Physicians as Advocates for Adolescent Reproductive Health Objectives

Physicians as Advocates for Adolescent Reproductive Health

Objectives List reasons for physician advocacy for adolescent reproductive health. Describe how to effectively use storytelling as a tool for advocacy. Discuss ways physicians can influence public policy and raise the physician’s voice in public arena. Identify your role as a physician-advocate for adolescent reproductive health.

What Is Physician Advocacy? Action by a physician to promote social, economic, educational, and political changes that ameliorate the suffering and threats to human health and wellbeing that he or she identifies through his or her professional work and expertise. Earnest MA, et al. Academic Medicine 2010; 85: 63– 67

Reflection External factors affecting patients’ health and/or your ability to provide the best care for your patients Existing advocacy skills and skills to develop Advocate in practice setting and/or community Advocate as individual and/or part of an organization

Why Advocacy?

Influences on Health Individual Patient Care Access to Care Direct Socio. Economic Influences Broad Socio. Economic Influences Adapted from: Gruen RL, et al. JAMA 2004; 291: 94– 98. Global Health Influences

Insurance Coverage President Obama signing the Patient Protection and Affordable Care Act into law

Policy Advocacy http: //www. aap. org/en-us/advocacy-and-policy/federaladvocacy/Documents/AAPGun. Violence. Testimony. Senate. Judiciary. Cmte. pdf

Policy Advocacy NEJM 2012

Why Adolescent Reproductive Health Advocacy?

Adolescents Need Physicians to Advocate on Their Behalf

Policy Issues Affecting Adolescent SRH Emergency Contraception Over-the-Counter (EC OTC), Rx only, age restrictions HPV vaccination policies Confidentiality and Explanation of Benefits (EOBs) Sexuality education policies and funding Condom distribution in schools Restrictions on contraception and abortion

Birth Rates, Females Aged 15 -19, U. S. 1991 -2013 National Vital Statistics System. July 2014.

Teen Birth Rates by State

Disparities in Teen Pregnancy Rates Persist

Access to Contraception Cumulative Failure Contraceptive Failure at 1, 2, or 3 Years According to Contraceptive Method 10. 0% 9. 0% 8. 0% 7. 0% 6. 0% 5. 0% 4. 0% 3. 0% 2. 0% 1. 0% 0. 0% 9. 4% 4. 8% Year 1 Year 2 0. 3% 0. 1% 0. 7% LARC DMPA PPR Contraceptive Method Winner B, et al. N Engl J Med 2012; 366: 1998– 2007. Year 3

Pregnancy Rates: U. S. vs. CHOICE N Engl J Med 2014; 371: 1316 -23

Unintended Pregnancy and Abortion Rate Decline Attributed to Contraceptive Access Abortions per 1, 000 Women Ages 15 -44 35 30 25 20 15 10 5 19 73 19 75 19 77 19 79 19 81 19 83 19 85 19 87 19 89 19 91 19 93 19 95 19 97 19 99 20 01 20 03 20 05 20 07 20 09 20 11 0 Jones RK, Jerman J. Perspect Sex Reprod Health 2014; 46: 3– 14 doi: 10. 1363/46 e 0414

State-Level Legislation Number of Abortion Restrictions 100 205 80 60 189 40 20 19 85 19 87 19 89 19 91 19 93 19 95 19 97 19 99 20 01 20 03 20 05 20 07 20 09 20 11 20 13 0 Nash E, et al. Guttmacher State Center 2014 http: //www. guttmacher. org/media/inthenews/2013/07/08/

State-Level Restrictions In 2000, 31% of women of reproductive age lived in one of the 13 states considered hostile to abortion y WA OR NV MT ID UT CA AZ WY CO NM AK NH ME ND MN VT MA WI SD NY RI MI CT PA IA NE NJ IL INOH DE WVVA KS MD MO KY NC TN OK AR SC GA MS AL TX LA FL By 2013, 56% of women lived in one of the now 27 hostile states y WA OR NV MT ID WY UT CO AZ NM KS OK TX AK MN WI SD NE CA HI ND NH ME VT NY MI PA IL IN OH WVVA MO KY NC TN AR SC GA MS AL LA IA FL HI Supportive Middle-ground Hostile Adapted from: http: //www. guttmacher. org/media/inthenews/2014/01/02/index. html MA RI CT NJ DE MD

Barriers to Abortion Access Insurance bans No local provider or clinic Biased and non-evidencebased counseling Parental consent requirement Waiting periods Mandatory ultrasounds Provider or institutional refusal to provide options Adapted from: http: //www. guttmacher. org/media/infographics/barriers-to-access 2. html

Physicians as Advocates

70% in 2012 56% in 1976 http: //www. gallup. com/poll/1654/honesty-ethics-professions. aspx

Voting Adjusted Odds of Voting Compared to General Population 2. 5 2 1. 5 Physicians 1 Lawyers 0. 5 0 1996 1998 2000 2002 Grande D, Asch DA, Armstrong KA. J Gen Intern Med 2007; 22: 585– 589.

Need for Public Education http: //www. slate. com/blogs/the_slatest/2014/04/21/scientific_poll_most_americans_ question_big_bang. html

Political Influence “This bill is also problematic because it unduly restricts the physician-patient relationship. All patients, particularly expectant mothers, require the best, most unfettered medical judgment and advice from their physicians regarding treatment options. Gov Earl Ray Tomblin W. Virginia 3/28/2014 Vetoed HB 4588 “The medical community has made it clear to me that the criminal penalties this bill imposes will impede that advice, and those options, to the detriment of the health and safety of expectant mothers. ”

Professionalism 100. 0% 80. 0% Rated as Important 60. 0% 40. 0% Activity in Past 3 Years 20. 0% Community Participation Political Involvement Collective Advocacy Data from: Gruen RL, et al. JAMA 2006; 296: 2467– 2475.

ACGME Requirements Common Program Requirement “Residents are required to…advocate for quality patient care and optimal patient care systems. ” Specialty Program Requirement Adolescent Medicine Pediatrics Family Medicine Psychiatry https: //www. acgme. org/acgmeweb/Portals/0/PFAssets/Program. Requirements/CP Rs 2013. pdf

Questions to Consider Professional Impact Part of your work (internal) or with another group or organization (external)? Can you integrate advocacy with your career path? What is your institutional policy?

Questions to Consider Impact on Quality of Life Will advocacy lead to improved job satisfaction? How will advocacy affect your personal life? Could advocacy result in unexpected support from colleagues? Do you risk criticism or alienation from colleagues?

Advocacy Skills and Competencies

Innate Physician Skills Patient stories Credibility Technical and scientific knowledge Access to and understanding of research Experience with advocating for individual patients

Skills to Develop Defining your goal and your audience Crafting personal stories to frame your issue Developing and sticking to your message Recognizing opportunities for advocacy Developing relationships with partners, media, and legislators

Using Stories Dr. Lin-Fan Wang, “Not My Boss’s Business” Rally, Supreme Court hearing on contraceptive coverage through ACA “I am here because science, medicine, and common sense are on our side. I am here, because like all of you, I believe that the decision to use birth control is best made by a woman and her doctor – not by a woman and her boss. ” https: //www. youtube. com/watch? v=7 ovsrg. XU 93 s&feature=youtu. be

What Was Effective? Summarized patient’s problem and how existing law hurt her and her husband Used lay terms, not medical jargon Provided a few details about the patient to make her come alive Let her passion show Used pseudonym Ended with an ask—what she wants the audience to do

Models of Advocacy

Advocacy Models Media and communications Traditional New Policy Legislative Regulatory Medical education Professional associations and societies Others?

Media Advocacy Traditional print media Letters to the editor (LTEs) Op-Eds New media Social media Online/digital media Health websites Online chats

Letter to the Editor As a pediatrician and adolescent-medicine specialist, I welcome additional evidence that the HPV vaccine has no impact on young people’s sexual behavior (“An HPV Vaccine Myth Debunked, ” editorial, Oct. 19). This new study should reassure parents who are reluctant to let their children be vaccinated because they fear that it will be a catalyst for sexual activity. I’ve found that such worries distract parents from a far more significant factor in teenagers’ decision-making: the parents themselves. I often remind parents that their behavior, messages and expectations play a key role in their children’s decisions regarding sex and relationships; the HPV vaccine has nothing to do with it. Communicating with your son or daughter, starting in childhood, about these expectations is critical for all families. Accurate information, realistic approaches and parental support help raise a teenager who is better prepared to make healthy decisions when the time comes. Michelle Forcier, MD, MPH Providence, RI http: //www. nytimes. com/2012/10/31/opinion/influencing-teenagers-advice-from-apediatrician. html? _r=0

Contributor AAP Issues Birth Control Guidelines for Teen Girls Dr. Kate Greenberg, adolescent medicine specialist at Golisano Children's Hospital, said the AAP guidelines echo the recommendations of other expert groups in the past several years. "Including the American College of Obstetricians and Gynecologists since about 2012, which is that these longer-acting and reversible methods of birth control are the safest and most effective and most appropriate for teenagers. " http: //wxxinews. org/post/aap-issues-birth-control-guidelines-teen-girls

OP-ED “Today, I am a family physician who believes in providing comprehensive health care. We deserve to be in healthy, positive relationships and to decide when and with whom we want to have sex. We should have affordable contraception and quality health care. We should be able to choose to continue a pregnancy without judgment or shame, regardless of our backgrounds. I believe that my adolescent patients have the resiliency to build strong positive relationships. And yes, these relationships involve sex. So my job involves providing solid and accurate information about sex. Too many of us don’t support teen parents. But when a pregnant teenager enters my office and declares she is ready to be a mother, I believe her. I support her. ” -Rebecca Trotzky-Sirr, MD, MSc Los Angeles http: //feministing. com/2013/05/08/for-the-mamas-who-dont-get-love-on-mothers-day/

Using Research "I try to emphasize that teens should have emergency contraception at home, just like they have Tylenol for a headache—don't wait until you need it to try and go get it. " http: //medicalxpress. com/news/2013 -12 -pharmacy-staff-frequently-misinform-teens. html

New Media Advocacy http: //teenology 101. seattlechildrens. org/plan-b-emergency-contraception-anupdate/

Google Hangout http: //www. motherjones. com/mojo/2013/03/google-hangout-keeping-choicealive-state-level

Finding Media Opportunities Put yourself in the press—stay LOCAL for best results Talk to your institution/public affairs Write letters or editorials for medical journals Become a source or a contributor

Legislative Advocacy Work with your legislators Join an Advocacy or Lobby Day Join an organization Provide testimony at the local or state level

Regulatory Advocacy Administrative and governmental agencies Institution, hospital, and clinic committees

Medical Education Advocacy Training requirements Reproductive health training

Medical Society Advocacy

Tips to Make Advocacy Easier Join an advocacy organization Write down patient stories once a week Find a faculty champion Establish advocacy day for residents Volunteer as a delegate with a medical organization

Finding Time Activity Estimated Time Voting 10 min—one day Signing a petition One minute Writing email to legislator 1– 15 minutes Calling your legislator 5– 10 minutes Writing a letter to the editor 15– 60 minutes Testifying Half/whole day

Reflection Questions External factors affecting patients' health and/or your ability to provide the best care for your patients Existing advocacy skills and skills to develop Advocate in practice setting and/or community Advocate as individual and/or part of an organization

Take Away Messages Physicians are effective and sought-after advocates. Advocacy is strategic, learnable, and builds on existing skills. Variety of opportunities available—work with others. Stick with it—long-term process of speaking truth as doctors.

Get Involved www. prh. org

Advocacy Resources National Medical Organizations (SAHM, AAP, AAFP, ACOG, ACP, AMA, etc. ) National Physicians Alliance www. npalliance. org Doctors for America www. drsforamerica. org Physicians for Social Responsibility www. psr. org Association of Reproductive Health Professionals www. arhp. org/Policy-and-Advocacy Reproductive Health Access Project www. reproductiveaccess. org/advocacy/ National Abortion Federation www. prochoice. org/get_involved/activistkit. html

Provider Resources and Organizational Partners www. advocatesforyouth. org—Advocates for Youth www. aap. org—American Academy of Pediatricians www. aclu. org/reproductive-freedom American Civil Liberties Union Reproductive Freedom Project www. acog. org—American College of Obstetricians and Gynecologists www. arhp. org—Association of Reproductive Health Professionals www. cahl. org—Center for Adolescent Health and the Law www. glma. org Gay and Lesbian Medical Association

Provider Resources and Organizational Partners www. guttmacher. org—Guttmacher Institute janefondacenter. emory. edu Jane Fonda Center at Emory University www. msm. edu Morehouse School of Medicine www. prochoiceny. org/projects-campaigns/torch. shtml NARAL Pro-Choice New York Teen Outreach Reproductive Challenge (TORCH) www. naspag. org North American Society of Pediatric and Adolescent Gynecology www. prh. org—Physicians for Reproductive Health

Provider Resources and Organizational Partners www. siecus. org—Sexuality Information and Education Council of the United States www. adolescenthealth. org—Society for Adolescent Health and Medicine www. plannedparenthood. org Planned Parenthood Federation of America www. reproductiveaccess. org Reproductive Health Access Project www. spence-chapin. org Spence-Chapin Adoption Services

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