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. Author manuscript; available in PMC: 2023 Feb 21.
Published in final edited form as: J Aging Health. 2014 Oct;26(7):1209–1224. doi: 10.1177/0898264314531617

Prevalence and Correlates of Elder Mistreatment in a Community-Dwelling Population of U.S. Chinese Older Adults

XinQi Dong 1, Ruijia Chen 1, Terry Fulmer 2, Melissa A Simon 3
PMCID: PMC9941853  NIHMSID: NIHMS1865940  PMID: 25239973

Abstract

Objective:

This study aimed to examine the prevalence and correlates of elder mistreatment among U.S. Chinese older adults.

Method:

Data were drawn from the Population-Based Study of ChINese Elderly (PINE) study, a population-based epidemiological survey of 3,159 U.S. Chinese older adults in the Greater Chicago area. The study design was guided by a community-based participatory research approach.

Results:

This study found a prevalence of 15.0% for elder mistreatment among community-dwelling Chinese older adults. In addition, higher levels of education (r = .16, p< .001), fewer children (r = .1, p< .001), lower health status (r = .11, p< .001), poorer quality of life (r = .05, p< .01), and worsening health over the past year (r = .08, p< .001) were positively correlated with any elder mistreatment.

Discussion:

Elder mistreatment is prevalent among U.S. Chinese older adults. The findings point to a pressing need for researchers, community service workers, health care providers, and policy makers to increase efforts on reducing elder mistreatment in U.S. Chinese communities.

Keywords: elder mistreatment, Chinese older adults, Prevalence, population-based study

Introduction

Elder mistreatment is a significant health issue across all socio-economic and cultural backgrounds. According to the World Health Organization (2002), the prevalence of elder mistreatment in developed countries ranges from 1% to 10%. The U.S. National Elder Mistreatment Study reported that 11.4% of older adults suffered from elder mistreatment in the previous year (Acierno et al., 2010). As detrimental to one’s health and well-being, elder mistreatment has been linked to increased risks of morbidity and mortality (Dong et al., 2009; Dong, Chang, Wong, Wong, & Simon, 2014; Lachs, Williams, O’Brien, Pillemer, & Charlson, 1998). In addition, elder mistreatment is likely to increase nursing home placement, emergency department utilization, and adult protective services (APS) utilization (Dong & Simon, 2013a, 2013b; Lachs et al., 1998). In view of its public health significance, the Institute of Medicine gathered experts in the field of elder mistreatment to discuss prevention programs in April 2013. Despite the growing attention, we still have rudimentary knowledge on the issue of elder mistreatment in minority populations.

Cultural beliefs greatly influence the occurrence, perception, and care plans for elder mistreatment. Chinese cultural ideals highly emphasize children’s obligations of obeying, respecting, supporting, and caring for older adults, whereas disrespect may be considered as a form of mistreatment toward older adults (Ho, 1996; Tam & Neysmith, 2006). However, given the substantial social changes brought about by modernization and industrialization, younger generations, especially those who are acculturated in the United States, may be less likely to adhere to traditional cultural values and practices. The pressure from older parents to fulfill filial obligations and the growing disparity in values and interests between generations may intensify family conflicts and increase caregiver burdens that predispose older adults to elder mistreatment.

In addition, influenced by the value of collectivism that encourages conformity and cohesiveness (Ho & Chiu, 1994), Chinese older adults may be less likely to disclose elder mistreatment and seek professional help. A prior study on Chinese older adults’ perceptions of elder mistreatment suggested that there was a tendency for older adults to tolerate elder mistreatment so as to protect family reputation (Dong, Chang, Wong, Wong, & Simon, 2011). Another study among Asian American older adults further suggested that such tolerance for elder mistreatment may be associated with not favoring reporting and outside intervention (Moon, Tomita, & Jung-Kamei, 2001). Consequently, the scope of elder mistreatment among Chinese older adults is very likely to be under-reported (Chan, Chun, & Chung, 2008).

There is a growing body of literature that has helped improve the understanding of elder mistreatment in the Chinese communities. Prior studies suggested that elder mistreatment was common among Chinese older adults in Mainland China, with overall prevalence rates ranging from 20% to 40% (Dong, Simon, & Gorbien, 2007; Wu et al., 2012). Empirical evidence further demonstrated that elder mistreatment resulted in psychological distress among Chinese older adults (Yan & Tang, 2001). However, the majority of studies on elder mistreatment focused on Chinese older adults in Mainland China or Hong Kong, and very few studies have investigated elder mistreatment in U.S. Chinese older populations.

The Chinese community is the largest and the fastest growing Asian American subgroup population in the United States, numbering approximately 4 million (American Community Survey, 2011). The population of U.S. Chinese adults aged 65 and above has increased by 55% in the past decade, far exceeding the population growth rate of 15% among U.S. older adults (U.S. Census Bureau, 2010). Compared with the general population, the Chinese population is older in average age and less acculturated among U.S. immigrant groups (Shinagawa, 2008). A lack of language competency, coupled with cultural barriers and social isolation, may exacerbate frailty and dependency, and further dispose U.S. Chinese older adults to higher risk of elder mistreatment.

Despite the vulnerability of U.S. Chinese older adults, there is a dearth of investigations examining elder mistreatment in the U.S. Chinese communities. The purposes of this study were to (a) investigate the prevalence of elder mistreatment in U.S. Chinese older adults and (b) examine socio-demographic and health-related correlates of elder mistreatment in U.S. Chinese older adults.

Method

Population and Settings

The Population-Based Study of ChINese Elderly (PINE) is a community-engaged, population-based epidemiological study of U.S. Chinese older adults aged 60 years and above conducted in the Greater Chicago area. Briefly, the purpose of the PINE study is to collect community-level data of U.S. Chinese older adults to examine the key cultural determinants of health and well-being. The project was initiated by a synergistic community–academic collaboration between the Rush Institute for Healthy Aging, Northwestern University, and many community-based social services agencies and organizations throughout the Greater Chicago area (Dong, Wong, & Simon, 2014).

To ensure study relevance to the well-being of the Chinese community and increase community participation, the PINE study implemented extensive culturally and linguistically appropriate community recruitment strategies strictly guided by a community-based participatory research (CBPR) approach. The formation of this community–academic partnership allowed us to develop appropriate research methodology in accordance with the local Chinese cultural context, in which a community advisory board (CAB) played a pivotal role in providing insights and strategies for conducting research. Board members were community stakeholders and residents enlisted through more than 20 civic, health, social and advocacy groups, community centers, and clinics in the city and suburbs of Chicago. The board worked extensively with investigative team to develop and examine study instrument to ensure cultural sensitivity and appropriateness.

More than 20 social service agencies, community centers, health advocacy agencies, faith-based organizations, senior apartments, and social clubs served as the basis of study recruitment sites, where eligible participants were approached through routine social services and outreach efforts serving Chinese American families in the Chicago city and suburban areas. Out of 3,542 eligible participants who were approached, 3,159 agreed to participate in the study, yielding a response rate of 91.9%.

Based on the available census data drawn from U.S. Census 2010 and a random block census project conducted in the Chinese community in Chicago, the PINE study is representative of the Chinese aging population in the Greater Chicago area with respect to key demographic attributes, including age, sex, income, education, number of children, and country of origin (Simon, Chang, Rajan, Welch, & Dong, 2014). The study was approved by the Institutional Review Board of the Rush University Medical Center.

Measurements

Socio-demographics.

Basic demographic information included age (in years), sex (female and male), education (years of education completed), annual personal income ($0-$4,999 per year; $5,000-$9,999 per year; $10,000-$14,999 per year; or more than $15,000 per year), marital status (married, separated, divorced, or widowed), number of children, and living arrangement (living alone, living with 1 person, living with 2–3 persons, or living with 4 or more persons).

Overall health status, quality of life, and health changes over the last year.

Overall health status was measured by “in general, how would you rate your health?” on a 4-point scale (1 = poor, 2 = fair, 3 = good, 4 = very good). Quality of life was assessed by asking “in general, how would you rate your quality of life?” on a 4-point scale ranging from 1 = poor to 4 = very good. Health changes over the last year was measured by “compared to one year ago, how would you rate your health now?” on a 3-point scale (1 = worsened, 2 = same, 3 = improved).

Elder mistreatment.

Elder mistreatment was measured using a 10-item self-reported instrument, derived from the Hwalek–Sengstok Elder Abuse Screening Test (H-S/EAST) and the Vulnerability to Abuse Screening Scale (VASS; Hwalek & Sengstock, 1986; Schofield & Mishra, 2003). Participants were asked whether they had (a) family conflicts at home, (b) felt uncomfortable with someone in the family, (c) felt that nobody wanted them around, (d) been told by someone that they gave too much trouble, (e) been afraid of someone in the family, (f) felt that someone close tried to hurt or harm them, (g) been neglected or confined, (h) been called names or put down, (i) been forced by someone to do things, or (j) had belongings taken without permission. Each question elicited a yes or no answer. A “yes” response to any questions defined a participant as having experienced elder mistreatment. Modified VASS has been administered in Chinese elderly populations both in Mainland China and the United States (Dong, Beck, & Simon, 2009; Dong et al., 2007). The scale demonstrated good reliability in this study sample, with Cronbach’s alpha of .80.

Data Analysis

We used descriptive statistics to summarize demographic information of the participants. Chi-square statistics were used to compare the socio-demographic and health-related characteristics between groups with and without any elder mistreatment. Pearson correlation coefficients were calculated to determine the relationships of socio-demographic and health-related variables with elder mistreatment. All statistical analyses were undertaken using SAS, Version 9.2 (SAS Institute Inc., Cary, NC).

Results

Sample Characteristics

Of the 3,159 participants, 58.9% were female. Characteristics of the study participants by the presence of any elder mistreatment are presented in Table 1. Elder mistreatment was found in 15.0% of the participants. Compared with the group without any elder mistreatment, the group with any elder mistreatment had a greater proportion of older adults who aged less than 80 years (83.6% vs. 78.1%, p< .01), had an educational level of more than 13 years (35.3% vs. 18.6%, p< .001), were separated or divorced (8.1% vs. 3.5%, p< .001), had zero to one child (21.8% vs. 13.6%, p< .001), had poor overall health status (29.3% vs. 17.1%, p< .001), reported poor quality of life (5.9% vs. 2.6%, p< .001), and perceived worsened health status in the past year (53.7% vs. 40.4%, p< .001).

Table 1.

Characteristics of PINE Study Participants by Presence of Elder Mistreatment.

Any mistreatment (n = 475) No mistreatment (n = 2,665) χ2 df p value
Age group, number (%)
 60–64 90 (19.0) 588 (22.1)
 65–69 108 (22.7) 532 (20.0)
 70–74 106 (22.3) 495 (18.6)
 75–79 93 (19.6) 463 (17.4)
 80–84 53 (11.2) 336 (12.6)
 85 and over 25 (5.3) 251 (9.4) 16.0 5 .007
Sex, number (%)
 Male 183 (38.5) 1,107 (41.5)
 Female 292 (61.5) 1,558 (58.5) 1.5 1 .22
Education level, number (%)
 0 year 14 (3.0) 177 (6.7)
 1–6 years 120 (25.4) 1,055 (39.8)
 7–12 years 172 (36.4) 927 (34.9)
 13–16 years 142 (30.0) 432 (16.3)
 17 and over 25 (5.3) 62 (2.3) 85.2 4 <.001
Income in US$, number (%)
 $0-$4,999 169 (36.0) 870 (33.0)
 $5,000-$9,999 218 (46.4) 1,389 (52.6)
 $10,000-$14,999 48 (10.2) 261 (9.9)
 $15,000 and over 35 (7.5) 120 (4.6) 10.9 3 .013
Marital status, number (%)
 Married 336 (71.2) 1,891 (71.4)
 Separated 22 (4.7) 35 (1.3)
 Divorced 16 (3.4) 58 (2.2)
 Widowed 98 (20.8) 663 (25.1) 29.9 3 <.001
Number of children (%)
 0 23 (4.9) 104 (3.9)
 1 80 (16.9) 258 (9.7)
 2–3 276 (58.2) 1,466 (55.1)
 4 or more 95 (20.0) 834 (31.3) 38.2 3 <.001
Living arrangement, number (%)
 Living alone 108 (22.7) 564 (21.2)
 With 1 person 204 (43.0) 1,106 (41.5)
 With 2–3 persons 73 (15.4) 404 (15.2)
 With 4 or more 90 (19.0) 590 (22.2) 2.6 3 .46
Overall health status, number (%)
 Very good 13 (2.7) 127 (4.8)
 Good 132 (27.8) 961 (36.1)
 Fair 191 (40.2) 1,122 (42.1)
 Poor 139 (29.3) 455 (17.1) 43.7 3 <.001
Quality of life, number (%)
 Very good 34 (7.2) 182 (6.8)
 Good 179 (37.7) 1,195 (44.9)
 Fair 234 (49.3) 1,216 (45.7)
 Poor 28 (5.9) 70 (2.6) 19.7 3 <.001
Health status changes over the past year, number (%)
 Improved 54 (8.3) 222 (11.4)
 Same 165 (51.3) 1,367 (34.9)
 Worsened 254 (40.4) 1,067 (53.7) 43.3 2 <.001
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Note. PINE = Population-Based Study of ChINese Elderly.

Prevalence of Elder Mistreatment

The prevalence of elder mistreatment is shown in Table 2. Feeling uncomfortable with someone in the family was the most common form of elder mistreatment (9.1%), followed by having family conflicts at home (6.7%) and being called names or put down (5.5%). In addition, 4.7% of the study participants felt that nobody wanted them to be around, and 3.3% of the participants had been told that they gave too much trouble.

Table 2.

Percentage of Participants Agreeing With the Mistreatment Items.

n %
Felt uncomfortable with someone in the family 288 9.1
Had family conflicts at home 211 6.7
Someone close to you called you names or put you down 174 5.5
Nobody wanted you around 147 4.7
Someone told you that you gave too much trouble 104 3.3
Someone forced you to do things 45 1.4
Had belongings taken by someone without permission 45 1.4
Afraid of someone in the family 29 0.9
Someone close tried to hurt or harm 23 0.7
Someone made you stay in bed or told that you were sick when you know you were not 5 0.2
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Note. Percentage represents the prevalence of elder mistreatment within each of the screening item.

Prevalence of Elder Mistreatment by Health Status

We further examined the prevalence of elder mistreatment by health status (Table 3). Elder mistreatment was most prevalent among older adults with poor overall health status (23.4%, p< .001). Likewise, the prevalence of elder mistreatment was highest among older adults with poor quality of life (28.6%, p< .001). In addition, the proportion of elder mistreatment victims in older adults with a worsened health status over the last year (19.1%) was similar to those with an improved health status over the last year (19.6%). Both proportions were much higher than that in older adults with a same health status over the last year (10.8%).

Table 3.

Prevalence of Elder Mistreatment by Health Status.

Overall health status Very good (n = 140) Good (n = 1,093) Fair (n = 1,313) Poor (n = 594)
n % n % n % n %
13 9.3 132 12.1 191 14.6 139 23.4
Quality of life Very good (n = 216) Good (n = 1,374) Fair (n = 1,450) Poor (n = 98)
n % n % n % n %
34 15.7 179 13.0 234 16.1 28 28.6
Health status changes over the past year Improved (n = 276) Same (n = 1,532) Worsened (n = 1,330)
n % n % n %
54 19.6 165 10.8 254 19.1
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Note. Percentage represents the prevalence of elder mistreatment within each of the subgroup.

Correlation of Socio-Demographic and Health-Related Factors With Elder Mistreatment

Higher levels of education (r = .16, p< .001), fewer children (r = .1, p< .001), lower overall health status (r = .11, p< .001), poorer quality of life (r = .05, p< .01), and worsening health status over the past year (r = .08, p< .001) were positively correlated with elder mistreatment.

Discussion

This study represents the first large-scale population-based epidemiological study of the prevalence of elder mistreatment in a community-dwelling setting. It demonstrates that elder mistreatment was prevalent in community-dwelling U.S. Chinese older adults. Moreover, our findings suggest that older adults with higher educational level, fewer children, lower health status, poorer quality of life, and worsened health over the last year were more likely to experience elder mistreatment.

Building on prior studies on elder mistreatment in other Chinese populations, this study demonstrates that elder mistreatment is common among U.S. Chinese older adults. A study with 412 Chinese older adults in a clinical setting in China revealed that 35% of the older adults experienced elder mistreatment (Dong et al., 2007). Given that the study was based in a primary care setting with a larger proportion of vulnerable older adults, the prevalence of elder mistreatment may be higher than that of community-dwelling older adults. In addition, Chinese older adults in Mainland China or Hong Kong may be subjected to substantially different socio-economic influences, which may affect the prevalence of elder mistreatment. For example, a cross-sectional survey conducted in rural China reported the prevalence of elder mistreatment among older adults aged 60 and above was 36.2% (Wu et al., 2012). This high prevalence of elder mistreatment reported in rural China may be attributed to financial strains, a lack of access to health care and social service, and a large number of left-behind older adults resulting from recent trends of internal migration among rural Chinese.

In our study, the oldest of the old age group appeared to have no significant correlation with elder mistreatment. Previous studies yielded inconsistent results on the association between older age and elder mistreatment. The majority of studies suggested positive associations between older age and elder mistreatment (Choi & Mayer, 2000; Cooney & Mortimer, 1995; Lachs, Williams, O’Brien, Hurst, & Horwitz, 1997). However, the National Elder Mistreatment Study showed that older adults in the younger cohort were more likely to experience emotional, physical, and financial mistreatment as compared with the oldest older adults (Acierno et al., 2010). A telephone survey with 82 community-dwelling caregivers also reported that younger demented older adults had a higher possibility of experiencing elder mistreatment (Cooney, Howard, & Lawlor, 2006). Despite these findings, the researchers acknowledged that the exclusion of institutionalized older adults may contribute to the lower rate of elder mistreatment among oldest older adults (Acierno et al., 2010). Future studies are needed to clarify the association between age and elder mistreatment.

With respect to the relationship between socio-economic factors and elder mistreatment, the study demonstrates that higher levels of education were positively correlated with elder mistreatment. It is possible that older adults with higher education levels were more willing to identify and acknowledge elder mistreatment. In addition, better educated older adults may possess more available financial assets that place them at higher risk of financial exploitation. Furthermore, we suspect that positive effects of educational attainment on elder mistreatment may be counteracted by the influence of immigration. A study with low-income Latino immigrant older adults yielded similar findings that the prevalence of elder mistreatment was higher among older adults with higher education (DeLiema, Gassoumis, Homeier, & Wilber, 2012). Better educated older adults may have higher social and economic status in their country of origin. However, language and cultural barriers experienced in the new country may lead to lower levels of self-esteem and increased risk of acculturation stress and depressive symptoms, all of which may be associated with elder mistreatment (Dong, Li, Chen, Chang, & Simon, 2013; Mui, Kang, Kang, & Domanski, 2007).

This study demonstrates that older adults with fewer children were more likely to be mistreated. Influenced by the cultural value of filial piety, adult children are often the primary caregivers for Chinese older adults. A larger number of children can share caregiver burdens, improve levels of social support, and mitigate caregiver stress. By contrast, fewer number of children may increase the dependency of older adults to each child and exacerbate caregiver stress, and thus result in an elevated rate of elder mistreatment (Wolf, 1998). A study conducted with a cohort of Hong Kong Chinese older adults supported this explanation by showing that the absence of a domestic helper may increase the risk of exhibiting mistreatment (Yan & Kwok, 2011). It is noteworthy that family structure has undergone substantial changes since the implementation of the One-Child policy in China. Consequently, older adults with only one child may make up an increasing proportion of the U.S. Chinese aging population in the next decade. Considering the effect of the number of children on elder mistreatment, special attention may need to be paid to childless older adults or older adults with one child.

In this study, elder mistreatment was negatively correlated with overall health status and health changes over the past year, lending credence to our prior study in Mainland China that elder mistreatment may have adverse health outcomes among Chinese older adults (Dong et al., 2007). Yet, health status is an inconsistent risk factor for elder mistreatment in Western studies (Lachs et al., 1997). By linking a cohort of 2,812 community-dwelling older adults with elderly protective service records over a 9-year follow-up period, researchers found that functional disability and cognitive impairment were longitudinal risk factors for elder mistreatment (Lachs et al., 1997). However, in a study of 67 caregivers, the level of physical disability was not associated with elder mistreatment (Cooney & Mortimer, 1995). Different sampling procedures and assessment tools may account for the inconsistency of the findings. The inverse association between health status and elder mistreatment indicates that poorer health status may contribute to elder mistreatment in older adults. We suspect that lower levels of health status may give rise to higher demands on support from children, thus increasing the risk of caregiver stress and elder mistreatment. Community-based longitudinal studies are needed to further clarify the association between health status and elder mistreatment.

The results of this study should be interpreted with limitations. First, this study did not examine the subtypes of elder mistreatment in Chinese older adults. It is suggested that the prevalence and severity of elder mistreatment may vary by the types of mistreatment (Cooney et al., 1995). The National Elder Mistreatment Study further demonstrated that financial exploitation may be the most prevalent type of elder mistreatment affecting older adults (Acierno et al., 2010). Future investigations should explore the prevalence, risk factors, and outcomes associated with all types of elder mistreatment in the Chinese aging population. Second, we did not have available data on the characteristics of potential perpetrators. A prior study by Fulmer et al. (2005) found that personality traits of potential perpetrators may be significantly associated with elder mistreatment. Future studies could implement a dyadic approach to understand elder mistreatment in a more comprehensive way.

Third, the use of the self-report measure for accessing elder mistreatment may be subject to reporting bias. Future studies may need to incorporate definitive elder mistreatment by APS determination to better understand the extent of elder mistreatment among U.S. Chinese older adults. Last, this study utilized a cross-sectional design, and we could not postulate on the potential temporal relationships. Future longitudinal studies should examine risk factors and outcomes associated with elder mistreatment among U.S. Chinese older adults.

This study has important implications for researchers, community gate-keepers, health care providers, and policy makers. First, this study points to the need for improved investigations on elder mistreatment in Chinese older adults. Due to our CBPR approach, participants may have been more comfortable conversing in their preferred dialects, more trusting of research assistants, and more willing to express emotions and acknowledge their feelings. Researchers are encouraged to adopt the CBPR approach to overcome cultural barriers pertaining to elder mistreatment research in Chinese older adults. Special efforts should be given into developing culturally sensitive approach to screen and treat elder mistreatment victims (Dong & Simon, 2014; Fulmer, Guadagno, Dyer, & Connolly, 2004).

Second, health care professionals should improve detection of elder mistreatment in clinical settings. Physicians may need to enhance their understanding of cultural aspects of elder mistreatment and be more aware about older adults who are at higher risk of elder mistreatment—including those with fewer children, lower overall health status, and poorer quality of life. Moreover, community-based social service organizations should increase efforts on improving knowledge in relation to elder mistreatment in the Chinese community (Dong et al., 2013). Given that the majority of older adults may lack knowledge on help-seeking channels, considerable efforts should be put in creating a linkage between service and the aging populations. In addition, support groups that incorporate efforts from family members could be created.

Furthermore, the findings from this study should have implications to the Elder Justice Act of 2010, the first federal legislation addressing elder mistreatment at the national level. As the Elder Justice Act is being implemented currently, policy makers should pay special attention to cultural issues surrounding elder mistreatment. At the state level, government should provide culturally appropriate resources and education to APS and other frontline workers (Dong & Simon, 2011).

Conclusion

Elder mistreatment is a pervasive health issue in U.S. Chinese older adults. Higher levels of education, fewer children, lower overall health status, poorer quality of life, and worsening health over the past year were positively correlated with any elder mistreatment among U.S. Chinese older adults. Future longitudinal studies are needed to advance our knowledge of risk factors and health outcomes associated with elder mistreatment in this population.

Acknowledgments

We are grateful to Community Advisory Board members for their continued effort in this project. Particular thanks are extended to Bernie Wong, Vivian Xu, Yicklun Mo with Chinese American Service League (CASL); Dr. David Lee with Illinois College of Optometry; David Wu with Pui Tak Center; Dr. Hong Liu with Midwest Asian Health Association; Dr. Margaret Dolan with John H. Stroger Jr. Hospital; Mary Jane Welch with Rush University Medical Center; Florence Lei with CASL Pine Tree Council; Julia Wong with CASL Senior Housing; Dr. Jing Zhang with Asian Human Services; Marta Pereya with Coalition of Limited English Speaking Elderly; and Mona El-Shamaa with Asian Health Coalition.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Dr. Dong was supported by National Institute on Aging grants (R01 AG042318, R01 MD006173, R01 AG11101, & RC4 AG039085), Paul B. Beeson Award in Aging (K23 AG030944), the Starr Foundation, American Federation for Aging Research, John A. Hartford Foundation, and the Atlantic Philanthropies.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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