|Year : 2020 | Volume
| Issue : 4 | Page : 189-197
COVID-19 strikes: An assessment on psychological vulnerability among quarantined subjects in hospital of city of Kolkata, India
Tanmoy Mitra1, Kedar R Banerjee1, Suman Nandi2
1 Department of Psychiatry, National Institute of Behavioral Sciences, Moulali, Kolkata, West Bengal, India
2 Department of Medicine, KPC Medical College and Hospital, Jadavpur, Kolkata, West Bengal, India
|Date of Submission||29-May-2020|
|Date of Decision||17-Jul-2020|
|Date of Acceptance||17-Jul-2020|
|Date of Web Publication||09-Dec-2020|
Dr. Tanmoy Mitra
National Institute of Behavioral Sciences, P-7, CIT Road, Moulali, Kolkata 700014, West Bengal.
Source of Support: None, Conflict of Interest: None
Introduction: Pandemic of coronavirus disease-2019 (COVID-19) appeared as the most precarious yet unforeseen threat to the existence of mankind. From China it has spread throughout the world and till today the number of infected and death tolls reported are appalling and terrifying. Apart from physical health, the mental well-being of those who are exposed to possible infection is seriously at stake. Aim: This study was an investigation of the mental health status of quarantined subjects in Kolkata Hospital. It aimed to assess how the psychological constructs of quarantined subjects may play a role in psychogenic vulnerability and risk adjustments at the outbreak of this pandemic. Materials and Methods: A total of 60 quarantined subjects in the hospital were assessed for the internal and external locus of control, high and low resilience, upper and lower anxiety symptoms, and high low trait anxiety. The above eight groups were investigated on 18 emotional and dispositional factors on a Likert scale. Results: Significant intragroup differences observed between locus of control and resilience groups in regard to most dispositional and emotional elements. Anxiety symptoms and trait anxiety groups reflected no such intragroup significant differences. Comparisons between the high resilience group and high anxiety group displayed significant differences in most emotional and dispositional measures. Conclusion: Internal locus subjects appeared to be anxious and particular about health and ready to comply with new imposition of health rule. The low resilience group reacted negatively to the most dispositional and emotional measures when compared to the higher resilience group. The high trait anxiety group and high anxiety symptoms group reflected mostly similar responses. All groups acknowledged the health workers’ roles and recognized the need for medical spending for pandemics. Clinical Significance: This study indicates that quarantined subjects with high resilience can fare better facing a psychological crisis as the pandemic of COVID-19.
Keywords: COVID-19, health anxiety, locus of control, quarantine, resilience, trait anxiety
|How to cite this article:|
Mitra T, Banerjee KR, Nandi S. COVID-19 strikes: An assessment on psychological vulnerability among quarantined subjects in hospital of city of Kolkata, India. MGM J Med Sci 2020;7:189-97
|How to cite this URL:|
Mitra T, Banerjee KR, Nandi S. COVID-19 strikes: An assessment on psychological vulnerability among quarantined subjects in hospital of city of Kolkata, India. MGM J Med Sci [serial online] 2020 [cited 2021 Jan 15];7:189-97. Available from: http://www.mgmjms.com/text.asp?2020/7/4/189/302801
| Introduction|| |
The first detection of coronavirus disease-2019 (COVID-19) was from Wuhan, China on December 31, and the outbreak was declared as Public Health Emergency International Concern (PHEIC) on January 30, 2020 and Pandemic on March 11 by the World Health Organization (WHO). Till April 20, more than 2.5 million infections had been detected or reported across 185 countries, with approximately 1,68,000 deaths along with 6,30,000 recoveries accounted for.
Primary spreading happens between people through close contact as by transmission by touch (human to human or by contaminated surface) by droplets (coughing and sneezing). It has been reported that viruses can survive up to 72h outside. It is reported that sputum and saliva both can carry a viral load (droplets) causing infection., The information that coronavirus can be highly contagious and can spread by mere touching or getting close to someone who is infected but asymptomatic induces high anxiety and uncertainty among patients and caregivers. Some commonly arising symptoms such as fever, cough, fatigue, and shortness of breath can indicate COVID infection, which again are very misleading for people. Some other general ailments as gastrointestinal symptoms such as nausea, vomiting, and diarrhea are also reported to be related to corona infection.,
There is no doubt that a great change in lifestyle has been initiated to control the spreading of the dreadful virus., Social distancing and strict use of hygiene rules have been imposed on people., Although measures as staying at home, avoiding crowded places or going to markets or assembly for religious purposes along with the use of masks and repeat hand washing means to control infection––those measures create ordeal causing psychological distress among some people.
The effects of disasters in the form of physical as earthquakes, floods, tsunamis, cyclones, tornadoes, or droughts have certainly affected mankind since the early historic era. Medical diseases causing epidemics or pandemics throughout history, including the plague of Rome, Black Death of Europe, Yellow Fever, polio, Spanish flu, and AIDS, Swine Flu and Ebola have been reported to have significant physical as well as mental liability bourn by mankind. The COVID-19 as it emerged and spread has almost no geographical boundaries or limitations for any population or community that marks this pandemic as the most transmittable deadly virus for man. The mode of transmission through respiratory droplet (SARS-COV-2) makes this highly contagious, creating anticipation of infection among all.
The new frontier of dealing with deadly COVID-19 infection poses a challenge to the psychological welfare of the general population––more so on the population exposed and tested positive for coronavirus. A study on the Indian population by Roy and Tripathy indicated more than 80% of the people were preoccupied with the thoughts of COVID-19 and 72% reported the need to use gloves, and sanitizers. In that study, sleep difficulties, paranoia about acquiring COVID-19 infection and distress related social media were reported in 12.5%, 37.8%, and 36.4%, respectively.
It is understandable that those who are exposed to disease COVID-19 (sick or quarantined), assuming high mortality rates, are surely affected by unbearable psychological stress. It can also be assumed that those who are quarantined but come out negative can undergo significant mental trauma even after the end of the long quarantine period. Some research found that 29% of those quarantined during the SARS outbreak showed signs of posttraumatic stress (PTSD) and approximately 31% showed typical symptoms of depression.
| Materials and methods|| |
A total of 60 subjects were chosen from two hospitals from Kolkata for the study who had been quarantined. Inclusion criterion followed as being highly exposed to COVID-19 and waiting for the COVID test and or subjects detected positive on the COVID test. These subjects were asymptomatic otherwise. At least 1 week of stay at quarantine was necessary to be eligible for inclusion. Any high comorbid patients or patients having acute symptoms were not included in the study. This being a critical emergency situation, other strict inclusion criteria could not be enforced for practical purposes. The mean age was 45.83, with 73.30% males and 26.7% females. Although 66.70% were married and 90% came from lower-middle economic backgrounds [Table 1].
Psychiatric assessments for evaluation
The quarantined subjects were evaluated on four different psychological constructs namely the locus of control (LOC), anxiety symptoms (ASQs), trait anxiety (TAI), and resilience scale (BRS) measures. The median points of each of the above measures had been detected and above and below that point taken for categorizing the groups. Overlapping scores near the median had been discarded. Thus, LOC has been divided into external and internal types and the ASQs, TAI, and resilience groups are separated into high and low categories. Thus all subjects were sorted in eight types based on the above four measures.
Any previously detected major psychiatric disorders, other comorbid serious respiratory, diabetic, or cardiac diseases were excluded from this study and a note was kept about any previous illness history among included subjects.
A COVID questionnaire has been prepared to assess the responses in the context of the COVID-19 pandemic. The questionnaire is a modification of a previously used survey for similar infective diseases and the purpose was to keep the probes simple and to the point., Enquiries targeted toward dispositional and emotional areas that need to be studied in relation to the COVID-19 epidemic. A total of 18 variables were identified for the quarantined subjects. A Bengali version was also used where necessary. The five variables (consisting of health anxiety (Heal), economic hardship (Econ), social distancing (Soc), distress for quarantine (Quar1, Quar2) and discrimination (Stigma) allotted two queries and the other eight variables were on media influence (Media), false belief (Falsebelf), hoarding behavior (Hoard), health checkups (Healchek), washing cleaning practices (Washclean), the role of health workers (Healwork), individual social responsibility (Response), and medical spending(Spendmed). For variables Heal, Econ, and Soc, one for each had been used and thus a total of 14 item variables used for our study as shown in all groups comparing tables [Table 2][Table 3][Table 4].
|Table 2: Two sample t test between groups of external and internal locus of control|
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|Table 4: Two sample t test between high anxiety and high resilience group|
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All subjects were tested on the above emotional, belief, and personality constructs (LOC, ASQ, TAI, and BRS) first and then asked to fill out the COVID questionnaire the next day. Answers were scaled of a 4-point Likert scale marking strongly disagree, somewhat disagree, somewhat agree, and strongly agree. Likert scale is a psychometric scale developed by Rensis Likert (1932) and has been widely used in research and surveys that employ questionnaires. When responding to a Likert item, respondents specify their level of agreement or disagreement on a symmetric agree-disagree scale for a series of statements. We used a 4-point Likert scale, thus make forced choices by subjects (no option for “neutral” or “no comment”).
Statistical Package for the Social Sciences (SPSS) software program, version 25.0 has been used for analysis. The samples are grouped based on highs and lows in constructs of LOC, ASQ, TAI, and BRS. The two samples tested were used to determine whether there was statistical evidence that the group’s meanings were significantly different in tables.
| Results|| |
The descriptive statistics on the sample are presented in [Table 1]. Individual sample t tests between groups were performed to find any significant difference in regard to various COVID related queries. [Table 2] shows the difference between external and internal LOC in regard to query variables. Two sample t tests between high and low resilience are shown in [Table 3]. The contrast between the high resilience group and the high ASQs group t test is in [Table 4].
Our findings show that significant differences (P = 0.000) exist among internal and external groups of LOC and between high and low resilience groups in regard to health anxiety. Internal locus groups were found to be more anxious about their own health compared to external groups. Although the high and low ASQs group reflected no difference, the high TAI group indicated a significant difference (P = 0.028) as being more anxious about health [Table 3].
Although the possibility of getting infected was evaluated, a significant difference (P = 0.002) among internal and external groups of locus of the control surface. External locus groups were found to be less anxious about getting the infection compared to internal groups. Low fear of infection seen in low ASQs group and low TAI group also indicated similar results as being less anxious about infection (P = 0.013). Higher infection fear is documented in subjects with low resilience scores (P = 0.006) [Table 4].
In regards to financial crisis or loss, LOC groups, TAI groups, and resilience groups show no significant differences among groups. The high ASQs group reflected higher apprehension about finance loss (P = 0.012).
Although family hardship due to lockdown was investigated, none of the above groups revealed any significant difference between them. The concern about being at home (social isolation) was not trouble for internal locus (P = 0.000), high ASQs (P = 0.031), high TAI groups (P = 0.025) and high resilience (P = 0.018) while compared to the respective groups. Imposed social restrictions were perceived as distressing by an external LOC (P = 0.000), lower ASQs (P = 0.018), and low TAI (P = 0.025) while compared to the other groups. A significant difference (P = 0.000) reflected between high resilience and high anxiety––high resilience group adjusted better with being at home for prevention.
Inquiries about quarantine distress indicated that external locus (P = 0.000), high ASQs (P = 0.003), high TAI (P = 0.000), and low resilience groups (P = 0.000) found significant trouble in quarantine. In contrast, the higher resilience group reflected better adjustment with the quarantine system.
When asked if quarantine acts as preventive, no significant difference among either group was reflected. Intolerance toward certain groups (Prejudice) revealed significant differences (P = 0.000) among LOC, ASQ (P = 0.004), and TAI (P = 0.022) groups. High resilience and low anxiety groups revealed more tolerance and less prejudice.
LOC, ASQs, and trait groups reflected no significant difference stating no such action was needed against certain groups. The low resilience group revealed the answer in affirmative and significantly (P = 0.015) differs from the high resilience group.
The media effect was considered perturbing by internal locus (P = 0.000), but between groups were not significantly different in high ASQs and high resilience groups. Thus, media effects remained the same in those groups (not distressing). In regard to belief (faith) of prevention by special immunity, alternate/religious treatment, etc. difference existed between high and low resilience (P = 0.005) and between external and internal LOC (P = 0.000). No difference was found among other groups. Although the intention of storing/stocking extra food or meds for months was evaluated, only significant differences existed among groups of LOC (P = 0.000). No other groups revealed any significant differences between them.
Issue of the necessity of health checkup showed a significant difference (P = 0.000) in the LOC groups as internal locus was affirmative about the necessity of checkup. Also, resilience groups differed significantly (P = 0.036) about that requirement. Both ASQs groups and TAI groups did not differ regarding health checkups.
Maintaining cleanliness/hygiene was considered as important for internal locus subjects, whereas the external group differed (P = 0.002). In contrast, resilience groups, ASQ groups, and TAI groups reflected no difference within. All groups––such as LOC, ASQs, TAI, and resilience––had recognized the role of health workers as important and indispensable. Justification of lockdown in the future despite hardship was considered appropriate by all study groups of quarantined subjects.
| Discussion|| |
Considering the unknown nature of infection and the rapid progression of the disease, the nature of trauma experienced by those exposed subjects is dissimilar to any previous somatic concern (considering Ebola or SARS) and worth reviewing., The psychological responses of an epidemic for which people have no immunity can itself create a catastrophe of mental sanity. In the Indian scenario, lesser health awareness and scarcity of health services entail another perspective of the epidemic response.
The status of patients with detected premorbid psychiatric disorders at the onset of COVID-19 understandably becomes more vulnerable as shown by some recent studies. In China, early damage detection and online psychological intervention along with counseling in-person, have been suggested in hospitals with COVID patients. The help of nurses, psychologists, social workers, and volunteers are encouraged in Chinese hospitals to fight the gravid situation., No doubt that those groups with psychiatric disorders needed special attention.
High anxiety and apprehension about being infected with the disease can be intense mental trauma. The initial reaction to pandemic COVID-19 was disbelief and then gradual fear followed by panic reactions in this part of India. In our study, we carefully evaluated emotions such as suspicion, distrust, uncertainty, and indecision followed by agitation and frustration among quarantined or suspected positive patients. The usually sought care from caregivers is not available and even discouraged causing an atmosphere of cynicism and loss of faith in the social support system in general. Thus, the evaluation of precipitated anxiety––cognitive and otherwise is necessary for these subjects. Results of this study indicate that although the internal locus has more concern about health and prevention, the high ASQs group reveals higher somatic concerns. Thus, both of those groups reflect higher anxiety about health. Lower health anxiety has been shown by the high resilience group as they have higher confidence and self-esteem.
Throughout the human evaluation, the need for the social network has been emphasized for both physical and mental health welfare. But in the event of epidemics, the much needed social support structures are torn apart, leaving individuals isolated and vulnerable. The places which are known for providing support (religious places, educational institutions, and social welfare organizations) are no longer available and even visiting relatives or friends are prohibited for the spread of infection of COVID. The imposed social restriction on the minds of quarantined subjects was investigated in this study to understand the burden of pathology. Subjects with both groups of LOC, ASQs, and TAI accepted social isolation, though reasons assumed to be different for them. Internal locus subjects needed protection as they tended to adhere to medical regimes. High anxiety groups feel safer and protected at home.
It has been a historic fact that righteous explanation and understanding play a role in epidemic outbreaks. Certain types of people or some groups were condemned for spreading or producing disease as previously seen in the Plague of Cyprian, Gay AIDS, etc. This time also the Chinese origin of coronavirus caused much revulsion among people. Thus, “Wuhan virus” will lead to stigmatization and a disgrace to certain groups that needed investigation. Another area of concern has been rumors about the spread of this the virus in certain communities for some reason. It is not uncommon for those people who are under tremendous pressure of being COVID positive with the disease to think that it is a moral crusade against certain people who are responsible for the disease and they need to be punished or destroyed. Needless to say, people who are suspected to be positive with the disease are quarantined and before any confirmation about being positive, there have been reports of them being ostracized in the community as a source of infection. Our study indicated that the internal locus group takes any threat to physical wellness very seriously and they along with the high ASQs group felt that some communities or regions were to blame for the disease spreading. In contrast, the high resilience group reflected no such discriminating thoughts, which indicates their better-coping capability with anxiety and dissatisfaction.
It has a tremendous impact on the human mind when typically nonthreatening day-to-day things such as touching the door handle, touching one’s own face, shaking hands, hugging one’s own child now causes unexpected fear and danger. This new sense of high risk of infection had not been with us before and thus causes a novel threat to mental well-being., How much these day-to-day ordeals of cleaning and repeat hand washing are affecting subjects in quarantine and how much they consider it as a health requirement and how much it becomes a preventive constraint. The study found that groups differ in recognizing the need to maintain hygiene. Although the internal locus group felt the necessity, the external group differed. Surprisingly, both high ASQ groups and high TAI groups also did not feel the urgency of hygiene maintenance. The high-resolution group emphasized the need for hygiene. The result may indicate that overtly anxious subjects are not sure about preventive measures to follow, thus apprehension simply affects cognitive logical thinking about the need to follow the preventive actions.
Previous studies have noted that new illness anxiety causes psychological numbness even though it may have less morbidity than any known disease., At present, fear of the unknown cannot be considered the same as fifty years ago. Media now plays a profound role in manifold spreading the news about any new epidemic or deadly disease. Although media has been doing a great service by providing the needed information and circulating the latest situation about any epidemic or pandemic, one cannot ignore the fact that access to media flooding with corona news may work as an obvious cradle of psychopathology. Vacillating between high anticipatory anxiety and complacency has been shared mutually as in the morning people can feel reassured by some medical news about measures of prevention and again at night feel extremely panicked by the media declaring a high number of deaths from corona. The measure of that psychological parameter has been included in this study for reflection of that state of ambivalence. In our study, media blast on COVID-19 adversely affects internal locus, high ASQs, and high TAI groups. Other groups reflected lesser impressions, and high-resolution groups reported the least impact of perceived negative media influence.
With other disarrays, epidemic psychology calls for extreme reflections of self-interest to the extent of hoarding things, depriving even next-door neighbors. In this part of India, we have witnessed storing food in households unnecessarily causing the artificial shortage, huge stocking of disinfectants, soaps, masks, or gloves. Normal fellow-feelings and cooperation have been sacrificed in the face of a threat to survival. While addressing that behavioral deviation, we found that unnecessary storing and hoarding for any possible emergency had been sustained by internal locus, high ASQs, and high TAI groups. The high-resolution group did not find any more storing or stoking required for sustenance.
Among other adverse outcomes of this pandemic psychology, this study reflects the light of hope in recognizing that even the most vulnerable groups understand the necessity of social responsibility and lenience for various restrictions over their own self-interest, abide by rules for greater interest and overall accept medical recommendations and guidance. Our study reveals that distress from quarantine was considered bearable by an internal LOC and high-resolution groups. Internal locus temperamentally adheres to medical guidelines and disease prevention and is ready to tolerate the hassle of being quarantined whereas higher resolution understands the requirement of force isolation to prevent further spread.
Looking at the biology of emotions of fear, a certain area of the brain has been found to be associated with detecting newness in surroundings. The amygdala part indicated to have a role in detecting novelty and also processing fear or phobia. A study at the University of Wisconsin–Milwaukee by Nicholas Balderston and colleagues found that activity in the amygdala increased when participants looked at unfamiliar flowers right after seeing pictures of snakes.
According to some research, the most important phenomenon of epidemic psychology has been a weird feeling that our comfortable familial environment suddenly changed to an atmosphere of high-risk unknown danger. All simple work now asks for serious checks and scrutiny to avoid contamination and thus routines and recipes of daily life have been interrupted., News about children getting infected and diabetes or hypertension complicating the COVID infection make people feel helpless., Psychological intervention requirements were noted for this crisis.,, Enquiries about health checkups in this study revealed that both external locus and low resilience groups did not consider that necessary. External locus was found temperamentally reluctant about conforming to health rules if no immediate advantage was achieved.
In India, as may be the case in some developed countries also, using some groups of medication, finding some alternate medicine, unconventional treatment, or even some spiritual “cure” for COVID-19 has been discussed by people and media. It raises a serious issue of whether people believe or try out those things as that has an immense effect on psychological well-being. Life events can shape mental health outcomes and our previous studies have shown appraisal of life events plays a significant role in the vulnerability of psychiatric patients., Our study on quarantined subjects found that groups with an external LOC somewhat indulge in the belief that either some meds or alternative cure are available that can control the disease. That reflects this group’s strong inclination toward considering “powerful others” controlling and making things happen.
Government and political parties have their shares in forming public opinion about pandemic behavior. Different countries have adopted different strategies to face this health emergency. Adherence to set up strategies is not successful all over the world. In India, especially in West Bengal, the emphasis has been given on social isolation, lockdown at home, and maintaining personal hygiene and this study evaluated how high-risk people perceive those as an essential tool to combat the spread of disease. It should be emphasized that in spite of many hardships during locked down months and being quarantined without any apparent symptomology - people are still quiescent.
There has been speculation about the necessity of repeating detailed instructions in media by various political and media personnel about maintaining personal hygiene such as hand-washing, wearing masks and gloves, and keeping social distance. Our study points to the findings that repeated infographics and visuals detailing handwashing, and mask-wearing help to comply with the rules of prevention. Thus the repeat media visuals about preventive measures can be beneficial for the people to transmit that to action for eventual well-being. During the present investigation, clinical interview and the verbal reports revealed that ritualistic cleaning and disinfecting habits may be related to obsessive patterns of behavior, and people who have that trait may get some temporary relief from anxiety by doing those rituals.
Although historically epidemics have their individual psychological manifestations, COVID-19 pandemic too has its own indexes. We noted that this pandemic reflected initial intense anticipatory anxiety among high and middle-income groups (lower resilience) of people in urban West Bengal and that they somewhat mentally prepared themselves to follow the lockdown and other imposed restrictions. There has been less political interference to make that happen. But the same is not true for people of lower socioeconomic status with higher resilience who rather reflected the type of carefree attitude toward preventive measures––but yet agreed to comply with laid down restrictions even at the cost of their livelihood and sustenance. Our study confirmed that financial loss and economic hardship are withstood by all groups of subjects keeping in mind the ultimate benefit of preventing the spread of the disease. This probably indicates higher social responsibility and compassion and this conviction can be a reflection of better psychological adaptation.
This study reveals that subjects with higher ASQs, whereas under considerable stress (as in this case being in quarantine) often yield psychological vulnerability. Apart from physical symptoms, pre-dispositional factors identified for such vulnerability were the elevated level of health anxiety, fear, and apprehension of being ill, impatience about being in “locked down” state, and high disliking about being in quarantine. Additionally, those anxious subjects were found to be skeptical about the importance of maintaining personal hygiene and doubted the need for a health checkup. They expressed being highly worried about media coverage about epidemic (TV, print, and others) and even considered treatment with a counterfeit drug or alternative medicines with an uncertain prognosis. The high resilience group revealed the absence of the above predisposal indicators while compared with the high anxiety group. Thus, emphasis on building on psychological resilience can help to fight the COVID-19 milieu of panic and convalescence.
Other outcomes with regard to the perceived positive role of medical and health professionals at this time are noteworthy notwithstanding occasional skepticism and avoidance. The crucial part played by health professionals at this high-risk time has been acknowledged and despite little negative publicity, their works have been held high in the public eye. Our study pointed to the fact that the roles of health workers were admired and regarded as positive by all groups. Another related issue may also be mentioned here that the health professions need to have a sound psychological status while being engaged in serving patients of this pandemic risking their own life and well-being of their families. As quarantined subjects also included exposed health professionals finding areas of vulnerability that could also help build up psychological resilience for themselves while fighting the fatal disease.
Limitations of this study include samples being somewhat loaded with the male majority and urban population which can arguably partially blur the general propositions. Not all subjects received their COVID test results during the study. But considering that quarantine is a special isolating treatment encompassment, the random sampling criteria could not be entertained. Another area of concern could be using a study survey questionnaire to ascertain constructs or statues. Considering the unforeseen gravity of the epidemic outbursts and no available time for formal validity and reliability issues, the present questionnaire was designed following previous similar studies. Use of two sample t tests, whereas samples were different on a continuum, has been previously documented.
| Conclusion|| |
We believe that the epidemic response should also include mental health issues of the population which on one hand will improve psychological well-being by preventive measures recalibration and on the other hand aid in fighting the invading depression––as poor mental health surely impedes the battle against the deadly disease. Our study reflects how psychological construct shapes COVID-19 pandemic behavior and based on those findings some interventions can be planned in the future.
The authors are grateful to all medical and health workers involved in COVID-19 wings of AMRI Hospitals, Salt Lake and KPC Hospital, Jadavpur, Kolkata, India.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]