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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 15  |  Issue : 2  |  Page : 118-126

Comparative study of patients' satisfaction between national health insurance scheme-insured and un-insured patients attending a Northern Nigerian tertiary hospital


1 Department of Community Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
2 Department of Community Medicine, Bayero University, Kano, Nigeria

Date of Web Publication14-Sep-2018

Correspondence Address:
Dr. Muhammad Rayyan Garba
Department of Community Medicine, Aminu Kano Teaching Hospital, Kano
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njbcs.njbcs_48_16

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  Abstract 


Background: Periodic patients' satisfaction surveys provide feedback to hospital management and staff regarding the quality of services rendered. Objectives: This study assessed and compared clients' satisfaction between National Health Insurance Scheme (NHIS) insured and un-insured patients attending Aminu Kano Teaching Hospital. Materials and Methods: A cross-sectional design, using a mixed method of data collection was used to assess the levels of satisfaction of 149 NHIS-insured and 150 un-insured patients selected by systematic sampling. Using structured interviewer-administered questionnaires and focused group discussions (FGD), patient satisfaction was assessed and analysed using SPSS statistical software, with p-value set at 0.05. Results: The two study arms were not statistically different in all the socio-demographic characteristics assessed (P > 0.05). Eight aspects of care were significantly different between the two study groups at bi-variate level. However, on multivariable logistic regression, only two factors remained independent predictors of difference between the two groups: 'overall time spent in the hospital' (aOR; 95% CI: 0.41; 0.23, 0.69) and 'satisfaction with last visit out of pocket expenditure' (aOR; 95% CI: 0.40; 0.21, 0.83). 'Duration of NHIS registration', 'time taken to hospital' and 'last visit out of pocket expenditure' were found to be determinants of satisfaction. The FGDs revealed improvements in services upon getting insured, with the main areas of dissatisfaction being; waiting time, appointment intervals, missing laboratory results and costs. Conclusion: Patients generally expressed high levels of satisfaction with the different aspects of care provided in the hospital, with the insured patients having higher levels of satisfaction in nearly all domains. Improved NHIS coverage could markedly improve patients' access and satisfaction with services.

Keywords: Insured, National Health Insurance Scheme, Northern Nigeria, patients, satisfaction, un-insured


How to cite this article:
Garba MR, Gadanya MA, Iliyasu Z, Gajida AU. Comparative study of patients' satisfaction between national health insurance scheme-insured and un-insured patients attending a Northern Nigerian tertiary hospital. Niger J Basic Clin Sci 2018;15:118-26

How to cite this URL:
Garba MR, Gadanya MA, Iliyasu Z, Gajida AU. Comparative study of patients' satisfaction between national health insurance scheme-insured and un-insured patients attending a Northern Nigerian tertiary hospital. Niger J Basic Clin Sci [serial online] 2018 [cited 2018 Sep 22];15:118-26. Available from: http://www.njbcs.net/text.asp?2018/15/2/118/241160




  Introduction Top


Satisfaction is the feeling of contentment felt when one has achieved what one needs or desires.[1] Patients' satisfaction represents the extent to which patients feel their needs and expectations are being met by the service provided. Patients' satisfaction is a health-care recipients' reaction to salient aspects of the context, process and result of their experience.[2] Patients who feel comfortable with their physicians interpersonally and who are involved in their own health care are more likely to be satisfied with treatment and are more likely to comply with treatment regimens, which has a direct effect on health outcomes. Satisfied patients are also more likely to return to the same health-care provider, which benefits both the patient and provider.[2]

Studies have identified the top drivers of patient satisfaction that correlate most to patients' overall satisfaction with an organisation. These drivers include: having a prompt and emphatic physician; how well staff worked to care for the patient; overall cheerfulness of the hospital; response to concerns/complaints made during patients' stay; amount of attention paid to patients' personal and special needs; staff sensitivity to the inconvenience of hospitalisation; how well nurses kept patients informed; staff's efforts to include patients in decisions about their treatment; nurses attitude toward patients' requests; skill of nurses and friendliness of nurses.[3],[4]

It is also known that care which is less satisfactory to the patient is also less effective because dissatisfaction is associated with non-compliance with treatment instructions, delay in seeking further care and poor understanding and retention of medical information. Satisfaction is thus an intermediate outcome which may reflect ability or failure to answer patients' needs, meet their expectations or provide an acceptable standard of service. Patients' satisfaction is therefore, a legitimate goal of medical care.[5] Poor patients' satisfaction has, for example, led to poor adherence to anti-retroviral drug and possible drop out from the treatment programme.[6] Treatment drop outs associated with dissatisfaction with care (7.4% and 39.3%) have been reported among different Americans ethnic groups.[7] Therefore, there is a need to find out the determinants of patients dissatisfaction to eliminate them, to avoid poor adherence to treatments and failure to come for follow-up.

National Health Insurance Scheme (NHIS) is a social insurance scheme established by law, under the NHIS Act 35 of 1999, to improve the health of all Nigerians at a cost the government and the citizens can afford.[8] It is designed to solve the financing and accessibility problems of the Nigerian health sector.[9] Nigerian studies have found that the NHIS improved access to, and quality of, services provided in many hospitals. However, since the scheme covers only employees in the organized formal sectors, it provides insurance to <5% of Nigerians.[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20]

Periodic patients' satisfaction surveys provide feedback to hospital management and staff considered the quality of services rendered. These surveys have become routine as part of total quality management in developed countries.[21] Patients' satisfaction could therefore, be considered an indicator of the quality of care from the patients' perspective.[22] This shows that programme's service delivery will be improved with the inclusion of patients' views of the performance of the programme's services.[23] This study aimed at assessing and comparing the levels of satisfaction with services between NHIS-insured and un-insured patients attending Aminu Kano Teaching Hospital (AKTH), Kano – A major referral centre located in the most populous Nigerian state, inhabited by over ten million people.[24] The study will also identify areas of dissatisfaction, if any, among the NHIS-insured and un-insured patients, thereby advising the hospital management on any shortcomings in the services provided to these two categories of patients.


  Materials and Methods Top


The study was conducted in AKTH which is the main referral hospital in Kano state, North-Western Nigeria, with the following geographical coordinates: 12° 37' North, 9° 29' East, 9° 33' South and 7° 43' West.[25] It was comparative cross-sectional in design, with the study population comprising of all adult patients and parents/guardians of paediatric patients registered with NHIS clinic and the general outpatient department (GOPD) of the hospital for at least 1 year. The formula for calculating minimum sample size in comparative studies was used to obtain 150 respondents per group, making a total of 300 respondents.[26]

Stratified sampling technique was used for the study. In the first stratum, the clinics were stratified into an adult and paediatric outpatient departments (OPDs). Based on attendance records of the year 2014, 40.3% of the patients were seen at the paediatric OPD (i.e., below 18 years), whereas 59.7% were seen at the adults OPD (i.e., 18 years and above).[27] Hence, proportionate allocation of the sample size (150) was made to the two clinics, making 60 patients at the paediatric clinic and 90 patients at the adult clinics of each of the study groups (NHIS-insured and un-insured). In the second stratum, patients attending the two clinics were sampled using systematic sampling technique, with sampling intervals of 2 and 3 in the insured and un-insured groups, respectively. The first patients were selected by Simple random sampling using a random number table. The sample selection for the focus group discussions (FGDs) was purposive, from attendance register of NHIS and GOPD.

Quantitative data were obtained by the use of a pretested questionnaire, adapted from the clinical Quality Service Branch of the Bureau of Primary Health Care in the United States of America,[28],[29] and has been used in a previous Nigerian study.[30] The questionnaire was translated into the native language (Hausa) at the department of Nigerian languages of Bayero University Kano, to avoid any ambiguity. The questionnaire was back-translated to make sure the meaning was retained. The first section of the questionnaire obtained the sociodemographic data of the respondents, while the second section contained questions that covered the standard domains of satisfaction. The domains included accessibility to services including waiting time, continuity of care, humaneness of staff, comprehensiveness of care and effectiveness of services. The domains contained appropriate number of items. Each item was scored using a five-point Likert Scale: 'excellent' = 5, 'very good' = 4, 'good' = 3, 'fair' = 2 and 'poor' = 1.

On the other hand, qualitative data were obtained by conducting FGDs with some members of the target population, with 8–10 participants per se ssion and with each session lasting 45–60 min. A total of 12 FGDs were conducted, six per study groups and two for each of the three categories of patients: Adult males (males aged 18 years and above); adult females (females aged 18 years and above); and parents/guardians of paediatric patients (<18 years of age). Saturation was reached after conducting the 12 FGDs. Proceedings were timed, noted and transcribed with the help of research assistants.

Data obtained from the questionnaires were analysed using SPSS Version 22.0 (IBM Corp., Armonk, New York, USA). The five-point Likert scale items were grouped to give a bivariate outcome, with 'excellent', 'very good' and 'good' considered as being satisfied. While 'fair' and 'poor' were considered as being unsatisfied, as used in a previous study.[21] The indicator for assessing the level of satisfaction across all domains was the percentage of patients satisfied with that domain, with the numerator being the number of patients satisfied with the domain and the denominator being the total number of patients, multiplied by 100. The indicator for factors associated with satisfaction was the significance/non-significance at 5% alpha level, using Chi-squared test for categorical variables and two-sample t-test for continuous variables; The indicator for out of pocket expenditure was the mean score of the amounts (in naira) in each of the study groups, and also the percentage of patients satisfied with the out of pocket expenditure in each group of patients. Factors considered as a priori confounders from the majority of previous studies, as well as factors found to be significantly associated with patients' satisfaction on the bivariate analysis in each category of patients were included in a logistic regression model to control for confounding. The level of statistical significance for this logistic regression was set at <5% (0.0 5). Data obtained from the FGDs was transcribed verbatim, translated (where necessary) and compared with the field notes made. Common themes were extracted from the FGDs; quotes were also obtained to highlight some of the responses to issues discussed.

Institutional Review Board ethical approval for the study was obtained from the research ethics review committee of AKTH. All participants in the study signed an informed consent form after detailed explanation of the purpose and process of the study.


  Results Top


One hundred and forty-nine NHIS-insured and 150 un-insured patients consented and participated in the study, giving a response rate of 99.7%. The age distribution of the two study arms was not statistically different, with the mean age of NHIS insured patients and un-insured patients as 33.9 ± 7.90 years and 32.9 ± 10.56 years, respectively (P > 0.05). The two study arms were also not statistically different in all the other sociodemographic variables assessed, i.e., sex, ethnic group, religion, marital status, occupational status and highest educational level compositions (P = 0.908, 0.842, 0.654, 0.450, 0.858 and 0.955, respectively).

Mann–Whitney U-tests showed that the two study arms were not statistically different in terms of their 'time taken to hospital' and 'transport money to hospital' (P > 0.05), but were statistically different in terms of their 'out of pocket expenditure in the last visit', with the un-insured patients spending more (median N2100) than the insured (median N1200) (P < 0.001)

[Table 1] shows that 'ease of getting care', 'ability to get in to be seen', 'time spent in consulting room' and 'overall time spent in the hospital' were significantly different between the insured and un-insured group of patients, with the insured patients having higher percentages of satisfaction (P < 0.05). However, the other aspects of access and waiting time domains were not significantly different between the two study arms, even though, the insured patients had higher percentages of satisfaction (P > 0.05).
Table 1: Comparison of patients' satisfaction with ‘access to care’ and ‘waiting time’

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[Table 2] shows that 'time spent with doctors' and 'nurses giving good advice and treatment' were significantly different between the insured and un-insured group of patients, with the insured patients having a higher percentage of satisfaction (P < 0.05). The other aspects of care received from doctors and nurses were not significantly different between the two study arms (P > 0.05).
Table 2: Patients' satisfaction with aspects of care received from doctors and nurses

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[Table 3] shows that satisfaction with the 'last visit out of pocket expenditure' and overall services received from the hospital' were significantly different between the insured and un-insured groups of patients, with the insured patients having a higher percentage of satisfaction (P < 0.05).
Table 3: Comparison of patients' impressions about the hospital in general

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No aspect of care received from the laboratory was significantly different between the insured and un-insured group of patients, even though the insured patients had higher percentages of satisfaction (P > 0.05). The aspects of care assessed in the laboratory include: establishing good rapport on arrival, explaining the test procedure, the time taken to take sample, the time taken to collect results and overall services received from the laboratory.

No aspect of care received from the pharmacy was significantly different between the insured and un-insured group of patients, even though the insured patients had higher percentages of satisfaction (P > 0.05). The aspects of care assessed in the pharmacy include: giving drugs regularly, Time taken to receive drugs, giving clear instruction on drug dosage, explaining side effects of drugs and how to cope and overall services received from the pharmacy.

No aspect of care received from the record staff was significantly different between the insured and un-insured group of patients, even though the insured patients had higher percentages of satisfaction (P > 0.05). The aspects of care assessed in records department include: established good rapport on arrival, time taken to retrieve folder, completeness of document, keeping folder safe, overall services received from the record staff.

A multivariable logistic regression model incorporating all the eight aspects of care found to be statistically significant on bivariate analysis, as well as the socio-demographic variables considered as a priori confounders (age, sex and educational status), was conducted. After this, only 'overall time spent in the hospital' (P = 0.015) (adjusted odds ratio [OR]; 95% of confidence interval [CI]: 0.41; 0.23, 0.69) and 'satisfaction with last visit out of pocket expenditure' (P = 0.011) (adjusted OR; 95% CI: 0.40; 0.21, 0.83) remained independent (intrinsic) predictors of difference between the two study arms.

[Table 4] shows that 'duration of registration with NHIS' was significantly associated with satisfaction, with those having shorter duration being more satisfied (P < 0.05). Time taken to the hospital was significantly associated with satisfaction among the insured patient (P < 0.05), not but significantly associated among the un-insured patients (P > 0.05). Last visit 'out of pocket expenditure' was significantly associated with satisfaction in both the insured and un-insured patients, with those paying less being more satisfied (P < 0.05).
Table 4: Mann-Whitney U-test comparing the taken time to hospital, transports money to hospital and out of pocket expenditure in the last visit

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However, age, sex, ethnicity, religion, marital status, occupational status and educational status were not found to be significantly associated with satisfaction status. On the other hand, [Table 5], [Table 6], [Table 7], [Table 8] present findings of the focus group discussions, which further strengthen findings of the quantitative component of the study.
Table 5: Focus group discussion results

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Table 6: Focus group discussion results continued

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Table 7: Focus group discussion results continued

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Table 8: Focus group discussion results continued

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  Discussion Top


The very high response rate of 99.7% is not unexpected of a hospital study.[21] The absence of significant difference in the sociodemographic characteristics of the two study arms is partly because they were matched for age group and highest educational qualification, and also likely because people generally perceive the hospital as that of elites, thus, naturally selects patient with fairly similar sociodemographics. These similarities allowed for better comparison of outcomes, as some of the variables such as age, gender, education status and marital status are known to be a priori confounders for satisfaction.[31],[32],[33],[34] Therefore, outcomes of the study were more likely to be due to intrinsic differences in the two study arms, rather than a difference in their sociodemographic characteristics, i.e., the confounding effects of respondents' sociodemographic characteristics have been eliminated.

On the domain of 'access to care', patients expressed high levels of satisfaction, but only the components of 'ease of getting care' (P < 0.05) and 'ability to get in to be seen' (P < 0.05) were found to be statistically different between the two study groups, with the insured group being more satisfied compared to the un-insured patients. This was corroborated by findings of the FGDs where the insured patients expressed improvement in their access to care on getting insured compared to when they were not insured. These are consistent with the findings of other Nigerian studies, which showed that NHIS increased access to care.[12],[15] The increase in access resulting from NHIS enrollment is likely to be because there are fewer patients attending the NHIS clinic, hence, a lower staff-patient ratio.

The higher percentages of satisfaction among the insured patients in the waiting time domain may be due to the lower number of patients attending the NHIS clinic, resulting in decreased waiting time and better contact with doctors. The higher proportion of insured patients reporting satisfaction with the 'time spent with doctor' sub-component of the doctor–patient relationship domain could be because doctors in the NHIS clinic usually attend to fewer numbers of patients. Hence, they spent more time with them. This was also reflected in the FGDs findings. The implication of this finding is that patients' satisfaction can be improved by improving the staff-patient ratio. This can be best optimised by reviewing patients' attendance registers and planning for the presence of staff commensurate to the attendances at particular times, and recruitment of additional staff were budget permits. Similarly, insured patients had a higher satisfaction with the 'giving good advice and treatment' sub-component of nurse–patient relationship relative to uninsured patients. This could be attributed to diminished patient load at the NHIS clinic; hence, nurses have enough time to advice patients.

The findings on staff–patient relationships are consistent with findings of the FGDs, where most of the discussants in both groups expressed overall satisfaction with staff-patients relationships, with some areas of concern needing improvement. Even though, most of the previous studies assessed staff-patient relationship as a whole, not breaking down to the different cadre of staff as done in this study, they reported similarly high levels of satisfaction as follows: 88% from the same center,[21] and 81.5% versus 78% (P = 0.062) for NHIS insured versus un-insured patients in south-eastern Nigeria respectively.[19] These high levels of satisfaction would add weight to the overall satisfaction score, because a Boston study showed that, the provider–patient relationship factor explains about 56% of patients' satisfaction.[35] The higher percentages of satisfaction with staff-patient relationships in the insured group could also be because staff knew they were insured. Hence, they deliberately gave them more attention and better services.

The insured patients were found to be significantly more satisfied with the out of pocket expenditure in their last visits compared to their un-insured counterparts. This can be explained by the fact that insured patients pay only 10% of what their un-insured counterparts pay according to the NHIS act.

About 92% of the insured and 86% of the un-insured patients were likely to refer their friends/relatives to this facility (P = 0.097). This is consistent with the finding of a Nigerian study that reports a 91.7% willingness to recommend the facility to acquaintances.[17] These are indicative of the high levels of satisfaction with services obtained in the hospital by the two study groups. The need to sustain this level of satisfaction in the hospital is paramount. Evaluation in, and comparison with other hospitals in the State and the region would allow for experience sharing, that would be of general benefits to the patients in the State.

The two study groups were not statistically different in their perceptions of the hospital neatness and cleanliness. This is consistent with findings of the FGDs, where the majority of the discussants in both groups expressed satisfaction with the hospital neatness and cleanliness. These findings are consistent, but much higher, than the 68.2% versus and 72% (for insured vs. un-insured, respectively) satisfaction obtained in other Nigerian studies.[10],[16] Comparative analysis with other health-care facilities scoring lower on this domain would have potential benefits to keeping hospitals clean, which can have benefits on both infection control in the hospital and patients' satisfaction.

Both study arms reported high levels of satisfaction with the comfort, safety and privacy of the hospital. This is also consistent with the findings of the FGDs, where discussants in both groups expressed overall satisfaction with privacy and confidentiality of the hospital. The findings are consistent with the 87% satisfaction obtained in another study conducted at the same centre.[21] This implies that the hospital maintains high patients comfort and privacy over the years, which is a marker of quality management. This needs to be sustained and replicated in other facilities that may have a problem with this domain.

The overall satisfaction with services received from the hospital was high and significantly different in the two study groups, with 94% of the insured and 83% of the un-insured assessed to be satisfied with the hospital services. This is consistent but much higher, than the 68.8% versus 62% (P = 0.04) satisfaction for insured and un-insured patients, respectively, found in another Nigerian study.[19] This implies that getting insured with NHIS increases general patients' satisfaction with services obtained from Nigerian hospitals. This is very essential in maintaining good patient care and points to the central role of care affordability in engendering patients' satisfaction, with all the attendant benefits.

Factors that remained significant on multivariate analysis were independent (intrinsic) factors distinguishing the two study arms regarding satisfaction. The duration of registration with NHIS was found to be significantly associated with (hence, a determinant of) satisfaction status, with the satisfied patients having a median duration of 1 year and the un-satisfied patients having a median duration of 4 years of enrollment in the NHIS. The lack of satisfaction in patients registered with NHIS for longer duration could probably be due to longer period of accumulated negative experiences. It could also be because the unsatisfied patients registered with NHIS since when services were not good enough, and now their overall judgements are affected by their cumulative experiences with the NHIS. The NHIS service managers should institute regular patients' satisfaction survey, in addition to commissioning a further study to evaluate this differential satisfaction based on the duration of enrollment.

'Time taken to hospital' was found to be significantly associated with (hence, a determinant of) satisfaction among the NHIS insured patients, but not a determinant of satisfaction among the un-insured patients. This could be because the insured patients usually go to hospitals they are insured (irrespective of the distance) to get affordable service, while the un-insured patients can decide to go to any near-by hospital for convenience. The accreditation of more facilities as primary care providers for NHIS can go along away in reducing dissatisfaction of insured patients with this domain of care.

Out of pocket expenditure on the last visit was found to be significantly associated with (hence, a determinant of) satisfaction in both the insured and un-insured groups of patients. The satisfied insured patients had a median expenditure of 1000 Naira while the un-satisfied insured patients had a median expenditure of 1750 Naira in their last visits. Similarly, the satisfied un-insured patients had a median expenditure of 2000 Naira, while the un-satisfied un-insured patients had a median expenditure of 2600 Naira in their last visits. This shows that satisfaction increases, as out of pocket expenditure decrease, further giving credence to the benefit of universal health insurance coverage in postering patients' satisfaction, with all the attendant medical and social benefits.


  Conclusions Top


Patients generally expressed high levels of satisfaction with the different aspects of care provided in the hospital, with the insured patients having higher percentages of satisfaction in almost all the components. Out of the eight aspects of care found to be statistically different between the insured and un-insured groups of patients on bivariate analysis, only two remained independent (intrinsic) predictors of difference between the two study arms when entered into a logistic regression model, these are: 'overall time spent in the hospital' and 'satisfaction with out of pocket expenditure in the last visit'.

Duration of registration with NHIS was found to be a determinant of satisfaction among the insured group, with patients registered recently being more satisfied than those with longer duration of registration. Similarly, 'time taken to hospital' was also found to be a determinant of satisfaction among the insured group, but not a determinant of satisfaction among the un-insured group of patients. Furthermore, 'out of pocket expenditure in the last visit' was found to be a determinant of satisfaction in both the insured and un-insured groups of patients. The last visit 'out of pocket expenditure' was found to be significantly different between the two study arms, with the insured patients being more satisfied.

Recommendations

To government/policy makers:

  1. There is a need for government to ensure universal coverage of the health insurance scheme to reduce dependence on out of pocket expenditure, which is not always reliable, even among the relatively wealthy individuals
  2. More health facilities should be registered with the NHIS to increase access to health facilities and shorten the time taken to the hospital.


To the hospital management:

  1. There is need to reduce unnecessary bureaucracies and provide information charters, leaflets, directions and information desks
  2. There is also a need for the hospital to introduce strategies to reduce patients waiting times; such as employing more staff and/or giving patients timed appointments (not just date) so they do not have to come and wait for long
  3. There is need to provide a separate building for the NHIS clinic to reduce congestion, as noticed in the present location in the GOPD
  4. There is a need for the management to review down the cost of services, where possible (most especially for the un-insured patients), as this would increase patients' access to care, which is a component of satisfaction.


Financial support and sponsorship

Nil.

Conflicts of Interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]



 

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