https://doi.org/10.15218/ejnm.2024.20 Erbil j. nurs. midwifery, Vol. 7, No. (2), Nov 2024 Original Article Impact of an Educational Program on Quality of Life among Patients Undergoing Hemodialysis in Akre/ Iraqi Kurdistan Region ABSTRACT Background and Objective: Chronic kidney diseases is an international public health is- sue, and it has a rising extent, occurrence and significant treatment expenditures. The guidance is a crucial step in raising the standard of dialysis care and improving the results of quality of life for end- stage renal disease patients. Therefore, the study's objectives were to establish, implement, and evaluate the impact of the educational program on he- modialysis patients' quality of life at the study site. Methods: A quasi-experimental research study was conducted at the Urology Center's hemodialysis units at Golan General Hospital in Akre. Data were collected from 30 adult dialysis patients who were undergoing dialysis regularly. Results: According to the current study, patients' overall mean quality of life scores in- creased in many aspects of quality of life (physical, psychological and social) with a statis- tically significant difference shortly after the program's introduction. This increased level was marginally reduced after a month of program implementation. Conclusion: The overall quality of life of the patients who underwent the intervention saw an improvement in score, all metrics relating to quality of life and health were significant- ly improved by the educational program. Key words: End-stage renal disease; Hemodialysis; Educational program; Quality of Life. Zikri Mahmood Mirza; Department of Nursing, Akre Technical Institute/ Akre University for Applied Sciences, Duhok, Kurdistan Region, Iraq. (Correspondence: zekri.mirza@dpu.edu.krd) 214 Received: 07/06/2024 Accepted: 01/11/2024 Published: 30/11/2024 Copyright ©2024The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. mailto:Zekri.mirza@dpu.edu.krd?subject=Zekri.mirza@dpu.edu.krd%20 mailto:Zekri.mirza@dpu.edu.krd?subject=Zekri.mirza@dpu.edu.krd%20 mailto:Zekri.mirza@dpu.edu.krd mailto:jawdat.baker@hmu.edu.krd?subject=jawdat.baker@hmu.edu.krd%20%20%20 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.20 Erbil j. nurs. midwifery, Vol. 7, No. (2), Nov 2024 Original Article Renal function is thought to permanently deteriorate in end-Stage Renal Disease (ESRD). It is considered a fatal condition for which only hemodialysis (HD) or peritoneal dialysis can guarantee a life[1].End-stage renal disease requires lifetime treatment, which may include renal replacement ther- apy, education, and dietary and hydration restrictions. As a result, it significantly affects the affected patients' QOL, morbidi- ty, and death [2].Information from the lit- erature indicates that the health of ESRD patients is extremely low when compared to the general population's state of health [3]. This is the rationale behind the in- creased focus given to health-related quali- ty of life (HRQOL).[4] Some medical treat- ments for people with renal failure focus more on enhancing QOL than they do on addressing the underlying pathology and consequences. Consequently, it is recog- nized that HRQOL evaluation is subjective [5].Patients with renal failure must adjust their lifestyles in a number of ways be- cause HD is a chronic condition in order to manage its complications and cope with their sickness [6].The care of patients with ESRD is thought to focus primarily on im- proving QOL [7].Because of the worrisome increase in the prevalence of renal failure, expensive therapy, and general reduction in patients' QOL, the adoption of efficient treatment is crucial [3].Approaching pa- tients' QOL through an educational pro- gram is essential since QOL is seen as a main goal in the therapy of renal failure [8].As it significantly increases a patient's alertness of their ailment, active patient participation in their method of therapy and managing is a crucial element to the enhancement of their QOL generally[9]. This educational program aims to educate ESRD patients with HD to improve their health condition and their overall QOL. A quasi-experimental study design was carried out in Akre Golan General hospital in order to evaluate the impact of an instructive program on HRQOL among HD patients undergoing treatment at HD facilities. The present study was executed in Akre General hospital at Akre district during the period from 2nd January to 20th June 2023. The study included 30 patients, who were on regular dialysis; they were ready to share willingly in the study, and agreed to grant consents. For the purpose of this study, a two-part instrument to evaluate patients' quality of life while receiving hemodialysis was created. The demographic data sheet is concerned with the determination of the demographic characteristics of patients (age, gender, place they grew up, level of education, and duration hours of dialysis).Also, the Construct questionnaire for Q.o.L was created by the WHOQOL- BREF, or World Health Organization Instrument of Quality of Life [10]. questionnaires with 24 items to evaluate the level of hemodialysis patients' quality of life.Physical health, psychological health, social relationships, and environmental domains, these domains are commonly used in research and evaluation to understand various aspects of an individual's well-being.Regarding the (WHOQOL-BREF) part, data was gathered through direct interviews (face-to-face) which had been completed by all samples of the study for 20 - 30 minutes by using the (WHOQOL-BREF) questionnaire. The patients QOL was assessed by the score cutoff point to poor was (1-3), good (< 3- 5). An official administrative satisfactory from the Akre Directorate of Education was acquired before the data was collected by the Planning Department to conduct the present study. The data was 215 Copyright ©2024 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. INTRODUCTION METHODS https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.20 Erbil j. nurs. midwifery, Vol. 7, No. (2), Nov 2024 Original Article Table 1 illustrates of the sociodemograph- ic features of 30 patients undergoing he- modialysis that attends to Golan General Hospital (hemodialysis unit). Concerning patients age about 43.3% of the patients belonged to the age group above 40 years, 53.3% of them were male, and 46.7% fe- male. Also, it shows that 26.6% had no for- mal education. With regard to the place where he grew up the highest percentage 56.7% was in urban areas. The greatest percentage with regard to the duration of dialysis 56.7%, remains 4 hours on the di- alysis machine. collected during the time from 1st May to 5th July 2023 in Akre Teaching hospital. The educational intervention was imple- mented at Akra Golan General Hospital in Akra City, and focused on four main do- mains (Physical, Psychological, Social and Environmental). The educational was im- plemented through four meetings, where patients were divided into five groups, each group included six patients according to the number of dialysis machines availa- ble in the hospital. Information was provid- ed in each session related to the patient's quality of life on dialysis, and the evalua- tion phase focused on knowing the impact of the educational program by using a simi- lar quality of life questionnaire that was used in the initial tests directly and after one month of implementing the program. The primary guideline for gathering data was ethical considerations. Therefore, be- fore beginning the interview, patient must sign the informed permission form that the researcher has produced. Before collection of data, the researcher clarified the study's goals for the patient and its appeal for par- ticipation. Statistical Package for the Social Sciences software was used to evaluate the data after it was collected. “SPSS 19” software. To determine the statistical sig- nificance of specific variables, the out- comes were given as frequencies, percent- ages, chi-square tests, and paired t-tests. A result is significant when the p-value is less than or equal to 0.05. 216 Copyright ©2024The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. RESULT Table 1: Sociodemographic characteristics of (30) patients. Variables Characteristics No. (%) Age 20-30 years 8 (26.7) 31-40 years 9 (30) Above 40 years 13 (43.3) Gender Male 16 (53.3) Female 14 (46.7) Level of education No formal education 8 (26.6) Illiterate 5 (16.7) Primary school 5 (16.7) Middle school 6 (20) Collage and above 6 (20) The place where he/ she grew up Urban 17 (56.7) Rural 13 (43.3) Duration hours of dialysis 3 hours 13 (43.3) 4 hours 17 (56.7) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.20 Erbil j. nurs. midwifery, Vol. 7, No. (2), Nov 2024 Original Article 217 posttest2 mean=64.2) and the p-value was shown (pre. p= 0.14, immediately. p= 0.00, and posttest. 2 p=0.02), although the mean scores of patients’ Q.o.L. de- creased statistically significant after thirty days of executing the program in com- parison to right away subsequently carry- ing out the program. Table 3 illustrates Q.o.L scores of all pa- tients in dialysis patients before, right away, and one month after the program's implementing. Most of the studied pa- tients 43.3% gained good Q.o.L as soon as the program was implemented com- pared to 3.3% prior to putting the proto- col into action. This high quality of life declined to 20% after thirty days from executing the program. Figure 1 shows the total mean scores of patient’s Q.o.L in dialysis patients prior to, immediately after and one month the pro- gram's implementation there was a statisti- cally significant rise in patients’ Q.o.L both immediately and one month after starting the program in comparison to prior to the program's implementation (pretest mean=57.3, posttest 1 mean = 68.3 and Table 2 demonstrations mean scores of patient’s Q.o.L in dialysis patients prior to, right away and one month after the pro- gram's implementation: the mean patient Q.o.L scores increased statistically signifi- cantly in all domains except environmental during right away and thirty days after pro- gram execution in comparison to before program execution, while the quality of life decreased marginally significantly in all domains thirty days after program execu- tion in comparison to right away after im- plementing a program. Copyright ©2024 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Figure (1) shows total mean scores of patient’s Q.o.L in dialysis patients pre, Immediately, after one month the program's implementation. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.20 Erbil j. nurs. midwifery, Vol. 7, No. (2), Nov 2024 Original Article 218 Copyright ©2024 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table 2: mean scores of patient’s Q.o.L in dialysis patients pre, right away, and one month after the program's implementation. (n=30). Table 3: Total patient’s Q.o.L scores in dialysis patients pre, right away, and one month after the program's implementation (n=30). Domain No. of items Pre- test Mean ± SD Right away post test Mean ± SD Post- test after 1 month Mean ± SD Significance test T1 T2 T3 Physical 7 19.67±5.07 21.70±3.97 21.17±3.73 T= (-3.47) P = 0.002 T=(- 2.36) P= 0.025 T= (2.44) P=0.021 Psychological 7 15.9±3.94 18.47±3.20 18.23±3.35 T= (-4.06) P= >0.001 T=(-3.48) P= 0.002 T= (2.25) P= 0.032 Social 3 6.1±1.21 7.83±2.45 7.43±2.58 T= (-2.85) P= 0.008 T=(-7.95) P= 0.015 T= (2.35) P=0.026 Environmental 8 21.90±5.50 21.97±5.58 22.03±5.70 T=(- 1.44) P=0.16 T= (-1.28) P= 0.21 T= (-1) P = 0.327 (T1) test = Pre-test and immediately post-test paired samples t-test. (T2) test=Paired Samples T-test between pre-test and thirty days post-test. (T3) test = Paired Samples T-test between immediately and thirty days post-test. P = Significance Score Pre test immediate- ly post test After one month post test Significance test X2 1 X2 2 X2 3 No (%) No (%) No (%) X2= 23.86 P = 0.000 X2=7.8 P = 0.02 X2=6.18 P = 0.046 Poor <50 % 23 (76.7) 5 (16.7) 13 (43.3) Fair 50 -75% 6 (20) 12 (40) 11 (36.7) Good >75% 1 (3.3) 13 (43.3) 6 (20) (X2 1) = Chi square (significance) between pre-test and immediately post-test. (X2 2) =Chi square (significance) between pre-test and thirty days post-test. (X2 3) = Chi square (significance) between immediately and thirty days post-test. P = Significance https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.20 Erbil j. nurs. midwifery, Vol. 7, No. (2), Nov 2024 Original Article sociodemographic traits and quality of life except level of education in the pretest, right away and after the one-month posttest. Table 4 illustrates the association between patients Q.o.L scores in dialysis patients and sociodemographic traits: There was no significant different between 219 Copyright ©2024 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table 4: shows relationship between total patient’s Q.o.L score in dialysis patients and sociodemographic characteristics(N=30) P; Poor F; Fair G; Good X21= Base line relationship between level patient’s Q.o.L score in dialysis patients and sociodemographic characteristics. X22 = immediately posttest relationship between level patient’s Q.o.L score in dialysis patients and socio- demographic characteristics. X2 3= after 1 month posttest relationship between level patient’s Q.o.L score in dialysis patients and socio- demographic characteristics. Variables pretest n=30 Right away posttest n= 30 After 1 month posttest n= 30 Significance test Q.o.L Q.o.L Q.o.L P F G P F G P F G X2 1 X2 2 X2 3 Age 20-30 years 6 1 1 1 3 4 6 1 1 X2= 7.59 P = 0. 11 X2= 2.76 P = 0. 599 X2= 5.74 P = 0.22 31-40 years 5 4 0 3 3 3 4 3 2 Above 40 years 12 1 0 1 6 6 3 7 3 Gender Male 10 5 1 2 6 8 7 6 3 X2= 3.94 P = 0. 14 X2= 0.76 P = 0. 68 X2= 0.35 P = 0.98 Female 13 1 0 3 6 5 6 5 3 Level of education No formal education 6 1 1 0 0 8 1 1 6 X2= 3.67 P = 0.88 X2= 15.68 P = 0.04 X2= 21.74 P = 0.005 Illiterate 4 1 0 1 2 2 3 2 0 Primary school 4 1 0 1 3 1 2 3 0 Middle school 5 1 0 2 3 1 3 3 0 Collage and above 4 2 0 1 4 1 4 2 0 The place where he/she grew up Urban 14 2 1 3 8 6 8 7 2 X2= 2.26 P = 0.32 X2= 1.1 P = 0.58 X2= 1.67 P = 0.43 Rural 9 4 0 2 4 7 5 4 4 Duration hours of dialysis 3 Hours 11 1 1 3 3 7 5 6 2 X2= 3.23 P = 0.19 X2= 2.79 P = 0.25 X2= 0.93 P = 0.63 4 Hours 12 5 0 2 9 6 8 5 4 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.20 Erbil j. nurs. midwifery, Vol. 7, No. (2), Nov 2024 Original Article total QOL. The aggregate average results for the patient's quality of life increased in a statistically meaningful way directly and thirteen days from executing the program in comparison to before executing the pro- gram, whereas statistically significant dete- rioration was seen in the mean patient Q.o.L scores one month following the exe- cution of a program compared to the pro- gram's initial implementation. This out- come was in line with the results of Mo- hammed et al.[16] which they found in their study that patient counseling might enhance patients' health-related quality of life (QOL) by raising their level of aware- ness and dispelling any misconceptions they may have regarding their disease's course and how to manage it. The current study revealed that no statistically signifi- cant difference existed between total qual- ity of life and their age, gender, the place where they grew up, and duration of hours of dialysis. This finding conflicted with Bay- oumi et al.[17] who narrated that age and being a man were poor predictors of life quality. This conclusion also contradicted Seica et al.,[18] claims that female gender and older age were all linked to lower quality of life. The study also revealed that there was a statistically significant differ- ence between their level of education and their overall quality of life. This could be ascribed to an improvement in the pa- tients' quality of life due to effective knowledge transmission from the re- searcher to them. This result is in disagree- ment with Alshraifeen et at.,[19] Studies have indicated a beneficial association be- tween education level and quality of life. Also, Sathvik, B. S. et al.,[20] Studies have revealed a favorable correlation between gender, education level, and quality of life. From the researcher’s point of view, per- haps the reason for this difference is due to the patients not receiving educational programs in hospitals that would increase A major side effect of chronic kidney dis- ease (CKD) progression is end-stage renal disease (ESRD), which has a meaningful global impact on morbidity and death. Pa- tients with HD deal with a variety of issues that have an impact on many areas of their lives[11]Evaluation of HRQOL in pa- tients with chronic diseases like CKD has become a cornerstone of patient care and medical management. Therefore, as- sessing QOL in hemodialysis patients will assist in evaluating the level of care given and the effectiveness of medical treat- ment[12].Regarding the effect of the edu- cational program offered to patients, ac- cording to the current study, the average rating of patients' quality of life significant- ly improved both right away and one month after using the program compared to previously. These results are very com- parable to the research of Bakarman et al.,[13] the educational program's effects on HD patients' improved QOL were evalu- ated eight weeks later, according to their statement. After health education, the re- sults revealed a considerable enhance- ment in each domain. Also, this finding goes with Ghadam et al.,[14] demon- strating that after completing a self-care education program, HD patients' QOL im- proved in all dimensions of direct commu- nication training groups (p 0.001). Regard- ing total patients' Q.o.L score, the pa- tients’ level was good of Q.o.L soon follow- ing implementation of the program, which partially reduced after one month. This issue is agreement with the finding of Abraham et al.,[15],which was demon- strated a striking disparity. During their first and second visits, HD patients in the test group experienced significant im- provements in QOL, but the control group experienced little to no change. When in comparison to the control group, the pa- tients in the test group had an advanced 220 Copyright ©2024 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. DISCUSSION https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.20 Erbil j. nurs. midwifery, Vol. 7, No. (2), Nov 2024 Original Article (8) D. L. Mapes et al., “Health-related quality of life as a predictor of mortality and hospitali- zation: the Dialysis Outcomes and Practice Patterns Study (DOPPS),” Kidney Int., vol. 64, no. 1, pp. 339–349, 2003. (9) F. Yang et al., “Health-related quality of life of Asian patients with end-stage renal dis- ease (ESRD) in Singapore,” Qual. Life Res., vol. 24, pp. 2163–2171, 2015. (10) S. M. Skevington, M. Lotfy, and K. A. O’Con- nell, “The World Health Organization’s WHOQOL-BREF quality of life assessment: psychometric properties and results of the international field trial. A report from the WHOQOL group,” Qual. life Res., vol. 13, pp. 299–310, 2004. (11) M. K. Jahromi, S. Javadpour, L. Taheri, and F. Poorgholami, “Effect of nurse-led telephone follow ups (tele-nursing) on depression, anx- iety and stress in hemodialysis patients,” Glob. J. Health Sci., vol. 8, no. 3, p. 168, 2016. (12) C. Bale et al., “Psychosocial factors in end- stage kidney disease patients at a tertiary hospital in Australia,” Int. J. Nephrol., vol. 2016, 2016. (13) M. A. Bakarman, M. K. Felimban, M. M. Atta, and N. S. Butt, “The effect of an educational program on quality of life in patients under- going hemodialysis in western Saudi Arabia,” Saudi Med. J., vol. 40, no. 1, p. 66, 2019. (14) M. S. Ghadam, F. Poorgholami, Z. B. Jahromi, N. Parandavar, N. Kalani, and E. Rahmanian, “Effect of self-care education by face-to-face method on the quality of life in hemodialysis patients (relying on Ferrans and Powers Questionnaire),” Glob. J. Health Sci., vol. 8, no. 6, p. 121, 2016. (15) S. Abraham, A. Venu, A. Ramachandran, P. M. Chandran, and S. Raman, “Assessment of quality of life in patients on hemodialysis and the impact of counseling,” Saudi J. Kid- ney Dis. Transplant., vol. 23, no. 5, pp. 953– 957, 2012. (16) I. S. Salam and M. A. Abdelhady, “Impact of teaching guidelines on quality of life for he- modialysis patients,” Nature and Science,vol. 8 , no. 9, p. 219, 2011. (17) M. Bayoumi, A. Al Harbi, A. Al Suwaida, M. Al Ghonaim, J. Al Wakeel, and A. Mishkiry, “Predictors of quality of life in hemodialysis patients,” Saudi J. Kidney Dis. Transplant., vol. 24, no. 2, pp. 254– 259, 2013. the quality of life in renal failure at its last stage. The results of the present study indicate that enhancing educational initiatives and hemodialysis patients' counseling results in an improvement that is both clinically and statistically meaningful in their QOL. Also, these initiatives will raise social, emotional, physical, and overall HRQOL scores. Fur- thermore, the results demonstrate the im- portance of providing routine counseling during the daily lives of dialysis patients in order to improve their quality of life. (1) K. Landreneau, K. Lee, and M. D. Landreneau, “Quality of life in patients un- dergoing hemodialysis and renal transplanta- tion-a meta-analytic review,” Nephrol. Nurs. J., vol. 37, no. 1, p. 37, 2010. (2) 2E. Nemati and M. Motalebi, “A Better Quali- ty of Life in Hemodialysis Patients With Viral Hepatitis: Is it a Reality?,” Hepat. Mon., vol. 13, no. 11, 2013. (3) Z. Wen et al., “Health related quality of life in patients with chronic gastritis and peptic ulcer and factors with impact: a longitudinal study,” BMC Gastroenterol., vol. 14, pp. 1– 10, 2014. (4) A. H. A. Mazairac et al., “Differences in quali- ty of life of hemodialysis patients between dialysis centers,” Qual. life Res., vol. 21, pp. 299–307, 2012. (5) S. W. Klarenbach, M. Tonelli, B. Chui, and B. J. Manns, “Economic evaluation of dialysis therapies,” Nat. Rev. Nephrol., vol. 10, no. 11, pp. 644–652, 2014. (6) A. H. Pakpour, I. M. Zeidi, N. Chatzisarantis, S. Molsted, A. P. Harrison, and R. C. Plot- nikoff, “Effects of action planning and coping planning within the theory of planned be- haviour: A physical activity study of patients undergoing haemodialysis,” Psychol. Sport Exerc., vol. 12, no. 6, pp. 609–614, 2011. (7) Y. Lii, S. Tsay, and T. Wang, “Group interven- tion to improve quality of life in haemodialy- sis patients,” J. Clin. Nurs., vol. 16, no. 11c, pp. 268–275, 2007. 221 Copyright ©2024 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. CONCLUSION REFERENCES https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.20 Erbil j. nurs. midwifery, Vol. 7, No. (2), Nov 2024 Original Article (18) A. Seica et al., “Factors affecting the quality of life of haemodialysis patients from Roma- nia: a multicentric study,” Nephrol. Dial. Transplant., vol. 24, no. 2, pp. 626–629, 2009. (19) A. Alshraifeen, M. McCreaddie, and J. M. M. Evans, “Quality of life and well‐being of peo- ple receiving haemodialysis treatment in S cotland: A cross‐sectional survey,” Int. J. Nurs. Pract., vol. 20, no. 5, pp. 518–523, 2014. (20) B. S. Sathvik, G. Parthasarathi, M. G. Nara- hari, and K. C. Gurudev, “An assessment of the quality of life in hemodialysis patients using the WHOQOL-BREF questionnaire,” Indian J. Nephrol., vol. 18, no. 4, p. 141, 2008. 222 Copyright ©2024 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/