Name: _________________________________

1
 TABLE OF CONTENTS

A definition of determinants and health..…………………

………………3
The determinants of health………………………………………
………...4

The Determinants of Health in NZ……………………………

……………5

Activity 1: Explaining and linking determinants…………

……………….8

Activity 1A: Determinants of health comparative

study………………….9

Activity 2: Linking determinants to health outcomes –

market rents……10

Activity 3: Personal Profiles………………………………………

………12

Activity 4: Determinants of health in our school…………

………………15

Activity 5: In Sickness and Inequity…………………………

……………16

Activity 6: Recommendations for Equitable

Outcomes…………………..18

Activity 7: Putting it all together – the overview in

health………………20

Getting the Whole Picture of Health.…………………………

……………21

Additional note pages………………………………………………

……..22

2
 A definition of “determinants” and “health”
We have looked at the determinants of health in year 12 but in year 13
we need to have a wider understanding of what determines our health
and how these determinants affect our wellbeing.

Determinant = factor, thing, influence

Determinants of health are those factors which

influence our health

It is important, when looking at determinants, to define the meaning of

“health & wellbeing”.

The World Health Organisation:

“health is a state of complete physical, mental and social
wellbeing and not merely the absence of disease or infirmity”

The Ottawa Charter for Health Promotion:

“health is created and lived by people in settings of their
everyday life; where they learn, work, play and love”

Whare Tapa Wha (hauora)

“The four cornerstones of Maori health that contribute to
wellbeing: Taha wairua, taha hinengaro, taha whanau and
taha tinana”.

INEQUITY: A lack of fairness or justice in the treatment or

situations between individuals or groups. Inequities can be reduced
(so people can enjoy equal good health) by taking action to promote
social justice.

INEQUALITY: A difference in the social or economic status between

individuals/groups based on unequal distribution of goods, ie some
have more than others. May or may not be linked to inequity issues.

It is important to note there is a difference between these two terms,

and they are not interchangeable. For instance, if after a major storm a
section of the country was without power, we would say there was
inequality in the situation because some people had power but some
did not. However, it was not an inequitable situation, as it did not
involve unfair treatment. If the power companies decided to only
supply power to those who were wealthy, then it would become
inequitable. However, inequity can sometimes be quite overt. Taking
this same analogy, if the power companies decided they would put the
power cables underground in Pakeha neighbourhoods, but keep them
3
above ground in predominantly Maori or Polynesian neighbourhoods,
then again there is inequity in the situation because the above-ground
cables are more susceptible to storm damage, and Maori and
Polynesian neighbourhoods run a greater risk of being without power in
times of bad weather.

For a really good explanation of this, you can look up this article:
http://www.beyondintractability.org/essay/power_inequities/

4
http://www.who.int/hia/evidence/doh/en/

The determinants of health

Introduction

Many factors combine together to affect the health of individuals and

communities. Whether people are healthy or not, is determined by
their circumstances and environment. To a large extent, factors such as
where we live, the state of our environment, genetics, our income and
education level, and our relationships with friends and family all have
considerable impacts on health, whereas the more commonly
considered factors such as access and use of health care services often
have less of an impact.

The determinants of health include:

• the political, economic, cultural, and social environment;

• the physical environment; and
• the person’s individual characteristics and behaviours.

The context of people’s lives determine their health, and so blaming

individuals for having poor health or crediting them for good health is
inappropriate. Individuals are unlikely to be able to directly control
many of the determinants of health. These determinants—or things
that make people healthy or not—include the above factors, and many
others:

• Political determinants – who is in power affects health in

several ways – type of governing (oppressed versus democratic),
funding for social welfare, funding for health and education, laws
and policies ie alcohol purchasing age, market rents for state
houses and the involvement in any war.
• Economic determinants – these include the global economy,
financial markets and trade that can have a positive or negative
effect on health, ie trade in tobacco has a negative effect, but
the increased telecommunications that enables health
information to be shared can have a positive effect.
• Environmental determinants – safe water and clean air,
access to sport and recreation facilities, healthy workplaces, safe
houses, communities and roads all contribute to good health.
• Cultural determinants – spiritual beliefs, identity issues,
philosophies, practices and values all relating to culture can
contribute greatly to a person’s health.

5
 • Personal determinants – genetics, age or gender play a part in
determining lifespan, healthiness and the likelihood of
developing certain illnesses.
• Lifestyle determinants – these include our personal
behaviours and coping strategies, ie balanced eating, keeping
active, smoking, drinking, and how we deal with life’s stresses
and challenges all affect health.
• Social determinants – these include the social and
psychological environments, early childhood environments and
work conditions that can directly affect health and wellbeing.
Everything from where a person is on the social gradient, if they
have social support or are socially excluded, in employment or
not, access to transport, their early life conditions, any
addictions, access to healthy food and stress can have either a
positive or negative impact on a person’s health.

The Determinants of Health in NZ:

Information and research findings
The National Health Committee’s paper “Social, economic and cultural
determinants of health” outlines information and research findings
about major determinants of health for New Zealanders.

• Risk Factors: Factors that place people at increased risk

of poor health
• Protective Factors: Factors that increase chances of
good health

Within each determinant, there will be risk and protective factors,

depending on what is going on in someone’s life in relation to that
determinant. Eg: Sociability: Social isolation = risk factor and social
support/cohesion = protective factor.

Links between Determinants: The determinants all link together to

create a picture of overall good/poor health. Eg: Income relates to
education, housing, the environment (area in which you live), type of
work/ or whether you are employed – this relates to social
support/isolation and so on.

THE DETERMINANTS

Income
Income inequality has increased dramatically in NZ. The number of
people on benefits is increasing and Maori and Pacific Islanders are
over-represented in low income groups. Housing costs are the largest
single cause of poverty (refer to Activity 2 on page xxxx). The
strongest evidence about those who are vulnerable to ill health relates
to low income. Single-parent households with children are by far the
largest household type living in poverty.

Housing

6
Houses which are damp, cold and overcrowded are not healthy
environments and are associated with higher rates of meningitis,
tuberculosis, measles and mental health problems. Rising rental costs
and house prices will worsen the problem.

Education
Education is critical in determining people’s social and economic
position and thus their health. Initiatives such as Te Kohunga Reo have
improved Maori educational opportunities; however, many more Maori
students are leaving school without qualifications, and the gap
between Maori and non-Maori achievement is widening.

Socio-economic Factors
Low birth weight, which is a risk factor for health problems throughout
life, has been found to be associated with lower social class. People in
higher socio-economic groups are less likely to smoke and rate their
health as poor. Chronic infections are more common in lower socio-
economic groups, including HPV (genital warts) which is associated
with cervical cancer.

Un/employment
Occupational injuries are an issue in NZ. Eg: Exposure to toxins,
machinery accidents, falls, driving accidents. Position in the
workplace is also a factor: Top managers have better health and longer
lives than people below them in the workplace. Having control over
your work is important for good health.

The importance of earning a living is not only for financial reasons, but
also mental health and social reasons. Unemployment increases the
risk of premature death (particularly men).

Distribution of Income
Links have been made between the distribution of income in a society
and the health of people in that society. Death and poor health is
lower in countries with a more egalitarian distribution of income (a
narrow gap between peoples’ earnings) than in countries with a large
gap between the rich and the poor.

Sociability
Social support enhances health. Social isolation is associated with
illness. People who are married have lower mortality rates than those
who are single, divorced or widowed. Individuals with strong ties to
family, friends and community have better health than those who live
alone or do not belong to any groups.

Environmental Factors
Environmental pollution causes 2% of cancer deaths throughout the
world. Rates for meningitis are 74% higher in overcrowded areas. Low
income people have greater exposure to environmental toxins. Some
areas are more toxic than others due to industrial waste sites and
factories. These areas are also likely to be more deprived in amenable

7
services such as schools, transport, or health care facilities.
Employment opportunities may be hard to come by.

Gender
Women have longer life expectancy than men, but suffer more
psychological problems throughout life. Women also have more time
off from work due to sickness than men. Women receive less specialist
operations in NZ than men.

Ethnicity
Internationally, being a minority ethnicity is a risk factor for sickness,
low birth weight and early death. Maori and Pacific Island life
expectancies are lower than Pakeha, and infant mortality is higher.
Fewer Maori or Pacific Islanders rate their health as being good
compared to Pakeha or Asians.

Reference

Howden-Chapman, P. & Cram, F (1998). Social, Economic and Cultural

Determinants of Health. National Health Committee: Background
Paper 1

8
9
 Activity 1: Explaining and linking
determinants
Learning Outcome: Students will investigate and explain the
definition of a determinant of health for individuals and groups in
society.

Use the information provided so far in this workbook to complete the

following:

1. Explain a determinant of your choice for each of the following

levels.
-Personal or Individual (eg: age, gender, personal behaviours)
-Interpersonal (eg: Socio-economic/social - sociability, income,
employment)
-Societal (eg: income distribution, political system)

Your explanation should include:

-What the determinant is
-How it is a risk and protective factor for individuals/groups
-What other determinants it links to and how it links to these
others.

Determinant Explanation of how this determinant is a risk/protective

factor and the links to other determinants
1. Personal
(Individual)

2. Interpersonal

3. Societal

10
11
 Activity 1A: Determinants of health
comparative study
Learning Outcome: Students will demonstrate understanding of how
determinants of health impact on the health and wellbeing of NZ youth.
Instructions: Below are listed the determinants of Health that WHO and The
New Zealand Health Strategy have decided are critical for population health
and wellbeing. Individually list the determinants you believe are critical for
your health and wellbeing and place these in the third column. Discuss as a
class and add ideas. Decide whether these determinants link to the WHO
and/or Health Strategy determinants, and tick in the respective columns to
the right.

WHO: Social NZ HEALTH OUR CLASS: LINKS TO WHO AND

Determinants of STRATEGY: Determinants of NZ HEALTH
Health Determinants of Health STRATEGY
Health
What affects your
health and WHO NZ HEALTH
wellbeing? STRATEGY

1. The social 1. Genetic

gradient inheritance

2. Stress 2. Age

3. Early life 3. Gender

4. Social 4. Ethnicity
exclusion

5. Work 5. Income

6. Unemployment 6. Employment

7. Social support 7. Education

8. Addiction 8. Housing

9. Food 9. Sense of
control over
life
circumstances
10. Transport
10. Access to
health care
services

12
 Activity 2: Linking determinants to health outcomes – market rents
Learning Outcome: Students will demonstrate understanding of the links between a determinant and health
outcomes for a particular situation.

Using the PHAC model, choose any specific determinant and plot similar links to the effects on the health outcomes of the
people affected on the next page.

Increase in Increase in Increase in

People living in people living in respiratory
substandard cold and damp disease eg
housing conditions asthma

Housing Poorer mental

insecurity Stress health

Introduction of Reduced Reduced Poorer

market-related Higher disposable access to health
rents for state rents income health care
housing

Increase in
infectious diseases
Overcrowding
eg meningococcal
disease

Possible causal pathways

between a
housing policy change and Stress Poorer mental
adverse health outcomes health

13
Sourced from Public Health Advisory
 Possible causal pathways between _____________________________ and
health outcomes for people in this
situation:_____________________________________.
14
 Activity 3: Personal Profiles
Learning Outcome: Students will demonstrate knowledge and
understanding of the effects the determinants of health have on
individuals, including themselves.

Task One:
For the profiles below, suggest the determinants of health that could be
affecting the person and how these determinants could be
helping/harming their health.

Write your answer in paragraph form.

Refer to all of the determinants that you believe are relevant, such as:
Lifestyle (personal behaviours), social status, social support, physical
environment, education, gender, political system, age.

ONE
Sarah is 43 years old. She has a high-stress job and she often has to work late.
Consequently she doesn’t get much exercise and has to eat on the run. Sarah
lives by herself in an apartment in the middle of Auckland city. She earns a
good salary and can afford health insurance. Lately she has been smoking and
drinking more than normal because work is extra-busy.

TWO
Jeff is in his mid-30’s. He is a fitness-freak – he goes to the gym every day of
the week. He is a vegetarian and eats a lot of fresh fruit and veges. Jeff does
not smoke and drinks socially with his friends (they get together a couple of
times a week). Jeff loves his job – he is an architect and gets to go out on work
sites quite often. Jeff lives in a small city in Canada and enjoys the free health
care system and political stability his country has to offer.

THREE
Nkosi lives in South Africa in a shanty town. He lives just out of a main city,
where 20% of the population is HIV positive. Nkosi does not have HIV. Nkosi
has a job that gives him an average wage in his area – this converts to about
$25 NZ dollars a month. He walks 10KM each morning and night to get to work.
Nkosi does not smoke or drink alcohol, and his diet is very limited because he
can’t afford to spend much on food (he eats mostly rice).

Task Two:

Write a page on the topic: “What are the main determinants that affect
my health”.
Include:
--Helping and harming factors
--A mix of all levels of the determinants
--Reasons why these determinants are the main determinants that affect
your health
--What determinants could be altered to improve your health (if any).
--Make some comparisons between you and someone who has a life like
Nkosi.

15
  Compare (what is the same?)
 Contrast (what is different?)

16
Task One: The main determinants that are affecting each
person’s health

Sarah:
_____________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

_____________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

Jeff:

_____________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

_____________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

17
Nkosi:
_____________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

_____________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

18
Task Two: The main determinants that affect my health

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

_____________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

_____________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

_____________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

_____________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

19
___________________________________________________________________________________

20
 Activity 4: Determinants of health in our school
Learning Outcome: Students will investigate the links between the
determinants in the school and the effects on the health or well-being of
the students enrolled at that school.

Use the profile of our school below to suggest the determinants of health
that could be affecting the students/teachers at this school and how these
determinants could be helping/harming their health.

Write your answer in paragraph form.

Refer to all of the determinants that you believe are relevant, such as:
Lifestyle (personal behaviours), social status, social support, physical
environment, education, gender, political system, age.

[insert profile information for relevant school. The latest ERO

report is a good source of information]

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

21
___________________________________________________________________________________

___________________________________________________________________________________

22
 Activity 5: In Sickness and Inequity
Reference: The Ministry of Education (2004). The Curriculum in Action:
Making Meaning, Making a Difference. Learning Media; Page 56.

Learning Outcome: Students will identify and explain how the

determinants of health contribute to inequities in the health outcomes of
various populations and explore the ethical issues relating to inequity in
health outcomes.

Use the article: In Sickness and Inequity to complete this activity.

Read the article provided and answer the following questions:

1. What is the most important determinant of health, according to Ichiro

Kawachi?

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

2. What evidence does he have to support this view? (Try to find 3

excerpts).

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

3. Do you agree or disagree with this point of view? Explain your answer
in relation to the determinants of health.
___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

4. Use your understanding of the determinants of health to explain some

implications of “social capital”.
___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

23
5. What are the advantages and disadvantages of an egalitarian society?

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

24
In sickness and inequity
In an interview with Kelly Andrew for The Press (Christchurch, 4 August
2001), Professor Ichiro Kawachi, an ex-New Zealander and now an
associate professor at the Harvard School of Public Health, expressed
concern that the growing gap between the rich and the poor in New
Zealand could be hazardous to its health. Extracts from the article follow.

Eating the right food, exercise, and well-funded public hospitals are
virtually irrelevant to the good health and longevity of a society. Instead,
the most important determinant of health is living in an egalitarian
society.

"What really makes a difference for wellbeing is whether there's equality

in growth of incomes and standard of living. It's well documented that as
a result of the economic policies of the 1980s, New Zealand has become a
much more unequal society."

But, he reassures, we are nowhere near the level of his home for the past
10 years. The United States is one of the unhealthiest countries in the
world, and the most unequal. The US spends 13 per cent of its gross
domestic product (GDP) on health care. New Zealand spends about half
that amount. Yet New Zealanders have a longer life expectancy and lower
infant-mortality rate than US residents.

"There is zero correlation between how much is spent on health care and
how healthy society tends to be ... Americans are obsessed about
maintaining their health ... but they have terrible health statistics."

By contrast, in Japan, where many businessmen are chain smokers, the

life expectancy is eight years longer than in the US. Professor Kawachi
says this is because Japanese society is more egalitarian. In the US, a top
chief executive would earn 400 times the income of a blue-collar worker.
In Japan, typically the highest paid would earn just seven times [as much
as] their lowest paid employee.

"I firmly believe in the benefits of the free market. I believe the market
should deliver what people want. But there are things that the market
does poorly, like trying to provide for social cohesion."

The former Soviet Union is an example. As it moved rapidly into a free

market environment, social values disintegrated and life expectancy
slipped by eight years within two years of the economic transformation.
He believes inequality has a devastating effect on social capital – which
he defines as relationships between citizens, trust, volunteerism, and
community participation – as well as [on] health.

"When the gap between rich and poor widens there's an accompanying
erosion of social capital. People become more selfish, less trusting of each
other. Volunteerism and civic engagement goes down and we become a
careless society."

25
 from Andrew, K., 'In Sickness and Inequity', The Press (Christchurch),
4 August 2001, page 6

26
 Activity 6: Recommendations for Equitable
Outcomes
Learning Outcome: Students will investigate and explore the health
promoting strategies and recommendations for ensuring more equitable
outcomes for different individuals and groups in society.

By now you will have a very good understanding of the determinants of

health and how they work together to influence whether people are
healthy or unhealthy. Most of the achievement standards in level 3 health
require you to come up with recommendations for future action in relation
to a health issue.

Choose three determinants of health and give recommendations for

action to create equitable outcomes for health (where people are treated
fairly in having good health) in relation to that determinant.

You will need to give details of your recommendations and explain why
you believe this would be useful. Refer back to the information on
determinants (particularly the NZ information and research) to help you.

Example:

Distribution of income:

I recommend a taxation system to reduce inequities between what

people are earning in NZ. People who are earning more pay a higher
level of tax. People who are earning less pay a lesser level of tax and so
have more money in their pocket. This will enable them to improve their
living conditions and it will bring income differences between rich and
poor closer. I also recommend re-training people with low/no
qualifications. If NZ had a more skilled and educated workforce (at the
lower end of the pay scale) they would demand higher salaries and
these people’s pay conditions would improve. This would also reduce
the difference in income between the highest and lowest income
earners.

Determinant 1:__________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________
27
_____________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

Determinant 2:__________________________

___________________________________________________________________________________

___________________________________________________________________________________

_____________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

_____________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

Determinant 3:__________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

28
_____________________________________________________________________

___________________________________________________________________________________

_____________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

29
 Activity 7: Putting it all together – the overview
in health
Learning Outcome: Students will demonstrate knowledge and
understanding of how the determinants of health link into the ‘bigger
picture’ of the underlying concepts in the health curriculum.

By now you should have a solid understanding of how the determinants

can affect an individual’s or group’s health status, and that to make things
more equitable there needs to be action taken to ensure social justice.

The NZ Health curriculum is based on four underlying concepts; that of

Hauora, Health Promotion, a Socio-ecological Perspective, and Attitudes
and Values to enhance the wellbeing of individuals and society.

On the following page, fill in the blanks with the four underlying concepts
that you see best fit into the diagram of the overview in health. Put the
relevant determinants into the spaces that contribute to health issues for
individuals and groups in society.

From: HPE Curriculum, Ministry of Education 1999

30
 Getting the Whole Picture of Health

OVERALL UNDERLYING CONCEPT

UNDERLYING CONCEPT

UNDERLYING CONCEPT

UNDERLYING CONCEPT

7.
6.

5. Personal,
Personal, CONSEQUENCES for interpersonal and
interpersonal personal, interpersonal societal STRATEGIES
and societal and societal well-being
4. to bring about health-
INFLUENCES on the related to the health enhancing change
stated health issue issue
3.

2. …sometimes,
Sustainable health
consequences can’t be
strategies need to
ignored and need to be
1. emphasise the actions
addressed as well
needed to change the
factors that influence
the health issue

31
ADDITIONAL PAGES FOR NOTES:

_____________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

_____________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

_____________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

_____________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

_____________________________________________________________________

___________________________________________________________________________________

32
___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

_____________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

_____________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

_____________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

_____________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

33
_____________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

_____________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

_____________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

_____________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

_____________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

34
___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

_____________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

35