Vector Volume 12 Issue 2

VOLUME 12 ISSUE 2 FOUNDED 2006

FEATURE: Manifesto à la mode (p.2) REVIEW: Pornography - the psychological and FEATURE: Manifesto REVIEW: Pornography - the neurobiological effects of a à la mode (p.2) psychological and neurobiological $97 billion industry (p.14) effects of a $97 billion industry (p.15)

ORIGINAL RESEARCH: Comprehensive healthcare interventions ORIGINAL RESEARCH: Comprehensive in Ethiopian STI clinics 1 STI healthcare interventions in Ethiopian (p.36) clinics (p.33)

Advisory Board The Advisory Board consists of academic mentors who provide guidance for the present and future direction of Vector Journal.

Dr Claudia Turner Consultant paediatrician and clinician scientist with the University of Oxford and chief executive officer of Angkor Hospital for Children.

Professor David Hilmers Professor in the Departments of Internal Medicine and Pediatrics, the Center for Global Initiatives, and the Center for Space Medicine at the Baylor College of Medicine.

Associate Professor Nicodemus Tedla Associate Professor in the School of Medical Sciences at the University of New South Wales.

Dr Nick Walsh Medical doctor and regional advisor for viral hepatitis at the Pan American Health Organization / World Health Organization Regional Office for the Americas.

Thank you to the peer-reviewers of Vector Journal 12 Issue 2: Professor Michael Toole AM Dr Rahul Gupta Dr Paul Simpson Associate Professor Nicodemus Tedla

Dr Stuart Wark Dr Bridget Haire Dr Renju Cherian

Vector Journal 2018 Committee Editor-in-chief Aidan Tan aidan.tan@amsa.org.au Senior Editors Nicholas Mattock

Koshy Mathew

Associate Editors Sophia Moshegov

Matthew Martin Simran Dahiya Tasmyn Soller

Aimy Yan Kyrollos Hanna Tessa Tan Nina Li

Publication Director Nina Li Promotion Director Tessa Tan Design and layout Š 2018, Vector Journal vector.amsa.org.au Content Š 2018, The Authors Cover design image by Ryoji Iwata, accessed from https://unsplash.com/photos/_dVxl4eE1rk. Backpage design image by Cristian Newman, accessed from https://unsplash.com/photos/wGKCaRbElmk.

Vector Journal is a peer-reviewed and student-run global health journal.

Responsibility for article content rests with the respective authors. Any views contained within articles are those of the authors and do not necessarily reflect the views of the Vector Journal.

i

CONTENTS Foreword Aidan Tan

1

FEATURES Manifesto Ă la mode 2 Aneka R Larsen Exploring the ethics and legality of conducting clinical trials in developing nations 6 Rosemary B Kirk The changing landscape of artificial neural stimulation and its introduction to the developing world 10 Stephanie Kirkby REVIEWS Pornography: the psychological and neurobiological effects of a $97 billion industry 14 Bridie H Peters

Improving interactions between transgender and other gender-diverse persons and the healthcare system 18 Meredith Grey & Imogen Janus The public perception of major depressive disorder in South Asia: a literature review 24 Marisse Sonido

Guidelines for low birth weight: a literature review comparing national guidelines in Lao PDR with WHO guidelines

28 Line M Pederson

ORIGINAL RESEARCH The experience of Mekelle University in provision of comprehensive healthcare interventions at STI clinics for FSWs in Ethiopia 36 Tesfay Gebregzabher Gebrehiwot

EDITORIAL An open letter to our social media overlords Nina Li

43

United Nations Climate Conference Georgia Behrens & Katherine Middleton

46

CONFERENCE REPORT

BOOK REVIEW There is No Me Without You

Juliana Wu

50

ii

Foreword Aidan Tan

Once, standing ankle deep in the wet sand, I thought that I heard the Pacific Ocean in a conch shell. The conch shell, I theorised, was an Earth-bound black hole in thermal equilibrium, absorbing the temper of the tide and emitting a lost Vivaldi, ‘The Four Seasons of the Submerged’. Turns out, there are no oceans in conch shells, only the attenuated frequencies of ambient noise in a calcium carbonate cavity. I prefer the ocean.

Now, with an active imagination and origami instructions, you can turn this issue of Vector Journal into your own conch shell. If you listen carefully, you might just hear a call for ethical fashion by medical students, debate on clinical trials in developing nations, dialogue on developments in artificial neural stimulation, discussion on the effects of internet pornography, report on transgender and other gender-diverse persons, critique of South Asian perceptions of depression, summary of low birth weight in Laos, study of sexually transmitted infections in Ethiopia, commentary on social media causing psychological distress, recount of the United Nations Climate Conference, or review of a book on AIDS in Africa. Whatever you hear, I hope it strikes a chord with you.

1

Manifesto à la mode Feature article Aneka R Larsen Aneka R Larsen is a final year medical student at the University of Sydney who spends far too much time thinking about clothes, and not enough time studying.

Despite what your mother may have told you, it’s not just what’s on the inside that counts. As medical students, our external image matters greatly. We dress to impress, to show patients that we are capable and trustworthy. But how would our patients feel if they knew who made our clothes? Sustainable fashion is by no means a new idea, and most people I know support the idea, yet many of us still wear brands that are known to engage in unethical practices.

Although we as medical students generally wish to improve others’ quality of life, too often we put ethics on the backburner as we convince ourselves that we are too busy, too tired, too whatever-it-happens-to-be that day, to think of the consequences of our actions. If we were truly compassionate, it would seem incongruent that we would not also express this in choosing which brands to support.

After becoming increasingly concerned, I discussed the issue with a friend who told me

that given the opportunity, most people will choose to do good. That is, most people don’t want to benefit from the exploitation of others but will unthinkingly ignore the reality of how most clothes are made. Every day we are exposed to marketing on billboards, bus stops, shop windows, YouTube, Facebook, fashion blogs, and Instagram feeds. Our first thought is not ‘who made this?’, but ‘I want that’. It’s automatic, and that’s why it works. I choose to believe that my peers are not consciously deciding to fund a harmful industry, and that instead their choices simply reflect a lack of opportunity to consider their purchases. Here is said opportunity. Think carefully and buy ethically, so as to avoid a fashion faux-pas that’s more than just embarrassing— one that results in child slavery, abysmal wages and factory collapses causing thousands of deaths. If you would like to join me in protesting an industry that fuels the maltreatment and exploitation of others, then read on. This is my manifesto to fashion, and all the illnesses, injuries 2

and deaths that it can cause when not held accountable.

Do no harm The famous, perhaps trite, Hippocratic oath often comes to mind when considering the part that many medical students have played in the illnesses inflicted on sweatshop workers. It is a turn of phrase strongly associated with the medical profession, and one that most doctors and medical students take very seriously.

While much has changed since the oath was created 2,500 years ago, human nature is still very much the same. This oath is important because it sets clear boundaries for minimum decency. To paraphrase Hippocrates, —‘Guys, I know you’re busy and all, but at least don’t give Bangladeshi women gastric ulcers and deprive them of food and sleep for days on end.’

Bangladeshi sweatshop workers receive one of the lowest minimum wages in the world,[1] and women often feel obliged to prostitute themselves at work for extra money.[2] To help understand how severely impoverished they are, let’s take into account their average monthly wage, 3000 taka, which is approximately $50 Australian Dollars.

Working 16 hours a day for 7 days a week, they have made the shirt on your back for 10 cents an hour. For an extra 7 cents an hour, they would have enough to meet the “living wage”,[3] defined as “the minimum required to provide a family with shelter, food and education”.[3] If you add on the other burdens associated with sweatshops; the cramped living, lack of maternity care, and risk of silicosis from all the sand blasting so your denim can have that worn aesthetic, Hippocrates would be turning in his grave.[4]

[5, 6] While this disaster was widely discussed, it is one of many examples of the deaths inflicted on Bangladeshi workers. Another 7 deadly accidents were reported to have occurred in Bangladesh between 2005 and 2015.[7] An example of the response from companies involved is the one provided by H&M after the Rana Plaza collapse. “It is important to remember that this disaster is an infrastructure problem in Bangladesh and not a problem specific to the textile industry”.

[8] This response shifts the blame to a poverty-stricken country and should not absolve them from participating in the exploitation of Bangladeshi workers. Although these disasters may seem far away from our comparatively comfortable lives, the deplorable crimes committed by the fashion industry are being committed by the fashion industry in our names. Many of the clothing brands worn by my peers here in Australia have been remonstrated for their manufacture practices, including Tigerlily, UNIQLO, Gorman, Ralph Lauren, Lacoste, Boohoo, and Dotti.[9] Choosing which pretty dress or flash new suit to buy for the next ball can seem like a life or death situation, but instead of only stressing over which looks best, also ask yourself where and how it was made. There are actual lives at stake, not just social ones, and they are lives that you can help to save simply by asking the right questions.

‘Our first thought is not who made this, but I want that’

No cause justifies the deaths of innocent people Averting the deaths of innocent civilians seems like another no-brainer, but in a globally reported disaster in April 2013, an eight-story sweatshop in Dhaka, Bangladesh, collapsed, killing over a thousand people and injuring over two thousand.[5] The sweatshop supplied clothes to international brands such as Primark and H&M.

Practice what you preach Do what your favourite soul singer tells you to do and “Practice What You Preach” (Barry White, 1994). How could you resist that deep baritone anyway? Sustainable fashion is generally seen as an ethical “thumbs up”, and yet so many people don’t practice it. There are a range of reasons that beliefs may not necessarily transfer to action, but the difficulty in keeping track of which brands treat their workers fairly seems to be a key one.

One way to combat this challenge is to refer to an organisation that conveniently does it for you, such as Ethical Clothing Australia (ECA), which maps the local supply chain of brands to ensure the fair treatment of clothing workers. It provides a list of those brands which provide fair wages and decent living conditions, and its website lists

A Kmart t-shirt‘s $3 price tag may be appealing to some, but their supply chain is untraceable and the workers receive a “minimum wage”, less than a “living wage”, the amount required to meet basic costs of living.

3

these brands for your perusal. Some included brands are Cue, Manning Cartell, Thurley, Scanlan Theodore and Nobody.[10] As a general rule, however, it helps to ask if the price tag on an item really reflects the amount of work that went into making it.[11] A Kmart t-shirt‘s $3 price tag may be appealing to some, but their supply chain is untraceable and the workers receive a “minimum wage”, less than a “living wage”, the amount required to meet basic costs of living.[11] When considering price, it is obviously very important to acknowledge that not everyone can afford to pay for organic, handmade clothes. Some ways to overcome this include participating in the events run by charities like Fashion Revolution that work at raising awareness, shopping secondhand so that your money does not go directly to exploitative companies, learning to make your own clothes and writing to companies to put pressure on them to subscribe to ethical practice.

[12] Go on, make Barry proud.

There are alternatives to supporting exploitative fashion labels. Protesting the unethical choices of the fashion industry doesn’t mean you have to look like a hessian sack. Fashion is about making you feel like your best self, which is hard to accomplish when your new look endorses an industry that is directly responsible for the illnesses, injuries and deaths of women and children from third world countries. Next time you’re worried about committing a fashion fauxpas at Med Ball, remember your commitment to improving the lives of others. That commitment shouldn’t just remain within the confines of the hospital.

Acknowledgements None Photo credit Ricardo Gomez Angel, accessed from https:// unsplash.com/photos/rNXy6ngoyQ0 Conflict of interest None declared Correspondence alar9706@uni.sydney.edu.au References

1. International Labour Organisation, Characteristics of minimum wage setting system and minimum wage levels, [Internet]. Available from: https://www.ilo.org/ wcmsp5/groups/public/---asia/---ro-bangkok/documents/ genericdocument/wcms_223988.pdf, (accessed 2 September 2018) 2. Inter Press Service News Agency, Women Suffer Most in Garment Sweatshops in Bangladesh, [Internet], 1998. Available from: http://www.ipsnews.net/1998/12/labour-bangladeshwomen-suffer-most-in-garment-sweatshops/, (accessed 25 August 2018).

3. War on Want, Sweatshops in Bangladesh [Internet].

Available from: http://www.waronwant.org/sweatshopsbangladesh (accessed 20 March 2017).

4. Akgun M, Araz O, Ucar EY, Karaman A, Alper F, Gorguner M, et al. Silicosis Appears Inevitable Among Former Denim Sandblasters: A 4-Year Follow-up Study. Chest.

2015;148(3):647-54.

5. The Independent, Bangladesh factory collapse: 41 charged over deadly Rana Plaza tragedy, [Internet], 2015.

Available from: http://www.independent.co.uk/news/world/ asia/bangladesh-factory-collapse-41-charged-over-deadlyrana-plaza-tragedy-a6781876.html, (accessed 22 March 2016).

6. Clean Clothes Campaign, Evaluation of H&M Compliance with Safety Action Plans for Strategic Suppliers in Bangladesh, [Internet], 2015. Available from: https:// cleanclothes.org/resources/publications/hm-bangladeshseptember-2015.pdf, (accessed 25 August 2018).

7. CBC, Timeline: Deadly factory accidents in Bangladesh, [Internet].

Available from: http://www.cbc.ca/news2/ interactives/timeline-bangladesh/, (accessed 22 March 2016).

What you need to know: • The fast fashion industry is responsible for illnesses, injuries and deaths of sweatshop workers internationally.

• Workers live in cramped living conditions, do not have access to maternity care, receive exploitative wages and are exposed to occupational hazards ranging from silicosis to factory collapses.

• The ubiquitous nature of fast fashion makes it particularly difficult to forgo, however.

• This article aims to raise awareness of the issue and outline some simple steps that we can take to minimise the amount we each contribute to this harmful industry.

4

8. Business and Human Rights Resource Centre, Response by H&M: Rana Plaza factory collapse in Bangladesh; over 1100 dead, [Internet], 2013. Available from: https://business-humanrights. org/sites/default/files/media/documents/company_responses/ h&m-response-re-bangladesh-building-collapse.pdf, (accessed 20 March 2017) 9. Baptist World Aid, The 2018 Ethical Fashion Report, [Internet].

Available from: https://baptistworldaid.org.au/ resources/2018-ethical-fashion-report, (accessed 25 August 2018) 10. Ethical Clothing Australia, Brands, [Internet], 2016, http:// ethicalclothingaustralia.org.au/brands/, (accessed 20 March 2017) 11. Choice, Ethical clothing, [Internet], 2014. Available from: https://www.choice.com.au/shopping/everyday-shopping/ clothing/articles/ethical-clothing#ethically, (accessed 22 March 2016).

12. Independent, Katharine Hamnett interview: How to shop ethically on a student budget, [Internet], 2014. Available from: www.independent.co.uk/student/student-life/katharine-hamnettinterview-how-to-shop-ethically-on-a-student-budget-9882406. html, (accessed 22 March 2016).

5

Exploring the ethics and legality of conducting clinical trials in developing nations Feature article Rosemary B Kirk Rosemary B Kirk is a fourth year medical student at the University of New South Wales. She has an interest in research and bioethics, and the point where the two intersect.

Introduction The number of clinical trials conducted in developing countries has increased dramatically in recent decades due to globalisation and increased need for trial subjects. For example, between 2002 and 2007 the number of United States (US) sponsors conducting pharmaceutical research abroad increased by 15% annually, while US-based trials decreased by 5.5%.[1] All trials involving human subjects require ethical discussion, and this is of particular importance in developing nations, where risk of exploitation is high. In this article I will describe the legislation surrounding these trials, summarise the benefits of clinical trials to developing nations and researchers, analyse the ethical issues raised by this practice through a principles-based and utilitarian lens, and discuss how future legislation could align the potential benefits of these trials with reality.

Legislation surrounding clinical trials To understand why clinical trials in developing

countries are conducive to exploitation, the issues with the legislation in place must first be understood.

International Numerous international bodies have created documents outlining clinical trial guidelines. One of the most commonly referenced documents is the Declaration of Helsinki (DoH), developed and regularly updated by the World Medical Association. International guidelines such as this are not legally binding, but are referred to in the legislation of many countries.[2] These international guidelines have been criticised for being vague and thereby allowing researchers to circumvent their recommendations.[3] For example, the DoH states that new interventions must be tested against the current best intervention, that researchers should make provisions for posttrial access to their intervention, and that medical research on a group is only justified if 6

it is responsive to their health needs.[4] However, the DoH lists circumstances in which placebo use is acceptable, does not specify the duration of availability or price of the intervention post-trial, and does not define how significant a health need must be for a community to justify participation in a trial.

Developed nations Developed nations have regulations to protect subjects in trials within their country that are enforced by ethics committees. However, depending on who is funding the research, such regulations do not always have to be followed when conducting research internationally.[5] It can also be problematic to apply laws from one culture to another. For example, in the US, sponsors do not have to compensate subjects for treatment of research-related injuries, but this cannot reasonably be applied to nations where subjects cannot afford treatment.[6]

tested.[11] Furthermore, through conducting clinical trials, researchers can provide equipment and knowledge to advance local research, and can boost local economies.[12] Ethical perspectives If research is conducted ethically and following international guidelines, it is possible for all of the benefits described above to be realised. However, as long as clinical trials in developing countries are not properly policed, there are ethical issues implicit in this practice and a risk of exploitation.

While there are countless ethical issues to be considered in this area, I will focus on the issues of informed consent, the dangers of trials, placebo use, testing of interventions that target health needs, and post-trial availability of interventions. These will be analysed using a principlesbased and a utilitarian lens.

‘...44% of studies in developing nations did not undergo any review from the country in which they took place’

Developing nations Developing nations are less likely to have established and financially-supported clinical trial regulation, and the increase in clinical trials in developing nations in recent years has overwhelmed existing ethical review systems.[7] This makes it easy for researchers to avoid investigation, and a 2004 study found that 44% of studies in developing nations did not undergo any review from the country in which they took place.[8] Arguments for clinical trials in developing countries

For companies The advantages for companies of conducting clinical trials in developing countries are numerous. Costs are significantly reduced as a result of lower salaries, cheaper facilities, and less time being required to receive approval for a trial.

[9] Participant recruitment is also easier, due to the higher prevalence of diseases and paucity of treatment options.[10] Finally, subjects are less likely to have received prior treatment, increasing result significance.[2] For communities While it can be easy to assume that clinical trials in developing nations are inherently exploitative, these trials are not without their benefits to local communities. Trials provide pharmaceuticals to people who may otherwise have extremely limited access, and if the recommendations made in the DoH are implemented, these communities may have continued access to the drugs being

Autonomy Autonomy describes a state in which individuals are free to make their own decisions; one consequence of the principle of autonomy is informed consent.

To make decisions, people must be provided with the relevant information in a form they can understand.[13] Informed consent has particular relevance for trials in developing nations, because gaining consent requires understanding local languages and analogies, and obtaining written consent can be difficult in the context of low education rates.[14,15] Additionally, in many communities it is essential to also obtain consent from elders, religious leaders, or heads of families.

[16] Thus, in order for clinical trials in developing countries to be considered ethical from the perspective of autonomy, researchers must show cultural awareness in acquiring informed consent.

Beneficence and non-maleficence Non-maleficence is the principle that actions should not expose individuals to unnecessary harm, while beneficence describes acting in a manner that benefits others.[13] In any clinical trial there is potential for significant harm to come to study subjects. This is particularly true when clinical trials are poorly regulated. For example, up to 2,644 people died in clinical trials of 475 new drugs over a 7-year period in India, with the majority of these trials being conducted by international sponsors.[17] In the context of murky international legislation and the potential for negligent trial structure and administration, such deaths can be considered a violation of the principle of non-maleficence by the researchers. Conversely, clinical trials can 7

also be a force for beneficence in developing nations through the provision of medication and research infrastructure, as previously described.

It is thus important that the potential harms and benefits of any trial to a community be carefully considered in order to maximise both principles of beneficence and non-maleficence.

A further ethical issue relating to beneficence and non-maleficence is the use of placebos in clinical trials, a pertinent case study being the 1994 African Zidovudine trials. These trials tested Zidovudine as a means of preventing vertical transmission of HIV, with comparison to control groups who received a placebo.[18] During the trial, many women in the control group transmitted HIV to their offspring. This violates the principle of beneficence, as researchers did not act to benefit all trial subjects (which could have been achieved by giving the control group an existing intervention). Whether or not this violates the principle of non-maleficence depends on how harm is defined. If harm requires an individual to be worse-off relative to a baseline, then this placebo use could be considered ethical in a nation where women otherwise receive no treatment.[10,19] However, this creates a double standard for developing countries, as using a placebo when there is existing treatment would be unethical in developed nations, as per recommendations established in the DoH. Views on placebos from this perspective, therefore, may vary.

Justice The principle of justice involves fair distribution of scarce resources and respect for personal rights and laws.[20] Trials in developing countries are often for ailments primarily affecting developed nations, such as overactive bladder and allergic rhinitis, rather than for diseases that disproportionately affect developing countries.

[1] People in developing nations are therefore assuming the risks of research while receiving little benefit. This practice is possible because there are many health needs in developing nations and, as previously stated, the DoH does not specify how important a health need must be for it to be an appropriate research target.[21] From a justice perspective, in order for a trial to be ethical it should target a health priority, not just a health issue present in a community. If this principle is followed, clinical trials may become a means of combatting global healthcare inequalities; indeed, as it stands today, 90% of the global healthcare budget targets illnesses responsible for only 10% of the global disease burden.[22] Another issue pertaining to the principle of justice is continued access to interventions post-trial. Basic medications are often absent or expensive in developing countries; therefore,

continuing to offer treatments after a trial ends is one way of fighting this distributive injustice, especially if the intervention is offered to a wider community and the researchers are allied with broader access programmes.[11] Utilitarianism Utilitarianism deems actions good if such actions maximise the amount of good for a maximum number of people.[13] Using a utilitarian lens, it can be argued that since clinical trials in developing countries are mutually beneficial, imposing further constraints is not justified.[23] For example, if placebo use was not permitted in the African Zidovudine trials, the trial may not have been conducted, meaning no one would receive treatment.

In the context of extreme utilitarianism, it can even be argued that all clinical trials in developing countries are ethically justifiable because the results can potentially help many more people than might be harmed in the trial process.

Utilitarianism thus provides a very different overall view of clinical trials in developing countries than a principles-based perspective. In practice, the views of most ethical theorists and international guidelines align with a principlesbased perspective, while some developed nations follow the utilitarian perspective and favour scientific arguments and economic advantages over ethical concerns for people in developing countries.[24] Proposed future changes It is evident that the current guidelines and legislation surrounding international clinical trials are inadequate to protect trial subjects from exploitation. Because of deficiencies in international legal capacity and infrastructure in developing nations, the responsibility for protecting subjects of clinical trials in developing countries must fall to developed nations. Examples of beneficial changes to current legislation include adjusting laws to be culturally appropriate for developing communities,[24] enforcing governments to commit a portion of tax revenue to research that is responsive to the health priorities of developing countries,[21] and having governments provide incentives to support health policy improvement and appropriate research practices in developing nations.[25] However, such legislation is far from being realised, and is unlikely to be implemented provided that current legislation remains beneficial to developed nations and wealthy researchers.

Conclusion There are many layers of legislation to be considered when conducting a clinical trial in a 8

developing nation, with considerable potential for contradiction or legislative gaps. Trials can therefore result in exploitation, and require numerous ethical issues to be considered.

Exploring these issues using a principles-based perspective reinforces the need for improved legislation surrounding trials; conversely, however, purely utilitarian perspectives support maintenance of the current status quo. While legislation is unlikely to change dramatically in the near future, many ethicists agree that if developed countries improve their legislation, clinical trials in developing nations can become a part of the solution to global health inequality, rather than part of the problem.

Acknowledgements None Photo credit Louis Reed, accessed from https://unsplash. com/photos/pwcKF7L4-no Conflict of interest None declared Correspondence rosemary.kirk@unsw.edu.au References

1. Glickman SW, McHutchison JG, Peterson ED, Cairns CB, Harrington RA, Califf RM, et al. Ethical and scientific implications of the globalization of clinical research. N Engl J Med. 2009;360(8):816-23 2. Weigmann K. The ethics of global clinical trials. EMBO Rep. 2015;16(5):566-70 3. Omonzejele PF. Is the codification of vulnerability in international documents a sufficient mechanism of protection in the clinical research ethics context?. Med Law. 2011;30:497515 4. World Medical Association. WMA Declaration of Helsinki – Ethical Principles for Medical Research Involving Human Subjects [Internet]. Geneva: The World Medical Association; 2018 July 9 [cited 2018 Aug 10]. Available from: https://www.wma.net/policies-post/wma-declaration-ofhelsinki-ethical-principles-for-medical-research-involvinghuman-subjects/ 5. Schneider JL. Professional codes of ethics: Their role and implications for international research. J Contemp Crim Justice. 2006;22(2):173-92 6. Mamotte N, Wassenaar D, Singh N. Compensation for research-related injury in NIH-sponsored HIV/AIDS clinical trials in Africa. J Empir Res Hum Res Ethics. 2013;8(1):45-54 7. Simpson B, Khatri R, Ravindran D, Udalagama T. Pharmaceuticalisation and ethical review in South Asia: Issues of scope and authority for practitioners and policy makers. Soc Sci Med. 2015;131:247-54 8. Hyder AA, Wali SA, Khan AN, Teoh NB, Kass NE, Dawson L. Ethical review of research: A perspective from developing country researchers. J Med Ethics. 2004;30(1):68-72 9. Alemayehu C, Mitchell G, Nikles J. Barriers for conducting clinical trials in developing countries – a systematic review. Int J Equity Health. 2018;17(1):37-47 10. Botha M, Zeier MD. Clinical trials in developing countries: An overview. In: Stefan DC, editor. Cancer research and clinical trials in developing countries. Cham: Springer; 2016. p.41-54 11. Okpechi IG, Swanepoel CR, Venter F. Access to

medications and conducting clinical trials in LMICs. Nat Rev Nephrol. 2015;11(3):189-94 12. Lorenzo C, Garrafa V, Solbakk JH, Vidal S. Hidden risks associated with clinical trials in developing countries. J Med Ethics. 2010;36(20):111-5 13. McNeill P, Torda A, Little JM, Hewson L. Ethics Wheel.

Sydney: University of New South Wales. 2004.

14. Emanuel EJ, Wendler D, Killen J, Grady C. What makes clinical research in developing countries ethical? The benchmarks of ethical research. J Infect Dis. 2004;189(5):930-7 15. Diemert DJ, Lobato L, Styczynski A, Zumer M, Soares A, Gazzinelli MF. A comparison of the quality of informed consent for clinical trials of an experimental hookworm vaccine conducted in developed and developing countries. PLoS Negl Trop Dis. 2017;11(1):e0005327 16. Martellet L, Sow SO, Diallo A, Hodgson A, Kampmann B, Hirve S, et al. Ethical challenges and lessons learned during the clinical development of a group A meningococcal conjugate vaccine. Clin Infect Dis. 2015;61(suppl 5):S422-7 17. Mahapatra D. 2,644 died during clinical trial of drugs in 7 years: Govt to SC. The Times of India. 2013 Apr 25 [cited 2018 Aug 11]. Available from: https://timesofindia.indiatimes.com/ india/2644-died-during-clinical-trial-of-drugs-in-7-yearsGovt-to-SC/articleshow/19719175.cms 18. Lavery JV, Grady C, Wahl ER, editors. Ethical issues in international biomedical research: a casebook. Oxford: Oxford University Press; 2007 19. Hawkins JS, Emanuel EJ, editors. Exploitation and developing countries: The ethics of clinical research. Princeton: Princeton University Press; 2008 20. Brizi AP, Filibeck U, Kangaspunta K, O’Neil AL. Biomedical research in developing countries: The promotion of ethics, human rights and justice. Italy: UNICRI; 2009 21. Hughes RC. Justifying community benefit requirements in international research. Bioethics. 2012:28(8);397-404 22. Wertheimer A. Rethinking the ethics of clinical research: widening the lens. Oxford: Oxford University Press; 2010 23. Mitra AG. Off-shoring clinical research: Exploitation and the reciprocity constraint. Dev World Bioeth. 2012;13(3):111-8 24. Garrafa V, Lorenzo C. Moral imperialism and multicentric clinical trials in peripheral countries. Cad Saude Publica.

2008;24(10):2219-26 25. Pratt B, Loff B. Health research systems: Promoting health equity or economic competitiveness?

Bull World Health Organ.

2012;90(1):55-62

9

The changing landscape of artifical neural stimulation and its introduction to the developing world Feature article Stephanie Kirkby Stephanie Kirkby is a medical student at Deakin University. Stephanie has previously completed a Bachelor of Science (Hons) at The University of Melbourne, majoring in Neuroscience, where she completed an Honours project with the National Vision Research Institute.

With Commentary from Professor Michael Ibbotson The artificial electrical stimulation of neurons for the treatment of neurological disease and impairment is a well-established field that is undergoing rapid development in the treatment of diseases such as Parkinson’s disease,[1] obsessive compulsive disorder,[2] epilepsy,[3] as well as auditory and visual impairments using cochlear[4] and retinal implants.[5] The basic principle underlying these treatments arises from the inherent electrical excitability of all neurons in the body. By using electrical impulses to stimulate neurons, we can attempt to manipulate their functions. Thus, if there is a dysfunction in the firing of some neurons in the network, we can seek to replace them using electrodes. Generally, this is an area of research only being explored

in the context of the developed world, however, particularly in the case of cochlear implants, there may soon be an evolving role for artificial neural stimulation in the developing world.

To appreciate the potential of artificial neural stimulation, we must first appreciate the way in which the neural network operates. The communication between neurons within the brain is the primary control point of all human behaviours, ranging from the movement of our limbs to the control of our deepest thoughts and emotions. These neurons communicate via unique patterns of electrical activity within synchronous neuronal networks, which are composed of billions of cells. Different sensations and behaviours each depend upon a unique subset of neurons within this synchronous network for 10

their function. For instance, the neurons recruited for vision differ in appearance, location, electrical signature, and distribution when compared to those required for hearing. However, when the health of these neurons is compromised, so too is their ability to produce these complex patterns of activity. Artificial neural stimulation takes advantage of the electrical potential of neurons, whose function is dependent upon the flow of charge from one cell to the next. By injecting such neurons with an electrical stimulus using electrodes, we can artificially generate new patterns of neuronal activity that can replace the role of any dysfunctional cells in the network.

Bionic vision is still in its infancy but has made significant strides in the treatment of retinitis pigmentosa, the leading cause of inherited blindness.[6] There are also plans to utilise it for the treatment of macular degeneration, the leading cause of blindness in the developed world.[7] A United States Food and Drug Administration (FDA) approved model, developed by Second Sight in the USA, has already been implanted in hundreds of patients for the treatment of retinitis pigmentosa,[8] restoring ‘functional vision’ to its recipients.

Functional vision is significantly different from normal vision and relies on ‘phosphenes’ to produce visual percepts of the surrounding world.[9] Phosphenes are ‘spots’ within the visual field that can be perceived as either light or dark, such that a recipient may be able to perceive a horizon, navigate a dining room table, or see obstacles on a street. Phosphene vision is distinct from normal vision, being unable to depict colour or fine detail, as well as being limited by the number of phosphenes that a patient can see. Each phosphene corresponds to an electrode that has been placed on the retina, so with more electrodes, the patient will be able to perceive more sections of the visual field distinctly. However, there are multiple limitations to achieving higher visual acuity with more electrodes within retinal prostheses such that phosphene vision remains ‘functional’ but rudimentary compared to normal human vision.

implantation and the increased biocompatibility of the materials used. Recent advances have made it possible to both record from and stimulate neurons in different areas of the brain.

For instance, we could record sensory neural information from one part of the brain and then feed it back into motor neurons to emulate more natural movements of the body.”

“However, in many cases although we do not perfectly replicate the original neural network’s function, there are still significant positive outcomes for patients psychologically to have a lost sense restored.[10, 11] Despite the difficulty inherent in reading a text with bionic vision, patients would prefer to utilise that sense, which otherwise would be lost to them, rather than opt for an easier means of reading such as an audiobook.” What has been restored for these patients is much more than their sight or their hearing, but rather a restoration of their sense of self.[11]

‘Despite the difficulty inherent in reading a text with bionic vision, patients would prefer to utilise that sense, which otherwise would be lost to them, rather than opt for an easier means of reading such as an audiobook.’

Michael Ibbotson, Director of the National Vision Research Institute and Professor at The University of Melbourne believes that “the sky is the limit” when it comes to the potential of artificial neural stimulation. “Two key factors have driven the rapid expansion of bionics in recent years; the improvement of surgical techniques for

According to Professor Ibbotson, it seems possible that the future of bionics may expand well beyond the medical world, stating that “once it becomes normal within medicine, it would not surprise me if bionics became cosmetic”.

As the technology develops and becomes normalised as a treatment for various impairments and diseases, the public may eventually see an opportunity for self-improvement through artificial neural stimulation. For instance, breast implantation was originally developed for mastectomy patients before it became one of the most popular cosmetic surgeries of the modern world. [12] “If it were possible to improve memory function by selectively stimulating memory circuits at particular times, this could dramatically change the way in which students approached education, as well as in the treatment of memory disorders”. Although it seems closer to science fiction than reality, the cosmetic use of artificial neural stimulation, if it were realised, would have the potential to increase the profitability of this technology. If this were the case, it may be possible to fund its use in less developed regions, where it is currently unavailable.

The expanding range of pathologies that can be treated by neural stimulation is promising, particularly for the developed world, but its 11

implementation in the developing world is far more complex.[13] There are many obvious hurdles in utilising this technology beyond high-income countries. The first issue is the prioritisation of resources to ensure the greatest possible impact on public health outcomes. There are many other competing health priorities that require attention before advanced interventions to improve neurological health can be implemented.[14, 15] “The cochlear implant appears to be the exception to the rule” according to Professor Ibbotson. Since its initial clinical introduction for patients in 1985, the cochlear implant has undergone significant developments and is now widely utilised in the treatment of hearing impairment, particularly in paediatrics where its impact is more dramatic in younger brains due to increased neuroplasticity. The cochlear implant has also seen recent introductions into low and middle-income countries in South America, Egypt, India and China, where it has faced multiple ethical and practical challenges.[13] However, recent studies have shown that its use can remain cost-effective, even in regions where there is a scarcity of health resources.[13] This is largely due to both the use of low-cost materials and the high health benefit associated with hearing restoration in patients.

The health priorities of patients also need to be aligned with access to neural implants, regardless of the product’s availability. If patients do not feel the need for such health interventions, then such interventions are unlikely to be utilised. For instance, the cochlear implant is still met with some resistance in the deaf community due to the fear of compromising their cultural identity. [16] Visual impairment is one such example where there is a significant variation between the priorities of the developing world and the developed world. In low-income countries, cataracts are the leading cause of blindness, [17] whilst in the developed world, the leading cause of blindness is age-related macular degeneration.

[7] Naturally, there is a gap in the prioritisation of treatment availability where surgical intervention is a successful treatment for cataracts but remains difficult to deliver to disadvantaged regions of

the world. The treatment of age-related macular degeneration and other degenerative retinal diseases has inspired the development of the bionic eye, but is less likely to be considered a treatment priority for the developing world until it becomes far more affordable.

Global health priorities are consistently evolving to reflect the needs of the wider population.

Although it may be in the distant future, the wider utility of artificial neural stimulation will remain unclear until the technology has sufficiently advanced. It will be important for patients to have an awareness and understanding of such technology in the future, so that it is more likely to be accepted as a potential treatment for future health initiatives.

At a recent public forum, Professor Ibbotson also reported that one of the primary concerns of the public surrounding the use of neural implants was the potential for ‘mind control’. This demonstrates a significant gap in the public’s understanding of what artificial neural stimulation aims to achieve, as well as what it is capable of.

The potential for this type of neural control is wellbeyond the capabilities of current technology, which aims to stimulate otherwise inactive local networks of the brain to restore a lost function such as vision or hearing.[18] However, these patient concerns are still important to consider if such technology is ever to be widely implemented in medicine in the future.

The human brain is infinitely complex and research is only recently gaining significant momentum in our understanding of its function.

The development of artificial neural stimulation is an expanding field for the treatment of degenerative neural diseases. Although this technology is in its infancy, it has enormous potential for public health outcomes in both the developed and developing worlds, which are yet to be fully realised. The range of pathologies treated with artificial neural stimulation is expanding as rapidly as our understanding of the brain itself, making the development of this research an important area to watch in the future of medicine.

‘Although it may be in the distant future, the wider utility of artificial neural stimulation will remain unclear until the technology has sufficiently advanced. It will be important for patients to have an awareness and understanding of such technology in the future, so that it is more likely to be accepted as a potential treatment for future health initiatives.’

12

Acknowledgements Commentary and revisions provided by Professor Michael Ibbotson.

Photo credits Meo, accessed from https://www.pexels. com/photo/photo-of-head-bust-printartwork-724994/ Conflict of interest Stephanie Kirkby is currently working with the National Vision Research Institute on a followup project relating to her Honours research with Professor Michael Ibbotson.

Correspondence skirkby@deakin.edu.au References

1. Aviles-Olmos I, Kefalopoulou Z, Tripoliti E, Candelario J, Akram H, Martinez-Torres I, et al. Long-term outcome of subthalamic nucleus deep brain stimulation for Parkinson’s disease using an MRI-guided and MRI-verified approach. J Neurol Neurosurg Psychiatry. 2014; 85: 1419-25 2. Alonso P, Cuadras D, Gabriëls L, Denys D, Goodman W, Greenberg BD, et al. Deep brain stimulation for obsessivecompulsive disorder: a meta-analysis of treatment outcome and predictors of response. PloS one. 2015;10(7): e0133591 3. Cukiert A, Cukiert CM, Burattini JA, Lima AM. Seizure outcome after hippocampal deep brain stimulation in a prospective cohort of patients with refractory temporal lobe epilepsy. Seizure. 2014;23(1):6-9.

4. Mäki-Torkko EM, Vestergren S, Harder H, Lyxell B. From isolation and dependence to autonomy–expectations before and experiences after cochlear implantation in adult cochlear implant users and their significant others. Disability and rehabilitation.

2015;37(6):541-7.

5. Hadjinicolaou AE, Meffin H, Maturana MI, Cloherty SL, Ibbotson MR. Prosthetic vision: devices, patient outcomes and retinal research. Clinical & Experimental Optometry.

2015;98(5):395-410.

6. Hartong DT, Berson EL, Dryja TP. Retinitis pigmentosa.

2006;368(9549):1795-809.

7. Wong WL, Su X, Li X, Cheung CMG, Klein R, Cheng C-Y, et al. Global prevalence of age-related macular degeneration and disease burden projection for 2020 and 2040: a systematic review and meta-analysis. The Lancet Global Health. 2014;2(2):106-116 8. Second Sight Announces Record Number of Argus II Retinal Prosthesis Systems Implants and Completes First-inHuman Orion Cortical Implant [press release]. California: Second Sight 2018.

9. Pérez Fornos A, Sommerhalder J, da Cruz L, Sahel JA, Mohand-Said S, Hafezi F, et al. Temporal properties of visual perception on electrical stimulation of the retina. Investigative Ophthalmology & Visual Science. 2012;53(6):2720-31.

10. Duncan JL, Richards TP, Arditi A, da Cruz L, Dagnelie G, Dorn JD, et al. Improvements in vision related quality of life in blind patients implanted with the Argus II Epiretinal Prosthesis.

Clinical and Experimental Optometry. 2017;100(2):144-50.

11. Da Cruz L, Coley BF, Dorn J, Merlini F, Filley E, Christopher P, et al. The Argus II epiretinal prosthesis system allows letter and word reading and long-term function in patients with profound vision loss. British Journal of Ophthalmology. 2013;97:632-6 12. Champaneria MC, Wong WW, Hill ME, Gupta SC. The evolution of breast reconstruction: a historical perspective. World journal of surgery. 2012;36(4):730-42.

13. Fagan JJ, Tarabichi M. Cochlear implants in developing countries: practical and ethical considerations. Current opinion in otolaryngology & head and neck surgery. 2018;26(3):188-9.

14.

Allegranzi B, Kilpatrick C, Storr J, Kelley E, Park BJ, Donaldson L, et al. Global infection prevention and control priorities 2018–22: a call for action. The Lancet Global Health.

2017;5(12):1178-80.

15. Chao TE, Sharma K, Mandigo M, Hagander L, Resch SC, Weiser TG, et al. Cost-effectiveness of surgery and its policy implications for global health: a systematic review and analysis.

The Lancet Global Health. 2014;2(6):334-45.

16. Goldblat E, Most T. Cultural Identity of Young Deaf Adults with Cochlear Implants in Comparison to Deaf without Cochlear Implants and Hard-of-Hearing Young Adults. The Journal of Deaf Studies and Deaf Education. 2018;23(3):228-39.

17. Khairallah M, Kahloun R, Bourne R, Limburg H, Flaxman SR, Jonas JB, et al. Number of people blind or visually impaired by cataract worldwide and in world regions, 1990 to 2010.

Investigative ophthalmology & visual science. 2015;56(11):67629.

18. Lebedev MA, Nicolelis MA. Brain-machine interfaces: From basic science to neuroprostheses and neurorehabilitation.

Physiological reviews. 2017;97(2):767-837.

What you need to know: • The artificial electrical stimulation of neurons for the treatment of neurological disease and impairment is a well-established field that is undergoing rapid development in the treatment of disease.

• The expanding range of pathologies that can be treated by neural stimulation is promising, particularly for the developed world, but its implementation in the developing world is far more complex.

• According to Professor Michael Ibbotson of the National Vision Research Institute, the future of bionics may expand beyond the medical world and potentially be used cosmetically for selfimprovement.

• Although this technology is in its infancy, it has enormous potential for public health outcomes in both the developed and developing worlds, which are yet to be fully realised.

The

Lancet.

13

Pornography: the pyschological and neurological effects of a $97 billion industry Review article Bridie H Peters

“

Bridie H Peters is a third year medical student at the University of New England. She’s far from impartial to a chocolate dusting on cappuccinos, a ripper sunset and some great evidence-based medicine.

Abstract Aims: This review aims to summarise the research exploring the health effects of internet pornography on its users. It focuses on pornography’s addictive potential, impact on sexual behaviours and mental health.

Methods: The relevant literature concerning the health effects of internet pornography was reviewed.

Resources were sourced from databases such as PubMed and JSTOR. Results: This review finds significant evidence for the addictive potential of pornography, validating the consideration of pornography addiction as a clinical diagnosis. Pornography may also cultivate misogynistic beliefs, affect the sexual functioning of its users and have some role in promoting sexually aggressive behaviours. Poor mental health and pornography appear to have a bi-directional association.

Conclusions: The potential health effects of pornography are extensive and well-established. Given the ubiquitous nature of this media, there may be significant clinical implications for these findings.

Background The proliferation of the Internet has fostered a wild-fire growth of the pornography industry.

[1] Pornography is more accessible and widely disseminated than ever before, accounting for a quarter of all internet searches and 1.5% of all websites.[2] However, this growth doesn’t come without concern. The cultivation of sexual abuse, misogyny and poor mental health are among some of the startling accusations made against this industry.

[1,3,4] Given that 84% of Australian males and 23% of females aged 16-25 years use this media daily or weekly,[5] if these accusations hold water, they may have significant and widespread impacts. The following review aims to summarise the research on the health effects of pornography on its users.

Compulsive pornography use and addiction There is considerable debate as to whether pornography has addictive potential and if it does, whether it is comparable to those of other addiction disorders (e.g. alcoholism, compulsive gambling).

[6] These well-established addiction disorders are

”

characterised by several common thought and behavioural patterns. These include but are not limited to: (a) perceived lack of control over the substance/ object of abuse; (b) adverse consequences from is use (e.g. relationship, social, work or school problems); (c) an inability to stop its use despite these negative consequences; and (d) preoccupation with the substance/ object of abuse.[7]

These symptoms are being increasingly reported in patients who complain of pornography overuse. [6] Pornography addiction is not at present a formallyrecognised clinical disorder in the DSM-V or ICD-10, however, the prevalence of these findings has led to the widespread use of Compulsive Pornography Use as a working clinical diagnosis. Many of the studies mentioned in this paper have recruited patients suspected to have this disorder. There is no consensus on the definition of this disorder, but as with other addictions, the aforementioned thought patterns are characteristic[7]. The prevailing argument contesting the recognition of Compulsive Pornography Use as a clinical disorder is the thought that these symptoms reflect a high sex drive in certain populations and are not suggestive of a pathological addiction.[8] 14

The cultivation of sexual abuse, misogyny and poor mental health are among some of the startling accusations made against this industry.[1,3,4] Given that 84% of Australian males and 23% of females ages 16-25 use this media daily or weekly,[5] if these accusations hold water, they may have significant and widespread impacts.

Due to this debate, researchers have attempted to draw direct comparisons between those with suspected Compulsive Pornography Use and those with addiction to substances where the disorder is better defined and established (e.g. alcohol). One of the hallmarks of a substance use disorder is an increased desire for a substance without proportional pleasure from its use.[6] On fMRI neuroimaging this can be visualised as decreased striatal responsiveness to dopamine as the brain becomes tolerant to its effects.[9] Very similar findings have been found in patients with suspected pornography addiction. Their desire for this media far exceeds the pleasurable effects it has on them[10] and fMRI changes resemble those in patients with other substance use disorders.[11] Studies have found reduced grey matter volume in the right caudate and dampened putamen activation in those who compulsively use pornography.[12] These patients are also likely to have escalating levels of pornography usage, which supports the theory that a tolerance to pornography can develop.[13] A predominant counter to these findings is that reduced striatal volume is a precondition for, not a result of increased pornography use.[12] This model argues that people with naturally lowered striatal volume require additional stimuli for dopaminergic responses. They are therefore more likely to consume large amounts of pornography. With this model, those with decreased striatal volume should be able to achieve the full pleasurable effects of pornography, even if more of it is needed.[12] However, there does not seem to be this expected positive dose-effect relationship between pornography use and pleasure.

[10] Additionally, laboratory fMRI studies have shown that repeated viewing of sexual images can cause a down-regulation of the brain’s reward pathways.[14] This suggests pornography can play an active role in down-regulating the striatum. The dose-response relationship of this finding is yet to be established, and it remains unclear whether these findings are exclusive to high-volume users or those with other risk factors for addiction.

Gender roles and sexual behaviour Another charge made against pornography is its potential to promote misogynistic attitudes and behaviours, particularly in males. In a review of 135

studies on the topic, it was found that sexualised media, of which pornography was included, was directly associated with “sexist beliefs … and greater tolerance of sexual violence toward women” in males.

[15] This media may play a role in cultivating views that support female objectification, patriarchal ideologies and permissiveness towards female harassment.

[1] This association is greatest when pornography is accessed during early adolescence (12-14 years).

[16] Longitudinal research in this area is lacking, therefore these findings may simply suggest that people with these views consume greater amounts of pornography as it reaffirms their beliefs. Additionally, if pornography is to have a role in promoting sexist attitudes, the extent to which these opinions go on to influence interactions with others is unclear and difficult to determine.

The research attempting to establish the impact of pornography on sexual encounters is highly conflicted.

A prevalent thought is that the violence depicted in its material desensitises viewers to sexual assault, increasing their propensity to commit sexual crimes.

[17] This view is supported by findings that porn can increase acceptance of rape and sexual assault in males.[3,18] This influence on sexual violence seems to be greatest and perhaps limited to males with other risk factors for sexually aggressive behaviour.

[1] These include: a history of family violence, a cultural upbringing promoting male dominance and toughness, attitudes accepting of violence and impersonal views of sex.[19] Pornography use in these high-risk individuals has been associated with an increased prevalence of forced vaginal, oral and digital penetration, sexually aggressive remarks and sex with animals.[1] This research challenges the argument of a cathartic role for pornography – that its usage can reduce the prevalence of sexual crimes committed in males as these sexual impulses are somewhat acted upon through pornography usage.

The active role of pornography usage in promoting sexual assault is well-established in people with other risk factors for sexual assault, however, the causal link between pornography and sexual assault in most users is less strongly established and highly debated.[20] Therefore, pornography may play a role in fostering and validating attitudes that predispose some men to rape women, however, it may have little to no impact in males with no other risk factors for sexually aggressive behaviour.[1] There are many 15

barriers to research into this question, not least the underreporting of sexual assault and the ubiquitous nature of this media.

While pornography may have a limited role in promoting sexually aggressive behaviour in most men, lowered libido and erectile dysfunction are widespread in pornography users.[21] In a study of adolescent males, 16% of those who consumed pornography more than once weekly reported low sexual desire, compared to 0% of those who did not.[22] Other sexual performance problems associated with pornography use include difficulty orgasming, decreased enjoyment of sexual intimacy, less sexual and relationship satisfaction and a preference for pornography over a sexual partner.

[23] Erectile dysfunction is also strongly associated with pornography use and when present, often occurs during intimate sexual relationships, but not to sexually explicit material.[10] Males who use pornography to stimulate sexual desire likely partially account for these findings. However, cessation of pornography use has on numerous accounts been recorded as an effective treatment for patients with sexual dysfunction, suggesting it does also play a causal role in this condition.[24,25] One longitudinal study has also found that pornography usage has a statistically significant role in predicting poor marital quality. Pornography usage was found not only to be a product of martial dissatisfaction, but a causal factor for such dissatisfaction. This media was the second greatest predictor of poor marital quality in the study, following only marital quality at the commencement of the study. These effects increase with frequency of pornography use and seemed to only apply to husbands who use pornography and not to wives.

[26] Mental health With our society’s increasing interest in mental health, pornography’s impact in this area is being heavily researched. Pornography usage is strongly associated with mental health disorders, loneliness, poor self-esteem and reduced quality of life.

[5,27,28,29] An Australian study of 914 adolescents found that those who reported mental health problems in the last 6 months were 52% more likely to watch pornography at least once weekly

than those who did not.[5] Masturbation to internet pornography has also been strongly associated with dissatisfaction in offline life and feelings of poor social support.[29] Pornography may play a causal role in this relationship, but equally, it may be a means by which adolescents aim to aid feelings of loneliness. Exploring the causal nature of this relationship, a study published earlier this year found that intentional exposure to pornography in adolescence was a predictive factor for depression and low self-esteem in later life.[30] On the other hand, a longitudinal study has also found that low self-esteem and depressive feelings in adolescent males are predictive of compulsive pornography use.[31] The extent to which poor mental health and pornography encourage each other is unclear. The increasing ubiquity of this media makes controlled longitudinal trials in this field difficult to conduct.

Additional research exploring the therapeutic benefits of pornography cessation in patients with mental health disorders would be of great clinical benefit.

Conclusion While much of the research exploring the health impacts of pornography is still inconclusive, there is still substantial and warranted concern surrounding this media. This field would greatly benefit from additional longitudinal studies which further clarify the causal role of pornography in promoting the health issues addressed above. The prolific use of this media does serve as a barrier to controlled studies in this field, but also stresses the need for further research, given the extensive clinical implications such findings may have. Additionally, this industry has transformed substantially this century with the proliferation of the internet, and the full impacts of this may yet be apparent.

Acknowledgements Koshy Matthew & Tim Hanna.

Conflicts of interest None declared.

Correspondence bpeters7@myune.edu.au

An Australian study of 914 adolescents found that those who reported mental health problems in the last 6 months were 52% more likely to watch pornography at least once weekly than those who did not.[5] 16

References

1. Owens E, Behun R, Manning J, Reid R. The Impact of Internet Pornography on Adolescents: A Review of the Research. Sexual Addiction & Compulsivity. 2012;19(1-2):99-122.

2. Papadopoulos L. Sexualisation of Young People [Internet].

Home Office; 2010 p. 45. Available from: http://webarchive. nationalarchives.gov.uk/20100408115835/http://www. homeoffice.gov.uk/documents/Sexualisation-young-people.html 3. Allen M, Emmers T, Gebhardt L, Giery M. Exposure to Pornography and Acceptance of Rape Myths. Journal of Communication. 1995;45(1):5-26.

4. Weaver J, Weaver S, Mays D, Hopkins G, Kannenberg W, McBride D. Mental and Physical Health Indicators and Sexually Explicit Media Use Behavior by Adults. The Journal of Sexual Medicine. 2011;8(3):764-772.

5. Lim M, Agius P, Carrotte E, Vella A, Hellard M. Young Australians’ use of pornography and associations with sexual risk behaviours. Australian and New Zealand Journal of Public Health.

2017;41(4):438-443.

6. Love T, Laier C, Brand M, Hatch L, Hajela R. Neuroscience of Internet Pornography Addiction: A Review and Update. Behavioral Sciences. 2015;5(3):388-433.

7. Doornwaard S, van den Eijnden R, Baams L, Vanwesenbeeck I, ter Bogt T. Lower Psychological Well-Being and Excessive Sexual Interest Predict Symptoms of Compulsive Use of Sexually Explicit Internet Material Among Adolescent Boys. Journal of Youth and Adolescence. 2015;45(1):73-84.

8. David L. Your Brain on Porn - It’s NOT Addictive [Internet].

Psychology Today. 2013 [cited 27 August 2018]. Available from: https://www.psychologytoday.com/au/blog/women-whostray/201307/your-brain-porn-its-not-addictive 9. Allen M, Emmers T, Gebhardt L, Giery M. Exposure to Pornography and Acceptance of Rape Myths. Journal of Communication. 1995;45(1):5-26.

10. Voon V, Mole T, Banca P, Porter L, Morris L, Mitchell S et al. Neural Correlates of Sexual Cue Reactivity in Individuals with and without Compulsive Sexual Behaviours. PLoS ONE. 2014;9(7):e102419.

11. Volkow N, Koob G, McLellan A. Neurobiologic Advances from the Brain Disease Model of Addiction. New England Journal of Medicine. 2016;374(4):363-371.

12. Kühn S, Gallinat J. Brain Structure and Functional Connectivity Associated With Pornography Consumption. JAMA Psychiatry. 2014;71(7):827.

13. 4th International Conference on Behavioral Addictions February 20–22, 2017 Haifa, Israel. Journal of Behavioral Addictions.

2017;6(Supplement 1):1-74.

14. Banca P, Morris L, Mitchell S, Harrison N, Potenza M, Voon V. Novelty, conditioning and attentional bias to sexual rewards.

Journal of Psychiatric Research. 2016;72:91-101.

15. Ward L. Media and Sexualization: State of Empirical Research, 1995–2015. The Journal of Sex Research. 2016;53(45):560-577.

16. Brown J, L’Engle K. X-Rated Sexual Attitudes and Behaviours Associated With U.S. Early Adolescents’ Exposure to Sexually Explicit Media. Journal of Geriatric Psychiatry and Neurology.

2009;36(1):129-151.

17. The Concerning Connection Between Sex Crimes And Porn [Internet]. Fight the New Drug. 2018 [cited 29 June 2018]. Available from: https://fightthenewdrug.org/the-disturbing-link-betweenporn-and-sex-crimes/ 18. Flood M. Youth and Pornography in Australia [Internet].

Canberra: The Australia Institute; 2003. Available from: https:// eprints.qut.edu.au/103421/1/__qut.edu.au_Documents_ StaffHome_StaffGroupR%24_rogersjm_Desktop_M%20Flood_ AAA%20PDF%20but%20public%20-%20Copies_Flood%20 Hamilton%2C%20Youth%20and%20pornography%20in%20 Australia%2003.pdf 19. Malamuth, N., & Huppin, M. (2005). Pornography and teenagers: The importance of individual differences. Adolescent Medicine, 16, 315–326.

20. Ferguson C, Hartley R. The pleasure is momentary… the expense damnable?. Aggression and Violent Behavior.

2009;14(5):323-329.

21. Park B, Wilson G, Berger J, Christman M, Reina B, Bishop F et al. Is Internet Pornography Causing Sexual Dysfunctions? A Review with Clinical Reports. Behavioral Sciences. 2016;6(3):17.

22. Pizzol D, Bertoldo A, Foresta C. Adolescents and web porn: a

new era of sexuality. International Journal of Adolescent Medicine and Health. 2015;0(0).

23. Park B, Wilson G, Berger J, Christman M, Reina B, Bishop F et al. Is Internet Pornography Causing Sexual Dysfunctions? A Review with Clinical Reports. Behavioral Sciences. 2016;6(3):17.

24. Doidge N. The Brain That Changes Itself: Stories of Personal Triumph from the Fontiers of Brain Science. 1st ed. New York: Penguin Books; 2007.

25. Porto R. Habitudes masturbatoires et dysfonctions sexuelles masculines. Sexologies. 2016;25(4):160-165.

26. Perry S. Does Viewing Pornography Reduce Marital Quality Over Time? Evidence from Longitudinal Data. Archives of Sexual Behavior. 2016;46(2):549-559.

27. Leppink E, Chamberlain S, Redden S, Grant J. Problematic sexual behavior in young adults: Associations across clinical, behavioral, and neurocognitive variables. Psychiatry Research.

2016;246:230-235.

28. Yoder V, Virden T, Amin K. Internet Pornography and Loneliness: An Association?. Sexual Addiction & Compulsivity.

2005;12(1):19-44.

29. Boies S, Cooper A, Osborne C. Variations in Internet-Related Problems and Psychosocial Functioning in Online Sexual Activities: Implications for Social and Sexual Development of Young Adults.

CyberPsychology & Behavior. 2004;7(2):207-230.

30. Ma C. Relationships between Exposure to Online Pornography, Psychological Well-Being and Sexual Permissiveness among Hong Kong Chinese Adolescents: a Three-Wave Longitudinal Study. Applied Research in Quality of Life. 2018;.

31. Doornwaard S, van den Eijnden R, Baams L, Vanwesenbeeck I, ter Bogt T. Lower Psychological Well-Being and Excessive Sexual Interest Predict Symptoms of Compulsive Use of Sexually Explicit Internet Material Among Adolescent Boys. Journal of Youth and Adolescence. 2015;45(1):73-84.

17

Improving interactions between transgender and other gender-diverse persons and the healthcare system Review article Meredith Grey & Imogen Janus

“

Meredith Grey is a third year medical student at the University of Sydney. She studied public health in her undergraduate degree, and maintains a strong interest in health justice.

Imogen Janus is a third year medical student at the University of Sydney who is passionate about gender-diversity within medicine. She is hopeful for future cultural change within medicine that will benefit people of all sexes, genders, and sexualities.

Abstract Background: Individuals who do not identify with the normative gender identities experience differences in access and treatment in the healthcare system as compared with their gender-binary counterparts, both as patients and professionals. These disparities are hard to quantify due to a paucity of specific and appropriate research to date.

Aims: To identify and explore the main barriers faced by gender-diverse individuals in accessing appropriate healthcare, and by gender-diverse healthcare professionals in entering the health workforce.

Methods: We reviewed the interactions between gender-diverse individuals and healthcare systems by searching key databases including Google Scholar, EMBASE, and PubMed, as well as grey literature from selected research bodies and peak community organisations. Search terms included: transgender, transsexual, gender-diverse, gender dysphoria, health, healthcare, mental health, sex, and gender.

Results: Many large studies looking at gender-diverse healthcare do so under umbrella terms like LGBTQI, and lack specific information about our target population. Some smaller international studies and anecdotal reports highlight areas of focus for future research. From the available literature, it appears that the primary barriers to care are a lack of knowledge about and erasure of the genderdiverse experience, subsequent discrimination, inadequate and inappropriate healthcare, and a consequent strained relationship between gender-diverse people and the mainstream healthcare system.

Conclusions: Gender-diverse people experience barriers to healthcare at the individual, institutional and societal level due to obvious challenges like discrimination and lack of understanding, and more insidious issues like erasure, bureaucratic and financial barriers. Assessing the scope of these factors with robust research and taking pragmatic steps towards increasing visibility, education and societal support will go a long way to changing the healthcare landscape and the experience of genderdiverse people within it.

Introduction Individuals that do not identify with the normative gender expectations set by society often suffer significant negative health disparities when compared with their binary counterparts. These disparities are often hard to identify and quantify due to a paucity of evidence specific to these individuals.

This article reviews current interactions between gender-diverse individuals and healthcare systems

�

with reference to the available literature. The article explores barriers faced by gender-diverse patients, as well as gender-diverse healthcare professionals in forming a part of the health workforce. We conclude that the primary barrier is a lack of knowledge about the gender-diverse experience, which leads to discrimination, inadequate or even inappropriate healthcare, and a consequent withdrawal from the mainstream healthcare system. Structural factors such as the binary description of gender used by medical systems leads to a lack of visibility of these

18

individuals, both within healthcare organisations and research. Further, for healthcare professionals, there are actual or perceived potential professional ramifications of expressing their gender-identity. We propose that the identification and understanding of these barriers will assist healthcare workers and organisations in Australia to begin to address these disparities.

Terminology

needs can and do differ within sub-groups – for example, transgender men and transgender women have different experiences within the healthcare system and different specific needs as patients, which can be overlooked when considering the health of transgender people more broadly.

Recently, however, smaller-scale surveys and data have been emerging parsing out health and wellbeing outcomes specifically for gender-diverse people. This research suggests that health outcomes are poorer among trans-identifying people than the wider population, as well ‘In Australia, there as other groups that are part of have not yet been any the LGBTQI community. Patientreported health outcomes such national population- as in Private Lives 2, a 2012 based data collected health survey of more than 3,000 gay, lesbian, bisexual regarding gender and transgender Australians, identity.

Currently demonstrated that transgender men and women reported lower the Australian levels of general health than both Bureau of Statistics the national average, and than cis-gendered gay, lesbian and is reviewing its Sex bisexual respondents.[4] Specific Standard, which disparities faced by genderdiverse people include reduced currently codes only engagement with cervical ‘male’ and ‘female’ in cancer screening programs and increased rates of smoking and the census, but as yet associated diseases.[5,6]

To accurately and respectfully interact with issues about gender and healthcare, it is important to use terminology that is appropriate and specific. Here we outline the terminology most pertinent to this article. Cisgender refers to people whose gender identity is the same as the sex they were assigned at birth. In this paper, the choice to use the term ‘genderdiverse’ encompasses any and all gender identities outside the cisgender ‘male’ and ‘female’. This encompasses transgender people, who often identify as ‘male’ or ‘female’, but whose gender differs from the sex they were assigned at birth, as well as intersex, gender nonbinary and gender-queer people whose gender identity may not fall within the categorical binary. These definitions are not absolute nor comprehensive, and we acknowledge that gender terminology no new policies have is an evolving and dynamic field. For Mental health is a particular a more comprehensive explanation of been outlined.[2]’ area of disparity, with both different terms used when regarding transgender men and women sex and gender, we recommend the averaging scores of 23.2 on University of Technology, Sydney’s LGBTIQ+ glossary: the Kessler Psychological Distress Scale, indicating Physical Sex, Sexuality, Gender Identity and Gender high psychological stress,[7] with more than half of Expression.[1] gender-diverse people experiencing a diagnosis of depression in their adult lifetime.[6] Suicidality is of Gender-diverse patients and the healthcare particular concern, with transgender people 12 times system more likely to contemplate and 11 times more likely to commit suicide than the general population in Understanding the unique needs of Australia’s Australia.[7] As well as high rates of depression and gender-diverse community is a major public anxiety, transgender individuals also report higher health challenge. This is due to the lack of research than average rates of other psychiatric conditions, specifically aimed at addressing the health needs of with 23.4% of transgender men reporting such this community, the exclusion of non-binary gender conditions, compared to 3.2% of cis-gendered men. identities in research and policy, and the conflation [4] With this in mind, it is still difficult to confidently of sex, gender and sexuality in the data collected. quantify the particular health challenges faced by In Australia, there have not yet been any national gender-diverse populations, as these conclusions population-based data collected regarding gender come from small studies and/or studies looking more identity. Currently the Australian Bureau of Statistics broadly at LGBTQI groups. is reviewing its Sex Standard, which currently codes only ‘male’ and ‘female’ in the census, but as yet There are a myriad of factors contributing to no new policies have been outlined.[2] Studies that the healthcare disparities experienced by genderdo look at health outcomes for gender-diverse diverse populations, and these issues range from people often do so as part of umbrella-terms, such interpersonal challenges between patient and as LGBTQI, encompassing various gender identities, practitioner, to hospital and institutional practices, sexual orientations and sexual behaviours,[3] which policies and structures and finally political and can fail to identify unique issues affecting these societal context. It is important to note, as found diverse subgroups. Finally, health priorities and in research conducted by the Australian Research 19

Centre in Sex, Health and Society between 2007 and 2014, that the poorer health outcomes experienced by gender-diverse people in Australia are due to these contextual factors like stigma and access, and are not due to anything inherent to this identity.[6] In the 2011 National Transgender Discrimination Survey of more than 6000 transgender people in the United States, large numbers of respondents reported experiencing violence, harassment, and discrimination when seeking medical care, with 23% being denied care altogether.[8] These negative interactions reportedly lead to individuals postponing or avoiding medical care.[8] Healthcare providers are also lacking in both understanding the transgender experience and delivering quality care to gender-diverse people due to a lack of basic knowledge in these areas. This begins with a failure to understand the continuums of and differences between sex, gender, and sexuality, and the tendency to conflate and confuse these terms. It also relates to the lack of education surrounding the specific healthcare needs of genderdiverse people, including gender-affirming therapies and their side effects, sexual health, and fertility.

The National Transgender Discrimination Survey found that half of respondents reported having to teach their healthcare providers about transgender health.[8] While some specialties such as General Practice have higher reported rates of positive clinical experiences for gender-diverse people, stigma and misunderstanding is present even among those professions that are most likely to be involved in providing care to gender-diverse people,

including psychiatrists, gynaecologists and paediatric endocrinologists.[9–11] There are also socio-political structures that create barriers to healthcare access at an institutional level.[6] Many of the healthcare disparities faced by gender-diverse people in this setting relate to their lack of visibility. Simply, most healthcare organisations collect patient data about sex or gender - often used interchangeably - as a binary of ‘male’ or ‘female’.

This method excludes those who do not identify within the binary, while simultaneously rendering transgender experience invisible, as it fails to capture the difference between an individual’s sex-at-birth and current gender identity. The purported aim of collecting this information is two-fold: to identify the sex-specific healthcare needs of a person, for example, the likelihood of pregnancy, and to provide gender-appropriate interactions, for example, the appropriate use of pronouns. However, the method of presenting patients as either ‘male’ or ‘female’ fails to serve either of these aims in relation to genderdiverse people.[12] In this binary system, transgender, intersex and other gender-diverse people are effectively invisible, a process termed ‘erasure’.[13] The erasure that exists in health data collection is mirrored in many bureaucratic contexts, which themselves contribute to the substantial barrier to care that gender-diverse people face. For example, a large survey in the United States in 2015 found that only 11% of gender-diverse respondents had their accurate name and gender on all their official identity documents, with reasons for not changing their 20

legal name including financial capacity and lack of procedural knowledge.[14] In Australia, most states and territories have significant barriers to correcting gender markers on official documentation such as being unmarried or having had surgery to alter their reproductive organs.[6] If individuals are provided avenues to change or correct their gender marker within their medical record, these processes can be insensitive, often requiring intrusive forms of ‘proof’, and imposing significant administrative burden and psychological distress on people seeking to do so.[6] It is important to note that the inconsistent and inappropriate use of gender markers extends beyond clinical practice. This erasure exists across all levels of data-gathering and makes collecting and locating data about the health and wellbeing of genderdiverse people difficult, which in turn makes it hard to identify areas of need and action. Both demographic information and data regarding cause and effects of outcomes are necessary to create an evidence-based approach to the healthcare of gender-diverse people.

Indeed, standardised tools have been created for use at various levels from population to individual clinic,[15] but large-scale implementation of these standards are still required to fill gaps that exist in our knowledge of both specific health challenges for gender-diverse people and appropriate strategies to address them. [15] If and when basic issues of visibility can be overcome, gender-diverse people face real pragmatic barriers to care in the form of governmental regulations and priorities. For example, the financial burdens placed on transgender people seeking gender-affirming therapies not currently funded by public or private health insurance. In recent years, there have been proposed changes to governmental policy in an attempt to address systemic barriers that gender-diverse people face in the healthcare system. Access to many Medicare and Pharmaceutical Benefits Scheme (PBS)-subsidised items are dependent on patients’ Medicare gender classification (either ‘male’ or ‘female’), making access to certain procedures and medications difficult for gender-diverse people. 6,000 such procedures and treatments were proposed to be modified to remove gender-dependent classifications, for example, making cervical cancer screening available to anyone with a cervix, as opposed to people whose marker is ‘female’.[6] As of 2014, only 15 of the particular Medical Benefits Scheme billing codes had been changed.[6] Furthermore, some gender-affirming management options are still classified as cosmetic procedures and as such are not covered by Medicare.

These policy-related issues contribute both to the significant barriers gender-diverse people face generally in accessing care both for their well being, and those faced by transgender people seeking specific transition-related care.[6] The Australian Medical Association (AMA) recognises transgender, intersex and gender-

diverse people as a priority population in sexual and reproductive health.[16] Their 2014 policy document on sexual and reproductive health stresses the importance of reducing stigma in the healthcare setting, encouraging access to gender affirming procedures and medications, and improving data collection and research to identify gaps and improve the experience that gender-diverse people have with our healthcare system.[16] Similarly, the Australian Medical Student Association (AMSA) released a policy statement in 2016, echoing the sentiment of the AMA document, as well as outlining specific recommendations for government bodies, medical schools and student societies to promote LGBTQI health and wellbeing.

[17] As well as presenting recommendations for the provision of more competent healthcare to genderdiverse patients, AMSA’s policy guidelines address changing the professional culture and the roles that medical schools and student societies play.

The document calls on medical schools to promote visibility of LGBTQI health with integrated, accurate and destigmatised curricula, as well as inviting the participation of LGBTQI health care providers and community members to be involved in teaching and curriculum building. It also highlights the role of student societies in protecting and promoting the interests of LGBTQI students as well as raising the quality of teaching around gender and sexuality.[17] Gender-diverse healthcare professionals While only a small amount of research is available regarding gender-diverse patients, there is an even greater paucity of data regarding gender-diverse healthcare providers. However, with personal accounts of gender-diverse people who have chosen to write about their experience as medical students and doctors, as well as some small studies and reports of gender-diverse groups in the health workforce, we can begin to build a picture of gender-diversity among healthcare professionals.

Barriers for gender-diverse people in the healthcare workforce can emerge early, as evidenced by recent studies looking at how gender and sexuality is addressed and taught in medical schools.

A 2015 survey conducted at Stanford Medical School investigated the experience of LGBT-related education by both LGBT and non-LGBT medical students. One quarter of LGBT students and 8% of non-LGBT students found the quality of their teaching surrounding LGBT issues to be ‘very poor’, and the discrepancy between these numbers highlights that the LGBT students did not feel their experience was represented appropriately.[18] Jai NicAllen, a British medical student wrote of their experience as a transperson in medical school in an article for the Student British Medical Journal, noting challenges including factually inaccurate information about gender and health, and a generalised lack of knowledge among peers and teachers.[19] Furthermore, while the majority of medical schools provided at least 3 hours

21

of teaching on sexuality broadly, it is difficult to know what and how gender is included in these curricula, and many reported little to no information about gender-diversity in their teaching.[20] The potential result of the educational failures suggested by these studies is a medical workforce that lacks the confidence and capacity for caring appropriately for gender-diverse patients, but it also fosters an unwelcoming environment for genderdiverse medical students and professionals. With fear of discrimination from medical schools and residency programs being the two most common reasons among medical students for choosing not to disclose gender-diverse gender identity or sexuality, the failures of medical schools surrounding genderdiversity teaching carry on into the workplace with ongoing stigma and professional consequences for gender-diverse doctors.[18] In the absence of formalised information and support for genderdiverse students and young doctors, informal peer spaces like student forums and chat rooms provide some of the only reliable and confidential aid in navigating educational and career-related decisions.

Most LGBT physicians continue to work in settings where they are invisible”

The data available about gender-diverse doctors and other healthcare providers paint a similar picture of deficits and discrimination. A 2011 report put it powerfully: “most LGBT physicians continue to work in settings where they are invisible”.[20] Robust policies surrounding gender-related issues in the workplace including harassment and reporting, pronoun use, dress codes, appropriate facilities, and general employee education surrounding gender identity are becoming more common and exist in various guidelines.[21–23] However, there is little adoption or creation of such guidelines in the healthcare employment setting, and many genderdiverse physicians are not even aware of their workplace policies regarding gender and sexuality both for patients and employees, with 28% of respondents in the 2011 study noting they did not know whether their employer’s non-discrimination policy included gender identity at all.[20] Rates of harassment and ostracisation of LGBT physicians based on gender identity and sexuality have shown improvement over the last 20 years, but still sit at 15% and 20% respectively in one reported study.

[20] These discriminatory experiences can be at the hands of peers and bosses, but also patients, with a 2007 national study in the United States reporting that 30% of responders would change healthcare providers upon learning theirs identified as LGBT. [24] Finally, when considering reporting instances of

discrimination, gender-diverse healthcare workers also have to consider how their identity and the perception of it by their superiors could affect their careers, for example regarding exclusion from promotions or other opportunities.[20] Conclusions The lack of large scale and robust data representing experiences of gender-diverse people in the Australian health system speaks to their lack of visibility, acceptance and representation within the healthcare system both as patients and professionals.

Furthermore, the data and perspectives that are available highlight that the erasure and inappropriate treatment of gender-diverse people in healthcare is not uncommon, nor is it uncommon knowledge.

The challenges that affect both the health outcomes of gender-diverse people and their experience in the healthcare industry are due to barriers that exist at several levels. Individual factors in patient-carer interactions including prejudice and lack of awareness or confidence negatively influence gender-diverse people’s access to and engagement with healthcare professionals. Institutional factors such as the binary description of gender used by medical systems leads to a lack of visibility of gender-diverse individuals, both within healthcare organisations and research.

Policy and structural considerations including governmental focus, financial subsidies and public policy define the context in which gender-diverse people exist and interact with the healthcare system.

Finally, for healthcare professionals, there are real workplace ramifications of expressing their genderidentity, as well as associated fear or anxiety of doing so. We propose that the identification and understanding of these barriers will assist healthcare workers and organisations in Australia to begin to address these disparities.

Despite the perspectives of our large professional bodies, as well as the growing body of data, anecdotal experiences of gender-diverse people and the availability of guidelines, templates and recommendations both for gender-diverse patient care and employee relations, healthcare institutions in Australia are slow to change. In this case, the resources are available, and many of the necessary steps outlined in the relevant guidelines are simple, inexpensive and quick to implement on an institutional level. Reevaluating policy, practice and attitudes relating to gender-diverse patients and employees, and creating institution and industrywide practical standards emphasising visibility, education and appropriate structural supports for gender-diverse people is possible and overdue.

Abbreviations LGBTQI: Different studies referred to in this paper use different umbrella or categorical terms such as LGBT, LGBTQI and GLBT. With this in mind, inconsistencies in the use of these terms may exist 22

in this review and are reflective of the terms used in the specific studies or papers referenced.

Acknowledgements This work is part of a larger research project done on behalf of Level Medicine, an organisation working towards gender equity in medicine.

If you have feedback about the contents of this article or think that there are any particular actions Level Medicine can take to improve the experience of transgender and other genderdiverse people within the healthcare system, please contact the corresponding author.

Photo credits Daniel Watson, accessed from https://unsplash. com/photos/IEtUye-b28A Conflicts of interest The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, beyond an affiliation with Level Medicine.

Correspondence mgre7512@uni.sydney.edu.a References

1. LGBTIQ+ Terminology [Internet]. University of Technology Sydney. [cited 2018 Sep 24]. Available from: https://www.uts. edu.au/partners-and-community/initiatives/social-justice-uts/ equity-and-diversity-uts/gender-sexuality-1 2. Review of the Sex Standard [Internet]. Australian Bureau of Statistics. 2014 [cited 2018 Mar 13]. Available from: http://www.abs.gov.au/websitedbs/D3310114.nsf/home/ Review+of+the+Sex+Standard 3. Morris S. Snapshot of Mental Health and Suicide Prevention Statistics for LGBTI People and Communities. National LGBTI Health Alliance; 2016 Jul. 4. Leonard W, Pitts M, Mitchell A, Lyons A, Smith A, Patel S, et al. Private Lives 2: The second national survey of the health and wellbeing of gay, lesbian, bisexual and transgender (GLBT) Australians. 2012; Available from: http://arrow.latrobe.edu. au:8080/vital/access/manager/Repository/latrobe:35653 5. Cochran SD, Björkenstam C, Mays VM. Sexual Orientation and All-Cause Mortality Among US Adults Aged 18 to 59 Years, 2001-2011. Am J Public Health. 2016 May;106(5):918–20.

6. Department of Health & Human Services, Government of Victoria. Transgender and Gender Diverse Health and Wellbeing.

Government of Victoria; 2014.

7. The Statistics At a Glance: The Mental Health of Lesbian, Gay, Bisexual, Transgender and Intersex People in Australia National LGBTI Health Alliance | National LGBTI Health Alliance [Internet]. National LGBTI Health Alliance. [cited 2018 Sep 7].

Available from: https://lgbtihealth.org.au/statistics/ 8. Grant JM, Mottet L, Tanis JE, Harrison J. Injustice at every turn: A report of the national transgender discrimination survey.

2011; 9. Vance SR Jr, Halpern-Felsher BL, Rosenthal SM. Health care providers’ comfort with and barriers to care of transgender youth. J Adolesc Health. 2015 Feb;56(2):251–3.

10. Unger CA. Care of the transgender patient: a survey of gynecologists’ current knowledge and practice. J Womens Health . 2015 Feb;24(2):114–8.

11. Riggs DW, Coleman K, Due C. Healthcare experiences of gender diverse Australians: a mixed-methods, self-report survey.

BMC Public Health. 2014 Mar 6;14:230.

12. Bauer GR, Hammond R, Travers R, Kaay M, Hohenadel KM, Boyce M. “I Don’t Think This Is Theoretical; This Is Our Lives”: How Erasure Impacts Health Care for Transgender People. J Assoc Nurses AIDS Care. 2009 Sep 1;20(5):348–61.

13. Namaste V. Invisible Lives: The Erasure of Transsexual and Transgendered People. University of Chicago Press; 2000. 340 p.

14. James SE, Herman J. The Report of the 2015 US Transgender Survey: Executive Summary. National Center for Transgender Equality; 2017.

15. Reisner SL, Deutsch MB, Bhasin S, Bockting W, Brown GR, Feldman J, et al. Advancing methods for US transgender health research. Curr Opin Endocrinol Diabetes Obes. 2016 Apr;23(2):198–207.

16. Position Statement Reproductive Health And Reproductive Technology [Internet]. Australian Medical Association; 2005.

Available from: https://ama.com.au/sites/default/files/ documents/Position_Satement_on_Reproductive_Health_And_ Reproductive_Technology_1998_revised_2005.pdf 17. Policy Document: Lesbian, Gay, Bisexual, Transgender, Intersex, and Queer (LGBTIQ) Health Policy [Internet]. Australian Medical Students’ Association; 2016. Available from: https://www. amsa.org.au/sites/amsa.org.au/files/LGBTIQ%20Health%20 %282016%29.pdf 18. Stanford University School of Medicine Lesbian, Gay, Bisexual, and Transgender Medical Education Research Group.

Lesbian, Gay, Bisexual, and Transgender Medical Student Experiences: “Out” in Medical School and Perspectives on Curricular Content [Internet]. 2015. Available from: https://myhs. ucdmc.ucdavis.edu/documents/41620/0/ 19. NicAllen J. The reality of being transgender in medicine.

Student BMJ [Internet]. 2016;23. Available from: http://student. bmj.com/student/view-article.html?id=sbmj.h6648 20. Eliason MJ, Dibble SL, Robertson PA. Lesbian, gay, bisexual, and transgender (LGBT) physicians’ experiences in the workplace. J Homosex. 2011;58(10):1355–71.

21. Managing Gender Transition in the Workplace [Internet]. Society for Human Resource Management. june 5 2007 [cited 2018 Jul 29]. Available from: https://www.shrm. org/resourcesandtools/tools-and-samples/toolkits/pages/ managinggendertransitionintheworkplace.aspx 22. Guideline: Transgender people at work: Complying with the Equal Opportunity Act 2010 in employment [Internet]. Victorian Equal Opportunity and Human Rights Commission. 2013 [cited 2018 Jul 29]. Available from: https:// www.humanrightscommission.vic.gov.au/our-resources-andpublications/eoa-practice-guidelines/item/632-guidelinetransgender-people-at-work-complying-with-the-equalopportunity-act-2010 23. Model Transgender Employment Policy: Negotiating for Inclusive Workplaces [Internet]. Transgender Law Centre; 2013.

Available from: https://transgenderlawcenter.org/wp-content/ uploads/2013/12/model-workplace-employment-policyUpdated.pdf 24. Lee RS, Melhado TV, Chacko KM, White KJ, Huebschmann AG, Crane LA. The dilemma of disclosure: patient perspectives on gay and lesbian providers. J Gen Intern Med. 2008 Feb;23(2):142– 7.

23

The public perception of major depressive disorder in South Asia: a literature review Review article

Marisse Sonido

“

Marisse Sonido is currently a 4th year medical student at the University of New South Wales. She is both an aspiring doctor and writer and has recently discovered, much to her excitement, that the two are not mutually exclusive.

Abstract Aims: To understand: the perception of depression as an illness in South Asia and the language used to describe it, its perceived aetiology, how individuals with depression are perceived by the community and the beliefs in the community surrounding the treatment of depression.

Methods: Articles were found through a database search of MedLine, PSYCINFO, and GoogleScholar.

They were included if they discussed depression within the context of a South Asian culture.

Results: Depression is widely understood in South Asia as a disease with primarily somatic presentations stemming from stresses associated with difficult socioeconomic circumstances. Those with depression are often stigmatised but they are generally not excluded from the community. Alongside medical intervention, assistance from family and the community are the most accepted methods of addressing depression.

Conclusions: South Asian perceptions of depression accord with a psychosocial model of illness.

Incorporating these perceptions is essential to the success of interventions and educational programs hoping to resonate with a general population and improve communication with health professionals.

Introduction Depression, suffered by more than 300 million people worldwide, represents the single greatest contributor to global non-fatal health loss.[1, 2, 3] Its impacts are not limited to the Western world. While developed countries draw much of the research focus, the South Asian prevalence of depression was calculated at 26.3% based on primary care presentations.[1] In India in 2004 it accounted for a greater number of disability adjusted life years per 100,000 people than both cancer and diabetes mellitus combined.[1] Depression is particularly under-recognised and undertreated in rural areas.[4] The presentations, sequelae and understandings of depression are known to depend on culture, a relationship maintained in the South Asian context.

[5, 6, 7, 8] Existing research highlights significant differences between developed and developing world perspectives on the disease—the extent to which depression is seen as somatic, the role of socioeconomic factors in its aetiology and

�

community responsibilities in addressing it.[4] The strict biomedical conception of depression favoured by some health professionals may translate poorly across cultures and pose obstacles to improving recognition, treatment and education.[9]

This paper aims to discuss general perceptions of depression in developing countries in South Asia.

It will identify community views on: (1) depression as an illness, including the way it is described and presents; (2) its aetiology; (3) opinions about individuals with depression; and (4) beliefs about treatment. In synthesising the trends and repeating themes revealed by research, it hopes to provide a foundation for tailoring clinical and public health interventions to a South Asian cultural context.

Methods Articles were found through a database search of MedLine, PSYCINFO, and GoogleScholar using the following keywords and MESH terms: Mental Disorders OR Depression; Developing Countries OR

24

Asia OR Afghanistan OR India OR Sri Lanka OR Nepal OR Bhutan OR Maldives OR Pakistan; and Stigma, Public Perception, Understanding, OR Health Literacy.

Studies were excluded if they were not published English language articles relating to depression in South Asian cultures.

Results Relevant studies were found about samples in India (n = 3), Pakistan (n = 1), Afghanistan (n = 1), Bangladesh (n = 1) and Sri Lanka (n = 1). The Afghan sample reflected a migrant Afghan population. No depression-specific articles were found about the Maldives, Bhutan and Nepal.

Understanding of depression as a disease Participants generally professed a poor medical understanding of depression and other mental illnesses. Many in the Liu et al. study (42.77%) could not answer what the word ‘depression’ meant to them.[4] In the Indian state of Maharashtra, 87.5% of community members did not acknowledge depression as a real medical illness.[10] However, participant groups frequently employed locally appropriate terminology when presented with a depression case study or vignette. Bangladeshi respondents referred to chinta rog or “worry illness”.

[5] The Dari language speaks of asfurgdadi, the low mood and grief associated with hardships.[11] Using tailored vocabulary greatly improved communication between researchers and participants.[5]

A number of participants attributed depression to religious, supernatural or spiritual factors. A vignette about a woman with depression in Liu et al.’s study prompted participant theories about divine punishment and black magic.[4] Many raised the possibility of spiritual possession.[4] The Liu et al. study was an outlier in terms of biological explanations for aetiology— 54% of respondents linked depression to a disease of the brain and 33.8% believed it was inheritable.[4] The presentation of these options in a questionnaire, as opposed to the open-ended interviews of other studies, may have contributed to this divergence. But some of the external causative factors identified by participants, like “problems in the environment”[6] and polluted air,[4] also hint at a biological understanding of depression’s causes.

Perception of individuals with depression Expressions of stigma were common. In two of the Indian studies the majority of individuals believed depression is a sign of weakness.[4, 10] In the Kermode et al. study,[10] 40% of community members concurred that people with depression are dangerous, 52.1% said they are erratic and 42.5% believed they should be avoided. Similarly, a large minority of respondents in the Liu et al. study described those with depression as unpredictable (43.8%), hard to talk with (40.5%), and a cause of familial shame (45.1%).[4]

Both participants with depression and communities in general stressed the physical manifestations of the disease.[4, 5, 6, 9] The most commonly identified somatic symptoms associated with depression included fatigue, pain, numbness, sleeplessness, headache, breathlessness, and shaking.[5, 6, 9, 11] While several psychological symptoms were also listed,[5, 11] the physical aspects of the disease dominated and were often the main reasons to seek help.[6]

Despite this, most individuals expressed a willingness to remain the neighbours, friends and co-workers of someone with depression.[4, 10] These opinions were more likely in respondents who regarded depression as a “sign of weakness” instead of a genetic or biological disease. However, only 60.8% of participants were willing to accept someone with depression marrying into their family.[10] Bangladeshi respondents echoed these doubts about the marriage prospects of people with depression.[5]

Aetiology of depression An overwhelming majority of study participants described depression through a psychosocial understanding of its origins, emphasising the suffering individual’s social context. In rural Indian villages, depression is seen as an accumulation and escalation of grief or stress.[4] Many studies identified poverty and unemployment as major contributors to these pressures.[5, 6, 9] In Bangladesh it is believed that all tension rogs or “anxiety illnesses” are due to obhab, a (typically material) need of some kind caused by poverty.[5] Culturally specific financial stressors included an inability to provide dowry and education for all of one’s daughters.[5] Other stressors ranged from female reproductive problems and domestic violence to social inequality, injustice, and trauma.[4, 6, 9, 11] Refugees interviewed by Alemi et al. described language difficulties, family separations and cultural clashes.[11]

Understandings of treatment Most participants across the studies thought depression would be difficult—if not impossible—to remedy without assistance.[4, 10, 11] Pharmaceutical treatments were often poorly understood and warily regarded. Medication was restricted to treating the physical symptoms of depression.[9] Some participants were concerned about the addictive potential of using drugs to treat depression.[4] In Bangladesh, tablets were the option of last resort, partly due to cost.[5] Bangladeshi respondents instead prioritised poverty alleviation, good health and positive family relations.[5] Opinions of medical practitioners were generally positive. The patients in the Naeem et al. study professed a strong faith in doctors despite minimal 25

awareness of their role in depression management and limited familiarity with non-pharmacological treatments like psychotherapy.[6] Sri Lankan undergraduate students who saw depression as a mental illness had confidence in medical experts[12] and refugees in Afghanistan also expressed faith in psychiatrists.[11] Opinions about traditional and religious healing modalities were mixed across the studies. In India, some respondents reported using herbal medicine to treat depression’s somatic symptoms,[9] and participants from Afghanistan sometimes consulted a tabib or herbal specialist.[11] A minority in the Indian, Bangladeshi, and Afghan samples identified religious practices, mantras and amulets as possible remedies.[5, 9, 11] Conversely, in another study, 63% of participants doubted traditional healers could successfully remedy depression, with more enthusiasm for their effectiveness only in conjunction with medical treatment.[4] None of the participants in the Pakistan study had visited a traditional healer, though one participant did recite passages from the Quran and perform the practice of do dum (or blowing air) on themselves as a form of self-help.[6] Several studies highlighted familial or social support as a particularly popular treatment option.[4, 5, 9] Bangladeshi respondents typically approached family members and close relatives before seeking help from other sources. Many of these individuals believed a community-based program would be the ideal way to address depression.[5] Other suggested treatments included involvement in communal activities,[5, 9] internal dialogue[9] and lifestyle changes such as eating right and exercising.[11] In Alemi et al., cultural activities, such as listening to Afghan music and visiting Afghanistan, were also named.[11] Discussion

stigma efforts may have more success if framed through this understanding of the disease compared to approaches rooted in biomedicine. In Kermode et al., individuals who related depression to a personal flaw (“weakness”) or extrinsic factors (e.g., family and financial problems) were less likely to socially distance themselves from people with depression compared to those who believed in a biological cause.[10] Biology may be seen to imply a lack of agency and the possibility of hereditary transmission, both of which negatively impact marriage prospects.

This aetiological understanding of depression affects the acceptance of pharmacological interventions. While Indian respondents used pharmacological treatments for somatic symptoms, and drugs are seen as a valid last resort in Bangladesh,[5] the expense and arcane mechanisms of action of antidepressants may compromise adherence when they are prescribed. Nonpharmacological methods might be more acceptable despite remaining mostly unheard of in more rural areas. A study on university students in Pakistan, for example, found that cognitive behavioural therapy could be successful in that population provided interventions are tailored to South Asian cultural and religious values.[13] As depression is commonly attributed to external socioeconomic factors, programs addressing these wider social issues may reduce its prevalence. Studies investigating poverty alleviation as an intervention for depression have reported conflicting results in Uganda and Mexico.[14, 15] The evidence suggests depression interventions demand a multi-faceted approach.

‘... depression in South Asia is widely understood as a stress-related disease that emerges out of difficult socioeconomic circumstances and has primarily somatic manifestations.’

The reviewed literature suggests depression in South Asia is widely understood as a stress-related disease that emerges out of difficult socioeconomic circumstances and has primarily somatic manifestations. While those with depression are still subject to stigma, communal exclusion is rare.[4, 10] Familial and community assistance are the most accepted treatments for depression with medical intervention reserved for physical symptoms.

[4, 5]

South Asian respondents overwhelmingly favoured a psychosocial model of depression’s aetiology with minimal emphasis on biology.

Empathy and understanding seemed highest when causal explanations of depression were linked to relatable hardships. Education campaigns and anti-

The importance of family and the community support for individuals with depression was a motif across the reviewed studies. South Asian countries are characterised by collectivistic cultures emphasising close family ties.[16] While family and the community participation in interventions can be extremely beneficial, the isolation and interpersonal conflict associated with stigma can be especially damaging.

Communitybased interventions were the ideal approach for participants in the Selim et al. study.[5] Education campaigns targeting the family and communities around individuals with depression may be fruitful.

Limitations Due to the limited body of research on this topic as it relates to this region, not every South Asian country could be represented in this review. The included studies cannot be interpreted as reflecting universally 26

held beliefs within their respective countries. The review also only included English-language studies, narrowing its scope further and perhaps excluding significant contributions from local research. It is possible participants were reluctant to openly share their traditional and religious beliefs with medical professionals or as part of a scientific study, resulting in their underrepresentation.[6] Conclusion This review aimed to present a general overview of how depression is perceived in the developing countries of South Asia. Considering these synthesised findings may help shape future public health efforts seeking greater success in improving education about depression and its treatment and prevention—in South Asia, and potentially in other developing countries where depression is similarly understood.

study in Sri Lanka. BMC Psychiatry. 2015;15(1):269.

13. Naeem F, Gobbi M, Ayub M, Kingdon D. University students’ views about compatibility of cognitive behaviour therapy (CBT) with their personal, social and religious values (a study from Pakistan). Ment Health Relig Cult. 2009;12(8):847–55.

14. Ozer EJ, Fernald LCH, Weber A, Flynn EP, VanderWeele TJ. Does alleviating poverty affect mothers’ depressive symptoms?

A quasi-experimental investigation of Mexico’s Oportunidades programme. Int J Epidemiol. 2011;40(6):1565–76.

15. Green EP, Blattman C, Jamison J, Annan J. Does poverty alleviation decrease depression symptoms in post-conflict settings? A cluster-randomized trial of microenterprise assistance in Northern Uganda. Glob Ment Health. 2016;3:e7.

16. Chadda RK, Deb KS. Indian family systems, collectivistic society and psychotherapy. Indian J Psychiatry. 2013;55(Suppl 2):S299–S309.

Acknowledgments None Conflicts of Interest None declared Correspondence marisse.sonido@gmail.com References

1. Reddy R. Depression: the disorder and the burden. Indian J Psychol Med. 2010;32(1):1–2.

2. World Health Organisation. Depression: World Health Organisation; 2018 [cited 2018 Aug 16]. Available from: http:// www.who.int/news-room/fact-sheets/detail/depression 3. World Health Organisation. Depression and other common mental disorders: global health estimates [Internet]. Geneva: World Health Organisation; 2017 [cited 2018 Aug 16]. Available from: http://apps.who.int/iris/bitstream/handle/10665/254610/ WHO-MSD-MER-2017.2-eng.pdf?sequence=1 4. Liu MC, Tirth S, Appasani R, Shah S, Katz CL. Knowledge and attitudes toward depression among community members in rural Gujarat, India. J Nerv Ment Dis. 2014;202(11):813–21.

5. Selim N. Cultural dimensions of depression in Bangladesh: a qualitative study in two villages of Matlab. J Health, Popul Nutr.

2010;28(1):95–106.

6. Naeem F, Ayub M, Kingdon D, Gobbi M. Views of depressed patients in Pakistan concerning their illness, its causes, and treatments. Qual Health Res. 2012;22(8):1083–93.

7. Kleinman A. Anthropology and psychiatry: the role of culture in cross-cultural research on illness. Br J Psychiatry.

1987;151(4):447–54.

8. McClelland A, Khanam S, Furnham A. Cultural and age differences in beliefs about depression: British Bangladeshis vs.

British Whites. Ment Health Relig Cult. 2014;17(3):225–38.

9. Pereira B, Andrew G, Pednekar S, Pai R, Pelto P, Patel V. The explanatory models of depression in low income countries: listening to women in India. J Affect Disord. 2007;102(1):209–18.

10. Kermode M, Bowen K, Arole S, Pathare S, Jorm AF. Attitudes to people with mental disorders: a mental health literacy survey in a rural area of Maharashtra, India. Soc Psychiatry Psychiatr Epidemiol. 2009;44(12):1087–96.

11. Alemi Q, Weller SC, Montgomery S, James S. Afghan refugee explanatory models of depression: exploring core cultural beliefs and gender variations. Med Anthropol Q. 2017;31(2):177–97.

12. Amarasuriya SD, Jorm AF, Reavley NJ. Quantifying and predicting depression literacy of undergraduates: a cross sectional

27

Guidelines for low birth weight: a literature review comparing national guidelines in Lao PDR with WHO guidelines Review article Line M Pederson

“

Line M Pederson is an intern with the UN Refugee Agency in Copenhagen, and soon to be working as a research assistant for the Danish Statens Serum Institut in Guinea-Bissau. Her key interest and priority is to contribute to building initiatives that ensure cultural and local appropriateness in health development.

Abstract Background: In Lao PDR (LPDR), the prevalence of low birth weight (LBW) is as high as 15%. Maternal nutrition is one of the most crucial interventions in reducing the burden of LBW and its consequences including perinatal and neonatal mortality, childhood stunting and increased risk of NCDs in adulthood. Guidelines for LBW can be an important tool in prevention and care for LBW infants when adapted to local contexts.

Objectives: To compare LPDRs and WHOs availability of guidelines for LBW, covering the period from conception until 6 months postpartum, and to identify barriers for utilisation. This review also aims to determine the appropriateness of these guidelines for reducing the LBW burden and consequences.

Methods: This literature review was conducted in three steps: identification of global and local risk factors for LBW; retrieval and comparison of guidelines from WHO and Ministry of Health in LPDR involving key informants from WHO regional and WHO LPDR office; and searching for barriers and facilitators for implementation of guidelines. Databases (Pubmed, Proquest and Cochrane Library) were searched using a combination of key terms: low birth weight, guidelines, Lao PDR, risk factors, prevention and barriers.

Results: Guidelines were available and accessible by WHO and WHO LPDR office. Based on current literature, various infrastructural, cultural and financial factors contributes to guidelines often not being implemented nor accepted among health workers and mothers. Discrepancies between WHO and local guidelines may have contributed to this, including the current non-aligned cut-off for referral of LBW infants.

Conclusion: Despite guidelines being available, they were not always applied in LPDR. Inclusion of vulnerable women in LPDR guidelines were inappropriate for reducing LBW and the risk of adverse outcomes, but can be strengthened with the launch of guidelines for adolescent reproductive health.

Background This study was prompted by the persisting high prevalence of low birth weight (LBW) in Lao PDR (LPDR), which reached 15% in 2012.[1] LBW is defined as an infant weighing less than 2500g.

It is a leading cause of perinatal (22 weeks of gestation to 7 days postpartum) and neonatal (0-28 days) deaths globally.[2] It contributes to 40-60% of newborn mortality.[2] LBW is the most important criteria for determining both immediate and long-term outcomes of

�

neonates and infants. Such outcomes include chance of survival, healthy growth and freedom from morbidities including infectious and cardiovascular diseases and type 2 diabetes.[3-5] Maternal nutrition has a major impact on LBW and associated infant morbidity and mortality.

[6-8] Nutritional factors implicate biological processes, which subsequently affect the foetal and maternal physiology.[9, 10] The most important maternal risk factors[11] increasing LBW risk are; undernutrition and low BMI at

28

In Lao PDR (LPDR), the prevalence of low birth weight (LBW) is as high as 15%. Maternal nutrition is one of the most crucial interventions in reducing the burden of LBW and its consequences including perinatal and neonatal mortality, childhood stunting and increased risk of NCDs in adulthood. conception[8, 9, 12-15]; short stature[15, 16]; suboptimal gestational weight gain[11, 15, 17], deficient intake of micronutrients (iron[18, 19] and iodine[20]), maternal age (age<18[21-26], age>35[27, 28]) and certain cultural food habits and behaviours.[29-32] Maternal and paediatric nutrition researchers have found that adequate maternal pre-partum health status, immediate care of the LBW infant and exclusive breastfeeding (EBF) for 6 months comprise a set of crucial activities for reducing the burden of LBW.[33] Guidelines are important as they act as a tool for quality assurance. This seeks to improve the quality of care provided by informed healthcare workers.[34] Evidence-based and appropriate guidelines have the potential to promote beneficial interventions and discourage ineffective practice.[35] However, guidelines function in the interplay between structural factors and processes including economic, social and political environments. This may affect a guidelines’ desired effect.

Methods A Quick Scoping Review was performed to evaluate existing knowledge of LBW. This involved a rapid review of literature on LBW risk factors. Guidelines were obtained from the WHO’s website, online and through formal email correspondence with the WHO LPDR country office and WHO Western Pacific Regional office to ensure the newest updated guidelines were included.

An extensive literature search was then conducted to identify barriers for proper implementation of LBW guidelines in LPDR. Databases (Pubmed, ProQuest, Cochrane Library, Google Scholar, WHO and UNICEF) were searched using combinations of keywords including low birth weight, guidelines, barriers, attitude, beliefs, maternal health/nutrition, health services utilisation, satisfaction and quality of care.

Additional articles were identified and retrieved by reviewing references in relevant articles.

Further report materials from organisations and governments were identified manually and found online.

Only English papers published between 1990

and 2016 were included. Articles pertaining to women with co-morbidities were excluded as a separate set of guidelines exist for these mothers and newborns. Besides the WHO’s guidelines, only studies relating to LPDR were included.

Furthermore, only studies related to antenatal care (ANC), perinatal care, postnatal care (PNC) and breastfeeding (BF) practices with a focus on LBW were included. The studies were critically evaluated by looking at the study methodology, perceived objectivity, study provenance, research evidence and the contribution of the study to the literature.

The review was conducted by one author from February to June 2016 as part of a master thesis.

Subsequently, the LPDR Ministry of Health (MoH) has launched The National Adolescent and Youth Friendly Services (NAYFS) guidelines in February 2018, to strengthen the capacity for responding to the needs of adolescent mothers. No significant changes have been made in WHOs guidelines for LBW. Results Variances between WHO guidelines and national guidelines in Lao PDR Variances between WHO’s guidelines and national guidelines in LPDR are analysed to see whether LPDR follow the evidence-based guidelines proposed by WHO. As shown in table 1 below, national guidelines in LPDR are largely in agreement with WHO guidelines. However, significant disagreements still exist as highlighted in the table.

Barriers to guideline adherence in Lao PDR 1. Health sector Implementation of standard routines such as weight recording and monitoring of newborn care is low in LPDR.[1, 45-47] This poses a significant challenge for effective implementation of maternal, newborn and child health (MNCH) services as data can help inform policy makers about necessary and appropriate changes to improve access and utilisation of high quality services to achieve better maternal and LBW infant outcomes. Duysburg et al. (2014) conducted interviews with government officials, organisations and MNCH care providers in LPDR who identified several implementation barriers. This included the 29

current decentralisation of authority and responsibilities of the health sector from national to provincial, district and municipality level, as well as limited MNCH management capacity and skills which created confusion regarding roles and Table 1. Guidelines for LBW in WHO and Lao PDR WHO Guidelines[36-41] 4 ANC visits (at week: 8-12, 2426, 32, 36-38)

ANC

Perinatal care

PNC

Particular attention to vulnerable women suffering

Lao PDR[42-44]

4 ANC visits (1 per trimester, third visit ideally at 36 weeks, and 4th visit at 40 weeks/term) Maternal weight/ Maternal weight height Fetal growth (uterine height) Promoting Counselling on healthy lifestyle nutrition and diet Support on early Counselling on BF BF and EBF Skin-to-skin contact Advice on early BF Immediate identification of LBW Cut-off for Cut-off for referral referral 2000g 1500/2000g 1st visit as early 1st visit within 24 as possible hours if at home, 24 within 24 hrs if at hrs later if in facility home Care for at least 24 hrs after birth if in facility (+) 3 PNC visits (+2) PNC visits (48 - 72 hr, (within 7d + 6 7-14d, 6 weeks) weeks) Counselling on nutrition and EBF for 6 months Poverty Women/ Young age family-friendly Domestic or (respecting beliefs gender-based and provision of biolence quality care)

responsibilities in practice.[46] Inadequate facilities and equipment for MNCH care have been reported in LPDR, e.g. lack of hygiene facilities and weighing scales.[47-49] Furthermore, lack of skilled health workers[47, 48, 50] has been identified as the highest risk factor for under-5 mortality in LPDR.[48, 51] Health workers have reported poor remuneration, insufficient time, low status, weak technical supervision and training contributing to low motivation and thus, poor implementation of MNCH services.[45, 48, 49] Furthermore, guidelines do not propose

guidance in prioritising crucial components in case of lacking equipment or staff-shortages – an additional barrier of guideline adherence.

In LPDR, pre-service medical curricula fall under the Ministry of Education whereas the MoH issues inservice guidelines. Thus, national guidelines are likely to be reflected only during in-services rather than preservice training for health workers. A mixed-methods study and three qualitative studies involving mothers and MNCH care providers found a lack of awareness, understanding, availability and adherence to some key MNCH policies and guidelines.[46, 48, 49, 52] An average consultation time of only 5 min was reported.[49] This suggests that guidelines might be used minimally or incorrectly due to time constraints and/or availability. However, due to small sample sizes generalisability of results might be limited.

2. Mothers and cultural factors For most care procedures, coverage declines with lower education status’ and wealth level.[50, 53-57] This explains the lower coverage in rural areas compared to urban areas (Table 2).[1, 46, 58] Additional barriers of MNCH care utilisation in such socio-economic settings include infrastructural and financial constraints such as transport time and costs.

[46-48, 50, 54, 56, 58-62] Mothers with inadequate knowledge of healthy pregnancy practices carry an eight-fold increased risk of developing LBW infants in LPDR.[25] Reported reasons for delaying or not receiving MNCH services include a lack of time, feeling in sufficient health[56], embarrassment[56, 60], reluctance towards male nurses[47, 58, 59] and a lack of privacy during care.

[59, 63] Both mothers and health workers have also reported ethnic discrimination, possibly due to language barriers.[47, 48, 60] Other barriers for MNCH care attendance found in the literature include prolonged waiting times,[47, 56, 61] poor attitude and quality of care provided by health workers’[57, 59] and misconceptions about ANC usefulness.[56] Home births are still frequent in LPDR[50, 53, 54, 58, 61] due to the convenience of traditional practices and lower costs.[48, 58, 59] However, traditional practices can be unbeneficial and contribute to delayed or under-utilisation of MNCH services.[48, 53, 54, 62, 64] Traditions include roasting, entailing resting on a ‘hot bed’ or chair over a fire for up to 4 weeks[30, 31, 52, 61, 64], diet restrictions[29-31, 52, 61, 64], discarding colostrum[31], and complementary feeding, e.g., rice, water and porridge.[30, 31, 52, 64-69] Interestingly, influence of the husband, and female relatives[31, 48, 52, 57-60, 62, 63, 65, 70, 71] have been found as both a threat and facilitator to uptake and progress of evidence-based practices.

[48, 52, 72] However, most studies were conducted in rural areas. Adaptation to modern practices seems to be increasing and conducive for BF promotion in some rural[69, 73] and urban areas.[47, 52] This has been reinforced and facilitated by increased access to health care[30, 52, 64, 65] and skilled health workers.

30

[31, 52, 55, 65, 70] Traditionally, colostrum is discarded and formula milk, water or pre-chewed rice are instead fed the first days thus reducing early BF.[30, 31, 64-66] Though, Lee et al. (2013) found that most urban first-time mothers recognized the importance and low cost of colostrum compared to infant formula.[52] Furthermore, this could be facilitated by better access to health care.[30, 52, 64] Lack of EBF practice has been identified as the second highest risk factor for under-5 mortality in LPDR.[51] Based on national representative Lao Social Indicator Survey data, two studies found a significant association between Hmong ethnicity, EBF for 6 months[65] and higher child weight-for-height scores, all of which indicate better nourishment amongst Hmong ethnicity.

[74] On the other hand, complementary feeding before the age of 6 months is widespread and varies in introduction and diversity among ethnic groups. This is a prime factor for suboptimal infant feeding practices, contributing to stunting.

[30, 31, 64, 70, 75-77] The caregiversâ&#x20AC;&#x2122; ethnicity therefore needs to be considered in provision of nutrition/feeding counselling. A facilitating factor for EBF for 6 months could be involvement and Table 2. Coverage of interventions: early BF, EBF, ANC, skilled birth attendants, iinstitutional delivery and PNC Lao PDR Total Urban Rural Early BF (within 1hr of birth), % EBF for 6 months, % Antenatal care (>4visits), % Skilled attendant at birth, % Institutional delivery, % PNC for newborns within 2 days after delivery, %

39.1 40.4 36.9 41.5 37.5 7.4

46.7 39.2 70.6 79.6 74.2 12.6

36.9 41.0 27.2 30.7 27.0 5.9

Sourced from: Lao Social Indicator Survey 2011-2012.[1]

encouragement from the father.[70, 75] 3. Inconsistence/Confounding policies for LBW prevention and care Enforcement, monitoring and compliance with the International Code of Marketing of Breastmilk Substitutes (BMS)[78] is lacking and subsequently undermining the promotion of EBF for 6 months in LPDR,[75, 79-81] in particular, among low-literate women.[82] Frequent and common violations of the code are; BMS companies affiliating with health workers[83], biased and misleading information on labelling and systematic advertising and promotion in public hospitals and health facilities.

[70, 75, 80] Another confounding policy is the presence of 3 months paid maternity leave. In case of illness, women workers are entitled to 30 days supplementary leave whereby approximately

50% of normal pay is provided.[84] Furthermore, up until one year postpartum, women workers are entitled daily one-hour breaks to care for the child. However, some mothers have expressed a lack of workplace support as a major barrier for EBF.[52, 73] Thus, aligning current guidelines with the International Labour Organisationâ&#x20AC;&#x2122;s recommendation of 14 weeks maternity leave could be conducive for promotion of EBF for 6 months and reducing LBW morbidity and mortality.[80] Discussion As evident from this study, developing coherent guidelines and aligning strategies preventing LBW is difficult at national and international levels.

Even more challenging is implementation of such guidelines where it is most needed, i.e. in countries with high prevalence of LBW and neonatal morbidity and mortality. A study conducted in three central hospitals in LPDR suggested some improvements of LBW care through the implementation of the WHO Pocketbook of Hospital Care for Children over a 1-year period.

[85] The appropriateness of current guidelines for the prevention and management of LBW infants in LPDR will be discussed, with emphasis on areas of improvement if better coherence was present.

Appropriate cut-off for referral of LBW Different cut-offs for referral of LBW infants were found in two current WHO WPR documents: a 2000g cut-off and a 1500g cut-off in the WHO WPR Action Plan 2014-2020[39] and the WHO WPR EENC guide (2014),[86, 87] respectively.

This demonstrates disparity within a pronounced organisation. Due to low resources and poor referral functions in LPDR, a higher cut-off for referral (2000g) would not necessarily lead to a better outcome in practice. However, LPDR could consider introducing an alternative growth assessment for when scales are not available, in particular in rural areas. Measuring chest circumference was in rural India found as the best surrogate parameter for identifying LBW infants.

[88] Additionally, this could help strengthen timely referral and avoid unnecessary referrals burdening the referral centers.

Qualifying as a LBW infant might not necessarily increase risk of mortality - known as the LBW paradox.[89, 90] In LPDR, factors such as high altitude may be a risk factor for LBW, but not necessarily for mortality.[89, 90] Knowledge on the predominant distribution (weight distribution of term births) and the residual distribution (percentage of small and preterm births) are hence essential in gaining insight into the gestationalage characteristics. Such epidemiological data is necessary to provide a better basis to judge the appropriateness of cut-off values.

31

Appropriate number and timing of ANC visits Despite WHO recommending 4 ANC visits[37], the exact timing of ANC visits has been debatable.

[91] The recommendation is based on a large WHO ANC randomized trial comparing the standard model of ANC (12 visits) with the new ANC model (4 visits). No differences in maternal and perinatal outcomes were found between the two models.[92] A systematic review of studies from developed and developing countries provided similar findings where good perinatal outcomes persisted despite reduced ANC visits.[93] However, it proposed that in a setting of low ANC-coverage, visits should not be reduced without close monitoring of foetal and neonatal outcomes.[93] The recommendation of 4 ANC visits might be inappropriate for LPDR due to a lack of financial and human resources. However, the unspecified timing of ANC visits in LPDR might be appropriate, as it seems unrealistic for mothers to adhere and attend ANC at specific times due to the infrastructural and financial constraints. However, recommending the 4th visit at week 40/term might delay or miss detection and management of LBW births as 44 % of neonatal deaths are due to prematurity.[94] Conversely, reducing ANC to 3 visits could reduce maternal satisfaction with ANC which has been evident from the systematic review comparing the two ANC models.[93] Declining satisfaction can adversely influence ANC attendance and thus, the burden of LBW. A pre-requisite for appropriate ANC guidelines is improvement in the quality of resources and services at both structural levels (e.g., distribution of guidelines and human resources), and in practice (e.g., education, training and adherence to guidelines).

Otherwise, a discussion of recommending 3 or 4 visits is unreasonable.

Appropriate number and timing of PNC visits A Cochrane review conducted by Yonemoto et al (2013), found no strong evidence associating frequency and timing of home-visits with improvements in neonatal and maternal mortality.[95] However, this review found 4 studies providing evidence to suggest that home visits may encourage women to EBF. On the contrary, an association between home visits and increased maternal satisfaction with PNC was described. This suggests PNC is beneficial in alleviating the burden of LBW. Unlike the WHO, the MoH in LPDR does not recommend a PNC visit at 7-14 days. Considering the high neonatal mortality within the first week of life,[96, 97] a PNC visit at 7-14 days might be inappropriate. Furthermore, the current LPDR PNC schedule articulates well with the Expanded Programme on Immunisation.[98] However, due to the low rate of EBF and growing importance of educating mothers in feeding practices for LBW infants, a recommendation of PNC visit at 7-14 days could be appropriate. Adding a PNC visit should be considered only after evaluating availability of

resources and assessing morbidity and mortality risk after the first week of life. Thus, the focus should be on content and quality of care to facilitate optimal BF practices as opposed to increasing PNC visits, which carry costs towards the mother and society without documented benefit.

Attention to vulnerable women WHO guidelines[37] mention vulnerable women, including adolescents, as a group that needs special attention. Low maternal age (<18 years) has been found independently associated with LBW in LPDR, after adjustments for family income and education[25]. This reflects the high burden of LPDRâ&#x20AC;&#x2122;s high adolescent fertility rate[1] and young mothers. Although not included in the LPDR ANCPNC manual,[43] this is recognised in the national strategy[42]with the launch of the NAYFS guidelines.

Thus, efforts are made to ensure integration of adolescent and youth friendly services to overcome barriers in provision of MNCH care and information to young people. However, guideline implementation will require strong leadership and management support to avoid unavailability and nonadherence to guidelines in practice.

There is potential for better inclusion of traditional practices and vulnerable ethnic minorities into guidelines and modern perinatal care through culturally acceptable maternity waiting homes.

[61] However, it would demand more respect for traditional birth customs among health workers and research for appropriateness of compromising modern medical practice for non-harmful traditional practices such as birthing position, certain food restrictions and family inclusion.

Strengths and limitations of the review While based on secondary data and essential material supplied by key stakeholders, it is assumed that the retrieved materials of this review represented the current state of guidelines for LBW and its associated barriers and implementation. However, a literature review is dependent on the current state of research. The reviewed research into LBW was overall limited, especially with regards to guidelines in LPDR which sometimes display contradiction. Small sample sizes in individual studies may have further limited the validity, reliability and generalisability of this study to all areas of LPDR. Larger prospective studies of current practice and potential improvements are recommended, but with a focus on the users of current guidelines e.g. first line healthcare workers and the women â&#x20AC;&#x201C; before, during and after birth.

Persistently high rates of neonatal morbidity and mortality in LPDR call for future studies to address relatively simple questions, including the discrepancy between available guidelines regarding the threshold of referral.

Conclusions Guidelines on ANC, perinatal care, PNC and BF for

32

review suggested that structural factors including culture, infrastructure and economy appeared to be major barriers for adherence and acceptance of guidelines.

In the context of barriers and facilitators for implementation of LBW guidelines, appropriateness of LBW guidelines needs further research. However, 4 ANC visits in LPDR were found appropriate due to the risk of decreasing satisfaction and thus utilisation of ANC if reduced to 3 ANC visits. In line with recommendations by the WHO, BF and skinto-skin contact were found appropriate for LPDR given its potential to reduce the burden of LBW morbidity and mortality in low-resource settings.

A recommendation is made on implementing culturally acceptable maternity waiting homes due to strong and widespread cultural practices in LPDR. The internal institutional alignment and coherence of guidelines, particularly the cut-off for referral of LBW infants, should also be monitored to ensure hard-working healthcare workers are appropriately informed of appropriate practices and complications of nonadherence. Further studies comparing divergent WHO guidelines, local guidelines and local cultural norms and traditions are recommended for future studies.

Acknowledgments None Declarations The materials used during the current study are available from the corresponding author on reasonable request. The author declares that submissions are neither intentionally nor able to be construed as defamatory or unfairly derogatory of any persons or organisations.

Conflicts of Interest None declared Correspondence linemp89@gmail.com References

1. Ministry of Health, Lao Statistics Bureau [Internet]. Lao PDR: Lao Social Indicator Survey (LSIS) 2011-12. 2012. MoH Lao PDR and LSB [cited 2016 Mar 10]. Available from: http://lao.unfpa.org/ sites/default/files/resource-pdf/LSISReportEnglish2011-2012%20 %281%29.pdf.

2. United Nations Children’s Fund [Internet]. The state of the world’s children 2009: Maternal and Newborn Health. 2008.

UNICEF [cited 2016 Feb 4]. Available from: https://www.unicef.org/ publications/index_47127.html.

3. Edmond K, Bahl R [Internet]. Optimal feeding of low-birthweight infants: technical review. 2006. WHO [cited 2016 Feb 2].

Available from: http://www.who.int/maternal_child_adolescent/ documents/9241595094/en/.

4. Ashworth A. Effects of intrauterine growth retardation on mortality and morbidity in infants and young children. Eur J Clin Nutr. 1998;52 Suppl 1:S34-41; discussion S-2.

5. McCormick MC. The contribution of low birth weight to infant mortality and childhood morbidity. N Engl J Med. 1985;312(2):82-90.

6. Edmond KM, Kirkwood BR, Amenga-Etego S, OwusuAgyei S, Hurt LS. Effect of early infant feeding practices on

infection-specific neonatal mortality: an investigation of the causal links with observational data from rural Ghana. AM J Clin Nutr.

2007;86(4):1126-31.

7. Debes AK, Kohli A, Walker N, Edmond K, Mullany LC. Time to initiation of breastfeeding and neonatal mortality and morbidity: a systematic review. BMC Public Health. 2013;13(Suppl 3):S19-S. 8. Ahmed T, Hossain M, Sanin KI. Global Burden of Maternal and Child Undernutrition and Micronutrient Deficiencies. Ann Nutr Metab. 2012;61(Suppl. 1):8-17.

9.

Kramer MS. Determinants of low birth weight: methodological assessment and meta-analysis. Bull World Health Organ. 1987;65(5):663-737.

10. Black RE, Victora CG, Walker SP, Bhutta ZA, Christian P, de Onis M, et al. Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet 2013;382(9890):427.

11. United Nations Children’s Fund [Internet]. Low Birthweight: Country, regional and global estimates. 2004. UNICEF [cited 2016 Feb 2]. Available from: https://www.unicef.org/publications/ index_24840.html.

12. Han Z, Mulla S, Beyene J, Liao G, McDonald SD. Maternal underweight and the risk of preterm birth and low birth weight: a systematic review and meta-analyses. Int J Epidemiol.

2011;40(1):65-101.

13. Mavalankar DV, Gray RH, Trivedi CR. Risk factors for preterm and term low birthweight in Ahmedabad, India. Int J Epidemiol.

1992;21(2):263-72.

14. Kelly A, Kevany J, de Onis M, Shah PMAA. A WHO collaborative study of maternal anthropometry and pregnancy outcomes. Int J Gynecol Obstet. 1997;57(1):1-15.

15. Ota E, Haruna M, Suzuki M, Anh DD, Tho le H, Tam NT, et al. Maternal body mass index and gestational weight gain and their association with perinatal outcomes in Viet Nam. Bull World Health Organ. 2011;89(2):127-36.

16.

Siega-Riz AM, Adair LS. Biological determinants of pregnancy weight gain in a Filipino population. Am J Clin Nutr.

1993;57(3):365.

17. Han Z, Lutsiv O, Mulla S, Rosen A, Beyene J, McDonald SD. Low gestational weight gain and the risk of preterm birth and low birthweight: a systematic review and meta-analyses. Acta Obstet Gynecol Scand. 2011;90(9):935-54.

18. Allen LH. Anemia and iron deficiency: effects on pregnancy outcome. Am J Clin Nutr. 2000;71(5 Suppl):1280S. 19. Lassi ZS, Majeed A, Rashid S, Yakoob MY, Bhutta ZA. The interconnections between maternal and newborn health evidence and implications for policy. J Matern Fetal Neonatal Med. 2013;26 Suppl 1:3-53.

20. Black R, Allen LH, Bhutta Z, Caulfield L, de Onis M, Ezzati M, et al. Maternal and child undernutrition: global and regional exposures and health consequences. Lancet. 2008;371:243-60.

21.

Qadir M, Bhutta Z. Low Birth Weight in Developing Countries. Pediatr Adolesc Med 2009;13:148-62.

22.

Kushwaha KP, Rai AK, Rathi AK, Singh YD, Sirohi R. Pregnancies in adolescents: fetal, neonatal and maternal outcome.

Indian Pediatr. 1993;30(4):501-5.

23. Gubhaju B. Adolescent reproductive health in the Asia and Pacific Region. Asian Popul Stud 2010;156.

24. Khan A, Nasrullah FD, Jaleel R. Frequency and risk factors of low birth weight in term pregnancy. Pak J Med Sci. 2016;32(1):13842.

25. Viengsakhone L, Yoshida Y, Harun-Or-Rashid MD, Sakamoto J. Factors affecting low birth weight at four central hospitals in vientiane, Lao PDR. Nagoya J Med Sci. 2010;72(1-2):51.

26. Rah JH, Christian P, Shamim AA, Arju UT, Labrique AB, Rashid M. Pregnancy and lactation hinder growth and nutritional status of adolescent girls in rural Bangladesh. J Nutr. 2008;138(8):1505-11.

27. Nair NS, Rao RS, Chandrashekar S, Acharya D, Bhat HV. Socio-demographic and maternal determinants of low birth weight: a multivariate approach. Indian J Pediatr. 2000;67(1):9-14.

28. Rizvi SA, Hatcher J, Jehan I, Qureshi R. Maternal risk factors associated with low birth weight in Karachi: a case-control study.

East Mediterr Health J. 2007;13(6):1343.

29. Barennes H, Sengkhamyong K, Rene JP, Phimmasane M. Beriberi (thiamine deficiency) and high infant mortality in northern Laos. PLoS Negl Trop Dis. 2015;9(3):e0003581.

30.

Barennes H, Simmala C, Odermatt P, Thaybouavone T, Vallee J, Martinez-Ussel B, et al. Postpartum traditions and nutrition practices among urban Lao women and their infants in

33

Vientiane, Lao PDR. Eur J Clin Nutr. 2009;63(3):323-31.

31.

Holmes W, Hoy D, Lockley A, Thammavongxay K, Bounnaphol S, Xeuatvongsa A, et al. Influences on maternal and child nutrition in the highlands of the northern Lao PDR. Asia Pac J Clin Nutr. 2007;16(3):537-45.

32. Klainin P, Arthur DG. Postpartum depression in Asian cultures: a literature review. Int J Nurs Stud. 2009;46(10):1355-73.

33. Bhutta ZA, Das JK, Rizvi A, Gaffey MF, Walker N, Horton S, et al. Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost? Lancet.

2013;382(9890):452-77.

34. Scott GW. Guidelines are essential for quality assurance in practice. Can Med Assoc J. 1990;143(6):473-4.

35. Grimshaw JM, Russell IT. Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations.

Lancet. 1993;342(8883):1317-22.

36. Villar J, Bjergsjø P. WHO Antenatal Care Randomized Trial: Manual for the Implementation of the New Model. World Health Organ, Department of Reproductive Health and Research. 2002.

37.

World Health Organization [Internet]. Standards for Maternal and Neonatal Care. 2007. WHO [cited 2016 Feb 12]. Available from: http://www.who.int/reproductivehealth/ publications/maternal_perinatal_health/a91272/en/.

38.

World Health Organization [Internet].

WHO recommendations on newborn health: guidelines approved by the WHO Guidelines Review Committee. 2017. WHO [cited 2017 Mar 16]. Available from: http://apps.who.int/iris/bitstream/ handle/10665/259269/WHO-MCA-17.07-eng.

39.

World Health Organization Western Pacific Region [Internet]. Action plan for healthy newborn infants in the Western Pacific Region (2014–2020). 2014. WHO [cited 2016 Feb 4].

Available from: http://www.wpro.who.int/child_adolescent_health/ documents/regional_action_plan_newborn/en/.

40. World Health Organization [Internet]. Guidelines on optimal feeding of low birth-weight infants in low- and middle-income countries. 2011. WHO [cited 2016 Feb 2]. Available from: http:// www.who.int/child_adolescent_health/documents/infant_feeding_ low_bw/en/.

41.

World Health Organization [Internet].

WHO recommendations on postnatal care of the mother and newborn.

2013. WHO [cited 2016 Feb 2]. Available from: http://www.who. int/maternal_child_adolescent/documents/postnatal-carerecommendations/en/.

42. Ministry of Health Lao PDR. National Strategy and Action Plan for Integrated Services on Reproductive, Maternal, Newborn and Child Health 2016-2025. 2015.

43. Ministry of Health Lao PDR. Antenatal and Postnatal care (ANC-PNC) manual.

44. Ministry of Health Lao PDR. National Nutrition Strategy to 2025 and Plan of Action 2016-2020. 2015.

45. Sychareun V, Hansana V, Phengsavanh A, Chaleunvong K, Eunyoung K, Durham J. Data verification at health centers and district health offices in Xiengkhouang and Houaphanh Provinces, Lao PDR. BMC Health Serv Res. 2014;14:255-.

46. Duysburgh E, Kerstens B, Diaz M, Fardhdiani V, Reyes KAV, Phommachanh K, et al. Newborn care in Indonesia, Lao People’s Democratic Republic and the Philippines: a comprehensive needs assessment. BMC Pediatr. 2014;14:46-.

47. Ngan DK, Kang M, Lee C, Vanphanom S. “Back to Basics” Approach for Improving Maternal Health Care Services Utilization in Lao PDR. Asia Pac J Public Health. 2016;28(3):244-52.

48. Sychareun V, Phommachanh S, Soysouvanh S, Lee C, Kang M, Oh J, et al. Provider perspectives on constraints in providing maternal, neonatal and child health services in the Lao People’s democratic republic: a qualitative study. BMC Pregnancy Childbirth.

2013;13:243.

49. Manithip C, Edin K, Sihavong A, Wahlström R, Wessel H. Poor quality of antenatal care services -Is lack of competence and support the reason? An observational and interview study in rural areas of Lao PDR. Midwifery. 2013;29(3):195-202.

50. Scopaz A, Eckermann L, Clarke M. Maternal health in Lao PDR: repositioning the goal posts. J Asia Pac Econ. 2011;16(4):597611.

51. United Nations Children’s Fund. Progress for Children: A child Survival Report Card. New York: UNICEF. 2004;vol. 1.

52. Lee HMH, Durham J, Booth J, Sychareun V. A qualitative study on the breastfeeding experiences of first-time mothers in Vientiane, Lao PDR. BMC Pregnancy Childbirth. 2013;13:223.

53. Committee for Planning and Investment (CPI), National Statistics Centre (NSC) [Internet]. Lao Reproductive Health Survey

2005. 2007. Vientiane Capital: CPI [cited 2016 Apr 27]. Available from: http://lao.unfpa.org/sites/default/files/resource-pdf/ LAOREPRODUCTIVEHEALTHSURVEY.pdf.

54. Phathammavong O, Ali M, Souksavat S, Chounramany K, Kuroiwa C. Antenatal care among ethnic populations in Louang Namtha Province, Lao PDR. Southeast Asian J Trop Med Public Health. 2010;41(3):705-16.

55. Sirivong A, Silphong B, Simphaly N, Phayasane T, Bonouvong V, Schelp FP. Advantages of trained TBA and the perception of females and their experiences with reproductive health in two districts of the Luangprabang Province, Lao PDR. Southeast Asian J Trop Med Public Health. 2003;34(4):919-28.

56. Ye Y, Yoshida Y, Harun-Or-Rashid M, Sakamoto J. Factors affecting the utilization of antenatal care services among women in Kham District, Xiengkhouang province, Lao PDR. Nagoya J Med Sci. 2010;72(1-2):23-33.

57. Manithip C, Sihavong A, Edin K, Wahlstrom R, Wessel H. Factors Associated with Antenatal Care Utilization Among Rural Women in Lao People’s Democratic Republic. Matern Child Health J 2011;15(8):1356-62.

58. Alvesson HM, Lindeiow M, Khanthaphat B, Laflamme L. Changes in pregnancy and childbirth practices in remote areas in Lao PDR within two generations of women: implications for maternity services. Reprod Health Matters 2013;21(42).

59.

Sychareun V, Hansana V, Somphet V, Xayavong S, Phengsavanh A, Popenoe R. Reasons rural Laotians choose home deliveries over delivery at health facilities: a qualitative study. BMC Pregnancy Childbirth. 2012;12(1):1-10.

60. Alvesson HM, Lindelow M, Khanthaphat B, Laflamme L. Coping with uncertainty during healthcare-seeking in Lao PDR. BMC Int Health Hum Rights. 2013;13.

61. Eckermann E, Deodato G. Maternity waiting homes in Southern Lao PDR: The unique ‘silk home’. J Obstet Gynaecol Res. 2008;34(5):767-75.

62. Lamxay V, de Boer HJ, Björk L. Traditions and plant use during pregnancy, childbirth and postpartum recovery by the Kry ethnic group in Lao PDR. J Ethnobiol Ethnomed. 2011;7(1):1-16.

63. Khammany P, Yoshida Y, Sarker MA, Touy C, Reyer JA, Hamajima N. Delivery care satisfaction at government hospitals in xiengkhuang province under the maternal and child health strategy in lao pdr. Nagoya J Med Sci. 2015;77(1-2):69-79.

64. de Sa J, Bouttasing N, Sampson L, Perks C, Osrin D, Prost A. Identifying priorities to improve maternal and child nutrition among the Khmu ethnic group, Laos: a formative study. Matern Child Nutr. 2013;9(4):452-66.

65.

Kounnavong S., S. Pak-Gorstein, K. Akkhavong, U. Palaniappan, V. Berdaga, J. Conkle, et al. Key Determinants of Optimal Breastfeeding Practices in Laos. Food Nutr Sci. 2013;Vol. 4 (No. 10A):pp. 61-70.

66. Food and Agriculture Organization of the United Nations [Internet]. FAO Nutrition Country Laos. 2003. FAO [cited 2016 Apr 26]. Available from: http://www.fao.org/tempref/AG/agn/ nutrition/ncp/lao.pdf.

67. Food and Agriculture Organization of the United Nations [Internet]. Laos ‐ Food and Nutrition Security Profiles. 2014. FAO [cited 2016 Apr 26]. Available from: http://www.fao.org/fileadmin/ templates/rap/files/nutrition_profiles/DI_Profile_-_Lao_People_s_ Democratic_Republic_160914.pdf.

68. Dibley MJ, Senarath U, Agho KE. Infant and young child feeding indicators across nine East and Southeast Asian countries: an analysis of National Survey Data 2000-2005. Public Health Nutr.

2010;13(9):1296-303.

69.

Coghlan B, Toole MJ, Chanlivong N, Kounnavong S, Vongsaiya K, Renzaho A. The impact on child wasting of a capacity building project implemented by community and district health staff in rural Lao PDR. Asia Pac J Clin Nutr. 2014;23(1):105-11.

70. Putthakeo P, Ali M, Ito C, Vilayhong P, Kuroiwa C. Factors influencing breastfeeding in children less than 2 years of age in Lao PDR. J Paediatr Child Health. 2009;45(9):487-92.

71. Manithip C. Quality and utilisation of antenatal care services in rural Lao PDR. [Thesis]. Stockholm, Sweden: Karolinska Institutet; 2012.

72. World Bank. Grandmothers Promote Maternal and Child Health: the Role of Indigenous Knowledge Systems’ Managers.

Washington, DC: World Bank. 2006.

73. Gillespie A, Creed-Kanashiro H, Sirivongsa D, Sayakoummane D, Galloway R [Internet]. Consulting with caregivers: using formative research to improve maternal and newborn care and infant and young child feeding in the Lao People’s Democratic Republic. 2004. HNP discussion paper. Washington DC: World

34

Bank. Available from: http://documents.worldbank.org/curated/ en/2004/10/5271938/consulting-caregivers-using-formativeresearch-improve-maternal-newborn-care-infant-young-childfeeding-lao-peoples-democratic-republic.

74.

Kamiya Y. Socioeconomic Determinants of Nutritional Status of Children in Lao PDR: Effects of Household and Community Factors. J Health Popul Nutr. 2011;29(4):339-48.

75.

Barennes H, Empis G, Quang TD, Sengkhamyong K, Phasavath P, Harimanana A, et al. Breast-Milk Substitutes: A New Old-Threat for Breastfeeding Policy in Developing Countries. A Case Study in a Traditionally High Breastfeeding Country. PLoS ONE. 2012;7(2):e30634.

76.

Food And Nutrition Technical Assistance III Project [Internet]. Nutrition Profile: Lao PDR. 2014. FANTA. Available from: http://www.fantaproject.org/sites/default/files/download/LaosNutrition-Profile-Apr2014.pdf.

77.

Barennes H, Simmala C, Odermatt P, Thaybouavone T, Vallee J, Martinez-Ussel B, et al. Postpartum traditions and nutrition practices among urban Lao women and their infants in Vientiane, Lao PDR. Eur J Clin Nutr. 2007;63(3):323-31.

78.

World Health Organization. Code of marketing of breastmilk substitutes. Board of directors of the Ambulatory Pediatric Association. Pediatrics. 1981;68:432-4.

79. Slesak G, SFE Medical Project, P. Douangdala, S. Inthalad, B. Onekeo, S. Somsavad, et al. Misuse of coffee creamer as a breast milk substitute: a lethal case revealing high use in an ethnic minority village in Northern Laos. BMJ. 2008;337:a1379.

80. International Baby Food Action Network [Internet]. Report on the situtation of infant and yung child feeding in Lao Peoples Democratic Republic. 2011. IBFAN [cited 2016 Mar 2]. Available from: http://www.ibfan.org/art/IBFAN-56_LaoPDR2011.pdf.

81. Barennes H, Andriatahina T, Latthaphasavang V, Anderson M, Srour LM. Misperceptions and Misuse of Bear Brand Coffee Creamer as Infant Food: National Cross Sectional Survey of Consumers and Paediatricians in Laos. BMJ. 2008;337(7671):67981.

82. Barennes H, Slesak G, Goyet S, Aaron P, Srour LM. Enforcing the International Code of Marketing of Breast-milk Substitutes for Better Promotion of Exclusive Breastfeeding: Can Lessons Be Learned? J Hum Lact. 2016;32(1):20-7.

83.

Barennes H, Sayavong E, Vilivong K, Rajaonarivo C [Internet]. Investigation into violations of the International Code of Marketing of Breastmilk Substitutes in Lao PDR. 2012. [cited 2016 Mar 26]. Available from: http://archive.babymilkaction.org/ pdfs/UNICEF_Lao_report_8April2013.pdf.

84. International Labour Office [Internet]. Maternity at work: A review of national legislation. 2010. ILO: Conditions of Work and Employment Branch - Second edition [cited 2016 May 20]. Available from: http://www.ilo.org/wcmsp5/groups/public/---dgreports/--dcomm/---publ/documents/publication/wcms_124442.pdf.

85. Zigrida GA, Douangdao S, Bandith S, Trevor D. Implementing WHO hospital guidelines improves quality of paediatric care in central hospitals in Lao PDR. Trop Med Int Health. 2015;20(4):48492.

86.

World Health Organization Western Pacific Region [Internet]. Early Essential Newborn Care: Clinical Practice Pocket Guide. 2014. WHO [cited 2016 Feb 15]. Available from: http://iris. wpro.who.int/handle/10665.1/10798.

87. Obara H, Sobel H. Quality maternal and newborn care to ensure a healthy start for every newborn in the World Health Organization Western Pacific Region. BJOG. 2014;121 Suppl 4:1549.

88. Ahmed M, Colaco S, Ali M, Ahmad Z. Birth weight status of newborn and its relationship with other anthropometric parameters. Int J Med Sci Public Health. 2014;3(1):1-6.

89. Wilcox AJ. On the importance—and the unimportance— of birthweight. Int J Epidemiol. 2001;30(6):1233-41.

90. Cogswell ME, Yip R. The influence of fetal and maternal factors on the distribution of birthweight. Semin Perinatol.

1995;19(3):222-40.

91. Carroli G, Villar J, Piaggio G, Khan-Neelofur D, Gülmezoglu M, Mugford M, et al. WHO systematic review of randomised controlled trials of routine antenatal care. Lancet. 2001;357(9268):1565-70.

92. Villar J, Ba’aqeel H, Piaggio G, Lumbiganon P, Belizán JM, Farnot U, et al. WHO antenatal care randomised trial for the evaluation of a new model of routine antenatal care. Lancet.

2001;357(9268):1551-64.

93. Villar J, Carroli G, Khan-Neelofur D, Piaggio G, Gulmezoglu M. Patterns of routine antenatal care for low-risk pregnancy.

Cochrane Database Syst Rev. 2001(4).

94.

World Health Organization Western Pacific Region [Internet]. Neonatal and child health country profile: Lao PDR. 2012. WHO WPR. 95. Yonemoto N, Dowswell T, Nagai S, Mori R. Schedules for home visits in the early postpartum period. Cochrane Database Syst Rev 2013.

96. World Health Organization [Internet]. Newborns: reducing mortality. 2017. WHO [cited 2017 Jan 18]. Available from: http:// www.who.int/mediacentre/factsheets/fs333/en/.

97. Jehan I, Harris H, Salat S, Zeb A, Mobeen N, Pasha O, et al. Neonatal mortality, risk factors and causes: a prospective population-based cohort study in urban Pakistan. Bull World Health Organ. 2009;87(2):130-8.

98.

World Health Organization [Internet]. Immunization, Vaccines and Biologicals: Table 2 - Recommended Routine Immunizations for Children. WHO [cited 2016 Apr 26]. Available from: http://www.who.int/immunization/policy/Immunization_ routine_table2.pdf?ua=1.

35

The experience of Mekelle University in provision of comprehensive healthcare interventions at STI clinics for female sex workers in Ethiopia Review article Tesfay Gebregzabher Gebrehiwot Additonal authors: Dejen Yemane, Zerihun Abebe, Solomon Gmariam, Yemane Ashebir, Afework Mebrat, Alemayehu Mekonen & Loko Abrham

â&#x20AC;&#x153;

Dr. Gebregzabher Gebrehiwot has been working as a nurse and non physician clinician. Additionally working in the zonal health department, district health office and regional health bureau in the health system organization, Dr Gebregzabher Gebrehiwot is currently working as Head of Public Health at Mekelle University.

Abstract Background: Evidence suggests that the presence of untreated sexually transmitted infections (STIs) increases the chance of human immunodeficiency virus (HIV) transmission during unprotected sex.

In the Ethiopian context, many female sex workers live in poor conditions in rented slums and are not typically known or recognised by local authorities, making them unable to access health facilities.

Methods: Data were obtained from a register of female sex workers recorded for purpose of service provision at confidential STI clinics in Mekelle and Adigrat, Ethiopia, from May 2010 to August 2015 and from May 2011 to August 2015, respectively. A simple descriptive analysis of services delivered to patients was performed.

Results: Among the 6288 patients included in this study, the prevalence of STIs was 23.4%. Of these, 12.9% (814/6288) of patients presented with vaginal discharge, 7.9% (490/6288) with genital ulcers and 2.3% (158/6288) with lower abdominal pain (as per the World Health Organisation (WHO) syndromic approach to STIs). Moreover, 180 cases of genital ulcer were tested for syphilis with the Venereal Disease Research Laboratory (VDRL) test; 36 (20%) tested positive for active infection. The HIV prevalence declined from 10% in 2010 to 1.1% in 2015. The frequency of STIs amongst repeat patients was considerably lower than that in new presentations.

â&#x20AC;?

Conclusions: Clinic and workplace geography, hours of clinic operation, confidentiality and peer outreach are important factors in the prevention and control of STI/HIV infection in key female sex worker populations. A comprehensive clinic intervention enhances early diagnosis and treatment of STIs and increases the proportion of female sex workers accessing HIV treatment services.

Introduction Sexually transmitted infections (STIs) are among the most common causes of illness in the world, and have far-reaching health, social, and economic consequences.[1, 2] STIs affect the health and social wellbeing of women by compromising their reproductive potential, with women of reproductive age and adolescents most affected. Women often feel uncomfortable discussing issues regarding sexuality, potentially resulting in further disempowerment in developing countries. STIs create a significant health and economic burden, especially for developing countries, where they account for

17% of economic losses caused by ill-health.[3, 4]

Management of STIs in many developing countries has been complicated by the lack of simple and affordable diagnostic tests. STIs often exist without symptoms; for example, up to 70% of women with gonococcal and/or chlamydial infections may be asymptomatic.[5, 6] human immunodeficiency virus (HIV) remains one of the most important STIs in developing countries, in part due to high prevalence and associated social, economic, and health burdens. It is wellestablished that the concomitant presence of non-HIV STIs increases the transmission of

36

HIV during unprotected sex.[5-8] Therefore, effective prevention messages, treatment for concomitant STIs, and promotion of condoms in such populations can have a substantial impact on HIV transmission.[8-10] STIs and the Ethiopian context STIs remain a major public health threat in Ethiopia, with most cases affecting adolescents and young adults.[11, 12] Indeed, STIs are grossly underreported in Ethiopia, largely because these infections have traditionally been stigmatised, many infections are asymptomatic and diagnostic and treatment facilities are scarce. As a result, many patients with STIs seek treatment in various settings, including traditional healers, pharmacists, and informal drug-vendors and marketplaces, none of which report cases to the Ministry of Health. As with many countries internationally, STIs in Ethiopia have become a more complex issue in recent years, in part reflecting changing attitudes with respect to risk behaviours.[13, 14] Not only has prostitution become more open and widespread, but increasing poverty, postponement of marriage, urbanisation, socio-cultural change, and increasing youth unemployment have contributed to earlier and often unprotected sex.

[7, 8, 11, 15-17] Rationale for the intervention Female sex workers (FSWs) are particularly vulnerable to the changing sociocultural environment in Ethiopia, due to ongoing stigmatisation, economic disadvantage, and a high rate of sexual partner turnover. Consequently, FSWs pose a high risk of transmitting these infections to their clients and other sexual partners.[18] Although some reports indicate that condom use by FSWs with paying clients has increased in recent years, there remains concern that condom use with non-paying partners is low.[19, 20] This is a serious gap in sexual health practices: non-paying partners can transmit HIV and other STIs from FSWs to the general population. Furthermore, the number of FSWs in regional towns has increased. As a result, the average age of FSWs has shifted towards younger women, with a consequent decrease in understanding and implementation of safe sexual practices.[19, 21-24] The majority of FSWs live in poor conditions in rented slums, with limited access to services.

Even if they have access to health facilities, they cannot afford to pay bills for drugs and diagnostic services.[25-27] Improving access to STI clinics in such areas can mitigate the socioeconomic barriers faced by FSWs, thus increasing capacity to treat STIs and prevent HIV transmission.[28, 29] To address gaps in sexual health services

in these communities, the College of Health Sciences at Mekelle University has entered into a cooperative agreement with the Centers for Disease Control and Prevention (CDC) Ethiopia/ Atlanta from 2009 to 2014.[30] The purpose of this paper is to evaluate the outcome of a comprehensive STI/HIV prevention and treatment service, and to quantify STI/HIV cases in FSWs visiting the confidential clinics in Adigrat and Mekelle.

Methods Data were collected from a register of FSWs recorded for purpose of service provision at confidential STI clinics in Mekelle and Adigrat, Ethiopia, from May 2010 to August 2015 and from May 2011 to August 2015, respectively.

Following consultation with authorities at the Tigray Regional Health Bureau, the first confidential STI clinic was established in Mekelle in May 2010, functioning under the College of Health Sciences, Mekelle University. The second STI clinic was established in Adigrat town, where a high number of FSWs reside, due to its proximity to the Eritrean border and consequent military population.

Typically, a client visiting the clinic is evaluated according to her presenting complaint for common STI syndromes, as per the WHO syndromic approach to STIs. The syndromic approach reduces the requirement for costly and time-intensive diagnostic procedures by assigning probabilistic STI diagnoses to patients presenting with specific symptoms in the context of high-risk behaviours. In particular, the syndromes evaluated in this paper include vaginal discharge syndrome (gonorrhoea/chlamydia, and other genitourinary pathogens), genital ulcer syndrome (syphilis), and lower abdominal pain (presumed pelvic inflammatory disease).

Using this approach, patients receive treatment according to the pathogens of greatest concern, as listed above.

Owning to the unique nature of the clinic, there is no sign for the confidential STI clinic; FSWs visit the clinic only through peer referrals made by specifically trained peer promoters who are FSWs themselves. More than 250 trained FSWs educate their peers on STIs/HIV and refer cases for treatment and care to the clinic. Importantly, when needed, clients are routinely provided with a range of contraceptive options including condoms, targeted health education and antibiotics, all free of charge.

Follow up appointments and consultations with a dermato-venerologist are also made when necessary for cases that require continuation of care. Regulatory checks of equipment, drugs and laboratory resources have been performed to ensure standards of care are maintained, and 37

ongoing review is enabled by fortnightly meetings.

Data retrieval and analysis Data pertaining to consultations and service provision were obtained from a registration book in the confidential STI clinic. New and repeat clients were tabulated separately and categorised based on the type of services provided. Thereafter, data were recorded in an Excel sheet and a simple descriptive analysis was performed. Data are presented as frequency (percentage) unless otherwise stated.

This study received ethics approval from the Mekelle University College of Health Sciences Ethics Committee (approval number ERC0027/2011), who waived the necessity for written informed consent given the nature of the data presented.

Results STI statistics - Mekelle The Mekelle STI clinic provided sexual health services to 2549 new clients during the 5-year study period (2010-2015), of which 889 (34.9%) were diagnosed with and treated for an STI. As per the WHO syndromic approach to STIs, the most common diagnosis was vaginal discharge syndrome (n = 445, 50.1%). Genital ulcers were noted in 381 women (42.9%). Relatively few women were diagnosed with lower abdominal pain (n = 63, 7.1%). Of note, throughout the 5-year study period, only 15 repeat clients presented with STI infection, suggesting that the preventative practices promoted by the service and peer workers were effective.

In the first year at Mekelle clinic, a total of 891 new FSWs were examined from May 2010 to August 2011, of which 302 (33.9%) were diagnosed with and treated for an STI (Table 1). Most women were in the 15-29 age group (n = 710, 79.7%). Of the 302 cases with an STI, 122 manifested with 1 of the 3 STI syndromes: genital ulcer, 56 (45.9%); vaginal discharge, 54 (44.2%); and lower abdominal pain, 12 (9.8%).

Moreover, 180 cases were tested for syphilis with the Venereal Disease Research Laboratory (VDRL) test, of

which 36 (20%) tested positive for active infection.

The remaining cases were managed empirically as per the WHO syndromic approach. Unfortunately, the true prevalence of active syphilis could not be accurately assessed, due to a lack of VDRL reagents, and a consequent lack of consistent testing amongst clients. The prevalence of STIs rose significantly during the second year of the project (2011-2012), with 301 (76.9%) of all new clients screened (n = 391) found to have an STI. During the subsequent years, the prevalence of STIs ranged from 29-34.8%.

In 2014-2015, the prevalence reduced rapidly from 30% to 17%; of 468 FSWs screened, only 80 STI cases were diagnosed and treated (Table 2). The number of FSWs (new and repeat clients) visiting the Mekelle STI clinic increased considerably throughout the study period; however, the number of new clients remained relatively constant throughout the 5-year study period.

STI statistics â&#x20AC;&#x201C; Mekelle and Adigrat As discussed above, the Adigrat clinic was not established until the second year of the study. The total number of screened cases among the 2 sites was 6288, with 1462 STI cases diagnosed and treated.

The prevalence of STIs throughout the 5-year study duration at both sites was 23.4%. Based on the WHO syndromic approach, 814 (55.7%) patients were diagnosed with vaginal discharge syndrome, 490 (33.5%) with genital ulcer syndrome, and 158 (10.8%) with lower abdominal pain. Inferences regarding the distribution of causative pathogens can be made according to the WHO syndromic approach, as discussed above. Of all diagnosed STIs, vaginal discharge syndrome was present in more than half of patients.

HIV counselling and testing service From May 2010 to August 2011, of 598 women who attended the Mekelle clinic, 55.7% (n = 333) were provided HIV testing and counselling. Of FSWs recruited for opportunistic screening, 48 (14.4%) had positive HIV results. The remaining individuals declined testing; many of these women claimed that

Table 1. Trends in STI presentations to Mekelle STI clinic from May 2010-August 2011 Age

FSWs

Treated for STI

<15 15-19 20-24 25-29 30-34 35-40 40-44 >45

15 212 285 213 92 47 10 17

0 48 63 94 42 31 6 18

Total

891

302

STI syndromes

Vaginal discharge 0 6 13 21 7 5 0 2 54

Genital ulcer 0 4 11 17 8 11 1 4 56

Lower abdominal pain 0 2 1 5 1 0 0 3 12

FSWs, female sex workers; LAP, lower abdominal pain. *NB: Not all patients were diagnosed using the STI syndrome approach, therefore, discrepancies may exist in frequency tallies.

38

and to quantify the prevalence of STIs and response to education regarding preventative health activities.

The link between STI and HIV co-infection was examined, with an increased rate of HIV infection noted in those presenting for investigation of an STI syndrome, as consistent with previous literature.

the test had been performed within the previous 3 months, however, several women also refused to be tested due to the fear of stigma and discrimination associated with a positive test. On subsequent follow-up for those women who refused screening, further opportunities for screening were offered, as appropriate. All FSWs who received a positive test result for HIV were referred to higher health institutions for antiretroviral therapy (ART) and to other organisations for related services.

Establishing the clinic and peer outreach In the first 2 months following establishment of the clinic, the number of FSWs attending was minimal.

Subsequent efforts to educate peer promoters were successful in increasing the number of FSWs accessing services at the clinics. Furthermore, staff working at the clinic also played a role in disseminating key information to FSWs during outreach sessions.

During the 5-year period, different strategies were implemented to mobilise FSWs for HIV testing and counselling. Providing peer education, engaging with bar and hotel owners, conducting forums with various stakeholders, providing outreach services and opening the STI clinics on weekends were among the strategies used, with good effect.

When both clinics were included, a total of 5302 FSWs were tested for HIV over the 5-year study duration, with 181 having positive results, giving a prevalence of 3.4%; however, of those also diagnosed with an STI (n = 1462), the prevalence was 12.4% (Table 3). This suggests that concomitant STI infection is a risk factor for HIV infection. Notably, the prevalence of HIV decreased from 10% in 2010 to 1.1% in 2015 (Table 4).

Discussion

The Mekelle STI clinic provided sexual health services to 2549 new clients during the 5-year study period (2010-2015), of which 889 (34.9%) were

This study aimed to describe the experience of 2 confidential sexual health clinics in northern Ethiopia,

Table 2. Provision of STI services at Mekelle STI clinic from 2010 to 2015 Screening

Year

Total visits

2010 2011 2012 2013 2014 2015

803 4059 5691 5474 2388 1229

STI syndromes

Screened

VDS

New 500 391 710 502 446 468

New 39 148 126 53 79 52

Total 18415 2549

Rpt 303 3668 4981 4972 1942 761

15866

445

GUS

Rpt 0 2 1 1 2 0

New 60 126 68 77 50 26

6

381

Contraceptives and interventions

LAP Rpt 0 0 0 2 1 0

New 6 27 13 10 7 2

3

63

Condoms provided

Rpt 2 1 1 1 1 0

Visits 650 3468 4520 4122 3922 1548

6

Condoms 65,000 499,392 594,100 618,300 595,800 154,800

Depo OCP

Pregnancy test

111 502 791 808 1153 799

42 282 436 360 526 361

16682 2,372,592 3365

18 285 342 306 388 242

1339 1646

VDS, vaginal discharge syndrome; GUS, genital ulcer syndrome; LAP, lower abdominal pain; OCP, oral contraceptive pill; Depo, Depo-Provera contraceptive injection.

Table 3. HIV testing and STI screening at Mekelle and Adigrat clinics Screening Year

Total visits

2010 2011 2012 2013 2014 2015

803 4619 8003 7841 4494 2165

Screened

New 500 951 2373 930 814 720

Total 27925 6288

Rpt 303 3668 5630 6911 3680 1445

21637

STI syndromes

VDS

New 39 199 229 127 146 74

814

Rpt 0 2 1 1 2 2

8

GUS

New 60 135 102 92 66 35

490

Rpt 0 0 0 2 1 0

3

LAP

New 6 57 57 18 14 6

158

Rpt 2 1 1 1 1 0

6

Treated STIs New

Rpt

HIV tested New1

HIV+

650 3468 4520 4122 3922 1548

65,000 499,392 594,100 618,300 595,800 154,800

111 502 791 808 1153 799

18 285 342 306 388 242

16682

2,372,592

3365

1339

NB: 2010 refers to the Mekelle clinic alone, as Adigrat was not in operation until 2011. VDS, vaginal discharge syndrome; GUS, genital ulcer syndrome; LAP, lower abdominal pain.

1. Only new patients receiving HIV tests have been included here.

39

Table 4. HIV prevalence among female sex workers attending the STI clinics (Mekelle & Adigrat), 20102015 Year

2010 2011 2012 2013 2014 2015 Number of FSWs 200 626 1514 1200 950 tested (HCT) Positive cases 21 52 42 26 27

812 13

diagnosed with and treated for an STI. In general, the number of consultations for FSWs, particularly for repeat clients, grew throughout the study. The overall STI positivity rate among FSWs who received care at the STI clinics remained stable. Similar FSWspecific STI clinics in Uganda have reported rates of STIs approaching 70%.[31] This difference could be explained by the study setting, in particular the abovementioned clinics in Uganda were located in major commercial centres, and lacked the peer education component delivered in the Ethiopian clinics. The prevalence of STIs throughout the 5-year study duration at both sites (Mekelle and Adigrat) was 23.4%. This finding is consistent with other studies conducted among FSWs in Finote Selam (Ethiopia) and Malawi, where the prevalence of STIs were 20.6% and 25%, respectively.[18, 24] However, STI rates in Ethiopia vary considerably; for example, 47.9% of FSWs were found to have an STI in Addis Ababa.[13] Similar international FSW-specific clinics have reported much lower rates of STI positivity, such as in the Netherlands (9.5%).[32] A combined intervention focusing on peer education, voluntary and anonymous clinic attendance, condom promotion and STI testing, as administered in this study, has previously been successful in decreasing STI rates in other African countries, such as CĂ´te dâ&#x20AC;&#x2122;Ivoire and Benin,[33, 34] and internationally in India.[27, 29] HIV counselling and testing service Of all FSWs who attended the Mekelle clinic in 2010 (n = 598), 333 (55.7%) were provided HIV testing and counselling, with 48 (14.4%) returning positive HIV results. The remaining individuals declined testing.

Sex workers face stigma and discrimination in different forms; for example, it is common for FSWs to be exposed to violence and social discrimination.

FSWs are highly vulnerable to HIV due to high risk sexual behaviours; limited access to HIV prevention, diagnosis, and treatment services; high-level stigma associated with sex work; and social and economic marginalization.[13, 26, 35] Despite growing efforts to increase HIV testing and counselling services for the most at-risk populations in Ethiopia, the uptake of such services by FSWs remains poor. Previous studies in Zambia and Ethiopia have shown that lack of confidentiality is a major barrier to HIV testing.[35, 36] Over the 5-year study period at both clinics, the prevalence of HIV was 3.4%, with a concomitant STI infection rate of 12.4%. The prevalence of HIV

exhibited a marked decline from 10% in 2010 to 1.1% in 2015. This finding is lower than a previous baseline survey in Ethiopia conducted from 1989 to 1990, which reported a mean sero-prevalence of 17%.[23] The current study observed a marked decline in HIV prevalence. This is consistent with studies conducted in Adama, Ethiopia.[26] Such a decline likely reflects a number of factors, including increased accessibility to ART, but also a decline in the prevalence of STIs and condom promotion.

Lessons learned Good connection and collaboration with the community is required to mobilise services for vulnerable populations. Furthermore, maintaining confidentiality is crucial in building and maintaining rapport. Whilst traditional services are typically inaccessible for FSWs and similar vulnerable populations, the model described in this paper provides a realistic and reproducible approach to preventative health for FSWs. Collaboration with appropriate governmental and non-governmental stakeholders is required to guarantee the sustainability of such services.

Future directions After establishment of the clinics, high service demand was observed. Such demand requires mapping and census of FSWs, with the view to increase the number of confidential STI clinics in areas with the greatest need. The preliminary results observed in this study suggest that it is possible to reduce the burden of STIs and HIV by provision of targeted health interventions for vulnerable populations, using a model that is cognisant of the unique demands FSWs face. Further research is needed to both confirm the results observed in this study, and to explore aspects of stigma and discrimination faced by FSWs when seeking medical advice from traditional health providers.

Conclusion The HIV prevalence declined from 10% in 2010 to 1.1% in 2015. Compared to new cases, the frequency of STIs among repeat clients was extremely low, suggesting that the cumulative effect of peer promotion and preventative sexual health education is effective in reducing the rates of STIs among vulnerable populations. The clinic intervention enhances early diagnosis and treatment of STIs, and increases the proportion of FSWs linked with ART services. Therefore, it is reasonable to suggest that such an approach be encouraged in future models of service provision.

Author contributions TG was responsible for conception and design of the project, completing grant applications, overseeing project activities and reviewing data compilation, analysis and composition of the manuscript. DY was responsible for coordinating part of the project and involved

40

in data retrieval and manuscript composition. ZA was responsible for monitoring and evaluating as a business official, supervising data retrieval and manuscript composition. SG, YA, AM, AM, and LK contributed equally in supervision of data retrieval and manuscript composition.

Abbreviations AIDS: Acquired immunodeficiency syndrome CDC: Centers for Disease Control and Prevention FSWs: Female sex workers HIV: Human immunodeficiency virus PEPFAR: President’s Emergency Plan for AIDS Relief STIs: Sexually transmitted infections VDRL: Venereal Disease Research Laboratory WHO: World Health Organization Conflicts of interest None declared Correspondence tesfig@gmail.com Acknowledgments Provision of sexual health services as discussed in this manuscript would not have been possible without funding granted by CDC/PEPFAR; the authors wish to acknowledge the assistance of the CDC/PEPFAR in enabling this service. The authors also wish to acknowledge users of the service, in particular peer educators who have been pivotal in mobilizing beneficiaries. Further acknowledgements go to the College of Health Sciences at Mekelle University, Tigray Regional Health Bureau and all project staff members, in particular clinic staff. Finally, the authors wish to acknowledge Dr. Belete Assefa (School of Public Health, Mekelle University) for his support in editing and reviewing the manuscript.

References

1. WHO. Global health sector strategy on sexually transmitted infections 2016–2021: Towards ending STIs [Internet]. WHO Document Production Services. 2016. Available from: http://apps. who.int/ 2. Newman L, Rowley J, Hoorn SV, Wijesooriya NS, Unemo M, Low N, et al. Global estimates of the prevalence and incidence of four curable sexually transmitted infections in 2012 based on systematic review and global reporting. PLoS ONE. 2015;10(12).

3. Mayaud P, Mabey D. Approaches to the control of sexually transmitted infections in developing countries: old problems and modern challenges. Sex Transm Infect. 2004;80(3):174-82.

4 Mullick S, Watson- JD, Beksinska M, Mabey D. Sexually transmitted infections in pregnancy: prevalence, impact on pregnancy outcomes, and approach to treatment in developing countries. Brit Med Bull. 2005;81:294-302.

5. WHO. Sexually transmitted infections (STIs). Fact sheet RHR/12.31. World Health Organization; 2012.

6. Celum N Celum, Gail B, Mellisa K, Karen C, Peter L, Cora S, et al. Patients attending STD clinics in an evolving health care environment: demographics, insurance coverage, preferences for STD services, and STD morbidity. Sex Transm Dis. 1997;24(10):599605.

7. HIV/AIDS Prevention and Control Office. Multi-sectoral HIV/AIDS response: annual monitoring and evaluation report; Ethiopian Fiscal year (July 2008-June 2009). HIV/AIDS Prevention and Control Office; 2009.

8. HIV/AIDS Prevention and Control Office. National guidelines

for the management of STIs using syndromic approach. PEPFAR/ CDC; 2001.

9. Ngugi EN, Roth E, Mastin T, Nderitu MG, Yasmin S. Female sex workers in Africa: Epidemiology overview, data gaps, ways forward. SAHARA J. 2012;9(3):148-53.

10. Mayaud P, McCormick D. Interventions against sexually transmitted infections (STIs) to prevent HIV infection. Brit Med Bull. 2001;58:129–53.

11. Central Statistical Agency (CSA). Ethiopia Demographic and Health Survey 2016. Addis Ababa, Ethiopia: Ministry of Health CaI; 2016.

12. Yohannes B, Gelibo T, Tarekegn M. Prevalence and associated factors of sexually transmitted infections among students of Wolaita Sodo University, Southern Ethiopia. Int J Sci Tech Res. 2013;2(2):86-94.

13. Alem A, Kebede D, Mitike G, Enqusellase F, Lemma W. Unprotected sex, sexually transmitted infections and problem drinking among female sex workers in Ethiopia. Ethiop J Health Dev. 2006;20(2):93-8.

14. Andualem H, Anteneh K, Astehun L, Atalay N, Tafesse L. Knowledge, attitude and practice of risky sexual behavior and condom utilization among regular students of MizanTepi University, South West Ethiopia. J Child Adolesc Behav.

2015;3(5):244.

15. Policy Plan Directorate FDRoE. Health and Health Related Indicators. Ministry of Health, Ethiopia; 2010.

16. Kahsay AG, Daba F, Kelbore AG, Getachew S. Prevalence and associated factors of sexually transmitted infections based on the syndromic approach among HIV patients in ART Clinic; Ayder Referral Hospital, Northern Ethiopia. Clin Med Res. 2015;4(5):1328.

17. Tadesse G, Yakob B. Risky sexual behaviors among female youth in Tiss Abay, a Semi-urban area of the Amhara Region, Ethiopia. PLoS ONE 2015;10(3): e0119050.

18. Alamrew AZ, Amare AY, Molalign T. Sexually transmitted diseases among female commercial sex workers in Finote Selam town, northwest Ethiopia: A community-based cross-sectional study. HIV/AIDS. 2017;9:43.

19. Berhane Y. Mekonnen Y, Seyum E, Gelmon L, Wilson D. HIV/ AIDS in Ethiopia: An epidemiological synthesis. Addis Ababa: HIV/ AIDS Prevention & Control Office and Global AIDS Monitoring & Evaluation Team; 2008.

20. Tamene MM, Tessema GA, Beyera GK. Condom utilization and sexual behavior of female sex workers in Northwest Ethiopia: A cross-sectional study. Pan Afr Med J. 2015;21:50.

21. Vuylsteke B, Ghys PD, Mah-bi G, Konan Y, Traoré M, Wiktor SZ, et al. Where do sex workers go for health care? A community based study in Abidjan, Côte d’Ivoire. Sex Transm Inf. 2001;77:3512.

22. Islam M, Conigrave KM. HIV and sexual risk behaviors among recognized high-risk groups in Bangladesh: need for a comprehensive prevention program. Int J Infect Dis. 2008;12:36370.

23. Mihret M, Khodakevich L, Shanko B, Ayohunie S, Gizaw G, Manore H-M, et al. HIV-1 Infection and Related Risk Factors Among Sex Workers in Urban Areas of Ethiopia. Ethiopian J Health Develop. 1990;4(2):163-70.

24. Zachariah R, Spielmann MP, Harries AD, Nkhoma W, Chantulo A, Arendt V. Sexually transmitted infections and sexual behavior among commercial sex workers in a rural district of Malawi. Int J STD AIDS. 2003;14:185-8.

25. Dhana A, Luchters S, Moore L, Lafort Y, Roy A, Scorgie F, et al. Systematic review of facility-based sexual and reproductive health services for female sex workers in Africa. Global Health.

2014;10:46.

26. Mooney A, Kidanu A, Bradley HM, Kumoji EK, Kennedy CE, Kerrigan D. Work-related violence and inconsistent condom use with non-paying partners among female sex workers in Adama City, Ethiopia. BMC Public Health. 2013;13(1):771.

27.

Ramesh BM, Beattie TSH, Shajy I, Washington R, Jagannathan L, Reza-Paul S, et al. Changes in risk behaviours and prevalence of sexually transmitted infections following HIV preventive interventions among female sex workers in five districts in Karnataka state, south India. Sex Transm Infect 2010;86(Suppl 1):17-24.

28. Ghys PD, Diallo MO, Ettiègne-Traore V, Satten GA, Anoma CK, Maurice C, et al. Effect of interventions to control sexually transmitted disease on the incidence of HIV infection in female sex workers. AIDS. 2001;15:1421-31.

29. Gurnani V, Beattie TS, Bhattacharjee P; CFAR Team, Mohan

41

HL, Maddur S, et al. An integrated structural intervention to reduce vulnerability to HIV and sexually transmitted infections among female sex workers in Karnataka state, south India. BMC Public Health 2011;11(755).

30.

Mekelle Univeristy College of Health Sciences.

Strengthening STI/HIV services for most at-risk group population; Program implementation support through local universities in the Federal Democratic Republic of Ethiopia under the President’s Emergency Plan for AIDS Relief (PEPFAR). Mekelle University; 2011.

31. Mayanja Y, Mukose AD, Nakubulwa S, Omosa-Manyonyi G, Kamali A, Guwatudde D. Acceptance of treatment of sexually transmitted infections for stable partners by female sexual workers in Kampala, Uganda. PLoS ONE. 2016;11(5):e0155383.

32. Verschijden MMA, Woestenburg PJ, Götz HM, van Veen MG, Koedijk FDH, van Benthem BHB. Sexually Transmitted Infections among female sex workers tested at STI clinics in the Netherlands, 2006-2016. Emerg Themes Epidemiol. 2015;12:12.

33.

Alary M, Mukenge-Tishibaka L, Bernier F, Geraldo N, Lowndes CM, Meda H, et al. Decline in HIV prevalence and sexually transmitted diseases among female sex workers in Cotonou, Benin, 1993-1999. AIDS. 2002;16(3):463-70.

34. Ghys PD, Diallo MO, Ettiègne-Traore V, Kalé K, Tawil O, Caraël M, et al. Increase in condom use and decline in HIV and sexually transmitted disease among female sex workers in Abidjan, Cote d’Ivoire 1991-1998. AIDS. 2002;16(2):251-58.

35. Chanda MM, Perez-Brumer AG, Ortblad KF, Mwale M, Chongo C, Kamungoma N, et al. Barriers and facilitators to HIV testing among Zambian female sex workers in three transit hubs.

AIDS Patient Care STDs. 2017;31(7):290-6.

36. Ameyan W, Jeffery C, Negash K, Biruk E, Taegtmeyer M. Attracting female sex workers to HIV testing and counselling in Ethiopia: a qualitative study with sex workers in Addis Ababa. Afr J AIDS Res. 2015;14(2):137-44.

ese- and sex-matched non-students.[4] Such a finding

42

An open letter to our social media overlords Editorial Nina Li Nina Li is a fourth year medical student at the University of New South Wales. She is passionate about evidence-based medicine and when she isn’t working with Vector Journal, she can be found drawing instead of paying attention in lectures.

As I scrolled through my Facebook News Feed on my millennial pink iPhone, I noticed a bitter tone creeping into my thoughts. A friend was on a European vacation in Santorini. #blessed. Another friend had just completed a marathon run in a personal best time. I’m not sure that I could complete a marathon even if someone carried me to the finish line.

Someone else had posted an image of the kale and quinoa power bowl they had consumed for lunch— complete with cold-pressed juice accompaniment— and affectionately captioned it “healthy habits”.

Silently stashing away my half-priced, greasy hot chip lunch on a bus most definitely not in Europe, I was overcome with feelings of inadequacy and dissatisfaction. In my mind, none of my achievements or positive attributes could hold a candle to what my peers were accomplishing. It was all too easy to forget the meticulous curation inherent in social media’s highlights reel of life, complete with the option to edit out any pesky sharp edges of reality.

I know I’m not alone in having these intrusive thoughts. As of June 2018, Instagram has one billion monthly active users.[1] Let us pause for a second and consider what this number means. Not one million, but one billion regular users. One billion individuals

routinely scrolling through images purposefully presented to make you chuckle, elicit a tear, provide inspiration, or perhaps trigger self-loathing. One billion other individuals also stalking beauty gurus, unintentionally consuming native advertising and living vicariously through celebrities.

If my mortifying Emo phase has taught me anything, it’s that adolescence and the turbulent transition to young adulthood represents a critical time of self-discovery and emotional maturation. Amidst continually evolving technological advancement, young adults come of age in an era where communicating and expressing one’s individuality (or lack thereof) on social media platforms is the norm.

[2] Young adults represent the highest proportion of social media users, with 92% of Australians aged 16–17 years frequenting social media,[3] compared to only 30% of individuals aged 65 and over.[4] Considering the centrality of social media in establishing connections, shaping self-identity and providing access to a previously unimaginable wealth of knowledge, its ties to psychological health are inextricable. Facebook continues to reign supreme over other user-generated social networking platforms, which include Twitter, Google+, LinkedIn, Pinterest, Instagram and Snapchat.[5] Despite its 43

ubiquity, we remain largely ignorant to the potential mental health ramifications of navigating the social media minefield.[2] The speed of change has only widened the distinct generational gap between the internet-indoctrinated millennials who face the pressures of this novel online world firsthand and the law-enforcers and policymakers attempting to moderate and improve it.

It was all too easy to forget the meticulous curation inherent in social media’s highlights reel of life, complete with the option to edit out any pesky sharp edges of reality.

Growing up as a so-called ‘digital native’,[6] my relationship with social media was always slightly dysfunctional (and occasionally bordering on Stockholm Syndrome). Each brief jaunt to a different social networking platform would spark an uncontrollable spiral of comparison, envy and self-loathing. Yet while I could rely on social media to stir up negative emotions within me, it was also an essential channel of communication for group projects, organising events and simply chatting with peers. Try as I might, social media’s utility made it inescapable; the red notification icon acted like a time-bomb, ticking upwards until I surrendered and reopened the apps I had tried so hard to avoid.

Indeed, social media has been described by many young adults as more addictive than smoking or alcohol use.[7] In one study involving social media habits,[8] 5% of young adult participants were afflicted by social media addiction, fulfilling at least five of nine DSM-V criterion also used to tentatively diagnose Internet Gaming Disorder.[9]

common sentiment, known colloquially as FOMO (Fear Of Missing Out), has alarming associations with lower mood, greater anxiety and feelings of inadequacy, and is strongly linked with higher levels of social media engagement.[10] Body image remains a significant issue for young adults and adolescents, with 9 out of 10 girls citing dissatisfaction regarding their figure.[11] Social media provides an infinite pool of candidates to compare oneself to online, all just a click or tap away.

With 80 million photographs uploaded to Instagram daily,[12] young adults are continually bombarded with heavily edited, meticulously staged images presented as if they were “natural”. How often have I found myself subconsciously assessing my worth through superficial, appearance-based comparisons using social media? Far more often than I will ever admit to.

Inevitably, this has significant ramifications. Not only has perusing Facebook been linked with higher rates of body image concerns from women and girls, but also an amplified desire for physical appearance changes, which may be associated with the increasing rates of cosmetic surgery in young adults.[2] The mounting pressure to become this ‘perfect’ individual can fuel feelings of inadequacy and low self-esteem, potentially contributing to the rise of anxiety and depression among young adults.[13] In studies by Lin et al. (2015) and Sampasa-Kanyinga & Lewis (2015), youths spending a disproportionate amount of time (>2 hours) on social media platforms were more likely to report poor mental health, psychological distress and suicidal ideation.[14, 15] Researchers have even coined the term ‘Facebook depression’ to describe the growing evidence supporting the association between the unattainable demands of the online world and poor mental health.[16] My attempted character assassination of social media notwithstanding, the substantial benefits of these novel communication platforms deserve recognition. Social media have presented revolutionary opportunities for young individuals to express themselves and their beliefs. Established

The endless influx of photographic proof that my friends were leading fulfilling, fun-filled lives made my own situation feel mundane. Why was I lounging at home in sweatpants instead of enjoying a night out with friends? I burdened myself with unhealthy expectations of matching what I was observing on social media, lest I fail to live life to its fullest. But achieving this seemed to demand even more attention, more self-critical comparisons, more dedication to the platforms perpetuating this destructive cycle. It didn’t matter that I barely knew these people on my social media—they simply provided a benchmark, however unrealistic, to juxtapose my life against. This 44

in the aftermath of the 2018 Marjory Stoneman Douglas High School shooting, The Never Again MSD Movement’s gun control advocacy is a prime example of social media’s ability to amplify the voices of young adults in a world where attempting to do so by conventional means presents difficulties. For many, social media has revitalized dormant relationships, strengthened existing friendships and helped form online support networks that overcome geographical separation. The ability to connect with like-minded peers and receive emotional support, especially for individuals belonging to real-world minority groups, remains invaluable.

‘How often have I found myself subconsciously assessing my worth through superficial, appearance-based comparisons using social media? Far more often than I will ever admit to.’

Nearly half of all Australians (45%) will experience a mental illness during their lifetime,[17] with prevalence remaining the highest amongst Australian aged 18-24 years (21.2% of all Australians within this age group).[18] Clearly, these are not paltry numbers. While research remains sparse, there is increasing evidence that social media usage may contribute to psychological distress and poorer mental health. Since social media services are not destined for obsolescence anytime soon, a thorough consideration of their lasting psychological impacts grows ever more imperative, especially for young adults and adolescents.

Acknowledgements None Photo credits Image 1: Pixabay, accessed from https:// www.pexels.com/photo/facebook-applicationicon-147413/ Image 2: Thought Catalog, accessed from https:// unsplash.com/photos/xVRdDDe6M1A Conflicts of interest None declared

References

1. Christine, J. Instagram hits 1 billion monthly users, up from 800M in September [Internet]. San Francisco US: TechCrunch; 2018 [updated 2018 June 20; cited 2012 Nov 20]. Available from: https:// techcrunch.com/2018/06/20/instagram-1-billion-users/ 2. Keracher M. #StatusOfMind. London UK: Royal Society for Public Health; 2017. pp. 5, 10, 24-26. Available from: https:// www.rsph.org.uk/uploads/assets/uploaded/62be270a-a55f-4719ad668c2ec7a74c2a.pdf 3. Newspoll Market and Social Resources. Like, post, share: Young Australians’ experience of social media. Canberra ACT: Australian Communications and Media Authority; 2013. p. 8.

Available from: https://www.acma.gov.au/-/media/mediacomms/ Report/pdf/Like-post-share-Young-Australians-experience-ofsocial-media-Quantitative-research-report.pdf?la=en 4. Australian Bureau of Statistics. Older persons internet use – 2012 – 2013 Multipurpose Household survey [Internet]. Canberra ACT: Australian Bureau of Statistics; 2014 [updated 2016 February 17; cited 2012 Nov 20]. Available from: http://www.abs.gov.au/ ausstats/abs@.nsf/Lookup/ 5. Sensis. Sensis Social Media Report 2017. Melbourne VIC: Sensis; 2017. Chapter 1. Available from: https://irp-cdn. multiscreensite.com/535ef142/files/uploaded/Sensis-SocialMedia-Report-2017.pdf 6. VanSlyke T. Digital natives, digital immigrants: some thoughts from the Generation Gap. The Technology Source [Internet]. 2003 May/June [cited 2018 Nov 20]. Available from: http://technologysource.org/article/digital_natives_digital_ immigrants/social media addiction 5% - 3 7. Hofmann W, Vohs KD, Baumeister RF. What people desire, feel conflicted about, and try to resist in everyday life. Psychological Science. 2012 Jun [cited 2018 Nov 20];23(6):582-8.

8. Jenner F. At least 5% of young people suffer symptoms of social media addiction [Internet]. Brussels BEL: Horizon: the EU Research & Innovation Magazine; 2015 [updated 2015 April 29; cited 2018 Nov 20]. Available from: 9. https://horizon-magazine.eu/article/least-5-youngpeople-suffer-symptoms-social-media-addiction_en.html 10. van den Eijnden RJ, Lemmens JS, Valkenburg PM. The social media disorder scale. Computers in Human Behavior. 2016 Aug [cited 2018 Nov 20] 1;61:478-87.

11. Dossey L. FOMO, digital dementia, and our dangerous experiment. Explore: The Journal of Science and Healing. 2014 Mar 1 [cited 2018 Nov 20];10(2):69-73.

12. Lamb B. 2015. Human diversity: Its nature, extent, causes and effects on people [Internet]. Singapore: World Scientific Publishing; 2015.

13. Smith K. 41 incredible Instagram statistics [Internet].

Brighton UK: BrandWatch; 2015 [updated 2018 April 25; cited 2018 Nov 20]. Available from: https://www.brandwatch.com/blog/ instagram-stats/ 14. Primack BA, Shensa A, Escobar-Viera CG, Barrett EL, Sidani JE, Colditz JB, James AE. Use of multiple social media platforms and symptoms of depression and anxiety: A nationally-representative study among US young adults. 2017 April 1 [cited 2018 Nov 20]; 69:1-9.

15. Lin LY, Sidani JE, Shensa A, Radovic A, Miller E, Colditz JB, Hoffman BL, Giles LM, Primack BA. Association between social media use and depression among US young adults. Depression and anxiety. 2016 Apr [cited 2018 Nov 20];33(4):323-31.

16. Sampasa-Kanyinga H, Lewis RF. Frequent use of social networking sites is associated with poor psychological functioning among children and adolescents. Cyberpsychology, Behavior, and Social Networking. 2015 Jul 1 [cited 2018 Nov 20];18(7):380-5.

17. O’Keeffe GS, Clarke-Pearson K. Clinical report—the impact of social media on children, adolescents, and families. Pediatrics.

2011 Mar 22 [cited 2018 Nov 20]:peds-2011.

18. Australian Bureau of Statistics. National Survey of Mental health and Wellbeing: summary of results, 4326.0, 2007 [Internet].

Canberra ACT: Australian Bureau of Statistics; 2007. Available from http://www.ausstats.abs.gov.au/Ausstats/subscriber.

Correspondence nina.li@student.unsw.edu.au 45

United Nations Climate Conference Conference report

Georgia Behrens & Katherine Middleton Georgia Behrens and Katherine Middleton are second-year medical students at the University of Notre Dame and the University of Western Australia respectively. They are the 2018 Project Coordinators for AMSA Code Green, and the 2019 National Student Rep-Elect for Doctors for the Environment Australia.

Who are you, and what is AMSA Code Green?

We are Katherine Middleton and Georgia Behrens, second-year medical students with a passion for the environment and health. With a national team, we run AMSA Code Green, which is AMSA’s climate change and health project. We provide a platform for Australian medical students to respond to our planet’s health emergency - educating, engaging and advocating on the health challenges posed by climate change.

In May 2018, we joined the International Federation of Medical Students’ Associations (IFMSA) delegation to the United Nations (UN) Climate Conference in Bonn, Germany. We spent two weeks watching, learning, sightseeing, and doing a bit of casual international environmental activism.

What is the UN Climate Conference?

The UN Climate Conference is an international meeting of diplomats, policy-makers, scientists, academics and non-governmental organisations, all working together to confront the challenges posed by climate change.[1] This meeting occurs every year in Bonn, Germany, and focuses on continual implementation of the Paris Agreement.

The Paris Agreement, which came into force in late 2016, unites countries around the world to take action on climate change. 178 countries are currently signed up as parties to the Paris Agreement, and are thus committed to acting for climate change mitigation and adaptation.

The Paris Agreement commits nations to actively prevent increases in global temperatures to well below 2oC. The key aim of this year’s UN Climate Conference was to develop the operating manual for the implementation of the Paris Agreement, also known as the “Paris Agreement 46

Rulebook”. This rulebook will be a guide for all involved countries as to how they should go about conducting climate change mitigation and adaptation activities in the upcoming years.[2] The rulebook is due to be finalised at the end of 2018 at the 24th Conference of Parties (COP24) in Katowice, Poland. The significance of COP24 has earned its name “Paris 2.0” (COP21 was where the Paris Agreement was signed).

What did we do there?

We did so many wonderful things while attending the conference. First and foremost, we had the opportunity to meet amazing people from around the world, all working incredibly hard to fight climate change and ensure the ongoing health of our planet. These included other globally-minded medical students and youth environmental activists from a wide variety of countries. We also had the privilege to interact Why do medical students go? with representatives from the World Health At every UN Climate Conference, hundreds of Organisation (WHO), and the Executive Secretary people from around the world of the UN’s main climate change come as “observers” to watch, the United Nations ‘... the IFMSA believes organisation, learn and contribute to the UN Framework Convention on Climate Climate process, even though that climate change Change (UNFCCC). they are not parties to the Paris is an immense global Agreement. Youth observers We sat in on the international health issue, an issue negotiation sessions between (‘YOUNGOs’) are a particularly important group at every which future medical different countries about the conference, as the UN “recognizes Paris Rulebook, which was an doctors should be the key role that youth play in incredible experience. Getting to tackling climate change”.[3] working hard to see how the UN works in reality address as a matter of is a fascinating (if sometimes The IFMSA has been sending bewildering) experience. Alongside urgency.’ youth observers to UN Climate the negotiations, we were able to Conferences for a number of attend a range of presentations and years. This is because the IFMSA workshops that were being run at the conference. believes that climate change is an immense This included the WHO’s talk regarding health global health issue, an issue which future medical impacts of air pollution; a legal team aiding a group doctors should be working hard to address as a of Swiss grandparents in their action of suing the matter of urgency. government for a lack of action towards climate change; and many presentations addressing the The preamble of the Paris Agreement need to empower women and youth to lead the acknowledges “climate change is a common charge on climate activism. concern of humankind” and states that climate action must respect “obligations on human rights Finally, we got involved in a bit of activism to [including] the right to health”.[4] Over the past help remind all the delegates of the urgent health few years, IFMSA delegates have been working issues posed by climate change. In both weeks hard at UN Climate Conferences to ensure that of the conference, the IFMSA delegation held a parties to the Paris Agreement remember that little “action” in the main lobby where we dressed climate change is a significant health issue. up in lab coats, stethoscopes and more. We were 47

extremely appreciative at how well-received we were, and the never-ending interest of others regarding climate change and health.

about the following questions with regards to climate change: Where are we? Where do we want to go? How do we get there?

What did we learn?

There is a tremendous amount of bureaucracy.

At first, it seemed a bit overwhelming and sometimes even counterproductive. But as the week progressed, its purpose became evident.

The complexity of climate action on a global scale is such that a one-size-fits-all approach to climate mitigation is not feasible. Discussions within the conference were at times tense for this reason.

A phrase we heard time and time again was the need for a “just transition” towards a more renewable future. It taught us that at a global level, climate action needs to be well considered and carefully planned, which is the key to the UNFCCC process. Climate action can seem complex in a developed country such as Australia, and global climate action is no different.

From this sharing of stories we came to realise that globally, we are all in a similar place in terms of climate change, but it is manifesting differently across nations. We all think that education, in a way that people can understand and relate to their own lives, is of utmost importance moving forward. However, climate change cannot be approached from only one discipline. It needs to become integrated into all aspects of public policy. These stories from our peers were inspiring and invigorating. We learnt about the current state of affairs around the world, and became hopeful that if we work together we can figure out how to effectively tackle climate change.

‘... climate change cannot be approached from only one discipline.

It needs to become integrated into all aspects of public policy.’

However, young people are playing a key role in shaping climate action. The voices of YOUNGOs are surprisingly being listened to, especially as the youth are increasingly contributing to UN processes. We also learnt that Pacific nations, in particular Fiji, are leading the way in the climate change conversation. The Fijian COP23 President called for an international dialogue, whereby party delegates and stakeholders levelled to share stories and take stock of collective efforts to achieve targets of Paris Agreement. A Talanoa is a traditional word used in Fiji to describe a process of sharing ideas, skills and experiences through storytelling.[5] We were fortunate enough to join with other YOUNGOs in our own Talanoa, where youth from all around the world shared stories

Acknowledgements None Photo credits Georgia Behrens & Katherine Middleton Conflicts of interest None declared

Correspondence georgia.behrens@amsa.org.au katherine.middleton@amsa.org.au References

1. United Nations Framework Convention on Climate Change (UNFCCC). What are United Nations Climate Change Conferences? [Internet]. New York City, US: UNFCCC; 2018 [updated n.d.; cited 2018 Oct 5]. Available from: https://unfccc. int/process/conferences/what-are-united-nations-climatechange-conferences 2. United Nations Framework Convention on Climate

48

Change (UNFCCC). Understanding the UN Climate Change Regime [Internet]. New York City, US: UNFCCC; 2018 [updated n.d.; cited 2018 Oct 5]. Available from: https://bigpicture. unfccc.int/ 3. United Nations Framework Convention on Climate Change (UNFCCC). Partnerships [Internet]. New York City, US: UNFCCC; 2018 [updated n.d.; cited 2018 Oct 5]. Available from: https://unfccc.int/topics/education-and-outreach/ workstreams/youth-engagement/partnerships 4. United Nations Framework Convention on Climate Change (UNFCCC). The Paris Agreement [Internet]. New York City, US: UNFCCC; 2018 [updated n.d.; cited 2018 Oct 5].

Available from: https://unfccc.int/sites/default/files/english_ paris_agreement.pdf 5. United Nations Framework Convention on Climate Change (UNFCCC). 2018 Talanoa Dialogue Platform [Internet].

UNFCCC. New York City, US: UNFCCC; 2018 [updated n.d.; cited 2018 Oct 5]. Available from: https://unfccc.int/topics/2018talanoa-dialogue-platform.

What you need to know: â&#x20AC;˘ In May, AMSA Code Green Project Coordinators attended the UN Climate Conference in Bonn, Germany. At the conference, politicians, NGO representatives and citizens from around the world met to discuss the implementation of the Paris Agreement, in order to limit global temperature rises to well below 2.0 degrees celsius. â&#x20AC;˘ The AMSA Code Green Project Coordinators joined a delegation of medical stduents advocating for the consideration of the health impacts of climate change in the Paris Agreement implementation process.

49

There is No Me Without You Book review Juliana Wu Juliana Wu is a first year medical student at the University of Melbourne.

There is No Me Without You: One Woman’s Odyssey to Rescue Africa’s Children.

Melissa Fay Greene’s traveller’s account, There is No Me Without You, is the story of Haregewoin Tefarra, a middle-class Ethiopian widow, who opens up her dwelling as a refuge for hundreds of children orphaned by acquired immunodeficiency syndrome (AIDS). The book presents a stark image of the AIDS crisis in Africa and its decimating effects on Ethiopia. Against prevailing stigmas and the blind eye taken by the international community in its denial of the humanitarian crisis taking place in Ethiopia, Haregewoin’s selfless acts shine as a joyous counterpoint to the bleak reality that continues to consume large parts of Africa.

Greene’s book is an overdue reminder that our humanity is the key ingredient in combating the global fight against AIDS. By illustrating each child’s haunting story of becoming an orphan, Greene not only addresses, but confronts, many paradigms in popular culture. Specifically, she tackles the widespread suggestion that promiscuity and hypersexual behaviours are to blame for the continuation of the AIDS epidemic in Africa. Her stories render this stigma as unfair and over-simplified. Instead, a prevailing feeling of defeat and a distinct lack of alternatives dominate the stories. One woman contracted AIDS from a man who had “lied in saying he would marry her” and fled when he found out she had the disease.[1] The inexorable shame and guilt she felt in bringing a baby into this world without the capacity to support it became a driving factor behind the mother’s decision to abandon the child. Her story is a testament to the helplessness of those under the pressure of extreme marginalisation. Others in the book would come to feel the force of unimaginable accusations and violence after being infected with human immunodeficiency virus (HIV) by a single unsterile injection.[1] Thus, the book exemplifies the dangerous stigma towards those who contract the “unspeakable” disease, and although Greene does not explicitly state it,

she certainly alludes to the systemic failure of both domestic and international governments in allowing the crisis to escalate and social stigmas to linger.[1] Although the social, economic and political insufficiencies of Ethiopian governance are all too obvious throughout the book – for instance, Greene mentions that Ethiopia ranked 170th out of 177 nations for its Human Development Index, and 134th out of 140 nations for its gender inequality-related development index – one cannot help but sympathise with the Ethiopian context.[1] The so-called “free-fall” of health and happiness in Ethiopia is the result of a multiplicity of domestic issues, including border wars, 50

a history of weak and irresponsive leadership, and the lasting effects of colonisation and international oppression. Moreover, the onset of social collapse has been hastened by international politics and imposition. First world trade policies, which forced African countries to assimilate and compete against the global market in the name of “economic modernisation”, with a climate that heavily favoured Western economies, meant that African countries were becoming increasingly dependent on foreign food imports whilst their exports rapidly declined in value. This, in combination with stringent conditions associated with developmental loans, eventually required the slashing of vital public sectors such as health and education as a means of reducing government expenditure. Despite this, Greene is careful not to lay the blame purely on international delinquency in the domains of political, economic and social governance. She notes that instances of governmental failure and corruption in Ethiopia’s history, including concealment of famine, vastly excessive military expenditure, and ongoing ethnic tensions, have all contributed to the rampant state of HIV/AIDS in Ethiopia.

Yet one could argue that by the time the AIDS epidemic had hit Ethiopia, the sustained stagnation of the Ethiopian economy and international impositions had rendered it almost impossible for Ethiopia to properly handle the crisis without international intervention. It follows then, that the AIDS epidemic is a blatant example of deliberate ignorance by the Western world. In a country where two-thirds of school-age children are not in school, only 41% of adults can read, and 81% of people live on less than two dollars a day, the country is simply not equipped with the resources and administration it needs to win the war against AIDS.[1] Indeed, it could be argued that the delay in the provision of antiretroviral treatments is an issue of international irresponsibility rather than domestic governance.

For instance, Greene mentions that the Unites States government stood against mass-producing cheap drugs as a method of protecting the profits of American multinational pharmaceutical corporations.

This was done at the expense of some millions of people in Africa dying of AIDS under the illusory pretence of “public health realism”.[1] Without lifesaving antiretroviral treatment, the helplessness and impossibility of resurrecting the AIDS situation is made manifest by the character, Dr Rick Hodes.

Although he was an American doctor, he knew that “without the antiretroviral medication, he couldn’t save a single life”.[1] Arguably then, Ethiopians, especially those who contracted HIV, fell victim to misallocated resources and the neglect of the international community.

However, this argument is limited in many ways, a point that Greene is quick to emphasise. In the age

of the AIDS pandemic, there were those both within Ethiopia, such as Haregewoin, and those outside the borders of the country, such as Dr. Rick Hodes, who worked tirelessly to suppress the epidemic that had infiltrated the country. More specifically, Greene emphasises families from foreign countries who provided lifelines to orphaned children through adoption. In direct opposition to the widespread negligence of the West in failing to provide lifesaving medication to Ethiopia, the adoption of unwanted, psychologically traumatised, and at times deathly sick orphans by otherwise well-off families is a testament to the fortitude and love of the human spirit. Thus, just as Ethiopia may be considered a victim of international immobility, it was also arguably the recipient of an altruistic salvation by the international community.

In conclusion, the book discusses the African AIDS crisis in a powerful yet sensitive manner. Greene does well in addressing the multiple facets of the AIDS pandemic: the relentless social stigmas, lack of treatment options, international neglect and the burgeoning number of families destroyed by the pandemic. Although the book itself brims with grief, it also stands as a testament to what a single human being or family can do for others “in a place with no people”.

‘Against prevailing stigmas and the blind eye taken by the international community in its denial of the humanitarian crisis taking place in Ethiopia, Haregewoin’s selfless acts shine as a joyous counterpoint to the bleak reality that continues to consume large parts of Africa.’

Acknowledgements None Photo credits There is No Me Without You: One Woman’s Odyssey to Rescue Africa’s Children Melissa Fay Greene]. Bloomsbury USA. 2016 [cited 5 October 2018]. Available from: https://www. bloomsbury.com/uk/there-is-no-me-withoutyou-9781596912939/ Conflicts of interest None declared Correspondence julianaw@student.unimelb.edu.au References

1. Greene, M. (2006). There is No Me Without You [Book]. New York: Bloomsbury [cited 2018 Sept 17].

51

Complimentary Membership & Cover

Discounts on Eligible QBE Travel Insurance Policies+ Free Access to The Electives Network

Discounted Medical Texts

Medico-legal Blogs & Resources

24-Hour Medico-legal Helpline in Emergencies

Live Well, Study Well Activities

Medical Society Alliances

Student Ambassador Network

52

53