Failure to Follow Through: How the OvarianCancerAwareness.org Campaign Leaves Massachusetts Women Scared and Helpless – Emily White

Introduction
Ovarian cancer is a very serious disease that afflicts more than 20,000 women each year (1). Diagnosis of ovarian cancer is extremely problematic because there is currently no reliable screening test for early detection of the disease. While several methods are used to try and detect the presence of ovarian cancer, surgery is the only fool-proof method of diagnosis. Due to these challenges, it is often detected only after it has spread to other parts of the body (2). For this, ovarian cancer has earned the nickname “The Silent Killer.” While the five-year survival rate for cases detected before the disease spreads is 92%, only 19% of cases are detected at this stage. The overall 5-year survival rate is only 45% (1).
In 2007, the Gynecologic Cancer Foundation announced the first national consensus on ovarian cancer symptoms. This consensus lists symptoms such as bloating, gas, abdominal pain, urinary symptoms, and difficulty eating and recommends that women experiencing these symptoms daily for longer than two weeks should consult a physician (3). The statement also encourages women to ask to see a gynecologic oncologist if ovarian cancer is suspected. In response to the consensus statement, several Massachusetts organizations teamed up to form the OvarianCancerAwareness.org coalition. The coalition is responsible for developing and carrying out the OvarianCancerAwareness.org campaign (4), which began in September 2007, for National Ovarian Cancer Awareness month, and will continue to campaign each year. The campaign consists of a two-pronged approach. One component targets clinicians and legislators in an attempt to change practice while the other targets the general population to increase awareness of symptoms and courses of action. This critique will focus on the latter portion of the campaign, which utilizes many different media including the website itself (ovariancancerawareness.org), television commercials, transit and outdoor advertisements, pay stub enclosures for state employees, cards given at tollbooths, and radio broadcasts (5).
The OvarianCancerAwareness.org campaign is based on the principles of the Health Belief Model (HBM) developed in the 1950s which states that an individual will engage in a particular health behavior if perceived susceptibility and severity of not engaging in the behavior are both high, there are clear and worthwhile benefits to engaging in the recommended behavior, and the barriers to engaging in the behavior are low (6). The HBM, however, does not address many important factors that may play a role in health behavior because it assumes that rational thinking leads directly to action and neglects any of the intervening factors that may exist (7). The OvarianCancerAwareness.org campaign in Massachusetts attempts to reach women at risk for ovarian cancer in an effort to make them more aware of the disease and to teach them how to respond to early warning signs. The campaign, however, in its reliance on the health belief model, stops short of being truly inspiring or educational. It relies heavily on the distribution of scientific information and assumes that this alone will compel women to take action, all the while failing to acknowledge the needs of its target audience.

Failure to Consider the Informational Needs of the Target Audience
The OvarianCancerAwareness.org campaign utilizes its website as the primary method of contact with the target audience (4). The website is available in Spanish, Portuguese, and English and includes pages for basic information about the coalition and ovarian cancer, survivor stories, a quiz to test users’ knowledge of ovarian cancer, and links to collaborating institutions and other ovarian cancer resources. The site also lists an email address to request further information; however, it is no longer a valid address and messages addressed to it are returned to the sender (8). Also available through the main website is a webcast that aired live in September 2007 and can be downloaded for viewing at any time. All of the other media used by the campaign (transit advertisements, television commercials, paystub enclosures, etc) provide very basic information, then direct people to the website for details.
Despite utilizing various media for the dissemination of information, the OvarianCancerAwareness.org campaign fails to reach the target audience because it neglects the main tenets of social marketing theory. Social marketing theory is based on the concept of using marketing analysis and planning to affect a social agenda. In the case of a public health campaign, this means identifying the social and psychological needs of the target audience, then meeting these needs (9). Social marketing theory is a powerful tool for reaching narrowly-targeted audiences such as women at the highest risk for developing ovarian cancer.
A major failure of the OvarianCancerAwareness.org campaign, a social marketing campaign by nature, lies in the coalition’s neglect to consider the needs of its target population. Risk of developing ovarian cancer increases with age and is highest among women in their 70s (10). This subset of women should arguably be targeted most aggressively by this campaign. It is clear, however that the OvarianCancerAwareness.org coalition did not consider the needs of this high-risk group in developing the campaign. As of 2004, only 63% of persons over the age of 55 have internet access in the home (11). Any woman who not does have internet access is unlikely to view the website directly. In addition, because all components of the campaign lead the consumer back to the website for additional information, women who do not have internet access may simply ignore the other media completely. For those who are able to access the website, they will find a site that gives very limited information on ovarian cancer symptoms and provides no instruction for women who have the listed symptoms (12). For detailed information, women must view the hour-long webcast available for download. The webcast, however, in addition to being lengthy, is very technical in places. It uses scientific and medical jargon to detail the staging and biologic basis of ovarian cancer and is likely to lose the interest of the average viewer who may not understand these details. The spokespersons featured in the webcast are ineffective speakers and do not provide a new or fresh perspective on the issue. Overall, the campaign attempts to disseminate information without considering how best to do so based on the highest risk population and, therefore, fails to reach its target audience.

Failure to Promote Self-Efficacy
Assuming the OvarianCancerAwareness.org campaign is able to reach members of the target audience, the campaign then fails to inspire self-efficacy among women at risk and, therefore, does not send a compelling message. The campaign relies heavily on the dissemination of statistics with the assumption that these statistics alone will inspire women to take action. The statistics provided (1), however, are discouraging because they imply that the survival and early-detection rates are so low that there may be no hope. Advertisements and spokespersons for the campaign commonly use discouraging language to describe ovarian cancer screening throughout various media, referring to the “Silent Killer” and “subtle” early symptoms, and informing the target audience that very little is known about ovarian cancer prevention or detection (5). In addition, these media draw attention to the differing opinions on effective prevention, diagnosis, and treatment that currently exist in the scientific community (13) and acknowledge that physicians often do not take the early symptoms of ovarian cancer seriously (5), both of which make for a weak campaign message.
The importance of self-efficacy in health behavior models was first introduced by Albert Bandura (14). The theory of self-efficacy explains that in order for an individual to engage in a particular behavior, he or she must believe that they are capable of successfully completing the behavior, and that doing so will produce desired results. Self-efficacy has been shown to play an important role in behavior change and be good predictor of behavior (15) . The OvarianCancerAwareness.org campaign blatantly ignores this important component of behavior by failing to make women think that they can make any difference. Experts tell women directly that their doctors will likely not listen to them if they present with the symptoms described, then solidify this hopelessness with statistics that show them how dismal it is even if they do take action. In addition, the campaign, in offering different views of ovarian cancer prevention, fails to commit to and then communicate a single confident message. The message women receive, therefore, is that ovarian cancer is deadly, that it may affect them, that a particular set of symptoms may be associated with the disease, but that there is little they can do about it, particularly since the experts cannot even agree on a clear course of action. Women are left with uncertainty, not self-efficacy. This low self-efficacy decreases their likelihood of following the OvarianCancerAwareness.org Coalition’s recommendation to seek medical care in response to the early symptoms of ovarian cancer because the behavior may be viewed as ineffectual. Women may not expect to be heard by their physicians or not feel capable of self-advocating. Moreover, because early detection is so difficult from a medical standpoint, it may not be clear that the seeking medical care will elicit better health outcomes. If women do not believe they can make any difference, they will likely simply choose not to try. In failing to inspire self-efficacy in the target audience, the OvarianCancerAwareness.org campaign becomes self-defeating and, therefore, ineffective.

Failure to Address Barriers to Obtaining Healthcare
In a critical failure of the campaign, the OvarianCancerAwareness.org coalition fails to acknowledge or address the unique barriers that women face in obtaining healthcare and, in doing so, fails to adequately educate women at risk. Women, by virtue of gender alone, have been traditionally underserved by the healthcare system. In a broad sense, women have been socialized to be passive recipients of medical care, often from male physicians. This socialization is based on a long history of oppression and gender disparities in the healthcare profession. This plays out in healthcare relationships wherein physicians often see women’s complaints as trivial or based on neurotic disorders. This has bred a culture where women do not receive adequate healthcare (16). The HBM, in its reliance on individual factors to explain behavior disregards these important societal truths (17). These issues are particularly salient in elderly women, who are at the highest risk for developing ovarian cancer (1). As a result of general ageism in the population, elderly women are virtually invisible in most areas of society, and particularly so in medical literature (18). Moreover, women of all ages are known to be less likely to advocate for themselves in opposition of their doctors’ opinions. Women have been found to be less assertive and have lower self-esteem than men (19) and, therefore, may require additional skill training to become effective self-advocates, particularly in confrontations with authority. In order to be effective in communicating concerns with their physicians, women need to learn how best to educate and advocate for themselves (20). Without these crucial skills, women are simply unable to respond appropriately to warnings about ovarian cancer. In neglecting to consider these aspects of women’s experiences, the recommendations of the OvarianCancerAwareness.org campaign fall flat.
In addition to ignoring factors true for all women, the OvarianCancerAwareness.org campaign also disregards socioeconomic barriers that influence health behavior. These factors may include lack of access to basic healthcare, including insurance and physician care for members of the target population. Among those who do have financial access, there may be additional barriers to obtaining the care recommended by the campaign. Women may be unable to receive care from a gynecologic oncologist based purely on where they live. Rural women, in particular, may be affected by this barrier. As of 2008, there are three U.S. states (Idaho, North Dakota and Wyoming) where no board-certified gynecologic oncologists practice. In other states such as Maine, Alaska, Alabama, New Hampshire, Utah and New Mexico there are only a few of these specialists, and they are concentrated in a single city, making them difficult to access for a large subset of the population (21). While the OvarianCancerAwareness.org campaign recommends that women demand to see a gynecologic oncologist, in many cases this is a completely unrealistic recommendation. In this scenario, even the most self-aware and conscientious women may be left worried and helpless. By failing to address these barriers to healthcare, the OvarianCancerAwareness.org campaign provides information to women but does not give them enough skills or resources to take appropriate action. The campaign, therefore, cannot be truly effective and may be psychologically detrimental to many women.

Conclusion
The OvarianCancerAwareness.org campaign is ineffective in its attempt to educate women and raise awareness about ovarian cancer because it fails to inspire self-efficacy in the target population, is not based on the needs and wants of the target population, and does not address the barriers that women face in obtaining the recommended healthcare. Because the campaign does not look beyond the antiquated and misogynistic HBM, it cannot succeed in inspiring the desired change in health behavior. This campaign’s failure does a disservice to women at risk for developing ovarian cancer. Approximately 15,000 ovarian cancer deaths are predicted in 2008 (1). Women at risk for the disease need to understand the importance of being aware of their symptoms and demanding care under a gynecologic oncologist. It has been shown that women who see gynecologic oncologists for the treatment of ovarian cancer are more likely to receive aggressive treatment and have better outcomes than those who are treated by general surgeons or other specialists (22). It is, therefore, very important that women receive a clear message and are provided with the knowledge, skills, and resources required to obtain the right treatment for this serious disease. The OvarianCancerAwarness.org coalition has a very important message to send to women throughout the United States but has unfortunately failed to do so effectively.

REFERENCES
1. American Cancer Society. Cancer Facts and Figures 2008. Atlanta, GA: American Cancer Society, 2008.
2. U.S. Preventive Services Task Force. Screening for Ovarian Cancer. Screening for Ovarian Cancer. Recommendations and Rationale. Rockville, MD: Agency for Healthcare Research and Quality, 2004.
3. Gynecologic Cancer Foundation. First National Consensus on Ovarian Cancer Symptoms Stresses Education for Earlier Diagnosis. Women's Cancer Network Chicago, IL: Gynecologic Cancer Foundation, 2007 http://www.wcn.org/ov_cancer_cons.html.
4. OvarianCancerAwareness.org Coalition. OvarianCancerAwareness.org Coalition, Boston, MA http://www.ovariancancerawareness.org/.
5. OvarianCancerAwareness.org Coalition, An Online Discussion on Ovarian Cancer. 26 September 2007.
6. Rosenstock I. Historical Origins of the Health Belief Model. Health Education Monographs 1974; 2:328-335.
7. Marks D. Health Psychology in Context. Journal of Health Psychology 1996; 1:7-21.
8. White E. Email Communication, OvarianCancerAwareness.org Coalition. 2008: Boston, MA.
9. Walsh DC, et al. Social marketing for public health. Health Aff (Millwood) 1993; 12(2):104-19.
10. U.S. Cancer Statistics Working Group. United States Cancer Statistics: 2004 Incidence and Mortality. Atlanta, GA: Department of Health and Human Services Centers for Disease Control and Prevention and National Cancer Institute, 2007.
11. NetRatings Inc. Three out of four Americans have access to the internet, according to Nielsen//NetRatings: Online Populations Surges Past 200 Million Mark for the First Time: Press Release March 18, 2004.
12. OvarianCancerAwareness.org Coalition. Boston, MA: OvarianCancerAwareness.org Coalition, 2007 http://www.ovariancancerawareness.org/.
13. Allen S. Doctors debate ovarian cancer warning signs, in The Boston Globe. June 25, 2007, Boston, MA: Globe Newspaper Company, 2007.
14. Bandura A. Self-efficacy mechanism in human agency. American Psychologist 1982; 37(2):122-147.
15. Salazar MK. Comparison of four behavioral theories. A literature review. AAOHN Journal 1991; 39(3):128-35.
16. Halas M. Sexism in women's medical care (pp. 4-8) In: Worcester N and Whatley M, ed. Women's Health: Readings on Social, Economic and Political Issues, Third Edition. Dubuque, IA: Kendall/Hunt Publishing Co., 2000.
17. Thomas L. A Critical Feminist Perspective of the Health Belief Model: Implications for Nursing Theory, Research, Practice, and Education. Journal of Professional Nursing 1995; 11:103-22.
18. Sceriha M. Women and Ageing: The dreaded old woman fights back (pp. 309-314) In: Worcester N and Whatley M, ed. Women's Health: Readings on Social, Economic, and Political Issues, Third Edition. Dubuque, IA: Kendall/Hunt Publishing Co, 2000.
19. Feingold A. Gender differences in personality: A meta-analysis. Psychological Bulletin 1994; 116(3):429-456.
20. Hunt M. How to tell your doctor a thing or two (pp. 309-314) In: Worcester N and Whatley M, ed. Women's Health: Readings on Social, Economic, and Political Issues, Third Edition. Dubuque, IA: Kendall/Hunt Publishing Co, 2000.
21. American Board of Medical Specialties. The Official ABMS Directory of Board Certified Medical Specialists, 2008. St. Louis, MO: Elsevier Saunders, 2008.
22. Chan JK, et al. Influence of the gynecologic oncologist on the survival of ovarian cancer patients. Obstetrics and Gynecology 2007; 109(6):1342-50.

Fast Food Tax: Economic Coercion and the Obesity Epidemic – Nicole Tinkey

In response to the increasing number of Americans suffering from obesity, some states have contemplated levying a tax on fast food (1). Supporters of fast food taxes argue that implementing an economic disincentive to purchasing fast food will lead to lower rates of fast food consumption, and ultimately, lower rates of obesity (1). The argument in favor of a fast food tax is too simplistic, however, because it overlooks the complex interaction of social and economic circumstances that drive obesity in the United States.

Taxing fast food will not economically pressure low-income consumers into eating more nutritious foods.
Taxes on fast food overlook many of the social factors that lead people to consume fast food in the first place. An individual makes food choices based on “taste, convenience, family structure and traditions, [and his/her] age, health status, knowledge, and lifestyle” (2). Unsurprisingly, studies have shown that the taste of food is an important factor influencing individual food choices (3). In a survey of low-income mothers, women reported that one reason they refrained from buying vegetables was because they did not know how to prepare vegetables “in ways that tasted good” and preferred other foods to vegetables (3). Many women were reluctant to buy vegetables because they lacked sufficient space in their homes to store fresh and frozen vegetables (3). Importantly, women also reported that cooking vegetables for meals was inconvenient and time-consuming (3). Over the past few decades, the demand for “convenience food” has increased as American women have worked increasingly longer hours outside the home (4). The association between the demand for convenience food and hours worked outside the home is particularly strong for women in low-income populations (4). One study concluded that because “[working] mothers have less time for cooking . . . children from low-income households are more likely to eat in fast food restaurants” (4). In addition, despite the fact that most fast food is consumed by people in low-income populations, some studies indicate that fresh foods are actually less expensive than fast food (5, 6). This suggests that disadvantaged individuals do not choose fast food over fresh foods simply because fast food is a more cost-efficient option (5). If cost-efficiency were the driving force behind food choice in low-income populations, disadvantaged individuals would be consuming more fresh foods than fast food – and this is clearly inconsistent with consumer behavior in low-income populations (7). The economic burden imposed by a fast food tax (usually only a few additional cents per item) will probably not be a significant enough cost to outweigh the perceived benefits of fast food to its most frequent consumers (1). Therefore, raising the price of fast food is not likely to compel people in low-income populations, who consume the most fast food, to stop purchasing fast food.

Fast food taxes fail to address issues surrounding access to nutritious food.
Fast food taxes can only successfully combat obesity if people who are deterred from purchasing fast foods replace these with healthy alternatives. Problematically, poor people, who consume the most fast food and are the most likely to suffer from obesity (5), may not have access to healthy food alternatives. People in low-income populations report an “inability to access healthy and nutritional food, particularly fresh fruits and vegetables” (5). Low-income areas are far less likely to have supermarkets than higher income areas (7). In addition, food outlets in low-income areas have a limited variety of food choices and are much less likely to offer nutritious food options than supermarkets in high-income areas (5, 7). Because disadvantaged individuals are often unable to visit supermarkets because of lack of transportation (5), food shopping may be entirely restricted to local food outlets. It is not surprising then that people living in low-income areas are more likely to consume “energy dense food, composed of refined grains, added sugars, and fats that represent the lowest cost options available to people [living in low income areas]” (5).
In the absence of programs that make nutritious food choices more accessible to habitual fast food consumers, fast food is more likely to be replaced with other high-calorie, low-cost foods that are readily available in low-income food outlets (5,7). As one study succinctly concluded, “Without a change in access to [nutritious] foods, individuals cannot change their eating behaviors” (5). Because fresh, nutritious foods are unavailable to many habitual fast food consumers, a fast food tax is not likely to result in people replacing fast food with healthier food choices.

Fast food taxes are under-inclusive and fail to discourage a wide range of poor food choices.
Studies of food economics have demonstrated that “the increase in the price of a food tends to drive consumption away towards its substitutes” (1). Thus, a fast food tax is likely to drive consumers to purchase foods that readily replace fast food – foods which are convenient, inexpensive, and calorie-dense. In order for a food tax to impact unhealthy eating habits, the base of taxable foods must be “sufficiently broad to induce better choices” (2). In other words, a decline in consumption of fast food will be accompanied by an increase in consumption of unhealthy substitute foods unless substitute foods are also taxed and made less attractive to consumers (1). Problematically, many food establishments offering unhealthy foods will evade taxation because they are not traditionally classified as fast food. While restaurants like McDonalds and Burger King seem to clearly fall within the realm of fast food, pizza parlors and take-out Chinese restaurants are more questionable (8). Family style restaurants and sit-down chain restaurants will also escape the fast food tax although many of these are notorious for offering high-fat, high-sugar foods in oversized portions (8). A fast food tax will also fail to reach snack foods and calorie-dense convenience foods. Thus, while the object of a fast food tax is to provide an economic disincentive to consuming unhealthy foods, it will not curb consumption of unhealthy food at a number of establishments that will not be subject to the tax. If prices at some restaurants increase, fast food consumers may simply be driven to eat at different, but equally undesirable, establishments.

Conclusion
A fast food tax is intended to combat obesity through providing an economic disincentive to fast food consumption. In order to succeed, the tax must effectively deter people from purchasing fast food; at the same time, nutritious, weight-loss promoting foods must replace fast food in people’s diets. Unfortunately, a fast food tax is unlikely accomplish either of these goals. People consume fast food for a number of reasons (3): besides being inexpensive, fast food is tasty, convenient and ubiquitous. A fast food tax fails to address these important social considerations. Tired, working mothers are not likely to be motivated to cook healthy, vegetable-based meals for their families because the price of fast food increases by a few cents. Moreover, studies show that even if people were inclined to replace fast food with fresh fruits and vegetables, many living in low-income communities may simply not have access to these healthier alternatives. Thus, the most likely effect of a fast food tax is to increase the consumption of unhealthy substitute foods among people who formerly purchased fast food.

REFERENCES
1. Schmidhuber J. The Growing Global Obesity Problem: Some Policy Options to Address It. Journal of Agricultural and Developmental Economics 2004; 1:272-290.
2. Crutchfield SR, Golan E, Kutcher F, Variyam JN, Obesity Policy and the Law of Unintended Consequences. Amber Waves 2005; 3:26-33.
3. Sisson A. Fruit and Vegetable Consumption by Low-Income Americans. Nutrition Noteworthy 2002; 5:1-5.
4. Chou S. An Economic Analysis of Adult Obesity: Results From the Behavioral Risk Factor Surveillance System. The Economics of Obesity 2002; 1:10-13.
5. Sutton E. Obesity, Poverty, and the Case for Community Supported Agriculture in New York State. Hunger Action Network of New York State 2005; 1:1-8.
6. Raynor HA. A Cost-Analysis of Adopting a Healthful Diet in a Family-Based Obesity Treatment Program. J Am Diet Assoc 2002; 5:645-56.
7. Baker, EA. The Role of Race and Poverty in Access to Foods That Enable Individuals to Adhere to Dietary Guidelines. Preventing Chronic Disease 2006; 3:1-11.
8. Kuchler F. Taxing Snack Foods: What to Expect for Diet and Tax Revenues. Current Issues in Economics of Food Markets 2004; 1:1-12

Needle Exchange Programs: An Unrealistic Approach to Decreasing Rates of HIV/AIDS – Elyssa Pesin

The HIV/AIDS Epidemic
Human Immunodeficiency Virus (HIV), the virus that causes AIDS, attacks the immune system, leaving the body vulnerable to a variety of life-threatening infections and cancers [1]. This devastating disease is the focus of many public health interventions in the United States, especially among intravenous drug users (IDUs), a recognized risk group. Nevertheless, current efforts are inadequate to address the complex risks associated with injection drug use, particularly among disadvantaged populations [2]. The nature of intravenous drug use, specifically the process of preparing and injecting drugs, is conducive to the spread of HIV. As the CDC reports, “many opportunities for contamination with and transmission of HIV or other blood-borne viruses” exist among IDUs, due to the mechanics of drug injection [3].

Introduction: A Public Health Intervention
Needle Exchange Programs (NEPs), in which IDUs exchange dirty needles for clean replacement needles, are intended to be a critical strategy for containing the spread of HIV and other blood-borne diseases within this population. However, issues relating to social and behavioral sciences, differences in socioeconomic stratum and sociopolitical issues contribute to the failure of implementation in the United States. Contrary to the 1980’s United States Drug Campaign known as the “war on drugs,” using the slogan “Just say no,” the NEPs’ ideology is based on “Just say yes,” as these programs prioritize HIV/AIDS prevention over reducing drug use.
In a social and behavioral context, the Health Belief Model (HBM) was developed to explain health-related behavior at the individual, decision-maker level. The focus of this model is preventative health behavior of individuals, assuming that human behavior is determined by an objective, logical thought process. HBM includes four concepts: “perceived susceptibility,” “perceived severity,” “perceived barriers to taking that action,” and “perceived benefits of an action” [4]. With regard to NEPs, the former three concepts are skewed and lead to NEP failures. First, instead of realizing that the perceived susceptibility of drug use is the chance IDUs will overdose, develop neurological problems, or acquire multiple chronic and acute illnesses, the perceived susceptibility is the realization that IDUs could only contract HIV/AIDS through dirty needles. Second, IDUs overlook the perceived severity, that is, how severe the effects of transmitted diseases might be, as they continue to use drugs and reject other ways blood borne diseases are transmitted - through sexual contact [5]. Lastly, the perceived barriers and costs of emotionally and financially supporting drug use are overlooked by NEP creators and supports. Interestingly, NEPs use an HBM limitation to their advantage – that is, if drug users have the intent to do a particular behavior, they will do it. Thus, NEPs are structured around the susceptibility to HIV/AIDS and the perceived benefits of preventing the transmission of the disease through shared needles.
By expecting drug-users to seek out these programs on their own using undersupplied and underprovided distribution methods and providing limited geographic locations, needle exchange programs fail to decrease HIV/AIDS through shared needles within the IDU population. More specifically, failures of NEPs can be seen in their inability to reach many drug users due to geographic disparities, broad target populations, and limited distribution strategies.

Reason for Failure #1 – Geographic Disparities
Failures of NEPs are attributed to several different models of social and behavioral science. First, the Stages-of-Change model applies to IDUs who utilize NEPs, who realize they engaged in drug use, who contemplated the risks of intravenous use, and who decided to address those risks by participating in a needle exchange program. Nevertheless, the “action” and “maintenance” stages of change in NEPs, where individuals begin to engage in a new behavior and attempt keep that pattern going or sustain the new behavior respectively, is flawed [6]. This relates to an IDUs use of NEPs, as research shows there are inconsistencies in location, equal distribution of supplies, and accessibility [7]. As a result, IDUs are not able to engage in and maintain this new behavior consistently. Herein lies the first problem: NEP geographic disparities.
Geographic disparities in access to NEPs present clear difficulties to program utilization. Indeed, NEP locations do not always correspond to a demand for such a program in the area. In 1999, a study reported the existence of NEPs in 81 cities and 31 states as well as the District of Columbia. The study concluded that many of these programs were heavily concentrated in four states: California, New York, Washington, and New Mexico. Yet, data suggest that New Jersey – a state with high demand for NEPs –disproportionately lacks in access to these programs [8]. As Barbara Tempalski reports, “injection drug use is the most frequent reported risk behavior among HIV-positive individuals” in New Jersey, and in Jersey City, Newark, and Bergen-Passaic have some of the highest rates of IDU related AIDS in the country [9].
Even within existing NEPs, inequalities in supplies inhibit the efficacy of these programs; twelve of the largest programs, for example, receive 62 percent of available syringes, leaving other NEPs without adequate supplies [10]. The unequal distribution of NEPs and NEP-related resources do not address disparities in HIV prevalence among socially disadvantaged groups or the geographical distribution of IDUs.
One last social and behavioral theory can be attributed to the first reason for NEP failure. The last several stages of the Diffusion of Innovations (DOI) theory are interrupted, as the NEP geographic and inventory shortages prohibit the success, wider implementation, and unrestrained use of this public health intervention. Within the DOI theory, the “adoption process,” is affected by insufficient locations, supplies, and geographic representation, prohibiting the “uptake” of the behavior by IDUs. According to this principle, “uptake” requires movement through knowledge of NEPs, persuasion or attitude development (about adopting behavior), decision (to adopt behavior), implementation, and confirmation, and none of these steps can occur, as NEPs fail to be equally accessible or sufficiently equipped [11].

Reason for Failure #2 – Broad Focus
Two additional social and behavioral principles can be applied to a second reason for NEP failure. On one hand, the success of NEPs relies largely on selecting a target population, where IDUs among different socioeconomic strata are the targets. The widespread use of the intervention relies on these social groups or networks to communicate the benefits of the program. On the other hand, failure to account for the “political economy,” which has an important bearing on why and how people do what they do, and consequently, how people change what they do, affects the efficacy of NEPs [12]. Both political economy and behavior are factors that must be addressed when assessing the inadequate and very broad focus of NEP interventions as it contributes to the crisis of HIV/AIDS in poor, urban communities. Because HIV/AIDS has such a disproportionate effect on poor, minority, and urban communities, NEPs are suffering because they frame HIV/AIDS as just a health problem, rather than the product of a larger set of social relationships, particularly relationships of socioeconomic structure, class, ethnicity, and gender [13]. Consequently, the NEP failure is rooted in its very broad focus, as they do not take into account the aforesaid larger set of social and political relationships.
Despite drug regulation, illegal drug use continues among the underserved and the needs of those who seek prevention or treatment have not been met. As Dr. Adewale Troutman states in his on-line tutorial Creating Health Equity Through Social Justice, “the existence of social injustice typified by the continued growth of the gap between the have and the have-nots, lack of access to services and care, preventive and curative is unethical and immoral” [14]. This inequality is ever-present among IDUs. According to Richard Hofricter, although overall life expectancy has increased and mortality rates have decreased in the twentieth century, “an increasing level of inequality in the health status and mortality of those with less material resources in relation to their social class, particularly in ‘communities of color’ persists” [15]. Moreover, disadvantaged groups do not benefit equally from advances in HIV and AIDS intervention, treatment and prevention.
While the HIV/AIDS epidemic has had a disproportionate impact on certain populations, particularly racial and gender minorities, NEPs do not effectively narrow their focus among these groups. Within the IDU population, disadvantaged groups are especially vulnerable to HIV infection. In certain racial and ethnic groups, half of the deaths due to HIV in both African American and Latino populations can be attributed to injections with contaminated needles. Furthermore, African American IDUs are 5 times as likely, and Latinos are 1.5 times as likely as white IDUs to develop AIDS [16]. These statistics highlight the limitations in the breadth of NEP, as programs do not have specific strategic plans to reach each group.
The African American experience portrays an obstacle that NEPs do not address or overcome with regard to ethnicity. African Americans are increasingly vulnerable to the transmission of HIV/AIDS. With this, another social and behavioral principle accounts for the larger HIV/AIDS cases in this group: the Social/Environmental Context, and more specifically within this context, the Historical Context. Historically, African American communities have greatly opposed NEPs as a consequence of their distrust of the government and medical trials in general. According to Stephen Thomas, African Americans’ adverse response to NEPs is connected to the “persistent neglect of the drug abuse epidemic, mistrust of public health authorities, and fear that the broader society may consider large segments of the black population expendable consumers of scarce human and economic resources” [17]. Many of these opponents worry that needle exchange programs will ultimately lead to Tuskegee-like abuse of research subjects [18]. Within many African American communities, NEP initiatives are held in high suspicion due to historic exploitation and discrimination [19]. With these factors, one can observe that throughout various segments of the American public, NEPs prove controversial. This Social/Environmental Context is relevant, as the Tuskegee-mentality is shared across this group, contributing to an African American experience made up of historical influence and personal experience interacting with the environment that inhibits this group from utilizing NEPs [20]. The failure of NEPs in this group is rooted in the history of the African American experience for which NEPs do not account.

Reason for Failure #3 – Methods of Distribution and Legal Implications
A third reason for the failure of NEPs lies in their distribution strategies, which are neither private nor anonymous. When using NEPs, IDUs must make themselves publicly available to the needle “exchanger” and must make behavioral changes through regular needle exchanges. For this reason, there is a great deal of social and personal responsibility, motivation and social and personal acceptance of help. The two primary methods of delivery are fixed NEPs located in pharmacies or health and community centers and NEP vans that drive through areas with known groups of IDUs [21][22]. Both of these methods of delivering exchange services require IDUs to seek out needle-exchange programs, which deter many from utilizing them. For this reason, drug-users typically refrain from using NEPs, consequently transmitting disease.
Many states have opted to utilize pharmacies in addition to local community centers to allow IDUs to obtain sterile syringes if businesses choose to participate. Nevertheless, while the pharmacy model has been shown to dramatically reduce the risk associated with IDU, not all geographic areas have benefited from these programs. For example, in New York, it is legal for pharmacies and other organizations to register and to provide up to ten syringes to individuals over the age of eighteen without prescriptions [23]. However, many pharmacists have refrained from participating in such services due to personal beliefs of fear that the presence of IDUs are detrimental to their businesses [24]. Moreover, the exchange of syringes in this model is not necessarily free, so many IDUs are unwilling or unable to participate [25]. For this reason, implementation of the pharmacy exchange model has been piecemeal and inadequate, contributing to the failure of NEPs in pharmacies.
Mobile exchange services are the second method of distribution which intend to reach more drug users. These mobile programs, which have predetermined van routes, are interventions for including hard-to-reach individuals and those who do not typically access mainstream services. For instance, an analysis of a 1997 Baltimore program revealed that mobile services attracted twice as many high-frequency injectors as pharmacy programs [26]. Furthermore, a study of the Vancouver program, which consisted of a variety of different facilities, reported that 65 percent of participants obtained some of their needles from the van and 17 percent used the van as their main needle source. Typically, users of this mobile exchange injected more frequently, were younger, more likely to engage in prostitution, and less likely to enroll in a drug treatment plan [27].
The mobile exchange model, whose intention is to reach those who are unable to access participating pharmacies, has several limitations [28]. First, the mobile programs offer fewer opportunities for counseling and other educational service, as the mobile programs do not afford lengthy time intervals during which the staff and clients can interact. Second, in the case of the San Diego, California NEP, IDUs refrained from visiting this site because legislation fails to protect IDUs from state laws prohibiting the transport of drug paraphernalia. In fact, reports confirm that law enforcement officers wait outside NEPs and arrest individuals suspected of carrying syringes [29]. Two social and behavioral theories, the Social Cognitive Theory and more specifically the Social/Environmental Context applies to the existing laws pertaining to drug paraphernalia in each state [30]. Drug paraphernalia laws, which exist in all states except Alaska, hinder the sale, distribution, purchase, and possession of syringes. In fact, 20 states have drug paraphernalia laws that are used against IDUs who possess a syringe [31]. Additionally, pharmacies may implement their own requirements and regulations that inhibit access [32]. The fear that this regulatory environment and existingpolicies instill in IDUs prevents them from accessing either method of distribution, even though the presence of these programs is acceptable. A third theory known as Political-Economic Space - a space that is governed by a specific political system, with regulations, values, and procedures –applies to the existing regulations and laws that affect health [33]. In this framework, many states, even those that support NEPs, continue to restrict the sale of syringes to pharmacies and require IDUs to have a prescription, provide valid identification, or disclose their reasons for purchasing the syringe [34]. This barrier to access is associated with the Political Economy, as NEPs encompass a wide range of theory and history about the links between politics and behavior, and their functions in society [35]. While NEPs focus on reducing disease transmission through sharing needles among IDUs, NEPs have failed to address the legal implications of the program such that the legal framework and Political Economy deter users for fear of identification and police harassment.
The lack of anonymity in these two methods of distribution makes IDUs vulnerable to the ever-present legal and regulatory barriers to access and to possess sterile syringes. Barriers include: drug paraphernalia laws, syringe prescription laws (both of which place restrictions on syringe exchange programs), pharmacy regulations and practice guidelines, fear of identification and police harassment - presenting obstacles to participation and decreased disease transmission. Further, the fear instilled in IDUs is largely derived from a Social Cognitive Theory known as Reciprocal Determinism, in which a person acts based on individual factors and social environment cues, receiving a response from that environment, and adjusting behavior accordingly [36]. In this fashion, IDUs act based on their personal responsibility and motivation to use NEPs, but ultimately react to the negative “cues,” that is regulation and punishment for attempting to use this intervention. Lastly, the concept of Self-Efficacy applies, as IDUs’ past experiences with NEPs will affect whether they are motivated to use this intervention. IDUs with low Self-Efficacy regarding NEP use may feel more hesitation, and when they actually use the program, may be reluctant to use it for fear of being punished. Once IDUs feel comfortable and confident in their chosen NEPs, this sense of Self-Efficacy may help the IDU continue this intervention and spread the word about NEPs in their networks [37].

Conclusion
NEP programs, meant to decrease HIV/AIDS transmission, are unsuccessful not only structurally, but also for reasons surrounding social and behavioral sciences, socioeconomic strata, and sociopolitical issues. More specifically, NEPs fail to address their geographic disparities, political patterns, and relationships of ethnicity that contribute to the efficacy of this intervention. This intervention fails to identify groups of IDUs on which to focus their strategies, as the target population is much too large to see positive results, that is, a decrease in HIV/AIDS transmission. After this assessment, it is clear that HIV/AIDS affects a wide-ranging population of potential NEP users who, in one form or another experience barriers to access.

References
1. Centers for Disease Control and Prevention. Prevention Among Injection Drug Users. US Department of Health and Human Services, January 2007. http://www.cdc.gov/idu/default.htm. Date accessed: 27 Mar 2008
2. Ibid.
3. Ibid.
4. Rosenstock, Irwin M. Ph.D. Historical Origins of the Health Belief Model. Health Education Monographs 2 (4): 328-335, 1974.
5. Centers for Disease Control. op.cit.
6. Prochaska JO, Reding CA, Evers KE. The transtheoretical model and stages of change. In: Glanz K, Rimer BK, Lewis FM, eds. Health Behavior and Health Education, 3rd ed. San Francisco, CA: John Wiley & Sons; 2002.
7. Centers for Disease Control and Prevention. Epidemiology of HIV/AIDS—Unites States, 1981- 2005. Morbidity and Mortality Weekly, 55(21):589–592, June 2006.
8. Robert E. Fullilove and Mindy Thompson Fullilove. HIV/AIDS in the African American Community: The Legacy of Urban Abandonment.
9. B. Tempalski, P.L. Flom, S.R. Friedman, D.C. Des Jarlais, J.J. Friedman, C. McKnight, and R. Friedman. Social and Political Factors Predicting the Presence of Syringe Exchange Programs in 96 US Metropolitan Areas. American Journal of Public Health, 97(3):437, 2007.
10. M.P. Singh, C.A. McKnight, D. Paone, S. Titus, D.C. Des Jarlais, M. Krim, D. Purchase, J. Rustad, and A. Solberg. Update: Syringe Exchange Programs–United States, 1998. Morbidity and Mortality Weekly Report, May, 18:384–87, 2001.
11. Rogers EM. Diffusion of Innovations, 4th ed. New York: Free Press; 1995.
12. Edberg, Mark, Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett, 2007, 72.
13. Bandura A. Social Learning Theory. Englewood Cliffs, NJ: Prentice Hall;
1977.
14. Adewale Troutman. Creating Health Equity Through Social Justice. Satellite broadcast originally aired February 20, 2003.
15. R. Hofrichter. Health and Social Justice: Politics, Ideology, and Inequity in the Distribution of Disease. Jossey-Bass, 2003.
16. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report. US Department of Health and Human Services, 2004.
17. S.B. Thomas and S.C. Quinn. The Burdens of Race and History on Black Americans’ Attitudes toward Needle Exchange Policy to Prevent HIV Disease. Journal of Public Health Policy, 14(3):320–347, 1993.
18. Ibid., p337
19. Ibid., p343
20. Edberg, Mark, Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett, 2007, 52.
21. Institute of Medicine of the National Academies. Preventing HIV Infection among Injecting Drug Users in High Risk Countries: An Assessment of the Evidence. The National Academies Press, 2006.
22. Riley E.D., M. Safaeian, S.A. Strathdee, M.A. Marx, S. Huettner, P. Beilenson, and D. Vlahov. Comparing New Participants of a Mobile Versus a Pharmacy-Based Needle Exchange Program. JAIDS Journal of Acquired Immune Deficiency Syndromes, 24(1):57–61, 2000.
23. Institute of Medicine of the National Academis. op.cit.
24. Institute of Medicine of the National Academis. op.cit.
25. Institute of Medicine of the National Academis. op.cit.
26. Riley, E.D. op.cit. p59.
27. M.W. Tyndall, J. Bruneau, S. Brogly, P. Sptal, M.V. O’Shaughnessy, and M.T. Schechter. Satellite Needle Distribution Among Injection Drug Users: Policy and Practice in Two Canadian Cities. JAIDS Journal of Acquired Immune Deficiency Syndromes, 31(1):98–105, 2002.
28. Riley, E.D. op.cit. p60.
29. Kaiser Family Foundation. Syringe Exchange and AB 136: The Dynamics of Consideration in Six California Communities, February 2002. Pub 6018.
30. Bandura A. Social Cognitive Theory: an agentic perspective. Ann Rev
Psychol. 2001;52:1-26.
31. T.S. Jones and P.O. Coffin. Preventing Blood-Borne Infections Through Pharmacy Syringe Sales and Safe Community Syringe Disposal. Journal of the American Pharmacists Association, 43:6–9, 2002.
32. Ibid., p 6-9.
33. Edberg, Mark. op. cit. p52.
34. Ibid., p52.
35. Ibid., 72.
36. Bandura A. The Self System in Reciprocal Determinism. Am Psychol. 1978; 33:344-358.
37. Bandura A. Social Learning Theory. op. cit.

Why Blaming Parents Fails to Prevent Rx and OTC Drug Abuse Among Teens: An Analysis Of Downfalls In Using Upstream Framing – Valerie Kong

For years, public health campaigns have used billboards, television and print advertisements to reach out to a wide range of audiences. Recently, public health outreach campaigns began fighting with more and more pharmaceuticals for primetime spots to drive their sales on national television (1). Newly approved medications are now advertised on television and other media outlets to promote products directly to consumers (2). A recent national survey reveals an emerging trend of prescription (Rx) and over-the-counter (OTC) medication abuse becoming more prevalent than illicit drugs among teenagers (3). The study concluded with two major findings that were alarming outcomes to public health. Study data indicates there is a common misconception regarding the use of prescription drugs. Two in five teens believe that Rx medicines are “much safer” than using illegal drugs (4). In addition, only a third of parents speak to their teenagers about the risks of abusing prescription drugs (5). Partnership for a Drug-Free America (PDFA), a New York-based non-profit group, launched a new campaign to warn parents that their teenagers may be misusing medications (5). This campaign includes broadcasting ads on multiple expensive TV spots, as well as web content providing information on how to communicate the risks of abusing Rx and OTC drugs to teens.
The framing of public health campaigns can be classified in two categories: upstream frame and downstream frame. An upstream frame refers to campaigns that target the causes preceding the issue as a preventive approach, while a downstream frame aims to implement a resolution to rectify the issue (6). This paper will analyze the pitfalls of using an upstream approach to prevent teens from abusing prescription drugs.
Choosing the best frame or model is crucial when developing a public health campaign in order to achieve maximum effectiveness with increase in desired behavior changes. As a result of downfalls in campaign message, design and direction, the new PDFA campaign targeting parental influence with an upstream frame fails to prevent teens from abusing prescription and over-the-counter drugs.

Evaluating Teens’ Intention
Traditionally, many public health interventions use the Health Belief Model (HBM) based on the belief that knowing different health risks and benefits will lead to an intention to modify behavior (7). This model fundamentally supports programs and campaigns to rid these bad habits through educating risks and consequences of undesired behaviors (8). The PDFA campaign encourages parents to “educate, communicate and safeguard” their teenagers against abusing prescription and OTC drugs (5). The main message of PDFA campaign fails because it relies too heavily on the Health Belief Model and its constructs: perceived susceptibility and perceived severity. However, many teenagers capable of learning about different effects of Rx and OTC drugs through the internet already know of the potential side effects of medications (9). In this case, increasing the perception of how likely one is to result in the negative consequences from medication overdose may not be effective in preventing abuse.
The campaign’s attempt to raise awareness of this new trend of substance abuse focuses entirely on perceived susceptibility and severity using an authoritative stance. Previous abuse-prevention programs involving parents with an instructional approach experienced low parental participation, diminishing effect of behavior change on teens (10). Teenagers often view their parents as authority figures who understand little about what it means to be an adolescent (11); hence, targeting this sensitive issue with such a harsh tone impairs its receptivity.
This campaign draws attention to Rx and OTC medications made accessible to teens by their parents. But little emphasis is placed on the key element of adjusting the parents’ personal perspectives towards this abusive trend (12). Social norms, including parental attitudes on prescription drugs, influence how teenagers perceive the dangers of drug abuse (11). A study done by Slone Epidemiology Unit at Boston University School of Public Health found that “in any given week, the large majority of US adults take at least 1 prescription of OTC medication, and substantial numbers take multiple products.”(13, p. 344) Yet this campaign to reduce the rate of abuse among neglects the blatant factor of addressing the how adults exercise behaviors of self-medication casually. Without further investigation to understand causes of misuse in teens’ adult counterpart, this public health problem is likely to grow rapidly among both age groups. A campaign to educate teens about the dangers of abuse without attempting to reform the practice of frequent buying and taking Rx and OTC drugs among parents proves an incomprehensive solution.

Rethinking Teenage Decision-making
Many public health campaigns utilize models that are based entirely on a rational thought process (14). The Health Belief Model makes multiple assumptions that a person’s intention has a direct effect on behavior. Perceived severity and susceptibility may influence a person’s intentions, based on thoughtful weighing of cost and benefit. However, the strong desire to use prescription pain killers, similar to other substance abuse, may supercede the rational thinking. The design of this PDFA campaign fails due to an excessive reliance on rational decision-making.
In American society, consumers are given the right to choose from shelves of pills at their local pharmacies or convenience stores. In 2002, a poll of 1011 adult Americans found that many do not recognize the potential risks of taking OTC medicines incorrectly, stating that one in three adults -- over 64 million consumers, say they have taken more than the recommended dose of a nonprescription medicine (15). Humans tend to act readily on immediate feelings rather than use logical reasoning when engaging in health behaviors (16). Rational decision-making can fall short in cases such as substance abuse where instant gratification overcomes healthy intentions. Thus, following the cognitive model imposed by the HBM can be detrimental to the design of a successful campaign against abusive behaviors driven by irrational decisions.
As for teenagers, many of them are exposed to pharmaceutical advertising and information on the web about numerous categories of chemicals that react with the body differently such as stimulants and anti-depressants (9). The HBM does not account for these luring factors affecting teenagers to abuse who are well aware of harmful effects by taking prescription drugs without a doctor’s advice. There is a weak relationship between intention and action when impulse drives behavior among teens (17). Overlooking this flaw in the HBM makes this campaign less effective in preventing teenagers from becoming caught in the helpless spiral of abuse.

Fighting for Independence
As mentioned earlier, the PDFA campaign uses an upstream frame of targeting parents as the direct cause for Rx and OTC abuse among teens. The media ads created for this campaign point to parents as guilty offenders for bringing prescription and OTC medication into their homes, making it accessible to teens easily. In addition, the message of “educate, communicate and safeguard” encourages learning about the risks of abusive behaviors and promoting the concept of modeling behavior of teenagers after their parents (18). However, this depressing and negative emotion directed towards the parental figure opposes the idea of building a constructive relationship between parents and their teenagers set forth by the campaign’s main message. The direction of this campaign fails because it relies too heavily on parental modeling.
Developmental psychology studies suggest defiant behavior among adolescents is a common stage of teens’ desire to gain independence from their parents (18). During the teen years, the uptake of substance abuse as an act of rebellion is highly prevalent (19). Using parental modeling neglects the issue of rebellion that plays a big role in predicting teenagers’ behaviors. Teens receive pressures from school, peers, and family members to act and behave a certain way, and many lack the capacity to face each issue with maturity (20). Due to the rebellious nature of this younger population, the focus on parental modeling results in a futile attempt to influence behavior.
Besides the desire to oppose authority, teenagers tend to search for scapegoats and blame external factors for their actions (21). Buying into the campaign’s portrayal of parents guilty of making Rx and OTC drugs accessible permits teens to blame parents for their abusive behavior. Shifting accountability towards parents perpetuates risky behaviors by lowering self-efficacy among teenagers. This shift in responsibility leads teens into believing that parents are the primary cause for their abuse and lacks the ability to influence their own behavior. Not only does this aspect of the campaign fail to empower teenagers to take control of their own fates, but also generates a scapegoat for their risky behavior.

Looking Ahead and Asking Harder Questions
In analyzing approaches to improve the main message, design, and direction of this PDFA campaign, the following areas that require improvement should be addressed after reviewing the pitfalls.
Re-examining the gap between theory and reality can change how public health campaigns are developed. Involving models other than HBM to account for preventing impulsive behavior can make campaigns more relevant to lowering rates of prescription drug abuse among teens. Instead of choosing from traditional cognitive models of reasoned actions, PDFA should build messages to change attitudes of Rx abuse in both parents and teens. Public health messages need to bring in emotional attachment rather than intellectual lessons to influence the audience’s feelings towards the targeted behavior.
Reprogramming how formative research is conducted prior to developing the campaign can reveal how teenagers and parents begin to develop the practice of self-medicating and explore ways to change behavior in both groups (22). Understanding the motives and what drives teens to use Rx and OTC drugs provides deeper insight to external factors that impacts their behavior at a contextual level (22). Before accusing parents for neglecting their teens’ behaviors, detailed analyses are warranted to explore deeper motives which drive teens to abuse Rx and OTC drugs (20), which aids in determining the root causes behind this new trend of abuse.
After reviewing the pitfalls of this PDFA campaign, this analysis provides evidence that using an upstream approach to prevent Rx and OTC drug abuse among teens remains an ineffective approach. The growing teen population abusing Rx and OTC drugs calls for critical attention to provide resources for social scientists to innovate better models to predict health behaviors. Public health officials must consider these implications when developing policies that can have great impact on trends in Rx/OTC drugs misuse and abuse.

REFERENCES
1. Terzian TV. Direct-to-Consumer Prescription Drug Advertising. American Journal of Law and Medicine 1999; 25: 149-167
2. Rosenthal MB et al. Promotion of Prescription Drugs to Consumers. New England Journal of Medicine 2002; 346:498-505
3. Manchikanti L. National Drug Control Policy and Prescription Drug Abuse: Facts and Fallacies. Pain Physician 2007; 10:399-424
4. Partnership for a Drug-free America. Generation Rx: National Study Confirms Abuse of Prescription and Over-The-Counter Drugs. New York, NY: Partnership for a Drug-Free America http://www.drugfree.org/General/Articles
5. Partnership for a Drug-free America. Partnership Launches First Educational Campaign Targeting Abuse of Prescription and Over-The-Counter Medications. New York, NY: Partnership for a Drug-free America. http://www.drugfree.org/General/Articles
6. Verplanken B and Wood W. Interventions to Break and Create Consumer Habits. Journal of Public Policy and Marketing 2006; 25: 90-103
7. Rosenstock IM. Historical origins of the health belief model. Health Education Monographs 1974; 2: 328-335.
8. Janz N and Becker M. The Health Belief Model: A Decade Later. Health Education and Bebavior. 1984; 11: 1-47
9. Borzekowski DL, Rickert VI. Adolescent Cybersurfing for Health Information: A New Resource That Crosses Barriers. Archives of Pediatrics and Adolescent Medicine 2001;155;813-817
10. Cohen DA, Rice JC. A Parent-Targeted Intervention for Adolescent Substance Use Prevention. Evaluation Review 1995; 19:159-180
11. Health Psychology in context Journal of Health Psychology 1996; 1:7-21.
12. Dembo R et al. Parents and Drugs Revisited: Some Further Evidence in Support of Social Learning Theory. Criminology 1986;24:85-104
13. Kaufman DW et al. Recent Patterns of Medication Use in Ambulatory Adult Population of the United States: The Slone Survey. Journal of the American Medical Association 2002;287:337-344
14. Office of National Drug Control Policy Prescription for Danger: A Report on the Troubling Trend of Prescription and Over-the-Counter Drug Abuse Among the Nation’s Teens. United States
15. National Council on Patient Information and Education. Press Release May 2002. New York, NY: National Council on Patient Information and Education 2002
16. Dewey J. Human Nature and Conduct An Introduction to Social Psychology New York, NY: The Modern Library, 1922
17. Greydanus DE, Patel DR. The Adolescent and Substance Abuse: Current Concepts. Current Problems in Pediatric and Adolescent Health Care 2005
18. Salazar MK. Comparison of four behavioral theories. AAOCHN Journal 1991; 39:128-135.
19. Kandel DB, Kessler RC, Margulies RZ. Antecedents of Adolescent Initiation Into Stages of Drug Use: A developmental Analysis. Journal of Youth and Adolescence. 1978;7:13-40
20. Harmon A. Young, Assured and Playing Pharmacist to Friends. The New York Times.2005. http://nytimes.com/2005/11/16/health
21. Engagement in Child and Adolescent Treatment: The Rold of Parental Cognitions and Attributions. Clinical Child and Family Psychology Review 1999;2:183-198
22. Boyd et al. Adolescents’ Motivations to Abuse Prescription Medication. Pediatrics 2006;118:2472-2480

Massachusetts Health Care Reform: Ingenuous… or Ignorant? - Chris Hoedt

In 2006, the Massachusetts Health Care Reform Bill pioneered drastic social changes, in an effort to alleviate the national health care crisis, by attempting to ensure all state residents have medical health insurance. Chapter 58 mandates that all state residents acquire health insurance, privately or through their employer, or face financial penalty (1). Through this plan, the state sought to blaze the trail in creating an effective method of containing health care costs and ensuring a basic level of medical accessibility. Originally, the state estimated that about 400,000 residents were uninsured, 6% of the state population (2,3), while the federal government surveyed this figure to be closer to 650,000 uninsured residents, about 10% of the state population (4). The legislation provides a gradient of partial subsidization of insurance policies for individuals with an adjusted gross income less than 300% the Federal Poverty Level (FPL) and full subsidization for those individuals under 150% FPL; in 2008, 300% FPL is $31,212 for an individual and $63,612 for a family of four (5). The Uncompensated Care Pool (“Free Care Pool”), which previously paid providers for the medical expenses of those who could not afford their care, has been dissolved into the Health Care Safety Net Trust Fund, which serves as an emergency pool of finances for hospitals experience operating hardships and funds the subsidization of premiums for state health insurance programs (6).
Established as a program to facilitate the universal health insurance coverage for all Massachusetts residents, the Commonwealth Connector is composed to two major programs. Commonwealth Care assists qualifying residents, who have a financial income with respect to FPL was previously mentioned, obtain state subsidized insurance policies. Commonwealth Choice assists residents in securing insurance policies that fit their particular needs and have at least the minimum state requirements for coverage; these residents have an income too high to qualify for subsidization. Current estimates by the Commonwealth Connector believe that over 300,000 citizens have obtained health insurance since the implementation of the Chapter 58 legislation (4). Although it would seem that health insurance is no longer a barrier to obtaining care in the state and that medical cost inflation would decrease, hundreds of thousands of underinsured have chosen to pay penalties instead of obtaining insurance (7) and accessibility has not significantly changed (8). More importantly, the stated goal of Chapter 58: to improve health care access and affordability of Massachusetts citizens (9), has be ineffectively implemented as this policy neglects significant social factors affecting health outcomes that may lead to this program’s failure.

Mandates do not produce effective improvements in health outcomes
Forcing all citizens to have health insurance does not mean that people will have better health outcomes. Although studies have shown that patients with health insurance generally have better health outcomes (10), this is in under the context of comparing those who are insured to those uninsured. Mandating health insurance for everyone, especially to those patients in the bottom strata does not guarantee better health outcomes, since they would remain the bottom strata. Moving the bottom line up will likewise shift the quality of care provided and maintain similar health outcomes for these people (11). The Massachusetts mandate does not ensure that those who need health care the most are more likely to obtain effective health treatment and prevention. Many social and behavioral factors are neglected by this mandate, which have enormous correlation to the health outcomes of individuals. Education level, socioeconomic status, and race have been found to be very important predictors of health outcomes for individuals (12). One study found that correcting the education level associated-mortality disparity in our nation could have saved over one million lives; eight times the number predicted to have been saved that same year by medical technology/procedure advancements (13). Improving the education of Commonwealth residents would produce a multitude of benefits, which would include substantially better health outcomes overall. Twenty percent of physicians care for more than 80% of the Black population and this illustrates the necessity for significant social reform in our nation (14). Further contributing to the disparities in providing adequate access to health care services, minority cultures frequently comprise a considerable amount of people uninsured or underinsured in the state. This past year in Massachusetts, Blacks were 1.5 times more likely, and Hispanics more than twice as likely, to be uninsured as compared to Whites (15). These same cultures have been found to be less likely to seek out health care in Massachusetts, even when they have health insurance. Similarly, compared to Whites, medical or dental preventive care check-ups within the last year were obtained by Blacks 1.5 times less frequently and Hispanics over twice less frequently (15). An estimated 90,000 illegal immigrants in the state of Massachusetts are not even considered in the Chapter 58 policy or the survey of those without insurance in the state (16). Programs targeted to provide insurance for minorities and increase their likelihood of seeking preventive care should have been a major focus of Chapter 58 and would have been ingenious. The health insurance mandate of Massachusetts has failed to appropriately address the need for health programs targeted towards minorities and improving education levels, shown to improve the accessibility and affordability of health care.

Effective spending on health for residents
Originally it was estimated by former Governor Romney that the average individual insurance premium would cost about $300 per month, but when the plans insurance companies developed were announced, they averaged almost $400 per month (8). Furthermore, in order to create health insurance policies affordable for persons with limited income, insurance companies have cut services covered in policies. Services have been reduced to the state minimum requirements, co-payments have substantially increased with respect to the amount projected by the state government, and deductible levels have more than double on average compared to previously speculated amounts (3). The money spent to obtain a plan, which is already poor coverage, takes almost a 10% proportion of the income for individuals just above the individual qualification maximum of $50,000 (17). This money could have been used on other things that would have improved the lives of those people, possibly more than having low quality health insurance coverage.
Many daily activities and medical treatments, which are very inexpensive, can significantly improve an individual’s health. A flu shot that can cost up to $25 (18) can reduce the likelihood of contracting the influenza virus by 70-90% (19), which afflicts millions of people in the United States each year. Membership at a fitness center has been found to have enormous benefits for a multitude of health issues (20) and can cost as little as $360 annually (21). Food could even be an expenditure some people of Massachusetts can barely afford. For the 2007 tax year, many people, hundreds of thousands just above the $50,000 income max (7), have chosen to spend their money elsewhere than purchasing more costly health insurance, at the penalty of a $4,125 tax exemption loss (22). Most plans cost a significant amount more than the penalty and thus this mandate is forcing these persons to make a choice of the least worst result.

Effective allocation of resources by the Commonwealth
The money and time dedicated to funding this program has proven ineffective in its first year compared to projected results and has caused a large number of physicians to sign an open letter to everyone in the United States giving Chapter 58 a “failing grade” (23). Without the support of hospitals and physicians, it is politically unfeasible for this mandate to take root and succeed at improving access and quality of health care. These resources should have been dedicated towards other programs that would have produced more effective outcomes and had more health care provider support. Furthermore, resentment is growing, because of an exceptional miscalculation in the finances necessary to fund this program. In order to account for misjudged numbers of uninsured and underinsured individuals, Governor Patrick has requested an additional $200 million for the $700 million budgeted to this reform plan for the 2009 fiscal year (4). This money will be acquired by cutting funding to other projects, increasing taxes, and increasing the cost of health insurance policies (24). With regard to previous estimates, the state found there were about 40,000 residents of Massachusetts that would be required to purchase more comprehensive plans for the 2009 fiscal year health insurance policy coverage requirement increase (4). Yet, recent predictions estimate there are about 200,000 residents that this minimum coverage policy will affect (3). Furthermore, hundreds of thousands of residents have chosen to not adhere to the mandate in the last year, causing a lack of funding that was expected for state health insurance subsidized plans (4). Based on the significant lack of adherence to the mandate and underestimation of how many residents the increase in policy requirements would affect, the support for the mandate is diminishing (25). Recently, the state legislature approved an additional 3.5 million dollar campaign to promote awareness of the mandate (26); less than 25% of the population believe this mandate helps them in any way and many people are completely unaware of the policy changes: 26% of people 18-35 years of age, 21% with an income less than $25,000, and 22% of the uninsured (25). It is a significant problem that about 25% of residents have not heard of the mandate, since the aforementioned groups (persons 18-35 years of age, with an income less than $25,000, and/or uninsured) are the targeted demographic of residents this policy seeks to affect. Many administrative, financial, and promotional errors would have been prevented if more subgroup targeting had been implemented in the plans for Chapter 58.
Programs created by the state to promote funding for health care interventions of these target demographics would have been more effective to improve overall accessibility and affordability to health care. These demographics are generally those people that cost the health care system the most money (15). Often these persons have worse health and lack finances to pay for preventive care and comprehensive health insurance (14). Programs targeting their care would provide the best direct intervention methods of containing overall costs, because better health for these people mean less costs to the system. Furthermore, the loss of the “free care pool,” before having a significant majority of those uninsured in compliance with the new policy, creates financial strain on many hospitals. A more effective program that should have been implemented would target providing preventive care for those who cannot afford it and/or subsidizing health care for those persons making too much money to qualify for Medicaid assistance.
One year after the implementation of the Massachusetts Health Care Reform plan, most of the nation has withdrawn their original support and confidence in Chapter 58. Further contributing to the dwindling political feasibility are the many physicians of the state who have come together to express their concern for the plan. They hold a universal belief that the plan will make health outcomes worse in the state (23). A significant lack of social and behavioral health perspective in to effective measures of improving health care accessibility and affordability could prove to be extremely costly to the state of Massachusetts.

References
1. Massachusetts Department of Public Health. Chapter 58 of the Acts of 2006. 12 April 2006. 3 Apr 2008 http://www.mass.gov/legis/laws/seslaw06/sl060058.htm.
2. Commonwealth Connector. Health Care Reform: Overview. 2008. 03 Apr. 2008. http://www.mahealthconnector.org/portal/site/connector/menuitem.d7b34e8 8a23468a2dbef6f47d7468a0c?fiShown=default.
3. Raymond, Alan G. The 2006 Massachusetts Health Care Reform Law: Progress and Challenges After One Year of Implementation. BCBSMA Foundation, MA Medicaid Policy Institute, MA Health Policy Forum. Boston, 2007.
4. Commonwealth Connector. Health Connector Facts and Figures. Boston, 2008. 3 Apr. 2008. http://64.233.169.104/search?q=cache:BxgnyrNyvVEJ:www.mahealthconnector.org/portal/binary/com.epicentric.contentmanagement.servlet.ContentDeliveryServlet/About%252520Us/News%252520and%252520Updates/Current/Week%252520Beginning%252520March%2525209%25252C%2525202008/Facts%252520and%252520Figures%2525203%25252008.doc+health+connector+facts+and+figures&hl=en&ct=clnk&cd=1&gl=us.
5. The Commonwealth of Massachusetts. Health Care Access and Affordability Conference Committee Report. Boston, 2008. 3 Apr. 2008. http://64.233.169.104/search?q=cache:E6-Qynob6kEJ:www.mass.gov/legis/summary.pdf+health+care+access+and+affordability+summary&hl=en&ct=clnk&cd=1&gl=us.
6. Henry J. Kaiser Family Foundation. Massachusetts Health Care Reform Plan: an Update. Washington, D.C.: Kaiser Family Foundation, 2007. 3 Apr. 2008. kff.org/#7494-02.
7. Mahar, Maggie. Massachusetts Health Care Reform : the Canary in the Coal Mine. Health Beat (2007). 23 Oct. 2007. 3 Apr. 2008, http://www.healthbeatblog.org/2007/10/universal-cover.html.
8. Dembner, Alice. Sticker Shock for State Care Plan. The Boston Globe 20 Jan. 2007. 03 Apr. 2008. http://www.boston.com/yourlife/health/other/articles/2007/01/20/sticker_shock_for_state_care_plan/?page=1.
9. Massachusetts Health Care Reform Coalition. FAQs on the New Health Reform Law. 2008. 03 Apr. 2008. http://www.masshealthreform.org/faqs.html.
10. McWilliams, Michael J., MD. Health of Previously Uninsured Adults After Acquiring Medicare Coverage. The Journal of the American Medical Association.298(24), (2007):2886-2894.
11. Garson, Arthur, MD, MPH, and David Blumenthal, MD, MPP. State-Federal Partnerships for Access to Care. Journal of the American Medical Association ns 297 (2007): 1112-1115.
12. Wharam, J. Frank, MB, BCh, BAO and Norman Daniels, Ph.D. Toward Evidence-Based Policy Making and Standardized Assessment of Health Policy Reform. Journal of the American Medical Association ns 298 (2007): 676-679.
13. Woolf, Steven, MD, MPH, and et al. Giving Everyone the Health of the Educated: an Examination of Whether Social Change Would Save More Lives Than Medical Advances. American Journal of Public Health os 97 (2007): 679-683.
14. Lurie, Nicole, MD, MSPH, and Tamara Dubowitz, MSC, SM, SCD. Health Disparities and Access to Health. Journal of the American Medical Association ns 297 (2008): 1118-1121.
15. Coombs, Alice. Dealing with Disparities: One of the Real Measures of Success. MA Medical Society. Boston: CommonHealth, 2007.
16. Estimated Number of Illegal Immigrants (Most Recent) by State. StateMaster.Com. 2000. US Citizenship and Immigration Services. 03 Apr. 2008. http://www.statemaster.com/graph/peo_est_num_of_ill_imm-people-estimated-number-illegal-immigrants.
17. Holahan, John, and Linda Blumberg. Massachusetts Health Care Reform: A Look At the Issues. Health Affairs 10 (2006): w423-w443.
18. Powell, Kimberly, and Albrecht Powell. Where to Get a Flu Shot in Pittsburgh. About.Com: Pittsburg (2007). 3 Apr. 2008. http://pittsburgh.about.com/od/health/a/flu_shot.htm.
19. Influenza (Flu) Prevention. MayoClinic.Com. 21 Sept. 2007. 3 Apr. 2008. http://www.mayoclinic.com/health/influenza/DS00081/DSECTION=8.
20. Atlantis E., Chow et. al. An effective exercise-based intervention for improving mental health and quality of life measures: A randomized controlled trial. (2004) Preventive Medicine, 39 (2), pp. 424-434.
21. South End Fitness Center. Membership. 3 Apr. 2008. http://www.southendfitness.org/membership.htm
22. Massachusetts Health Care Reform Bill Summary. Blue Cross Blue Shield of Massachusetts. BCBS, 2007. 3 Apr. 2008. http://www.masshealthreform.org/faqs.html.
23. Physicians for a National Health Program. Doctors Give Massachusetts Health Reform a Failing Grade - Poor Early Outcomes Raise Red Flags, Only Private Insurers Profit. 14 Jan. 2008.
24. Luddy, Katie. FY09 House 2 Budget Recommendation: Issues in Brief. Health Care Reform. http://www.mass.gov/bb/h1/fy2009h1/exec2_09/hbudbrief8.htm
25. Harvard School of Public Health, Kaiser Family Foundation, BCBSMA. Massachusetts Health Reform Tracking Survey. Menio Park, CA: Kff.Org, 2007.
26. Dembner, Alice. Healthy Advice: Outreach Workers Making Sure People Know of New Law. The Boston Globe 7 July 2007.

The Failure of Abstinence-Only Sexual Education in Secondary Schools – Megan Edson Grandin

Over $270 million of federal funds have been dedicated to abstinence-only sexual education programs (1). Supported primarily through the Special Programs of Regional and National Significance (SPRANS), Section 510 of the 1996 Welfare Reform Act, and the Adolescent Family Life Act, these programs promote abstinence from all sexual activity as the only means of preventing pregnancy and sexually transmitted diseases (1). In order to receive federal funding, programs must adhere to strict standards, such as, “teaching abstinence from sexual activity outside marriage as the expected standard for school age children,” “teaching that abstinence from sexual activity is the only way to avoid out-of-wedlock pregnancy, sexually transmitted diseases, and other associated health problems,” “teaching that a mutually faithful monogamous relationship in the context of marriage is the expected standard of human sexual activity,” and “teaching that that bearing children out-of-wedlock is likely to have harmful consequences for the child, the child’s parents, and society” (2). These programs teach that engaging in sexual intercourse before marriage can have serious, lasting, negative effects on the mind and body (3).
Nationwide, 46.8% of students in grades 9-12 have engaged in sexual intercourse (4). Teenage pregnancy and rate of infection with sexually transmitted diseases remains a public health problem. Each year, nearly 750,000 females between the ages of 15 and 19 become pregnant (5). Nearly 25% of annual new cases of sexually transmitted diseases occur in teenagers (6). Clearly, students need to receive education on how to prevent these outcomes. However, studies have shown that, despite the amount of money spent on abstinence-only sexual education, it has little to no effect on teen pregnancy or rate of sexually transmitted diseases (1). This broad failure can be attributed to the programs’ lack of consideration of various factors that influence individuals’ decisions regarding their health.

Abstinence-Only Sexual Education Relies on the Health Belief Model
Federally funded abstinence-only programs rely on a number of traditional health behavior models to format their teachings. The Health Belief Model, widely used in public health settings, has distinct components which determine how likely people are to take actions to prevent a negative health outcome. One component is individuals’ perceived susceptibility to a health consequence, or how likely people feel that they will suffer from the outcome. Another such component is the perceived severity of the health consequence, or the degree to which individuals believe that they will suffer from the health outcome. These two components are weighed against the perceived costs of taking the action (7). The Health Belief Model dictates that these components will determine individuals’ health intentions, and that the intentions will lead to specific health behaviors (8). This model relies on the assumption that logical thought processes determine health decisions. It also relies on the hypothesis that health decisions are made on an individual level (8).
Health decisions are not always rational. While many teenagers may be well aware of the risks of sexual activity, they are not necessarily rational about their behavior. When faced with temptation, it may be difficult for teenagers to remain abstinent, despite their intentions to do so (9). In conducting research for the “Truth” anti-tobacco campaign, researchers found that teenagers’ reasons for health decisions had little to do with rational decisions, and much to do with emotions (10). In addition, many decisions regarding sexual behaviors are made under the influence of alcohol, which impairs people’s abilities to be rational. Even those with the strongest of intentions to remain abstinent can have their resistance lowered with the aid of alcohol (6).
It is also difficult to factor perceived susceptibility into this equation, because studies have shown that teenagers often have low perceived susceptibility to diseases. Although many abstinence-only sexual education programs teach about sexually transmitted diseases, many teenagers do not believe themselves to be at high risk for such diseases (11, 12). Therefore, the health belief model would not be applicable or helpful to use in this situation. Furthermore, even if teenagers know how susceptible they will be to a sexually transmitted disease or pregnancy, and how severe the disease may be, it may not necessarily matter when caught up in the moment of desire.
The Health Belief Model fails to account for other factors that affect health decisions, such as social norms (8). Many abstinence-only programs fail to consider social norms, and assume that adolescents are making decisions on an individual basis. Students are taught such lessons as, “abstinence from sexual activity outside marriage [is] the expected standard for all school age children” (2). However, nearly half of American teenagers are sexually active (4). Social networks play a large role in teenagers’ decisions to engage in intercourse (12). Through wider social networks, students see that abstinence is not, in fact, the standard. Teenagers will be much more likely to listen to their friends than to their teachers (3). Clearly, if sexual education programs are to work, they need to take these wider social networks into account. Studies have shown that in smaller, more insular communities of students, when remaining a virgin is considered to be socially acceptable, teenagers will be more likely to do so (11).
The most effective sex education programs “include activities that address social pressures that influence sexual behavior” (13). Teenagers are deluged by societal forces that use sex as a marketing tool. The media widely displays images that show that being sexually active is the social norm. Marketing campaigns that use sex to sell their products may enforce fears in teenagers that being a virgin is not the social norm. If sexual education is to make an effective, measurable impact on teenagers, it must account for the myriad factors that account for teenage health behavior (13). Adolescents do not always make rational decisions, and societal forces, such as social networks and the media, impact their health behavior more than teachers do.

Many Abstinence-Only Programs Fail to Account for Self-Efficacy
Self-efficacy refers to “individuals’ beliefs about their ability to perform the behavior of interest” (8). Many health decisions are affected by self-efficacy. If people believe that they can achieve a desired health behavior, they are more likely to take steps to achieve that desired health behavior. Conversely, if people believe that they will be unable to achieve a desired health behavior, it is much less likely that those people will even attempt the steps necessary for the behavior.
Many abstinence-only programs are taught in moral terms (9). Students are taught that those who remain abstinent are morally superior to those who are sexually active (9). This may lower the self-efficacy of sexually active teens, due to feelings of shame and embarrassment. These negative feelings may cause people to hide their behaviors, thereby leading to a lack of desire to take further preventive action. Such students are less likely to see a doctor about sexual concerns (9, 11). The students feel that they are already at risk for a disease, and that there is nothing that can be done to change that fact. Therefore, they do not make healthy decisions, and expose themselves to more of the negative consequences. One study showed that adolescents who had already engaged in sexual intercourse prior to receiving abstinence-only education were more likely to drop out of the programs. Furthermore, such programs had no measurable effect on their sexual practices (14). Conversely, higher self-efficacy is linked to higher rates of contraception use (6). When people feel more in control of their health behavior, they will be more likely to take preventive actions.
Problems with self-efficacy are also seen in homosexual teenagers in abstinence-only courses. By its definition, abstinence-only-until-marriage education implies gay and lesbian students are not part of the social norm. These educational programs teach that, “sexual activity outside of the context of marriage is likely to have harmful psychological and physical effects” (2). However, in all but one state, homosexuals are legally unable to marry. The only option presented to gay teens is a life of abstinence, which is quite unrealistic. Homosexual teens tend to be ignored in these programs, and this exclusion creates a stigma (9). By creating this stigma, and telling adolescents that they fall outside of the social norm, it can lower their self-esteem and force them to engage in riskier health behaviors. Those who feel that their sexual practices are “unclean,” or “wrong,” may take extra steps to hide their relationships and desires. They would be less likely to seek preventive measures for fear of further stigmatization (15).
When people feel the stigma of being “different,” whether they are gay, or have already engaged in sexual behavior, their self-efficacy is affected. Students are placed at a higher risk for negative consequences. As demonstrated by studies of condom use in gay men, people need to feel in control of their bodies and lives in order to feel empowered enough to make healthy decisions (16). Many sexual education programs reflect a single view of a single kind of sexuality, neglecting alternate forms of love (9).

Messages in Abstinence-Only Curricula are Often Unclear
Messages in abstinence-only education courses are sometimes unclear. Many times, “abstinence” is defined in moral terms, and can be colored by interpretation (9). It may be difficult for teenagers to understand what they are being asked to do. In addition, some abstinence-only education classes present conflicting information. As demonstrated by the creators of the “Truth” campaign, teenagers do not respond well to being deceived (10).
One study showed that not every teenager who received abstinence-only education actually knew what “abstinence” was. When asked to define “abstinence,” answers varied depending on age, grade, school, and amount of personal sexual experience, suggesting marked confusion about the term (17). Teenagers are more likely to engage in other kinds of unprotected sexual activity when they interpret the meaning of “abstinence” as merely refraining from vaginal intercourse (9).
Numerous studies have shown that abstinence-only education lies about the effects of condom use and risks of sexually transmitted infections (1). For example, one curriculum compared condom use to playing Russian Roulette, in that there is a one in six chance that the user will be killed (18). Another curriculum states that AIDS can be transmitted via skin-to-skin contact (19). This information is blatantly false. If students do not know whom they can trust, their perceived susceptibility to pregnancy and sexually transmitted infections may be altered. Studies have shown that those who doubt the effectiveness of contraceptives will be more likely to engage in unprotected sex (20, 21).
Teenagers without accurate information are at a higher risk for sexually transmitted infections and pregnancy (9). The most effective sex education courses enforce a clear and consistent message about using contraception, as well as the risks of pregnancy and HIV (13).

Conclusion
Studies have shown that sexual practices adopted by teenagers have effects on their adult sexual practices (6). High school should be a time when safe sexual practices are learned, so that they may be carried into adulthood. There must be programs in place that appeal to teenagers, and will account for the differences in interpretation. Current federal policies are not working, and have been shown to have little to no effect on teenagers’ sexual practices. Before more money is spent on ineffective practices, influences that determine health behavior must be examined.
Teenagers need a clear message, presented without moral interpretation. They should be made to feel that they are capable of taking control of their own health decisions, regardless of past sexual activity or sexual orientation. At no time should teenagers be made to feel ashamed about past decisions. Most importantly, teenagers should be equipped with information that they can use to make healthy choices.

REFERENCES
1. The Content of Federally Funded Abstinence-Only Education Programs, US House of Representatives Committee of Government Reform, prepared for Rep. Henry Waxman (D-CA), December 2004.
2. Personal Responsibility and Work Opportunity Reconciliation Act of 1996. Pub. L.No. 104-193, 1996.
3. Howell, M. The future of sexuality education: science or politics? Transitions. 2001;12 1013.
4. Department of Health and Human Services Centers for Disease Control and Prevention. Youth risk behavior surveillance – United States, 2005. Morbidity and Mortality Weekly Report 2006;55:1-108.
5. Guttmacher Institute. U.S. Teenage Pregnancy Statistics National and State Trends and Trends by Race and Ethnicity. New York, NY: Guttmacher Institute, 2006.
6. Shafii T, Stovel K, Davis R, Holmes, K. Is condom use habit forming? Condom use at sexual debut and subsequent condom use. Sexually Transmitted Diseases 2004; 31:366-372.
7. Rosenstock IM. Historical origins of the health belief model. Health Education Monographs 1974; 2:328-335.
8. Salzar MK. Comparison of four behavioral theories. AAOHN Journal 1991; 39:128-135.
9. Santelli J, Ott MA, Lyon M, Rogers J, Summers D, Schleifer R. Abstinence and abstinence-only education: A review of U.S. policies and programs. Journal of Adolescent Health 2006: 38(1): 72-81.
10. Hicks JJ. The strategy behind Florida’s “truth” campaign. Tobacco Control 2001; 10:3-5.
11. Bruckner H, Bearman P. After the promise: The STD consequences of adolescent virginity pledges. Journal of Adolescent Health 2005; 36(4): 271-278.
12. Stanton B, Li X, Black M, et al. Sexual practices and intentions among preadolescent and early adolescent low-income urban African-Americans. Pediatrics 1994;93:966-973.
13. Kirby D. Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy. Washington, DC: The National Campaign to End Teen Pregnancy, 2001.
14. Haignere CS, Gold R, McDanel HJ. Adolescent abstinence and condom use: Are we sure we are really teaching what is safe? Health Education and Behavior 1999; 26:43-54.
15. Choi K, Yep GA, Kumekawa E. HIV prevention among Asian and Pacific Islander men who have sex with men: a critical review of theoretical models and directions for future research. AIDS Education and Prevention 1998; 10 (Supplement A):19-30.
16. Siegel M. The importance of formative research in public health campaigns: an example from the area of HIV prevention among gay men (Appendix 3-A), pp. 66-69. In: Siegel M, Doner L. Marketing Public Health: Strategies to Promote Social Change. Sudbury, MA: Jones and Bartlett Publishers, 2004.
17. Ott M., Pfeiffer EJ, Fortenberry JD. Perceptions of Sexuality among High-Risk Early and Middle Adolescents. Journal of Adolescent Health 2006; 39(2): 192-198.
18. Roach N, Benn L. Me, My World, My Future. Spokane, WA: Teen-Aid, 1993.
19. Duran MG. Reasonable Reasons to Wait. Chantilly, VA: A Choice in Education, 2003.
20. Advocates for Youth. Toward a Sexually Healthy America: Roadblocks Imposed by the Federal Government’s Abstinence-Only-Until-Marriage Education Program. Washington, DC: Advocates for Youth, 2001.
21. Landry D, Kaeser L, Richards CL. Abstinence promotion and the provision of information about contraception in public school district sexuality education policies. Family Planning Perspectives 1999;31:280-286.