Conclusion Worthy Climax for a Cumulative Cultural Experience

As the day came to a close the 15 of us sat in a stasis of serenity and tranquil sequility to have experienced an African safari, a BBQ in the bush, and a night of dancing, singing, and drumming to attain the closure sought for in a study abroad experience unlike anything we could have imagined. We traveled through border control, we relieved ourselves in the shadiest of gas stations, we entered our paradise of a lodge from whence we would transfer our minds from the traditional American life to the beauty of beasts only dreamed of in our wildest thoughts. We were in Pilansburg South Africa – the place in which my dreams came true. My whole life I have been waiting to see lions, leopards, elephants, zebras, white and black rhinos, wildebeests, hyenas, and giraffes. To be honest, never did I think that this African safari possibility would come to fruition. Readily the possibility did come true thanks to the even more fulfilling service opportunity to Botswana.

Botswana grew me in directions I did not know existed. I learned how to communicate with children who are seemingly incapable of communicating with the outside world. Thanks to the lovely ladies (students) and professors in SLP I learned that even though children with autism have difficulty communicating with the outside world there are strategies to get these children to communicate with the world around them. Because of this, I have such a deeper understanding and respect for the scope of practice that the SLPs have. From Audiologist I learned how deeply connected communication is to the ability to hear. Its logical isn’t it? A person has to be able to hear properly in order to communicate. This fact being true, actually seeing the practice and implementation of the scope of audiology gave me such a deeper respect and understanding for the importance of hearing – something I took for granted – as well as the majesty of providing the ability to hear. As physio’s Shandra, Makayla, and I have a deeper appreciation and gratefulness to how truly lucky we are as Americans with all the access to information and education, and resources possible. Did you know, here it is considered childish to squat with good body mechanics? In the states, it is common knowledge the importance of proper body mechanics to protect your back from injury, whereas in Botswana not so much.

Our crew that united as a bastillion of Botswana brethren and as learners and educators furthered our own respective disciplines in manners that can only be elucidated in the perfection of our respective crafts. Each individual grew in unique ways and has a deeper appreciation and respect for one another individually as well as each other’s disciplines. This all being true, I can say that I have an even deeper appreciation for each person as a human being. Our professors guided us through the often tumultuous growing pains of becoming a high functioning interdisciplinary team while allowing us to struggle. I believe their choice of allowing us to learn from mistakes to be the best lessons and the way in which we will have the most retention of learning. It was amazing, it was frustrating, it was edifying. I am eternally grateful to our professors Janice Wright (SLP), Janice Howman (PT), and Rebecca Meier (Aud).

As imagined, on a trip to Botswana for 19 days, our crew got close. Each person was awarded a ‘spirit animal,’ an award from the professors, and a nick name for me. I will update the awards from the professors at a later date because I don’t have them at this moment in South Africa. The list as of now is their spirit animal and then my nickname for them and goes as follows:

Lauren Hancher: Cow (because she likes lying around and eating grass apparently), and Hancher the head Honcho

Lauren Muscari: Cheetah (because she’s so sleek and sneaky), *muscari*(in a whisper)

Gabbie Mayer: Owl (she’s so wise), Gaborone

Shandra Hamilton: Giraffe (she’s so long), Sweet Shandy (she’s had numerous versions of this for years)

Makayla Conley: Impala (she’s so quick, has loads of endurance, and she’s so impala-like), Mak (also had this knick-name for years)

Morgan Beul: Zebra (she’s so majestic), Magnificent Morgan

Sarah Scarberry: Badger (she’s so fierce), Sarrrah (with a rolled R that I can’t really produce)

Hana : Tantbane Horse (because she loved them so much and they are so Hana-like), Hana no N no H

Nicole Ritter: Goat (for obvious reasons, she’s the Greatest Of All Time), Nikki from the block (I have no idea why I chose that one)

Kailey Clark: Toy Poodle (because she’s so cuddly and beautiful), KK

Bre: Peacock (because she has such a bright and bold personality), Bresome (cause she’s so awesome)

Profs

Rebecca Meier: Elephant (because of her quiet all-knowing wisdom), Becky (hope Dr. Meier isn’t mad about that one! Yikes!)

Janice Wright: Rafiki (from lion king because she’s wise and not afraid to pop us on the head when we don’t get something), JM Dubs

Janice Howman: Kangaroo (because she just wants to put us all in her pouch and carry us around), J How (borrowed from my SLP and Aud counterparts)

If I am being honest, I don’t want to finish this blog. My heart is still in Africa, and though I am still in South Africa, I feel like I lost part of my heart when this trip concluded. Concluding this blog feels like I am truly closing the chapter of Botswana in my life. I am so much more fulfilled and grateful for our professions after this trip. We have an opportunity to effect change in every individuals’ life that we encounter. We are so lucky. I am so honored to be a part of the 2017 version of the OU Botswana trip.

Michael Holmes

A Weekend for the Stars… and the Adventurous

Saturday 8/5- The infamous Ambrose Academy Tea…. This is one aspect of our trip that has been talked about since the early stages of planning and man-oh-man did it live up to its name.  Members of the Ambrose Trust, teachers from Ambrose Academy, parents of children attending Ambrose Academy, and their brilliant children filled the banquet hall dressed in their finest evening attire. Tables were set with beautifully stitched black runners and vibrant center pieces that held a multitude of flowers. We were ever so lucky to have the privilege to sit at the front tables and to be recognized as one of the guests of honor for the evening. The night began with thanks and offerings of appreciation to those that have joined them this evening, to those who had made donations to the trust, and even to us the, Ohio University students and faculty, for donating our time to this academy. But, it wasn’t until about midway through this event that I realized just what we were helping to accomplish not only in this city/country,  also been in our country. Having a child with developmental disability can come as a shock or as an unexpected circumstance to any parents and may at first seem like a daunting task and not just a blessing. To some in Botswana, having a child with developmental disability is deemed as an unsurpassable circumstance in which their children are not able to have  close to a normal life. What the partnership between Ohio University and Ambrose Academy is trying to accomplish is an understanding that having a child with disability is not and “end of life” sentence for that child and family, but rather a sentencing for a unique and joy filled life with the same opportunities as any other child may have with the help and support from their parents, teachers, families, and friends. Every child has a purpose; every human being has a purpose. I hope to bring some of their inspiring thoughts and ideas, back to the states with me and help to instill parents of children with disabilities that these differences should not limit them from completing tasks and enjoying life, but rather enable them to accomplish all of their goals.

At the Ambrose Academy Tea, we were not only blessed with the ability to hear inspiring stories from parents with children with developmental delays, but we were also able to provide education on how to use technology to compliment educational activities and how to prevent the less beneficial aspects of technology. We were also able to display the standing frame that would be donated to Ambrose Academy and demonstrate how it is to be used, benefits of use, and when to use the standing frame. The entire tea was recorded for National Broadcasting purposes, and a little birdy told us that we all are now slightly famous in the Country of Botswana (do not worry, we did have pictures printed and we are willing to sign autographs at no cost to you J ).

 

Sunday 8/6- A trip to the Village…….Tribal songs, dances, and theatrical scenes met us as we arrived to the village early this morning. From the instant we stepped off the bus we were immersed in the cultural aspects of one of many tribes in Botswana. The day started with a song and dance that welcomed us to the Quotla (village) and a musical escort to the chief. Once we were seated in front of the chief we were welcomed with the tradition of the throwing of the bones. Many people in Botswana believe in the evil spirits associated with black magic and witch craft have and the throwing of the bones is said to show if the individuals visiting the tribe are of good spirit and pure intentions or if they are filled with evil spirit. Luckily the bones welcomed us. J We  were taken through the cultural aspect of a traditional wedding and were able to visit the area where they house their domestic animals. The day ended with us learning how they prepared their traditional meal and then getting to eat the meal. Oh yeah… and I almost forgot the most important take away from the day…. If you are feeling a little under the weather, no worries, just stand on a pile of cow dung outside of your home until all the sickness leaves the body. I guess this is the real reason why manure smells so bad. J

 

Just a few days left…. I cannot believe this trip is coming to an end. Until next time, stay hungry, stay seeking, stay adventurous.

 

-Shandra

Back to IPP

Wednesday through Friday we participated in Interprofessional Practice (IPP) once again at the Ambrose Academy. Learners who attend that school have diagnoses ranging from Autism to cerebral palsy to Down Syndrome. Primarily we saw kids with Autism who have difficulty communicating, I will attempt to describe what these screenings entail. As I have written in previous blogs, we have at least one audiologist, speech language pathologist, and physical therapist in each interdisciplinary team for a total of 3 teams. At Ambrose we had an hour with each child by appointment. I specifically mention ‘by appointment’ because appointments seemingly are a rarity with our last screening experiences. It was much more fluid and we were a well-functioning team.

 

Our first experiences with IPP were choppy and rough. We screened people at schools, in the villages, and at a physio clinic (physical therapy in Botswana). Our professors kept pushing us to screen together. When conducting the screens, typically PT would come in and screen, then SLP, and then audiology. Our professors kept pushing us to do the screens together, they would say, “While PT’s doing their screen SLP can check vocalization and audiology can assess hearing.” If I am being honest, I was skeptical of the feasibility of a fluid and accurate screen being conducted by 3 separate disciplines. As it was, the profs kept pushing, “interdisciplinary practice, IPP, and IPP.” At Ambrose Academy the teams were all functioning in the ideal manner. PT was screening upper extremity function while audiology was conducting their hearing screen. While SLP was accessing speech production, PT could have them roll a ball. Interestingly to me as a PT student, having the children request the ball with verbalization required effort in cognition and speech production that I would have never considered. I was amazed to see the harmony my team achieved mastering the integration of three disciplines in a screen. Admittedly having a set schedule and an idea of the type of patient (mostly autistic pediatric children at Ambrose Academy) made the transition much smoother and easier.

 

Ambrose Academy is also the place at which the stander (picture featured) was unveiled. The stander is a project that PT student Shandra Hamilton and PT professor Janice Howman had been working on for over a year. The stander is Shandra’s cap stone project, the culmination of the three years of PT school, shipping something so large to Africa and getting it here on time was an endeavor in and of itself. Shandra and Janice collaborated with Ohio University’s engineering department to design the stander with materials readily available in Botswana. The stander included instructions (at no cost) and materials needed (at minimal cost) to recreate the stander in country. Makayla and myself were also able to help with delivery and build execution of “Project Standing Frame” as Shandra so termed it. When the standing frame arrive we all were very eager to put it back together, see in one piece again, and be put to use. After watching the instructional videos taken before leaving the state on how to re-build this engineering masterpiece, I was able to get my hands on some tools and help whip the stander back into shape. Shandra’s flawless presentation prowess was on display as she demonstrated proper utilization of the stander to the Ambrose Academy. It is safe to say that she left an impression on the teachers at the academy, one teacher even wanted to name her daughter after Shandra. The stander is so important and vital for children who are unable to stand on their own. Stander’s have been shown to improve bone mass density in the lower extremity. While stander’s do not directly impact the ability to walk, walking requires higher bone mass density in the legs and research has shown that standers can increase bone mass density. There are several children at the academy and around the nation of Botswana who will benefit from this affordable and quality design. We are honored to be a part of the work of the engineers at Ohio University, Shandra and Professor Janice Howman’s impact on the entire country.

 

 

Gaborone Hospital

The gals have much better titles than I do. The past few days (Monday through Wednesday) we have been at the Princess Mariana Hospital. This trip has focused on interdisciplinary education and practice, but this week the PTs, SLPs, and AUDs have been separated.

 

The PTs have been treating patients in their outpatient sector (from home) and in the inpatient portion of the hospital. The Mariana Hospital calls the inpatient side, or the acute care side, the ‘wards.’ There is the maternity ward, ortho ward, medical ward, pediatric ward etc. Each ward has a male and female side. Each ward is a small building connected to each other by walkways.  Its definitely a different setup than we are used to in the US. The PTs here work on both the outpatient side and the acute care side daily to get some variety and stay keenly fresh and aware of what is happening on both sides of treatment. The schedule on the outpatient side is kept by written books. The craziest thing to me is that each patient is responsible for maintaining their own medical records. This means that the patient transports their medical records with them at all times!! This presents several problems: the obvious is the patient could lose their medical records and all their referrals and past medical history. Second, the therapists have no idea what they are about to encounter until the patient walks through the door. Third, hand writing is not a strong suit for any of the doctors here so it is very difficult to read the writing in the patients’ charts. Another difference is the ‘screening’ process. Screens exist in order to avoid 6 months to a year wait for the referral process. Patients would get a PT referral, but PT would be filled and the patient wouldn’t be able to be seen for a long time – up to a year. The people of Botswana came up with the screening process. The patient can walk in, be screened, and given some home exercises until they are given a proper evaluation a couple of weeks later. The system is way different, but it gives the patient something to work on until they can be given a proper evaluation.

 

The SLPs have had an interesting experience at Princess Mariana Hospital. They only encountered outpatient clients, as they received no inpatient referrals during the two days they were there. There were only 2 practicing SLPs at Princess Mariana- one who prefers to work with children and one who prefers to see adults. Our SLPs had the pleasure of working with Miracle, only seeing children in the outpatient setting Monday and Tuesday. Sadly, the other SLP, Anita, was out of town.  The SLPs got to see clients from 8am- 2pm on Monday and Tuesday and then Miracle took them on a tour of the hospital Tuesday after seeing patients. The highlight of those two days was seeing a little boy whose family drove 8 hours just to see our students and have their child evaluated. This couple lives near Gaborone, but was on vacation up north in Botswana. They had learned we were coming to Gaborone and decided to make the 8 hour drive back to see the SLPs while they were still here. It was amazing to hear how involved the parents were, vigorously taking notes and writing down strategies Lauren and Morgan had to offer! Hearing stories like this gives us a great sense of satisfaction that we are making a difference.

 

 

The Audiology students were able to participate in evaluations for all ages and a hearing aid fitting while at Princess Mariana. The patients and practice here had many similarities and differences to the United States. It was comforting to see the parents being so involved and caring for their children, a common theme across our experiences in Botswana. The patients were so grateful to get help and understand what was going on they took any and all advice given to them. The hearing aid patient was so appreciative of their new ability to hear with better quality and clarity.  They gave our audiology students and the Botswana audiologist profuse thanks. We learned that sometimes less information is more with the hearing aid patients and may need to modify our process at home in the states.

City Tour of Botswana

It was city tour day in Botswana!

Yesterday, we drove around Botswana and had multiple stops to dive deeper into the city and their culture. Our first stop was driving through the University of Botswana. This was interesting for us because we all caught ourselves comparing the campus to OU. We saw both run down buildings and some extremely nice ones. The campus overall is growing and expanding in both buildings and career opportunities.

Our next stop was the visual arts center. Driving up to the center, they have different animals and plants made out of different metals and wires. Immediately we were attracted to the booth where you could play music. Kailey and I were able to show off our music abilities (or lack there of for me) and play a couple things. Each booth offered different items that were extremely beautiful! There were paintings, quilts, woodwork, and sculptures. I think we all were bummed that we couldn’t buy bigger items because shipping would be so expensive!

The next stop was the dam! Wow! We drove just outside the city to get there. Technically we weren’t supposed to go in but the wonderful woman let us in to see. We hiked up about 100 stairs to get the most spectacular view of the dam and the city of Botswana! Since Botswana is a land locked country, this damn provides the city with water. Last year, the group before us experienced a water outage because their water level was so low. This year is a different story and the damn was filled with water! The president made a point to go visit the dam to pray and thank God for all the water they have.

On our way to our next stop, we saw BABOONS along the tree line. Wild baboons! We stopped to take pictures and just admire how close we were to these wild animals. Our driver told us we could feed them. So guess what we did? We fed them potato chips! We saw an old baboon with hand contractures and immediately our interproffesional minds thought we should refer him to PT! As a group, I think we collectively can see when to refer to other the professions so we had to relate it to the animals we saw!

Next we went to the three chiefs statue. We had a phenomenal and passionate tour guide to tell us the history of Botswana. Last year, Botswana celebrated their 50th year of independence and throughout the country everything was painted in their colors to show their pride! The three chiefs were the ones who asked queen Victoria for protection of their land and that initiated the process of Botswana becoming their own country. Along with the statues, they had 6 pillars to represent the history leading up to independence. The pillars are refuge, heroism, protection, endurance, global responsibility, and independence.

We ended the tour with lunch because we were starving! We ended up splitting up for this meal because a party of 15 does not get food quickly! One thing we noticed here, service is not fast and ask for your bill immediately when you get your food. While service takes awhile here, I must say we have all gotten to bond and know each other pretty well. It’s been so nice to get to know the other people on this trip. I can definitely say that I am so proud to experience this trip with them. I have learned so much about them, their profession, and how we can tie our professions together. Thank you to this outstanding group of people for making each day so fun!

Morgan Beul

 

A Different Kind of Blog

I must admit writing this blog has given me unforeseen challenges. I ask that you bear with me as I attempt to fumble my way through writing these blogs in order to convey some semblance of the reality of traveling across the world in a different hemisphere, and the magnitude of the impact this trip to Botswana is having on all of us. I was reading my last blog and realized the inadequacy of what I was communicating. The blog sounded too formal and not personal enough. Then I saw the statistics and was overwhelmed that over 100 people are reading these blogs. That is both and honor and kind of terrifying. I want to do the best I can to tell you what your loved ones are experiencing without trying to ‘speak’ for them too much. In lieu of all this I read my favorite author’s blog (John Scalzi) and found that there are pretty much two types of blogs that can be written: the informative and the conversational. My last two blogs were informative. They have the rhythm of, “then we did this, then we did this..” In reading Sclazi’s blog I realized that the ‘conversational’ blogs were a lot more personal and interesting to read. The informative blogs are still important to convey a lot of information in a limited amount of time. In the future I will request others to write blogs like Shandra did so eloquently, but I will also include both informative and conversational. I must admit, at times I have stared at the computer for hours and thought, “How am I supposed to convey this information?” Here is my attempt at being conversational. (The scary thing is, conversational blogs break all the rules, like switching tenses and going from first, to second, to third person point of view!)

Let me tell you about one of the top 5 days of my life (possibly the best day of my life). We were on a trip to Tantebane Nature Reserve to do some team building activities. Here I am with 15 of some of the world’s best people. On a side note, I am the only male on this trip. When I was in the military for 8 years, the infantry had only males so this experience is the exact opposite for me. I must give the ladies on this trip all the credit in the world for including me and not making me feel like an outcast.

Going in to the team building activities some of us had an idea what to expect based on past teambuilding experiences. Almost all activities were new to me. The two workers, who’s job title can best be described as ‘motivational guides,’ immediately expressed their genuine excitement to lead us through the team building activities and then fed us the best grill cheese and ham sandwiches I could have imagined. Today was going to be a great day.

One of the first activities they challenged us with was where everyone was in a large circle with a hula hoop in the middle. A team of two was set to be in the middle with one in the hula hoop and the other guarding the person in the hula hoop. The rest of us threw 3-4 balls to try and hit the person in the middle. To say the least, it was tough. Afterwards the question was asked if we felt safe when the balls were being tossed? Did we trust the person blocking for us? The motivational guides did a flawless job of relating these games to actual applications in real life. They have perfected their craft and demonstrated excellence at their job.

One incredibly frustrating activity I have participated in 3 times in my life and have seen attempted a few more times. I have never seen or heard of it being accomplished. I was led to believe that it was an impossible task. I was told it could not be accomplished and it was used as a method to teach learners to be ok with failure. The task was to lower a hula hoop to the ground as a group with each of us 14 people putting a finger on the hoop without a single person losing contact with the hula hoop. The rules are the finger must be pointed at the person across you in a ‘gun’ shape so there is no hooking the hoop with a person’s finger to pull it to the ground. A hula hoop weighs approximately 1.5 – 2 lbs. Broken down this means that each person, all 14 people, must engage with less than 2 ounces of pressure without losing contact while lowering to the ground. This task took forever. I had zero confidence in our ability to accomplish this goal. We tried numerous plans. We failed at least 25 attempts. All that being said, not a single person quit. Everyone stayed amongst some of the most frustrating and infuriating attempts. People lamented on this being the most difficult task they’d ever been assigned. People expressed exasperation on not being heard in the planning phases. But no one quit. For the first time I’ve heard of we accomplished the goal of lowering the hoop to the ground. I debated about how much to write about this frustrating task. The activity really stressed us as a team and brought us down. I look at it now as a victory that amongst the frustrations and anger we remained a team and did not quit.

Two more activities that shaped us. First we had a task of being blind folded and grabbing a rope and creating a square while linking the ends. Amazingly, we accomplished this task incredibly quickly. However, we had zero organization and no plan. As a group we have struggled to engage in the planning phase on this trip. This task reinforced that. This task mirrored our ability to perform under pressure without adequate planning. At the same time, we all agree that if we put a little more time into planning then the days (or in this case the activity of creating a box with a rope while blindfolded) would go smoother. It is almost like the professors asked the motivational guides to arrange this scenario.

Our championing moment came after this revelation during the blindfolded-rope-box game. Our task was to take a bucket of “toxic” waste (a bucket full of ping pong balls and muddy water) and dispose of it in a bowl in the middle of a large circle. The rules were we had ropes at our disposal, but the ropes were not allowed to touch the center of the circle while we dumped the toxic waste into the large bowl. Obviously we were going to have to tie a rope to the handle of the toxic waste bucket and then to tie the ends of the rope to two other people to act as anchors while somehow managing to dump the bucket into the bowl without spilling it or letting the ropes or bucket touch the ground. Easier said than done. We accomplished this task incredibly well. We accomplished it by planning, engaging with one another, listening to each other, and make a solid, executable plan.

Later in the evening we were invited to Matilda’s (our contact in Botswana who graduated from Ohio University PT school in the 90s) for a cook out. Anders and Matilda had provided more food than you can imagine. I had the honor to help on the grill. There was filet mignon, sirloin steak, chicken legs, sausage, the best potato salad, mixed salad, fruit dessert, and a couple of traditional tswana foods that I can’t remember the name of currently – I’ll add them later. Many commented that it was the best meal of their lives. As I sat at the table I was so overwhelmed with joy I was nearly in tears. This trip is changing me, it is molding humans, it is forging friendships and bonds that will stand the test of time, it is reaching out to a population that is growing in knowledge, access, and understanding of their own health, it is reaching out to the people of Botswana to show that we care, it is teaching us that we have so much more to learn about life. It was a tremendous day. I sat with my eyes welled and grateful for the hospitality of Matilda, the people of Botswana, and the opportunity to be a part of this trip.

OH! Did I mention we saw giraffes, zebras, impalas, monkeys, and these very large birds while at Tantebane!

 

The Inspired, the Empowered and the….. Tired

The past two days have left us inspired, empowered, and…. very tired. However, this tired has been one that I think all of us have welcomed with arms wide open and we would not have it any other way.

Yesterday began with the opportunity for the physical therapy students to present an in-service to a group of 50+ teachers and government officials for the city of Francistown. This city is very blessed to have so many teachers, teachers’ aides, and caregivers in their school systems that are willing and ready to learn all information to help them provide care to children with special needs. They are actively advocating for their “learners” (how they refer to the students here in Botswana) on a daily basis. The PT students were able to instruct them in the proper way to perform transfers and range of motion exercises and also educate them in proper body mechanics. The teachers were so proud of themselves and each other every time they would successfully complete a transfers and they were so appreciative of our help.

Meanwhile, the SLP and Audiology students were busy at the Progressive Physical Therapy clinic screening more than 50 children during the morning session alone. They were able to provide recommendations and advice to help improve each child’s impairments and guide them to where they needed to seek further medical attention. Not only were they able to help screen children with speech and hearing needs, but they were also able to provide screening and helpful recommendation for children with physical impairments despite being short resources due to the PT students being absent. PT students then joined in the afternoon to continue helping to screen additional children. I have to say that my favorite part of that day was my discussion with the Speech and audiology students about the physical care they were able to give to the children and hear how excited they were to be able to help the children in that way. This is just one reason that I am proud to call these individuals my teammates and my future colleagues. Understandably, when the day finally ended I can 100% confirm that we were all dragging our feet on the walk home, tired, but feeling accomplished.

Today we were able to visit one of the many villages in Botswana, the Tatitown Kgotia, and perform, balance, hearing, and cognitive screenings to members of their community. One of the best parts about this trip, is that nothing goes as we planned, but somehow turns out to be better than we could have imagined. We were able to provide fall prevention strategies, hearing recommendations, and strategies to improve memory to over 50 individuals and we were so blessed by their many words of thanks and appreciation. Today was not only a day of encouragement for the individuals we were able to work with, but it was also a day of growth for our teams. We were able to identify areas that needed improvement in order to best benefit the patient and we were also able to make modifications and adjust to unexpected obstacles while appreciative the integral part that we had in making today go smoothly.

We're not in Athens anymore. Follow some Ohio University Physical Therapy Students and Speech Language Pathology Students as they experience life and the healthcare system in Botswana.