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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 29  |  Issue : 1  |  Page : 63-69

Knowledge and attitude towards, and the utilisation of cervical and breast cancer screening services by female healthcare professionals at a tertiary care hospital of Eastern India: A cross-sectional study


Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India

Date of Submission07-Dec-2021
Date of Decision05-Jan-2022
Date of Acceptance06-Jan-2022
Date of Web Publication28-Jan-2022

Correspondence Address:
Dr. Swayam Pragyan Parida
Department of Community and Family Medicine, All India Institute of Medical Sciences, 3rd Floor, Academic Block, Bhubaneswar, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/npmj.npmj_760_21

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  Abstract 


Background: Breast and cervical cancers are the two leading causes of cancer-specific mortality and morbidity amongst Indian women. Screening methods are cost-effective. However, the uptake of screening methods in India is very low. Knowledge and attitude of healthcare professionals (HCPs) play an important role in reducing the mortality related to cancer. Materials and Methods: This study aimed to assess the knowledge and utilisation of screening methods for cervical and breast cancer and to elaborate barriers for non-utilisation amongst female HCPs, both doctors and nurses. A cross-sectional study was carried out from April to July 2017 in a tertiary healthcare hospital of eastern India amongst 200 female HCPs using a pre-designed, pre-tested, self-administered questionnaire. Data were analysed using the Statistical Package for the Social Sciences version 20.0. Statistical tests such as proportion and mean were calculated and the Chi-square test was used as a test of significance for categorical variables. Results: Clinical breast examination and mammography were practiced by only 26.5% and 7% of respondents, respectively. Only seven doctors and one nurse had ever undergone Pap smear. More than 90% of respondents knew risk factors, signs and symptoms and the availability of screening tools for the detection of cervical and breast carcinoma. Conclusions: The utilisation of breast and cervical cancer screening was unsatisfactory despite having good knowledge of the preventable cancers and screening methods amongst HCPs. There is a need for attitudinal change amongst HCPs by continuous sensitisation programmes.

Keywords: Attitude, breast cancer, cancer screening, cervical cancer, female healthcare professionals, knowledge, practice


How to cite this article:
Subba SH, Parida SP, Sahu DP, Kumari J. Knowledge and attitude towards, and the utilisation of cervical and breast cancer screening services by female healthcare professionals at a tertiary care hospital of Eastern India: A cross-sectional study. Niger Postgrad Med J 2022;29:63-9

How to cite this URL:
Subba SH, Parida SP, Sahu DP, Kumari J. Knowledge and attitude towards, and the utilisation of cervical and breast cancer screening services by female healthcare professionals at a tertiary care hospital of Eastern India: A cross-sectional study. Niger Postgrad Med J [serial online] 2022 [cited 2022 Oct 1];29:63-9. Available from: https://www.npmj.org/text.asp?2022/29/1/63/336749




  Introduction Top


Worldwide, carcinoma of cervix and carcinoma of breast are the leading causes of cancer-related morbidity and mortality amongst women.[1] In India, breast and cervical cancers are the two most common cancers amongst females accounting for 27.7% and 16.5% of the female cancers, respectively.[2] Deaths due to these cancers are high owing to higher prevalence. Recent estimates have shown that the morbidity and mortality related to these two cancers can be reduced to 50%–70% by regular screening the women in the reproductive age group.[3] Therefore, in advanced countries, the incidence of breast cancer and cervical cancer has shown downward trend with the advent of cancer screening methods such as mammography and Pap test, respectively, and emphasis on routine screening amongst eligible women.[4]

Effective screening tools such as Papanicolaou (Pap) test and clinical breast examination (CBE) and mammography are available for these two cancers.[5] Under the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke in India, Pap smear test and CBE are available in primary healthcare settings. However, in India, the utilisation of cancer screening services is quite low even amongst healthcare professionals (HCPs).[6],[7] Further knowledge regarding the availability of screening methods and overall information on signs and symptoms of cancer amongst the population is very low, leading to the late detection of cancer.[5] Recent studies have revealed the disturbing fact that even the attitude and practice of HCPs towards screening methods are unsatisfactory.

Very few studies have been undertaken to find the utilisation of cancer screening services by female HCPs. Hence, this study was undertaken with the aim to assess the knowledge and utilisation of breast and cervical cancer screening and also to find out the reasons for its non-utilisation amongst HCPs.


  Materials and Methods Top


Ethical approval was obtained from the Institute Ethics Committee of All India Institute of Medical Sciences, Bhubaneswar, prior to the commencement of the study. The study was approved with Ethical Approval Number IEC/AIIMS BBSR/STS_UG/2017-18/5 on 18 May 2017. Written informed consent was obtained from the participants before data collection. The study was conducted between May and July 2017.

Study design and study participants

A cross-sectional study was carried out between April and July 2017 in a tertiary care hospital of eastern India amongst 200 female HCPs including faculty members, resident doctors and nursing staff of different departments. All female HCPs (faculty, junior and senior residents and nursing staff) irrespective of their age were included in the study. Those who were not willing to participate were excluded from the study. The sample size was calculated using the formula Zα2pq/d2, taking Pap smear practice of 11.6% from a study by Rahman and Kar,[8] absolute precision of 5% and the desired confidence level of 95%. The sample size came out to be 158. The sample size was 189 after assuming a non-response rate of 20%, which was approximated to 200. The participants were selected using convenience sampling.

Study tool and data collection

A pre-designed, pre-tested, self-administered questionnaire was utilised for data collection. The questionnaire contained the sociodemographic profile of female HCP, their knowledge of symptoms and risk factors regarding breast and cervical cancer and the utilisation of screening methods for these two cancers. Knowledge and practice regarding cancer screening were also assessed.

Statistical analysis and ethical consideration

Data were entered in MS Excel Word 2010 and analysed using Statistical Package for the Social Sciences (SPSS) version 20, IBM Armonk, New York, USA. Statistical parameters such as proportion, mean and standard deviation were used to find out the result. The Chi-square test was applied to assess the level of significance between two groups for categorical variables, and binary logistic regression was applied to find out the association. P < 0.05 was considered statistically significant.


  Results Top


Demography of the study participants

Of the total 200 participants, 68 (34%) were doctors and the remaining 132 (66%) were staff nurses. The mean age of respondents was 30.5 ± 6.24 years. The majority of the respondents 148 (74%) were from Odisha. Of the total respondents, 134 (67%) were married and 7 (5.2%) were using any hormonal contraceptive. Only 3 (1.5%) and 8 (4%) respondents had family history of cervical and breast cancer, respectively. Majority of the respondents belonged to 21–30 years' age group (61.5%).

Cervical cancer screening practice

Only seven doctors (10.3%) and one nurse (0.8%) had ever undergone screening with Pap smear. As many as 26 (38.2%) doctors and 45 (34.1%) nurses did not advise eligible patients for cervical cancer screening [Table 1]. Of the respondents, 86 (43%) never got themselves screened citing lack of symptoms. Five (7.4%) doctors and 18 (13.6%) nurses mentioned that they had no reason to undergo screening [Figure 1]. Pap smear practice was found to be significantly associated with occupation, marital status, years of experience, family history of cervical cancer and oral contraceptive pill use [Table 2].
Table 1: Knowledge and practice about cervical cancer screening amongst respondents

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Figure 1: Attitude of respondents towards cervical cancer screening

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Table 2: Association of screening practice with different factors

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Breast cancer screening practice

Breast self-examination was done regularly by 54 (79.4%) doctors and 101 (76.5%) nurses. However, screening with mammography was abysmally low, where only 14 HCPs had undergone mammography. More than 50% of the doctors and around one-third (34.8%) of the nurses did not ask their patients to undergo screening [Table 3]. Almost 11% responded that they had no reason for not getting screened and 22 (32.4%) doctors and 50 (37.9%) nurses mentioned not having symptom as the reason [Figure 2]. Only one respondent was diagnosed with a precancerous lesion of the thyroid and none with any cancer. The practice of CBE was found to be significantly associated with occupation, marital status and years of experience [Table 1].
Table 3: Knowledge and practice regarding screening for breast cancer

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Figure 2: Reasons for not getting screened and not advising others for getting screened amongst healthcare respondents

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Knowledge regarding cervical cancer and its screening

Majority of the respondents knew risk factors for cervical cancer such as a family history of cancer, multiple sexual partners, poor genital hygiene and sexually transmitted diseases. Only 22 (16.7%) nurses and 39 (57.4%) doctors knew that age at first pregnancy is a risk factor. Age at marriage as a significant risk factor was known to 36 (27.3%) nurses and 39 (57.4%) doctors. Amongst the respondents, 66 (97.1%) doctors and 104 (78.8%) nurses knew that human papillomavirus infection is linked to cervical cancer and the difference is statistically significant [Table 4]. Post-coital bleeding was mentioned as one of the symptoms of cervical cancer by 65 doctors (95.6%) and 105 (79.5%) nurses [Table 4].
Table 4: Knowledge about risk factors and symptoms of cervical cancer amongst respondents

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All doctors were aware of cervical cancer screening, and amongst nurses, 131 (99.5%) were aware of the availability of any screening method for cervical cancer. Almost all the respondents knew about Pap smear, except 4.6% of the nurses. Eligible age for Pap smear was known to 23 (33.8%) doctors and 20 (15.3%) nurses. Only 10% of the doctors and none of the nurses knew about visual inspection after acetic acid application. Furthermore, 51 (75%) doctors and 48 (36%) nurses stated that cervical biopsy is the diagnostic modality for cervical cancer [Table 1].

Knowledge regarding breast cancer and its screening

All of the respondents were aware of breast cancer, and the majority of them (all doctors and 91.7% of nurses) responded that family history of breast cancer was an important risk factor. Knowledge regarding breast cancer is detailed in [Table 5]. A significant difference in knowledge about risk factors was observed between doctors and nurses for major risk factors such as age, family history, obesity, early menarche and late menopause [Table 5].
Table 5: Knowledge about risk factors and symptoms of breast cancer amongst respondents

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Most of the doctors and nurses were aware of the screening tools for breast cancer. Only 19 (27.9%) doctors and 80 (60.6%) nurses could mention the appropriate age for starting CBE, and the difference was statistically significant. Amongst all participants, less than half mentioned that mammography should be started at or above 40 years [Table 3].

For breast cancer symptoms, the knowledge of doctors was found to be satisfactory. Inversion of the nipple and skin changes, which are important findings in breast cancer, was mentioned by 60 (88.2%) doctors and 83 (62.9%) nurses, and the difference was found to be statistically significant [Table 3].


  Discussion Top


A country's cancer screening programme is as good as the healthcare providers' utilisation of the same; for those who take it seriously enough are more likely to advise their patients. In the current study, only one-tenth of the doctors and fewer than 1% of the nurses had ever undergone screening. Pap smear test practice in various Indian studies ranged from 0% by Pegu et al. to 18.4% by Anantharaman et al.[9],[10] Pap smear screening practice ranged from 7% to 16% in Indian studies.[6],[8],[11],[12] The mean age in the study was 44.07 years, whereas it was 30 years in the current study.

Lack of symptoms or 'no reason' was the major reason for not undergoing screening in the study. Similarly, the absence of symptoms was the most common reason by Swapnajaswanth et al., Thippeveeranna et al. and Rahman and Kar.[6],[8],[13] Similarly, Kosambiya et al. reported, 60.8% had no reason and 43.8% due to a lack of symptoms.[14] In our study, around 35% of professionals did not advise eligible beneficiaries to undergo screening. Shekhar et al. reported, nearly 90% of them had never referred patients for screening.[12] This shows a poor attitude towards cancer screening. The cancer prevention and uptake of screening modalities are affected by the knowledge of the beneficiaries regarding the disease. Similar to our result, Swapnajaswanth et al. also reported where knowledge about risk factors was better amongst doctors than the nurses.[13]

The majority of the respondents in the current study mentioned post-coital bleeding (85%) and foul-smelling discharge (88.5%) as symptoms of cervical cancer. Kosambiya et al. in Surat also reported foul-smelling discharge (57.4%) and post-coital bleeding (40.6%) as major symptoms of cervical cancer.[15] Menstrual abnormality and vaginal discharge were the most recognised symptoms by Shah et al. in Ahmedabad.[11] Foul-smelling discharge (63.8%) and irregular bleeding (50.6%) were common symptoms recognised by Rahman and Kar.[8] The knowledge about symptoms was poor in all the three mentioned studies as compared to the current study. In our study, both nurses and doctors were included, whereas in theirs, only nurses were part of the study.

Pap smear as a screening modality for cervical cancer was known to 95% of the participants in the current study, which is better than most other Indian studies, where the knowledge range was wide at 61% to 95%.[8],[9],[10],[11],[12],[14] The minimum of 61% was reported by Shah et al. in Ahmedabad.[11] The highest reported knowledge regarding cervical cancer screening modality was by Anantharaman et al., which was similar to our result.[9] The reason could be the similarity of the study population. Both the studies included doctors and nurses, and all other studies were on nurses only. In Indian studies, the knowledge about Pap smear ranged from 79% to 88.8%.[6],[8],[10],[11],[12],[14] A similar result was reported by Udigwe in Nigeria.[16] In the present study, one-fifth of respondents correctly mentioned eligible age, whereas 54% of respondents mentioned so in the study done by Singh et al.[17]

The level of knowledge about the risk factors of breast cancer amongst HCPs in our study was satisfactory. Family history of breast cancer and radiation exposure were the most commonly mentioned risk factors by the respondents. Similarly, family history, radiation exposure and lack of exclusive breastfeeding were mentioned as major risk factors in the studies by Khokhar et al. in Delhi, Chate et al. in Maharashtra, Fotedar et al. in Himachal Pradesh and Santhanakrishnan et al. in Puducherry.[18],[19],[20] The knowledge of risk factors about breast cancer amongst nurses was poorer as compared to doctors in our study. This shows the need of training of HCPs regarding cancer screening.

In the current study, a lump in the breast (98%) and change in breast shape (84%) were the common symptoms mentioned by the respondents. Similar responses were observed by Lemlem et al. in Ethiopia.[21] Despite good knowledge, practice of screening was found discouraging (26.5% for CBE and 7% for mammography) in our study. The practice was even poorer in other areas as reported in the literature. Only 1.9% of the participants had ever undergone mammography and 81.9% of the participants practiced BSE in Nigeria.[22] Lack of symptoms was the most common reason for not undergoing screening procedure. Similar responses were also observed in a study from India and Singapore.[7],[23] This implies that there was lack of knowledge amongst HCPs that screening should be done even without symptoms.

The study is first of its kind in eastern part of India which assessed both practice and knowledge of breast and cervical cancer screening amongst HCPs. The strength of the study was the comprehensive assessment of knowledge, attitude and practice of cervical and breast cancer screening. The major limitation of the study was the convenient sampling of the study participants, which affects the external validity. Another limitation of the study was that the responses were self-reported and there is a chance of social desirability bias in the study.


  Conclusion Top


The findings of the present study revealed that knowledge about risk factors, symptoms, signs and screening methods of breast and cervix cancer were satisfactory amongst HCPs. However, practice concerning undergoing screening for self or advising eligible women was not encouraging. An important reason cited for not undergoing routine screening was the lack of symptoms amongst nurses and doctors.

It is well established that routine screening for cancer of the breast and cervix goes a long way in early detection, proper management and thereby reduction in morbidity, mortality and disease burden. The practice of routine screening for self amongst HCPs should be given emphasis which then percolates to advising eligible patients and family members for screening. This attitudinal change requires continuous effort from the medical fraternity, by sensitising them with conducting continuing medical education, and periodic training of doctors and nurses regularly. A regular awareness campaign on breast self-examination needs to be done. Then, the knowledgeable HCPs can educate the populace to improve the health-seeking behaviour of women, which should lead to cancer detection at early stages with expected better prognosis.

Acknowledgement

We are thankful to all the healthcare professionals for participating in the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Globocan. International Agency for Research on Cancer, World Health Organization. GLOBOCAN; 2018. Available from: https://gco.iarc.fr/today/data/factsheets/populations/900-world-fact-sheets.pdf. [Last accessed on 2020 Feb 03].  Back to cited text no. 1
    
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International Agency for Research on Cancer, World Health Organization. Globocan India; 2019. Available from: https://gco.iarc.fr/today/data/factsheets/populations/356-india-fact-sheets.pdf. Last Accessed 20th January 2022.  Back to cited text no. 2
    
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Sankaranarayanan R. Screening for cancer in low- and middle-income countries. Ann Glob Heal 2014;80:412-7.  Back to cited text no. 3
    
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National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS). Ministry of Health & Family Welfare Government of India. Available from: https://dghs.gov.in/content/1363_3_NationalProgrammePreventionControl.aspx. [Last accessed on 2019 Nov 19].  Back to cited text no. 4
    
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Goldie SJ, Gaffikin L, Goldhaber-Fiebert JD, Gordillo-Tobar A, Levin C, Mahé C, et al. Cost-effectiveness of cervical-cancer screening in five developing countries. N Engl J Med 2005;353:2158-68.  Back to cited text no. 5
    
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Thippeveeranna C, Mohan SS, Singh LR, Singh NN. Knowledge, attitude and practice of the pap smear as a screening procedure among nurses in a tertiary hospital in north eastern India. Asian Pac J Cancer Prev 2013;14:849-52.  Back to cited text no. 6
    
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Seah M, Tan SM. Am I breast cancer smart? Assessing breast cancer knowledge among health professionals. Singapore Med J 2007;48:158-62.  Back to cited text no. 7
    
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Rahman H, Kar S. Knowledge, attitudes and practice toward cervical cancer screening among Sikkimese nursing staff in India. Indian J Med Paediatr Oncol 2015;36:105-10.  Back to cited text no. 8
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Anantharaman VV, Sudharshini S, Chitra A. A cross-sectional study on knowledge, attitude, and practice on cervical cancer and screening among female health care providers of Chennai corporation, 2013. J Acedmic Med Sci 2012;2:124-8.  Back to cited text no. 9
    
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Pegu B, Dhiman N, Chaturvedi J, Sharma SK. Nurse's knowledge and attitude regarding cervical cancer screening at a tertiary care hospital. Int J Reprod Contracept Obstet Gynecol 2017;6:907-10.  Back to cited text no. 10
    
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Shah V, Vyas S, Singh A, Shrivastava M. Awareness and knowledge of cervical cancer and its prevention among the nursing staff of a tertiary health institute in Ahmedabad, Gujarat, India. Ecancermedicalscience 2012;6:270.  Back to cited text no. 11
    
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Shekhar S, Sharma C, Thakur S, Raina N. Cervical cancer screening: Knowledge, attitude and practices among nursing staff in a tertiary level teaching institution of rural India. Asian Pac J Cancer Prev 2013;14:3641-5.  Back to cited text no. 12
    
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Swapnajaswanth M, Suman G, Suryanarayana SP, Murthy NS. Perception and practices on screening and vaccination for carcinoma cervix among female healthcare professional in tertiary care hospitals in Bangalore, India. Asian Pac J Cancer Prev 2014;15:6095-8.  Back to cited text no. 13
    
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Kosambiya RJ, Gohil A, Kamdar ZN, Patel P, Modi A. Knowledge, attitude and practices about cervical cancer and screening among nurses of a tertiary care centre in western India. Natl J Community Med 2018;9:391-5.  Back to cited text no. 15
    
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Udigwe GO. Knowledge, attitude and practice of cervical cancer screening (PAP smear) among female nurses in Nnewi, South Eastern Nigeria. Niger J Clin Pract 2006;9:40-3.  Back to cited text no. 16
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Singh E, Seth S, Rani V, Srivastava DK. Awareness of cervical cancer screening among nursing staff in a tertiary institution of rural India. J Gynecol Oncol 2012;23:141-6.  Back to cited text no. 17
    
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Chate NN, Deshmukh SB, Dange SY. Awareness of breast cancer risk factors among nurses in a tertiary rural health care centre in India. IJSS J Surg 2017;3:57-60.  Back to cited text no. 18
    
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Fotedar V, Seam RK, Gupta MK, Gupta M, Vats S, Verma S. Knowledge of risk factors and early detection methods and practices towards breast cancer among nurses in Indira Gandhi Medical College, Shimla, Himachal Pradesh, India. Asian Pac J Cancer Prev 2013;14:117-20.  Back to cited text no. 19
    
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Santhanakrishnan N. Knowledge, attitude, and practice regarding breast cancer and its screening methods among nursing staff working in a tertiary-care hospital located in south India. Int J Med Sci Public Heal 2016;5:1650-5.  Back to cited text no. 20
    
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Lemlem SB, Sinishaw W, Hailu M, Abebe M, Aregay A. Assessment of knowledge of breast cancer and screening methods among nurses in university hospitals in Addis Ababa, Ethiopia, 2011. ISRN Oncol 2013;2013:470981.  Back to cited text no. 21
    
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Madubogwu CI, Egwuonwu AO, Madubogwu NU, Njelita IA. Breast cancer screening practices amongst female tertiary health worker in Nnewi. J Cancer Res Ther 2017;13:268-75.  Back to cited text no. 22
    
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Sahu DP, Subba SH, Giri PP. Cancer awareness and attitude towards cancer screening in India: A narrative review. J Family Med Prim Care 2020;9:2214-8.  Back to cited text no. 23
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    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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