The Gardasil Campaign: Merck, Take a Look at it from a Public Health Perspective – Maithili Jha

In 2008, the American Cancer Society (ACS) estimated that 11,070 women in the United States were diagnosed with invasive cervical cancer, and 3,870 women died of cervical cancer (4). A leading cause of cervical cancer is human papillomavirus (HPV) that is passed sexually from one person to another (1). In response to both the rate of cervical cancer and the cause of cervical cancer, pharmaceutical companies have been racing to find a vaccine against HPV. One such pharmaceutical company, Merck claims that they have succeeded in finding a vaccine against HPV called Gardasil. Merck’s marketing approach to promote the drug was to lobby for mandatory vaccinations for 11 year-old girls in junior high, and infiltrate the media with the “One less” advertisement. The Food and Drug Administration and the Center for Disease Control have approved and recommended Gardasil, for women between the ages of 9 and 26. The FDA and the CDC also convey the message that women who are already infected with HPV will not be protected by the vaccine (5). While some may see the importance in vaccinating a female before potential exposure to HPV, others have seen Merck’s lobbying of mandatory vaccination of young girls in schools as a point of controversy and the “One Less” campaign as misleading. This paper will review and evaluate the means with which Merck has promoted the Gardasil vaccine, from a public health perspective.
The Premature Promotion of Gardasil, Merck could have used HBM
The FDA approved Gardasil for marketing and sale in 2006. Soon after, Merck began lobbying for mandated vaccinations in schools (14). The lobbying campaign ended in February 2007, but the opposition and views against compulsory vaccinations for a sexually transmitted virus still linger for two reasons. First, the vaccine was marketed and promoted before the entire public even knew what HPV was or that HPV may lead to cervical cancer. And, second, because representatives in at least 24 states and DC have initiated legislation to require vaccination in schools (9).
Rick Perry, the Governor of Texas, issued an executive order requiring Texan schoolgirls to be vaccinated against HPV. The conclusion that "the governor of Texas provided a solution to a problem before many were even aware of the problem. Educating the public after the fact is much harder” (11) remains even though three months after Rick Perry issued the order, he passed a bill undoing the mandate. Rather than using policy to market the vaccine, the promoters of Gardasil would have benefited from the use of traditional health behavior models such as the Health Belief Model. To an unaware public, education relaying the risks associated with HPV, marketing the benefits of preventing HPV, and addressing the perceived barriers to getting the vaccine may have muffled the backlash against expedited vaccinations.
In 2004, Holcomb, Bailey, Crawford and Ruffin conducted a study assessing adults’ knowledge of HPV. They concluded that adults seen in a physician’s office have a limited knowledge of HPV (7). In 2008, Gerend and Magloire conducted a similar study, and found that awareness of HPV was relatively high and increasing amongst sexually active individuals. They then went on to say that “With the release of Gardasil, Merck has since initiated its ‘One Less’ marketing campaign, which has received regular television airplay. High levels of awareness observed in the present study, coupled with the fact that television, radio, and magazines were cited as the most common sources of HPV information, provide some evidence for the effectiveness of these campaigns” (6). However, even though Gerend and Magloire’s study found that the awareness of HPV among sexually active individuals was relatively high, women who may have benefited the most from the vaccine, namely those who are not yet sexually active, were more likely to communicate the least interest in getting vaccinated (6). Had the campaign addressed the perceived risks of being sexually active and getting HPV, and the perceived benefits of being vaccinated, then maybe the parents or guardians of the eleven-year-old school girls and women who are not yet sexually active would be more receptive to the idea of endorsing and using Gardasil, and feel like they are at risk.
The perceived barriers associated with implementing mandatory vaccinations are multi-faceted. The monetary cost of Gardasil may be too high for some women, and calculating the return on the investment of being vaccinated may be difficult. The Gardasil vaccine costs $125 per dose, and $375 for the full series consisting of three vaccinations. While some health insurance companies may cover the costs being vaccinated, others may not (8). If a young girl is required to be vaccinated against the virus, and she does not have adequate health insurance then her parents or guardians would be forced to pay on their own. Once approached with a bill for a vaccine against a sexually transmitted virus, the parents and/or guardians may question why they should pay for a vaccine, if there is a chance their child may not get HPV. A parent’s acceptance of the idea of their child being sexually active is variable. As a writer for the National Health Federation states, “…many parents are opposed to making the vaccine mandatory, and in some states, like Massachusetts, the efforts have stalled. Some parents are opposed to mandatory vaccination on moral grounds, believing that vaccinating their daughters against a sexually transmitted disease sends the message that sexual activity at such a young age, or even prior to marriage, is acceptable. Others simply believe that the government has no right to usurp parental authority by mandating a vaccine for a disease that is not spread through casual contact” (2). Religious views, conservative values, education, and socio-economic status are all examples of what may affect how willing a parent is to consider the risks of their child being sexually active, even if their daughter will not be sexually active until she is older.
Mandatory vaccination of 11-year-old girls does not provide the parents and guardians with a sense of self-efficacy. Along with the vaccination, the lobbyists have not proposed a method for the parents to approach their daughters with the topic of sexual activity and consequences thereof. The mandate does not provide HPV education for the parents and children, leaving the parents and children to learn about the causes and effects of the virus on their own. Incorporating educational materials administered by the schools for the parents and children into the mandate may ease the transition into having children be vaccinated.
Social Cognitive Theory says, “Don’t just look at the 11 year-old, look at her environment too”
The Gardasil campaign failed to consider the individuals environment, when proposing mandatory vaccinations, and could have better incorporated how an individual responds to cues from the environment and visa versa, or reciprocal determinism into the campaign. In the 1960s, Albert Bandura proposed a behavioral theory that looked beyond the individual, and into the individual’s environment (3). He suggested that behavioral change is dependent on three constructs: individual characteristics, environmental factors, and reciprocal determinism (3).
Environmental factors like social norms, culture, and religion, affect an individual’s decisions. Before educating the public with the “One less” campaign or lobbying for mandatory vaccinations, the Gardasil campaign should have taken into account that the vaccine is to guard against the result of a behavior – sexual activity. In conservative groups, religious or political for example, the reception of learning about sexual behavior differs. A conservative Muslim woman may not be open to talking about her sexual behavior, or may not consider herself at risk for HPV, because of her conservative background and the understanding that she only has one partner. Yet, that Muslim woman is as much at risk of getting HPV as anyone else, simply because the virus is sexually transmitted. Merck should have borrowed from Bandura’s theory, evaluated the situations in which HPV occurs, and the perceptions of those situations within a social group by the individuals themselves (3).
Follow the Communications Theory, Avoid a False Sense of Security
As stated earlier, the Gardasil vaccine was the fasted drug to be approved and endorsed by the FDA and CDC. Because of this, the drug was prematurely marketed as a cervical cancer vaccine and not an HPV vaccine for certain strains. And, Merck’s marketing department and the lobbyists petitioning for mandatory vaccinations unsuccessfully communicated the vaccine’s purpose and benefits, while providing a false sense of security to the public (10). Previous public health campaigns had similar shortcomings until they started utilizing theories like the Communications Theory (CT). It is unknown as to whether Merck’s marketing department followed the CT when promoting Gardasil. But, it is apparent that when applying CT to the Gardasil campaign, weaknesses in Merck’s marketing approach begin to surface.
The Communications Theory states that one must consider the source of the message, the message itself, the channel by which the message is communicated, the receivers of the message, as well as feedback and understanding from the receiver (3). The Gardasil campaign is vulnerable to criticism, because it did not consider the message, the receiver, or whether there is feedback and understanding from the receiver.
Within the constructs of CT, the sources of the Gardasil campaign are Merck, lobbyists, and the policy makers in favor of mandatory vaccination. The message that Merck conveys in its “One less” campaign is that Gardasil is a vaccine against cervical cancer and that women should make the decision on their own, without the influence of policy to be vaccinated. The lobbyists say that schools should implement mandatory vaccinations. The lobbyists are sending a message that the vaccine will be effective if made mandatory by policy makers for grade schools, and this message is incongruent with Merck’s ad campaign highlighting personal initiative. Merck used media (television, print ads, news channels) and policy as the channels to convey their messages. In the “One less” campaign, the receivers of the message are the women receiving the vaccine, and the policy makers who could implement mandatory vaccinations. And, to the lobbyists, the receivers are the policy makers and other people able to influence whether the vaccine becomes a requirement for eleven-year-old school girls.
Either Merck should have enlisted the aid of public health organizations to formulate its message and educate the receivers that Gardasil is a vaccine against the strains of HPV that are the leading cause of cervical cancer, or they should have incorporated that education into their own advertisements. “One less,” that is, “one less woman with cervical cancer” does not relay why women should take Gardasil, a vaccine against HPV, resulting in a false sense of security against the cancer. The lobbyists and some policy makers have endorsed the idea of mandatory vaccinations of eleven year-old girls. Their proposals should include education plans for schools, physicians and parents about HPV, how it relates to cervical cancer, and behaviors leading HPV, instead of just proposing vaccinations.
Merck’s advertisements use young women and mothers as subjects. However, young women and mothers are not the only receivers in the campaign. On the one had, the lobbyists are saying that it is best to implement mandatory vaccinations for girls who are eleven and twelve years old before they are sexually active. And, on the other hand, Merck is not using eleven and twelve year olds as the subjects for their advertising, but young women making decisions on their own. Both the lobbyists and Merck’s advertising team are not taking into consideration other receivers of their message: the parents of eleven and twelve year old female students, those families and young women who cannot afford the vaccine for their children or themselves, the sexual partners of the women who are not infected with HPV yet, but could be in the future, religious and conservative groups, and physicians. Again, advertisements directed to parents of the children who would be vaccinated, as well as education programs for all the receivers of the message should be integrated into the campaign.
While it is difficult to gauge understanding of a concept, it is important for Merck and the lobbyists to continue market research on whether all the receivers know what HPV is, and what Gardasil does. Even if the eleven year olds do not fully understand why they are receiving the vaccine, the parents and guardians of the children should understand why they must vaccinate their children against a sexually transmitted virus.
Bridging Private and Public Domains
While this has not been a critique of Gardasil, the vaccine, but it has been a critique of Merck’s approach to promoting the vaccine. Public health is still developing and improving upon its models for influencing behavioral change, private companies such as Merck would benefit from utilizing established traditional and non-traditional health behavior models in their marketing campaigns, and promotions of therapeutics. By learning from the Gardasil campaign, one hopes that in the future private industry, and public health will be able to form a liaison and prevent the educational holes in the public’s awareness of pharmaceutical effectiveness.
Two-Step Marketing, a New Approach to Vaccine Promotion
When Merck used marketing techniques in combination with policy promotion for the Gardasil campaign, they had the potential to positively impact a wide population. However, Merck fell short of its potential. Instead of focusing on ways to limit controversy surrounding the nature of the virus, or barriers to receiving the vaccine, they rushed to have the vaccine approved and promoted by the FDA and the CDC, and lobbied for mandatory vaccinations of girls in grade school. This section will propose an alternative approach to promoting the vaccine, addressing the three previously stated arguments for why Merck’s Gardasil campaign failed, while staying within Merck’s constructs of coupling marketing and public policy. This new two-stage approach would allow Merck to use policy to influence its advertising schemes, and would allow policy to steer Merck’s advertising schemes as well, splitting the marketing efforts into two phases: education (Stage I), and product promotion (Stage II).
Premature Promotion of Gardasil Leading to an Uneducated Public : Stage I
Merck marketed the Gardasil vaccine using the “One Less” advertisement, before the entire public knew what HPV was or that it may lead to cervical cancer, resulting in the misconception that Gardasil prevents cervical cancer. To thwart this reaction, State and Federal lawmakers should propose legislation requiring the pharmaceutical company producing the vaccine to advertise their product in two stages. First, in Stage I they would need to use market research techniques to gauge the public’s knowledge about HPV and cervical cancer, and release a preliminary set of educational advertisements. Then, Stage II of advertising would be for the drug itself.
With a policy in place requiring pharmaceutical companies to assess the knowledge of the public about the product, Merck would need to find out how much people know about HPV, cervical cancer, and their relationships to sexual activity. Asking questions like: ‘Do you know what the vaccine guards against?’ ‘Do you know the causes of HPV?’ ‘Are you comfortable talking to your children who are under the age of twelve about sex, and the risks involved with sexual behavior?’ would provide insight as to whether the “One Less” campaign is informative or misleading. And, asking these questions would lead to the first stage of advertising involving education in HPV, not Gardasil. The ads may involve mothers and fathers talking to their daughters about HPV, or could be in the form of educational pamphlets and web-based seminars for health care providers
In return, Merck would not just lobby for mandatory vaccinations, but for vaccinations and HPV/vaccine education in grade schools. The education in the school systems would involve informing the parents and guardians of the children about the benefits of the vaccine, thereby minimizing the impact of addressing sexual behavior with children. Merck would be able to incorporate finding out when parents and guardians are comfortable with learning about HPV vaccinations into their market research efforts for Stage I. Thus, Merck would be able to determine how much time parents need to be educated in the subject, and lobby for the amount of parental education necessary.

Does one Ad Apply to Everyone, Everywhere? : Stage II
For Stage II, Merck would use all of the information gathered during the market research phase, and determine how answers to their questions may vary according to race, ethnicity, age, gender, culture, and socio-economic status amongst other variables. Currently, there are not many variations to the “One Less” advertisements. Merck, has not marketed to conservative groups, transgender individuals, immigrants, or partners of those getting the vaccine. By performing the necessary market research for Stage I, Merck’s marketing directors would understand the challenges faced with being from a conservative culture and bringing up the topic of sexual behavior with children, and the impact of a partner asking their loved one to be vaccinated.
In one example of a Gardasil commercial there are eight different women individually, in the form of a soliloquy saying they want to be “One Less.” And they are saying everything during the commercial in perfect English, and with “American” mannerisms. It is not until the last ten seconds of the ad do they show a group of young girls, jump roping, saying “O-N-E-L-E-S-S,” appealing to a group of people who collectively agree that one should be vaccinated with Gardasil. There is not a single example of a mother saying the importance of talking to their daughter(s) about HPV, a partner talking to another partner, be it a heterosexual or a homosexual relationship, about getting vaccinated, or an example of a religiously conservative person expressing the importance of the vaccine (12). By going through the steps of Stage I, Merck would have known that a Muslim mother still may not feel comfortable talking to their husband or boyfriend about being vaccinated or having their daughters vaccinated, after seeing the advertisement described above. And, Merck would understand that some cultures are more community oriented, and the opinions of others matter more than their own individual opinion. After doing the research, and learning about the different educational requirements for each culture, Merck might have benefited from including a group of ethnic women who do not speak perfect English, sitting together, discussing HPV in their ads.
Avoid a False Sense of Security, a Riled Up Crowd : Stage I & Stage II
On June 9, 2006, Gardasil was approved by the FDA. And, on November 23, 2006 Merck launched its print, online and television advertising campaign for the vaccine (13). By February of 2007, Merck had already started lobbying for mandatory vaccinations in schools. They had only been marketing the vaccine for two months with advertisements like the one involving eight women mentioned earlier. In that same ad, one woman says “Gardasil will not treat cervical cancer,” and the woman right after her says, “Ask your doctor about getting vaccinated with the only cervical cancer vaccine” (12). Merck prematurely marketed the vaccine as one that prevents cervical cancer to a public that, in two months of advertising, had not been educated in HPV, the causes of cervical cancer, the fact that HPV is not the only cause of cervical cancer, and that even if one is vaccinated they still might end up with the cancer. Once Merck started lobbying for mandatory vaccinations, the public knew two things: that Gardasil is a cervical cancer vaccine, and that HPV is related to sexual activity. Gardasil is not a cervical cancer vaccine, so the public was misinformed and had a false sense of security in the vaccine. And, even though HPV is caused by sexual activity, they were not ready to be introduced to a mandatory vaccine for a controversial topic: sexual activity.
Had Merck followed a two-stage process for promoting the vaccine, and included a broader educational portfolio into their marketing campaign, their lobbying attempts and advertisements may not have caused such a great sense of distrust in a FDA approved vaccine. Instead of releasing the Gardasil ads five months after approval, Merck could have waited, done the research for Stage I of advertising, and been more effective by gaining the trust of the public. The two-stage approach of educating and then promoting the vaccine would force Merck to fully inform the public in HPV, and then push for mandatory vaccinations. By the time the lobbying efforts would be known to the different communities, the individual people making up the communities would be more accepting to the idea of having their daughters vaccinated, and they would have understood the value in having mandatory vaccinations in schools.
Conclusion : Money was not Discussed, and it won’t be
The two-stage approach to promoting a vaccine discussed in this paper, does not take into consideration the monetary impact of having twice as many marketing campaigns. However, one would hope that for FDA approved vaccines, and products affecting a person’s health, pharmaceutical companies will be able to fabricate, and re-organize their Research and Development and Marketing budgets to allow for better education of the public, and find value in equating education and product promotion. And, one would hope that lawmakers would see the benefit in aiding pharmaceutical companies in providing more information on the vaccines and the viruses. Maybe, one day it will become common practice to conduct Stage I type activities while doing clinical trials for the vaccine or drug at the same time. But, until education and product promotion have equal weight in the public and private sectors, we will continue to have vaccines quickly marketed to an ignorant public, and public opposition to effective vaccines.
References
"Cervical Cancer Basic Information." Centers for Disease Control and
Prevention: Your Online Source for Credible Health Information. 22 Dec. 2008. Department of Health and Human Services. 27 Mar. 2009.
2."Efforts to Make Gardasil Mandatory Stall in Some States." The National Health Federation: A Not-For-Profit Health-Freedom Organization. 24 Apr. 2008. National Health Federation. 4 Apr. 2009.
Edberg, Mark. Essentials of Health Behavior: Social and Behavioral
Theory in Public Health. Boston: Jones and Bertlett, 2007
4. "Facts about Cervical Cancer." Michigan Cancer Consortium. Feb. 2009. Michigan Department of Community Health. 4 Apr. 2009.
5. "FDA Licenses New Vaccine for Prevention of Cervical Cancer and Other Diseases in Females Caused by Human Papillomavirus." U.S. Food and Drug Administration. 8 June 2006. U.S. Department of Health & Human Services. 27 Mar. 2009.
6. Gerend, Mary A., and Zita F. Magloire. "Awareness. Knowledge, and Beliefs about Human Papillomavirus in a Racially Diverse Sample of Young Adults." Journal of Adolescent Health 42 (2008): 237-42.
7. Halcomb, Bryan, Joanne M. Bailey, Kathleen Crawford, and Mack T. Ruffin IV. "Adults' KNowledge and Behaviors Related to Human Papillomavirus Infection." Journal of the American Board of Family Medicine 17 (2004): 26-31.
8. "HPV Vaccination Information for Young Women." Centers for Disease Control and Prevention. 26 June 2008. Department of Health and Human Services. 27 Mar. 2009.
9. "HPV Vaccine." National Conference of State Legislatures: The Forum for America's Ideas. Apr. 2009. 4 Apr. 2009.
10. Jones, Bethany. "Gardasil Marketing Campaign for Cervical Cancer Misses the Mark." Associated Content: Information from the Source. 10 Oct. 2007. 27 Mar. 2009.
11. "Mandatory Vaccination with Merck's Gardasil Raises Eyebrows." Seeking
Alpha. 7 Feb. 2009. 23 Mar. 2009.
12. Merck. "Gardasil Commercial." YouTube. Nov. 2006. .
13. "Merck Launches National Advertising Campaign For GARDASIL, Merck's
New Cervical Cancer Vaccine." Medical News Today. 23 Nov. 2006. 27
Apr. 2009 .
14. "Merck lobbying States to mandate Gardasil for school girls." News-Medical.Net-Medical and Health News Headlines. 30 Jan. 2007. 4 Apr. 2009.

AIDS Intervention Strategies in India: A Socio-Political Approach Explaining Why They Are Ineffective – Nandini Ravishankar

India, a country with a population of one billion, is experiencing a rapid and extensive spread of AIDS. When HIV infection was discovered in India in 1986, the health authorities set up the National Aids Control Organization (NACO), which was primarily funded by the World Bank and technically supported by the World Health Organization (WHO) (9).

The current AIDS estimate suggests that the national adult HIV prevalence in India is 0.36 percent, amounting to between 2.5 and 3 million people. This number has seen a drop of nearly 50 % from the previous estimate of 5.2 million people living with HIV/AIDS (9). However despite a decrease in the overall number of people afflicted with AIDS, the current numbers are considerably high with most of the affected population losing out on the productive years of their lives. The prevalence rate for men is 0.43% while for women it is 0.29%. Prevalence is also high in the 15-49 age group (88.7% of all infections) indicating that AIDS still threatens the cream of society, those in the prime of their working life (20,23).

However, despite the work being done to tackle the crisis, there are some hurdles that may hamper the progress of the current interventions. Disparities still exist in the effectiveness and applicability of the interventions to vulnerable populations. The strategies adopted by the National AIDS Control Organization (NACO) to mitigate AIDS in India have been ineffective because social and political pressures prevent the right groups from being targeted.

1. Adolescents are not provided with adequate education about HIV/AIDS

Social Learning Theory is based on the tenet that people do not learn behaviors in a vacuum, isolated from external interactions (1). The theory stressed that a large contribution to adopting behaviors stems from observing and then emulating the actions of others within an individual’s community. In Indian society, there is a high level of taboo associated with talking about sex. Much of the information is communicated through a non-verbal channel and there are estimates that about two-thirds of meaning is communicated nonverbally (13). When adolescents see their parents and other elders hesitating to talk about sex, it leads them to believe that sex is something to be embarrassed about and something that is negative in nature. Adolescents may also experience confusion as the message projected in the interventions may not be in line with their core values, the core values being ‘sex is not something to be discussed’. They are less likely to accept interventions that are against their core values and may thus dismiss the information and education provided.

As mentioned earlier, in India it is taboo to talk about sex and it is an even greater taboo for parents to talk about sex with their children. There have been many barriers that have been identified which impede parents from communicating with their children about sex and sexually transmitted diseases (STDs). Studies report that parents often feel inadequately informed, embarrassed and ineffective and have difficulty finding the right place and time for communication (12). Thus parents often do not talk about sex and the adolescent is reprimanded for asking questions about sex. Parental education allows the adolescent to incorporate the idea of sex in a way that is in line with their core values. This would enable the adolescent to be better informed and better adjusted to the concept of sex and sexually transmitted diseases. Parents can also tailor the presentation of information to the life circumstances and social and familial context of the adolescent (12).

In the absence of parental communication, adolescents often turn to other sources to get more information. Recent work has supported the position that peers are often responsible for the onset of risk behaviors in adolescents (25). This work implies that although teens acquire information regarding risk behaviors from parents, teachers and the media, peers may also play a crucial role in a child’s development by shaping his/her normative beliefs and interpretation of information regarding risk activities (24). Becoming a member of a peer group is one of the primary developmental tasks of adolescence (4). Peer groups influence adolescent socialization and identity by allowing young individuals to explore individual interests and uncertainties while retaining a sense of belonging and continuity within a group of friends (8). Although a key aspect of normal adolescent development, there may be costs associated with becoming a member of a group of people. Some have considered peer pressure the ‘price of group membership’ (3), which research has linked to a variety of potential problems including substance abuse, risk-taking behavior and delinquency as well as dating attitudes and sexual behavior. For many young persons, substance use, risk-taking behavior and sexual activity may represent efforts to ‘conform to the norms of the group and to demonstrate commitment and loyalty to other group members’ (15).

Another frequent source of information for adolescents is the media, which influences how adolescents think and is likely to have a great impact on their behavior. The modeling theory is particularly relevant to the study of mass communications because the portrayal or description of social life is a frequent subject in the media. The actors who portray real people in visual, auditory or print media often serve as role models for others to imitate (6). As seen with other behavioral influences, the negative consequences of risk-taking behavior are rarely mentioned in the media in a way that would provide adolescents with important information. In the current scenario, the message that adolescents get is that it is acceptable to indulge in risky sexual behavior without experiencing any negative consequences. This contributes to an increase in sexual risk taking behavior among adolescents as they believe in the ‘feel good’ message being projected without considering the reality of the situation (8).

2. Social Stigma attached to HIV/AIDS

In many Asian countries including India, homosexuality is still a taboo. The social ostracism is also evident from the fact that homosexuality is considered a crime by the Judicial System in India. The statute does not directly state the ban on homosexuality but follows a law that was set by the ruling British Government in 1860. The Indian Penal Code (Section 377) states that: “Whoever voluntarily has carnal intercourse against the order of nature with any man, woman or animal, shall be punished with imprisonment for life, or with imprisonment of either description for a term which may extend to ten years, and shall also be liable to fine”. The punishment for this crime ranges from 10 years to life imprisonment. The word ‘carnal intercourse’ being vague, it has often been used against homosexuality (21). To bring about change in the current status of the HIV/AIDS epidemic in India, drastic changes need to be brought about not only at the societal level but also at the judicial level.

Goffman (1963) defined stigma as any condition, attribute, trait of behavior that symbolically marked off the bearer as ‘culturally unacceptable’ or inferior with consequent feelings of shame, guilt and disgrace (10). There is a high level of stigma that is associated with HIV/AIDS and very often, people do not confess that they have the illness which explains why the heterosexual partner, in most cases the woman is afflicted with the virus as well. The spread of HIV in India has been at its peak in the Western and Southern part of the country (19). Stigma associated with HIV-AIDS negatively impacts people’s decision regarding whether and when to be tested for the virus (26). Stigma therefore is a crucial aspect that needs to be understood in the management of people with HIV/AIDS. Stigma not only exists in the general community but also exists within the homosexual community itself. Results of a study indicated that many HIV-positive gay men perceived a division within the gay community related to HIV/AIDS. Their perceptions that HIV-negative men held stigmatizing attitudes toward HIV-positive men included feelings of sexual rejection and discrimination (5).

Social stigma and ostracism against homosexuality are held not only by society, but by the families as well. Homosexual men often are faced with the difficulty of dealing with the cultural expectations of their parents. They experience parental pressure to get married, have children, carry on the family name and traditions and not bring shame to the family by individual behavior choices and nonconformity (2). As a result of these expectations, many homosexual men choose not to come out of the closet. This prevents them from obtaining and having access to the right preventive information regarding HIV/AIDS. The perceived failure of meeting parental expectations associated with the role of the son, as well as the shameful stigma associated with homosexuality often leads the gay son to hold negative emotions like guilt, shame, low self-esteem, social inhibitions and insecurities (2). Very often, homosexual relations are maintained in secret without the knowledge of the family and in such situations, safe sex and the use of condoms take a backseat as keeping the relationship secret becomes the first priority. Choi et al. (1998) also conducted another study where they found that family obligations and homophobia in the community, along with negative sterotyping, marginalization contributed to low self-esteem and in turn resulted in risk-taking and lapses to unsafe sex (2).

The law criminalizing homosexuality has led to interventions that are designed to tackle HIV/AIDS but have not taken into account the needs of the gay community. Few published research studies have delved into the lives, the minds and the hearts of gay men to understand their feelings, attitudes, experiences and values. As a result, the public health interventions have failed because they have not targeted the core values of one of their target audiences: the gay community (18). One example of a shortcoming evident in the HIV/AIDS intervention programs that stems from a lack of insight into the lives, feelings and experiences of gay men is the virtual disregard for risk reduction as opposed to risk elimination strategies and the reluctance to candidly discuss, rather than merely dismiss as deviant, unsafe sex. As a consequence of the failure of the interventions, a sense of hopelessness and complete lack of control has arisen among gay men (18). Because they do not really believe that they will use a condom each time, many men assume that they are destined to become infected and therefore see no point in using condoms at all (11). This is an important issue to consider when initiating HIV/AIDS interventions. The needs, feelings and attitudes of the gay community must also be included. Thus, to tackle the HIV/AIDS crisis in India, interventions must not only focus on the heterosexual population and youth but must also address the fears and concerns of the gay community.

While it is important to address the individual behavioral factors that contribute to HIV/AIDS, it is also important to contextualize the risk factors, that is, attempt to understand how people come to be exposed to the individually based risk factors to design more effective interventions. By this, interventionsists must use an interpretive framework to understand why people come to be exposed to risk factors and the circumstances that shapes their exposure to the risk factors (14). For example, it is important in the framing of interventions to contextualize the risk factors for HIV/AIDS which would give a better understanding of why some people cannot avoid the risk. In a patriarchal society like India, it is important to understand the reasons why commercial sex workers are unable to get the men to practice safe sex which consequently may lead to an increase in the levels of HIV/AIDS in the sex workers.

3. Political factors impede HIV/AIDS Interventions

In a developing country like India with a population of one billion, there are structural inequalities that come with the treatment of HIV/AIDS. There are often other diseases and illnesses which take precedence over AIDS and the social taboos often play a role in influencing political agenda as well (16). Parker (2002) reported that a range of structural inequalities intersect and combine to shape the HIV/AIDS epidemic. There is an increasing gap between the rich and poor states with regard to public resources available for health, with resultant disparities in health outcomes (16). A major political concern that interventions need to consider and address is the reduction in the role of the central government in health care delivery. With decentralization and privatization being the answer to fill the gap in health care delivery, safety nets for the poor, especially those in the rural areas are being threatened. According to the WHO, India continues to bear the burden of the highest number of tuberculosis patients (7). With TB being an overwhelming burden and the leading cause of death in the country, there is less emphasis and priority given to HIV/AIDS. NACO programs are also supplemented by state level agencies, with great variabilty in terms of emphasis given by each state to the HIV/AIDS crisis. Many states are still in denial about the spread of HIV/AIDS within the state and thus are unwilling to provide money to tackle the crisis (7). Thus in order to address these concerns, more HIV/AIDS interventions need to be conducted at the state level to ensure that all citizens of the country have access to the same level of services and state governments must be required to co-ordinate activities in accordance with NACO. The partisan views of the various political parties must be addressed and modified for any effective change to occur in HIV/AIDS interventions at the political level.

Framing according to Tversky and Kahneman (1981) is ‘focusing the attention of people within a field of meaning’. Framing theory suggests that how something is presented (‘the frame’) influences the choices people make. The agenda setting theory is also closely related to the Framing theory (22). This theory states that agenda setting not only tells individuals what to think of an issue but also how to think about that issue. The agenda setting theory states that in order to get people to pay attention to the information, they have to view it as important and relevant (27). Thus, the moral, core values and principles of the current ruling political party determine how the crisis of AIDS will be tackled. The framing and agenda setting theory explain why conservative political parties would be more likely to promote the thinking that commercial sex workers are the most high risk populations as this is in line with social thinking and is likely to garner them more election votes. Thus by projecting AIDS as an issue among heterosexual individuals, the conservative political parties ignore the presence of AIDS among the homosexual population.

The Health Belief Model (HBM) was developed to explain health-related behavior at the level of the individual decision maker. The Health Belief Model (HBM) proposes that individual health beliefs associated with a disease or medical condition (i.e. perceived vulnerability to HIV/AIDS) determines their likelihood of engaging in preventive health actions (eg: use of condoms to prevent exposure) (17). The interventions developed by NACO also operate on the same rationale. It is believed that as long as individuals are provided with the interventions, they will utilize it based on their health beliefs. However the model and the consequent interventions fail to take into account socio-cultural factors. According to Choi et al., HBM has limited utility in addressing environmental factors affecting HIV risk because they ignore the wider social context within which the individual must circulate such as the family, and any communities of which an individual may be a member (2). Furthermore, the model assumes that all behavior is the result of a cost/benefit analysis, of calculated rational thought following the principle of self-interest. The Health Belief Model views the individual as devoid of emotion even though interacting with the wider social environment may entail situational and emotional difficulties for the individuals that consequently affect HIV risk (2). As seen with the model, there is a tendency for those in power to operate with an ‘inside the box’ rationale and an unwillingness to explore new avenues for progress. Combined with the bureaucratic and political pressure, there is an increased likelihood of interventions being built on top of earlier interventions with few modifications. While this may work for a certain period of time, it is important to acknowledge that interventions need to change with the changing times.

Implications for Future Interventions and Policy Decisions

In the light of the above mentioned factors, future interventions undertaken by NACO must therefore take into account socio-political factors. The crisis of AIDS can be successfully addressed only when all individuals who are at risk of contracting AIDS are targeted to receive the interventions. By excluding a particular group or ignoring important factors that may impact the prevalence of AIDS, the current interventions exhibit a lack of informed implementation. Despite being the largest democracy in the world, India still faces political hurdles that diminish the effectiveness and applicability of public health interventions. With the AIDS epidemic being a threat to the population of the country, more steps need to be taken to tackle the concerns at the grass root levels. While the current interventions have been shown to be marginally effective, it becomes more imperative to develop interventions that don’t just follow what has been done before but which incorporate the concerns of the diverse at-risk populations. Changes must originate at the grass roots level and must address individuals in the rural and urban areas. Changes need to be brought about at the societal and the judicial level for the gay community to feel accepted and acknowledged. Only when interventions addressing all populations and all concerns are developed will the battle on HIV/AIDS be successful.

REFERENCES

1. Bandura A. Social Learning Theory. New York: General Learning Press, 1977.
2. Choi KH, Yep GA and Kumekawa E. HIV Prevention among Asian and Pacific Islander American Men who have Sex with Men: A Critical Review of Theoretical Models and Directions for Future Research. AIDS Education and Prevention 1998; 10:19-30.
3. Clasen DR and Brown BB. The Multidimensionality of Peer Pressure in Adolescence. Journal of Youth Adolescence 1985; 14:451-468.
4. Coleman J and Hendry L. The Nature of Adolescence. London and New York: Routledge, 1987.
5. Courtenay-Quirk C, Wolitski RJ, Parsons JT and Gomez CA. Is HIV/AIDS Stigma Dividing the Gay Community? Perceptions of HIV-Positive Men who have Sex with Men. AIDS Education and Prevention 2006; 18:56-67.
6. Defleur ML and Ball-Rokeach SJ. Socialization and Theories of Indirect Influence (pp. 202-227). In: Defleur ML and Ball-Rokeach SJ. Theories of Mass Communication. New York, NY: Longman, 1989.
7. Ekstrand M, Garbus L and Marseille E. HIV/AIDS in India. University of California San Francisco: AIDS Policy Research Center, 2003.
8. Gardner M. and Steinberg L. Peer Influence on Risk Taking, Risk Preference and Risky Decision Making in Adolescence and Adulthood: An Experimental Study. Developmental Psychology 2005; 41:625-635.
9. Godbole S. and Mehendale S. HIV/AIDS epidemic in India: Risk factors, Risk behavior and Strategies for prevention and control. Indian Journal of Medical Research 2005; 121:356-368.
10. Goffman E. Stigma: Notes on the Management of Spoiled Identity. New York: Simon and Schuster, 1963.
11. Green J. Flirting with Suicide. The New York Times Magazine 1996; 39-85.
12. Jaccard J, Dodge T and Dittus P. Parent-Adolescent Communication about Sex and Birth Control: A Conceptual Framework. New Directions for Child and Adolescent Development 2002; 97:9-41.
13. Burgoon JK. Nonverbal Signals. In Knapp ML and Miller GR, eds. Handbook of Interpersonal Communication. Thousand Oaks, CA: Sage, 1985.
14. Link BG and Phelan J. Social Conditions as Fundamental Causes of Disease. Journal of Health and Social Behavior 1995; Extra Issue: 80-94.
15. Newman PR and Newman BM. Early Adolescence and its Conflict: Group Identity versus Alienation. Adolescence 1976; 11:261-274.
16. Parker R. The Global HIV/AIDS Pandemic, Structural Inequalities, and the Politics of International Health. American Journal of Public Health 2002; 92:343-346.
17. Salazar MK. Comparison of Four Behavioral Theories: A Literature Review. AAOHN Journal 1991; 39:128-135.
18. Siegel M and Doner L. The Importance of Formative Research in Public Health Campaigns: An Example from the Area of HIV Prevention among Gay Men (pp. 66-69). In: Siegel M and Doner L. Marketing Public Health: Strategies to Promote Social Change. Sudbury, MA: Jones and Bartlett, 2004.
19. Thomas BE, Rehman F, Suryanarayanan D, Josephine K, Dilip M, Dorairaj VS, and Swaminathan S. How stigmatizing is the Stigma in the Life of people living with HIV: A Study on HIV Positive Individuals from Chennai, South India. AIDS Care 2005; 17:795-801.
20. National AIDS Control Organization. HIV Data. New Delhi: National Aids Control Organization. http://www.nacoonline.org/Quick_Links/HIV_Data/
21. The Indian Penal Code - http://nrcw.nic.in/shared/sublinkimages/59.pdf
22. Tversky A and Kahneman D. The Framing of Decisions and the Psychology of Choice. Science 1981; 4481:453-458.
23. UNAIDS. 2006 Global Report on the AIDS Epidemic. http://data.unaids.org/pub/GlobalReport/2006/2006_GR_ANN1A-L_en.pdf
24. Cox AD and Cox D. Beyond “peer pressure”: A Theoretical Framework for Understanding the Varieties of Social Influence on Adolescent Risk Behavior. Washington DC: Social Marketing Conference, 1998.
25. Wentzel KR. Social Influences on School Adjustment: Commentary. Educational Psychology 1999; 34:59-69.
26. Chesney MA and Smith AW. Critical Delays in HIV Testing and Care: The Potential Role of Stigma. American Behavioral Scientist 1999; 42:1162-1174.
27. Edberg M. Communications Theory (pp. 67-68). In Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett, 2007.

Why Promoting Abstinence-Only-Until-Marriage Is Not The Right Solution For Fighting The STD Problem Among American Adolescents - Andrea Niederhauser

The Center for Disease Control and Prevention (CDC) estimates that out of the 19 million new STD infections that occur every year, approximately half of them affect sexually active adolescents between 15 and 24 years (1). Furthermore, the CDC identified “sexual behaviors that contribute to unintended pregnancy and sexually transmitted diseases (STDs), including human immunodeficiency virus (HIV)” (2) as one of the six leading causes of morbidity and mortality among adolescents. This is reason enough to consider STD-infections among adolescents as a major public health issue and to examine the main prevention and intervention activities which target this problem.

In 2004, President Bush incorporated the STD problem among adolescents in his State of the Union Address and declared that “Each year, about 3 million teenagers contract sexually-transmitted diseases that can harm them, or kill them, or prevent them from ever becoming parents. In my budget, I propose a grassroots campaign to help inform families about these medical risks. We will double federal funding for abstinence programs, so schools can teach this fact of life: Abstinence for young people is the only certain way to avoid sexually-transmitted diseases”(3). This quotation demonstrates that the government is of the opinion that STDs and other health threats due to sexual behavior can be effectively prevented through the promotion of sexual abstinence.

First started in 1981, federal funding for abstinence-only-until-marriage programs has currently reached up to 176 million dollars annually (4). However, while the government continues to pour money into these educational programs, more and more studies show that the abstinence-only approach to STD prevention is not successful. Programs which promote abstinence-only-until-marriage fail in preventing STD-infections among adolescents for three main reasons; they consider sexuality as inherently problematic, they neglect the fact that imposing a normative behavior on teenagers can be counterproductive and they don’t take into account the various social and cultural norms which influence the sexual behavior of adolescents.

Definition and prevalence of STDs among adolescents

The term Sexually Transmitted Disease (STD) refers to a number of diseases, including Chlamydia, Gonorrhea, Genital Herpes and Syphilis, which are passed on from one person to the other through any sort of direct sexual contact. One particularity of STDs is that they are often asymptomatic; as a result, the diseases can be present and transmitted without the knowledge of the infected person and measuring the prevalence of STDs in a population can be imprecise or inadequate. STDs can be diagnosed through blood tests or a culture and can be treated with antibiotics. Having an STD can be a major health threat; it can damage the female reproductive organs and lead to infertility, cause genital infections and can be passed on to a baby during pregnancy or birth (5).

Estimates for the year 2000 suggest that out of a total of 18.9 million new STD infections, 9.1 million or 48% occurred among young people aged 15 to 24 (6). A recently released CDC study found that one in four, or 26% of all American teenage girls aged 14 to 19 have at least one STD (7). For that reason there is no doubt that STD infections among adolescents are a major public health threat and need to be addressed as such.

The flaws of the abstinence-only-until-marriage concept

The American government realized already in 1981 that sexual health problems among American teenagers are a growing public health concern. As a consequence, the Regan administration decided to address the crisis through the promotion of sexual abstinence as the only way to avoid negative health outcomes and established the Adolescent Family Life Act in order to promulgate this concept (8). As mentioned in the introduction, President Bush has carried on with this ideology and has even strengthened the federal stance on the topic by steadily increasing the annual funding into abstinence-only programs.

In 2007, the US government has allocated a total of $176 Million into three separate abstinence-only programs; the Community-Based Abstinence Education Program, the Social Security Act, Title V, Section 510 education programs and the Adolescent Family Life programs (9).

The Social Security Act, Title V includes a list of the eligibility criteria for programs to receive funding. It defines abstinence education as “an educational or motivational program” which “(A) has as its exclusive purpose, teaching the social, psychological, and health gains to be realized by abstaining from sexual activity; (B) teaches abstinence from sexual activity outside marriage as the expected standard for all school age children; (C) teaches that abstinence from sexual activity is the only certain way to avoid out-of-wedlock pregnancy, sexually transmitted diseases, and other associated health problems; (D) teaches that a mutually faithful monogamous relationship in context of marriage is the expected standard of human sexual activity; (E) teaches that sexual activity outside of the context of marriage is likely to have harmful psychological and physical effects; (…)” (10).

This quotation gives an idea of how the government conceptualizes abstinence and sexuality. Sexual activity and marriage are strongly tied together; (heterosexual) marriage is defined as the norm of human relationships and sexual intercourse is expected to exclusively take place within the boundaries of this social institution. In addition to that, premarital sexuality and adultery are condemned as problematic and harmful. Throughout the paper, we will see how this understanding of sexual activity and abstinence is one of the main reasons why abstinence-only programs cannot be successful in preventing STDs among adolescents.

Sexuality as a deviant behavior

One of the principal flaws of the abstinence-only programs is the assumption that the rate of STDs can be decreased by preventing youth from engaging in sexual intercourse. However, sexual activity is a crucial part in the life of teenagers and cannot simply be eliminated.

“What we believe sexuality is, or ought to be, structures our responses to it (11)” Jeffrey Weeks writes in his book on sexuality. The author argues that a belief that accepts sexual activity only within the boundaries of social institutions such as heterosexuality, family and marriage and otherwise blames it to be harmful and disruptive and in need of strict regulation, can be called an absolutist position (12). Accordingly, the US government has clearly adopted an absolutist position in regard to teenage sexual behavior. Sexual activity is perceived as “likely to be harmful”, point proven by the high STD prevalence among adolescents (along with teenage-pregnancy and HIV-infections). By consequence, the logical response appears to be the suppression of such harmful behavior and the promotion of sexual abstinence.

While the federal government clings to this essentialist concept of sexuality, it neglects the fact that various social processes in Western cultures over the last four decades have brought by a new understanding of sex. The use of contraceptives allowed women to have more control over the outcomes of sexual intercourse and increased sexual activity outside marriage. The weaker commitment to authorities such as religion and the higher individualism and self-reliance emphasized the idea of personal liberation and sexual fulfillment (13). Finally, academic discourse shifted the understanding of sexuality from an essentialist to a constructivist approach, pointing out that the meaning that a society attributes to sexuality is always shaped by various social and cultural forces (14).

These examples show that American teenagers currently experience their sexuality in the midst of the tensions between the restrictive, conservative moral embodied by abstinence-only programs and the messages of a sexually liberated culture. As Lynn Ponton puts it “American teens are faced with taboo, miscommunication, and often direct prohibition that may contradict other messages they receive from the culture at large (15).

After an increase of sexual activity in the 1960s and 70s, especially among teenage girls, the number of adolescents having sexual contacts has stabilized in the last few years (16). According to the CDC Youth Risk Behavior Survey of 2005, 46% of all the surveyed 9^th through 12^th graders have had experienced sexual intercourse; 33% of them were sexually active in the three month preceding the survey (17). There has been a slight decrease in the number of adolescents who are sexually active, compared to previous years. This fact is often used as a proof of success of the abstinence-only programs. However, a national congress authorized evaluation of four abstinence-only programs concluded that abstinence-only programs did not have a significant impact on the sexual behavior of the adolescents. The findings suggested that teens enrolled in abstinence-only programs were not more likely to abstain from sex than the ones in the control group (18). The same conclusion can be found in the study of Jemmott and colleagues, which showed in a randomized controlled trial that abstinence intervention did not have a long-term effect in reducing sexual activity among the African American girls in the study (19).

The aforementioned statistics show that sexuality is a vital part in the life of almost half of the adolescent population. This is not only due to the fact that the teenage years are a period of biological “awakening”, but also because sexual behavior is a much encouraged behavior in modern society. Abstinence-only programs will continue to be inefficient because they are asking “that they [the adolescents] “just say no” to sex despite the ubiquitous message that it will transform their lives” (20). In addition to that, the negative attitude towards adolescent sexuality can result in adverse health effects, because they stigmatize the individuals who have already chosen to have sex and the ones who have already contracted an STD, as well as the homosexual teenagers who won’t be able to satisfy the “expected standard” of heterosexual marriage.

In order to address negative health outcomes related to sexual activity, public health interventions need to challenge the traditional position which labels adolescent sexuality as deviant behavior outside tolerable standards. Instead, they should accept the fact that teenagers do have sex, promote responsible sexual activity as the new social norm and engage in an open-minded and honest discussion around the topic.

Imposing a normative behavior is counterproductive

Adolescence is a period when young people are starting to detach themselves from their parental “shelter”, and when they want to take control over their lives and make their own decisions. Rather than acknowledging that young people want to decide on their own what is best for them, abstinence-only programs try to make adolescents adopt one normative behavior. This can be counterproductive, as it can provoke rebellion against the norm and encourage teenagers to engage in sexual risk behavior.

Youth does in general not appreciate when they are being told what to do (21). The more adolescents feel they are forced to do something that others believe is best for them, the more likely they will rebel against this imposed behavior. A paper on adolescent alcohol consumption for example suggests that “Drinking may become a behavior that is symbolic of defiance of authority; it may become an expression of rejection of the normative demands of the social order and of those who enforce them” (22). Rather than complying with the standards set by parents or school teachers, adolescents adopt a certain deviant behavior as a sign of rebellion against the expected norm. It can be argued that this is not only true for alcohol consumption or smoking, but also for sexual behavior. Abstinence-only programs try to tell youth what is good for them and what they should do and not do. By preaching to them which behavior is socially expected, abstinence-only programs might therefore cause adverse reactions in youth and give them incentives to adopt these “forbidden” behaviors.

In Europe, STD and HIV prevalence is a much less significant problem than in the US. One reason for this could be that in general, European countries adopt a different approach to adolescent sexuality. European sexual health interventions do not try to prevent adolescents from having sex and do not stigmatize sexuality as a problematic behavior. Instead, they acknowledge that adolescent sexuality as a vital component of their life and therefore empower teenagers to adopt a healthy and safe sexual behavior. These interventions show adolescents that they are being taken seriously and trusted to make their own, responsible decisions when it comes to engaging in sexual relations (23).

Public health interventions need to recognize that adolescents want to be capable of “thinking, feeling, and making moral decisions that are truly your own, rather than following along with what others believe” (24). Acknowledging this fact can transform sex from an act of rebellion against the social norms and expectations, and can be rather serve as a domain where adolescents can prove their autonomy and ability to make responsible decisions.

The limitations of an individual-centered approach

Abstinence-only based STD interventions can also be criticized by the fact that they attempt to change an individual’s behavior without taking into consideration the various social and cultural factors influencing and determining this behavior.

The risk of the sexual transmission of diseases is tightly linked to the frequency of unprotected sex; intervention strategies therefore need to focus on reducing this frequency. This can be done in two ways; either by promoting abstinence from any sexual contact or by promoting responsible, safe sex (25). Both approaches include a change of behavior, however, while the first one focuses on imposing a restrictive, normative behavior on the individual, the latter acknowledges the complexities of adolescent sexuality.

One traditional theory of health behavior is the Health Belief Model, which suggests that adopting or changing a certain behavior is a process of rational decision making based on the evaluation of costs and benefits (26). The abstinence-only programs can be understood in terms of this model, because they expect that teaching adolescents the harmful outcomes of sexual activity will increase the perceived susceptibility to these risk as well as the perceived severity of the outcomes; the teenagers will then conclude that the benefits of abstaining from sex are higher than the negative consequences of being abstinent and will be incentivized to restrain from sexual activity.

Studies mentioned earlier in this paper however have shown that abstinence-only programs are neither successful in reducing sexual activity among adolescents sexual, nor in reducing the numbers of STD infections among adolescents. One of the main reasons for this is that abstinence-only programs do not account for the various norms, values and expectations which inform the behavior of the adolescents and their attitude towards sexuality, but rather treat the individual as an entity detached from any social context.

Public health research has increasingly shown that human behavior is embedded in a complex environment and that a person always acts within a network of interdependent individual, cultural, socioeconomic, political and environmental factors (27).

On an individual level, factors such as the awareness and level of information about health risks can influence the decision whether or not to engage in unprotected intercourse. This is what the classic Health Belief Model and the abstinence-only programs focus on.

Most often however, this decision depends on a larger set of social and cultural factors; for example the beliefs and values attached to sexuality through religious traditions and the positive or negative messages communicated through the family, peers, teachers and the media.

Pressure from peers or the media can be especially important in influencing adolescent sexual behavior. Peer pressure can be defined as a “subjective experience of feeling pressured, urged, or dared by others to do certain things” and can lead teenagers to willingly or reluctantly do some actions sanctioned by the group as a whole, because of the need for popularity, conformity and integration (28). A study among 1011 black and white middle-school kids showed furthermore that mass media had an important influence on the attitude of adolescent towards sexual as well. The media was found to be a major source of information for adolescents and, mostly depicting risk-free, recreational and non-married sex, often in contrast with the values taught at school or in the family (29).

On an even more fundamental level, sexual behavior can also be influenced by socioeconomic and structural factors. Financial reasons might restrain adolescents from accessing health care and confidentiality reasons or distrust in the system can be other reasons why adolescents would not seek out for care or counseling when needed (30).

While abstinence-only campaigns often treat adolescents as a monolithic, white, middle-class, heterosexual group (31), statistics also show that females and members of minority groups are disproportionately higher affected by STDs (and other sexually related health problems) than others. Unfortunately there are not many estimates on adolescents; however the currently released CDC study indicates that teenage girls are much more affected by STDs than men and that the rates are highest among African American girls (48% compared to 20% among white and Hispanic girls) (32). Racial disparities in health are associated with lower socio-economic status, poverty and poor education, but also with different cultural understandings and personal experiences of racism and discrimination (33). In relation to sexual behavior, research has for example shown that living in impoverished, racially segregated neighborhoods can be conducive to adolescent sexual risk behavior, because “in these neighborhoods, positive adult role models and adult supervision are scarce, and youth sexual activity may be considered normal and not an obstacle to future attainment” (34).

These findings suggest that interventions - such as the abstinence-only programs – which try to apply a one-size-fits-all solution to individual risk behavior, do not understand the fundamental factors which influence this behavior and do not acknowledge the complex web of interactions which govern the actions and decisions of the individual; therefore they will not be likely to provoke any change in behavior.

All these different points show that the decision of an adolescent to engage in (risky) sexual relations is influenced by a very complex set of factors and cannot be solely understood on an individual level. Rather than concentrating on preaching abstinence, STD interventions need therefore to embrace a comprehensive approach to teenage sexuality. Rational-empirical interventions are crucial in order to make sure that adolescents receive accurate information on the possible health threats of sexual intercourse, that they have the opportunity to evaluate strategies to avoid these risks and that all teenagers have equal access to condoms and STD screenings. However, public health interventions have to go beyond this level in order to understand the social context within which adolescents are socialized, the norms, expectations and pressures with which they are confronted in their daily social interactions and the fundamental structures which influence and determine their decisions.

Synthesis

Abstinence-only programs are not an effective strategy to prevent STDs among adolescents. They consider sexuality as harmful and uniquely acceptable within the boundaries of heterosexual marriage. Adolescents who cannot or do not want to comply to this standard, either because they already had sex, are sexually active or are homosexual are thereby stigmatized and deprived from vital information on alternative strategies how to avoid or treat STDs. In addition to that, abstinence-only programs try to regulate sexual behavior by telling adolescents what is good for them; an approach which likely can cause rebellion and higher risk behavior among adolescents. Lastly abstinence-only programs consider sexuality as a biological drive which can be suppressed through the will of the individual. However, it does not acknowledge that changing behavior is more than just a pure individual act of will and that behavior is often determined by larger social and cultural factors, such as socio-economic status, family processes and peer-pressure.

References

1. http://www.cdc.gov/std/stats/trends2006.htm; accessed on 2/28/2008.

2. Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance– United States, 2005. Surveillance Summaries, MMWR 2006;55(No. SS-5), page 1.

3. http://www.whitehouse.gov/news/releases/2004/01/20040120-7.html; accessed on 3/12/2008

4. http://www.siecus.org/policy/SpecialReports/Alabama_Report.pdf; accessed on 2/28/2008.

5. http://www.cdc.gov/std/; accessed on 4/2/2008.

6. Weinstock H., Berman S. and Cates W. Jr. Sexually transmitted diseases among American youth: incidence and prevalence estimates, 2000. Perspectives on Sexual and Reproductive Health 2004:36(1), p. 6-10

7. http://www.cdc.gov/stdconference/2008/media/summaries-11march2008.htm#tues1; accessed on 4/2/2008.

8. Perrin, K. and Bernecki DeJoy, S. Abstinence-Only Education: How We Got Here and Where We're Going. Journal of Public Health Policy, 2003:24(3/4), p. 445-459.

9. http://www.siecus.org/policy/SpecialReports/Alabama_Report.pdf; accessed on 4/2/2008.

10. http://www.socialsecurity.gov/OP_Home/ssact/title05/0510.htm#ft19; accessed on 3/19/2008.

11. Weeks, J. Sexuality. 2^nd ed. New York: Routledge, 2003, p. 105.

12. ibid. p. 105-106.

13. Joyner K. and Laumann, E.O. “Teenage Sex and the Sexual Revolution”. In: Laumann E.O. and Michael R.T (Eds). Sex, Love and Health in America. Chicago: The University of Chicago Press, 2001, p. 41-71.

14. Weeks, J. Sexuality. 2^nd ed. New York: Routledge, 2003, p.20.

15. Ponton, L. The sex lives of teenagers : revealing the secret world of adolescent

boys and girls. New York: Dutton, 2000, p.4.

16. Moore, S., Rosenthal, D. and Mitchell A. Youth, AIDS and sexually transmitted diseases. London: Routledge, 1996.

17. Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance – United States, 2005. Surveillance Summaries, MMWR 2006;55(No. SS-5).

18. Mathematica Policy Research Report http://www.mathematica-mpr.com/publications/pdfs/impactabstinence.pdf; accessed on 2/20/2008.

19. Jemmott, J. B. et al. Abstinence and Safer Sex HIV Risk-Reduction Interventions for African American Adolescents. A Randomized Controlled Trial. JAMA, 1998:279, p. 1529-1536.

20. Irvine, J. M (Ed). Sexual cultures and the construction of adolescent identities. Philadelphia: Temple University Press, 1994.

21. Hicks, J. The strategy behind Florida's "truth" campaign. Tobacco Control 2001:10, p. 3-5.

22. Norman, A.C. Alcohol and Adolescent Rebellion. Social Forces 1967:45(4), p. 542-550.

23. http://www.advocatesforyouth.org/publications/european.pdf, accessed on 4/10/2008.

24.http://www.ianrpubs.unl.edu/epublic/pages/publicationD.jsp?publicationId=54; accessed on 4/13/2008.

25. Jemmott, J. B. et al. Abstinence and Safer Sex HIV Risk-Reduction Interventions for African American Adolescents. A Randomized Controlled Trial. JAMA, 1998:279, p. 1529-1536.

26. For a discussion of the Health Belief Model see for example

Edberg, M. Essentials of Health Behavior. Social and behavioural Theory in Public Health. Sudbury: Jones and Bartlett, 2007, p.35-38.

27. Edberg, M. Essentials of Health Behavior. Social and behavioural Theory in Public Health. Sudbury: Jones and Bartlett, 2007, p.35-38.

28. Santor, D.A., Messervey, D. and Kusumakar, V. Measuring Peer Pressure, Popularity, and Conformity in Adolescent Boys and Gils: Predicting School Performance, Sexual Attitudes, and Substance Abuse. Journal of Youth and Adolescence, 2000:29(2), p. 163-182.

29. Ladin L’Engle, K., Brown J.D. and Kenneavy K. The mass media are an important context for adolescents’ sexual behavior. Journal of Adolescent Health 2006:38, p. 186-192.

30. American Social Health Association, State of the Nation 2005: Challenges

Facing STD Prevention Among Youth – Research, Review, and Recommendations, Research Triangle Park, NC: ASHA, 2005.

31. Irvine, J. M (Ed). Sexual cultures and the construction of adolescent identities. Philadelphia: Temple University Press, 1994.

32. http://www.cdc.gov/stdconference/2008/media/release-11march2008.htm; accessed on 3/12/2008.

33. SB721 Course Readings from March 27^th 2008.

34. Ramirez-Valles J., Zimmerman, M.A, Newcomb, M.D. Sexual Risk Behavior among Youth: Modeling the Influence of Prosocial Activities and Socioeconomic Factors. Journal of Health and Social Behavior, 1998:39(3) p. 237-253.