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The Future Is Here

9 Dec, 14 | by shaworth

Most of us, as healthcare professionals, would consider access to the internet to be an essential part of our work, whether this is for communicating with each other or keeping up to date with our field. For patients, the benefits of access to the internet are many. Being able to contact peer-support and information about health issues encourages self-reliance, and being able to receive appointment reminders and results by text or email is the preference of some of our population; however, despite increasing access to mobile phone services, and internet connections, there is a digital divide within our population.

In the UK, 93% of adults had a mobile phone in 2013, according to Ofcom; although it not possible to break this down by social deprivation. It is also not possible to obtain statistics for PAYG versus contract plans. Our use of landlines appears to be static, with subscriptions remaining steady over the last twelve months. It is possible in the UK for those on benefits to obtain reduced landline subscriptions, and reduced rate broadband subscription on top of this via BT. Only 16% of our population live in a mobile-only home, and 77% have access to fixed or mobile (through a dongle) broadband.

In Scotland, the government published a study of internet use broken down by social deprivation in 2012. In those earning over £40,000 98% of the population have access to home internet, but in those earning less than £15,000, this drops to 50%.

A paper by published last month (online first) “Resources: A technology maintenance perspective Cell phone disconnection disrupts access to healthcare and health” by Gonzales et al and published in New Media and Society, discusses the issue of the digital divide and the effect of poverty on access to mobile phones. This small study looked at the US population, and the findings are not wholly transferrable immediately to other populations, but highlight some of the problems faced by those in poverty with regard to the availability of technology. In the US, it is possible for those on benefits to obtain government subsidised mobile phones (nicknamed “Obamaphones”) with reduced pay-as-you-go (PAYG) plans. Landline use in the US is falling, and the population appears to be increasingly reliant on mobile phone use. As demand for mobile orientated services increase, and healthcare providers choose to provide access to services via telephone or internet, this potentially excludes the population who cannot maintain connectivity.

To quote science fiction author William Gibson “The future is here, it’s just not widely distributed yet.” Those in poverty might be able to access equipment that improves their connectivity, but the it is the maintenance of this through equipment and skills that ensures continued benefit. This issue creates a secondary digital divide, with the rich, being able to access the latest technology and education to use it efficiently, gaining the most benefit and leaving the poor behind.

This invisible privilege is an important factor to consider when commissioning services through encourage patients to access information or services through the internet or mobile phones. Services through chew through data and minutes may not be as cost-effective as face-to-face meetings when access through PAYG is considered.

Sex Ed

27 Nov, 14 | by shaworth

The teaching of sex education in British schools remains a divisive topic at the forefront of media attention as the Government considers its position on whether or not the teaching of Sex and Relationship Education (SRE) should become mandatory in England and Wales

At the moment, all maintained secondary schools must provide SRE. This means that Free Schools and Academies, which are not obliged to follow the National Curriculum are excluded from this requirement, and primary schools can choose to provide it depending on the decision of their governing body. The National Curriculum contains a mandatory component on the teaching of reproduction as part of the science curriculum, but parents have the right to withdraw children from the teaching of SRE as part of Personal, Health and Social Education (PHSE) teaching, a right laid down by the Education Act of 1996.

The Government’s initial investigation into the state of SRE in England and Wales found that a third of schools did not provide adequate sex education, often with too much focus on the mechanics of reproduction, and little emphasis on the importance of relationships.

Obviously, as time marches on, the relationships and the pressures on young people change over time. The age of internet communication has brought with it new social problems that could not have been predicted when the idea of sharing information with computers was first postulated. The first generation of people growing up with access to the internet have access to explicit sexual imagery and obscure fetishes that their parents went in ignorance of. The government’s review of whether or not SRE should be compulsory, one might therefore argue, comes several years too late.

The fundamental question at the heart of the current Parliament Select Committee is whether or not all children have a right to SRE, and whether all schools should therefore be required to provide it. Last week the committee took views from witnesses representing both interdenominational and faith schools to try to answer this question.

Faith schools often have moral standpoints on sex and relationships laid down with the code of their religion. A interesting point raised is that students attending the school, and therefore followers of that religion, may feel that SRE which doesn’t take into account faith views to not be applicable to them, which was a reason raised by both the Catholic (Philip Robinson, Religious Education Adviser, Catholic Education Service), and Islamic (Yusuf Patel, Founder, SRE Islamic) representatives as to why SRE should not have a mandatory curriculum, allowing schools the freedom to teach within the confines of their faith. It was also suggested that if parents felt their children could not be taught SRE viewpoints consistent with their own religious views would feel pressured to withdraw them from the lessons.

This point was rather eloquently put down by one of the questioning MPs, Siobhain McDonagh (around 10:10am for those watching the video), who enquired as to whether the faith viewpoints on alcohol and drug misuse education as part of PHSE was a concern to parents whose faiths had particular teachings on the subject. The response of the witnesses was that it would be hard to argue against an education on the dangers of alcohol and drug misuse, even if a faith had strict prescriptions against their use. Naturally a comparison to the potential dangers of sex was drawn, and to which neither faith representative could voice an argument against in this context.

Ultimately, the only way to find out if compulsory SRE improves the quality of SRE delivery, and as a secondary outcome improves our unplanned pregnancy rate, rates of STIs and sexual assaults, is to implement and carefully evaluate what the effect on these outcomes are. In the meantime, as professionals, we just have to do our best to educate the young people who cross our paths, and provide them with the best service possible.

EMA recommends availability of ellaOne® emergency contraceptive without prescription

24 Nov, 14 | by shellraine, e-Media Editor

Change in status to facilitate access for women across Europe

The European Medicines Agency’s Committee for Medicinal Products for Human Use (CHMP) has recommended a change in classification status from prescription to non-prescription for the emergency contraceptive ellaOne® (ulipristal acetate). This means that the medicine could be obtained without a prescription in the European Union (EU).

This recommendation is the first-ever of its type regarding an oral contraceptive product, which should apply in all EU member states in 2015, after a final endorsement by the European Commission.

ellaOne® first became available in Europe with a medical prescription at the end of 2009. This was then followed by its launch in the United States in 2010 after approval by the Food and Drug Administration (FDA). These approvals were based on full clinical tests and research. ellaOne®  has already been used by more than 3 million women in 70 countries over the past 5 years.

Based on the assessment of available data, the CHMP found that ellaOne® can be used safely and effectively without medical prescription.

Professor Anna Glasier, from the University of Edinburgh (Scotland), agreed that the newly announced enhanced access for women is a key milestone and said, “ellaOne® is a highly effective emergency contraceptive which we’ve been using for 5 years now, and making it more accessible and available more quickly from pharmacies is a logical and sensible thing to do. Women need to get access to emergency contraception as soon as possible in order to be in the best position to avoid an unintended pregnancy; this is a matter of public health”.

This CHMP recommendation will now be sent to the European Commission for a legally binding decision within 2 months.
HRA Pharma expects ellaOne® to be available directly from pharmacies in 2015 across the European Union.

The Three Ghosts of Child Protection

9 Oct, 14 | by shaworth

It’s been a depressing time for child protection in the UK recently. Admittedly, child protection work rarely hits the headlines for the right reasons, as confidentiality restricts the pronouncement of victory, and the media rarely gets excited about restoring safety and normality. The prevention of bad outcomes doesn’t make for headlines that sell newspapers in the same way that terrible events do.

This year, historical accusations of abuse have been a recurring feature in the news, sometimes too late for justice to be served, but sometimes with successful convictions against perpetrators who probably thought they had gotten away with it. Many of us felt that the public figures involved in these crimes were people that we could trust, and feel a sense of revulsion that we innocently did so. At the same time, it is some comfort to see that fame is no protection from justice.

Unfortunately, the same cannot be said for the widespread sexual abuse of vulnerable children in Rotherham, which has garnered widespread media attention, sometimes for the wrong reasons, with several media outlets quick to place the blame on the race of the perpetrators, and ignoring the police inefficiency at following up complaints. Perhaps what’s most worrying are the disturbing reports of attempts to silence those who spoke up to report the abuse, and the repeated instances of incompetence such as losing or destroying evidence.

Earlier this month, the Liberal Democrat leader Nick Clegg announced new legislation that will make a failure to report child abuse a crime. The motion was originally tabled by the Prime Minster in July, and takes the form of an amendment to the Series Crimes Act, which is currently sponsored by the Bishop of Durham and Baroness Walmesly. Concerns have been raised that this may result in malicious or nuisance reports, but where similar legislation has been enacted abroad, the proportion of reports deemed to be nuisance, has not been shown to have increased.

For those of us who work with vulnerable children and adolescents, the knowledge that our attempts to keep children safe, and bring justice to those who seek to harm them are being undermined elsewhere is disheartening in the extreme. We as medical professionals can only so much to collect evidence and share with external agencies, in the hope that due processes will be followed.

We can but hope that an increased media focus on child protection issues will encourage the government to fund social work and charitable organisations which work to safeguard children, but for all the talk of Big Society, the lack of cohesion between voluntary sector organisations and local authorities has been thrown into sharp relief by the publication of the Centre for Social Justice’s Report “Enough Is Enough” earlier this year, which worked with the charity Kids Company to detail instances of failure to act by local authorities where the charity had voiced concerns.

In Ofsted’s 2013 social care report, the cost of looked after children had increased by £173 million pounds, and at the same time, funding for social work had decreased by a quarter over the last four years, with an overall 4% decrease in social worker psoters. Whilst local authorities with difficulties achieving good quality safeguarding services for children have complex problems underneath, a lack of funding is a chronic drain on any social work budget.

In the last month, in an attempt to rectify child protection serves which had been found to be inadequate, Doncaster has removed child services from the local authority, instead setting up a third party, not-for-profit organisation to manage services instead. Obviously, this had raised accusations of stealth attempts at privatisation; although the company will continued to be funded by the local authority. This is not the first attempt to manage childrens’ services in this way, and results from previous similar initiatives have been mixed, largely blamed on chronic budget cuts.

Ultimately, children are safer now than previously, and it’s a testament to the hard work of those in child protection that this is the case; however, we cannot continue to make gains in this area unless we are willing to priorities support for the most vulnerable who need our help.

Marie Stopes International launches “Time to Act: Achieving a world where no woman dies from unsafe abortion”

25 Sep, 14 | by shellraine, e-Media Editor

Ahead of World Contraception Day (September 26th) Marie Stopes International (MSI) is launching Time to Act: Achieving a world where no woman dies from unsafe abortion to coincide with the UNGA’s deliberations on the 1994 Cairo agenda and the post-2015 goals.  A copy of the report is available here: http://www.makewomenmatter.org/timetoact.

Part of MSI’s Make Women Matter campaign, the report brings to light the damage being caused by the unmet need for contraception and unsafe abortions and warns how much worse the situation is yet to become as the developing world faces its biggest population growth in history.

FGM Awareness

24 Sep, 14 | by shaworth

Female Genital Mutilation has come to the forefront of media attention this summer, with the government allocating a quarter of a million pounds of funding towards the eradication of the practice earlier this year. and readers of the Journal have probably noticed an increasing focus on this issue. Last week Yvette Cooper, the shadow home secretary, as part of an interview with the House magazine, outlined proposals to detain girls at risk of being removed from the UK for the purpose of FGM being performed. These measures are similar to those outlined previously in the 2007 Forced Marriage Act.

As part of the push against the practice of FGM in the UK, the UK Border Agency is being supported by officers with specialist child protection training, who are attempting to identify those at risk on both exiting and entering the UK. This year, whilst the team has been deployed at Gatwick, 30 cases have been identified compared with none previously.

In support of the move, the UK Muslim Council issued a statement earlier this year condemning the practice as being against the principles of Islam, an important move considering that religious reasons are often cited as being part of the rationale of continuing the practice. Meanwhile in Kenya, there seems to have been some progress at reducing the incidence of the practice with several cases coming to court prosecuting those who perform FGM, with increased sentencing against fatalities.

At the moment, there are UK Government interim guidelines for professionals with regard to FGM which were issued in July of this year and due to be updated in November. Readers may also be interested in the work of the Orchid Project, a charity in the UK dedicated to assisting the eradication of the practice.

21 Sep, 14 | by shaworth

Readers might be interested to know that Pfizer are sponsoring a series of educational events on womens’ healthcare, encompassing  aspects of sexual health and family planning. These are taking place in England through October and November.

Manchester – Saturday 4th October 2014
Nottingham – Saturday 11th October 2014
Durham – Tuesday 4th November 2014
Blackburn – Wednesday 18th November 2014
Maidstone – Tuesday 18th November 2014

Agendas for the meetings can be found here.

Those attending should be aware that the session feature talks about the prescribing of Depo-Provera, and that this is manufactured by the sponsors.

Crowdsource, Contraception and No Small Potatoes

14 Sep, 14 | by shaworth

Contraception for men has been an area of dashed dreams for many years, so the ongoing trials of potentially reversible vas deferens occlusion by polymer injection represents an interesting development. Reported in the UK press as an “injectable contraceptive for men”, a description that seems grossly inaccurate in some respects as it’s not equivalent to the injectable contraceptives for women which work using high dose progestrogen; although it is injected into the vas itself, Valsagel is currently undergoing testing in animal models with hopes to begin trials in humans if this is deemed to be a success.

Valsagel is not the first polymer injected vas-affecting agent to be developed, and the work was inspired by the ongoing trials of RISUG in India, covered by Wired in 2010 in an extensive article that also details how Valsagel came to be and containing an account of a consenting process that seems less than entirely rigorous. RISUG was passed over by the WHO after phase II trials in 1997, due to production problems, but interest in the project was renewed in India in recent years and Phase III trials continue locally.

Valsagel works slightly differently to RISUG, by occluding the vas deferens using the polymer. Theoretically, the polymer can be subsequently dislodged using another injectable agent; although whether this is true in humans, only time will tell. Interested clinicians can follow the Valsagel trials through the Parsemus Foundation, who are partly funding the trials through crowdsourcing initiatives.

This is not the first crowd-sourced initiative in medial research discussed in the blog, and it also remains to be seen whether this will represent a useful source of funding for medical research in future, by bringing patients and small donors into contact with large-scale projects.

Those following developments in this field may also be interested in the attempt of an American woman, known only as Bailey, who attempted to crowd-fund her termination of pregnancy through the website GoFundMe (which the website subsequently revoked; although she did receive the funds allocated). Bailey was interviewed about her decision in the fashion and design magazine Vice*, where she discusses that her decision to crowd-fund donations was due to being unable to finance the procedure herself, and the use of crowd-funding to help people achieve their goals. She makes reference to the $50,000 raised to produce a single serving of potato salad, something that suggests the world has not yet run out of ways to waste money.

*This magazine contains content, including nudity and profanity, which is probably in violation of your work internet use policy, but you can read the interview here.

Young People And Their Experiences of Anal Sex

21 Aug, 14 | by shaworth

Readers of the Journal may have come across the recent study into teenage attitudes towards anal sex in heterosexual couples by the London School of Hygiene and Tropical Medicine, published last month via their Online First initiative already, but if you’ve not, it makes interesting reading for anyone working in young people’s sexual health.

Existing data suggests that anal sex between heterosexual couples is on the rise, and often increased access to pornographic materials in the digital age is cited as the reason behind this; although the evidence to suggest this is limited. Recent data, according to this study, suggests that 1 in 5 young people has tried anal sex.

The study took place in three centres in England, surveying 130 young people in total with various levels of interviews. Questions involved their perceptions of their own experiences, their partner’s experience and their reasons for trying anal intercourse. The answers seem to confirm some of the previous hypotheses, but with pornographic material being a small factor in why young people explored the idea of anal intercourse; although the belief that anal intercourse would be more pleasurable for the male partner due to a linked believe that “tightness” was integral to male sexual pleasure during penetrative intercourse, and encouragement from peers to try anal intercourse as part of a sexual conquest, were also prevalent attitudes amongst male interviewees.

Perhaps what’s most worrying is the evidence that some men felt that they had a right to coerce partners into trying anal intercourse, despite holding the belief that female partners would find anal sex painful. To those of us interested in the wider climate of sexual equality and sexual behaviour, this isn’t a shocking finding. The idea that some men feel entitled to sexual favours from women, and how this defines their behaviour and attitudes towards them, has been a centrepoint of modern feminist debate in recent years.

The study is of value to those working in sexual health, particularly with young people. It highlights that young people are unaware of the risks to their sexual health with regard to anal intercourse, and suggests that targeted interventions to improve condom use and safe anal intercourse is needed in this group. It also suggests that the worrying disparity between male and female experiences of anal intercourse needs to be addressed, perhaps through initiatives that empower young women to control their own sexual experience, and perhaps through initiatives that educate young men on how to achieve sexual pleasure for their partner as well as themselves.

Sexual Function In Childhood Cancer Survivors

12 Aug, 14 | by shaworth

Journal readers may be interested to know about a recent study published in the Journal of Clinical Oncology, a cohort study of over two thousand women who had suffered from childhood cancer compared with their female siblings, which demonstrated an excess of psychosexual morbidity in those who had suffered cancer as children.

It is known that the treatment of cancer can affect sexual functioning in a variety of ways, from premature menopause to the direct effects on the genital tract; however in these women, it would appear that the effects of the cancer, and treatment, persisted into adulthood. Compared with their sisters, they reported having less sex, less desire for sexual and less satisfaction with sexual intercourse. Speaking to Reuters Health, the study lead Jennifer Ford, expressed her surprised at the persistence of these effects.

About ten percent of women in the study experienced premature menopause, and only half of these were taking some form of hormone replacement; although this did not seem to improve the outcomes measured.

The study did not measure similar outcomes in men, so it is not clear if their experience is similar; however, the study does suggest that sexual function should be addressed in adolescents who have suffered cancer, and opened up for discussion with those who are facing cancer treatment.

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