Category: Guest Blog

Global Mental Health Agenda and Pandemic Preparedness

by ihsection, posted in APHA IH Section, Guest Blog, mental health

This is the fourth part of a IH Blog series, Global Mental Health: Burden, Initiatives and Special Topics.

Part IV – Global Mental Health Agenda and Pandemic Preparedness

The COVID-19 pandemic has exposed a need to improve preparedness for mental health care services provision in the context of pandemics. The mental health burden associated with COVID-19 and prior pandemics is pervasive, highlighting a critical need for preparedness plans to incorporate a mental health response. As discussed in our previous blog, there are initiatives related to global mental health and COVID-19 that are being implemented, but a fully adaptive and comprehensive approach is needed to mitigate mental health consequences.

The agenda and priority setting of international governing bodies provides the foundation for establishing and implementing comprehensive preparedness plans and approaches. For the first time in 2015, the United Nations (UN) established mental health as a priority by including substance abuse and mental health in the 2030 Agenda for Sustainable Development. A total of 17 Sustainable Development Goals (SDGs) were created and adopted by all UN Member States. Mental health is specifically a part of SDG 3: “Ensure healthy lives and promote well-being for all at all ages.” Within Goal 3, two targets are directly related to mental health. Target 3.4 states: “by 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being.” Target 3.5 focuses on drug addiction, proposing that countries: “strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol.” 

In 2013, the World Health Assembly published a Comprehensive Mental Health Action Plan for 2013-2020 in response to the growing burden of mental illness. In the action plan’s foreword, Director-General Dr. Margaret Chan stated that mental health is a fundamental part of WHO’s definition of health. The action plan was extended to 2030 at the 72nd World Health Assembly to align with the UN’s 2030 Agenda for Sustainable Development. The plan’s framework is intended to be adapted at the regional level in order to address regional priorities and circumstances. 

With this action plan, all WHO Member States committed to contributing efforts to meet the global targets around improving mental health. The plan includes four objectives around effective leadership and governance, service provision in community-based settings, promotion and prevention, and strengthening research. Each objective is broken down into specific, measurable targets and their respective indicators. This structure allows countries to monitor progress and impact and report these data back to WHO to monitor progress and impact. The full action plan, published in 2013, can be read here.  This article by the Lancet, also published in 2013, summarizes the plan. 

WHO has created practical tools that national authorities can use to improve mental health service resilience during and after public health emergencies such as the WHO Recovery Toolkit. These resources can help national authorities develop or update national pandemic preparedness plans. Even though there has been increased prioritization of global mental health by the UN and WHO, there is significant work to be done on integrating mental health into emergency preparedness and pandemic planning. 

Given the current global agenda, the revision and implementation of preparedness planning that supports care for mental health is critical. With revised multisector pandemic preparedness plans that incorporate new and emerging evidence, we could lessen the lingering mental health effects of future pandemics. A recently published JAMA article highlights the need for prevention and early intervention to proactively prepare for an increase in mental health conditions from the COVID-19 pandemic. The authors mention the necessity of having mechanisms in place for surveillance, reporting and intervention, as well as bolstering mental health systems in preparation for increased service demands.

About the Authors:

Screen Shot 2020-03-31 at 7.52.50 PMElena Schatell MPH (c) MMS (c)

Elena Schatell is a current student at Arcadia University enrolled in the Dual Master of Public Health/Master of Medical Science in Physician Assistant Program. She aims to promote public health in underserved communities as a future physician assistant. Her current public health interests include access to mental health services, stigma surrounding mental illness, and the relationship between faith and mental health. She has interned at the National Alliance for Mental Illness (NAMI) national office in Arlington, Virginia, working closely with the Advocacy and Public Policy team on conducting research on service barriers and state mental health policy. During her time at NAMI, she also authored articles for the Advocate magazine and blog.

McClintock.PictureDr. Heather F. McClintock PhD MSPH MSW

Dr. McClintock is an IH Section Member and Assistant Professor in the Department of Public Health, College of Health Sciences at Arcadia University. She earned her Master of Science in Public Health from the Department of Global Health and Population at the Harvard School of Public Health. Dr. McClintock received her PhD in Epidemiology from the University of Pennsylvania with a focus on health behavior and promotion. Her research broadly focuses on the prevention, treatment, and management of chronic disease and disability globally. Recent research aims to understand and reduce the burden of intimate partner violence in Sub-Saharan Africa. Prior to completing her doctorate she served as a Program Officer at the United States Committee for Refugees and Immigrants and a Senior Project Manager in the Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania. At the University of Pennsylvania she led several research initiatives that involved improving patient compliance and access to quality healthcare services including the Spectrum of Depression in Later Life Study and Integrating Management for Depression and Type 2 Diabetes Mellitus Study.

Happy World Breastfeeding Week!

by ihsection, posted in Guest Blog, Maternal and Child Health, Women's Health

Happy World Breastfeeding Week (8/1-8/7)! This year’s theme, “Empower parents, enable breastfeeding” is a particularly poignant reminder of how the U.S. government is doing neither for parents and infants entering at the southern border. It is critical to consider the effects of involuntary separation of breastfeeding mothers and their children.

There are short- and long-term physical, emotional, and economic consequences of abrupt discontinuation of lactation. Lactating individuals need to express milk to relieve the pain and fullness in their breasts to avoid plugged ducts and mastitis, a breast infection requiring medical attention. If there is no provision of time, space, and privacy for regularly expressing milk, those individuals will gradually lose their milk supply. Shortened, suboptimal lactation increases risks for breast and ovarian cancers, and metabolic and other diseases and costs $302 billion globally [1].

Infants who no longer receive human milk need a substitute, which will be inherently nutritionally inferior to human milk and cannot provide them the immunologic protection they received from their mothers’ milk [2]. Those infants will need to learn how to feed from a bottle, which may cause distress, can introduce bacteria, and may teach them to ignore satiety cues [3], increasing their risk for overeating as they get older.

Emotionally, the parent–infant bond is severed with involuntary separation. Breastfeeding is not just a feeding method, but also provides an infant with temperature regulation and comfort. We have witnessed maternal distress from this inhumane practice [4]; it is likely that an infant’s distress would be extreme.

On top of the life changing health effects of abrupt discontinuation of breastfeeding, the most egregious offense may be the negation of these individuals’ rights to breastfeed. They were feeding their children optimally until a poor substitute was imposed upon them for political reasons. Now those children have higher risks of infections and chronic disease, from the moment they were taken from their parents and for the rest of their lives.

There have been many discussions about the traumatic effects of parent-child separation but we have not seen or heard a discussion of effects due to abrupt cessation of lactation and breastfeeding. Those effects provide more compelling reasons to end this inhumane practice immediately.

Guest Blog Written By: Jennifer Yourkavitch, MPH, PhD, IBCLC – International Health Section Breastfeeding Forum Liaison, APHA and Research Scientist, University of North Carolina, Greensboro; Whitney P. Witt, PhD, MPH – Chair, Maternal and Child Health Section, APHA and Inaugural Dean and Professor, College of Health, Lehigh University; Briana Jegier, PhD – Chair, Breastfeeding Forum, APHA and Associate Professor, Health Services Administration, D’Youville College

References

1.      Lancet. (2016). Series on Breastfeeding. http://thelancet.com/series/breastfeeding. Accessed July 31, 2018.

2.      Mannel R., Martens P., & Walker M. (eds.). Core Curriculum for Lactation Consultant Practice. Burlington, MA: Jones & Bartlett Learning, LLC, 2013.

3.      Li R., Fein S.B. & Grummer-Strawn LM. (2010). Do infants fed from bottles lack self-regulation of milk intake compared with directly breastfed infants? Pediatrics125(6).

4.      CNN. June 14, 2018, https://www.cnn.com/2018/06/12/us/immigration-separated-children-southern-border/index.html. Accessed July 29, 2018.

Outcomes and Interventions for Sexually Transmitted Infections in sub-Saharan Africa

by ihsection, posted in Guest Blog, HIV/AIDS, Infectious Disease

By Samantha Dulak BS and Heather F. McClintock PhD MSPH MSW

This is the second part of a IH Blog series featured this summer, Sexually Transmitted Infections in sub-Saharan Africa: Determinants, Outcomes, and Interventions.

Part II: Outcomes and Interventions for Sexually Transmitted Infections in sub-Saharan Africa

Sexually transmitted infections (STIs) are a significant public health burden globally and are a leading cause of mortality in lower middle income countries (LMICs). In 2016, there were 988,000 women infected with syphilis worldwide, resulting in 350,000 deaths and delivery complications (Korenromp, Rowley, Alonso, et al., 2019). Human papillomavirus (HPV), an incurable STI, leads to over half a million new cases of cervical cancer every year (Bray, Ferlay, Soerjomataram, et al., 2018). Cervical cancer can be the result of other factors, however, in 90% of all cervical cancer cases that resulted in death, the cancer was caused by HPV (WHO, 2018). Of the 1.8 million newly diagnosed HIV infections each year, 940,000 individuals died globally from AIDS related factors (UNAIDS, 2019a). Unfortunately, a third of those deaths (302,700) are among females aged 15-49 living in sub-Saharan Africa (UNAIDS, 2019b). Higher rates of complications are found in sub-Saharan Africa because of inadequate clinician training, delayed diagnosis, and limited care seeking behaviors (Mayaud & Mabey, 2004). STI surveillance systems are absent or poorly functioning in Africa causing unreliable data on the prevalence of these infections.

STIs are common in low resource settings and their impact can be catastrophic on the lives of individuals. The list of potential complications is extensive. Untreated gonorrhea and chlamydia are associated with the development of arthritis, hepatitis B with liver cancer, and syphilis with central nervous system disorders (Aral, Over, Manhart, & Holmes, 2006). While all individuals are at risk, women and children are disproportionately affected by a greater burden of disability, as assessed by disability adjusted life years. Women suffering without treatment can experience chronic pelvic and abdominal inflammation leading to infertility, spontaneous abortions, and many adverse pregnancy outcomes (Chesson, Mayaud, & Aral, 2017). 

International attention on STI outcomes is imperative to reducing the incidence of STIs not only in sub-Saharan Africa, but globally. Most attention has focused on HIV due to the public health crisis we are experiencing now. The World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) reported that Africa has the highest burden of STIs compared to all other continents (Lewis, 2011). The UNAIDS 2018 report on the global AIDS epidemic found that there are 37.9 million people living with AIDS in the world and 20.6 million of them live in eastern and southern Africa (UNAIDS, 2019a). 

Prevention strategies in sub-Saharan Africa place a heavy emphasis on sexual health education. A meta analysis of 51 papers reported that while school-based sexual health education significantly increased condom usage, there was no significant effect on the incidence of STIs (Sani, Abraham, Denford, & Ball, 2016). This information is promising, though. School aged children are experiencing positive behavior changes through the use of physical protection methods. Some studies even report a change of attitude towards persons living with HIV/AIDS (Paul-Ebhohimhen, Poobalan, & van Teijlingen, 2008). However, a focus on at-risk groups is missing. Sex workers, men who have sex with men, and intravenous drug users all have high susceptability to contracting an STI and greater attention needs to be directed towards prevention in these populations to reduce the incidence of STIs. 

To address the vast number of cases of cervical cancer caused by HPV, many sub-Saharan countries now qualify for assistance from the Global Alliance for Vaccines and Immunization. As of 2018, eight countries have HPV vaccine programs for school aged children, with pilot programs implemented in nearly 16 additional countries (Black and Richmond, 2018). Data for all 8 countries is not public as of now, but of the five countries with available data, the success rate for at least one dose of the vaccine is 83% (Black and Richmond, 2018). Rwanda was the only country to successfully complete three doses, covering 98.7% of girls (Black and Richmond, 2018).

From a global perspective, Sustainable Development Goals (SDGs) aim to ensure access to sexual and reproductive care and end the AIDS epidemic by 2030 (UN General Assembly, 2015). Primary prevention strategies have become popular among many countries to promote these goals. In 2018, the WHO reported on global STI surveillance, indicating that 44% of countries have HPV vaccines in their immunization programs (WHO, 2018). To reach those who are not benefiting from immunization initiatives, the 2016 Global STI Strategy, along with strategies for HIV and viral hepatitis, fight to meet the SDG 2030 agenda (WHO, 2018). The Global STI Strategy focuses on creating affordable interventions for at-risk individuals and adolescents in all countries. These plans are financed and delivered by promoting universal health care coverage to keep costs low (WHO, 2018). Additionally, the Gonococcal Antimicrobial Surveillance Programme (GASP) has improved national monitoring of antimicrobial resistance to gonorrhea in order to provide stronger data for new treatment research (Wi et al., 2017).

Samantha Dulak BS

Ms. Dulak was a biology major and global public health minor at Arcadia University. She has a strong interest in nutrition as well as maternal and child health. She now hopes to attend graduate school for public health and pediatrics.

Heather F. McClintock PhD MSPH MSW 

Dr. McClintock is an IH Section Member and Assistant Professor in the Department of Public Health, College of Health Sciences at Arcadia University. She earned her Master of Science in Public Health from the Department of Global Health and Population at the Harvard School of Public Health. Dr. McClintock received her PhD in Epidemiology from the University of Pennsylvania with a focus on health behavior and promotion. Her research broadly focuses on the prevention, treatment, and management of chronic disease and disability globally. Recent research aims to understand and reduce the burden of intimate partner violence in Sub-Saharan Africa. Prior to completing her doctorate she served as a Program Officer at the United States Committee for Refugees and Immigrants and a Senior Project Manager in the Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania. At the University of Pennsylvania she led several research initiatives that involved improving patient compliance and access to quality healthcare services including the Spectrum of Depression in Later Life and Integrating Management for Depression and Type 2 Diabetes Mellitus Studies.

References

Aral, S.O., Over, M., Manhart, L., Holmes, K.K. (2006). Sexually Transmitted Infections. In Jamison, D.T., Breman, J.G., Measham, A.R, Alleyne, G., Claeson, M., Evans, D.B., Jha, P., Mills, A., Musgrove, P. (Eds), Disease Control Priorities in Developing Countries, second edition. 311–30. Washington (DC): World Bank and Oxford University Press.

Black, E., Richmond, R. (2018) Prevention of Cervical Cancer in Sub-Saharan Africa: The Advantages and Challenges of HPV Vaccination. Vaccines, 6(3), 61. doi: https://doi.org/10.3390/vaccines6030061

Bray, F., Ferlay, J., Soerjomataram, I., Siegel, R.L., Torre, L.A., Ahmedin, J. (2018). Global Cancer Statistics 2018: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA: A Cancer Journal for Clinicians, 68: 394–424.

Chesson, H.W., Mayaud, P., & Aral, S.O. (2017). Sexually Transmitted Infections: Impact and Cost-Effectiveness of Prevention. In Holmes, K.K., Bertozzi, S., Bloom, B.R., & Jha, P. (Eds.), Major Infectious Diseases, third edition. Washington (DC): The International Bank for Reconstruction and Development and The World Bank.

Mayaud, P., Mabey, D. (2004). Approaches to the Control of Sexually Transmitted Infections in Developing Countries: Old Problems and Modern Challenges. Sexually Transmitted Infections, 80(3), 174–182. doi: 10.1136/sti.2002.004101

Korenromp, E.L., Rowley, J., Alonso, M., Mello, M.B., Wijesooriya, N.S., et al. (2019) Global burden of maternal and congenital syphilis and associated adverse birth outcomes—Estimates for 2016 and progress since 2012. PLOS One, 14(2): e0211720.

Lewis, D.A. (2011). HIV/sexually transmitted infection epidemiology, management and control in the IUSTI Africa region: focus on sub-Saharan Africa Sexually Transmitted Infections. BMJ, 87(2), ii10-ii13. doi: 10.1136/sextrans-2011-050178

Paul-Ebhohimhen, V.A., Poobalan, A., van Teijlingen, E.R. (2008). A systematic review of school-based sexual health interventions to prevent STI/HIV in sub-Saharan Africa. BMC Public Health, 8(4). doi: 10.1186/1471-2458-8-4

Sani, A.S., Abraham, C., Denford, S., & Ball, S. (2016). School-based sexual health education interventions to prevent STI/HIV in sub-Saharan Africa: a systematic review and meta-analysis. BMC Public Health, 16, 1069. doi: 10.1186/s12889-016-3715-4

UN General Assembly. (2015). Transforming our world : the 2030 Agenda for Sustainable Development. Retrieved 16 July 20219 from https://www.un.org/sustainabledevelopment/health/

UNAIDS. (2019a). Global HIV & AIDS statistics — 2019 fact sheet. Retrieved 16 July 2019 from https://www.unaids.org/en/resources/fact-sheet

UNAIDS. (2019b). In sub-Saharan Africa, three in five new HIV infections among 15–19-year-olds are among girls. Retrieved 15 July 2019 from https://www.unaids.org/en/resources/infographics/women_girls_hiv_sub_saharan_africa

Wi, T., Lahra, M. M., Ndowa, F., Bala, M., Dillon, J. R., Ramon-Pardo, P., . . . Unemo, M. (2017). Antimicrobial resistance in Neisseria gonorrhoeae: Global surveillance and a call for international collaborative action. PLoS Medicine, 14(7). doi:10.1371/journal.pmed.1002344

The World Health Organization [WHO]. (2018). Report on global sexually transmitted infection surveillance. Retrieved 15 July 2019 from https://apps.who.int/iris/bitstream/handle/10665/277258/9789241565691-eng.pdf?ua=1.

Sexually Transmitted Infections in Sub-Saharan Africa

by ihsection, posted in Guest Blog, HIV/AIDS, Infectious Disease

By: Samantha Dulak BS and Heather McClintock PhD MSPH MSW

This is the first part of a IH Blog series featured this summer, Sexually Transmitted Infections in Sub-Saharan Africa: Determinants, Outcomes, and Interventions.

Part I: Sexually Transmitted Infections in Sub-Saharan Africa

Sexually transmitted infections (STIs) are common acute conditions that while exacting a tremendous toll on health and well-being currently receive minimal media coverage and attention. This is likely due to resources being allocated to other new and emerging conditions, the stigma associated with people who are perceived to be able to contract STIs, and a lack of education about STI symptoms and treatment. STIs range from curable (syphilis, gonorrhea, chlamydia, and trichinosis) to incurable (HPV and HIV/AIDS) infections. The nearly 30 STIs are most commonly transmitted through sexual encounters, but contact with blood and mother to child transmission during pregnancy are other ways STIs can be spread (Newman et al., 2015). Comparing the four curable STIs globally, sub-Saharan Africa had the highest incidence and prevalence of syphilis and gonorrhea (Chesson, Mayaud, & Aral, 2017). Unfortunately, STIs can raise HIV transmission up to four times which is why controlling STIs is at the top of the public health professional’s radar (Stillwaggon & Sawers, 2015). The highest prevalence of HIV is found in sub-Saharan Africa with 53% of the world’s HIV population living there and 56% of those individuals being women (UNAIDS, 2018). Although incidence rates are falling globally, 1.8 million people were newly diagnosed in sub-Saharan Africa in 2017; there is much more work to be done to reach the 2020 goal of less than 500,000 new cases in this region (UNAIDS, 2018). The current estimates state that 66% of all new global HIV infections occur in sub-Saharan Africa (UNAIDS, 2018).

STIs affect people of all socioeconomic classes in every country. Without proper precautions, no one is immune from these infections. STIs in sub-Saharan Africa are particularly important because the largest estimates are reported in this region and public health advances can provide insight and hope to other countries that are affected. Combating the negative stigma around STIs will increase the amount of people who will know their status, subsequently increasing treatment for those infections that are treatable. Furthermore, globalization perpetuates the spread of STIs across geographic boundaries highlighting the importance of acknowledging and addressing STIs on a broad scale.

STIs cause major pregnancy complications such as ectopic pregnancies, infertility, and spontaneous abortions (Chesson, Mayaud, & Aral, 2017). In both men and women, liver cancer, central nervous system diseases, and arthritis are all common comorbidities (Aral, Over, Manhart, & Holmes, 2006). Due to insufficient diagnosis and treatment in many lower and middle income countries, the rates of complications are much higher. This inadequacy can be attributed to the asymptomatic nature of some STIs, lack of education on the topic, or poor care-seeking behaviors (Mayaud & Mabey, 2004).

There are many at-risk groups for contracting STIs, including men who have sex with men, female sex workers, children born to women with STIs, and intravenous drug users. An interesting connection to be made exists for women who experience intimate partner violence (IPV). IPV can include physical or sexual violence, stalking, and psychological control over one’s spouse or dating partner (Centers for Disease Control, 2019). Women are already disproportionately affected by STIs, and these rates are greatest in women who also have reported cases of IPV. One answer for this is that women who have experienced IPV are more likely to have high-risk partners (Miller, 1999). Abusive partners may express coercive behaviors both within and outside of the relationship (Miller, 1999). Additionally, people experiencing IPV can suffer psychological trauma leading them to have impaired decision-making skills and experience increased risk-taking behavior (Miller, 1999).

As of 2018, the World Health Organization has been utilizing the Joint United Nations Programme on HIV/AIDS (UNAIDS) Global AIDS Monitoring system to quantify cases of STIs at the country level and the Gonococcal Antimicrobial Surveillance Programme (GASP) to follow antimicrobial resistance for the treatable STI, gonorrhea (Wi et al., 2017). For GASP to have continued success, international collaboration must be strengthened to develop advanced screening procedures and novel antibiotic treatments. By continually improving both monitoring systems, there may be hope for new vaccines for STIs we are still not protected from. Since antimicrobial resistance is not evolving at the same time across all countries, sharing data and laboratory methods for new pharmaceutical development is imperative to control the spread of STIs in sub-Saharan Africa (Wi et al., 2017).

References

Aral, S.O., Over, M., Manhart, L., Holmes, K.K. (2006). Sexually Transmitted Infections. In Jamison, D.T., Breman, J.G., Measham, A.R, Alleyne, G., Claeson, M., Evans, D.B., Jha, P., Mills, A., Musgrove, P. (Eds), Disease Control Priorities in Developing Countries, second edition. 311–30. Washington (DC): World Bank and Oxford University Press.

Center for Disease Control [CDC]. (2019). Preventing Intimate Partner Violence. Retrieved May 27, 2019, from https://www.cdc.gov/violenceprevention/intimatepartnerviolence/fastfact.html

Chesson, H.W., Mayaud, P., & Aral, S.O. (2017). Sexually Transmitted Infections: Impact and Cost-Effectiveness of Prevention. In Holmes, K.K., Bertozzi, S., Bloom, B.R., & Jha, P. (Eds.), Major Infectious Diseases, third edition. Washington (DC): The International Bank for Reconstruction and Development and The World Bank.

Mayaud, P., Mabey, D. (2004). Approaches to the Control of Sexually Transmitted Infections in Developing Countries: Old Problems and Modern Challenges. Sexually Transmitted Infections, 80(3), 174–182. doi: 10.1136/sti.2002.004101

Miller, M. (1999). A model to explain the relationship between sexual abuse and HIV risk among women. AIDS Care, 11(1), 3-20. doi:10.1080/09540129948162

Newman, L., Rowley, J., Hoorn, S. V., Wijesooriya, N. S., Unemo, M., Low, N., . . . Temmerman, M. (2015). Global Estimates of the Prevalence and Incidence of Four Curable Sexually Transmitted Infections in 2012 Based on Systematic Review and Global Reporting. PLos One, 10(12). doi:10.1371/journal.pone.0143304

Stillwaggon, E., & Sawers, L. (2015). Rush to judgment: The STI-treatment trials and HIV in sub-Saharan Africa. Journal of the International AIDS Society, 18(1), 19844. doi:10.7448/ias.18.1.19844

UNAIDS. UNAIDS: Data 2018. 2018. https://www.unaids.org/sites/default/files/media_asset/unaids-data-2018_en.pdf (accessed 26 May 2019).

Wi, T., Lahra, M. M., Ndowa, F., Bala, M., Dillon, J. R., Ramon-Pardo, P., . . . Unemo, M. (2017). Antimicrobial resistance in Neisseria gonorrhoeae: Global surveillance and a call for international collaborative action. PLoS Medicine, 14(7). doi:10.1371/journal.pmed.1002344

Samantha Dulak

Samantha Dulak is a recent graduate from Arcadia University. She received her Bachelor of Science in Biology and a Minor in Global Public Health. Her enthusiasm for medicine and disease prevention perfectly intertwine these two fields of study. Her current public health interests are in maternal and child health and nutrition. Since graduation, Samantha has applied to naturopathic medical school with a goal of becoming a pediatric physician. In her free time, she enjoys reading, playing sports, and baking.

Dr. Heather F. McClintock PhD MSPH MSW

Dr. McClintock is an IH Section Member and Assistant Professor in the Department of Public Health, College of Health Sciences at Arcadia University. She earned her Master of Science in Public Health from the Department of Global Health and Population at the Harvard School of Public Health. Dr. McClintock received her PhD in Epidemiology from the University of Pennsylvania with a focus on health behavior and promotion. Her research broadly focuses on the prevention, treatment, and management of chronic disease and disability globally. Recent research aims to understand and reduce the burden of intimate partner violence in Sub-Saharan Africa. Prior to completing her doctorate she served as a Program Officer at the United States Committee for Refugees and Immigrants and a Senior Project Manager in the Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania. At the University of Pennsylvania she led several research initiatives that involved improving patient compliance and access to quality healthcare services including the Spectrum of Depression in Later Life and Integrating Management for Depression and Type 2 Diabetes Mellitus Studies.

Interventions and Strategies for Addressing Global Intimate Partner Violence

by ihsection, posted in APHA IH Section, Guest Blog, Policy and Advocacy, Women's Health

This is the fourth part of a IH Blog series featured this summer, Intimate Partner Violence: Global Burden, Risk Factors and Outcomes.

Written by: Ewinka Romulus MPH and Dr. Heather de Vries McClintock PhD MSPH MSW

Intimate Partner Violence (IPV) continues to be a serious global public health concern affecting millions of women (and in some cases, men). IPV refers to any harmful behavior within an intimate relationship that includes physical, psychological or sexual harm. Existing research suggests that different types of violence often coexist. For instance, we tend to see physical IPV often accompanied by sexual IPV and emotional abuse. While the extent of IPV varies across regions, higher prevalence exists amongst poorer countries and within communities of a lower socioeconomic level. The World Health Organization (WHO) reports a higher prevalence of IPV among African, Eastern Mediterranean, and South-East Asia Regions (approximately 37%). Whereas, lower rates of IPV are found among women in European and Western Pacific regions.

To date, different theories and models have been used to explain IPV behavior within communities. The most widely used model for understanding intimate partner violence is the Social-Ecological Model which considers the complex interaction between the individual, relationship, community and societal factors that may influence IPV. The societal level identifies broad societal factors including social and cultural norms, health, economic, educational, and social policies, which may create an environment where IPV is either encouraged or inhibited. Researchers are continuously examining the factors associated with IPV at these different levels and factors.

Relying on this conceptual framework interventions and strategies to address IPV globally require a multi-level approach. Accordingly, the World Health Organization’s Global Plan of Action to Address IPV 2016, calls for a multi-sectoral approach in which strategies for addressing IPV occur on all levels of the Social-Ecological Framework (e.g. individual, relationship, community, etc.). The goal of this plan is to strengthen the role of the health system in all settings and within a national multisectoral response to develop and implement policies and programmes, and provide services that promote and protect the health and well-being of everyone, and in particular, of women, girls and children who are subjected to, affected by or at risk of interpersonal violence. The plan calls for several actions that respond to and prevent gender-based violence against women and girls (VAWG). These include “creating an enabling legal and health policy environment that promotes gender equality and human rights, and empowers women and girls; provision of comprehensive and quality health-care services, particularly for sexual and reproductive health; evidence-informed prevention programmes promoting egalitarian and non-violent gender norms and relationships; improving evidence through collection of data on the many forms of VAWG and harmful practices that are often invisible in regular surveillance, health and crime statistics.”

Several countries, such as Uganda, India, and Nigeria have integrated multiple approaches encompassing the key principles mentioned above. For instance, in Uganda, an organization called Raising Voices works to prevent violence against both women and children. Raising Voices focuses on transforming attitudes and behaviors to promote gender equity in communities through a tool called SASA!. SASA! is a well-known intervention that has been adapted and implemented across regions, namely, the Caribbean, the Middle East, and Southeast Asia. The SASA! intervention includes four steps: Start, Awareness, Support, and Action which focus on educating communities through a series of activities that address the importance of power and awareness in relationships. A recent evaluation of SASA! in Uganda demonstrated a significant reduction in the reported level of physical partner violence against women. In Haiti the MDG Achievement Fund  partnered with local women’s organization to establish health clinics and provide counsel and care for victims of violence. Local leaders are trained to educate and spread awareness about domestic violence within communities and to report a witnessed crime to local authorities. The MDG Achievement Fund partners with UN Women to create educational and socio-economic opportunities for vulnerable women to increase economic independence and autonomy. There has also been an increase in the number of One-Stop Crisis centers worldwide to help recent victims of violence.

Contextual factors shape the etiology and manifestation of IPV and thus effective interventions differ within communities and across countries. Programs that employ models that are specific to cultural norms while including community members have been found to be effective in addressing IPV. In addition, structural and systematic intervention strategies (economic, social, political, and physical) to reduce IPV or its impact may also be essential to reduce IPV’s global burden (Bourey C, 2015). An example, of an issue embedded in underlying structural and systemic inequities is that may be potentially modified to improve IPV is that of literacy.  Regions with lower literacy levels show a higher prevalence of IPV among women. One study conducted in Ethiopia (Deyessa, 2010) found illiterate women were more likely to justify the reasons for a man beating his wife, compared to literate women. The study also found that literate women with a literate spouse were least likely to have experienced physical violence compared to literate women with an illiterate spouse. Similar findings were reported in a study in India (Ackerson, 2008) in which women residing in neighborhoods with high literacy rates were were less likely to experience IPV. Literacy can also have an important impact on other indicators of well-being entwined with outcomes for IPV such as contraceptive knowledge and use. In our recent work we found that literacy was significantly associated with the utilization of modern contraceptives (adjusted odds ratio (AOR) = 1.166, 95% CI = 1.015, 1.340). Thus, interventions that seek to modify systemic and structural components that influence literacy may have important implications for IPV.

Intimate partner violence is a common problem worldwide that needs to be addressed incorporating contextual needs. The World Health Organization calls for a collaborative, coordinated and integrated response for addressing this significant public health issue. It is evident that interventions should be multi-sectoral and a comprehensive approach should aim to address IPV implications on individual, relationship, community and societal levels.

Screen Shot 2018-08-17 at 11.00.41 AM.pngEwinka Minerva Romulus, MPH is a recent graduate from Arcadia University’s MPH program. Her master’s thesis focused on the influence of literacy on contraceptive knowledge and use among women in Swaziland. Prior to her graduate career, she studied Bio-behavioral Health at the Pennsylvania State University where she gained an understanding of the interactions among biological, behavioral, psychological, sociocultural, and environmental variables that influence health. Ewinka gained interest in global health after observing the existing issues around poverty, health, and inequality in her own country – Haiti.  She is planning on continuing her studies at Drexel University in the fall of 2018 to obtain a certificate in Epidemiology and Biostatistics. Her current interests are in women’s health, global health, and nutrition. Her global health experience includes traveling to Guatemala with Mayanza Organization to provide health education and health screenings to school-children. She is also involved in organizations in Haiti with a mission of eradicating many communicable diseases. During her free time, Ewinka enjoys reading, traveling, and learning to play the guitar.

McClintock.PictureDr. Heather F. de Vries McClintock is an IH Section Member and Assistant Professor in the Department of Public Health, College of Health Sciences at Arcadia University. She earned her Master of Science in Public Health from the Department of Global Health and Population at the Harvard School of Public Health. Dr. McClintock received her PhD in Epidemiology from the University of Pennsylvania with a focus on health behavior and promotion. Her research broadly focuses on the prevention, treatment, and management of chronic disease and disability globally. Recent research aims to understand and reduce the burden of intimate partner violence in Sub-Saharan Africa. Prior to completing her doctorate she served as a Program Officer at the United States Committee for Refugees and Immigrants and a Senior Project Manager in the Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania. At the University of Pennsylvania she led several research initiatives that involved improving patient compliance and access to quality healthcare services including the Spectrum of Depression in Later Life and Integrating Management for Depression and Type 2 Diabetes Mellitus Studies.