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Conhecimento e comportamento preventivo de gestantes sobre Toxoplasmose no município de Imperatriz, Maranhão, Brasil

Toxoplasmosis knowledge and preventive behavior among pregnant women in the city of Imperatriz, Maranhão, Brazil

Ivone Pereira da Silva Moura1
Ilma Pastana Ferreira2
Altem Nascimento Pontes1
Cléa Nazaré Carneiro Bichara1, 3

1 Programa de Pós-graduação em Ciências Ambientais, Centro de Ciências Naturais e Tecnologia (CCNT), Universidade do Estado do Pará (UEPA). Tv. Enéas Pinheiro, 2626, Marco, 66.095-100 Belém, Pará, Brasil. ivonepds@hotmail.com
2 Departamento de Enfermagem, Universidade do Estado do Pará, Belém, Brasil.
3 Instituto de Ciências Biológicas, Universidade Federal do Pará, Belém, Brasil.

ABSTRACT

The aim of this study was to assess toxoplasmosis knowledge and preventive behavior, and relate these to socioeconomic, pre-natal and environmental issues among pregnant women served by the Family Health Strategy in the municipality of Imperatriz, Maranhão, Brazil. This is a cross-sectional study performed by applying a structured and pre-tested questionnaire to a sample of 239 pregnant women. Only 23.4% of the pregnant women had good knowledge of the disease, primarily in the area of prevention, and 58.9% adopted suitable preventive behaviors. The results obtained show a significant association of various toxoplasmosis risk factors, such as drinking untreated water (OR=2.1245; IC95%=1.20-3.73; p=0.0128), contact with cats (OR=7.6875; IC95%=4.22-13.97; p<0,0001), cleaning cat feces (OR=6.8738; IC95%=3.02-15.60; p<0.0001), eating raw meat (OR=5.7405; IC95%=3.21-10.24 and handling sand/cat litter OR=10.7376; IC95%=4.64-24.85; p<0.0001). This shows a need for continued education on toxoplasmosis for the pregnant women seen by the Imperatriz FHS, and for more comprehensive preventive measures, with public health and education policies that take into consideration economic, social, environmental and cultural issues.

Keywords: Toxoplasmosis; Knowledge; Attitude; Pregnant Women.

RESUMO

O objetivo desse estudo foi avaliar o conhecimento e comportamento preventivo sobre a toxoplasmose e relacionar com as condições socioeconômicas, do pré-natal e ambientais entre as gestantes da Estratégia Saúde da Família (ESF), do município de Imperatriz, Maranhão, Brasil. A pesChisa realizada foi um estudo transversal, no qual foi aplicado um questionário estruturado e pré-testado, com amostra de 239 gestantes. Somente 23,4% das gestantes apresentaram bom conhecimento sobre a doença, com ênfase no domínio prevenção; 58,9% adotaram adequadamente os comportamentos preventivos. Os resultados obtidos chamam a atenção pela associação significativa a vários fatores de risco para a toxoplasmose, como: consumo de água sem tratamento (OR=2,1245; IC95%=1,20-3,73; p=0,0128), contato com gatos (OR=7,6875; IC95%=4,22-13,97; p<0,0001), limpeza das fezes do gato (OR=6,8738; IC95%=3,02-15,60; p<0,0001), consumo de carne crua (OR=5,7405; IC95%=3,21-10,24; p<0,0001) e mexer com areia (OR=10,7376; IC95%=4,64-24,85; p<0,0001), gerando a necessidade de uma educação continuada sobre a toxoplasmose para as gestantes atendidas na ESF de Imperatriz, e o estabelecimento de medidas preventivas mais integrais, com políticas públicas de saúde e educação que levem em consideração questões econômicas, sociais, ambientais e culturais.

Palavras-chave: Toxoplasmose; Conhecimento; Atitude; Gestantes.

INTRODUCTION

Toxoplasmosis is a global zoonosis caused by Toxoplasma gondii, a single-cell obligate protozoa. In a pregnant woman the disease is a serious public health program and the vertical rate of transmission is proportional to the gestational age at first infection, ranging from 6 to 10% in the first trimester to 70 to 90% in the third trimester1,4,5. However, the disease is more serious at the start of gestation, at which time it can cause serious clinical manifestations in the fetus8,9.
T. gondii is one of the microorganisms that can be transmitted perinatally, a group that includes cytomegalovirus, HIV, Herpes simplex, rubella and hepatitis B, among other viruses10. In light of this possibility, more importance should be assigned to knowledge and prevention of such diseases among pregnant women.
Most of the studies on toxoplasmosis in pregnancy attempt to estimate the prevalence of the disease or infection and the associated risk factors1,2,3. Knowledge and prevention of toxoplasmosis during pregnancy can contribute to the start of primary prevention activities, which are essential to build public policies 6,11,12.
In light of this, some studies have analyzed toxoplasmosis-related knowledge, showing that pregnant women are unaware of how the disease is transmitted and do not adopt preventive behaviors11,13,14. In the US there is little knowledge of the risk factors, even though a large percentage of the pregnant women claim to practice good preventive behaviors15.
Assuming that healthy behavior is based on a sequential process that starts with acquiring scientifically accurate knowledge, leading to a favorable attitude and adopting healthy practices16. We find that the lack of knowledge about toxoplasmosis could be significantly associated with disease incidence, and is considered an important risk factor17.
Given the importance of this disease and its impact on pregnancy, we felt it important to investigate the theme of toxoplasmosis knowledge and preventive behavior among pregnant women in northeast Brail, specifically in a municipality of the state of Maranhão. This location was chosen in part as it offered the structured logistics of the Family Health Strategy, which aims to develop basic care prevention measures in pre-natal care.
We attempted to answer the following fundamental questions: (1) Are pregnant women potentially at risk for toxoplasmosis, given the low-level of knowledge and failure to take preventive measures? (2) Are pregnant women adopting disease-prevention behavior?

Method

This is a cross-sectional, analytical, descriptive study employing a quantitative approach. It was performed between June 2016 and February 2017 in the city of Imperatriz-MA (5°31\'32" S and 47°26\'35" W). The city has some 252,123 inhabitants, 27 primary healthcare units (PHI) and 38 Family Health (FH) teams in the urban perimeter, which is where this study took place. It was approved by the University of the State of Pará Ethics Committee for Research on Human Beings, opinion n. 1.622.428.
The study population consisted of pregnant women under pre-natal care at the PHU and considered by the Ministry of Health as being at risk for infection by T. gondii and consequent placental transmisison, leading to a congenital form of the disease18,19. The sample "n" is based on the expected 50% frequency of women with knowledge of toxoplasmosis and who display preventive behaviors among the finite population of 876 pregnant women registered in the urban area of Imperatriz in 2016 (source: SIAB, primary care information system). This enabled estimating the parameter with a 5% sample error and 95% confidence level. The ideal size was 275 pregnant women, however five of the primary care units do not use the same routine for pre-natal visits, so we were left with 239 randomly selected pregnant women meeting the inclusion criteria (aged 18 or over, registered with an urban FH team, residing in the district of the respective PHU, willing to sign the Free and Informed Consent Form FICF). We excluded women in their first pre-natal visit and those registered with a PHU in a rural area.
Data was gathered using a structured, pre-tested questionnaire made up of sociodemographic, environmental and pre-natal care questions, as well as questions related to the disease. The questionnaire was comprised of 24 items in four domains to assess knowledge of disease transmission, clinical symptoms, congenital toxoplasmosis and infection prevention1,14,15,20. Closed questions were used with possible answers being True, False or Don\'t Know. A correct answer in the knowledge section was assigned a score of 1, and an incorrect answer or Don\'t know was assigned a score of 0.
Additional data, such as the date of first pre-natal care, number of visits and serological tests during pre-natal care were obtained from the records in the patient card. This field was populated when the card contained the information.
For quantitative analysis of toxoplasmosis knowledge and behavior among pregnant women we applied descriptive and inferential statistical methods. The qualitative variables are presented as absolute and relative frequency distributions. The quantitative variables are presented as central trend and variations. Distribution was assessed using the D\'Agostino-Pearson test.
To quantify knowledge and preventive behavior among the pregnant women we assigned a scale that varies with the number of correct answers regarding suitable knowledge and behavior. The knowledge score ranges from 0% (all questions wrong) to 100% (all questions right). The behavioral score ranges from 0% (all inadequate behaviors) to 100% (all adequate behaviors). We defined the level of knowledge as follows: Good (≥70%), Fair (>51% and <69%) and Poor ≤ 50%). Behavior was classified as Suitable (≥70%), Fair (>51% and <69%) and Poor ≤ 50%). The criteria chosen to indicate pregnant women at higher potential risk for toxoplasmosis was a score of less than 70% in both the knowledge and behavior scales.
In order to assess potential risk, the sample (n=239) was split into two groups: GA (poor or inadequate knowledge and behavior, n=84 - High Risk) and GB (good or adequate knowledge and behavior, n=155 - Low Risk). We applied G and Chi-squared tests, followed by the Odds Ratio test. For rejection of the null hypothesis Alpha was previously set at 0.5 (Alpha Error 5%). For statistical processing we used SAM (Statistical Analysis Model) and BioEstat version 5.3.

RESULTS

Sociodemographic characteristics

The average age of the 239 pregnant women participating in the study was 24.4. Most (77.8%) were married or living with their partner, 41.8% had completed secondary school, 52.3% claimed not to be employed (formally or informally) and 34.3% claimed they did not work to take care of the home. For 77.3% of the subjects, household income ranged from 1 to 2 minimum salaries. The number of people living with them ranged from one to eight. No significant association was found between the group at risk for toxoplasmosis and the sociodemographic variables (Table 1).
Pre-natal characteristics

For 38.1% of the subjects this was their first pregnancy, and the average age of first gestation was 23.9 ± 4.8. Gestational age ranged from 5 to 40 weeks (average of 26.8±8.0); 6.7% were in the first trimester, 48.9% in the second and 43.9% in the third trimester). The number of visits ranged from one to eight pre-natal visits (average of 4.1 visits). Only 23.0% of the pregnant women went to six or more pre-natal visits. Pre-natal care started on average at 2.5 months of gestation. 86.2% started pre-natal care in the first trimester. A gestational complication was miscarriage, mentioned by 12.6% of pregnant women.
Most of the pregnant women (93.7%) were submitted to toxoplasmosis serology, 62.8% in the first trimester. Only 7.9% had the test more than once. The share of pregnant women by toxoplasmosis risk group does not differ statistically regarding the pre-natal variables (Table 2).
Environmental characteristics

Regarding environmental characteristics, 98.7% of the pregnant women used town water. For drinking water, 64.1% filtered the water (OR=0.4705; IC95%=0.27-0.81; p=0.0098), 28.7% were in the group of pregnant women with adequate knowledge and behavior (low risk), whereas 71.3% were in the group with inadequate knowledge and behavior (high risk). 31.6% used untreated water (OR=2.1245; IC95%=1.20 - 3.73; p=0.0128). Analyses show that filtering water is a factor of protection against the disease, and using untreated water is a risk factor.
Regarding sewage, 35.1% mentioned being hooked up to the city sewage system, (OR=0.5323; IC95%=0.29 a 0.95; p=0.0463) and 4.2% claimed their sewage went directly to rivers or streams (OR=4.6061; IC95%=1.15 - 18.30; p=0,0434). There was no significant difference in risk for toxoplasmosis among pregnant women for destination of solid waste and the condition of the street they live on (Table 3).
Knowledge of Toxoplasmosis

Most of the pregnant women (55.6%) claimed not to know anything about toxoplasmosis. Those claiming to be aware of the disease said things like: "It\'s a disease caused by cats" (28.3%), "you get it from cat feces" (17.9%), "you get the disease by eating contaminated food" (5.6%); 64.0% claim they have received no instructions form healthcare professionals on how to avoid the disease. Among those who received some instruction, 51.2% claim they were told to wash fruits and vegetables very well, not feed cats raw or underdone meat, not have any contact with cats and not have any contact with cat feces. Nurses were the health professionals who most often shared this information (65.1%); 43.9% claimed to know that toxoplasmosis during pregnancy can affect the baby. The problems mentioned were: "mental disease", "the baby can get it", "malformation", "blindness", "impairment", "eats their eyes".
Analyzing knowledge of toxoplasmosis shows that 17 of the 24 items showed a statistically significant relationship with protection factors. There was no significant difference in the groups of pregnant women by toxoplasmosis risk factors and the items in the clinical status domain. There were more correct answers in the prevention area of the knowledge domain than in the disease transmission and congenital toxoplasmosis areas. The total knowledge score ranged from 0 to 22 (out of 24 points). Only 23.4% of the pregnant women had good knowledge about the disease (Table 4).
Toxoplasmosis-related preventive behaviors

Regarding pets, 53.1% of the women claim to have a pet. Of those with cats, 35.3% had more than one cat, and more than half of them (63.6%) were kittens. 38.6% claim they clean up pet feces, none of them using gloves. Over 43.0% of the pregnant women feed their cats raw meat and allow them out of the house (48.8%).
Regarding eating rare meat, 38.1% claim they eat rare meat an average of 1.9 times a week, 5.5% eat rare meat daily. The type of meat eaten most often is beef (72.7%).
Washing fruits and vegetables with water only, and cleaning kitchen utensils were mentioned by 84.% and 24.7% of the pregnant women respectively. Sixteen point three percent of the women mentioned having direct contact with sand/soil, and 48.7% of them had a vegetable garden at home.
Behavior to prevent toxoplasmosis was adopted by 58.9% of the pregnant women, while 41/1% did not present this behavior.
If we compare toxoplasmosis behavior between pregnant women we found a positive association for protection against toxoplasmosis for:= washing kitchen utensils with warm water and detergent after contacting raw meat or unwashed fruits and vegetables (OR=0.4547; IC95%=0.25-0.80; p<0.0093) and not going fishing or swimming (OR=0.4910; IC95%=0.25-0.94; p<0.0488). However, other behavioral items are associated with disease risk factors, and the proportion of pregnant women by risk for toxoplasmosis group is statistically different regarding these behaviors (Table 5).
DISCUSSION

There have been studies on toxoplasmosis in several parts of the world, given the importance of this disease if acquired during pregnancy. This is the first primary care study that explores toxoplasmosis in relation to knowledge and preventive behavior among pregnant women in the municipality of Imperatriz and in the state of Maranhão. The importance of the theme derives from the fact that unawareness of the disease and failure to engage in toxoplasmosis prevention behavior can increase the risk of becoming ill.
Many authors claim sociodemographic factors reveal risk factors for toxoplasmosis. These include low income12,21 and few years of schooling3,10. However, unlike previous studies, in this case we found no significant association between sociodemographic factors and toxoplasmosis. Most (42.7%) of the pregnant women in this study were between the ages of 18 and 22 , and 41.8% had completed secondary school. The vast majority (83.3%) came from households with incomes of between 1 and 2 minimum salaries. These results are very close to those in a similar study in the state of Tocantins, which also found no correlation between toxoplasma infection and age, years of schooling or origin2.
It is important to point out that although there is no statistical association with demographic profiles, previous reports show that education is an important risk factor for T. gondii infection. As a rule, people with more years of schooling have more knowledge of infection and prevention2. Another study in Rio Grande do Sul shows that fewer years of schooling and pre-natal care in the public healthcare system are associated with less information about the disease among pregnant women22.
Even though years of schooling did not show any significant association with risk of infection, a study in Niteroi-RJ showed that completing secondary was a factor of protection against a positive serum test for T. gondii8. Most of the pregnant women in this study claimed to have completed secondary school, which may be associated with more information about toxoplasmosis prevention.
Pre-natal care is considered the best time to implement measures to prevent diseases capable of maternal-fetal transmission, such as toxoplasmosis3,23. The first pre-natal visit should be as early as possible, and pregnant women should go to at least 6 pre-natal visits, as per Ministry of Health24 recommendations, which to a large extent is the number of visits among the pregnant women in the study sample. The average number of pre-natal visits was 4.1 and, for the most part, pre-natal care started in the first trimester (86.2%)/ Only 23.0% of the women in the sample went to six or more visits. The number of visits in the present study was smaller than those found in studies conducted in Belo Horizonte and Goiania, where the average was 725,26.
It was encouraging to find that 62.8% of the pregnant women were tested for toxoplasmosis in the first trimester, a far larger number than in Belo Horizonte (34.7%)25, Mato Grosso do Sul (35.4%)27 and Goiânia (54.6%)26.
Although this study found no significant association with pre-natal variables, the percentages reflect that starting pre-natal care in the first trimester is essential, including serology tests for early identification of acute gestational toxoplasmosis. Pregnant women with a negative test in the first trimester should repeat the test in the second trimester19. These guidelines are in disagreement with the data revealed in this study, where only 7.9% of the pregnant women were tested a second time. Furthermore, it is assumed that the more pre-natal visits the more information pregnant women will receive regarding congenital toxoplasmosis, risk factors and prophylaxis25,26.
Regarding environmental conditions, we found a significant association between drinking untreated water and sewage discarded in rivers/streams as a risk factor for toxoplasmosis. Drinking treated and filtered water and sewage disposal in a city sewage system were considered factors of protection against the disease, unlike other studies that found no significant association between sanitation and the pregnant women in the study1,2,11.
The fact that the pregnant women in our sample drank potable water differs from the results of a study performed in Michelena, Venezuela where more of the participants drank non-potable water28, a fact associated with a 4.5 times larger risk of infection by T. gondii29. In fact, there are numerous reports of toxoplasmosis outbreaks in Brazil and elsewhere in the world where water was associated as a factor for infection by T. gondii. Town water contamination with the feces of infecting cats disseminates oocytes, potentially leading to epidemics8,30,31.
The analysis was also negative regarding lack of general knowledge, given that only 44.4% of the interviewees had read about, seen or heard about the disease. Looking each domain of knowledge of toxoplasmosis in the study, the number of pregnant women with good knowledge was Quite small (23.4%).
Similar studies show limited knowledge on parasite infections, such as the study in the state of Paraná, where most pregnant women were unaware of measures to prevent congenital toxoplasmosis11, and in Belo Horizonte, where fewer than 10% of the pregnant women were aware of the disease25.
Knowledge of toxoplasmosis among pregnant women was also the topic of study in three Asian countries, where most interviewees did not know or were unsure about infection with toxoplasma10. The same is true among pregnant women in the United States15.
Another important piece of evidence was the small percentage (36.0%) of pregnant women receiving instructions regarding toxoplasmosis. This corroborates other studies with a smaller percentage of women receiving instructions7,25. In terms of knowledge of toxoplasmosis risk and transmission factors, the number of correct answers, statistically associated with protection against the disease, was largest (75.3%) the item "toxoplasmosis can be found in cat feces". Andiappan et al. (2014) showed that only 19.4% of the pregnant women interviewed correctly identified contact with cat feces as the main mechanism of toxoplasmosis transmission10. In a study conducted in the US, 61.0% of the pregnant women associated cats with toxoplasmosis transmission, but only 30.0% were aware of the risk of infection from consuming raw or rare meat15.
The item with the largest number of correct answers in the congenital toxoplasmosis domain were "toxoplasmosis can be treated in pregnant women and in the newborn". Even though these are statistically considered as a protective factor, it is likely that the pregnant women were encouraged to provide a correct answer by believing that the disease is treatable, regardless of pregnancy. Still in this domain, 39.0% of the pregnant women were aware that toxoplasmosis can lead to vision problems in the infant. A study of pregnant teenagers found little knowledge regarding the problems it can cause to the infant20.
Among the domains investigated, there was more knowledge of prevention, estimated as a statistically significant protection factor. Pregnant women mentioned that washing and peeling all fruits and vegetables before eating them and thoroughly cooking meats can avoid toxoplasmosis. Most were aware of the role of cats and cat litter in disease prevention. Contrary to the results of the present study, in the study of pregnant women conducted in the state of Paraná there was a lack of knowledge of preventive measures against congenital toxoplasmosis11. Pregnant women in the Netherlands mentioned that not changing the cat litter, not eating under-done meats and washing and peeling fruits and vegetables can help prevent toxoplasmosis13.
Although there is a lack of knowledge of toxoplasmosis in several of the items investigated in this study, the pregnant women claim to practice behaviors that help avoid toxoplasmosis. In general, this study shows that pregnant women have a good amount of knowledge of preventive measures. This was corroborated by a study in the US, where most of the pregnant women interviewed revealed correct preventive measures to avoid infection14. Some studies show that suitable knowledge of toxoplasmosis risk factors supports preventive behaviors against severe complications resulting from congenital infection, and that it is only this knowledge that enables pregnant women to reduce the risk of fetal infection14,10.
Another analysis of the potential risk for toxoplasmosis revealed that a significant number of the pregnant women (n=155) had good or suitable knowledge and behavior (>70%). Although most did not receive suitable instructions regarding the disease during pre-natal care, it is likely that the pregnant women behaved appropriately as they were aware of the possibility of contracting an infectious disease during pregnancy, a fact that helped determine changes in behavior as normally women take better care of themselves when they are pregnant13,32. Since most of the pregnant women claimed good preventive behavior, we wonder if these women were motivated to answer correctly as they are enrolled in a healthcare unit15.
Understanding the preventive behavior of pregnant women can help provide advice, which is essential to reduce fetal risk14. In this study, contact with cats and dogs was similar to that reported in other studies, with a statistically significant association with the risk of toxoplasmosis2,8,33. However, another study of pregnant women revealed different results, finding no association between contact with cats and the possibility of infection with T. gondii34.
Among pregnant women who had contact with cats and picked up their feces, none used gloves for this, which is considered a strong risk factor for infection. Unlike the results of the present study, Costa et al. (2012)12 reported that pregnant women used gloves to clean cat litter boxes. Contact with kittens was statistically associated with toxoplasmosis transmission, likely increasing the risk of infection as infected kittens eliminate millions of oocytes, which can remain in the environment, sporulate and become infecting34,35.
Another behavior considered a statistically significant risk is eating rare or poorly cooked beef, and artisanal sausage. Infection with toxoplasmosis during pregnancy is strongly associated with consumption of rare or raw beef336, and although more than half the pregnant women claimed to be aware of this, only a small percentage said they avoided this behavior. A study in northeast Brazil failed to show any association between a positive serum test for T. gondii in pregnant women and artisanal sausage1.
Contact with soil and having a vegetable garden at home were associated with the risk of infection with toxoplasmosis The habit of handling soil or sand should also be considered for infection with toxoplasmosis34,36. Unlike the present study, results in Niterói (Rio de Janeiro) found no such associaiton8, although it is widely mentioned in the literature as a risk factor for the disease. Washing kitchen utensils with warm water and soap is statistically associated with protection against the disease. Similar results were found among Saudi Arabian pregnant women14.
Studies on this theme have shown that toxoplasmosis education increased knowledge of the disease and prevention among pregnant women12,14,32. In Belgium, there was a significant decrease in toxoplasmosis seroconversion after intense counseling of pregnant women was instituted37.
This study provides information to better understand toxoplasmosis knowledge and preventive behavior among pregnant women in the region. It also reiterates the importance of continued health education in this target group, as suitable awareness about health and toxoplasmosis can help decrease the incidence of the disease and the burden of the effects of congenital toxoplasmosis10. Health education in infectious diseases is essential from the very start of pre-natal care, especially for those with severe complications such as toxoplasmosis, in the form of campaigns, lectures and other educational programs to teach women how to avoid contact with potentially contaminated materials3,15,32.

CONCLUSION

In general, there was limited knowledge among the interviewees of this study, however a considerable number was aware of measures to prevent and avoid toxoplasmosis during pregnancy. Most of the pregnant women practiced suitable preventive behaviors, in particular food hygiene (washing kitchen utensils with warm soap and water after contact with raw meats or unwashed fruits and vegetables) and refraining from swimming or fishing. However, non-preventive behaviors are strongly associated with risk factors such as contact with cats, eating raw or rare meat, contact with kittens in the home, cleaning cat feces or handling cat litter.
Sociodemographic and pre-natal characteristics show no significant association with the risk of toxoplasmosis among pregnant women. However, this does not exclude the possibility that these may facilitate contact with T. gondii during pregnancy. Among environmental conditions, drinking untreated water and sewage disposed of in rivers and/or streams are important risk factors for disease transmission.
Given the limited amount of knowledge of the disease, continued education on toxoplasmosis and other infectious diseases with the potential for congenital transmission for pregnant women seen by the primary care system would be helpful for disease prevention and hence congenital toxoplasmosis.
It is important to stress the need for serological follow-up of pregnant women as a routine in healthcare units, where pregnant women will receive more detailed instructions from healthcare professionals on the importance of this test, risk factors and preventive behaviors. Furthermore, more comprehensive preventive measures are required, with public healthcare and education policies that bear in mind economic, social, environmental and cultural aspects.

Collaborators

IPS Moura helped design the study, field work, data tabulation, analyses and drafting. CNC Bichara helped design, analyze and draft the article, and approved the version for publication. IP Ferreira and AN Pontes did a critical review of the article.


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