REVIEW ARTÍCULO DE REVISIÓN
Assessing equitable care for indigenous and afrodescendant women in Latin America
Equitatividad de la atención a las mujeres indígenas y afrodescendientes de América Latina
Arachu Castro; Virginia Savage; Hannah Kaufman
Institute for Health Equity in Latin America, Department of Global Community Health and Behavioral Sciences, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana, United States of America. Send correspondence to Arachu Castro, email: firstname.lastname@example.org
OBJECTIVE: To identify and understand the barriers to equitable care within health care settings that women of ethnic minorities encounter in Latin America and to examine possible strategies for mitigating the issues.
METHODS: This was a comprehensive review of the literature from 2000-2015 available from the online databases PubMed, Google Scholar, EBSCOhost, and SciELO in Spanish, English, and Portuguese, using a keyword search that included the Region and country names.
RESULTS: Health provider discrimination against Indigenous and Afrodescendant women is a primary barrier to quality health care access in Latin America. Discrimination is driven by biases against ethnic minority populations, women, and the poor in general. Discriminatory practices can manifest as patient-blaming, purposeful neglect, verbal or physical abuse, disregard for traditional beliefs, and the non-use of Indigenous languages for patient communication. These obstacles prevent delivery of appropriate and timely clinical care, and also produce fear of shame, abuse, or ineffective treatment, which, in addition to financial barriers, deter women from seeking care.
CONCLUSIONS: To ensure optimal health outcomes among Indigenous and Afrodescendant women in Latin America, the issue of discrimination in health care settings needs to be understood and addressed as a key driver of inequitable health outcomes. Strategies that target provider behavior alone have limited impact because they do not address women's needs and the context of socioeconomic inequality in which intra-hospital relations are built.
Key words: Equity; health inequality; ethnicity and health; minority health; health of Indigenous peoples; health services, Indigenous; social discrimination; prejudice; gender and health; Latin America; Caribbean Region.
OBJETIVOS: Determinar y comprender las barreras que impiden en los entornos de atención de salud de América Latina la asistencia equitativa a las mujeres pertenecientes a minorías étnicas, y analizar las posibles estrategias dirigidas a mitigar los problemas.
MÉTODOS: Se llevó a cabo una evaluación exhaustiva de la bibliografía publicada del 2000 al 2015 en las bases de datos en línea PubMed, Google Académico, EBSCOhost y SciELO en español, inglés y portugués, mediante una búsqueda de palabras clave que incluyó los nombres de la Región y los países.
RESULTADOS: La discriminación por parte de los proveedores de servicios de salud contra las mujeres indígenas y afrodescendientes constituye una barrera primaria que impide a estas el acceso a una atención de salud de calidad en América Latina. La discriminación surge de los prejuicios contra las poblaciones de minorías étnicas, las mujeres y los pobres en general. Las prácticas discriminatorias se pueden manifestar en forma de culpabilización de las pacientes, negligencia intencionada, maltrato verbal o físico, falta de respeto a las creencias tradicionales y no utilización de los idiomas indígenas para comunicarse con las pacientes. Estos obstáculos impiden la prestación de una atención médica apropiada y oportuna, y también provocan temor a pasar vergüenza, al maltrato o a un tratamiento ineficaz que, junto a las barreras económicas, disuaden a las mujeres de acudir en busca de asistencia.
CONCLUSIONES: Para garantizar resultados óptimos en materia de salud entre las mujeres indígenas y afrodescendientes de América Latina, es preciso comprender y abordar el problema de la discriminación en los entornos de atención de salud como factor clave de los resultados no equitativos en materia de salud. Las estrategias dirigidas exclusivamente al comportamiento de los proveedores tienen una repercusión limitada, porque no abordan las necesidades de las mujeres y el contexto de desigualdad socioeconómica en el que se forjan las relaciones intrahospitalarias.
Palabras clave: Equidad; desigualdades en la salud; origen étnico y salud; salud de minorías; salud de poblaciones indígenas; servicios de salud del indígena; discriminación social; prejuicio; género y salud; América Latina; Región del Caribe.
In 2010, there were at least 826 Indigenous groups in Latin America, comprising approximately 45 million people or 8% of the total population (1). While many countries in Latin America lack comprehensive data on ethnicity, existing reports indicate that as a proportion of each country's population, Afrodescendant communities range from less than 0.1% in Guatemala to 31% in Belize to 51% in Brazil (2). The map in Figure 1 shows Indigenous and Afrodescendant populations as a percentage of the total population, by country.
In many parts of Latin America, Indigenous and Afrodescendant populations are subject to widespread social exclusion and discrimination (1, 3, 4); that is, they are denied of rights, resources, and services available to the dominant ethnic groups, based on racist, prejudicial treatment. Moreover, poor, Indigenous or Afrodescendant women receive "triple discrimination;" by being female, being an ethnic minority, and of low-socioeconomic status, they have far fewer opportunities for educational, political, social, and economic participation (4-6). In fact, in 2014, the United Nations (UN) Economic Commission for Latin America and the Caribbean (ECLAC) reported that none of its countries had achieved the UN standards for recognizing the territorial rights of Indigenous populations; that in 2000-2005, a disproportionate number of Indigenous children had suffered some form of material deprivation (88% vs. 63% of the area's total population); and that Indigenous women remain widely underrepresented in decision-making positions at the political party, municipal, and federal levels, although Indigenous men are gaining increased political representation in Bolivia, Guatemala, Nicaragua, and Panama (1).
Throughout the world, broad social exclusion and discrimination against women, ethnic minorities, the poor, sexual minorities, and other populations whose rights are often infringed upon have a significant negative impact on mental and physical health that result from stress responses (7, 8). In segmented health systems in which users of public health facilities are overwhelmingly from the lowest wealth quintiles, the clinical encounter in the public system becomes the locus of reproduction of unbalanced social and gender power dynamics between patients and healers (doctors, nurses, and nurse assistants) (9) and between and within health care providers and other workers of different hierarchical strata. In these contexts, discrimination is systematically embedded as an intrinsic component of the clinical encounter, contributing to differential health outcomes, not only as a stressor, but as a result of poor quality of care or outright neglect. Therefore, differences in access to quality health care and in health outcomes that result from exclusion and discrimination constitute forms of health inequity-they are "unnecessary, avoidable, unfair, and unjust" (10).
In 2014, the World Health Organization published a statement advocating for the elimination of disrespect and abuse of women during childbirth in health facilities through the improvement of quality of care (11). But incisive calls for action at the global level have stressed the importance of studying the root causes of this phenomenon as the power structure of the medical field (12) and as "a symptom of fractured health systems" (13) that needs to be addressed by focusing on the intentional mistreatment of women (14)-even though the intent may be so ingrained that discriminatory practices may be generated spontaneously (12). Given how deeply rooted social and gender discrimination can be in health care, some authors have argued that it not be considered just another quality of care issue or a lack of professional ethics, but rather, a complex sociological problem (12) requiring structural transformation.
Although several countries in Latin America have enacted measures to achieve universal health care (UHC), national and regional reports indicate that health equity remains elusive, standing as an impediment to reaching UHC (15-18). This may be particularly true regarding Indigenous and Afrodescendant women, who frequently suffer worse health outcomes and shorter life expectancy (15, 16), and migrant women, who may experience difficult access to timely and quality health care (17, 18), among others.
Consequently, this study seeks to assess how social exclusion and discrimination in the health care setting affect Indigenous and Afrodescendant women in Latin America in order to raise awareness and identify strategies for improving health equity in response to their needs; that is, responsive to women's living conditions, concerns, and priorities. Although a global, systematic review of mistreatment of women during childbirth has been published and it included studies from Latin America (19), to the authors' knowledge this is the first review of discrimination against Indigenous and Afrodescendant women in the health care setting in Latin America.
MATERIALS AND METHODS
This was a comprehensive review of the literature published in 2000-2015 available from the online databases PubMed, Google Scholar, EBSCOhost, and SciELO. In addition to the Region and individual country names, the following key word search was conducted in English, Spanish, and Portuguese, respectively: (a) Afrodescendants, barriers to care, discrimination, disrespect, equity, health care, Indigenous, inequality, intercultural care, maltreatment, marginalization, maternal health, minority, quality of care, rejection, shame, women; (b) afrodescendientes, atención médica, barreras, calidad, desigualdad, discriminación, estigmatización, equidad, etnia, indígenas, interculturalidad, maltrato, salud, servicios de salud; and (c) afro-descendentes, barreira de acesso, desigualdade em saúde, desumanização, discriminação, equidade, estigmatizacão, indígenas, maltrato, saúde. Only documents pertaining to Latin America were retained.
Results included a total of 60 publications-reports, journal articles, books, and other scholarly papers-published in 2000-2015; of these, 32 were in English, 18 in Spanish, and 10 in Portuguese. For analysis, they were grouped into three categories:
(a) Studies of discrimination against women in the health care setting: 40 publications, of which 26 specifically focused on women of ethnic minorities; the remaining did not mention ethnicity specifically, but had been conducted in areas inhabited by Indigenous and Afrodescendant populations.
(b) Studies on the causes of discrimination and its effects on health outcomes: 15 publications.
(c) Studies or reports on interventions and strategies aimed at reducing discrimination in the health care setting: 17 publications.
Nineteen of the publications fell into more than one category.
Discrimination in the health care setting as a public health issue
A synthesis of existing literature-based on studies conducted in Argentina, Brazil, Bolivia, Chile, Colombia, Costa Rica, Cuba, Dominican Republic, Guatemala, Mexico, and Peru-indicates that widespread provider discrimination and violence are chief barriers that prevent women of ethnic minorities from accessing quality health services in Latin America. The majority of these studies (n = 28) draw primarily from qualitative research methods, including interviews and focus groups with women of ethnic minority, health care providers, indigenous medicine practitioners, and others; 5 studies used mixed qualitative and quantitative methods; and 7 studies employed only quantitative methods. Descriptions of these studies (5, 6, 12, 17, 18, 20-55) can be found in order of publication in Table 1.
As shown in Table 1, discrimination and violence can manifest through numerous behaviors practiced by medical personnel. Primarily, language and communication barriers, which occur frequently, can constitute forms of discrimination (46) by promoting inequitable power structures between doctors and patients (6, 21, 23) and limiting the provider's ability to address patient needs. Cultural insensitivity and a lack of intercultural care are also common among health care providers throughout Latin America (47). Specific examples include: disregard for a woman's opinion concerning her condition and treatment (33, 42, 44, 49); condemnation of traditional concepts of medicine and healing (6, 46); and active rejection of benign or even beneficial cultural practices, such as giving birth in a vertical position (30), drinking tea after childbirth, or giving birth in a room with a warm temperature (6). Additionally, provider discrimination can take the form of verbal abuse, such as patient blaming, public humiliation, scolding, and name-calling (22, 24, 30, 34, 37, 50, 54)-causing shame and creating exclusion (17, 34, 36, 54). Physical abuse is another form of discrimination, in which providers perform unnecessary procedures or hit, slap, or touch women in painful or uncomfortable ways (20, 23, 37) or refuse to administer pain medication (28, 37). Discrimination also appears in providers' purposeful neglect of patients, such as was found among Nicaraguans living in Costa Rica (17), Indigenous women in Peru (6), Haitian women in the Dominican Republic (41), Afro- Brazilian women in Brazil (28), and Mayan women in Guatemala (43). Finally, research highlights incidents of Indigenous women in Peru (18) and Nicaraguan immigrants in Costa Rica (17) being denied medical attention for both minor and life-threatening health concerns.
Further regarding issues of humiliation, a 2013 study of Jalisco in northwestern Mexico found reports of Huichol Indigenous women feeling shame and being treated as morally and intellectually inferior by the local health personnel (50, 54). Similar experiences of shame were reported among Nicaraguan health care users in Costa Rica (17), Indigenous women in Peru and in the Yacapaní area of Bolivia (6, 34), and Peruvian women seeking care in Chile (18). A 2011 study in Guatemala concluded that social exclusion of Indigenous people was particularly manifest in clinical settings, where non-Indigenous health care providers often reject the Mayan people and their beliefs, and blame their illnesses on cultural practices (43). Similarly, a 2008 study from Colombia described inequities within health care systems as the product of broader social and structural patterns of exclusion for Afrodescendants and other ethnic minorities (32). Reports from Peru also suggest that shortages of human health resources and medical supplies in health facilities may fuel increased provider discrimination (6).
Health outcomes and discrimination in health facilities
Thus far, few studies have specifically quantified the effects of discrimination on health outcomes among Indigenous and Afrodescendant women in health facilities in Latin America. However, the studies included in this review indicate numerous short and long-term effects that may result from this phenomenon. Primarily, health care discrimination may fuel inequitable health outcomes between women of dominant and those of minority ethnicity. A 2010 ECLAC report attributed the high maternal mortality ratio (MMR) in Latin America and the Caribbean to health system discrimination against Indigenous and Afrodescendant women (40). This report claimed that unequal health outcomes between women of dominant ethnic groups and those of ethnic minorities resulted from institutionalized racism (40). A 2007 report by Physicians for Human Rights also attributed high maternal mortality ratios in Peru to the social and political marginalization of Indigenous women manifested in the country's health care system (6).
Latin American maternal and infant mortality statistics support these arguments. As an example, in 1996, the infant mortality rate (IMR) among Afro-Brazilian children was 62.3 per 1 000 live births, which was almost double the 37.3 IMR among children of predominant- ly European descent (56). Data from six countries showed that Indigenous and Afrodescendant infants experienced higher infant IMR than other infants (57). Additionally, in 2006, Indigenous women in Latin America experienced MMRs that were 2-3 times higher on average than national ratios (58). According to a 2013 report from the International Federation of Red Cross and Red Crescent Societies, the highest MMRs in Bolivia, Guatemala, Guyana, Honduras, and Panama are all found in primarily Indigenous areas (59). Data from 2007 (3) showed drastic inequities in MMR between Brazilian women identified as black (preta) and those identified as white (branca): in the 20-24 year age group, black women had an MMR of 44.5 per 100 000 live births, while white women had a ratio of 23.4; for those 25-29 years of age, it was 61.9 for black women and 40.5 for white.
The effects of provider discrimination directly compromise access to treatment (60). Various qualitative studies state that provider discrimination, coupled with financial barriers, affect health care utilization rates among women of ethnic minorities (6, 25, 26, 31, 34). A 2010 ECLAC report identified the cultural and language inaccessibility of maternal health services as a key factor deterring women of ethnic minorities from seeking medical care (40). Among community- level studies, three found that in 2004, 2007, and 2014, numerous Mayan women in Guatemala chose to give birth at home due to fear of personnel neglect, verbal abuse, and culturally inappropriate treatment (26, 31, 53). Indeed, only 13% of the women participants in the 2014 study delivered in a hospital because they feared a lack of quality care, communication barriers with doctors, and mistreatment from personnel (53). Similarly, in a 2008 study in the Yacapaní Indigenous area of Bolivia, 37% of women participants cited fear of mistreatment by staff as a key deterrent to seeking medical care (34). A 2007 report also found that the perceived low quality and inappropriateness of maternal health care services discouraged Indigenous women in Peru from seeking care (6).
Two ECLAC reports included disaggregated health care utilization according to the Indigenous status of women in five and seven selected countries, respectively. Figure 2 shows that in Bolivia, Ecuador, Guatemala, Nicaragua, and Peru, the percentage of Indigenous women who attended prenatal care, gave birth in a health facility, and received follow-up attention was systematically lower than among the non- Indigenous (40). Similarly, skilled birth attendance in Bolivia, Colombia, Ecuador, Guatemala, Mexico, Nicaragua, Paraguay, and Peru (Figure 3) was more frequent among non-Indigenous than among Indigenous women (1).
Health provider discrimination against Indigenous and Afrodescendant women may also obstruct the development or implementation of policies promoting Indigenous rights (25, 61). As discussed in a 2004 qualitative study from Chile, medical providers should have a role in the development and advocacy of policies to mandate intercultural care practices, but providers are not likely to support such policies if they view intercultural care as unnecessary or if they deem Indigenous health as unworthy of special initiatives (25). Furthermore, medical personnel with racial biases may not comply with anti-discrimination policies that are enacted.
Reducing discrimination in health care
Thus far, numerous countries and organizations have enacted small-scale initiatives that have shown promise in mitigating discrimination against women of ethnic minorities in Latin American health care settings. Such initiatives can be grouped into two categories according to purpose. The first includes various initiatives that promote the humanization of medical care and focus on improving women's experiences during labor and delivery (37, 49, 62). These humanization-of-childbirth programs seek to empower women giving birth with the agency to communicate openly with their health providers, express concerns and wishes for their birthing experiences, and receive safe, evidence-based care. Effective humanization-of-childbirth initiatives train professionals to provide culturally appropriate, non-discriminatory, and high quality care to women from all ethnic, social, and economic backgrounds and should inspire medical personnel to respect female patients as humans rather than treat them as merely laboring bodies (62).
The second group of interventions have focused on promoting intercultural care. Designed to improve the quality of medical attention for Indigenous or other ethnic minorities, intercultural care incorporates languages spoken by ethnic minorities and recognizes the existence of alternative models of health and healing (25). Intercultural care practices are tailored to suit the needs of the specific populations they serve and ultimately seek to create cultures of non-discrimination, respect, and cultural competency within health care systems (25). Specific components of intercultural care programs frequently include: communication workshops for medical staff to learn Indigenous languages as well as techniques for establishing an open dialogue with patients (25, 26, 63), training sessions to promote cultural sensitivity and humility among providers (64-66), and installations of traditional medicine practitioners within biomedical health facilities (26, 61). Programs have both been implemented directly into medical and educational systems by local governments and health ministries or have been implemented as separate training programs overseen by independent organizations.
The list of interventions addressing provider discrimination can be found in Table 2 (40, 49, 61, 64, 66-72). Of note, the vast majority of interventions have focused on Indigenous women or Indigenous populations in general. This literature search did not find evidence of interventions specifically targeted to women of Afrodescendant or other minority backgrounds. As described in Table 2, humanization-of-care and intercultural health programs have achieved varying levels of success, with some interventions offering important lessons for future strategies in reducing provider discrimination against Indigenous, Afrodescendant, or other women of ethnic minorities. First, some interventions demonstrate that program success relies heavily on consistent Ministry of Health funding and support. The Cuetzalán Hospital in Puebla, Mexico, temporarily decreased its number of intercultural services in 2000 when the State Health Secretariat stopped funding culturally- focused programs as a cost-saving measure (64); whereas the 2012 case study of the Makewe Hospital in Chile revealed that a lack of Ministry of Health support posed one of the chief barriers to continuation of the hospital's successful intercultural care program to address the needs of the Mapuche populations (71).
Another lesson from these interventions is that incorporating traditional medicine practitioners into biomedical service facilities does not necessarily ensure the provision of non-discriminatory care. While the United Nation's Children's Emergency Fund (UNICEF) and the Ministry of Health of Peru were able to improve maternal health care by incorporating culturally-appropriate maternity houses, vertical-position birthing chairs, and other physical structures into medical facilities (40), other interventions achieved less. For example, a 2013 study in Potosí, Bolivia, found that medical providers showed little respect for or desire to collaborate with traditional healers, placed in public health facilities to improve intercultural care for the indigenous (61). Similarly, although Guatemala created a law in 2000 to incorporate traditional Mayan birth attendants in medical facilities, a 2013 study discovered that many felt disregarded by medical staff and that Mayan women expressed barriers to accessing culturally- appropriate care (49).
As these programs illustrate, successful interventions need to go beyond merely implementing a legal framework dictating that traditional and biomedical practitioners coexist in medical facilities. Collaboration likely requires increased cultural humility and respect from medical providers; some interventions offer insights on possible strategies to accomplish that goal. First, a program in Guatemala demonstrated that simulation-based training could effectively improve cultural humility among providers (66). Another project in Brazil also proved it could augment the humanization of childbirth by conducting in-service training of medical staff (67). While a 2002 project in Peru did not measure outcomes specific to personnel discrimination and attitudes, its results showed increased satisfaction and health care utilization rates among Indigenous women, implying that the human-rights approach may be an effective strategy for encouraging non-discriminatory practices among medical providers (68). Furthermore, many of the successful intercultural care programs listed in Table 2 encouraged and included the target population's direct participation in its design and administration (70, 71).
Discrimination in the health care setting can deter Indigenous and Afrodescendant women from seeking medical care in the first place. When they do seek care, women of ethnic minorities may be more vulnerable than other women to receiving substandard quality of care or be subjected to longer delays-both of which preclude optimal health outcomes-along with experiencing shame, humiliation, exclusion, and other forms of human rights violations. Even though under-staffing, medication shortages, outdated or unrepaired medical equipment, lack of adherence to protocols, and weak referral systems, among others, are known to compromise quality of care for health services users regardless of ethnicity, discrimination in the health care setting is a driver of inequitable health outcomes that needs to be better understood and addressed.
This initial review can make a few overarching points. First, discrimination and violence against women of ethnic minorities in clinical settings in Latin America are pressing and overlooked issues that merit further investigation and action at the national and Regional levels. The impunity with which these violations occur and how normalized they are by women and providers alike is a reflection of society at-large (13). Second, critical to reducing discrimination is the formation of collaborative and horizontal partnerships between women of ethnic minorities and their health care providers. This form of community participation must occur within the context of broader discussions concerning gender equity and the rights of Indigenous and Afrodescendant populations. Third, health providers should be trained in the impact of discrimination and violence on health outcomes of minority ethnic groups and on their contribution to persistent health inequity.
Finally, alleviating discrimination requires health system-wide policy and structural changes that go beyond targeting individual health provider behaviors. We contend that strategies aimed solely at changing providers' behaviors will have limited impact because they fail to address the broader context: women's needs and the socioeconomic inequality in which intra-hospital relations are built. As argued by numerous studies conducted in Mexico, the mistreatment of female patients is a form of institutional violence, embedded in both the country's medical education system and in the hierarchical power structures within hospitals. Discriminatory actions by medical providers certainly reflect personal prejudices, however, they also stem from the medical field's overarching norms that all too often portray women as inferior or undeserving of medical citizenship and other rights (12, 38). Larger-scale policies and strategies that transform power dynamics inside medical schools, health facilities, and in society at-large are critical to uprooting the cause of a prevalent manifestation of health care inequity, that is, social discrimination and violence against women and ethnic minorities.
This review did not find clear evidence of such large-scale interventions in Latin America, save in a recent case. In 2007, the Government of Venezuela enacted the "Right of Women to a Violence-free Life" law (Ley Orgánica Sobre el Derecho de las Mujeres a una Vida Libre de Violencia) to address discrimination and economic, social, and political inequalities affecting women throughout the country and to define "obstetric violence" as a criminal offense subject to fines (73, 74). According to a study of 500 medical personnel surveyed 3 years later, 89% were familiar with the term "obstetric violence" and 87% with the law's existence; however, 73% were unfamiliar with the procedures for reporting these offenses (75). Consequently, while the legal criminalization of obstetric violence sets a precedent for future policy strategies, their success requires complementary programs that familiarize health care staff with specific definitions of obstetric violence and with accountability mechanisms.
Some limitations of this review should be noted. Despite important advances, such as including ethnicity data in census and surveys across Latin America since 2000, there continues to be a dearth of information on health outcomes among ethnic minorities, particularly the Indigenous and Afrodescendants. In addition, this search was limited to studies with published results that could be identified via searchable databases. This excluded most books and chapters in books. Furthermore, by focusing on ethnic minorities, this review may have excluded women, who regardless of their ethnicity, might have experienced health care discrimination due to poverty or other stigmatizing conditions.
Health provider discrimination against Indigenous and Afrodescendant women is a primary barrier to quality health care access in Latin America. Ultimately, discriminatory practices deter women from seeking care. That said, strategies that target only provider behavior have limited impact because they do not address women's needs and the context of socioeconomic inequality present in the health care setting. To ensure optimal health outcomes for people of all ethnicities in Latin America, discrimination in health care settings needs to be understood as a key driver of inequitable health outcomes and eradicated.
Overall, more research is needed to determine the various forms and effects of discrimination and violence experienced by Indigenous and Afrodescendant women in health care settings, as well as to define best practices for designing, implementing, and evaluating programs to promote non-discriminatory care and to respond to women's needs.
Acknowledgements. Arachu Castro was funded through gifts from the Zemurray Foundation for her position as the Samuel Z. Stone Chair of Public Health in Latin America at the Tulane School of Public Health and Tropical Medicine (New Orleans, Louisiana, United States). The authors wish to thank Amparo Gordillo for earlier discussions on the topic; Madeline Noble for her research assistantship; and Óscar Mujica, Anna Coates, and Roberto Castro for their encouraging input.
Conflicts of interest. None.
Disclaimer. Authors hold sole responsibility for the views expressed in the manuscript, which may not necessarily reflect the opinion or policy of the RPSP/ PAJPH and/or PAHO.
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Manuscript received on 30 April 2015.
Revised version accepted for publication on 10 July 2015.