Winning the War against STIs: Why Public Health Interventions have failed to reduce STI rates among Adolescents- Oluwakemi Olukoya

Sexually transmitted diseases (STDs) remain a major public health problem in the United States. The CDC estimates that approximately 19 million new infections occur each year and almost half of the infections occur among young people 15-24 years of age. Though several public health campaigns have been conducted to curb the spread of sexually transmitted diseases (STD) among adolescents, the rate of STDs continues to soar. The failure of these campaigns can be linked to their reliance on traditional health behavior models which have limited ability to change behavior. The traditional health models are limited by their individualistic approach to change behaviors and by their assumption that individuals have mastery and control over decision making and behavior change.

An example of a public health campaign which is based on traditional health behavior models is the It’s Your (Sex) Life (IYSL) national campaign. IYSL is an ongoing partnership of MTV and the Kaiser Family Foundation to help young people make responsible decisions about their sexual health (1). IYSL campaign has distinguished itself from other public health campaigns by winning the Emmy and Peabody award for public information campaign on HIV/AIDS, other sexually transmitted diseases and related sexual health issues. In addition, the recent extension of IYSL partnership with Planned Parenthood Federation of America to promote the GYT (Get Yourself Tested) campaign- aimed at removing the taboos surrounding STD testing- through celebrities seems promising. Despite the above strengths of the IYSL campaign, its’ message, based on traditional health behavior change models (Health Belief Model and Social Learning Theory), has limited ability to change adolescents risky sexual behaviors to preventive behaviors. This article critically reviews the It’s Your (Sex) Life national campaign and presents three arguments which explain the limitations of the IYSL from the perspective of social and behavioral sciences.

I.) Health Belief Model
By using the Health Belief Model, It’s Your (Sex) Life campaign presumes that by promoting ads which emphasize on the consequences and statistics of sexually transmitted diseases, an individual will perceive his susceptibility to acquiring STD and perceive the severity of STD on his life; thus he would rationally weigh the benefits of not engaging in risky sexual behaviors to barriers which leads to intention and safe sex practices. For example, one ad featured a lady instructing a “teenage girl” to break up immediately with her boyfriend who refused to use a condom because she is at risk of contracting HIV.

Though the ad provides factual information, studies have shown that early prevention efforts that involved providing factual information about HIV/AIDS to promote safer sexual practices among adolescents and young adults were not strongly correlated with preventive behaviors(2). Thus, knowledge is necessary but not sufficient for HIV/AIDS risk reduction (2; 3). In addition, findings from various studies(4) that applied the HBM to promote preventive sexual behaviors among heterosexual college students have been inconsistent and provided only partial support for the model. Overall, perceived barriers (to condom use) received the most consistent support as a significant predictor of engaging in preventive behaviors (5). The fact that the extension components of the HBM did not significantly increase the prediction of condom use among college students may reflect the limitations of the HBM in promoting protective behaviors (5).

Furthermore, there is a wider social context within which individuals must circulate such as families and communities, which in turn affect the individuals’ decisions and behavior. HBM does not account for such social and environmental factors. (6) The HBM focus on individual-level factors and its’ reliance on the individual’s ability to make rational decisions and develop intention (7) to engage in protective behaviors constitute a major weakness of this approach. Intention does not always lead to behavior and human actions are mostly irrational. Also, HBM does not take into account the spontaneous activity that characterizes much of human behavior (7)

II.) Self-efficacy versus Self-control
IYSL draws from SLT by promoting self-efficacy. The IYSL campaign assumes that by instructing adolescents to take charge of their sex life by being in control and making smart choices, adolescents will be empowered and thus develop self-efficacy to practice safer sex. However, this assumption is false because individuals lack self-control over their actions due to other influences.

Studies indicate that patterns of social cognitive development in adolescence vary as a function of the content under consideration and the emotional and social context in which the reasoning occurs (8). Adolescents’ reasoning about real-life problems is not as advanced as their reasoning about hypothetical dilemmas (9) (e.g. a female practicing negotiation of condom use in a non-aroused state versus an aroused state). Adolescents’ when faced with a logical argument are more likely to accept faulty reasoning or shaky evidence when they agree with the substance of the argument than when they do not. (10-11). In other words, adolescents’ social reasoning, like that of adults, is influenced not only by their basic intellectual abilities, but by their desires, motives and interests (12).

Behavioral data have made it appear as though adolescents are poor decision-makers (i.e. their high-rates of participation in dangerous activities, automobile accidents, drug use and unprotected sex) however, there is substantial evidence that adolescents engage in dangerous activities despite knowing and understanding the risks involved (13-15). Thus, in real-life situations, adolescents do not simply rationally weigh the relative risks and consequences of their behavior – their actions are largely influenced by feelings and social influences (16). In addition, research has shown that sexual motivation can distort judgments on the risk of contracting sexually transmitted disease (17). Results from a study suggests that arousal does not change an individual’s general knowledge about the risks of unprotected sex, but when it comes to concrete steps involving condoms, sexual arousal changes one’s perceptions of the tradeoffs between benefits and disadvantages in a fashion that decreases the tendency to use them. (18)

III.) Social Determinants
IYSL campaign fails to account for diverse array of factors influencing adolescents’ risk taking behavior (Figure 1). Such factors include familial characteristics such as parental support, peer influence, school environment, community, socioeconomic status, racial disparities and societal factors such as media exposure (19). IYSL campaign may have no influence on adolescents who do not belong to a stable and supportive family system. Families provide role models, shape sexual attitudes, set standards for sexual conduct, control and monitor adolescents’ behaviors. Parental monitoring is associated with older ages of sexual initiation, smaller numbers of sexual partners and more consistent contraceptive use, all of which suggest lower STD risk (20). Thus how will the IYSL campaign account for teenagers, particularly homeless teens, who do not have family support and are predisposed to engage in risky behaviors?

In addition, though IYSL campaign used teenagers to promote its’ message to other teens, the campaign failed to recognize the power of group dynamics in shaping an adolescent decision with regards to which norms to abide to. Peer norms surrounding sexual behaviors and condom use have been shown to be major influences on both risky and protective sexual behavior. When adolescents perceive that friends and similar-aged teens engage in risky sexual behavior, even if their perception is skewed, then they are more likely to adopt those same behaviors (19). IYSL campaign needs to be more strategic in using teenagers in its’ ads in promoting safe sex practices rather than showing teenagers who are willing to adopt condom use because of the consequences of acquiring STDs.

The IYSL campaign failed to take full advantage of the effect of school environment on sexual risk taking behaviors. In one ad, a Professor told a group students that “there is hardly any healthy sexual relations…… they should learn to stop and have a conversation” about sex. Through this ad, IYSL campaign assumes that students have self-control and schools are a good place to let adolescents know they can take charge of their sex life. Though schools play a vital role in sex education, how does IYSL account for other aspects of school social environment associated with risky sexual behaviors? School structural attributes affect norms and attitudes about dating practices and sexual behaviors (21). Studies of the effects of school characteristics on sexual risk-taking behaviors found that racial composition and school type (public or private) are associated with age at first intercourse and number of sexual partners (22). Compared to private schools, teenagers in public schools have a higher STD risk. (21-22).

In addition, IYSL campaign failed to take into consideration racial differences in an ad which lead to counterproductive responses from adolescents. In the commercial, a white teenage girl refused to have sex with a black teenage boy because he did not have a condom to use. Though the ad was trying to tell adolescent females to be firm in their decision of practicing safe sex, the public interpreted it as her being a racist as illustrated by several comments on You Tube. This commercial also failed to use effective communication principles by ensuring a similar group was used as the source of message to the receiving group. The media plays a significant role in socialization of adolescents and therefore impacts their sexual risk and protective behavior. For example, studies have found that greater exposure to rap music videos and X-rated movies were associated with having multiple sex partners, more frequent sexual intercourse, and testing positive for an STD (23, 24). It is ironic that MTV, partners of IYSL campaign, hopes to promote protective sexual behaviors while they show more of music videos promoting sexual activity.

Overall, we cannot hope to optimize changes in adolescents’ sexual behavior without addressing the broad range of factors that influence adolescents’ decision-making process and, in turn, their likelihood of engaging in risky sexual behavior (24).


COnclusion
In order to achieve greater success, “It’s Your (Sex) Life” campaign must move beyond the traditional health behavior models- focused on individual level factors. Merely examining individual-level determinants in isolation provides a limited perspective on a complex issue and, furthermore, precludes a more in-depth understanding of how higher-level variables (e.g., family, peers, school, community, and society) may be independently associated with STD risk behaviors in the presence of other individual-level factors (19). Thus, while efficacious in promoting the adoption of STD/HIV-preventive behaviors in the near-term, individual-level interventions appear to be insufficient in sustaining newly adopted preventive behavior changes over protracted periods of time (19). What is needed is a complementary approach that addresses these multiple spheres of influence and adopts alternative health behavior change models capable of changing people’s behavior en masse to the desired or protective health behavior.

Section 2
To address the problem of rising STD’s rates among adolescents, I propose an intervention/strategy that promotes condom use at a group level by utilizing the following alternative health behavior models: marketing (social marketing) and framing theories.

Marketing is defined by the American Marketing Association as the activity, set of institutions, and processes for creating, communicating, delivering, and exchanging offerings that have value for customers, clients, partners, and society at large. Social marketing is the systematic application of marketing strategies along with other concepts and techniques to achieve specific behavioral goals for a social good. Social marketing seeks to influence social behaviors and to benefit the target audience, the general society and not the marketer.(26)
The defining features of social marketing emanate from marketing’s conceptual framework and includes exchange theory, audience segmentation, competition, “the marketing mix,” consumer orientation and continuous monitoring. (27)
Framing comes from cognitive science, which defines a frame as a conceptual structure involved with thinking.(28) Frames are a composition of elements—visuals, values, stereotypes, messengers— which together trigger an existing idea. Frames tell us what a communication message is about. They signal to us what to pay attention to (and what not to), and they set up a pattern of reasoning that influences decision. Framing, therefore, is a translation process between incoming information and the pictures in our heads (29)

Intervention: Ignite Campaign- bringing out the fire in you

This intervention builds on the growing evidence which indicate that promoting pleasure in condom use, alongside safer sex messaging, can increase the consistent use of condoms and the practice of safer sex.(30) Ignite campaign aims to reduce STD’s rate by increasing the consistent use of condoms among sexually active adolescents. It aims to achieve this by reframing the use of condoms as being pleasurable rather than a just a protection “tool” from sexually transmitted diseases; also by using effective marketing strategies to spread its’ message.

Components of the Intervention

1) Form partnership with a condom manufacturing company in order to make Ignite pleasure condoms.

2) Use strategic adverts to reframe condoms as being pleasurable. I created two commercials which use pleasurable activities (dancing, and going to the beach) to appeal to core values (such as attractiveness, pleasure, vitality, sex) which adolescents value more than health.


Commercial One:
Several teens are gathered in an arena to watch a Salsa dance competition (illustrated by showing contestants (adolescents) with their partners (male and female) wearing salsa dance costumes)
Scene: Presenter of the show: Let’s welcome our final contestants for the night
(The crowd cheers)
Two teams come on stage and as the salsa music plays both teams start dancing.
Team 2: The female partner suddenly stops dancing…..she tells her partner “I can’t continue dancing…..my wrist hurts severely”. Her partner smiles and brings out a pack of Ignite condom (she smiles), he opens the condom pack and ties it around her wrist. Immediately vibrant salsa music plays, team 2 does amazing dance steps and wins the competition. At the end of the commercial, Ignite condom- bringing out the fire in you is displayed.

Commercial two:
Four teenage boys sitting on the beach suddenly get excited when four attractive females walk up to them. The boys stare so hard that “fire” comes out of their eyes. Each of the girls show the boys a box of ignite condom…..strangely the boxes become “alive”, grow so big and each female enters the box. Happily each boy grasps one Ignite condom box.

The two commercials use the power of visual imagery to frame the message. Imagery in brand marketing helps to create the external ideal (e.g. a figure, image or symbol that embodies socially desirable characteristics). Thus an individual will aspire to close the gap between his or her own self image and the idealized external image (e.g. Ignite condom brands).

3) Spread the message via a multi-channel approach by using a combination of traditional media channels, including TV, radio, print (billboards, celebrity, sports and other youth magazines), and new media such as internet websites (blogs, download materials, videos, games, celebrity and Ignites’ own website), E-mail services, Social networks (Facebook, Myspace), Youtube, Desktop agents, mobile phone texting and placing ads on other hand held computing devices.

4) Organize community based events such as concerts, cultural festivals, fairs where free Ignite condoms can be distributed. Distribution can be extended to recreational centers, school health centers, summer camps, hair salons etc. Flyers that have the logo of Ignite and the picture of the star couple in the Salsa dance ad will be distributed. Also, members of the community will be engaged in advocacy for the provision of sufficient resources (e.g. comprehensive adolescent health centers) for adolescent health.

5) Regular evaluation of the campaign to gauge the responses of the target audience to all aspects of the intervention, from the broad marketing strategy to specific messages and materials.

Argument: Why the Ignite campaign is better than It’s Your (Sex) Life campaign
1.) Strength of the alternative health theories over the health belief model
Unlike the HBM that relies completely on individual level factors to change behavior, the alternative health models utilize the group phenomenon to change people’s behaviors en masse. Groups are not just a collection of individuals; they have certain characteristics which individuals tend to adopt. For example, though an adolescent may not want to engage in risky sexual behaviors, when he/she perceives that friends and similar-aged teens engage in risky sexual behavior, then he/she is more likely to adopt those same behaviors (19). The alternative health theories do not focus on predicting individual behavior rather they take advantage of the predictable group “mentality” (the herd mentality) to change an entire group at the same time. The Ignite campaign uses effectively two alternate health theories (Framing and Marketing) which have been proven to yield desirable results in the commercial and political sector. There is substantial evidence that social marketing is effective in changing health behaviors on a population level (31). The VERB campaign, It’s what you do, promoted by the CDC is a good example of how social marketing can change health behavior at a group level. Marketing alters the environment to make the recommended health behavior more advantageous than the unhealthy behavior it is designed to replace (27).

The Ignite campaign uses the framing theory to appeal to other core values (sex, attractiveness, pleasure) more compelling to adolescents than health as used by the IYSL and other public health campaigns. Framing an issue on core values more important to individuals (level 1) is vital because they are the ones that connect to individuals in the deepest way (29) which can trigger the ‘jolt’ necessary for instantaneous behavior change. According to Lakoff (1996), people’s support or rejection of an issue will largely be determined by whether they can identify and connect with the Level 1 values rather than the minute details of issues (e.g. statistics of sexually transmitted diseases) which may “crowd’ level 1 core values and make the campaign message ineffective. The national Truth campaign used the framing theory to appeal to the rebellious core value of adolescents. By successfully framing non-smoking as being rebellious and promoting a teen focused “counter marketing” brand, Truth campaign was able to account for 22 percent of the decline in adolescent smoking prevalence from 25.3% to 18.0% from 200-2002. (32)



2.) Self control
Unlike the IYSL campaign which assumes that adolescents have self control over their actions and can take charge of their sex life, the Ignite campaign takes cognizance of the fact that people have difficulty with self control and their social reasoning is influenced not only by their basic intellectual abilities, but by their desires, motives and interests (12). In addition, the alternative health models used in the Ignite campaign take advantage of the fact that human behavior is influenced by expectations, predictably irrational and not planned. For example, there are “seasons” in the stock market when investors (skilled and unskilled) “rush” to buy a particular stock at unreasonable high prices because such companies have strategically raised the expectations of consumers (via branding, framing and marketing theories) and taken advantage of the predictable irrational “herd” mentality. Similarly, by successfully associating the Ignite condom brands with the core values (sex, attractiveness and pleasure) that appeal to adolescents, the Ignite campaign can take advantage of adolescents lack of self control (which contributes to risky behaviors) and predictable irrational behavior in order to increase the use of Ignite condoms. Trust campaign, conducted by the U.S.-based Population Services International (PSI) promoted an HIV/AIDS prevention social marketing campaign that was effective in reaching adolescents and young adults in Kenya. The Trust campaign promoted the social desirability of condom use by making condom use seem cool. Studies show that the campaign increased adolescents and young adult awareness of the Trust condom brand and increased condom use among those with repeated exposure to the brand. (33)

It is important to note that while the commercial marketing strategies benefit the marketer, the social marketing strategy used by Ignite campaign benefits the target audience and the society at large by reducing STD rates and its consequences. In addition, by actually making pleasurable condom packs, Ignite campaign is not deceiving the target audience.

3.) Social Determinants



Though the Ignite campaign may not be able to address all the societal factors that influence adolescents’ behaviors, it offers a more comprehensive approach for addressing these factors than the IYSL campaign. Firstly, because adolescents are increasingly less subject to parental influence and more subject to peer and media influence (31), there is a dire need for public health professionals to promote media campaigns that can influence adolescents. Campaigns that appeal to the core values of adolescents are more influential than campaigns which emphasize on the negative consequences of acquiring STD’s. The use of negative messaging (“don’t do this behavior”) counters the rebellious core value of adolescents. Adolescents rebel against external restrictions on their independence and self-control (31), thus they develop opposing reactions to negative — “don’t do it” —messages. For example adolescent boys who associate displeasure strongly with condom use are likely to rebel against outside forces who try to “impose” condom use on them without offering them an immediate, tangible, gratifying and valuable exchange that will not make them feel a loss. Thus by reframing condom use as pleasurable and using ads that do not counter the rebellious nature of adolescents and appeals to their other core values (pleasure, attractiveness, sex), the Ignite campaign has superiority in using the media to influence adolescents’ behaviors than the IYSL campaign. The success of the Trust campaign in increasing condom use by framing condom use as being cool, illustrates the power of branded messages that convey positive behavioral alternatives for young people (33).

Secondly, through the extensive use of multi-channels by the Ignite campaign, the campaign is capable of fighting the “battle” against other media and marketing exposures that can promote risky health behaviors. The VERB campaign, It’s what you do, is an excellent example of a public health campaign that used several multi channels to reach its target population. The VERB advertising and promotions reached “tweens” in their homes, schools, and in their communities. The primary vehicle was paid advertising in the general market and in ethnic media channels. The VERB made use of TV, radio channels, print advertising in dozens of youth publications, websites, social networks (Facebook, MySpace) and other media agents such as text messages. Evaluation of the VERB campaign showed that as these same children became more aware of VERB, they engaged in more free-time physical activity sessions. The average 9-to 10-year old youth who were aware of VERB engaged in 34 percent more free-time physical activity sessions per week than did 9- to 10-year-old youths who were unaware of the campaign. (31)

Thirdly, the Ignite campaign also offers a comprehensive approach to promoting preventive behaviors through its outreach to the communities and school based centers. In addition, by involving community members in advocacy for provision of comprehensive adolescent centers, the Ignite campaign takes advantage of the “power” of social marketing in affecting policy makers through the media to frame public debate in support of enacting health policies; thus by influencing policy makers, they can address the broader social and environmental determinants of health (27).

Conclusion
The alternative health behavior models (Framing and Social Marketing Theories) used by the Ignite campaign have the potential to promote preventive sexual behaviors among adolescents; and thus reduce STD rates. Public health professionals need to abandon the “myth” that using such strategies to promote healthy behaviors is manipulative and unethical. It is time for public health campaigns/interventions to look beyond the traditional health models which have failed to curb STD rates among adolescents. The Ignite campaign provides a strong model that can be used to win the war against sexually transmitted diseases.

REFERENCES
1.) Music television channel (MTV).IT’S YOUR SEX LIFE. http://itsyoursexlife.com/iysl
2.) Johnson E. H, Gant L, Hinkle Y. A., Gilbert D, Willis C, Hoopwood T. Do African American men and women differ in their knowledge about AIDS, attitudes about condoms and sexual behaviors? Journal of National Medical Association.1992; 84(1):49-64.
3.) DiClemente R. J, Forrest K. A, Mickler S. College students’ knowledge and attitudes about AIDS and changes in HIV-preventive behaviors. AIDS Education and Prevention. 1990; 2(3): 201-212
4.) Lollis C. M, Johnson E. H, Antoni M. H.The efficacy of the Health Belief Model for predicting condom usage and risky sexual practices in university students. AIDS Education and Prevention. 1997; 9(6): 551-563.
Sands T, Archer J, Puleo S. Prevention of health-risk behaviors inn college students: Evaluating seven variables. Journal of College Student Development. 1998; 39(4): 331-342. Steers W. N, Elliott E, Nemiro J, Ditman D, Oskamp S. Health beliefs as predictors of HIV-preventive behavior and ethnic differences in prediction. Journal of Social Psychology. 1996; 136(1): 99-110.
5.) Evelyn B. Winfield and Arthur L. Whaley A Comprehensive Test of the Health Belief Model in the Prediction of Condom Use Among African American College Students. Journal of Black Psychology. 2002; 28(4):330-346
6.) Kyung-Hee Choi; Gust A. Yep; Eugene K. HIV Prevention Among Asian and Pacific Islander American Men Who Have Sex with Men: A Critical Review of Theoretical Models and Directions for Future Research. AIDS Education and Prevention. 1998; 10(A): 19-30.
7.) Mary K. Salazar MN, COHN. Comparison of four behavioral theories. AAOHN Journal. 1991; 39(3):128-135.
8.) Eisenberg N, Morris A. Moral cognitions and pro-social responding in adolescence (pp. 155–188). In: Lerner R. and Steinberg L ed. Handbook of Adolescent Psychology. Wiley, 2004
9.) Sobesky W. The effects of situational factors on moral judgments. Child Dev. 1983;
54:575–58
10.) Klaczynski P.A. Bias in adolescents’ everyday reasoning and its relationships with intellectual ability, personal theories, and self serving motivation. Dev. Psychol. 1997; 33:273–283
11.) Klaczynski P, Gordon D. Everyday statistical reasoning during adolescence and young adulthood: Motivational, general ability, and developmental influences. Child Dev. 1996; 67: 2873–2891
12.) Laurence Steinberg. Cognitive and affective development in adolescence. Trends in Cognitive Sciences. 2005; 9(2 ):69-74
13.) Benthin A. Adolescent health-threatening and health enhancing behaviors: A study of word association and imagery. J. Adolesc. Health. 1995; 17:143–152
14.) Cauffman, E. and Steinberg, L.The cognitive and affective influences on adolescent decision-making. Temple Law Rev. 1995; 68:1763–1789
15.) Slovic, P. What does it mean to know a cumulative risk? Adolescent’s perceptions of short-term and long-term consequences of smoking. J. Behav. Decis. Making. 2000; 13:259-266
16.) Steinberg, L. Risk-taking in adolescence: What changes, and why? Ann. N. Y. Acad. Sci. 2004; 1021: 51–58
17.) Blanton H, Gerrard M. Effect of sexual motivation on men’s risk perception for sexually transmitted disease there must be 50 ways to justify a lover. Health Psychology. 1997; 16:374–37
18.) Dan Ariely, George Loewenstein. The Heat of the Moment: The Effect of Sexual Arousal on Sexual Decision Making. Journal of Behavioral Decision Making. 2006; 19: 87–98
19.) DiClemente R.J, PhD, Salazar L.F, PhD, Crosby R.A, PhD. A Review of STD/HIV Preventive Interventions for Adolescents: Sustaining Effects Using an Ecological Approach. Journal of Pediatric Psychology. 2007; 32(8):888-906
20.) Hogben M, PHD, Leichliter J.S, PHD. Social Determinants and Sexually Transmitted Disease Disparities. Sexually Transmitted Diseases. 2008; 35(12):S13–S18.
21.) Upchurch D.M, Mason W.M, Kusunoki.Y, Johnson M. Social and Behavioral Determinants of Self-Reported STD Among Adolescents. Perspectives on Sexual and Reproductive Health.2004;36 (6):276–287
22.) Teitler JO and Weiss CC. Effects of neighborhood and school environments on transitions to first sexual intercourse. Sociology of Education. 2000; 73(2):112–132
23.) Wingood GM, DiClemente RJ, Bernhardt JM, Harrington K, Davies SL, Robillard A. A prospective study of exposure to rap music videos and African American female adolescents’ health. American Journal of Public Health. 2003; 93(3):437–439
24.) Wingood GM, DiClemente RJ, Harrington K, Davies S, Hook EW. Exposure to X-rated movies and adolescents’ sexual and contraceptive-related attitudes and behaviors. Pediatrics. 2001; 107(5):1116–1119
25.) Maton K. Making a difference: The social ecology of social transformation. American Journal of Community Psychology .2000; 28(1):25–57
26.) Kotler P, Andreasen A. Strategic Marketing for Nonprofit Organizations.
New York: Prentice Hall, 1996.
27.) Grier S, Bryant A.C. Social marketing in public health. Annu. Rev. Public Health. 2005; 26:319–39
28.) Lakoff, G. Don’t Think of an Elephant! Know Your Values and Frame the Debate. Chelsea Green: White River Junction, 2004
29.) Dorfman L, Wallack L, Woodruff K. More than a message: Framing public health advocacy to change corporate practices. Health Education & Behavior. 2005 ; 32 (3): 320-336
30.) Philpott A, Knerr W, Boydell V. Pleasure and Prevention: When Good Sex Is Safer Sex. Reproductive Health Matters. 2006; 14(28):23–31
31.) National Institute for health care management. Recommended Adolescent Health Care Utilization: How Social Marketing Can Help. NIHCM Foundation Issue Brief March 2009.
http://www.nihcm.org/pdf/NIHCM-SocialMarketing-FINAL.pdf
32.) Farrelly MC, Davis KC, Haviland ML, Messeri P and Healton CG. Evidence of a Dose-Response Relationship Between ‘truth’ Antismoking Ads and Youth Smoking. American Journal of Public Health. 2005; 95(3):425–431.
33.) Agha S. The Impact of a Mass Media Campaign on Personal Risk Perception, Perceived Self-Efficacy and on Other Behavioral Predictors. Aids Care. 2003; 15(6):749–62

The Funding that has Fueled an Ineffective Intervention-Isadora Nogueira

Intervention: The President’s Emergency Plan For AIDS Relief (PEPFAR) and the Official AB Policy in Uganda

Although a public health intervention’s purpose is for societal improvement, it may be ineffective end harmful if not implemented adequately. In 2004, the Bush administration approved its plan for AIDS relief in Africa- the Presidents Emergency Plan for AIDS Relief (PEPFAR). PEPFAR provides a total of fifteen billion dollars within a five-year period to fourteen African and Caribbean countries. The White House will give $6 billion this year for global AIDS. However one of the requirements for the country receiving the funding is that one third of the overall prevention budget and two thirds of the behavioral prevention budget be spent on abstinence/being faithful (AB) programming. Not only does it dictate that thirty-three percent of the funding go to abstinence-until marriage programs, it limits condom-distribution to “high risk” groups and does not allow the funding to be spent on sex workers (1). In Uganda, with the PEPFAR funding, the government established an official “AB” policy in 2004, undermining the previous ABC policy which included promoting condom (C) usage. Before the AB policy, HIV activists in Uganda had spent the last two decades trying to normalize condom usage. PEPFAR’s guidelines for funding, which has fueled the official AB policy is ineffective and may do the opposite of its intended purpose: to decrease the spread of HIV. The past couple of years HIV in Uganda has actually increased (2). PEPFAR is ineffective because it places too much emphasis on internal characteristics of the individual. Furthermore, it does not universally address all the groups in the community while increasing the stigma on those who become infected. Lastly, it does not take into account the cultural behaviors prevalent in the community.

The AB plan heavily emphasizes internal characteristics, failing to take into account external factors.
Abstinence and Be Faithful policies emphasizes self-control and will-power of the individual. Albert Bandura’s Social Cognitive Theory (SCT) addresses the interplaying factors of behavior- the individual characteristics, environmental factors, and interactive process between the individual and social/environmental cues (3). Using the SCT, the AB method fails to consider the variety of other factors that affect behavior, and only emphasizes the internal characteristics such as behavioral capability, expectations, and self-control. However, solely addressing these characteristics is not enough. Even if the individual has the intention to avoid sexual intercourse, it may not necessarily translate into action, for we are influenced by much more than our own characteristics but by those around us. Furthermore, even excluding the environmental and social influence, sticking to the AB policy is difficult nonetheless. According to past research and interventions, abstinence is tough and even people who swear by it have a hard time sticking with it (4). Ninety-five percent of the American population has premarital sex (5). In the study Promising the future: virginity pledges and first intercourse, teens who pledged not to have premarital sex were followed over the period of six years. Sixty percent of these teens had broken their vow, which supports the notion that intention does not translate into behavior. Furthermore these teens who pledged to refrain from sexual intercourse until marriage were more likely to engage in oral and anal intercourse and less likely to use condoms compared to non-pledging teens (6). In the United States, the abstinence approach has been ineffective in twelve different states(2).

Not only has the abstinence approach been ineffective in other countries, it also goes against empirical evidence on what has been effective in Uganda. In the last decade, HIV incidence in Uganda has decreased due to comprehensive preventative efforts. The AIDS prevention campaign which was initiated in 1982 has been credited with helping decrease HIV prevalence from around 15% in the early 1990s to around 5% in 2001. This first AIDS prevention campaign was called the ABC approach - encouraging sexual Abstinence until marriage; advising the sexually active individuals to Be faithful to one partner; and advising Condom use (7). The ABC approach was effective because it took into account the possibility of the individual being affected by others around him, considering the overall social and physical environment, where it is common to have sexual intercourse before marriage. The individual may be influenced by modeling, the behavior of others and by positive or negative reinforcements from that behavior. Since the adolescent or adult are not completely resistant to societal influence, a public health intervention must include a preventative method that takes these factors into account. Hence encouraging condom usage and increasing their availability are key for HIV prevention. The number of condoms delivered and promoted by international groups rose from 1.5 million in 1992 to nearly 10 million in 1996. Within the last decade the C for condom in ABC has been removed. Uganda did not implement abstinence education on a large scale until the United States began promoting these programs internationally around 2001. During the 2000-2005 period when the PEPFAR was passed the HIV prevalence has increased to 5.4% and continues to increase since the shift to abstinence interventions were made. There are currently 940,000 people currently living with HIV in Uganda (8). Health policies in Uganda should be dictated by what has been effective in the past, which should address more than just individual characteristics, but external factors and the interactive process between the social/environmental cues and the individual.

The AB policy is not completely effective, increases stigmatization of HIV, and discriminates against certain groups.
Even if the individual is able to stick to the AB program, it does not guarantee that he or she will not be infected by the HIV virus. Abstinence does not protect faithful couples if one is already infected, married couples who have sexual intercourse outside of the marriage, rape victims, injecting drug used, sex workers and people who are already infected. And since in the AB policy, the person is expected to wait until marriage to have sexual intercourse, it assumes that everyone has the intention and capability of getting married, which is discriminatory and excludes certain groups of people. Homosexuals are not by law permitted to get married, so how does abstinence until marriage apply to the gay population? The abstinence policy also discriminates against sex workers, in which the person makes their living off of sexual intercourse. Those who support their families by this profession will most likely not follow the abstinence policy (2). The AB approach has also contributed to increase in stigma on those infected with HIV. The Behavior Change Communications (BCC) theory is an approach developed primarily in the global health context integrates several behavioral change theories ranging from Diffusions of Innovations to Social marketing theory. The BCC has been widely used in designing HIV interventions. One of the major goals of a BCC program are to reduce stigma and discrimination, an important characteristic of what makes a public health intervention effective (3). The AB policy does the opposite, and actually increases stigma and discrimination related to AIDS. Solely promoting messages that advocate abstinence and partner reduction stigmatizes and demoralizes those who do become infected. The message that for the person to prevent infection, he or she must resist temptations and maintain fortitude puts an overwhelming pressure on the individual and demoralizes him if he does become infected. And in countries where 90% of the population does not know their HIV status, how does one identify and avoid sexual interaction with those who are infected and those who are not (2)? Furthermore, for those who know of their HIV positive status, is he expected to not have any sexual interactions with anyone for the rest of their lives? Abstinence would promote that no one should have sexual encounters with the HIV positive person, an extremely demoralizing stigmatization to carry throughout life if the person is the one who is infected. The overemphasis on abstinence and faithful relationships increases stigma and discrimination on those who become HIV positive, precludes certain groups of people, and is not completely effective in certain cases.

Also, the program does not target all populations equally which furthers
contributes to the stigma. In terms of testing for HIV, instead of having widespread testing, the program heavily promotes couples getting married to be tested rather than encouraging universal testing. Also, the Ugandan government does not address the gay, lesbian, and transgendered community in any kind of AIDS prevention service, and therefore discriminates against specific groups. It also does not provide AIDS prevention service or education to sex workers. Sex workers should be a priority target due to the high risk of contracting and spreading the HIV virus, however the government does not acknowledges this fact. Furthermore, the United States only provides funding for countries that sign a contract saying the money for HIV prevention will not be spent on sex workers, therefore supporting this kind of exclusion and contributing the spread of the HIV virus. To reiterate, in the AB policy, condoms are only do be given to “high-risk” groups. However two extremely high risk groups are the gay community and sex workers, yet they are treated as if they did not exist. Currently in Uganda, the newly diagnosed HIV cases are being seen with greater intensity in married women, which is not an expected high risk group. Therefore if condoms are to be given out, they must be made available to everyone and not just certain groups that are considered “high risk”. The funding for the AB plan does not address all populations equally, for it literally excludes certain groups from being included in the funding. And since the AB plan is not applicable to everyone, it is discriminatory intervention.

The AB plan does not take into account prevalent community behavior and cognition that are entrenched in the culture
The AB plan fails to take into account the overall culture in Uganda, disregarding common behaviors and cognition prevalent in the community. According to cultural anthropologists, there is a strong connection between culture and personality and its expression as behavior. Using the Anthropological approach, the public health specialist would focus on the health behavior prevalent in the community and relate it to a larger context. In Uganda, the estimated age girls have their first sexual experience is 16.7 years for girls and 18.8 for boys as of 2001(9). According to the Uganda AIDS Commission, “Ugandan youth begin sexual activity at fairly young ages and with little sexuality information.”13. With a large population of adolescents starting sexual intercourse at a relatively young age and before marriage, the abstinence policy would be hard to push in this sort of community. A public health interventionist who uses the anthropological approach would most likely consider alternatives to address the AIDS epidemic in this community. Furthermore, one fifth of marriages are polygynous, which increases the chances the HIV transmittance if one of the people already have the virus or are unfaithful. Women also marry at a much younger age usually with men who have already been sexually active for several years and who may not have used a condom in the past. In marriages, Forty percent of women experience domestic violence. In the majority of the marriages, the woman is expected to have sex whenever the husband demands it, and the chances of her convincing the husband to use a condom are much lower than with a man who she is not married to(2). The women in the Ugandan community, based on their culture, most likely do not perceive they have power over the man in remaining abstinent and demanding condom usage. The AB plan takes away from the importance of the condom and reinforces the husband’s behavior of failing to use a condom and discourages more women to demand condom. It contributes to stigmatization of condom by denormalizing its usage. In Uganda, the overall belief of the community is that condom does protect against HIV but the AB plan is minimizing the protective power of condom usage (2). Consequently less people are using condoms and more people are infected each day. The Anthropological approach would take into account these overall behaviors and make sure the health intervention fits into the cultural behaviors.

In the Anthropological model, the culture’s cognition of health and disease are important determinants of behavior. The problem with the AB policy is that it is withholding critical information about condom protection without explaining the possible risks associated with abstinence until marriage (10). Therefore the AB policy impacts the cognition in the community, but in a negative way. The AB program was implemented in halls and classrooms of primary and secondary schools across Uganda. Although the Ugandan government had initially said that condom usage would continue to be promoted, it did not maintain this position, for according to them, it conflicts with the abstinence promotion. Out of the funding the United States is giving to Uganda, 3 million is given to a program called te Presidential Initiative on AIDS Strategy for Communication to Youth (PIASCY), which provides abstinence-until-marriage through assemblies, youth rallies, classroom activities. Inclusion of objective health information with images depicting ejaculation, body changes during puberty, the effectiveness of condoms, and proper cleaning of the foreskin were vetoed from being shown in the educational materials. The materials also includes some false statements about condom usage, minimizing their protective value and emphasizing overall religouss values (2). If the individual makes decisions based on cognition but the cognition turn out to be false, the individuals actions may be of great damage to himself and to those around him. The Ugandan government must promote honest messages and not withhold information in order for people make decisions based on truths rather than faulty information.

Uganda needs to maintain what has been effective in the past based on empirical data and not change solely based on funding requirements set by the United States. The AB program does not address alternatives to abstinence or provide preventative education that includes other contraceptive methods. Improved contraceptive use is responsible for 86 percent of the decline in the U.S. adolescent pregnancy rate between 1995 and 2002 (12). Uganda must reduce HIV by promoting effective behavioral strategies - which includes condom usage. It must make condoms available and affordable throughout the country. It must have HIV testing not only for married but for everyone. Finally, it must not discriminate against the gay community and sex workers, which right now are excluded from their HIV programs. The program must reach individuals of all educational levels, social economic backgrounds, genders. It must take into account cultural factors, statistics on what has been effective in the past in Uganda and in other countries.

The AB policy has shown to be ineffective on many levels. The AB policy places too much emphasis on individual factors, is not completely effective while contributing to stigmatization, and does not address behaviors prevalent in the culture. An effective HIV intervention in Uganda should not ignore empirical data and be based off of religious principles. Public health interventions should be effective and have the purpose to contribute to the well-being of the community.

Counter Intervention

Solution to: “The AB plan heavily emphasizes internal characteristics, failing to take into account external factors that impact behavior”
To decrease the emphasis on the internal characteristics, an intervention should promote alternatives to preventing HIV that go beyond being faithful or abstinent. To address the flaws of the AB plan, I propose reverting back to the ABC approach in Uganda, where “C” stands for condom usage. An intervention that focuses on promotion of condom usage, if implemented appropriately could address factors that go beyond the individual level. Although both the AB plan and the ABC plan to an extent rely on “internal” characteristics of the individual(e.g willpower), it has been consistently supported that remaining abstinent is significantly more difficult for the individual compared to condom usage (13). Albert Bandura’s Social Cognitive Theory (SCT) addresses the interplaying factors of behavior- the individual characteristics, environmental factors, and interactive process between the individual and social/environmental cues (14). An effective intervention would apply the SCT at some level. To address environmental factors that affect HIV infection, one would consider societal and social influences on the individual. Although condom usage still relies on the individual’s “internal” characteristic, if it is heavily promoted and widely available, the social and physical environment may be framed to help the individual make the decision to wear condoms. The intervention would educate in schools, health clinics, work-places, and throughout the community by lecturing about condom usage and HIV protection. Along would promoting their usage, condoms must be widely distributed and available. Condom usage must be encouraged by community leaders, whether it is in schools or in health clinics. By having community leaders and health workers, and other well-respected individuals advocate condom usage, the rest of the community may model their behavior. School programs could have individuals with HIV as spokespersons to tell their stories in order for the students to vicariously learn through them. Condom usage must be normalized and through behavior modeling within their social groups, a greater number of individuals will chose to use a condom or demand that the partner uses one. If there are a significant number of positive messages associated with condom usage, seeing the message would make someone who uses condoms positively reinforced to continue using them. Workshops should be incorporated in the health intervention in order to promote self-efficacy. It is important for schools to communicate with parents as well to gain their support in encouraging their children to protect themselves and to be good role-models by promoting safe-sex practices. Using the SCT model, not only would the internal characteristics, but the external characteristics would be addressed. There are endless interventions that could be done applying the SCT, but promoting condom usage, increasing its accessibility, and educating about the importance of condoms would make the physical and social environment more condom-friendly. With this, the external environment is more positively shaped to help the individual make the right decision.

Solution to: “The AB policy is not completely effective, increases stigmatization of HIV, and discriminates against certain groups.”
The second flaw of the AB approach is that it has shown to not be effective in the past within Uganda and in other countries. The new intervention would be based on facts of what has been effective in the past. The AB policy is not completely effective, for it ignores data that supports the fact that the AB policy generally does not work in preventing the spread of HIV. During the 2000-2005 period when the PEPFAR was passed the HIV prevalence has increased to 5.4% and continues to increase since the shift to abstinence interventions were made. There are currently 940,000 people currently living with HIV in Uganda (15). A public health interventionist who seeks to carry out an effective intervention must be aware of what has been effective in the past within that specific community and perhaps beyond it. Prior to the recent increase in HIV, there was a steady decline in HIV due to the public health intervention that implemented the ABC (Abstincence, Be-faithful-Condom) approach. The AIDS prevention campaign which was initiated in 1982 has been credited with helping decrease HIV prevalence from around 15% in the early 1990s to around 5% in 2001. The program included widespread availability and distribution of condoms, increasing the normalization of its usage and decreasing the spread of the virus. The number of condoms delivered and promoted by international groups rose from 1.5 million in 1992 to nearly 10 million in 1996 (16). The ABC program has been effective, while the abstinence approach has been ineffective not only in Uganda, but in many several other places including the United States. A public health interventionist would look at past data and evaluate the effectiveness of different programs. Clearly, the ABC approach is what has been effective in Uganda while the AB approach has been ineffective and therefore the ABC approach is clearly what should be implemented.

Furthermore, the AB approach increases stigmatization of those infected with HIV and discriminates against certain groups of people by not providing preventative services. The new program would decrease stigmatization of HIV and would target the entire community, rather than focusing on specific groups. A program that would prevent the increase of stigmatization of HIV would provide alternatives to abstinence and being faithful, for neither protect if the person already has HIV. An effected intervention would consider the fact that abstinence until marriage and being faithful would not prevent the virus from spreading if the person is already an HIV carrier. If it is known that the person has HIV, most likely no one will want to marry or have any kind of sexual relations with the person, feeding on to the stigmatization of HIV. An effective program would focus on how condom usage protects the spread, and therefore the person with HIV would not carry such a heavy stigma. Furthermore, a significant number of people with HIV are unaware they carry the virus, and therefore only through condom usage can it be certain that the virus will not spread. The public health intervention would promote widespread HIV testing rather than promoting only couple that are getting married to be tested. It would promote condom usage to the entire population, rather than to high-risk groups. Unlike the current approach in Uganda, the new public health intervention would not discriminate against certain groups of people (17). An effective intervention should target all segments of the population, despite social class, gender, ethnicity, occupation, and sexual preference. The gay, lesbian, and transgendered community would be included in AIDS prevention service. The new intervention would also provide AIDS prevention service or education for sex workers. Sex workers should be a priority target due to the high risk of contracting and spreading the HIV virus, The public health practitioner knows it is unwise to ignore one specific group not only because it us inhumane, but for the well-being of all the other groups as well. HIV will spread between the groups, therefore neglecting to target one group may actually harm all of the others. The program must decrease the stigma of HIV by focusing on condom promotion and it much reach individuals of all educational levels, social economic backgrounds, genders in order to be completely effective.

Solution to: “The AB plan does not take into account prevalent community behavior and cognition that are entrenched in the culture”
The new intervention would consider Anthropological factors upheld in the community. The AB plan does not take into account prevalent community behavior and cognition that are entrenched in the culture. Using the Anthropological approach, the public health specialist would focus on the health behavior prevalent in the community and relate it to a larger context (18). Since a large part of the community starts sexual intercourse at a young age, safe sex practices must be advocated to the youth, in school settings. Furthermore, the high prevalence of polygomous relationships and marriages fuel the need to invest in contraceptive education as opposed to abstinence, and further supports the need for widespread distribution of condoms(19). The normalization of condoms must occur in order to decrease stigmatization, which will occur once promotion and access to condom is available. Women must be empowered to demand condom usage through community education and workshops. The protective power of the condom must be advocated in order for the belief that it will prevent HIV infection become more widespread. Although the majority of the population is aware that condoms may protect against HIV, the AB plan is fueling the belief that it can be ineffective. The school programs must send out a clear message about the protective power of the condom, rather than focusing on other alternatives such as abstinence. The programs must teach factual, and comprehensive information regarding HIV and condom usage, without imposing any kinds of religious values. The information must not leave out pictures or figures that would be helpful for the students to understand the HIV virus and its transmittance. The intervention would educate using facts about condom usage taking into account community behaviors and cognition prevalent in the community.

As opposed to the AB policy, the ABC public health intervention would be effective if implemented appropriately. It addresses external factors rather than emphasizing internal characteristics. It decreases the stigma individuals with HIV carry. It is encompassing and target all within the population. It considers prevalent cognition and behaviors entrenched in the Ugandan community. More importantly, it has been proven effective in the past within the same community and therefore must be reimplemented in order to reverse the damages the AB intervention has caused.





References

1) Health Gap Global Access Project. 2009. President’s Emergency Plan for AIDS Relief (PEPFAR). Retrived from http://www.healthgap.org/camp/pepfar.html April 2009

2) Human Right’s Watch.2009 The Less They Know, the Better Abstinence-Only HIV/AIDS Programs in Uganda. Retrieved from http://www.genderhealth.org/pubs/HRWuganda0305.pdf . April 2009.

3) Edberg, Mark. Essentials of Health Behavior. Sudbury, MA. Jones and Bartlett, 2007.

4) Advocates for Youth. 2009. Abstinence-Only-Until-Marriage Programs: Ineffective, Unethical, and Poor Public Health. Retrieved from
http://www.advocatesforyouth.org/PUBLICATIONS/policybrief/pbabonly.html. April 2009.

5) Finer L. Trends in premarital sex in the United States, 1954-2003. Public Health Reports, 2007; 23: 73.
6) Bearman PS, Brückner H. Promising the future: virginity pledges and first intercourse. American Journal of Sociology 2001; 106:859-912.
7)The American Prospect. 2008. How Bush's AIDS Program is Failing Africans. Retrieved from
http://www.prospect.org/cs/articles?article=how_bushs_aids_program_is_failing_africans. April 2009

8)Avert. 2008. HIV and AIDS in Uganda. Retrieved from avert.org/aidsuganda.htm. April 2009.

9) Those surveyed were women between twenty and forty-nine, and men between twenty and fifty-four. UgandaBureau of Statistics (UBOS) and ORC Macro, Uganda Demographic and Health Survey 2000-2001 (Calverton, MD: UBOS and ORC Macro, 2001), p. 79.

10)Uganda AIDS Commission. 2001. “National Young People HIV/AIDS Communication Program for Young People: Concept Paper”. Retrieved from http://www.aidsuganda.org/pdf/piacy_doc.pdf. April 2008

11) Health Gap Global Access Project. 2005. 10 Months and Counting: The Condom Crisis in Uganda. 2005. Retrieved from http://www.healthgap.org/press_releases/05/082905_HGAP_Uganda_call_transcript.html, April 2009.
12) Santelli, Julia.and Laura Lingberg. Explaining Recent Declines in Adolescent Pregnancy in the United States: the Contribution of Abstinence and Improved Contraceptive Use
Am J Public Health. 2007;97(1):150-156



13) Advocates for Youth. 2009. Abstinence-Only-Until-Marriage Programs: Ineffective, Unethical, and Poor Public Health. Retrieved from
http://www.advocatesforyouth.org/PUBLICATIONS/policybrief/pbabonly.html. April 2009.


14) Edberg, Mark. Essentials of Health Behavior. Sudbury, MA. Jones and Bartlett, 2007.

15) Avert. 2008. HIV and AIDS in Uganda. Retrieved from avert.org/aidsuganda.htm. April 2009.

16) Uganda AIDS Commission. 2001. “National Young People HIV/AIDS Communication Program for Young People: Concept Paper”. Retrieved from http://www.aidsuganda.org/pdf/piacy_doc.pdf. April 2008

17) The American Prospect. 2008. How Bush's AIDS Program is Failing Africans. Retrieved from http://www.prospect.org/cs/articles?article=how_bushs_aids_program_is_failing_africans. April 2009

18) Edberg, Mark. Essentials of Health Behavior. Sudbury, MA. Jones and Bartlett, 2007.

19)Those surveyed were women between twenty and forty-nine, and men between twenty and fifty-four. UgandaBureau of Statistics (UBOS) and ORC Macro, Uganda Demographic and Health Survey 2000-2001 (Calverton, MD: UBOS and ORC Macro, 2001), p. 79.

Foundations Of A New HIV Intervention Among Young Black MSM –Allan Welter

Introduction
Evidence shows that individual, interpersonal and community level HIV behavioral interventions are effective in reducing the odds of unprotected anal intercourse considerably among MSM (men who have sex with men) (5, 6, 12). The individual-level component of an intervention is effective when modifying HIV-related knowledge, attitudes and beliefs held by MSM. Increasing perceived self-efficacy among MSM in relation to safer-sex behaviors is also crucial in the individual-level component of the intervention. The interpersonal-level component of an intervention is effective when aimed at changing knowledge, attitudes and beliefs about MSM in small groups of people. Group intervention among family members and close acquaintances of MSM is the main focus of the interpersonal-level. Finally, the community-level component of an intervention is effective in motivating and reinforcing behavior change among those who do not participate directly in the individual and interpersonal levels of the intervention (6).
A Hypothetical Alternate HIV-Intervention to the “Use a Condom Every Time” Campaign
New studies have shown that the annual increase of HIV among young black MSM is as high as 15% (3). In response, the public health department of Washington DC chose young Black MSM in metropolitan Washington DC as the key population of interest for a new culturally sensitive HIV intervention campaign running on individual, interpersonal, and community levels. The goal of this intervention was to increase rates of safer sex practices among young Black MSM.
Individual-Level Component of the Intervention for Young Black MSM:
To modify HIV-related knowledge, attitudes, and beliefs among young Black MSM, culturally sensitive advertisements were spread throughout the metropolitan DC area via brochures, dance clubs, radio stations, top40 podcasts, NPR, and common MSM-oriented websites. Advertisements promoted positive attitudes toward safer sex practices among young Black MSM. These attitudes were promoted through images of men participating in safer sex practices. Young black MSM couples were shown valuing safer-sex practices by saying slogans such as, “I love my Boo. Safer Sex is one way we Show our Love” (13). Men in the advertisements were young and relatable to young Black MSM in the metro DC area.
A general sense of well-being and perceived self-efficacy in relation to safer-sex practices were promoted through confidential private and group sessions in open, supportive environments. Sessions were held on weekdays and weekends and were conducted by trained professionals. These sessions ranged from safer-sex demonstrations to discussing difficulties associated with having sex with men and being a young Black man (5). Young Black MSM were recruited through social websites and after-school programs. Incentives such as food, public transportation tokens, and free passes into local 18+ and 21+ clubs were offered to increase turnout rates.
Interpersonal-Level Component of the Intervention:
To modify the knowledge, attitudes, and beliefs of young Black MSM among families and proxy contacts of young Black MSM (5), culturally sensitive messages were spread via brochures, the media, grocery stores, fast-food restaurants, the Internet, and any other accessible place. Respectful images showing families embracing MSM children were circulated. Individual MSM and MSM couples were shown everyday settings being welcomed, loved, and respected by family and friends. Culturally sensitive images were also circulated showing parents and close contacts of MSM playing active, respectful and positive roles in accepting a young Black MSM’s sexuality (6).
Through social networking, use of bulletins, media sources, and Internet advertisements, families and proxy contacts of MSM were actively recruited into the intervention. Incentives such as food, public transportation tokens, BP gasoline cards equal to the value of public transportation tokens, and $20 gift cards to whole foods with free delivery were offered to increase turnout rates. Sessions were offered on weekdays and weekends and were led by experts in this area of intervention. Counseling for families and proxy contacts were aimed at increasing open communication about sexuality with young Black MSM and transitioning to more positive attitudes relating to MSM persons. Support groups composed of multiple families and contacts were formed to help share experiences related to raising MSM children. Social networks supportive of gay children were introduced to families holding negative attitudes toward young Black MSM (5).
Community-Level Component of the Intervention:
A community intervention among young Black MSM was run on the national-level. Upon research, the campaign discovered that most young Black MSM considered safer-sex to be labeled as “good” and unsafe safe to be labeled as “bad” by the public. These beliefs were problematic for two reasons. First, there was a strong sense of masculinity among young Black MSM that corresponded with being “tough” and daring. Engaging in “bad” and unsafe sex could lead to a conscious or subconscious increase in perceptions of masculinity. Second, young Black MSM felt a sense of homophobia imposed upon them when told to use condoms. They felt heterosexuals imposed the belief that engaging in unsafe sex among MSM individuals is and will always be bad, regardless of any relationship circumstances (6). The campaign also discovered that definitions of “healthy” differed between public health officials and young Black MSM. Young Black MSM did not consider an HIV+ person unhealthy until they were diagnosed with AIDS. This potentially rises from high recognition between young Black MSM of effective HIV treatment (11). There were high levels of awareness of the high HIV infection rates among young Black MSM. This awareness may have led to the feeling infection as inevitable and therapy as painless. Low self-efficacy in relation to protecting oneself from HIV may be leading to higher rates of unsafe sex among young Black MSM.
The nationwide intervention used mass-media campaigns, taking advantage of the culturally sensitive data gained. Prime-time commercials, newspapers, popular magazines, websites commonly frequented by young Black MSM, NPR, and various radio stations transmitted the intervention. Advertisements portrayed HIV as sneaking into the body and hiding in an infected human’s DNA so the treatment could not touch the virus. This shifted the young Black MSM view of engaging in safer-sex as “good” to engaging in safer-sex as actively defending oneself against the sneaky and cowardly virus. It also challenged the notion of having only HIV as being in a healthy state because it made visible the fact that the virus lives inside the individual. To combat the perception of masculinity, advertisements showed young Black MSM protecting others from HIV through engaging in safer-sex practices, effectively associating masculinity with safer sex practices.
Peers of young Black MSM began delivering messages advocating for safer-sex practices. MSM oriented safer-sex demonstrations were made mandatory in public schools [through the wand of Barack Obama?], increasing the perceived self-efficacy relating to safer-sex among young Black MSM. To deconstruct homophobic undertones of safer-sex interventions, open dialogue relating to engaging in unprotected sex within monogamous MSM couples was encouraged. The term monogamous was emphasized, just as is true for heterosexual couples. Finally, role model stories of young Black MSM were distributed throughout the country over various forms of media in an attempt to increase a sense of value and well-being among young Black MSM.
Improvements of Proposed Intervention on the “Use a Condom Every Time” Campaign
Proposed Intervention Does not Run Only on the Individual Level:
One fundamental improvement of this intervention over the “Use a Condom Every Time” campaign is that it is not run merely on the individual level. Accounting for the group dynamic (4), this intervention will be able to shift behaviors of entire groups of young Black MSM rather than individual MSM (4). Essentially, people who do not participate in the intervention on the individual level are still influenced by the intervention through the cultural shift of attitudes related to safer-sex practices (5). The community and interpersonal proportions of this intervention attempt to shift HIV-related beliefs for entire groups rather than individuals.
Additionally, this intervention specifically addresses the wider social context affecting health related behaviors of individuals (4). Contextual issues are put forth regarding masculinity and unprotected sex among young Black MSM. Young Black MSM may have had unprotected sex to increase their sense of masculinity. This intervention used masculinity as a contextual tool of intervention, showing young Black MSM protecting others through safer-sex as masculine. This would not be possible in the “use a condom every time” campaign.
Homophobic Societal Undertones related to Condom Use are Eliminated:
MSM have “experienced hatred, abuse, and a lack of acceptance by their families, friends, communities, and society in general” (5, 6, 14). We have shown that these negative experiences, potentially leading self-destructive psychological natures, can result in MSM engaging in unprotected sex because it is dangerous (6, 14).
This intervention works on the interpersonal level to decrease homophobia among families, friends, and close contacts of MSM. This will hopefully lead to a decrease in self-destructive tendencies caused by homophobia. A potential decline their rates of unprotected anal sex may be observed as a result (14). Additionally, homophobia is addressed on the national level. Counter to the “use a condom every time” campaign, this intervention opens publicly accepted discussion among monogamous MSM couples to decide whether they want to use condoms in their relationship. In effect, the intervention removes society’s homophobic desire to dictate the behaviors of MSM through “always use a condom” campaigns. This allows MSM and the intervention to interact without the negative pretense of perceived homophobia. In circumstances such as these, MSM are less likely to be defensive and more likely to listen to the message being put forth by the campaign (5, 14). Intervening at the group and interpersonal level allows maximum efficiency in decreasing homophobic experiences of MSM individuals, leading to increases in safer-sex practices (12).
Health Not Assumed to be Highly Valued by most MSM:
The proposed intervention directly addresses the fact that the definition of “healthy” differs between young Black MSM and public health professionals. To get around this discrepancy in definitions, the intervention circulated images depicting HIV as deceptive and cowardly. This image of deception leads to young Black MSM acting in defense of their body, regardless of the definition of health.
MSM may hold a high value for not contracting HIV, but they may also have a low perception of self-efficacy in relation to engaging in safer sex. The new intervention addressed this potential low perceived self-efficacy for using a condom among young Black MSM, an aspect completely left behind by the “use a condom every time” campaign. Since the new intervention does not require that MSM use a condom every time, the pressure associated with having to use a condom in every sexual encounter for the rest of one’s life is diluted. Additionally, confidential group and private sessions were run that showed MSM how to engage in safer-sex practices. Role-playing was implemented to help MSM gain the strength and courage to insist to their partners that a condom be used if they feel it is necessary. Note that both individual and group level interventions were required to address the potential effects of low perceived self-efficacy relating to safer sex among young Black MSM.
Concluding Statement
The proposed intervention improves upon the “how to use a condom every time” campaign in three significant ways. First, this campaign is run on the individual and group level. While increasing perceived self-efficacy relating to safer-sex practices among young Black MSM, we are also shifting beliefs and behaviors of entire groups with relation to HIV (4, 12). Second, young Black MSM men do not perceive the intervention as homophobic. As a result, it is more likely for young Black MSM to take in messages of the intervention. The campaign also addresses homophobia through interventions among families and proxies of young Black MSM. Lower levels of homophobia among MSM proxies will lead to an increased sense of well-being. Young Black MSM will feel more valued and welcomed in everyday aspects of life, which can lead to decreased self-destructive actions and increases in the frequency of safer-sex practices. Finally, the proposed campaign improves on the “use a condom every time” campaign in that it does not assume “health” to be highly valued among most young Black MSM. Without this contextual assumption, the intervention was able to target factors that were truly related with low frequencies of safer-sex practices and intervene based on those factors.
Evidence shows that individual-level, interpersonal-level and community level HIV behavioral interventions are effective in reducing the odds of unprotected anal intercourse considerably among MSM (5, 12). It is crucial for all three components to be a part of the intervention. The community level component is necessary because it allows those who were not directly involved in the intervention to still be influenced by the intervention and because it analyzes health-related behaviors within the cultural context (4). The interpersonal level is essential because reduced levels of homophobia among proxies of MSM will lead to higher senses of well-being among MSM. This may correlate with decreases in self-destructive behavior, and potentially increases in safer-sex practices. Finally, the individual level component is essential because it provides HIV-related knowledge directly to individuals and increases individual perceived self-efficacy relating to safer-sex practices. Implementing all three components into an intervention significantly improves on the “use a condom every time” campaign, and will be effective in increasing the frequency of safer-sex practices within the target population.
REFERENCES:
1. Department of Health and Human Services. Basic Information. Centers for Disease Control and Prevention. http://www.cdc.gov/hiv/resources/qa/index.htm.
2. Sterk C. The health intervention project: HIV risk reduction among African American women drug users. Public Health Rep. 2002; 117(Suppl 1): S88–S95.
3. Brown D. HIV rate up 12 percent among young gay men: Steepest rise is in black males ages 13 to 24. (2008, June 27). The Washington Post, p. A14.
4. Edberg M. Essentials of health behavior: Social and behavioral theory in public health (pp 65-76). In: Edberg M, ed. Social, Cultural, and Environmental Theories (Part II). Sudbury, MA: Jones and Bartlett Publishers, 2007.
5. Choi K. H., Yep, G. A., & Kumekawa, E. HIV prevention among asian and pacific islander american men who have sex with men: A critical review of theoretical models and directions for future research. AIDS Education and Prevention. 1998; 10: 19-30.
6. Siegel M. The importance of formative research in public health campaigns: an example from the area of HIV prevention among gay men (pp. 66-69). In: Siegel M, ed. Marketing Public Health: Strategies to promote social change. Sudbury MA: Jones and Bartlett Publishers, 2004.
7. The Complete HIV/AIDS Resource. HIV/AIDS Among Women. The Body. http://www.thebody.com/index/whatis/women_basics.html.
8. Huebner D. et al. The Impact of Internalized Homophobia on HIV Preventive Interventions. American Journal of Community Psychology 2002; 30(3):327-348.
9. Salazar K. Comparison of Four Behavioral Theories: A Literature Review. AAOHN Journal 1991; 39(3):128-135.
10. S A. Bug Chasing: Why Some Men Want to Become HIV Positive. Associated Content: Information from the source. Published Nov 09, 2005. http://www.associatedcontent.com/article/13507/bug_chasing_why_some_men_want_to_become.html?singlepage=true&cat=5
11. Jaffe H, Valdiserri R, De Cock K. The Reemerging HIV/AIDS Epidemic in Men Who Have Sex With Men. JAMA Nov 28, 2007;298(20):2412-2414.
12. Herbst J, Beeker C, Mathew A, McNally T, Passin, W, Kay L, Crepaz N, Lyles C, Briss P, Chattopadhyay S, Johnson R. Effectiveness of Individual, Group, and Community-Level HIV Behavioral Risk-Reduction Interventions for Adult Men Who Have Sex with Men. American Journal of Preventive Medicine 2007; 32: S38-S67.
13. Gay Men’s Health Crisis. GMHC launches two new HIV awareness campaigns. New York City: Gay Men’s Health Crisis. Retrieved February 13, 2009, from GMHC: Press Web site: http://www.gmhc.org/about/releases/080319.html.
14. Huebner D, Davis M, Nemeroff C, Aiken L. The Impact of Internalized Homophobia on HIV Preventive Intervention. American Journal of Community Psychology 2002; 30:327.

Why Abstinence-only Education Fails: A Critique from a Social Behavioral Perspective – Christine Connolly

Introduction

Sexual activity during adolescence can have a myriad of public health consequences; including but not limited to increased rates of sexually transmitted disease (STD) and unintended pregnancy. In the United States, recent estimates have suggested that adolescents account for almost half of all new STD cases while only representing a quarter of the ever sexually active population (1). Although pregnancy and birth rates among girls ages 15-19 years have decreased since 1991, approximately 400,000 infants were born to mothers in this age group in 2006. More than 80% of these pregnancies were unplanned. Among developed countries, the United States has the second highest adolescent pregnancy and birth rates. (2)

To help address these issues, the United States federal government began funding programs to promote abstinence in 1982, with the passage of the Adolescent Family Life Act (AFLA). Since this time, federal funding for abstinence programs has increased; first under Section 510 of the Social Security Act in 1996 and again under the Special Projects of Regional and National Significance Community-Based Abstinence Education Program (CBAE) in 2000. In particular, passage of Section 510 of the Social Security Act was significant, as this legislation outlines an eight-point definition of abstinence; the interpretation of which has gone on to define the characteristics of programs to receive federal funding. Based on this eight-point definition (and later, on strict guidelines introduced by CBAE), funding has shifted from comprehensive sex education programs (promoting abstinence in conjunction with other health-related behaviors such as contraception use) to education programs advocating abstinence-only until marriage. Under current legislation, federally funded programs must promote only abstinence and are prohibited from disseminating information regarding contraception services, sexual orientation and gender identity, and other aspects of human sexuality. (3)(4)(5)

Despite immense funding to date ($204 million was appropriated in 2008 alone (5)), there is evidence to suggest that abstinence-only education (AOE) largely fails to reduce negative public health consequences of adolescent sexual activity. This paper will present three arguments for why AOE has failed as a public health initiative from a social behavioral perspective.

Argument 1: Intention vs. Behavior

The notion that intention leads to behavior is a common theme among traditional health behavior change models, including the Health Belief Model and the Theory of Reasoned Action. Intention is a cornerstone of many AOE programs, where it is assumed that adolescents who develop intention to remain abstinent will carry this forward behaviorally. As is the case with the aforementioned traditional models, the idea that intention (in this case abstinence) leads to behavior (forgoing sexual activity) is fundamentally flawed.

Studies have shown that intention to abstain does not always lead to abstinence behavior among adolescents. Perhaps the most straightforward evidence of this is demonstrated by AOE programs that include public virginity pledging; where adolescents publicly declare their intention to abstain from sexual activity in the form of an oral or written promise. Studies on the effectiveness of public virginity pledges have generally shown that adolescents who have pledged do not delay sexual initiation longer than their non-pledging counterparts (except in some specific social contexts). Adolescents who have pledged versus those who have not have comparable rates of STDs. Further, many adolescents go on to deny having pledged if they break their pledge. (6)(7)(8)

Perhaps this discrepancy can be explained in part by a new model of adolescent risk behavior called the prototype/willingness (P/W) model, first proposed by Gibsons and Gerrard in 1995. According to this model, much of adolescent risk behavior is unplanned and is influenced by an adolescent’s willingness to engage in a behavior. An adolescent’s willingness is function of four factors: whether the adolescent’s peers have positive attitudes toward the behavior, whether the adolescent has positive attitudes toward the behavior, whether the adolescent has engaged in the behavior in the past, and finally, whether the adolescent associates a positive social image or prototype with the behavior. In this model, an adolescent’s engagement in risk behavior is based on social reactivity. So, in a risk-conducive situation, an adolescent may react by engaging in risk behavior conditional on his or her willingness to engage in the behavior. This reaction is completely unplanned. The P/W model acknowledges the presence of intention, but views it as independent from but related to willingness. In this model, an adolescent can fully intend to abstain from a behavior (such as sexual activity), but can go on to engage in the behavior anyway if the situation presents itself and they are willing. (9)

Even if intention always led to behavior, some studies have suggested that adolescents do not consider abstinence and sexual activity to be opposing constructs. This is problematic in the context of AOE programs, as an adolescent could both intend to abstain and intend to be sexual active simultaneously. Several studies to date have shown intention to have sex to be a stable predictor of sexual activity among adolescents (10). Expanding on this, a recent study examined how adolescents think about abstinence as well as sexual activity. This study found that intention to abstain did not consistently predict abstinence or reduction in sexual behavior. In fact, the association between abstinence intention and subsequent behavior differed by an adolescent’s intention to have sex. For example, when an adolescent’s intention to have sex was positive but low, intention to abstain from sex had little impact on sexual activity. However, when both intentions to have sex and to abstain were high, intention predicted an increased likelihood of sexual activity. The authors of this study feel this could be due to a perception among some adolescents that there is a natural linear progression between abstinence and initiation of sexual behavior. When considered temporally, it is possible to have strong non-oppositional intentions regarding both. (11)

Argument 2: Perceived Susceptibility

Although discussion of contraception use is prohibited, contraception is often described in AOE programs with an emphasis on failure rates. In addition, there is no requirement for scientific accuracy in educational materials provided by AOE programs and inaccuracies often involve exaggerations of failure rates. (6)(12) When discussion of contraception is limited to downplay of possible positive health effects, AOE programs become a flawed public health approach. By limiting information and/or distorting facts, AOE programs attempt to enhance an adolescent’s perceived susceptibility to negative health outcomes. The flaw inherent to such an approach is that adolescents may not be particularly influenced by this construct in the context of risk behavior.

This effect may be particularly pronounced among young women. A study of 209 adolescent women conducted in 2003, found that the majority of participants (88.9%) perceived themselves to be at little to no risk for contracting and STD. This was despite the fact that the majority of participants (73.8%) had reported previously contracting an STD and/or engaging in risky sexual behaviors, such as unprotected sex. (13)

Perhaps this can be explained by research which suggests that adolescents (as well as adults) can exhibit unrealistic optimism regarding the development of negative health outcomes. Unrealistic optimism is a form of cognitive bias and can be defined as the tendency for individuals to perceive their risk of harm as below average as compared with others. (14) Such a bias could certainly render perceived susceptibility ineffective, given that individuals with this bias may not truly believe they are susceptible to the same negative health outcomes as other individuals.

A second explanation may stem from the fact that adolescents tend to be oriented in the present and generally do not focus on future outcomes. Adolescents tend to plan ahead, think about the future, and anticipate future consequences of their actions less than their adult counterparts. Adolescents also tend to favor small rewards delivered sooner over large rewards delivered at a later time point. These effects appear to be more pronounced in younger adolescents and decrease as adolescents move towards adulthood. (15) This is significant in the context of sexual behavior, as adolescents may not fully comprehend possible long term consequences associated with their actions. Because of this they may feel less susceptible to negative health outcomes that will not manifest until much later in life (such as the development cervical cancer from contracting HPV).

Argument 3: Unaddressed Contextual Factors

As with traditional health behavior change models, AOE attempts to cultivate health behavior change on an individual level and fails to address contextual factors that may inhibit or promote health behaviors. For this reason, AOE is a flawed public health approach, as it fails to account for contexts where it may be virtually impossible for adolescents to abstain.

For example, AOE ignores that individuals may make very different decisions in contexts that leave them in dispassionate versus aroused states. In his book, Predictably Irrational, Dan Ariely discusses an experiment he conducted where college students were asked to predict a number of decisions they would make (for example, the decision use or not use a condom) in both dispassionate and aroused states. The results of this experiment showed that students in dispassionate states were more likely to predict making rational decisions, but the same students in aroused states were more likely to predict making irrational decisions. He goes on to suggest that this phenomenon may be exacerbated in adolescents and that adolescents may not be able to resist sexual behavior once they are in an aroused state, even if they would have earlier decided to abstain. (16)

AOE ignores social contexts which may influence an adolescent’s decision to abstain. In the case of virginity pledges, pledging is at times associated with delay of first sexual intercourse among adolescents. However, this delay appears to be mediated by social contexts. In situations where too many or too few adolescents within a community pledge, pledging is not associated with delay in sexual activity. Specifically, pledging seems to work when adolescent pledging can assume a minority identity as a result of their pledge. This is a common phenomenon related to identity movements. (17) The influence of identity within a social context can also be seen in a recent study that found retraction of virginity pledges by those who had pledged previously was strongly associated with the abandonment of a born again religious identity. Together, these findings suggest that identity in social contexts may be a motivating factor for adolescents when it comes to abstinence. (7)

Further, AOE programs largely ignore the influence of family dynamics and socioeconomic status (SES) on adolescent sexual activity. For instance, multiple studies have shown greater parent-child connectedness (parental support, closeness, and warmth) is related to delay in the timing of first intercourse and reduction of sexual activity. Living with a single parent and/or having sexually active older siblings has been associated with higher rates of adolescent pregnancy. Lower SES has been associated with earlier first intercourse and lower rates of contraception use. (18)

Conclusions

Abstinence-only education is not flawed because abstinence is ineffective. In fact, as argued by many proponents of AOE, abstinence is the only way to completely avoid negative consequences related to sexual activity. Rather, the fundamental flaw inherent to AOE is the uncertainty around whether adolescents can successfully remain abstinent. As argued above, an abstinence-only approach may not be a realistic option for adolescents for a number of reasons. To a large extent, social factors appear to be related to whether an adolescent remains abstinent, regardless of whether an adolescent intends to abstain. In addition, AOE programs do not take into account how adolescents may cognitively process their own sexual development or risks for subsequent health issues. An effective program must acknowledge that adolescents may not be able to abstain and therefore must provide them with tools to protect themselves if they become sexually active.

A Counter-Proposal to Abstinence-Only Education

Abstinence can be used as one part of an effective strategy to avoid negative health outcomes associated with sexual activity. An effective public health intervention could utilize abstinence by incorporating it as one of several methods an adolescent could employ to avoid negative health consequences. Such an intervention could further improve outcomes by addressing fundamental flaws inherent to AOE-based interventions.

An Alternative Intervention

An alternative approach to AOE programs could consist of a hypothetical country-wide network of community-based outreach and education programs collectively called the Rainbow Project. Across the Rainbow Project network, programs would have three primary goals. First, programs would endeavor provide adolescents and their families with scientifically accurate information regarding a variety of topics related to human sexuality. Topics covered would include, but not be limited to: abstinence, effectiveness and proper use of contraception, sexual orientation, and gender identity. Second, programs would endeavor to cultivate social environments where adolescents feel supported and empowered to be responsible for their sexual health. Third, programs would endeavor to provide services designed to strengthen relationships between adolescents and their families, such as parent-child activities, parenting classes, and family counseling.

How individual programs would achieve the goals described above would be relatively flexible. Individual programs would be housed within neighborhood community centers and would receive funding to conduct community-level research to design and fine tune initiatives to fit community needs. However, despite this flexibility, a few general concepts would be implemented across the board.

Overall, programs would engage adolescents and their families both together and one-on-one. Programs would provide comprehensive sex education directly to adolescents via classes and workshops within their schools. Adolescents would also be addressed outside of their schools through after school programs and activities organized within their community. Parents and other family members would be engaged through school and community activities as well. The community center would serve as a place for impromptu contacts between programs and community members. Programs would be staffed at hours to promote accessibility, based on the needs of the community

The initiative described above would incorporate abstinence as one of many methods to be used to protect adolescents from negative health outcomes. Further, the initiative described above would address a number of flaws inherent to AOE-based programs. How the Rainbow Project would address the specific flaws discussed previously is discussed below.

Flaw 1: Intention vs. Behavior

Similar to traditional health behavior change models, AOE programs fail in their assumption that abstinence intention will lead to abstinent behavior. The Rainbow Project does not share this flaw, as it does not assume that intention leads to behavior.

Instead, the Rainbow Project arms adolescents and families with a myriad of strategies to avoid negative health outcomes related to sexual activity. In this sense, the fact that people can have a number of intentions and may only be able to translate a few into behavior is acknowledged. By providing a number of options, the Rainbow Project will give adolescents alternative strategies to use if they are unable to follow through with their initial intentions.

This could be significant in cases where adolescents may have positive intentions regarding both abstinence and sexual behavior. In such cases, adolescents would now be armed with methods to protect themselves if their intention to engage in sexual activity leads to behavior. In addition, the Rainbow Project would foster social environments where abstinence intention could lead to behavior more often. A recent study suggests that adolescents may experience negative social and emotional consequences as a result of abstaining from sexual activity. In this study, adolescents who remained sexually inexperienced over the course of the study reported having a bad reputation as a result and regretted abstaining. (19) This is significant in the context of the prototype/willingness model, where an adolescent’s willingness to engage in a behavior is based in part on whether the adolescent associates a positive social image with the behavior. The Rainbow Project will work towards changing social perceptions among adolescents by promoting positive social images related to reproductive health responsibility.

Flaw 2: Perceived Susceptibility

AOE programs are flawed when they fail to take into account that perceived susceptibility is not an effective tactic to influence adolescent behavior. The Rainbow Project improves upon this in that it does not attempt to emphasize perceived susceptibility and instead focuses on disseminating scientifically accurate information regarding contraception, as well as other aspects of human sexuality.

There is ample evidence to suggest that providing adolescents with medically accurate information about contraception is an effective strategy. Multiple studies have found that providing such information to adolescents does not encourage early sexual activity. Rather, such initiatives were found to increase contraception use among adolescents who were already sexually active. In fact, declines in unintended pregnancies among adolescent women observed in the 1990s have largely been attributed to an increased knowledge regarding and appropriate use of contraception. (20)

Providing adolescents with medically accurate information regarding contraception acknowledges the existence of cognitive bias, such as unrealistic optimism, and the tendency for adolescents to be oriented to the present rather than the future. When adolescents cannot abstain from sexual activity due to cognitive bias or lack of forethought regarding future outcomes, contraception can provide an alternative method to safeguard their reproductive health.

Flaw 3: Unaddressed Contextual Factors

AOE programs fail as public health policy as they do not address contextual factors that may influence adolescent sexual behaviors. The Rainbow Project improves upon this as it strives to address contextual factors related to sexual activity among adolescents.

First, as mentioned previously, the Rainbow Project will arm adolescents and their families with a myriad of strategies they can employ to avoid negative outcomes. This is significant in the context of decisions made by adolescents in dispassionate versus aroused states. In this context, an adolescent who has made an irrational decision to engage in sexual activity based on their physiologic state will still have options available, such as using the functional knowledge required to use contraception effectively.

In addition, the Rainbow Project will not ignore social contexts which may influence an adolescent’s decision to become sexually active. Instead, it will directly acknowledge and try to address issues within social contexts by fostering environments where adolescents are influenced to make responsible decisions regarding their reproductive health.

Further, the Rainbow Project will address issues related to family contexts by strengthening communication and relationships between adolescents and their caregivers. Strengthening both will help to alleviate negative health outcomes, as there is evidence to suggest the adolescents who feel that their parents are involved in their lives (who know where they are and who they are with) are less likely to engage in at-risk sexual activity. Further, there is evidence to suggest that positive parental influence can mediate effects of peer influence that can lead to sexual behavior. (21)

Conclusions

The Rainbow Project is a hypothetical intervention to reduce negative health outcomes associated with sexual behavior among adolescents. It avoids strategies employed by both traditional health behavior change models and AOE programs and instead recognizes the importance of innate human behavior, social behavior, and environmental contexts. Perhaps the most compelling strength of the Rainbow project from a contextual perspective is its emphasis on community-based research to define new and augment existing programs. It is in this way that the Rainbow Project recognizes heterogeneity between communities and will be able to better address contextual issues specific to the communities they serve.

REFERENCES

1. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2007. Atlanta, GA: National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, December 2008.

2. Centers for Disease Control and Prevention. Adolescent Reproductive Health. Atlanta, GA: Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion. http://www.cdc.gov/Reproductivehealth/AdolescentReproHealth/index.htm.

3. Advocates for Youth. The History of Federal Abstinence-Only Funding. Washington, DC: Advocates for Youth. http://www.advocatesforyouth.org/publications/factsheet/fshistoryabonly.htm.

4. Santelli J. et al. Abstinence and abstinence-only education: A review of U.S. policies and programs. Journal of Adolescent Health 2006; 38: 72-81.

5. Duffy K. et al. Government support for abstinence-only-until-marriage education. Clinical Pharmacology and Therapeutics 2008; 84 6: 746-748.

6. Kantor L. Abstinence-only policies and programs: An overview. Sexuality Research & Social Policy 2008; 5 3: 6-17.

7. Rosenbaum JE. Reborn a virgin: Adolescents’ retracting of virginity pledges and sexual histories. American Journal of Public Health 2006; 96 6: 1098-1103.

8. Rosenbaum JE. Patient teenagers? A comparison of the sexual behavior of virginity pledgers and matched nonpledgers. Pediatrics 2009; 123: e110-120.

9. Gibbons F. and Gerrard M. et al. Reasoned action and social reaction: Willingness and intention as independent predictors of health risk. Journal of Personality and Social Psychology 1998: 74 5: 1164-1180.

10. Buhi E. and Goodson P. Predictors of adolescent behavior and intention: A theory-guided systematic review. Journal of Adolescent Health 2007; 40: 4-21.

11. Masters NT. The opposite of sex? Adolescents’ thoughts about abstinence and sex, and their sexual behavior. Perspectives on Sexual and Reproductive Health 2008; 40: 87-93.

12. United States House of Representatives Committee on Government Reform. The Content of Federally Funded Abstinence-Only Education Programs. Washington, DC: Minority Staff Special Investigations Division, 2004.

13. Ethier KA. et al. Adolescent women underestimate their susceptibility to sexually transmitted infections. Sexually Transmitted Infections 2003; 79: 408-411.

14. Greening L. et al. Predictors of children’s and adolescent’s risk perception. Journal of Pediatric Psychology 2005; 30 5: 425-435.

15. Steinberg L. et al. Age differences in future orienting and delayed discounting. Child Development 2009; 80 1: 28-44.

16. Ariely D. Predictably Irrational the Hidden Forces that Shape Our Decisions. New York, NY: HarperCollins, 2008.

17. Bearman P. and Bruckner H. Promising the future: Virginity pledges and first intercourse. American Journal of Sociology 2001; 106: 859-912.

18. Miller B. Family influences on adolescent and contraceptive behavior. Journal of Sex Research 2002; 39: 22-26.

19. Brady S. and Halpern-Felsher B. Social and emotional consequences of refraining from sexual activity among sexually experienced and inexperienced youth in California. American Journal of Public Health 2008; 98 1: 162-168.

20. AIDS Policy Research Center & Center for AIDS Prevention Studies. Abstinence Only vs. Comprehensive Sex Education: What are the arguments? What is the evidence? San Francisco, CA: AIDS Research Institute University of California, March 2002

21. DiClemente R. et al. Psychosocial predictors of HIV-associated sexual behaviors and the efficacy of prevention interventions in adolescents at-risk for HIV infection: What works and what doesn’t work?. Psychosomatic Medicine 2008; 70: 598-605.