Part 4: Perspectives on Global Health from Pharmacists Around the World

As healthcare continues to morph and adapt based on the requirements of kind, compassionate, evidence-based care, pharmacists are playing a vital role in ensuring patient needs are met in countless regions across the world. In this four-part IH Blog series, the pharmacy role accompanied by profession-related challenges and pharmacist-led global health initiatives will be explored within a profession that is often underappreciated. The following perspectives, shared by practicing pharmacy professionals from the United Arab Emirates (UAE), India, Cambodia, and the United States of America (USA) aim at highlighting various aspects of healthcare that should be properly addressed by governmental bodies, NGOs, and all stakeholders by both sustainable political will and empowering solutions. 

This fourth and final segment explores targeted populations in each of the aforementioned countries, the health ailments that burden these groups, and each pharmacist’s proposed pathway to overcome these concerns within these nation states. 

In every corner of this vastly diverse planet, healthcare access and delivery affects countless aspects of humanity’s well-being. These aspects can range from the capability of obtaining the correct medications for treating dermatitis or receiving prophylaxis isoniazid therapy to accessing cancer screening with a pap smear and purchasing levemir at an affordable price. In addition to these direct implications on one’s life, healthcare possesses indirect factors such as social relationships influenced by health, hours lost working due to health commitments, and the emotional burden due to certain ailments. The global health community recognizes that health disparities exist throughout various regions of the world which affect these aforementioned facets. However, the inequalities that exist within explicit populations in these regions are often overlooked or overshadowed by more broad global initiatives.

In this final post for the IH Connect blog series, four practicing pharmacists reveal major concerns in their areas of inhabitation for specific populations: older adults, pediatrics, pregnant mothers, women’s health, and men’s health. These healthcare leaders then offer initiatives and solutions to address these complications to improve the lives of each member of their cherished communities. 

Dr. Moeung Sotheara, Ph.D. 
Clinical Research Assistant & Part Time Lecturer – University of Health Sciences
Phnom Penh, Cambodia 

Cambodia has achieved some remarkable health outcomes in recent decades such as improving newborn and child health, ensuring provision of HIV/AIDS treatment to over 80 percent of the infected population, and expanding vaccination coverage. However, there are a number of population-specific concerns that need to be addressed in order to further improve the overall healthcare and wellbeing of the people.

Older Adults

One of the top concerns regarding older adults in Cambodia is the lack of care centers for older adults and state pension provision. Consequently, the older adults in Cambodia are physically and financially dependent on their children to get access to health services from going to see a doctor to buying medicines. This results in older adults not willing to seek immediate medical care when they have health problems as they feel hesitant to ask for their children to help. Moreover, as they cannot go to the pharmacy on their own, they often miss out on crucial information regarding appropriate drug use. The solution is to provide all Cambodian workers with a social pension scheme and to build care centers for older adults, where they can easily gain access to healthcare.

Pediatrics

The top concern regarding pediatrics is the common and widespread use of fluid infusion. This dangerous practice has become a tradition in Cambodia. When a person is sick, most physicians prescribe intravenous (IV) drips either intentionally or on the patient’s demand even if he/she shows no sign of dehydration or fluid loss and often without careful monitoring. And children are no exception! To solve this problem, there should be campaigns to raise the public’s awareness about the danger of incorrectly used IV drips and to reinforce the doctors’ medical ethics.

Pregnancy

One of the top concerns regarding pregnant women is the use of traditional medicine. Traditional medicine is commonly described at two time points: one month before birth to ease child delivery and postpartum to increase breast milk production and prevent Tos (madness, depression). The most common form of traditional medicine used is herbal medicine which often consists of a mixture of different parts of multiple plants. The toxicity of these plant combinations has poorly been studied. To resolve the problem, a number of well-designed studies should be carried out to investigate the potential toxicity of herbal medicine during pregnancy and post-partum period.

Women’s health

The top concern regarding women’s health in Cambodia is the overuse of skin whitening and skin bleaching products. In a culture where lighter skin is often idealized, whitening is a common practice in Cambodia, especially for women despite the reported danger of those products. Whitening cream or lotion can be dangerous, and many counterfeit products are now on the market, making the practice even more dubious. The problem is of more concern as more and more creams are locally produced without the right standards, by mixing whitening cream with other vitamins and dangerous chemicals. Moreover, they are increasingly available online, or via social media where they are not sufficiently regulated. The immediate solution to this problem is to re-enforce the law regarding online cosmetic products advertisement. Furthermore, all production sites of sub-standard creams or lotions must be closed down. Additionally, any products must be screened for dangerous chemicals before they can be advertised and sold on the market. The public’s education of the danger of sub-standardly-produced skin whitening and skin-bleaching products is also of prime importance. The collective idealization of white skin should be changed and people should be educated to perceive beauty beyond the skin color.

Men’s health

Health impacts related to alcohol overconsumption has become a top concern regarding men’s health in Cambodia. A report by the Asia Foundation in 2015 showed that Cambodian men are drinking 9.7 litres of pure alcohol a year – 3.5 litres above the global average of annual alcohol consumption per capita. Furthermore, the study also found that Cambodian men tend to drink six times as much as their female counterparts. Social, economic and cultural factors together with the influential role of advertising are the predominant drivers of increased alcohol consumption among the Cambodian population, particularly men. Alcohol abuse has resulted in more than 60 major types of diseases including cardiovascular disease, cirrhosis of the liver, cancer and sexually transmitted diseases including HIV/AIDS. Restrictions on alcohol product advertisements, price control strategies and education of the public on the harmful effects of alcohol abuse are among the measures that can be taken to tackle the problem.

Dr. Maneesha Erraboina, PharmD.
International Business Manager – Helics Group Scientific Networks 
Hyderabad, India 

Older Adults

Most older adults use multiple drugs simultaneously for different conditions or for one condition. Polypharmacy causes poor adherence which leads to adverse drug events (ADRs) or medication errors (MEs). To avoid these ADR’s and ME’s, healthcare providers should educate patients about the medication in order to maintain good adherence and try to increase the knowledge of the health condition by performing patient counselling.

Pediatrics

Cost analysis is a ubiquitous problem for all types of diseases in each category of patient populations. In one of my research work entitled “Pharmacoeconomic Analysis and Treatment Pattern in Sepsis Patients: A Cross-sectional Prospective and Retrospective Study”, this publication infers about the cost analysis in sepsis patients particularly in the pediatric population. The major barrier is to overcome situations where health leaders are focused on cost rather than looking at the whole picture in order to provide equitable care. This can be accomplished by having input from these specific populations and reflecting on the role a healthcare provider should have in treatment. 

Pregnancy

For pregnant mothers, perinatal conditions that occur before, during and after the pregnancy can lead to perinatal mortality. In India, the most common conditions resulting in death are haemorrhage, trauma, and severely underweight babies. To avoid perinatal mortality, continuous assessment of pregnant women on medication and diet is needed by encompassing more prenatal and antenatal care health facility visits.

Women’s Health

Breast cancer is one of the top concerns in women’s health throughout the world, and this includes in India. In India, the etiological factors are difficult to identify for this type of cancer; however it mostly occurs in older women. It may occur due to older age and genetics. To decrease the risk of breast cancer, one should focus on non-pharmacological therapy that includes dietary and social changes.

Men’s Health

Commonly, pancreatitis occurs mostly in men with social history of alcohol consumption in India. In a study examining the main causes of pancreatitis, it was found that approximately 1/3rd of all pancreatitis cases was caused by alcohol. Counseling on decreases in alcohol consumption should be undertaken by all healthcare professionals in order to prevent this ailment.

Nazgul Bashir, B. Pharm
Registered Pharmacist – Super Care Pharmacy
Dubai, United Arab Emirates

As a pharmacist, we encounter a number of various types of populations seeking our care, both gender-specific and age-specific. Dubai, being a cosmopolitan city, sees many different ethnic groups and nationalities. With so much of diversity in the community, we see a number of different issues and it is our sole responsibility to identify them, recommend the most appropriate over the counter treatment to fulfill the need of the concerned person, or refer to a prescriber for more serious issues. One of the best aspects about being a pharmacist is that we have the opportunity to encounter new types of people and novel ailments every day. On the other end, some of the ailments encountered are difficult to manage due to a variety of reasons. Different groups of people who visits the pharmacy can be divided into men, women, older adults, pediatrics, and soon to be parents. In each population there are multiple issues which I will describe in detail in the following sections.

Pediatrics 

I would like to start talking about my most favorite population, pediatrics. Multiple concerns are present when it comes to children in the UAE including obesity, vitamin D deficiency, genetic problems, diabetes, and, most commonly, allergies and asthma. Out of these concerns, asthma and vitamin D deficiency are frequent ailments patients seek the care of a pharmacist for. One in every five children is suffering from asthma which initially, parents don’t realize. They self-diagnose it as night time coughing, chest congestion or persistent nagging. The cause is not simple. it could be anything airborne like construction dust (In the UAE, there is constantly large buildings being constructed), sand (UAE being the desert) and pollen from palm trees. Another major cause can be going in and out of air conditioner due to hot & humid weather. Cough suppressants and expectorants are first requests by parents and desperate patients even ask for montelukast or steroid based inhalers which is not an appropriate avenue to address the issue. First and foremost, the triggering allergen should be identified as airborne, smoke, or a viral cold. Educating parents about the importance of flu shots, the use of a peak flow meter to find out a child’s lung function and supplementing them with Echinacea, zinc, Elderberry or even Vitamin C to keep their immune boosted are also viable methods to address this ailment. Vitamin D deficiency is another common concern in children. Because hot and sunny summers last for a long time, children stay indoors rather than going out for any physical activities. Most of the body parts are covered with clothes which is common in UAE. 90% of the population is suffering from vitamin D deficiency including men, women and children. Pharmacists should recommend Vitamin D supplementation during these months in order to prevent this deficiency. 

Men’s Health 

Men’s health is often the most difficult to discuss because males make limited health visits. This could be because men ignore the illness affecting them or they could be uncomfortable discussing their health problems. Mainly, I want to talk about erectile dysfunction (ED) in men. One in every 3 men from age 40-70 suffer from ED, but due to cultural issues, the topic is often avoided. They avoid asking for professional help on this sensitive issue because they feel challenged, embarrassed and/or guilty. High diabetes and obesity rates and smoking/alcohol use are the main factors causing ED. Pharmacist counseling can provide significant help with lifestyle advice, proper supplementation, and education for reasons to follow up with a prescriber.

Older Adults

No matter which part of the world we belong to, a majority of older adults we see are on poly-pharmacy. This creates unique challenges in this population by having multiple health issues and taking a number of medications. In the UAE, proper guidance on use of these medications is often missing which leads to non-adherence to medications. From a patient’s perspective, taking 5 or more medications, either prescription or non-prescription, can be time-consuming and frustrating. For older adults with cognitive issues, issues surrounding medication adherence is exacerbated. As a community pharmacist, I would like to raise awareness about poly-pharmacy, adherence, and its effect on older adults. Many steps can be taken to increase the adherence. Color-coded pill boxes, properly labelled vials and easily read fonts should be used. Technology reminders should also be utilized to improve adherence. Another commonly noticed concern in older adults is drug induced nutritional deficiency which is defined as being on multiple medications that lead to a number of important nutrients being depleted. As pharmacists,  we should inform the patients the importance of this issue and help patients to identify the nutrition depletion by the medications they are taking.

Women’s Health 

Last but not the least, about 60% of the female population has issues regarding women’s health and are visiting pharmacists more often. Women’s health concerns are almost all interlinked including irregular menstruation, infertility, post menopausal symptoms, and urogenital complications. There are many more complications which could contribute to the larger discussion about this population. However, the one problem I would like to discuss is polycystic ovary syndrome (PCOS) which is infrequent or irregular menstruation or increase in androgen levels. It can be difficult to diagnose,  but many symptoms are excessive hair loss, acne/oily skin, weight gain and infertility. UAE has the highest rate of PCOS than any other part of the world. PCOS is a more recent disease which could be linked to modern lifestyles, more indoor activities and a decrease in outdoor activities, stress, and junk food intake. It can be caught initially if any adolescents discover a missed period or heavy periods. Most of the time, they don’t take it seriously and realize it when it is too late which could result in difficulties with conception or infertility. PCOS can not only lead to infertility but also anxiety and depression. Rates of infertility are increasing. When I investigate patients on their cycle most of the time, I find out they were having irregular periods in their early 20s, missed 3-4 months, and no action was taken because of it being such an intimate topic. I believe if we have any female patients coming to the pharmacy with issues like hair loss, excessive oily skin, facial hair, they should be advised for early screening of PCOS. Folic acid supplementation should be advised to people who are trying to conceive with PCOS or anyone with an irregular menstrual cycle. Lifestyle modification and weight loss should be emphasized as well.

Dr. Bryce Adams, Pharm D., RPh.
Oncology Medical Science Liaison
Washington D.C., United States of America 

Older Adults

I believe the biggest health concern for older adults in the USA is Alzheimer’s disease. This has been a growing concern as the human race’s lifespan has been exponentially increasing. While billions of dollars have been spent in research looking for a treatment, there hasn’t been much success. The current treatment options, cholinesterase inhibitors or N-Methyl-D-aspartate (NMDA) antagonists, only slow the progression of the disease, albeit, with limited success. Therefore, these agents are most effective when initiated before the severity of the disease reaches a certain point. To address this concern, I believe we need to work on detecting the disease earlier and continue to research new options. Alzheimer’s screening needs to be incorporated into routine check ups in older adults, and implemented at a younger age with those with a family history of this ailment. Additionally, there needs to be continued research regarding the disease. This includes research to gain a better understanding of the pathophysiology as well as new agents to treat the disease. Most of our current research has been in regards to amyloid beta. While this could lead to better treatments, most of the efforts focusing on this have failed, therefore, I think we should start to focus more efforts elsewhere.

Pediatrics

The biggest health concern for American pediatric patients is the lack of novel treatments. While there have been great strides and new medicines for adult patients, there is typically a delay for access to these medicines for pediatrics. One way to combat this is to ensure there are a proportionate amount of clinical trials that include pediatric patients. This work is currently underway and hopefully will result in greater access to medicines for pediatric patients.

Pregnancy

I believe preeclampsia is the greatest concern during pregnancy as it is fairly common and can result in the death of the mother and/or child. While there are some treatments for this condition, there is still much room for improvement in terms of early diagnosing, prevention, and more effective therapy options. I believe we can improve outcomes by focusing our efforts on the aforementioned methods of improvement: identifying risks for preeclampsia more efficiently and preventative measures. 

Men and Women’s Health

I’ve combined men’s and women’s health into one as I believe the greatest concern is the same: heart disease. While there are several treatments currently for heart disease with decent success, there hasn’t been much advancement in recent years. Our current agents can manage the disease and reduce symptoms, but for the most part, they are unable to cure the disease. In order to combat this issue, American researchers and practitioners need to improve screening to identify the disease earlier on as well as focusing on new treatment options that have the potential to cure the disease.

Happy World Breastfeeding Week!

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.

Interventions and Strategies for Addressing Global Intimate Partner Violence

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.

 

Happy Breastfeeding Week! #WBW2018

World breastfeeding week takes place from August 1st to 7th this year. This year’s theme is Breastfeeding: Foundation of Life.

There are tools for all of your advocacy and information needs!

WHO has infographics and webinar information: http://www.who.int/news-room/events/detail/2018/08/01/default-calendar/world-breastfeeding-week-2018

The World Alliance for Breastfeeding Action (WABA) has an action folder in several languages (http://worldbreastfeedingweek.org/actionfolder/) and a social media toolkit (http://worldbreastfeedingweek.org/social-media-kit/).

WABA is also hosting a Thunderclap! Those who join will automatically share the same breastfeeding message at the same time across FaceBook and Twitter on August 1. https://www.thunderclap.it/projects/70825-world-breastfeeding-week-2018

In related news: In the U.S., Idaho and Utah recently passed bills legalizing breastfeeding in public for their residents. It is now legal in all 50 U.S. states to breastfeed in public. Appropriately, this week also kicks off our own National Breastfeeding Month in the U.S. (http://www.usbreastfeeding.org/nbm).

Weekly themes:

  • Week 1: Policy Pulse 
    Finding Solutions: Small policy changes can go a long way toward supporting breastfeeding families
  • Week 2: Special Circumstances & Emergency Preparedness 
    Always Ready: Resources and guidance on how to manage feeding during an emergency
  • Week 3: Call to Action 
    Answering the Call: Everyone can help make breastfeeding easier
  • Week 4: Black Breastfeeding Week 
    Love on Top: On top of joy, on top of grief, on top of everything

Happy messaging! Support breastfeeding everyday!

 

Outcomes of Global Intimate Partner Violence

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

Written by: Erica Hartmann MPH, MMS (c) and Dr. Heather de Vries McClintock PhD MSPH MSW

Intimate partner violence (IPV) is defined by the Center for Disease Control (CDC) as physical violence, sexual violence, stalking and psychological (or emotional) aggression by a current or former intimate partner (Violence Prevention, 2017). Consequences of intimate partner violence (IPV) can be immediate, long lasting, and invisible. The physical impact of  IPV includes broken bones, lost teeth, hearing damage, and vocal cord damage due to attempted strangulation (Garcia-Moreno C et al., 2005). The World Health Organization’s multi-country study showed that women who were ever abused by their partner were twice as likely to report poor health and physical and mental problems when compared to women who were never abused (Garcia-Moreno C et al., 2005). Diagnoses resulting from IPV include irritable bowel syndrome, fibromyalgia, chronic pain syndromes, and asthma exacerbation (Crofford, 2007; Heise,Garcia Moreno, 2002). Additionally, violence during pregnancy is associated with miscarriage, late entry into prenatal care, stillbirth, premature labor, fetal injury, and low birthweight (Bailey, 2010; Garcia-Moreno C et al., 2005; Silverman, Decker, Reed, and Raj, 2006). IPV can have lasting, and often unseen consequences.

Intimate partner violence can be harmful to the victim and to the children in the home where violence is occuring. Studies from around the globe find that IPV is a leading predictor of child maltreatment (Hunter, et al., 2000; Family Violence Prevention Fund, 2006). Growing up in a home where the mother experienced violence is considered an adverse childhood experience, and is associated with greater likelihood of poor outcomes in later life such as alcoholism, drug abuse, and suicide attempts (Felitti, 1998).

Intimate partner violence (IPV) has previously been linked with child mortality in countries including Bangladesh, the United States, India, Malawi, and Timor Leste (Hossain, Sumi, Haque, Bari, 2014; Mwale, 2004; Silverman et al., 2011; Taft, Powell, and Watson, 2015; Garoma, Fantahun,and Worku, 2012). A recent study using data from the Timor Leste’s 2013 Demographic Health Survey (DHS) showed that women who experienced physical violence were 30% more likely to experience child loss (the death of one or more children), and women who experienced combined forms of violence were 45% more likely to experience child loss when compared with women who had not experienced violence (Taft, Powell, and Watson, 2015).

We sought to uncover the relationship between intimate partner violence and child loss using the Togo demographic health survey (DHS) administered between 2013-2014. In addition, we investigated the effect of emotional violence which to our knowledge, has not been investigated in associated with child loss.  The Demographic Health survey is a nationally representative household survey that is administered by the United States Agency for International Development (USAID). This survey provides a wide range of monitoring and impact evaluation indicators and is developed in collaboration with the surveyed country. The Togo 2013-2014 DHS survey was translated into 13 languages and was administered by 90 highly trained individuals after gaining privacy and consent of the participant. The DHS survey assessed lifetime victimization of physical, emotional, and sexual violence (yes/no), and child loss (difference between the number of childbirths and number of living children, 1 or more coded as yes/ 0 coded as no). Covariates assessed included age, education, marital status, wealth index, employment, justification of wife-beating, and urban/rural residence. Data were weighted and analyzed through a bivariate logistic regression adjusting for covariates using SPSS version 14.

In total, 4842 Togolese women completed the domestic violence module of the Demographic health survey. In all, 36.5% of women reported victimization of physical, sexual, or emotional IPV in their lifetime. Women who experienced any form of IPV were 1.415 times as likely to experience child loss when compared to women who never experienced IPV (adjusted odds ratio (AOR) =1.415, 95% confidence interval (CI)=1.227,1.633). Women were significantly more likely to experience child loss if they experienced physical IPV (AOR=1.340, 95% CI = 1.135,1.582), sexual IPV (AOR=1.488, 95% CI = 162,1.905) or emotional IPV (AOR= 1.325, 95% CI = 1.143,1.536). Women who experienced combined forms of violence were at significantly increased odds of experiencing a child’s death when compared to women who never experienced violence (AOR=1.479, (95%CI = 1.231,1.778). We saw a significant association between all forms of intimate partner violence and child loss among this population of Togolese women. This finding indicates a need for child mortality interventions that address intimate partner violence to reduce Togo’s child mortality rate.

Addressing IPV requires strategies implemented at the individual, community, and policy levels. Screening for intimate partner violence during prenatal visits and providing social worker counseling to future mothers reduces recurrent episodes of IPV and improves childbirth outcomes (leading to higher birth weights and fewer premature births) (Kiely, Elmohandes, El-khorazaty, & Gantz, 2011). Data also indicates that policies including support programs for survivors such as shelters, housing programs, legal services, have been effective in reducing negative outcomes. The World Health Organization outlines strategies through which policy can most effectively reduce the burden of IPV suggesting that the healthcare and other sectors should have minimum standards for addressing this issue. These standards include establishing clear working protocols encompassing clear referral pathways for survivors of IPV (WHO Response to IPV, 2016). The degree to and nature in which countries follow these recommendations varies dramatically with some countries aggressively attempting to address the issue while others failing to even acknowledge its existence. The consequences of IPV are vast and impact people all over the world. Public health professionals are at the forefront of tackling this issue and will continue to play a critical role in reducing the global burden of IPV.

Please stay tuned for Part IV in this series: Interventions and Strategies for Addressing Global Intimate Partner Violence.

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Erica Hartmann, MMS (c), MMS (c) 2020 is a student at Arcadia University who hopes to prevent violence by serving as a physician assistant specializing in primary care in communities with limited access to healthcare. Erica worked under Dr. Heather McClintock to uncover links between IPV and child loss in Togo, and hopes to continue researching global violence prevention interventions after graduating from Arcadia.

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.

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