Comparing Changes in IPV Risk by Age Group over Time in Conflict-Affected Northeast Nigeria
Abstract
:1. Introduction
2. Materials and Methods
2.1. Data Sources and Study Population
2.2. Measures
2.2.1. Dependent Variables
2.2.2. Independent Variables
2.3. Covariates
2.4. Analysis
3. Results
4. Discussion
Limitations
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
- World Health Organization. Violence against women prevalence estimates, 2018: Global, regional and national prevalence estimates for intimate partner violence against women and global and regional prevalence estimates for non-partner sexual violence against women. In Executive Summary; World Health Organization: Geneva, Switzerland, 2021. [Google Scholar]
- The Lancet Public Health. Violence against women: Tackling the other pandemic. Lancet Public Health 2022, 7, e1. [Google Scholar] [CrossRef]
- Hindin, M.J.; Kishor, S.; Ansara, D.L. Intimate Partner Violence Among Couples in 10 DHS Countries: Predictors and Health Outcomes. In DHS Analytical Studies No. 18; Macro International Inc.: Calverton, MD, USA, 2008. [Google Scholar]
- Stöckl, H.; March, L.; Pallitto, C.; Garcia-Moreno, C. Intimate partner violence among adolescents and young women: Prevalence and associated factors in nine countries: A cross-sectional study. BMC Public Health 2014, 14, 751. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- UNICEF. A Statistical Snapshot of Violence Against Adolescent Girls; UNICEF: New York, NY, USA, 2014. [Google Scholar]
- Corboz, J.; Jewkes, R.; Chirwa, E. Evidence Brief: Violence Against Younger and Older Women in Low-and Middle-Income Settings. 2020. Available online: https://www.whatworks.co.za/documents/publications/397-age-and-ipv-low-and-middle-income/file (accessed on 10 January 2021).
- Black, E.; Worth, H.; Clarke, S.; Obol, J.H.; Akera, P.; Awor, A.; Shabiti, M.S.; Fry, H.; Richmond, R. Prevalence and correlates of intimate partner violence against women in conflict affected northern Uganda: A cross-sectional study. Confl. Health 2019, 13, 35. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Harwell, T.S.; Spence, M.R. Population surveillance for physical violence among adult men and women, Montana 1998. Am. J. Prev. Med. 2000, 19, 321–324. [Google Scholar] [CrossRef] [PubMed]
- Romans, S.; Forte, T.; Cohen, M.M.; Du Mont, J.; Hyman, I. Who Is Most at Risk for Intimate Partner Violence?: A Canadian Population-Based Study. J. Interpers. Violence 2007, 22, 1495–1514. [Google Scholar] [CrossRef]
- Vest, J.R.; Catlin, T.K.; Chen, J.J.; Brownson, R.C. Multistate analysis of factors associated with intimate partner violence. Am. J. Prev. Med. 2002, 22, 156–164. [Google Scholar] [CrossRef]
- Jewkes, R.; Sen, P.; Garcia-Moreno, C. Sexual Violence. In World Report on Violence and Health; Krug, E.G., Dahlberg, L.L., Mercy, J.A., Zwi, A.B., Lozano, R., Eds.; World Health Organization: Geneva, Switzerland, 2002; pp. 149–181. Available online: https://apps.who.int/iris/bitstream/handle/10665/42495/9241545615_eng.pdf (accessed on 20 August 2020).
- Izugbara, C.O.; Obiyan, M.O.; Degfie, T.T.; Bhatti, A. Correlates of intimate partner violence among urban women in sub-Saharan Africa. PloS ONE 2020, 15, e0230508. [Google Scholar] [CrossRef] [Green Version]
- Ekhator-Mobayode, U.E.; Hanmer, L.C.; Rubiano Matulevich, E.C.; Arango, D.J. The effect of armed conflict on intimate partner violence: Evidence from the Boko Haram insurgency in Nigeria. World Dev. 2022, 153, 105780. [Google Scholar] [CrossRef]
- Wodon, Q.; Male, C.; Onagoruwa, A.; Savadogo, A.; John, N.; Petroni, S. Economic Impacts of Child Marriage: Women’s Health Brief. 2017. Available online: https://www.icrw.org/wp-content/uploads/2018/08/ICRW_ThematicBrief_WomensHealth_v2_WebReady.pdf (accessed on 20 August 2020).
- Murphy, M.; Bingenheimer, J.B.; Ovince, J.; Contreras, M. Violence against Adolescent Girls: Trends and Lessons for East Africa; Global Women’s Institute: London, UK, 2018; Available online: https://www.gage.odi.org/publication/violence-against-adolescent-girls/ (accessed on 20 August 2020).
- Alleyne-Green, B.; Kulick, A.; Matsuzaka, S.; Betancourt, T.S. War Violence Exposure, Reintegration Experiences and Intimate Partner Violence Among a Sample of War-Affected Females in Sierra Leone. Glob. Soc. Welf. Res. Policy Pract. 2018, 6, 97–106. [Google Scholar] [CrossRef]
- Kelly, J.T.D.; Colantuoni, E.; Robinson, C.; Decker, M.R. From the battlefield to the bedroom: A multilevel analysis of the links between political conflict and intimate partner violence in Liberia. BMJ Glob. Health 2018, 3, e000668. [Google Scholar] [CrossRef]
- Stark, L.; Ager, A. A Systematic Review of Prevalence Studies of Gender-Based Violence in Complex Emergencies. Trauma Violence Abus. 2011, 12, 127–134. [Google Scholar] [CrossRef] [PubMed]
- Stark, L.; Roberts, L.; Wheaton, W.; Acham, A.; Boothby, N.; Ager, A. Measuring violence against women amidst war and displacement in northern Uganda using the “neighbourhood method”. J. Epidemiol. Community Health 2010, 64, 1056–1061. [Google Scholar] [CrossRef] [PubMed]
- Saile, R.; Neuner, F.; Ertl, V.; Catani, C. Prevalence and predictors of partner violence against women in the aftermath of war: A survey among couples in Northern Uganda. Soc. Sci. Med. 2013, 86, 17–25. [Google Scholar] [CrossRef]
- Uganda Bureau of Statistics-UBOS; Macro International. Uganda Demographic and Health Survey 2006; UBOS: Calverton, MD, USA; Macro International: Calverton, MD, USA, 2007; Available online: http://www.measuredhs.com/pubs/pdf/FR194/FR194.pdf (accessed on 22 August 2020).
- Murphy, M.; Bingenheimer, J.B.; Ovince, J.; Ellsberg, M.; Contreras-Urbina, M. The effects of conflict and displacement on violence against adolescent girls in South Sudan: The case of adolescent girls in the Protection of Civilian sites in Juba. Sex. Reprod. Health Matters 2019, 27, 181–191. [Google Scholar] [CrossRef] [Green Version]
- Logie, C.H.; Okumu, M.; Mwima, S.; Hakiza, R.; Irungi, K.P.; Kyambadde, P.; Kironde, E.; Narasimhan, M. Social ecological factors associated with experiencing violence among urban refugee and displaced adolescent girls and young women in informal settlements in Kampala, Uganda: A cross-sectional study. Confl. Health 2019, 13, 60. [Google Scholar] [CrossRef] [PubMed]
- Stark, L.; Asghar, K.; Yu, G.; Bora, C.; Baysa, A.A.; Falb, K.L. Prevalence and associated risk factors of violence against conflict-affected female adolescents: A multi-country, cross-sectional study. J. Glob. Health 2017, 7, 010416. [Google Scholar] [CrossRef]
- Center for International Security; Cooperation Mapping Militant Organizations. “Boko Haram”. Stanford University. 2018. Available online: https://cisac.fsi.stanford.edu/mappingmilitants/profiles/boko-haram (accessed on 19 November 2019).
- Campbell, J. Nigeria Security Tracker. 2019. Available online: https://www.cfr.org/nigeria/nigeria-security-tracker/p29483 (accessed on 19 November 2019).
- BBC News. Nigeria Chibok Abductions: What We Know. 2017. Available online: https://www.bbc.com/news/world-africa-32299943 (accessed on 21 November 2019).
- Read, J. Sexual Violence and the Boko Haram Crisis in North-East Nigeria. Humanitarian Practice Network. 2017. Available online: https://odihpn.org/magazine/sexual-violence-and-the-boko-haram-crisis-in-north-east-nigeria/ (accessed on 21 November 2019).
- National Population Commission-NPC/Nigeria; ICF Macro. Nigeria Demographic and Health Survey 2008; NPC/Nigeria and ICF Macro: Abuja, Nigeria, 2009; Available online: https://dhsprogram.com/publications/publication-fr222-dhs-final-reports.cfm (accessed on 13 November 2019).
- National Population Commission-NPC/Nigeria; ICF. Nigeria Demographic and Health Survey 2018; NPC: Abuja, Nigeria; ICF: Rockville, MD, USA, 2019; Available online: https://dhsprogram.com/publications/publication-fr359-dhs-final-reports.cfm (accessed on 13 November 2019).
- Armed Conflict Location & Event Data Project (ACLED). Available online: https://www.acleddata.com/ (accessed on 19 November 2019).
- Callands, T.A.; Sipsma, H.L.; Betancourt, T.S.; Hansen, N.B. Experiences and acceptance of intimate partner violence: Associations with sexually transmitted infection symptoms and ability to negotiate sexual safety among young Liberian women. Cult. Health Sex. 2013, 15, 680–694. [Google Scholar] [CrossRef] [Green Version]
- Spencer, R.A.; Usta, J.; Essaid, A.; Shukri, S.; El-Gharaibeh, Y.; Abu-Taleb, H.; Awwad, H.; Nsour, H.; Nsour, H.; Clark, C.J. Alianza por la Solidaridad. United Nations Population Fund-Lebanon. Gender Based Violence Against Women and Girls Displaced by the Syrian Conflict in South Lebanon and North Jordan: Scope of Violence and Health Correlates. 2015. Available online: https://reliefweb.int/report/lebanon/gender-based-violence-against-women-and-girls-displaced-syrian-conflict-south-lebanon (accessed on 29 November 2019).
- United Nations Department of Economic and Social Affairs (UNDESA). 2015. Available online: https://www.un.org/esa/socdev/documents/youth/fact-sheets/youth-definition.pdf (accessed on 29 November 2019).
- Woldetsadik, M.A. Long-Term Effects of Wartime Sexual Violence on Women and Families: The Case of Northern Uganda. 2018. Available online: https://www.rand.org/pubs/rgs_dissertations/RGSD417.html (accessed on 20 August 2020).
- Kohli, A.; Perrin, N.; Mpanano, R.M.; Banywesize, L.; Mirindi, A.B.; Banywesize, J.H.; Mitima, C.M.; Binkurhorhwa, A.K.; Bufole, N.M.; Glass, N. Family and community driven response to intimate partner violence in post-conflict settings. Soc. Sci. Med. 2015, 146, 276–284. [Google Scholar] [CrossRef] [Green Version]
- WHO. Guidelines for Medico-Legal Care for Victims of Sexual Violence; WHO: Geneva, Switzerland, 2003; Available online: https://www.who.int/violence_injury_prevention/resources/publications/en/guidelines_chap2.pdf (accessed on 19 November 2019).
- Global Women’s Institute; the International Rescue Committee. No Safe Place: A Lifetime of Violence for Conflict-Affected Women and Girls in South Sudan; Global Women’s Institute: Washington, DC, USA; International Rescue Committee: Washington, DC, USA, 2017; Available online: https://www.rescue-uk.org/sites/default/files/document/1580/southsudanlgsummaryreportonline.pdf (accessed on 5 August 2020).
- UNESCO Institute for Statistics. 2020. Available online: http://data.uis.unesco.org/ (accessed on 5 August 2020).
- Connected Development. An Examination of Girls’ Education Policies in Nigeria with Focus on the Northeast. 2017. Available online: https://www.connecteddevelopment.org/wp-content/uploads/2017/02/Girl-Child-Education-Policies-in-Nigeria-and-Its-North-Eastern-Part.pdf (accessed on 1 September 2020).
- Chapter 3: Why Security Is Important. 2017. Available online: https://giwps.georgetown.edu/wp-content/uploads/2017/10/Chapter-3-Why-Security-Is-Important.pdf (accessed on 20 November 2019).
- Refworld. Nigeria: Violence Against Persons (Prohibition) Act, 2015 (VAPP). 2015. Available online: https://www.refworld.org/docid/556d5eb14.html (accessed on 30 August 2020).
- Cooley, D. SocialMedia is Latest Tool Against Gender Violence in Nigeria. 2017. Available online: https://www.voanews.com/africa/social-media-latest-tool-against-gender-violence-nigeria (accessed on 30 August 2020).
- Ikekhua, J. Speaking Up and Out: How Nigerian Women Are Resisting and Changing Cultural Silence by Sharing their Experiences. 2019. Available online: https://pulitzercenter.org/reporting/speaking-and-out-how-nigerian-women-are-resisting-and-changing-cultural-silence-sharing (accessed on 30 August 2020).
- Grose, R.G.; Chen, J.S.; Roof, K.A.; Rachel, S.; Yount, K.M. Sexual and Reproductive Health Outcomes of Violence Against Women and Girls in Lower-Income Countries: A Review of Reviews. J. Sex Res. 2021, 58, 1–20. [Google Scholar] [CrossRef] [Green Version]
- Murphy, M.; Ellsberg, M.; Contreras-Urbina, M. Nowhere to go: Disclosure and help-seeking behaviors for survivors of violence against women and girls in South Sudan. Confl. Health 2020, 14, 6. [Google Scholar] [CrossRef]
- Moore, M. Reproductive Health and Intimate Partner Violence. Fam. Plan. Perspect. 1999, 31, 302–312. [Google Scholar] [CrossRef]
- WhatWorks to Prevent Violence Against Women; Girls Programme. What Works to Prevent Violence against Women and Girls in Conflict and Humanitarian Crisis: Synthesis Brief. 2016. Available online: https://www.rescue-uk.org/sites/default/files/document/2051/p868ircsynthesisbriefreportlr.pdf (accessed on 30 August 2022).
- Sawyer, S.M.; Afifi, R.A.; Bearinger, L.H.; Blakemore, S.J.; Dick, B.; Ezeh, A.C.; Patton, G.C. Adolescence: A foundation for future health. Lancet 2012, 379, 1630–1640. [Google Scholar] [CrossRef] [PubMed]
Characteristics | Adolescent Girls and Young Women (15–24) | Older Women (25–49) | ||
---|---|---|---|---|
2008 (n = 1235) | 2018 (n = 432) | 2008 (n = 2583) | 2018 (n = 1063) | |
Age (*/ ) | 19.80 (2.53) | 20.09 (2.33) | 34.12 (7.20) | 33.91 (6.87) |
Years of Education (***/***) a | 1.77 (3.49) | 2.46 (4.18) | 2.07 (3.93) | 3.33 (5.09) |
Marital Status (*/ ) | ||||
Married or living with a partner | 1209 (97.89%) | 414 (95.83%) | 2462 (95.32%) | 1005 (94.54%) |
Widowed, Divorced, or Separated | 26 (2.11%) | 18 (4.17%) | 121 (4.68%) | 58 (5.46%) |
Location (*/ ) | ||||
Urban | 253 (20.49%) | 66 (15.28%) | 591 (22.88%) | 264 (24.84%) |
Rural | 982 (79.51%) | 366 (84.72%) | 1992 (77.12%) | 799 (75.16%) |
Wealth Index ( /***) | ||||
Poorest | 636 (51.50%) | 206 (47.69%) | 1330 (51.49%) | 407 (38.29%) |
Poorer | 299 (24.21%) | 123 (28.47%) | 563 (21.80%) | 272 (25.59%) |
Middle | 175 (14.17%) | 62 (14.35%) | 388 (15.02%) | 213 (20.04%) |
Richer | 106 (8.58%) | 33 (7.64%) | 237 (9.18%) | 116 (10.91%) |
Richest | 19 (1.54%) | 8 (1.85%) | 65 (2.52%) | 55 (5.17%) |
Religion (*/***) | ||||
Islam | 1077 (87.21%) | 385 (89.12%) | 1948 (75.42%) | 822 (77.33%) |
Christian or Catholic | 140 11.34%) | 47 (10.88%) | 588 (22.76%) | 240 (22.58%) |
Other, Traditionalist, Missing | 18 (1.46%) | 0 (0%) | 47 (1.82%) | 1 (0.09%) |
Ethnicity (*/**) | ||||
Fulani | 382 (30.93%) | 139 (32.18%) | 632 (24.47%) | 240 (22.58%)) |
Hausa | 257 (20.81%) | 94 (21.76%) | 400 (15.49%) | 199 (18.72%) |
Kanuri/Beriberi | 214 (17.33%) | 47 (10.88%) | 351 (13.59%) | 111 (10.44%) |
Other/Don’t Know | 382 (30.93%) | 152 (35.19%) | 1200 (46.46%) | 513 (48.26%) |
Number of children ( /***) | 1.59 (1.35) | 1.61 (1.21) | 5.57 (2.95) | 5.18 (2.70) |
Married as a Child (**/***) | ||||
Yes | 1052 (85.18%) | 364 (84.26%) | 1875 (72.5%) | 655 (61.62%) |
No | 183 (14.82%) | 68 (15.74%) | 708 (27.41%) | 408 (38.38%) |
Acceptance of Wife-beating (***/***) * | (n = 1221) | (n = 430) | (n = 2552) | (n = 1062) |
Yes | 702 (57.49%) | 211 (49.07%) | 1326 (51.96%) | 461 (43.41%) |
No | 519 (42.51%) | 219 (50.93%) | 1229 (48.16%) | 601 (56.59%) |
Father Beat her Mother (***/***) | (n = 1225) | (n = 2570) | ||
Yes | 60 (4.90%) | 45 (10.42%) | 231 (8.99%) | 149 (14.02%) |
No | 1104 (90.12%) | 361 (83.56%) | 2189 (85.18%) | 861 (81.00%) |
Don’t know | 61 (4.98%) | 26 (6.02%) | 150 (5.84%) | 53 (4.99%) |
Partner’s Age | (n = 1194) | (n = 414) | (n = 2427) | (n = 1005) |
29.56 (6.61) | 30.09 (6.68) | 44.58 (10.52) | 44.25 (10.04) | |
Partner’s Education Attainment (***/***) | (n = 1223) | (n = 414) | (n = 2567) | (n = 1005) |
None | 782 (63.94%) | 236 (57.00%) | 1645 (64.08%) | 503 (50.05%) |
Incomplete primary | 63 (5.15%) | 9 (2.17%) | 105 (4.09%) | 27 (2.69%) |
Complete primary | 121 (9.89%) | 29 (7.00%) | 256 (9.97%) | 88 (8.76%) |
Incomplete secondary | 55 (4.50%) | 21 (5.07%) | 135 (5.26%) | 43 (4.28%) |
Complete secondary | 147 (12.02%) | 71 (17.15%) | 221 (8.61%) | 190 (18.91%) |
Higher | 49 (4.01%) | 41 (9.90%) | 194 (7.56%) | 141 (14.03%) |
Don’t know | 6 (0.49%) | 7 (1.69%) | 11 (0.43%) | 13 (1.29%) |
Partner’s Employment (***/***) | (n = 1223) | (n = 414) | (n = 2549) | (n = 1005) |
Any | 1219 (99.67%) | 403 (97.34%) | 2531 (99.29%) | 971 (96.62%) |
None | 4 (0.33%) | 11 (2.66%) | 18 (0.71%) | 34 (3.38%) |
Partner’s Alcohol Use (*/**) | (n = 1234) | (n = 432) | (n = 2578) | (n = 1063) |
Yes | 43 (3.48%) | 26 (6.02%) | 261 (10.12%) | 147 (13.83%) |
No | 1191 (96.52%) | 406 (93.98%) | 2317 (89.88%) | 916 (86.17%) |
AGYW | Older Women | |||||
---|---|---|---|---|---|---|
2008 | 2018 | % Point Change | 2008 | 2018 | % Point Change | |
Emotional | 0.16 (0.14, 0.18) | 0.38 (0.33, 0.42) | 0.22 (0.17, 0.27) *** | 0.22 (0.21, 0.24) | 0.42 (0.39, 0.45) | 0.20 (0.16, 0.23) *** |
Physical | 0.10 (0.08, 0.12) | 0.18 (0.14, 0.21) | 0.08 (0.04, 0.11) *** | 0.16 (0.15, 0.17) | 0.16 (0.14, 0.18) | −0.00 (−0.03, 0.03) |
Sexual | 0.05 (0.03, 0.06) | 0.15 (0.11, 0.18) | 0.10 (0.07, 0.14) *** | 0.05 (0.04, 0.06) | 0.09 (0.07, 0.11) | 0.04 (0.02, 0.05) *** |
Emotional IPV | Physical IPV | Sexual IPV | |
---|---|---|---|
Time*Youth | −0.04, 0.03, 0.25 (−0.10, 0.03) | 0.03, 0.02, 0.28 (−0.02, 0.07) | 0.06, 0.02, 0.02 (0.01, 0.10) |
Time | 0.19, 0.02, <0.001 (0.14, 0.23) | 0.01, 0.02, 0.56 (−0.02, 0.05) | 0.03, 0.01, <0.01 (0.01, 0.05) |
Youth | −0.01, 0.02, 0.46 (−0.05, 0.02) | −0.03, 0.02, 0.06 (−0.06, 0.00) | 0.01, 0.01, 0.54 (−0.02, 0.03) |
R-squared | 0.0789 | 0.0930 | 0.0351 |
Proportion (SE) | 95% Con. Interval | % Point Change | |
---|---|---|---|
Currently Married or Living with Partner | |||
AGYW (2008) | 0.6518 (0.0098) | 0.6324, 0.6708 | −14.42 *** |
AGYW (2018) | 0.5076 (0.0090) | 0.4900, 0.5253 | |
Older women (2008) | 0.9357 (0.0039) | 0.9275, 0.9430 | −3.58 *** |
Older women (2018) | 0.8999 (0.0044) | 0.8908, 0.9082 | |
Widowed, divorced, or separated | |||
AGYW (2008) | 0.0224 (0.0030) | 0.0172, 0.0293 | 0.36 |
AGYW (2018) | 0.0260 (0.0029) | 0.0209, 0.0323 | |
Older women (2008) | 0.0454 (0.0034) | 0.0594, 0.0035 | 1.40 ** |
Older women (2018) | 0.0594 (0.0035) | 0.0529, 0.0666 | |
Never partnered | |||
AGYW (2008) | 0.3257 (0.0096) | 0.3071, 0.3449 | 14.06 *** |
AGYW (2018) | 0.4663 (0.0009) | 0.4488, 0.4840 | |
Older women (2008) | 0.0189 (0.0022) | 0.0151, 0.0238 | 2.19 *** |
Older women (2018) | 0.0408 (0.0029) | 0.0354, 0.0469 |
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content. |
© 2023 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).
Share and Cite
Ogunbiyi, B.O.; Maclin, B.J.; Bingenheimer, J.B.; Vyas, A. Comparing Changes in IPV Risk by Age Group over Time in Conflict-Affected Northeast Nigeria. Int. J. Environ. Res. Public Health 2023, 20, 1878. https://doi.org/10.3390/ijerph20031878
Ogunbiyi BO, Maclin BJ, Bingenheimer JB, Vyas A. Comparing Changes in IPV Risk by Age Group over Time in Conflict-Affected Northeast Nigeria. International Journal of Environmental Research and Public Health. 2023; 20(3):1878. https://doi.org/10.3390/ijerph20031878
Chicago/Turabian StyleOgunbiyi, Bolatito O., Beth J. Maclin, Jeffrey B. Bingenheimer, and Amita Vyas. 2023. "Comparing Changes in IPV Risk by Age Group over Time in Conflict-Affected Northeast Nigeria" International Journal of Environmental Research and Public Health 20, no. 3: 1878. https://doi.org/10.3390/ijerph20031878
APA StyleOgunbiyi, B. O., Maclin, B. J., Bingenheimer, J. B., & Vyas, A. (2023). Comparing Changes in IPV Risk by Age Group over Time in Conflict-Affected Northeast Nigeria. International Journal of Environmental Research and Public Health, 20(3), 1878. https://doi.org/10.3390/ijerph20031878