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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 36  |  Issue : 4  |  Page : 351-358

Knowledge and understanding of suicide in rural and suburban community of Chandigarh


Department of Psychiatry, Government Medical College and Hospital, Chandigarh, India

Date of Submission16-Mar-2020
Date of Decision25-May-2020
Date of Acceptance21-Jun-2020
Date of Web Publication31-Dec-2020

Correspondence Address:
Dr. Ajeet Sidana
Department of Psychiatry, Government Medical College and Hospital, Sector-32, Chandigarh (UT) - 160 030
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_46_20

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  Abstract 


Background: Communities play a crucial role in suicide prevention. Community knowledge and understanding are essential for planning intervention strategies at community level. Aims and Objectives: To study the knowledge and understanding of people in rural and suburban areas about suicide and its prevention. Methodology: On the basis of convenient sampling, two places in the periphery of Chandigarh were selected. The participants were recruited from among those who were attending the program on suicide prevention on the occasion of World Mental Health Week (2019) and were administered a questionnaire (developed after 2 focused group discussions) after taking their informed consent. Results: There were 90 participants predominantly from rural background (74.4%), males (70%), and in the age range of 40–50 years (37%). Majority of the males from middle socioeconomic status and rural background reported 11–20 cases of suicide every year in their area and which was statistically significant. About 87% agreed that mental illness was not the only cause of suicide, and most of them felt that suicide occurred due to financial problems (34%), stress (33%), depression (22%), mental illness (21%), family disputes (15%), and unemployment (15%). Majority (47%) of the respondents preferred to “talk with friends and near ones” for suicide prevention. Conclusion: Study concluded that there is inadequate knowledge about incidence of suicide in the rural and suburban community of Chandigarh.

Keywords: Community, financial problem, knowledge, suicide


How to cite this article:
Sidana A, Gupta S, Saroye R. Knowledge and understanding of suicide in rural and suburban community of Chandigarh. Indian J Soc Psychiatry 2020;36:351-8

How to cite this URL:
Sidana A, Gupta S, Saroye R. Knowledge and understanding of suicide in rural and suburban community of Chandigarh. Indian J Soc Psychiatry [serial online] 2020 [cited 2021 Jan 28];36:351-8. Available from: https://www.indjsp.org/text.asp?2020/36/4/351/305954




  Introduction Top


Suicide has been recognized as a major public health problem.[1] According to the WHO, suicide is a global phenomenon and occurs throughout the lifespan. Suicide was the ninth leading cause of death in India in 2016 with an age-standardized suicide death rate of 17.9/100,000 population, accounting for 2.35% of all deaths, with 94,380 deaths in women and 135,934 in men.[2] Over 800,000 people commit suicide every year, representing one person every 40 s, and for each death, there are more than 20 suicide attempts.[3] Suicide is the final common pathway for various predisposing, precipitating, and perpetuating factors, and there is no single risk factor or condition responsible for it.[4] Emerging theories of suicide show how cultural meaning influences suicidality.[5] Recent theories of suicide mainly consider “Western individualism,” i.e., individual's motives are factors.[6] Suicide is however a private and personal act, and a wide disparity exists in the rates of suicide across different countries. Consideration of cultural or area-specific factors would enable development of better prevention strategies.

Suicides are preventable. Awareness of suicide as a public health issue needs to be raised through a multidimensional approach, considering the social, psychological, and cultural impacts. Comprehensive multisectorial strategies for the prevention of suicide are essential for suicide reduction worldwide, and community-level approaches should be employed as part of an effective strategy. The prevention of suicide is not only important for individuals and families but also benefits the well-being of communities, the healthcare system, and society at large.

Community engagement is an active and participatory bottom-up process by which communities can influence and shape policy and services.[7] Hence, to determine which groups would be more vulnerable to suicide, it is important to understand the local context in each community. This allows community suicide prevention activities to be targeted at those who are at the maximum risk of suicide.[8]

Further, suicide is shrouded in stigma, shame, and misunderstanding which are the barriers for its prevention. Suicide prevention cannot be done by one organization or institution alone; it requires support from the whole of the community. Moreover, communities can reduce risk and reinforce protective factors by providing social support to vulnerable individuals, engaging in follow-up care, raising awareness, fighting stigma, and supporting those bereaved by suicide.[9]

Community can extend the help to affected families only if the community is aware about the incidence of suicide in the area, prevailing attitude, and various psychosocial–cultural–religious factors associated with it. Hence, this study was planned to assess the perspectives of community about suicide. The results of this study are expected to provide critical input to the policymakers to redesign psychoeducative and clinical services which are consonant with patient's needs and expectations. The index study was carried out with the aim to assess the knowledge and understanding of people in rural and sub-urban areas about suicide and its prevention.

Aim

To study the knowledge and understanding of people in rural and suburban areas about suicide and its prevention.


  Methodology Top


Background of the study

The theme of World Mental Health Day 2019 was Suicide Prevention. The Department of Psychiatry, Government Medical College and Hospital, Chandigarh, organized mental health week from December 4–10, 2019, and carried out various awareness, educational, and informative activities through delivery of public lectures, role-plays on the early identification of suicidal behavior, and preventive steps along with clinical services in the adjoining areas of Chandigarh.

Design of the study

It was a cross-sectional, exploratory study.

Setting

For the purpose of the study, based on convenient sampling, two places in the periphery of Chandigarh were selected (one village and one suburban community, each has population of around 7000). The participants were recruited from those who attended the program on suicide prevention during the World Mental Health Week (2019).

Sample

Ninety participants were administered a questionnaire after taking their informed consent. No exclusion criteria were kept, keeping the sample as identical as real community setting/real-world sample.

Development of questionnaire

The department is providing community psychiatry services in the adjoining villages of Chandigarh since more than two decades and is aware of the psychosocial milieu of the catchment area. The department has also published papers on psychological autopsy of suicide cases.[10]

Since there is a lack of tool to tap the people's understanding regarding suicide, a semi-structured questionnaire was drafted pertaining to various domains, i.e., prevalence, epidemiology, causes, myths, and prevention.

All the investigators sat together and searched the available literature about the community perspective on suicide and incorporated their experience. Finally, a set of 15 open-ended questions was prepared, and it was shown and discussed with other faculty members in the department for their inputs and suggestions to see the construct validity of the questionnaire.

Two focused group discussions (FGDs) each consisting of 10 persons were held, and a set of open-ended questions prepared by the investigators was presented to the group for their responses to see the feasibility and appropriateness of the questionnaire, as well as to generate the response of persons to these questions. The agreed responses were recorded as the consensus statement.

The discussion was audio-recorded and the responses were generated by two psychiatrists, and in case there was any disagreement between the two consultants, the question was referred to the third psychiatrist and the best responses from the three were considered (shown in [Table 1]). Finally, a set of questionnaires was finalized after including responses obtained from FGD and after discussion among three psychiatrists.
Table 1: Questionnaire developed for the study

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The questionnaire was read out by the investigators, all questions were explained one by one in the vernacular language to 90 participants, and all the responses to the questionnaire were recorded along with the explanation and additional remarks, if any given by participants. Data were analyzed using statistical analysis system software (IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp). Frequency tabulation was carried for nominal variables. All the responses were compared for difference between participants depending on their sociodemographic details. Significance level was kept at less than or equal to 0.05. The study was approved by the institutional research committee.


  Results Top


There were a total of 90 participants who were predominantly from rural background (74.4%). Most of them males (70%), majority of the participants were aged ranged 40–50 years (37%), and majority of the participants were belonged to middle class (86.6%). Out of the total, 30 were students, 18 farmers, 14 laborers, 6 shopkeepers, 5 professionals, 4 drivers, 2 electricians, 2 gurusewaka (Gurudwara workers), and 9 homemakers.

Incidence of suicide

Of 90 participants, 54 people agreed that suicide have occurred in their area, but six were unaware about the incident of suicide in their area. Twenty-eight (31.1%) out of 90 respondents reported cases of suicide up to five per year, and there was significant difference in responses between males and females, males reported more incidence than females (P = 0.028), whereas 11 (12.2%) subjects reported an incidence of suicide up to 8–9 cases per year in their catchment area, out of which participants with age more than 40 years showed statistically significant difference with P = 0.043. Against this, 30 respondents reported no case of suicide as shown in [Table 2].
Table 2: Comparison between participants' responses and their sociodemographic variables for incidence of suicide

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At-risk people

Majority of the participants (60%) considered that persons with depression were at highest risk of suicide. Statistically significant difference was observed for the responses between the age groups of 18-40 years and more than 40 years (p=0.002); and those belonging to rural background (p=0.046) considered substance use as major risk factor for suicide. A significant number of patients (37.7%) stated that poor people who have financial problems could commit suicide as nowadays without money, basic needs are not fulfilled. Urban population considered substance use as the most common risk, and rural population considered examination failure as risk factor for suicide. For the consideration of examination failure as the risk factor, majority of suicide victims were <20 years of age (56%). Males belonging to rural background and lower socioeconomic status expressed that farmers were at major risk for suicide. Others (23.3%) also considered family disputes and domestic violence as the risk factors for suicide.

Causes of suicide

While trying to find out what was the community's view regarding the causes of suicide, the participants mentioned various causes for suicide. About 87% of the participants agreed that mental illness was not the only cause of suicide.

Significant number of urban population considered harassment at workplace as one of the most common causes of suicide (P = 0.0002).

Most of them felt that suicide occurred due to financial problems (34%), stress (33%), depression (22%), mental illness (21%), family disputes (15%), and unemployment (15%). Significant number of participants belonging to rural background (P = 0.086) felt that frequent family disputes and depression were the leading causes of suicide, others being drug abuse, harassment, tragedy, education pressure or examination failure, and problems related to workplace. Males belonging to more than 40 years of age group with middle socioeconomic status and rural background considered unemployment as the cause of suicide; older participants considered that unemployment could lead to financial constraints further increasing suicidal ideation.

About 50% of the participants mentioned “possession by an evil spirit or ghost” as one of the causes of suicide. Participants with older age showed more responses when asked if “uperisaya” was the cause of suicide. Most of the participants who considered financial problems as a major cause of suicide belong to rural background (90%), mainly working as farmer or as laborer. Statistically significant females (P = 0.044) considered marital discord as the main cause of suicide. Problems related to workplace were regarded as a cause of suicide by a significant number of male participants belonging to urban background (P = 0.02) as shown in [Table 3].
Table 3: Comparison between participants' responses and sociodemographic variables about the causes for suicide

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Suicide prevention

About 97% of the study population suggested that suicide is an important, largely preventable public health problem. In an attempt to explore the pathways that should be used by the people whenever someone has suicidal ideation, majority (47%) of the participants preferred to “talk with friends and near ones.” Many (17%) added that people with suicidal thoughts should “think positive/about good things” by rural population (P = 0.05). Eleven percent of them also preferred to visit a “psychiatrist” even though they did not have much knowledge about it, with more responses by urban participants (P = 0.01). Worshiping God was considered as one the methods by significant number of rural participants (P = 0.026). Further, they mentioned about increasing awareness of mental illness in the community along with availability of adequate facilities as reflected in [Table 4].
Table 4: Comparison between participant responses and sociodemographic variables about the prevention of suicide

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Other responses about suicide

Male participants belonging to middle socioeconomic status agreed that suicide is preventable.

When asked about “if only persons with mental illness commit suicide?,” there is difference between the viewpoints of male and female participants, and females agreed that mental illness is the only cause of suicide as shown in [Table 5]. Further, participants belonging to younger age group (P = 0.036) and lower socioeconomic status agreed upon this.
Table 5: Comparison between participants' responses and sociodemographic variables

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Viewpoints of people on legal aspects of suicide in light of Mental Health Care Act 2017 were also recorded. When asked about the decriminalization of suicide, the participants agreed that it is a valid step as it helps in reducing the stigma in the community.

When asked “if suicide eliminates all problems,” 91% replied with statistically significant response by males (P = 0.036), participants belonging to older age (P = 0.075) added that it would increase the problems for the family members (survivors), could lead to depression further making them emotionally vulnerable and might result in suicide.

Majority of males belonging to middle socioeconomic status also denied the myth that “people who talk about suicide do not intend to commit it.” Rather this reflects help-seeking behavior or an attempt to solve their problems. They also agreed that “one should talk about suicide openly” so that necessary steps could be taken to prevent suicide, majority of these were males, older age group, and of middle socioeconomic status. The person who has suicidal thoughts can be prevented from suicidal attempt as he/she might not have taken a definite decision for the same. Even a talk could help prevent the suicide.

Even though participants did not have a proper qualification, they mentioned that suicide does not just happen abruptly. Symptoms may proceed in form of aloof behavior, sadness of mood, and decreased appetite. One should not ignore such warnings.


  Discussion Top


The current study looked in to the knowledge and attitude of rural and suburban community of Chandigarh about suicide and factors related to it. To the best of our knowledge, this is the first study conducted in Northern India. Our findings suggest key sociodemographic differences in knowledge and understanding of suicide, yielding results that may be useful for shaping prevention efforts.

About 60% of the participants were aware of the incidence of suicide in their area, whereas more than 33% of the participants denied about its occurrence and a very small number was unaware about the incidence of suicide. It indicates that about one-third of the studied population is either not aware or denied incidents of suicide in their area, which denotes poor knowledge about suicide in the community. In addition, there is wide variation in reporting the number of cases per year by different age groups and socioeconomic strata, which denotes the variation of knowledge about suicide with various sociodemographic variables. A study by Elias et al. showed that adolescents have poor knowledge and conservative attitude about suicide and it is not associated with sociodemographic variables.[11] It has also been reported in the literature that youth overestimate the incidence of suicide.[12] Hence, over-reporting of suicide is not a new phenomenon. However, we did not find literature to support the views of participants about no suicide in the community. Participants who reported an incidence of suicide in the community have the knowledge and awareness about higher incidence of suicide in men as compared to women, and people with poor socioeconomic status are at high risk of committing suicide and the same has been reported in earlier studies too.[13],[14]

Nearly 60% of the participants reported persons with depression are at highest risk of suicide, as suicidal ideation and thinking of suicide are the common features of depression. Our findings indicate that examination failure is one of the risk factors of suicide which has been reflected in the National Crime Reports Bureau report.[15] Reason is a pressure on the students by their parents to score maximum marks. When they are unable to perform well and fail in examinations and to avoid criticism by parents and society, they choose suicide as a means of escape.[14]

Financial constraints were considered as the most common cause of suicide by the participants, which is also reflected in other study.[16] It has been observed that the persons who committed suicide were under debts or had financial constraints. In the absence of any help, they perhaps chose to end their lives.

Significant urban population felt harassment at workplace as one the common causes of suicide, as it leads to hindrance in the successful advancement in the career. Due to this, the person feels himself/herself as worthless and considers suicide as the only option to escape from this. About 5.5% of the study population considered farmers to be vulnerable/at risk for suicide as they are one of the high-risk populations who face financial stressors in their life, which has been endorsed by Radhakrishnan and Andrade.[17] Our study also reflects association between unemployment rates and suicide. Unemployment may afflict the suicide risk through factors, such as financial constraints and domestic difficulties. Earlier research has reported that, socioeconomic variables such as low income, environmental incidences: conflict, disputes have a strong influence on suicidal rates.[18]

Interpersonal stress/psychosocial stress at work or at home is a common cause of suicide which has been replicated by various authors.[16],[19],[20],[21] Demonic possession as a cause of suicide is a common belief in 50% of the study population. This could be due to differences in the sociocultural background.

About 21% of the study population considered positive thinking as the mode for prevention of suicide. When an individual develops a positive outlook toward life, it instills hope to live and hence helpful in the prevention of suicide. Talking to a friend or a family member aids in reducing the mounted tension and may abate suicidal behavior, highlighting the importance of social and emotional support.[22],[23],[24] However, only 13% of the study population emphasized on the importance of psychiatric consultation as a means of prevention. This is because 50% of the participants believed in possession by an evil spirit as cause of suicide, and this also reflects stigma related to psychiatry that seeking psychiatric help increases the risk of exposing the patient's personal problems to the public and could result in shaming not only the individual but also their family.[25]

About 5.6% of the participants suggested that by “Worshipping God,” suicide can be prevented which may hinder an individual with thoughts of suicide not presenting to the clinician and this finding is consistent with study done in rural Haiti.[19] When asked about the decriminalization of suicide, 52% of the study population agreed that it is justified. People are not willing to seek official help when they get suicidal thoughts as it further increases the suicidal ideations. However, authors did not find literature about views of community on decriminalization of suicide.

Common notions such as people with mental illness commit suicide or those talking about suicide do not commit it, person with suicidal ideations takes definite decision to commit suicide, and suicide eliminates all the problems were also busted during the study. Awareness regarding the psychosocial factors associated with suicide along with its prevention was also spread after knowing the perceptive of study population.

Although the study was conducted in real community setting and all the questions were explained to the participants in their vernacular language (Hindi and Punjabi), it has certain limitations as: India is a country of great diversity and this small sample may not indicate the real picture about the knowledge and understanding of community about suicide. Second, the convenient sampling technique could have led to selection bias, and the sample was heterogeneous which might have caused response bias also, owing to sociodemographic variations; this limits the generalization of results and warrants further research.


  Conclusion Top


This can be concluded from the study that there is inadequate knowledge about the incidence of suicide in the rural and suburban community of Chandigarh and there is need to impart the knowledge about the same through regular awareness campaign. This study addresses the need to identify various risk factors for suicide, which may ultimately contribute to programs to increase the use of suicide prevention resources in remote communities where counseling and discussion of mental health problems are largely a taboo.

Our study suggests that specific focus in suicide prevention strategies should be on the persons belonging to low socioeconomic status. For early identification of risk factors, family education programs are required in India.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Fleischmann A, Arensman E, Berman A, Carli V, De Leo D, Hadlaczky G, et al. Overview evidence on interventions for population suicide with an eye to identifying best-supported strategies for LMICs. Glob Ment Health (Camb) 2016;3:e5.  Back to cited text no. 1
    
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Bachmann S. Epidemiology of suicide and the psychiatric perspective. Int J Environ Res Public Health 2018;15:1425.  Back to cited text no. 2
    
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World Health Organization. Mental Health. Prevention of Suicidal Behaviors: A Task for All. Available from: http://www.who.int/mental_health/prevention/suicide/information/en/. [Last accessed on 2019 Dec 22].  Back to cited text no. 3
    
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Jacob KS. Suicide in India: Part perceptions, partial insights, and inadequate solutions. Natl Med J India 2017;30:155-8.  Back to cited text no. 4
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Cheng JK, Fancher TL, Ratanasen M, Conner KR, Duberstein PR, Sue S, et al. Lifetime suicidal ideation and suicide attempts in Asian Americans. Asian Am J Psychol 2010;1:18-30.  Back to cited text no. 5
    
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Boldt M. The meaning of suicide: Implications for research. Crisis 1988;9:93-108.  Back to cited text no. 6
    
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McLeroy KR, Norton BL, Kegler MC, Burdine JN, Sumaya CV. Community-based interventions. Am J Public Health 2003;93:529-33.  Back to cited text no. 7
    
8.
Wasserman D. Can suicide be prevented ? Eur Psychiatry 2016;33:2.  Back to cited text no. 8
    
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World Health Organization. Preventing Suicide: A Community Engagement Toolkit. World Health Organization; 2018. Available from: https://apps.who.int/iris/handle/10665/272860. [Last accessed on 2019 Dec 16].  Back to cited text no. 9
    
10.
Chavan BS, Singh GP, Kaur J, Kochar R. Psychological autopsy of 101 suicide cases from northwest region of India. Indian J Psychiatry 2008;50:34-8.  Back to cited text no. 10
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Elias E, Sreedevi PA, Sreejamol MG. Assessment of knowledge and attitude of adolescents regarding suicide. Indian J Psynursing 2015;9:17-20.  Back to cited text no. 11
    
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Beautrais AL, John Horwood L, Fergusson DM. Knowledge and attitudes about suicide in 25-year-olds. Aust N Z J Psychiatry 2004;38:260-5.  Back to cited text no. 12
    
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Knipe DW, Carroll R, Thomas KH, Pease A, Gunnell D, Metcalfe C. Association of socio-economic position and suicide/attempted suicide in low and middle income countries in South and South-East Asia-a systematic review. BMC Public Health 2015;15:1055.  Back to cited text no. 13
    
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Manoranjitham S, Charles H, Saravanan B, Jayakaran R, Abraham S, Jacob KS. Perceptions about suicide: A qualitative study from southern India. Natl Med J India 2007;20:176-9.  Back to cited text no. 14
    
15.
Accidental Deaths and Suicides in India 2008. National Crime Records Bureau. New Delhi: Ministry of Home Affairs, Government of India; 2010.  Back to cited text no. 15
    
16.
Das A. Farmers' suicide in India: Implications for public mental health. Int J Soc Psychiatry 2011;57:21-9.  Back to cited text no. 16
    
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Radhakrishnan R, Andrade C. Suicide: An Indian perspective. Indian J Psychiatry 2012;54:304-19.  Back to cited text no. 17
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Patel V, Chisholm D, Parikh R, Charlson FJ, Degenhardt L, Dua T, et al. Global Priorities for Addressing the Burden of Mental, Neurological, and Substance Use Disorders 2016;4:1-27.  Back to cited text no. 18
    
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Gururaj G, Isaac MK. Epidemiology of Suicides in Bangalore. Report no.: Publication No 43. Bangalore: National Institute of Mental Health and Neuro Sciences; 2001.  Back to cited text no. 19
    
20.
Hagaman AK, Wagenaar BH, McLean KE, Kaiser BN, Winskell K, Kohrt BA. Suicide in rural Haiti: Clinical and community perceptions of prevalence, etiology, and prevention. Soc Sci Med 2013;83:61-9.  Back to cited text no. 20
    
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Manoranjitham SD, Rajkumar AP, Thangadurai P, Prasad J, Jayakaran R, Jacob KS. Risk factors for suicide in rural south India. Br J Psychiatry 2010;196:26-30.  Back to cited text no. 21
    
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Walls ML, Hautala D, Hurley J. “Rebuilding our community”: Hearing silenced voices on Aboriginal youth suicide. Transcult Psychiatry 2014;51:47-72.  Back to cited text no. 22
    
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    Tables

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



 

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