Epidemiological profile of reports of violence against older adults in Rio Grande do Norte, Brazil (2018-2019)

Abstract

Objective

to characterize the reports of violence against older people made via the Dial 100 service in the state of Rio Grande do Norte (RN), Brazil, between December 2018 and November 2019.

Methods

a cross-sectional study involving a descriptive analysis of data contained in excerpts from reports of violence made via the Dial 100 service was conducted and an exploratory spatial analysis carried out. The cities of residence of the victims, types of violence, place of occurrence and referrals to the Network for Securing Rights were analyzed, along with age, sex and race/color of both victims and suspected perpetrators, besides the relationship between them.

Results

In total, 878 reports of violence against 1,014 older people were registered, the majority in the city of Natal-RN (46.9%). The most prevalent complaints were neglect (77%), psychological violence (44.9%) and financial abuse (19%). Acts of violence were perpetrated predominantly in victims’ homes (95.3%) and affected mainly women (66.9%). Most suspected perpetrators were children of the victim (62.1%) and female (49.3%).

Conclusion

The results suggest a weakness in the family support/nucleus and the need for state assistance to deliver care in this context. In addition, the fact that the main forms of violence do not always leave physical evidence highlights the role of the population in helping to identify violence against the older population. Finally, the results suggest a lack of awareness about the Dial 100 service among residents in the interior of the state, pointing to the need for greater dissemination of the channels for denouncing violence against this group, allowing a more accurate analysis of the problem in the state and more effective actions to tackle the issue.

Keywords
Aged; Violence; Elder Abuse

Resumo

Objetivo

caracterizar as denúncias de violência contra pessoas idosas no Disque 100 no Rio Grande do Norte, Brasil, entre dezembro de 2018 e novembro de 2019.

Métodos

estudo transversal no qual foram analisados descritivamente os dados contidos nos extratos das denúncias de violência efetuadas no Disque 100 e, posteriormente, realizada uma análise espacial exploratória. Foram analisados os municípios de residência das vítimas, tipos de violência, local de ocorrência e os encaminhamentos para a rede de garantia de direitos. Além disso, idade, sexo e raça/cor das vítimas; e idade, sexo, raça/cor dos suspeitos e parentesco com a vítima

Resultados

No total, 878 denúncias contra 1.014 pessoas idosas foram registradas, a maioria de Natal, RN (46,9%). As denúncias mais prevalentes foram: negligência (77%), violência psicológica (44,9%) e abuso financeiro (19%) e ocorreram predominantemente na residência das vítimas (95,3%), atingindo principalmente as mulheres (66,9%). Os suspeitos das violências foram na maioria os filhos (62,1%) e do sexo feminino (49,3%).

Conclusão

Os resultados sugerem uma fragilidade do apoio/núcleo familiar e a necessidade da atenção do Estado para o cuidado nesse âmbito. Ademais, o fato de que as principais formas de violência nem sempre deixam marcas físicas alerta a população para a sua contribuição na identificação da violência contra a pessoa idosa. Finalmente, os resultados sugerem o desconhecimento do Disque 100 pelos indivíduos que residem no interior, fazendo-se necessário melhor divulgação dos canais de comunicação de violência para esse público, para uma análise mais realista dessa problemática no estado e um enfrentamento mais efetivo.

Palavras-Chave:
Idosos; Violência; Maus-tratos ao Idoso

INTRODUCTION

Ageing is part of the human life course and varies from person to person according to associated biological and social contexts. Typically, this phase is characterized by a decline in social relationships and a great role in the life of older adults by the family. Although protected by law, the elderly are more vulnerable in terms of health care needs and due to limitations imposed by the aging process, often becoming the victims of violence¹. According to the Statute for the Elderly, article 19, §1, Chapter IV, “violence against the elderly constitutes any action or omission practiced in a public or private place which may cause death, harm, physical or psychologic suffering”². This is a problem found in all societies that affects different cultures, irrespective of socioeconomic status, race or religion³.

Violence against older adults can manifest in different forms, namely: (1) physical, involving the use of physical force with intent to hurt, cause pain, disability or death; (2) psychological, including verbal or gestural aggression and humiliation; (3) sexual, including sexual arousal of the suspected perpetrator, sexual intercourse or erotic practices without the victim´s consent; (4) abandonment, which involves omission of governmental, institutional entities or family members responsible for the provision of the necessary services of care or protection; (5) neglect, defined as refusal or omission in the provision of the necessary care by institutions or family members responsible; (6) financial, involving the improper exploitation of older individuals or use of their financial resources and assets; (7) self-neglect, characterized as the behavior of older individuals which threatens their own personal health or safety, due to a refusal to care for oneself ⁴.

In this respect, it is often difficult to identify acts of violence perpetrated against older people, given that not all acts of aggression targeting these individuals leave physical evidence⁵. Besides physical injuries, older adults subjected to violent acts may experience moral and psychoemotional trauma. Violence against older adults can result in dependence and disability, and in some cases, death⁶. According to a meta-analysis of 52 studies published between 2002 and 2015, an estimated 1 in 6 older individuals are victims of aggression worldwide⁷.

In view of the magnitude of this problem posing society, in 2010, the Secretariat of Human Rights of the Presidency of the Republic of Brazil, the body overseeing the National Policy on the Elderly, set up the Dial 100 service with a specific module for reporting acts of violence acts against older individuals, the “Elderly Module of Dial Human Rights”.

A nationwide study in Brazil identified a total of 233,383 reports of violence against older persons via the Dial 100 service between 2011 and 2018⁹. In addition, the Northeast region of Brazil ranked the 2nd highest in number of cases of violence reported against older individuals⁸. Also according to data from the Dial 100 service, Rio Grande do Norte was ranked the 3rd highest state, between 2011 and 2015, in number of acts of violence reported against older individuals per 100,000 population¹⁰.

A significant amount of information characterizing the victims and suspected perpetrators of violence is lost, highlighting the need for future studies to elucidate the dynamic of the problem of violence against older adults. This information can help inform political strategies for promoting health, early identification of infractions, tackle violence against this group and provide victims and family members with follow-up support. Although nationwide studies have quantified reports of violence against older people in Rio Grande do Norte state, no investigations characterizing the most common types of violence or mapping the profile of victims and perpetrators of violence have been carried out in the state. Thus, the objective of the present study was to characterize reports of violence against older people made via the Dial 100 service in cities of Rio Grande do Norte state, Brazil.

METHODS

A cross-sectional descriptive epidemiological study involving analysis of excerpts of reported acts of violence against older people was performed. These reports of violence were collected via the Dial 100 service, having been received by the Ministry of Women, Family and Human Rights and submitted to the State Board of Rights for Older Persons (CEDEPI/RN). The study period spanned from December 2018 to November 2019, corresponding to the time interval for which data was available from the CEDEPI-RN. All reports of violence against individuals aged ≥60 years received during the study period were included in the analysis. The project was approved by the Research Ethics Committee for Human Research (CEP) of the University Teaching Hospital Onofre Lopes, part of the Federal University of Rio Grande do Norte (permit nº 3.898.143). Given the study was based solely on secondary data, the need for a Free and Informed Consent Form was waived. However, a Granting of Permission Form was signed by the CEDEPI/RN authorizing the use of the data from the reports for analysis and disclosure.

The Dial 100 service is for use by the public to communicate with the Government National Human Rights Ombudsman – which seeks to provide conflict resolution in cases of suspected rights violations and operates a 24/7 free-phone service, with reports screened and referred to the relevant bodies¹¹.

The geographic area of interest of the study was Rio Grande do Norte (RN), a Brazilian state which has a total of 167 cities and an elderly population of 342,890, representing 9.7% of the total population of the state. Of this group, 55.9% were female and 44.1% male, according the latest census¹². The state has a HDI of 0.684, ranking 16th among Brazil´s states¹³.

Observational investigations were conducted in spectator fashion with no interference on the part of the researchers. After data collection from excerpts of reports of violence made to the Dial 100 service, referred to the CEDEPI/RN via a report, the authors produced a database containing all the variables analyzed according to the sociodemographic profile of the victims and characterization of the violence suffered. For this phase of the study, 2 researchers were trained to standardize the reports recording the type of violence reported, in an effort to minimize observer bias.

The variables covered in the study encompass those related to the acts of violence reported: the cities where acts of violence occurred, the referrals to the Network for Securing Rights, types of violence perpetrated (physical, psychological, sexual, financial, abandonment, neglect and self-neglect), in addition to the location where the violent acts took place. The description of the profile of the victims of violence included the number of victims per report, victim age, gender and race. The description of the suspected perpetrators included number of suspects, age, gender, race/color and relationship between victim and perpetrator.

Regarding the data gathered, the reports of violence against the older individual often involved concomitant types of aggression where, in some cases, the same individual may have been subjected to several acts of violence registered in a single report of violence. Similarly, a large proportion of the reports were referred to more than one body of the Network for Securing Rights.

A descriptive analysis of the data collected was performed. Results were expressed as absolute frequency (n) and relative frequency (%), with a 95% confidence interval (95%CI) for categorical variables, and as mean and standard deviation for quantitative variables. The data lost due to failure to complete the report excerpt were also described, in order to keep the same sample number of reports for all the variables analyzed. Subsequently, an exploratory spatial analysis was carried out to identify the distribution of the reports of violence against older people in the state of Rio Grande do Norte.

RESULTS

In the state of Rio Grande do Norte, between December 2018 and November 2019, a total of 878 acts of violence were reported on the Dial 100 service against 1,014 individuals aged ≥60 years, where Natal was the city registering the highest number of victims (n=411; 46.9%; 95%CI: 43.8–50.0), followed by Mossoró (n=69; 8.0%; 6.3–9.7) and Parnamirim (n=64.7.3%; 5.7–8.9). The distribution of reports by city in the state is depicted in Figure 1.

Figure 1
Spatial distribution of number of reports of violence against older persons made via the Dial 100 service in the state of Rio Grande do Norte, between December 2018 and November 2019.

Regarding types of violence reported, neglect situations predominated (n=781; 77%; 95%CI=74.4–79.6), followed by psychological violence (n=506; 49.9%; 95%CI=46.8–53.0), financial abuse (n=455; 44.9%; 95%CI=41.8–48.0) and physical violence (n=193; 19%; 95%CI= 16.6–21.4), respectively, where these occurred alone or concomitantly (see Table 1). Abandonment (n=17; 1.7%; 95%CI=0.9–2.5) and/or self-neglect (n=11; 1.1%; 95%CI=0.5–1.7) accounted for only a small proportion of cases. There were no cases of sexual violence reported during the period studied. In addition, some of the reports showed that victims were socially vulnerable (n=46; 4.3%; 95%CI: 3.1–5.5).

Table 1
Characteristics of type of violence against older persons made via the Dial 100 service between December 2018 and November 2019 in the state of Rio Grande do Norte.

Variable	Category	n (%)	CI (95%)
Neglect	Yes	781 (77)	74.4 – 79.6
	No	233 (23)	20.4 – 25.6
Psychological violence	Yes	506 (49.9)	46.8 – 53.0
	No	508 (50.1)	47 – 53.2
Financial violence	Yes	455 (44.9)	41.8 – 48.0
	No	558 (55.1)	52.0 – 58.2
Physical violence	Yes	193 (19)	16.6 – 21.4
	No	823 (81)	78.6 – 83.4
Abandonment	Yes	17 (1.7)	0.9 – 2.5
	No	983 (98.3)	97.5 – 99.1
Self-neglect	Yes	11 (1.1)	0.5 – 1.7
	No	989 (98.9)	98.3 – 99.5
Sexual violence	Yes	0 (0)	0.0 – 0.0
	No	(0) 100	100.0 – 100.0
Social vulnerability	Yes	46 (4.3)	3.1 – 5.5
	No	1024 (95.7)	94.5 – 96.9

Information on the profile of victims and suspected perpetrators, together with the place where acts of violence occurred, are given in Table 2. Regarding profile of victims, mean age was 76.9±9.3 years (range 60 -105 years), and most victims were women (n=79; 66.9%; 95%CI: 28.8–34.5). For race of the individuals subjected to violence, most were declared white by those lodging the complaint (n= 384; 37.9%; 95%CI: 34.9–40.9), followed by brown (n=345; 34%; 95%CI: 31.1-36.9) and black. The main place where violence occurred was at the victims´ home (n=837; 95.3%; 95%CI=94.0–96.6).

Table 2
Characteristics of place, victim and suspected perpetrator of violence against older persons made via the Dial 100 service between December 2018 and November 2019 in the state of Rio Grande do Norte.

Variables	N (%)	CI (95%)
Place of occurrence
Home	837 (95.3)	94.0 – 96.6
Street	19 (2.2)	1.3 – 3.1
Others	18 (2.0)	1.1 – 2.9
Not informed	4 (0.5)	0.1 – 0.9
Gender of victim
Male	321 (31.7)	28.8 – 34.5
Female	679 (66.9)	64.0 – 69.8
Not informed	14(1.4)	0.7 – 2.1
Race of victim
White	384 (37.9)	34.9 – 40.9
Brown	345 (34.0)	31.1 – 36.9
Black	81 (8.0)	6.3 – 9.7
Others	11 (1.1)	0.46 – 1.74
Not informed	193 (19.0)	16.6 – 21.4
Gender of suspect
Male	609 (42.4)	39.4 – 45.4
Female	707 (49.3)	46.2 – 52.4
Not informed	119 (8.3)	6.6 - 10.0
Race of suspect
White	403 (28.1)	25.3 – 30.9
Brown	435 (30.3)	27.5 – 33.1
Black	96 (6.7)	5.2 – 8.2
Yellow	6 (0.4)	0 – 0.7
Not informed	495 (34.5)	31.6 – 37.4
Relationship
Son	891 (62.1)	59.1 – 65.1
Grandchild	128 (8.9)	7.2 – 10.6
Son/Daughter-in-law	72 (5.0)	3.7 – 6.3
Others	274 (19.1)	16.7 – 21.5
Not informed	70 (4.9)	3.6 – 6.2

With regard to the characteristics of the suspected perpetrators, there was a prevalence of females (n=707; 49.3%; 95%CI: 46.2–52.4). For race/color of suspected perpetrators, most were reported as brown (n=435; 30.3%; 27.5-33.1) and white (n=403; 28.1%; 95%CI: 25.3–30.9), followed by black (n=96; 6.7%; 95%CI: 5.1–8.3). Moreover, the victims´ children were the suspected perpetrators in most cases (n=891; 62.1%; 95%CI: 59.1–65.1), followed by grandchildren (n=128; 8.9%; 95%CI: 7.2–10.6) and sons- or daughters-in-law (n=72; 5%; 95%CI: 3,7–6,3).

Of the reports registered via the Dial 100 service, 1,640 were referred to the entities of the Network for Securing Rights, predominantly to the Marcos Dionísio Referral Center for Human Rights of the Federal University of Rio Grande do Norte (CRDH/UFRN) (n=394; 44.9%; 95%CI: 41.6–48.2), overseen by the Department of Women´s Rights and Minorities (CODIMM) of the Department of Public Security and Social Defense of Rio Grande do Norte (SESED) (n=221; 25.2%; 95%CI: 22.3-28.1) and of the State Prosecutor for Defense of Disabled and Older persons of the city of Natal, RN state (26^th PmJ) (n=21; 2.1%; 95%CI: 1.2–3.0).

In 14.7% (n=129; 95%CI: 12.4-17.0) of cases reported, the individual reporting the incident had contacted the Dial 100 service on more than 1 occasion, where 97 (75.2%; 95%CI: 72.9–78.5) had called twice, and the greatest number of calls made by the same individual was 52. A large number of incidents involved more than one suspected perpetrator (37.2%; n=327; 95%CI: 34.0–40.3), with one case involving up to 9 suspects. Also, a relatively large proportion of reports involved more than one victim (13.8%; n=120; 95%CI: 11.5–16.1).

Table 3
Characteristics of reports of violence against older persons made via the Dial 100 service between December 2018 and November 2019 in the state of Rio Grande do Norte.

Variables	n (%)	CI (95%)
Referrals
CRDH/UFRN*	394 (44.9%)	41.6 – 48.2
CODIMM**	221 (25.2%)	22.3 – 28.1
26th PmJ***	21 (2.1%)	1.2 – 3.0
Others	317 (31.3%)	28.3 – 34.3
Number of repeat contacts
1	759 (14.7%)	12.4 - 17.0
2	97 (11.0%)	(8.9 - 13.1)
≥3	32 (3.6%)	(2.3 – 4.9)
Number of suspects
1	561 (62.7%)	(49.5 – 65.9)
≥2	327 (37.3%)	34.0 – 40.3
Number of victims per case reported
1	758 (16.2%)	13.8 – 18.6
≥2	120 (13.8%)	11.5 – 16.1

• *Marcos Dionísio Referral Center for Human Rights; **Department of Women´s Rights and of Minorities; ***State Prosecutor for Defense of Disabled and Elderly persons of Natal, RN state.

DISCUSSION

In the present study, the cities associated with most reports of violence were Natal, Mossoró and Parnamirim, representing the 3 most populous cities in Rio Grande do Norte state. The higher frequency of reports of violence against older adults in these cities and the low incidence in others may be explained by several factors, including aspects related to the size of the local populations. The cities associated with the highest number of reported incidents were also the most populous¹⁴. Also, in more sparsely populated towns, fewer cases of violence against older people might be reported because the public may be unaware of the Dial 100 service. Thus, the data collected from the incidents reported may not represent the full number of cases of violence against older people in the state.

In a previous study of reported cases of violence against older adults via the Dial 100 service between 2011 and 2018, a higher rate of notifications was found for the states of Paraná, Rio Grande do Norte and São Paulo¹⁴. With the exception of Rio Grande do Norte, the higher rate of reports in more developed areas supports the notion that the present study data is strongly influenced by the recognition among the cities of the importance of reporting incidents and awareness of the Dial 100 service.

Violence against older adults is a complex phenomenon with individual, social and political implications that has a multi-causal nature³. In the present investigation, neglect, psychological violence and financial abuse were the most commonly reported acts of aggression and occurred concomitantly with other types of violence in most cases reported. Corroborated by the current findings, the most prevalent types of violence against older individuals in Brazil as a whole are neglect, followed by psychological, financial and physical abuse⁷,¹⁵.

These acts of violence may stem from lack of respect and appreciation for the elderly and the social stigma attached to the aging process pervading society. This group bears the brunt of a society which places an emphasis on maximum productivity and youth, with the older population not given due recognition. This phenomenon is especially evident when examining the way society intrinsically fuels prejudice and stereotypes related to aging, where the older population is seen to display socially undesirable characteristics¹⁶.

Neglect is a type of violence found at a domestic and institutional level in Brazil, and often leads to other types of violence¹⁷. According to previous studies, the burden of caring for an older person represents a relevant risk factor for neglect ¹⁸.

Psychological violence is more commonly reported than physical aggression, a finding possibly explained by the cycle of violence, where the victim is often first threatened with, or is subject to, psychological violence before physical aggression ensues¹⁹. It is also noteworthy that psychological abuse often goes unrecognized as such, leading to under-reporting of this kind of violence. Financial abuse, another prevalent type of violence in this study, is widely described in the literature. Financial dependence of the aggressor on the older individual is a factor contributing to the occurrence of financial violence, where lower incomes tend to be associated with neglect, and higher incomes with psychological violence²⁰.

The data collected via the Dial 100 service on acts of violence against older people reported in RN revealed that over 95% (n= 837) of cases occurred in the homes of victims. The results of two studies in the city of Recife, Pernambuco state, Brazil, contrast with the findings of the present study, showing the lower rates of 47.52%²¹ and 59.3%²² of incidents of violence in the home. This disparity, however, can be explained by the source of the data employed. The first comparative study was based on data from the national Institute of Forensic Medicine²¹, while the second drew on data from the Brazilian Disease Notification System (Sinan)²², both comprising notifications made by health professionals.

However, results of another study, also based on analysis of incidents reported via the Dial 100 service, between 2011 and 2015 in Brazil, showed the higher percentage of cases at victims´ homes of 72.47%)¹⁰, a rate similar to the present study. Given that the Dial 100 service is an open system for public use, and thus more readily accessible for reporting incidents with commensurately more calls²³, there is a greater likelihood of recording incidents of violence at the home.

In this respect, the intrafamily environment is the main setting in which older individuals are subject to acts of aggression. Consequently, older victims are often reluctant to report cases and denounce the perpetrators, perhaps to avoid negatively impacting the family with whom they have ties, or for fear of exacerbating the situation within their home²⁴.

In parallel, it is important to devise strategies for tackling domestic violence against older adults which are underpinned by public policies safeguarding the rights of these individuals. To this end, a concerted collaborative effort is needed between primary healthcare, family members, friends and individuals from the community. In this context, the role of the primary healthcare system is important, comprising the Basic Health Units (UBS) and the Family Health Care Strategy (ESF). This support network can, through closer contact between professionals and users, detect and deal with situations of family violence, particularly among the more vulnerable members of society, thanks to the ready access to care delivered under this healthcare model ²⁵.

Besides the domestic environment, 3 private and 12 public institutions were cited as being suspected of ill-treating older adults, one of which was a Long-Term Care Facility (LTCF). In Brazil, studies point to the need for continued training of LTCF staff, for addressing the existence of institutional neglect and other forms of violence, accessibility problems, access to medications, difficulties receiving treatment by the national health system (SUS), barriers to social interaction with the community and the need for improvements in devising and implementing Brazilian public policies²⁶.

In the analysis of violence against older people, it is important to consider the relationship problems often emerging during the care process. The caregiver is typically a family member not well prepared for the role who, when not receiving help in the act of caring, can suffer high levels of stress, leading to abusive behavior and acts of violence²⁷. Consistent with this notion, most of the suspected perpetrators identified in the study were next-of-kin, most commonly son or daughter. This finding is similar to results found in a previous study in the state of Pará, Brazil, in which the main aggressors of older people were also the children of victims.

In the present study, the suspected perpetrators of violence were mostly women, explained by the fact that the role of caregiver is invariably performed by women. In this scenario, the State support of family is important, providing long-term care facilities, especially amid the current sociodemographic scenario of families were fewer children and greater participation of women in the job market²⁸.

Most of the victims were female, echoing findings of other studies in the scientific literature showing that women are more often victims of domestic violence than men¹¹,²⁷. This fact might be attributed to the social construction concerning women´s role in society, still strongly associated with subordination and lack of recognition²⁹. Moreover, in Brazil the higher mortality rate of males over females, from birth through into adult life ³⁰, together with the lower propensity of males to seek medical services³¹, may have some bearing on this scenario, given there are more older women than men in the population.

With regard to color/race, victims of violent acts were more commonly white or brown, a pattern likely related to the composition of the Brazilian population, comprising 45.2% white, 45.1% brown and 8.9% black¹² . Furthermore, the socially vulnerable status of some of the individuals in this study, whether associated with additional infringements or otherwise, may be associated with the structural violence in Brazil, particularly in the Northeast. This is characterized by inequalities in the organized and institutionalized structures of the family and in economic, cultural and political systems, leading to oppression of these individuals, rendering them more vulnerable ³²,³³. As a consequence, individuals from this group are often exposed to greater risk of developing illness or of worsening of pre-existing conditions, while also facing more limited access to health services, lack of social support and low education, potentially exacerbating health or contributing to a poor health³⁴. Besides structural violence, social determinants are also key factors associated with interpersonal violence³⁵.

This study has several limitations. First, the data analyzed were collected from a single reporting channel, precluding the building of a broader picture of the profile of violence against older people in RN. In addition, it is important to mention the low representativeness of the cases of violence with respect to a significant contingent of smaller towns in the state, for which few or no reports are available, a situation attributable to a lack of awareness of the Dial 100 service in these places. Lastly, missing data on race/color in the Dial 100 records also proved a factor limiting the mapping of a clearer profile of both victims and perpetrators.

CONCLUSION

The study results showed that most cases of violence against older people in RN state took place at the home of victims and were perpetrated predominantly by their children. The most commonly reported types of violence were neglect, psychological violence and financial abuse. Given their more prominent role as caregivers of older people, women were more frequently the suspects of perpetrating violence, while at the same time main victims of it. Regarding race/ethnicity, most victims were white and brown, according to those reporting the violence. The number of reports of violence was proportional to the population density of the cities, where higher rates of violent incidents were observed in the 3 most populous cities in RN state (Natal, Mossoró and Parnamirim).

Therefore, greater investment in expanding and disseminating the services for reporting violence against older persons is paramount, particularly in less populous cities where a large contingent are unaware of these channels. Investment should also be made in apparatus dedicated to the investigation and resolution cases of violence. In addition, public policies in support of older people and their caregivers should be devised to engage the government, society and families in the delivery of quality care, thereby securing the rights of the older population.

• No funding was received in relation to the present study.

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Edited by

Edited by: Tamires Carneiro de Oliveira Mendes

Publication Dates

• Publication in this collection
  29 Oct 2021
• Date of issue
  2021

History

• Received
  16 Mar 2021
• Accepted
  16 July 2021