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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 2  |  Issue : 1  |  Page : 24-34

A knowledge, attitude, and practice study of diabetic retinopathy in an urban population


Department of Ophthalmology, Bhaskar Medical College and General Hospital, Ranga Reddy, Telangana, India

Date of Submission15-Nov-2021
Date of Decision05-May-2022
Date of Acceptance06-May-2022
Date of Web Publication05-Oct-2022

Correspondence Address:
Dr. Ramya Reddy Keesara
Flat No. 203, Road No. 4, Zahara Nagar, Banjara Hills, Hyderabad - 500 034, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jocr.jocr_29_21

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  Abstract 


Background: As the global prevalence of diabetes is on the rise, diabetic retinopathy (DR) is also projected to escalate. DR is one of the major causes of preventable blindness. Aims and Objectives: The rationale of this study is to ascertain and record knowledge, attitude, and practice (KAP) patterns among diabetics on diabetes and DR and to recognize the barriers to compliance to regular screening. Materials and Method: A cross-sectional study using a 43-point questionnaire was conducted in an urban population. Each response was assigned a score to attain aggregates and was further cataloged into “good,” “average/moderate,” and “poor” KAP categories using Microsoft Excel/SPSS (Statistical Package for the Social Sciences). Results: One hundred and ninety-six diabetics with a mean age of 59.89 ± 11.83 years were included in this study. “Good” knowledge scores seen in 28.6% showed a statistically significant association (P < 0.001) with “positive” attitude (28.6%) and “good” practice (33.7%) patterns. Women had better overall KAP scores. Good vision (65.6%) and unawareness (31.3%) were the major barriers to compliance. Conclusions: Awareness of DR is lagging even amid educated urban population. Establishing diabetic morbidity and retinopathy awareness with emphasis on necessity of timely screening and treatment might be the way forward in this pandemic period.

Keywords: Diabetic retinopathy, diabetic retinopathy questionnaire, screening, knowledge, attitude, and practice study


How to cite this article:
Keesara RR, Ather M, Reddy J M. A knowledge, attitude, and practice study of diabetic retinopathy in an urban population. J Ophthalmol Clin Res 2022;2:24-34

How to cite this URL:
Keesara RR, Ather M, Reddy J M. A knowledge, attitude, and practice study of diabetic retinopathy in an urban population. J Ophthalmol Clin Res [serial online] 2022 [cited 2022 Nov 29];2:24-34. Available from: http://www.jocr.in/text.asp?2022/2/1/24/357893




  Introduction Top


According to the International Diabetes Federation 9th edition of diabetic  Atlas More Details, the number of adults (20–79 years) living with diabetes in India is 77 million and it is projected to increase to 134.2 million by 2045.[1] One in three diabetics is estimated to develop diabetic retinopathy (DR) in their lifetime.[1] Undiagnosed diabetes remains a significant problem in India and DR is an emerging cause of preventable blindness.

Vision loss in DR has been largely attributed to low propensity to screening rather than treatment ineffectiveness. The presence of proliferative DR or diabetic macular edema significantly reduces the vision-related quality of life for the patient (P = 0.000).[2]

Living with diabetes is a challenge in itself; hence, better comprehension of its complications will have an optimistic impact on health-seeking behavior. Early detection and timely treatment of vision-threatening DR can prevent 95% of blindness from this cause.[3]

Majority of the patients presenting with late or untreated DR at our tertiary eye care hospital were completely naive about this complication and the need for regular screening. Awareness of the disease is a prime necessity to seek presumptive care and this has propelled the need for this study. Understanding the barriers might help us in comprehending future strategies, surmounting the glitches and thereby improving the current lag in timely diagnosis. To the best of our knowledge, no such study of DR with knowledge, attitude, and practice (KAP) grading was done in an urban population of Hyderabad.

The rationale of this study is to, therefore, ascertain and record KAP patterns among diabetics on diabetes and DR and to recognize the barriers to compliance to regular screening.


  Materials and Methods Top


This was a cross-sectional questionnaire-based study conducted over a period of 3 months (January to March 2021) in the south Indian city of Hyderabad, among educated diabetics.

The questionnaire has been formulated after a comprehensive literature search.[4],[5],[6],[7] Subject experts have assessed the questionnaire for its relevance and acceptability, following which an internal pilot study was conducted, and with slight modifications, the present 43-point questionnaire was framed.

After obtaining informed consent, the questionnaire was administered in a single language (English) to urban diabetic patients who were willing to participate [Annexure 1].

Sample size was estimated using the formula, Z1-α/22 p (1-p)/d2.

Here, Z1-α/2 is the standard normal variate at 5% Type 1 error (P < 0.05); it is 1.96. P is the expected proportion in the population based on previous studies. Since no accurate value on knowledge for DR has been established in the previous studies, it is considered as 50. d is the absolute error (7%). Using the above values, at 95% confidence level, a sample size of 196 subjects was calculated [Annexure 2].

The data obtained were methodically analyzed using Microsoft Excel, SPSS (Statistical Package for the Social Sciences), and Python software. Each of the response was scored, with +1/+2 for correct response, 0 for neutral response, and negative marking for wrong answers. Aggregates were obtained in the sections of KAP and were further cataloged into “good,” “average/moderate,” or “poor” categories. The categories were labeled based on 33rd, 66th, and 100th percentile of aggregate scores in the respective sections of KAP sections.


  Results Top


One hundred and ninety-six diabetic urban residents who fulfilled the inclusion criteria were enrolled into the study. The sample comprised 110 men (56.10%) and 86 women (43.9%) with a mean age of 59.89 ± 11.83 years. A complete demographic detail of the current sample is enlisted in [Table 1]. Forty-nine percent of them have been diabetic for more than 10 years. 40.8% of participants had coexisting hypertension. Majority of the participants were on oral hypoglycemic agents, while 27.6% of participants stated to be using insulin for their routine therapy. 15.3% of participants assumed that diabetic remedy should be continued only until the blood sugars are controlled.
Table 1: Demography of the study population

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42.9% of participants had spotted that diabetes can have an effect on the eye, whereas only 38.8% had recognized its possible effect on retina. 56.1% of participants had never heard of DR, while 55.1% had never had a dilated eye examination before and 23.7% believed that, even for a diabetic, visiting an optometrist is sufficient. 27% had identified family/friends as their source of information on diabetic retinopathy, while ophthalmologists and physicians together constituted to a majority of 49.2%, other identified sources remained mass media (TV/web portals/news) and books. 35% consider that perhaps patients with diabetes often waste their time and money on eye checkups as most of the time their eyes are normal.

50.5% of participants remained completely ignorant of the available treatment modalities; nevertheless, 34.7% (n = 66) identified systemic blood sugar control, 21.1% reckoned diet and lifestyle modification, 18.9% (36) thought laser, 11.6% (22) considered surgery, and a meager 3.2% had recognized intraocular injections as offered therapeutic approaches.

Twenty (10.2%) diabetic patients had professed to prior diagnosis of DR in their lifetime. 20% (4) of these patients had stated that they undergo eye examinations as and when recommended by the doctor and a negligible (5%) percent believed that they have been treated of DR, so there is no need for follow-up visits.

Although 88.7% of participants had vouched to getting their blood glucose levels checked at least once in 6 months, 51% ignorantly believed that eating excess sugars is the prime origin of diabetes.

39.8% of participants had indicated refraction as their dominant motive to routine hospital visits; however, 13.3% had been advised to be under regular ophthalmic follow-up and are uninformed of the grounds. 64.3% of participants said exclusive eye care centers as their choice of health care in case of an ophthalmic event.

There were fourteen questions pertaining to “knowledge and awareness” of diabetes and DR, ten in the “attitude” and nine in the “practice” sections, respectively. Every answer provided by the study participants in these sections was assigned a score based on the correctness and acceptability of the response. After obtaining aggregates in each of these three KAP categories, they were further cataloged into “good,” “average/moderate,” and “poor” KAP patterns [Table 2]. 28.6% (56) of them had “good” knowledge and another 28.6% had “positive” attitude; however, 33.7% (66) showed “good” practice patterns. 36.7% (72) of the samples exhibited “poor” knowledge and awareness of diabetes and DR, whereas 40.8% (80) had “poor attitude” and 34.7% (68) displayed “poor practice” patterns.
Table 2: Knowledge, Attitude and Practice (KAP) grading

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On comparing the mean scores of KAP for men and women, women were found to have superior scores in all the three sections and better overall scores as well [Table 3].
Table 3: Gender comparison of Mean KAP scores

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An overall KAP pattern grading was also assigned based on comprehensive scores of all the three sections, of which 31.63% of them had “good” KAP patterns, 34.69% had “average,” and 33.67% had “poor” KAP patterns.

The study revealed a positive linear correlation between knowledge and attitude (r = 0.59; moderate positive), knowledge and practice (r = 0.34; low positive), and attitude and practice (r = 0.29; negligible) [Table 4]. Thereby, we can deduce that by improving the knowledge of a patient, their attitude and practice are projected to improve [Annexure 3].
Table 4: Knowledge, Attitude and Practice correlation

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Having good vision (65.6%) and being unaware of the need for screening (31.3%) were acknowledged as the significant barriers to compliance to routine ocular examination. A meager 3.2% of the participants had stated financial/geographical elements as their concern. An additional 3.2% of the participants had expressed COVID-19 pandemic as their hurdle to screening.


  Discussion Top


This was a cross-sectional study conducted among 196 urban diabetic patients.

Good knowledge of DR was observed to be only in 28.6% of the current samples compared to the study findings by Srinivasan et al.[4] in a tertiary eye care center, although in a similar KAP study conducted by Hussain et al.,[6] 55.6% of the samples exhibited good knowledge of DR. However, in these studies,[4],[6]> nearly 70% of their test samples were acquainted with the fact that diabetes can have ocular consequences; this fact was acknowledged by only 43% in the present study.

Studies by Rani et al.[8] and Dandona et al.[9] depicted higher awareness levels pertaining to impaired vision in diabetes in individuals over 30 years; however, no such trend was observed in this study. This study could not establish age, literacy rates, or duration of diabetes to have any statistical significant association with KAP scores. In contrast to this, Koshy et al.[10] found that awareness of the disease seemed to increase with increasing duration.

Women had better average scores in all the three sections; conversely, no such trend was observed in a study by Muecke et al.;[11] nevertheless, Rani et al.[8] found knowledge of diabetes and not DR to be higher in their female study population.

For a majority (49%) of this study population, the source of information for their existing awareness of DR remained doctors (physicians and ophthalmologists), which was reported to be even higher (71%) by Srinivasan et al.[4] These findings were also consistent with reports by Venugopal et al.[12] (56%), and 26% of their samples showing a similar tend as ours (27%) had attributed their awareness to family and friends; however, it was noted to be higher (49%) in a study by Hussain et al.[6]

A significant positive correlation (0.59) was obtained between good knowledge levels and positive attitude (P < 0.001); on the other hand, in a study by Venugopal et al.,[12] it was noted to be insignificant; however, practice patterns were strongly associated with knowledge of DR (odds ratio = 7.47, 95% confidence interval, P < 0.001). Improving the awareness and knowledge of the people will have an impact on developing optimistic attitude and positive practice patterns, as deduced from this study.

The pandemic (3.2%) and economic/topographical concerns to medical facilities (3.2%) have been stated as hurdles to seeking DR screening. Lamichhane et al.[13] found 8.5% of their samples stating unaffordability and 6.2% stating inaccessibility as barriers, although unawareness (79.4%) was their major concern. However, our sample best represents upper class urban population, so the existing cost-effectiveness or the medical outreach of DR screening cannot be commented upon. Majority of our study population (65.6%) indicated that they possessed good vision and hence did not see a need for comprehensive examination and 31.3% were completely unaware of the need. Fear of hospital communicability in this pandemic state could prove to be a major setback to regular screening practices and positive health-seeking behavior.

With diabetic prevalence on an alarming rise, an upsurge in DR has been estimated. Hence, it is all the more important to revisit and assess the lacunae in screening and treatment approach protocols to curb preventable vision loss from it.

Better scores obtained by women as observed by this study hint at a better understanding and improved practice patterns by them. Accordingly, they should be ensured a place in counseling sessions for themselves or as an attendant to reinforce the significance of screening.

Delayed treatment has been proven to be harmful to prognosis of DR. Significance and relevance of habitual eye screening in preventing the visual complications of DR needs to be well established. A doctor's recommendation to the patients and their family members with regard to diabetes and its ocular complications with emphasis on screening regardless of their existing eyesight seems to be of utmost importance to build their awareness and understanding of the disease and to ultimately propel positive practices.

Strengths of this study

  • Framing a comprehensive KAP questionnaire, followed by its extensive assessment.
  • Score-based cataloging of the study participants
  • Analyzing the statistical strength of correlation among KAP patterns.


Weaknesses of this study

  • Diabetic control and retinopathy status of the participants could not be established
  • Subanalysis of the KAP status in poorly controlled diabetics could not be obtained.



  Conclusion Top


Knowledge and awareness was limited even amid well-educated patients in this study. Women have been found to score higher than men. Good knowledge was significantly associated with positive attitude and improved practice patterns. Unawareness pertaining to the necessity for screening was found to be a major barrier to compliance. There is a basic need to expand strategies to educate diabetics about this potentially blinding complication and persuade to preemptive ocular assessment.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.


  Annexures Top


Annexure 1: Diabetic Retinopathy – knowledge, attitude, and practice study

Questionnaire

DEMOGRAPHY

1. Name:-

2. Gender?

□ Female

□ Male

3. Age?

□ <30 years

□ 30-40 years

□ 40-50 years

□ 50-60 years

□ 60-70 years

□ >70 years

4. Highest obtained education level?

Primary school (4th standard)

□ High school (10th standard)

□ Intermediate and/or diploma

□ College/Graduate

□ Post graduate/any other equivalent

5. Economic status (family income/month)

□ <19,000 Rs

□ 19,000-47,000 Rs

□ 47,000-63,000 Rs

□ 63,000-1,20,000 Rs

□ >1,20,000 Rs

6. Are you a diabetic (Sugar patient)?

□ Yes

□ No

Section 2- Diabetic status

7. Years since diagnosed with diabetes?

□ <5 years

□ 5-10 years

□ 10-20 years

□ 20-30 years

□ >30 years

8. Your current treatment for diabetes?

□ Tablets

□ Insulin

□ lifestyle (diet & exercise)

□ Not taking any treatment

□ Other:-

9. Is your diabetes under control (blood sugar levels; HbA1c)?

□ Yes

□ No

□ Maybe/Don't know

10. Are you a hypertensive (High BP) patient?

□ Yes

□ No

□ Maybe

Section 3 - Knowledge

11. Which of these body parts do you think diabetes has effect on?

□ Kidney

□ Blood vessels and circulatory system

□ Nerves (tingling, numbness)

□ Eye

□ Feet

□ Brain

□ NONE

□ Don't know

□ Other:

12. How long do you think diabetic patients should continue their treatment?

□ Only until blood sugar levels are controlled

□ lifelong

□ Don't know

13. Do you think diabetic patients should have a regular eye check-up?

□ Yes

□ No

□ Maybe

□ Don't know

14. If yes, then how often?

□ Once every 6 months

□ Once a year

□ Only when eyesight is effected

□ Only if blood sugars are not in control

□ Other:

15. Can diabetes affect your vision (eyesight)?

□ Yes

□ No

□ Maybe

□ Don't know

16. Diabetes can affect which parts of an eye?

□ Conjunctiva

□ Eyelids

□ Cornea

□ Lens

□ Retina

□ NONE

□ Don't know

□ Other:

17. When should a diabetic patient visit an eye doctor?

□ There is no need to visit an eye doctor

□ Only when they have an eye problem

□ As soon as he/she is diagnosed

□ After 5-10 years of being diabetic

□ Other:

18. Have you ever heard of DIABETIC RETINOPATHY?

□ Yes

□ No

19. If yes, what was your source of information?

□ TV/News/Internet

□ Books

□ Family doctor

□ Eye doctor

□ Family/Friends

20. Can a diabetic retinopathy patient have normal vision?

□ Yes

□ No

□ Maybe

□ Don't know

21. Can diabetic retinopathy cause blindness?

□ Yes

□ No

□ Maybe Don't know

22. If diabetic retinopathy causes low vision, then

□ It can be treated

□ It cannot be treated

□ It is treatable only if detected early

□ Don't know

23. Risk of eye complications in diabetics can increase with?

□ Poor control of diabetes

□ longer duration of diabetes

□ Added hypertension (BP)

□ There is no increased risk of eye problems in diabetic patients

□ Other:

24. If you think Diabetic Retinopathy is treatable, what are the available treatment options?

□ lifestyle & diet modification

□ blood sugar control

□ laser surgery

□ injections into the eye

□ Don't know

□ Other:

Section 4 - Attitude

25. Eating excess sugars causes diabetes?

□ Yes

□ No

□ Maybe

□ Don't know

26. Can diabetes be cured completely?

□ Yes

□ No

□ Maybe

□ Don't know

27. Even if I forget to take diabetes medicines/treatment for a day or two it is alright

□ Yes

□ No

□ Maybe

□ Don't know

28. Even if my blood sugars are in control, I need to visit an eye doctor

□ Yes

□ No

□ Maybe

□ Don't know

29. Diabetics are more likely to develop eye problems than non-diabetics?

□ Yes

□ No

□ Maybe

□ Don't know

30. Seeing an optometrist (regular eyeglass store) is enough for people with diabetes?

□ Yes

□ No

□ Maybe

□ Don't know

31. Timely treatment can prevent/delay the progression of diabetic retinopathy

□ Yes

□ No

□ Maybe

□ Don't know

32. Lasers if taken for diabetic retinopathy is painful

□ Yes

□ No

□ Maybe

□ Don't know

33. If my eye problem due to diabetes is under control

□ I don't have to go back to the eye doctor

□ I do not have to continue diabetes medicines

□ Both the above options are correct

□ None of the above options are correct

34. Patients with diabetes often waste their time & money on eye check-ups as most of the time their eyes are normal?

□ Yes

□ No

□ Maybe

Section 5 - Practice

35. How often do you get your blood sugars checked?

□ every one month

□ once in every 6 months

□ once a year

□ only on advice

□ Never

36. When did you last visit your doctor (physician/endocrinologist) for your diabetes?

□ In the past 6 months

□ In the past one year

□ more than 1 year

□ Don't remember

□ NEVER

□ Other:

37. When did you last visit an eye doctor?

□ In the past 6 months

□ In the past one year

□ more than 1 year

□ Never

□ Don't remember

□ Other:

38. Did you ever have a dilated eye/retina examination?

□ Yes

□ No

39. To whom do you go your eye examination?

□ Physician at a local hospital

□ Local optical dispensary/store

□ Eye doctor at local hospital

□ Eye doctor at eye hospital

□ Eye camps

□ Never visited an eye doctor

□ Other:

40. Why do you go for regular eye check-up?

□ been advised but do not know the reason

□ Spectacle (glasses) prescription

□ Screening/treatment for diabetic retinopathy

□ Other eye problems

□ I do not go for regular check-ups

□ Other:

41. Have you ever been diagnosed with diabetic retinopathy?

□ Yes

□ No

42. If yes, how often do you visit your eye doctor?

□ Once in 6 months Once in a year

□ As and when advised

□ I have been treated, so do not have to follow up

43. Why have you not visited an eye doctor for a regular check-up?

□ Financial problems

□ Have good vision, so there is no need

□ Far away from home

□ Was not aware of the need

□ Other:

Annexure 2: Sample size calculations

Sample size was estimated by using the proportion of subjects with Knowledge on DR at 50% since no studies in literature showing accurate knowledge levels on DR. Sample size was estimated by using the formula, Z1-α/22 p (1-p)/d2. Here, Z1-α/2 is the standard normal variate (at 5% type 1 error (P < 0.05); it is 1.96, and at 1% type 1 error (P < 0.01), it is 2.58. as in majority of studies P values are considered significant below 0.05 hence 1.96 is used in the formula, P is the expected proportion in the population based on previous studies (50) and d is absolute error (7%). Using the above values at 95% Confidence level a sample size of 196 subjects was calculated.





Annexure 3:

Additional statistics

The following table provides the Correlation values amongst KAP scores.

Correlation is significant at the 0.01 level (2-tailed).







 
  References Top

1.
International Diabetes Federation and the Fred Hollows Foundation. Diabetes Eye Health: A Guide for Health Care Professionals. Brussels, Belgium: International Diabetes Federation; 2015. Available from: http://www.idf.org/eyecare. [Last accessed on 2021 Oct 20].  Back to cited text no. 1
    
2.
Radhakrishnan C, Shahanas CK, Sreejith K, Bindu S. Quality of life in type 2 diabetic patients with and without proliferative retinopathy and macular edema. Diabetes 2018;67 Suppl 1:2213-PUB.1.  Back to cited text no. 2
    
3.
Vujosevic S, Aldington SJ, Silva P, Hernández C, Scanlon P, Peto T, et al. Screening for diabetic retinopathy: New perspectives and challenges. Lancet Diabetes Endocrinol 2020;8:337-47.  Back to cited text no. 3
    
4.
Srinivasan NK, John D, Rebekah G, Kujur ES, Paul P, John SS. Diabetes and diabetic retinopathy: Knowledge, attitude, practice (KAP) among diabetic patients in a tertiary eye care centre. J Clin Diagn Res 2017;11:NC01-7.  Back to cited text no. 4
    
5.
Khandekar R, Harby SA, Harthy HA, Lawatti JA. Knowledge, attitude and practice regarding eye complications and care among Omani persons with diabetes – A cross sectional study. Oman J Ophthalmol 2010;3:60-5.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Hussain R, Rajesh B, Giridhar A, Gopalakrishnan M, Sadasivan S, James J, et al. Knowledge and awareness about diabetes mellitus and diabetic retinopathy in suburban population of a South Indian state and its practice among the patients with diabetes mellitus: A population-based study. Indian J Ophthalmol 2016;64:272-6.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Lingam S, Rani PK, Sheeladevi S, Kotapati V, Das T. Knowledge, attitude and practices on diabetes, hypertension and diabetic retinopathy and the factors that motivate screening for diabetes and diabetic retinopathy in a pyramidal model of eye health care. Rural Remote Health 2018;18:4304.  Back to cited text no. 7
    
8.
Rani PK, Raman R, Subramani S, Perumal G, Kumaramanickavel G, Sharma T. Knowledge of diabetes and diabetic retinopathy among rural populations in India, and the influence of knowledge of diabetic retinopathy on attitude and practice. Rural Remote Health 2008;8:838.  Back to cited text no. 8
    
9.
Dandona R, Dandona L, John RK, McCarty CA, Rao GN. Awareness of eye diseases in an urban population in southern India. Bull World Health Organ 2001;79:96-102.  Back to cited text no. 9
    
10.
Koshy J, Varghese DL, Mathew T, Kaur G, Thomas S, Bhatti SM. Study on KAP of ocular complications due to diabetes among type II diabetics visiting a tertiary teaching hospital. Indian J Community Health 2012;24:27-31.  Back to cited text no. 10
    
11.
Muecke JS, Newland HS, Ryan P, Ramsay E, Aung M, Myint S, et al. Awareness of diabetic eye disease among general practitioners and diabetic patients in Yangon, Myanmar. Clin Exp Ophthalmol 2008;36:265-73.  Back to cited text no. 11
    
12.
Venugopal D, Lal B, Fernandes S, Gavde D. Awareness and knowledge of diabetic retinopathy and associated factors in Goa: A hospital-based cross-sectional study. Indian J Ophthalmol 2020;68:383-90.  Back to cited text no. 12
[PUBMED]  [Full text]  
13.
Lamichhane G, Khanal R, Singh S, Gurung S, Pandey A, Adhikari S. Knowledge, attitude and practice (KAP) on diabetic retinopathy among diabetic patients living in Hilly areas of Lumbini Zone of Nepal. Int J Curr Res Med Sci 2018;4:50-5.  Back to cited text no. 13
    



 
 
    Tables

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



 

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