How long-term benefits override upfront costs: using research and evaluation to justify a female condom intervention

In a time where economic interests override public health concerns, a new study published in AIDS and Behavior shows that public health spending can reduce costs in the long run. In general, female condoms are more expensive than male condoms. However, after cost-analyzing an initiative that distributed 200,000 condoms to women in a neighborhood with high rates of HIV-diagnosis in Washington D.C., the authors found that for every $1 spent, $15 was saved.

D.C. has the highest prevalence of HIV in the United States. 1 in every 33 residents is infected with the virus, and 1 in 14 residents in their 40’s have tested positive. The sexual health initiative began two years ago after a report noted these high levels of HIV/AIDS diagnoses.

The campaign, called D.C.’s Doin’ It!, chose to target sub neighborhoods with high HIV-diagnosis rates. Officials justified the distribution using study findings that showed large numbers of African American heterosexuals in the District engaging in risky sexual behaviors: http://doh.dc.gov/doh/frames.asp?doc=/doh/lib/doh/pdf/dc_hiv_heterosexualstudy.pdf. (Something to consider: 92.3% of study’s participants self-identified as black. Is it possible to compare this to the other 7% of the study and make these same conclusions?)

The report also found that women had a higher HIV prevalence than men (6.3% versus 3.9% respectively). To empower and increase women’s autonomy, officials chose female condoms as the intervention. Female condoms give women the power to make healthy choices, even when a partner does not give them this choice.

The campaign dispensed these at convenience stores, beauty salons and community clinics and trained community members to discuss sexual health with peers in informal settings (UMN professor also used this approach, calling it “Barbershop Conversations”- check it out! http://www.advances.umn.edu/2011/06/barbersho/). The initiative plans to continue the project, by distributing between 250,000-300,000 female condoms a year.

Playing with issues of women empowerment, race, socioeconomic status, and class, critics argue that the intervention targeted a subgroup of D.C.  residents. Is this justified/ethical? Can public health interventions target subpopulations, rather than a community at large? Are there any other issues to consider when implementing a similar campaign?

Although there are concerns with the study and intervention, public health should not disregard evaluation results. Upstream care can and should be utilized to promote population health, including within the reproductive health sphere.

MAMA: Motherhood Around the Globe

An online exhibition of global art, voices, and ideas, MAMA: Motherhood around the Globe is an inspiring community for anyone who is a mother, knows one, or works with one (that’s all of you!). Housed through the International Museum of Women, the website includes videos, facts, and figures promoting healthy moms and its significance with delivering healthy babies. Graphic designs describe the status of Millennium Development Goals in related to gender equity, reproductive health and maternal mortality.

Visit the art gallery for paintings, photographs, drawings and sculptures of the beauties and perils of pregnancy, childbirth and motherhood.  Read stories of motherhood from women around the world. Explore global MCH heroes and their novel ideas in preventing maternal mortality and supporting the health of women everywhere.

Do you have an experience (either domestically or globally) working with mothers you would like to share? As a mother, do you have stories you would like to tell others? What did you find most inspiring about the website? Let us know below or send us your anecdotes!

Global Efforts in MCH- Female Genital Cutting

Female Genital Cutting (FGC) is a practice that completely or partially removes the external female genitalia. FGC has been reported in various cultures and countries across the world, but according to the U.S. Department of Health and Human Services (HHS), almost ½ of all incidents occur in Egypt or Ethiopia. In communities that practice FGC—some Islamic– many proponents believe that FGC is sanctioned by the Quran (also spelled Koran; Islamic religious text); in fact, no religion, including Islam, is associated with FGC (HHS Office on Women’s Health). Debates continue as many do not understand that formal religious endorsement of FGC has never occurred.

Tradition and superstitions, such as cleanliness and family honor, contribute to the continuation of the practice. For communities that practice the tradition, fears drive families to participate: if a girl is not cut, she will be viewed as an outsider to a community and runs the risk of being unwed. Intervention strategies target men to abandon FGC as a norm, focusing on patriarchal belief systems and the subordination of women.

Although some groups point to the issue of cultural competence, human rights groups and the World Health Organization (WHO) argue that the health risks of FGC outweigh this. Article 25 of the Universal Declaration of Human Rights (UDHR) (created by the United Nations General Assembly in 1948) states that every person has the right to health, well-being, and security. Although critics have argued that the UDHR is framed in a Western lens, the document guides issues that compromise the safety and health of humans, especially if inflicted by another being. According to the World Health Organization, health problems related to FGC include: bleeding; hemorrhaging; increased risk of Sexually Transmitted Infection (STI) and HIV infection; infection of the genitals and urethra; painful scarring and menstruation; trauma and emotional distress; infertility; and problems during labor/pregnancy (http://www.who.int/mediacentre/factsheets/fs241/en/).

Other strategies to decrease the incidence of FGC are seen in the below PBS documentary as well as in a New York Times focus. Grassroots social mobilization agents teach the community about the harms of female genital mutilation by moving this taboo topic out into public discourse. Their efforts are based on the belief that “before abandonment, comes communication and awareness.”

For more information on Female Genital Cutting, please visit the WHO’s website: http://www.who.int/mediacentre/factsheets/fs241/en/. The New York Times video report is available at: http://video.nytimes.com/video/2011/10/16/world/africa/100000001115488/the-fight-against-female-genital-cutting.html

Is there a Plan b for Plan B?

Plan B One-Step is a single-dose emergency contraceptive pill that contains higher levels of levonorgestrel, a hormone found in some birth control pills, and has been available in the U.S. since 2009. Its effectiveness is linked with timeliness of use: the drug should be taken within 72 hours of intercourse. The Food and Drug Administration (FDA), after reviewing the scientific evidence on its safety and effectiveness, recommended that it be available–without prescription–to females of any age.

On December 7, 2011, Secretary of Health and Human Services (HHS) Kathleen Sebelius overruled this FDA recommendation. While the Secretary of HHS has the authority to override the FDA, The New York Times reported that this issue was the first time a HHS secretary has publicly overruled the FDA. Secretary Sebelius’ action limits an attempt by the FDA to improve the accessibility of Plan B One-Step among young girls, but it does not affect the legality of the drug. Plan B One-Step remains available, without a prescription, to women who are 17-years old and older; and it is still approved for use, with a prescription, for females who are younger than 17.

Sebelius argued that there should be no change in the current law requiring females younger than 17 to obtain a prescription for Plan B One-Step because they require health-care provider guidance to use the pill properly and safely (to see Sebelius’ counterstatement to the FDA’s recommendation, click: http://www.hhs.gov/news/press/2011pres/12/20111207a.html). However, as FDA Commissioner Dr. Margaret Hamburg stated, “Based on the information submitted to the agency, [the FDA’s] CDER [the Center for Drug Evaluation and Research] determined that the product was safe and effective in adolescent females, that adolescent females understood the product was not for routine use, and that the product would not protect them against sexually transmitted diseases. Additionally, the data supported a finding that adolescent females could use Plan B One-Step properly without the intervention of a healthcare provider.” Further, young girls are able purchase a variety of over-the-counter medications and personal products that could be harmful in large doses, such as Tylenol, with no ill effects. President Barack Obama had the opportunity to overrule Sebelius’ decision, but instead agreed with her, noting that he felt uncomfortable, as a father, with the FDA’s decision.

What’s at play here?  What’s going on in this dance between science and good health policy? Did upcoming presidential race play a role here? Are there additional moral or ethical considerations about the proper age for emergency contraception? What’s going on?

How much should, or do,  data really matter in creating health policy? How we talk about – frame – this and other politically charged health issues matters. Consider the language used in various news sources covering the issue. The emotionally charged responses to this specific drug from both evidence-based and ethical-based sides merge to create a unique and complicated discussion. As we launch into an election year, how can we expand the conversation on the topic with our peers and colleagues to further consider the multiple dimensions influencing the availability and accessibility of Plan B for women of all ages across the U.S.?

December 13, 2011 Coverage Update:  14 U.S. Senators, including Minnesota’s Al Franken, have called for further explanation of Sebelius’ decision made on December 7, 2011. The letter–defending the importance of using science to create policy—asks Sebelius for “specific rationale and scientific data” behind limiting Plan B’s accessibility. To see the letter and co-signers, visit: http://murray.senate.gov/public/index.cfm/newsreleases?ContentRecord_id=77e3d54b-bb6b-4c7c-9f05-bfe8c8d3b304. Sebelius has not yet released a response.

Ad Council takes on Unintended Pregnancies

Today CNN covered an opinion piece from Laura Sessions Stepp, a Pulitzer Prize journalist and former Washington Post reporter, on young adults and contraception. The Ad Council has accepted a proposal from The National Campaign to Prevent Teen and Unplanned Pregnancy to run a series of ads targeting adults in their 20’s to use birth control. The campaign, called Bedsider.org, was created as a support network for women and includes PSA’s, a YouTube channel, and website. The website shows the less serious side to sex, while at the same time answering questions about contraception and the best method for the user. Videos use humor to promote annual doctor visits, birth control effectiveness, and set the record straight on recent news reports. Below is an example of a question and answer on IUD’s:

A study by the Guttmacher Institute surveying 1,800 unmarried men and women between the ages of 18-29 found that only 50% use birth control carefully and consistently. Using a weighted representative sample through telephone interviews (both landline and cell phone), the researchers also found that 31% of the women surveyed say they have had an unintended pregnancy. You can find more information about the study’s method and results here: http://www.thenationalcampaign.org/fogzone/PDF/FogZone.pdf.

With results like these, using mass communication and social media to promote birth control use may help 20-somethings feel more comfortable about talking to their doctor and accessing care.