• Users Online: 115
  • Print this page
  • Email this page


 
 
Table of Contents
FIELD REPORT
Year : 2021  |  Volume : 19  |  Issue : 1  |  Page : 21-25

The Comfort Dog Project of Northern Uganda: An Innovative Canine-Assisted Psychosocial Trauma Recovery Programme


Warrior Canine Connection, Boyds, Maryland, USA

Date of Submission15-Jun-2020
Date of Decision18-Aug-2020
Date of Acceptance09-Feb-2021
Date of Web Publication31-Mar-2021

Correspondence Address:
Meg Daley Olmert
Warrior Canine Connection, P.O. Box 147, Wittman, MD 21676
USA
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/INTV.INTV_16_20

Get Permissions

  Abstract 


In 2012, BIG FIX Uganda, an American-based animal welfare organisation, began offering veterinary health services and animal welfare education in northern Uganda to improve the wellbeing of animals and their guardians. In 2014, the organisation expanded its inclusive health platform with the creation of the Comfort Dog Project − an animal-assisted psychosocial intervention for survivors of war trauma through the facilitation of human-dog companionship. This article focuses on how blending community trauma counselling with dog training and bonding instruction can improve the social and emotional skills of dog guardians while creating loving, stress-buffering relationships with their dogs. Fifty-nine guardians and their comfort dogs graduated this 20-week animal assisted trauma intervention between 2015 and 2020. Psychological assessments taken pre- and post-graduation, as well as annual follow-up testing over a 4-year-period, indicate that this therapeutic model can be effective at reducing the symptoms of posttraumatic stress disorder and improving the wellbeing of both the guardians and their comfort dogs.

Keywords: animal-assisted therapy, human-animal bond, humanitarian assistance, northern Uganda, One Health Initiative, posttraumatic stress disorder, psychosocial support, rabies prevention


How to cite this article:
Olmert MD. The Comfort Dog Project of Northern Uganda: An Innovative Canine-Assisted Psychosocial Trauma Recovery Programme. Intervention 2021;19:21-5

How to cite this URL:
Olmert MD. The Comfort Dog Project of Northern Uganda: An Innovative Canine-Assisted Psychosocial Trauma Recovery Programme. Intervention [serial online] 2021 [cited 2021 Aug 3];19:21-5. Available from: https://www.interventionjournal.org/text.asp?2021/19/1/21/312762




  Introduction: “You Will Heal Like a Dog” Top


Gulu District in Northern Uganda is the birthplace of Joseph Kony and was the epicentre of the civil war between the Lord’s Resistance Army (LRA) and the Ugandan state that started in 1986 and officially ended in January 2007 (Akello, 2013). Ninety percent of the population of Northern Uganda had to abandon their homes and land to live in Internally Displaced Person camps established by the Ugandan government. Conditions in the camps were squalid and unsafe from kidnapping raids by rebel forces. The impact of those decades of violence has left a wake of poverty and social instability that undermine recovery from the trauma experienced in the war. The rising rate of suicide, domestic violence and substance abuse among the survivors is a measure of the enduring trauma and the need for more and better mental health psychosocial interventions (Vinck et al., 2007; Rokhideh, 2017).

Northern Uganda is also home to tens of thousands of household dogs whose lives have always been brutish and short in times of war or peace. Most households have at least one dog, but they are not considered companion animals. They are largely kept for hunting and protection. Despite the important services they provide to their guardians, dogs are generally considered useless and calling someone a “dog” implies they too are useless and not worthy of respect. Dogs may be found chained in shoddy shelters or left to fend for themselves. They are often covered in ticks, fleas and suffer from mange. They are rarely offered clean water or decent food. Many dogs, forced to roam, are stoned to death for fear of rabies. For the 20-year duration of the war, there was no veterinary care available for sick or injured dogs. There is a bleak saying in northern Uganda for people who fall sick and have no family to support them: “You will heal like a dog.”

In 2012, the nonprofit organisation, BIG FIX Uganda, began offering free veterinary health services and animal welfare education in three districts in northern Uganda. Hundreds of people walked miles to the first veterinary field clinics to get their dogs vaccinated against rabies. Most people may have been driven by self-preservation rather than concern for the welfare of their dogs, but all were surprised when organisation volunteers set up grooming stations to bathe the dogs. Grooming dogs in northern Uganda was a novel idea. Still, the guardians’ laughter and resistance faded away when they saw their dogs’ transformation. People were pleased with their shiny clean dogs. Some refused to put their dogs back on the ground, carrying them the whole way home. In this unexpected response, the organisation recognised an opportunity to literally bring people closer to their dogs and help nurture social bonds that might improve the health and happiness of both.


  The Comfort Dog Project Top


In 2014, the organisation created The Comfort Dog Project (programme; CDP), an animal-assisted trauma therapy model that combines weekly 90-minute group psychosocial counselling sessions with basic dog training and bonding instruction and exercises. It is modelled on the best animal-assisted therapy (AAT) practices with a commitment to the interconnections between human and animal health that are highlighted in the One Health Initiative (One Health Initiative, n.d.).

The field of AAT originated in Western countries but has now been successfully incorporated into a range of mental health practices on all continents (Curran et al., 2019). A growing body of research supports decades of anecdotal reports that friendly interaction with dogs can facilitate therapist rapport, patient communication and improve patient attendance and satisfaction with treatment (Jones et al., 2019; Nimer & Lundahl, 2007). Studies investigating the effects of training service dogs on United States veterans with posttraumatic stress disorder (PTSD) found that this intensive form of interspecies social engagement resulted in greater PTSD symptom reduction than standard evidence-based trauma treatment of the same duration (Abraham et al., unpublished; Bergen-Cico et al., 2018; Kloep et al., 2017; O’Haire & Rodriguez, 2018; Woodward et al., 2017). One of these studies also found that training and partnering with service dogs increased the perception of the therapeutic value of standard trauma interventions (O’Haire & Rodriguez, 2018).

The organisation hired a community psychologist from Gulu to manage the new programme. He is a member of the main ethnic group (Acholi) in northern Uganda and a war survivor who was blinded by shrapnel at the age of 12. He began conducting bi-weekly radio broadcasts from two local stations in Gulu that reach a wide audience across northern Uganda. His shows focused on the long-term effects of war trauma that can continue to cause emotional and behavioural difficulties in the present day. Listeners also learned they could attend his psychosocial counselling sessions conducted twice a month in five villages in the Gulu region. Prior to Covid-19 restrictions, an average of 20 to 25 people regularly participated in each of these group sessions to discuss their war experiences and post-conflict stressors and to learn cognitive behavioural coping skills to gain more control over their lives.


  Becoming Dog Guardians Top


Eleven clients from these village counselling sessions were identified by the psychologist as people who might benefit further from participating in the pilot AAT programme. All had been abducted and forced to commit violence or been the victim of violence. A clinical screening interview, conducted by the programme psychologist, determined the seven men and four women met diagnostic criteria for PTSD (American Psychiatric Association, 2013). The severity of PTSD symptoms was assessed using the Posttraumatic Symptom Scale (PSS-I; Foa et al., 2016). PSS-I scores were interpreted using the Manual for the Administration and Scoring of the PTSD Symptom Scale-Interview (Hembree, Foa, and Feeney, 2002). Five candidates were found to be in the moderate range and three scored in the severe range.

Most candidates had been raised to avoid or fear dogs and some had negative interactions with them or knew friends and family who had died from rabies. Although some candidates did express a degree of timidity around dogs, all were willing to learn new ways to engage with dogs and be open to bonding with them. They next completed a brief class in dog health, care, feeding and welfare. The organisation also assessed their ability to provide a safe, loving home for a comfort dog. Finally, they signed the “Guardian’s Commitment” pledge to take full responsibility for the wellbeing of their comfort dog. With these prerequisites completed, the guardians and their dogs were ready to begin 20 weeks of trauma counselling integrated with dog training and bonding instruction.

Comfort dogs are local dogs who have been donated to or rescued by the organisation. Dogs that are rehabilitated, vaccinated, neutered and pass temperament tests can be eligible for placement with a guardian. The sex, temperament, size, age, history and physical appearance of both dog and guardian are taken into consideration in the pairing process. The dogs are given collars, identification tags and leashes before they are delivered to their new homes with a bag of grooming supplies and an initial stock of food. (Dog food is provided during the 20-week programme. After graduation, guardians in need can apply for dog food assistance.) The organisation’s dog welfare officer makes regular checks of the new homes to ensure that all is progressing well and that the early interactions between the dog and their new family members are positive and productive. The organisation also commits to provide free, lifetime health care for its comfort dogs and continued psychosocial support for their guardians.

Three participants in the 2015 class moved away before completing the full course. The remaining eight participants completed the 20-week long programme. They learned how to communicate with their dog and to use patience, consistency and generous encouragement to shape their dogs’ behaviour. The guardians first had to master the “Watch Me” command—the cornerstone of gaining the dog’s attention and respect—before they advanced to other basic tasks such as “sit,” “stay” and “loose-leash walking.”

Dog training is challenging. It requires mastery of the cognitive and emotional social skills that are often compromised by trauma (Stevens & Jovanovic, 2019). Dog training exercises offered experiential learning opportunities for guardians to practise emotional control and concentration. It also required them to monitor their verbal and nonverbal cues while assessing their dog’s point of view. Positive dog training methods bear a strong resemblance to good parenting practices and the dog’s response provides an instant and honest indicator of success (Yount, 2013). The project psychologist observed that at times the inability to achieve a certain level of progress in the dog training caused stress to some of the participants. More advanced training manoeuvres were eliminated from the programme and a greater emphasis was placed on other bonding activities such as going for walks with dogs, washing and grooming.

The guardians were also encouraged to explore their dog’s individual talents. If a dog liked to play, guardians were shown how to teach their dog to retrieve a ball or disk. Other dogs learned to shake hands, roll over and perform other feats that brought joy to the guardians as well as the dogs. Because dogs are rarely viewed as social companions in northern Uganda, the concept of walking a dog on a leash, giving dogs obedience commands, or engaging in friendly play with a dog was something most people had never seen or explored.

The guardians, accompanied by their comfort dogs, also attended weekly 90-minute group psychosocial counselling sessions. (Individual counselling was available when deemed appropriate by the programme psychologist or requested by a guardian.) The comfort dogs were an intricate part of the guardians’ therapeutic process. Guardians were encouraged to hold and stroke their dogs as they talked about their war experiences. They reported that the presence of the dogs soothed them and made sharing those memories easier—stress-buffering effects shown to be facilitated by dog companionship (Hunt et al., 2014). The guardians also said that their dogs were always happy to see them and offered them warmth and love. They reported that their dogs filled the social void experienced when they were stigmatised by their community for their actions during the war.


  Monitoring Programme Effect on Trauma Symptom Severity Top


Eight out of 11 participants graduated from the 2015 pilot class and completed post-programme PSS-I testing. The PSS-I is a 17-item, semi-structured interview that assesses the presence and severity of DSM-V PTSD symptoms experienced in the “past 2 weeks.” Scores measure the frequency and severity of PTSD symptoms in the following three categories: re-experiencing, avoidance and arousal. The total score ranges from 0 to 51. The scoring levels used by the programme were (0–11) mild, (11–33) moderate and (34–51) severe.

At graduation, seven guardians showed symptom reduction levels from −62% to −14% of their baseline levels. One guardian who abused alcohol had an 8% increase in his PSS-I score. Post-programme bonding assessments were also completed. All eight graduates reported that their dog made them happy and less lonely and that they considered their dog a sibling or a child.

The eight 2015 graduates continued to receive psychosocial counselling and dog training support. They also volunteered to support programme activities such as mentoring new guardians, hosting village dog bathing events, working in the field clinics and visiting schools to demonstrate their dog training skills. Their PSS-I scores were reassessed each year, except for 2019 when funding was not available. In 2020, the PSS-I scores of six 2015 graduates indicated they no longer met the DSM criteria for PTSD. One guardian whose scores had remained in the mild range since graduation showed an increase into the moderate range after experiencing domestic difficulties in 2020. One graduate moved away and another graduate passed away in 2017. At the time of his death, his symptom severity scores had fallen 47% from his preprogramme level.

Since the first class of 2015, 51 guardians have graduated from four subsequent classes. PSS-I pre-programme scores were completed by 24 of those participants. Seventeen had baseline scores that fell in the moderate range and seven fell in the severe range. PSS-I post-programme (graduation) scores showed that 23 of 24 graduates experienced symptom reduction. Fifteen scored in the mild range, eight in the moderate range, one in the severe range. One participant’s score of zero fell below the DSM criteria for PTSD.

A total of 30 guardians from all five classes continued to have their trauma symptoms monitored each year, except in 2019. Out of the 30 guardians, 28 showed symptom reduction from their graduation PSI-I scores. Follow-on testing in 2020 showed that seven guardians scored in the moderate range and 16 were in the mild range. Seven no longer met the DSM criteria for PTSD. Because PSS-I scores were taken over a 4-year-period, these findings indicate the majority of programme graduates, experienced both acute and long-term PTSD symptom reduction.


  Case Study Top


When “Grace” was a child, she was abducted from school by the Lord’s Resistance Army. After her abduction, she was repeatedly raped. She witnessed the brutal murder of her best friend and watched her brother being hacked to pieces. Another beloved brother was killed by crossfire in her presence. Grace and her third brother contracted cholera in the bush. Although she managed to survive, her brother died. When Grace finally returned to her village, the community thought she was possessed by evil spirits. She and her mother were rejected and abused adding to her loneliness and despair.

In 2015, Grace joined the first CDP class and adopted her dog, Tam-Pira. In the beginning, she found it very difficult to connect with and control her young dog. She also had difficulty looking at or speaking with her classmates. She had to “find her voice” in order to earn her dog’s attention, providing clear and consistent leadership and joyful reward for jobs well done. By the end of the programme, Grace had gained confidence and Tam-Pira was by far the best-trained dog in the group. A powerful social bond had developed between them and Grace views Tam-Pira as a sister. With Tam-Pira at her side, Grace discovered the skills and leadership ability to be an excellent mentor for the next class of guardians. In 2017, Grace was hired to be CDP’s lead dog trainer. This accomplishment is particularly impressive in a culture where dog handling is usually a job for men and boys. Grace was recently honoured by the Silent Heroes Foundation as their “Silent Hero of the Month.” Grace and Tam-Pira are featured in the BBC documentary series, “100 Women” (Martyn-Hemphill, 2019).


  Discussion Top


The Comfort Dog Project was conceived as an animal-assisted trauma intervention to promote psychosocial resiliency through mental health counselling and the creation of loving partnerships with dogs. A total of 64 clients diagnosed with PTSD began the programme, all walking great distances to attend the weekly classes. Fifty-nine (92%) guardians have completed the 20-week long intervention.

The 29 guardians who are still alive and in the area continue to volunteer as mentors to new programme members, assist in animal rescue efforts, host dog bathing parties and support field clinic activities. Eight have completed veterinary technician training paid for by the organisation. All graduates have the opportunity to serve as field educators. Field educators provide important community health services. They participate in radio broadcasts about animal welfare issues and rabies awareness and prevention. They help administer rabies vaccinations, de-worming, flea and tick treatment and provide surgical support for over 9000 dogs who are brought to field clinics each year. They also demonstrate their dog training skills to children in 60 district schools every year. The children are always amazed and delighted to see the dogs respond to commands and do tricks and that dogs can be safe and loving friends.

In 2017, the organisation began offering day pay to the field educators. Two guardians are now full-time employees of the organisation. One has become the lead dog trainer and one is a veterinary technician in the animal hospital. Guardians are not only the most qualified people to fill these positions, they strengthen the programme by bringing their shared understanding of the post-conflict dynamics and challenges people face every day. It is difficult to assess the influence that even limited employment opportunity might have on the guardians’ alignment with programme objectives or possible underreporting of symptoms. Although field educators now earn day pay, the majority of programme goals and activities are supported by dedicated, long-term volunteers. The long-term involvement and continued counselling of so many guardians also make it possible to regularly observe their interactions with other guardians, the organisation staff, the wider community and their dogs. At this point, the programme psychologist has not noticed any trends of underreporting symptom severity.

An unexpected programme benefit has been the strong bonds guardians have developed with each other. Through their dog training classes, group counselling and field educator work, they have learned to trust and cooperate with each other. They have become a close-knit family that celebrates each other’s successes and comes together to ease each other’s pain.

Over the past 5 years, the Comfort Dog Project has become well known in the Gulu region and the number of people who would like to be part of it is growing. In 2020, over 100 people expressed interest in participating in the programme. Following Grace’s lead, more women are taking over the care of household dogs. The growing number of female guardians being seen in the community with their obedient and well-socialised comfort dogs is sparking a reconsideration of what a dog can be and who might handle them. One female guardian was recently recruited to become a special police constable because of the dog handling skills she gained in the programme. She is now respectfully addressed by the title, “The lady who knows how to handle dogs.”

Project goals for 2020 were impacted by the government’s shutdown orders to prevent the spread of COVID-19. Although the animal hospital has been able to remain fully operational, field clinics, education activities and village counselling sessions were temporarily suspended in March, 2020. The programme has still been able to provide individual and group counselling services for the guardians by phone and at its Gulu headquarters. A new class of 13 guardians and dogs also completed the programme and graduated in October 2020. (PSS-I scores not available at this time.)When schools reopen in February 2021, the project will invite students from 56 primary and secondary schools to participate in a new educational initiative. This programme will teach children and adolescents how to become dog guardians and transform their household dog into a comfort dog. The curriculum, taught by field educators and the programme psychologist, will focus on dog communication and training skills that promote social bonds between the students and their dogs. The goal is to improve students’ social cognition skills through the experience of training and caring for their dogs. The socioemotional skills practised in this programme may be of help to those experiencing secondary combat trauma and help them become more resilient and less likely to develop mental health issues later in life (Akello, 2013; Tedeschi et al., 2015; Winkler et al., 2015). Students will also create 20 murals in prominent locations throughout Gulu to celebrate the new healing friendships they make with their dogs.


  Conclusion Top


Programme performance and dog bonding surveys indicate that this animal-assisted trauma programme has been successful in creating social bonds between the northern Ugandan guardians and their comfort dogs. Repeated trauma symptom measures, clinical observation and guardian testimonies indicate that these human-dog bonds may provide similar psychosocial buffering and trauma relief as seen in AATs developed within a Euro-American mental health framework. The programme’s strong retention rate, trauma relief effects and burgeoning popularity suggest this One Health model may transcend cultural differences to provide a new approach to trauma relief that improves the health and happiness of northern Uganda’s dogs and their guardians.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.







 
  References Top

1.
Akello G. (2013). Experiences of forced mothers in northern Uganda. Intervention, 11 (2), 149-156. https://doi.org/10.1097/wtf.0b013e3283625d  Back to cited text no. 1
    
2.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Association.  Back to cited text no. 2
    
3.
Bergen-Cico D., Smith Y., Wolford K., Gooley C., Hannon K., Woodruff R., Spicer M., Gump B. (2018). Dog ownership and training reduces post-traumatic stress symptoms and increases self-compassion among veterans: Results of a longitudinal control study. The Journal of Alternative and Complementary Medicine, 24 (12), 1166-1175. https://doi.org/10.1089/acm.2018.0179  Back to cited text no. 3
    
4.
Curran B. J., Jenkins M. A., Tedeschi P. (2019). The global and cross-cultural reach of trauma-informeed animal assisted interventions. In Tedeschi P., Jenkins M. A. (Eds.), Transforming trauma: Finding resiliency and healing through animals (pp. 423-461). Purdue University Press.  Back to cited text no. 4
    
5.
Foa E. B., McLean C. P., Zang Y., Zong J., Rauch S., Porter K., Knowles K., Powers M. B., Kauffman B. Y. (2016). Psychometric properties of the Posttraumatic Stress Disorder Symptoms Scale Interview for DSM-5 (PSSI-5). Psychological Assessment, 28, 1159-1165. https://doi.org/10.1037/pas0000259  Back to cited text no. 5
    
6.
Hembree E, Foa E. B., Feeny N. C. (2002). Manual for the Administration and Scoring of the TSD Symptom Scale − Interview (PSS-I). Published manual.  Back to cited text no. 6
    
7.
Hunt M. G., Chizkov R. R., Hunt M. G., Chizkov R. R. (2014). Are therapy dogs like xanax? Does animal-assisted therapy impact processes relevant to cognitive behavioral psychotherapy? Anthrozoos, 27 (3), 457-469. https://doi.org/10.2752/175303714 × 14023922797959  Back to cited text no. 7
    
8.
Jones M. G., Rice S. M., Cotton S. M. (2019). Incorporating animal-assisted therapy in mental health treatments for adolescents: A systematic review of canine assisted psychotherapy. PLoS One, 14 (1), 1-27, e0210761. https://doi.org/10.1371/journal.pone.0210761  Back to cited text no. 8
    
9.
Kloep M., Hunter R., Kertz S. (2017). Examining the effects of a novel training program and use of psychiatric service dogs for military-related PTSD and associated symptoms. The American Journal of Orthopsychiatry, 87(4), 425-433. https://doi.org/10.1037/ort0000254  Back to cited text no. 9
    
10.
Martyn-Hemphill A. (2019). “If it wasn’t for him, I’d be dead” − BBC News. BBC NEWS 100 WOMEN. https://www.bbc.com/news/av/world-49409125/ugandan-war-survivors-partnered-with-therapy-dogs  Back to cited text no. 10
    
11.
Nimer J., Lundahl B. (2007). Animal-assisted therapy: A meta-analysis. Anthrozoos, 20 (3), 225-238. https://doi.org/10.2752/089279307 × 224773  Back to cited text no. 11
    
12.
O’Haire M. E., Rodriguez K. E. (2018). Preliminary efficacy of service dogs as a complementary treatment for posttraumatic stress disorder in military members and veterans. Journal of Consulting and Clinical Psychology, 86 (2), 179-188. https://doi.org/10.1037/ccp0000267  Back to cited text no. 12
    
13.
One Health Intiative (n.d.). Mission Statement. https://onehealthinitiative.com  Back to cited text no. 13
    
14.
Rokhideh M. (2017). Peacebuilding and psychosocial intervention: the critical need to address everyday post conflict experiences in northern Uganda, Intervention, 15(3), 215-229, https://doi.org/10.1097/WTF.0000000000000161  Back to cited text no. 14
    
15.
Stevens J. S., Jovanovic T. (2019). Role of social cognition in post-traumatic stress disorder: A review and meta-analysis. Genes, Brain and Behavior, 18 (1), 1-10. https://doi.org/10.1111/gbb.12518  Back to cited text no. 15
    
16.
Tedeschi P., Sisa M. L., Olmert M. D., Parish-Plass N., Yount R. (2015). Treating human trauma with the help of animals: trauma informed intervention for child maltreatment and adult post-traumatic stress. In Fine A. (Ed.), Handbook on animal-assisted therapy (4th ed., pp. 305-319). Elsevier. https://doi.org/10.1016/B978-0-12-801292-5.00022-5  Back to cited text no. 16
    
17.
Vinck P., Pham P.N., Stover E., Weinstein H. M. (2007). Exposure to war crimes and implications for peace building in northern Uganda. The Journal of American Medical Association, 298(5), 543-554. https://doi.org/10.1001/jama.298.5.543  Back to cited text no. 17
    
18.
Winkler N., Ruf-Leuschner M., Ertl V., Pfeiffer A., Schalinski I., Ovuga E., Neuner F., Elbert T. (2015). From war to classroom: PTSD and depression in formerly abducted youth in Uganda. Frontiers in Psychiatry, 6(2), 1-10. https://doi.org/10.3389/fpsyt.2015.00002  Back to cited text no. 18
    
19.
Woodward S. H., Jamison A. L., Gala S., Holmes T. H. (2017). Canine companionship is associated with modification of attentional bias in posttraumatic stress disorder. PLoS ONE, 12 (10), e0179912. https://doi.org/10.1371/journal.pone.0179912  Back to cited text no. 19
    
20.
Yount R., Ritchie E. C., Laurent M. S., Chumley P., Olmert M. D. (2013). The role of service dog training in the treatment of combat-related PTSD. Psychiatric Annals, 43 (6), 292-295. http://dx.doi.org/10.3928/00485713- 20130605-11  Back to cited text no. 20
    




 

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: &#...
The Comfort Dog ...
Becoming Dog Gua...
Monitoring Progr...
Case Study
Discussion
Conclusion
References

 Article Access Statistics
    Viewed1885    
    Printed36    
    Emailed2    
    PDF Downloaded141    
    Comments [Add]    

Recommend this journal