RMHP-A-3249384105..4111.pdf

20 Apr,2022

R E V I E W

Review of the Psychological Impact of COVID-19 Pandemic on Healthcare Workers in Saudi Arabia

Ahmed S Bahamdan

Family and Community Medicine Department, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia

Purpose: The Covid-19 pandemic has significantly burdened healthcare systems worldwide and substantially affected the psychological state. The objective of this narrative review was to summarize the psychological outcome of the “Coronavirus (COVID-19) pandemic” on healthcare workers in kingdom of Saudi Arabia to assess their mental health outcome that can aid in development of guidelines and psychological interventions that can improve healthcare workers' quality of life, work and decision-making capability toward patient treatment during the pandemic.Materials and Methods: A comprehensive research was done to overview current avail-able literature on psychological and mental health issues observed among healthcare workers “HCW” in Saudi Arabia. The search included all articles published since the beginning of the pandemic from January 2020 till February 2021 relevant to the subject of the review. In this review, a total of 10 primary research articles were included following a cross-sectional survey method to analyze the impact of various psychological variables.Results: Anxiety symptoms were reported by between 33.3% and 68.5% of HCWs. Between 27.9% and 55.2% of HCWs reported depressive symptoms. HCWs reported anxiety, depression, sleep disturbances and distress with a range comprised between 27.9% and 68.5%.Conclusion: The Covid-19 pandemic has certainly led to multifaceted and vigorous psy-chological and mental impact on healthcare providers, it is now both an opportunity and challenge to design further studies that can lead to development of guidelines in Saudi Arabia and worldwide to improve mental health infrastructure that strengthen patient oriented treatment of care plan during this pandemic.Keywords: anxiety, depression, stress, insomnia

IntroductionIn the year 2020, the World Health Organization (WHO) declared the coronavirus outbreak as a global emergency. A year has been passed to this pandemic and the prevalence of psychological issues is rising day by day as the pandemic progresses. It has come across as an unprecedented dispute for healthcare systems. Generally, pandemics require immediate and efficient response from healthcare systems, with many healthcare workers (HCWs), either involved directly such as doctors and nurses or indirectly like laboratory and radiology technicians providing patients with care, fighting at the frontline and addressing challenges that threaten healthcare systems.1

History has showed that dynamic stress is experienced by HCWs during out-breaks. In a Chinese study among HCWs during the Ebola outbreak, extreme anxiety, depression, somatization and obsession-compulsions were reported.2

Correspondence: Ahmed S Bahamdan Family and Community Medicine Department, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, 34221 – 4237, Saudi Arabia Tel +966 546004777 Fax +966 133330220 Email bahamdan.as@gmail.com

Risk Management and Healthcare Policy 2021:14 4105–4111 4105© 2021 Bahamdan. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work

you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php).

Risk Management and Healthcare Policy Dovepressopen access to scientific and medical research

Open Access Full Text Article

Received: 23 June 2021Accepted: 16 September 2021Published: 1 October 2021

Ris

k M

t a

alth

care

licy

loa

d f

rom

htt

ps:

//w

.do

vep

ress

.co

5.2

.20

9.1

5 o

n 1

😯

ct-2

rso

l use

ly.

Also, in a study in Saudi Arabia, almost two thirds of HCWs reported feeling at risk of getting Middle East respiratory syndrome coronavirus (MERS-CoV) infection and felt unsafe working during the MERS outbreak.3

In Saudi Arabia, since the beginning of the pandemic until the 1st of December, 2020, there were 347,157 con-firmed (Covid-19) cases, with 5907 deaths.4 Until this date, there is no cure or approved vaccine for Covid-19. On top of that, an increase in depression, stress and anxi-ety symptoms has been reported in the general population and, especially, in HCWs. Increased working duties and the need to make difficult decisions on prioritizing care of patients may have strong effects on HCWs’ physical and mental health. Their resilience can be further affected by isolation and loss of social support, risk of infections or infecting family and friends as well as desperate, often unsettling changes in their work responsibilities.5

Thus, HCWs especially frontline staff face critical con-ditions which increase their risk of disturbing their mental health after dealing with unfavorable situations that can range from psychological distress to psychological symp-toms more than the general population.6,7 Fighting against a new virus with an unknown nature for a prolonged time is a crisis that affects the sustainability of healthcare sys-tems. Maintaining the maximum possible care provided fully relies on protecting the health of those responding to such crisis. Yet, the published findings of psychological distress among HCWs might indicate that healthcare sys-tems are currently unable to effectively protect the helpers.8

Psychological impacts and fear or hesitancy in HCWs may affect the efficiency, and quality of work as well as willingness to report to work which can have a dramatic effect on healthcare systems especially during pandemics.9

Reported physicians committing suicide with the psycho-logical impacts reported worldwide, led me to review the current literature of this pandemic on HCWs in Saudi Arabia and the latest recommendation regarding their mental health.10,11

The objective of this narrative review is to summarize the psychological outcome of the “Coronavirus (Covid-19) pandemic” on healthcare workers in kingdom of Saudi Arabia to assess their mental health outcome that can aid in development of guidelines and psychological interven-tions that can improve healthcare workers' quality of life, work and decision-making capability toward patient treat-ment during pandemic.

Materials and MethodsA comprehensive research was done to overview current available primary literature on psychological and mental health issues observed among healthcare workers “HCW” in Saudi Arabia. Literature search was conducted in “PubMed (MEDLINE)”, “ProQuest” and “Web of Science” database. Data were retrieved using the following search terms (“medical staff” OR “healthcare” OR “health-care professionals” OR “Physicians”) AND (“coronavirus” OR “COVID-19”) AND (“anxiety” OR “depression” OR “insomnia” OR “psychological” OR “mental health” OR “Stress”) AND (in “Saudi Arabia” OR “KSA”) in our search engines.

Our search included all primary articles published in peer reviewed journals since the beginning of pandemic from January 2020 till February 2021 relevant to the sub-ject of the review catering original research. Review arti-cles, correspondence, case reports and non-English articles were excluded. A final total of 89 citations were identified through search terms collectively from all databases. During initial screening 19 citations were removed as duplicate. Out of 70 after removing duplicate articles, 45 articles including review articles, correspondence and case reports were removed. Out of 25, a further 15 articles were removed as they were not conducted on HCW and assessed knowledge, attitude and practices. A total of final 10 full texts, primary articles were included. Results of the potential 10 articles were summarized in the form of Table 1 and health variables including anxiety, stress, sleep and depression are assessed in all studies (Figure 1).

ResultsIn this review, a total of 10 citations were included follow-ing a cross-sectional survey method to analyze the impact of various psychological variables including anxiety, stress, sleep and depression among Saudi healthcare work-ers during the Covid-19 pandemic. All 10 studies were evaluated to assess psychological symptom prevalence in both males and females. The psychological symptom pre-valence was profoundly observed in females (6 studies) in comparison to males (4 studies) (Figure 2). The most frequently used assessment tools were General Anxiety Disorder (GAD-7) and Patient’s Health Questionnaire (PHQ-9) respectively. However, other tools including Depression Anxiety Stress Scale-21 (DASS-21) and the psychological distress using the COVID-19 Peritraumatic Distress Index (CPDI) were also used.

https://doi.org/10.2147/RMHP.S324938

DovePress

Risk Management and Healthcare Policy 2021:14 4106

Bahamdan Dovepress

Ris

k M

t a

alth

care

licy

loa

d f

rom

htt

ps:

//w

.do

vep

ress

.co

5.2

.20

9.1

5 o

n 1

😯

ct-2

rso

l use

ly.

Tab

le 1

Des

crip

tion

Stud

y M

etho

dolo

gy, N

umbe

r of

Ws,

Anx

iety

, St

ress

, Sle

ep, D

epre

ssio

n Var

iabl

es a

nd A

sses

smen

t To

ols

Use

d in

Sel

ecte

d St

udie

Stu

tho

ear

Met

logy

Tota

l N

o o

f S

aud

i H

xiet

tres

leep

Dep

ress

ion

Ass

essm

ent

ols

Use

rafa

et a

l12

2021

Cro

sect

iona

surv

151

58.9

0%55

.90%

37.3

0%69

epre

ssio

n, A

nxie

ty a

nd S

tres

s Sc

ale

(DA

SS-2

lmat

et a

l13

2020

Onl

ine

surv

ey10

746

.70%

Low

28%

mode

rate

68.

2%,

Hig

h 3.

44.9

0%50

.50%

Nin

e-item

Pat

ient

Hea

lth

Que

stio

nnai

re (

PHQ

-9), s

even

-ite

m G

ener

aliz

Anx

iety

Dis

ord

er (

D-7

), s

even

-ite

m I

nsom

nia

Seve

rity

Ind

ex (

ISI)

lAte

et a

l14

2020

Cro

sect

iona

surv

502

51.4

0%55

.20%

Patien

t H

ealth

Que

stio

nnai

re (

PHQ

-9), G

ener

aliz

ed A

nxie

ty D

isord

er 7

(GA

D-7

)

lena

et a

l16

2020

Onl

ine

surv

ey49

2068

.50%

rt s

cale

lzai

et a

l22

2020

Cro

sect

iona

surv

441

33.3

0%G

ener

aliz

ed A

nxie

ty D

isord

er 7

-7)

Han

awi

et a

l17

2020

Cro

sect

iona

surv

950

40.0

0%Fi

ve s

cale

d re

spons

es t

o c

ons

truc

t a

CPD

lqut

et a

l18

2021

Cro

sect

iona

surv

2094

27.6

0%27

.60%

The

Kes

sler

psy

cholo

gica

l di

stre

ss s

cale

(k1

l Su

lais

et a

l19

2020

Cro

sect

iona

surv

529

Worr

y 67

.5%

Isola

tion

56.9

%, fe

49.7

rt s

cale

mar

et a

l20

2020

Cro

sect

iona

surv

1130

78.8

8%85

.83%

76.9

3%9-

item

pat

ient

hea

lth

ques

tionn

aire

(PH

Q-9

), t

he 7

-ite

m g

ener

aliz

anxi

ety

diso

rder

sca

le (

D-7

), a

nd 7

-ite

m ins

nia

seve

rity

ind

ex (

ISI)

10A

jwa

et a

l15

2020

Cro

sect

iona

surv

577

14%

7%G

ener

al A

nxie

ty D

isord

er (

D-7

) an

d Pa

tien

t’s H

ealth

Que

stio

nnai

(PH

Q-9

)

bre

viat

ion

s: C

ID-1

9, c

oro

navi

rus;

RS,

Sev

ere

Acu

te R

espi

rato

ry S

yndr

e; H

s, h

ealthc

are

work

ers;

MER

S-C

oV,

Mid

dle

East

Res

pira

tory

Syn

drom

e C

oro

navi

rus;

Worl

d H

ealth

Org

aniz

atio

n; G

-7,

Gen

eral

nxie

ty D

isord

er;

PHQ

-9, Pa

tien

t’s H

ealth

Que

stio

nnai

re; D

ASS

-21,

Dep

ress

ion

Anx

iety

Str

ess

Scal

e-21

; PD

I, Pe

ritr

aum

atic

Dis

tres

s In

dex.

Risk Management and Healthcare Policy 2021:14 https://doi.org/10.2147/RMHP.S324938 DovePress

4107

Dovepress Bahamdan

Ris

k M

t a

alth

care

licy

loa

d f

rom

htt

ps:

//w

.do

vep

ress

.co

5.2

.20

9.1

5 o

n 1

😯

ct-2

rso

l use

ly.

In this study, Arafa et al12 reported highest progres-sion of depression symptoms 69% in comparison to anxi-ety 58.90%, stress 55.9% and inadequate sleep 37.3% respectively among healthcare providers. He further graded depression as 29.6% with severe depressive symptoms and 39.4% with mild to moderate depression. Another study by Almater et al13 had further explained grading of stress among healthcare practitioners with stress low levels (28%), moderate levels (68.2%) and high levels (3.7%).

Two studies by AlAteeq et al14 and Nancy Ajwa et al15

explained both anxiety and depression among healthcare professionals and observed more depressive and anxious symptoms were observed in professionals deputed in med-ical wards as compared to dental ward. The largest study

was done in a nation-level cross-sectional study of parti-cipants from all the 13 administrative regions in Saudi Arabia with a sample of 4920 HCWs. They divided them into three groups according to anxiety level on the Dispositional cancer worry scale, 1552 (31.5%) low, 1778 (36.1%) medium, and 1590 (32.3%) high anxiety.16

In Al-Hanawi et al17 the study sample was 950 and (28.9%) showed normal, (33.7%) mild and (39.9%) severe distress using the COVID-19 Peritraumatic Distress Index which is a self-reported questionnaire that was originally used by a study in China to assess peritraumatic psycho-logical distress during the pandemic. Another study by Alqutub et al18 used the Kessler psychological distress scale (k10) question, and found that 27.6% healthcare workers were in psychological distress.

Figure 1 Eligibility criteria for inclusion and exclusion of studies in the review.

https://doi.org/10.2147/RMHP.S324938

DovePress

Risk Management and Healthcare Policy 2021:14 4108

Bahamdan Dovepress

Ris

k M

t a

alth

care

licy

loa

d f

rom

htt

ps:

//w

.do

vep

ress

.co

5.2

.20

9.1

5 o

n 1

😯

ct-2

rso

l use

ly.

Al Sulais et al19 used a questionnaire designed by Reynolds et al and observed that the most common feel-ings reported by the physicians during the pandemic were: worry (67.5%), isolation (56.9%) and fear (49.7%) through using a Likert scale. Similarly, Al Ammari et al20

with participation of 1130 participants from the healthcare sector showed 78.88% symptoms of work induced psycho-logical anxiety, 85.83% disturbance in sleep cycle or inability to sleep properly which ultimately led to 76.93% symptoms of depression.

DiscussionThis review provided the psychological impact of the COVID-19 pandemic on healthcare workers in Saudi Arabia. Overall, 60% of the studies reviewed in this article found out that more than 50% of the healthcare workers had psychological impact in terms of depression, anxiety and stress during the global emergency.

The studies included in our review reflected females as predominant participants in 6 studies (64.40–72.80%). Similarly, Lai et al7 in their study reflected professional women showed moderate to severe depression, anxiety and stress. Arafa et al12 in their study stated that mostly allied healthcare providers missed family emotional sup-port and indulged in watching covid news that increased likelihood of stress, disturbed sleep, anxiety and depres-sion among patients. In correlation to it, to improve overall HCW mental health status, Banerjee21 emphasized on psychiatrist significance in terms of education on pan-demic psychological impact on public, motivation to

develop and adopt strategies to prevent the spread of novel virus through basic practices and its integration in available healthcare setups. It also suggested how to adopt a problem solving approach and empowering both care-givers and patients through provision of quality mental healthcare services to care providers.

In a study conducted in China, prevalence distress symptoms were highest (71.5%), followed by depression (50.4%), anxiety (44.6%) and insomnia (34.0%) respectively.7 Overall, our studies have showed more prevalence of depression and anxiety in comparison to stress and insomnia symptoms. In another study by Almater et al13 impact of Covid-19 was observed in ophthalmologist setup. During earlier pandemics health-care professionals felt unprotected and lethargic, stressed during working in high-risk areas, however no significant previous work was identified regarding safety and psy-chological counseling of ophthalmologists during expo-sure with patients during work. Ophthalmologists are also at higher risk of virus transmission because of increased exposure to droplet or contact routes while performing slit lamp examination.

Longitudinal research studies are important to follow up on HCWs' mental health and develop intervention strategies that are evidence-based. Routine mental health screening is encouraged especially during pandemics.16,17,22 The World Health Organization’s mental health department published strategies to decrease the negative psychological impact of the COVID-19 pandemic to the general population and HCWs. A well-balanced lifestyle including regular exercise,

Figure 2 Gender-wise psychological variable prevalence.

Risk Management and Healthcare Policy 2021:14 https://doi.org/10.2147/RMHP.S324938 DovePress

4109

Dovepress Bahamdan

Ris

k M

t a

alth

care

licy

loa

d f

rom

htt

ps:

//w

.do

vep

ress

.co

5.2

.20

9.1

5 o

n 1

😯

ct-2

rso

l use

ly.

healthy diet and enough sleep is advised. Staying connected with families and friends is also encouraged with the differ-ent virtual applications.23

This study provided the review of merely 10 original articles as limited primary data were available relevant to our objective. We could not apply the quality assessment tool in this review yet we performed a detailed assessment of every included article. Regarding the type of the study, as this pandemic was started in 2020 and a short time span has passed, primary data were scarce and most of the studies were cross sectional and none of the longitudinal studies could be reviewed. The response variability might occur as studies were conducted in different medical insti-tutes and different stress, anxiety and depression scales were used.

ConclusionThe COVID-19 pandemic has certainly led multifaceted and vigorous psychological and mental impact on health-care providers, it is now both an opportunity and chal-lenge to design further studies that can lead to development of guidelines in Saudi Arabia and world-wide to improve mental health infrastructure that strengthen patient oriented treatment of care plan during this pandemic through development of mental health interventions that can overall improve productivity of healthcare provider.

AcknowledgmentsThe author is thankful to all the associated personnel, who contributed to this study by any means.

DisclosureThe author reports no conflicts of interest in this work.

References1. Preti E, Di Mattei V, Perego G, et al. The psychological impact of

epidemic and pandemic outbreaks on healthcare workers: rapid review of the evidence. Curr Psychiatry Rep. 2020;22:1–22. doi:10.1007/ s11920-020-01166-z

2. Ji D, Ji YJ, Duan XZ, et al. Prevalence of psychological symptoms among Ebola survivors and healthcare workers during the 2014–2015 Ebola outbreak in Sierra Leone: a cross-sectional study. Oncotarget. 2017;8:12784. doi:10.18632/oncotarget.14498

3. Abolfotouh MA, AlQarni AA, Al-Ghamdi SM, Salam M, Al-Assiri MH, Balkhy HH. An assessment of the level of concern among hospital-based health-care workers regarding MERS outbreaks in Saudi Arabia. BMC Infect Dis. 2017;17:1. doi:10.1186/s12879-016- 2096-8

4. Saudi Ministry of Health; 2020. Available from: https://covid19.moh. gov.sa/. Accessed December 1, 2020.

5. Pappa S, Ntella V, Giannakas T, Giannakoulis VG, Papoutsi E, Katsaounou P. Prevalence of depression, anxiety, and insomnia among healthcare workers during the COVID-19 pandemic: a systematic review and meta-analysis. Brain Behav Immun. 2020;88:901–907. doi:10.1016/j.bbi.2020.05.026

6. Zhou Y, Wang W, Sun Y, et al. The prevalence and risk factors of psychological disturbances of frontline medical staff in China under the COVID-19 epidemic: workload should be concerned. J Affect Disord. 2020;277:510–514. doi:10.1016/j.jad.2020.08.059

7. Lai J, Ma S, Wang Y, et al. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Netw Open. 2020;3:e203976. doi:10.1001/jamanetworkopen.2020.3976

8. Muller RA, Stensland RS, van de Velde RS. The mental health impact of the covid-19 pandemic on healthcare workers, and inter-ventions to help them: a rapid systematic review. Psychiatry Res. 2020;293:113441. doi:10.1016/j.psychres.2020.113441

9. Almaghrabi RH, Huda A, Al HW, Albaadani MM. Healthcare work-ers experience in dealing with Coronavirus (COVID-19) pandemic. Saudi Med J. 2020;41:657–660. doi:10.15537/smj.2020.6.25101

10. NBC New York. NYC emergency room doctor dies by suicide after treating COVID-19 patients; 2020. Available from: https://www.nbcne wyork.com/news/coronavirus/nyc-emergency-room-doctordies-from- suicide-after-treating-covid-19-patients/2391978/. Accessed December 1, 2020.

11. NST Online. French doctor commits suicide after Covid-19 diagnosis. New Straits Times; 2020. Available from: https://www. nst.com.my/world/world/2020/04/581620/french-doctor-commits- suicide-after-covid-19-diagnosis. Accessed December 1, 2020.

12. Arafa A, Mohammed Z, Mahmoud O, Elshazley M, Ewis A. Depressed, anxious, and stressed: what have healthcare workers on the frontlines in Egypt and Saudi Arabia experienced during the COVID-19 pandemic? J Affect Disord. 2021;278:365–371. doi:10.1016/j.jad.2020.09.080

13. Almater AI, Tobaigy MF, Younis AS, Alaqeel MK, Abouammoh MA. Effect of 2019 coronavirus pandemic on ophthal-mologists practicing in Saudi Arabia: a psychological health assessment. Middle East Afr J Ophthalmol. 2020;27:79. doi:10.4103/meajo.meajo_220_20

14. AlAteeq DA, Aljhani S, Althiyabi I, Majzoub S. Mental health among healthcare providers during coronavirus disease (COVID-19) outbreak in Saudi Arabia. J Infect Public Health. 2020;13:1432–1437. doi:10.1016/j.jiph.2020.08.013

15. Ajwa N, Al Rafee A, Al Rafie H, et al. Psychological status assess-ment of medical and dental staff during the covid-19 outbreak in Saudi Arabia. Med Sci. 2020;24:4790–4797.

16. Alenazi TH, BinDhim NF, Alenazi MH, et al. Prevalence and pre-dictors of anxiety among healthcare workers in Saudi Arabia during the COVID-19 pandemic. J Infect Public Health. 2020;13:1645–1651. doi:10.1016/j.jiph.2020.09.001

17. Al-Hanawi MK, Mwale ML, Alshareef N, et al. Psychological dis-tress amongst health workers and the general public during the COVID-19 pandemic in Saudi Arabia. Risk Manag Healthc Policy. 2020;13:733. doi:10.2147/rmhp.s264037

18. Alqutub S, Mahmoud M, Baksh T. Psychological impact of COVID-19 on frontline healthcare workers in Saudi Arabia. Cureus. 2021;13(5):e15300.

19. Al Sulais E, Mosli M, AlAmeel T. The psychological impact of COVID-19 pandemic on physicians in Saudi Arabia: a cross-sectional study. Saudi J Gastroenterol. 2020;26:249. doi:10.4103/sjg.sjg_174_20

20. Al Ammari M, Sultana K, Thomas A, Al Swaidan L, Al Harthi N. Mental health outcomes amongst health care workers during COVID 19 pandemic in Saudi Arabia. Front Psychiatry. 2020;11. doi:10.3389/fpsyt.2020.619540.

21. Banerjee D. The COVID-19 outbreak: crucial role the psychiatrists can play. Asian J Psychiatr. 2020;50:102014. doi:10.1016/j. ajp.2020.102014

https://doi.org/10.2147/RMHP.S324938

DovePress

Risk Management and Healthcare Policy 2021:14 4110

Bahamdan Dovepress

Ris

k M

t a

alth

care

licy

loa

d f

rom

htt

ps:

//w

.do

vep

ress

.co

5.2

.20

9.1

5 o

n 1

😯

ct-2

rso

l use

ly.

22. Alzaid EH, Alsaad SS, Alshakhis N, Albagshi D, Albesher R, Aloqaili M. Prevalence of COVID-19-related anxiety among health-care workers: a cross-sectional study. J Fam Med Prim Care. 2020;9:4904. doi:10.4103/jfmpc.jfmpc_674_20

23. Who.int; 2020. Available from: https://www.who.int/docs/default-source /coronaviruse/mental-health-considerations. Accessed December 1, 2020.

Risk Management and Healthcare Policy Dovepress

Publish your work in this journal Risk Management and Healthcare Policy is an international, peer- reviewed, open access journal focusing on all aspects of public health, policy, and preventative measures to promote good health and improve morbidity and mortality in the population. The journal welcomes submitted papers covering original research, basic science, clinical & epidemiological studies, reviews and evaluations,

guidelines, expert opinion and commentary, case reports and extended reports. The manuscript management system is completely online and includes a very quick and fair peer-review system, which is all easy to use. Visit http://www.dovepress.com/testimonials.php to read real quotes from published authors.

Submit your manuscript here: https://www.dovepress.com/risk-management-and-healthcare-policy-journal

Risk Management and Healthcare Policy 2021:14 DovePress 4111

Dovepress Bahamdan

Ris

k M

t a

alth

care

licy

loa

d f

rom

htt

ps:

//w

.do

vep

ress

.co

5.2

.20

9.1

5 o

n 1

😯

ct-2

rso

l use

ly.

Notwithstanding the ProQuest Terms and Conditions, you may use this contentin accordance with the terms of the License.