of every 33 babies born in USA. Venezuela has the highest prevalence of 38.9 percent. Some Latin American countries show a low prevalence rate of 7.7 percent. In Asia, India has the highest prevalence rate of 181.8 percent. Pakistan has the lowest of 11.76 percent. A thirty year review (1966 – 1995) of neural tube defectshas shown India (Asia) with frequency of 181.8 in 10,000 individuals having the highest prevalence in the world.2

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The prevalence rate per 1,000 total births for cleft lip with and without cleft palate were high during the period from1952-1986.3 More than 300 (39.5 percent) of children from Bradford have prevalence of many disabling conditions.4

The presence of congenital anomalies not only affects children but also parents and families of children with congenital anomalies. The practical day to day needs of the child creates challenges for parents, causing an impact on both psychological and physical health of the parents. This can lead to additional strain on the mother who plays a significant role in caring for the family that also includes the child. The greater the parental stress the poorer will be the quality of life of parent. Even milder levels of stress can negatively influence parental quality of life.

6.1 NEED FOR THE STUDY

Chronic illness and disability have substantial effects on the family function. A child born with congenital anomaly places a tremendous stress on the family. Some parents may accept and take appropriate steps to face it, whereas others may not.

Congenital anomalies occur in 2 %( 2percent) to 4 %( 4percent) of all live born children.5 Review of an anomaly with large absence of neural tissue of new born shows highest prevalence of 87%(87 percent) in China. State of Michigan in the USA has the highest rate of 10.5%(10.5 percent). Review of spina bifida shows, the state of Arkansas in American continent with 7.8%(7.8 percent) and in Europe, England with 23.1%(23.1 percent) have the highest prevalence rate. An investigation carried out by the authors in a maternity hospital in Tehran, Iran, out of 13037 births, (17.6 percent in 10,000) 23 new born had neural tube defect with 3.8percent spina bifida, 0.8 percent with anencephaly. India with frequency rate of 181.8 percent in 10,000 individuals has the highest prevalence rate.2

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The province of Alberta records some 40,000 births each year and presence of congenital anomalies.6

A comparative study was conducted on the quality of life among 1092 parents of children with congenital heart disease, 112 parents with other disease and 293 parents of healthy children. The findings of this study report that parents of children with heart disease have lower quality of life compared to parents of healthy children. This finding indicates that any kind of stress present in parent can lower quality of life and therefore it is necessary to identify those stressors in order to improve their quality of life.7

A cross-sectional study among 42 parents of children with cerebral palsy was performed. Maladaptive behaviour scores explained 27percent of the total variance in the parenting stress index, which showed parent domain scored the highest stress score. This emphasizes the importance and the need for interventions that support the parents and family as a whole and improve their quality of life.8

A meta analysis study was undertaken to summarize the finding on parents’ psychological adjustment in families of children with spina bifida.15 studies were identified, and analyses of these studies revealed stressors that influence the psychosocial adjustment of the parents that is child’s age and condition, parenting competence, family income, relationship with spouse, family environment and social support. These findings indicate a need for health professionals to be alert to the stressors in parents.9

The investigator during her contacts with the parents of children hospitalized especially with major congenital anomalies found that it was stressful for the parents when child has a congenital anomaly with repeated hospitalization. There have been studies to describe the aspects of stress of parents and parental coping strategies among parents of children with chronic illness. But the investigator could not find any

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reported studies on the association of stress with the quality of life among parents of children with different congenital anomalies.

Therefore, the investigator felt the need to explore into the area and assess the stress and its association with the quality of life of the parents. This would help the nurse to be alert and competent in educating parents in caring for the child and the family, which would reduce the stress of the family and improve the quality of life.

6.2 REVIEW OF LITERATUREThe present study is undertaken to assess the stress and its association with the quality of life of parents of children with congenital anomalies. The investigator did extensive search of the existing literature, and organized it under the following topics:-

a) Congenital Anomaliesb) Parental Stressc) Quality of life

CONGENITAL ANOMALIESCongenital anomalies are defects that occur during the development of the fetus. The word “Congenital means “at birth” and the word “anomalous” is derived from a Greek word meaning “ uneven” or “irregular”. The normal development of the baby ensures normal formation and maturation of all body parts and organs. When this process is interrupted or altered in any way, congenital anomalies result.

The prevalence of congenital anomalies in India is high. There are about 495,000 infants born with congenital anomalies every year.10

The exact cause of congenital anomalies in humans is unknown. A report of a study conducted showed that 20-25 percent of anomalies are caused by complex interaction of minor genetic abnormalities and environmental

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risk factors. 10-13 percent of them are caused due to prenatal factors such as infections, illness like diabetes mellitus or drug use in mothers.11

A study was conducted on short, mid and long term consequences of smoking during pregnancy. They concluded that maternal or paternal smoking during pregnancy has many effects on the new born, the infants, and even the adult exposed during intrauterine life. In the new born, measurements at birth are lower than those observed in non-exposed newborns and the risk of preterm birth is increased. There is also a slightly increased risk of cleft lip or cleft palate.12

A meta analysis study was conducted. The findings of the study reveal that Spina Bifida is the second most common birth defect worldwide. Since the chances of survival in children with severe Spina Bifida forms have increased, medical care has shifted its emphasis from life saving interventions to fostering the quality of life for these children and their families.9

Anorectal malformation is the most common type of congenital anomaly with an incidence of 1 in 4000 children.13 In another study done in surgical unit at the All India Institute of Medical Sciences, out of the 754 neonates admitted over a period of six years, 16.4% neonates were with anorectal malformation.14

IMPACT OF CONGENITAL ANOMALIES IN CHILDREN Impairment of any organ system can create disabilities that

influence physical, cognitive, behavioural, psychological and cosmetic concerns. A comparative study was conducted on 56 families of children with Myelomeningocele and 53 matched comparison families. Findings of the study revealed that children with Myelomeningocele were found to have lower self-concept than the comparison children.15 Related literature has shown ARM (Anorectal malformations) had a negative impact on the social life of the child in 52%(52 percent) and on family functioning in 50%(50 percent), 80%(80 percent) of the children had one or more behavioural problems and 15%(15 percent) expressed suicidal thoughts.

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Children with anorectal malformation have ongoing physical and social morbidity. Congenital anomalies often involve repeated hospitalization and invasive treatment procedures that can have traumatic impact on child’s development.16

IMPACT OF CONGENITAL ANOMALIES ON PARENTS The presence of malformations puts lot of strain on parents. Parents may face challenges in many aspects of parenting.

Between 1990-1995, 160 babies with malformations were born in Quebec .In a study on eight families from this population, the author examines ways in which they communicate, share tasks, react to difficulties, show interest and solve problems. By interviews and three questionnaires the author determined that the first three months following the birth are the most crucial for the parents.17

PARENTAL STRESSThe word ‘stress’ is defined as a state of affair involving demand on physical or mental energy, a condition or circumstance, (not always adverse) which can disturb the normal physical and mental health of an individual. A study was conducted on stress of parents having children with congenital anomalies. 78 mothers of medically fragile infants with differing congenital problems were recruited. During their infants’ hospitalization, the outcome measures of the study revealed that the highest source of worry and stress were medical problems, followed by worry and stress about whether the child would be normal, when the child could come home and whether the child would always be sick. Parents of critically ill infants, regardless of the type of diagnosis, have stress and worry about aspects of their infants’ health.18

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Parents of children with congenital anomalies who are from a lower economic status, experience more stress than those parents with higher economic status. This is evidenced by a pilot study conducted on child rearing practices among parents of low economic status which states that they found areas of concern and sought seek help related to play, help for school activities and the greatest concerns of both parents were their child’s future and sufficient income to support the child and family.19

A study was conducted on use of resources, use of time and division of household chores among 22 families of child with a spina bifida aged between 4- 6 years and compared with 22 families having a normal child of the same age group. The findings have shown that in families with a spina bifida child, both parents spent more time in child care and depended more upon friends, parents and neighbours. The mothers experienced lack of sleep and increased stress.20

A study was done on parents of children with high and intermediate imperforate anus and aimed at illuminating the experiences and psychosocial situation of patients and their parents. It was found that in addition to the financial stress, parents had physical, emotional, social and family problems due to the malformation in the child. Parents in this study expressed that they felt isolated and lonely. The most frequently described emotional effects were sorrow, pain and disappointments, but despite all their problems, the parents expressed that they have managed to lead a normal life as much as possible.21

A study was conducted to assess the level of stress among parents of children with anorectal malformation. Parents of 109 children with anorectal malformation were investigated, after completing the Nijmegan questionaire on child rearing situations.

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The findings of the study showed that stress of parents with the anomaly did not differ from that of healthy children, but within the group of parents with anorectal malformation – afflicted children, the parents of older, incontinent children experienced more stress especially if the child was male. Parents were concerned regarding the implications of the disorder for everyday life and indicated a need for specific counseling.22

QUALITY OF LIFEQuality of life refers to well being of persons in all domains of function including physical, psychological, social and educational. Quality of life is unique for each person. It is an important health outcome to assess especially in parents of children with any major illness that totally disrupts the family functioning. Quality of life of parents will be affected in parents when they are under stress. Congenital anomalies of major kinds of their offspring can have tremendous effects on quality of life of parents.

A study was conducted to identify factors influencing the quality of life of families having children with anorectal malformation. 167 children were operated for anorectal malformation between 1982-2000. Questionaires to assess both clinical and psychological outcomes were evaluated among which 80%(80 percent) of children had one or more behavioural problems and15%(15 percent) expressed suicidal thoughts. Anorectal malformation had a negative impact on the social life of the child in 52 %(52 percent) of children and on family functioning in 50%(50 percent) .71%(71 percent) of children below 12 Years show average global hopelessness score. Parents of children with anorectal malformation indicate the need for support to optimize their quality of life.16

A study was conducted to evaluate the quality of life in parents of children with Spina Bifida. They found that parents of children with Spina bifida suffered psychological problems. The overall scores on quality of life and health were lower compared with parents of healthy children.23

EFFECTS OF STRESS ON THE QUALITY OF LIFE OF PARENTS

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Stress greatly influences quality of life. Presence of stress can lower the quality of life of parents; the less the stress, the better will be the quality of life.

A study was conducted on bladder exstrophy and its psychological impact on parents. In the study 7 boys and 8 girls, 3-18 years old under treatment were involved. Medical and psychological evaluations were performed through child behavior checklists, questionnaire. Quality of life was estimated using the multiattribute health status mark II classification system. Quality of life declined in most cases to limited self-care and stress. Although emotional problems were few, 5 parents had psychiatric symptoms.24

A study conducted on the impact on quality of life of parents having children with Myelomeningocele described that spinal cord lesions affect colorectal motility, anorectal sensation and anal sphincter function. Questionaires describing age, gender, neurologic deficit, bowel function, child behaviour and psychological impact, were evaluated among 208 parents, among which 125 responded. Bowel dysfunction had some or major impact on social activities or quality of life in 48(40%)parents. Colorectal problems are common in children with Myelomeningocele, but as children get older, stress too increases which has a tremendous impact on quality of life which becomes severe.25

Similarly another study conducted on gastrointestinal motility and sensory abnormalities reveal that within families, mothers of children with gastric sensory abnormalities, who develop aversion to food and have persisting vomiting, have higher levels of parenting stress and poorer quality of life.

The results showed that severity of illness, gender and social support had an impact on quality of life.26

6.3 STATEMENT OF THE PROBLEM

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A descriptive study to assess the level of stress and its association with the quality of life of parents having children with major congenital anomalies attending the pediatric inpatient and outpatient departments at Indira Gandhi Institute of child health, in Bangalore.

6.4 OBJECTIVES OF THE STUDY

To assess the level of stress of parents having of children with major congenital anomalies.

To assess the quality of life of parents having children with major congenital anomalies.

To determine the association of parental stress with their quality of life.

To determine the co-relation between stress and quality of life.

6.5 OPERATIONAL DEFINITIONS

Stress: - It refers to non-specific response to any situation that is experienced by parents with children having congenital anomalies.

Quality of life:- It refers to parents’ satisfaction with their level of functioning or day to day living.

Congenital anomalies:- It refers to any anomaly present at birth, that results from genetic and environmental factors, parental factors, which are present at birth.

Parents: - It refers to mother and father of a child. Major congenital malformation:- structural abnormality at birth

with serious medical, surgical or cosmetic consequences such as congenital anomalies like urogenital, gastro-intestinal system such as anorectal malformations, exstrophy of bladder, cleft lip and cleft palate, meningomyocele, neurogenic bladder, spina bifida only.

6.6 HYPOTHESIS:-

There is an association between stress and the quality of life.

6.7 VARIABLES:-11

Independent variables-level of stress of parents of Children with Major congenital anomalies.Dependent variable:-Quality of life of parents of children with major congenital anomalies.

6.8 ASSUMPTIONS:-

Parents of children with congenital anomalies will have stress. Stress will influence the quality of life of parents of children with

congenital anomalies. Parental stress will vary based on the types of congenital anomaly

and age. Parental stress will vary depending upon different age of children.

6.9 DELIMITATIONS

This study is limited only to either mother or father. This study is limited to selected hospitals in Bangalore. This study is limited to study period of 30 days. This study is limited to parents of children with selected major

congenital malformations, exstrophy of bladder, cleft lip and palate, meningomyocele, neurogenic bladder, spina bifida only.

6.10 PROJECTED OUTCOME

The issues raised in this study would help with the identification and prioritization of medical and psychological services. The findings of this study would help health care providers to understand the different stressors and quality of life of parents of children with different congenital anomalies and to promote family health during the child’s hospitalization and at home.

The study would make it simple for the nurses to assess parenting stress and to provide support and anticipatory guidance to families of children

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with congenital anomalies. The findings of the study would be able to suggest various coping strategies for parents that suggest ways to reduce stress thereby improving the quality of life.

7. MATERIALS AND METHODS

SOURCE OF DATA

The data will be collected from parents of children with selected major congenital anomalies at Indira Gandhi Institute of child health in Bangalore

RESEARCH APPROACH

The research approach used for the study is non-Experimental approach.

RESEARCH DESIGN

The research design which is more suitable for this study is descriptive design.

RESEARCH SETTING

Study will be conducted at Indira Gandhi Institute of child health, in Bangalore.

POPULATION

The study of population comprises parents of children aged 1 – 15 years with major congenital anomalies.

SAMPLE SIZEThe sample of the study consists of 60 parents of children with major congenital anomalies at Indira Gandhi Institute of child health, in Bangalore.

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SAMPLE TECHNIQUE

Purposive convenient sampling is used for selection of the samples.

7.1 SAMPLINGCRITERIA:-

INCLUSION CRITERIA

1. Parents of children with urogenital anomalies, gastrointestinal anomalies such as anorectal malformations, exstrophy of bladder, urogenic bladder, cleft lip & cleft palate, meningomyocele, spina bifida.

2. Parents who are willing to participate.

EXCLUSION CRITERIA

1. Parents of children below the age of 1 year and above 15 years are not included.

2. Parents who do not agree to participate.

3. Parents who cannot speak Kannada / English

7.2 METHOD OF COLLECTION OF DATA

INSTUMENTS USED FOR STUDY-

The instruments that will be used for the data collection for this study are:-

PART-A: Demographic and clinical data.

Demographic variables like age, sex, occupation, monthly income, history of child birth, education.

Clinical data includes type of congenital anomaly, duration of illness, number of hospitalization, prognosis.PART-B: Parental stress scale.

It would be prepared by the investigator, which will have six dimensions such as physical, family, psychological, emotional, financial, child and medical care stressors.

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PART-C: Quality of life questionnaire.

It will be taken from the version of WHOQOL-BREF scale.

DATA COLLECTION TOOL OR METHOD

A formal administrative permission will be obtained from the respective authority. The investigator would introduce self, explain to the subjects the purpose of the study, assure confidentiality and obtain a written consent from the subjects. After establishing rapport with the parents, the investigator would collect data using questionnaire relating to demographic and clinical variables after which the self-administrated scale will be handed to educated participants. For those who are unable to read the questionnaire, an interpreter would be used to translate kannada version of the scale.

DATA ANALYSIS PLAN

The data will be analyzed using descriptive and inferential statistics.

–Descriptive statistics would be used to assess the level of stress of parents and quality of life of parents.

-Association of parental stress and quality of life with demographic and clinical variables will be done using chi-square method.

-Pearson correlation will be used to determine the correlation between stress score and quality of life scale.

7.3 Does the study require any investigator or intervention to be conducted on patients or other humans or animals ?

“No” this is a descriptive study.

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7.4 Has ethical clearance obtained from your institution in case of the above?

1. The ethical clearance will be sought from Acharya college of nursing.

2. Written permission will be obtained from concerned authority.3. Permission will be obtained from parents of children with major

congenital anomalies.

8. LIST OF REFERENCES

1. C.Allison Russo, M.P.H. and Anne Elixhauser, Ph.D., “Hospitalization for birth defects”, January,2007.Available at http://www.hcup_us.ahrq.gov/reports/statbriefs/sb24.jsp.

2. Farshud, D.D, Hadavi, and Sadighi.H, “ Neural tube defects in developing and developed countries”, Available at http://www.consang.net/index.php/Abstracts_papers_html.

3. Soo – hong uh, Carlos Caraveo, Leslie. T. Foster, R. Brian Lowry, Birth prevalence of left lips & left palate in British Columbia between1985 – 2004Available at www.phac_aspc.gc.ca/ct2005 .

4. Corry, P.c., Sinha, G., Karbani, G., Woods, C.G., Markham, A.F. and Mueller, R.F, Intellectual disability and cerebral Palsy, UK.Available at postmaster@pecorry.demon.ac.uk.

5. Whaley & Wong DL, Nursing Care of infants and children, 7th Edition, 2003, mosby Philadelphia, chapter – 5, page No – 111.

6. Fu Lin Wang, Stephan Gabos, Barbara Sibbald and R Brian Lowry, Completeness and Accuracy of the birth Registry data on congenital Anomalies in Alberta, Cannada.Available at http:// www.phac_aspc.gc.ca/publicat/cdic-mcc/22-2/c_c.html.

7. Lowoko.S, soares, J.J, Quality of life among parents of children with other diseases and parents of healthy children 2003, Journal of quality of life research, 12 (6).

8. Ketalar. M, Volman M.J., Gorter JW, Vermeer A, “Stress in parents of children with cerebral palsy” Netherlands.

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Available at M. Ketelar@ dehoogstraat.nl.

9. Vermaes. I.P, Janssens.J.M and Bosmon. A.M, Gerris JR,” Parents psychological adjustment in families of children with Spina Bifida,” a meta Analysis, BMC Pediatrics, 2005, Aug 25;5:32.

10.Verma I.C, and Bijarnia. S, The burden of genetic disorder in India and a frame work for community control. Community genetics, 5 (3) 193 – 196.Available at http://content.karger.com/ProdukteDB/produkte.asp?Aktion=ShowPDF&ProduktNr =224224&Ausgabe=228733&ArtikelNr=66335

11.Kumar, Abbas, & Fausto, Robins & Cotron’s,” Pathologic basis of disease,” 7th edition, 473.Available at http://en.wikipedia.org/wiki/congenital.

12.Heilbronner. C, “What are the short, mid and long term consequences of smoking during pregnancy” J. Gynecol obstet Biol Reprod, Paris, 2005, Apr 34, Spec No 1: 3s390 – 446.

13. Goyel, A., Williams, J.M, Kenny S.E & Lwin. R “Functional outcome and quality of life in children with anorectal malformation,” 2006.Journal of pediatric surgery, 412, 318 – 322.

14. R.K.Ghrittahary, .Budhwani, D.K.Shrivastava, G.Gupta, A.S.Kushwaha, R.Chanchlani, M.Nanda., Anorectal malformation and their impact on survival, 2005, Indian journal of pediatrics, 72 (12), 1039 – 1042.Available at http://www.jiaps.com

15. Kazak A.E, Clark.M.W, “Stress in families of children with myelomeningocele,” Dev med child Neurol, 1986 April 28 (2) 220 – 8.

16. Hamid .C.H, Hollad A.J, Martin H.C, “Long term outcome of aonrectal malformations : the patient perspective,“ Pediatr. Surgical Int.2007, Feb; 23 (2) : 97 – 102 Epub 2006 Dec – 14.

17. Chapados.C, “When a child is born with a cleft lip and palate,” 1997, Jan; 93 1 : 31 – 6.Available at http://www.ncbi.nlm.nih.gov/pubmed/9095769.

18. Docherty .S.L, Miles M.S, Holditch – Davis. D, “Worry about child health in mothers of hospitalized medically fragile infants. “Adv Neonatal care, 2002 Apr; 2 (2) : 84 – 92.

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19. Samuelson. J.J, Foltzy, Foxall M.J, “Stress and copying in families of children with Myelomeningocele” Arch Psychiatr nurs, 1992, Oct; 6 (5) : 287 – 95.

20. Joosten. J, “Accounting for changes in family life of families with Spina Bifida children,” Z. Kinderchir Grenzeb, 1979, Dec; 28 (4) : 412 -7.

21. Nisell, M, Ojmyr-Joelsson M, Frenckner B, Rydelius PA, Christensson K, “How a family is a affected when a child is born with anorectal malformation,” J. Pediatr nurs, 2003, Dec; 18 6 : 423 – 32.Available at margret.nisell@ks.se.

22. Hassink. E.A, Brugman-Boezeman AT, Robbreckx LM, Rieu PN, Van Kuyk EM, Wels PM, Festen C,” Parenting children with anorectal malformations; Implications and experiences”, Pediatr.surg Int. 1998, Jul; 13 5-6 : 377 – 83.

23. Zipitis C.S, Paschalides. C, “Caring for a child with Spina Bifida : Understanding the child and carer,” J.Child health care, 2003, June 7 (2) : 101 – 12.

24. Stjernqvist. K, Kockum. C.C,” Bladder exstroghy, : Psychological impact during childhood,” J.Urol, 1999, Dec; 162 (2) : 2125 – 9.

25. Krogh. K, Lie. H.R, Bilenberg. N, Laurberg S, Bowel function in Danish Children with Myelomeningocele” APMIS Suppl, 2003; (109) : 81 – 5.Available at www.krogh@akh.aaa.dk.

26. Zangen. T, Ciarla C, Zangen S, Di Lorenzo C, Flores AF, Cocjin J, Reddy SN, Rowhani A, Schwankovsky L, Hyman PE, Gastro intestinal motality and sensory abnormalities may contribute to food refusal in medically fragile toddless” J. Pediatr, Gastroenterol, Nutr. 2003, Sep; 37 (3) : 287 – 93.

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9. Signature of the candidate

10. Remarks of the guide

11. Name and designation of( In Block Letters)

11.1 Guide

11.2 Signature

11.3 Co-Guide (If any)

11.4 Signature

11.5 Head of the department

11.6 Signature

12. 12.1 Remarks of the chairman and principal

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12.2 Signature

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