Indian Journal of Psychological Medicine
Users Online: 268 
  Home | About Us | Editorial Board | Search | Ahead of print | Current Issue | Archives | Instructions | Contact | Advertise | Submission | Login 
Wide layoutNarrow layoutFull screen layoutHome Print this page Email this page Small font sizeDefault font sizeIncrease font size


 
 Table of Contents    
ORIGINAL ARTICLE
Year : 2018  |  Volume : 40  |  Issue : 6  |  Page : 528-533  

Prevalence and predictors of abuse in elderly patients with depression at a tertiary care centre in Saurashtra, India


1 Department of Psychiatry, M. P. Shah Government Medical College, Jamnagar, Gujarat, India
2 Department of Community Medicine, M. P. Shah Government Medical College, Jamnagar, Gujarat, India

Date of Web Publication9-Nov-2018

Correspondence Address:
Dr. D S Tiwari
Department of Psychiatry, M. P. Shah Government Medical College, C 7 Medical Campus, Jamnagar, Gujarat
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJPSYM.IJPSYM_18_18

Rights and Permissions
   Abstract 


Context: Elder abuse has devastating consequences such as poor quality of life, psychological distress and loss of property and security. Abuse of elderly patients with depression has not been adequately researched in India. Aims: To explore the prevalence and predictors of abuse and its relation to various sociodemographic variables in elderly patients with depression. Settings and Design: A cross-sectional, observational study carried out at a tertiary care centre in Jamnagar. Methods and Materials: In all, 100 elderly patients with depression, attending Out Patient Department of Psychiatry at Shree M. P. Shah Government Medical College and Guru Gobind Singh Hospital, Jamnagar, were selected using simple random sampling by lottery method. Actual Abuse Tool and Elder Abuse Suspicion Index were used to detect abuse. Geriatric Depression Scale was used to assess depression, and Mini Mental State Examination was used to rule out dementia. Statistical Analysis: Descriptive statistics, Chi-square test, and binary logistic regression were used. Results: The prevalence of abuse was 24%. Among those who had experienced abuse, 50% had experienced psychological abuse, 17% had experienced neglect, 8% had experienced exploitation and 4% had experienced physical abuse. About 54% of patients with severe depression had experienced abuse. Daughters-in-law (54%) and sons (42%) were the most common perpetrators. Illiteracy and severe depression were found to be the predictors of abuse. Conclusion: Prevalence of abuse in elderly patients with depression is high. Severe depression and illiteracy are important predictors of experiencing abuse.

Keywords: Abuse, elderly depression, predictors, prevalence


How to cite this article:
Patel V K, Tiwari D S, Shah V R, Patel M G, Raja H H, Patel D S. Prevalence and predictors of abuse in elderly patients with depression at a tertiary care centre in Saurashtra, India. Indian J Psychol Med 2018;40:528-33

How to cite this URL:
Patel V K, Tiwari D S, Shah V R, Patel M G, Raja H H, Patel D S. Prevalence and predictors of abuse in elderly patients with depression at a tertiary care centre in Saurashtra, India. Indian J Psychol Med [serial online] 2018 [cited 2018 Dec 15];40:528-33. Available from: http://www.ijpm.info/text.asp?2018/40/6/528/245074




   Introduction Top


Older adults (60 years and above) are the fastest growing segment of the population worldwide. Urbanisation, industrialisation, exposure to western lifestyle and a decrease in coresidence of adult children with elderly erode the family's caring ability for the elderly. Increased lifespan has resulted in higher chronic functional disabilities, creating a need for assistance to manage activities of daily living.[1]

Mistreatment of older people – referred to as 'elder abuse' – was first described in British scientific journals in 1975 as the term 'granny battering'.[2],[3] According to World Health Organization (WHO),'Elder abuse is defined as a single or repeated act or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person'.[4] The above definition was developed by Action on Elder Abuse in the United Kingdom.[5] Older people may be abused by family members, spouses, friends, visitors, home care workers or professionals. The negative attitude of perpetrators towards elderly and their interdependency are risk factors for abuse.[6]

Elder abuse is divided into physical, psychological or emotional, financial or material, neglect and sexual abuse.[7],[8],[9] Elder abuse has devastating consequences such as poor quality of life, psychological distress and loss of security and property. It is also associated with increased mortality and morbidity.[10],[11],[12] A prospective, population-based study reported that abuse of older adults is associated with increased rates of hospitalisation.[13] Elder abuse is a violation of human rights. Prevention of elder abuse and protection of elder people should, therefore, be key priorities.

Help Age India's national survey (2013)[1] and a community-based urban study from Chennai[14] reported abuse in 23% and 14% of elderly, respectively. A comparative study between the psychogeriatric and internal ward in a mental hospital of Kromeriz, Czech Republic, reported 23.8% of elder abuse, and another cross-sectional study in a geriatric clinic of a medical college hospital in Bangalore reported 16% of elder abuse.[15],[16] On exploring database till date, no Indian study designed about abuse in elderly patients with depression was found; hence, this study would contribute towards filling this gap. This study was designed to explore the magnitude of the problem of abuse and its relation to various sociodemographic variables in patients with old age depression attending Psychiatry Out Patient Department (OPD) of Shree M. P. Shah Government Medical College (MPSGMC) and Guru Gobind Singh Hospital (GGH), Jamnagar.


   Materials and Methods Top


Study design

This was a 12-month cross-sectional hospital-based study conducted in the Department of Psychiatry of MPSGMC and GGH, Jamnagar, from May 2013 to April 2014. Patients attending OPD were screened for major depressive disorder (MDD).

On an average, 1200 elderly patients with depression per year are consulting psychiatry OPD for the past 3 years. A sample of 100 participants of the 1200 elderly patients with depression was selected through simple random sampling by lottery method. According to the study protocol, participants were explained the objectives, and their written informed consent was obtained. No patient denied consent for our study.

Subjects

A total of 100 elderly patients with MDD age 60 years and above were recruited. Patients with acute medical/surgical emergency conditions, major neurocognitive disorder (e.g., dementia), severe difficulties in vision, hearing or speech, psychiatric morbidity other than depression and those who refused to participate were excluded. The study was approved by the Institutional Ethical Committee Shree M. P. Shah Government Medical College and Guru Gobind Singh Hospital, Jamnagar.

Screening tools

Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) diagnostic criteria were used for diagnosis of MDD.[17] Subjects were administered Geriatric Depression Scale – short form (GDS-SF) and the scores were used to quantify depression. GDS scores of 5–8 indicate mild, 9–11 moderate and 12–15 severe depression. GDS can be used in healthy, medically ill and mild to moderately cognitively impaired adults. The GDS-SF is a subset of 15 questions from the original GDS-LF (long form) with the highest correlation with depressive symptoms. The GDS was found to have 92% sensitivity and 89% specificity.[18] Mini Mental State Examination was used to rule out cognitive deficits. The cut-off score for inclusion in the study was 25.[19] Elder Abuse Suspicion Index (EASI) was developed to raise a doctor's suspicion for referral and evaluation of elder abuse. The EASI has a sensitivity and specificity of 0.47 and 0.75, respectively. All six questions should be asked to the patient, and a response of 'yes' to any question from two to six numbers establishes concern to confirm abuse.[20] The first five questions of EASI have shown cultural and geographical acceptance for the detection of elder abuse by WHO.[21] Actual Abuse Tool was used to confirm abuse in suspected participants screened by EASI. The Actual Abuse Tool provides a list of the major forms of abuse and violence along with examples of physical abuse, psychological abuse, neglect and exploitation. A single check indicates the perceived presence of elder abuse.[22],[23]

Assessment

The participants were interviewed and a semi-structured proforma was used to record information about demographic characteristics, abuse experienced by the elderly and the perpetrators of abuse. A senior psychiatrist assessed and diagnosed depression clinically using DSM-5 diagnostic criteria. The severity of depression was assessed using GDS score and those reporting elder abuse was assessed by EASI and Actual Abuse Tool.

Statistical analysis

Collected data were subjected to appropriate descriptive statistics using frequencies, and percentages of different variables were calculated. Chi-square test was used for qualitative data, and a P value of <0.05 was considered statistically significant. Binary logistic regression analysis was used to calculate the odds ratio. Statistical Package for the Social Sciences (SPSS) version 15 was applied to analyse the data.[24]


   Results Top


Sociodemographic details

In the study population, 74% of the respondents belonged to young-old (60–69 years) age group, 22% were old-old (70–79 years) and 4% came under the oldest old category (80 years and above). About 42% were male, and 58% were female. About 80% of patients were Hindu, and the remaining were Muslims. Around 23% of the elderly were illiterate, and 77% were literate. Approximately 28% of patients were employed, 40% were homemakers and 32% were unemployed. About 48% patients came from rural population and 52% from urban. Around 74% of patients were married, and 26% had lost their spouse (widowed/widower). Around 47% of patients were living in a nuclear family and 53% in a joint family; 54% of patients belonged to socioeconomic class III, 36% to class IV, 8% to class II and 2% to class V.

Abuse

The experience of abuse was reported by 24% of the participants in our study. Participants reported the following types of abuse: 50% psychological, 17% neglect (by self or others), 8% exploitation, 4% physical and 21% mixed (both psychological and by self or others) abuse. The perpetrators of abuse were daughter-in-law (54%), son (42%) and others (4%). Participants reported 16.6% psychological abuse, 12.5% neglect, 20.8% both psychological and neglect and 4% exploitation by daughter-in-law. They reported 29% psychological, 4% neglect, 4% exploitation and 4% physical abuse by son. They also reported 4% of psychological abuse by the other perpetrators.

There was a statistically significant association between elder abuse and family type, educational status, marital status and depression on univariate analysis [Table 1] and [Table 2]. Distribution of type of abuse according to the severity of depression is depicted in [Table 2]. Independent variables showing statistically significant association using Chi-square test were selected for further analysis using binary regression. Illiteracy and severe depression emerged as factors statistically significantly associated with abuse [Table 3].
Table 1: Distribution of abuse in sociodemographic variables

Click here to view
Table 2: Distribution of abuse and its types with the severity of depression

Click here to view
Table 3: Binary logistic regression analysis for the factors related to elder abuse

Click here to view



   Discussion Top


In this study, 24% of elderly patients with depression had an experience of abuse. The most commonly reported abuse was psychological type, followed by neglect. In this study, a few participants reported physical abuse and no one reported sexual abuse. It was not possible to compare findings of this study with other studies due to a lack of published research available in elderly patients with major depression. Therefore, data from a few hospitals and community-based studies are discussed.

Studies conducted in patients attending a geriatric clinic of Bangalore, India, and senior in-patients with psychiatric morbidity of Czech Republic found 23.8% and 16% prevalence of elder abuse, respectively.[15],[16] Large surveys in India, Europe and China reported elderly abuse rates of 23%, 29.3%, 36.2%, respectively.[1],[25],[26] The studies conducted in communities of urban Chennai and rural Bangalore showed 14% and 40.94% prevalence of elder abuse, respectively.[14],[27] Vida et al. and Dong et al. reported 16% and 35.2% prevalence of abuse in elderly. respectively.[28],[29] The differences in the prevalence rate of abuse reflect a variation across the cultural populations and a possible difference in defining and measuring of abuse.

Most of the studies from India and abroad show that psychological abuse and neglect are more common compared with the other types of abuse in the elderly.[1],[14],[25],[26],[27] In our study, no patient reported sexual abuse. A review on sexual violence against older people found 0.2%–1.2% prevalence of sexual abuse.[30] No sexual abuse was found in a comparative study on perceived abuse and social neglect among rural and urban geriatric population of India, which is consistent with this study.[31] The reason might be that the elderly are less inclined to talk about sexual abuse which may be due to feeling of shame, confidentiality of family matter and fear of further abuse.

The results of this study suggest that, amongst elderly with depression, groups significantly more likely to experience abuse include widowed women, housewives, illiterate, unemployed, and widowed. Many other studies have reported more abuse in widowed women with lower education, economic dependence, poor social support and longer life.[9],[26],[28],[32],[33],[34] According to WHO, childless and widowed women are the most affected by elder abuse.[35]

The illiterate and unemployed patients experienced more abuse in this study. The elderly educated below primary education reported more abuse compared with those with higher education in the Indian studies.[32],[36] Wu et al. and Rufus and Beulah reported that elderly with 5 years or less of school education and economically dependent were more vulnerable to abuse.[26],[37] In this study, patients living in joint and low-income families had more experience of abuse. This is similar to Naughton et al. reporting a higher prevalence of abuse in complex households, that is, sharing with adult children or another extended family.[38] In addition, WHO reported in the 'Missing Voices' that elder abuse affects all the social classes in which economically poor and older people suffer the most.[35]

The main perpetrator of abuse was the daughter-in-law, followed closely by the son, and the more common types of abuse were psychological and neglect in this study. Daughters-in-law have increased likelihood of being the perpetrators as they are entrusted with primary care giving and remain in contact for longer hours. This finding is consistent with rural and urban community-based studies in India.[14],[27]

Elderly patients with severe depression significantly reported abuse, and especially psychological type of abuse in this study. Higher abuse is reported in severe depression and this could be due to stigma, discrimination and perception of ill health. Increased burden of care in severe depression is another likely possibility. This finding of higher prevalence of abuse is supported by LuznyandJurickova in the seniors with psychiatric morbidity.[15] In addition, a hospital-based study from India reported that elder abuse was positively and significantly associated with depressive symptoms.[16] The feeling of dissatisfaction with life, often being bored, feeling helpless and feeling worthless were associated with an increased risk of elder abuse.[39] Depression was the consistent risk factor for psychological and neglect subtypes of elder mistreatment.[26] Dong et al. and Cisler et al. reported that elder mistreatment was significantly correlated with loneliness, lower levels of social support, higher levels of depression and self-reported emotional symptoms.[29],[34],[39] Also, Burnett et al. reported a statistically significant difference in the distribution of abnormal GDS-SF scores between the self-neglect and the control group.[40] Strasser et al. reported that the depressed respondents were six times more likely to have a positive elder mistreatment screen than their nondepressed peers.[41] Cooper et al. reported that severity of cognitive impairment, depression and delusions were the predictors of elder abuse.[42] The studies from India and other countries have clearly found an association between elder abuse and depression or depressive symptoms which can have an impact on diagnosis, outcome and treatment.

This study emphasises the role of abuse in elderly patients with depression. Limitations of this study are that it is a cross-sectional, observational and hospital-based study. Clinical diagnosis and severity of depression were done using GDS. The sample used to analyse with regard to perpetrators and predictors was 24 of 100. No control group of elderly without depression was taken in the study. The symptoms of depression may also affect the perception in elderly patients.


   Conclusion Top


Abuse against the elderly is recognised as an important challenge to their healthcare. This is the first Indian study that highlights the high prevalence of abuse (24%) in elderly patients with depression. In depressed elderly, female gender, fewer educational years, widowhood status, and living in a joint family are significantly associated with experience of abuse, with the commonest being psychological. Daughters-in-law followed by sons were the most common perpetrators of abuse. Severe depression and illiteracy are important predictors of experiencing abuse in elderly patients with depression. Future research could look at studying the abuse in older adults with other mental illness including dementia in the Indian setting.

Acknowledgement

The authors are grateful to the community medicine department for suggestions in statistical analysis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
A Help Age India Report; Elder Abuse in India; 2013. Available from: https://www.helpageindia.org/wp-content/themes/helpageindia/pdf/ElderAbuseIndia13.pdf. [Last accessed on 2018 Jan 28].  Back to cited text no. 1
    
2.
Baker AA. Granny Battering. Mod Geriatr 1975;5:20-4.  Back to cited text no. 2
    
3.
Burston GR. Granny-battering. Br Med J 1975;3:592.  Back to cited text no. 3
    
4.
World Health Organization. Chapter 5, Abuse of the Elderly. Available from: http://www.who.int/violence_injury_prevention/violence/global_campaign/en/chap5.pdf. [Last accessed on 2018 Jan 13].  Back to cited text no. 4
    
5.
Jaroszewski D. What is elder abuse? Action on Elder Abuse Bulletin 1995;11.  Back to cited text no. 5
    
6.
Pillemer K, Burnes D, Riffin C, Lachs MS. Elder abuse: Global situation, risk factors, and prevention strategies. Gerontologist 2016;56:194-205.  Back to cited text no. 6
    
7.
Beaulaurier RL, Seff LR, Newman FL. Barriers to help-seeking for older women who experience intimate partner violence: A descriptive model. J Women Aging 2008;20:231-48.  Back to cited text no. 7
    
8.
O'Connor D, Hall MI, Donnelly M. Assessing capacity within a context of abuse or neglect. J Elder Abuse Negl 2009;21:156-69.  Back to cited text no. 8
    
9.
Se'ver A. More than wife abuse that has gone old: A conceptual model for violence against the aged in Canada and the US. J Comp Fam Stud 2009;40:279-92.  Back to cited text no. 9
    
10.
Lachs MS, Williams CS, O'Brien S, Pillemer KA, Charlson ME. The mortality of elder mistreatment. J Am Med Assoc 1998;280:428-32.  Back to cited text no. 10
    
11.
Dong XQ, Simon MA, Beck TT, Farran C, McCann JJ, Mendes de Leon CF, et al. Elder abuse and mortality: The role of psychological and social wellbeing. Gerontology 2011;57:549-58.  Back to cited text no. 11
    
12.
Baker MW, Andrea Z, LaCroix, Wu C, Cochrane BB, Wallace R, et al. Mortality risk associated with physical and verbal abuse in women aged 50 to 79. J Am Geriatr Soc 2009;57:1799-809.  Back to cited text no. 12
    
13.
Dong X, Simon MA. Elder abuse as a risk factor for hospitalization in older persons. JAMA Intern Med 2013;173:911-7.  Back to cited text no. 13
    
14.
Chokkanathan S, Lee AE. Elder mistreatment in urban India: A community-based study. J Elder Abuse Negl 2005;17:45-61.  Back to cited text no. 14
    
15.
Luzny J, Jurickova L. Prevalence of elder abuse and neglect in seniors with psychiatric morbidity. Iranian J Publ Health 2012;41:27-32.  Back to cited text no. 15
    
16.
Nisha C, Manjaly S, Kiran P, Mathew B, Kasturi A. Study on elder abuse and neglect among patients in a medical college hospital, Bangalore, India. J Elder Abuse Negl 2016;28:34-40.  Back to cited text no. 16
    
17.
American Psychiatric Association. Depressive disorder, Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: APA; 2013. p. 160-1.  Back to cited text no. 17
    
18.
Yesavage JA, Sheikh JI. 9/Geriatric Depression Scale (GDS): Recent evidence and development of a shorter version. Clin Gerontol 1986;5:165-73.  Back to cited text no. 18
    
19.
Folstein MF, Folstein SE, McHugh PR. Mini-Mental State: A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189-98.  Back to cited text no. 19
    
20.
Yaffe MJ, Wolfson C, Lithwick M, Weiss D. Development and validation of a tool to improve physician identification of elder abuse: The Elder Abuse Suspicion Index (EASI). J Elder Abuse Negl 2008;20:276-300.  Back to cited text no. 20
    
21.
World Health Organization. A Global Response to Elder Abuse and Neglect: Building Primary Health Care Capacity to deal with the Problem Worldwide: Main Report. WHO Geneva 2008. Available from: http://www.who.int/ageing/publications/ELDER_DocAugust08.pdf. [Last accessed on 2018 Jan 28].  Back to cited text no. 21
    
22.
Cohen M. Screening tools for the identification of elder abuse. J Clin Outcomes Manage 2011;18:261-70.  Back to cited text no. 22
    
23.
Bass DM, Anetzberger GJ, Ejaz FK, Nagpaul K. Screening tools and referral protocol for stopping abuse against older Ohioans: A guide for service providers. J Elder Abuse Negl 2001;13:23-38.  Back to cited text no. 23
    
24.
Statistical Package for Social Sciences. SPSS version 20.0; 2016. Chicago, IL: SPSS Inc.  Back to cited text no. 24
    
25.
Garre-Olmo J, Planas-Pujol X, Lo´pez-Pousa S, Juvinya D, Vila A, Vilalta-Franch J. Prevalence and risk factors of suspected elder abuse subtypes in people aged 75 and older. J Am Geriatr Soc 2009;57:815-22.  Back to cited text no. 25
    
26.
Wu L, Chen H, Hu Y, Xiang H, Yu X, Zhang T, et al. Prevalence and associated factors of elder mistreatment in a rural community in people's Republic of China. PLOS One 2012;7:1-8.  Back to cited text no. 26
    
27.
Gaikwad V, Sudeepa D, Suwarna M. A community based study on elder abuse and depression in Bangalore rural. Int J Public Health Hum Right 2011;1:1-4.  Back to cited text no. 27
    
28.
Vida S, Monks RC, Rosiers PD. Prevalence and correlates of elder abuse and neglect in a geriatric psychiatry service. Can J Psychiatry 2002;47:459-67.  Back to cited text no. 28
    
29.
Dong X, Simon MA, Gorbien M, Percak J, Golden R. Loneliness in older Chinese adults: A risk factor for elder mistreatment. J Am Geriatr Soc 2007;55:1831-5.  Back to cited text no. 29
    
30.
Bows H. Sexual violence against older people: A review of the empirical literature. Trauma Violence Abuse 2017:1-17.  Back to cited text no. 30
    
31.
Kaur J, Kaur J, Sujata N. Comparative study on perceived abuse and social neglect among rural and urban geriatric population. Indian J Psychiatry 2015;57:375-8.  Back to cited text no. 31
[PUBMED]  [Full text]  
32.
Sebastian D, Sekher TV. Extent and nature of elder abuse in Indian families: A study in Kerala. Help Age India Res Develop J 2011;17:20-8.  Back to cited text no. 32
    
33.
Dong X, Simon MA. A Descriptive study of sex differences in psychosocial factors and elder mistreatment in a Chinese community population. Int J Gerontol 2008;2:206-14.  Back to cited text no. 33
    
34.
Cisler JM, Begle AM, Amstadter AB, Acierno R. Mistreatment and self-reported emotional symptoms: Results from the national elder mistreatment study. J Elder Abuse Negl 2012;24:216-30.  Back to cited text no. 34
    
35.
World Health Organization. Missing Voices: views of older persons on elder abuse. Geneva 2002. Available from: http://apps.who.int/iris/bitstream/10665/67371/1/WHO_NMH_VIP_02.1.pdf. [Last accessed on 2018 Jan 28].  Back to cited text no. 35
    
36.
Skirbekk V, James KS. Abuse against elderly in India – The role of education. BMC Public Health 2014;14:336.  Back to cited text no. 36
    
37.
Rufus D, Beulah S. A study on victims of elder abuse: A case study of residents of old age homes in Tirunelveli District. Help Age India Res Develop J 2011;17:29-39.  Back to cited text no. 37
    
38.
Naughton C, Drennan J, Lyons I, Lafferty A. The relationship between older people's awareness of the term elder abuse and actual experiences of elder abuse. Int Psychogeriatr 2013;25:1257-66.  Back to cited text no. 38
    
39.
Dong X, Simon MA, Odwazny R, Gorbien M. Depression and elder abuse and neglect among a community-dwelling Chinese elderly population. J Elder Abuse Negl 2008;20:25-41.  Back to cited text no. 39
    
40.
Burnett J, Coverdale JH, Pickens S, Dyer CB. What is the association between self-neglect, depressive symptoms and untreated medical conditions? J Elder Abuse Negl 2006;18:25-34.  Back to cited text no. 40
    
41.
Strasser SM, Smith M, Weaver S, Zheng S, Cao Y. Screening for elder mistreatment among older adults seeking legal assistance services. West J Emerg Med 2013;14:309-15.  Back to cited text no. 41
    
42.
Cooper C, Katona C, Finne-Soveri H, Topinkova E, Carpenter GI, Livingston G. Indicators of elder abuse: A crossnational comparison of psychiatric morbidity and other determinants in the Ad-HOC study. Am J Geriatr Psychiatry 2006;14:489-97.  Back to cited text no. 42
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

Top
 
 
  Search
 
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
    Abstract
   Introduction
    Materials and Me...
   Results
   Discussion
   Conclusion
    References
    Article Tables

 Article Access Statistics
    Viewed156    
    Printed0    
    Emailed0    
    PDF Downloaded23    
    Comments [Add]    

Recommend this journal