|Year : 2022 | Volume
| Issue : 1 | Page : 54-62
Psychosocial effects of COVID-19 pandemic on dental patients
Hani Mawardi1, Mohammed Zahran2, Dania Sabbahi3, Siraj Dakhil4, Lena Elbadawi5, Rawah Eshky6, Danish Pathan7
1 Department of Oral Diagnostic Sciences, King Abdulaziz University – Faculty of Dentistry, Jeddah, Saudi Arabia
2 Department of Prosthodontics, King Abdulaziz University – Faculty of Dentistry, Jeddah, Saudi Arabia
3 Department of Dental Public Health, King Abdulaziz University – Faculty of Dentistry, Jeddah, Saudi Arabia
4 Department of Endodontics, King Abdulaziz University – Faculty of Dentistry, Jeddah, Saudi Arabia
5 Department of Periodontics, King Abdulaziz University – Faculty of Dentistry, Jeddah, Saudi Arabia
6 Department of Pediatric Dentistry and Orthodontics, Taibah University Dental College and Hospital, Al-Madinah Al-Munawwarah, Saudi Arabia
7 Department of Dentistry, Inamdar Multispecialty Hospital, Pune, Maharashtra, India
|Date of Submission||10-Aug-2021|
|Date of Decision||10-Sep-2021|
|Date of Acceptance||18-Oct-2021|
|Date of Web Publication||29-Apr-2022|
Dr. Hani Mawardi
Departments of Oral Diagnostic Sciences, King Abdulaziz University – Faculty of Dentistry, Jeddah
Source of Support: None, Conflict of Interest: None
Introduction: The spread of coronavirus infection (COVID-19) has been increasing exponentially with significant impact on every aspect of people's lives. Dentists in particular are at a greater risk of disease contraction since majority of the procedures are based on direct contact with patients.
Aim: This study attempted to understand the attitude of patients seeking dental treatment during the pandemic.
Materials and Methods: This was a cross-sectional, self-administered survey which included validated questions on (1) sociodemographic information of participants; (2) participants' basic knowledge on COVID-19; and (3) the willingness and mindset of participants to pursuit dental treatment during, and after the curfew period. Data were collected and statistically analyzed for significance.
Results and Discussion: A total of 904 residents from 25 countries. Participants who, or their family members, experienced dental complaints during the curfew period were able to manage via in-office emergency visit, using over counter medication, tele-dentistry or following friends' advice. In total, 48% (433/904) stated to likely seek dental treatment (if needed) with local curfew lifting and 50.4% (456/904) were likely to wait for more than 4 weeks before visiting the dentist. In total, 70% of participants reported sufficient social distancing and wearing masks by the dental staff would address their concerns during dental treatments.
Conclusion: Personal financial conditions, lack of awareness, and fear of contracting COVI-19 were identified as important influencing factors for the general public to return for professional dental care. Future, long-term studies to better understand the psychosocial effects of the current pandemic on individuals should be considered.
Keywords: COVID-19, dental, impact, patients, psychosocial
|How to cite this article:|
Mawardi H, Zahran M, Sabbahi D, Dakhil S, Elbadawi L, Eshky R, Pathan D. Psychosocial effects of COVID-19 pandemic on dental patients. Saudi J Oral Sci 2022;9:54-62
|How to cite this URL:|
Mawardi H, Zahran M, Sabbahi D, Dakhil S, Elbadawi L, Eshky R, Pathan D. Psychosocial effects of COVID-19 pandemic on dental patients. Saudi J Oral Sci [serial online] 2022 [cited 2022 May 21];9:54-62. Available from: https://www.saudijos.org/text.asp?2022/9/1/54/344404
| Introduction|| |
Since the first case of the novel coronavirus infection (COVID-19) contraction to human was reported in the city of Wuhan (China), the spread of this pandemic has been exponentially increasing with several millions deaths and significant impact on every aspect of people's lives. COVID-19 is caused by a single-stranded RNA virus which belongs to corona viridae family and resides naturally in animals such as bats and pigs. Based on the current evidence, COVID-19 can be transmitted from symptomatic patients through respiratory droplet or direct contact with others. The mode of transmission and rapid rate of spread on a massive scale raised global concerns and significant demand for medical and health-care services. Therefore, the general public were forced to develop ways to adapt to the new normal of daily activity while waiting for cure and/or an effective vaccine.
Dentists and dental patients are among the most impacted population during COVID-19 pandemic., For instance, dentists in particular are at a greater risk of disease contraction since majority of the procedures are based on direct contact with people in a work environment naturally surrounded by fluids and vapors which may facilitate virus spread., In addition, several reports discussed the psychological impact of the pandemic on dentists and auxiliary staff, as well as, the general public., Hence, the fear from contracting the disease led to an exponential anxiety for people to visit their dentists even when they are in an urgent need., Yet, data on perception of individuals seeking dental treatment and change in attitude and behavior in relation to COVID-19 pandemic is lacking., Furthermore, factors related to the level of patients' apprehension and willingness to address their dental needs are yet to be clarified.
This study attempts to understand the initial impact of COVID-19 on patients seeking dental treatment during and after the local curfew. We believe the outcome of this study will potentially help policymakers and clinicians, as well as dentists, to understand the primary concerns in formulating comprehensive dental interventions needed in the era of COVID-19.
| Materials and Methods|| |
The study was approved by the Ethical Committee at King Abdulaziz University - Faculty of Dentistry (No. 068-06-20). This was a cross-sectional, self-administered survey conducted primarily to enrol general public between April and June 2020. Study inclusion criteria were (1) adults willing to participate in the study and (2) speaking English and/or Arabic languages. No subjects were excluded from this study.
Participation in the study was voluntary and anonymous. All study subjects consented electronically before participating in the survey. A customized, online survey using Google Forms (Alphabet Co., Mountain View, CA) in both Arabic and English languages was prepared, validated, and included questions related to three main domains. The first part included questions on sociodemographic information of participants (e.g., age, gender, occupational status, city of residence). The second part focused on participants' basic knowledge on COVID-19 in addition to the psychological effect of the pandemic curfew on each individual. The third part of the survey explored the willingness and mindset of participants to pursuit dental treatment during and after the curfew period imposed by local authorities.
All survey questions were validated before launching the study. This process was conducted using face validity by field experts to ensure the ability of the survey to capture the study proposed aims and potential errors. Next, the survey was evaluated through enrolment of ten subjects and collections of answers and feedback to modify total of three questions. The survey was distributed using personal communications, local dental societies, e-mails, and social media platforms (i.e., Facebook®, Instagram®, Twitter®). On average, each participant needed 5–8 min to complete the survey. Data were collected, tabulated, and statistically analyzed to estimate descriptive statistics based on frequencies and percentages. Chi-square test was used to compare the responses to different questions among different levels of sociodemographic variables and the medical condition. All statistical analyses were conducted using IBM Statistical Package for the Social Science for Windows (SPSS, Version 23, SPSS Inc., IBM, Somers, New York, USA) at a significance level of 0.05.
| Results|| |
A total of 904 participants were enrolled in this study. Overall, 77.3% (699/904) were females and 62.9% (569/904) aged between 21 and 40. The geographic distribution of study participants included 25 countries with 87.3% (789/904) living in Saudi Arabia [Figure 1]. In total, 52.8% (477/904) of participants were holders of a bachelor's degree, followed by high school (24.7%; 223/904) as the highest earned educational degree. In addition, 81.1% (733/904) were participants with medical/dental background, 21.5% (194/904) had a monthly income of SR 10-15K, and 55.8% (504/904) were singles. Detailed sociodemographic data are included in [Table 1].
Knowledge on COVID-19 pandemic
Overall, 642 (71.1%) participants were up to date on the global situation of COVID-19 pandemic. In addition, 27.5% (248/904) and 1.3% (11/904) were either less or not aware of the pandemic current situation, respectively. Official websites and news were reported by 74.9% (677/904) of participants as main sources of COVD-19 information followed by social media (61.6%; 556/904) [Table 2] and [Figure 2]. When asked about specific COVID-19-related terms including “aerosol,” “sterilization,” and “cross-contamination,” 74% (676/904) were familiar with all of these terms, while 23% (207/904) were partially familiar and 3% (27/904) were not aware of these terms.
|Table 2: Awareness of study participants on the global situation of COVID-19 pandemic in relation to highest education degree|
Click here to view
|Figure 2: Source of information used by dental patients regarding COVID-19 (n = 904)|
Click here to view
Dental visits before, during, and after Covid-19 pandemic
To understand the impact of COVID-19 on dental care, 36.3% (328/904) of participants reported to visit the dentist on a regular basis before the pandemic onset. When asked about their dental needs during curfew period, 38% (343/904) had no dental complaints. Participants who, or their family members, experienced dental complaints during the curfew phase, were able to manage their symptoms via in-office emergency visit, using over-the-counter medications, tele-dentistry or asking for friends' advise [Figure 3].
|Figure 3: Pain management experienced by dental patients during curfew period (n = 904)|
Click here to view
When asked about the likelihood of seeking dental treatment (if needed) following local curfew lifting, 48% (433/904) stated to likely do so. Furthermore, 15.6% (141/904) of participants had a dental visit already, 49% (443/904) did not need one and 35.4% (320/904) refrained from attending the dental clinic though needed. In addition, 17.8% (161/904) of participants were more likely to seek tele-dental consultation and 50.4% (456/904) were likely to wait for more than 4 weeks before visiting the dentist once the pandemic is over. Further data are included in [Table 3].
|Table 3: Dental visits pattern before and after COVID-19 pandemic (n=904)|
Click here to view
Accounting for sociodemographic parameters, participants with lower monthly income were less likely to visit the dentist even if indicated (P < 0.05). In addition, participants with chronic medical conditions were more likely to visit the dentist when needed (P < 0.05) [Table 4]. When asked about the wait time until they feel safe to visit the dentist, younger and highly educated subjects were likely to do so in < 2 weeks (P < 0.05) [Table 5].
|Table 4: Association between sociodemographic variables and visits to the dentist after COVID-19 pandemic (n=904)|
Click here to view
|Table 5: Anticipated time frame for the general public to seek dental treatment once the COVID-19 curfew is over (n=904)|
Click here to view
Participants concerns over Covid-19 with dental visits
Study participants were asked to rank their concerns over Covid-19 cross-infection with dental visits. In total, 50% (452/904) of the participants ranked insufficient disinfection and lack of social distancing as their primary concerns when visiting the dentist [Figure 4] and [Figure 5]. In addition, 70% of participants reported sufficient social distancing and wearing masks by the dental staff all times as main measures to relief their concerns while receiving dental treatments [Figure 4]. When asked about their spending plan, participants of 41 years and older were more likely to limit their dental treatments to emergencies only [Table 6]. However, participants who are 20 years old and younger were planning to increase their average spending to treat pending dental problems (P < 0.05).
|Figure 4: Ranking the top concerns of dental patients when visiting dental clinics after COVID-19 (ranked from 1 (highest importance) to 5 (least importance)) (n = 904)|
Click here to view
|Figure 5: Ranking different measures that dental clinics can take to make participants feel safe to visit during this time and post-COVID-19 ranked from 1 (highest importance) to 5 (least importance) (n = 904)|
Click here to view
|Table 6: Attitude toward dental treatment following COVID-19 pandemic (n=904)|
Click here to view
| Discussion|| |
Since December 2019, COVID-19 pandemic has been spreading all over the world with a disastrous effect on all aspects of human lives with psychosocial impact being the main one. As a result, individuals' daily and routine activities have been compromised to a larger extent forcing the general public to make tough decisions such as postponing elective medical and dental care., With local curfew imposed by many governments as a way to slow-down COVID-19 transmission, understanding the attitude and perception of patients visiting dentists and management of dental needs were investigated in this study.
Population-based questionnaires are often applied for assessment of knowledge, attitude as well as psychological parameters such as phobia, panic disorders, and anxiety., It is a simple and effective way to better understand peoples' behavior which has been used globally during and after COVID-19 pandemic on a widescale. This study was conducted during the peak period of the curfew implemented by local authorities and gave a glimpse into the psychosocial impact it had on current and potential dental patients. In total, 71% of the participants were abreast with the current world affairs related to the pandemic and 74% were familiar with terms related to COVID-19 infection such as aerosol and sterilization. These results indicated that most of the participants were interested in gathering information from different resources related to COVID-19 in terms of routes of infection, complications, and precautions obtained through different social medial portals. The current data are confirms the common observation of change in public interests and in corelation with another study indicating a hike in demand by general public for technology and media access searching for updates and information related to COVID-19 pandemic.
One public health concern in countries who implemented a local curfew to control the spread of COVID-19, is the handling of urgent dental treatment for affected populations., In this study, 38% of participants had no dental emergencies during the curfew. However, 560 participants (62%) who, or their families, experienced dental problems during the same phase were able to manage through urgent in-office dental visits and over-the-counter medications. The utilization of tele-dental consultations was reported by participants in this study as a viable option to avoid close contact with people and reduce the risk of contracting COVID19 which supports the vital role of this tool in the field of medicine and dentistry. This was also in line with the data reported by Song et al. indicating that the highly contagious nature of the virus may be the factor for this apprehension. The fact that local governments imposed curfews with different durations and hours per day may have influenced participants' attitude. However, this data was not captured in the current study and could be considered one of the study limitations.
To understand the impact of COVID-19 pandemic on dental patients, participants were asked about their interests in visiting dentists for treatment once the curfew is over. In total, 35.4% were unlikely to visit a dentist due to the fear of contracting the disease and 17.8% preferred tele-consultation when possible as opposed to visiting the dental clinic primarily [Table 3]. This was noteworthy, particularly in people with low income indicating a role for potential pandemic-related financial impact in addition to concerns of families over contracting the virus (P < 0.05). A cross-sectional study from Italy reported similar data with 93% reduction in dental activity and cancelation of potential patients. Yet, 48% were likely to visit the dentist and 15.6% already had at least one visit to address a dental problem. This data may suggest that this group of participants to likely be in urgent need for dental treatment and/or convinced that the risk of disease transmission in the dental office is minimal. In this study, more than half of participants (50.4%) were on the cautious side and decided to wait for few weeks past curfew lifting before planning to visit the dentist if needed. The fact that dental offices are known to be high-risk sites for transmitting COVID-19 between dentists and patients stated by the World Health Organization (WHO) may justify the participants attitude and behavior toward seeking dental care.,,, Therefore, assurance combined with guidance over best practice and precautions provided by public health officials were reported as important tools to encourage the general public to return back to dental clinics for needed care.
Several factors may have influenced the participants' attitude and decision-making process to pursuit dental treatment including personal health status. For instance, subjects with chronic medical conditions were more likely to visit the dentist compared to healthy subjects. One explanation could be emerging of major health concerns with untreated dental problems. Age and educational levels were other factors with impact on patients' attitude, as younger and more educated participants expressed more interests in visiting the dentist at first opportunity. Furthermore, participants who were 20 years old and younger were planning to increase their average spending to treat pending dental problems in the coming few weeks (P < 0.05). With 81% of participants earning between 10 and 14K (SR) per month, the willingness to seek dental treatment postpandemic was seen in younger individuals which were similar to other study findings. The lack of stable family income or the fear of job loss due to the pandemic could be a potential explanation for this finding. A recent study have demonstrated older age and agreement with positive attitude toward dental care to be positively related to susceptibility for contracting COVID-19 in the dental office. In addition, higher valuation for dental care and appreciation of COVID-19 as a serious disease were also positively related to caution in visiting a dentist.
The safety measures in the dental office and/or the lack of awareness with regards to the standard dental operating procedures may have been major driving forces for the reported participants' attitude in this study. Insufficient disinfection of equipments by the dental staff and lack of social distancing were reported by 50% of participants as the primary concerns when visiting the dental office. In addition, social and demographic differences should be considered when analyzing the current data, as majority of the participants included in this study were female (77%) and the participants were residents of 25 different countries. As reported by 70% of study participants, maintaining sufficient social distancing and wearing masks by the dentists and dental staff all the time could be helpful measures to relief population concerns and encourage patients to visit the dentist when needed.
This study has several limitations. The sample size of the survey was minuscule given the widespread effect and the consequences the pandemic had worldwide. A larger sample size incorporating more participants would be ideal to study the true psychological impact of the pandemic on dental patients. Considering the fact that this study was conducted through an online questionnaire, people with the availability and access to technology were more likely to participate as opposed to people with limited technological resources and knowledge coupled with lack of information and poor ability to attract attention. Second, this was a survey conducted mainly through personal communications, e-mails, and social media. Exploring other communication portals would carry the possibilities for a broader reach to participants with variable sociodemographic backgrounds. In addition, most of the study participants were professionals in the dental field which can be also linked to the method of study distribution. Equal representation of the general public would allow for a better generalization of the current data. Third, including different perspectives of individuals living in different countries with variety of restrictions would be significant in assessing delivery of dental care in general during the time of the pandemic. However, 87.3% of participants were residents of Saudi Arabia accounting for majority of sample pool due to the study convenient design. Fourth, the current study had a cross-sectional design and ran for 2 months only. A prospective study design with longer duration may have had a wider range of responses due to the apparent nature of the curfew instilled for each country and the limited knowledge of future consequence it could have on individuals. This would also track all changes that may occur with the advent of newer guidelines that are laid down by the authorities. Fifth, all the collected data in this survey were self-reported and the lapse in personal information cannot be verified.
| Conclusion|| |
The current study provides an insight on patients perception toward seeking dental treatment during and postcurfew phases. Personal financial conditions, lack of awareness, and fear of contracting COVI-19 due to improper or unclear knowledge of guidelines stated by local authorities or WHO were identified as important influencing factors for the general public to return for professional dental care. With digitalization and social distancing being the new “normal,” there is a need for a greater focus on the psychosocial ramifications on medical treatment in general and dental treatment in particular, with growing need for dental services within local communities. Future, long-term studies to better understand the mental effects the current pandemic had on individuals should be considered.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Rollett R, Collins M, Tamimy MS, Perks AG, Henley M, Ashford RU. COVID-19 and the tsunami of information. J Plast Reconstr Aesthet Surg 2021;74:199-202.
Pearson CF, Jeffery R; Oxford-Cardiff COVID-19 Literature Consortium, Thornton EE. Mucosal immune responses in COVID19 - a living review. Oxf Open Immunol. 2021;2:iqab002. doi: 10.1093/oxfimm/iqab002.
Shahriar S, Rana MS, Hossain MS, Karim A, Mredula TN, Nourin N, et al.
COVID-19: Epidemiology, pathology, diagnosis, treatment, and impact. Curr Pharm Des 2021;27:3502-25.
Boudjelal M, Almajed F, Salman AM, Alharbi NK, Colangelo M, Michelotti JM, et al.
COVID-19 vaccines: Global challenges and prospects forum recommendations. Int J Infect Dis 2021;105:448-51.
Nguyen TM, Tonmukayakul U, Calache H. Dental restrictions to clinical practice during the COVID-19 pandemic: An Australian perspective. JDR Clin Trans Res 2021;6:291-4.
Oyedele T, Ladeji A, Adeyemo Y, Abah A, Coker M. Assessment of knowledge, practice, and level of preparedness of dentists practicing in Nigeria toward COVID-19 pandemic. Saudi J Oral Sci 2021;8:90-7. [Full text]
Alqahtani S, Alshahrani M, Alnefaie M, Almofrej A, Aldaghsh F, Alamri N, et al.
Knowledge and perception regarding personal protection equipment and infection control measures against COVID-19 among dental practitioners of Saudi Arabia. Saudi J Oral Sci 2021;8:98-103. [Full text]
Uziel N, Gilon E, Meyerson J, Levin L, Khehra A, Emodi-Perlman A, et al.
Dental personnel in Israel, Canada, and France during the COVID-19 pandemic: Attitudes, worries, emotional responses, and posttraumatic growth. Quintessence Int 2021;0:444-53.
Bastani P, Mohammadpour M, Ghanbarzadegan A, Kapellas K, Do LG. Global concerns of dental and oral health workers during COVID-19 outbreak: A scope study on the concerns and the coping strategies. Syst Rev 2021;10:45.
Xiao S, Yan Z, Zhao L. Physical activity, screen time, and mood disturbance among Chinese adolescents during COVID-19. J Psychosoc Nurs Ment Health Serv 2021;59:14-20.
Xiao X, Zhu X, Fu S, Hu Y, Li X, Xiao J. Psychological impact of healthcare workers in China during COVID-19 pneumonia epidemic: A multi-center cross-sectional survey investigation. J Affect Disord 2020;274:405-10.
Al-Khotani A, Al-Huraishi H, Meisha D. A memory-recall checklist for dental services during the COVID-19 outbreak: A clinical recommendation. Saudi J Oral Sci 2020;7:131-8. [Full text]
Shrivastava S, Shrivastava P. Coronavirus disease 2019 and oral health: Changing paradigms and the public health perspective. Saudi J Oral Sci 2021;8:118-9. [Full text]
Kenny G, Mallon PW. COVID19- clinical presentation and therapeutic considerations. Biochem Biophys Res Commun 2021;538:125-31.
Moffat RC, Yentes CT, Crookston BT, West JH. Patient perceptions about professional dental services during the COVID-19 pandemic. JDR Clin Trans Res 2021;6:15-23.
Srivastava KC, Shrivastava D, Sghaireen MG, Alsharari AF, Alduraywish AA, Al-Johani K, et al
. Knowledge, attitudes and practices regarding COVID-19 among dental health care professionals: a cross-sectional study in Saudi Arabia. J Int Med Res. 2020;48:300060520977593. doi: 10.1177/0300060520977593.
Turna J, Zhang J, Lamberti N, Patterson B, Simpson W, Francisco AP, et al.
Anxiety, depression and stress during the COVID-19 pandemic: Results from a cross-sectional survey. J Psychiatr Res 2021;137:96-103.
Melnyk YB, Stadnik AV, Pypenko IS, Kostina VV, Yevtushenko DO. Impact of COVID-19 on the social and psychological state of athletes. J Sports Med Phys Fitness. 2022;62:297-99. doi: 10.23736/S0022-4707.21.12401-6.
Torous J, Jän Myrick K, Rauseo-Ricupero N, Firth J. Digital mental health and COVID-19: Using technology today to accelerate the curve on access and quality tomorrow. JMIR Ment Health 2020;7:e18848.
Ilyas N, Sood S, Radia R, Suffern R, Fan K. Paediatric dental pain and infection during the COVID period. Surgeon. 2021;19:e270-5. doi: 10.1016/j.surge.2020.12.011.
Amato A, Ciacci C, Martina S, Caggiano M, Amato M. COVID-19: The dentists' perceived impact on the dental practice. Eur J Dent 2021;15:469-74.
Almazrooa SA, Mansour GA, Alhamed SA, Ali SA, Akeel SK, Alhindi NA, et al.
The application of teledentistry for Saudi patients' care: A national survey study. J Dent Sci 2021;16:280-6.
Song Z, Xu Y, Bao L, Zhang L, Yu P, Qu Y, et al.
From SARS to MERS, thrusting coronaviruses into the spotlight. Viruses 2019;11:E59.
Aquilanti L, Gallegati S, Temperini V, Ferrante L, Skrami E, Procaccini M, et al.
Italian response to coronavirus pandemic in dental care access: The DeCADE Study. Int J Environ Res Public Health 2020;17:6977.
Ali K, Raja M. Coronavirus disease 2019 (COVID-19): Challenges and management of aerosol-generating procedures in dentistry. Evid Based Dent 2020;21:44-5.
Ashtiani RE, Tehrani S, Revilla-León M, Zandinejad A. Reducing the risk of COVID-19 transmission in dental offices: A review. J Prosthodont 2020;29:739-45.
Benzian H, Niederman R. A dental response to the COVID-19 pandemic-safer aerosol-free emergent (SAFER) dentistry. Front Med (Lausanne) 2020;7:520.
Alsalman W, Alharbi S, Albattah A, Almas K. Effects of the outbreak of COVID-19 on oral health-care workers (HCWs) at the regional dental center in Qassim, Saudi Arabia. Saudi J Oral Sci 2021;8:81-9. [Full text]
Shigemura J, Ursano RJ, Morganstein JC, Kurosawa M, Benedek DM. Public responses to the novel 2019 coronavirus (2019-nCoV) in Japan: Mental health consequences and target populations. Psychiatry Clin Neurosci 2020;74:281-2.
Tang B, Bragazzi NL, Li Q, Tang S, Xiao Y, Wu J. An updated estimation of the risk of transmission of the novel coronavirus (2019-nCov). Infect Dis Model 2020;5:248-55.
Ahmad AR, Murad HR. The impact of social media on panic during the COVID-19 pandemic in Iraqi Kurdistan: Online Questionnaire Study. J Med Internet Res 2020;22:e19556.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]