Health Care Providers' Training Needs Related to Human Trafficking: Maximizing the Opportunity to Effectively Screen and Intervene

Human trafficking is a complex and multifaceted problem that takes the form of economic, physical and sexual exploitation of people, both adults and children, who are reduced to simple products for commerce. Human trafficking in the United States also has both a domestic and an international aspect. Health care providers are in a unique position to screen for victims of trafficking and may provide important medical and psychological care for victims while in captivity and thereafter. Trafficked persons are likely to suffer a wide spectrum of health risks that reflect the unique circumstances and experiences in a trafficked victim’s life. Although trafficked victims typically have experienced inadequate medical care, once contact is made by the victim with the health care professionals, the opportunity then exists to identify, treat, and assist such victims. The range of services and supports required to appropriately respond to human trafficking victims once identified is broad and typically goes beyond just what is immediately provided by the health care professional and includes safe housing, legal advice, income support, and, for international victims, immigration status related issues. An informed and responsive community is necessary to serve both the international and domestic victims of human trafficking, and needs assessments demonstrated a number of barriers that hindered the delivery of effective services to human trafficking victims. One of the consistent needs identified to combat these barriers was enhanced training among all professionals who might come in contact with human trafficking victims. We highlight the efforts of the Houston Rescue and Restore Coalition (HRRC), a local grassroots non-profit organization whose mission focuses on raising awareness of human trafficking in the Greater Houston Metropolitan area. HRRC responded to the consistent recommendation from various community needs assessments for additional training of front line professionals who would have the opportunity to identify human trafficking victims and supported the design and pilot testing of a health professions training program around human trafficking. Dissemination of this type of training along with careful evaluation and continued refinement will be one way for health care professionals to engage in a positive manner with human trafficking victims.

The results of a barrier analysis on complementary feeding practices among mothers in the Central River Division of the Gambia

Currently, the barriers to appropriate infant feeding practices are largely unknown in the Central River Division of the Gambia. A questionnaire was developed and implemented by a local Non Governmental Organization (NGO), the Gambia Food and Nutrition Agency, in order to gain more information and ultimately to improve the child mortality rate of the country. There were two participant groups: 88 Doers who are women who had adopted the appropriate complementary feeding practice guidelines as defined by the World Health Organization and 87 Non Doers who are women who had in some way strayed from the appropriate complementary feeding practice guidelines. The questionnaire included aspects of the Health Belief Model which can be used in the development of a future intervention. The Yes/No questions were analyzed using the Chi-square statistical method and the open-ended questions used a descriptive analysis method of evaluation. The constructs for perceived susceptibility, perceived action efficacy, perceived self efficacy, cues for action and perception of divine showed significant differences between the Doers and the Non Doers (p<0.05). The descriptive analysis revealed that both participant groups had a limited understanding of the preventative qualities of the adoption of appropriate complementary feeding practices. The women in both of groups also showed a strong perception of divine will. Women in the Central River Division perceive their husband and in-laws to be the most influential in the decision-making process regarding infant feeding practices. Recommendations for future interventions must acknowledge the importance and influence of the community surrounding the women in their adoption of the appropriate infant feeding practices. It would also be important to educate women about of the specific guidelines of the appropriate complementary feeding practices, specifically the delay in early initiation of complementary feeding. The results of this barrier analysis provide useful information to plan and implement an effective intervention to improve the child mortality rate in the Gambia. ^

Houston Rescue and Restore Coalition human trafficking needs assessment

Background. Human trafficking, or "modern day slavery", is a complex public health issue that we must understand more fully before it can be effectively tackled. There have been very few empirical studies on human trafficking and estimates of global and national human trafficking victims vary widely. Free the Slaves, a non-profit organization, estimates that there are at least 27 million people in the world at any given time that can be classified as victims of human trafficking. Houston, Texas has been identified as a place where human trafficking may be more likely to exist due to its close proximity to Mexico and due to economic and population factors. Houston Rescue and Restore Coalition (HRRC) is a local organization that exists to raise awareness of human trafficking in Houston, Texas. To better serve victims of human trafficking, HRRC commissioned a community assessment of the services available to victims of human trafficking in the greater Houston metropolitan area.^ Purpose. The current study assessed the capacity of organizations and agencies within the greater Houston metropolitan area to deal with human trafficking issues; in particular, knowledge regarding human trafficking issues among these organizations and agencies was evaluated.^ Methods. A cross-sectional study design was used to conduct surveys with key informants/stakeholders from organizations and agencies within the greater Houston metropolitan area. The survey instrument included 41 items in three parts, and consisted of multiple choice questions, open-ended essay questions, and closed-ended 5 point Likert questions.^ Results. The findings from this study indicate that efforts must be made to increase comprehensive awareness of the issue of human trafficking, including the federal and state laws that have been enacted to combat this problem. The data also indicate that there are limited services provided to human trafficking victims within the greater Houston metropolitan area.^ Conclusion. The results of the survey will provide Houston Rescue and Restore Coalition with information that will assist them in targeting their efforts to combat human trafficking in Houston, Texas.^

Commercial Sexual Exploitation and Missing Children in the Coastal Region of Sao Paulo State, Brazil

The commercial sexual exploitation of children (CSEC) has emerged as one of the world’s most heinous crimes. The problem affects millions of children worldwide and no country or community is fully immune from its effects. This paper reports first generation research of the relationship that exists between CSEC and the phenomenon of missing children living in and around the coastal regions of the state of Sao Paulo, Brazil, the country’s richest State. Data are reported from interviews and case records of 64 children and adolescents, who were receiving care through a major youth serving non-governmental organization (NGO) located in the coastal city of Sao Vicente. Also, data about missing children and adolescents were collected from Police Reports – a total of 858 Police Reports. In Brazil, prostitution is not a crime itself, however, the exploitation of prostitution is a crime. Therefore, the police have no information about children or adolescents in this situation, they only have information about the clients and exploiters. Thus, this investigation sought to accomplish two objectives: 1) to establish the relationship between missing and sexual exploited children; and 2) to sensitize police and child-serving authorities in both the governmental and nongovernmental sectors to the nature, extent, and seriousness of many unrecognized cases of CSEC and missing children that come to their attention. The observed results indicated that the missing children police report are significantly underestimated. They do not represent the number of children that run away and/or are involved in commercial sexual exploitation.

THE ULTRASTRUCTURAL ORGANIZATION OF THE HYPOGLOSSAL NUCLEUS IN THE RAT (SYNAPTOLOGY, CRANIAL NERVES)

An ultrastructural study of the hypoglossal nucleus (XII) in the rat has revealed two distinct neuronal populations. Hypoglossal motoneurons comprised the largest population of neurons in XII and were identified following injection of horseradish peroxidase (HRP) into the tongue. Motoneurons were large (25-50(mu)m), multipolar in shape and distributed throughout XII. The nucleus was large, round and centrally located, and the cytoplasm was characterized by dense lamellar arrays of rough endoplasmic reticulum. In contrast, a second population of small (10-18(mu)m), round to oval shaped neurons was found restricted to the ventral and dorsolateral regions of XII. The nucleus was markedly invaginated and eccentric, the cytoplasm scant and filled with free ribosomes, and the absence of lamellar arrays of rough endoplasmic reticulum was conspicuous. Neurons of this type were never found to contain HRP reaction product. These results demonstrate that the hypoglossal nucleus does not consist solely of motoneurons, but includes a distinctly separate, presumably non-motoneuronal pool. Arguments are presented in favor of this second neuron population being interneurons. The functional significance of these findings in relation to tongue control is discussed. ^

The impact of 1995--1996 health sector reforms in the effectiveness of malaria control program in the state of Orissa, India

Malaria poses a significant public health problem worldwide. The World Health Organization indicates that approximately 40% of the world's population and almost 85% of the population from the South–East Asian region is at risk of contracting malaria. India being the most populous country in the region, contributes the highest number of malaria cases and deaths attributed to malaria. Orissa is the state that has the highest number of malaria cases and deaths attributable to malaria. A secondary data analysis was carried out to evaluate the effectiveness of the World bank-assisted Malaria Action Program in the state of Orissa under the health sector reforms of 1995-96. The secondary analysis utilized the government of India's National Anti Malaria Management Information System's (NAMMIS) surveillance data and the National Family Health Survey (NFHS–I and NFHS–II) datasets to compare the malaria mortality and morbidity in the state between 1992-93 and 1998-99. Results revealed no effect of the intervention and indicated an increase of 2.18 times in malaria mortality between 1992-1999 and an increase of 1.53 times in malaria morbidity between 1992-93 and 1998-99 in the state. The difference in the age-adjusted malaria morbidity in the state between the time periods of 1992-93 and 1998-99 proved to be highly significant (t = 4.29 df=16, p<. 0005) whereas the difference between the increase of age-adjusted malaria morbidity during 1992-93 and 1998-99 between Orissa (with intervention) and Bihar (no intervention) proved to be non significant (t=.0471 df=16, p<.50). Factors such as underutilization of World Bank funds for the malaria control program, inadequate health care infrastructure, structural adjustment problems, poor management, poor financial management, parasite resistance to anti-malarial drugs, inadequate supply of drugs and staff shortages may have contributed to the failure of the program in the state.^

A comprehensive framework for evaluating funder's performance

Evaluation methods for assessing the performance of non-profit funders are lacking. The purpose of the research was to create a comprehensive framework that systematically assesses the goals and objectives of a funder, how these relate to the funder's allocation of resources, and the potential impact of programs and services selected by the funder for resource allocation to address organizational goals and objectives. The Houston Affiliate of Susan G. Komen for the Cure, a local chapter of a national breast cancer awareness advocacy organization, was selected as the funding agency whose performance assessment was to assist in the creation of this framework. Evaluation approaches from the government sector were adapted and incorporated into the research to guide the methods used to answer the three research questions corresponding to the three phases of research within the study: (1) what are the funding goals and objectives of the Affiliate?; (2) what allocation scheme does the organization use to address these goals and objectives and select programs for funding?; and, (3) to what extent do the programs funded by the Affiliate have potential long-term impact? ^ Within the first stage of the research, document reviews of the Affiliate's mission-based documents and bylaws and interviews with organizational and community informants revealed a highly latent constellation of broad objectives that were not formalized into one guiding document, thus creating gaps in management and governance. Within the second phase of the research, reviews of grant applications from the 2008-2009 funding cycle and interviews with employees and volunteers familiar with the funding process revealed competing ideas regarding resource allocation in light of vague organizational documents describing funding goals and objectives. Within the final stage of the research, these findings translated to the Affiliate selecting programs with highly varying potential long-term impact with regards to addressing goals and objectives relating to breast cancer education, screening, diagnostics, treatment, and support. The resulting performance assessment framework, consisting of three phases of research utilizing organizational documents and key informant interviews, demonstrated the importance of clearly defined funding goals and objectives, reference documents and committee participation within the funding process, and regular reviews of potential long-term impact for selected programs, all supported by the active participation and governance of a funder's Board of Directors.^

Patient satisfaction in government health facilities in the state of Qatar

This study provides data which can contribute to improving services and delivering quality health care in government health facilities in the state of Qatar. To measure the satisfaction with current care of selected patients who receive care in Hamad General Hospital and the Khalifa Town Health Center in the city of Doha, a cross-sectional survey and a self-administered questionnaire were used.^ Analysis was performed on data from 444 patients on eight dimensions of patient satisfaction with medical care. These include: general satisfaction, availability of services, convenience of services, facilities, humaneness of doctors, quality of care, continuity of care, and aspects of the last visit. Patient satisfaction parameters were compared for males vs. females, for citizens vs. non-citizens, and for patients seen in the hospital vs. those seen in the health center.^ Results indicate that patients seen in the hospital were more satisfied with care than patients seen in the health center, that non-citizens were more satisfied than citizens, and that males were slightly more satisfied than females with medical services. ^

THE DEVELOPMENT OF COMMUNITY COMPETENCE THROUGH A NEIGHBORHOOD ORGANIZATION (LOS ANGELES, MEXICAN-AMERICAN)

This investigation focused on how people cope with the demands of their environment in a competent manner. It sought to assess the effects of learning competent coping behaviors on self-reported well-being. The study chose a community-evolved, organized effort on the part of a group of neighborhoods to build competence in the Mexican-American community of East Los Angeles. This network was a citizen-action organization called the United Neighborhoods Organization. UNO was selected because it concentrated on developing community leaders by using spiritual beliefs and family values as shared community resources. Neighborhood leaders were encouraged to engage in risk-taking and confrontation maneuvers. They were also taught problem-solving skills and provided with social support.^ A survey instrument was developed to assess sociodemographic characteristics, acculturation history and status, willingness to engage in risk-taking and confrontation and self-perceived general well-being. The study relied on eight months of daily participant-observation of the organization, the East Los Angeles environment and the interaction between the two. At the end of the observation period, a sample of 150 UNO participants were given the survey questionnaire as was a matched group of 150 non-UNO participants who were ELA residents.^ The study sample was mostly women, in their middle age years who had lived in the area from 5 to more than 30 years. Significantly more single persons were found in the UNO group. The sample was almost equally divided into English and Spanish speaking respondents. Acculturatively almost all the sample fell in the Very Mexican and Mostly Mexican types. The survey found a trend of association between participating in UNO and reporting feeling well. A statistically significant association was found among UNO participants between taking risks and reporting feeling well, regardless of a tendency for all the sample to minimize risk. A trend was seen for married UNO participants to report feeling well. Slightly more UNO participants were willing to engage in confrontation and a substantial proportion of the participants who were confronters reported feeling well in comparison to their counterparts. Ethnic pride was positively associated with participation in UNO and showed a trend in the expected direction with reported self-perceived well-being. ^

THE FUNCTIONAL ORGANIZATION OF SYNAPTIC VESICLE POOLS IN A RETINAL BIPOLAR NEURON

Ribbon synapses are found in sensory systems and are characterized by ‘ribbon-like’ organelles that tether synaptic vesicles. The synaptic ribbons co-localize with sites of calcium entry and vesicle fusion, forming ribbon-style active zones. The ability of ribbon synapses to maintain rapid and sustained neurotransmission is critical for vision, hearing and balance. At retinal ribbon synapses, three vesicle pools have been proposed. A rapid pool of vesicles that are docked at the plasma membrane, and whose fusion is limited only by calcium entry, a releasable pool of ATP-primed vesicles whose size also correlates with the number of ribbon-tethered vesicles, and a reserve pool of non-ribbon-tethered cytoplasmic vesicles. However evidence of vesicle fusion at sites away from ribbon-style active zones questions this organization. Another fundamental question underlying the mechanism of vesicle fusion at these synapses is the role of SNARE (Soluble N-ethylmaleimide sensitive factor Attachment Protein Receptor) proteins. Vesicles at conventional neurons undergo SNARE complex-mediated fusion. However a recent study has suggested that ribbon synapses involved in hearing can operate independently of neuronal SNAREs. We used the well-characterized goldfish bipolar neuron to investigate the organization of vesicle pools and the role of SNARE proteins at a retinal ribbon synapse. We blocked functional refilling of the releasable pool and then stimulated bipolar terminals with brief depolarizations that triggered the fusion of the rapid pool of vesicles. We found that the rapid pool draws vesicles from the releasable pool and that both pools undergo release at ribbon-style active zones. To assess the functional role of SNARE proteins at retinal ribbon synapses, we used peptides derived from SNARE proteins that compete with endogenous proteins for SNARE complex formation. The SNARE peptides blocked fusion of reserve vesicles but not vesicles in the rapid and releasable pools, possibly because both rapid and releasable vesicles were associated with preformed SNARE complexes. However, an activity-dependent block in refilling of the releasable pool was seen, suggesting that new SNARE complexes must be formed before vesicles can join a fusion-competent pool. Taken together, our results suggest that SNARE complex-mediated exocytosis of serially-organized vesicle pools at ribbon-style active zones is important in the neurotransmission of vision.

Shifting the focus: Addressing breast cancer disparities at the health care organization level

The purpose of this study was to understand the scope of breast cancer disparities within the Texas Medical Center. The goal was to increase the awareness of breast cancer disparities at the health care organization level, and to foster the development of organizational interventions to reduce breast cancer disparities. The study seeks to answer the following questions: 1. Are hospitals in the Texas Medical Center implementing interventions to reduce breast cancer disparities? 2. What are their interventions for reducing the effects of non clinical factors on breast cancer treatment disparities? 3. What are their measures for monitoring, continuously improving, and evaluating the success of their interventions? ^ This research project was designed as a mixed methods case study. Quantitative breast cancer data for the years 2000-2009 was obtained from the Texas Cancer Registry (TCR). Qualitative data collection and analysis was done by conducting a total of 20 semi-structured interviews of administrators, physicians and nurses at five hospitals (A, B, C, D and E) in the Texas Medical Center (TMC). For quantitative analysis, the study was limited to early stage breast cancer patients: local and regional. The dependent variable was receipt of standard treatment: Surgery (Yes/No), BCS vs Mastectomy, Chemotherapy (Yes/No) and Radiation after BCS (Yes/No). The main independent variable was race: non-Hispanic White (NHW) , non-Hispanic Black (NHB), and Hispanic. Other covariates included age at diagnosis, diagnosis date, percent poverty, grade, stage, and regional nodes. Multivariate logistic regression was used to test the adjusted association between receipt of standard care and race. Qualitative data was analyzed with the Atlas.ti7 software (ATLAS.ti GmbH, Berlin). ^ Though there were significant differences by race for all dependent variables when the data was analyzed as a single group of all hospitals; at the level of the individual hospitals the results were not consistent by race/ethnicity across all dependent variables for hospitals A, B, and E. There were no racial differences in adjusted analysis for receipt of chemotherapy for the individual hospitals of interest in this study. For hospitals C and D, no racial disparities in treatment was observed in adjusted multivariable analysis. All organizations in this study were aware of the body of research which shows that there are disparities in breast cancer outcomes for patient population groups. However, qualitative data analysis found that there were differences in interest among hospitals in addressing breast cancer disparities in their patient population groups. Some organizations were actively implementing directed measures to reduce the breast cancer disparity gap in outcomes for patients, and others were not. Despite the differences in levels of interest, quantitative data analysis showed that organizations in the Texas Medical Center were making progress in reducing the burden of breast cancer disparities in the patient populations being served.^

Efficiency from pharmacy inventory technology: A means to improving quality in non-profit hospitals

Hospitals, like all organizations, have both a mission and a finite supply of resources with which to accomplish that mission. Because the inventory of therapeutic drugs is among the more expensive resources needed by a hospital to achieve its mission, a conceptual model of structure plus process equals outcome posits that adequate emphasis should be placed on optimization of the organization's investment in this important structural resource to provide highest quality outcomes. Therefore emphasis should be placed on the optimization of pharmacy inventory because lowering the financial investment in drug inventory and associated costs increases productive efficiency, a key element of quality. ^ In this study, a post-intervention analysis of a hospital pharmacy inventory management technology implementation at The University of Texas M.D. Anderson Cancer Center was conducted to determine if an intervention which reduced a hospital's financial investment in pharmaceutical inventory provided an opportunity to incrementally optimize the organization's mix of structural resources thereby improving quality of care. The results suggest that hospital pharmacies currently lacking technology to support automated purchasing logistics and perpetual, real-time inventory management for drugs may achieve measurable benefits from the careful implementation of such technology, enabling the hospital to lower its investment in on-hand inventory and, potentially, to reduce overall purchasing expenditures. ^ The importance of these savings to the hospital and potentially to the patient should not be underestimated for their ability to generate funding for previously unfunded public health programs or in their ability to provide financial relief to patients in the form of lower drug costs given the current climate of escalating healthcare costs and tightening reimbursements.^

Rescue of embryonic lethality in mdmx null mice by loss of p53 suggests a non-overlapping pathway with MDM2 to regulate p53

The tumor suppressor p53 is mutated in over 50% of human sporadic tumors originating from diverse tissues. p53 responds to DNA damage and cell stress by activating the transcription of a variety of target genes, the protein products of which then initiate either growth arrest or apoptosis. ^ A p53 target with a particularly intriguing function is the oncogene MDM2. MDM2 functions, in part, by binding to and inhibiting p53's activity. Overexpression of MDM2, by gene amplification, has been found in 30% of human sarcomas harboring a wild type p53, indicating that an increase in MDM2 levels is sufficient for p53 inactivation. Mice carrying a homozygous null allele for mdm2 exhibit an early embryonic lethality that is completely rescued in a p53-null background. These data indicate that MDM2's only critical function in early mouse embryogenesis is the negative regulation of p53. ^ The mdmx gene is the first additional member of the mdm2 gene family to be isolated. MDMX, like MDM2, contains a RING-finger domain, ATP binding domain and a p53 binding domain, which retains the ability to bind and inhibit p53 transactivation in vitro. However, mdmx does not appear to be transcriptionally regulated by p53. We have cloned and characterized the murine mdmx genomic locus from a mouse 129 genomic library. The mdmx gene contains 11 exons, spans approximately 37 Kb of DNA, and is located on mouse chromosome 1. The genomic organization of the mdmx gene is identical to that of mdm2 except at the 5′ end of the gene near the p53 responsive element. Northern expression analysis of mdmx transcripts during mouse embryogenesis and in adult tissues revealed constitutive and ubiquitous expression throughout adult tissues and embryonic development. To determine the in vivo function of MDMX, mice carrying a null allele of mdmx have been generated. Mdmx homozygous null mice are early embryonic lethal. Mdmx null mice do not develop beyond 9.5 dpc and can be discerned by gross dissection as early as 7.5 dpc. Utilizing TUNEL and BrdU assays on 7.5 dpc histological sections we have determined that the mutant embryos are dying due to increased levels of growth arrest, but not apoptosis. Surprisingly, Mdmx homozygous null mice are viable in a p53 null background, indicating that MDMX is also very important in the negative regulation of p53. ^