I am trying to learn how to live with my new neighbors. And I don’t mean the people. The blood sucking mosquitoes. gnats, horse flies, no-see-em’s etc are nearly debilitating…literally drawing blood in minutes of being outside. I have always been unusually prone to getting bug bites., but this is some serious harassment. I have had to take the dog for a walk armed with protection, and I’m not referring to the pepper spray or taser that I conveniently keep to ward off creepers. No, no, now when people see me walking towards them, they cross to the other side of the street. Yes, I am that weirdo walking the funny looking dog, wearing bright red knee-high rain boots, oversized basketball shorts, and a jacket with the hood pulled tight around my face. To make matters worse, Diesel, being so excited about all the new smells and places to pee, gets so distracted he forgets that he needs to poop. I can tell–everytime I see him get ready to get in the squatting postition, he seems to catch a whiff of interest nearby. He is in canine bliss while I get devoured by insects. I LOVE my new house. I am so happy with my new home, and I can’t help but spend all of my thoughts thinking of new, creative projects and ideas for the house. Most recently, the influence of my brilliantly handy father sparked my creativity as I attempted to rig up some extra night lights before bed (just in case I get paranoid in the middle of the night), rearranging lamps and extension cords etc to get more light and visibility…without turning on actual lights of course. Anyway, after about an hour of unplugging, replugging, and not getting anywhere, I gave up and decided to just settle with the half dozen nightlight plug-ins I started with. Despite my parents’ disagreements with my pack rat clutter, there was, surprisingly, a system to the madness. I cant seem to find anything lately. Not even important things, but simple things that are always in the way until when you need them. Like stamps. I used to keep them in the silverware drawer in the kitchen, only because they were with my groceries one day, and I put them in there so I didnt throw them out, and for months, thats where I kept stamps. Yesterday, (in my attempt at being organized) I specifically recall putting them in a designated safe place in my new office/study/guest room. This afternoon, I nearly unpacked half the house trying to remember where I put them. Similarly, out of my entire collection of random pens of every shape, size, and color that I would usually keep scattered throughout the house, the one day I am looking for a RED pen to do some editing, the only color (out of literally hundreds of pens) is black–not even a blue pen to give SOME kind of contrast. Nope. Go figure. How’s this for Murphy’s Law…I typically make it a habit to only buy wines with twist off tops instead of corks. You can probably imagine my frustration from my countless failed attempts to open a bottle of wine. Impossible. I don’t doubt it has everything to do with the constant slippery, soapy film I can’t seem to wash off my skin with the soft water around here. I tried to open a jug of milk this morning for breakfast, and couldn’t get a grip for the life of me. Or the fact that every dish I wash (and I have washed every single bowl/plate/fork and spoon I’ve used) won’t feel completely rinsed from slimey soap suds, making me feel the need to put more soap and start scrubbing again. Speaking of my cleaning concerns, as I was showering tonight I was just starting to put two and two together (about the constant soapiness and soft water) and absentmindedly realized I was trying to scrub my face with….conditioner. Is it the weekend yet???
A recurrent issue in healthcare today is the increasing prevalence of teen and unintended pregnancy rates. Although teenage initiation of sexual activity is similar throughout much of the world, the United States remains the leader in rates of teen pregnancy amongst the developed world (Guttmacher Institute, 2011a). Advances in contraceptive technology have most likely contributed to the slight decline in this trend over the past five years, however, teenagers are still facing significant barriers in obtaining quality reproductive health and contraceptive services. In surveys of adolescent contraceptive use in the last five years, only 84% indicated use of any method at the time of last sexual intercourse. Although condoms and birth control pills are the most commonly used methods amongst teens, only 68% actively used condoms, and 55% reported taking the pill (Guttmacher Institute, 2011a). Additionally, these contraception methods that have been made readily available to teenagers usually require consistent user compliance and responsibility, with higher failure and discontinuation rates than other methods. Studies have revealed roughly 48% of women who experienced an unintended pregnancy reported having used a contraceptive method in the same month they conceived (Finer & Henshaw, 2006). This is suggestive that nearly half of these unintended pregnancies were related to contraceptive failure.
The long-term contraceptive efficacy and convenient lack of daily involvement required by the Intrauterine Device (IUD) suggests a promising solution for preventing unintended pregnancy, especially in teens. Unfortunately, high up-front costs, limited reimbursement policies, and negative historical misconceptions have led to provider reluctance and contributed to the inadequate accessibility of the IUD to the adolescent population.
Aside from issues with adequate user compliance of available methods, recent political controversies regarding adolescent access and awareness of reproductive healthcare presents a crucial obstacle to teenagers seeking effective family planning services. Several states have prohibited the implementation of sexual education resources in public school systems. Consequently, perceived barriers and lack of knowledge on how to obtain available resources often deters teens from seeking these services (American Academy of Pediatrics [AAP], 2007). State laws governing parental consent and adolescent confidentiality have resulted in healthcare provider apprehension in providing reproductive services to minors (Guttmacher Institute, 2001b). Furthermore, much of the available contraceptive coverage is limited to minimum reimbursement of methods that have lower efficacy and greater user dependency, contributing to more contraceptive failure rates. Even with federal equity laws that mandate coverage of top tier methods such as the intrauterine device, high up front costs have deterred many contraceptive providers from even offering this method in their practice. Despite the growing demand for IUD contraception, more than half of family planning agencies reported not keeping IUDs stocked in their practice due to high costs (Lindberg, Frost, Sten, & Dailard, 2006).
In a time of economic struggles, rising rates of poverty and inflation have heightened the socioeconomic burden of unintended and teen pregnancy. The needs for optimal efficacy methods of contraceptives have opened a window of opportunity for cost saving innovations in health care. Improving adolescent access and affordability of IUD contraceptives offers a strategic approach to achieve quality reproductive health services to teenagers. Because less expensive forms of birth control are user dependent and have higher failure rates, IUD contraception has proven to be the most cost effective strategy to avoid unintended pregnancy and pregnancy related costs (Trussell et al., 2009). Designating provisions of the federal budget to fund programs to offer IUD contraception at little to no cost to teenagers can result in superior cost saving outcomes. Furthermore, barriers that restrict adolescents from seeking contraception can be eliminated through implementation of health policies that will encourage and protect clinicians providing reproductive services to minors without parental consent.
Public perception and actions toward issue.
In revisions to strict historical guidelines for appropriate IUD candidates, the American College of Obstetrics and Gynecology (ACOG) released an updated Committee Opinion in 2007, stating “intrauterine devices offer safe, effective, long-term contraception…appropriate for select nulliparous [women] and adolescents” (American College of Obstetrics and Gynecology [ACOG], 2007).
A 2008 survey exploring young women’s knowledge and perceptions of IUDs revealed that less than half of adolescent females had ever heard of the method, of which only 37% reported having a positive attitude about it (Whitaker, et al., 2008). California State Legislature established the Family PACT (Planning, Access, Care, and Treatment) program to improve adolescent access to affordable, confidential contraceptive services. Policies have set forth standards to ensure the provision of quality family planning services, offering coverage for top tier forms of contraception, including IUDs and implants (Brindis et al., 2003). Surprisingly, even after removing cost-related barriers, a review of the service utilization patterns revealed less than 0.5% of adolescents received an IUD contraceptive, possibly reflecting the limited awareness and accessibility in community clinics. Further, it seems it is not only the prospective patients that lack accurate knowledge of the IUD. A recent survey of contraceptive providers serving the Family PACT program revealed that only 39% perceived adolescents to be appropriate candidates for IUD contraception (Speidel, Harper & Shields, 2008). In an effort to correct previous beliefs, the UCSF Bixby Center for Global Reproductive Health LARC Project has funded provider-training courses to re-introduce to the IUD as a reliable form of contraception for most women, regardless of age or parity. The project also aims to increase opportunities for IUD provision by encouragement for immediate post-abortion IUD insertion, and implementation of a simplified criteria screening tool to quickly assess eligibility for IUD contraception to initiate same day insertion (Speidel, et al., 2008).
Examples of events illustrating the problem
The federally funded Title X family planning program offers financial assistance to adolescents and low-income individuals for free or reduced costs healthcare services that are not otherwise covered by Medicaid or private insurance companies (Lindberg, Frost, Sten, & Dailard, 2006). However, high up-front costs have resulted in limited the availability of top tier contraceptives to family planning agencies, and IUDs are not provided in nearly half of publicly funded clinics and health departments (Lindberg et al., 2006). A recent survey of federally funded family planning services in California found nearly half of contraceptive providers in the program did not dispense or kept IUDs in stock (Speidel, et al., 2008).
Current legislation aimed at the issue:
Amendments to Title V of the Social Security Act have included the addition of Sec. 2953. Personal responsibility education, which has allotted $75 million in federal funding to support evidence based programs to reduce teen pregnancy (H.R. 3590: Patient Protection and Affordable Care Act, 2010).
Contraceptive equity laws supported by the Pregnancy Discrimination Act have been established prevent employer insurance plans from discriminating against women seeking prescription contraception. This policy mandated that insurance companies providing prescriptive drug coverage be required to provide the same benefits for prescription contraceptives (Equal Employment Opportunity Commission [EEOC], 2010). However, some states allow insurers to impose restrictions on what types of contraceptive are covered, and for whom. For example, 2 states do not require coverage of emergency contraceptives, and West Virginia allows insurers to exclude dependent minors from contraceptive coverage (Guttmacher Institute, 2011c). Additional exemption policies permit some insurance companies and employer plans to refuse contraceptive coverage based on religious grounds and “conscience clauses” (Association of Reproductive Health Professionals [ARHP], 2008; Guttmacher Institute, 2011c).
Adolescent confidentiality laws allow explicit minor access to contraceptive services without parental consent in 21 states and the District of Colombia (Guttmacher Institute, 2011b). However, some state “refusal clauses” permit many insurance companies and employer insurance plans to exempt themselves from federal contraceptive equity laws (ARHP, 2008).
The manufacturer of the LNG IUS has established the ARCH (Access and Resources in Contraceptive Health) Foundation: a not for profit financial assistance program that offers free or reduced costs of IUDs to low-income women (Hubacher, Finer, & Espey, 2010).
Medicaid family expansion programs offer waivers to expand access to coverage by raising the income criteria threshold required for Medicaid eligibility (Guttmacher Institute, 2011a).
Recommendations to fix the problem.
With an open window of opportunity for political streaming, stakeholders have recommended a number of policy proposals to improve the availability of high quality reproductive care to adolescents to reduce the number of teen pregnancies and subsequent pregnancy-related costs. Amongst the highest priorities is to expand adolescent access and affordability to effective contraceptive methods. This can be accomplished by the development of more research initiatives to better understand the barriers to access, limitations in funding, and negative perceptions of youth and providers (Speidel, et al., 2008). With these findings, innovators can publish updated, accurate information to reestablish family planning services as an essential value to the public health system (Butler & Clayton, 2009). Further, programs offering providers with IUD education and skills training can improve accessibility by expanded provider base for these services. This base can better promote and facilitate IUD contraception by implementing simplified tools for candidate criteria screening, allowing better opportunities for same day insertions, and reducing the number of follow up visits (Speidel, et al., 2008). Because multiple pregnancies are becoming increasingly prevalent, stakeholders have proposed the establishment of federally funded programs to provide teenagers free IUD insertions immediately follow abortions or childbirth to prevent subsequent pregnancies (Yen, Saah, & Hillard, 2010). The Contraceptive CHOICE Project, in an effort to encourage the use of long-acting reversible contraception (LARC), sought to eliminate previously determined barriers to IUD contraceptives. Because high initial costs of the most effective methods, this program offered a full range of contraceptive choices to women enrolled in the project at no cost, thus removing financial obligations. Findings revealed that without the influence of cost barriers, 56% of participants chose IUD contraception (Secura, Allsworth, Madden, Mullersman, & Peiper, 2010).
As the demand for family planning continues to skyrocket, healthcare providers, policymakers, and funding agencies must collaborate to fill gaps between barriers and knowledge bases regarding effective contraception. Consequences of today’s youth serve as a determinant for future outcomes, thus making teenagers a particularly important population to target future innovations in contraceptive care. Goals for future projects should seek to eliminate barriers to access by addressing contraceptive supply shortages, correcting provider biases, maximize reimbursement coverage, raising contraceptive awareness, and reduce limitations on eligibility for contraceptive provisions amongst qualified health care professionals (Blumenthal, Voedisch, & Gemzell-Danielsson, 2011). Utilizing these strategies to improve the availability of affordable and effective contraceptives can reduce the risk long term pregnancy-related costs and consequences, and can provide an enhanced quality of life amongst the nation.
American Academy of Pediatrics. (2007). Contraception and adolescents. Pediatrics, 120(5):1135-1147.
American College of Obstetrics & Gynecology. (2007). ACOG Committee Opinion No. 392, December 2007. Intrauterine device and adolescents. Obstetrics & Gynecology, 110(6):1493-5.
Association of Reproductive Health Professionals [ARHP], (2008). Contraception. ARHP Policy Committee Position Statement on Contraceptive Access. Retrieved from: http://www.arhp.org/about-us/position-statements#11
Blumenthal, P., Voedisch, A., & Gemzell-Danielsson, K., (2011). Strategies to prevent unintended pregnancy: increasing use of long- acting reversible contraception. Human Reproduction Update,17(1):121–137
Brindis, C., Llewelyn, L., Marie, K., Blum, M., Biggs, A., & Maternowska, C., (2003). Meeting the reproductive health care needs of adolescents: California’s family planning access, care, and treatment program. Journal of Adolescent Health, 32S(62): 79-90
Butler, A. & Clayton, E., (2009). A review of the HHS Family Planning Program: Mission, management, and measurement of results. National Academies Press: Washington, DC
Equal Employment Opportunity Commission (2000). Decision on coverage of contraception. Retrieved from: http://www.eeoc.gov/policy/docs/decision-contraception.html
Finer, L., & Henshaw, S., (2006). Disparities in rates of unintended pregnancy in the United States, 1994 and 2001. Perspectives on Sexual and Reproductive Health, 38:90-96.
Guttmacher Institute, (2011a). Facts on American teens’ sexual and reproductive health.
Guttmacher Institute, (2011b). Minors’ access to contraceptive services. State Policies in Brief.
Guttmacher Institute, (2011c). Insurance coverage of contraceptives. State Policies in Brief.
6H.R. 3590: Patient Protection and Affordable Care Act, 2010). Public Law 111–148 111th Congress, 42 USC 18001
Hubacher, D., Finer, L., & Espey, E., (2011). Renewed interest in intrauterine contraception in the United States: Evidence and explanation. Contraception, 83(4): 291-294.
Lindberg, Frost, Sten, & Dailard, (2006). Provision of contraceptive and relatedservices by publicly funded family planning clinics, 2003. Perspectives on Sexual and Reproductive Health, 38(3):139-147.
Secura, G., Allsworth, J., Madden, T., Mullersman, J., & Peiper, J., (2010). The Contraceptive CHOICE Project: reducing barriers to long-acting reversible contraception. American Journal of Obstetrics & Gynecology, 203:115.e1-7.
Speidel, J., Harper, C., & Shields, W., (2008). The potential of long-acting reversible contraception to decrease unintended pregnancy. Contraception, 78(3):197-200
Thompson, K., Speidel, J., Saporta, V., Waxman, N., Harper, C., (2011). Contraceptive policies affect post-abortion provision of long-acting reversible contraception. Contraception 83:41–47
Trussel, J., Lalla, A., Doan, Q., Reyes, E., Pinto, L., & Gricar, J., (2009). Cost effectiveness of contraceptives in the United States. Contraception, 79:5-14.
UN Millennium Project 2005 Investing in development: a practical plan to achieve the millennium development goals. New York, NY: United Nations Development Programme.
Whitaker, A., Johnson, L., Harwood, B., Chiappetta, L., Creinin ,M., & Gold, M., (2008).
Adolescent and young adult women’s knowledge of and attitudes toward the intrauterine device. Contraception, 78:211
Yen, S., Saah, T., & Hillard, P., (2010). IUDs and adolescents: An under-utilized opportunity for
pregnancy prevention. Journal of Pediatric and Adolescent Gynecology, 23
The proposed idea of nurses being used to rehabilitate the pharmaceutical industry’s image is a complicated one. Because nurses are being more recognized as key players in health care, they hold a huge responsibility in how they collaborate with and make decisions regarding pharmaceutical advocacy. Additionally, the advancing prescriptive authority in the nursing profession has made Nurse Practitioners (NP’s) a desirable target for drug representatives who see them as expanding opportunities to make more sales. On one hand, this strategy offers a potential plethora of advantages for both the nursing profession and the PhRMA company. Promotional gifts and seminars offered by many drug companies allow nurses to receive benefits such as work tools and continuing education credits that they might not otherwise be offered, thus making nurses a more susceptible target for pharmaceutical marketing schemes (Jutel & Menkes, 2009). Additionally, as nurses strive to enhance their professional role in health care, participating in some of the promotional events can allow them to obtain information about new innovations and updates in pharmacologic treatment options (Crigger, 2005).
Furthermore, because NP’s have become more widely targeted, the nursing profession as a whole can use its association with drug companies as leverage for support in legislation for policy makers and stakeholders. By initiating a bond with pharmaceutical representatives, they can be enrolled to advocate for nurses in health care decision making, and further
promote growth of the profession. Likewise, the aforementioned bond between NPs and pharmaceutical companies can add many potential benefits to PhRMA: as NPs gain more support and prescriptive authority, there are more sales opportunities through nurses prescribing and recommending the company’s products. Additionally, nurses typically carry out orders and educate patients about their health and options; because nurses often display a caring, trustworthy image, patients may be more likely to accept treatment recommendations from their NP.
Conversely, the positive public perception of NPs may potentially be at stake by collaborating with pharmaceutical companies. Patients may question the integrity of the nurse-patient relationship, as well as the motives of the NP profession. Patients may perceive a nurse’s participation in pharmaceutical promotions as unethical, and conflicting with the patients best interests and the quality of care they receive. A recent study investigating the public’s perceptions of provider participation with pharmaceutical promotions found that a majority of patients believed that health care providers are greatly influenced by outside incentives from drug companies, and that the rising cost of medications were directly related to pharmaceutical provider marketing strategies and gift giving(Crigger, Courter, Hayes, & Shephard, 2009).
Because trustworthiness is a “cornerstone” of the nursing philosophy, any compromise in the trusting nurse-patient relationship may jeopardize the reputation of the nursing profession as a whole. The way a patient views a health care provider significantly impacts the patients perception of health beliefs and willingness to participate and adhere to a recommended plan of care. Therefore, it is crucial that nurses are not influenced by the conflicting obligations and biases often seen with participation in pharmaceutical marketing activities; providers must remain dedicated to keeping the patient’s best interest as their priority in decision making, and ensure they have the ability to recognize ethical dilemmas, and avoid situations that may compromise their moral judgment. Thus, providers must ensure that they fully acknowledge the impact of pharmaceutical marketing on the interest of the general public. The provision of free drug samples is a significant instance where a provider is faced with an ethical conflict of interest. Many providers will offer free samples to patients that are unable to afford the cost of treatment, believing they are serving the best interests of those patients in need. Further, it is often assumed that promotional accessories are afforded through the growing profits of the pharmaceutical companies supplying the products. However, they are often unaware of the financial obligations they are actually passing on to the public, ultimately, the expenses of these activities are obtained from the consumers that purchase their products. Additionally, newer samples that are intensely marketed are typically more expensive than older, similar drugs, and much of the cost is covered through increased federal taxes and higher insurance premiums, thus posing an undue burden of expenses to the general public (Crigger, 2005).
My personal experiences with promotional gifting and incentive programs from pharmaceutical sales representatives have demonstrated an inevitable influence on patient care. While discussing treatment options and educating patients on specific drug regimens, it is convenient to offer samples to determine the best fit for a patient. For example, a patient seeking contraceptive methods can benefit from having a variety of different brands and methods that they can experiment with to find the right choice. Moreover, providing free samples can reluctance to try a treatment for fear of losing money if they are not satisfied with the outcome. If a patient is satisfied with a particular product, they are more likely to continue using it long term or in the future, thus fueling the pharmaceutical industry. It is without a doubt this practice has a significant influence on which drugs are prescribed, recommended, and sold. While pharmaceutical gifting can serve as a way to improve the quality of health care, the extent of these advantages is circumstantial; the ethical intentions of interest are questionable. This prospect has both positive and negative implications for how health care providers address pharmaceutical marketing strategies and the contribution to their professional practice. Due to the significant impact on the future of the health care system, provider approaches to pharmaceutical promotions must be carefully considered. Nurses especially, should be particularly aware of their increased vulnerability to intense marketing strategies, and should recognize the potential advantages and dangers of pharmaceutical marketing, and how it will affect their patients, their practice, and their contribution to the nursing profession.