Going to #CPHA2014

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The 2014 CPHA conference will be held in Toronto, ON | Picture courtesy Wikimedia
Commons

Next week, I (Atif) will be heading to the Canadian Public Health Association Conference, where I’ll be presenting at two different points.

I’ll be chairing a session titled “Youth Injury Prevention in Canada – Where should we direct our intervention resources.” It promises to be an interesting presentation, where we’ll be discussing injury in Canada, and where to start tackling the problem of injury. This session is scheduled for Wednesday, May 28th from 1:30pm – 3:00pm.

Injury represents one of the most important negative health outcomes experienced by young people in Canada today. Injuries inflict a large burden on children and adolescents and their
families and communities. Injury events are costly in so many ways, whether measured in premature mortality, or the pain, disability, lost productivity and emotional consequence of non-fatal events.

This panel will be made up of child injury researchers and advocates who will make their case for different forms of injury prevention intervention. At the end of this panel, delegates will: understand more about the burden of youth injury in Canada; be aware of at least four different avenues for injury prevention intervention (primordial intervention, context-level interventions, safe sport and peer-influence interventions); have identified the rationale, strengths and limitations of each intervention approach; and have learned more about ways to undertake and gain support for youth injury prevention (from the CPHA conference program).

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Click to go to the conference website

My second presentation is one of the studies from my PhD, titled “The influence of location of birth and ethnicity on BMI among Canadian youth.” This is a study that’s in press (woo!), and represents my own research focus. This one will be in the Kenora Room, on Thursday May 29th 2014, from 11:00am to 12:30pm.

Background:
Body mass indices (BMI) of youth change when they immigrate to a new country. This occurs by the adoption of new behaviors and skills, a process called acculturation.

Objectives:
We investigated whether differences existed in BMI by location of birth (Canadian vs foreign born) across 7 ethnic groups, both individually and together. We also examined whether time since immigration and health behaviors explained any observed BMI differences.

Methods:
Data sources were the Canadian Health Behaviour in School-Aged Children Study and the Canada Census of Population. Participants were youth in grades 6-10 (weighted n = 19,272). Sociodemographic characteristics, height, weight, and health behaviors were assessed by questionnaire. WHO growth references were used to determine BMI percentiles.

Results:
Foreign-born youth had lower BMI than peers born in Canada, a relationship that did not decrease with increased time since immigration. Similarly, East and South East Asian youth had lower BMI than Canadian host culture peers. Finally, Arab/West Asian and East Indian/South Asian youth born abroad had lower BMI than peers of the same ethnicity born in Canada. These differences remained after controlling for eating and physical activity behaviors.

Conclusions:
Location of birth and ethnicity were associated with BMI among Canadian youth both independently and together.

Implications:
Our findings stress the importance of considering both ethnicity and location of birth when designing and implementing interventions. While currently either one or the other is addressed, our study shows there is heterogeneity in BMI by specific ethnic groups depending on whether they were born in Canada or not.

As always I’ll be trying to livetweet the conference. I’ll be using the #CPHA2014 hashtag, so feel free to follow along online! As always, there are a wide range of presentations and workshops, so I’m excited to attend.

If you’re attending the conference, leave a comment with details of your own presentation so that other readers can attend your talks. And if you see me at the conference, be sure to say hi!

This was posted simultaneously on MrEpidemiology.com

Category: Admin, Determinants of health, Epidemiology, Science Outreach, Social Media | Tagged , , , , , , | Leave a comment

The Revolution is Nike? Staying fit in the era of ‘Big Running’

Photo: Lindsay Kobayashi

Photo: Lindsay Kobayashi

Two nights ago, I ran the Nike ‘We Own the Night’ 10 kilometre run in London, United Kingdom.  ‘We Own the Night’ is targeted at women, encouraging health and fitness in a safe and non-competitive environment.

WE. JUST. RUN.

WE ARE GIRLS INSPIRED.

WE OWN THE NIGHT.

IT’S MORE THAN JUST A RACE.

IT’S A MOVEMENT.

'We Own the Night' race gear | Photo: Lorena Fuentes

‘We Own the Night’ race gear | Photo: Lorena Fuentes

What’s the movement? Well, it’s about being a healthy and fit runner, where you are also empowered as a woman by running at night time.  And of course, it’s about wearing Nike while you do it.  Is this a bad thing?  At a time when lack of physical activity and the epidemic of overweight and obesity is one of the biggest global health concerns, the increased popularity of running events like ‘We Own the Night’ could be a positive sign for social trends in activity.

Pre-race group shot | Photo: Lindsay Kobayashi

Pre-race group shot | Photo: Yegee Lee

I rolled up to Victoria Park in London with my two female friends who cajoled me into entering, and we marvelled at the watertight organisation of the event.  There might as well have been giant neon Nike signs directing us to the park.  In some places, there really were.  Bright green and purple (the race colours) lights illuminated the trees leading up to the park.  Feeling like lemmings, we joined the steady stream of girls dressed in neon spandex and the identical turquoise race t-shirt that we were all instructed to wear.  We checked our gear bags, danced around to the DJ already spinning beats from the massive festival stage, and went to warm up.

At this point, we began to realise that this event was not about running at all.  It was about Nike making money, capitalizing on a discourse of empowerment and health for women by partaking in ‘We Own the Night’.  On our way to warm up, we passed two girls decked out in their race gear, downing ice cream from the food carts – with 15 minutes to go before the race start.  Everyone was snapping pics with the Nike branding washed over the park and checking out the shopping and photo ops in the Elle tent (a co-sponsor of the event).

Aside from us and one lonely male runner – no one out of the 10,000 entrants warmed up on the park’s track specifically designed for running.

An empty running track at warm-up time

An empty running track at warm-up time | Photo: Lindsay Kobayashi

Instead, there was an official warm-up, where instructors decked out in Nike gear on the main stage led the group through a series of aerobics.  Ok, a warm-up is good… But since when have aerobics been a preparation strategy for long distance running?  When was the last time you saw Mo Farah do aerobics before crossing the start line of a 10k race?  I understand the nature of the group event that includes all fitness levels, but if Nike really wanted to empower women to begin and continue to include running in their lifestyles, maybe they should take away the pre-race ice cream cart and teach us how to properly warm up for a running distance that requires a delicate blend of speed and endurance.

The start line | Photo: Yegee Lee

The start line | Photo: Yegee Lee

And how was the race itself? It was mostly great.  The course was clearly marked, helpful volunteers were everywhere, and there were water stations and live music at various points.  The level of organisation, demonstrative of the power Nike has to throw around, was a nice benefit to being at corporate event.  At the finish line, we all received a custom-made necklace by a London designer, Alex Monroe.  Monroe designs jewellery for Liberty London, who also has a partnership with Nike.  The necklace was gorgeous.  I overheard many women laughing while citing the necklace as their main reason for entering.  Is that the right type of motivation for exercise?  Let’s not forget that Nike wants us (Londoners in particular) to purchase from their Nike X Liberty Collection and this run was a prime opportunity for advertising.  They have the money to spend on these necklaces if it generates future purchasing and brand loyalty, as I’m sure it will.

And what about feeling empowered, in the first place as being a woman who runs, but also as a woman running at night time?  Does ‘Owning the Night’ mean that I’m a strong, determined, goal-achieving, and perhaps even a feminist woman? If it means that I’ve just participated in a big-branded event that featured running in addition to major product placement under a tenuous discourse of empowerment and fitness, then not at all.  But sure, it can be about empowerment (and I would not say female empowerment, but rather athletic empowerment), if ‘Owning the Night’ is about completing, or hitting a personal best for a 10k run.  And that’s all it needs to be.  As a regular runner who’s done several long-distance races in the past, I didn’t feel like this was a huge milestone for me.  But, I do remember how gratifying and empowering it was when I first began running.  Discovering how far your body can go is a high that’s completely indescribable.  I’m sure that many women felt that way on Saturday, and that is a great thing.

The necklace | Photo: Lindsay Kobayashi

The necklace | Photo: Lindsay Kobayashi

Running doesn’t need to be so branded.  To be active and healthy, we don’t need to be ingrained to desire the latest Nike Free shoes or Nike+ SportWatch, or especially any of the women’s apparel from the ‘Own the Night’ Boutique (yes, it exists, and we were all encouraged to go shopping there before the race).  Running is one of the most accessible forms of exercise out there – all you need are shoes and pavement and you’re set.  If more people ran, the population would enjoy incredibly higher levels of health and well-being.  It’s important to not get tied up in the discourse of feeling fit and empowered because the branding makes you feel that way, rather than because you are actually getting fit and achieving goals.  Of course, the two things aren’t mutually exclusive – corporate sponsorship and athletics have gone hand in hand for years.

But, the bottom line remains that Nike, among all other brands, just wants us to buy their stuff.  It’s arguable that there are many greater evils than selling fitness, but that’s a whole other conversation.  Of course, Nike does do positive, action-based things – they hold races this like one, organise running clubs, donate to charities, and provide training plans, but that’s also part of their marketing strategy.  If you exercise, you are also a consumer and the bottom line of big companies like Nike is always to profit from you.  Don’t get me wrong, ‘We Own the Night’ was great fun and memorable event.  I will probably purchase from Nike in the future, and I am definitely going to wear my Alex Monroe/Nike branded necklace.  I just refuse to accept the subtle marketing idea that I need Nike (or any other big brand) to be an empowered, healthy, and fit individual.  We need to be aware of the effect branding can have on us, especially when it comes to health.  Focus on feeling empowered, healthy, and fit because it comes from within you and what you do, rather than from buying into a brand that sells you that image.

Category: Epidemiology, Fitness, Industry, Running, Social Media | 4 Comments

Male Circumcision Part 5: Measuring Health Provider Burnout

Since 2007, The WHO and UN AIDS have been recommending voluntary medical male circumcision (VMMC) as an important strategy for HIV prevention, particularly in settings with high HIV prevalence and low levels of male circumcision (1).

This is of course a lofty and ambitious goal. In order to obtain the 80% coverage they would need for this campaign to be successful, these public health professionals would have to perform 20.33 million circumcisions between 2011-2015, and a further 8.42 million from 2016-2025.

VMMC Collection Image CollageAs you can imagine, this campaign requires an incredible amount of time and resources, and the impact this can have on practitioners is an important aspect of delivery. Not only must these people be trained medically to perform these procedures quickly and efficiently, they must also be taken care of to ensure that they can sustain delivery of the program and quit. This is a particular problem in the countries participating in the study, as they have critical shortages of healthcare professionals who are qualified to perform these procedures, with none having more than 1 physician per 1000 people. However, very little research has focused on these individuals and the consequence of being involved in these interventions.

How does the VMMC campaign impact practitioners?

To further our understanding of what happens to these healthcare providers, Perry and colleagues conducted a research study, recently published in the journal PLOS ONE (7) as part of the new VMMC collection. Practitioners in Kenya, South Africa, Tanzania and Zimbabwe were surveyed in 2011 (n=357) and 2012 (n=591). The study intended to describe the medical professionals associated with VMMC in these countries, differences between the countries, as well as then look at factors associated with job-related burnout.

Their findings were striking. In 2011, Tanzanian providers had very specific surgical roles, with some only performing the surgery (47%), and some exclusively assisting (12%). However, by 2012, this had shifted, with 99% both performing and assisting depending on need.

Filling the Training Gap

Very few providers had received formal training in VMMC in medical and nursing school, with the notable exception being Kenya, where 21% of providers received training. In the remaining countries, less than 5% of providers received this training in medical school. To counter this in the VMMC scale-up, almost all providers received additional VMMC specific training (above 97% in all countries but South Africa).

Program Duration and Burnout

In terms of duration of work, the median number of months each provider was performing VMMC ranged from a low of 10 months in South Africa, to a high of 31 months in Kenya. Research findings showed that providers had performed between 400 and 2400 procedures during their time in the VMMC program, with some as high as 4700.Burnout was incredibly common, with a shocking 89% of Kenyan providers reporting that they had witnessed feeling burnout frequently or occasionally, a number that was considerably higher than their South African (49%) and Zimbabwean (36%) peers.

The chaps_soweto campaign. Image source:

So how do we prevent burnout?

Here’s where things get interesting. Once the researchers had all the information above, they could start looking at what predicts burnout, and thus provide guidelines on tangible issues that can be targeted for change. Factors such as age and number of months worked were significantly associated with burnout – the older you are, and the longer you work there, the more likely you were to burn out. Not all the findings were this predictable.

Conversely to what you might expect, according to the study, burnout was not due to number of surgeries performed. Those who performed a high volume of surgeries, i.e. 1000 or more, were less likely to report being burnt out than those who did a low number, i.e. less than 100.

In fact, those who performed a high number of surgeries were half as likely to burn out as those who did a low number. Speculatively, this may be due to a high dropout rate at the start of the process, or a “mental resiliency” that is built up from doing a high number of procedures. One of the most positive findings was that providers reported their work as being very fulfilling. However, this didn’t prevent burnout. Despite almost all Tanzanian providers reporting work fulfillment, burnout still persisted.

When asked about why they continued, many VMMC providers expressed pride in their work, and the reward that came from knowing they were helping their own community.

Tapping into this feeling of doing important and valuable work, as well as providing support for those who are new to the VMMC clinics, might help turn the tide on the spread of HIV.

References

1) World Health Organization. Voluntary medical male circumcision for HIV prevention. http://www.who.int/hiv/topics/malecircumcision/fact_sheet/en/ (accessed 22 April 2014).

2) Baily RC, Moses S, Parker CB, Agot K, Maclean I, Krieger JN, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. Lancet 2007;369(9562):643-56.

3) Njeuhmeli E, Forsythe S, Reed J, Opuni M, Bollinger L, et al. Voluntary medical male circumcision: modelling the impact and cost of expanding male circumcision for HIV prevention in eastern and southern Africa. PLOS Med 2011;8:e1001132. doi:10.1371/journal.pmed.1001132

4) Hankins C, Forsythe S, Njeuhmeli E. (2011) Voluntary Medical Male Circumcision: An Introduction to the Cost, Impact, and Challenges of Accelerated Scaling Up. PLOS Med 2011;8(11):e1001127 doi:10.1371/journal.pmed.1001127

5) Centres for Disease Control and Prevention. Male Circumcision. http://www.cdc.gov/hiv/prevention/research/malecircumcision/ (accessed 22 April 2014).

6) Patterson BK, Landay A, Siegel JN, Flener Z, Pessis D, Chaviano A, et al. Susceptibility to human immunodeficiency virus-1 infection of human foreskin and cervical tissue grown in explant culture. Am J Pathol 2002;161(3):867-73.

7) Perry L, Rech D, Mavhu W, Frade S, Machaku M, Onyango M, Adudde DSO, Fimbo B, Cherutich P, Castor D, Njeuhmeli E, Betrand J. Work experience, job-fulfillment and burnout among VMMC providers in Kenya, South Africa, Tanzania and Zimbabwe.

Go here to find all the papers in Voluntary Medical Male Circumcision (VMMC) for HIV Prevention: Improving Quality, Efficiency, Cost Effectiveness, and Demand for Services during an Accelerated Scale-up

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Male Circumcision Part 4: “Public Health is a Noble Profession”

As part of our special coverage of the Voluntary Medical Male Circumcision collection, I recently sat down with Emmanuel Njeuhmeli, a public health physician who was heavily involved with the VMMC initiative. For those interested in a career in public health, and in infectious disease epidemiology, his perspective is enlightening.

3_E Njeuhmeli_Iringa Tanzania External Quality Assurance Site Visit_Oct 2013

Emmanuel Njeuhmeli at Iringa,Tanzania for an External Quality Assurance SiteVisit_Oct-2013

1: Hi Emmanuel, and thank you for taking the time to speak with us. To start, could you tell me a little about yourself?

I am a public health physician holding a medical degree and two master’s degrees, one in public health and the other in business administration. I have been involved with HIV/AIDS prevention, care and treatment program design, coordination, implementation, monitoring, and evaluation since 1998 in various countries, mostly in Central, West, Eastern and Southern Africa. I have been involved with the scale-up of Voluntary Medical Male Circumcision (VMMC) since November 2008.

 

2: How did you get involved with USAID? How long have you been there?

 After graduating from medical school, I was involved with both public health and clinical medicine for several years, mostly implementing HIV/AIDS prevention, care and treatment in the field in several countries. I decided to go back to school and get a Master of Public Health degree (MPH) and an MBA to be able to work at a more strategic planning level, building on my skills and experience gained in the field. I have been with USAID since November 2008 as Senior Biomedical Prevention Advisor. In this position, I am the Agency technical lead for providing support to priorities countries in Southern and Eastern Africa to introduce and accelerate the scale-up of VMMC. During these years, I have also been Co Chair of the PEPFAR Male Circumcision Technical Working Group (ed note: PEPFAR = United States President’s Emergency Plan for AIDS Relief).

3: Why male circumcision? That’s not usually an approach you hear about when you consider HIV reduction strategies.

There is a biological explanation for why circumcised men have lower rates of infection with HIV and several other sexually transmitted infections. Studies have shown that the foreskin contains many immune system target cells, for example Langerhans cells. Like other immune cells, they have an affinity for foreign bodies including HIV. In addition, the warm, moist area under the foreskin promotes the growth of bacteria, particularly anaerobic bacteria, which are associated with inflammation and may recruit additional immune cells to the area, further increasing vulnerability to HIV infection. The foreskin is also a delicate mucosal tissue that is more vulnerable to micro-tears and other breaks in the skin than is the tougher, more keratinized skin of the circumcised penis. Finally, uncircumcised men have higher rates of other STIs, which we know are a risk factor for HIV acquisition.
4: How long has this project been in the pipeline?

The scientific papers summarizing the results of the three clinical trials were published in 2005 (South Africa) and 2007 (Kenya and Uganda). In March 2007, the World Health Organization and the Joint United Nations Program on HIV/AIDS (UNAIDS) issued a recommendation that countries with high HIV prevalence and low male circumcision rates should add VMMC to their prevention programming. Following this recommendation, many countries in the East and Southern Africa region began the process of adding VMMC to their HIV prevention programs, and shortly after that, PEPFAR and the Bill and Melinda Gates Foundation (BMGF) made resources available to support the scale-up of VMMC, engaging implementing partners to support Ministries of Health in the priority countries. In December 2011, global partners including UNAIDS, PEPFAR, WHO, BMGF, the World Bank, in consultation with the priority countries, launched a five- year action framework to further accelerate the scale-up of VMMC. The papers included in this PLOS collection summarize many of the lessons learned during the accelerated scale up, during which time nearly 6 million men and adolescent boys have been reached with comprehensive VMMC services. This includes risk reduction counseling, HIV testing and linkage to care if necessary, STI screening and treatment and condom provision and promotion.
5: What was the hardest part of doing this project?

 Introducing a new health product or service is never easy, but scaling up VMMC seemed particularly daunting at the outset because the task involved providing millions of surgeries – in countries with an acute shortage of healthcare workers and very limited surgical capacity – to a population (young men) that typically has very little interaction with the health system.

To be honest, many people doubted that it could be done at all, let alone safely. What these papers demonstrate is that it is indeed possible to rapidly scale up safe and high quality services, even in resource constrained settings. The VMMC community has worked hard to document our lessons learned so that others working in the HIV response and in other critical health areas can learn from our experiences.

 

6. What has the reaction been “on the ground”? Have people bought into the project or has it been a very slow process?

Overall the VMMC scale-up has been very successful, although progress has been greater in some countries than in others, largely due to differences in demand for the service. At present, all 14 countries have embraced the HIV prevention potential of VMMC and are moving forward with the scale-up. We find that in many settings, HIV prevention program managers and frontline healthcare workers embrace the opportunity afforded by VMMC, which is different from many other prevention strategies in that a relatively brief interaction with the health system will provide a man a lifetime of partial protection. This is not to say that it has been easy; male circumcision is closely associated with culture and religion in many African countries, and it has been very important to involve community and religious leaders, including traditional and political leaders, so that people understand that VMMC is about promoting health rather than changing one’s culture, ethnicity or religion. Adolescents have been early adopters of VMMC and in some cases have encouraged adults in their communities to examine their stance on medical male circumcision.
7: What could the future public health implications be of your work?

 My work over the past six years has focused on the introduction of VMMC as a new HIV prevention intervention, and subsequently, acceleration of the scale-up of VMMC in priority countries in Eastern and Southern Africa. VMMC was recommended in March 2007 by WHO and UNAIDS for countries with high HIV prevalence and low male circumcision prevalence as part of their HIV prevention portfolio.

Scaling up VMMC would avert millions of HIV infections, saving lives and significantly decreasing the future investments needed to provide HIV treatment. Modeling studies have shown that a combination approach of scaling up both VMMC and HIV treatment would have the largest impact on the epidemic and would be more cost-effective than scaling up treatment alone. VMMC is one of the most effective and cost-effective HIV prevention approaches currently available.

In 2011, we published results from mathematical modeling we did in collaboration with UNAIDS demonstrating that countries in Southern and Eastern Africa have the opportunity to avert potentially close to 3.4 million new HIV infections in the next 15 years and generate a potential cost savings of $16.5 billion in treatment costs if VMMC is  scaled up.  We also demonstrated that while the intervention focuses on males, the benefits are for both males and females. In a country like Zimbabwe, for example, scaling up VMMC alone could potentially avert up to 42% of new HIV infections that would have occurred otherwise. The faster the program can be brought to scale, the higher the impact will be, so any day or month that passes without this intervention being scaled up is a missed opportunity.
8: What advice do you have for future public health professionals who are interested in field work?

 Public health is a noble profession that allows us to save people’s lives millions at a time with our work. With adequate resources, one is able to identify health issues faced by specific populations, look for evidence in terms of what interventions can be implemented to overcome those issues, design the interventions and implement them efficiently. It is rewarding when you evaluate the work done and you can translate that work into numbers of lives saved.

My advice for any young public health professional is to gain experience in the field. They need to understand the population they intend to support and there is only one way to do that besides looking at the data, and that is to involve the community from the beginning in the solutions that are meant to address their health issues. Community buy-in is key in implementing any public health program.  The knowledge and experience you acquire while consulting with community stakeholders is invaluable.

 

We’d like to thank Emmanuel Njeuhmeli for offering his time and insight for this interview. For those interested in learning more, the PLOS open access VMMC collection can be found here:  Voluntary Medical Male Circumcision (VMMC) for HIV Prevention: Improving Quality, Efficiency, Cost Effectiveness, and Demand for Services during an Accelerated Scale-up


 

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Male Circumcision Part 3: Why Some Men Resist the Next Best Thing to an AIDS Vaccine

In the Zimbabwe campaign Lindsay wrote about yesterday, public health messages have the look of a party invitation for the modern man – and his female partner. An attractive couple looked out from a breezy ad offering a free “summer snip.” A group of legislators underwent the operation in a makeshift clinic outside the Parliament building in Harare. Celebrity musician Jah Prayzah got circumcised and then gave an interview wearing a shirt reading: “I DID IT. Why haven’t you?”

This poster from the "Stand Proud, Get Circumcised" campaign was hung above urinals in Zimbabwe. Used with permission. © 2011, Johns Hopkins University. All rights reserved.

This poster from the “Stand Proud, Get Circumcised” campaign was hung above urinals in Zimbabwe.
Used with permission. © 2011, Johns Hopkins University. All rights reserved.

A study in the new PLOS VMMC Collection, Barriers and Motivators to Voluntary Medical Male Circumcision Uptake among Different Age Groups of Men in Zimbabwe, describes the intent of this campaign to portray circumcised men as “confident, outgoing, sexually appealing, and set to succeed in life.” No question this is a cultural or “social norm” appeal.  And, although progress in Zimbabwe is slow, this message, built as it is around modernity and personal attractiveness, may yet work. Read more about the Zimbabwe VMMC campaign, and in particular the roles played by women, in Lindsay Kobayashi’s recent post.

But another paper in the new PLOS VMMC Collection, Attitudes, Perceptions and Potential Uptake of Male Circumcision Among Older Men in Turkana Couny, Kenya Using Qualitative Methods, suggests that staying away from such a cultural pitch in favor of a strictly health promotion message may prove to be a more viable way to reach different, particularly rural, and older audiences.

Cultural Complications

In Kenya, circumcision rates are generally already high, but men from certain ethnic groups are still vulnerable because they traditionally do not circumcise. One such group, the Turkana, is native to a semiarid area in the northwest corner of Kenya. There is a county headquarters and a few small towns, but most Turkana live outside of them, raising whatever livestock the minimal grass and water supply can support—often camels—and fending off raids from neighboring ethnic groups with whom they’ve been at war for decades.

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Photo by Filiberto Strazzari, CC-BY

 Minding A Significant Gap Between Generations

Kate-Macintyre_1

Kate Macintyre, a global health and infectious diseases researcher at Tulane University

Among the Turkana, some of the younger men are buying in, but circumcision is very rare in those over the age of 25.

Kate Macintyre set out to find out why. Macintyre, with Moses Natome, a young researcher from Turkana, put together a team of Turkana-speakers to conduct interviews and focus group discussions, asking community leaders to refer people to the study. They spoke with men who weren’t circumcised and men among the 5-10% of Turkana who are. They spoke with women about their opinion of circumcision in their male partners. And they spoke with people in a range of settings, rural, urban, and in-between.

HIV rates are high in this corner of Kenya; the trade route from Sudan and the one that brings fish from Lake Turkana into the desert may also be highways of HIV transmission. Geographically remote and socially isolated, Turkana are hard to reach with public health interventions. Poverty is rampant, and the area includes only a handful of hospitals and health centers. “They have been very isolated and apart from the social development of the country in the last 50 years,” says Macintyre.

Macintyre’s survey showed a range of opinion as to why older men might not want to get circumcised, and confirmed a major barrier: the fact that so many of the Turkana’s neighbors and enemies circumcise. Of Kenya’s 45 ethnic groups, the Turkana are one of just three that don’t practice circumcision as a traditional rite of passage. Natome sums up the consensus: “If you are an older, rural man, to get circumcised is to be ridiculous and to side with your enemies.”

In the interviews, many of the Turkana men explained that their culture’s ritual of Asapan holds the same significance that circumcision holds for the other groups. You can watch a video of Asapan here: it’s a ceremony that celebrates the social promotion of a man to senior elder status, and it is considered a great honor and privilege to go through it. One older uncircumcised man told Macintyre’s researchers: “On my side, God gave me ‘Asapan’ and circumcision to the other tribes as their culture.” Undergoing both, said several men, could cause a person to go mad from being caught between cultures.

But the Turkana may already be caught between cultures: urban and rural. Younger men who live in or near the big towns increasingly see circumcision as a social norm; to them, says Macintyre, forgoing the surgery is old-fashioned. While older rural men fear ridicule from circumcising, younger urban men fear it from not doing so. One described his friend persuading him: “Let’s go and circumcise. How can we continue like this and let other people ridicule us?”

Typical public health campaigns, like the one in Zimbabwe, aim to tie interventions to culture. But Macintyre warns that circumcision won’t take off in the remoter rural communities unless it’s presented as a purely medical intervention. It may not be traditional, but neither is the devastation of AIDS. A circumcised man described the shift:

 We used to hear our parents say ‘it’s the Pokot, Samburu, Borana and Somali who circumcised.’ But somewhere between there emerged this “Lokwakel” (HIV/AIDS), which wiped out families leaving destitute children. We cried and we decided to circumcise because it was important for us to take care of ourselves and our families.

This is the message Macintyre thinks will get through: protecting your family by making a healthy choice.

“It’s an extremely sensitive topic at the moment,” says Macintyre, but not as much as it was even five years ago. She believes some leaders in the rural areas see circumcision as the way of the future, but few are ready to say so publicly. “There’s still considerable resistance in the remotest areas the study reached,” she says. “It depends on leadership, and who’s talking, and whose son has been away to Nairobi and told them about life outside, and whether they see HIV as a risk close at hand.”

The circumcision campaign’s success also depends, she says, on the quality and consistency of health services. Many of the area’s health centers have no running water; ensuring that they can safely perform the operation is possible, but logistically complicated. The better the services the first few men see, she says, the more confidence everybody will have and the more men she expects to come forward.

The Public Health Perspectives introductory post to this seriesPart 1: How Male Circumcision Can Get Us Closer to an “AIDS-Free Generation”

Go here to find all the papers in Voluntary Medical Male Circumcision (VMMC) for HIV Prevention: Improving Quality, Efficiency, Cost Effectiveness, and Demand for Services during an Accelerated Scale-up

 

 

 

 

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Male Circumcision Part 1: How It Can Get Us Closer to an “AIDS-Free Generation”

This week the Public Health Perspectives blog team offers a total of five posts highlighting and interpreting findings in an important new PLOS research collection, Voluntary Medical Male Circumcision (VMMC) for HIV Prevention: Improving Quality, Efficiency, Cost Effectiveness, and Demand for Services during an Accelerated Scale-up. This research documents the work of global health doctors and public health workers toiling in the epicenter of the global epidemic – SubSaharan Africa – where over 16 million people currently live with HIV and where new HIV infection rates are highest. It also presents some surprising and enlightening results from surveys of VMMC clients and prospective clients, men and women with the most at stake in the battle against HIV-AIDS.

Circumcision clinic

Bapong Health Centre, Bapong, North West, South Africa Credit: Gaph Phatedi, CHAPS

The following introductory post includes some background on voluntary medical male circumcision (VMMC) with reporting by Public Health Perspectives bloggers Atif Kukaswadia,  Beth Skwarecki and Lindsay Kobayashi. In the course of the week, each PHP  team member will publish a separate post, incorporating interviews with collection authors, to examine individual papers and themes in the research.

We hope you’ll get involved with our PLOS-wide discussion on the important topic of HIV-AIDS prevention by reading the collection papers, offering comments on blog posts, posting on the PLOS Facebook page, or tweeting to the collection hashtags #MaleCirc  and #PLOSVMMC2014.

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How Voluntary Medical Male Circumcision Can Get Us Closer to an AIDS-free Generation

There’s still no vaccine for HIV, but it’s not for lack of trying. Thirty-seven trials are ongoing right now, according to the International AIDS Vaccine Initiative. If one were to prove even partially effective, it would be a major boon to public health: even a halfway effective vaccine, given to a fraction of its target population, could still save millions of lives in Africa. There, 1 in every 20 adults is living with HIV, and over 17 million children have lost one or both parents to AIDS.

Rather than waiting for the long-promised vaccine, public health agencies across the African continent, with major assistance from the US and other donors, are rolling out an intervention that trials have shown is almost as effective: circumcision for men.

First things first, what is VMMC and how does it prevent HIV infection?

Circumcision is the surgical removal of the foreskin on a male’s penis. In uncircumcised men, the area under the foreskin can be more vulnerable to infection by the HIV virus (and to other STIs including gonorrhoea and syphilis), due to its microenvironment. In the first decade of this century, epidemiological studies and randomised clinical trials have provided consistent and compelling evidence that male circumcision helps to prevent HIV transmission. As a result, the WHO and UNAIDS have been recommending since 2007 that voluntary medical male circumcision as an important strategy for HIV prevention, particularly in settings with high HIV prevalence and low levels of male circumcision, where the public health benefits will be maximized.

Because the skin cells under the foreskin are particularly vulnerable to HIV infection, circumcision reduces a man’s chance of being infected by 60%. (That’s about the same success rate as last winter’s flu shot). It’s not a complete solution to the AIDS epidemic, since it does nothing for male-to-female transmission; and because it’s only partially effective, condoms are still crucial. But safe sex messages have obviously fallen short. Circumcision is promising because it’s a one-time action: a few minutes in the operating room, and you’re (partially) protected for life.

The PLOS VMMC Collection assesses ongoing efforts in 14 countries in Eastern and Southern Africa to scale up voluntary medical male circumcision (VMMC) programmes to prevent HIV transmission. These countries are Botswana, Ethiopia, Kenya, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe.

Containing a comprehensive PLOS Medicine review, plus 13 original PLOS ONE research articles, the collection authors recommend increasing program efficiency and by identifying and prioritizing those most at risk of acquiring HIV, matching supply with demand and focusing on quality at all levels.

Because of its proven effectiveness when studied in multiple randomized, controlled clinical trials, male circumcision could be used almost like a vaccine to help prevent HIV. Based on modelling studies published in PLOS Medicine in 2011, if 80% of men aged 15 to 49 in these countries underwent circumcision, about 3.4 million new HIV infections would be prevented and US$16.5 billion in averted HIV-related costs would be saved.

In the resource-poor countries involved in the VMMC campaign, these savings would go a long way in supporting other forms of health infrastructure, not to mention the millions of human lives saved.

Today, voluntary medical male circumcision is designed to be part of a comprehensive package for HIV/AIDS treatment — one that includes treatment and counselling, screening, condom promotion and health education.

Some countries in southern Africa show low rates of HIV testing, and enrollment in Antiretroviral Therapy (ART) treatment is even lower. In countries such as Lesotho and Zimbabwe, voluntary medical male circumcision services are seen as an effective strategy to attract men to HIV testing and counselling and link them to continuing care and treatment, since early diagnosis of HIV and treatment initiation at higher CD4 counts improves outcomes and reduces HIV transmission.

The Multiplied Benefits of VMMC for Men and Women

VMMC involves a one-time procedure and offers men life-long benefits, including greatly reducing their risk of acquiring HIV and many other sexually transmitted infections (STIs), such as herpes, syphilis and human papilloma virus (HPV). In addition, female partners of circumcised men also have benefits, including lower rates of cervical cancer (the leading cancer killer among African women) and bacterial vaginosis, a condition that has been associated with pre-term birth.

Iringa campaign vmmc

Clients line up in Iringa, Tanzania to receive circumcision services; Credit: Jhpiego/Tanzania

In some parts of Africa, men are lining up to be circumcised—over 2 million in 2013, bringing the total since 2007 to around 6 million. However, in certain countries, particularly among rural people and those over the age of 25, slow uptake of VMMC is a concern to local and international health agencies. Reflecting this on-the-ground reality, several papers in the collection probe the causes and potential solutions to the challenge of “demand creation.”

emmanuel

Emmanuel Njeuhmeli, Senior Biomedical Prevention Advisor at the US Agency for International Development and lead author of the collection, “on the ground” during the VMMC campaign.

The importance of documenting lessons learned thus far in the VMMC program implementation was discussed by Emmanuel Njeuhmeli, Senior Biomedical Prevention Advisor at the US Agency for International Development and lead author of the collection, in an interview posted  on the PLOS Speaking of Medicine blog:

“Scale-up of VMMC is critically important to reduce the future burden of HIV, particularly in high prevalence regions, such as Eastern and Southern Africa. HIV infections are happening every day among uncircumcised men in the region and this can easily be prevented. Each day that this proven prevention method is not brought to scale represents a missed opportunity to bring us closer to reaching an AIDS-free generation.”

We invite you to stay with us throughout the week to learn more. Also posting today is an in-depth interview with Emmanuel Njeuhmeli about the program he oversees in 14 countries — and how researchers documented its progress and remaining challenges in the new PLOS VMMC Collection.

Read other posts in this series:

Male Circumcision Part 2: His Choice and Her Influence

Male Circumcision Part 3: Why Some Men are Resisting the Next Best Thing to an AIDS Vaccine 

Male Circumcision Part 4: Public Health is a Noble Profession

Male Circumcision Part 5: Measuring Health Provider Burnout 

 

Category: Epidemiology, Guest Posts, Health systems, Infectious disease | Tagged , , , , , , , , , , , | 30 Comments

Male Circumcision Part 2: His Choice and Her Influence

Circumcision can be done for a range of religious, cultural, or medical reasons, and it’s often a mix of these things. Being circumcised is somewhat of a social norm, and the success of the VMMC programmes in areas where men typically aren’t circumcised relies on creating a demand among adult men to be circumcised – a shifting of a social norm.

In Zimbabwe, the rate of male circumcision prior to implementation of the VMMC programme was among the lowest in the Southern African region at 10% (1). Since the programme began in 2009, the numbers of new adult circumcisions has been lower than expected, with only 170,000 men circumcised against a five-year target of 1.9 million.

A new study published as part of the PLOS VMMC collection explored the barriers and motivators for circumcision among men in Zimbabwe, to understand why the circumcision rates are so low (2). The study authors conducted a nationally-representative survey in February 2013 of 2350 Zimbabwean men and women aged 15 to 49. Half of the survey respondents were women and half were men, which provided an interesting opportunity: the chance to learn about women’s perspectives towards circumcision, as they may influence their male sexual partners’ decisions to be circumcised.

A gap between knowledge about circumcision and actually having it done

In the survey, two-thirds of the Zimbabwean men (68%) and just over half of the women (54%) had heard about VMMC as a way to prevent HIV transmission. Most men (over 80%) knew that VMMC can protect against sexually transmitted infections, that it improves penile hygiene, and that VMMC is only partially protective against HIV transmission and circumcised men still need to used other HIV prevention methods (2). So, it seems like most people have correct knowledge about VMMC. However, only 11% of men were actually circumcised (the same as the nation-wide rate in Zimbabwe). The remaining men either said that they intended to get circumcised (49%) or that they were not interested in getting circumcised (40%). This gap between knowledge and behaviour brings about an important question: why do men who know about a simple medical procedure to help prevent HIV not want to get it done?

healthy black men billboard

Why adult men do or don’t get circumcised

Among the men who said they were willing to be circumcised, over 90% said that they would do it to prevent HIV and other STIs (2). A second common reason among all men was to improve their hygiene. Interestingly, older men also said they would do it to improve their sexual performance and to set a good example for their community. When the men who did not want to be circumcised were asked why, the most important reason was fear of pain during the procedure. Other barriers to circumcision were that some men believed that they weren’t at risk for HIV and that they weren’t promiscuous. Misconceptions such as having the testes cut by mistake, and worry about having to take an HIV test before being circumcised were reported by some men as well.

The important influence of women

Importantly, social support was a major motivator for circumcision. Men who said that they had support from friends were three times more likely to have been circumcised than men who didn’t. Among older, married men, partner refusal was a major barrier to being circumcised. In the study, one man reported that his wife “confronted him and subsequently discouraged him from going for VMMC.

She [wife] asked ‘why do you want to go for circumcision when you are already married? They say it offers prevention from HIV; where do you think the HIV will come from?’” (2).

This issue of marital trust is a sticky issue, and may require careful communication to the public from VMMC programmes in order to increase support within committed couples. However, over 70% of women in the study who had heard of VMMC reported being supportive of their male partner being circumcised, which means that women may be an important source of influence in promoting circumcision as a social norm among men in Zimbabwe.

Promoting circumcision as the ‘smart’ choice for men
Image source: kubutanablogs.net

 

What does it all mean?

Clearly, lack of awareness or knowledge is not the major barrier to circumcision among adult men in Zimbabwe. Most men had heard about VMMC as a way to help prevent HIV, and had good knowledge about it. However, 40% of men still had no interest in being circumcised. The main barriers were fear of pain, misconceptions about circumcision, and lack of support from their partners. Importantly, only half of women had heard about VMMC to help prevent HIV, which means that women need to be better informed to help support their male partners. Given that the women who knew about VMMC were mostly positively towards having their partner circumcised, women probably represent an important influence upon the success of the VMMC programmes to reduce rates of HIV.

The Zimbabwe Ministry of Health and Child Care has used these and other research findings to inform a mass media campaign that frames VMMA as a lifestyle choice for the “’smart’ man, one who is clean and elegant” (2). Importantly, some of their messages have been tailored towards women to improve their knowledge by highlighting that VMMC improves a man’s hygiene and sexual appeal, while also protecting against cervical cancer.

Will the campaign work? It is a difficult thing to change health-related social norms at a population level, but we have seen it occur in Westernised countries with breast screening and mass immunisations.

The VMMC programmes and Zimbabwean health ministry are taking positive, evidence-based steps forward in promoting adult male circumcision. Hopefully time will tell us a major success story in the reduction of the HIV epidemic with these efforts.

References

1)      Central Statistical Office (CSO) [Zimbabwe] and Macro International Inc. 2007. Zimbabwe Demographic and Health Survey (ZDHS) 2005-6. Calverton, Maryland: CSO and Macro International.

2)      Hatzold K, Mavhu W, Jasi P, Chatora K, Cowan FM, Taruberekera N, et al. Barriers and motivators to voluntary medical male circumcision uptake among different age groups of men in Zimbabwe: results from a mixed methods study. PLOS One 2014; 9(5):e85051 doi: 10.1371/journal.pone.0085051

The Public Health Perspectives introductory post to this series, Part 1: How Male Circumcision Can Get Us Closer to an “AIDS-Free Generation”

Read all the papers in Voluntary Medical Male Circumcision (VMMC) for HIV Prevention: Improving Quality, Efficiency, Cost Effectiveness, and Demand for Services during an Accelerated Scale-up

 

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Why it’s so easy to believe our food is toxic

toxic waste

Photo by Hans-Peter via Flickr. There are more photos in this creative and beautiful series.

Nutrition is a wonderful playground for people who want to manipulate fear. We need food to live, yet can be poisoned by eating the wrong things. Learning from others which foods are safe and which are dangerous was essential to our survival in the days before grocery stores. We are primed to react to scares about food.

We make 200 food-related decisions every day. Food choices are one of the few things we can control as individuals. Believe that the government and big corporations are poisoning you? Just shop a little differently. (Then bond with your friends on facebook about the conspiracies you’ve foiled.)

I teach nutrition at a community college, to students who are interested in the subject but have little to no scientific background. I like to think I’m helping them develop their baloney detectors, but there is a lot of, ahem, baloney out there. I even presented some in class: they voted to watch Hungry For Change and I said fine—but we’ll unpack it and, literally, do our homework on the “experts” featured.

Because, as this review clued me in, the film is a bait-and-switch: it draws in the viewer with a lengthy lament on how unhealthy the western diet is, then turns into an infomercial for juicing. One of the experts is introduced as a filmmaker, but oh by the way he sells juice extractors. Another is the Dr. Oz-endorsed author of books about juice-based “cleansing.” (He believes that the problem with “toxins” is that they cause our bodies to produce a spiritual mucus that makes us sluggish.) Not everyone is juice-centric: some are selling other things, like weight-loss meditation CDs.

The movie even gives a specific warning in its first half: beware anybody selling you food that’s supposed to be healthy, because they don’t make money from your health. They make money by making the product attractive enough that you buy it.

Ironically, this describes the tactics used by the peddlers in Hungry for Change. It’s true of the people behind Mercola and Natural News (both of whom were featured in the movie, and both of whom hard-sell conspiracy theories about food and medicine right next to dubious products like earthing mats.) And it’s true of my favorite purveyor of facebook-borne rumors, the Food Babe.

She sells meal plans and endorses superfood supplements, but positions herself as an “investigator” of the dangers in foods. The tactic, it seems, is to make people feel that the world is so full of dangerous foods that they better pay for her meal plans that specify what she believes is safe to eat.

But behind the unified front (all processed food is dangerous!) lies a tangled web of factoids. Some are clearly not true, like her claims about GMOs (for a good read on which GMO claims are myths and which are real, I highly recommend Grist’s series.) Others are true, but only scary if you don’t think about them too much – like when she makes a big deal about “wood pulp” in your food. When you extract cellulose from anything, wood or otherwise, what you get is not chunks of trees in your food, but simply cellulose itself, better known as one type of dietary fiber, the stuff that veggies and whole grains are full of.

Maureen Ogle sent the Food Babe’s list of “shocking” beer ingredients to several actual brewers. MSG? Nope. Fish swim bladders? Sort of, yeah, but they don’t actually make it into the finished beer. Corn syrup? Possibly, but most of it would be food for the yeast, so that means it’s turned into alcohol by the time you drink it.

Alcohol, by the way, is an actual toxin.

Poison

Photo by Andrew Kuznetsov, CC-BY

All this misinformation is a version of the Fear, Uncertainty, and Doubt tactic that’s been recognized as a marketing tool in other contexts. It operates on a guilt-by-association model: if bread contains a chemical that’s also used in yoga mats, you claim that yoga mats are in our food. Nevermind that TUMS contain the same chemical used in gravestones; that’s a great example from Joe Schwarcz’s critique of the Food Babe.

Countering this misinformation is, I think, an important but overlooked target for public health. Education helps: many of the misconceptions about GMOs can be overcome once you actually understand what genetic modification is—although it’s a tricky subject. I survey my students about GMOs, and most are usually suspicious of it. When I ask what’s wrong with GMOs, they respond with some serious, legitimate concerns: pesticide residues, Monsanto’s control over farmers, environmental effects of fertilizer runoff. The only problem with these concerns? They aren’t really about GMOs. Once they learn what GMOs can and can’t do, and how the other problems in modern agriculture would exist with or without GMOs, they’re better equipped to form opinions that, whether I agree or not, are based on something closer to fact.

I’m not often a fan of the deficit model; educating people doesn’t always change their mind. But you can’t spread rumors about Bt toxin in GM corn if you know what Bt toxin is – a bacterial product that has a long history in organic farming and is naturally abundant in soil. (If you boycott GMOs because of it, you have to boycott organic food too.) Ask critics what bothers them about the toxin, and they’ll start talking about RoundUp, a chemical herbicide that’s involved with a completely different GMO crop. (There’s a good explanation of these two GMOs here.)

So how can we baloney-proof people who are honestly trying to find the best information about how to be safe and healthy? I’ll keep teaching and writing about the real science behind what’s in our food, but in the meantime, maybe this message will appeal: when you hear somebody trying to scare you about food, ask what they’re selling. If you distrust Big Ag and Big Pharma, you won’t find any better treatment from Big Juice.

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Vitamin D – should you take it?

Egg yolks contain a small amount of vitamin D istockphoto.com

Egg yolks contain a small amount of vitamin D
iStockphoto.com

My hunch is that it depends. Vitamin D is a nutrient that helps our bodies regulate the metabolism of calcium and phosphate (1). Most vitamin D comes from sunlight, while it is also found in certain foods including fatty fish, mushrooms, egg yolks, vitamin-D fortified foods. For example, milk in many countries is always fortified with vitamin D, and some brands of breakfast cereals and orange juice are fortified as well (2).  Vitamin D can also be obtained through taking vitamin D supplements found at your local grocery or health food store. The classic health consequences of inadequate vitamin D are rickets in children, and low bone mineral density and osteoporosis in older adults (3). Low vitamin D has also been associated with increased risk for many other health conditions including breast, prostate, and colorectal cancer, multiple sclerosis, and cardiovascular disease (4-6). However, the quality of scientific evidence for these relationships varies because it is actually quite challenging methodologically to study the cause-effect relationship of vitamin D on health.

Because definitive high-quality evidence is lacking, the actual beneficial effect of vitamin D on health has been heavily debated in recent years. Like many other dietary or lifestyle factors that have been linked to health outcomes with scientific uncertainty (examples: coffee, alcohol, vitamin C, herbal supplements), the available information about whether to take vitamin D supplements can be very confusing. Here is where we stand right now:

In 2011, the American Institute of Medicine released an expert report on the dietary reference intakes for vitamin D (3). They stated that, for people aged 1 to 70 years old including pregnant and lactating women, the recommended dietary allowance (RDA) is 600 IU per day of vitamin D. For adults aged over 70 years the RDA is 800 IU per day. Intake should not exceed 4000 IU per day for people aged 9 years and over. The full RDA guidelines can be found here. Interestingly, their expert panel concluded that current scientific evidence is insufficient to conclude that vitamin D plays a causal role in non-bone-related health conditions (3). Now, this statement may or may not mean that vitamin D has no effect on health aside from bone conditions, simply that our current knowledge is insufficient.

Supplements can be a good source of vitamin D istockphoto.com

Supplements can be a good source of vitamin D
iStockphoto.com

Fast forward to today, and it doesn’t seem like our evidence base has evolved much. An ‘umbrella’ review of evidence on the link between blood plasma concentrations of vitamin D and 137 unique health outcomes was published in the British Medical Journal earlier this month (7). The review was the largest synthesis of knowledge to date, and the authors unfortunately had to conclude that:

“Despite a few hundred systematic reviews and meta-analyses, highly convincing evidence of a clear role of vitamin D does not exist for any outcome, but associations with a selection of outcomes are probable”

The authors concluded that vitamin D supplementation is probably linked to decreased dental caries (cavities) in children, reduced parathyroid hormone concentrations in patients with chronic kidney disease requiring dialysis, and to an increase in maternal vitamin D concentrations at term, and an increase in birth weight (7). These are very specific conditions that apply only to children, pregnant mothers, and chronic kidney disease patients. The authors also concluded that the evidence is ‘suggestive’ for a correlation between higher blood vitamin D concentrations and a lower risk of several conditions including colorectal cancer, non-vertebral fractures, cardiovascular diseases, depression, high body mass index, and type 2 diabetes (7). However, a major point to note is that these are correlations, which means that although vitamin D has been associated with these health conditions, it may not cause them. Because of the limitations of current research, including the difficulty in measuring the actual vitamin D intake of people, and how much of this actually gets absorbed and has a biological effect, the timing between vitamin D intake and disease onset, and determining the actual dose of vitamin D that may protect against disease, we don’t have definitive answers right now.

So, what should we do about our own health? It is clearly too soon to make any strong recommendations about population-level vitamin D supplementation. Following the current RDA for vitamin D is good, and achieving this level for yourself may include supplementation if you don’t eat many foods containing vitamin D. Always talk to your family physician if you have any concerns about your own health or vitamin D intake. And finally, as always, keep yourself informed with high quality information to make decisions for your own health.

References

1)      National Health Service. Vitamins and minerals – vitamin D. http://www.nhs.uk/Conditions/vitamins-minerals/Pages/Vitamin-D.aspx (accessed 21 April 2014).

2)      National Institutes of Health. Vitamin D: Fact sheet for consumers. http://ods.od.nih.gov/factsheets/VitaminD-QuickFacts/#h3 (accessed 21 April 2014).

3)      Committee to Review Dietary References Intakes for Vitamin D and Calcium, Institute of Medicine: Dietary Reference Intakes for Calcium and Vitamin D. Edited by Ross AC, Taylor CL, Yaktine AL, Del Valle HB. Washington, DC: The National Academies Press; 2011.

4)      Holick MF. Vitamin D deficiency. N Engl J Med 2007;357:266-81.

5)      Munger KL, Zhang SM, O’Reilly E, Hernán MA, Olek MJ, Willett WC, et al. Vitamin D intake and incidence of multiple sclerosis. Neurology 2004;62(1):60-5.

6)      Wang TJ, Pencina MJ, Booth SL, Jacques PF, Ingelsson E, Lanier K, et al. Vitamin D deficiency and risk of cardiovascular disease. Circulation 2008;117:503-11.

7)      Theodoratou E, Tzoulaki I, Zgaga L, Ioannidis JPA. Vitamin D and multiple health outcomes: umbrella review of systematic reviews and meta-analyses of observational studies and randomised trials. BMJ2014;348:g2035

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Public Health Perspectives: Guest Post Policy

Since we launched Public Health Perspectives, we’ve published several guest posts. We’re big fans of them – they’ve provided diverse and different perspectives on issues, and have been able to provide insight on issues we haven’t covered. The response from our readers has also been very positive, and so we’ve decided to open the process.

In the interests of transparency, we have developed a series of guidelines for anyone interested in posting with us, as well as an outline of how we approach guest posts. If you have any other questions, don’t hesitate to contact us at the email below.

We have three basic guidelines for those interested:

1) No self-promotion. While we appreciate that people will post about issues they are passionate about, we will not accept posts promoting your business, fundraising, or publicizing an event you’re organizing. However, if you have done an event or published recently and want to discuss or reflect on it, that is okay.

2) All posts must have scientific backing. Commentaries and opinion pieces can be considered, however, they have to be backed up with evidence. Sensationalist language and fear-mongering are unacceptable.

3) Posts must be written for a generalist audience. We have a diverse reader base, and so we will be looking specifically for pieces that explain ideas and concepts clearly to non-specialists in the field.

We’re interested in broadening our perspectives at the blog, so anyone from students, to researchers, to teachers, to healthcare professionals (among others) are all welcome. We’re looking for diverse views on public health, and to lend a voice to those outside of our areas of expertise.

What we suggest is that anyone interested in posting with us send us an email with a 1-2 paragraph outline of your piece. We will provide feedback, and let you know if there are any red flags that come up. Assuming everything is fine, we’ll then send it back to you to write up into a 600-1000 word blog post. We’ll provide input on the final document, and if we still think it’s a good fit, we’ll schedule it for publication. If not, the piece is yours, so you’re welcome to submit it anywhere else that accepts guest posts.

If you have any questions, don’t hesitate to let us know!

Atif, Beth and Lindsay
PLOSPublicHealthPerspectives[at]gmail.com

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