Piercing the veil: the marginalization of midwives in the United States

This paper investigates the marginalization of certified nurse-midwives (CNMs) in the US. This marginalization occurs despite ample evidence demonstrating that a midwifery model delivers high-quality cost-effective care. Currently midwives attend only 7% of births, compared to 50-75% of births in other developed countries. Given the escalating costs of health care and relatively poor maternal and child health indicators in comparison with other developed countries, these findings are disturbing. This paper investigates this paradox through a qualitative case study of two prestigious but declining midwifery services in a large US city. Fifty-two multi-sited in-depth interviews were conducted along with an analysis of relevant archival sources. It was found that institutions successfully altered maternity care and diminished midwifery services without accountability for their actions. These findings illuminate the larger political-economic forces that shape the marginalization of midwifery in the US.     

MIGRATION,ACCULTURATION, DISPLACEMENT: MIGRATORY WORKERS AND “SUBSTANCE ABUSE”

The following essays represent the topics and issues raised by the panel presenters. A diverse group of researchers came together to compare and contrast the substance use and “abuse” practices and patterns of marginalized groups in their region of the world. The panelists included researchers discussing: the hill people of Burma, Mäori in New Zealand, Algerians in France, Mexican-Americans in the United States and predominantly African-American homeless males in New York. We found many common themes. In particular, we found that each of the marginal populations increased their use of substances with increased time in the host society/culture. It was agreed that substance use is not only a process of adaptation but also a coping mechanism in, for the most part, hostile and unwelcoming environments. We also agreed that “abuse” of substances is not common to traditional cultures. Migration to a more modern society was accompanied by initiation and/or increase in substance use. When used at all, indigenous people tend to use substances in the controlled form of ritual and ceremony. The use of substances as a method of desensitizing to day-to-day stressors was adopted with exposure to the practises of their new surroundings. We found that there are more commonalities in the processes we examined than differences independent of location and race/ethnicity.     

从澳大利亚护理实践的演变看中国社区护理的发展(一)——澳大利亚护理实践的演变及社区护理面临的挑战

目的从历史纵深角度,探讨澳大利亚护理的发展沿革及社区护理面临的严峻挑战,揭示阻碍社区护理发展的历史、宗教和文化渊源,从而为制定社区护理的发展政策,迎接老龄化社区卫生服务挑战提供有意义的依据。方法以文献研究和政策分析作为主要的研究手段。结果西方护理从家庭走向社区受宗教深刻影响,并随医学和医院发展走向机构化服务的路径。南丁格尔的护理革命把护理发展成为职业,并通过严格的教育和制度,构建了以医院为中心的、依从于医生阶层制度的护理系统。第一次卫生革命带来了公共卫生护士,而现代医学模式、人口老龄化和卫生制度改革催生了社区护士,其在社区兼顾临床护理和初级卫生保健服务。结论对护理发展史的观察,可以帮助我们更好地理解社区护理教育边缘化和护理服务去机构化,理解社区护理面临挑战的历史和系统原因,从而研讨和开发相应的政策措施,发展适宜的社区护理战略。     

Reflections on the consequences of conflict beyond the front line and their sequelae for marginalized communities

All conflicts affect people unfortunate enough to be in or near the affected area. Health Unlimited's philosophy is to reach marginalized communities, isolated by persecution, discrimination or conflict. Beyond the battle‐zone are people who may be unaware of the causes of the conflict, they may not have any part in it, but the consequences can be devastating to them and their way of life. They are powerless to influence events and the loss of traditional culture, livelihood and support structures further weaken their resources.     

The 2011 and 2016 iterations of the Ontario Marginalization Index: updates,consistency and a cross-sectional study of health outcome associations

ObjectivesThe Ontario Marginalization Index (ON-Marg) is an area-based measure used widely to measure health inequalities in Ontario. Recently, the index was updated for 2011 and 2016. The loss of the 2011 long-form census required the use of alternative data sources for the 2011 version. This paper describes the update of ON-Marg, assesses consistency in the indices across census years using Dissemination Areas, and examines associations between ON-Marg 2016 and four health and social outcomes to demonstrate its potential to measure health inequalities.MethodsON-Marg was created using factor analysis. Differences in quintile assignment was compared over time to assess whether the use of taxfiler, immigration, property assessment, and health card address data in 2011 affected consistency in measurement of marginalization. Inequalities in rates of overall mortality, gonorrhea incidence, mental health emergency department visits, and alcohol retail locations across quintiles of ON-Marg 2016 were quantified using the Relative Index of Inequality.ResultsDepending on the dimension, between 81% and 96% of DAs showed limited or no changes in quintiles of marginalization between 2006, 2011 and 2016. Of the 45–64% of DAs that did not change quintile between 2006 and 2016, 1.8% to 8.8% of DAs in 2011 differed by two or more quintiles. Findings showed significant differences in rates of health and social outcomes across quintiles of ON-Marg 2016, with strength and directionality varying by dimension of ON-Marg.ConclusionAlternative data sources did not substantially affect the consistency of the 2011 version of ON-Marg. The updated ON-Marg is a comprehensive tool that can be used to study health inequalities in Ontario.     

Drug Identity Change Processes,Race, and Gender. II. Microlevel Motivational Concepts

Events and experiences that are damaging and which sever young people from normative ideals and positively sanctioned statuses (marginaliza-tiori) create feelings of alienation or social isolation within them and earn them undesired statuses and treatment from important others. An underlying premise of the drug-use identity change model is that individuals are motivated toward drug-related identity change because of such socially defined problems with existing ego identities (ego identity discomfort and lost control in defining an identity) in childhood and early adolescence and that certain macrolevel phenomena (e.g., social appraisal sources and social climate conducive to drug use) provide an opportunity structure for that change. Part 2 of this paper describes each of the three motivational concepts and how they vary by race and gender in the process of becoming a drug misuser. Part 3 discusses the two macrolevel opportunity concepts and how they vary by race and gender.     

Drug Use and the Role of Homelessness in the Process of Marginalization

The marginalization theory of life histories implies that drug users who are considered as marginalized manifest more serious social, economical, physical, and psychological problems than nonmarginalized drug users. The degree of marginalization is assumed to be an indicator of homelessness. The theory argues that homelessness is a stage in the life of a user that is associated with the loss of control of use. In this paper the effects of the dimensions of marginalization on homelessness are reported. The marginalization theory emerged from ethnographic fieldwork research among the drug users population in Parkstad Limburg, the Netherlands. Ethnographic fieldwork is often restricted to a (selective observed) part of the total population. To verify whether the marginalization theory was valid for the total unknown population, we used quantitative data obtained in 1999 by a two-mode network sample (n = 58). As a conclusion homelessness was more likely to be present among marginalized than nonmarginalized drug users.     

从医学人文教学现状谈医学人文精神的回归路径

医学本质上具备双重属性,它既是一门科学,又是一门人学,因此,需要丰厚的人文精神的滋养。当前,由于医学技术的泛化、医学社会化的畸形发展以及人文学科对医学的照护不够等诸多原因,造成了医学的人文精神的缺失。为纠正这种“失常”的现象,应积极探寻有效的手段,为医学人文性的回归提供有力的支撑。因此,在大学课堂中以适当的方法加强对医学生的人文教育和关注,不失为医学人文精神回归的有益路径。     

Together we can make a difference: the case for transnational action for improved health in prisons

In spite of international differences in the treatment of incarcerated persons, as a group, they are vulnerable to poor health status and lack of access to quality health care. The health care of prisoners is affected by knowledge and commitment to ideas of human rights and social justice, as well as economic conditions. Prisoners are at increased risk of both acute and chronic diseases, and may constitute a threat to the health of other prisoners, their attendants or outside communities upon release. Mental illness and related problems of substance abuse are prevalent in prison populations, with many US prisons serving as modern asylums. Public health workers and organizations can stimulate and implement action to improve health in prisons. The World Federation of Public Health Associations can play a leadership role in co-ordinating and facilitating collaborative international action and research to enhance the health of prisoners and their communities worldwide.     

Understanding marginalization as a social determinant of health

Population-based studies have drawn attention to the associations between social and material disadvantage and poor mental and physical health over the life course, thereby contributing to inequalities in health. More recently, research in Britain has demonstrated that the effects of such disadvantage are cumulative through childhood and has shown that ‘ethnic minorities’ are at particular risk. This study gathered data from persons at risk, specifically first-generation migrant teenaged girls and their mothers, in Britain and Canada, and identified marginalization as a central feature of their relationships with others. Bourdieu's theoretical perspective is drawn on to examine the processes that contribute to marginalization and the conditions of broader society that sustain and reproduce them. It was the participants’ experience that their potential goes unrecognized, their opportunities to develop new relationships curtailed and possibilities to acquire new competences were eclipsed by others’ assumptions about them. The authors illustrate the social processes that contribute to the creation of tensions between seeking to belong and being assigned to the margins and consider their attendant influences on health. Taking direction from Bourdieu they illustrate ways in which discourses of marginalization and marginalizing practices associated with them can be interrupted, and in so doing work towards redressing processes that create a context for health inequalities.