• Users Online: 281
  • Print this page
  • Email this page


 
 
Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 4  |  Issue : 2  |  Page : 121-131

Anomie, Loneliness, and Psychopathology: Results from the Study of Youth in Istanbul


1 Department of Psychiatry, University of Florida Gainesville; Department of Psychiatry, Division of Child and Adolescent Psychiatry, University of Florida College of Medicine, Gainesville, FL, USA
2 Department of Psychiatry, University of Florida Gainesville, Gainesville, FL, USA
3 Department of Psychiatry, Virginia Commonwealth University, Richmond, VA, USA
4 Department of Psychiatry, Cooper University Hospital/Cooper Medical School of Rowan University, Camden, NJ, USA
5 Department of Psychiatry, National Institute for Health and Welfare (THL), Alcohol, Drugs and Addictions Unit, Helsinki, Finland

Date of Submission26-Jun-2022
Date of Decision29-Jun-2022
Date of Acceptance30-Jun-2022
Date of Web Publication22-Aug-2022

Correspondence Address:
Dr. Mariam Rahmani
Department of Psychiatry, Division of Child and Adolescent Psychiatry, University of Florida College of Medicine, Springhill 2 Building, 4197 N.W. 86th Terrace, Gainesville, FL 32606
USA
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/wsp.wsp_13_22

Rights and Permissions
  Abstract 


Objective: “Anomie” describes social dysregulation or a social condition in which individuals feel isolated instead of united with other members of the society. The literature on the association of anomie and loneliness with suicidality and youth psychopathology has been demonstrated in some studies based in Western nations. This study aims to compare the association of anomie and loneliness, substance use, and psychosocial risk factors with suicidal ideations in a sample of high school (HS) students in Istanbul. The context of modern-day Turkey provides a setting where stress from socio-economic and cultural transitions resulting from globalization could contribute to higher degrees of anomie and isolation/loneliness. Methods: The study data were collected from a 66-question survey of 31,604 HS students administered by the Istanbul Department of Education. The primary questions and subquestions were used to generate variables of interest to explore the relationship between anomie, loneliness, and psychopathology. In addition to the descriptive analyses, logistic regressions were used with anomie and loneliness as dependent variables, and psychosocial variables and psychiatric symptoms were used as two main independent variable clusters. Results: Our findings show that 45% of Turkish youth experienced anomie and 17% experienced loneliness. Both anomie and loneliness are strongly associated with particular psychosocial variables. More time spent with family and higher parental education are protective factors, whereas peer influences and substance misuse increase the risk of anomie and loneliness. Both anomie and loneliness are also associated with psychiatric symptomatology, particularly suicidality. Conclusions: Identification of youth struggling with anomie and loneliness can be an important approach to reaching out to at-risk youth, particularly in a context of socioeconomic and cultural transition.

Keywords: Anomie, loneliness, psychopathology, psychosocial, Turkey, youth


How to cite this article:
Rahmani M, Pumariega AJ, Prajapati P, Dalkilic A, Burakgazi-Yilmaz H, Unlu A. Anomie, Loneliness, and Psychopathology: Results from the Study of Youth in Istanbul. World Soc Psychiatry 2022;4:121-31

How to cite this URL:
Rahmani M, Pumariega AJ, Prajapati P, Dalkilic A, Burakgazi-Yilmaz H, Unlu A. Anomie, Loneliness, and Psychopathology: Results from the Study of Youth in Istanbul. World Soc Psychiatry [serial online] 2022 [cited 2022 Sep 26];4:121-31. Available from: https://www.worldsocpsychiatry.org/text.asp?2022/4/2/121/354171




  Introduction Top


The word anomie is derived from a Greek word that means lawlessness. Anomie may be defined as social dysregulation or a social condition in which individuals feel isolated and alienated instead of united with other members of the society. Anomie entails feelings of mistrust, aimlessness, demoralization, disconnectedness, meaninglessness, normlessness, and powerlessness. People who experience anomie often experience loneliness and isolation, struggle with forming social bonds with other members of the society, and participating in solutions to the problems in the society.

Srole proposed that five elements are necessary to develop anomie: (1) a sense that leaders are detached from the individual's needs, (2) believing that social order is unpredictable and unstable, (3) feeling that the life of people like the individual is worsening, (4) loss of internalized social norms and values, and (5) a perception that no one, not even close relations, can be trusted.[1]

Anomie is associated with social change, fragmentation, and transition where individuals in society get “left behind.” For example, several studies have shown that although high socioeconomic status (SES) is a protective factor against anomie, African Americans have high anomie rates regardless of their SES. African American women have higher rates of anomie than African American men, likely due to experiences of sexism in addition to racism and historical trauma.[2]

Anomie is associated with high suicide risk. For example, French sociologist Emile Durkheim recognized suicide as a social, rather than psychiatric, problem that becomes prevalent when individuals experience a high degree of anomie and are unable to integrate into a society. Durkheim posited that suicide was a self-destructive behavior that resulted from existing in complex societies where individuals are separated from one another by division of labor, moral values, political views, and economic shifts.[3] A relatively recent example of Durkheim's theory is the study of high suicide rates in Aboriginal youth, which is found to be correlated with poverty and food insecurity.[4] On the other hand, those Aboriginal communities that were able to exert control over their lands, remain connected with their culture, have some form of self-government and a control over the laws that govern their society's health, education, policing, and welfare services, were found to have very low suicide rates.[5]

In contrast to the adult population, there are limited data available on the experience and impact of anomie in youth. One study of US high school (HS) seniors found that adherence to economic values of a society is positively related to certain forms of delinquency and that commitments to noneconomic institutions (for example, family, religion, education, and politics) reduce delinquent behavior.[6] In Iran, attachments to parents and peers are found to be protective against youth suicidality by indirect effects on anomie.[7] The rise in the “NEET” (people between 15 and 34 years of age who are not engaged in employment, education, and training) population in Japan is thought to be related to anomie as well, especially an aversion to conform to the societal expectation of economic stability.[8]

Because the societal fabric in different geographic regions varies, it is important to study anomie, the unique factors that contribute to it, and the impact that anomie has on youth in different parts of the world before exploring the possibility whether these findings are generalizable to other countries. This paper examines the impact of anomie, and its closely related factor loneliness, on Turkish adolescents, their mental health, and the association between social stressors and anomie. We hypothesize that (1) anomie and loneliness are positively correlated to psychopathology and (2) anomie positively correlates to social stressors (particularly immigration and family related).


  Methods Top


The study population

The participants in this survey study were HS students in of the city of Istanbul, Turkey, in 2010. Out of 39 provinces of Istanbul, 28 inner cities were selected for sampling. The schools in each province are divided into three categories as regular, vocational, and Anatolian based on the regulations of the Ministry of Education and each school type had a special structure, focus, and curriculum. In general students in three types of high schools represent a continuum of socioeconomic to clarify backgrounds, as the Anatolian HSs are more college preparatory and accessed by higher SES populations via entrance examination, the regular HS have more students from the middle class, and the vocational HSs are preferred by students from lower SES, as their curriculum includes vocational skill training, as well.

Data sampling and distribution

In 2010, there were 232 regular, 242 vocational, and 88 Anatolian HSs with a total of 562 schools in Istanbul. In each category, the schools were listed alphabetically and every third school was selected from the list starting from A. The sampling design included 65 regular, 62 vocational, and 27 Anatolian high schools in the study with the total of 154 high schools. The sample represents approximately 20% of the total school population. The survey sample consisted of 31,604 youth between the ages of 14 and 19 in the city of Istanbul, representing 20% of the Istanbul HS population. Systematic sampling was used to select the allocated sample of classrooms. Every third classroom from each grade was included in the sampling. As the schools and classes were selected by stratified sampling method, the sample is representative of schools in their districts and the city of Istanbul. Ninth graders represent the largest student group, and student numbers decrease toward the higher grades among total number of students and in our sample [Figure 1].
Figure 1: Sampling and sample size

Click here to view


Survey instrument

The survey instrument used in the study was a combination of the European School Survey Project on Alcohol and Other Drugs[9] and Youth in Europe Survey.[10] Both of these surveys were translated into Turkish and used in research previously.[11],[12],[13] A total of 27 items were used from these surveys. The total students surveyed were 31,604, but a “trick” substance named “relevin” was included in the questionnaire, and the responses from students who endorsed its use were removed from the analysis as their responses were deemed not credible. They consisted 1.05% (332) of the sample, pointing to an acceptable face validity ratio. The final sample size was 31,272 which consisted of 14,477 (46.6%) male and 16,581 (53.4%) female students.

Method of collection

Trained counselors and teachers who were assigned as pollsters distributed the survey, and its completion was anonymous and based on self-report, with full right of refusal. To improve validity, classroom teachers were not allowed to be present during the survey period. To maximize confidentiality, students were provided anonymous optical forms, and the booklets were collected in closed unmarked envelopes, with computers compiling responses. Data were entered into electronic spreadsheets and analyzed using SPSS Inc. Released 2007. SPSS for Windows, Verson 16, SPSS, Inc., Chicago, Illinois, US. Participants who answered at least one question were included in the data analysis and missing values were eliminated on a case-by-case basis.

Human subjects/Institutional Review Board review

The survey was conducted according to the procedures of the Nuremberg Code and Declaration of Helsinki with permission from the Governance of Istanbul during the period of May to June 2010. The Institutional Review Board of Cooper University Medical Center and the Ethics Committee of the Security Sciences Institute of the Turkish Police Academy both approved the use of the dataset for research purposes.

The variables and statistical methods used to evaluate the relationship between anomie and loneliness with psychosocial variables, suicide, and other psychopathology are described below.

Variables

Dependent

  1. The dependent variable used to measure loneliness was obtained directly from the survey question assessing for loneliness: “In the past two weeks have you felt lonely?” The answer choices included “almost never,” “seldom,” “sometimes,” and “often.” The reference category was “almost never”
  2. The second dependent variable anomie was obtained by adding the survey questions assessing anomie characteristics. Utilizing the Anomie Scale of Exteriority and Constraint,[14] all responses to the subquestions were added to give an anomie score ranging from 1 to 37; a higher score reflects lower anomie. The scale score was then divided into quartiles and categorized into “very low,” “low,” “high,” and “very high” categories with lower scores representing higher anomie in the participants.


Independent

  1. Income, immigration statuses, and parental education were used as categorical variables
  2. Substance use categorical variables for alcohol, tobacco, and cannabis were kept as binary variables
  3. Age, faith scale, time spent with peers, time spent with family, parental involvement, family substance use, peer influence, school grade, depression scale, anxiety scale, conduct disorder traits scale, and any drug use were treated as continuous variables. Parental involvement and peer influence were reverse scales; the higher the score, the lower is the value of these variables.


Statistical analyses

Descriptive statistics reporting total number (n) and percentage (%) for categorical variables and mean (μ) and standard deviation for continuous variables were calculated.

Multinomial logistic regressions for four model equations were run with a P value for statistical significance below 0.05, and odds ratios were obtained with confidence intervals.

The model equations that were run are listed below:

  1. Anomie with psychosocial variables (age, income, immigration statuses, parental education, faith scale, time spent with peers, time spent with family, parental involvement, family substance use, peer influence, and school grade). This variable was further categorized using quartiles and the reverse scale was rearranged to give four categories: “very low,” “low,” “high,” and “very high” anomie features of the participants. For example, the subcategory “very high” reflected the participant's higher anomie levels
  2. Loneliness with psychosocial variables (age, income, immigration statuses, parental education, faith scale, time spent with peers, time spent with family, parental involvement, family substance use, peer influence, and school grade)
  3. Anomie with psychiatric scale variables (depression scale, anxiety scale, conduct disorder traits scale, and any drug use)
  4. Loneliness with psychiatric scale variables (depression scale, anxiety scale, conduct disorder traits scale, and any drug use).



  Results and Embedded Discussion Top


Descriptive statistics

[Table 1] presents descriptive information on the variables (categorical and continuous) used. In this sample of Turkish youth, 45% experienced high levels of anomie (with 23% having very high levels). Twenty percent experienced loneliness sometimes and 17% experienced loneliness often. This sis comparable to 14% of Belgian youth and 16% of Dutch youth reporting loneliness [Table 1].[15]
Table 1: Variables used in the analysis and their sample sizes with mean (μ) and standard deviations (Σ)

Click here to view


Model 1: Anomie and psychosocial factors

All the independent variables except immigration had a statistically significant relationship with anomie in this model [Table 2]. For age, a 1-year increase in age contributes to about 7% increased odds of experiencing high anomie. Literature review shows an inconsistent relationship between age and anomie. For example, in US teens and young adults, anomie increased with age.[16] A study in China showed that age had no significant effect on anomie.[17] A study of French-Canadian adolescents showed that younger age was associated with higher anomie.[18]
Table 2: Parameter estimates for the regression model depicting associations between anomie and psychosocial variables

Click here to view


The protective effects of faith among participants were evident by its inverse relationship with anomie for the participants with high and very high anomie. Literature review shows that faith has a complex relationship with anomie. On the one hand, people with unmet societal needs may turn to religion for support. On the other hand, politicians and governments may use religion as a manipulative tool to control the public, especially in underdeveloped and developing countries.[19]

Time spent with peers was positively associated with anomie which shows that the participants being at increased odds by 1.017, 1.030, and 1.036 times in the low, high, and very high anomie groups as compared to those in the very low anomie group. This corroborated with “peer influence” wherein the participants who experience high and very high anomie tend to have higher peer influence as compared to those who experience very low anomie.

Low parental education significantly predicted the participants experiencing high or very high anomie. As compared to the parents with higher education, the participants whose parents were illiterate or with HS education were at 1.18 and 1.20 times increased odds of experiencing very high anomie. This is similar to U. S. adolescents, whose feelings of anomie decreased as their parents' level of education rose.[20]

In addition, some of the other predictors such as “time spent with family,” “parental involvement,” “family substance use,” and “school grades” also show negative associations (potentially protective effects) versus anomie, indicating that youth experiencing parental involvement, have support for school performance, and have no exposure to parental substance abuse have lower risk of experiencing anomie.

Model 2: Loneliness and psychosocial factors

In the group who experienced very high loneliness, age, time spent with family, peer influence, school grades, low socioeconomic class, being native to Istanbul city, and low parental education were statistically significantly associated with P < 0.05. For instance, for every year of increase in age from 13 years, the participants were at 10.2% increased odds of experiencing loneliness often, as compared to those who do not experience loneliness. Those who spent more time with family and those who spent less time with peers were at 0.94 times and 0.97 times decreased odds of experiencing loneliness often, respectively. The participants whose parents were illiterate were at 1.16 times increased odds of experiencing very high loneliness as compared to those whose parents received higher education [Table 3].
Table 3: Parameter estimates for the regression model depicting associations between loneliness and psychosocial variables

Click here to view


Model 3: Anomie and psychiatric symptoms

The participants with very high anomie scores had several variables that had statistically significant associations. For instance, a unit increase in depression, anxiety, and conduct disturbance leads to 1.023, 1.094, and 1.012 times increased odds of experiencing very high anomie, respectively. In substance use variables, a unit increase in drinking alcohol and smoking tobacco was associated with 1.43 and 1.46 times increased odds of experiencing very high anomie in the participants [Table 4]. This finding is similar to Canadian HS students, who consumed more alcohol as their feelings of anomie increased.[21] The participants with very high anomie were at 1.43 times increased odds of abusing alcohol as compared to those with very low anomie. Interestingly enough, cannabis and other illicit drug use were not significant contributors to the anomie, but tobacco use was 1.46 times increased odds. The most important relationship in this model was between suicidal ideations and anomie which was significant at all levels. The odds of experiencing suicidal ideations among participants with different levels of anomie was significantly high as compared to those who have very low levels of anomie. This finding is consistent with Durkheim's view of suicide as associated with anomie, a social factor. Several studies across different cultures have shown that anomie is associated with an increased risk of suicide.[4],[16],[22]
Table 4: Parameter estimates for the regression model depicting associations between anomie and psychiatric symptoms

Click here to view


Model 4: Loneliness and psychiatric symptoms

Anxiety scale in the participants did not predict loneliness with a statistical significance in any category. Depression scale predicted statistically significant loneliness in all the categories. For example, higher depression scale scores placed the participants at 77.8%, 46.6%, and 26.6% increased odds of experiencing loneliness as compared to those who do not. Opposite results were obtained for the conduct disturbance traits scale in the participants who experience loneliness “sometimes” and “often [Table 5].” The literature suggests that youth who report loneliness are more likely to consider themselves to have poor overall health; to report depression, anxiety, suicidal ideation, and low self-esteem; and to engage in risky behaviors such as drug use.[23],[24],[25]
Table 5: Parameter estimates for the regression model depicting associations between loneliness and psychiatric symptoms


Click here to view



  Conclusions Top


This analysis shows that for Turkish youth enrolled in Istanbul HS s, low SES, and low parental education predicted high levels of anomie. These results are similar to those found in Ireland that lower parental education predicted higher risk of suicide attempts by youth, mediated by anomie.[22] Anomie was found to be associated with a high risk for psychopathology, including depression, anxiety, conduct disturbance, alcohol use, and tobacco use, but particularly for suicidality. The question here is the directionality of the relationships, which is impossible to determine form a cross-sectional study. One would need a prospective study to elucidate the directionality of these relationships. However, it is safe to further hypothesize that anomie and loneliness are both outcomes as well as precipitants/aggravators of psychopathology and functional problems in youth.

Recent data from the U. S.[26] suggest that suicidality and psychiatric symptoms, particularly suicide and substance use, have further increased from already rising levels among young adults during the COVID pandemic. These are thought to be related to the significant psychosocial impact from COVID morbidity and mortality, particularly disparities in both across minority racial ethnic groups, and concomitant cultural and social transitions that the U. S has been undergoing. A fair hypothesis is that the mediating factors for such recent rise in psychiatric morbidity and possible mortality are the development of an environment of anomie and loneliness as the pandemic becomes a chronic stressor and requires extended and disruptive lockdown and social distancing measures. The associations found in this study are likely at play in the U. S. and possibly in Turkey and other nations similarly affected.

As anomie remains a significant risk factor for suicide, screening HS students for psychiatric disorders, substance use, and psychosocial stressors can help identify youth who could benefit from support programs to enhance social networks and the use of prosocial community resources. Such programs can focus on peer support but also possibly support for families facing parallel isolation and socioeconomic challenges within an urban environment. Such support programs can not only result in improved function but also help reduce their risk for loneliness and suicide. This is likely a conclusion that applies not only to Istanbul and Turkey but to youth around the globe.

Acknowledgments

All individuals listed as authors have contributed substantially to this manuscript.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Srole L. Social integration and certain corollaries: An exploratory study. Am Sociol Rev 1956;21:709-16. Available from: http://www.jstor.org/stable/2088422. [Last retrieved on 2020 Mar 01].  Back to cited text no. 1
    
2.
Thomas M. “It's hardly fair to bring a child into the world with the way things look”: Anomie, mistrust, and the impact of race, SES, and gender. Sociol Inq 2018;88:254-73.  Back to cited text no. 2
    
3.
Niezen R. The Durkheim-Tarde debate and the social study of aboriginal youth suicide. Transcult Psychiatry 2015;52:96-114.  Back to cited text no. 3
    
4.
Pollock NJ, Mulay S, Valcour J, Jong M. Suicide rates in aboriginal communities in Labrador, Canada. Am J Public Health 2016;106:1309-15.  Back to cited text no. 4
    
5.
Chandler MJ, Lalonde C. Cultural continuity as a moderator of suicide risk among Canada's First Nations. In: Kirmayer LJ, Valaskakis GG, editors. Healing Traditions: The Mental Health of Aboriginal Peoples in Canada. Vancouver, Canada: UBC Press; 2009. p. 221-48.  Back to cited text no. 5
    
6.
Stults BJ, Falco CS. Unbalanced institutional commitments and delinquent behavior: An individual-level assessment of institutional anomie theory. Youth Violence Juv Justice 2014;12:77-100.  Back to cited text no. 6
    
7.
Heydari A, Teymoori A, Nasiri H. The effect of parent and peer attachment on suicidality: The mediation effect of self-control and anomie. Community Ment Health J 2015;51:359-64.  Back to cited text no. 7
    
8.
Norasakkunkit V, Uchida Y. Psychological consequences of postindustrial anomie on self and motivation among Japanese youth. J Soc Issue 2011;67:774-86.  Back to cited text no. 8
    
9.
Hibell B, Guttormsson U, Ahlström S, Balakireva O, Bjarnason T, Kokkevi A, et al. The 2011 ESPAD Report: Substance Use among Students in 36 European Countries. Stockholm: The Swedish Council for Information on Alcohol and Other Drugs (CAN); 2012. Available from: http://www.espad.org/Uploads/ESPAD_reports/2011/. [Last accessed 01 Apr 01].  Back to cited text no. 9
    
10.
Kristjansson AL. Concepts and Measures in the 2006 and 2008 Youth in Europe Survey. Reykjavik: Icelandic Centre for Social Research and Analysis; 2008.  Back to cited text no. 10
    
11.
Ogel K, Tamar D, Evren C, Cakmak D. Prevalence of substance use among high school students in Istanbul. J Clin Psychiatry 2000;3:242-5.  Back to cited text no. 11
    
12.
Ogel K, Corapçioğlu A, Sir A, Tamar M, Tot S, Doğan O, et al. Tobacco, alcohol and substance use prevalence among elementary and secondary school students in nine cities of Turkey. Turk Psikiyatri Derg 2004;15:112-8.  Back to cited text no. 12
    
13.
Altuner D, Engin N, Gurer C, Akyay I, Akgul A. Substance use and crime: The results of a survey research. J Med Investig 2009;7:87-94.  Back to cited text no. 13
    
14.
Bjarnason T. Parents, religion and perceived social coherence: A Durkheimian framework of adolescent anomie. J Sci Study Relig 1998;37:742-54.  Back to cited text no. 14
    
15.
Spithoven AW, Lodder GM, Goossens L, Bijttebier P, Bastin M, Verhagen M, et al. Adolescents' loneliness and depression associated with friendship experiences and well-being: A person-centered approach. J Youth Adolesc 2017;46:429-41.  Back to cited text no. 15
    
16.
Boor M. Anomie and United States suicide rates, 1973-1976. J Clin Psychol 1979;35:703-6.  Back to cited text no. 16
    
17.
Cao L. Returning to normality: Anomie and crime in China. Int J Offender Ther Comp Criminol 2007;51:40-51.  Back to cited text no. 17
    
18.
de Man AF, Labrèche-Gauthier L, Leduc CP. Correlates of anomie in French-Canadian adolescents. J Soc Psychol 1993;133:141-5.  Back to cited text no. 18
    
19.
Chima SC. Religion politics and ethics: Moral and ethical dilemmas facing faith-based organizations and Africa in the 21st century-implications for Nigeria in a season of anomie. Niger J Clin Pract 2015;18 Suppl:S1-7.  Back to cited text no. 19
    
20.
Clemens PW, Rust JO. Factors in adolescent rebellious feelings. Adolescence 1979;14:159-73.  Back to cited text no. 20
    
21.
Albas D, Albas C, McCluskey K. Anomie, social class and drinking behavior of high-school students. J Stud Alcohol 1978;39:910-3.  Back to cited text no. 21
    
22.
Thorlindsson T, Bernburg JG. Community structural instability, anomie, imitation and adolescent suicidal behavior. J Adolesc 2009;32:233-45.  Back to cited text no. 22
    
23.
Mahon NE, Yarcheski A, Yarcheski TJ. Loneliness and health-related variables in early adolescents: An extension. Psychol Rep 2003;93:233-4.  Back to cited text no. 23
    
24.
Page RM, Dennis M, Lindsay GB, Merrill RM. Psychosocial distress and substance use among adolescents in four countries: Philippines, China, Chile, and Namibia. Youth Soc 2011;43:900-30.  Back to cited text no. 24
    
25.
Stickley A, Koyanagi A, Koposov R, Schwab-Stone M, Ruchkin V. Loneliness and health risk behaviours among Russian and U.S. adolescents: A cross-sectional study. BMC Public Health 2014;14:366.  Back to cited text no. 25
    
26.
Czeisler MÉ, Lane RI, Petrosky E, Wiley JF, Christensen A, Njai R, et al. Mental health, substance use, and suicidal ideation during the COVID-19 pandemic – United States, June 24-30, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1049-57.  Back to cited text no. 26
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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
Methods
Results and Embe...
Conclusions
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed254    
    Printed6    
    Emailed0    
    PDF Downloaded17    
    Comments [Add]    

Recommend this journal