Research

Recherche

Psychosocial effects of SARS on hospital staff:

survey of a large tertiary care institution
Leslie A. Nickell, Eric J. Crighton, C. Shawn Tracy, Hadi Al-Enazy, Yemisi Bolaji, Sagina Hanjrah,
Ayesha Hussain, Samia Makhlouf, Ross E.G. Upshur
ß See related article page 811

D
Abstract uring the spring of 2003, Toronto was in the midst
of the first of 2 phases of a SARS outbreak. As the
Background: The outbreak of SARS in 2003 had a dramatic effect principal tertiary referral hospital, Sunnybrook and
on the health care system in Toronto. The main objective of Women’s College Health Sciences Centre (SWC) admitted
this study was to investigate the psychosocial effects associated 71 patients with SARS, of whom 23 were health care work-
with working in a hospital environment during this outbreak. ers, between Mar. 14 and May 24. Over 1000 patients were
Methods: Questionnaires were distributed to all willing employ-
seen at the SWC SARS assessment clinic.
ees of Sunnybrook and Women’s College Health Sciences
The effect of SARS on the health care system in the
Centre between Apr. 10 and 22, 2003. The survey included
questions regarding concern about SARS, precautionary mea- greater Toronto area was dramatic.1–6 At various times dur-
sures, personal well-being and sociodemographic characteris- ing the outbreak, 3 hospitals were closed. Health care work-
tics; a subsample also received the 12-item version of the ers were at increased risk and many were quarantined, which
General Health Questionnaire (GHQ-12). resulted in severe staff shortages. On Mar. 28, following the
Results: Of the 4283 questionnaires distributed, 2001 (47%) were closure of a second hospital, new and intensive infection con-
returned, representing 27% of the total hospital employee popu- trol directives were issued for all hospitals in the greater
lation of 7474. The proportions of respondents who were allied Toronto area and surrounding area. At SWC the directives
health care professionals, nurses and doctors and who worked included cancellation of all hospital-based outpatient clinics,
in areas other than patient care were representative of the hospi- significant visitor restrictions, mandatory wearing of surgical
tal staff population as a whole. Of the 2001 questionnaires, 510 masks by all staff at all times (and N95 masks in patient care
contained the GHQ-12. Two-thirds of the respondents reported areas), limited hospital entrance and mandatory screening of
SARS-related concern for their own or their family’s health. A to-
everyone entering the building (symptom/exposure ques-
tal of 148 respondents (29%) scored above the threshold point
on the GHQ-12, indicating probable emotional distress; the rate
tionnaire and temperature reading). Health care workers
among nurses was 45%. Masks were reported to be the most were instructed to work at 1 health care institution only, and
bothersome infection control precaution. Logistic regression off-work contact between health care workers from different
analysis identified 4 factors as being significantly associated with institutions was discouraged. The SWC SARS Management
increased levels of concern for personal or family health: per- Team met daily to implement Ministry of Health directives,
ception of a greater risk of death from SARS (adjusted odds ratio organize care of patients with and without SARS and deal
[OR] 5.0, 95% confidence interval [CI] 2.6–9.6), living with with staffing issues. With clinic and operating room closures
children (adjusted OR 1.8, 95% CI 1.5–2.3), personal or family and quarantined staff, staff redeployment to screening at en-
lifestyle affected by SARS outbreak (adjusted OR 3.3, 95% CI trances and other essential services became necessary. After
2.5–4.3) and being treated differently by people because of Apr. 17, staff not involved in patient care no longer had to
working in a hospital (adjusted OR 1.6, 95% CI 1.2–2.1). Four wear masks; however, most of the other infection control di-
factors were identified as being significantly associated with the
rectives were kept in place well into the summer months.
presence of emotional distress: being a nurse (adjusted OR 2.8,
Little is known about the psychological effects of this type
95% CI 1.5–5.5), part-time employment status (adjusted OR 2.6,
95% CI 1.2–5.4), lifestyle affected by SARS outbreak (adjusted of disease outbreak on health care and other hospital work-
OR 2.2, 95% CI 1.4–3.5) and ability to do one’s job affected by ers. Maunder and colleagues1 described the experiences of a
the precautionary measures (adjusted OR 2.9, 95% CI 1.9–4.6). small number of patients and staff at a Toronto hospital dur-
Interpretation: Our findings indicate that the SARS outbreak had ing the initial SARS outbreak. They observed that the staff
DOI:10.1053/cmaj.1031077

significant psychosocial effects on hospital staff. These effects were fearful for their own and their family’s health and found
differed with respect to occupation and risk perception. The caring for colleagues as patients emotionally difficult.
effect on families and lifestyle was also substantial. These find- Mitchell and associates7 reported increased feelings of
ings highlight the need for interventions to address psychoso- stigmatization among nurses during an outbreak of van-
cial distress and concern and to provide support for employees comycin-resistant enterococci in a hospital in Australia; feel-
during such crises. ings of alienation and isolation were also noted. A literature
CMAJ 2004;170(5):793-8 review revealed no large, systematic studies of the effect of a

CMAJ • MAR. 2, 2004; 170 (5) 793

© 2004 Canadian Medical Association or its licensors

Nickell et al

disease outbreak on hospital staff, particularly in cases with a Questionnaires were distributed to all willing employees (both
high risk of nosocomial spread, as is the case with SARS.2,4,8–10 health care and non-health-care workers) entering the hospital
The main objectives of this study were (a) to determine between 5:45 am and 7:15 pm (covering all major shift changes)
over a 3-day period. Access at each campus was limited, making it
the self-reported psychosocial effects associated with work-
possible to ensure that most people working that day were handed
ing in a hospital environment during the peak of a disease a questionnaire and explanatory letter. Completed questionnaires
outbreak, specifically psychological distress and effects on were deposited in drop boxes located at specified hospital loca-
the work and personal lives of employees, and (b) to exam- tions over the following 2 weeks. Reminders to staff were sent out
ine the determinants of these effects. by email. Announcements were made at 2 staff fora on SARS held
during the study period, and questionnaires were handed out to
Methods those who, when asked, stated that they had not received a ques-
tionnaire previously.
We distributed a self-administered questionnaire to employees The questionnaire consisted of 5 main sections: occupation and
of SWC, a large teaching hospital, between Apr. 10 and 22, 2003. work history; closed and open-ended questions about the respon-
The hospital comprises 3 campuses: the Sunnybrook site, the dent’s concerns about SARS; closed and open-ended questions
Women’s College site and the Orthopaedic and Arthritic site. about the use and effects of SARS precautionary measures; stan-
During the first phase of Toronto’s SARS outbreak most patients dard sociodemographic characteristics; and the 12-item version of
with SARS were admitted to the SARS unit of the Sunnybrook the General Health Questionnaire (GHQ-12),11 a frequently used
site. The Women’s College site was the location for Toronto’s and well-standardized measure of recent emotional distress. We
first SARS screening and assessment clinic. pilot-tested the survey instrument among clinicians and health care
services researchers to assess its face validity. Owing to resource
constraints, the distribution of the GHQ-12 was limited to a sub-
Table 1: Demographic characteristics of 2001 staff at sample of staff made up of only those who received the question-
Sunnybrook and Women’s College Health Sciences Centre naire on day 2 of data collection. A copy of the questionnaire is
surveyed during the first phase of the SARS outbreak in 2003 available from the authors on request.
We coded the response categories on the GHQ-12 items us-
No. (and %) of ing the GHQ-12 scoring method as recommended by Goldberg
Characteristic respondents and Williams11 and calculated a total score. Following the example
Sex n = 1983
of numerous authors,12–15 we used a threshold score of greater than
3 to identify the presence of emotional distress manifested as a
Male 420 (21.2)
break from normal functioning (e.g., loss of sleep, loss of self-
Female 1563 (78.8) confidence or inability to make decisions). The α reliability coeffi-
Age, yr n = 1983 cient for the GHQ-12 in this study was 0.85.
< 30 269 (13.6) We analyzed the data using SPSS (version 11.1, SPSS Inc.,
30–39 510 (25.7) Chicago) and included bivariate and multivariate techniques. Bi-
40–49 606 (30.6) variate analysis was used to identify potential explanatory variables
≥ 50 598 (30.2) for outcomes of interest. Multivariate logistic regression analysis
Education n = 1986 was used to assess the association between outcome variables and
potential predictors, while adjusting for other identified explana-
High school or less 152 (7.6)
tory variables.
Undergraduate university or college 1357 (68.3)
We constructed 2 logistic regression models for the dependent
Medical or graduate school 477 (24.0)
Occupation n = 1857
Allied health care professional* 615 (33.1) Table 2: Reported levels of SARS-related health concerns and
Non-patient-care occupation† 593 (31.9) emotional distress
Nurse 476 (25.6)
No. (and %)
Doctor 173 (9.3)
Variable of respondents
Tenure in current occupation, yr n = 1982
<1 212 (10.7) Degree of concern about personal health n = 1988
1–3 374 (18.9) Not concerned 701 (35.3)
4–9 380 (19.2) Slightly to somewhat concerned 810 (40.7)
≥ 10 1016 (51.3) Very to extremely concerned 477 (24.0)
Employment status n = 1966 Degree of concern about family’s health n = 1971
Full-time 1645 (83.7) Not concerned 735 (37.3)
Part-time/casual 321 (16.3) Slightly to somewhat concerned 660 (33.5)
Self-rated health n = 1956 Very to extremely concerned 576 (29.2)
Very poor to fair 260 (13.3) Emotional distress* n = 510
Good to excellent 1696 (86.7) No 362 (71.0)
Yes 148 (29.0)
*Includes social workers, pharmacists, medical imaging technologists, physiotherapists,
dietitians, audiologists and respiratory therapists. *Measured with the 12-item version of the General Health Questionnaire.11 We used a
†Includes administration, food services, maintenance and research. threshold score of greater than 3 to indicate the presence of emotional distress.

794 JAMC • 2 MARS 2004; 170 (5)

 Psychosocial effects of SARS

variables: GHQ-12 threshold score and concern for the health of their sex, 1563 (78.8%) were women. Of the 1857 who indi-
oneself or one’s family. We ran models using a backward stepwise cated their occupation, 615 (33.1%) were allied health care
selection algorithm. Variables were determined to contribute to professionals, 593 (31.9%) worked in areas other than pa-
the model if the significance level for the Wald inclusion test sta-
tient care (e.g., administration, food services, maintenance
tistic was less than 0.05. Owing to its a priori importance, sex was
forced into every model, regardless of its contribution. The analy-
or research), 476 (25.6%) were nurses, and 173 (9.3%) were
sis of the data for all open-ended questions involved grouping like doctors; these proportions are representative of the hospital
responses into categories and then analyzing the categories quan- staff population as a whole. Half of the respondents stated
titatively using bivariate and multivariate techniques, as described that they had worked 10 or more years in their current oc-
in the preceding paragraph. cupation, and 83.7% (1645/1966) reported full-time status.
Ethics approval for the study was obtained from the SWC Re- In all, 64.7% of the respondents reported concerns about
search Ethics Board. their own health during the SARS outbreak, and almost the
same proportion (62.7%) reported concerns about their
Results family’s health (Table 2). Among the various occupations,
nurses were most frequently concerned (363 [76.3%]), and
We distributed 4283 questionnaires across the 3 hospital doctors were least frequently concerned (104 [60.1%]). Al-
sites, of which 2001 (47%) were returned, representing 27% most all (93.8%) of those who reported concerns felt that
of the total SWC employee population of 7474. Of the they had friends, family or other people to talk to about
2001 returned questionnaires, 510 contained the GHQ-12. those concerns (data not shown).
With the exception of occupation, no significant differences Of the 510 respondents who completed the GHQ-12,
were found between the subsample that completed the 148 (29.0%) scored above the threshold of greater than 3,
GHQ-12 and the full sample. There was a higher propor- indicating probable emotional distress (Table 2). Statisti-
tion of nurses and a lower proportion of allied health care cally significant differences (p < 0.001) were found between
professionals in the full sample than in the subsample.
The demographic characteristics of the respondents are
Table 4: Other effects of the SARS outbreak
shown in Table 1. Of the 1983 respondents who indicated
No. (and %)
Effect of respondents
Table 3: Perceptions of SARS-related precautionary measures
Changes to regular job duties n = 1972
No. (and %) of
Yes 1015 (51.5)
Perception respondents
No 957 (48.5)
Precautionary measures in workplace were: n = 1970 Working overtime n = 1975
Sufficient 1460 (74.1) Yes 449 (22.7)
Not sufficient 156 (7.9) No 1526 (77.3)
Don’t know 354 (18.0) Financial losses n = 1973
Most bothersome precaution* n = 1970 Yes 285 (14.4)
Mask 1386 (70.2) No 1688 (85.6)
Restricted access (own hospital) 276 (14.0) Being treated differently because of working in
Restricted meetings 108 (5.5) hospital n = 1952
Restricted access (other hospitals) 98 (5.0) Yes 542 (27.8)
Gloves 61 (3.1) No 1410 (72.2)
Goggles 59 (3.0) Personal or family’s lifestyle affected n = 1986
Other† 96 (4.9) Yes 749 (37.7)
Precautionary measures affect ability to do job n = 1966 No 1237 (62.3)
Yes 820 (41.7) SARS situation had positive outcomes n = 2001
No 1146 (58.3) Yes 1161 (58.0)
Wearing mask is particularly bothersome n = 2001 No 840 (42.0)
Yes 1710 (85.4) If yes, what? * n = 1200
No 291 (14.5) Increased awareness of disease control 493 (41.1)
If mask is bothersome, in what way? ‡ n = 1710 Learning experience 317 (26.4)
Physical discomfort 1588 (92.9) Increased sense of togetherness and cooperation 285 (23.8)
Difficulty communicating 804 (47.0) Less busy than usual 44 (3.7)
Difficulty recognizing people 409 (23.9) Greater appreciation of life and work 26 (2.2)
Sense of isolation 222 (13.0) Other† 35 (2.9)
*The sum of responses is greater than 2001 because some respondents reported 2 precautions *The sum of responses is greater than 1161 because some respondents reported more than
as most bothersome. 1 outcome.
†Includes responses such as constant hand washing and protective gowns. †Includes responses such as examinations cancelled and good business for mask and glove
‡The sum of responses is greater than 1710 owing to multiple responses. companies.

CMAJ • MAR. 2, 2004; 170 (5) 795

Nickell et al

the occupational groups in the proportion with a score restaurants and shopping centres) and avoiding interaction
greater than 3: 45.1% (37/82) of nurses, 33.3% (66/198) of with family or friends. Over half of the respondents (1161
allied health care professionals, 17.4% (8/46) of doctors [58.0%]) also reported at least 1 positive effect (Table 4). A
and 18.9% (28/148) of staff not working in patient care total of 493 (41.1%) felt there was an increased awareness
(data not shown). of disease control, 317 (26.4%) found the SARS outbreak
Wearing a mask was the precaution most frequently to be a learning experience, and 285 (23.8%) felt an in-
cited as most bothersome (Table 3). The most commonly creased sense of togetherness and cooperation. Other posi-
cited difficulty with the mask was physical discomfort tive aspects included being less busy than usual and feeling
(92.9% [1588/1710] of respondents). Three-quarters of the a greater appreciation of life and work.
respondents reported that the control measures were suffi- Logistic regression analysis identified 4 factors as being
cient to prevent contracting SARS. significantly associated with increased levels of concern for
Reported negative effects of the SARS outbreak in- personal or family health: perception of a greater risk of
cluded financial losses, being treated differently by people death from SARS (adjusted odds ratio [OR] 5.0, 95% confi-
because of working in a hospital and changes to personal dence interval [CI] 2.6–9.6), living with children (adjusted
and familial lifestyle (Table 4). Frequently mentioned OR 1.8, 95% CI 1.5–2.3), personal or family lifestyle af-
lifestyle changes included avoiding public spaces (e.g., fected by the SARS outbreak (adjusted OR 3.3, 95% CI

Table 5: Factors associated with experiencing SARS-related concern for personal or family’s health
No. (and %) of respondents*
Unadjusted OR Adjusted OR
Variable Concerned Not concerned (and 95% CI) (and 95% CI)†
Sex
Male 280 (66.7) 140 (33.3) 1.0 1.0
Female 1115 (71.4) 447 (28.6) 1.3 (0.99–1.6) 1.0 (0.8–1.3)
Age, yr
< 30 196 (72.9) 73 (27.1) 1.0 1.0
30–39 383 (75.1) 127 (24.9) 1.1 (0.8–1.6) 0.9 (0.6–1.3)
40–49 424 (70.1) 181 (29.9) 0.9 (0.6–1.2) 0.7 (0.5–1.0)
≥ 50 392 (65.6) 206 (34.4) 0.7 (0.5–0.97) 0.6 (0.4–0.9)
Managerial/supervisory
position
No 1206 (73.2) 442 (26.8) 1.0 1.0
Yes 186 (57.4) 138 (42.6) 0.5 (0.4–0.6) 0.6 (0.4–0.8)
Personal or family’s lifestyle
affected
No 765 (61.9) 471 (38.1) 1.0 1.0
Yes 635 (84.8) 114 (15.2) 3.4 (2.7–4.3) 3.3 (2.5–4.3)
Being treated differently
because of working in hospital
No 929 (65.9) 481 (34.1) 1.0 1.0
Yes 441 (81.5) 100 (18.5) 2.3 (1.8–2.9) 1.6 (1.2–2.1)
Perceived death rate of SARS, %
<5 798 (64.7) 436 (35.3) 1.0 1.0
5–9 267 (75.6) 86 (24.4) 1.7 (1.3–2.2) 1.6 (1.8–2.1)
≥ 10 125 (90.6) 13 (9.4) 5.2 (2.9–9.3) 5.0 (2.6–9.6)
Don’t know 190 (81.5) 43 (18.4) 2.4 (1.7–3.4) 2.2 (1.5–3.3)
Precautionary measures sufficient
No or don’t know 442 (86.7) 68 (13.3) 1.0 1.0
Yes 944 (64.7) 515 (35.3) 0.3 (0.2–0.4) 0.4 (0.3–0.5)
Live with children
No 648 (65.8) 336 (34.1) 1.0 1.0
Yes 741 (75.0) 247 (25.0) 1.6 (1.3–1.9) 1.8 (1.5–2.3)
Note: OR = odds ratio, CI = confidence interval.
*Subtotals may vary owing to missing data.
†We used a backward stepwise selection procedure to select the model from the following variables: hospital campus, occupation, management position, length
of time in occupation, employment status, lifestyle affected, being treated differently, perceived SARS risk, ability to follow precautions, perception of precautions,
ability to do job affected, mask bothersome, financial loss, working overtime, change in job duties, sex, age, education, marital status, live with children and self-
rated health.

796 JAMC • 2 MARS 2004; 170 (5)

 Psychosocial effects of SARS

2.5–4.3) and being treated differently by people because of zation and concern is in keeping with an earlier finding in a
working in a hospital (adjusted OR 1.6, 95% CI 1.2–2.1) study of an outbreak of vancomycin-resistant enterococci in
(Table 5). Three factors were found to be significantly asso- an Australian hospital.7 In our study, being in a management
ciated with decreased levels of concern: working in a man- or supervisory position reduced the likelihood of reporting
agement or supervisory position (adjusted OR 0.6, 95% CI concerns. This is consistent with previous research indicat-
0.4–0.8), belief that the precautionary measures in the work- ing that having some level of control (real or perceived) over
place were sufficient (adjusted OR 0.4, 95% CI 0.3–0.5) and a situation reduces the risk of psychosocial effects.1,16–18
age 50 years or more (adjusted OR 0.6, 95% CI 0.4–0.9). A total of 29% of the respondents experienced emo-
Regression analysis identified 4 factors as being signifi- tional distress, as evidenced by their score on the GHQ-12.
cantly associated with the presence of emotional distress, as This rate is more than double that found in a recent study
identified with the GHQ-12: being a nurse (adjusted OR of the general adult population in Canada.19 Other North
2.8, 95% CI 1.5–5.5), part-time employment status (ad- American and British studies have typically shown preva-
justed OR 2.6, 95% CI 1.2–5.4), lifestyle affected by the lence rates of emotional distress in general populations of
SARS outbreak (adjusted OR 2.2, 95% CI 1.4–3.5) and 10% to 24%.20–22 In a study of nurses working under normal
ability to do one’s job affected by the precautionary mea- circumstances in 3 Singapore hospitals, 14.8% scored
sures (adjusted OR 2.9, 95% CI 1.9–4.6) (Table 6). above the threshold point on the GHQ,23 as compared with
45% of the nurses in our study. We found that part-time
Interpretation staff were more likely than full-time staff to experience
emotional distress; we attribute this to part-time staff’s re-
During the peak of the first phase of the SARS outbreak ceiving less current information, having a reduced sense of
in Toronto, two-thirds of SWC staff experienced concern involvement in the hospital’s response to the SARS situa-
for their own or their family’s health. This finding is consis- tion and having a weaker social support network within
tent with a recent study by Maunder and colleagues.1 Those their work environment.
who felt that they were being treated differently by people Positive aspects of the SARS outbreak were also re-
because they worked in a hospital were more likely to report ported. For instance, staff noted an increased awareness of
health concerns than were those who did not feel they were infection control, which may continue to benefit the hospi-
being treated differently. This association between stigmati- tal community in the future. Some respondents found that

Table 6: Factors associated with the presence of emotional distress

No. (and %) of respondents*
Emotional No emotional Unadjusted OR Adjusted OR
Variable distress distress (and 95% CI) (and 95% CI)†

Sex
Male 20 (20.8) 76 (79.2) 1.0 1.0
Female 128 (31.1) 283 (68.9) 1.7 (1.0–2.9) 1.3 (0.7–2.4)
Occupation
Non-patient-care occupation 28 (18.9) 120 (81.1) 1.0 1.0
Doctor 8 (17.4) 38 (82.6) 0.9 (0.4–2.2) 0.7 (0.3–1.8)
Allied health care professional 66 (33.3) 132 (66.7) 2.1 (1.3–3.6) 1.7 (1.0–2.9)
Nurse 37 (45.1) 45 (54.9) 3.5 (1.9–6.4) 2.8 (1.5–5.5)
Employment status
Full-time 134 (30.6) 304 (69.4) 1.0 1.0
Part-time/casual 13 (20.0) 52 (80.0) 1.8 (0.9–3.4) 2.6 (1.2–5.4)
Personal or family’s lifestyle
affected
No 63 (20.3) 247 (79.7) 1.0 1.0
Yes 82 (41.8) 114 (58.2) 2.8 (1.9–4.2) 2.2 (1.4–3.5)
Precautionary measures affect
ability to do job
No 53 (18.7) 231 (81.3) 1.0 1.0
Yes 95 (43.4) 124 (56.6) 3.3 (2.2–5.0 ) 2.9 (1.9–4.6)
*Subtotals may vary owing to missing data.
†We used a backward stepwise selection procedure to select the model from the following variables: hospital campus, occupation, management position,
length of time in occupation, employment status, concern for personal or family’s health, lifestyle affected, being treated differently, perceived SARS risk,
ability to follow precautions, perception of precautions, ability to do job affected, mask bothersome, financial loss, working overtime, change in job duties,
sex, age, education, marital status, live with children and self-rated health.

CMAJ • MAR. 2, 2004; 170 (5) 797

Nickell et al

the situation provided a positive learning experience and an Acknowledgements: We acknowledge Leo Steven, Greg Shaw, Craig DuHamel,
Dr. Robert Lester, Dr. Andrew Simor, Dr. Mary Vearncombe and the SARS Man-
increased sense of togetherness and cooperation among the agement Team of Sunnybrook and Women’s College Health Sciences Centre for
hospital staff, which may provide an opportunity to con- permitting and supporting the conduction of the study and for providing opportu-
tinue to build stronger relationships. nities for advertising the survey among the staff. We also acknowledge Jason Nie
and Iram Shaikh for entering and formatting the data, Linda Vrbova for helping
Our study has several potential limitations. First, the fact with data collection and Shari Gruman for formatting the paper. Finally, thanks to
that the response rate was relatively low (47%) adds to the the hundreds of hospital staff who took the time to participate in the survey.

possibility of response bias. Second, staff who were in quar-

antine or away because of illness or vacation were not in- References
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Competing interests: None declared.
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Contributors: Dr. Nickell conceived the study, contributed to study design, partici-
pated in data collection and was the principal writer of the paper. Mr. Crighton
contributed to the study design and data collection and entry, performed the statis-
tical analysis and contributed to the writing of the paper. Mr. Tracy contributed to Correspondence to: Dr. Leslie A. Nickell, Department of Family
data collection, statistical analysis and editing. Dr. Upshur assisted with study de-
sign and editing. Drs. Al-Enazy, Bolaji, Hanjrah, Hussain and Makhlouf con-
and Community Medicine, E-352, Sunnybrook and Women’s
tributed to the study design, data collection and entry, and final editing and revi- College Health Sciences Centre, 2075 Bayview Ave., Toronto
sion of the paper. All the authors have read and approved the final draft. ON M4N 3M5; fax 416 480-4536; [email protected]

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