Epidemiological surveillance study of female genital mutilation in the UK.

OBJECTIVES: Describe cases of female genital mutilation (FGM) presenting to consultant paediatricians and sexual assault referral centres (SARCs), including demographics, medical symptoms, examination findings and outcome. DESIGN: The well-established epidemiological surveillance study performed through the British Paediatric Surveillance Unit included FGM on the monthly returns. SETTING: All consultant paediatricians and relevant SARC leads across the UK and Ireland. PATIENTS: Under 16 years old with FGM. INTERVENTIONS: Data on cases from November 2015 to November 2017 and 12 months later meeting the case definition of FGM. MAIN OUTCOME MEASURES: Returns included 146 cases, 103 (71%) had confirmed FGM and 43 (29%) did not meet the case definition. There were none from Northern Ireland. RESULTS: The mean reported age was 3 years. Using the WHO classification of FGM, 58% (n=60) had either type 1 or type 2, 8% (n=8) had type 3 and 21% (n=22) had type 4. 13% (n=13) of the cases were not classified and none had piercings or labiaplasty. The majority, 70% had FGM performed in Africa with others from Europe, Middle East and South-East Asia. There were few physical and mental health symptoms. Only one case resulted in a successful prosecution. CONCLUSIONS: There were low numbers of children presenting with FGM and in the 2 years there was only one prosecution. The findings may be consistent with attitude changes in FGM practising communities and those at risk should be protected and supported by culturally competent national policies.

Metodología de diálogos interculturales / Methodology of intercultural dialogues

Contiene un marco legal sobre la salud de los pueblos indígenas. El objetivo del documento es el de "Propiciar un espacio de encuentro y consenso entre las percepciones y expectativas de terapeutas tradicionales y prestadores de salud institucional, basado en la generación de la auto-identidad y el respeto a las diferencias." Señala además que, "La atención primaria en salud requiere de establecimientos adecuados y personal sensibilizado para prestar sus servicios con pertinencia cultural, la cual, es un enfoque de intervención que busca que la atención sanitaria sea conceptualizada, organizada e implementada tomando como referentes los valores de la cosmovisión de los pueblos indígenas." Enfatizando ser una estrategia institucional, agrega que: "El Departamento de Promoción y Educación en Salud de la DGSIAS propone esta metodología para la realización de diálogos interculturales que tiene como objetivo principal generar un proceso estratégico para la adecuación de los servicios de salud y la sensibilización del personal hacia una atención con pertinencia cultural." Hace referencia al documento: "Normas con pertinencia cultural: hacia la interculturalidad", que también puede encontrarse en eBlueInfo En el marco conceptual, aborda términos relacionados, y específicamente enumera los nombres (en lengua) y sus "especialidades" en la medicina tradicional. "Esta metodología fue construida con acompañamiento de la Unidad de Atención en Salud para Pueblos Indígenas e Interculturalidad (UASPIIG) y validada en campo entre los años 2014 y 2015 como ejercicio de diálogos entre comadronas y proveedores de servicios de salud del MSPAS, en la plataforma de intervención del Proyecto Mesoamérica 2015." Incluye además, talleres de concientización intercultural, tanto para "terapeutas tradicionales", como para el personal médico.

Coming to America: Regulatory Oversight of United States Immigration Policies: A Brief History.

This article briefly covers the history of immigration from the US perspective, including the demographic variation over time and the ever-changing policies. Displaced children and their families are facing increasing challenges to their health and overall wellbeing. Since enactment of the Immigration and Nationality Act of 1965, the needs of minors have been caught up in complex immigration policy. Recognition of the unique needs of minors and the Dreamers must be addressed as part of comprehensive immigration reform or in more targeted legislative proposals. The challenges posed by the magnitude and scope of the immigration problem are discussed.

Acesso à saúde de populações vulneráveis: uma visão sob o enfoque da bioética / Acceso a la salud de poblaciones vulnerables: una visión desde la bioética / Vulnerable population's access to healthcare: A view from Bioethics / Accés a la salut de poblacions vulnerables: una visió des de la bioètica

Este artigo discute as questões em torno do acesso à saúde dos grupos étnicos denominados quilombolas. Os quilombos contemporâneos são grupos tradicionais com organização política-econômica-histórica-cultural, que ao longo do tempo lutam pela inclusão social por meio das políticas públicas e ações de atenção integral. O Sistema Único de Saúde (SUS) defende que efetivar o direito humano à saúde da população é estabelecer padrões de equidade na política de saúde do país. Nessa perspectiva, a Bioética torna-se um instrumento de inclusão social pautando discussões democráticas acerca dos problemas que reduzem à população ao acesso equitativo e as melhores condições de vida, saúde e bem-viver

Este artículo discute las cuestiones en torno al acceso a la salud de los grupos étnicos denominados quilombolas. Los quilombos contemporáneos son grupos tradicionales con organización político-económica-histórica-cultural, que a lo largo del tiempo luchan por la inclusión social por medio de las políticas públicas y acciones de atención integral. El Sistema Único de Salud (SUS) de Brasil defiende que el derecho humano a la salud de la población es establecer estándares de equidad en la política de salud del país. En esta perspectiva, la Bioética se convierte en un instrumento de inclusión social que guía las discusiones democráticas acerca los problemas para el acceso equitativo y las mejores condiciones de vida, salud y bienestar de la población

This article discusses the issues related to access to healthcare of ethnic groups called quilombolas. Contemporary quilombos are traditional groups with political-economic-historical-cultural organization, which over time struggle for social inclusion through public policies and actions of comprehensive care. The Unified Health System (SUS) states that implementing the human right to health of the population is establishing equity standards in the health policy of the country. In this perspective, Bioethics becomes a social inclusion instrument guiding democratic discussions about the problems that reduce equitable access and better living, health and good living conditions of the population

Aquest article discuteix les qüestions entorn de l'accés a la salut dels grups ètnics anominats quilombolas. Els quilombos contemporanis són grups tradicionals amb una organització polític-econòmica-històrica-cultural pròpia que al llarg del temps lluiten per la inclusió social per mitjà de les polítiques públiques i accions d'atenció integral. El Sistema Únic de Salut de Brasil defensa que el dret humà a la salut de la població exigeix que s’ estableixin estàndards d'equitat en la política de salut del país. Des d’aquesta perspectiva, la Bioètica es converteix en un instrument d'inclusió social que guia les discussions democràtiques sobre els problemes per a l'accés equitatiu i les millors condicions de vida, salut i benestar de la població

Racial and Ethnic Disparities in Meeting MTM Eligibility Criteria Based on Star Ratings Compared with the Medicare Modernization Act.

BACKGROUND: Previous research found racial and ethnic disparities in meeting medication therapy management (MTM) eligibility criteria implemented by the Centers for Medicare & Medicaid Services (CMS) in accordance with the Medicare Modernization Act (MMA). OBJECTIVE: To examine whether alternative MTM eligibility criteria based on the CMS Part D star ratings quality evaluation system can reduce racial and ethnic disparities. METHODS: This study analyzed the Beneficiary Summary File and claims files for Medicare beneficiaries linked to the Area Health Resource File. Three million Medicare beneficiaries with continuous Parts A, B, and D enrollment in 2012-2013 were included. Proposed star ratings criteria included 9 existing medication safety and adherence measures developed mostly by the Pharmacy Quality Alliance. Logistic regression and the Blinder-Oaxaca approach were used to test disparities in meeting MMA and star ratings eligibility criteria across racial and ethnic groups. Multinomial logistic regression was used to examine whether there was a disparity reduction by comparing individuals who were MTM-eligible under MMA but not under star ratings criteria and those who were MTM-eligible under star ratings criteria but not under the MMA. Concerning MMA-based MTM criteria, main and sensitivity analyses were performed to represent the entire range of the MMA eligibility thresholds reported by plans in 2009, 2013, and proposed by CMS in 2015. Regarding star ratings criteria, meeting any 1 of the 9 measures was examined as the main analysis, and various measure combinations were examined as the sensitivity analyses. RESULTS: In the main analysis, adjusted odds ratios for non-Hispanic blacks (backs) and Hispanics to non-Hispanic whites (whites) were 1.394 (95% CI = 1.375-1.414) and 1.197 (95% CI = 1.176-1.218), respectively, under star ratings. Blacks were 39.4% and Hispanics were 19.7% more likely to be MTM-eligible than whites. Blacks and Hispanics were less likely to be MTM-eligible than whites in some sensitivity analyses. Disparities were not completely explained by differences in patient characteristics based on the Blinder-Oaxaca approach. The multinomial logistic regression of each main analysis found significant adjusted relative risk ratios (RRR) between whites and blacks for 2009 (RRR = 0.459, 95% CI = 0.438-0.481); 2013 (RRR = 0.449, 95% CI = 0.434-0.465); and 2015 (RRR = 0.436, 95% CI = 0.425-0.446) and between whites and Hispanics for 2009 (RRR = 0.559, 95% CI = 0.528-0.593); 2013 (RRR = 0.544, 95% CI = 0.521-0.569); and 2015 (RRR = 0.503, 95% CI = 0.488-0.518). These findings indicate a significant reduction in racial and ethnic disparities when using star ratings eligibility criteria; for example, black-white disparities in the likelihood of meeting MTM eligibility criteria were reduced by 55.1% based on star ratings compared with MMA in 2013. Similar patterns were found in most sensitivity and disease-specific analyses. CONCLUSIONS: This study found that minorities were more likely than whites to be MTM-eligible under the star ratings criteria. In addition, MTM eligibility criteria based on star ratings would reduce racial and ethnic disparities associated with MMA in the general Medicare population and those with specific chronic conditions. DISCLOSURES: Research reported in this publication was supported by the National Institute on Aging of the National Institutes of Health under award number R01AG049696. The content of this study is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Cushman reports an Eli Lilly grant and uncompensated consulting for Takeda Pharmaceuticals outside this work. The other authors have no potential conflicts of interest to report. Study concept and design were contributed by Wang and Shih, along with Wan, Kuhle, Spivey, and Cushman. Wang, Qiao, and Wan took the lead in data collection, with assistance from the other authors. Data interpretation was performed by Wang, Kuhle, and Qiao, with assistance from the other authors. The manuscript was written by Spivey and Qiao, along with the other authors, and revised by Cushman, Dagogo-Jack, and Chisholm-Burns, along with the other authors.

Denying access of Particularly Vulnerable Tribal Groups to contraceptive services: a case study among the Baiga community in Chhattisgarh, India.

Baigas are a Particularly Vulnerable Tribal Group (PVTG), categorised as the most vulnerable amongst indigenous communities in India. As a strategy to stall their decreasing population, due mainly to high mortality, in 1979 the government restricted their access to permanent contraceptive methods, and this is enforced as a "ban". Using a case study design with mixed methods, this study aims to understand the experiences and perceptions of Baigas in Chhattisgarh in accessing contraceptive services. Data was collected through: a household survey (n = 289) in 13 habitations; individual interviews and group discussions with Baiga men and women and health service providers; and anthropometry. The Baiga suffer poor nutritional status and poverty, out of proportion with district and state averages. Of the women interviewed, 61.3% have had four or more pregnancies and 61.3% have experienced the loss of child at least once during pregnancy or later. Baiga women's forehead tattoo, a marker of their identity, is used to deny them contraceptive services. Baiga women either have to travel to the neighbouring state to avail themselves of services, or lie about their identity. They are usually unable to access even the temporary methods. This coercive policy has led to their further impoverishment. Baigas have been demanding the right to contraceptive services. Denying contraceptive services is a violation of reproductive and human rights and the right to self-determination and bodily autonomy.

Improvements in Outcomes for Ethnic Minorities During the Share 35 Era Are Not Due to Decreased Rates of Early Graft Loss.

OBJECTIVES: Our aim was to investigate the effects of the Share 35 policy on outcomes in ethnic minorities and recipients who experienced early graft failure. MATERIALS AND METHODS: We analyzed donor and recipient data from the United Network for Organ Sharing database before (June 6, 2011 to June 18, 2013) and after (June 18, 2013 to June 30, 2015) implementation of Share 35. Graft and patient survival outcomes were compared. RESULTS: There were significant differences in 1- and 2-year graft and patient survival rates between ethnicities pre-Share 35 (P = .03, P < .001, P = .01, P < .001, respectively). There were no significant differences in 1- and 2-year graft and patient survival between ethnicities post-Share 35 (P = .268, P = .09, P = .343, P = .087, respectively). There were no differences in early graft failure rates pre- and post-Share 35 at 7 days (2.1% vs 2.0; P = .71) and 30 days (4.0% vs 3.8%; P = .47) after transplant, with a decreased early graft failure rate shown at 90 days after transplant (6.8% vs 5.8%; P = .003). When analyzed separately, the low Model for End-Stage Liver Disease (score of < 35) and the high Model for End-Stage Liver Disease recipients (score of ≥ 35) both exhibited reduced early graft failure rates post-Share 35 (6.1% vs 5.3% and 10.8% vs 7.8%, respectively; P < .05). CONCLUIONS: Share 35 was associated with a short-term reduction in ethnic disparities. Most ethnic groups experienced improved survival in the Share 35 era. Share 35 was not associated with an increase in early graft failure and is an efficacious policy with regard to short-term outcomes.

Reducing Racial and Ethnic Disparities in Access to Care: Has the Affordable Care Act Made a Difference?

ISSUE: Prior to the Affordable Care Act (ACA), blacks and Hispanics were more likely than whites to face barriers in access to health care. GOAL: Assess the effect of the ACA's major coverage expansions on disparities in access to care among adults. METHODS: Analysis of nationally representative data from the American Community Survey and the Behavioral Risk Factor Surveillance System. FINDINGS AND CONCLUSIONS: Between 2013 and 2015, disparities with whites narrowed for blacks and Hispanics on three key access indicators: the percentage of uninsured working-age adults, the percentage who skipped care because of costs, and the percentage who lacked a usual care provider. Disparities were narrower, and the average rate on each of the three indicators for whites, blacks, and Hispanics was lower in both 2013 and 2015 in states that expanded Medicaid under the ACA than in states that did not expand. Among Hispanics, disparities tended to narrow more between 2013 and 2015 in expansion states than nonexpansion states. The ACA's coverage expansions were associated with increased access to care and reduced racial and ethnic disparities in access to care, with generally greater improvements in Medicaid expansion states.

Injuries sustained during contact with law enforcement: An analysis from US trauma centers.

BACKGROUND: Injuries sustained by civilians from interaction with police are a polarizing contemporary sociopolitical issue. Few comprehensive studies have been published using national hospital-based data. The aim of this study was to examine the epidemiology of these injuries to better understand this mechanism of injury. METHODS: Patients entered into the National Trauma Data Bank (NTDB) (January 2007 to December 2012) with E-codes E970.0 to E976.0 (International Classification of Diseases, Ninth Revision, Clinical Modification), identifying injuries associated with law enforcement in the course of legal action, were enrolled. Patients' demographics, injury characteristics, procedures, and outcomes were collected and analyzed. Patients injured by other civilians (E960.0-E968.0) were used for comparison. RESULTS: Of 4,146,428 patients in the NTDB, 7,203 (0.17%) were injured during interaction with police. The numbers of patients in consecutive study years were 858, 1,103, 1,148, 1,274, 1,316, and 1,504. The incidence of these injuries was stable over time (0.17-0.18%) (p = 0.129). Patients had a median age of 31 years (range, 0-108), and 94.3% were male. Median injury severity score was 9 (interquartile range [IQR], 4-17). The most common mechanism of injury was gunshot wound (44%).Patients were white, 43%; black, 30%; Hispanic, 17%; Asian, 1%; and Other, 9%. As a proportion of the total race-specific NTDB trauma population, there was an average of 1.13 white patients, 2.71 Hispanic patients, and 3.83 black patients per 1,000. Mechanism, injury severity score, and outcomes did not vary by race. Compared to patients injured by civilians, patients injured by police are more likely to be white (43% vs 25%, p < 0.001) and injured by gunshot wounds (44% vs 32%, p < 0.001). CONCLUSIONS: Based on data from trauma centers across the United States, the rate of injuries sustained during interactions with police has been stable over time. Gunshot wounds are the most common mechanism of injury. Proportionally, black patients are the most frequently injured race. When compared to patients injured by civilians, however, patients injured by police are more likely to be white. This study provides a step toward a better understanding of police-associated injuries. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III.

The effects of China's universal two-child policy.

In October, 2015, China's one-child policy was replaced by a universal two-child policy. The effects of the new policy are inevitably speculative, but predictions can be made based on recent trends. The population increase will be relatively small, peaking at 1·45 billion in 2029 (compared with a peak of 1·4 billion in 2023 if the one-child policy continued). The new policy will allow almost all Chinese people to have their preferred number of children. The benefits of the new policy include: a large reduction in abortions of unapproved pregnancies, virtual elimination of the problem of unregistered children, and a more normal sex ratio. All of these effects should improve health outcomes. Effects of the new policy on the shrinking workforce and rapid population ageing will not be evident for two decades. In the meantime, more sound policy actions are needed to meet the social, health, and care needs of the elderly population.

Specialty courts: Who's in and are they working?

The effectiveness of specialty courts has been well established in the literature; however, previous studies have not taken into account referral biases that may exist based on offenders' race, socioeconomic status (SES), attorney status, and so forth. The current study hypothesized that (a) Participants who are racially diverse, of lower SES, and represented by privately retained attorneys would be referred less frequently to specialty courts, and (b) Participants in specialty courts would evidence reductions in missed court appointments and failed urinary analyses (UAs) compared with peers not enrolled in specialty courts. Participants (N = 274) were probationers who were involved in 1 of 3 specialty court programs (i.e., drug, driving while intoxicated [DWI], or reentry courts) or a matched sample of probationers not in specialty court services. Results indicated that, in general and with few exceptions, specialty courts did not have differential referral rates based on offender demographics including race, ethnicity, SES, or attorney status (court appointed vs. privately retained). Results examining the effectiveness of the specialty courts were mixed. Participants in the in-prison treatment program reentry court missed a greater proportion of scheduled court meetings than did their matched sample counterparts; however, the other specialty court programs did not significantly differ from their matched-sample counterparts. Participants in the DWI court had a significantly smaller proportion of UA failures to total UAs than did their matched sample peers; however, the drug court and reentry court programs did not significantly differ from their matched sample counterparts. Implications, future directions, and limitations are discussed. (PsycINFO Database Record

"Coming Out" of Prison: An Exploratory Study of LGBT Elders in the Criminal Justice System.

This two-phase qualitative study explores the experiences of 10 formerly incarcerated LGBT elders' experiences prior to, during, and after release from prison. A core theme of self and the social mirror emerged from the data that represented LGBT elders ongoing coming-out process of unearthing their "true selves" despite managing multiple stigmatized identities or social locations, such as being LGBT, elderly, HIV positive, formerly incarcerated, and a racial/ethnic minority. These findings further our awareness of an overlooked population of LGBT who are older and involved in the criminal justice system. Recommendations that incorporate suggestions from formerly incarcerated LGBT elders for services and policy reform are presented.

Creating a cultural analysis tool for the implementation of Ontario's civil mental health laws.

Ethno-racial people with mental health disabilities experience multiple inequities and differential outcomes when interacting with Ontario's civil mental health laws. Given the increasing multi-racial population in Ontario, there is a need to develop mechanisms to address these intersecting issues. Other countries that have created evaluative tools for mental health legislation include the United Kingdom and Australia. Australia's Rights Analysis Tool, the United Kingdom's Race Equality Impact Assessment, the Scottish Recovery Tool, and the World Health Organization's Mental Health and Human Rights checklist are examples of evaluative tools developed for mental health legislation. Such a tool does not exist in Canada, let alone in Ontario specifically. Thus, this study developed a Cultural Analysis Tool (CAT) consisting of specific and meaningful thematic questions that can be used by practitioners when addressing issues of culture and equity for ethno-racial people with mental health disabilities interacting with Ontario's civil mental health laws. It is hoped that the CAT, and the research underlying its development, will enable practitioners to critically question whether cultural and intersecting concerns are being appropriately addressed within an ethno-racial client's case and, furthermore, how equitable outcomes can be achieved. This article describes and analyzes the methodology, research and qualitative data used to develop the CAT. It then presents and examines the CAT itself. The qualitative data was drawn from thirty-five semi-structured interviews with seven members of each of the following groups: (1) ethno-racial people with mental health disabilities including in-patients and ex-patients, (2) lawyers who practice in the area of mental health law, (3) health care professionals including psychiatrists, nurses and social workers, (4) service providers such as front-line case workers at mental health agencies and (5) adjudicators, government advisors and academics. After an analysis of these data, the CAT's questions were refined through an expert review (involving the qualitative technique of member-checking) using three focus groups comprised of ethno-racial people with mental health disabilities, mental health lawyers and service providers and health care professionals.