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Delivery and immigration: the experience of an Italian hospital
European Journal of Obstetrics & Gynecology and Reproductive Biology 116 (2004) 170–172
Delivery and immigration: the experience of an Italian hospital Nicola Rizzo, Valentina Ciardelli, Giulia Gandolfi Colleoni*, Benedetta Bonavita, Chiara Parisio, Antonio Farina, Luciano Bovicelli Department of Obstetrics and Gynecology, Policlinico S. Orsola-Malpighi, University of Bologna, via Massarenti 13, Bologna 40139, Italy Received 7 August 2003; accepted 18 February 2004
Abstract Objective: We studied mode of delivery and prevalence of complications in pregnant women from the western world (WW) and immigrant mothers from non European Union (non-EU) countries at a third level Italian Obstetric Department. Study design: The study was population based and used data from the local Birth Registry at the University of Bologna. A 1:1 case control was performed by matching 510 single live births from immigrant mothers (non-EU) during the period 1997–2001 with 510 controls in chronological order (WW). Data were matched by age and parity. Results: No differences between the two groups were noted as concerns preterm delivery, percentage of infants transferred to neonatal intensive care unit, perinatal mortality, caesarean section rate, episiotomies, instrumental deliveries and post-partum complications. Significant differences were noted in the rate of elective caesarean section (which was higher in the WW women: P < 0:01) and in the rate of vaginal lacerations and neonatal malformations (which was higher in the non-EU group: P < 0:05). Conclusions: There was no substantial variation in the mode of delivery between non-EU immigrants and western women; only the rate of elective caesarean section was significantly higher in the WW group. A higher rate of vaginal lacerations and neonatal malformations was found in the non-EU group. In our experience the standard of medical care is achievable regardless of ethnic group. # 2004 Elsevier Ireland Ltd. All rights reserved. Keywords: Delivery; Pregnancy; Immigration
1. Introduction The movement of people across national borders is one of the critical issues of our time [1]. Large numbers of people from different countries are coming to Italy, legally or illegally, in search of better employment and living conditions. In 1998, 53.5% of the legal immigrants in the USA were women with a median age of 29 years. In Italy, data from Ministero degli Interni (Ministry of Internal Affairs) dated 1st Jan 2001 report a total of 1,464,589 immigrant individuals regularly registered (792,591 males and 671,998 females) with an increasing trend of approximately 15%, compared to the previous year [2]; sources from CARITAS reveal that in 2001 women represented around 46% of the immigrant population [3]. Referring only to our region (Emilia Romagna, in north east Italy) over a three year period between 1997 and 2000, the live births to immigrant mothers numbered 9254 out of a *
Corresponding author. Tel.: þ39-051-6364393; fax: þ39-051-6364393. E-mail addresses: [email protected] (N. Rizzo), [email protected] (G. Gandolfi Colleoni).
total of 116,544 live births of with a significant increasing trend: 1745 non-EU live births in 1997 to 3090 in 2000, with a percentage rise from 5.8 to 9.1%. Immigrant women are often in their prime reproductive years and arrive with myriad health care needs [4,5]. We studied mode of delivery and maternal and perinatal outcomes in pregnant women from the western industrialized world (WW) and non-EU immigrant women at our University Hospital over a 5 year period (1997–2001). The number of deliveries at our Centre is approximately 3500 per year accounting for 10% of the total deliveries in our region. Immigrant pregnant women have been growing in number since 1997; from 102 in 1992 to 342 in 2001 giving a percentage rise from 3.2 to 9.6%. The main purpose of our study was to investigate the differences in terms of mode of delivery and perinatal outcomes between WW and non-EU pregnant women.
2. Materials and methods This is a retrospective population based study. Data were recorded from the Hospital Birth Registry at the University
0301-2115/$ – see front matter # 2004 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejogrb.2004.02.018
N. Rizzo et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 116 (2004) 170–172 Table 1 Countries of origin of western world (WW) women Country
WW women
Italy Other-EU Australia Canada–USA
446 58 1 5
(87.4) (11.3) (0.19) (0.9)
The values in parenthesis are in percentage. Table 2 Continents of origin of non European Union (non-EU) women Continent
Non-EU women
Africa Asia East-Europe South-America
187 144 120 59
(36.6) (28.2) (23.5) (11.5)
The values in parenthesis are in percentage.
of Bologna in a progressive chronological order. A total of 1020 live births were studied, including 510 births to immigrant women from non-EU (Tables 1 and 2). A 1:1 case control was performed, matching 510 single live births from immigrant mothers (non-EU) by age and parity with 510 controls (WW). Only singleton pregnancies were considered. Analysis was conducted on the following outcomes: intra-uterine growth retardation (IUGR), preterm delivery, transfer to neonatal intensive care unit (NICU), perinatal mortality, fetal malformations (major and minor), episiotomies, vaginal repair, operative delivery, caesarean section and post-partum complications. Univariate test for comparison of two proportions was used, and statistical significance was set at P < 0:05.
3. Results There were no differences in the two groups (Table 3) referring to the rate of preterm delivery (3.53% in the WW versus 2.16% in the non-EU), and IUGR (5.88% both in the WW and in the non-EU). Likewise, the percentage of neonates transferred to neonatal intensive care units (NICU) and the perinatal mortality (PNM) was similar between groups (NICU: 3.3% both in the WW and in the non-EU; PNM: 0.2% in the WW versus 0.39% in the non-EU). Nor was any statistical difference found in the caesarean section rate (20.59% in the WW versus 19.22% in the non-EU), episiotomies (7.84% versus 9.8%), instrumental deliveries (1.18% in both groups), emergency caesarean section (10% versus 13.14%) and post-partum complications (1.37% versus 1.18%). The significant differences found concerned the rate of elective caesarean sections (Table 3): the percentage of elective cesarean sections (10.59% in the WW versus 6.08% in the non-EU; P < 0:01), vaginal lacerations (6.08% versus 9.8%; P < 0:05) and neonatal malformations (0.2% in the WW versus 1.37% in the non-EU; P < 0:05).
171
Table 3 Pregnancy outcome of western world (WW) and non European Union (non-EU) women Variable
WW (n ¼ 510)
Non-EU (n ¼ 510)
P value
PTB (<34 W) IUGR Fetal malformations NICU PNM CS Elective CS Emergency CS Instrumental deliveries Lacerations Episiotomies Post-partum complications
18 30 1 17 1 105 54 51 6 31 40 7
11 30 7 17 2 98 31 67 6 50 50 6
ns ns <0.05 ns ns ns <0.01 ns ns <0.05 ns ns
(3.53) (5.88) (0.2) (3.33) (0.2) (20.59) (10.59) (10) (1.18) (6.08) (7.84) (1.37)
(2.16) (5.88) (1.37) (3.33) (0.39) (19.22) (6.08) (13–14) (1.18) (9.8) (9.8) (1.18)
PTB: pre term birth;PNM: perinatal mortality; IUGR: intra uterine growth retardation; NICU: neonatal intensive care unit; CS: cesarean section; ns: non significant (P > 0:05). The values in parenthesis are in percentage.
4. Discussion The number of non-EU immigrants is visibly growing in our country. Currently, in our region (Emilia Romagna), the rate of births of immigrant pregnant women is 1/10 [5]. Nearly all obstetricians will see these patients in daily practice, especially those who work in regions with high immigration rates [6]. Few immigrants who are seen for care arrive with their history and medical records in hand. Hence, obstetricians must determine what care is needed for both immediate symptom relief and ongoing prevention and screening. All physicians and nurse-clinicians need to have cultural competence training and deserve better evidencebased practice guidelines for delivering care to immigrants than are currently available. Medical schools, nursing schools, and residency training programs need to promote such training [7]. In addition to cultural competence training, health care professionals of all types must seek appropriate translation and interpretation services locally [8]. Current law requires hospitals to provide these services. Physicians need training to maximize effectiveness when working with interpreters [7]. Having family members translate is not an acceptable solution because it causes potential stress, and can introduce bias in interpretations of symptoms and history. By learning about the barriers to care faced by patients who have recently immigrated, physicians and other health care providers better understand how the health system works, or fails to work, for vulnerable groups. In this study the mode of delivery and hence the care given to the immigrant pregnant woman in our hospital did not differ from that of non-immigrants. The only exception was the elective caesarean section rate. To obtain these uniform results, efforts were made to offer similar standard medical care regardless of ethnic group. In our region (Emilia Romagna), immigrant women have access to special medical
172
N. Rizzo et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 116 (2004) 170–172
services where interpreters, nurses, midwives and doctors are properly trained. This leads to correct pregnancy care which often means fewer difficulties when delivering. Caesarean section is more hazardous than vaginal birth and, especially in uncomplicated pregnancies, is associated with increased neonatal morbidity, predominantly related to respiratory problems [9]. The cesarean section rate has increased markedly in recent years all over the world. Ethnic differences in the use of transabdominal delivery have been reported in USA [10]. Another study reported that caesarean section was more common among immigrants than among ethnic Norwegians [11,12] but more data are needed to establish whether caesarean section is more common in particular ethnic groups or if it is a general phenomenon among immigrants. In our study, the percentage of elective caesarean section was significantly higher in the WW women (P < 0:01). A more confident obstetrical approach to the immigrant expectant is common, probably due to less fear of medical litigation, partly explaining the different management of labour in the two groups. Different traditional and cultural concepts of pregnancy and delivery may explain the different approach to childbirth from the women’s points of view. Further studies are required to better investigate the correlation between female genital mutilation (FGM) and chosen mode of delivery and outcome, due to the essential role this practice plays in the physiologic and psychologic mechanism of birth. The slight difference between the two groups could be due to FGM and therefore merits further investigation. The slight disproportion in neonatal abnormalities could be due to a less common culture of prenatal diagnosis among the non-EU group. It can be assumed that similar malformations discovered antenatally by routine investigation in the WW group ended in termination of pregnancy. The medical care of recently immigrated women should reach beyond the western focus in identifying pathologic processes that cause a symptom or might lead to disease. Physicians face a population with a variety of backgrounds and experiences, all of which may
have health consequences and effects on communication, modesty, and the use of health services [13].
References [1] Ackerman LK. Health problems of refugees. J Am Board Fam Pract 1997;10:337–48. [2] From the national registry of statistics on line: http://www.istat.it In: Gabrielli D, Giovanelli C, editors. Servizio Popolazione e Cultura, February 2001. [3] CARITAS data on immigration web site: http://www.caritas.it. [4] Statistics Branch, Office of Policy and Planning. Annual Report: Legal Immigration, Fiscal Year 1998. Washington, DC: Immigration and Naturalization Service, US Department of Justice July 1999, no. 2. Available at http://www.ins.gov/graphics/publicaffairs/newsrels/ 98Legal.pdf. Accessed March 29, 2001. [5] Dati di attivita`—Anno 2000—Spazi donne immigrate e loro bambini Regione Emilia Romagna. Assessorato alla Sanita` Servizio assistenza distrettuale. Pianificazione e sviluppo dei servizi sanitari, p. 14–19. [6] US Preventive Services Task Force. Guide to clinical preventive services. second ed. Baltimore: Williams & Wilkins, 1996. [7] Putsch RW. Cross-cultural communication. The special case of interpreters in health care. JAMA 1985;254:3344–8. [8] University of California, Berkeley-University of California, San Francisco Health and Medical Sciences Program. Joint Medical Program [curriculum brochure]. Berkeley: University of California, 2001. [9] Hook B, Kiwi R, Amini SB, Fanaroff A, Hack M. Neonatal morbidity after elective repeat cesarean section and trial of labor. Pediatrics 1997;100:348–53. [10] Braveman P, Egerter S, Edmonston F, Verdon M. Racial ethnic differences in the likehood of cesarean delivery, California. Am J Public Health 1995;85:625–30. [11] Stray-Pedersen B, Austweg B. V?re nye landsmenn. Utfordringer og muligheter. [Our new citizens. Challenges and possibilities.] (in Norwegian.) In: B1rdahl PE, Moen MH, Jerve F, editors. Midt i livet [In the center of life]. Trondheim: Tapir Forlag, 1996, 253–66. [12] Vangen S, Stoltenberg C, Skrondal A. Babill Stray-Pedersen. Cesarean section among immigrants in Norway. Acta Obstet Gynecol Scand 2000;79:553–8. [13] Riddick S, Linguistic issues. In: Kramer E, Ivey S, Ying Y, editors. Immigrant women’s health: problems and solutions. San Francisco: Jossey-Bass, 1999, p. 35–43 (Chapter 3).
Delivery and immigration: the experience of an Italian hospital Nicola Rizzo, Valentina Ciardelli, Giulia Gandolfi Colleoni*, Benedetta Bonavita, Chiara Parisio, Antonio Farina, Luciano Bovicelli Department of Obstetrics and Gynecology, Policlinico S. Orsola-Malpighi, University of Bologna, via Massarenti 13, Bologna 40139, Italy Received 7 August 2003; accepted 18 February 2004
Abstract Objective: We studied mode of delivery and prevalence of complications in pregnant women from the western world (WW) and immigrant mothers from non European Union (non-EU) countries at a third level Italian Obstetric Department. Study design: The study was population based and used data from the local Birth Registry at the University of Bologna. A 1:1 case control was performed by matching 510 single live births from immigrant mothers (non-EU) during the period 1997–2001 with 510 controls in chronological order (WW). Data were matched by age and parity. Results: No differences between the two groups were noted as concerns preterm delivery, percentage of infants transferred to neonatal intensive care unit, perinatal mortality, caesarean section rate, episiotomies, instrumental deliveries and post-partum complications. Significant differences were noted in the rate of elective caesarean section (which was higher in the WW women: P < 0:01) and in the rate of vaginal lacerations and neonatal malformations (which was higher in the non-EU group: P < 0:05). Conclusions: There was no substantial variation in the mode of delivery between non-EU immigrants and western women; only the rate of elective caesarean section was significantly higher in the WW group. A higher rate of vaginal lacerations and neonatal malformations was found in the non-EU group. In our experience the standard of medical care is achievable regardless of ethnic group. # 2004 Elsevier Ireland Ltd. All rights reserved. Keywords: Delivery; Pregnancy; Immigration
1. Introduction The movement of people across national borders is one of the critical issues of our time [1]. Large numbers of people from different countries are coming to Italy, legally or illegally, in search of better employment and living conditions. In 1998, 53.5% of the legal immigrants in the USA were women with a median age of 29 years. In Italy, data from Ministero degli Interni (Ministry of Internal Affairs) dated 1st Jan 2001 report a total of 1,464,589 immigrant individuals regularly registered (792,591 males and 671,998 females) with an increasing trend of approximately 15%, compared to the previous year [2]; sources from CARITAS reveal that in 2001 women represented around 46% of the immigrant population [3]. Referring only to our region (Emilia Romagna, in north east Italy) over a three year period between 1997 and 2000, the live births to immigrant mothers numbered 9254 out of a *
Corresponding author. Tel.: þ39-051-6364393; fax: þ39-051-6364393. E-mail addresses: [email protected] (N. Rizzo), [email protected] (G. Gandolfi Colleoni).
total of 116,544 live births of with a significant increasing trend: 1745 non-EU live births in 1997 to 3090 in 2000, with a percentage rise from 5.8 to 9.1%. Immigrant women are often in their prime reproductive years and arrive with myriad health care needs [4,5]. We studied mode of delivery and maternal and perinatal outcomes in pregnant women from the western industrialized world (WW) and non-EU immigrant women at our University Hospital over a 5 year period (1997–2001). The number of deliveries at our Centre is approximately 3500 per year accounting for 10% of the total deliveries in our region. Immigrant pregnant women have been growing in number since 1997; from 102 in 1992 to 342 in 2001 giving a percentage rise from 3.2 to 9.6%. The main purpose of our study was to investigate the differences in terms of mode of delivery and perinatal outcomes between WW and non-EU pregnant women.
2. Materials and methods This is a retrospective population based study. Data were recorded from the Hospital Birth Registry at the University
0301-2115/$ – see front matter # 2004 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejogrb.2004.02.018
N. Rizzo et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 116 (2004) 170–172 Table 1 Countries of origin of western world (WW) women Country
WW women
Italy Other-EU Australia Canada–USA
446 58 1 5
(87.4) (11.3) (0.19) (0.9)
The values in parenthesis are in percentage. Table 2 Continents of origin of non European Union (non-EU) women Continent
Non-EU women
Africa Asia East-Europe South-America
187 144 120 59
(36.6) (28.2) (23.5) (11.5)
The values in parenthesis are in percentage.
of Bologna in a progressive chronological order. A total of 1020 live births were studied, including 510 births to immigrant women from non-EU (Tables 1 and 2). A 1:1 case control was performed, matching 510 single live births from immigrant mothers (non-EU) by age and parity with 510 controls (WW). Only singleton pregnancies were considered. Analysis was conducted on the following outcomes: intra-uterine growth retardation (IUGR), preterm delivery, transfer to neonatal intensive care unit (NICU), perinatal mortality, fetal malformations (major and minor), episiotomies, vaginal repair, operative delivery, caesarean section and post-partum complications. Univariate test for comparison of two proportions was used, and statistical significance was set at P < 0:05.
3. Results There were no differences in the two groups (Table 3) referring to the rate of preterm delivery (3.53% in the WW versus 2.16% in the non-EU), and IUGR (5.88% both in the WW and in the non-EU). Likewise, the percentage of neonates transferred to neonatal intensive care units (NICU) and the perinatal mortality (PNM) was similar between groups (NICU: 3.3% both in the WW and in the non-EU; PNM: 0.2% in the WW versus 0.39% in the non-EU). Nor was any statistical difference found in the caesarean section rate (20.59% in the WW versus 19.22% in the non-EU), episiotomies (7.84% versus 9.8%), instrumental deliveries (1.18% in both groups), emergency caesarean section (10% versus 13.14%) and post-partum complications (1.37% versus 1.18%). The significant differences found concerned the rate of elective caesarean sections (Table 3): the percentage of elective cesarean sections (10.59% in the WW versus 6.08% in the non-EU; P < 0:01), vaginal lacerations (6.08% versus 9.8%; P < 0:05) and neonatal malformations (0.2% in the WW versus 1.37% in the non-EU; P < 0:05).
171
Table 3 Pregnancy outcome of western world (WW) and non European Union (non-EU) women Variable
WW (n ¼ 510)
Non-EU (n ¼ 510)
P value
PTB (<34 W) IUGR Fetal malformations NICU PNM CS Elective CS Emergency CS Instrumental deliveries Lacerations Episiotomies Post-partum complications
18 30 1 17 1 105 54 51 6 31 40 7
11 30 7 17 2 98 31 67 6 50 50 6
ns ns <0.05 ns ns ns <0.01 ns ns <0.05 ns ns
(3.53) (5.88) (0.2) (3.33) (0.2) (20.59) (10.59) (10) (1.18) (6.08) (7.84) (1.37)
(2.16) (5.88) (1.37) (3.33) (0.39) (19.22) (6.08) (13–14) (1.18) (9.8) (9.8) (1.18)
PTB: pre term birth;PNM: perinatal mortality; IUGR: intra uterine growth retardation; NICU: neonatal intensive care unit; CS: cesarean section; ns: non significant (P > 0:05). The values in parenthesis are in percentage.
4. Discussion The number of non-EU immigrants is visibly growing in our country. Currently, in our region (Emilia Romagna), the rate of births of immigrant pregnant women is 1/10 [5]. Nearly all obstetricians will see these patients in daily practice, especially those who work in regions with high immigration rates [6]. Few immigrants who are seen for care arrive with their history and medical records in hand. Hence, obstetricians must determine what care is needed for both immediate symptom relief and ongoing prevention and screening. All physicians and nurse-clinicians need to have cultural competence training and deserve better evidencebased practice guidelines for delivering care to immigrants than are currently available. Medical schools, nursing schools, and residency training programs need to promote such training [7]. In addition to cultural competence training, health care professionals of all types must seek appropriate translation and interpretation services locally [8]. Current law requires hospitals to provide these services. Physicians need training to maximize effectiveness when working with interpreters [7]. Having family members translate is not an acceptable solution because it causes potential stress, and can introduce bias in interpretations of symptoms and history. By learning about the barriers to care faced by patients who have recently immigrated, physicians and other health care providers better understand how the health system works, or fails to work, for vulnerable groups. In this study the mode of delivery and hence the care given to the immigrant pregnant woman in our hospital did not differ from that of non-immigrants. The only exception was the elective caesarean section rate. To obtain these uniform results, efforts were made to offer similar standard medical care regardless of ethnic group. In our region (Emilia Romagna), immigrant women have access to special medical
172
N. Rizzo et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 116 (2004) 170–172
services where interpreters, nurses, midwives and doctors are properly trained. This leads to correct pregnancy care which often means fewer difficulties when delivering. Caesarean section is more hazardous than vaginal birth and, especially in uncomplicated pregnancies, is associated with increased neonatal morbidity, predominantly related to respiratory problems [9]. The cesarean section rate has increased markedly in recent years all over the world. Ethnic differences in the use of transabdominal delivery have been reported in USA [10]. Another study reported that caesarean section was more common among immigrants than among ethnic Norwegians [11,12] but more data are needed to establish whether caesarean section is more common in particular ethnic groups or if it is a general phenomenon among immigrants. In our study, the percentage of elective caesarean section was significantly higher in the WW women (P < 0:01). A more confident obstetrical approach to the immigrant expectant is common, probably due to less fear of medical litigation, partly explaining the different management of labour in the two groups. Different traditional and cultural concepts of pregnancy and delivery may explain the different approach to childbirth from the women’s points of view. Further studies are required to better investigate the correlation between female genital mutilation (FGM) and chosen mode of delivery and outcome, due to the essential role this practice plays in the physiologic and psychologic mechanism of birth. The slight difference between the two groups could be due to FGM and therefore merits further investigation. The slight disproportion in neonatal abnormalities could be due to a less common culture of prenatal diagnosis among the non-EU group. It can be assumed that similar malformations discovered antenatally by routine investigation in the WW group ended in termination of pregnancy. The medical care of recently immigrated women should reach beyond the western focus in identifying pathologic processes that cause a symptom or might lead to disease. Physicians face a population with a variety of backgrounds and experiences, all of which may
have health consequences and effects on communication, modesty, and the use of health services [13].
References [1] Ackerman LK. Health problems of refugees. J Am Board Fam Pract 1997;10:337–48. [2] From the national registry of statistics on line: http://www.istat.it In: Gabrielli D, Giovanelli C, editors. Servizio Popolazione e Cultura, February 2001. [3] CARITAS data on immigration web site: http://www.caritas.it. [4] Statistics Branch, Office of Policy and Planning. Annual Report: Legal Immigration, Fiscal Year 1998. Washington, DC: Immigration and Naturalization Service, US Department of Justice July 1999, no. 2. Available at http://www.ins.gov/graphics/publicaffairs/newsrels/ 98Legal.pdf. Accessed March 29, 2001. [5] Dati di attivita`—Anno 2000—Spazi donne immigrate e loro bambini Regione Emilia Romagna. Assessorato alla Sanita` Servizio assistenza distrettuale. Pianificazione e sviluppo dei servizi sanitari, p. 14–19. [6] US Preventive Services Task Force. Guide to clinical preventive services. second ed. Baltimore: Williams & Wilkins, 1996. [7] Putsch RW. Cross-cultural communication. The special case of interpreters in health care. JAMA 1985;254:3344–8. [8] University of California, Berkeley-University of California, San Francisco Health and Medical Sciences Program. Joint Medical Program [curriculum brochure]. Berkeley: University of California, 2001. [9] Hook B, Kiwi R, Amini SB, Fanaroff A, Hack M. Neonatal morbidity after elective repeat cesarean section and trial of labor. Pediatrics 1997;100:348–53. [10] Braveman P, Egerter S, Edmonston F, Verdon M. Racial ethnic differences in the likehood of cesarean delivery, California. Am J Public Health 1995;85:625–30. [11] Stray-Pedersen B, Austweg B. V?re nye landsmenn. Utfordringer og muligheter. [Our new citizens. Challenges and possibilities.] (in Norwegian.) In: B1rdahl PE, Moen MH, Jerve F, editors. Midt i livet [In the center of life]. Trondheim: Tapir Forlag, 1996, 253–66. [12] Vangen S, Stoltenberg C, Skrondal A. Babill Stray-Pedersen. Cesarean section among immigrants in Norway. Acta Obstet Gynecol Scand 2000;79:553–8. [13] Riddick S, Linguistic issues. In: Kramer E, Ivey S, Ying Y, editors. Immigrant women’s health: problems and solutions. San Francisco: Jossey-Bass, 1999, p. 35–43 (Chapter 3).