|Year : 2015 | Volume
| Issue : 1 | Page : 30-36
Prevalence and determinants of sexually transmitted infections (STIs) among male migrant factory workers in Haryana, North India
Rizwan Suliankatchi Abdulkader1, Shashi Kant2, Sanjay Kumar Rai3, Kiran Goswami4, Puneet Misra3
1 Resident, Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
2 Professor, Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
3 Additional Professor, Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
4 Professor, Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India, India
|Date of Web Publication||9-Mar-2015|
Professor, Centre for Community Medicine, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Male migrant workers display high risk sexual behavior and have been shown to have higher prevalence of sexually transmitted infections (STIs), which make them more vulnerable to HIV infection. We aimed to estimate the prevalence of self-reported STIs and delineate their determinants among male migrant factory workers in Faridabad, Haryana. Materials and Methods: Male workers in two selected factories, who were aged ≥18 years, were born outside Haryana (destination), and who had migrated to Haryana after the age of 15 years were eligible. Socio-demographic information, HIV/AIDS knowledge and behavior, and self-reported STI symptoms in the last 1 year were ascertained by face-to-face interview. Determinants of STIs were identified by regression analysis. Results: Totally 755 eligible workers participated. Mean ± SD age was 31.4 ± 8.2 years and migration duration was 9.5 ± 6.7 years. At least one STI symptom was reported by 41.7% of the participants (burning micturition- 35%, inguinal bubos-5.2%, genital ulcers- 2.6%, urethral pus discharge- 1.3%). Factors associated with STIs were higher age at migration, lower HIV/AIDS knowledge, paid sex in the last year, non-use of condoms during the last non-spousal sex, and unfavorable intention to use condom. Conclusion: Prevalence of self-reported STIs among these migrant men was high. Targeted Interventions among migrant workers need to be strengthened for control and prevention of STIs.
Keywords: Determinants, Factory workers, India, Migrant factory workers, Migrants, Prevalence, Sexually transmitted infections
|How to cite this article:|
Abdulkader RS, Kant S, Rai SK, Goswami K, Misra P. Prevalence and determinants of sexually transmitted infections (STIs) among male migrant factory workers in Haryana, North India. Indian J Public Health 2015;59:30-6
|How to cite this URL:|
Abdulkader RS, Kant S, Rai SK, Goswami K, Misra P. Prevalence and determinants of sexually transmitted infections (STIs) among male migrant factory workers in Haryana, North India. Indian J Public Health [serial online] 2015 [cited 2023 Jan 27];59:30-6. Available from: https://www.ijph.in/text.asp?2015/59/1/30/152854
| Introduction|| |
The World Health Organization (WHO) estimated that 340 million new cases of curable sexually transmitted infections (STIs) occur globally every year, of which 150 million are from South and Southeast Asia, including 50 million from India.  The National AIDS Control Organisation (NACO) estimated that 12% of females and 6% of males attend Primary Health Centers for complaints related to STIs and that the prevalence of STIs among sexually active adults is about 5-6%.  According to National Behavioural Surveillance Survey (BSS), 2006, prevalence of self-reported STIs in the last 1 year among males was 3.1%. STIs are an important area of focus for the National AIDS Control Programme (NACP) in India, largely because of their intertwined relationship with HIV/AIDS and the amplifying effect of STIs on the spread of HIV. Similar type of behavior displayed by people affected by these two diseases provides an opportunity for simultaneous control and preventive measures. Studies have shown that pre-existing STIs in the form of ulcerative/inflammatory lesions of the genitalia greatly increase the transmission potential of HIV.  There is also evidence to suggest that treatment of STIs can reduce viral shedding and decrease HIV sero-conversion rates. 
STIs serve as a proxy indicator for HIV infection level in populations where the latter cannot be measured directly. Studies have shown a correlating prevalence of HIV among patients with STIs. , Since the behavioral pattern of people afflicted with STIs and HIV is similar, the prevalence of STIs can provide us with an indication of the existence of risk behavior in such populations. It is often not possible to have laboratory confirmation for the management of STIs, especially in primary care settings, and hence the need for symptom-based diagnoses and management. It has been found that symptom-based detection of STIs correlates well with laboratory diagnoses and, therefore, syndromic management has been effective at least for males.  This provides justification for the use of symptoms for estimation of STI prevalence in epidemiological studies.
The epidemiological features of STIs in India are morphing constantly due to reasons such as high proportion of sexually active population, rural to urban migration, stigma associated with STIs, irrational use of antibiotics, antimicrobial resistance, and behavior change subsequent to the HIV epidemic.  This makes the control of STIs a challenging public health problem. Migrant workers act as a bridge population in shifting the STI epidemic from the "core risk" groups to the general population. Thus, migrant workers provide an important intervention point to alter the course of STIs as a public health problem.  In this study, we aimed to determine the prevalence of self-reported STI symptoms as a proxy for risk behavior outcome and delineate its associated factors in male migrant factory workers.
| Materials and Methods|| |
This was a facility-based cross-sectional survey conducted in two factories located at Ballabgarh block of Haryana. Factories in the study area were assessed for the presence of migrant workers by liaising with local key informants and local union leaders. A list of 10 factories with large migrant workforce was prepared. Managements of these industries were approached for participation after explaining to them details of the study. Out of these, two factories agreed to take part and were selected. One of the sites was a steel bars producing unit with approximately 1500 workers, located 18 km from Comprehensive Rural Health Services Project (CRHSP) hospital, Ballabgarh and the other site was a turbine parts manufacturing unit with approximately 2000 workers, located 4 km form CRHSP hospital, Ballabgarh. Data were collected during July 2011. Male migrant workers aged 18 years or above, who were born outside Haryana, had moved to the current location after 15 years of age, had worked in the current factory for at least 1 year, were willing to participate, and were able to give valid consent were eligible for inclusion in the study. Face-to-face interview was conducted using pretested semi-structured questionnaire. Taking the prevalence of self-reported STIs as 6%,  confidence level of 95%, power of 80%, relative precision of 33%, and non-response rate of 20%, the sample size calculated was 705. For the purposes of this study, any person reporting any of the four types of self-reported STI symptoms in the last 1 year (frequent burning micturition, urethral pus discharge, genital ulcers, and inguinal bubos) was considered to have had STI. Due to operational constraints, a random sample could not be obtained. Instead, we followed a consecutive sampling technique in which workers attending the factory clinic were approached to take part in the study in a consecutive manner. In order to maintain data quality, not more than 20 interviews were conducted in a day. Although not as robust as a random sample, this type of sampling is an accepted methodology widely used in HIV sentinel surveillance activities in India.  Ethical approval was obtained from institutional review board (IRB) of the All India Institute of Medical Sciences, New Delhi. Informed written consent was obtained for all the participants.
All analyses were done using STATA/IC 11.1 (Stata Corp LP, College Station, TX, USA). Data were described in terms of proportions, means, standard deviations, and 95% Confidence Intervals (CI values) wherever applicable. An HIV/AIDS knowledge score was calculated by taking into account 22 variables. These included questions on routes of HIV transmission, methods of prevention, and diagnosis and treatment of HIV/AIDS. The total score range was 0-22 and was classified based on the proportion of the maximum possible score obtained into three categories as ≥80% (comprehensive), 50-79% (moderate), and ≤49% (poor). "Intention to use condoms" was measured on a four-item five-point Likert scale.  Briefly, in this scale, there were four statements relating to condom use. Each statement was given a score on the basis of the level of agreement or disagreement of the participant with the statement and all statement scores were added. Total score range was 4-20 (higher the score, more unfavorable the intention). Bivariate analysis was done and unadjusted odds ratio (OR) presented with 95% CI. Statistical significance of differences in proportions was tested using Chi-square test or Chi-square test for trend. Multivariable logistic regression was done by stepwise method. Variables with a P value of ≤0.20 were entered into the model. Variables entered in the model were age group, birth place, marital status, educational status, kind of work, salary, age at which migrated for work, duration of stay in Haryana, number of places migrated, number of home visits, total duration of migration, and HIV/AIDS knowledge score, "intention to use condoms" score, and other behavior variables. Variables retained in the final model were presented with adjusted OR values and 95% CI values. A P value of less than 0.05 was taken as being statistically significant.
| Results|| |
Socio-demographic profile and HIV risk behavior
A total of 767 men were approached for participation and 755 completed the interview. The mean (SD) age of the participants was 31.4 (8.2) years and nearly 70% belonged to the 25-45 years age group. The mean (SD) age at migration was 21.8 (4.9) years and nearly half had migrated for work-related purposes before the age of 21 years. The mean (SD) number of places migrated for work-related purposes was 3.6 (2.9), mean (SD) total duration of migration was 9.5 (6.7) years, and nearly 65% had completed at least 6 years of migration. The mean (SD) HIV/AIDS knowledge score was 14.7 (6.6); only 40% had comprehensive HIV/AIDS knowledge and 45.5% of the men had experienced non-spousal sexual intercourse (ever), among whom nearly 47% had involved in such behavior in the last 1 year, i.e., recent non-spousal sex. Nearly one-fourth of those reporting non-spousal sex also reported having paid money for sex in the last 1 year. Among the participants who were sexually experienced, only 53% had ever used a condom. Among the men who reported both use of condom (ever) and experience of non-spousal sex (ever), 40% did not use a condom at last sexual encounter with a non-spousal partner.
Prevalence of self-reported STI symptoms
"Burning micturition" was the most commonly reported symptom, followed by "swelling in groin," "genital ulcer," and "urethral pus discharge" [Table 1]. Among those who reported at least one STI symptom, majority had visited a private practitioner for treatment (41.6%), 19.7% visited a government doctor, and a large proportion (39%) did not take any treatment.
|Table 1: Self-reported STI symptoms among male migrant workers in selected factories of Faridabad (n = 755)|
Click here to view
Determinants of self-reported STI symptoms
In bivariate analysis, the factors that were found to be significantly associated with having an STI symptom were: Being older, being unmarried, higher age at migration, greater number of places migrated, being a semi-skilled worker, lesser income, lower education, staying in hostel, sharing a room, not knowing that AIDS can be spread by non-use of condom or from mother to child, not knowing that AIDS can be prevented by regular condom use and having one faithful partner, lower HIV/AIDS knowledge, younger age at initiation of sexual intercourse, having involved in non-spousal sex in the last 1 year, having paid money for sex in the last 1 year, never having used condom, not having used a condom at the last non-spousal sexual intercourse, inconsistent condom use, having consumed alcohol in the last 1 year, having consumed alcohol before last non-spousal sex, and unfavorable intention to use condoms [Table 2].
|Table 2: Bivariate analyses-effect of covariates on the prevalence of self-reported STI symptoms among male migrant workers in selected factories of Faridabad|
Click here to view
Multivariable logistic regression showed that higher age at migration, lower HIV/AIDS knowledge, having paid money for sex in the last 1 year, not having used a condom in the last non-spousal sexual intercourse, and having unfavorable "intention to use condoms" score were independently and significantly associated with self-reported STI. The model had a good fit to the data as assessed by the area under the receiver operating characteristic (ROC) curve (0.8) and the goodness of fit Chi-square test (P = 0.57) [Table 3].
|Table 3: Multivariable analysis-effect of covariates on the prevalence of self-reported STI symptoms among male migrant workers in selected factories of Faridabad|
Click here to view
| Discussion|| |
Almost half of the participants reported having at least one symptom of STI in the last 1 year. Among these men, more than one third reported having burning micturition, and other less-frequently reported symptoms were swelling in groin, genital ulcer, and urethral pus discharge.
Prevalence of genital discharge (1.3%) reported in this study was comparable to that reported among the general population males by BSS, 2006, which was 2% (Haryana males) and 1.6% (all India males), and that reported by National Family Health Survey (NFHS)-3, which was 1.2% (Haryana males) and 2.9% (all India males). Prevalence of genital ulcer (2.6%) reported by this study was comparable to that reported by BSS, 2006, which was 1.5% (Haryana males) and 3.4% (all India males), and that reported by NFHS-3, which was 0.6% (Haryana males) and 2.3% (all India males). , NFHS-3 also reported the prevalence of genital discharge and ulcer in two subgroups of interest. In the "men away from their homes for more than a month" subgroup, the proportions were 4.1 and 3.3% and in the "production workers" subgroup, the proportions were 3.1 and 2.3%, respectively, for genital discharge and ulcer.
Saggurti et al.  reported a prevalence of 64% for at least one symptom of STI among migrant workers and the Population Council study ,,, reported a prevalence of 36-68% for the same, which is comparable to the current study. Another study done among migrant workers in Surat reported a prevalence of about 10% for any STI, which was much lower than the current study possibly because these were laboratory-confirmed cases.  Across these different studies, the definition of STI was not constant and methods of determining their presence were also variable, hence limiting the across study comparability. Some studies included only three symptoms, whereas others included four symptoms. Some studies included scrotal swelling as a symptom, while others did not. Recall period varied from 3 months to 1 year to lifetime among studies.
Although several socio-demographic, migration-related, and risk behavior variables were found to be significantly associated with self-reported STIs in bivariate analysis, only five of them were found to be independently associated in multivariable analysis. Migration-related factors such as leaving home for work-related purposes at a later age as compared to an earlier age were associated with greater reporting of STI symptoms. This could be explained as being due to the greater amount of time spent in destination sites after migration that leads to more exposure to risky behavior and, therefore, higher risk of STIs. Other authors have reported migration as a risk factor for STIs, such as Zuma et al.  who reported in a study from rural South Africa that migrant men (OR = 1.5) as compared to non-migrant men were at higher risk for acquiring STIs. Migration, especially from rural to urban, as a risk factor for acquisition of STIs has been stressed adequately in literature. ,,, High-risk sexual behavior such as having recently paid money for sex and not having used condom at the last non-spousal sex were also associated with greater reporting of STI symptoms. Others author have reported risky behavior being associated with STI; for example, Zuma et al.  reported that younger age at initiation of sexual intercourse and having two or more recent sexual partners were associated with higher STI risk. A lower HIV/AIDS knowledge score and unfavorable "intention to use condoms" score were also found associated in our study. This finding helps us in postulating that lower knowledge regarding HIV/AIDS may increase the risk for acquiring STIs. However, we found that although knowledge was significantly associated in bivariate analysis, in multivariable analysis, knowledge was only marginally significant and the category also changed. Based on this, it cannot be conclusively stated that HIV/AIDS knowledge is highly significantly associated. It could be intuitively understood that an unfavorable intention to use condoms would reduce the condom use behavior and subsequently could lead to acquisition of STIs. But similar findings have not been reported by other studies in India. Other authors have reported determinants other than those reported in this study. For example, Dave et al.  reported factors like antibiotic use in the past 2 weeks, type of industry, and longer duration of stay at destination to be significantly associated with laboratory-confirmed STIs in migrant workers of Surat. The differences in results between our study and other studies may be due to the differences in sampling methodology, area of study, availability of local sex networks and health facilities, time period, and definitions of STI and migrant worker. The major strength of the study was its ability to examine a wide range of factors for association with STI symptoms. However, the social desirability bias inherent in the reporting of STI symptoms and sexual behavior was also applicable to this study. Since the STI symptoms were self-reported, the prevalence reported here might be an underestimate of the true prevalence.
We also examined the health-seeking behavior of those who had reported STI. BSS, 2006 reported that about 57% (Haryana males) and 58% (all India males) of those who reported STI symptoms had sought treatment from a health care provider, which was comparable to that (61%) found in this study.  But only one-fifth of our study participants reported having taken treatment from government facilities. This indicates the overall poor health-seeking behavior among these men. This may be due to lack of time, loss of wages, lack of awareness, and factors affecting accessibility to health facility. The NACO provides sexual and reproductive health services through designated STI/RTI clinics branded as "Suraksha Clinics" at district and sub-district level health facilities. A mechanism of designating a specific clinic to cater to a group of factories can be explored as a feasible option to reduce the burden of STIs among these men.
| Conclusion|| |
Finally, it can be stated that male migrant workers suffer from a significant burden of untreated STIs and that factors such as higher age at migration, lower HIV/AIDS knowledge, paid sex, non-use of condom at the last non-spousal sex, and unfavorable "intention to use condoms" were significantly associated with STI. As Targeted Intervention (TI) has been recognized as one of the core components in the control and prevention of STIs, interventions should be targeted specifically to reduce this burden and also their vulnerability.  Innovative approaches like linking Suraksha Clinics to a group of factories may also help in reducing the burden. Since STI and HIV epidemiology are intertwined to a large extent, control over STIs would provide indirect gains for HIV/AIDS prevention programs.
| References|| |
World Health Organization. Global Prevalence and Incidence of Selected Curable Sexually Transmitted Infections - Overview and Estimates. Geneva: World Health Organization; 2001. p. 8.
National AIDS Control Organisation. Ministry of Health and Family Welfare. Government of India. Operational Guidelines for Programme Managers and Service Providers for Strengthening STI/RTI Services. New Delhi: National AIDS Control Organisation; 2011. p. 9.
Hayes RJ, Schulz KF, Plummer FA. The cofactor effect of genital ulcers on the per-exposure risk of HIV transmission in sub-Saharan Africa. J Trop Med Hyg 1995;98:1-8.
Cohen MS, Hoffman IF, Royce RA, Kazembe P, Dyer JR, Daly CC, et al
. Reduction of concentration of HIV-1 in semen after treatment of urethritis: Implications for prevention of sexual transmission of HIV-1. AIDSCAP Malawi Research Group. Lancet 1997;349:1868-73.
Thappa DM, Singh S, Singh A. HIV infection and sexually transmitted diseases in a referral STD centre in south India. Sex Transm Infect 1999;75:191.
Ray K, Bala M, Gupta SM, Khunger N, Puri P, Muralidhar S, et al
. Changing trends in sexually transmitted infections at a Regional STD Centre in north India. Indian J Med Res 2006;124:559-68.
Zuma K, Lurie MN, Williams BG, Mkaya-Mwamburi D, Garnett GP, Sturm AW. Risk factors of sexually transmitted infections among migrant and non-migrant sexual partnerships from rural South Africa. Epidemiol Infect 2005;133:421-8.
Sharma VK, Khandpur S. Changing patterns of sexually transmitted infections in India. Natl Med J India 2004;17:310-9.
World Health Organization. Global Strategy for the Prevention and Control of Sexually Transmitted Infections: 2006 - 2015. Breaking the Chain of Transmission. Geneva: World Health Organization; 2007. p. 20.
National Institute of Health and Family Welfare. National AIDS Control Organisation. Ministry of Health and Family Welfare. Annual HIV Sentinel Surveillance: Country Report, 2008-09. New Delhi: National AIDS Control Organisation; 2011. p. 10.
Talukdar A, Bal R, Sanyal D, Roy K, Talukdar PS. Development of a scale for attitude toward condom use for migrant workers in India. Indian J Med Sci 2008;62:55-61.
National AIDS Control Organisation. Ministry of Health and Family Welfare. Government of India. National Behavioural Surveillance Survey (BSS): General Population. New Delhi: National AIDS Control Organisation; 2006. p. 74-8.
International Institute for Population Sciences (IIPS) and Macro International. 2007. National Family Health Survey (NFHS-3), 2005-06, India. Vol. 1. Mumbai: International Institute for Population Sciences (IIPS); p. 354-7.
Saggurti N, Verma RK, Jain A, RamaRao S, Kumar KA, Subbiah A, et al.
HIV risk behaviours among contracted and non-contracted male migrant workers in India: Potential role of labour contractors and contractual systems in HIV prevention. AIDS 2008;22(Suppl 5):S127-36.
Karnataka Health Promotion Trust (KHPT) and Population Council. Migration/Mobility and Vulnerability to HIV among Male Migrant Workers, Karnataka 2007-8. Bangalore: Karnataka Health Promotion Trust (KHPT); 2008. p. 32.
Population Council. Migration/Mobility and Vulnerability to HIV among Male Migrant Workers: Andhra Pradesh. New Delhi: Population Council; 2008. p. 37.
Tata Institute of Social Sciences (TISS) and Population Council. Migration/Mobility and Vulnerability to HIV among Male Migrant Workers: Maharashtra. Mumbai: Tata Institute of Social Sciences (TISS) and Population Council; 2008. p. 35.
Annamalai University and Population Council. Migration/Mobility and Vulnerability to HIV among Male Migrant Workers: Tamil Nadu. Chidambaram: Annamalai University; 2008. p. 38.
Dave SS, Copas A, Richens J, White RG, Kosambiya JK, Desai VK, et al.
HIV and STI prevalence and determinants among male migrant workers in India. PLoS One 2012;7:e43576.
Aral SO. Determinants of STD epidemics: Implications for phase appropriate intervention strategies. Sex Transm Infect 2002;78(Suppl 1):i3-13.
Poudel KC, Okumura J, Sherchand JB, Jimba M, Murakami I, Wakai S. Mumbai disease in far western Nepal: HIV infection and syphilis among male migrant-returnees and non-migrants. Trop Med Int Health 2003;8:933-9.
Mayaud P, Mabey D. Approaches to the control of sexually transmitted infections in developing countries: Old problems and modern challenges. Sex Transm Infect 2004;80:174-82.
He N, Detels R, Zhu J, Jiang Q, Chen Z, Fang Y, et al
. Characteristics and sexually transmitted diseases of male rural migrants in a metropolitan area of Eastern China. Sex Transm Dis 2005;32:286-92.
Centers for Disease Control and Prevention, World Bank. Sexually Transmitted Infections in developing Countries: Current Concepts and Strategies on Improving STI Prevention, Treatment, and Control. Available from: http://www.siteresources.worldbank.org/INTPRH/Resources/STINoteFINAL26Feb08.pdf. [Last accessed on 2013 Jul 30].
[Table 1], [Table 2], [Table 3]
|This article has been cited by|
||HIV and syphilis knowledge, perceptions, and practices among Myanmar migrant workers in Samut Sakhon Province, Thailand
| ||Alfrison Paloga, Dumrongkiet Arthan, Pannamas Maneekan, Patreeya Kitcharoen, Apichai Wattanapisit, Chirawat Paratthakonkun, Suparat Phuanukoonnon, Shoon Lei Nyan Wai Tun, Ngamphol Soonthornworasiri |
| ||BMC Public Health. 2022; 22(1) |
|[Pubmed] | [DOI]|
||Sexually Transmitted Infections (STIs) and Its Changing Scenario: A
| ||Sumit Aggarwal, Amit Kumar Singh, Sivaraman Balaji , Deepti Ambalkar |
| ||Combinatorial Chemistry & High Throughput Screening. 2022; 25(10): 1630 |
|[Pubmed] | [DOI]|
||Multifaceted Determinants of Sexual Intercourse with Non-Regular Female Sex Partners and Female Sex Workers among Male Factory Workers in China—A Cross-Sectional Survey
| ||Kechun Zhang, Siyu Chen, Shiben Zhu, Yuan Fang, Huachun Zou, Yong Cai, Bolin Cao, He Cao, Yaqi Chen, Tian Hu, Zixin Wang |
| ||International Journal of Environmental Research and Public Health. 2022; 19(23): 16008 |
|[Pubmed] | [DOI]|
||Covariates of Multiplicity of High-Risk Sexual Behavior Among Men in India: Evidence from the Latest Indian Demographic and Health Survey
| ||Shri Kant Singh,Santosh Kumar Sharma,Deepanjali Vishwakarma |
| ||Archives of Sexual Behavior. 2021; 50(1): 333 |
|[Pubmed] | [DOI]|
||Determinants of consistently high HIV prevalence in Indian Districts: A multi-level analysis
| ||Rajneesh Kumar Joshi,Sanjay M. Mehendale,Iratxe Puebla |
| ||PLOS ONE. 2019; 14(5): e0216321 |
|[Pubmed] | [DOI]|
||Are Opportunities Being Missed? Burden of HIV, STI and TB, and Unawareness of HIV among African Migrants
| ||Sónia Dias,Ana Gama,Ana Maria Tavares,Vera Reigado,Daniel Simões,Emília Carreiras,Cristina Mora,Andreia Pinto Ferreira |
| ||International Journal of Environmental Research and Public Health. 2019; 16(15): 2710 |
|[Pubmed] | [DOI]|
||Detection of genital chlamydial and gonococcal infection using urine samples: A community-based study from India
| ||Anjana Krishnan,Sasidharanpillai Sabeena,Parvati V. Bhat,Veena Kamath,Maity Hindol,Vahid Rajabali Zadeh,Govindakarnavar Arunkumar |
| ||Journal of Infection and Public Health. 2017; |
|[Pubmed] | [DOI]|