For every woman who speaks out about her experiences or reports the abuse, many more remain silent through fear, shame, or simply because they don’t know who to turn to. Many don’t even tell their closest friends, family members, or general practitioner, let alone pick up the phone to call a domestic violence hotline or counselling service.

This reluctance to seek help is alarming when we consider the grim statistics on domestic violence. One in five women in Australia have experienced physical or sexual abuse at the hands of an intimate partner. One woman is killed each week by her current or ex-husband, partner, or boyfriend. Seventeen women have already died this year, and it’s only March.

Thanks to activists such as Rosie Batty, there has been a renewed focus on challenging gender stereotypes and men’s attitudes towards women in an attempt to prevent violence from occurring. While this is certainly a vital piece of the puzzle, the patriarchy is unlikely to be dismantled overnight.

The proposed terms of reference for the Victorian government’s Royal Commission into Family Violence argue that domestic violence requires a coordinated response across government, services, and the community. But this will be difficult and time-consuming to achieve, particularly in light of the Abbott government’s cuts to critical domestic violence services.

Clearly, we need to think more innovatively about how we respond to this hidden epidemic. Technology – specifically, the internet and smartphone apps – may provide part of the solution.

Existing technology

The internet and smartphone apps are readily available to large numbers of people. They allow users to access help, information, or support anonymously and privately.
In the context of domestic violence, women who may not yet be ready to name their experiences as “domestic violence” can use the web or smartphone apps to assess their relationships and figure out the next steps. Most importantly, women can access help without the need to disclose the abuse to anybody, which may reduce concerns about judgement and stigma.

Globally, many countries are beginning to explore the possibilities for web- and smartphone-based applications to respond to domestic violence. In the United States, South Africa, and New Zealand, for example, interactive tools are being developed and evaluated to help women make decisions and learn about respectful relationships.

In Australia, we are also starting to recognise the potential of technology, with several domestic violence apps such as Aurora and iMatter already helping women connect to formal services and access practical information. iMatter, which is targeted at younger women, also promotes self-respect and empowerment.

Towards tailored support

Technology has the potential to do more than inform and link to services; it can help provide the individualised, tailored support women need when experiencing abuse at the hands of an intimate partner.

Our research team is developing a web tool called I-DECIDE, which allows women to reflect on an unhealthy or unsafe relationship and manage their situation.

I-DECIDE uses validated tools to identify the type of abuse (emotional, physical, or combined) a woman may be experiencing, as well as her level of danger and risk, and provides feedback. It also incorporates reflective exercises around relationship health and safety.

Drawing on a face to-face counselling program for general practitioners, I-DECIDE uses motivational interviewing and non-directive problem-solving techniques. These help women determine their own needs and the steps they might take to improve their safety and well-being, acknowledging that the step chosen may not always be leaving the relationship.

I-DECIDE responds to women’s individual priorities by providing strategies and resources that are unique to her situation, rather than general standardised links to information and resources. Perhaps most importantly, the program culminates in an individualised “action plan”.

Preliminary testing has been positive. One woman commented that after using I-DECIDE:

I feel affirmed and deserving. I feel it helped me recognise what I had been prioritising over my own health and well-being, and reminded me to keep perspective about my partner’s behaviour.

Potential barriers

There are, however, some challenges that need to be addressed when harnessing technology to respond to domestic violence.

The rise of online abuse and cyber-stalking by partners or ex-partners is a major concern. Appropriate security measures need to be put in place to ensure women’s safety when using websites or apps.

Additionally, it’s difficult to address the whole spectrum of relationship issues with one website or app. Telephone and face-to-face contact will still play an important role in responding to women’s needs.

Any response approach has the risk of alienating women through use of inappropriate language. Many women will not identify with “domestic violence”, “family violence” or “violence against women” language or services. We have carefully called this website “I-DECIDE About My Relationship” in an attempt to reach out to women who may not have named their relationships as abusive.

I-DECIDE is currently being evaluated through a randomised controlled trial, which will determine its effectiveness in addressing domestic violence in the wider population. Women eligible for the trial can access I-DECIDE immediately. It will be made available to all women in 2016.

If you or someone you know would like to participate in the I-DECIDE project, visit the website.

Anyone at risk of family and domestic violence and/or sexual assault can seek help 24 hours a day, seven days a week, either online or by calling 1800 RESPECT (1800 737 732). Information is also available in 28 languages other than English.

Read other articles in The Conversation’s ongoing domestic violence coverage.

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By Philip M Rosoff, Duke University

The Affordable Care Act has enabled millions of previously uninsured people to obtain health insurance at reasonably low rates and has fixed some of the most vexing – and unfair – peculiarities in the US commercial insurance market. It has eliminated lifetime coverage caps and denials for coverage because of pre-existing conditions, to mention just two of the most popular reforms.

This is a major step forward. But the ACA builds upon our existing health insurance system in many ways. And, thus, it represents a gift to all of those who seek to profit from the health and illness of others.

Remember – access to insurance and access to needed care aren’t always the same thing. And “affordable” is a relative term. The kinds of reasonably priced health insurance policies the previously uninsured can afford come with a catch. Yes, people are now covered against catastrophic events. But some of these affordable plans come with prohibitively high deductibles and co-pays. These extra costs can force patients to choose between going without care or seeing the doctor and paying the monetary price. This is partly because medical “necessity” is a term that means different things to patients, doctors and insurers.

Our current system of health care is ruled by cost-sharing, which is believed to cut costs by preventing people from over-utilizing unnecessary or unneeded health care. But it doesn’t do that (especially for less well-off people). Instead care is rationed based on what a person can afford. And rationing by limiting what is available by one’s ability to pay instead of a reasonable definition of medical need can amplify the inherent inequities already present.

Health insurance is different from other kinds of insurance

The sort of health insurance that has evolved in this country is not like the insurance we have for our homes or our cars. Those kick in when our house is damaged during a storm or we have an accident in our automobile. It insures us against major financial loss for unexpected or unforeseen events that can be expensive to repair.

Health insurance, on the other hand, is used for both catastrophic and everyday coverage: quadruple bypass surgery to routine vaccinations, emergency room visits to yearly physicals. And since even healthy people can get sick or injured, those whose job it is to maximize profits and hold down costs must figure out strategies to make patients think twice (or maybe thrice!) before they go to the doctor, and hence submit a claim.

And that is the purpose of high co-pays and high-deductible policies: to discourage patients from utilizing services, thus saving money for the insurers and presumably (or hopefully) for the insured as well.

The commercial insurance market makes more money if policyholders pay their premiums, and then don’t use their insurance. Profit margins are grounded on many more healthy people – sometimes called the young invincibles – paying premiums than sick people filing claims.

Similarly, placing barriers in front of patients to discourage usage of benefits minimizes expenses and maximizes financial yields for the companies. In effect, this is a form of rationing, where the decisions about what kinds of potentially beneficial interventions to use are made by the patient and contingent upon affordability.

For instance, the more expensive basic care is, the more likely someone with, say, shoulder pain, may try to treat themselves at home rather than risk a big co-pay by having it checked out by a doctor.

Necessity is a relative term

High-deductible health plans can leave some patients in a quandary. The premiums are low, but the costs for some needed services can lead to big bills. They are more akin to catastrophic health insurance, to be used only in case of true life-threatening emergency, rather than for routine preventative care or the common ills that plague most of us from time-to-time such as broken limbs or strep throat.

How one’s insurance company and policy defines medical necessity (the term of art for what they will and will not cover) and the various ever-increasing co-pays and, of course, the annual deductible in large part determine what kind of care you can aevfford and hence receive. For example, the ACA mandates coverage for standard prenatal and maternity care without additional patient expense. But what the ACA defines as “standard” is nominal: better than nothing but the uncovered services frequently thought to be important can add up rather quickly.

Cost-sharing doesn’t lower costs

The prevailing wisdom is that if the costs to the insured are low enough, they will over-utilize covered services because of the relatively low financial impact for themselves. In health care circles this is called “moral hazard,” which refers to how people behave when they’re safe or protected from the consequences of potentially risky actions, because someone else bears the burden for that risk. Our current system of cost-sharing between patients and insurers is meant to prevent this over-utilization.

But, however popular this theory is, the facts speak otherwise: cost-sharing doesn’t work very well at moderating patient behavior and thus controlling costs. This system does not save anyone money if patients have a difficult time accessing preventative care due to cost, only to require costly interventions further down the line.

Nevertheless, increasing point-of-service co-payments and multi-thousand dollar annual deductibles are aimed at stimulating patients to think twice (or more) before they drop in at their local emergency department to get their sore throat examined. This doesn’t help patients and can result in higher costs down the line. Think of it this way: many diseases – like cancer – can be treated relatively simply if caught early. But if having a doctor look at that growing bump on your arm is going to cost you several hundred or several thousand dollars, you may put it off until it’s too late. Cost-sharing may persuade some people to choose the lesser of two financial evils, and that’s a shame.

The bad and the good sides of rationing

In health care, some kinds of rationing aren’t bad. For instance, in some circumstances it can actually help lower costs and extend the benefits of modern medicine to more people.

It can also ensure a resource in short supply can get to people that need it most. This could be virtually anything that could potentially help someone, such as a scarce drug or intensive care beds during an influenza pandemic.

But most frequently, the US rations health care on the basis of money: people have limited access or are able to purchase less than what they might need because they have insufficient money to pay for it.

The ACA, while notionally intended to control costs by what might be called “hidden” or “subversive” rationing, is certainly not designed to ration openly and fairly to all.

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By Lynn T Kozlowski, University at Buffalo, The State University of New York

E-cigarettes and other vaping products are on track to out-sell cigarettes by the end of 2023. And more and more young people are trying e-cigarettes. So what do you need to know about them? Are they less harmful than using cigarettes or other burned tobacco products?

What are e-cigarettes?

First, they are not burned tobacco products. Most often, they contain nicotine solutions that are heated to make a vapor (hence the terms vape or vaping), and they’re usually powered by batteries. Some look like cigarettes and others can resemble flashlights. The first e-cigarettes were not produced by cigarette companies, but the cigarette companies have gotten into the business. E-cigarette and vaping products are available in specialty stores and convenience stores around the US with varying restrictions on purchase by youth under 18.

E-cigarettes don’t necessarily contain nicotine. Some popular products contain little or no nicotine and levels can vary from brand to brand. And nicotine isn’t always the reason someone might try e-cigarettes. In Canada – where nicotine-containing e-cigarettes are not approved, but still widely available – only 38% of adult cigarette smokers who also use e-cigarettes “always use nicotine” and 30% “sometime use nicotine” when vaping. And only 4% of those who never smoked tobacco reported using nicotine when vaping.

Why do young people use e-cigarettes?

A 2014 national high school survey finds more monthly vapers than monthly smokers: 17% of US 12th-grade students report using e-cigarettes in the past 30 days compared to 14% for tobacco cigarettes. We also know that patterns of infrequent, non-daily use of various tobacco and nicotine products may be increasing among young people. But trying e-cigarettes does not automatically lead to daily use.

Young people might also be influenced to try e-cigarettes because of how they are priced and promoted. They can be cheaper than traditional cigarettes and may be perceived as safer. Other features, like flavors can also support use in all age groups.

As e-cigarettes become more popular and more visible, young people will start trying and using these products. And because products keep changing, they will often try different kinds of e-cigarettes.

Youth is a time when individuals experiment with and get into trouble with psychoactive substances, including nicotine-containing e-cigarettes. In 2014, 44.4% of 12th-graders had ever used marijuana/hashish, and 35.1% had used in the past year; 41.4% reported being drunk in the past year. Users of one type of psychoactive substance are more likely to use others, like caffeine, alcohol, nicotine, THC or prescription drugs.

Is vaping safer than smoking?

The best evidence to date shows that using e-cigarettes is very dramatically less dangerous than cigarette smoking. Death from all causes within the ages of 25 to 79 is three times higher for smokers than never smokers. Compared to smoking, long-term health effects of e-cigarettes have been judged as likely “much less, if at all, harmful to users or bystanders.”

The 2014 Surgeon-General Report concluded that “The burden of death and disease from tobacco use in the United States is overwhelmingly caused by cigarettes and other burned tobacco products; rapid elimination of their use will dramatically reduce this burden.”

Recent reports suggest that vapers should be cautioned about how they use high-voltage devices because they can produce high levels of the carcinogen formaldehyde. But that, however, is not one of the common ways people use e-cigarettes. High voltage devices and long puffs can produce a bad taste that is avoided.

Burned cigarettes contain many carcinogens: the FDA lists 79 “harmful or potentially harmful” carcinogens in tobacco products and tobacco smoke.

Keep in mind that reports of a product being “not safe” in some way does not necessarily mean that it cannot overall be much safer than another product.

Are e-cigarettes a gateway drug?

The specter of some drugs being gateways to more dangerous drugs has preoccupied drug policy, and this is no different when it comes to tobacco products. E-cigarettes have been feared as possible gateways to cigarettes. If vaping has been acting largely as a gateway to cigarettes, one would expect to see more cigarette smoking with the rise in vaping. This has not happened. Smoking has continued to decline. Cigarette smoking by young people is the most powerful cause of smoking by adults.

In a broad sense, the world is full of products that can look like gateway products. The use of BMX bikes on dirt tracks by children could be gateways to the use of motorcycle dirt bikes by adults. But do the products cause the linkage or are individual tendencies more responsible for associations?

Much research on drug gateways supports a “common liability model” more than drug-based causal models. The Common Liability Model holds that characteristics (for example, liking to take risks) within individuals can be responsible for drug-use associations.

No matter whether you think (a) that trying of an e-cigarette is a causal gateway to later smoking that would not have otherwise happened or (b) that those who are more likely to try cigarettes are more likely to try e-cigarettes, once products become available to users, how these products are marketed influence which products are preferred. What is said and done about vaping can promote gateways to cigarettes. If you show more concern about vaping than smoking or if you downplay the deadly risks of smoking, you encourage young people to switch to cigarettes.

The policies that allow certain substances, like alcohol, tobacco and psychoactive substances, to be used quite freely by adults usually include prohibitions on use or purchase by youth. Without such policies, there might be even more experimentation by youth with these products. Prohibitions on sale of vaping products to youth should be supported.

What should you do if your teen smokes?

If you are faced with committed teenage smokers (who are probably also using other prohibited substances like drugs or alcohol), perhaps the best you can do is foster switching to e-cigarettes. Of course, do explore their interest in getting help with quitting smoking from quit-lines. For less-involved users of e-cigarettes who do not smoke regular cigarettes, encourage that regular use be avoided and that nicotine use be limited as much as possible.

Telling a teenager that vaping is just as bad for you as smoking or that e-cigs are worse than tobacco cigarettes could push them toward cigarettes and is not justified. It makes more sense to tell a young person that it is much better for their health if they stay away from tobacco cigarettes or cigarette-like tobacco cigars completely.

If you have teenagers who already both smoke and vape, encourage that they work to avoid cigarettes completely, and vaping could help them do so.

This article has been updated to correct mortality data for smokers.

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By Melinda R Ring, Northwestern University

Environmental health research has confirmed that chronic, low-level exposure to toxins in our environment – including our food, air and water – can have a significant impact on our health. We need to expand our understanding of these threats to help educate the public, industry and government regulators about how to reduce our risk now and for future generations.

Fifteen years ago, the NIH funded a study designed to monitor the effect of pollutants and other factors on children’s health. The National Children’s Study would have shed light on this issue and generated valuable information for doctors, research and policy makers. But in December 2014, the study was abruptly halted.

With our poor health-care ranking among developed countries – and our sadly worsening health outcomes despite our enviable resources – I question whether halting the NCS was the right decision.

Environmental pollutants can harm health

We know we have a problem. Study after study over the past three decades has demonstrated that exposure to environmental toxins and pollutants contribute to an increased prevalence of preventable disease. For example, asthma, the leading cause of hospitalization in children, has more than doubled in children since 1980.

A study of over 4,000 children in 12 California communities showed that kids with early persistent asthma were 10 times more likely to have been exposed to herbicides before their first birthday than asthma-free kids. Pesticides and ionizing radiation have been linked to multiple childhood cancers.

Exposures at a young age also translate to higher risk as we age. Bisphenol A (BPA), a petrochemical found widely in plastics, has been linked to conditions such as infertility and heart disease. Studies based on the US government’s National Health and Nutrition Examination Survey 1999-2002 found a correlation between blood levels of six common organic pollutants and a higher risk for diabetes. In December, the United Health Foundation released the 2014 America’s Health Rankings showing a doubling of the rate of diabetes since the mid 1990s to nearly 10% of adults.

The National Children’s Study

Since so many domains of health have been associated with early-life exposures, we must study population health beginning as early as pre-conception.

In 2000 Congress passed progressive legislation that led NIH to design and fund the National Children’s Study (NCS). The plan was to enroll women who were pregnant or were likely to become pregnant during the study, eventually studying 100,000 children. Then, over the next 21 years, researchers would collect blood, saliva and urine samples, as well as information from questionnaires and surveys. Researchers would also take air, water, soil, and dust samples from the child’s environment.

The pilot program launched in 2007, but was plagued with problems from the very start. Scientists disagreed on the ideal protocol for enrollment, methods for data collection and even whether the scope should be focused on a particular outcome. In response to criticism, significant adjustments were made, such as completely changing the enrollment strategy and even bringing in new leadership.

Despite those efforts, a NCS Working Group issued a negative report in December 2014, which prompted NIH Director Dr Francis Collins to halt the whole project before the main study could even begin. The decision was based on concerns with the study design and implementation. This was after US$1.3 billion had already been spent on research development and a pilot study of 5,700 children.

While the NCS suffered from inefficiencies and design flaws, it still could have helped us identify and understand much about childhood exposure to pollutants and toxins.

The NIH statement claims a plan to explore new research options that will “use mechanisms that can evolve with the science, employ the use of a growing number of clinical research networks, and capitalize on research and technology advances that have developed since the inception of the study.”

The canceled study would have provided valuable information about the links between environment and health, and thus how we can reverse these unhealthy trends. It is unfortunate that the NIH chose to start over, instead of giving the NCS investigators the time and information needed to incorporate suggested changes. Scrapping the study will delay us from finding clues to the causes of these trends.

Why we need an NCS

This goes beyond changing policy. In my integrative medicine practice, I hear patients’ stories every day of how past exposures contributed to their current health issues. I see how making changes, including what they put in their body, on their skin and in their surroundings, can have a dramatic impact on how they feel.

With the benefit of hindsight, I can say that I would have made much different choices regarding what I put in my body and had in our home during my pregnancies and my kids’ early childhood. At this point I try – and counsel my patients to try – to minimize our exposure and the exposure of our children to harmful toxins. But we all need more information such as what the NCS could have provided about what is harmful to guide our choices.

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