Forgetting Your ABC's- Stephanie Gould
Forgetting Your ABC’s
Although reports of the numbers of people infected with AIDS and HIV vary and are often unreliable, it is clear that HIV/AIDS , along with other STDs, remain a significant problem for the United States. Since the first AIDS case was identified in 1981, about 1.7 million people in the US have become infected (9). Among these, it is estimated that about half occur in people aged younger than 25, and about a quarter are found among those who are between 13 and 22 years of age (17). Similar trends are seen for STDs in general – there are roughly 19 million new infections each year, and half of these are among adolescents and young adults. Teenagers and young adults are also disproportionately affected; while they account for around half of all new STD infections, they represent only 25% of the sexually active population in the United States overall (11).
As such, it is clear that interventions need to be aimed at teens to decrease their susceptibility to STDs and HIV/AIDS. One such proposal has been the ABC program. ABC stands for “Abstinence from sexual activity, Be faithful to a single partner, and use Condoms”, three behaviors which are believed to reduce STD and HIV/AIDS transmission. This program has been reported to have had significant success in other countries, most notably Uganda, where, after implementation of this program, overall AIDS prevalence fell from 15% to 6.5% in Uganda nationally (18).
However, implementation of the ABC program was not all that Uganda did. The Ugandan government also targeted the stigma attached to HIV/AIDS, created more comprehensive educational opportunities, advocated testing and counseling, and improved the status of women, among other things (4). This suggests that the ABC approach was not sufficient to explain the decrease in HIV/AIDS prevalence alone (12). Specifically, the ABC approach, by itself, has significant limitations. It is an individual level based model that does not promote self-efficacy and is framed in such a way as to ignore contextual differences and create very limited possibilities for change. These three deficits together make ABC a particularly inappropriate intervention for teenagers.
Problem 1: Individual Level Model
One of the most important problems with the ABC intervention is that it is an individual level model. It focuses on the individual and actions the individual should take. It assumes that individual decision-making is what will ultimately determine action. It thus fails to take into account anything beyond the individual, including the social environment, such as social or cultural norms and racial or ethnic disparities among teenagers (6). Perhaps most importantly, there is no room in the ABC for social exchanges regarding abstinence or safer sex, which can have very detrimental health consequences.
Sex, and more specifically safe sex, among teens is inherently social and socially determined. For example, adolescents who discuss sex either with their peers or with their parents are more likely to use condoms. There is also evidence that the interaction is reciprocal – teens’ perceptions of what other teens think of a behavior affects how they think of that behavior. For example, if teens think that their peers think that condom usage, or abstinence for that matter, is ‘cool’, they are more likely to use condoms or remain abstinent respectively. Among those who’ve already had sex, those who are able to discuss sex on a social level are more likely to have safer sex by using a condom, while those who are unable to discuss it are less likely to engage in safe sex (8). This shows how sex is socially constructed. If there is no place within the ABC model for some sort of social exchange regarding sexual behavior change, the ABC model will fail.
There is also the concept of social modeling, the idea that if you see someone like yourself succeed, you are more likely to believe that you can succeed and are therefore more likely to try the beneficial behavior (1). Again, there is no room for this in the ABC intervention program. Because there is no social discussion or interaction built into the model, there is no way social modeling can take place. The ABC model thereby ignores a potentially very effective way to encourage actions that will limit the transmission and spread of HIV/AIDS and STDs. The ABC model ignores the social context of the specific individual and doesn’t place teenagers in a social framework within which they can operate as a collective group and influence one another in potentially beneficial ways.
One’s social environment as a whole can also significantly affect behavior. The ABC program doesn’t allow an individual to place him or herself in context, but rather leaves the person alone to change as an individual. It has been shown in a study regarding smoking that whether or not those in your social network smoke affects whether or not you will smoke. The more those around you do a certain behavior, the more likely you are to engage in that behavior (3). These findings can certainly be extrapolated to abstinence, fidelity, or condom use. Moreover, behavior change tends to happen on a social level, such that entire social networks adopt a certain behavior at the same time (3). An individual level model cannot account for such a phenomenon. By ignoring this, the ABC model again ignores a potentially useful strategy in promoting the ends they want to attain.
Change needs to happen within a social framework for it to be successful. No change can happen in isolation, either by an individual him or herself or by ignoring one’s social surroundings. Moreover, it has been proven that change happens on a social level, involving entire social networks at a time (3) and that social interactions can have positive effects on influencing change in an individual (8). The ABC model simply does not address this issue, and leaves individuals as mere individuals, ignoring all the potential benefits of including one’s social group as part of the intervention. In sum, the individual level model fails because sex is so inherently social that change regarding sexual behavior cannot happen or be modified in isolation. Group-level dynamics need to be taken into account for true change to occur, and the ABC does not do this because it works only on the individual level.
Problem 2: Lack of Self-Efficacy
Self-efficacy is one’s belief in his or her personal capabilities to change. In other words, it is the belief that one can change effectively and control his or her actions. It has been shown that people are more likely to act, and thus more likely to actually change, if they have higher self-efficacy. In order to gain self efficacy, individuals need to either have had positive outcomes in the past, have an opportunity to engage in social modeling with their peers, or have social persuasion, where they are persuaded by their peers to believe in themselves and their abilities to act effectively (1). Having self efficacy can then change one’s behaviors. For example, a study has shown that feelings of self efficacy around saying no to sex was associated with higher condom use with both regular and casual partners (16), showing that self efficacy can have very positive effects on behavior change when it comes to sexual behavior.
As we have seen, however, the individual-level ABC model does not foster self efficacy in any way. It actually keeps teenagers from building self efficacy in the ways suggested. It doesn’t allow for the last two methods of gaining self efficacy to happen, as social discussions and environments are ignored, so no social modeling or social persuasion can happen. As for the first method of building self efficacy, the ABC attempts to preempt any sexual activity, so teens would not have had experiences in the past from which they can learn. Although one might gain self efficacy by saying no to a sexual encounter effectively, the ABC model does not explain how to do this, only that you should do it, so it is unlikely that this will increase self efficacy significantly. There is no place in the ABC model for self efficacy to occur and, without self efficacy, one is less likely to successfully engage in behavior change (1).
It has been found that most Americans initiate sexual behavior during their teen years. Specifically, the median age for first intercourse for females is 17.4, while it is 17.7 for men (17). The 2001 National Youth Risk Behavior Survey indicated that around half of all high school students reported engaging in sexual intercourse, and rates of safe sexual intercourse vary widely across location (8). Therefore, it is clear that interventions need to happen during teenage years. Moreover, it is critical that teens are allowed to build self efficacy during this time, so that they feel confident in doing what ABC suggests they do – be abstinent, be faithful, and use a condom. Sexual education programs usual occur throughout high school, but are clearly not being effective as defined by the ABC model given the high prevalence of sexual activity among teens and the varying rates of safe sex. This may be in part due to a lack of self efficacy. As will be discussed, sexual education programs tend to focus on abstinence only in the United States, making it nearly impossible to build self efficacy regarding sexual activity or to go beyond abstinence only. Youths do not consider abstinence and sexual activity to be opposing constructs (11), and as such, are not as dichotomous as the ABC model would suggest or hope that teenagers are. It is therefore particularly important that teens build self efficacy around all three aspects of the ABC model if they ABC model is to have any positive effect. However, the ABC model makes it nearly impossible to create self efficacy around any of the three behaviors at all.
When it comes to self efficacy, it is also clear that there are gender differences. Women are the fastest growing population group with HIV (15), accounting for 35% of the HIV population in 1985 and growing to 50% in 2007 (6). This may be due to the fact that females need to be specifically targeted to improve their self efficacy. Gender norms create imbalances in power between the sexes, often to the detriment of females. The power imbalances often lead to women having less say in their sexual activities than their male counterparts, in all three aspects of ABC (12). While the power imbalance is clear in instances of rape or sexual violence, it is similarly relevant in consensual sex (13). Social context needs to be taken into account – stereotypes reinforce the idea that males should always want to have sex and should be having sex as often as possible. Stereotypes for females, however, often place them in a coerced position, where they are more likely to have sex even if they don’t feel ready for it and are less likely to make their desires (such as saying no or using a condom) heard (13). The Theory of Gender and Power posits that gender-based inequalities pervade society, which leads to male control over most sexual encounters (15). It is possible that if females had more self efficacy, they could regain some control in their sexual relationships and feel more empowered in either saying no to sexual intercourse, asking for a monogamous relationship, or asking to use a condom.
It is clear that the ABC program does not foster self efficacy, as it does not mention how to effectively engage in any of the specific behaviors mentioned in its model but only the actions one should engage in. The ABC model may even inhibit one from building any self efficacy by preempting any sexual activity and ignoring the social dynamics of sex (1). It is also clear that this lack of self efficacy can have very detrimental effects, particularly to females who suffer from a social environment in which they may be expected to be subservient to males when it comes to sex (15). As such, the ABC model again fails. If teens do not feel empowered or like they can successful engage in behavior change, they will not change their behaviors and the ABC model will be ineffective.
Problem 3: Framing – Lack of Context
A final limitation of the ABC model is how it is framed. This limitation is manifested in several ways. First, it ignores geographical differences and social norms, which in turn ignores the fact that HIV/AIDS and STDs are spread in different ways in different areas. Secondly, the way the intervention itself is framed, particularly in the Unites States – Abstinence until married, Be faithful to one partner, use a Condom – makes it a very limited model.
The ABC model is theoretically meant to be applied in the same way in every country and in every location. One can easily see how this is not a very good idea. For example, HIV/AIDS spread is different in geographic areas where the population is stable and in areas where there is heavy migration. It thus stands to reason that an intervention to stop or slow the spread of HIV/AIDS needs to be different in these two locations. More specifically, the stable population would need to focus on individuals being faithful while the migratory population would need to focus more on using prevention, as it is harder to be monogamous when potential partners keep moving (6). Differences in social norms will also change the way in which the ABC model is received and operates. In places where teens are already having sex and frequent sexual activity is the norm, a focus on abstinence will not be very helpful. However, the ABC model makes no reference to these distinctions, and assumes that the same intervention plan will work everywhere. It is obvious from these examples that it will not.
As for the second manifestation of this framing issue, it may be helpful to focus on the United States. The United States reauthorized the President’s Emergency Plan for AIDS Relief (PEPFAR) in 2007. A component of this plan was to encourage the use of the ABC model worldwide (5). However, the United States itself has interpreted the ABC model in a very limited way – Abstinence until married, Be faithful once married, and use a Condom always (unless trying to have a baby in wedlock) (14). Thus, given that the median age of marriage in the United States is 25.3 years for women and 27.1 years for men (17), the United States has emphasized abstinence only education for teenagers. This seems to makes sense, except that we know that around half of all high school teenagers are engaging in sexual intercourse (8). Regardless, the federal government will only give money to state schools that are willing to provide exclusively abstinence only education. The federal definition of an abstinence only education plan includes teaching that: abstinence is the only way to avoid out-of-wedlock pregnancy and STDs; a faithful, monogamous relationship within marriage is the expected standard of human activity; abstinence is the expected standard for all teenage children; sexual activity outside of wedlock is likely to have harmful psychological and physical effects; and that bearing children outside of wedlock is likely to have harmful consequences for the child, the child’s parents and society at large. While there is no clear definition of abstinence that the government provides, it is clear that, implicit in its definition, is a moral component that frames abstinence not merely as an act, but as an attitude (17).
These education programs, ostensibly following the ABC model that the US has funded internationally, provides no way to help teenagers who have not adhered to strict abstinence from sexual activity. Considering that most teenagers do not find abstinence and sexual activity to be mutually exclusive (11), it seems fair to assume that these programs are not helpful to most teens, especially the 50% who reported to the Nation Youth Risk Behavior Survey in 2001 that they had already had sex (8). Most importantly, these abstinence only education programs have not been proven to be effective in delaying onset of sexually activity. Rather, these programs increase the likelihood of these teenagers having unsafe sex and not using contraception (7). Promoting abstinence only, or even abstinence and fidelity, presents only part of the picture and can actually endanger teens by not giving them important information about protecting themselves from HIV/AIDS and STDs (14).
The United States may have also derived its limited interpretation of the ABC model from the way that the ABC model is framed. It is framed as a series of behaviors that may be seen as being presented in a sequential order, as in abstinence being the most optimal or the first option, then being faithful, and only then using a condom. This would explain why the United States federal government has focused its sexual education programs primarily on abstinence, then on fidelity and only then on condom use, even though there is consistent evidence that comprehensive sexual education programs are just as effective in promoting abstinence while at the same time providing important information to those who do not choose abstinence (17).
The framing of the ABC model, while named quite cleverly, makes it a very limited model. It doesn’t allow for contextual differences among different populations, and it seems to present the different behaviors in preferential order. This limits the model as well as its effectiveness by ignoring differences and applying the same model to everyone without accounting for discrepancies in specific situations. Without better framing that doesn’t allow for placing one behavior over the other as well as framing that allows different manifestations of the intervention strategy for different situations, the ABC model cannot effectively produce change.
All three of the critiques interact to make the ABC model an ineffective model for changing teenagers’ sex behavior. By ignoring the group-level and social dynamics that are inherent in teenagers’ sexual relationships, the model denies teenagers the ability to build any self efficacy. Without self efficacy, change is unlikely to be successful (1). The framing of the model underscores how the model ignores contextual and social differences, as well as self efficacy, which limits the effectiveness of the model in almost any setting.
It is clear from the data presented on the high number of teenagers having sex that abstinence does not work for everyone. The ABC model, with the emphasis that the United States places on abstinence, therefore clearly won’t work as it stands now. Even if we place equal value on all three behaviors, without room to contextualize and open up the model from the limited interpretation we currently use, as well as simultaneously fostering self efficacy, there is no way the model will be effective for teenagers. In sum, the ABC model ignores social groups and interactions, doesn’t foster self efficacy and is framed in such a way so as to not contextualize for different individuals or settings. It is therefore that the ABC model intervention fails.
The Alternative Sexual Revolution Model
As was demonstrated above, the ABC campaign has had some moderate success (18). However, it is clear that the model has several limitations. Specifically, these limitations include the fact that it is an individual based model, that it has no place for self efficacy, and that it is framed in such a way as to not account for contextual differences. Therefore, changes need to be made to help the ABC intervention create more powerful change. While its basis is good, as has been shown by the reduction in HIV rates in countries that use this intervention, such as Uganda (18), improvements definitely need to be made.
The new intervention I propose, the Alternative Sexual Revolution intervention, will build off of the old ABC model in that all three components – abstinence, be faithful, and use condoms – will still be an important part of the model. However, the new model will be based on a combination of the Marketing Theory and the Social Networks Theory. These theories are group level theories. Rather than focusing on the individual, these theories focus on a group level and on influencing change among social groups (19, 20). By using these models, it will be easier for individuals to gain self efficacy and for the intervention itself to change according to contextual differences.
The basis of the Marketing Theory posits that one finds what an individual or group of individuals want – autonomy, freedom, independence, control – and sells it back to them through the behavior change. The idea is to sell the desire, not the behavior change itself. It is through the individual’s “buying” or adopting that desire that the behavior change will come. In general, people don’t value health in of itself. They value the freedom and independence that comes with good health. The key steps to marketing are first to define the product, then to determine the promise or the benefit that product will offer, followed by developing an image for the product and finally to provide support for that promise (20). In that way, people will “buy” your product and adopt the behavior change.
The Social Networks Theory emphasizes the importance of the relationships between individuals, and how those relationships influence behavior. By researching individuals within the context of their social network, one can learn a lot about that individual and about how to influence that individual to change. Since change often happens on a social, group level, researching the dynamics within a social group can help with getting individuals to change (19).
Using these two theories, a new intervention can be created. The idea is to target entire social networks at a time. This can be done by focusing on high schools and even specifically on cliques within high schools. The products – abstinence, being faithful and using condoms – then need to be marketed effectively throughout the school. The promises that these products will provide are freedom, independence and control over one’s sexual life. The key is that we want to market to teens not the behaviors, but what these behaviors will give them – the promises (20). Using television, the internet, and school posters as mediums, we can create ads that showcase these values. For example, with abstinence, we can show an ad with a young girl, saying how she is free, telling audiences that she says no when she wants to because she can. With being faithful, we can show a couple who tout their monogamous relationship as a way to be independent. Finally, with condoms, we can show teens who use condoms as a way to control their lives both now and in the future, by protecting themselves. These will be the images. Using teens as models, we can support the marketing promise through real world examples of teens who have successfully engaged in the behavior (or “bought” the product and experienced the promise), as shown in the ads. Thus, the four basic requirements of marketing successfully are met (20).
By calling this intervention the Alternative Sexual Revolution Campaign (ASR) rather than ABC, we don’t place an emphasis on any one element. Even though we use ‘sex’ in the title, we also call it an alternative revolution, which can easily include abstinence. The ambiguity in the title allows each teen to interpret the model as they want to – either as a way to be abstinent, be faithful, or to use condoms. It is also a slightly rebellious title, which can be yet another promise for teens when it comes to sexual behavior (20). The title of the model reframes the intervention in a way that is much more positive than ABC.
Running these ads and displaying these posters are a way to get teens to think about sex, and safe sex, in a different light. They won’t think about using the behaviors of the ABC model for the sake of doing the behaviors themselves, but rather to help them gain freedom, independence and control over their own lives, which are clearly desirable attributes for any teen. By specifically targeting each ad or poster to teens in general or even to specific cliques within a school, such as suggested by the Social Networks Theory (19), we can account for contextual differences and create a much larger amount of change. Because these ads happen on a social level, the impact again can be much larger than the impact from the ABC model.
Individual Level Model
The ABC is an individual level model, targeted at changing individual behavior (6). However, it is clear that sex is socially constructed and that dialogues between teens can help promote healthy sexual behaviors (8). It is thus crucial that the new intervention account for the social exchanges that happen on a group level. Both the Marketing Theory and Social Networks Theory are alternative theories that happen on a social level. They don’t account for individuals, but rather assume that change happens on a group level. The Marketing Theory directs ads at entire populations at a time (20), and the Social Networks Theory focuses on the interactions and relationships within a social group, not on the individual (19). The emphasis in the ASR model is not the individual, but on the social network, by having ads that target entire populations at a time and allowing for social exchanges to occur.
There is evidence that change happens at a social level. As one study reported, smokers tend to quit as an entire social group, and those who continued to smoke while the rest of the group quit were marginalized (3). This is a direct application of the Social Networks Theory. The ASR intervention accounts for this. The ads are targeted at entire schools, not at individuals. The ASR intervention also assumes that teens will talk to each other about the ads they see and will make the changes as a social group, which has been shown to happen (3, 8). By changing the social relationships within the teenager’s environment through the use of these ads and posters, social norms will change and more teens will be likely to adopt the behavior change (19).
In the ASR intervention, there is also room for social modeling, which has also been shown to influence behavior change (1). With the new intervention, teens can model after one another because the ads are displayed throughout the school and are meant to encourage change that happens within entire social networks simultaneously (19, 20). These ads will allow for discussions between teenagers and within social groups, which in turn will create an atmosphere for social modeling, which will lead to behavior change on both a social and individual level (1).
Sex is inherently social, especially among teens (8). The ABC failed because it had no room for the social implications of sex or for possible behavior changes on a social level. However, the ASR model does, by focusing on social networks rather than individuals and by advertising to entire schools, and not just telling individuals what to do. The emphasis in the ASR intervention is placed on social groups and their interactions, and it is by getting to them as a social network that behavior will change.
The ABC model has no component that includes self efficacy, which can be very important to behavior change (1). The ABC model doesn’t include self efficacy even though having self efficacy is related to engaging in healthier sexual behaviors (16). This is partly because the ABC model is an individual level model and partly because it simply never discussed the issue. The ARS model, on the other hand, has self efficacy in it inherently.
Bandura suggested that the ways to gain self efficacy are to have had positive outcomes in the past, to have an opportunity to engage in social modeling with one’s peers, or to have social persuasion, where one is persuaded by his or her peers to believe in themselves and their abilities to act effectively (1). The ASR model allows for social persuasion and modeling to occur, because the model takes place on a social level. There is room in the ASR model for social discussion, which will lead to these behaviors that encourage self efficacy, which in turn promotes behavior change (1). Because individuals can engage in social persuasion and social modeling, self efficacy is more likely to be gained.
Self efficacy in the ASR model will be furthered by the ads themselves through social modeling. The ads will show teens who have successfully engaged in a behavior – abstinence, being faithful, or using condoms – and who also have gained the promises of independence, control and freedom. Teens can use these ads to socially model themselves, and then socially model after one other. This allows not only for self efficacy to occur, but for it to occur throughout the entire social network on a group level.
Moreover, the Marketing Theory suggests that the some of the promises used in the model are autonomy, independence and control (20), all of which contribute to feelings of self efficacy (1). If an individual feels he or she has autonomy, independence and/or control, it is more likely that he or she will feel that she or he has self efficacy and is therefore likely to engage successfully in the behavior change. The ads that show the promises and support the promises will serve to advance an individual’s gaining self efficacy.
In the ABC model, it seemed that self efficacy, or lack thereof, specifically affected females in a negative way, making it harder for them to effectively negotiate sexual experiences (13, 15). The ASR model can take this into account by targeting females in their ads, using female examples of successes in the ads and targeting the ads to female consumers. By informing females of the gender discrepancies when it comes to sexual negotiations and by showing more females who successfully engaged in the behavior changes, females can begin to reverse the gender inequalities. Using ads that show how women can engage successfully in the behavior will help in giving power to women when it comes to sex (6). This will serve to increase females’ self efficacy as a social group overall, thereby improving their chances of successfully engaging in behavior change (1).
Framing – Lack of Context
With the ASR model, we have drastically changed the way the intervention is framed. The emphasis is no longer on the behavior itself, but on promises of what behavior change will bring – independence, freedom and control (20). These are considerably more appealing to teenagers than merely urging them to engage in behavior change. Using the Marketing Theory, we are promising the teenagers something they deeply desire, and backing that promise with an appealing image and support from personal success stories of other teens, to whom teens can relate. The frame of the intervention is thus totally different from the ABC model, and the reframing makes it more appealing to teens (20), who are therefore more likely to engage in the behavior change.
The ASR model also allows for contextual differences. The crux of the new model is the advertising campaign. It is easy to see how each ad would be changed or altered to fit a different environment or social context. Similarly, ads can be easily changed to target a different social network. In different parts of the world, and even within the US, different stresses should be put on the intervention depending on the contextual situation. For example, the ABC model made no differentiation between migratory populations and stable populations, even though it is quite clear that they should have (6). The ASR will be able to do so. More ads for condom usage can be put in places where populations are migratory, placing the emphasis on a behavior that will actually work given the situational context. Similarly, depending on social norms within a given social network, the ads can change accordingly. Since the ASR model can contextualize itself in this way, it will be much more effective than the ABC model.
Because the ASR model does not list specific behaviors in any specific order, it is unlikely than an emphasis will be placed on any one behavior. Because its title is ambiguous and somewhat rebellious (yet another promise that teens value (20)), teens can interpret it as they want and use it to back whatever choice they make. This is contrary to what the United States currently does, which is to place a significant emphasis on abstinence till marriage (14). The emphasis on abstinence-only education has been shown to be harmful by not giving teens complete information regarding STDs and HIV/AIDS (17). The new title of ASR will give the United States less justification for promoting abstinence-only education, especially given the dearth of evidence that abstinence-only education works and the proof that it may even be harmful (7, 17).
The framing of the ASR model, as well as its composition, make it a more open ended model that can be transformed and re-imagined appropriately in different situations. This is diametrically different from the ABC, which was limited and strict in its interpretation. Because the ASR model can be contextualized, it’s applications are much more far-reaching than the ABC model. We can thus expect it to have greater effects on positive behavior change.
The ASR model works for several reasons. It takes what it good about the ABC model – the behaviors themselves – and reframes them so that the intervention can actually work in the real world of teenagers today. Because it is based on group-level theories, change can happen on a larger scale and social phenomenon that have been noticed (3) can be accounted for. The composition of the Marketing Theory and the Social Networks Theory allow for self efficacy by promoting promises that encourage one to gain self efficacy (such as autonomy, control and freedom (20)) and by encouraging social exchanges and social modeling (1, 19). Finally, the framing and flexibility of the ASR ad campaigns permit differences in different social and geographical settings. Put together, these changes make the ASR a potentially very effective model.
In sum, the ASR campaign does what the ABC model could not. This is because it is based on group level theories, rather than individual theories. Sex is inherently social (8), and the ABC model simply could not account for that, which meant that it could not account for self efficacy or for reframing of the intervention in different situations. Due to the group level nature of the ASR model, these problems have been corrected. It is because of this that the ASR model exceeds over the ABC model, and brings about hope for real change among teenagers when it comes to STD and HIV/AIDS prevention.
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