Nurses have long been concerned with health promotion activities. In the health promotion setting, the nurse must move beyond disease prevention and effect the more global outcome of promoting healthy lifestyle behaviors. Self-care activities are important strategies of healthy behaviors (Clark, 1998). In this article, perceived selfefficacy and barriers are proposed as significant concepts that influence the self-care activities of older adults. A review of the literature and a conceptual model are presented. Research questions generated by the conceptual model and discussion related to the application of this model to nursing science also are presented.
Self-care activities are health promotion behaviors that allow individuals to take initiative and responsibility to maintain their own health and functional ability (Levin, Katz, & Hoist, 1979; Pender, 1996). Maintaining functional ability is essential for older adults to maintain their independence as long as possible. Older adults evaluate their own health based on their perception of the level of functional abilities (Duffy, 1990). Participation in self-care activities is critical and enables older adults to maintain functional abilities and have productive, independent, and fulfilling lives. Examples of self-care activities include exercise, proper nutrition, rest and relaxation, and reduction of stress.
Motivation is an important factor in an individual's ability to perform functional and self-care activities (Kemp, 1988). According to Bandura (1982), self-efficacy is the motivational factor that determines if an individual participates in self-care activities and to what extent. Bandura (1977) posits that individuals avoid activities they believe exceed their capabilities, but they engage in and perform confidently those activities they judge themselves capable of managing. Furthermore, self-efficacy judgments influence the amount of effort an individual will expend for an activity (Bandura, 1997). According to Bandura and Schunk (1981), individuals with low self -efficacy doubt their capabilities, whereas individuals with a strong sense of self-efficacy exert great effort to accomplish their goals.
Another factor cited in the literature as a predictor of health behaviors is perceived barriers. Perceived barriers may be real or imagined. Examples of barriers are inconvenience, expense, difficulty, unavailability, or the time-consuming nature of an activity or action. Barriers are considered blocks to undertaking and conducting a given behavior (Bandura, 1997; Pender, 1996). A barrier might also be the loss of satisfaction from giving up an unhealthy habit (e.g., smoking) in striving for a healthier lifestyle. When perceived barriers are low, self-care activities are high. As an example, a study by Kinne, Patrick, and Maher (1999) revealed that individuals with lower perceived barriers have a high probability of engaging in exercise as a self -care activity.
IMPORTANCE TO NURSING
While nurses have always been concerned with longevity of life, in recent years, more attention has been focused on the quality of life in the aging years (Walker, Volkan, Sechrist, & Pender, 1988). Elderly individuals comprise 13% of the total U.S. population (American Association of Retired Persons, 1998). Predictions are that the number of elderly individuals will increase to 22% of the population by the year 2030. A goal of Healthy People 2010 is the achievement of health promotion and disease prevention for older adults (U.S. Department of Health & Human Services, 2000).
With the rapidly expanding elderly population, health care costs have elevated as well. An estimated 1 trillion dollars are spent annually on health care in the United States (Physicians for a National Health Program, 1995). Approximately 36% of the health care budget is spent on care of elderly individuals (American Association of Retired Persons, 1998).
Health disabilities and multiple impairments increase with age, with a significant increase after age 75 (U.S. Department of Health & Human Services, 1992). Therefore, while individuals 65 years and older comprise only 13% of the current population, they account for more than one third of the national health care budget. Self-care activities may be important strategies to contain the rapidly escalating cost of care. By participating in regular self-care activities, older adults maintain a higher level of functional abilities, slow the crippling process of aging, enjoy independent lifestyles, and may be less dependent on the health care system (Schneider & Guralnik, 1990).
Also relating to the importance of nursing is the emerging realization of the increasing demand for nursing services by chronically impaired older adults. The nursing needs of this rapidly growing segment of the population may exceed the capacity of professional nursing care resources. Effective self-care strategies for older adults will be essential for maintaining health (Hickey, Dean, & Holstein, 1986). Influences such as perceived self-efficacy and barriers must be explored to gain knowledge related to self-care strategies to meet health care needs of older adults in the future.
The purpose of this article is to examine perceived self-efficacy and barriers as significant concepts that influence the self-care activities of older adults. A conceptual model is presented depicting the influence of these concepts on self-care activities. This conceptual model differs from earlier health promotion models because it is specific for older adults. Older adults* perceived self-efficacy and perceived barriers are different from younger individuals. This difference may influence the creation of nursing interventions to improve self-efficacy and minimize barriers.
Many older adults have reached their later years in apparent good health while others' lack of self-care activities have greatly accelerated the process of aging (Duffy, 1990; Padula, 1997).
Review and comparison of the findings in related literature led to four conclusions:
* Self-efficacy may be perceived differently in older adults than in younger adults.
* Self-efficacy is a critical determinant of self-care activities in well and ill older adults.
* Self-efficacy can be enhanced through education and training.
* Perceived barriers in older adults differ from younger individuals.
Self-efficacy, health behaviors, and age. In older adults, self-efficacy problems arise from misappraisal of their capabilities. Using Bandura's Social Cognitive Theory as the conceptual framework, Conn (1997) conducted a study to examine the ability of self-efficacy expectations and outcome expectations to predict health behavior among older women. The convenience sample consisted of 25 women, age 65 or older, who were living in independent living situations. Data were collected via questionnaires. Findings showed a moderate correlation between self-efficacy and the health behaviors of exercise and diet (exercise, r = .56 and diet, r = .54). Higher levels of self -efficacy are associated with greater involvement in an activity and with the persistence and effort in performing that activity (Bandura, 1977; Bandura, 1982; Bandura, 1986; Bandura & Adams, 1977). As indicated in the proposed model, older adults may benefit from nursing interventions focused on improving self-efficacy through modeling, verbal encouragement, and education.
Two studies were found that examined self-efficacy and younger individuals. Perceived self-efficacy in young adults is related to previous successful behavior (Bandura, 1977). Martinelli (1999) used Pender's Health Promotion Model to explore the variables that influence health promotion behaviors in undergraduate college students (n = 238). Data were collected using questionnaires. Mean age for the sample was 20 years. Findings revealed that self-efficacy had the greatest affect on health promotion activities followed by perceived health status.
Using Pender's (1996) Model of Health Promotion, Weitzel (1989) examined the importance of health, perceived locus of control, health status, and self -efficacy. The sample consisted of employees (n = 179) on a campus university who volunteered to participate. Data were collected via questionnaires. Findings showed that the most powerful predictors of health-promoting activities were the perceptions of health status and selfefficacy. Again, participants were younger than age 65. With the older individual, self-efficacy is a single prominent factor for determining participation in self-care activities. In the younger individual, self-efficacy is coupled with health status to predict participation in self -care activities.
Self-efficacy in well and ill older adults. Self-efficacy is a critical factor in the development of favorable health practices in both well and ill older adults. Southerland (1988) used a nonprobability sample of 249 well adults older than age 65 (60% women, 40% men) to investigate the relationship of self-efficacy, health knowledge, and health practices. Findings indicated that self-efficacy had a significant effect on self-care practices. In a replication of Southerland's study, Moore's (1992) findings supported the earlier finding that self-efficacy played a major role in determining self-care practices in older adults. Furthermore, Moore's results also revealed that a greater number of health problems are correlated with lower self-efficacy.
While examining diseased-stricken individuals, Carroll (1995) used Bandura's Social Cognitive Theory to explore the importance of self-efficacy expectations in elderly patients recovering from coronary artery bypass graft (CABG) surgery. The sample consisted of 133 adults (32 women, 101 men) older than age 65 who had CABG surgery in two large teaching hospitals. Data related to self-care activities were collected via questionnaires at intervals up to 12 weeks after surgery related to self-care activities. Findings revealed that selfefficacy expectations were significantly predictive (p < .01) of self -care behavior at 6 and 12 weeks after CABG surgery.
Using Bandura's Social Cognitive Theory as a conceptual framework, research by Clark and Dodge (1999) provided evidence that self-efficacy is a strong predictor of disease management behavior. The convenience sample consisted of 570 women who were non-institutionalized, ambulatory, and clients of cardiac clinics and physician offices associated with six large hospitals in one state. The mean age of the women was 71.8 years, with a range of 60 to 93 years. Data were collected during a 12-month period using a questionnaire composed of a series of items related to self-care behaviors for managing heart disease. The findings revealed that higher selfefficacy consistently predicted better disease management behavior. A strength of the study is the large number of participants and the analysis of data over time.
Self-efficacy and education or training. Self-efficacy and behavior can be changed when individuals are informed, educated, and counseled (Bandura, 1986; Weinberg, Gould & Jackson, 1979). Most studies related to the improvement of self-efficacy through education and training have been conducted with relatively young individuals of moderate incomes. Research by Burke et al. (1999) used a nonprobability sample to determine self-efficacy for diet and physical activity and barriers to healthy behaviors in young married couples. The mean age for men was 29.1 years and 26.7 years for women. The 4month randomized controlled study solicited couples through the use of the public media. The sample consisted of 34 couples who were randomly assigned to the intervention or the control group. A health promotion program (six modules) was administered to the intervention group. By the end of the intervention, self -efficacy for diet and physical activity increased significantly in the intervention group and perceived barriers to healthy behaviors decreased.
Schott-Baer and Christensen (1999) used Bandura's Social Cognitive Theory to find that education related to self-care can improve selfefficacy. With a sample of 36 adult asthma patients (19 in the control group, 17 in the intervention group), the concepts of self-efficacy and selfcare were investigated. Age of participants ranged from 24 to 74 years with a mean age of 52 years in the control group and 44 years in the intervention group. A 3-hour educational program on the disease process and diary-keeping to monitor selfmanagement was used with the intervention group. Data were collected using a questionnaire. Findings revealed that self-efficacy was significantly higher in the intervention group compared to the control group immediately after the class.
The findings of these studies support the proposed model because nursing interventions can enhance self-efficacy. According to Bandura (1977), self -efficacy can be improved regardless of age, and self-efficacy problems in older adults are related to misappraisal of capabilities. In older adults, interventions of education, verbal encouragement, counseling, and modeling should be focused on helping the elderly individuals reappraise their capabilities. Self-efficacy enhancing interventions can strengthen efficacy beliefs and increase activity levels in older adults (Resnick, 1998a).
Perceived barriers in younger individuals. Bandura (1997) considered perceived barriers to be impediments or deterrents to undertaking and conducting a given behavior. Perceived barriers may differ in younger individuals as compared to older adults. In a qualitative study conducted by Timmerman (1999), the relationship between self-care strategies and perceived barriers was examined. The study sample (n = 95) ranged in age from 18 to 54 years. All participants were enrolled in a college health promotion course. The most common perceived barriers identified were lack of time (62.1%), environmental constraints (31.6%), lack of motivation (25.3%), and tiredness or fatigue (20.1 %). A limitation of this study was the possible influence that may have derived from being enrolled in a health promotion class as opposed to a different type of class.
Weinrich, Reynolds, Tingen, and Starr (2000) conducted a study exploring the association between perceived barriers and free prostate cancer screening. Data were collected from the sample (n = 1432) via questionnaire. The mean age of the men were 52.4 years. The three most frequently cited perceived barriers were "put it off" (12.8%), "didn't know I needed one" (10.1%), and "doctor hours not convenient" (10%). Findings revealed that perceived barriers were significant predictors for lack of participation in prostate cancer screening.
Another study by Lopez- Azpiazu, Martinex-Gonzalez, Kearney, Gibney, and Martinez (1999) explored the relationship between perceived barriers and a healthy diet. Data were collected from a sample (« = 1,009) of Hispanic participants via questionnaire. The main barriers identified were irregular work hours (29.7%), willpower (29.7%), and unappealing food (21.3%). The findings also showed the most frequently selected benefit of eating a healthy diet was disease prevention (73.6%). These results demonstrated that while individuals realized self-care activities were important for health promotion, perceived barriers deterred them from participating.
Perceived barriers to self-care activities and health promotion may be related to financial restriction of the individual. Paris, Dunham, Sebastian, Jacobs, and Nour (1999) surveyed a convenience sample (n = 50) of recipients of liver transplants in the United States. Findings suggested that medication non-adherence was significantly related to financial capability of the individual. Non-adherence was more likely to occur when the recipients did not have insurance and had to rely on indigent drug programs.
Situational barriers may also be significant to deter individuals from participating in health promotion activities. Hallion and Haignere (1998) studied employees (n = 293) of a medical center to determine the perceived barriers to participating in the center's health promotion program. Data were collected using a questionnaire. Findings revealed that non-participants cited situational barriers of being too busy and finding program time inconvenient to attend.
To identify perceived barriers to making changes toward a healthier lifestyle, Gulanick, Bliley, Perino, and Keough (1998) conducted a qualitative study with patients (n = 45) recovering from coronary angioplasty. The mean age of the sample was 61 years with 26 men and 19 women participating. Data were collected during focus groups and interview sessions with the researcher. Findings identified, that for this sample, lack of spousal or family support, lack of willpower, powerless attitude about disease progression, and fear of overexertion were barriers to making healthy lifestyle changes.
Perceived barriers in older individuals. Most research has been conducted with samples of young persons. Barriers perceived by older adults may be different than younger individuals. Lack of knowledge as a perceived barrier was identified in a study conducted by Peters (1995) who investigated the effect of influenza and pneumococcal immunization information and healthcare counseling using a random sample (age 65 and older) of older adults (n = 115). Principal perceived barriers identified were current state of health, being unaware of the vaccine, and lack of physician referral and counseling for the vaccine. A weakness of the study was that sample participants were predominantly White men.
Figure. Perceived self-efficacy and barriers as determinants of participation in self-care activities of older adults. The solid arrows indicate significant relationships between variables. The open arrows indicate the potential of positive change through nursing interventions.
Resnick (1998b) used a nonprobability sample of adults age 65 or older to conduct a survey to investigate participation in health promotion activities and explore reasons for non-compliance for behaviors known to promote health. Pain was identified by 41% of the sample as a perceived barrier for exercise. An attitude of indifference was also a barrier reported more frequendy by older individuals ages 81 to 104 (91%) as compared to the report (9%) by young-old individuals, age 65 to 80 years.
Perceived self-efficacy and barriers. Health behavior practices are affected by a combination of the factors of perceived self-efficacy and perceived barriers. In a descriptive, correlational study conducted by Tapler (1996), the relationship among health value, selfefficacy, health barriers, health benefits, and health behavior was examined. Data were collected from the members of the sample (n = 202) via several questionnaires. The mean age of the members of the sample was 35 years. Findings revealed that perceived barriers had the strongest relationship with health behaviors (r = -.56, p < ,01). Findings also revealed that self-efficacy and perceived benefits of action was positively related to health behavior at p < .01 (r = .33, r = .34, respectively). A limitation of the study was the convenience sampling procedure resulting in a sample that was predominantly young, White, married, and had college degrees.
Further studies support the influence of self-efficacy and perceived barriers on exercise. Exercise is an essential self-care activity for older adults (U.S. Department of Health & Human Services, 2000). Clark (1999) explored the relationship among physical activity, perceived barriers, and self-efficacy in individuals 55 and older. A random sample of 1,088 patients was selected from an urban primary care center used mainly by low socioeconomic, Black individuals. Data were collected via questionnaire. Women had significandy lower efficacy expectations than men.
Overall findings revealed that lower self-efficacy and high motivational barriers were associated with less physical activity. A limitation of this study was the under-representation of White men in the sample. Further research efforts are needed to understand self-care behaviors of disadvantaged older adults (Clark, 1999).
There is also evidence that motivators and barriers may be related to the age of the individual. Scharff, Homan, Kreuter, and Brennan (1999) conducted a study examining the factors associated with physical activity in women of various ages. Adult women (n = 653) from four family clinics completed a self-administered questionnaire while in the waiting area of the clinic. Age of women in the sample ranged from 18 to 75 years. Findings revealed that younger women (30 years and less) reported a higher self-efficacy for meeting their physical goals, but also the greatest number of barriers. Older women (49 years and older) were almost twice as likely to be unsure of meeting their physical activity goal, but reported fewer barriers. Motivators for physical activity include health for older women and weight maintenance for younger women.
Summary and Gaps in the Literature
Perceived self-efficacy has been found to be a primary factor for participating in self-care activities for older adults and young individuals. Perception of an older adult's selfefficacy differs from a younger individual as problems with self -efficacy in older adults stem from misappraisal of one's own capabilities. In addition, two studies focused on well older adults, and two studies focused on older adults with chronic illnesses. Findings of these studies revealed that self-efficacy expectations were predictive of self-care regardless of health status in older adults. Studies also revealed that education, training, verbal encouragement, and counseling can improve perceived self-efficacy.
There is a paucity of research examining the perceived barriers of health behaviors in older adults. Of the studies found, findings revealed that perceived barriers in older adults differ from younger individuals. Identifying barriers of older adults related to participation in self-care activities may lead to the development of nursing interventions to address these barriers, potentially enhance the quality of life of older adults, and reduce health care costs.
Perceived self-efficacy and barriers in combination have been researched as predictors of health behavior. However, much of this research has occurred in samples younger than age 65. Earlier studies targeted younger, White individuals of moderate income. These "gaps" in the literature must be addressed.
More research is needed in older adults with lower educational levels, lower income, and those with poor health. These disadvantaged individuals are rarely included in nursing research studies. Chronic disease and impairment may be increased for these individuals (Clark, 1999). Also, there is a serious dearth of studies involving Hispanic and Black elderly individuals. The effect of cultural beliefs of these groups on participation in self-care activities has not been well addressed.
Based on the analysis of the literature review, a conceptual model was derived depicting the influence of perceived self-efficacy and barriers on self-care (Figure). This model was adapted from Bandura's (1986) Social Cognitive Theory and Pender's (1996) Health Promotion Model. This conceptual model differs from earlier health promotion models because it is specific for older adults. Pender's Model of Health Promotion calls for application to all ages alike. Variables in the proposed model are limited to those consistently supported in empirical studies as impacting the health behavior of older adults.
In a comprehensive review of studies on health promotion, Janz and Becker (1984) found that barriers outweighed benefits as predictors of health promotion activities. Earlier models, such as Pender's model, included perceived benefits as a variable. However, in older adults, perceived barriers may outweigh benefits as a predictor of self-care activities (Janz & Becker, 1984). From a life span perspective, benefits are associated as most important for middle-aged adults when individuals are relatively disease-free, than in older adults, when disease may already be present. Because the target population for this model is older adults, perceived benefit is not proposed as a significant concept influencing self-care activities.
This author is not attempting to discredit previous models, but, rather, to add to the existing knowledge base of nursing by presenting a model focusing on two variables of importance specific to older adults engaging in self-care activities. This model is not intended to represent an all-inclusive model of determinants for health behavior in older adults. It is, however, a step undertaken to advance specific understanding of older adults' participation in self-care activities.
The proposed conceptual model may also be applicable to all races. Perceived self-efficacy and barriers may vary with racial or cultural differences as supported by the model. Testing of this model is suggested to provide a knowledge base for designing health promotion, strategies, maximizing cost containment strategies, and increasing quality of life for older adults of all racial backgrounds.
In this conceptual model, self-care activities are defined as positive health behaviors in which an individual engages to maintain health and functional ability. Maintenance of functional ability is essential for older adults to maintain their lifestyle and perform everyday activities. Self-care activities include regular exercise, proper nutrition, adequate rest and relaxation, reduction of stress, and regular health care practitioner check-ups.
Participating in regular self-care activities (e.g., exercise) maintains range of motion in extremities and physical level of exercise. Proper nutrition provides foods essential to muscle strength and well-being. Adequate rest and relaxation are essential for addressing physical and emotional stress.
Older adults may suffer from a variety of stressors including chronic illnesses, pain, family unrest, and fear of losing independence. Rest and sleep can provide temporary relief from stress and, thus, be therapeutic. Regular physician check-ups provide for screening and detection of illnesses and disabilities so that, if detected early enough, treatment can be initiated with a more positive health outcome.
The variable of perceived self-efficacy in this model is defined as "people's judgments of their capabilities to organize and execute courses of action required to attain designated types of performances" (Bandura, 1986, p. 391). Self-efficacy is acquired through four sources of information. This first source is the successful achievement of performing a task. Successes raise efficacy appraisals while repeated failures lower them.
Self-efficacy is also acquired by observing others performing a task. Through observation, individuals may model their own behavior after observing the success of others in performing certain tasks. A third source of self-efficacy information is verbal persuasion. Individuals can be encouraged to believe they possesses the capabilities to enable them to succeed at particular activities. Physiologic states, such as fear and anxiety, may affect an individual's beliefs about himself (Bandura, 1986). Eliminating emotional arousal to subjective threats functions to increase perceived self-efficacy with corresponding improvements in performance (Bandura & Adams, 1977).
All these sources interact to form an individual's general self-efficacy. After they are empowered with skills and beliefs in their capabilities, older adults can act to overcome perceived barriers and participate in self-care activities. As supported by the literature, this conceptual model emphasizes the influence of self-efficacy as well as perceived barriers on the selfcare activities of older adults.
In this model, perceived barriers also serve as a significant influence on participation in self-care activities (Lopez- Azpiazu et al., 1999; Timmerman, 1999). Barriers are impediments or deterrents to participation in self-care activities. These barriers may be imagined or real.
Lack of time is identified as a barrier. Individuals cannot fit self-care activities into their busy schedules (Timmerman, 1999). Individuals must also be knowledgeable or aware that activities for self-care are available (e.g., influenza immunizations). Lack of family support may be a barrier. In this case, one family member may need a strict cardiac diet, while other members rebel at eating such a diet. This situation would require the "cook" to prepare two types of meals for the family on a regular basis.
Other barriers may be physiologic states, such as fear, pain, fatigue, indifference, or lack of willpower and motivation. These states can inhibit or deter participation in selfcare activities (Gulanick et al., 1998; Hallion & Haignere, 1998; LopezAzpiazu, et al., 1999; Timmerman, 1999). Last, restrictions of a financial or environmental nature may deter participation in self-care activities. Lack of sufficient funds to pay for appropriate medications or immunizations are an example. Inclement weather, such as raining, may be a barrier to exercise, which is a selfcare activity. Altering the perception of or reducing these barriers should be a goal of nursing interventions.
This conceptual model demonstrates the role of nursing in effecting positive change, through appropriate nursing interventions, for both perceived self-efficacy and barriers. Education can be provided by nurses to increase knowledge of the value and role of self-care activities in maintaining health. Individuals need to be educated also on the availability of self-care measures, such as the influenza immunization.
Verbal encouragement to participate in self-care activities can also function to remove barriers and increase s elf- efficacy. Well-functioning older adults might be encouraged to serve as peer role models for engaging in self-care activities. Through counseling, feelings of fear and anxiety might be addressed. This conceptual model (Figure) identifies self-efficacy and perceived barriers as determinants of participation in selfcare activities and also depicts how nursing interventions can effect positive change in these determinants. From the present literature review and use of the conceptual model, several research questions emerged.
RESEARCH QUESTIONS AND KNOWLEDGE DEVELOPMENT FOR NURSING PRACTICE
Through the use of the conceptual model, the following research questions emerged, which may drive future knowledge development.
* What is the relationship among perceived self- efficacy, perceived barriers, and participation in selfcare activities in older adults?
* What is the relationship among nursing interventions that increase perceived self-efficacy and lower perceived barriers and result in decreased health care cost for older adults?
* What is the most cost-effective method for educating older adults related to the importance of self-care activities?
* What is the relationship among perceived self-efficacy, perceived barriers, and self-care activities for marginalized older adult populations?
The conceptual model presented in this article provides a basis for addressing these research questions. Older adults are particularly vulnerable in regard to self-efficacy. Bandura (1986) reports that self-efficacy problems of the older adult are related to misappraisal of their abilities. Television media and cultures that revere youth may unintentionally evoke images and stereotypes of elderly emaciation and senility. Older adults who are insecure about their self-efficacy may curtail their range of activities and decrease their efforts in the activities they do undertake.
The escalating cost of health care for older adults may also drive research related to health promotion for this group. Health disabilities and impairments increase with age. Within the older adult population, reported disabilities are high. Future research must be directed at preventing disabilities and maximizing cost containment through the promotion of better health and lifestyle practices (Seeman, Unger, McAvay, & Mandes de Leon, 1999). Knowledge needs to be developed regarding the role of nursing in increasing self-care activities of older adults through education and counseling. Provision of services is a major component of older adult health care cost. Using this model, strategies for increasing self-care activities can be designed and promoted with older adults to maximize their independence, maintain health care cost, and improve the quality of life.
Future knowledge development, based on this conceptual model, should also address the needs of minority groups, such as Black older adults. Most of the research studies used predominantly White older adult samples. Self-efficacy beliefs and perceived barriers may vary with different ethnic groups (Lipson & Steiger, 1996). Focusing on selfefficacy beliefs and identifying perceived barriers may guide the development of culturally competent nursing interventions for ethnic minority older adults.
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