An in-depth analysis of the mitochondrial phylogenetic landscape of Cambodia.

Cambodia harbours a variety of human aboriginal populations that have scarcely been studied in terms of genetic diversity of entire mitochondrial genomes. Here we present the matrilineal gene pool of 299 Cambodian refugees from three different ethnic groups (Cham, Khmer, and Khmer Loeu) deriving from 16 Cambodian districts. After establishing a DNA-saving high-throughput strategy for mitochondrial whole-genome Sanger sequencing, a HaploGrep based workflow was used for quality control, haplogroup classification and phylogenetic reconstruction. The application of diverse phylogenetic algorithms revealed an exciting picture of the genetic diversity of Cambodia, especially in relation to populations from Southeast Asia and from the whole world. A total of 224 unique haplotypes were identified, which were mostly classified under haplogroups B5a1, F1a1, or categorized as newly defined basal haplogroups or basal sub-branches of R, N and M clades. The presence of autochthonous maternal lineages could be confirmed as reported in previous studies. The exceptional homogeneity observed between and within the three investigated Cambodian ethnic groups indicates genetic isolation of the whole population. Between ethnicities, genetic barriers were not detected. The mtDNA data presented here increases the phylogenetic resolution in Cambodia significantly, thereby highlighting the need for an update of the current human mtDNA phylogeny.

Health determinants among refugees in Austria and Germany: A propensity-matched comparative study for Syrian, Afghan, and Iraqi refugees.

In recent years, Germany and Austria have been among the leading European receiving countries for asylum seekers and refugees (AS&R). The two countries have cultural and economic similarities, but differ, for example, in their health care systems, with AS&R having unrestricted access to health services upon arrival in Austria, but not in Germany. This study investigates the determinants of health among refugees in Austria and Germany, and how these determinants differ between the two countries. We analyze comparable and harmonized survey data from both countries for Syrian, Afghan, and Iraqi nationals aged 18 to 59 years who had immigrated between 2013 and 2016 (Germany: n = 2,854; Austria: n = 374). The study adopts a cross-sectional design, and uses propensity score matching to examine comparable AS&R in the two receiving countries. The results reveal that the AS&R in Germany (72%) were significantly less likely to report being in (very) good health than their peers in Austria (89%). Age and education had large impacts on health, whereas the effects of length of stay and length of asylum process were smaller. Compositional differences in terms of age, sex, nationality, education, and partnership situation explained the country differences only in part. After applying propensity score matching to adjust for structural differences and to assess non-confounded country effects, the probability of reporting (very) good health was still 12 percentage points lower in Germany than in Austria. We conclude that many of the determinants of health among AS&R correspond to those in the non-migrant population, and thus call for the implementation of similar health policies. The health disadvantage found among the AS&R in Germany suggests that removing their initially restricted access to health care may improve their health.

An overview of systematic reviews on mental health promotion, prevention, and treatment of common mental disorders for refugees, asylum seekers, and internally displaced persons.

BACKGROUND: Migrants who have been forced to leave their home, such as refugees, asylum seekers, and internally displaced persons (IDP), are likely to experience stressors which may lead to mental health problems. The efficacy of interventions for mental health promotion, prevention, and treatment may differ in this population. OBJECTIVES: With this overview of systematic reviews, we will map the characteristics and methodological quality of existing systematic reviews and registered systematic review protocols on the promotion of mental health and prevention and treatment of common mental disorders among refugees, asylum seekers, and IDPs. The findings from this overview will be used to prioritise and inform future Cochrane reviews on the mental health of involuntary migrants. METHODS: We searched Ovid MEDLINE (1945 onwards), Ovid Embase (1974 onwards), Ovid PsycINFO, ProQuest PTSDpubs, Web of Science Core Collection, Cochrane Database of Systematic Reviews, NIHR Journals Library, CRD databases (archived), DoPHER, Epistemonikos, Health Evidence, 3ie International Initiative for Impact Evaluation, and PROSPERO, to identify systematic reviews of mental health interventions for involuntary migrants. We did not apply any restrictions on date, language, or publication status to the searches. We included systematic reviews or protocols for systematic reviews of interventions aimed at refugees, asylum seekers, and internally displaced persons. Interventions must have been aimed at mental health promotion (for example, classroom-based well-being interventions for children), prevention of mental health problems (for example, trauma-focussed Cognitive Behavioural Therapy to prevent post-traumatic stress disorder), or treatment of common mental disorders and symptoms (for example, narrative exposure therapy to treat symptoms of trauma). After screening abstracts and full-text manuscripts in duplicate, we extracted data on the characteristics of the reviews, the interventions examined in reviews, and the number of primary studies included in each review. Methodological quality of the included systematic reviews was assessed using AMSTAR 2. MAIN RESULTS: The overview includes 23 systematic reviews and 15 registered systematic review protocols. Of the 23 published systematic reviews, meta-analyses were conducted in eight reviews. It was more common for the search strategy or inclusion criteria of the reviews to state that studies involving refugees were eligible for inclusion (23/23), than for asylum seekers (14/23) or IDPs (7/23) to be explicitly mentioned. In most reviews, study eligiblity was either not restricted by participant age (9/23), or restricted to adults (10/23). Reviews commonly reported on studies of diagnosis or symptoms of post-traumatic stress disorder or trauma (11/23) and were less likely to report on depression or anxiety (6/23). In 15 reviews the intervention of interest was focused on/ specific to psychological therapy. Across all 23 reviews, the interventions most commonly identified from primary studies were general Cognitive Behavioural Therapy, Narrative Exposure Therapy, and a range of different integrative and interpersonal therapies. Even though many reviews included studies of participants without a diagnosis of a mental health problem, they often assessed mental health treatments and did not usually distinguish between promotion, prevention, and treatment in the review aims. Together the 23 systematic reviews included 336 references, of which 175 were unique primary studies. Limitations to the methodological quality of reviews most commonly related to reporting of selection criteria (21/23), absence of a protocol (19/23), reporting of study design (20/23), search strategy (22/23), and funding sources of primary studies (19/23). AUTHORS' CONCLUSIONS: Gaps exist in the evidence on mental health interventions for refugees, asylum seekers, and internally displaced persons. Most reviews do not specify that internally displaced persons are included in the selection criteria, even though they make up the majority of involuntary migrants worldwide. Reviews specific to mental health promotion and prevention of common mental disorders are missing, and there is more evidence available for adults or mixed populations than for children. The literature is focused on post-traumatic stress disorder and trauma-related symptoms, with less attention for depression and anxiety disorders. Better quality systematic reviews and better report of review design and methods would help those who may use these reviews to inform implementation of mental health interventions.

How Should Unaccompanied Minors in Immigration Detention Be Protected From Coercive Medical Practices?

Current policies and ongoing border crossings have increased the number of unaccompanied minors and the length of time they spend in detention. The US Department of Health and Human Services Office of Refugee Resettlement and its detention facilities currently determine what constitutes appropriate medical care for unaccompanied minors in immigration detention. This care might not be in a child's best interest. In contrast, juvenile detention and human subject research regulations rely on child advocates and court orders to protect children from coercion and safeguard a child's best interest. It is urgent that the medical community advocate for these same safeguards to be put in place for the unaccompanied minors in immigration detention.

[Tuberculosis among asylum seekers].

Global migration is increasing, including migration from tuberculosis (TB) high-incidence countries to TB low-incidence countries as Denmark. Asylum seekers are at increased risk of having TB, and screening for TB is potentially highly relevant in Europe. However, there is a large variation in the ways screening is carried out and in the yield of the different screening programmes. There is a need of more quality data on how effectively to target the screening among asylum seekers, considering both the TB incidence in the country of origin and the risk factors along the migration route.

Reducing acquisition time for MRI-based forensic age estimation.

Radiology-based estimation of a living person's unknown age has recently attracted increasing attention due to large numbers of undocumented immigrants entering Europe. To avoid the application of X-ray-based imaging techniques, magnetic resonance imaging (MRI) has been suggested as an alternative imaging modality. Unfortunately, MRI requires prolonged acquisition times, which potentially represents an additional stressor for young refugees. To eliminate this shortcoming, we investigated the degree of reduction in acquisition time that still led to reliable age estimates. Two radiologists randomly assessed original images and two sets of retrospectively undersampled data of 15 volunteers (N = 45 data sets) applying an established radiological age estimation method to images of the hand and wrist. Additionally, a neural network-based age estimation method analyzed four sets of further undersampled images from the 15 volunteers (N = 105 data sets). Furthermore, we compared retrospectively undersampled and acquired undersampled data for three volunteers. To assess reliability with increasing degree of undersampling, intra-rater and inter-rater agreement were analyzed computing signed differences and intra-class correlation. While our findings have to be confirmed by a larger prospective study, the results from both radiological and automatic age estimation showed that reliable age estimation was still possible for acquisition times of 15 seconds.

[Diagnostics and initial estimation of refugee minors]. / Diagnostik und Ersteinschätzung bei minderjährigen Flüchtlingen.

The number of underage refugees arriving in Germany has rapidly increased since 2015. Many of these children and adolescents have been and still are, exposed to a large number of stressful circumstances. The group of those helping refugee minors is heterogeneous with both volunteers and professional workers from the fields of child welfare and healthcare services. Easily applicable instruments to assess both burdens and resources are needed in order to plan appropriate interventions. This paper focuses on instruments for assessing the circumstances of refugee minors and includes pilot data of an online-based screening instrument to assess burdens and resources (providing online resource and trauma assessment for refugees, PORTA). Field application was tested by the staff of a clearing and preclearing institution with 33 cases and good practical feasibility was reported. Applying a simple to use screening instrument for refugee minors and their helpers, which is available in several languages creates the possibility of a shared definition of problems and solutions and is beneficial to helpers (e.g. volunteers, youth welfare services and medical doctors) as well as refugee minors.

Maternal health and pregnancy outcomes comparing migrant women born in humanitarian and nonhumanitarian source countries: a retrospective, observational study.

BACKGROUND: The relationship between migration and pregnancy outcomes is complex, with little insight into whether women of refugee background have greater risks of adverse pregnancy outcomes than other migrant women. This study aimed to describe maternal health, pregnancy care, and pregnancy outcomes among migrant women from humanitarian and nonhumanitarian source countries. METHODS: Retrospective, observational study of singleton births, at a single maternity service in Australia 2002-2011, to migrant women born in humanitarian source countries (HSCs, n = 2,713) and non-HSCs (n = 10,606). Multivariable regression analysis assessed associations between maternal HSC-birth and pregnancy outcomes. RESULTS: Compared with women from non-HSCs, the following were more common in women from HSCs: age < 20 years (0.6 vs 2.9% p < 0.001), multiparity (51 vs 76% p < 0.001), body mass index (BMI) ≥ 25 (38 vs 50% p < 0.001), anemia (3.2 vs 5.9% p < 0.001), tuberculosis (0.1 vs 0.4% p = 0.001), and syphilis (0.4 vs 2.5% p < 0.001). Maternal HSC-birth was independently associated with poor or no pregnancy care attendance (OR 2.5 [95% CI 1.8-3.6]), late first pregnancy care visit (OR 1.3 [95% CI 1.1-1.5]), and postterm birth (> 41 weeks gestation) (OR 2.5 [95% CI 1.9-3.4]). Stillbirth (0.8 vs 1.2% p = 0.04, OR 1.5 [95% CI 1.0-2.4]) and unplanned birth before arrival at the hospital (0.6 vs 1.2% p < 0.001, OR 1.3 [95% CI 0.8-2.1]) were more common in HSC-born women but not independently associated with maternal HSC-birth after adjusting for age, parity, BMI and relative socioeconomic disadvantage. CONCLUSIONS: These findings suggest areas where women from HSCs may have additional needs in pregnancy compared with women from non-HSCs. Refugee-focused strategies to support engagement in pregnancy care and address maternal health needs would be expected to improve health outcomes in resettlement countries.

Use of country of birth as an indicator of refugee background in health datasets.

BACKGROUND: Routine public health databases contain a wealth of data useful for research among vulnerable or isolated groups, who may be under-represented in traditional medical research. Identifying specific vulnerable populations, such as resettled refugees, can be particularly challenging; often country of birth is the sole indicator of whether an individual has a refugee background. The objective of this article was to review strengths and weaknesses of different methodological approaches to identifying resettled refugees and comparison groups from routine health datasets and to propose the application of additional methodological rigour in future research. DISCUSSION: Methodological approaches to selecting refugee and comparison groups from existing routine health datasets vary widely and are often explained in insufficient detail. Linked data systems or datasets from specialized refugee health services can accurately select resettled refugee and asylum seeker groups but have limited availability and can be selective. In contrast, country of birth is commonly collected in routine health datasets but a robust method for selecting humanitarian source countries based solely on this information is required. The authors recommend use of national immigration data to objectively identify countries of birth with high proportions of humanitarian entrants, matched by time period to the study dataset. When available, additional migration indicators may help to better understand migration as a health determinant. Methodologically, if multiple countries of birth are combined, the proportion of the sample represented by each country of birth should be included, with sub-analysis of individual countries of birth potentially providing further insights, if population size allows. United Nations-defined world regions provide an objective framework for combining countries of birth when necessary. A comparison group of economic migrants from the same world region may be appropriate if the resettlement country is particularly diverse ethnically or the refugee group differs in many ways to those born in the resettlement country. SUMMARY: Routine health datasets are valuable resources for public health research; however rigorous methods for using country of birth to identify resettled refugees would optimize usefulness of these resources.

The association between immigrant subgroup and poor mental health: a population-based register study.

Ethnicity and immigrant subgroup (classified as refugee or nonrefugee) are associated with poor mental health among immigrants. The aim of this study was to assess whether national origin-based differences in poor mental health can be explained by immigrant subgroup and if its importance varies depending on origin. A cross-sectional, population-based study of Swedish residents was conducted in 2006. The outcome was poor mental health, measured with the proxy variable psychotropic drugs purchased. Explanatory variables included immigrant subgroup and origin. Potential confounders were age, marital status, education, time in Sweden, and children. Logistic regression was carried out. The total population was 5,507,262. Immigrants from countries outside the Organisation for Economic Co-operation and Development (OECD) numbered 298,641. Immigrant subgroup partly explained the higher likelihood of poor mental health among non-OECD immigrants; when each country or area was analyzed separately, most refugees had a higher likelihood than nonrefugees did. Immigrant subgroup partly explained the origin-based differences in mental health, but this varied between different groups of origin.

Using the International Classification of Functioning, Disability and Health (ICF) to describe the functioning of traumatised refugees.

The aim of this project was to use the International Classification of Functioning, Disability and Health (ICF) to develop an interdisciplinary instrument consisting of a Core Set, a number of codes selected from ICF, to describe the overall health condition of traumatised refugees. We intended to test 1) whether this tool could prove suitable for an overall description of the functional abilities of traumatised refugees before, during and after the intervention, and 2) whether the Core Set could be used to trace a significant change in the functional abilities of the traumatised refugees by comparing measurements before and after the intervention. In 2007, eight rehabilitation centres for traumatised refugees in Denmark agreed on a joint project to develop a tool for interdisciplinary documentation and monitoring, including physical, mental and social aspects of the person's health condition. ICF, developed and approved by WHO in 2001, was found suitable because it offers a common and standardised language and a corresponding frame of reference to describe health and associated conditions in terms of functioning rather than symptoms and diagnosis. Traumatised refugees are in most cases severely affected mentally by the traumas they have been subjected to, physically by injuries suffered during torture and war, psycho-somatically with pain, and socially by cultural uprooting, as well as by social difficulties in the exile community. The rehabilitation perspective thus seems to be more meaningful than the traditional treatment perspective because it takes into account the very complex situation of this group. The aim of the project was to find out whether any functional changes could be monitored using the instrument. The aim was neither to study nor to describe the effect of rehabilitation approaches, such as conditions related to traumatised refugees' networks or environments that might affect the refugees' living conditions. It was also not the intention to discuss the cause of the potential changes of the functional abilities. The project selected a Comprehensive Core Set of 106 codes among 1,464 possible codes (1) used by an interdisciplinary group of international and national experts in rehabilitation of traumatised refugees. The Comprehensive Core Set was furthermore reduced to a Brief Core Set of 32 codes by the interdisciplinary team (key persons) at the centres included in the project. From each centre six clients were randomly selected from those who fulfilled the inclusion criteria. All were scored within a four week period after the start, before any intervention was initiated, and up to a month after the first scoring. The results from this project led us to the conclusion that it is possible to develop an instrument based on the ICF classification. The instrument is useful for a general description of the total health condition (physical and mental functional ability as well as the environmental impact) of traumatized refugees. The tool helps describe changes in the functional abilities used in connection with the preparation of the plan of action. It can also be used to describe the refugees included in the study and their general condition. The ICF Core Set for traumatised refugees has not yet been validated, but the results of the project provide a basis for further development.

Language proficiency, gender and self-reported health: an analysis of the first two waves of the longitudinal survey of immigrants to Canada.

BACKGROUND: Most immigrants to Canada now come from Asia, the Middle East, the Caribbean and Africa, where cultures and languages often differ significantly from the Canadian context. Subgroups of immigrants experience disparities in health. Inability to communicate in an official language in Canada may be a marker of risk for poor health due to both pre- and post-migration factors. We aimed to study the relationship between language proficiency and self-reported health. METHODS: We conducted a cross-sectional analysis of the first two surveys of the Longitudinal Survey of Immigrants to Canada (2001, 2003), a population-based cohort study of new immigrants to Canada. Specifically, we used logistic regression analyses to examine the relationship between self-reported health and language proficiency by sex, controlling for a range of health determinants at 6 months (wave 1) and 2 years (wave 2) after arrival. RESULTS: After controlling for covariates (age, sex, education, region of birth, immigrant class, job satisfaction, access to health care), analysis of the wave 1 survey showed that poor proficiency in English or French is significantly related to the self-reported poor health (OR=2.0, p<0.01). And this relationship was consistent in the wave 2 survey (OR=1.9, p<0.01). We also found that this statistically significant association between poor language proficiency and self-reported health holds only for women (wave 1 survey OR=2.6, p <0.01, wave 2 survey OR=2.2, p<0.01), not for men. CONCLUSION: The association between poor language proficiency and poor self-reported health, and particularly its significantly greater impact on women, has implications for language training, health care and social services, and health information.

[Current pathologies among asylum seekers in Montreal: prevalence and associated risk factors]. / Pathologies courantes chez les demandeurs d'asile à Montréal: prévalence et facteurs de risque associés.

BACKGROUND: Canada received 22,873 asylum seekers in 2006. The screening of specific health problems in this population seems warranted. This study aims to estimate the prevalence of pathologies that were screened at the PRAIDA health service in Montreal, and to identify associations with certain risk factors. METHODS: A retrospective study was conducted on the files of patients who were screened between 2000 and 2004. Demographic and clinical information was compiled for computation of prevalence as well as multiple logistic regression analysis. RESULTS: Of the 289 files reviewed, 56.7% are for male and 43.3% for female patients, with a mean age of 34 years; 53% are Asians and 38% Africans. 59.4% of subjects received a psychiatric diagnosis (mainly depression and post-traumatic stress disorder). The paraclinical work-up showed: 20.3% anaemia, 9% eosinophilia, 29.7% HBcAb+, 5% HBsAg+, 1.5% hepatitis C (RNA+), 2.5% HIV+ and 45.9% TST+. 10.5% of stool samples contained a pathogen, and serologies for strongyloidiasis and schistosomiasis were positive in 17.3% and 3.9% of samples respectively. Significant associations included female gender with anaemia, African origin with rates of HBcAb and TST+, age with HBcAb and hepatitis C positivity, longer length of stay in Canada with eosinophilia and strongyloidiasis, shorter length of stay with HBcAb, and Asian origin with psychiatric disorders. CONCLUSIONS: This study suggests that the prevalence of screened pathologies as part of the PRAIDA health service work-up are high in this population and therefore warrant continuation of their screening until guidelines are constituted.

Sero-epidemiology of hepatitis B among new refugees to Minnesota.

Hepatitis B virus (HBV) infection is endemic in many parts of the world, and prevailing conditions in refugee situations result in greater risk of infection. The objectives of this study were to determine the period prevalence of HBV infection among primary refugees in Minnesota during 1998-2001; describe trends in prevalence over time and identify patterns of infection and immunity in various refugee populations. A retrospective analysis of health examination data from the Minnesota Department of Health was conducted to examine serologic markers for hepatitis B: HBcAb, HbsAg, and HBsAb among 12,505 refugees who participated in the voluntary domestic health examination from 1998 to 2001. One hundred and eleven refugees had at least one immunization before arrival and were excluded. There was documented HBV test results in 8,754 (70.6%) of refugees; period prevalence of hepatitis B infection was 7.1%. Africans were three times more likely and Asians 2.4 times more likely to be infected than Europeans (P < 0.001). Older African refugees and African males were more likely to be infected than younger African refugees and women African refugees (P < 0.001). Younger persons below 30 years of age accounted for over 70% of all infected refugees in this study. Reducing the burden of infection among refugees requires enhanced provider awareness as well as intensified efforts aimed at identifying new at-risk populations, modifying risk factors, and implementing preventive and treatment strategies at various levels in the refugee resettlement process.

Operation Child-ID: reunifying children with their legal guardians after Hurricane Katrina.

Children constitute a vulnerable population and special considerations are necessary in order to provide proper care for them during disasters. After disasters such as Hurricane Katrina, the rapid identification and protection of separated children and their reunification with legal guardians is necessary in order to minimise secondary injuries (i.e. physical and sexual abuse, neglect and abduction). At Camp Gruber, an Oklahoma shelter for Louisianans displaced by Hurricane Katrina, a survey tool was used to identify children separated from their guardians. Of the 254 children at the camp, 36 (14.2 per cent) were separated from their legal guardians. Answering 'no' to the question of whether the accompanying adult was the guardian of the child prior to Hurricane Katrina was a strong predictor (27.8 per cent versus 3.2 per cent) of being listed as 'missing' by the National Center for Missing and Exploited Children (NCMEC). All the children at Camp Gruber who were listed as 'missing' by the NCMEC were subsequently reunited with their guardians.

"They think we're OK and we know we're not". A qualitative study of asylum seekers' access, knowledge and views to health care in the UK.

BACKGROUND: The provision of healthcare for asylum seekers is a global issue. Providing appropriate and culturally sensitive services requires us to understand the barriers facing asylum seekers and the facilitators that help them access health care. Here, we report on two linked studies exploring these issues, along with the health care needs and beliefs of asylum seekers living in the UK. METHODS: Two qualitative methods were employed: focus groups facilitated by members of the asylum seeking community and interviews, either one-to-one or in a group, conducted through an interpreter. Analysis was facilitated using the Framework method. RESULTS: Most asylum seekers were registered with a GP, facilitated for some by an Asylum Support nurse. Many experienced difficulty getting timely appointments with their doctor, especially for self-limiting symptoms that they felt could become more serious, especially in children. Most were positive about the health care they received, although some commented on the lack of continuity. However, there was surprise and disappointment at the length of waiting times both for hospital appointments and when attending accident and emergency departments. Most had attended a dentist, but usually only when there was a clinical need. The provision of interpreters in primary care was generally good, although there was a tension between interpreters translating verbatim and acting as patient advocates. Access to interpreters in other settings, e.g. in-patient hospital stays, was problematic. Barriers included the cost of over-the-counter medication, e.g. children's paracetamol; knowledge of out-of-hours medical care; and access to specialists in secondary care. Most respondents came from countries with no system of primary medical care, which impacted on their expectations of the UK system. CONCLUSION: Most asylum seekers were positive about their experiences of health care. However, we have identified issues regarding their understanding of how the UK system works, in particular the role of general practitioners and referral to hospital specialists. The provision of an Asylum Support nurse was clearly a facilitator to accessing primary medical care. Initiatives to increase their awareness and understanding of the UK system would be beneficial. Interpreting services also need to be developed, in particular their role in secondary care and the development of the role of interpreter as patient advocate.

Experiences of hurricane Katrina evacuees in Houston shelters: implications for future planning.

OBJECTIVES: To shed light on how the public health community can promote the recovery of Hurricane Katrina victims and protect people in future disasters, we examined the experiences of evacuees housed in Houston area shelters 2 weeks after the hurricane. METHODS: A survey was conducted September 10 through 12, 2005, with 680 randomly selected respondents who were evacuated to Houston from the Gulf Coast as a result of Hurricane Katrina. Interviews were conducted in Red Cross shelters in the greater Houston area. RESULTS: Many evacuees suffered physical and emotional stress during the storm and its aftermath, including going without adequate food and water. In comparison with New Orleans and Louisiana residents overall, disproportionate numbers of this group were African American, had low incomes, and had no health insurance coverage. Many had chronic health conditions and relied heavily on the New Orleans public hospital system, which was destroyed in the storm. CONCLUSIONS: Our results highlight the need for better plans for emergency communication and evacuation of low-income and disabled citizens in future disasters and shed light on choices facing policymakers in planning for the long-term health care needs of vulnerable populations.