Masters assignment: study to analyse the incidence of sexual behaviour between men in order to better understand the spread of HIV/AIDS in a small rural community.

(Originally submitted as coursework towards my Masters in Global Public Health at the University of Manchester)

Introduction

This study aims to understand the sexual behaviours, attitudes to risk, and levels of health literacy of men who have sex with men (MSM) in a small rural community in sub-saharan Africa, in relation to the spread of HIV/AIDS. Research objectives include:

 

  • To gather data to improve the understanding of the links between behaviour and the spread of HIV/AIDS in MSM in this location. 
  • To improve health literacy and awareness of HIV/AIDS transmission.
  • To identify existing resources and community structures that could be utilised in health interventions.

 

Contextual considerations for the study will be explored, then study design itself, analysis and interpretations, followed by limitations and conclusions.

Design considerations

MSM, and individuals with HIV/AIDS have always been stigmatised: “What society judged was not the severity of the disease but the social acceptability of the individuals affected with it…” (Shilts, 1987). Studies show that while unprotected sex between MSM is commonplace in Africa, knowledge of the risk of HIV/AIDS is poor. Stigma, violence, and a lack of safe social and health resources is widely reported (Smith, 2009). 

 

As with any public health issue, it is critical to recognise “the importance of taking into account the characteristics of the relationships and interactions in which risk takes place” (Van Campenhoudt et al., 1997, from Dulor and Hubert, 2000). In this case, the stigmatised and illicit nature of sex between men is one in a complex array of factors which influence attitudes to risk and decision making.

 

MSM are particularly vulnerable to HIV/AIDS due to transmission via unprotected sex (Jaffe, 2007, Smith, 2009). Although this has prompted effective interventions to reduce transmission, it is still difficult to access and identify MSN for the purpose of needs assessment and other health-focused research. Reasons include that homosexuality in some regions is illegal or stigmatised, sex may occur under coercion and force, or MSM may not identify as gay (McKenna, 1996, from Boyce et al, 2004). 

 

This stigmatisation and marginalisation means that these groups are hard to reach, or hidden, and may be under-served by health research and interventions. Sydor (2013) describes this type of group as:

 

  • Hard to reach: a population that is difficult to access.
  • Hidden: a population with no defined limits, such that its exact size cannot be known.
  • Sensitive subject: a subject that some people prefer not to discuss publicly.

 

Not only are these groups difficult to identify and access, but people who engage in illicit or stigmatised behaviour may be reluctant to provide personal information to researchers or health practitioners. MSM may perceive threats to their livelihoods, social status or lives, should their sexual behaviour be revealed. 

 

A lack of understanding of research, mistrust in western medicine and a distrust of authority increases friction. Prevention and control programs for HIV/AIDS in sub-saharan Africa have seen patients refuse surgery or other medical treatment unless their traditional healer sanctions it. (Liverpool et al, 2004)

 

Another contextual factor to consider is that communities such as this may present low educational attainment (Williams, 2005); in one study, rural students in sub-saharan countries scored significantly lower in reading tests than their urban counterparts (Zhang, 2006). This low literacy alongside poor understanding of health risks can result in reduced condom use, low rates of HIV testing and higher incidence of HIV/AIDS, but crucially it also presents challenges in study design and obtaining informed consent.

 

Finally, exploring heuristics is important to this study in order to understand how people who may not possess the knowledge or information to make fully-informed, rational decisions make “short-cut” decisions instead: “Individuals use heuristics to rationalize uncertainty” (Bailey and Hutter, 2006). For instance, the perceived risk of HIV/AIDS may be lowered by knowing the sexual partner (Skidmore and Hayter, 2000), believing their partner is faithful, or sex occurring between consenting adults rather than being paid for (Vanlandingham and Trujillo, 2002). There may even be a belief that sex between men (opposed to women) does not pose a risk for HIV. (Zulu and Zulu, 2006)

Study Design

The study design chosen for this research is based upon the Rapid Assessment and Response (RAR) model of cross-sectional community-based qualitative research. Through this, the study will focus on the settings and contexts of the sexual behaviours, health literacy and attitudes to risk of MSM in this location. 

 

The study will adopt a Social Determinants of Health (SDH) approach, recognising that individual behaviours are not always an individual choice; health and choices are influenced by life circumstances and a complex web of social, political and economic conditions (Lins et al. 2010). As well as targeting individuals, interventions to control HIV should aim to change aspects of cultural and socio-economic context that increase the vulnerability of people and communities to HIV (Buve et al, 2001, from Marmot and Wilkinson, 2005). An SDH approach allows examination of systemic “causes of the causes” to better facilitate effective health interventions.

 

The study population is men aged 16+, living within this community who have engaged, or engage, in sex with men, even if they do not identify as being MSM. 

 

Participants will be identified and accessed by working with existing community groups, aid and outreach workers, and medical professionals. Recruitment posters will be placed in suitable locations. Screening questions will be used to ensure participants meet the criteria for the research. Whilst social media may provide an avenue for promotion, the small geographic study size in this case makes this approach unlikely to prove worthwhile.

 

Snowball sampling will be employed to increase the size of the survey group in this study, as it is an effective method for sampling hidden populations (Atkinson, 2001). Participants will be asked to recruit friends and acquaintances who also meet the criteria. It is recognised that selection bias, gatekeeper bias and the risk of only recruiting participants from a sub-group (Becker 1963) may limit the validity of the samples. However, as qualitative research, this study does not require significant representativeness for generalisability, and as such these potential issues are not of great concern (Bonevski et al, 2014).

 

Small payments for time and expenses will be provided to participants. The size of this payment will ensure that participants are not put at a financial disadvantage through their involvement, whilst avoiding the potential for acquiescence bias.

 

Focus groups of six to ten individuals will be used to build the exploratory information base, while providing a platform for improving the health literacy of participants. Then private semi-structured, questionnaire-driven interviews will be conducted to dive deeper into beliefs and contexts.

 

Questionnaires will be pre-tested for time taken, ease of use and any emotionally overly-burdensome questions, using volunteers from the same region with similar socio-economic and literacy status to the participants. 

 

Contextual questions include socio-demographic characteristics such as estimated birthdate, education and work status and multivariate poverty assessment. Sexual behaviour, spousal status, and sexual history will be discussed and recorded, alongside health literacy, including understanding of the transmission and effects of HIV/AIDS and other STIs. 

 

The use of substances including drugs and alcohol will be investigated as although findings are inconsistent, studies have shown that substance use can be correlated with high risk behaviours such as unprotected sex. (Myers et al, 2004)

 

The interviews will be written and tested to reduce bias related to question framing, anchoring and recency/recallability. Self-completion or electronic questionnaires could be used, and have shown to be useful when surveying sensitive topics (Gnambs and Kaspar, 2015, Johnson et al, 2001), but due to the variable literacy level of the target population, this is not considered viable in this case. 

 

As in research by Maher et al (2009), text messaging will be offered as an effective way to keep in touch with participants and remind them of interview sessions and focus group meetings. 

 

Building rapport with the participants is essential to generate deep insights given the sensitive nature of the issues, and to obtain interactive informed consent, particularly when participants may have low levels of literacy (Cortes et al, 2010). Researchers will be encouraged to initiate conversations with participants about the study itself, and about unrelated topics if they arise. Participants will also be encouraged to initiate contact with the researchers themselves: this provides participants with a degree of autonomy and control over the process that may aid communication. To further build rapport and trust, interviews will be carried out in the participants’ native language, by men of the same ethnicity as participants. 

 

The venue will be easily accessible and unrelated to the diagnosis and treatment of HIV/AIDS: the study is focussed on context, understanding and behaviours, and perceived “medicalisation” of the study could be detrimental. Similarly, although participants will be offered voluntary HIV tests, it will be made clear that testing is not compulsory or part of the research, as concerns about compulsory testing could reduce the sample size.

 

It is important to measure the MSM population size in this region in order to determine representativity of the study sample, and establish effective health interventions. A capture-recapture method as in Mastro et al (1994) would take too long, and other methods require data that is not available for this region. As the size of the general population is known, the network scale-up method as described by Bernard et al (2010) is a suitable approach. Each participant will be asked to estimate how many people they know, and how many of those are MSM. This method is subject to inaccuracies and will tend towards an underestimate as MSM may be hidden from other MSM in the same population, but accuracy is improved by increasing the number of respondents.

 

Reassuring participants that their data will be safeguarded is paramount in order to minimise loss to follow up. Researchers will demonstrate measures to safeguard data by visibly entering paper records and recordings at the conclusion of an interview into a lock box for transport. Data will be anonymised and participants will be offered the opportunity to provide pseudonyms.

 

The establishment of a longitudinal cohort as a by-product of this study is tempting, but requiring participants to agree to long term involvement is likely to reduce participation, and as such has been discarded.

Analysis and Interpretation

Questionnaire data will be analysed using SPSS and R. Regression analysis will be conducted to examine the association between variables such as health literacy and condom use. Level of significance will be set at a probability of less than or equal to 0.05. Metrics such as health literacy will be quantified by converting to a scale of 1-5 upon normalisation of recorded responses.

 

Study data and findings in the form of a comprehensive report will facilitate health interventions intended to reduce the incidence of HIV/AIDS, including education programs, public health communication, social and medical provision alongside influencing local and regional policy.

 

The insights gained from this study will steer proactive testing programs and improved services for those who are living with HIV/AIDS.

Limitations

A limitation of this study includes being unable to establish any causal links between associations: only correlation, not causation, can be demonstrated due to a lack of any temporal aspect to the study. Multiple confounding factors may be present; a further longitudinal cohort study may be able to demonstrate causal relationships between the factors examined in this research and eliminate confounding variables. This study is carried out in a specific temporal, spatial and cultural context, and as such, the findings will not be representative of other contexts. 

Conclusion

This study will generate rapid, actionable insight into health literacy and sexual behaviours of MSM in this region, while improving awareness and helping men make more informed decisions. Existing resources available for utilisation in further research and investigations will be identified.

 

Whilst policy makers and agencies may prefer quantitative research that is seen as more repeatable, rigorous and robust for decision making (Tierney and Clemens, 2011), the results of this study can be used to quickly inform potential health interventions and local decision making, along with directing future research.

 

 

 

 

Word count: 1999

 

References:

Atkinson, R. and Flint, J. (2001) Social research update. Department of Sociology, University of Surrey, (33).

 

Becker, H. S. (1963) Outsiders; studies in the sociology of deviance. London, Free Press of Glencoe.

 

Bernard, H.R., Hallett, T., Iovita, A., Johnsen, E.C., Lyerla, R., McCarty, C., Mahy, M., Salganik, M.J., Saliuk, T., Scutelniciuc, O. and Shelley, G.A., (2010). Counting hard-to-count populations: the network scale-up method for public health. Sexually transmitted infections, 86(Suppl 2), pp.ii11-ii15.

 

Bonevski, B., Randell, M., Paul, C., Chapman, K., Twyman, L., Bryant, J., Brozek, I. and Hughes, C., (2014). Reaching the hard-to-reach: a systematic review of strategies for improving health and medical research with socially disadvantaged groups. BMC medical research methodology, 14(1), p.42.

 

Boyce, Paul, Aggleton, Peter and Malcolm, Anne (2004) Rapid assessment and response adaptation guide on HIV and men who have sex with men. Technical Report. World Health Organization, Geneva.

 

Buvé, A., Lagarde, E., Caraël, M., Rutenberg, N., Ferry, B., Glynn, J.R., Laourou, M., Akam, E., Chege, J., Sukwa, T. and Study Group on Heterogeneity of HIV Epidemics in African Cities, (2001). Interpreting sexual behaviour data: validity issues in the multicentre study on factors determining the differential spread of HIV in four African cities. Aids, 15, pp.S117-S126. 

 

Cortés, D.E., Drainoni, M.L., Henault, L.E. and Paasche-Orlow, M.K., (2010). How to achieve informed consent for research from Spanish-speaking individuals with low literacy: a qualitative report. Journal of Health Communication, 15(S2), pp.172-182.

 

Delor, F. and Hubert, M., (2000). Revisiting the concept of ‘vulnerability’. Social science & medicine, 50(11), pp.1557-1570.

 

Gnambs, T. and Kaspar, K., (2015). Disclosure of sensitive behaviors across self-administered survey modes: a meta-analysis. Behavior research methods, 47(4), pp.1237-1259.

 

Jaffe, H.W., Valdiserri, R.O. and De Cock, K.M., (2007). The reemerging HIV/AIDS epidemic in men who have sex with men. Jama, 298(20), pp.2412-2414.

 

Johnson, A.M., Copas, A.J., Erens, B., Mandalia, S., Fenton, K., Korovessis, C., Wellings, K. and Field, J. (2001) ‘Effect of computer‐assisted self‐interviews on reporting of sexual HIV risk behaviours in a general population sample: a methodological experiment’, AIDS 15, 111‐115.

 

Lins, N. E., Jones, C. M., & Nilson, J. R. (2010). Commentary New frontiers for the sustainable prevention and control of non-communicable diseases (NCDs): a view from sub-Saharan Africa. Global Health Promotion, 27–30. 

 

Liverpool, J., Alexander, R., Johnson, M., Ebba, E.K., Francis, S. and Liverpool, C., (2004). Western medicine and traditional healers: partners in the fight against HIV/AIDS. Journal of the National Medical Association, 96(6), p.822.

 

Maher, J.E., Pranian, K., Drach, L., Rumptz, M., Casciato, C. and Guernsey, J., (2010). Using text messaging to contact difficult-to-reach study participants. American Journal of Public Health, 100(6), pp.969-970.

 

Marmot, M. & Wilkinson, R. (2005) Social Determinants of Health. OUP Oxford. ISBN 0191578487, 9780191578489

 

Mastro, T.D., Kitayaporn, D., Weniger, B.G., Vanichseni, S., Laosunthorn, V., Uneklabh, T., Uneklabh, C., Choopanya, K. and Limpakarnjanarat, K., (1994). Estimating the number of HIV-infected injection drug users in Bangkok: a capture–recapture method. American Journal of Public Health, 84(7), pp.1094-1099.

 

Mercer, C.H., (2010) Measuring sexual behavior and risk. London UK: Health Protection Agency.

 

Myers, J.P. Aguinaldo, D. Dakers, B. Fischer, S. Bullock, P. Millson & L. Calzavara (2004) How Drug using men who have sex with men account for substance use during Sexual Behaviours: Questioning assumptions of Hiv Prevention and Research, Addiction Research & Theory, 12:3, 213-229, DOI: 10.1080/16066350310001640161

 

Shilts, R. (1987) And The Band Played On. Politics, People and the AIDS Epidemic. St. Martin’s Press. ISBN 0-312-00994-1

 

Skidmore, D. and Hayter, E. (2000) Risk and sex: ego-centricity and sexual behaviour in young adults. Health, Risk and Society, 2, 23–32.

 

Smith, A.D., Tapsoba, P., Peshu, N., Sanders, E.J. and Jaffe, H.W., (2009). Men who have sex with men and HIV/AIDS in sub-Saharan Africa. The Lancet, 374(9687), pp.416-422.

 

Sydor A (2013) Conducting research into hidden or hard-to-reach populations. Nurse Researcher. 20, 3, 33-37.

 

Tierney, W.G. and Clemens, R.F., (2011). Qualitative research and public policy: The challenges of relevance and trustworthiness. In Higher education: Handbook of theory and research (pp. 57-83). Springer, Dordrecht.

 

Vanlandingham, M. and Trujillo, L. (2002) Recent Changes in Heterosexual Attitudes, Norms and Behaviour Among Unmarried Thai Men: A Qualitative Analysis. International Family Planning Perspectives, 28, 6–15.

 

Wensink, M., Westendorp, R.G. and Baudisch, A., (2014). The causal pie model: an epidemiological method applied to evolutionary biology and ecology. Ecology and Evolution, 4(10), pp.1924-1930.

 

Williams, J.H., (2005). Cross-national variations in rural mathematics achievement. Journal of research in Rural Education, 20(5), pp.20-5.

 

Zhang, Y., (2006). Urban-rural literacy gaps in Sub-Saharan Africa: The roles of socioeconomic status and school quality. Comparative Education Review, 50(4), pp.581-602.

 

Zulu K, Bulawo N, Zulu W. (2006) Understanding HIV risk behaviour among men who have sex with men in Zambia. AIDS 2006–XVI International AIDS Conference; Toronto, ON, Canada; Aug 13–18, 2006: abstr WEPE0719.

Rights Based Approaches to Increasing Access to Safe Abortion Services

(Originally submitted as coursework towards my Masters in Global Public Health at the University of Manchester)

Access to safe abortion services is a neglected issue in sexual and reproductive health worldwide. In 2008, more than 70,000 women died from complications related to unsafe abortions globally, whilst unsafe abortions account for 13% of all maternal mortality (WHO, 2012, A). In some regions such as sub-Saharan Africa, this figure can be as high as 520 deaths per 100,000 (Say et al, 2014). One third of all abortions worldwide between 2010 and 2014 were carried out in unsafe contexts, and 97% of unsafe abortions occurred in Lower and Middle Income countries (LAMICs). 

Chart 1. Maternal mortality vs fertility rate by country, 2015. (Our World In Data, 2015)

Chart 1. Maternal mortality vs fertility rate by country, 2015. (Our World In Data, 2015)

 

Whilst total abortion rates are similar between countries with highly restrictive abortion regulations and those where abortion is permitted (Vogelstein and Turkington, 2019), the proportion of unsafe abortions is significantly higher in states that impose more restrictive abortion laws than in states with less restrictive abortion laws (UN Department of Economic and Social Affairs, 2014, Ganatra et al, 2017). Additionally, as chart 1 shows, women suffer significantly higher maternal mortality as fertility rate increases, whilst removing restrictions to accessing abortion services reduces maternal mortality (WHO, 2012, B)

 

In Sierra Leone, where abortion is still illegal, around 1 in 75 pregnancies result in the death of the mother (Our World in Data, 2015). Laws legalising abortion were blocked by the President, Bai Koroma, in 2016 after protests by religious leaders, despite the bill being passed by MPs (BBC, 2016) and there remains a significant cultural pressure to restrict access to abortion in Sierra Leone and many other countries around the world.

 

Where abortion is restricted, survey data shows that the wanted fertility rate is on average 1 child lower than the actual fertility rate (Our World In Data, 2016), demonstrating a clear need and desire for improved access to reproductive and sexual health services to avoid unwanted pregnancies.

 

Evidence also shows a correlation between the number of children a woman has and a reduction in earning potential, through an inability to work whilst children are young, and a subsequent lowering in earnings upon returning to work (Lundborg et al, 2017). Permissive abortion laws are also shown to increase female labor force participation via a decrease in fertility rate (Bloom et al, 2009). The ability to choose whether to carry a pregnancy to term therefore impacts a woman’s right to work and to equal pay under Article 23 of the Universal Declaration of Human Rights (UDHR) (United Nations, 1948). Further rights, such as the right to an education, are impacted where young mothers are prevented from attending school as a result of childcare responsibilities. 

 

Whilst access to abortion improves access to education, education itself also influences the rates of abortion. In countries where abortion is legal and safe, a higher level of education is generally correlated with a lower frequency of abortion (Eskildet al, 2007) and a lower fertility rate (Leon, 2004), alongside an increased support for relaxed (“pro-choice”) abortion laws (Jelen and Wilcox, 2003). 

 

Human Rights and Abortion

 

A lack of access to family planning, contraception, and safe abortion services can be shown to impact womens’ rights in many ways, including the essential right to bodily autonomy and integrity and the ability to take paid employment and participate in cultural activities (Tzvetkova and Ortiz-Espina, 2017).

 

Article 27 of the UDHR states that everyone has the right to share in scientific advancement and its benefits. Safe pharmaceutical abortion practices have been available since 1988 (Baulieu & Rosenblum, 1991) and yet many abortions are carried out in unsafe contexts not because safe abortions are illegal, but because they are unavailable (Chemlal and Russo, 2019). 

 

The right to life and the right to health are enshrined in the UDHR and the 1966 International Covenant on Economic, Social and Cultural Rights (ICESCR) alongside more specific treaties such as the 1979 Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW). CEDAW affirms the right of all women “to decide freely and responsibly on the number and spacing of their children and to have access to the information, education and means to enable them to exercise these rights” (UN General Assembly, 1979). “There can be no right to health without the right to access safe abortion” (Priyanka, 2019, pp. 2359). 

 

However, despite this apparent consensus that access to safe abortion services should be an essential human right, in practice, access is still restricted.

 

Restricted Access to Abortion

 

The reasons for restricting access to abortion are often cultural or religious. Followers of many religions believe that abortion is morally wrong, often due to an assertion that a foetus is “alive” from the point of conception. Most abortion legislation recognises the difficult ethical compromise between the rights of women and the rights of an unborn child, usually differentiating between early and late-term abortions, with the cut-off around 12 weeks of pregnancy, beyond which abortion is only permitted if the mother’s life is at risk (Center for Reproductive Rights, 2021). 

 

Strict abortion laws aim to reduce the number of abortions by restricting access to cases only where the mother’s life is at risk or banning the procedure entirely. However, this often has the unintended consequence that women will travel to seek abortions elsewhere or access illegal and unsafe abortion services (Barr-Walker et al, 2019; Jerman et al, 2017).

 

Example: Northern Ireland

 

In the UK, abortion was decriminalised by the Abortion Act of 1967. However, due to conservative and religious pressure, an exemption to the 1967 Act was made for Northern Ireland (Jelen et al, 1993), and abortion remained illegal there until 2019. Women who wanted an abortion were forced to travel to England or self-manage a medical abortion at home, which was both stigmatised and criminalised (Aiken et al, 2018).

 

This situation was widely considered unacceptable on a human-rights basis, and a UN expert committee declared that the UK was in violation of women’s human rights through restricting access to safe abortion: “The situation in Northern Ireland constitutes violence against women that may amount to torture or cruel, inhuman or degrading treatment,” stated CEDAW Vice-Chair Ruth Halperin-Kaddari (OHCHR, 2018). 

 

In June 2018, in a case brought by Sarah Ewart against the Northern Ireland Executive, the UK Supreme Court concluded that “the current law in Northern Ireland breaches human rights, in particular women and girls’ right to private and family life under Article 8 of the European Convention of Human Rights” (NIHRC, 2019). The UK government subsequently clarified that the Northern Ireland Executive must make CEDAW-compliant changes to regulations to ensure that women seeking an abortion do not have to travel to England (House of Commons, 2019). 

 

Despite the UN declaration, the Supreme Court ruling, and clarification by Westminster, there is considered to be a cultural reluctance in Northern Ireland to fulfil the obligations placed upon the Department of Health (Gallen, 2020). Abortion services, despite being legal, remain sparse and many women seeking abortions must still travel to England. 

 

Example: The USA

 

During the 1960s, a number of US states began to decriminalise abortion under certain circumstances, such as cases of rape, incest, or if pregnancy could lead to permanent physical impairment of the mother (Kliff, 2013). Other states followed suit, and Washington and Hawaii passed laws allowing elective abortions. In 1973, the Supreme Court in Roe v. Wade declared all laws in the USA prohibiting abortion to be invalidated, and set guidelines for the availability of safe abortion services up to 12 weeks gestation. The court made this decision based upon the rights implied in the 14th Amendment of the Constitution of the United States of America: “No State shall make or enforce any law which shall abridge the privileges or immunities of citizens of the United States; nor shall any State deprive any person of life, liberty, or property…” (US Const. amend. XIV, sec. 1). The human rights in the US constitution were sufficent to change the laws of 30 states where abortion was previously illigal, and normalise laws in 20 further states.

 

Despite this, an anti-abortion stance persists in parts of the US and has shaped abortion policy. Just three years after Roe v. Wade, The United States Congress passed the “Hyde Amendment”. This amendment, introduced by conservative Congressman Henry J. Hyde, bars the use of federal funds (not state funds) to pay for abortion services except when the life of the mother would be endangered by carrying the pregnancy to term (ACLU, 2021). Implementation of the Hyde Amendment was blocked for some time by pro-choice organisations but was eventually passed in 1977. 

 

The Hyde Amendment violates CEDAW by restricting access to essential reproductive and sexual health services (RHS), and availability of abortion services in the US remains limited by a reluctance to recognise the fundamental rights of women to “decide freely and responsibly on the number and spacing of their children and to have access to the information, education and means to enable them to exercise these rights,” (CEDAW, Art. 16, e). The implementation of CEDAW in the U.S. “would radically change the basic equality rights of American women, including the right to an abortion.” (Benshoof, 2011. pp.105). However, the USA has to date refused to ratify CEDAW at federal level, though several US cities, counties and states have adopted the principles of CEDAW in local laws (Pierson, 2018). 

 

This anti-abortion stance spreads beyond the US via mechanisms such as the “Global Gag Rule” or the “Protecting Life in Global Health Assistance” policy. This policy bans foreign NGOs that receive US Government funds from using funds from any source to provide abortion services, counselling or advocate for progressive abortion laws. President Trump expanded this in 2017 to include funds through the “President’s Emergency Plan For AIDS Relief” (PEPFAR). PEPFAR constitutes nearly $9billion in funding and meant NGOs had to choose between complying with the rules and denying access to safe abortion, or losing funding (Priyanka, 2019). 

 

The impact of such policies increases unwanted pregnancies and unsafe abortions in LAMICs via two mechanisms: it makes it harder to access safe abortion services provided by NGOs, and it impacts the funding of NGOs providing reproductive and sexual health services, reducing access to contraception (Mavodza et al, 2019). 

 

However, under President Biden, there appear to be moves towards a rights-based approach. On January 28, 2021, he rescinded the Mexico City Policy, as part of “the administration’s plan to protect the rights of women both domestically and abroad” (Brennan, 2021). Foreign NGOs can now obtain PEPFAR and family planning funding whilst offering safe abortion services and counselling.

 

Example: Organisation of African Unity

 

In 1995, the OAU (Organisation of African Unity) Assembly, consisting of the heads of state of all 54 African member states, mandated the creation of a protocol to recognise and enshrine womens’ rights. The process took many years, but after lobbying by NGOs, the finished Protocol To The African Charter On Human And Peoples’ Rights On The Rights Of Women In Africa, better known as the Maputo Protocol, was adopted by the African Union in 2003. 

 

Article 14 of The Maputo Protocol explicitly defines access to safe abortion as a human right in cases of “sexual assault, rape, incest, and where the continued pregnancy endangers the mental and physical health of the mother or the life of the mother or the foetus” (African Union Maputo Protocol, 2003. Art. 14, 2, c) and additionally states that women’s reproductive rights are “inalienable, interdependent and indivisible” human rights.

 

Many African countries expressed reservations about Article 14 which specifically relates to womens’ health and reproductive rights, including Burundi, Senegal, Sudan, Rwanda and Libya (Viljoen, 2009), and the US-based anti-abortion organisation “Human Life International, described it as “a Trojan horse for a radical agenda.” (Vatican Radio, 2008)

 

Despite the Maputo Protocol, in many areas in Africa, abortion is still highly stigmatised. In many clinical settings, either through personal belief or fear of reprisals for conducting abortions, that despite abortion facilities being present, there are not the clinicians available to perform them (Favier et al, 2018). Thus, whilst the Maputo protocol advanced the rights of women in principle, in practice, governments have not ensured equitable availability of safe abortion services, and there is still a gap between governments recognising and fulfilling their obligations (Albertyn, 2015). 

 

Example: Israel

 

Abortion was made legal in Israel in 1977 and in 2014, the law was updated to allow for on-demand abortions at no cost to women between 20 and 33 years of age (Kamin, 2014). 

 

However, Israel implemented abortion laws as a result of many years of compromise. Chaika Grossman, one of very few female members of the Israeli Parliament in 1977, avoided any mention of human rights in relation to abortions in order to appease the highly conservative parliament. Instead, legislation was drafted based on “the assumption that such a reform would increase the birthrate among middle-class Jewish women on the one hand, and control the fertility of the less privileged sectors of the community on the other hand.” (Rimalt, 2017, pp. 329).

 

Thus, despite Israel’s abortion laws being some of the most permissive in the world (Kamin, 2014), this approach leaves them vulnerable to political influence and change. Without a grounding in “inalienable, interdependent and indivisible” human rights, laws drafted by legislators may be changed according to the whim of the government of the time, which leaves the women of Israel vulnerable to abortion services being restricted once again.

 

Conclusion

 

It is clear that human rights frameworks and rights-based approaches to access to abortion services:

 

  • Offer a framework for governments to shape policies, programmes, statutes and Protocols, as seen in the Maputo Protocol and by President Biden’s rescinding of the Global Gag Rule.
  • Provide clarity for courts to make decisions and turn rights into law, as seen in the USA in Roe v Wade. 
  • Empower individuals to know, understand, demand and exercise their rights, as exemplified by Sarah Ewart’s actions in Northern Ireland.
  • Enable governments to be held accountable when they do not protect those rights, as is ongoing in Africa and Northern Ireland, where women have the right to access abortion but accessibility remains limited.

 

The increasingly progressive standards codified by human rights frameworks serve to improve access to safe abortion services, through transforming abortion laws, advancing law and policy reforms, and putting in place frameworks that persist despite political change (Fine et al, 2017). Governments that recognise abortion as a human right must do more than make it legal; they are obligated to ensure that safe abortions are available, accessible, acceptable and of appropriate quality. 

 

The cases of the USA, Northern Ireland and Africa demonstrate the power of absolute, and inalienable human rights. Whilst governments change and cultures shift, human rights are immutable. Courts, in their power to define law, can utilise human rights frameworks, such as the UDHR, CEDAW, the Maputo Protocol or the US Constitution to make clear and lasting  decisions, including the decision to respect, protect and fulfil the right of every woman to access safe abortion services.

 

 

 

References:

 

ACLU, 2021. Access Denied: Origins of the Hyde Amendment and Other Restrictions on Public Funding for Abortion. Available at: https://www.aclu.org/other/access-denied-origins-hyde-amendment-and-other-restrictions-public-funding-abortion (Accessed: 21 April 2021).

 

Aiken, A. et al. 2018. “The impact of Northern Ireland’s abortion laws on women’s abortion decision-making and experiences”, BMJ Sexual & Reproductive Health, 45(1), pp. 3-9. doi: 10.1136/bmjsrh-2018-200198.

 

Albertyn, C., 2015. Claiming and defending abortion rights in South Africa. Revista Direito GV, 11(2), pp.429-454.

 

Barr-Walker, J., Jayaweera, R.T., Ramirez, A.M. and Gerdts, C., 2019. Experiences of women who travel for abortion: A mixed methods systematic review. PloS one, 14(4), p.e0209991.

 

Benshoof, J., 2011. US Ratification of CEDAW: An Opportunity to Radically Reframe the Right to Equality Accorded Women Under the US Constitution. NYU Rev. L. & Soc. Change, 35, p.103.

 

Baulieu, Etienne-Emile; Rosenblum, Mort, 1991. The “abortion pill” : RU-486, a woman’s choice.

New York: Simon & Schuster. 

 

Brennan, T. 2021. Biden’s decision to rescind the Global Gag Rule could have implications for the US approach to sexual health and reproductive rights at the UN | Universal Rights Group. Available at: https://www.universal-rights.org/universal-rights-group-nyc-2/bidens-decision-to-rescind-the-global-gag-rule-could-have-implications-for-the-us-approach-to-sexual-health-and-reproductive-rights-at-the-un/ (Accessed: 27 April 2021).

 

BBC News, 12 March 2016. Sierra Leone abortion bill blocked by President Bai Koroma again. Available at: https://www.bbc.co.uk/news/world-africa-35793186 (Accessed: 20 April 2021).

 

Bloom, D.E., Canning, D., Fink, G. and Finlay, J.E., 2009. Fertility, female labor force participation, and the demographic dividend. Journal of Economic growth, 14(2), pp.79-101.

 

Center for Reproductive Rights. 2021. The World’s Abortion Laws Available at: https://maps.reproductiverights.org/worldabortionlaws (Accessed: 27 April 2021).

 

Chemlal, S. and Russo, G., 2019. Why do they take the risk? A systematic review of the qualitative literature on informal sector abortions in settings where abortion is legal. BMC women’s health, 19(1), pp.1-11.

 

Eskild, A., Nesheim, B.I., Busund, B., Vatten, L. and Vangen, S., 2007. Childbearing or induced abortion: the impact of education and ethnic background. Population study of Norwegian and Pakistani women in Oslo, Norway. Acta obstetricia et gynecologica Scandinavica, 86(3), pp.298-303.

 

Favier, M., Greenberg, J.M. and Stevens, M., 2018. Safe abortion in South Africa:“We have wonderful laws but we don’t have people to implement those laws”. International Journal of Gynecology & Obstetrics, 143, pp.38-44.

 

Fine, J.B., Mayall, K. and Sepúlveda, L., 2017. The role of international human rights norms in the liberalization of abortion laws globally. Health and human rights, 19(1), p.69.

 

Gallen, E. et al. 2020. “Abortion is now legal in Northern Ireland – but why aren’t procedures actually being carried out?”, The Telegraph. Available at: https://www.telegraph.co.uk/women/life/abortion-now-legal-northern-ireland-arent-procedures-actually/ (Accessed: 9 March 2021).

 

Ganatra, B. et al. 2017 “Global, regional, and subregional classification of abortions by safety, 2010–14: estimates from a Bayesian hierarchical model”, The Lancet, 390(10110), pp. 2372-2381. doi: 10.1016/s0140-6736(17)31794-4.

 

Guttmacher Institute, 2017. Appendix Table 1: Status of the world’s 193 countries and six territories/nonstates, by six abortion-legality categories and three additional legal grounds under which abortion is allowed.

https://www.guttmacher.org/sites/default/files/report_downloads/aww_appendix_table_1.pdf (Accessed: 20 April 2021).

 

House of Commons Women and Equalities Committee. 2019. “Abortion law in Northern Ireland”. Available at: https://publications.parliament.uk/pa/cm201719/cmselect/cmwomeq/1584/158408.htm (Accessed: 9 March 2021).

 

Jelen, T., O’Donnell, J. and Wilcox, C. 1993. “A Contextual Analysis of Catholicism and Abortion Attitudes in Western Europe”, Sociology of Religion, 54(4), p. 375. doi: 10.2307/3711780.

 

Jelen, T.G. and Wilcox, C., 2003. Causes and consequences of public attitudes toward abortion: A review and research agenda. Political Research Quarterly, 56(4), pp.489-500.

 

Jerman, J., Frohwirth, L., Kavanaugh, M.L. and Blades, N., 2017. Barriers to abortion care and their consequences for patients traveling for services: qualitative findings from two states. Perspectives on sexual and reproductive health, 49(2), pp.95-102.

 

Kamin, D., 2014. Israel’s abortion law now among world’s most liberal. The Times of Israel, 6.

 

Kavaler, T., 2021. Israel’s abortion rate continues 32-year decline. Jerusalem Post. Available at: https://www.jpost.com/israel-news/israels-abortion-rate-continues-32-year-decline-654367 (Accessed: 27 April 2021).

 

Kliff, S., 2013. Charts: How Roe v. Wade changed abortion rights. The Washington Post, 22.

 

Leon, A., 2004. The effect of education on fertility: evidence from compulsory schooling laws. unpublished paper, University of Pittsburgh.

 

Lee, E., Ingham, R., 2004. A matter of choice?: exploring reasons for variations in the proportion of under-18 conceptions that are terminated. Joseph Rowntree Foundation, York.

 

Lundborg, P., Plug, E. and Rasmussen, A.W., 2017. Can women have children and a career? IV evidence from IVF treatments. American Economic Review, 107(6), pp.1611-37.

 

Mavodza, C., Goldman, R. and Cooper, B., 2019. The impacts of the global gag rule on global health: a scoping review. Global health research and policy, 4(1), pp.1-21.

 

NI Human Rights Commission (NIHRC), 2019. Human Rights Commission welcomes Sarah Ewart Judgment. Available at: https://nihrc.org/news/detail/human-rights-commission-welcomes-sarah-ewart-judgment (Accessed: 9 March 2021).

 

OHCHR. 2018 | UK violates women’s rights in Northern Ireland by unduly restricting access to abortion – UN experts. Available at: https://www.ohchr.org/en/NewsEvents/Pages/DisplayNews.aspx?NewsID=22693&LangID=E (Accessed: 21 April 2021).

 

Our World In Data, 2015. Maternal mortality ratio vs. Fertility rate. Available at: https://ourworldindata.org/grapher/maternal-mortality-vs-fertility (Accessed: 20 April 2021).

 

Our World In Data. 2016. Fertility vs wanted fertility. Available at: https://ourworldindata.org/grapher/fertility-vs-wanted-fertility (Accessed: 20 April 2021).

 

Pierson, J., 2018. Why the US Needs CEDAW: Abortion as a Human Right in the United States – Global Justice Center, Globaljusticecenter.net. Available at: https://globaljusticecenter.net/blog/1001-why-the-us-needs-cedaw-abortion-as-a-human-right-in-the-united-states (Accessed: 21 April 2021).

 

Priyanka, P., 2019. The devastating impact of Trump’s global gag rule. The Lancet. 390: 2359

 

Say, L., Chou, D., Gemmill, A., Tunçalp, Ö., Moller, A.B., Daniels, J., Gülmezoglu, A.M., Temmerman, M. and Alkema, L., 2014. Global causes of maternal death: a WHO systematic analysis. The Lancet global health, 2(6), pp.e323-e333.

 

The US Constitution. 1795: Amendments 11-27. Available at: https://www.archives.gov/founding-docs/amendments-11-27 (Accessed: 21 April 2021).

 

Tzvetkova, S. and Ortiz-Ospina, E., 2017. Working women: What determines female labor force participation. Our World in Data.

 

United Nations, 1948. Universal Declaration of Human Rights.

 

United Nations General Assembly, 1979. Convention on the elimination of all forms of discrimination against women. Available at: https://www.ohchr.org/en/professionalinterest/pages/cedaw.aspx (Accessed: 20 April 2021).

 

United Nations, Department of Economic and Social Affairs, Population Division, 2014. Abortion Policies and Reproductive Health around the World (United Nations publication, Sales No. E. 14. Available at: https://www.un.org/en/development/desa/population/publications/pdf/policy/AbortionPoliciesReproductiveHealth.pdf (Accessed: 27 April 2021).

 

Viljoen, F., 2009. An Introduction to the Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Women in Africa. Wash. & Lee J. Civil Rts. & Soc. Just., 16, p.11.

 

Vogelstein, R. B., Turkington,R. 2019. Abortion Law: Global Comparisons. Council on Foreign Relations. Available at: https://www.cfr.org/article/abortion-law-global-comparisons (Accessed: 27 April 2021).

 

World Health Organization, 2012 (A). Unsafe abortion incidence and mortality: global and regional levels in 2008 and trends during 1990-2008 (No. WHO/RHR/12.01). World Health Organization.

 

World Health Organization, 2012 (B). Safe abortion: technical and policy guidance for health systems. World Health Organization. Available at: http://apps.who.int/iris/bitstream/handle/10665/70914/9789241548434_eng.pdf%3Bjsessionid=32652906622D015D8FA4E4DEE2E52BF7?sequence=1 (Accessed: 27 April 2021).

 

Critical Review: Freckleton, I, Q.C., 2020. COVID-19: Fear, quackery, false representations and the law.

Critical Review: Freckleton, I, Q.C., 2020. COVID-19: Fear, quackery, false representations and the law. International Journal of Law and Psychiatry, 72, p.101611.

(Originally submitted as coursework towards my Masters in Global Public Health at the University of Manchester)

In this paper, Ian Freckleton Q.C. argues that depictions of previous epidemics and pandemics in religious texts, literature and television, as well as fictional depictions in books, film and video games, heighten and exacerbate fears related to the Covid-19 pandemic. He also suggests that this state of heightened fear and anxiety can cause people, particularly laypeople, to be more vulnerable to exploitation by ‘quackery’, or “the promotion of unsubstantiated methods that lack a scientifically plausible rationale” (Barrett, 2009). 

To conclude, the author posits three key recommendations to combat this problem.

  1. Provision of calm, “medico-scientifically, evidence-based” information to the public about effective treatments, and warnings about ineffective ones.
  2. ‘Cease and desist’ warnings against those promoting unproven treatments or making exaggerated claims. 
  3. Robust, well-publicised and assertive legal action against those who sell unproven and/or harmful treatments or prophylactics against Covid-19.

The paper begins with a vivid description from poet Ieuan Gethin of his 1349 experience of the plague, which killed him later that year (Alchemipedia, 2009). This sets an emotive tone which continues throughout the paper. The focus of the paper then is largely on the fear caused by the emergence of a pandemic-causing disease, particularly that felt by lay people who may not be able to “exercise medico-scientific discernment”. Arguably, Freckleton’s stance is a privileged one; he appears to adopt a deficit mindset, which considers lay people deficient in their ability to make rational decisions about their own health. He positions the emotionality and ignorance of lay people in stark contrast with the cool rationalism of the scientific ‘experts’. 

Freckleton’s lack of empathy with the ‘deficit lay people’ creates something of an irony in his failure to acknowledge the barriers they may face in accessing scientific information. The journal this paper was published in costs $35.95 to access, unless you happen to have access through an academic institution. An alternative would be to publish in an “Open Access” journal, which would have bolstered his stance by making sure members of the public are able to access it. Furthermore the language of the paper itself seems at times deliberately inaccessible. For example “The diathesis stress model is useful in this context. It postulates that if the combination of predisposition and stressor exceed a threshold, this can result in the development of pathology” (p. 4).  Even for those used to reading academic texts, the language is opaque. When asserting that lay people are more easily swayed by scams and quackery, it might have been illuminating for Freckleton to reflect on why people consume and trust information that they can access easily.

Another trap Freckleton seems to fall into is that of assuming causality. He spends two pages listing pandemics and diseases in ancient history, theology, literature and film, using this to assert that “a variety of influences can combine to generate high levels of fear and anxiety,” (pp.4). Whilst this may be true, no causal relationship between these influences in literature, films or video games and the lived experiences of those during Covid-19 is demonstrated or referenced.

Freckleton’s conclusions are similarly problematic. His first conclusion assumes that the provision of calm, “medico-scientific, evidence-based” information to the public about effective treatments, and warnings about ineffective ones, will result in reduced harm. However, no evidence is offered in this paper that communicating “medico-scientific” information would have any effect on the likelihood of people being able to discern a proven treatment from an unproven one. It is well documented that it can require much greater effort to refute falsehoods and misrepresentation than to create them, a phenomenon known as Brandolini’s Principle, or “The Bullshit Asymmetry Principle” (Williamson, 2016); it is easy, for example, to claim a teapot exists on the surface of Mars, but it would require much effort, including missions to Mars and accurate teapot-detection equipment to refute such a claim. Brandolini’s principle is highly relevant to claims of Covid-19 miracle treatments, and as shown by Vijaykumar (2021), combating these claims is not as simple as providing evidence-based information to the public. In some demographics, a “backfire” effect has also been shown, where “corrective” evidence-based information strengthens beliefs in falsehoods (Lewandowsky et al, 2012).  Provision of “medico-scientific, evidence-based” information to people can solidify the belief in unproven treatments via confirmation bias (Nickerson, 1998). The same confirmation bias, created by an “epistemic vacuum” left by a distrust in modern science, the pharmaceutical industry, or western medicine, can lead people to believe that the “evidence based” information is the falsehood, strengthening a belief in false or unproven claims (Pierre, 2020).

It may be that Freckleton is suggesting that evidence-based information needs to be presented to the public before they see misleading information. This would align with other studies which show that once people are exposed to misinformation, such as conspiracy theories, evidence refuting them is ineffective, whilst being presented with evidence prior to exposure can “inoculate” against those beliefs (Jolley and Douglas, 2017). However, the practicality of this is questionable, given that even pre-social media, “a lie can run round the world before the truth has got its boots on.” (Pratchett, 2000). In the age of the internet, false news spreads faster still (Vosoughi et al, 2018). To get in front of false news, with true, appropriate and accessible evidence in order to combat falsehoods would be challenging at best.

Freckleton accuses “laypeople” of being unable to apply proper scientific discernment, failing to recognise his own confirmation bias in the assumption that people, including himself, make objective judgements grounded upon evidence-based information. A single positive research paper for homeopathy can convince someone of its effectiveness, whilst thousands of papers showing otherwise will be ignored (Chirumbolo, 2013). Ironically, Freckleton’s conclusion that “evidence based information will result in people making the correct decisions” is not evidence based at all.

Freckleton’s second conclusion assumes that cease and desist warnings against those promoting unproven treatments or making exaggerated claims will result in decreased harm. Most worryingly, he fails to differentiate between claims made as a result of intentional deception for monetary gain, claims that well-intentioned are largely harmless such as the use of vitamin supplements, and folk medicine recommendations where no money changes hands. Folk medicine, it is important to note, is not “quackery” (Barrett, 2009), and whilst folk treatments may be unproven, they can be founded on solid evidential grounds, such as the potential for Clove (Syzygium aromaticum L.) in treatment of Covid-19 (Vicidomini et al, 2021). The “medico-scientific” approach to health in the West and the increased distancing of the health system from the patients it serves has contributed to the expansion of folk medicine (Bakx, 1991). It would be inappropriate and counterproductive to include folk medicine in the realm of quackery.

Freckleton’s failure to differentiate between malicious intent such as those marketing bleach as “Miracle Mineral Solution” and well-intentioned modern, homeopathic or folk remedies belies his own bias. At one end of the spectrum, bleach is sold as a treatment that “can rid the body of Covid-19” (Mark Grenon in his letter to Donald Trump, in Pilkington, 2020), and at the other end, Ayurvedic practitioners suggest drinking warm water, moving (“yogasana”), breathing (“pranayama”) and meditating. It should be fair to say that one end of the spectrum warrants legal action, and the other end is at worst a harmless way to spend time. Where the line should be drawn is surely a question worthy of consideration, and Freckleton fails to recognise this nuance. 

Freckleton’s third conclusion implies that robust, well-publicised and assertive legal action against those who sell unproven and/or harmful treatments for Covid-19 will reduce harm. Here it is worth noting Freckleton’s position as a practitioner of law; arguably this conclusion is a case of ‘a hammer looking for a nail.’ His narrative is sound – he shows that in early pandemics, unscrupulous quacks would take advantage of the desperate in order to make money from treatments they knew would not work. He also explains that as society has progressed, so too have the legal mechanisms by which these charlatans and quacks are prevented from exploiting the vulnerable. Fines have been issued in Australia to firms selling “Miracle Mineral Solution” as a treatment for Covid-19, and thus courts successfully protect consumers from the actions of unscrupulous and unethical businesses. However, he has not proven, nor shown any correlation that would suggest such a conclusion, that increased legal action would be an effective measure. Indeed, it is possible that stronger legal action may only strengthen the resolve of those who believe conspiracy theories and do not trust the motivations of ‘big pharma’ or western medicine. 

In summary, whilst the author has provided in-depth context on representations of pandemics in different media, and posited potentially useful suggestions to combat irrational fear and harm from “quackery”, it’s clear that Freckleton is observing through the lens of his practice of law. Given this, it is no surprise he came to the conclusions that he did, however none have been shown to have any significant evidential basis in this paper, a point that is ironic, given the author’s belief that providing “medico-scientifically, evidence-based” information to the public will help people make more rational decisions.

 

References

 

Alchemipedia, 2009. Jeuan Gethin (Welsh Poet) d. 1349 Bubonic Plague. Alchemipedia.blogspot.com. Available at: http://alchemipedia.blogspot.com/2009/11/jeuan-gethin-welsh-poet-d-1349-bubonic.html (Accessed: 2 June 2021).

 

Bakx, K., 1991. The ‘eclipse’of folk medicine in western society. Sociology of Health & Illness, 13(1), pp.20-38.

 

Barrett, S., 2009. “Quackery: how should it be defined?”. quackwatch.org. Available at: https://quackwatch.org/related/quackdef/ (Accessed: 2 June 2021).

 

Chirumbolo, S., 2013. Homeopathy: bias, mis-interpretation and other. Journal of Medicine and the Person, 11(1), pp.37-44.

 

Jolley, D. and Douglas, K.M., 2017. Prevention is better than cure: Addressing anti‐vaccine conspiracy theories. Journal of Applied Social Psychology, 47(8), pp.459-469.

 

Lewandowsky, S., Ecker, U.K., Seifert, C.M., Schwarz, N. and Cook, J., 2012. Misinformation and its correction: Continued influence and successful debiasing. Psychological science in the public interest, 13(3), pp.106-131.

 

Nickerson, R.S., 1998. Confirmation bias: A ubiquitous phenomenon in many guises. Review of general psychology, 2(2), pp.175-220.

 

Pierre, J.M., 2020. Mistrust and misinformation: A two-component, socio-epistemic model of belief in conspiracy theories. Journal of Social and Political Psychology, 8(2), pp.617-641.

 

Pilkington, E., 2020. Revealed: Leader of group peddling bleach as coronavirus ‘cure’ wrote to trump this week. The Guardian. https://www.theguardian.com/world/2020/apr/24/revealed-leader-group-peddling-bleach-cure-lobbied-trumpcoronavirus. (Accessed: 7 June 2021).

 

Pratchett, T., 2013. The truth (Vol. 25). Random House. ISBN 0-385-60102-6

 

Vicidomini, C., Roviello, V. and Roviello, G.N., 2021. Molecular Basis of the Therapeutical Potential of Clove (Syzygium aromaticum L.) and Clues to Its Anti-COVID-19 Utility. Molecules, 26(7), p.1880.

 

Vijaykumar, S., Jin, Y., Rogerson, D., Lu, X., Sharma, S., Maughan, A., Fadel, B., de Oliveira Costa, M.S., Pagliari, C. and Morris, D., 2021. How shades of truth and age affect responses to COVID-19 (Mis) information: randomized survey experiment among WhatsApp users in UK and Brazil. Humanities and Social Sciences Communications, 8(1), pp.1-12.

 

Vosoughi, S., Roy, D. and Aral, S., 2018. The spread of true and false news online. Science, 359(6380), pp.1146-1151.

 

Williamson, P., 2016. Take the time and effort to correct misinformation. Nature News, 540(7632), p.171.

 

Community Approaches to Health and Covid-19

I have been struck by the differential impact of Covid-19 on different communities. Black people in the UK are 4 times more likely to die from Covid-19 as white people, and when taking other socio-demographic factors into account, the risk of a Covid-19 related death for black people is still 1.9 times greater than white people (White and Nafilyan, 2020). The effect is not just restricted to the UK; the same effect has been seen in the USA, where predominantly black counties suffered significantly higher Covid-19 infection rates and deaths (Millett et al, 2020)

 

These statistics are alarming. From a biomedical perspective, the risk for black people who have contracted Covid-19 is nearly twice as great, whilst structural racism, socio-economic  disadvantages and other social determinants mean black people are more likely to contract the disease in the first place. Black people in the US are significantly less likely to trust physicians (Armstrong et al, 2007), are more likely to exhibit vaccine hesitancy (Razai et al, 2021), and are more likely to work in “essential” jobs, or roles that require in-person interaction that cannot be done from home (Dyer, 2020). The typical low pay of these types of roles mean that workers are less able to take time off, or practice protective measures such as isolating at home (Public Health England, 2020), and this impacts not just black communities but all those people in lower paid, “essential” and in-person jobs. 

 

The Covid-19 pandemic had disproportionate impacts on low-income families (Bitler et al, 2020), of which the results will be felt for years, possibly for generations. Even before the pandemic, life expectancy was stalling and inequalities were worsening in England (Taylor-Robinson, 2019), and the Covid-19 pandemic only served to amplify these inequities. Children, especially those living in low-income families have suffered significantly, with evidence showing that the pandemic caused low-income families’ expenditures to increase, whilst expenditures of higher income families decreased.

 

For many children living in poverty or in low-income families, schools are not just a place to learn, but to eat healthily. School closures meant that for many of these children, it wasn’t just their education that has been put on hold, but their nutrition too, which will only serve to widen the existing gaps in food security and learning (Van Lancker and Parolin, 2020).

 

There are efforts to redress these inequalities that have been growing over the past decade, and exacerbated by the Covid-19 pandemic. In “Build Back Fairer”, the Covid-19 Marmot Review, community approaches to health are recommended in an approach “based on the principles of social justice” (Marmot et al, 2020), in order to reverse these growing inequalities. Proposed measures include increasing funding for public health alongside an expanded focus on the social determinants of health, recognising that poverty, deprivation, employment, ethnicity, social class and culture strongly influence health and our individual perception of it.

 

 

References:

 

Armstrong, K., Ravenell, K.L., McMurphy, S. and Putt, M., 2007. Racial/ethnic differences in physician distrust in the United States. American journal of public health, 97(7), pp.1283-1289.

 

Bitler, M., Hoynes, H.W. and Schanzenbach, D.W., 2020. The social safety net in the wake of COVID-19. National Bureau of Economic Research. (No. w27796).

 

Dyer, O., 2020. Covid-19: Black people and other minorities are hardest hit in US. BMJ, p. m1483. doi: 10.1136/bmj.m1483.

 

Marmot, M., Allen, J., Goldblatt, P., Herd, E. and Morrison, J., 2020. Build Back Fairer: The COVID-19 Marmot Review. The Pandemic, Socioeconomic and Health Inequalities in England. London: Institute of Health Equity.

 

Millett, G.A., Jones, A.T., Benkeser, D., Baral, S., Mercer, L., Beyrer, C., Honermann, B., Lankiewicz, E., Mena, L., Crowley, J.S. and Sherwood, J., 2020. Assessing differential impacts of COVID-19 on black communities. Annals of epidemiology, 47, pp.37-44.

 

Public Health England, 2020. COVID-19: understanding the impact on BAME communities. Available at: https://www.gov.uk/government/publications/covid-19-understanding-the-impact-on-bame-communities (Accessed: 11 May 2021).

 

Razai, M.S., Osama, T., McKechnie, D.G. and Majeed, A., 2021. Covid-19 vaccine hesitancy among ethnic minority groups. BMJ, p. n513. doi: 10.1136/bmj.n513.

 

Taylor-Robinson, D., Barr, B. and Whitehead, M., 2019. Stalling life expectancy and rising inequalities in England. The Lancet, 394(10216), pp.2238-2239.

 

Van Lancker, W. and Parolin, Z., 2020. COVID-19, school closures, and child poverty: a social crisis in the making. The Lancet Public Health, 5(5), pp.e243-e244.

 

White, C. and Nafilyan, V., 2020. Coronavirus (COVID-19) related deaths by ethnic group, England and Wales: 2 March 2020 to 15 May 2020. Office for National Statistics.

 

Whitehead, M., Taylor-Robinson, D. and Barr, B., 2021. Poverty, health, and covid-19. BMJ; 372:n376

Course Review: Global Health Masters Degree (M.Sc.) at The University of Manchester (distance learning)

This is an in-progress review regarding module content, teaching delivery, curriculum, online teaching, assessment methods and tools for the online Global Health Masters Degree at The University of Manchester and the Humanitarian and Conflict Research Institute (HCRI), where I’m currently studying.

(Last updated: 19 March 2024)

I’ve now completed the second year of this taught Masters degree, and I would have to say that my experience of the teaching quality, content delivery, and assessment consistency has been somewhat variable. It’s quite clear that the University of Manchester doesn’t adequately support or design courses for adult, distance learners.

If you’re looking for a Masters Degree, as an adult, distance learner, I would not recommend this course. The content is generally satisfactory (though often out of date and disjointed between modules), but delivery, assessment, communication, and support is seriously lacking.

Curriculum and content

The course content and curriculum however is generally pretty good, it’s comprehensive, interesting, and covers research methods, epidemiology, and global health fundamentals to begin with, and lays good foundations for subsequent modules.

The first two modules were excellent in respect to curriculum and content. The third was a little muddled, and the fourth, which I’m studying now (community approaches to healthcare) feels very scattered, out of date and more about theoretical sociology than anything in the application or understanding of community approaches to healthcare. In many of the modules, the volume of assessment-based work has felt excessive, meaning that a lot of the learning work (of which there is a lot of mandatory reading – more so than previous modules) has to be dropped in order to make time for completing assessments, which is less than ideal. I’d love to read more about some of the topics in the syllabus, but assessments must take priority.

This is a “Level 7” course, so the demands are high, but students are not expected to be “at” level 7 at the inception of the course, despite a few comments from lecturers to the contrary. I can heartily recommend watching this video below that will REALLY help you take notes, learn, and write your assessments:

Having now completed the “Disaster response and Readiness” module, I will say that the content is excellent, though there is some overlap with previous modules. This isn’t necessarily a bad thing, as it helps to reinforce some of the stuff we’ve already learned.

Delivery

The delivery, I’ll be honest, is really variable, spanning from just ok to really poor at times. Compared to other institutions such as the Open University, the online offering does appear to be lacking in some areas. The QAA provide an excellent framework to help understand what you should expect from a higher education institution in respect to teaching, assessment, admissions, etc.

The course is advertised as:

“The course has been designed to recreate a classroom learning environment in an online format. You will be able to engage fully with the course content and with peers via lectures, discussion boards, group work, online chat, question and answer sessions with the tutor, and peer-to-peer feedback and assessment.”

I feel this is rather misleading. We haven’t had any lectures. We did have a group exercise, when we were placed into groups of 15 students to create a piece of work. This is far too large a group size, and resulted in a heavy management overhead for the 2-3 people who were capable of managing a collaborative, remote project.

We do have online chat – but only because we set up our own WhatsApp group.

We have had two Q&A sessions in module 3, and two in module four (though with very short notice, meaning many people, including myself, missed it due to work commitments.) The live sessions however, are in the UK daytime, so many people with full time jobs, or in very different time zones, were not able to attend or had to get up in the middle of their night.

Some of the weekly module material is rather out of date, with broken links and conflicting instructions regarding weekly assessments. The course would definitely benefit from improved QA processes so that students can spend more time learning and less time searching for papers referenced in the materials as essential reading. When your time is limited, it is very frustrating to be told to read a paper which is poorly referenced, missing from reading lists, and hard or impossible to find online.

What also surprises me is that the course material is only released each week. I’m not sure why it can’t be provided at the start of the module, so that we can learn at our own pace and better fit it in with work, family, and other commitments.

Assessment

The course is advertised as:

“You will also receive formative feedback and guidance throughout the course, which will enable you to progress and develop your confidence and analytical skills.”

There is a nod to formative assessment (formative assessments are essentially checks to make sure students are on the right track, so that teaching and content can be tweaked accordingly, prior to summative assessments), in the form of online discussion boards. However, the feedback and engagement on discussion boards is rarely from the module lecturer, and instead is provided by other post-graduate or post-doc students.

There is certainly no feedback loop in place to ensure that students on the course are learning the right things at the right time. It really is quite difficult to gauge if you’re doing well, or doing badly, until you receive your marks some weeks after the module has ended.

In respect to summative assessment, grades and feedback were often delayed, which I put down to the challenges of 2020. However, most of our cohort agreed that the feedback on submitted coursework was often sparse, and at times suggested that the coursework had only been given a cursory review. Worse still, marking criteria appear to change for different modules – for one module’s essay assignment, marks are taken off for not using subheadings, and another essay, marks were taken off for using subheadings. I have fairly serious concerns about the lack of consistency between modules.

As is so often the case with academic critique, suggestions are frequently made to discuss points further, add introductory text and expand in more detail – even where the essay is at the word limit, making it impossible to actually comply with the suggestion. In my opinion, this is simply lazy feedback: anyone can suggest you “expand in more detail”, but without actionable feedback about where you could improve your work, it’s meaningless.

Recently, we’ve also been asked to submit a critical review for assessment. Prior to the assessment, we’ve had no teaching regarding what constitutes a critical review, and despite many requests from multiple students for an example of a critical review so that we know what we’re supposed to be submitting, all the requests were refused. This makes for a somewhat stressful assessment delivery, since most of the communication on the whatsapp group for a few weeks was people asking each other for support.

I also believe the course is over-assessed; but this can be said of the majority of academic courses that don’t take into account the opportunity cost of assessment versus dedicated learning. Your mileage and opinion may vary. I’m personally of the opinion that learning is more important than assessment.

I’ve now completed the “Disaster Preparedness” module, and feeling very frustrated by how long it’s taking for essays to be marked. We’re nearly at the end of the following module, and still haven’t had our marks or feedback from the previous one.  This makes it very hard to take on any feedback and improve subsequent work. It’s not really acceptable to set a hard deadline for students who are paying large fees, and expect them to wait indeterminately long to receive their marks.

Update on assessment March 2024

This is rather more worrying, and I’ve made a formal complaint as a result. To be as brief as possible, in the “Leadership” module (which is a rather haphazard collection of organisational theory and project management topics) our primary summative assessment was an essay, described in the “module handbook” and listed as 2500 words. At the start of each module, I gather all the necessary information, collate it together and plan my work for the next few weeks around it – because I have a job and a family and I have to plan well ahead to fit everything in.

Unbeknownst to me, the module provider, Ayham Fattoum, changed the word limit to 2000 words. This was noted by him in a comment in a general forum thread on a different topic. There was no announcement or notification.

When I received the grade back for the essay, I had been penalised for going far over the limit. I was rather surprised by this and it took me a while to work out what had happened, and how I wrote a 2494 word essay with a 2000 word limit. Eventually I worked it out and emailed Ayham. He responded this:

Hi Tom,

Just to update you that your essay will be reviewed considering the quality of the essay (to what extent it has addressed the essay question, understanding, etc..) up to 2000 words. If the quality deserves a higher mark, then the penalty will be removed, and the assigned mark will be updated accordingly.

This may take a few working days.

I queried why only the first 2000 words were being marked and Ayham responded:

Hi Tom,

Now, the essay is not being penalised for exceeding the wordcount. The quality of the essay up to 2000 words was taken into consideration to decide on the mark. The feedback highlights areas for improvement for this essay. Let me know if you have questions about the feedback (which evaluates the quality of the essay).

Normally, we would not re-consider the penalty because the 2000 words have been communicated on the welcome page and in general forum on the discussion board weeks before the submission date. Moderators may argue that not spotting the change in word count is evidence that the student was not engaged in the module, especially that all other students met the 2000 words count.

So here, Ayham is implying it was my fault. The implication that I’m “not engaged” because I plan well ahead due to having a family to look after and a business to run is frankly offensive.

My concern is that many of the students on this course come straight from undergrad level and wouldn’t be aware that they can challenge this sort of issue, let alone have to put up with unprofessional communication. Unless this behaviour is challenged and addressed, I fear that it will likely continue. What’s really disappointing is that all of this could have been avoided with a simple apology and a reassessment.

January 2024:

I’ve completed the Diseases and Trauma in Developing Countries module now, which overlapped to a fair degree with previous modules. It was interesting, and took a different perspective, building more on non-communicable diseases than previous modules. The course content was good, but assessment unfortunately took far too long, and consisted again largely of “expand on this” and “more detail” feedback, which is not useful when you’re at the word limit of a 1500 word essay. Good feedback would include which bits to cut out or reduce – because we can’t keep adding content to an essay with no words left!

More serious issues – mitigating circumstances

I contacted the Student Support & Wellbeing Team (salc.mitcircs@manchester.ac.uk) to request a short extension to an essay deadline due to some serious family issues that had to be dealt with. This request was rejected out of hand, as you can see in the image below:

This is yet another example of how the University of Manchester doesn’t adequately support or design courses for adult, distance learners.

Assessment feedback: the university ask students to provide feedback at the completion of each module. However, the deadline for feedback is *before* you receive your own marking, grades, and feedback from the course lecturers – which makes it impossible to provide said feedback. Every time this happens, I’ve given the feedback office this feedback, and received no response!

Support

When you do need support, the course director is very responsive and helpful, as are many of the course leaders – in what must have been a very challenging year for them. Some of the course/module leaders are evidently quite new to teaching and good pedagogical (the theory and practise of learning) practices.

The University of Manchester provide some excellent student support facilities and services. The library is excellent (and the librarians are super helpful!), other student support services are great, and there are some fantastic extra-curricular activities and clubs too.

Costs

I paid £2100 in fees as a home (UK) student for entry in September 2020. I understand that the fees have now risen to £3,333 (correct as of 2022).

My perspective

My personal opinion is that there is at times little acknowledgement of the varying backgrounds and needs of PGT (Post Graduate Taught) students, who, particularly on remote courses, are often treated as second-class students. PGT students may have full-time jobs, caring responsibilities, particular timetables to stick to, and other differences to the typical undergraduate student. PGT courses such as this global health masters degree, should be designed with this in mind, so that we can better structure learning around existing commitments.

I feel (and this is purely conjecture) that it can sometimes be difficult for academics, particularly if their career has always followed an academic path, to empathise and understand that PGT students are not sitting at their desks all day every day. We may well be squeezing in study for an hour or two each evening, at the kitchen table, or simply allocating a full day every weekend to it, for example. This means that if something isn’t available, a link doesn’t work or a tool is broken, for some people, it can instantly set them a week behind.

Mitigations

As noted earlier, as a cohort of students, we realised early on that we needed to create a whatsapp group to communicate with each other. Instructions, marking criteria, or the tools provided (blackboard) were sometimes unclear, difficult to access, find or understand, as well as lecturers often taking a few days or sometimes weeks to respond to queries posted on the boards. A support group where it was safe to ask the “stupid questions” and get responses quickly was essential. When you only have an evening to get through your workload, you can’t wait another few days for an answer.

Also, the University tools are largely desktop browser based, so a communication platform such as whatsapp on mobile devices made for much easier communication inside our very mixed and globally distributed cohort.

Recommendations

If you’re considering the course, I can also recommend the below books, which if you haven’t read them already, can provide useful background and context:

Oh, and Greg Martin’s global health channel on youtube is a great resource!

If you’re looking for a high quality taught masters degree in global health, and would like to find out more, please get in touch via email at tom@tomgeraghty.co.uk, and I can provide a true and honest description of what to expect on this distance-learning masters degree.


The course is affiliated with the Humanitarian and Conflict Response Institute (HCRI) at the University of Manchester

The below is copied from the Global Health Masters Degree  (MSc) at The University of Manchester website pages

Community Approaches to Health : Examine issues of psycho-social care, behaviour change, aging, micro-insurance, advocacy, holistic health, HIV, nutrition, breast feeding, hygiene promotion and immunisation.

Ethics, Human Rights and Health : Consider the role of gender, health inequalities, dignity, legal frameworks, rights based approaches to health, reproductive rights, Millennium development goals 4, 5, and 6, child rights, and accessing illegal drug users and commercial sex workers.

Health Systems and Markets: Look at the social determinants of health, the work of civil society organisations, the interfaces between states and economies, organisational change, health financing, urban health, rural access, food security, agriculture, and eradication programming.

Risk, Vulnerability and Resilience: An introduction to public and global health, risk assessments and management, epidemiology, population ageing, the determinants of child survival, and pandemics.

You will be able to engage fully with the course content and other students via lectures, discussion boards, group work, online chat, question and answer sessions with the tutor, and peer-to-peer feedback and assessment.

PGCert, PGDip and MSc awards

You can exit the course with a PGCert award after Year 1, a PGDip after Year 2, or an MSc after Year 3.

Teaching and learning
The course will begin with an online induction session that explains how the course will progress and how you can fully engage with the curriculum and the online classroom environment. It will set out the key contacts and what each student can expect.

Academic and pastoral support will be offered online by the programme director, course leaders and teaching assistants, who will be responsible for monitoring progression through the course. A dedicated programme administrator will be responsible for dealing with day-to-day enquiries.

The course lasts for three years in total. You will study four course units in each of Years 1 and 2. Each of the four units comprises eight weeks of teaching followed by one week of assessment.

You will complete each unit in turn before progressing to the next. The format is designed to be adaptable to the needs of professional students and provides opportunity for reflection between units.

Year 3 comprises the dissertation for the MSc award. Students will submit a research proposal and be allocated a dissertation supervisor. You will then be guided through key milestones in the completion of your dissertation.

The course has been designed to recreate a classroom learning environment in an online format. You will be able to engage fully with the course content and with peers via lectures, discussion boards, group work, online chat, question and answer sessions with the tutor, and peer-to-peer feedback and assessment.

Coursework and assessment
All assessment will take place online. Each of the four units in Years 1 and 2 will conclude with a selection of assessments, including multiple choice tests, group assignments such as wikis, and prose-based assessments.

Certain academic pieces placed in the discussion forums are used as part of the overall assessment process for each unit (10%).

Each student will provide a 350 to 500-word (excluding references) written academic piece expressing a view or perspective upon a question raised by the tutor/convenor weekly during the course of the course.

This will provide eight pieces of primary work that will be submitted to the discussion board per course unit. Engagement on the discussion boards is required throughout the course.

You will also receive formative feedback and guidance throughout the course, which will enable you to progress and develop your confidence and analytical skills.

Course unit details
You will study four course units in each of Years 1 and 2. Each of the four units comprises eight weeks of teaching followed by one week of assessment.

Year 3 comprises the dissertation for the MSc award.

Exit awards

You will receive 60 credits for the successful completion of each year of the course, totalling 180 credits for the MSc award.

It is possible to exit the course earlier than this with 60 credits for a PGCert award or 120 credits for a PGDip.

All of the credits you earn will be transferable to other academic institutions.