Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 49  |  Issue : 1  |  Page : 40-46

Factors affecting compliance to quarantine and its psychological effects during the COVID-19 pandemic: A cross-sectional study from aspirational district of India


1 Department of Community Medicine, KD Medical College, Hospital and Research Centre, Mathura, Uttar Pradesh, India
2 Department of Community Medicine, SHKM Government Medical College, Nalhar, Haryana, India
3 Department of Community Medicine, NIIMS, Gautam Budh Nagar, Uttar Pradesh, India
4 Department of Community Medicine, Government Medical College, Shahdol, Madhya Pradesh, India

Date of Submission07-Sep-2021
Date of Acceptance17-Oct-2021
Date of Web Publication22-Apr-2022

Correspondence Address:
Vikas Gupta
Department of Community Medicine, Government Medical College, Shahdol, Madhya Pradesh
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jss.jss_123_21

Rights and Permissions
  Abstract 


Background: COVID-19 has caused pandemic during 2019–2020 and has presented with illnesses ranging from the usual mild flu to serious respiratory problems/complications, even leading to considerable mortality. Recent literatures have suggested that the health (especially psychological) impacts of quarantine are substantial and can be long lasting. Aim: The purpose of this study was to assess the mental health status (psychological distress) of experienced quarantine and compliance to quarantine during the outbreak of COVID-19 in Nuh district. Methods: The study included 543 subjects (adults aged 18 years or more) who were sent for quarantine at home or state-run facilities and included “Flu corner” screened patient and health-care staff working in COVID-19 outpatient and wards. The psychological impact was assessed using the Kessler Psychological Distress Scale (K10). Categorical data were presented as percentages (%), and bivariable logistic regression was applied to find out the association, and it was considered significant if the P < 0.05. Results: The doctors and nursing staff were among two-fifth of the subjects (217/543, 40.1%), and only 11.6% of quarantined subjects (63/543) were compliant with all protective measures. The mean score obtained on Kessler Psychological Distress Scale (K10) subjects was 18.69 ± 4.88, whereas out of 543 subjects, 152 (27.9%) had a score of 20 or more, and it has a significant association with the elderly age group, female gender, and workplace as exposure setting (P < 0.05). Conclusion: Given the developing situation with coronavirus pandemic, policymakers urgently need evidence synthesis to produce guidance for the public. Thus, the outcomes of this study will positively help authorities, administrators, and policymakers to apply quarantine measures in a better way.

Keywords: Compliance, health-care worker, Kessler psychological distress scale (K10), quarantine


How to cite this article:
Chauhan AK, Singh A, Ranjan R, Gupta V, Goel PK. Factors affecting compliance to quarantine and its psychological effects during the COVID-19 pandemic: A cross-sectional study from aspirational district of India. J Sci Soc 2022;49:40-6

How to cite this URL:
Chauhan AK, Singh A, Ranjan R, Gupta V, Goel PK. Factors affecting compliance to quarantine and its psychological effects during the COVID-19 pandemic: A cross-sectional study from aspirational district of India. J Sci Soc [serial online] 2022 [cited 2022 May 19];49:40-6. Available from: https://www.jscisociety.com/text.asp?2022/49/1/40/343698




  Introduction Top


COVID-19 has caused pandemic during 2019–2020 and has presented with illnesses ranging from the usual mild flu to serious respiratory problems/complications, even leading to considerable mortality.[1],[2],[3] The history has recorded the occurrence of plenty of previous pandemics including SARS (2002) resulted in eight hundred mortality; and MERS-CoV (2012) resulted in 860 mortality and just after 8 years of MERS-CoV, COVID-19 gave its worldwide representation.[3],[4] On March 24, 2020, the Government of India took a strong initiative to contain the spread of this virus and from the March 25, 2020 onward the closure of nearly all offices, industries, hotels, commercial and private establishments, shops, malls, and others were ordered to bring the life to stand still.[5],[6]

Latest reports showed that there were more than 2,475,699 cases of COVID-19 among 213 countries and territories, and it resulted in around 169,134 deaths, whereas in India, the active case counted 15859, 3960 cured, and 652 deaths.[2],[7] At that time, Nuh was the worst affected district among all 22 districts of Haryana state with a maximum number of positive cases. A large number of COVID-19 positive persons and their contacts were sent to quarantine.[8] Asymptomatic persons with a travel or contact history, visiting the COVID-19 screening health center or “Flu corner” were sent on home quarantine. Doctors and health-care staff discharging duties in close contact with COVID-19-positive patients were placed under quarantine at home/hostel or in state-run facilities. The district administration had taken over a number of colleges as quarantine centers in the district.[9]

Recent literatures have suggested that the health (especially psychological) impacts of quarantine are substantial and can be long lasting.[10],[11],[12],[13] As quarantine at such large scale was not undertaken since the last century, there is a need to know the psychological impact of quarantine as well as the factors influencing its compliance during the COVID-19 pandemic. The purpose of this study was to assess the mental health status (psychological distress) of experienced quarantine and barriers and facilitators for compliance to quarantine during the outbreak of COVID-19 in Nuh district.


  Materials and Methods Top


Study setting and design

The present quantitative study was cross-sectional in design, conducted at SHKM Government Medical College (GMC), Nalhar, situated in district Nuh, Haryana, during the 3rd week of April 2020.

Study population and sample size

The study subjects included subjects sent on home quarantine (adults aged 18 years or more) by “Flu corner” or “COVID 19 screening health center” run under the ages of Department of Community Medicine, SHKM GMC; and doctors and health-care staff placed under quarantine at home/hostels or in state-run facilities after discharging duties in close contact with COVID-19 positive patients; and it counted to 568 eligible subjects.

Study tool

A 21-element structured questionnaire with both open- and close-ended responses was developed which covered the domains of subject's characteristics; understanding the rationale, compliance, difficulties associated with quarantine; psychological impact; and barriers and facilitators among COVID-19 quarantine study subjects. A pilot study was done randomly among ten health-care worker and ten hospital visitors, and it took on an average 20 min for completing the questionnaire. The questionnaire was made precise, relevant, valid, and acceptable by presenting it among 15 randomly selected faculty members. Before distributing the questionnaire to the study subjects, further refining and organizing of the same was done to make it more comprehensive. The questionnaire had four divisions and consisted of total 21 elements. Division one consisted of five elements and gathered information regarding subjects' characteristics such as age, gender, exposure setting, exposure type, and quarantine type. Division two comprised four elements and aimed to gather the subjects understanding the rationale, compliance with all community and household protective measures, difficulties associated with quarantine. Division three comprised ten elements and aimed to measure the psychological impact using the Kessler Psychological Distress Scale (K10) which was modified for 14 days from 30 days, and it included statements related to the past 14 days, about how often did you feel “tired out for no good reason, nervous, so nervous that nothing could calm you down, hopeless, restless or fidgety, so restless you could not sit still, depressed, that everything was an effort, so sad that nothing could cheer you up and worthless” and the response to each element was based on a 5-point Likert scale pattern (all of the time = 5, most of the time = 4, some of the time = 3, a little of the time = 2, and none of the time = 1).[14] The K10 score ranged from 10 (minimum) to 50 (maximum). A score of 20 or more was considered as having a psychological impact on subjects during 14-day quarantine period. Division four comprised two elements and aimed to extract the barriers and facilitators among COVID-19 quarantine study subjects.

Data collection

A complete list of subjects sent on home quarantine (adults aged 18 years or more) by “Flu corner” was obtained, and their address and contact numbers were noted down. On the similar basis, a list of doctors, health-care staff, and housekeeping placed under quarantine at home/hostel or in state-run facilities was obtained from the Office of Medical Superintendent along with their contact details. Just after completion of their 14 days of quarantine period, they were contacted telephonically for their availability to conduct this study. They were explained about the purpose of this study and were requested to participate. Out of 568 subjects, only 543 subjects provided their written consent after understanding the study objectives and were included in the study. The questionnaire for subjects was administered by the investigator himself by face-to-face interview. Furthermore, the filled questionnaires were then checked for the completeness. The subjects suspected of having a psychological impact on Kessler Psychological Distress Scale (K10) were directed to the nearest health facility, and the information pertaining to subjects was kept anonymous and confidential. Being elective and not requite were the properties for participating in the study. The study was initiated after obtaining the ethical approval from the Institutional Ethical Committee (IEC), SHKM GMC, Nalhar (Letter No. SHKM/IEC/2020/40, Date: 24 April, 2020).

Data analysis

Collected data were entered into the MS Excel spreadsheet, coded appropriately, and later cleaned for any possible errors. Analysis was carried out using IBM SPSS Statistics for Windows, Version 22.0 (IBM Corp. Armonk, NY, USA). During data cleaning, more variables were created so as to facilitate the association of variables. Clear values for various outcomes were determined before running frequency tests. Categorical data were presented as percentages (%), whereas continuous data were presented as mean and standard deviation. Bivariable logistic regression had been done to find out the strength of association between dependent variables (Kessler Psychological Distress Scale [K10] ≥20) and independent variables (age group, gender, exposure setting, exposure type, quarantine type, compliant with all protective measures, and understanding of all rationale for quarantine). All tests were performed at a 5% level of significance; thus, an association was significant if the P < 0.05.


  Results Top


A total 543 subjects were involved in the present study. The doctors and nursing staff were among two-fifth of the subjects (217/543, 40.1%) and more than one-tenth of subjects (81/543, 14.9%) were housekeeping staff. The mean age group of the study subjects was 42.3 ± 14.4 years, and nearly half of the study subjects (262/543, 48.3%) were below the age of 40 years. The male subjects were around two-third (334/543, 61.5%) of total subjects. The travel history was noticed among more than one-tenth of study subjects (89/543, 16.4%) with 95% CI as 13.3–19.5. The home quarantine was mostly adopted among quarantine type as nearly two-third study subjects (326/543, 60.1%) were sent for home quarantine [Table 1].
Table 1: Baseline characteristics of COVID-19 quarantine study subjects (n=543)

Click here to view


[Table 2] shows that the rationale of quarantine was completely and correctly understood by only 17.3% of subjects (94/543), whereas 87.1% of subjects (473/543) believed that quarantine is mainly for the benefit of the community. Astonishingly, only 11.6% of quarantine subjects (63/543) were compliant with all protective measures with 95% CI as 9.0–14.4, whereas compliance with all community and household protective measures were 45.9% (249/543) and 28.2% (153/543), respectively. The most common difficulty faced by subjects during quarantine was the inability to go out of house “to socialize (397/543, 73.1%) or on errands (372/543, 68.5%).”
Table 2: Distribution of understanding the rationale, compliance, and difficulties associated with quarantine among COVID-19 study subjects (n=543)

Click here to view


The mean score obtained on Kessler Psychological Distress Scale (K10) to evaluate the psychological impact associated with quarantine among COVID-19 study subjects was 18.69 ± 4.88, whereas out of 543 subjects, 152 (27.9%) had score of 20 or more, i.e., having a psychological impact or distress among subjects during 14 days quarantine [Table 3].
Table 3: Psychological impact using Kessler Psychological Distress Scale associated with quarantine among COVID-19 study subjects (n=543)

Click here to view


When subjects were enquired about the barriers with noncompliance to quarantine using open-ended questions, the major barriers were duration of quarantine (376/543, 69.2%), fear of infection (357/543, 65.7%), and inadequate supply (395/543, 72.7%). Similarly, the enquired facilitators to make quarantine more compliant included keep it as short as possible, give people as much information as possible, provide adequate supplies, and assessing preexisting poor mental health [Table 4].
Table 4: Distribution of barriers and facilitators among COVID-19 quarantine study subjects (n=543)

Click here to view


[Table 5] shows the bivariate logistic regression analysis to find out the strength of association between dependent variables and psychological impact using Kessler Psychological Distress Scale (K10) score ≥20, and it was revealed that the elderly age group, female gender, workplace as exposure setting, inability to understand all rationale for quarantine, and noncompliance with all protective measures were having statistically significant association with higher K10 score (P < 0.05).
Table 5: Comparison of COVID-19 quarantine study subjects by psychological impact using Kessler Psychological Distress Scale score (n=543)

Click here to view



  Discussion Top


Quarantine has often been an unpleasant experience for those who undergo it. Separation from loved ones, the loss of freedom, uncertainty over disease status, boredom, and economic loss can, on occasion, create dramatic effects. People are facing several problems during lockdown from basic survival to fake and endless information on the COVID-19 pandemic period.

The present study has made an attempt to evaluate the psychological impact on quarantined subjects, and it was observed that, during quarantine period, 26.7% of subjects felt nervous all the time, 15.8% were felt so nervous that nothing could calm them down all the time, and 12.3% of subjects felt depressed all the time.

A recent study showed that 6.1% of individuals were facing severe depression, 10.0% faced severe anxiety level, and 16.5% had severe stress level.[15] The authors compared psychological outcomes during quarantine with later outcomes and found that, during quarantine, 7% showed anxiety symptoms and 17% showed feelings of anger, whereas 4–6 months after quarantine these symptoms had reduced to 3% (anxiety) and 6% (anger).[16]

The authors also found that 28% of subjects quarantined in the study reported compared posttraumatic stress symptoms sufficient enough to warrant a diagnosis of a trauma-related mental health disorder, compared with 6% of subjects who were not quarantined.[17] A study included two groups quarantined versus nonquarantined, and it revealed that SRQ-20, GAD-7, and PHQ-9 scores were significantly higher among quarantined subjects when compared nonquarantined ones. Furthermore, it was observed that psychological impact was higher among home quarantined subjects (24.5%) when compared to facility-based quarantine (12.6%) which was in contrast to the present study where psychological impact was higher among facility-based quarantine (35.6%) when compared to home quarantined subjects (24.7%).[18]

The present study has raised concern as the psychological impact was significantly higher among health care workers (31.8%), housekeeping staff (46.4%) compared to the patients (19.4%), and their households (21.7%). Author studied hospital staff and examined symptoms of depression 3 years after quarantine and found that 9% of the whole sample reported high depressive symptoms. In the group with high depressive symptoms, nearly 60% had been quarantined, but only 15% of the group with low depressive symptoms had been quarantined.[19]

In a study among hospital staff who might have come into contact with SARS found that immediately after the quarantine period (9 days) ended, having been quarantined was the factor most predictive of symptoms of acute stress disorder. In the same study, quarantined staff were significantly more likely to report exhaustion, detachment from others, anxiety when dealing with febrile patients, irritability, insomnia, poor concentration and indecisiveness, deteriorating work performance, and reluctance to work or consideration of resignation.[20]

Confinement, loss of usual routine, and reduced social and physical contact with others were frequently shown to cause boredom, frustration, and a sense of isolation from the rest of the world, which was distressing to subjects. This frustration was exacerbated by not being able to take part in usual day-to-day activities such as shopping for basic necessities or taking part in social networking activities through the telephone or internet.[21],[22]

This study also revealed that only 11.6% of quarantine subjects were compliant with all protective measures, whereas compliance with all community and household protective measures were 45.9% and 28.2%, respectively. An author in the United States during 2009 showed that students with suspected mumps were instructed to stay isolated, and 75% stayed isolated for the recommended number of days.[23] During swine flu outbreak (2011) in Australia, compliance observed in various studies had much variations among parents from households with children who were placed in quarantine during the outbreak, 84.5% reported full adherence at household level, parents who were employed from households with children who were placed in quarantine during the outbreak, half of all households fully adhered with quarantine recommendations and subjects tested for H1N1 and who were prescribed home quarantine for 7 days, among them 92.8% reported adherence to quarantine measures.[24],[25],[26] A study during 2006 showed that health-care workers in charge of SARS epidemic control at health centers in Taiwan were advised home quarantine for 10–14 days and all nurses reported poor adherence from quarantined individuals.[27]

The present study also attempted to obtain the opinion about the barriers with noncompliance to quarantine using open-ended questions, the major barriers were duration of quarantine (69.2%), fear of infection (65.7%), and inadequate supply (72.7%). The studies by author cited the barriers for adherence with the quarantine as length of quarantine, fear of infection, practical issues such as loss of income and need to work, needed to attend important events, and to seek medical care.[28],[29]

If the quarantine experience is negative, there can be long-term consequences that affect not just the people quarantined but also the health-care system that administered the quarantine and the politicians and public health officials who mandated it. Ever since the plague of Justinian, imposed quarantine has rightly remained part of our public health arsenal. But as with every medical intervention, there are side effects that must be weighed in the balance and alternatives that must be considered. Voluntary quarantine, for example, may be associated with good compliance and less psychological impact, particularly when explained well and promoted as altruistic. Whether the uncertain epidemiological benefits of this new form of mandatory mass quarantine outweigh the uncertain psychological costs is a judgment that should not be made lightly.[30]


  Conclusion Top


Given the developing situation with the coronavirus, policymakers urgently need evidence synthesis to produce guidance for the public. Thus, the outcomes of this study will definitely help authorities, administrators, and policymakers to apply quarantine measures in a better way. It shall also provide inputs to a health-care system that administers the quarantine and the public health officials who mandated it.

Recommendations

As governments update daily guidelines, the health-care setups formulate new policies, and the general population practices either social distancing or strict quarantine everyone seem to be proactively doing their bit to stop the physical spread of the disease. Tasks for public health leaders are to gather and utilize knowledge and expertise, monitor psychological effects, assist in resource identification, provision, operations, adaptability, and integration and integrate public health efforts with behavioral health services and systems.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Phan T. Genetic diversity and evolution of SARS-CoV-2. Infect Genet Evol 2020;81:104260.  Back to cited text no. 1
    
2.
World Health Organization. Novel Coronavirus (COVID-19) Situation. Geneva: WHO; 2020. Available from: https://experience.arcgis.com/experience/685d0ace521648f8a5beeeee1b9125cd. [Last accessed on 2020 Jun 06].  Back to cited text no. 2
    
3.
Zhou P, Yang XL, Wang XG, Zu B, Zhang L, Si HR, et al. A pneumonia outbreak associated with a new coronavirus of probable bat origin. Nature 2020;579:270-3.  Back to cited text no. 3
    
4.
Zhong NS, Zheng BJ, Li YM, Poon, Xie ZH, Chan KH, et al. Epidemiology and cause of severe acute respiratory syndrome (SARS) in Guangdong, People's Republic of China, in February, 2003. Lancet 2003;362:1353-8.  Back to cited text no. 4
    
5.
Eurosurveillance Editorial Team. Note from the editors: World Health Organization declares novel coronavirus (2019-nCoV) sixth public health emergency of international concern. Euro Surveill 2020;25:200131e.  Back to cited text no. 5
    
6.
Ministry of Home Affairs. Guidelines on the Measures to be Taken by Ministries/Department of Government of India, State/Union Territory Governments and State/Union Territory Authorities for the Containment of COVID-19 Epidemic in the Country. New Delhi: Ministry of Home Affairs, Government of India; 2020. Available from: http://164.100.117.97/WriteReadData/userfiles/Guidelines.pdf. [Last acessed on 2020 Jun 06].  Back to cited text no. 6
    
7.
Ministry of Health and Family Welfare. COVID-19 India: Guidelines. Ministry of Health and Family Welfare, Government of India; 2020. Available from: https://www.mohfw.gov.in/pdf/Guidance%20document%20-%202019-nCoV.pdf. [Last accesed on 2020 Jun 06].  Back to cited text no. 7
    
8.
COVID-19 Dashboard. India Fights Corona COVID-19. Available from: https://www.mygov.in/covid-19. [Last accessed on 2020 Jun 06].  Back to cited text no. 8
    
9.
State Data. COVID-19 INDIA. Ministry of Health and Family Welfare, Government of India; 2020. Available from: https://www.mohfw.gov.in/#. [Last accesssed on 2020 Jun 06].  Back to cited text no. 9
    
10.
Barbisch D, Koenig KL, Shih FY. Is there a case for quarantine? Perspectives from SARS to Ebola. Disaster Med Public Health Prep 2015;9:547-53.  Back to cited text no. 10
    
11.
Kumar A, Nayar KR. COVID-19 and its mental health consequences. J Ment Health 2021;30:1-2.  Back to cited text no. 11
    
12.
Chatterjee SS, Barikar C M, Mukherjee A. Impact of COVID-19 pandemic on pre-existing mental health problems. Asian J Psychiatr 2020;51:102071.  Back to cited text no. 12
    
13.
Rajkumar RP. COVID-19 and mental health: A review of the existing literature. Asian J Psychiatr 2020;52:102066.  Back to cited text no. 13
    
14.
Kessler RC, Barker PR, Colpe LJ, Epstein JF, Gfroerer JC, Hiripi E, et al. Screening for serious mental illness in the general population. Arch Gen Psychiatry 2003;60:184-9.  Back to cited text no. 14
    
15.
Upadhyay R, Sweta, Singh B, Singh U. Psychological impact of quarantine period on asymptomatic individuals with COVID-19. Soc Sci Humanit Open 2020;2:100061.  Back to cited text no. 15
    
16.
Jeong H, Yim HW, Song YJ, Ki M, Min JA, Cho J, et al. Mental health status of people isolated due to Middle East respiratory syndrome. Epidemiol Health 2016;38:e2016048.  Back to cited text no. 16
    
17.
Sprang G, Silman M. Posttraumatic stress disorder in parents and youth after health-related disasters. Disaster Med Public Health Prep 2013;7:105-10.  Back to cited text no. 17
    
18.
Zhu S, Wu Y, Zhu CY, Hong WC, Yu ZX, Chen ZK, et al. The immediate mental health impacts of the COVID-19 pandemic among people with or without quarantine managements. Brain Behav Immun 2020;87:56-8.  Back to cited text no. 18
    
19.
Liu X, Kakade M, Fuller CJ, Fan B, Fang Y, Kong J, et al. Depression after exposure to stressful events: Lessons learned from the severe acute respiratory syndrome epidemic. Compr Psychiatry 2012;53:15-23.  Back to cited text no. 19
    
20.
Bai Y, Lin CC, Lin CY, Chen JY, Chue CM, Chou P. Survey of stress reactions among health care workers involved with the SARS outbreak. Psychiatr Serv 2004;55:1055-7.  Back to cited text no. 20
    
21.
Reynolds DL, Garay JR, Deamond SL, Moran MK, Gold W, Styra R. Understanding, compliance and psychological impact of the SARS quarantine experience. Epidemiol Infect 2008;136:997-1007.  Back to cited text no. 21
    
22.
Robertson E, Hershenfield K, Grace SL, Stewart DE. The psychosocial effects of being quarantined following exposure to SARS: A qualitative study of Toronto health care workers. Can J Psychiatry 2004;49:403-7.  Back to cited text no. 22
    
23.
Soud FA, Cortese MM, Curns AT, Edelson PJ, Bitsko RH, Jordan HT, et al. Isolation compliance among university students during a mumps outbreak, Kansas 2006. Epidemiol Infect 2009;137:30-7.  Back to cited text no. 23
    
24.
McVernon J, Mason K, Petrony S, Nathan P, LaMontagne AD, Bentley R, et al. Recommendations for and compliance with social restrictions during implementation of school closures in the early phase of the influenza A (H1N1) 2009 outbreak in Melbourne, Australia. BMC Infect Dis 2011;11:257.  Back to cited text no. 24
    
25.
Kavanagh AM, Mason KE, Bentley RJ, Studdert DM, McVernon J, Fielding JE, et al. Leave entitlements, time off work and the household financial impacts of quarantine compliance during an H1N1 outbreak. BMC Infect Dis 2012;12:311.  Back to cited text no. 25
    
26.
Teh B, Olsen K, Black J, Cheng AC, Aboltins C, Bull K, et al. Impact of swine influenza and quarantine measures on patients and households during the H1N1/09 pandemic. Scand J Infect Dis 2012;44:289-96.  Back to cited text no. 26
    
27.
Hsu CC, Chen T, Chang M, Chang YK. Confidence in controlling a SARS outbreak: Experiences of public health nurses in managing home quarantine measures in Taiwan. Am J Infect Control 2006;34:176-81.  Back to cited text no. 27
    
28.
DiGiovanni C, Conley J, Chiu D, Zaborski J. Factors influencing compliance with quarantine in Toronto during the 2003 SARS outbreak. Biosecur Bioterror 2004;2:265-72.  Back to cited text no. 28
    
29.
Pellecchia U, Crestani R, Decroo T, Van den Bergh R, Al-Kourdi Y. Social consequences of ebola containment measures in Liberia. PLoS One 2015;10:e0143036.  Back to cited text no. 29
    
30.
Rubin GJ, Wessely S. The psychological effects of quarantining a city. BMJ 2020;368:m313.  Back to cited text no. 30
    



 
 
    Tables

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



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Materials and Me...
Results
Discussion
Conclusion
References
Article Tables

 Article Access Statistics
    Viewed210    
    Printed8    
    Emailed0    
    PDF Downloaded14    
    Comments [Add]    

Recommend this journal