Long-stay institutions for the elderly: physical-structural and organizational aspects

Instituciones de larga estancia para personas de edad: aspectos físico-estructurales y organizativos

Abstract

Objective:

To characterize long-stay institutions for the elderly in respect to physical-structural and organizational aspects.

Method:

This descriptive, cross-sectional, quantitative research was carried out in four long-stay institutions for the elderly in Salvador - Bahia, Brazil, between September and November 2013. Data were collected from the technical officers of the institutions using a questionnaire based on National Health Surveillance Agency standards.

Results:

This study highlights a partial compliance with current regulations both in respect to the physical-structural and organizational aspects. The elderly are exposed to an environment that is sometimes unhealthy with risk factors for health problems.

Conclusion and implications for practice:

There is need for adjustments in the institutions to comply with current legislation. This study shows the importance of a multidisciplinary team to provide comprehensive care of institutionalized elderly, with emphasis on the role of nurses in the qualification of institutions and valorization of the elderly.

Keywords:
Elderly; Homes for the aged; Health of the elderly; Structure of services

Resumen

Objetivo:

Caracterizar instituciones de larga estadía para los ancianos como los aspectos físicos estructurales y organizativas.

Método:

Transversal, la investigación cuantitativa descriptiva, llevado a cabo en cuatro instituciones de larga estadía para las personas mayores de Salvador - Bahia, Brasil, entre septiembre y noviembre de 2013. Los datos fueron recogidos entre los responsables técnicos de las instituciones a través de un cuestionario basado en estándares Agencia Nacional de Vigilancia Sanitaria.

Resultados:

Este estudio pone de manifiesto un cumplimiento parcial de la normativa vigente, tanto en los aspectos físicos y estructurales como de organización. Los ancianos están expuestos a un ambiente a veces factores insalubres y de riesgo de problemas de salud.

Conclusión e implicaciones para la práctica:

Existe la necesidad de ajustes en las instituciones para el cumplimiento de la legislación vigente. Aboga por la importancia de un equipo multidisciplinario para la atención integral a las personas mayores institucionalizadas, con énfasis en el papel de la enfermería para la calificación de las instituciones y la apreciación de las personas mayores.

Palabras clave:
Anciano; Hogares para ancianos; Salud del anciano; Estructura de los servicios

Resumo

Objetivo:

Caracterizar Instituições de Longa Permanência para Idosos quanto aos aspectos físico-estruturais e organizacionais.

Método:

Pesquisa descritiva, transversal, quantitativa, realizada em quatro Instituições de Longa Permanência para Idosos de Salvador - Bahia, Brasil, entre setembro e novembro de 2013. Os dados foram coletados entre os responsáveis técnicos das instituições através de um questionário baseado nas normas da Agência Nacional de Vigilância Sanitária.

Resultados:

Evidencia-se um atendimento parcial à regulamentação vigente tanto nos aspectos físico-estruturais quanto organizacionais. Os idosos são expostos a um ambiente, por vezes, insalubre e a fatores de riscos para agravos à saúde.

Conclusão e implicações para a prática:

Há necessidade de ajustes nas instituições para o atendimento à legislação vigente. Defende-se a importância de uma equipe multiprofissional para o cuidado integral às pessoas idosas institucionalizadas, com ênfase no papel da enfermagem para a qualificação das instituições e valorização dos idosos.

Descritores:
Idoso; Instituição de Longa Permanência para Idosos; Saúde do idoso; Estrutura dos serviços

INTRODUCTION

Long-stay Institutions for the elderly (LSIE) are defined by the Brazilian National Health Surveillance Agency (ANVISA) as residential spaces for collective housing of people 60 years of age or older, with or without family support. These institutions may be governmental or not, and should, through their services, guarantee the freedom, dignity and citizenship of their residents.¹ Despite the definition of LSIE proposed by ANVISA, some authors point out that there is no consensus regarding the conceptualization. In particular, it is common to find among workers in the sector denominations such as shelters, nursing homes and elderly asylums.²

LSIEs originated in ancient times linked to works of religious charities. These institutions, in turn, provided voluntary services to homeless, poverty-stricken people of all ages in need of health care and shelter who lived in times when there were no specific government support.^2,3 This led to LSIEs having a bad image, reinforced by low-quality care and the feeling of loneliness and abandonment reported by residents.³

However, despite this view, there has been a significant increase in demand for LSIEs in Brazil. Several factors contribute to this scenario, such as the structural changes of families with changes in the roles of members, as well as the reduction in their size and distinct family arrangements. These changes interfere with the availability of people to care for dependent elderly people at home.^3-5

Other factors are also worth mentioning. There has been an increase in the number of elderly people in the population, most of whom have chronic diseases and disabilities, together with insufficient public resources and services, both in the social sphere and in healthcare. Furthermore, homecare is expensive,⁶ there is often inadequate physical space in homes, which are sometimes small, with structural obstacles, creating risks for falls and violence⁴ and the aging process itself is associated with loss of capacity and dependence on other people to perform daily life activities.⁶

Public policies in Brazil state that care for the elderly should be shared between the family, society and the State, thereby providing the means to guarantee sociability, and protect the welfare, dignity and right to life. Thus, because of support structure deficits, there is a trend of increasingly transferring the elderly to LSIEs,^4,2 as an alternative to providing essential care to maintain life and provide a life with quality.^4,3

Brazilian LSIEs are regulated by the Collegiate Board Resolution (Resolução da Diretoria Colegiada - RDC) nº 283, of September 26, 2005 by ANVISA. According to this Resolution, these institutions must meet minimum criteria for their operation and for the provision of services to residents, especially with regard to physical-structural and organizational aspects. The residents' degree of dependence, ability to move around and care for themselves should be taken into account in the organization of the service.¹

Although LSIEs are considered necessary, institutionalization can expose the elderly to several risks that are closely related to physical-structural and organizational inadequacies. In particular, the risks of worsening functional and cognitive abilities, social isolation,^6,7 falls⁸ and sensory impairment should be highlighted.⁷

The services provided by LSIEs must be sensitive to the needs of the elderly in order to reduce the risks associated with institutionalization, thereby providing comfort, security, and quality of life and preserving independence. Thus, this study aims to characterize long-term institutions for the elderly regarding physical-structural and organizational aspects.

METHOD

This is a descriptive cross-sectional quantitative study carried out in four LSIEs in the city of Salvador, Bahia, Brazil, from September to November 2013. All the nursing homes are located in Itapagipe Sanitary District in the Cidade Baixa region and are identified in this study by the letters A, B, C and D. In total, the four institutions care for 160 elderly people.

The choice of Itapagipe Sanitary District was because it presented the largest number of regular LSIEs (11 of the 25 that exist in the city) registered with the counsel for the elderly in the city of Salvador. In addition, the only LSIE maintained by the city council is located in this district. To carry out the study, an invitation was sent to all the 11 institutions, however only four accepted to participate in the research.

This article, part of a master's thesis entitled "The health of elderly residents in long-stay institutions based on Nightingale's theory", presents the discussion of data regarding the physical-structural and organizational characteristics of the institutions. The data were collected using a questionnaire prepared by the researcher based on ANVISA regulations, which establishes parameters for the functioning of these institutions.¹

The instrument, applied to the technical officers (TO) of the institutions, included questions about the situation of the property (whether rented or owned), legal status of the LSIE, financial support, most recent Health Department certification, level of education of the TO, human resources, health care of residents, and physical-structural characteristics. The data are described as absolute frequencies and presented in tables.

The questionnaire was applied after the nature of the research had been carefully explained and a written informed consent form had been signed. The project was approved by a Research Ethics Committee (number 339.409/2013 and CAAE: 16049113.0.0000.5531).

RESULTS

This study presents the physical-structural and organizational characteristics of the four LSIEs. The physical-structural aspects include the adequacy of the bedrooms, bathrooms, circulation area and lighting. The organizational aspects comprise characteristics related to the nature of the property, the existence of Health Department certification, the health care of residents and human resources. The RDC Nº. 283/2005 of ANVISA was taken as reference for the classification of organizational aspects.¹

The data presented in Table 1 refer to the physical-structural aspects of the LSIEs investigated.

Table 1
Physical-structural characterization of long-stay Institutions for the elderly (LSIEs) in respect to bedrooms, bathrooms and circulation areas. Salvador Bahia Brazil. 2013.

LSIE	A	B	C	D
Bedrooms
Number of bedrooms	4	4	4	8
Separated by sex	*1	*1	Yes	Yes
Beds per room - Female	6	5	19	30
Beds per room - Male	*1	*1	12	15
A distance of 0.80 m between the beds	No	No	No	*2
Presence of rails on the beds	No	No	Yes	No
Waterproof covers on the mattresses and pillows	No	Yes	Yes	Yes
Night light at the door	No	No	No	No
Call bells in the bedrooms	No	No	No	No
Adequate hygiene	No	Yes	Yes	Yes
Adequate circulation of air	No	Yes	Yes	No
Adequate lighting	No	Yes	Yes	No
Bathrooms
Separate for sexes	*1	*1	Yes	Yes
Safety rails	No	No	Yes	Yes
Non-slip flooring	No	No	Yes	Yes
Adequate size for a shower chair to enter	Yes	Yes	No	No
Presence of steps	Yes	Yes	No	No
Adequate hygiene	No	Yes	Yes	Yes
Adequate lighting	No	Yes	Yes	Yes
Circulation area
Leisure area	No	No	Yes	Yes
Presence of stairs	No	Yes	No	Yes
Non-slip flooring	No	No	No	No

Source:
• Results of the research - The health of elderly residents in long-stay institutions based on Nightingale’s theory.
• ^1*
  The institution does not accept male residents;
• ^2*
  The beds are separated by screens.

Institutions C and D have dormitories separated by sex, and institutions A and B only accept women. It is noteworthy that institution D does not have a physical dormitory structure. This LSIE consists of two old two-floor houses, and on each floor, there is a large hall where beds are arranged which are separated from each other by screens without doors. The individual space only fits a single bed and a chest of drawers where the belongings of the residents are stored. In LSIEs A, B and C, the distance between the beds was less than 0.80 m, making it difficult for residents to move around.

Only in one of the four institutions (C), the beds are equipped with side rails. In three, the mattresses and pillows were found to be in precarious conditions, some of them worn, torn and with uneven surfaces. Three nursing homes (B, C and D) used waterproof covers. It was unanimous that there was no night light at the doors or a bell in the rooms near the beds.

In institutions B and C, the windows are open during the day, favoring natural light and air circulation. In institution D, although the windows are open during the day, they are not enough to guarantee air circulation and adequate lighting, leaving the atmosphere stuffy and dark.

In institution A, although the bedrooms have windows, they are not opened at any time. The environment is dark and stuffy and there is an accumulation of dust and some insects around the windows. Inside, there is a strong smell of urine in the bedrooms, demonstrating precarious hygiene aggravated by the lack of natural ventilation.

In LSIEs C and D, the bathrooms are separated by sex, the have safety rails and the floors are non-slip. However, the shower space is not large enough for a shower chair to enter. In institutions A and B, although the sizes of the bathrooms are suitable for the entry of a shower chair, a bar on the floor between the shower and toilet hampers mobility and increases the possibility of falls.

As for the areas of circulation, only institutions C and D have a space outside with gardens and a living area where recreational activities and celebrations are held on festive dates. Neither of the LSIEs has non-slip flooring in these areas and institutions B and D have stairs because they function in two-floor buildings. The stairs have a handrail, but the steps are narrow and high.

All the researched homes function in their own properties. Institutions A, B and C are philanthropic and do not receive any kind of government funding; they use the benefits of residents as a source of support for the upkeep and receive donations of clothing, furniture, medicines and food. Institution D is local government, but also receives donations from third parties.

All the institutions have a license to work issued by the Health Department. In the same way, they have TOs, with weekly working hours ranging from 20 to 40 hours. However, with regard to training, the TO of institution D is the only one to have a diploma.

This study did not find a uniform model to meet the health needs of the institutionalized elderly. LSIEs are not covered by the Family Health Program of the Sanitary District where they are located. The care given to the elderly refers only to mass vaccinations during campaigns. Only the elderly of LSIE D receive regular outpatient care at their nursing home.

Regarding health care associated with acute situations, all LSIEs refer the elderly to Brazilian National Health Service (SUS) hospitals and the use of the emergency ambulance service (SAMU) is common. Institution C, which caters for richer elderly subjects, has an agreement with a mobile emergency service. In addition, they also have the support of a philanthropic referral geriatric hospital.

All LSIEs investigated have TOs and people assigned to cleaning and cooking services. Only institution C has staff assigned to the laundry service. In institutions A and B, this service is performed at weekends by the cleaners, and in institution D, this service is outsourced. Institution D is the only one that has a health team including a doctor, nurse, nursing technician, nutritionist and social worker.

All the LSIEs have formal caregivers, as demonstrated in Table 2.

Table 2
Distribution of the human resources of four long-stay Institutions for the elderly (LSIEs) of the Sanitary District of Itapagipe, Salvador, Bahia - Brazil, 2013.

LSIE	A		B		C		D
Nº of elderly residents	14		17		69		60
Professional	Nº	WWH	Nº	WWH	Nº	WWH	Nº	WWH
Technical officer	1	20	1	30	1	40	1	40
Cleaning staff	1	55	1	40	2	40	4	40
Laundry staff	0	--	0	--	2	30	0	--
Kitchen staff	1	45	1	40	2	40	2	40
Caregiver	1	40	2	36	3	36	4	36
Nurse	0	--	0	--	0	--	2	30
Nursing technician	0	--	1	36	1	40	2	36
Doctor	0	--	0	--	0	--	1	4
Nutritionist	0	--	0	--	0	--	1	30
Social worker	0	--	0	--	0	--	1	30

Source:
• Results of the research - The health of elderly residents in long-stay institutions based on Nightingale’s theory WWH: Weekly working hours.

In institutions B and C, nursing technicians work only during the day and are responsible for dressing the residents, medications and for feeding. In institution D, these professionals only work at night.

DISCUSSION

In view of the results obtained, it is clear that these LSIEs partially comply with the regulations defined by RDC No. 283/2005 of ANVISA. None of the four LSIEs investigated follow the norms recommended in the legislation regarding the maximum number of four beds per room, at a distance of 0.80 m between beds, and a call bell and night light,¹ showing the precarious structure of the bedrooms.

The pillows and mattresses were unprotected by waterproof covers making cleaning and drying difficult, as well as favoring the proliferation of acari and fungi, which can trigger allergic and respiratory diseases in the elderly or even exacerbate existing pathologies.

Regarding the physical structure of bathrooms, RDC No. 283/2005 states that these must be separated by sex, have safety rails, non-slip flooring, absence of unevenness and sufficient space for the entry of shower chair.¹ The institutions investigated partially meet the demands of inspection agencies, however the infrastructures of the environments have risks to the health of residents. The bathrooms of LSIEs A and B are inadequate, and in institution A the illumination is unsatisfactory and hygiene is precarious.

A study carried out at LSIEs in Recife in the state of Pernambuco found a similar situation. There was little space in the dorms for residents to get around due to the excess of beds and furniture with the movement of more dependent elderly people using wheelchairs or walkers being impossible. There was no night light at the doors and no bells at the beds to call care staff if needs be. In some institutions, the bathrooms did not have non-slip flooring or safety rails, thus putting the safety of residents at risk, especially among those with postural instability.⁹

Concern with the assessment of the LSIE environment is related to situations that may lead to the elderly becoming ill. The inadequacy of the physical structure and poorly distributed furniture, poorly lit places that make it difficult to see as in LSIEs A and D, the absence of protective rails on beds (A, B and D), the absence of safety rails in the bathrooms (A and B), the absence of anti-slip flooring (A and B), as well as the presence of a bar on the floor that prevents the use of chairs to certain areas (C and D) are all extrinsic risk factors that can cause falls.¹⁰

Falls not only affect the mobility of the individual, but also impair the achievement of activities of daily living (ADLs) with a negative impact on the quality of life of the elderly. The consequence of falls in this age group can lead to serious injuries, impair functional capacity and even lead to death.¹¹

In addition to the risk of falls, unhealthy environments may also expose the elderly to other conditions. Research shows that the elderly, especially those who are bedridden, who remain in poorly lit environments, without distinction between periods of the day, are more likely to suffer cognitive deficits due to confinement.¹²

The concern with a healthy environment is fundamental for maintaining health. Florence Nightingale stated in her Environmentalist Theory that dark places with no air circulation, no proper cleaning and with odors are unhealthy and cause disease.¹³ Moreover, the room must be as airy as outdoors, thus the windows should remain open, allowing the penetration of sunlight and the distinction between the periods of the day.^13-15

Regarding circulation areas, the RDC No. 283/2005 emphasizes that institutions should have an outdoor area with plants and an area to sit in the sun, favoring socialization between residents and the development of outdoor activities. The resolution also stresses that in cases of uneven terrain, ramps must be constructed instead of stairs, and floors must have non-slip materials and be easy to clean.¹

In this study, not one of the institutions has non-slip flooring in the external areas and institutions B and D have stairs instead of ramps, thereby risking the safety of residents. Only two LSIEs have a leisure area that can be used for sociocultural and religious events. Independent older people practice physical activity once or twice a week and participate in other leisure activities outside the institution.

Research carried out in an LSIE of Italy revealed the importance of sociocultural activities for institutionalized elderly. The author emphasizes that these activities are not a simple pastime, since they favor the socialization of residents, preserving their mental capacity, expression and bearings in time and space, and enabling their active participation in the environment.¹⁶

As to the legal nature, three of the institutions are philanthropic and one is local government. By founding LSIEs, the legislation allows the private sector to provide care to the elderly however these institutions must ensure the civil rights, and the dignity of their residents, and provide quality services.¹

A study carried out in the state of São Paulo found a predominance of private institutions,¹⁷ and another study carried out in all LSIEs in Maceió, state of Alagoas found that most were religious charitable institutions (88%), with the remaining being private nursing homes (12%).⁵

Predominantly in Brazil, LSIEs are financed by the elderly themselves using their pensions.¹⁸ In for-profit LSIEs, 95.7% of the funding comes from monthly payments paid by the elderly and/or their families. Public funding is still considered incipient in light of the real needs. Only one study reported a government subsidy in 33% of LSIEs in a state city in the northeast of Brazil.⁵ Despite the legal framework on the operation of LSIEs, the resources needed for existing demand are still lacking.¹⁹

RDC No. 283/2005 states that all LSIEs must have an up-to-date permit issued by the local government Health Department and must have a TO with a diploma.¹ All the institutions of this study abided by the legislation in respect to the first issue, even though the existence of LSIEs operating without Health Department authorization it is still common in Brazil.⁵ It is worth noting, however, that the TO of only one institution had a diploma as required by ANVISA. Authors of other studies suggest that many nurses perform this function.¹⁷

Only institutions A and B have a sufficient number of professionals in the catering service to meet the demand of residents. In institutions C and D, the number of professionals is insufficient considering the specifications of RDC No. 283/2005. Not one of the four institutions has a staff member for leisure activities. Moreover, there is an irregularity in the function of cleaning staff in LSIEs A and B as they also perform the laundry service at weekends.

RDC No. 283/2005 establishes that LSIEs must have elderly health insurance that includes the forms of health care, referrals, means of transportation for consultations and communication with the family or caregivers.¹ However, in this research, none of the institutions met these requirements, as they did not have the support of the local health network nor articulation to guarantee the continuity of care for the institutionalized elderly. In addition, none had established healthcare plans and these LSIEs exist with scarce resources and thus fail to provide quality health care. This reality is also described by other authors, emphasizing the absence of calculations of healthcare indicators and permanent education in gerontology.⁵

Authors report that both government and philanthropic LSIEs predominantly use SUS⁴ for consultations, transportation and hospitalization, as found in this study. In addition, private individual healthcare plans of the elderly are used⁴ together with healthcare teams of the institution itself. The absence of systematic healthcare,⁵ even for LSIEs located in areas covered by a family health program is common in Brazil. Thus, there is the configuration of a reality in healthcare that does not see the elderly and, hence, reinforces their exclusion.¹⁹

The lack of leisure activities for the elderly was also reported in a study carried out in São Paulo, where 62.5% of the institutions investigated did not provide this service.¹⁷ Consequently, there may be little interaction among residents, excessive idle time, or only their involvement in passive activities.⁷

A study on the sensory and cognitive decline of 4156 elderly people living in nursing homes in eight European countries reported that factors such as hearing and visual impairment are directly associated with functional decline. This decline is higher in elderly people who present social isolation, resulting not only from a lack of interaction with other residents, but also from a lack of activities such as reading, listening to the radio, and watching television.⁷ Hence, the importance of developing diversified activities is emphasized with an expanded multi-professional team including professionals such as a physical educator and the existence of spaces that encourage the elderly to leave their beds to interact with other residents.

LSIEs provide social services as well as health services,¹⁸ and thus they are described as hybrids.¹⁹ The need to provide health services is justified by the profile of the elderly; many are bedridden, with a risk of falling, in a situation of social isolation, with chronic non-transmissible, dependent diseases,^18,19 debilitated, with skin lesions and taking various medications. Thus, a multi-professional team plays an important role in institutionalized elderly care.²⁰

Although RDC No. 283/2005 does not stipulate the health team, it is understood that there is a need of monitoring in respect to direct care as well as to prevent injuries. In this study, a team consisting of a nurse, a nursing technician, a physician and a nutritionist was found in only one institution (D). At this institution, the nurse works only during the day, while nursing technicians work only at night without proper supervision, even though the Brazilian Professional Nursing Code establishes that a nurse must be present whenever nursing activities are being performed.²¹ In addition to the points highlighted in the legislation, attention is also drawn to the need for technical and scientific training of nurses who work in the different care settings of the elderly, including LSIEs.

To provide care, LSIEs should have caregivers with variable workloads according to the number of elderly and their degree of dependency. Hence, based on the number of elderly residents (160), it is evident that the number of caregivers (10) is insufficient for uninterrupted 24-hour care without them experiencing work overload. The data of this research identify the size of the problem with respect to the adequacy to the needs of the elderly.

Another aggravating factor is the precariousness of providing care for the elderly due to inadequate technical training. It is common for LSIEs to employ staff without proper caregiver training.^18,22 In many institutions, there is also a diversion of the functions of caregivers who begin to perform tasks such as food preparation and cleaning.¹⁷ Another reality is the lack of clarity in the differentiation between the responsibilities of the caregiver and the nursing technician or assistant.²² Because of this the elderly are exposed to the risk of receiving unqualified care with the potential of incurring injuries.¹⁹

One study carried out in 14 LSIEs in a municipality of the state of Rio Grande do Sul identified the presence of a multi-professional team formed by nurses, psychologists, a physical educator, nutritionist and physiotherapist. However, the highest number of professionals and greatest workload are concerned with nursing, probably due to the work activities of the profession, which involves planning care and providing direct care for the basic needs of the elderly.¹⁸

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

This study characterized four LSIEs in Salvador, Bahia, Brazil, regarding the physical-structural and organizational aspects, in light of the regulatory norms of ANVISA. Although this is the portrayal of a local reality, it is similar to the reality reported in other Brazilian states. This makes a discussion on public policy related to care of the elderly necessary and strengthens the importance of training health professionals in this area.

It has been found that aspects such as the maximum number of beds per dormitory and the distance between them are not met by any of the institutions in this study. The requirement of rails on the sides of the beds is obeyed in only one of the nursing homes. The use of waterproof covers on mattresses and pillows was found in three institutions thus in compliance with the legislation. However, other aspects such as the lack of safety rails in the bathrooms, the absence of non-slip flooring and the lack of natural ventilation in two institutions expose the elderly to unhealthy environments and risk factors for health problems such as cutaneous and respiratory diseases, decline in functional capacity and falls.

As for the organizational aspects, it was verified that only one LSIE, a local government institution, receives financial assistance from the government. The others use the income of residents to pay the costs. Three LSIEs deviate from the norms, as their TOs do not have diplomas as required by legislation. Other aspects of this study were the lack of a comprehensive healthcare plan for the elderly, the absence of multi-professional health teams at three institutions, and the lack of systematic monitoring by SUS. It also highlights the insufficient number of formal caregivers to meet the needs of the residents.

In this sense, this research shows the need for adjustments in the LSIEs to comply with current legislation. It is believed that one of the greatest challenges for managers is to maintain the functioning of institutions with their available resources, to make physical-structural adjustments and have a multi-professional team for effective care.

Although the hiring of health professionals is not mandatory, the importance of a multi-professional team for the integral care of institutionalized elderly is recommendable. Among these professionals, we stress the importance of the nurse who works directly caring for the elderly by promoting qualified assistance and planning and with the prevention of injuries. Thus, nurses contribute to the qualification of LSIEs as welcoming, safe spaces that respect the dignity and life of their residents.

REFERENCES

• ¹
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• ²
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Publication Dates

• Publication in this collection
  2017

History

• Received
  24 Nov 2016
• Accepted
  24 Mar 2017