|ORIGINAL ARTICLE: BIOLOGICAL ANTHROPOLOGY AND PUBLIC HEALTH
|Year : 2020 | Volume
| Issue : 2 | Page : 98-108
Knowledge, attitude and practice towards family planning among married women in areas of low and no family planning in Giza governorate: Impact of educational intervention
Hend S Mohamed
Department of Public Health, Faculty of Medicine, Cairo University, Cairo, Egypt
|Date of Submission||10-Aug-2020|
|Date of Decision||30-Aug-2020|
|Date of Acceptance||29-Sep-2020|
|Date of Web Publication||06-Feb-2021|
PhD Hend S Mohamed
Department of Public Health, Faculty of Medicine, Cairo University, Al-Saray Street, El Manial, Cairo 12511
Source of Support: None, Conflict of Interest: None
Background/aim Little or incorrect knowledge about family planning (FP) is one of the main barriers to its use. The study aimed to identify areas of low or no FP utilization; assess married women characteristics, knowledge, attitude, and practice toward FP; and determine the effect of FP education.
Patients and methods This intervention study included 198 married women in the reproductive age. Areas of low and no FP utilization were identified by hot map software. All women in the pre-identified areas were selected. A structured questionnaire was used to assess their characteristics, knowledge attitude, and practice toward FP. FP health education sessions were done to discuss importance of FP, appropriate use of different methods, their effectiveness, and side effects. Participants’ concerns and misconceptions were also addressed. After intervention, the participants’ knowledge was assessed. Service utilization, FP demand, and contraception prevalence indicators were calculated.
Results Areas of low and no FP utilization were identified on the map. Mean age of women was 23.1±6.44 years. Most (82.83%) were school educated, and 61.11% were not working. The mean scores for knowledge and attitude were 12±7.89 and 93.41±8.17, respectively. The contraception prevalence was 31.8%. Intrauterine device was the most common method among 54%, followed by pills in 23%, and 6, 8, and 5% were relying on injections, condoms, and natural methods, respectively. After health education, the mean knowledge score was significantly increased, reaching 23±8.35, and contraceptive prevalence was 43.1%.
Conclusion Knowledge and attitude of the study participants toward FP was almost low. There is a need for health education and counseling sessions to enhance the utilization of FP methods.
Keywords: family planning, health education, knowledge
|How to cite this article:|
Mohamed HS. Knowledge, attitude and practice towards family planning among married women in areas of low and no family planning in Giza governorate: Impact of educational intervention. J Arab Soc Med Res 2020;15:98-108
|How to cite this URL:|
Mohamed HS. Knowledge, attitude and practice towards family planning among married women in areas of low and no family planning in Giza governorate: Impact of educational intervention. J Arab Soc Med Res [serial online] 2020 [cited 2021 Jun 24];15:98-108. Available from: http://www.new.asmr.eg.net/text.asp?2020/15/2/98/308871
| Introduction|| |
The world nowadays is facing high population growth, reaching 7.7 billion, and is projected to reach 9.8 billion by the year 2045 . Rising population has shifted resources from production to human services . This negatively affects the economic growth, increases rates of poverty and unemployment, and threatens food security, especially in developing low-income and middle-income countries ,. Thus, there is a need for stabilizing the population through universal access to family planning (FP) services.
Countries particularly the less developed ones strongly implement FP programs, and increased rates of contraception prevalence was observed . In Egypt, the contraception prevalence rate increased from 48% in 1991 to 59% in 2014. The total fertility rate, which is the most important determinant of population growth, reached 3.5 in 2014 and 3.4 in 2017, and then it sharply decreased, reaching 3.1 in 2018, with reduction in urban–rural gap. Despite these achieved progresses, FP use is still limited ,,.
In developing countries, 60% of couples use contraceptive methods, and nearly 25% of pregnancies are unintended . In Egypt, the total fertility rate is still above the global fertility rate, which is 2.5 live births per woman ,,. The 2014 EDHS reported that one in eight married women was in need for FP at the time of the survey. Overall, 16% of children born in the 5 years before the survey were not wanted at the time of conception . This percentage was higher than that reported in the 2008 EDHS, which was 14% . Moreover, there is increase in adolescent pregnancy (aged 15–19) from 9% in 2005 to 10% in 2008 and then 11% in 2014. Overall, 4% of the adolescents were pregnant and 7% had children according to 2014 EDHS. Child spacing has become a challenging issue, where almost 20% of births occur within 2 years of the preceding one ,,. As stated by Ministry of Health Statistic, approximately eight in 10 married women in Egypt did not want to have more children or wanted to space at least 2 years, yet a big proportion were not using FP methods . FP utilization is a challenge as a result of barriers hindering its utilization ,.
One of the most significant barriers of FP is lack of information and false misleading information that lead to negative attitude toward FP, especially in Upper Egypt ,. Studies showed that women wanted to have control on their fertility, but they did not have proper knowledge and were not receiving adequate FP education. Educating women about FP significantly increased their knowledge, and this would reflect on their attitude and behavior ,. Other mostly reported barriers include social pressure, culture, medical health services, age of mother, age of marriage, and education of mothers and their husbands. It is extremely important to identify and overcome barriers to FP .
Policy makers and mangers of programs can enhance FP programs by increasing their understanding of women and couples characteristics and overcome the identified barriers . The present study aimed first to identify areas of low or no FP utilization in the catchments area of the family health center (FHC); second, assess married women characteristics, knowledge, attitude, and practice toward FP in the targeted areas; third, provision of FP education; and fourth, determine the effect of education on their knowledge.
| Patients and methods|| |
Study design and settings
This intervention study was conducted at a FHC located at Giza governorate. According to the census conducted by National Heath Registration System 2016, of the FHC, it serves ∼30 000 (28 639) person within its catchment area. The center provides comprehensive integrated services for whole family. It contains FP clinic with a separated registration and archiving system than the center. The clinic operates daily. The doctor first sees the patients and provides counseling and consultation to them on different methods of FP. Then they were referred to a nurse who provides them with the FP method they have chosen. The study was done from May 2017 to February 2019.
The study was approved by Research Ethical Committee, Faculty of Medicine, Cairo University, with approval registration no I-111014. The researcher respected all the principles of ethics of the Helsinki declarations. The interviewer explained to the women the purpose of the study and assured them about confidentiality of their responses, and a signed consent was obtained from them.
The study included two phases
- Exploratory phase
- The researcher reviewed the patient records of the FP clinic retrospectively. These records included home address, age of patient, occupation, education, number of children, reason of the visit, type of the method of FP used, and if the patient has any health problems.
- Formation of hot spots on the center’s catchment area map.
The researcher introduced hot spot map software in the computer of the FP clinic using eSpatial Mapping Software (eSpacial Company based in Dublin, Ireland) . It is used to visualize FP utilization in the catchment area of the FHC. First, data of patients’ addresses was uploaded, and then population clusters on the map were highlighted. Areas with high level of population using FP methods were expressed with dark shades and lighter shades for areas of low FP method utilization. White shades were for areas of no FP utilization. The clinic nurses were educated on utilization of the software to be used in the routine registration afterward and warrant the sustainability of the method.
The researcher arranged with the district manager to perform exploratory outreach visits for the areas that appeared white shaded on the map. The department of statistics in the districted provided the number of housing blocks in these areas; there were 76 blocks. Arrangement of the teams took place. The teams consisted of nurses and social service specialists. The researcher divided and trained the teams to perform a structured interview with the married women in the reproductive age (15–49 years), and each team was assigned to interview three to four blocks each day, so all white shaded areas on the map were covered. The interviewee visited the houses to interview those women with eligible criteria, and if there were no eligible women, they visiting the next house. The interview was done in a period of 7 months.
Sampling technique and study population
The study included all married women in the reproductive age who accepted to participate in the study.
Face-to-face interviews were conducted using a structured questionnaire. The questionnaire was developed by adopting relevant questions from various sources and previous studies ,, and after consultation with the experts in the field. It included the following sections:
- (1) The first section of the questionnaire contained questions about the demographic characteristics and assessment of the socioeconomic status based on the questionnaire originally designed by Fahmy et al. .
(a) Mother’s education, (b) husbands’ education, (c) working status of the mother, (d) working status of the father, (e) use of computer, (f) per-capita income, (g) family size, (h) crowding index, (i) sewage disposal, and (j) refuse disposal.
A total percent score was calculated for each patient, and the results were categorized as follows: More than or equal to 70%, high socioeconomic status; 40 to less than 70%, middle socioeconomic status; and less than 40, low socioeconomic status.
- Assessing the knowledge of women about FP using 29-item questionnaire. The answers were either know or do not know. The questions were scored ‘1’ for know and ‘0’ for do not know, with a maximum total score of 29 for each participant.
- FP attitude scale was adapted from valid reliable FP attitude scale developed by Örsal and Kubilay . The scale was translated from Turkish language to English and Arabic language and then retranslated to ensure the validity. The Cronbach alpha value was 0.87. The scale consisted of three subgroups: society attitudes toward FP (14 items), attitudes of methods (12 items), and attitudes of pregnancy (eight items). The scale was graded as ‘strongly agree=1,’ ‘agree=2,’ ‘neutral=3,’ ‘disagree=4,’ and ‘strongly disagree=5.’ For analysis, they were categorized into agree and disagree.
All the items of each subgroup were added, and then all subgroups were added to obtain the total score. The lowest score was 34 and the maximum score 170. Higher score indicating favorable attitude toward FP.
Then the questionnaire included section about the practice of FP methods. Participant mothers were then asked open-ended questions about the reason of not using FP methods. Before asking the questions of this section, participant mothers were asked if they were pregnant or in the post-partum period. None of them had positive response on this.
The questionnaires were first designed in English language and then translated to Arabic (local language), and then translated back to English to ensure validity. The interview took 30–45 min to be completed. The questionnaire was pilot tested on 20 participants. The pilot results were only used to check the validity and clarity of the questions, estimate the time needed to complete the questionnaires, and detect difficulties that may arise and how to deal with them. Necessary modifications were done based on the responses. They were not included in the analysis.
At the end of every day, all completed questionnaires were checked to ensure their consistency and completeness.
Health education phase
After analysis of the gathered data, the researcher took approval from the district to perform targeted health education sessions for the women in the studied areas. It was arranged with a nearby youth club to conduct the health education sessions there. The coordinators of the youth club took the responsibly of sessions’ announcement. The researcher with the teams performed six health education sessions every month for a period of 7 months. Topics discussed during the health education sessions were benefits of FP, risks of having large number of children for parents and children, the appropriate use of different methods, and side effects. Issues regarding FP concerns, for example, fear of side effects and infertility, were also addressed. Moreover, issues concerning their knowledge and attitude were discussed after analysis of the pre-intervention survey. The used methods were posters, flip charts, and models of FP of the Ministry of Health and Population (MOHP) to enhance the awareness of the women toward FP. At the end of the sessions, the participant mothers were free to ask any questions and inquiries.
Posthealth education knowledge assessment
After the applying health education, the teams performed another interview for the mothers to assess their knowledge, attitude, and practice toward FP.
Indicators used for knowledge, attitude, and practice
The following indicators were used for knowledge, attitude, and practice:
- The percent of women having correct answer for each knowledge and attitude items before and after health education.
- Mean knowledge and attitude score and contraceptive prevalence before and after health education.
- Percent of the desire for additional children before and after health education.
- Percent of demand for limiting or spacing and total demand (for FP) before and after health education.
- Percent of service utilization before and after health education.
- Regular follow-up of the map and identification to identify areas of increased FP utilization.
Data were analyzed using the SPSS for Windows software package, version 22.0 (SPSS Inc., Chicago, Illinois, USA). χ2 was implemented for qualitative data, which were presented by numbers and percentages. t test was used to compare between two means and one-way analysis of variance for comparing more than two means. The P value 0.05 was considered as significant.
| Results|| |
Sociodemographic characteristics of the participated mothers
The mean age of the mothers was 23.1±6.44 years. The majority (82.8%) had school education, and 61.1% were not working. Nearly half of the participated mothers (47.98%) got married when they were less than 20 years old, and 41% had more than five children. Sociodemographic characteristics are illustrated in [Table 1].
The participants aged above 25 years, having higher level of education, working, married at elder age, and with better socioeconomic level had more favorable attitude toward FP. The differences between the groups were statistically significant ([Table 2]).
|Table 2 Mean family planning attitude score according to sociodemographic characteristics|
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The higher mean knowledge score was among mothers aged 20–25 years old, with high level of education, working, and having less than two children; the differences between groups were significant, as shown in [Table 3].
|Table 3 Mean family planning knowledge score according to sociodemographic characteristics|
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Participants’ knowledge of family planning
It was shown that the concept of FP was properly understood by the participants. More than half of the participants (56%) did not know the optimum gap between two births and 68% were not aware about the optimum number of children. The majority (91%) did not know how oral contraceptives are taken in relation to the cycle. Regarding intrauterine device, the majority gave wrong answers on time of its insertion and the duration it lasts in the uterus (70 and 76%, respectively). The general knowledge of the participants and awareness about the types of FP methods were significantly increased after provision of health education, as shown in [Table 4].
Attitude toward family planning utilization
Most participants (85.4%) agreed that they want more children to share in workload, nearly two-thirds had fear of side effects, 65.2% agreed that boys strengthen the power of the father, and the majority (86.4%) agreed that there is no need to learn about FP. The participants’ attitude significantly improved after provision of health education, as shown in [Table 5]. Of the 198 participated women who responded to the question concerning the sources of information about FP, relatives and friends were the most common source, as reported by 80%. Other sources such as health facilities and mass media made a minimal contribution (7 and 13%, respectively). The mean score of knowledge before health education was 12±7.89. After provision of health education, the score was significantly increased to reach 23±8.35 (P<0.01). Most women (89%) wanted to have more than two to five children. Overall, 8% wanted more than 5, and a minority (3%) wanted only one child.
Practice of family planning
Among the participant mothers (n=63), 31.8% were FP utilizers, and all of them were using only one method. Overall, 13% were visiting health facilities for FP follow-up. Most participants’ husbands (92%) were not using condoms. Moreover, 95% were not practicing any natural methods of FP, such as withdrawal, safe period, or breast feeding. After provision of health education, there was significant improvement in FP utilization.
[Figure 1] shows the change of FP utilization before and after health education provision, as there was significant improvement.
Intrauterine device was the most common method, as more than half (56%) of FP utilizers were utilizing it, and nearly a quarter (24%) were utilizing oral contraceptives. A minority (6, 9, and 5%) were relying on injections, condoms, and natural methods, respectively.
When the FP utilizers were asked about the sources of FP methods, 67% reported obtaining the methods from MOHP, 16% from a private health facility, and 12% from Non-Governmental Organizations. Only 3% of current users of FP methods reported obtaining the methods from their relatives and friends and 2% direct from pharmacies.
The most prevalent reason of not utilizing FP methods was to have children for working followed by social pressure. Other reasons were desire for male children, wanted to have big families, husbands’ refusal, religious issues, and fear of side effects, as shown in [Figure 2]. The proportion of FP utilizers was significantly increased from 31.8 to 43.1% after implementation of health education (P=0.02).
| Discussion|| |
The Egyptian government has led a National FP program and exerts continuous major efforts to increase service coverage and enhance accessibility. However, there are significant barriers facing FP services utilization. Main barriers include lack of knowledge, inadequate awareness, and misconception of women toward FP which reflected on unfavorable attitude and unreliable behavior . The study aimed to assess knowledge, attitude, and practice of women toward FP and determine the effect of health educational intervention.
The study revealed that most of the participants did not have adequate knowledge about FP which was a major barrier for FP utilization.
The majority obtained FP information from their relatives and friends and a minority (13%) from health facilities, which can be a reason for their inadequate knowledge. This is similar to another study conducted in Pakistan  but contradicts the study by Eittah and Amer , who found that the most preferable source of FP information was health facilities.
The current study showed that 7% of the participants obtained FP information from media. Contrarily, another study in Pakistan showed that media was the main source of FP information . According to 2014 EDHS, there was a sharp decline in acquiring FP information from media  from 90% in 2005 to 40% in 2014. Moreover, the proportion of those obtaining the information from radio decreased from 63% in 2005 to 5% in 2014 ,. Most households nowadays have got satellite and receiever. Women are unlikely to watch public channels where messages of FP are transmitted. In addition, there is scarcity of messages being publicized on public channels, especially TV, because the media decreases the time assigned to free public messages for the sake of other programs. Moreover, there is a lack of resources, as well as other managerial issues .
The mean knowledge score of the participants after health education significantly increased from 12±7.89 to 23±8.35. These findings were consistent with the study of Eittah and Amer  and that of Ali et al. . There was a depicted significant difference in the average score of knowledge before and after health education.
It was shown in the study that most women had unfavorable attitude toward FP. More favorable attitude was among mothers aged more than 25 years old, having higher number of children, working, or having husband with a job. Younger mothers had more fertility desire in contrary to elder mothers. This can be explained by early age of marriage and multiple pregnancies, exposing mothers to health problems and labor difficulties. Moreover, the mothers felt satisfied with the number of children they had. Level of education showed to be significantly related to participants’ attitude. This was similar to the study of EShak .
The study showed that attitude of mothers became significantly favorable after health education provision. This confirms that health education and improvement in knowledge reflects on better attitude .
The present study showed that 31.8% of the participants were FP utilizers using one method. This was lower than 2014 EDHS findings, as 59% of the currently married women were using contraceptive methods . Moreover, the findings were lower than the studies done in India  and Southwest Ethiopia .Although traditional methods of FP are available with no cost, heath concerns, or side effects, their utilization in Egypt decreased from 2.4% in 1995 to 1.6 in 2014 . In the current study, they were utilized by 5% of the participants.
Condom is a reliable method of contraception when used correctly and prevents sexually transmitted diseases. However, it has been stigmatized in many countries, and it is not a successful FP method in Egypt . The study showed that a minority of participants’ husband (8%) were using condoms.
Lack of knowledge and inadequate counseling is a considerable reason of the depicted low FP utilization. This was confirmed by a significant increase in utilization, reaching 43.1%, after health education provision. Most of the participants (67%) in the current study and in the study done by Eittah and Amer  were obtaining FP methods from MOHP facilities. This can be taken as an advantage to enhance health education and counseling in MOHP facilities.
Most of the reasons of not utilizing FP were social pressure from relatives, especially mother in law, as she wants her son to have a male child. Other reasons were husband’s refusal or religious reasons, which is the same as a study done in Tanzania . However, the results are in contradiction to the study by Eltomy et al. , where women had power and autonomy to make their own decisions. Nearly one-third were not using FP to compensate for sick or dead children. This was consistent with many studies showing association between child mortality and intention to have children. Parents may secure themselves by having more children to compensate for any lost child in the future .
| Conclusion|| |
It is concluded from the study that the main barrier to FP utilization was lack of knowledge, awareness, and misconceptions. The current study showed the effectiveness of electronic mapping and targeting areas of low and no FP utilization.
The study had strengths in using valid reliable questionnaires, and the qualitative data gave in-depth understanding. Including the same mothers in postintervention survey ensured no dropouts. However, not including a control group was a limitation in the study.
The study highlights that frequent health education, counseling sessions, and outreach services are highly recommended. Electronic mapping and addressing the underlying factors hindering FP utilization can be done on a large scale. Accordingly, health education can be tailored, which is effective in improving knowledge and will be reflected on the attitude and behavior. This can help policy makers and program planners in implanting cost-effective interventions.
The author is grateful to the team of nurses and social service specialists who contributed in interviewing the participants and in data collection. The author appreciate the help of physicians and nurses of the FHC, who cooperated in organizing and providing the health education sessions. The support of the district and FHC managers is highly acknowledged.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Van Bavel J. The world population explosion: causes, backgrounds and projections for the future. Facts Views Vis Obgyn 2013; 5:281–291.
Henderson K, Loreau M. An ecological theory of changing human population dynamics. People Nature 2019; 1:31–43.
FAO IFAD, UNICEF, WFP and WHO. The state of food security and nutrition in the world 2019. Safeguarding against economic slowdowns and downturns. Rome: FAO; 2019.
Garenne M. Family planning and fertility decline in Africa: from1950 to 2010. In: Amarin Z, (ed). Family planning. Londres: IntechOpen; 2018. 119–151.
Elzanaty K, Way A. Egypt demographic and health survey. Cairo, Egypt: Ministry of Health and Population, National Population Council; 2005. 44–89.
Zanaty F, Way A. Egypt demographic and health survey 2008. Cairo, Egypt: Ministry of Health, El-Zanaty and Associates, and Macro International; 2009. 47–113.
El-Zanaty F. Egypt demographic and health survey (EDHS). Cairo, Egypt: Ministry of Health, El-Zanaty and Associates, and Macro International; 2014.
Eltomy E, Saboula N, Hussein A. Barriers affecting utilization of family planning services among rural Egyptian women. East Mediterr Health J 2013; 19:400–408.
Eshak E. Myths about modern and traditional contraceptives held by women in Minia, Upper Egypt. East Mediterr Health J 2020; 26:417–425.
Marston C, Renedo A, Nyaaba GN. Fertility regulation as identity maintenance: understanding the social aspects of birth control. J Health Psychol 2018; 23:240–251.
Dansereau E, Schaefer A, Hernánde B, Nelson J, Palmisano E, Rios-Zertuche D et al.
Perceptions of and barriers to family planning services in the poorest regions of Chiapas, Mexico: a qualitative study of men, women, and adolescents. Reprod Health 2017; 14:129.
Eittah HA, Amer HM. Effectiveness of an educational program in raising women’s knowledge and awareness about family planning methods in a rural area. Egypt Nurs J 2019; 16:92–99. [Full text]
SemachewKasa A, Tarekegn M, Embiale N. Knowledge, attitude and practice towards family planning among reproductive age women in a resource limited settings of Northwest Ethiopia. BMC Res Notes 2018; 11:e577.
Gayathry D, Ramana BV, Rao V. A study on assessment of knowledge towards family planning practices among the couples of reproductive age group in the field practice area of Prathima institute of medical sciences, Karimnagar. Int J Comm Med Public Health 2017; 4:3740–3747.
Fahmy SL, Nofal LM, Shehata SF, Kady HME, Ibrahim HK. Updating indicators for scaling the socioeconomic level of families for health research. J Egypt Public Health Assoc 2015; 90:1–7.
Örsal Ö, Kubilay G. AilePlanlamasıTutumÖlçeğininGeliştirilmesi. İstanbul ÜniversitesiFloranceNigtingaleHemşirelikYüksekokuluDergisi 2007; 15:155–164.
Ochako R, Mbondo M, Aloo S, Kaimenyi S, Thompson R, Temmerman M, Kays M. Barriers to modern contraceptive methods uptake among young women in Kenya: a qualitative study. BMC Public Health 2015; 15:118.
Ali M, Azmat SK, Hamza HB, Rahman MM, Hameed W. Are family planning vouchers effective in increasing use, improving equity and reaching the underserved? An evaluation of a voucher program in Pakistan. BMC Health Serv Res 2019; 19:200.
Mahadeen AI, Khalil AO, Mansour AM, Hamdan Sato Sato T, Imoto A. Knowledge, attitudes and practices towards family planning among women in the rural southern region of Jordan. East Mediterr Health J 2012; 18:567–572.
Tun ZY, Sukartini T. Effectiveness of health education family planning guidelines on health beliefs and behaviours regarding family planning methods among married men in Myanmar. J Nurs 2017; 12:278–285.
Gupta V, Mohapatra D, Kumar V. Family planning knowledge, attitude, and practices among the currently married women (aged 15–45 years) in an urban area of Rohtak district, Haryana. Int J Med Sci Public Health 2016; 5:627–632.
Tilahun T, Coene G, Luchters S, Kassahun W, Leye E, Temmerman M et al.
Family planning knowledge, attitude and practice among married couples in Jimma Zone, Ethiopia. PLoS ONE 2013; 8:e61335
United Nations, Department of Economic and Social Affairs, Population Division (2017). World Family Planning 2017 - Highlights (ST/ESA/SER.A/414)
Wahdan I, Wahdan A, Gueneidy ME, Rahman IA. Prevalence and determinants of condom utilization among people living with HIV/AIDS in Egypt. East Mediterr Health J 2013; 19:967–974.
Sundararajan R, Yoder LM, Kihunrwa A, Aristide C, Kalluvya SE, Downs DJ, Mwakisole AH, Downs JA. How gender and religion impact uptake of family planning: results from a qualitative study in Northwestern Tanzania. BMC Women Health 2019; 19:99.
Bongaarts J, Casterline J. Fertility transition: is sub-saharan africa different?. Popul Dev Rev 2013; 38(Suppl 1):153–168.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]