Suicidal ideation in the perinatal period: findings from the Thailand-Myanmar border.

BACKGROUND: Suicide is a leading cause of maternal death globally. Migrant and refugee populations may experience higher risk of suicide. We report data on suicidal ideation from migrant and refugee women living on the Thailand-Myanmar border. METHODS: Women were recruited in their first trimester of pregnancy. Depression status was assessed by diagnostic interview in the first, second and third trimesters and at 1 month post-partum. We calculated prevalence of suicidal ideation and used logistic regression to identify associated socio-demographic factors. RESULTS: During the perinatal period, 5.3% (30/568) women experienced suicidal ideation. Refugee women were more likely to experience suicidal ideation than migrant women (8.0 versus 3.1%; P = 0.01). Most women with suicidal ideation did not have severe depression. Previous trauma (OR 2.32; 95% CI: 1.70-3.15) and unplanned pregnancy (OR 2.74; 95% CI: 1.10-6.86) were significantly associated with suicidal ideation after controlling for all other variables. CONCLUSIONS: Suicidal ideation represents an important symptom among migrant and refugee women on the Thailand-Myanmar border. Screening only those with severe depression may be insufficient to identify women at risk of suicide. Community-level interventions addressing social and gender inequalities and prioritization of family planning programmes are needed alongside targeted suicide prevention initiatives to help lower the rates of people dying by suicide.

Ethical guidance for health research in prisons in low- and middle-income countries: a scoping review.

OBJECTIVES: This study examined the extent, range and nature of the published literature, prison policies and technical guidance relating to the ethical conduct of health research in prisons in low- and middle-income countries (LMICs). STUDY DESIGN: Scoping Review. METHODS: We adhered to the five stages of the scoping review iterative process: identifying the research question, identifying relevant studies, study selection, charting the data, and collating, summarizing and content analysis of polices. Disagreements around allocation of content were resolved through team discussion. We also appraised the quality of the included articles. RESULTS: We included nine records that examined the ethical aspects of the conduct of health research in prisons in LMICs; eight of these were peer-reviewed publications, and one was a toolkit. Despite the unique vulnerabilities of this group, we could find no comprehensive guidelines on the ethical conduct of health research in prisons in LMICs. CONCLUSIONS: The majority of the world's imprisoned populations are in LMICs, and they have considerable health needs. Research plays an important role in addressing these needs and in so doing, will contribute to the achievement of the Sustainable Development Goals. With regards to health research, imprisoned people in LMICs are 'left behind'; there is a lack of clear, prison-focused guidance and oversight to ensure high quality ethical health research so necessary in LMICs. There is an urgent need for prison health experts to work with health research ethics experts and custodial practitioners for procedural issues in the development of prison-specific ethical guidance for health research in LMICs aligned with international standards.

The Five Nations model for prison health surveillance: lessons from practice across the UK and Republic of Ireland.

BACKGROUND: Prison populations experience an increased burden of physical, mental and social health needs compared to the community, further impacted by the prison environment. Surveillance systems to monitor health and well-being trends in prisons are lacking, presenting a challenge to services planners, and policy makers who often lack evidence to inform decisions. METHOD: The Five Nations Health and Justice Collaboration, a body of experts on prison health across the UK and Republic of Ireland (ROI), met to share and discuss challenges and opportunities to developing robust prison health surveillance systems that could inform local provision, guide national policy and enable cross-border comparisons. RESULTS: Challenges to robust prison health surveillance systems were shared across the UK and ROI. Methods of surveillance differed across nations and included performance indicators and outcome measures as part of local or national programs. All nations had strong public health infectious disease notification systems. CONCLUSIONS: The Five Nations Health and Justice Collaboration is proposing a new model for prison health surveillance, based on established guidelines for public health surveillance but with additional features that recognize the uniqueness of the prison environment and need for a whole prison approach, built on collaboration and sharing of data between health and justice sectors.

The prevention of female genital mutilation in England: what can be done?

BACKGROUND: Female genital mutilation (FGM) is a global public health issue. Women in the UK are at risk of FGM and its adverse health consequences but little is known about its practice. Since 1985 it has been a criminal offence to perform FGM in the UK and further legislation has tightened the law but FGM continues. METHODS: Four community researchers from the Kenyan, Nigerian, Somalian and Sudanese communities in Oxford conducted focus groups and interviews with 53 people to understand the communities' beliefs about how best to prevent FGM. RESULTS: Participants believed that the current UK legislation alone was not sufficient to tackle FGM and might in fact be counterproductive by alienating communities through its perceived imposition. They felt that there had been insufficient consultation with affected communities, awareness raising and education about the legislation. Community-led solutions were the most effective way to tackle FGM. CONCLUSIONS: FGM adversely affects communities globally. In the UK, researchers from affected communities gathered data demonstrating the feasibility and importance of involving communities in FGM prevention work. Further research is needed to understand how best to prevent FGM in affected communities and, very importantly, to examine the impact of the UK legislation relating to FGM.

Female genital mutilation in the UK- where are we, where do we go next? Involving communities in setting the research agenda.

BACKGROUND: Female Genital Mutilation (FGM) is all practices involving cutting, alteration or injury to the female genitalia for non-medical reasons. It is a form of violence against women and children, with no benefits and many harms. In 2014, the UK Government committed to working to eliminate FGM. Steps taken towards this aim included creation of educational and safeguarding resources for professionals, and legislative changes including a mandatory reporting duty for professionals in England and Wales (where if a girl under 18 discloses or is found on examination to have FGM then the professional is mandated to report this to the police), and an FGM Enhanced Dataset applicable to NHS organisations in England requiring the submission of personal data about women and girls who have had FGM to NHS Digital. To date, compliance with dataset returns from primary care services have been low. This report describes using patient and public involvement (PPI) to identify research and service priorities to support communities affected by FGM. METHODS: We held a series of PPI events (4 focus groups, and a multi-agency seminar) in 2015-2016, following the introduction of these legislative changes, speaking to community members, and professionals involved in their care. We asked participants to consider what they identified as research, knowledge and service priorities to support communities affected by FGM. RESULTS: The impact of these legislative and reporting requirements on the trust needed for community members to seek to consult health services was identified as important for further research. Priorities for service development were holistic services, that met a woman's needs throughout her lifecourse. Participants emphasised the importance of understanding how to listen, involve and utilise community voices in developing education for professionals, designing services, and developing policy. CONCLUSIONS: There was a desire for change to develop from within affected communities; any learning and resources need to be co-created and constructed in such a way that they can be effectively shared between women, communities, and professionals. Questions remain about how to define community consultation, how to recognise when it was adequate, and how to hear beyond community activists to hear a wider range of voices.

Looking behind the bars: emerging health issues for people in prison.

Introduction: There are more than 10 million people imprisoned worldwide. These individuals experience a higher burden of communicable and non-communicable disease, mental health and substance misuse problems than the general population and often come from marginalized and underserved groups in the community. Prisons offer an important opportunity for tackling health problems in a way that can deliver benefits to the individual and to the community. This paper focuses specifically on emerging health issues for prisons across the world. Sources of data: This paper uses sources of international data from published systematic reviews and research studies, the Ministry of Justice for England and Wales, the Prisons and Probations Ombudsmen Review and other United Kingdom government briefing papers. Areas of agreement: Deaths in custody are a key concern for the justice system as well as the health system. Areas of controversy: Suicide is the leading cause of mortality in prisons worldwide but non-communicable diseases, such as cardiovascular disease, are increasing in importance in high-income countries and are now the leading cause of mortality in prisons in England and Wales. Growing points: The prison population is ageing in most high-income countries. Older people in prison typically have multiple and complex medical and social care needs including reduced mobility and personal care needs as well as poor health. Areas timely for developing research: Further research is needed to understand the complex relationship between sentencing patterns, the ageing prison population and deaths in custody; to model its impact on prisons and healthcare provision in the future and to determine effective and cost-effective models of care. Research into the health of prisoners is important in improving the health of prisoners but there is considerable variation in quantity and quality between countries. Recent innovations seek to address this disparity and facilitate the sharing of good practice.

Critical appraisal skills teaching in UK dental schools.

Key publications on training in dentistry, including the latest version of the General Dental Council learning outcomes for dentists, recognise the importance of teaching evidence-based practice for dental students. However, dental curriculum designers have considerable flexibility on the scope and approach for teaching evidence-based dentistry (EBD) and there is no readily available information showing how EBD is taught across the dental schools in the United Kingdom (UK). Critical appraisal is one of the key steps of evidence-based decision making and so we investigated through an electronic survey whether and how critical appraisal skills (CAS) are taught and assessed across the UK dental schools. The survey included questions regarding teaching methods, duration and timing of CAS teaching, and assessment methods. Twelve out of the total 16 UK dental schools participated in this survey, giving an institutional response rate of 75%. While all 12 participating UK dental schools reported CAS were taught and assessed in their institution, there were very varied approaches between institutions in every surveyed aspect of CAS education. CAS teaching and assessment strategies should be regularly reviewed in line with the evolving dental curriculum. Regular inter- and intra-institutional review of teaching, specifically in evidence-based dentistry including CAS may encourage professional debate regarding facilitation of improved CAS and their integration into clinical practice.

Migration and perinatal mental health in women from low- and middle-income countries: a systematic review and meta-analysis.

BACKGROUND: Migrant women are at risk of perinatal mental disorders due to stressors experienced before, during and after migration. OBJECTIVES: This systematic review and meta-analysis summarises the prevalence, associated factors and interventions for perinatal mental disorders in migrant women from low- and middle-income countries (LMIC). SEARCH STRATEGY: We systematically searched nine electronic databases and the grey literature using a predefined search strategy. SELECTION CRITERIA: Studies were included if they assessed pregnant or postpartum migrants from LMIC, used a structured tool and a case-control, cross-sectional, cohort or intervention study design. DATA COLLECTION AND ANALYSIS: Data was double-extracted. We calculated pooled prevalence of depression and weighted mean anxiety and depression scores. We calculated crude odds ratios from risk factor studies and summarised intervention studies descriptively. MAIN RESULTS: Forty studies were identified from 10 123 references. Pooled prevalence was 31% [95% condidence interval (CI) 23%-40%] for any depressive disorder and 17% (95% CI 12-23%) for major depressive disorder. Previous depression and lower social support were associated with perinatal depression. There were insufficient data to assess the burden of anxiety, post-traumatic stress disorder or psychosis in this population. CONCLUSIONS: One in three migrant women from LMIC experiences symptoms of perinatal depression. Social support is an important protective factor. Evidence on LMIC women relocating to other LMIC is lacking. Given the adverse consequences of perinatal mental illness on women and their children, further research in low-resource settings is a priority. TWEETABLE ABSTRACT: One in three migrant women from low- and middle-income countries has symptoms of perinatal depression.

Ethnic differences in the health of women prisoners.

OBJECTIVES: The numbers of female and ethnic minority prisoners in the UK are increasing. Despite recent policy initiatives to improve both prison healthcare and the status of women and ethnic minority groups, there are few data with which to inform service development. This is the first study in the UK to examine differences in subjective health status and health behaviours between Black and White female prisoners. STUDY DESIGN: Retrospective secondary analysis of data from the Health of Women in Prison Study by the University of Oxford. The latter was a longitudinal survey. METHODS: Participants were given a questionnaire containing the Short Form 36 (SF-36) and questions about cigarette smoking, alcohol consumption, illicit drug use, physical exercise, diet, imprisonment history and ethnicity. Data from Black and White participants were compared. Physical and mental component summary scores from the SF-36 were assessed using the independent t-test for means. Differences in health behaviours between the Black and White women were assessed using a paired samples t-test for continuous variables or Chi-squared test for categorical data. RESULTS: Black women were more likely to have stayed in full-time education for longer and to have been legally employed prior to imprisonment. The average length of their current sentence was significantly higher than that for White women. Black women scored higher in general health perception, but there were no other significant differences in subjective health status. Significantly fewer Black women smoked or drank to excess, or had used drugs in the 6 months prior to imprisonment. Black women ate more healthily, but were more likely to be overweight and to have higher blood pressure than their White counterparts. Both groups, however, demonstrated poor health and health behaviours overall. CONCLUSION: Black women entering prison are more likely to be educated, employed, drug free and, in some ways, healthier than White women. However, all the prisoners, regardless of ethnicity, had poorer levels of mental and physical health than the general population; thus, a need exists for researchers and policy makers alike to examine the health of these groups within and out of prison.

The impact of imprisonment on health: what do women prisoners say?

BACKGROUND: Women prisoners tend to suffer poor health on a range of indicators. This study sought to explore women prisoners' perceptions of the impact of imprisonment on their health. METHODS: This qualitative study involved adult women prisoners in two closed local prisons. Focus groups and individual interviews were conducted. RESULTS: Women prisoners reported that imprisonment impacted negatively upon their health. The initial shock of imprisonment, separation from families and enforced living with other women suffering drug withdrawal and serious mental health problems affected their own mental health. Over the longer term, women complained of detention in unhygienic facilities by regimes that operated to disempower them, including in the management of their own health. Women described responses to imprisonment that were also health negating such as increased smoking, eating poorly and seeking psychotropic medication. However, imprisonment could also offer a respite from lives characterised by poverty, social exclusion, substance misuse and violence, with perceived improvements in health. CONCLUSION: The impact of imprisonment on women's health was mixed but was largely perceived to be negative. Despite policy initiatives to introduce health promotion in prisons, there is little evidence of the extent to which this has been effective. The current policy climate in the UK makes it especially timely to examine the reported experience of women prisoners themselves about the impact of imprisonment on their health and to re-evaluate health promotion in women's prisons.

Predictors of hepatitis B vaccination in women prisoners in two prisons in England.

BACKGROUND: Hepatitis B is an important public health issue, especially in the female prison population. The high prevalence in this population is largely accounted for by the high rates of injecting drug use and the fact that these women are more likely to exchange sex for drugs or money and practice unprotected sex. There is a national programme in English prisons to vaccinate everyone against Hepatitis B. This study aimed to investigate whether women who had been in prison before were more likely to have been vaccinated against hepatitis B and whether contact with community services was more likely to predict hepatitis B vaccination. METHODS: A questionnaire survey of new entrants into two women's prisons in England. RESULTS: Four hundred and eighty seven out of 613 women approached completed the questionnaire and gave complete data on hepatitis B vaccination status, giving a response rate of 79.4%. One hundred and thirty three women (27.3%) had received at least three vaccinations against hepatitis B. Previous imprisonment and intravenous drug use were independent predictors of vaccination. Six months or more in prison greatly increased an individual's odds of being immunized [odds ratio 12.01 (95% confidence interval (CI) 5.53-26.10)]. Registration with a general practitioner (GP), contact with drug or alcohol services and exchanging money or goods for sex were not independently associated with vaccination status. CONCLUSION: Prisons play an important role in the delivery of hepatitis B vaccination. However, this should not prevent providers of health services making greater efforts to engage this marginalized group and to ensure that they receive an appropriate level of healthcare in the community.

Factors affecting cervical screening uptake in prisoners.

Imprisoned women are at increased risk of cervical cancer but less likely to have been screened for this disease. There is very little information on the situation in prisons in the UK but this study indicates that, as anticipated, these women are less likely to have been screened in the last five years than women generally. Whilst there are no ethnic differences, it appears that women who had been in prison longer than three months were more likely to have had a smear in the last five years compared with those who had been in for three months or less (79.2% vs 37.5%, Chi-squared=9.7, p=0.002) suggesting that the prison health services had been able to use this opportunity to screen this disadvantaged population.