University of Groningen Exploring strategies to optimize pharmacotherapy with antiretrovirals in Papuans living with HIV Sianturi, Elfride

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University of Groningen

Exploring strategies to optimize pharmacotherapy with antiretrovirals in Papuans living with

HIV

Sianturi, Elfride

DOI:

10.33612/diss.116883036

IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite from it. Please check the document version below.

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Publication date: 2020

Link to publication in University of Groningen/UMCG research database

Citation for published version (APA):

Sianturi, E. (2020). Exploring strategies to optimize pharmacotherapy with antiretrovirals in Papuans living with HIV. Rijksuniversiteit Groningen. https://doi.org/10.33612/diss.116883036

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CHAPTER 5

Knowledge, empathy, and the willingness to

counsel HIV patients among Indonesian

pharmacists: a national survey of stigma

E.I Sianturi, E. Latifah, M. Pane, D.A Perwitasari, Satibi, S.A Kristina, E.B Hastuti, J. Pavlovich, K. Taxis

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Abstract

Background: Pharmacists could play an important role in providing care for people living with HIV (PLHIV) including counselling on ART. This study aimed to assess the level of HIV treatment knowledge, empathy, and HIV stigma of pharmacy students and pharmacists working with PLHIV in Indonesia and to investigate potential factors associated with stigma. Methods: This was a survey of hospital pharmacists working with PLHIV within 33 provinces in Indonesia and final-year pharmacy students of 9 Universities from the province of Java in Indonesia. The questionnaire was set up using Qualtrics, an online tool and was distributed by a mobile phone application.

Results: Overall, 1263 participants were included, 250 hospital pharmacists and 1013 students. The mean age of the participants was 24.7 years (SD = 5.3), and 80.0% were female. The mean knowledge score of students and pharmacists were 14.14 (SD=2.01) and 15.39 (SD=1.87), respectively, out of 21 points. The mean empathy score of students and pharmacists were 72.06 (SD=5.39) and 77.40 (SD=1.35), respectively, out of 104 points. The mean stigma scale score of students and pharmacists were 21.02 (SD= 4.65) and 20.66 (SD= 4.41), respectively, out of 48 points. Linear regression analysis indicated that empathy (β = -.138, p = 0.000), HIV treatment knowledge (β = -.089, p = 0.003) as well as the degree of willingness to counsel PLHIV (β = -.266, p = 0.000) was negatively associated with stigma. Being a pharmacist was positively associated with stigma (β = .133, p = 0.003).

Conclusions: Pharmacists and pharmacy students had reasonable knowledge on HIV, empathy and a moderate level of stigma. Improving undergraduate and postgraduate education may reduce stigma and strengthen the role of pharmacists in caring for PLHIV in Indonesia.

Keywords: HIV, Knowledge, Stigma, Empathy, Pharmacist, Pharmacy students, Survey, Indonesia

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BACKGROUND

Pharmacists have an important role in providing care for people living with HIV (PLHIV) [2]. Services include medication reviews to optimize polypharmacy [3],[4] and counselling

patients [2],[5]. Studies have shown that such services improve knowledge of patients in

general [6] and adherence to medication [7]. The pharmacists’ role is also expanding to

improve access to pre-exposure prophylaxis thereby contributing to HIV prevention [8]. A systematic literature review showed that dispensing of antiretroviral therapy (ART) could be

delegated to non-pharmacist personnel without worsening clinical outcomes [9].

To provide care for PLHIV, pharmacists need to have comprehensive knowledge about HIV, including transmission mode, diagnosis, treatment options and monitoring [10],[11]. Empathy, i.e., the ability of the health provider to see the patient’s perspective when providing services also plays a significant role in the care of PLHIV [12]. It has been shown that pharmacy students have positive attitudes and a higher willingness to provide services when they had sufficient HIV knowledge and empathy [13],[12]. Other studies on empathy focused on nursing students [14] and patients [15].

Stigma is described as the process of labelling, stereotyping, separating and discriminating people or groups from their community [16]. HIV related stigma is associated with worse health outcomes [17],[18],[19]. HIV stigma among healthcare providers has been defined as the irrational feeling and negative behavior and attitude towards PLHIV because of their HIV status [20]. Little is known about stigma among pharmacists and pharmacy students.

The overall prevalence of HIV in Indonesia is 0.4%, but large regional variances exist, with a prevalence of 2.3% in Papua and West Papua provinces [21]. The government has scaled up the initiation of antiretroviral therapy (ART) and care is increasingly shifted to primary

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healthcare. Even though the government provides ART free of charge, recent data suggest that only 25% of 600.000 of PLHIV were on ART [22]. Mortality rates as well as the HIV incidence have been increasing in the past 25 years [23]. Pharmacists could play an important role in providing care for PLHIV in Indonesia including counselling on ART [24], since counselling is mandatory before and after PLHIV start with ART [25]. Some work has been done on competences of Indonesian nurses in HIV care [26], but little is known about the knowledge, empathy and stigma of pharmacists and the final-year pharmacy students in Indonesia [27]. Therefore, the first aim of this study was to assess the level of HIV treatment knowledge, empathy, and HIV stigma of students and pharmacists working with PLHIV in Indonesia. The second aim was to investigate the potential factors associated with stigma for the two groups.

METHODS

Study design, setting and population

This was an online survey of pharmacists working with PLHIV within 33 provinces and final-year pharmacy students of 9 universities in Java, the most densely populated area in Indonesia. To recruit pharmacists, the Ministry of Health of the Republic of Indonesia send out the survey to the contact persons of all the health facilities providing antiretroviral therapy (ART) across Indonesia (n=675). The contact person was asked to forward the survey to the pharmacist in the health facility responsible for HIV patients. To recruit pharmacy students, the university lecturers of 9 universities located on the island of Java distributed the survey to all the final year pharmacy students who were on hospital training (n=1046).

The questionnaire was set up using Qualtrics an online questionnaire tool. The link to the online questionnaire was distributed to the privately owned mobile phones of the participants

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105 using a mobile phone application (WhatsApp) as this is a common method of communication in Indonesia. Participants were asked to complete the survey within 3 months and they received weekly reminders to complete the survey. Data were collected between June and September 2018. Participants were informed that all responses were anonymous, but they were asked to provide information on the university or province where they came from. The informed consent was provided at the end of the survey by ticking an “agree” button to indicate their agreements to join this study.

Ethical approval

The ethical approval was obtained from the Committee on Ethics Universitas Gadjah Mada, Yogyakarta Indonesia (project number: KE/FK/0507/EC/2018).

Measures

Demographic data on every participant, including age (18-27 years, 28-37 years, ≥ 38 years) gender (male/female), organization affiliation (without religious affiliation/religious affiliation), type of media to receive HIV information (education/ trained by the government / online / never), frequency providing services to HIV patient (never/1 or 2 times/ often), preference of counselling (face-to-face/ online counselling), status participants (student/ pharmacist), and the degree of willingness to counsel PLHIV were asked in the online survey. Degree of willingness to counsel PLHIV was assessed by clicking on a line between zero and 100, with a higher score indicating a higher degree of willingness to counsel PLHIV.

HIV treatment knowledge, empathy, and HIV stigma were assessed using existing questionnaires from prior studies. To assess HIV treatment knowledge a questionnaire [28],[29] consisting of 21 items was used. Correct answers received a score of one, incorrect

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answers scored zero. The total score ranged between 0-21, with higher scores indicating more knowledge. Empathy was assessed using an adapted questionnaire consisting of 15 items [30]. Those questions were answered on 7-point Likert scale ranging from strongly disagree to strongly agree. A total score (15-105) was calculated by summing up the scores of all

questions, with higher scores indicating greater perceived empathy. HIV stigma was assessed

in line with a previous study [28] using the adapted version of the AIDS-related Stigma Scale [31]. This is a brief, 12-item-self-report measure which assesses attitudes in the general population regarding HIV stigma beliefs (e.g., repulsion, avoidance, and persecution) about individuals living with HIV/AIDS. Answers were scored on a 4-point Likert scale ranging from strongly disagree to strongly agree. The total score ranged between 12 and 48 with higher scores indicating more stigma.

Translations and Reliability Assessments

All three questionnaires, HIV treatment knowledge, empathy and HIV stigma were developed in English. The obtain a version in Bahasa Indonesia (target language) we followed the process of backward and forward translations [32]. Translations were conducted by certified translators who had no information about the original versions of the questionnaires. The backward translations had to be modified several times because the target language does not recognize verb tenses. The translated questionnaires were assessed in a pilot study to ensure they were all understandable and applicable to the setting. The respondents who participated in the pilot study were not included in the study sample. We assessed the reliability for HIV stigma, and empathy in 79 pharmacists and pharmacy students. The Cronbach α HIV stigma,

and empathy were 0.782 and 0.806, respectively. We tested the reliability of the HIV

treatment knowledge questionnaire in line with the prior study [29] in a test-retest study in 32 participants (Pearson’s r =0.893).

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107 Statistical modelling

Data were described descriptively with means, medians, standard deviations, and interquartile range, depending on the nature of the variables. The categorical variables were represented in frequencies and percentages. The chi-squared tests were used to analyze dichotomous variables (i.e., age, sex, items of assessments with status participant (status participant; students, and pharmacists).

The primary outcome was stigma. A two-way ANOVA/t-test was conducted with the following independent variables: HIV treatment knowledge, empathy, age, gender, organization affiliation, type of media to receive HIV information, frequency meeting with HIV patient, status participants, and the degree of willingness to counsel PLHIV. Normality,

linearity, homoscedasticity and multicollinearity were assessed for continuous variables.

Because of multicollinearity, we selected status of the participants rather than age since the status of participants resulted in a better model than the model including age as a variable. Multiple linear regression analyses were performed to assess the influence of independent variables on stigma (appendix). We coded and entered data into SPSS software (version 23.0). A p-value <0.05 was considered statistically significant for all analyses.

RESULTS

Overall, 1263 respondents participated in the study, these were 1013 students and 250 pharmacists. The response rates of pharmacists and students were 37% and 96%, respectively. The mean age of the participants was 24.7 years (SD = 5.3), and 80.0% were female. The most commonly reported source of information about HIV treatment knowledge was education (75%), and more than half of the students reported that they had no experience with HIV patients.

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The mean knowledge score of students and pharmacists were 14.14 (SD=2.01) and 15.39 (SD=1.87), respectively. The mean empathy score of students and pharmacists were 72.06 (SD=5.39) and 77.40 (SD=1.35), respectively. The mean stigma scale score of students and pharmacists were 21.02 (SD= 4.65) and 20.66 (SD= 4.41), respectively (Table 1 in Appendix). Pharmacists scored better on HIV treatment knowledge, empathy, and the degree of willingness to counsel PLHIV than the student group. Questions which were frequently incorrectly answered were whether medication should be stopped in PLHIV with an ‘undetectable’ viral load, whether it was better to take half the dose of HIV medications than stopping the HIV medications, the consequences of using herbal medications during ART and whether ART could reduce the risk of babies being infected with HIV (Table 2 in Appendix).

Table 3 shows that perceived empathy among students was more diverse than pharmacists since there was a proportion of students having neutral perceptions. In particular, the ability of participants to build a strong relationship with patients and difficulties in identifying someone else’s feelings had a relatively low percentage of positive scores.

The results of the assessment of stigma towards PLHIV is shown in Table 4. In particular, relatively high percentages of negative responses were given on the items whether PLHIV should be far from children, should feel guilty and expect to be restricted in their freedom. The linear regression result is shown in Table 5. HIV treatment knowledge, empathy, and the degree of willingness to counsel PLHIV were associated with stigma. Linear regression analysis indicated empathy (β = -.139, p = 0.000), HIV treatment knowledge (β = -.087, p = 0.003) as well as the degree of willingness to counsel PLHIV (β = -.265, p = 0.000) was negatively associated with stigma. Being a pharmacist was positively associated with stigma

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109 (β = .133, p = 0.003). Overall, the effects were small, since R square was .098 which means that the model explained about 10 percent of the variability.

DISCUSSION

Our study showed that two thirds of respondents had good knowledge on HIV treatment. Pharmacists and pharmacy students showed reasonable levels of empathy and the overall level of stigma was moderate. Pharmacists had more HIV treatment knowledge and showed more empathy than students. Some of these differences may be due to many pharmacy students not having any experience in caring for PLHIV. Poorer knowledge and lower levels of empathy were associated with a higher level of stigma.

More than two-thirds of participants completed all items in HIV treatment knowledge, with pharmacists performing slightly better than students. But this was lower than prior studies, conducted in Guyana, Malaysia and Botswana [28],[33],[34]. In particular the questions when to stop, reduce doses or combine ART with herbal medication were often incorrectly answered. The latter is important, since herbal medicines are commonly used in Indonesia [35],[36],[37]. Although some research has been done on effects of combining ART with herbal medicines, a lot of uncertainties remain [38],[38]. Furthermore, almost one fourth of students did not know that ART reduced the HIV transmission risk to babies. Empathy scores in our study were lower than previous studies in developed countries [13],[39]. Pharmacists showed a higher level of empathy than students. Generally, higher levels of empathy have been shown to be associated with better quality of pharmacy services [12]. In a systematic review of studies done in general practice, a higher level of empathy of general practitioners was associated with improved clinical outcomes in patients [40].

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Overall, the level of stigma was moderate. In particular, pharmacy students felt that PLHIV should not work with children and should expect restrictions in their freedom. A fourth of respondents felt that PLHIV should feel guilty. In contrast, very few respondents felt that PLHIV cannot be trusted or should be isolated. In line with previous studies in developed and developing countries, poorer HIV knowledge as well as lower levels of empathy were significantly associated with stigma [41].

Increasing HIV treatment knowledge as well as increasing empathy may be a way to reduce the level of stigma and improve services for PLHIV. This may require a multi-level approach [42],[43]. Topics which need more attention in teaching at undergraduate and postgraduate level are effectiveness of ART, combining ART with herbal medication and transmission of HIV [44]. Furthermore, PLHIV should be involved as trainers or speakers in such training

courses [12],[38],[45],[46]. Such programs should reduce stigma and increase willingness of

pharmacists to provide services for PLHIV [19].

Strengths and Limitations

This study included pharmacists working with PLHIV in 33 provinces in Indonesia and final-year pharmacy students who had training in hospitals within 9 universities, achieving a reasonable response rate. The response rate by pharmacists may have been lower due to the poor internet in some areas in Indonesia due to a tsunami during the study period. We performed a cross-sectional study; we suggest that longitudinal research is needed to investigate whether increasing HIV treatment knowledge and empathy will reduce the stigma among pharmacists and students. Furthermore, our model could explain only 10% of the variance, so other factors need to be investigated which impact on stigma.

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CONCLUSIONS

Pharmacists and pharmacy students had reasonable knowledge on HIV, showed empathy towards PLHIV and a moderate level of stigma. Lower levels of HIV treatment knowledge and empathy were associated with stigma. Improving education and training at undergraduate and postgraduate level may reduce stigma and strengthen the role of pharmacists in caring for PLHIV in Indonesia.

Table 1.Sociodemographic characteristics of the final-year pharmacy students and pharmacists participating in the survey

*N=Number; SD: Standard Deviation

Independent variables Total

(N=1263) Final-year pharmacy students (N=1013) Pharmacists (N=250) Age, mean (SD) 24.68 (5.3) 22.94 (1.83) 34.75 (7.69) Age, N (%) 18-27 years 1022 (80%) 991 31 28-37 years 112 (8%) 18 94 ≥ 38 years 129 (12%) 4 125 Sex, N (%) Male 255 (20%) 207 48 Female 1008 (80%) 806 202 Religious affiliation, N (%) religious Without affiliation 522 (41%) 297 225 Religious affiliation 741 (59%) 716 25 Type of media to receive

HIV information, N (%) _{Trained by the}Education 951 (75%) 860 91 government 144 (11%) 0 144 Online 118 (10%) 116 2 Never 50 (4%) 37 13 Frequency meeting with

HIV patient, N (%) _{1 or 2 times}Never 788 (62%) _{353 (28%)} 781 ₂₂₅ ₁₂₈7 Often 122 (10%) 7 115 Preference of

counselling, N (%) Face-to-face _Online 608 (48%) 438 170 counselling 655 (52%) 575 80 Degree of willingness to give counselling,

mean (SD) 58.30 (24.19) 55.09 (23.78) 70.46 (21.78) Total Empathy, mean (SD) 73.12 (5.31) 72.06 (5.39) 77.40 (1.35) Total HIV Treatment knowledge, mean (SD) 14.39 (2.05) 14.14 (2.01) 15.39 (1.87) Total Stigma, mean (SD) 20.95 (4.61) 21.02 (4.65) 20.66 (4.41)

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Table 2 Results of the HIV treatment knowledge questionnaire presented as percentage of incorrect answers for final-year pharmacy students and pharmacists

No Questions Final-year pharmacy students

(%)

Pharmacists

(%) p-value 1 Once the HIV viral load results are ‘undetectable’, HIV

medications should be stopped 37.7 13.6 0.000 2 If HIV medications are not taken at the right time of

day, HIV drug resistance can occur. 17.7 13.2 0.033 3 HIV is cured when the HIV viral load blood test result

is ‘undetectable’ 35.3 10.4 0.000 4 Condoms during sex are not needed when the HIV

+blood test results are at ‘undetectable’ levels 16.1 18.4 0.200

5 It is better to take a half dose of HIV medications than

stopping the HIV combination medications completely 45.4 28.4 0.000 6 One can get infected with a drug-resistant type of HIV 32.9 40.0 0.000 7 HIV medications can cause unpleasant side effects

(e.g., nausea, diarrhea, vomiting) 3.3 0.8 0.017 8 If sexual partners are both HIV-positive condoms are

no longer needed 19.0 21.2 0.421 9 Treatments are available to reduce HIV medication

side effects 6.7 11.2 0.034 10 Recreational drugs (e.g., ecstasy) can affect the

effectiveness of HIV medications 10.9 12.0 0.607 11 Providing HIV medications to a pregnant woman

reduces the baby’s risk of being infected with HIV 24.4 8.4 0.000 12 There currently exists an HIV vaccine that prevents

HIV infection 44.2 11.2 0.000 13 HIV medications can be taken at a different time of day

on weekends or holiday 16.8 17.6 0.757 14 Over-the-counter herbal pills could make HIV

medications less effective 53.3 54.0 0.844 15 It is best to stop HIV medications as soon as you feel

better 2.8 0.4 0.025

16 Missing a few doses of HIV pills can increase the

amount of HIV virus in the body 16.6 10.4 0.015 17 After a few months, it becomes less important to take

HIV medications at the right time of day 4.8 0.4 0.001 18 HIV medications help the body’s immune system get

stronger (CD4 increase) 11.1 4.8 0.003 19 When HIV medications work well, the HIV viral load

increases 38.6 36.0 0.449

20 Taking antibiotic medication protects a person from

getting infected with HIV 18.5 11.2 0.006 21 Physical exercise (e.g., yoga, tai chi) can help reduce

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Table 3 Results of the empathy questionnaire, reported as number of respondents reporting perceived positive and neutral responses for final-year pharmacy students and pharmacists

No Item of Empathy Scale Students (N) Pharmacists (N) p-value Perceived

positive Neutral Perceived positive Neutral 1 It is necessary for a healthcare practitioner to

be able to comprehend someone else’s experiences

992 20 250 0 0.000 2 I am able to express my understanding of

someone’s feelings. 820 181 250 0 0.000 3 I am able to comprehend someone else’s

experiences. 971 39 250 0 0.000 4 I will not allow myself to be influenced by

someone’s feelings when determining the best treatment

971 39 250 0 0.000 5 It is necessary for a healthcare practitioner to

be able to express an understanding of someone’s feelings.

be able to value someone else’s point of view 976 33 250 0 0.000 7 I believe that caring is essential to building a

strong relationship with patients 218 212 250 0 0.000 8 I am able to view the world from another

person’s perspective 838 163 250 0 0.000 9 Considering someone’s feelings is not

necessary to provide patient-centered care 674 253 250 0 0.000 10 I am able to value someone else’s point of

view 895 112 250 0 0.000 11 I have difficulty identifying with someone

else’s feelings. 150 340 250 0 0.000 12 To build a strong relationship with patients, it

is essential for a healthcare practitioner to be caring.

be able to identify with someone else’s feelings

be able to view the world from another person’s perspective

898 104 250 0 0.000 15 A healthcare practitioner should not be

influenced by someone’s feelings when determining the best treatment.

791 244 250 0 0.000 *perceived positive reports the number of respondents who ticked very strongly or agree

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Table 4 Results of the HIV stigma questionnaire reported as percentage of respondents giving a negative response for final-year pharmacy students and pharmacists

No Questions Final-year pharmacy students

%

Pharmacists % p-value 1 People who have HIV/AIDS are cursed 1.8 2.0 0.038 2 It is safe for people who have HIV/AIDS to work with children

(R) 30.7 14.0 0.000

3 People who have HIV/AIDS should be ashamed 7.4 7.2 0.070 4 People who have HIV/AIDS have nothing to feel guilty about 26.1 24.8 0.803 5 People who have HIV/AIDS should be isolated 1.2 0.4 0.016 6 I do not want to be friends with someone who has HIV/AIDS 4.8 1.2 0.040 7 People who have HIV/AIDS should not be allowed to work 10.1 0 0.000 8 A person with HIV/AIDS must have done something wrong and

deserves to be punished 3.3 3.2 0.442 9 People who have HIV/AIDS cannot be trusted 1.4 1.6 0.404 10 People with HIV/AIDS must expect some restrictions on their

freedom 22.4 11.2 0.001

11 Most people become HIV-positive by being weak or foolish 12.0 13.6 0.517 12 People who have HIV/AIDS are dirty 3.4 0.8 0.045 *negative response is the total percentage of strongly disagree to disagree

Table 5 Results of the univariate and multivariate linear regression analysis on factors associated with HIV-stigma score

***significant

Independent variables Univariate Multivariate

ß Upper Lower ß Upper Lower p-value Age (28-37 years, ≥ 38 years) -.021 -0.547 0.247 - - - - Status participants -.030 -0.992 0.286 0.133 0.510 2.497*** 0.003 Sex .019 -0.421 0.848 -0.003 -0.651 0.591 0.924 Religious affiliation .035 -0.186 0.848 -0.006 -0.663 0.558 0.866 Type of media to receive HIV

information -.039 -0.531 0.092 -0.026 -0.470 0.175 0.369 Frequency meeting with HIV

patient -.047 -0.709 0.056 -0.026 -0.709 0.353 0.511 Degree of willingness to give

counselling -.277 -0.063 -0.042 -0.265 -0.061 -0.039*** 0.000 Total Empathy -.159 -0.186 -0.091 -0.139 -0.171 -0.068*** 0.000 Total HIV Treatment knowledge -.099 -0.345 -0.098 -0.087 -0.322 -0.068*** 0.003 Overall model

R2_=0.098

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118 AP PENDIX De cisi on to us e status par tic ipants i nstea d a ge Ta ble 1 Co efficie nts a M ode l Un sta nd ard ize d Co efficie nts Stan da rd ize d Co efficie nts t Sig . 95 ,0 % Co nf id en ce In terv al fo r B Co llin ea rit y Statisti cs B Std . Err or Be ta Lo we r Bo un d Up pe r Bo un d To lera nc e VIF 1 (Co nsta nt) 24, 14 1 ,9 16 26, 35 3 ,0 00 22, 34 4 25, 93 8 rea l_ TOTAL _p en ge tah ua n -,2 22 ,0 63 -,0 99 -3, 517 ,0 00 -,3 45 -,0 98 1, 000 1, 000 a. D epe nde nt V ariab le: to tal_ STI G M A Ta ble 2 Co efficie nts a M ode l Un sta nd ard ize d Co efficie nts Stan da rd ize d Co efficie nts T Sig . 95 ,0 % Co nf id en ce In terv al fo r B Co llin ea rit y S tatist ic s B Std . Err or Be ta Lo we r Bo un d Up pe r Bo un d To lera nc e VIF 1 (Co nsta nt) 24, 23 0 ,9 42 25, 71 3 ,0 00 22, 38 1 26, 07 9 stu den t_ ph ar maci st -,2 59 ,6 01 -,0 22 -,4 32 ,6 66 -1, 438 ,9 19 ,2 92 3, 426 age _c odi ng ,1 33 ,3 70 ,0 19 ,3 60 ,7 19 -,5 93 ,8 60 ,2 96 3, 375 real _TOTAL _p en ge tah ua n -,2 18 ,0 65 -,0 97 -3, 356 ,0 01 -,3 46 -,0 91 ,9 41 1, 063 a. De pe nd en t Va riab le: to tal_ STI G M A In tabl e 2 shows a mul tic oll inea rity be twe en age , a nd st atus par tic ipant ( st ude nt and pha rma cist ) 118

stigma towards people living with HIV/AIDS in Botswana,” African J. AIDS Res., vol. 18, no. 1, pp. 58–64, 2019.