Knowledge is Power: Government Funded Abstinence-Only Programs Omit Crucial Information on Sexual Health -Diana Theriault

“Vows of abstinence break more easily than latex condoms (1).” Yet America is still taught to abstain from sex. Education is important. How can anyone make an informed decision when much of the information is not provided? Abstinence-only education is ineffective at preventing many teens from engaging in sex before marriage and only hurts those who do have sex without the knowledge of how to do so safely.
When you think of the word sex, what comes to mind? For many there is a negative connotation that comes along with that word. In America, people don’t talk about sex openly. We keep that part of our lives a secret. It is almost like you have to hide it. Sex should be a topic that everyone is comfortable talking about. This is the first step in having a safe and healthy sexuality. Communication is key in this area. If the only thing we tell the children of America is, “don’t do it,” then what happens if and when they do? Are we just supposed to say, “I told you not to?” No. We should be promoting abstinence, but saying “in the event you do have sex, here is how to protect yourself.” Because when it is all said and done, teenagers are going to have sex whether or not you tell them to.
The data shows that people do have sex before marriage. “The average age of first intercourse is 16.9 for boys and 17.4 for girls (2).” Yet the “average age of first marriage continues to rise. for women the average age is 25.6 and for men it is 27.5 in 2007 (3).” This is a major drawback of these types of programs. We can see that the programs don’t work, that people are still having sex anyway, and many are just ignorant to the way contraception works and how it can protect them. Still, abstinence-only education is valuable right? The following studies show otherwise.
Abstinence-Only Education: More harmful than helpful?
If you think about it, almost everything that we engage in, such as driving a car, jumping on a trampoline, smoking cigarettes, taking prescriptions, swimming in pools and many more, have safety guidelines to abide by. Also in case of an emergency, there are steps to take to prevent any further harm. But why is it that when it comes to sex, we fail to teach those safety guidelines? It’s like throwing someone in the driver’s seat of a car and saying go! If you don’t know how to drive, you don’t know the rules of the road, how to be safe and what to do incase of an emergency, do you really want that person to be behind the wheel? I surely don’t. “In 2005, 37.2 percent of sexually active high school students and 44.6 percent of sexually active twelfth grade students did not use a condom during their last sexual intercourse (4).” Many of them ‘got behind that wheel’ without learning about safety. Unprotected sex can lead to unintended pregnancies and sexually transmitted infections which can lead to other complications. Even more distressing is that, “One-quarter of sexually active adolescents nationwide have an STD, and many STDs are lifelong viral infections with no cure (4).”
A survey from the Kaiser Family Foundation found that young adults want to learn. “They want to know more about how to use condoms, how to recognize the signs of STD and HIV infection, what STD and HIV testing involves, and where they can get tested. They also want more instruction on communicating effectively with partners about sensitive sexual concerns and relationship issues (5).”
Abstinence-only education programs have been funded by the government for many years, however, comprehensive sex education programs have suffered from new restrictions on what can be taught to receive funding. Essentially any program that teaches about contraception has been limited in the funding they can receive under the Bush administration. This allows for more programs that refuse to teach about contraception and safety. If teens want to learn about safety and healthy sexual relationships, shouldn’t we give them guidance?
A study done following over 2000 students from elementary school to middle school and through high school that had abstinence-only education failed to prove that this education is valuable. The study found that there was no difference between those who participated in abstinence-only education versus those who did not. This study confirmed what other studies have already shown. "The most effective programs are those that say abstinence is the best choice but birth control and protection are also worth knowing about (6)." Yet abstinence is still funded heavily by the government. I like the way one woman, Martha Kempner, put it when she said,”Abstinence-only was an experiment and it failed (6)." Failed experiments should not be continued and especially not funded with tax payers dollars.
These programs have not taught our kids properly. Some adolescents even believe they are being safe by using contraception, but they may be using it in correctly. I believe that this proves the point: “One in five young people believe that birth control pills offer protection from STDs and HIV/AIDS. The same amount of people believe that condoms are not effective in preventing the transmission of STDs and HIV/AIDS (5).” If people believe they are protecting themselves or that using condoms won’t protect them from contracting diseases this is a serious misconception. The lack of knowledge about sexual behavior and protection is astounding. I do believe that abstinence is an important thing to teach the young people of America. Children need to develop feelings of self-confidence, independence, and all in all, just grow and mature to make these complicated sexual decisions. But abstinence taught alone leaves people with the knowledge of the dangers of sex but no way to prevent the dangerous consequences.
Not only do these programs fail to educate, but they give out false and misleading information. A report put out by the House of Representatives actually proves that 80% of the curriculum guarantees to contain false, misleading, or distorted information about reproductive health. This false information includes the effectiveness of contraceptives, the risks of abortion, and even scientific errors such as the number of chromosomes that an individual has (7). These things are important. Everyone should know the true facts. How can you make an important judgement like this without having all of the correct information? The same report states that, “youth who pledge abstinence are significantly less likely to make informed choices about precautions when they do have sex (7).”
Community Influence on the Development of Sexuality
Abstinence-only programs teach an ideological view. We set the bar very high when we expect everyone to abstain from sex until marriage. Although this may prevent a few sexual encounters out-of-wedlock, it certainly does not apply to everyone. As kids, we are taught values and morals to live by. As we get older, we discover our own morals and values that we wish to live by. However, when society pushes virginity as the only option, it makes it seem like sex is a bad thing. Therefore, if you have sex, you are bad. This can have social and emotional implications.
Abstinence-only education is an example of the Health Belief Model applied in practice. The Health Belief Model is a theory that suggests that an individual will make a rational decision based on perceived benefits weighed against perceived barriers. It also implies that if a person feels susceptible and that the consequence is severe enough, a person would take action to avoid that behavior (8). Abstinence-only educators believe that if one is taught the severity of consequences and how easily susceptible they are to pregnancy and disease that everyone will abstain. They portray it in such a way that the barriers greatly outweigh the benefits. Even the governments definition of abstinence-only education includes “teaching the social, psychological, and health gains to be realized by abstaining from sexual activity its exclusive purpose (4).” They are trying to prove the benefits of abstinence. These benefits are real, however, we know that decisions are not only based on the individual level alone and so these benefits may not be as important as the beliefs of others for example.
“ ASRH (Adolescent Sexual and Reproductive Health) programming should be approached from an ecological perspective, with the belief that individual behaviors and decisions are not made or practiced in a vacuum, and that social norms and institutions often determine the choices available to most individuals (9).”
There is a large factor of social influence that abstinence only programs come along with. Social norms stereotype men and women as well as heterosexual and homosexuals into different categories. These stereotypes portray “girls as naturally chaste and boys as constantly struggling to control their rampant sexuality and raging hormones (10).” Sexist views put gender roles on men and women. In education like this these stereotypes are taught as facts. The are biological sciences that makes men and women act differently towards sex. This teaches women that if they do express desires and wish to talk about sex, they may be found as promiscuous where men are just generally curious because they have testosterone and it is natural for them to feel these desires (10). This conservative thinking heeds much guilt for women and leaves both sexes uneducated about safety and communication among adolescents. Although gender stereotypes have an enormous impact on teens, stigmas of sexual orientation have an even greater impact. Abstinence-only education programs do not even bring up the subject of homosexuality. This is deliberately left out because programs like these are actually “required by the federal funding guidelines to instruct students that heterosexual marriage is the ‘expected standard’ (10).” Since gay marriage is not recognized nationally in the United States as legal, it is easy to see why the government would leave this discussion out of the program. Because how can you stay abstinent until marriage if you can’t even get married? And we already know that sex out-of-wedlock can be a burden on society so those who do not follow the ‘expected standard’ must also be a burden, right? That is what these programs teach us. It almost allows for discrimination and increases homophobic beliefs which is not right. In society today, everyone should be treated equal regardless of gender, sexual orientation or any other differences we have between us.
As we can see, society and our surrounding communities can greatly influence our views and what we consider social norms. We must adopt a culture open to communication and discussing all sexualities. Teaching teens about contraceptive options, physical differences between men and women, and sexual orientation does not encourage adolescents to go explore what they just learned. We are just providing the facts and allowing them to make an informed decision on their sexuality and bringing about safe options while doing so.
A Violation of Basic Human Rights
Abstinence-only education fails to allow access to basic health information. To educate our children we must provide the full spectrum of options and information. When you hear questions like: “You can’t get pregnant the first time right? Isn’t everyone having sex? Can you get pregnant if you use birth control (11)?,” you know there is much more that teens have to learn before having sex. A person who is in the contemplating stages of having sex should first know their beliefs and feelings about sex. If they feel that they are ready then the next question to ask would be “in what kind of sexual relationship would sexual involvement be comfortable or OK for me (12)?” And when someone is ready to have sexual intercourse they need to be prepared for all of the consequences with that decision including emotional feelings. If kids are not taught the full spectrum of sexual responsibility they can not make informed decisions. Leaving information out or distorting truthful information is harmful to all. Health information should be freely provided and true. By giving out wrong information, these programs are violating our human right to education and information about sexual health.
“Individuals who lack information about sexual and reproductive health care thus also lack the ability to protect themselves from STIs, including HIV/AIDS, and unplanned pregnancy (10).” It is everyone’s right to seek out truthful information. This is why it is not only important for educators to teach the facts, but for parents to divulge all pertinent information as well. Most teens are influenced by many factors when making decisions about health. Parents, peers, and school education are at the top of the list for influencing children on sex. If your peers are taught the same as you, then they are most likely going to base their decisions on the same information you received which does not promote anything but continued misinformation. However, if parents step in, they may be able to influence the child and teach them the right things. Many adults however do not know everything about sex. Even the parent has the right to information and education. That is why it is up to the educators who are supposed to have up to date information on sex and sexual consequences to teach the future of America. Children only learn what they are taught, that is why it is our job to teach, and their right to learn health education.
“Major human rights documents discourage states from limiting access to contraceptives, and other means of maintaining sexual and reproductive health, from censoring, withholding, or intentionally misrepresenting health-related information, including sexual education, as well as from preventing people’s participation in health-related matters, or allowing third parties to do so (10).”
Abstinence-only education violates these rights which has a negative effect mostly on those who do not receive the knowledge. It puts those who do have sex at greater risk for health consequences that they do not even know about, or for that matter, how to prevent negative health effects and unintended pregnancies. Abstinence only education violates the rights of all humans, but has an even greater potential risk in LGBT (lesbian, gay, bi-sexual, and transgendered) individuals and their families by failing to provide “useful and appropriate sexual health information (10).” Men who have sex with men have the highest risk for developing HIV/AIDS (13). These statistics need to be known. Even for those who do not consider themselves gay when they are younger, may realize later in life that they are homosexual or bisexual and should have the facts on both homosexual and heterosexual encounters.
Final Thoughts on Abstinence-Only Education Programs
“The communities should provide access to education about sexual health and responsible sexual behavior that is thorough, wide-ranging, begins early, and continues throughout the lifespan” (14). Such education should give them knowledge about pregnancy, STD's, contraceptives and responsible choices. Abstinence-only education cannot provide this comprehensive education. It should be taught as part of an education program but not as the only program.
A New Perspective
“Comprehensive sex education teaches about abstinence as the best method for avoiding STIs and unintended pregnancy, but also teaches about condoms and contraception to reduce the risk of unintended pregnancy and of infection with STIs, including HIV. It also teaches interpersonal and communication skills and helps young people explore their own values, goals, and options (15).” This type of sex education is important for teenagers to get the full spectrum of knowledge on this topic. Comprehensive sex education have been proven to work (16). Mandates prohibiting educating the youth about the benefits of condoms and contraception make these programs ineligible for federal funding (17). Teens need to learn about all aspects of sexual health to protect them from the dangers of infection and pregnancy. This is something that abstinence-only education cannot provide.
Does Comprehensive Sex Education Provide Benefits?
A concern of many with comprehensive sex education is that it will encourage teenagers to want to have sex at a younger age than they would have had they had abstinence-only education. Research however shows that this is not the case. “Evaluations of comprehensive sex education and HIV/ STI prevention programs show that they do not increase rates of sexual initiation, do not lower the age at which youth initiate sex, and do not increase the frequency of sex or the number of sex partners among sexually active youth (15).” Knowing that these programs do not have an influence on increasing sexual activity of teenagers, we can say that they are not harmful. How though do these programs provide a benefit?
Findings put out by the National Campaign to Prevent Teen and Unplanned Pregnancy, stated that almost all of the comprehensive sex education programs they evaluated had a positive effect on the behavior of teenagers. “In particular, they improved factors such as knowledge about risks and consequences of pregnancy and STD; values and attitudes about having sex and using condoms or contraception; perception of peer norms about sex and contraception; confidence in the ability to say ‘no’ to unwanted sex...communication with parents or other adults about these topics.(18).” Comprehensive sex education is teaching teenagers responsibility, giving them confidence and teaching self-esteem. Not only this but this education is teaching them about risks and prevention. The APA stated, “Based on over 15 years of research, the evidence shows that comprehensive sexuality education programs for youth that encourage abstinence, promote appropriate condom use, and teach sexual communication skills reduce HIV-risk behavior and also delay the onset of sexual intercourse(19).” With all of the evidence shown, it is clear that comprehensive sex education has many benefits and proves to be the superior method to teach teenagers about sexuality.
Influence on Development of Sexuality
Comprehensive education also plays off of the Health Belief Model, although it includes other tools to educate as well. “Rather than trying to deter or frighten young people away from having sex, effective sex education includes work on attitudes and beliefs, coupled with skills development, that enables young people to choose whether or not to have a sexual relationship taking into account the potential risks of any sexual activity (20).” Teenagers need the opportunity to form their own opinions on this subject matter. Have they been taught the consequences of their actions? Have they been taught how to handle such consequences? Do they know where to get support? If one does become pregnant, do they know all the options? Are they emotionally prepared for such consequences? Also, can they communicate with parents and other adults from whom they are educated? There are so many more questions that need to be asked and answered pertaining to sex and the development of sexuality. These questions cannot be answered in an abstinence-only classroom. “Programs designed to prevent pregnancy need to give young women information about pregnancy and opportunities to discuss the topic so that they form opinions. Furthermore, programs should emphasize positive attitudes toward contraception, because effective contraceptive use is shaped by such attitudes and is strongly associated with reduction of pregnancy risk (21).”
Pregnancy is not the only topic discussed in comprehensive sex education. Sexual development, such as physiological, anatomical and emotional changes in puberty are also discussed. For this education to be comprehensive in all aspects it must also include discussions on healthy relationships. “In terms of information about relationships they need to know about what kinds of relationships there are, about love and commitment, marriage and partnership and the law relating to sexual behavior and relationships as well as the range of religious and cultural views on sex and sexuality and sexual diversity (20).” Like I said before, teenagers are going to have sex whether you tell them to or not. Given the tools, teenagers will make the right choice for themselves, and learn about their own sexuality armed with knowledge on how to be safe. The right attitudes and beliefs on sexuality and the known dangers of what sex can be without protection being taught to teenagers is great. Abstinence-only education may be able to provide these things. However, comprehensive sex education goes beyond the concepts in the Health Belief model and brings in the tools needed to develop a healthy sexuality and be safe when engaging in these activities.
Right to Information and a Right to Equality
America has always prided itself on freedom. We are the land of the free. Though many people do not feel this way. Shouldn’t all Americans have the right to decide if and when they want to engage in sexual activity? Abstinence-only education teaches teenagers that this is not a right. One must not engage in such activities until marriage. Well if one doesn’t have that right, than can’t they choose with whom they would like to engage in this activity with? According to abstinence-only education, that too is not a right. By definition marriage is between a man and a woman (22). Which leaves lesbian, gay. bisexual and transgendered teens to believe they do not have the same rights. So if one cannot decide with whom, or when to have sexual encounters, than at least the information on how to be protected and have safe sex is given, right? Wrong again. Contraceptives and other methods of protection are not taught in abstinence-only education programs because teenagers shouldn’t be having sex anyway (23). So when a teenager gets older and maybe does wait until marriage to have sex, do they know how to protect themselves? If never given the information to learn how to fully prepare for sex and the consequences that come with it, physically and emotionally, than no matter how old you get you still are not prepared. Comprehensive sex education prepares you for all of what is to come. You are given the knowledge and information needed to make the right decisions, so when it comes down to it, you can decide if, when and with whom you want to engage in sexual activity with knowing how to stay protected when that decision comes. “State parties must ensure that children have the ability to acquire the knowledge and skills to protect themselves and others as they begin to express their sexuality (23).” These are the rights and freedoms Americans are entitled to.
Culminating Thoughts
Given all of the information about abstinence-only education programs and comprehensive sex education programs, one is clearly able to see the benefits that comprehensive education provides over abstinence-only education. I believe that abstinence is necessary to teach and to instill core values and morals in teenagers. I also believe though that teenagers are rebellious in nature and because they are told not to do something they are more apt to do so. So when educating teens about sex, one should also be taught about contraceptives and how to respect one another’s choices. Whether those choices are to have sex or not, or whom they may choose as a partner, or even how to handle the event of an unintended pregnancy. Developing their own attitudes and beliefs about sexuality is essential. With comprehensive education, one can make an educated decision and learn about sexuality. Comprehensive sex education should be available to all teenagers, it is a right of Americans. Therefore, comprehensive sex education should be funded by the government instead of abstinence-only education. It is important that the children of America have the freedom to make their own choices when it comes to sexuality and they should be guided on how to make the right choices.
REFERENCES
1. Elders, Joycelyn M. “Vows of Abstinence Break More Easily Than Latex Condoms.” Rethinking Schools Online. 2002. Milwaukee, WI. 20 November 2008 <http://www.rethinkingschools.org/sex/elders.shtml>.
2. Guttmacher Instutute. In Their Own Right: Addressing the Sexual and Reproductive Health Needs of American Men. 2002.
3. U.S.Census Bureau. Estimated Median Age at First Marriage, by Sex: 1890 to the Present. 2007.
4. Trenholm C. et al. Impact of Four Title V Section 510 Abstinence Education Programs. Final Report. Princeton: Mathematica Policy Research; 2007. http://www.mathematica-mpr.com/publications/pdfs/impactabstinence.pdf
5. The Henry J. Kaiser Family Foundation. (2003). National Survey of Adolescents and Young Adults: Sexual Health Knowledge and Experiences. http://www.kff.org/youthhivstds/upload/National-Survey-of-Adolescents-and-Young-Adults.pdf
6. Stepp, Laura Sessions. “Study Casts Doubt on Abstinence-Only Programs.” Washington Post. April 14, 2007. http://www.washingtonpost.com/wp-dyn/content/article/2007/04/13/AR2007041301003.html
7. UNITED STATES HOUSE OF REPRESENTATIVES COMMITTEE ON GOVERNMENT REFORM — MINORITY STAFF SPECIAL INVESTIGATIONS DIVISION. “The Content of Federally Funded Abstinence-Only Education Programs: Prepared for Rep. Henry A. Waxman.” December 2004. http://oversight.house.gov/documents/20041201102153-50247.pdf
8. Rosenstock, I. M. (1974). Historical Origins of the Health Belief Model. Health Education Monographs. Vol. 2, No. 4. 328 – 335.
9. Community Pathways to Improved Adolescent Sexual and Reproductive Health: A Conceptual Framework and Suggested Out come Indicators. December 2007. Washington, DC and New York, NY: Inter-Agency Working Group (IAWG) on the Role of Community Involvement in ASRH. http://www.advocatesforyouth.org/publications/iawg.pdf
10. Kay J.K., Jackson A. Sex, Lies and Stereotypes. How Abstinence-Only Programs Harm Women and Girls. Legal Momentum; 2008
11. “Facts & Stats.” The National Campaign To Prevent Teen Pregnancy. 2002. Washington, D.C. 20 November 2008. <http://www.teenpregnancy.org/resources/teens/facts/default.asp>
12. “Sexual Responsibility.” Olin Health Center. 2002. Michigan State University, MI. <http://www.healthed.msu.edu/fact/sexual_responsibility_1.shtml>
13. Centers for Disease Control and Prevention. “A Glance at HIV/AIDS among Men Who Have Sex with Men.” January 2006.
14. “The Surgeon General's Call to Action to Promote Sexual Health and Responsible Sexual Behavior: At a Glance: Vision for the Future.” U.S. Department of Health & Human Services. July 2004. Washington, D.C. <http://www.surgeongeneral.gov/library/sexualhealth/glancetable.htm>
15. Advocates for Youth. “Sex Education Programs: Definitions & Point-by Point Comparison.” Accessed on December 6, 2008. http://www.advocatesforyouth.org/rrr/definitions.pdf
16. Kirby D. Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy. Washington, DC: National Campaign to Prevent Teen Pregnancy, 2001.
17. American Foundation for AIDS Research. Assessing the Efficacy of Abstinence-Only Programs for HIV Prevention among Young People. [Issue Brief, no. 2] Washington, DC: Author, 2005.
18. Kirby D, Emerging Answers 2007: Research Findings on Programs to Reduce Teen Pregnancy and Sexually Transmitted Diseases, Washington, DC: The National Campaign to Prevent Teen and Unplanned Pregnancy, 2007, p. 4, Accessed Dec. 6, 2008. http://www.thenationalcampaign.org/EA2007/EA2007_full.pdf
19. American Psychological Association (APA). (Feb. 2005). “Comprehensive Sex Education is More Effective at Stopping the Spread of HIV Infection.” Accessed December 8, 2008. http://www.apa.org/releases/sexeducation.html
20. Avert: AVERTing HIV and AIDS.“Sex Education that Works.” Accessed on December 8, 2008. http://www.avert.org/sexedu.htm
21. Perspectives on Sexual and Reproductive Health, Vol. 36, No. 6, Findings from Add Health (Nov. - Dec., 2004), pp. 248-257 http://www.jstor.org/stable/1520257 Accessed Dec. 10, 2008
22. "Marriage." Merriam-Webster Online Dictionary. 2008.Merriam-Webster Online. Accessed December 10, 2008 <http://www.merriam-webster.com/dictionary/marriage>
23. Santelli, John S., MD, MPH, Schleifer, Rebecca, JD, MPH, and Lande, Lila J., MPH. “Abstinence and U.S. Abstinence-Only Education Policies: Ethical and Human Rights Concerns.” Accessed on December 10, 2008. http://www.protectchoice.org/downloads/Reproductive%20Justice%20Briefing%20Book.pdf

Critique of an Initiative to Train Peers to Help HIV-Positive People Link to Care and Adhere to Treatment

Part I: An analysis based on the ecological model
INTRODUCTION
The initiative
No one understands the reality of HIV better than someone who lives with it every day. Matching a newly diagnosed individual with an HIV-positive peer from that person’s community who has been successful in adhering to treatment has been found to be a promising strategy for helping HIV-positive individuals link to care, adhere to HAART (Highly Active Antiretroviral Therapy) regimens, or return to care if they have dropped out (1). Working as part of an interdisciplinary care team, peers provide a wide range of practical and emotional support services to clients. Recognizing the success of peer programs as an effective treatment adherence intervention (2), particularly among underserved, minority and marginalized populations, the Minority AIDS Initiative (MAI) and U.S. Health Resources and Services Administration (HRSA) funded an initiative in 2005 designed to help health care organizations nationwide establish peer programs to serve their HIV-positive clients. The peer initiative consists of four separate grants: three to national peer education centers, and one to a central resource and evaluation center, called the PEER Center.
The three national peer education centers, each of which has experience with a successful peer program, provide peer training and capacity-building expertise to organizations seeking to establish peer programs. Their efforts are supported and coordinated by the PEER Center, a collaboration between the Boston University School of Public Health’s Health & Disability Working Group (HDWG) and the Justice Resource Institute (JRI). The PEER Center conducts evaluation for the project and draws on the expertise of the three national centers to provide capacity-building resources for organizations who want to establish peer programs.
Now in its third year of a five-year grant, the PEER Center has conducted a nationwide needs assessment of health care organizations with respect to peer programs, collected extensive data on the peer training and peer-client interactions of the three national centers and their associated peer programs, created a website which provides resources and information about peer programs to organizations (www.hdwg.org/peer_center) (3), and is actively promoting the establishment of peer programs through conference presentations, webinars, an email newsletter, and contacts with partners at the national centers. It is also in the process of creating an online peer training-of-trainers (TOT) toolkit which provides best practices, curricula and materials drawn from the three national centers. The toolkit is intended as a resource for trainers, peer supervisors or program directors in organizations who want to train new peers or expand the skills of their existing peers who work to engage and retain people living with HIV in the health care system. The TOT toolkit focuses on three core competencies which peers need to carry out this mission: HIV-related information, communication skills, and the role of the peer within an interdisciplinary care team.
Methods
This paper focuses on the TOT toolkit, examining the role of peers as it is portrayed in the toolkit and how well the toolkit addresses the requirements of the organizations it is intended to serve. It examines this toolkit in the context of the peer initiative based on the ecological model (4-5) to determine its strengths and limitations. It looks at how well the initiative as a whole and the toolkit in particular addresses individual, group, structural, political and environmental factors related to combating HIV disease, focusing on program interactions at two levels: 1) at the peer-client level, assessing the roles for which peers are trained to work with clients, as laid out in the peer training toolkit, and 2) at the center-organization level, assessing how well the toolkit meets the needs of the organizations it is designed to serve.
Summary
The TOT toolkit will be a valuable resource when it is released next year, and organizations who want to establish peer programs have expressed interest in gaining access to it. However, there are three ways in which it could be improved: 1) by providing modules intended to provide greater support for clients generally by leveraging the client’s existing network, combating the effects of stigma, and providing ideas for greater support to rural clients who have difficulty in reaching care 2) by focusing more attention on the cultures and challenges of the various organizations whose clients would benefit from a peer program, with an eye to providing curricula more closely tailored to the peer training needs of these organizations and 3) by expanding the TOT toolkit to include curricula which support additional peer roles, reflecting the range of roles peers play within various AIDS service organizations and a more holistic approach to addressing HIV disease.
FACTORS AT THE INDIVIDUAL LEVEL
Program strength: individual behavioral theories appropriately used
Treatment adherence varies widely according to an individual’s circumstances, so it is appropriate that much of the peer-client interaction is focused at the individual level. In the peer-client relationship as envisioned by the peer initiative, the peer provides both emotional and practical support to the individual client in her attempts to learn to cope with the daily stresses of living with HIV. This peer-client relationship of care builds on the strengths of several behavioral theories which are appropriate to interventions focused at the individual level.
For example, the peer is trained to provide the client with information about the HIV life cycle and how medications work to slow the disease progression, as well as brainstorm ways to solve problems integrating treatment into the client’s daily life. This intervention appropriately uses the Health Belief Model (6-8) to influence a client’s perceived severity of the disease, perceived benefits and costs of adherence, and sometimes a client’s perceived susceptibility to the disease—despite an HIV-positive diagnosis, clients are sometimes in denial about having contracted the disease, especially in the absence of symptoms.
The TOT toolkit also makes effective use of the Transtheoretical Model (9) to help the peer work with the client to move through the process of adopting treatment adherence behavior. For example, one training module outlines the five stages of change—precontemplation, contemplation, preparation, action, maintenance—so the peer can identify where in the process of adapting to treatment a client is. If a client is in the stage of “contemplation: the client wants to change behavior within the next six months,” the peer will provide a different type of support than if the client has already met with a doctor and started a treatment regimen.
FACTORS AT THE SOCIAL/CULTURAL/GROUP
Program strength: Good use of Social Cognitive and Social Network Theories
At the Social/Cultural/Group level, the peer initiative makes good use of Social Cognitive Theory (10-11) principles to encourage client treatment adherence. As someone who is not only effectively adhering to treatment himself but also helping others to do so, the peer is a strong role model to individuals new to treatment. As one peer described it, “You have to let the client know that you are like them, that you have gone through these things before and that if you can go through it, they can go through it. (12)” By coaching the client, the peer reinforces the client’s efforts and helps shape his adherence behavior. This also strengthens the client’s self-efficacy; as the peer and client work through adherence issues together step by step, the client sees that she is able to manage a new behavior that may have seemed overwhelming at the start. Conversely, being a role model to others reinforces the peer’s own self-efficacy and motivation to adhere to treatment as well as increasing her self-esteem.
The behavioral theory which is most apparently at work in the peer-client intervention, however, is the Social Network Theory (13-17). The peer acts as a non-judgmental “natural helper” in the client’s social network. As a member of the client’s community, the peer often shares the same background, experiences, cultural assumptions, and language as the client and provides a communication channel that the client is more likely to understand and accept. This is the major strength of the peer-client interaction and has generally proven very effective. (One caveat, however: One must be careful not to assume that because two people share the same culture, they will work well together or trust each other. The interplay of individual factors is complex--two people from the same culture may find themselves on different sides of a political dispute; two people from the same country of origin may be from rival ethnic groups within that country (18).
Critique #1: More focus on helping the network to support the individual’s behavior
It is in the application of the Social Network Theory that one limitation of the peer intervention manifests itself: although the TOT toolkit provides peer training around helping clients disclose their status to family and friends and encouraging clients to build a support network, it does not address support or education for members of the client’s network. While the decision whether or not to disclose one’s status is a personal one and not every HIV-positive person chooses to let family and friends know his status, individuals who do disclose their status to those close to them have been shown to have a better quality of life (19). In these cases, providing support and education to family members and friends affected by HIV can be a powerful tool in helping to strengthen the client’s adherence behavior. It can also help reduce stigma within the community by providing information, dispelling myths, and exploring/influencing the community’s perceptions and social norms around HIV/AIDS. Leading support groups and participating in programs for family members and others affected by HIV is a role which HIV-positive peers within community-based organizations sometimes take on. For example, Christie’s Place in San Diego, CA, a community-based organization “for families and individuals living with HIV/AIDS (20),” offers peer-led support groups and organized events targeted to children of HIV-positive people or HIV-positive individuals and affected family members. Providing training modules and tools within the TOT toolkit to train peers to take on this role would provide a valuable resource to organizations who want to train peers to provide support to a client’s network.
Critique #2: More focus on contexts of various organizations
Critics of the Social Network Theory point out that it is a limited intervention which works at a small group level but does not lend itself to broader application (21). The peer initiative seeks to overcome this limitation by helping organizations throughout the country to start or strengthen peer programs. The initiative encourages the replication of peer programs in a wide range of organizations—clinics, community-based organizations, AIDS service organizations—yet it has made limited efforts to understand the cultures and challenges of different types of organizations or in different regions of the country. The program would benefit from using anthropological methods to learn more about the climate and challenges of these organizations in order to develop resources more closely targeted to helping these organizations overcome some of the issues they face in implementing a peer program.
For example, the South is the primary focus area for capacity-building efforts because of the rapid expansion of HIV infection in the region. Hence the PEER Center conducted a needs assessment of Ryan White Care Act Parts A, B, C, and D grantees in the South based on a questionnaire. However, this questionnaire provides little in the way of open-ended questions or opportunities for uncovering issues not specifically addressed by the questions in the questionnaire. Yet through conversations with organizations in the South, PEER Center members have learned that stigma is a major barrier not only in adherence to treatment but in recruitment of peers. Further, one of the national education centers has observed that HIV care efforts are often undertaken by faith-based organizations in the South. These organizations are likely to have very different requirements for peer training and peer roles within their organizations than peer programs in clinical settings or California-based community organizations, which is where the peer initiative draws its expertise. By systematically asking more in-depth questions and gathering more qualitative data (22) about the various kinds of organizations being targeted, the PEER Center can begin to gain a richer understanding of the assumptions, constraints and challenges under which these organizations operate. This would help in the identification of underlying causes which may prevent these organizations from establishing a peer treatment adherence program for their clients.
One tangible outcome of a more in-depth study of organizations might be the creation of new models for peer programs. Currently the peer initiative presents target organizations with two models for peer programs: an internal model, where the organization manages its peers as employees within the organization, and an external model, where peers act as external consultants managed by an outside organization. This distinction has proven valuable to some organizations who want to develop a peer program but have insurmountable obstacles in employing peers as part of their organization. The external model was developed based on the experience of the WORLD (www.womenhiv.org) (23) program, a community-based organization with a different organizational culture and mission from the peer programs associated with the other two national centers, both of which operate in a clinical setting. By learning more about the context of different organizations, the PEER Center may be able to come up with additional models that would address challenges these organizations have encountered.
Within the context of the TOT training manual, a more in-depth understanding of various kinds of organizations seeking to start peer programs would help the PEER Center create several pre-packaged model curricula according to prevalent organizational profiles. This would give the organization a more comfortable starting point than simply looking at the more than 150 training modules available to them to try to decide which ones would meet their organization’s need for peer training.
FACTORS AT THE SOCIOECONOMIC/STRUCTURAL LEVEL
Program strength: navigating the system
Factors at the socioeconomic level include the effects of poverty, education, access to care and services and social stressors on HIV treatment adherence. One area of strength of the peer-client interaction is the one-on-one support clients receive to navigate a sometimes bewildering maze of health care and social services, many of which the client may not trust or understand. Peers often accompany clients to doctor, dentist or social service appointments and help clients ask appropriate questions and understand the doctor’s advice. Peers also make referrals to case managers and other members of the care team to address issues of housing, food security and other practical assistance—although the support the client receives is only as good as the services the referring agencies provide, which vary greatly.
Critique #3: Not adequately addressing stigma and physical distance
Two social stressors affecting peer programs generally and more particularly in the South are stigma within the community and isolation in rural areas. The stigma surrounding HIV prevents people from getting tested, seeking care if they are diagnosed with the disease, revealing their status to family and friends, and adhering to treatment. People who live in fear of being stigmatized may suffer from low self-esteem, depression, and even unemployment and loss of income, all of which contribute to poor health and lower quality of life. Furthermore, if a person has more than one stigmatizing condition, the chances of that person suffering from these effects is greatly increased (24).
As members of a group which is stigmatized, peers are in a unique position to play an advocacy role in combating stigma. Peers may provide a voice of authority at churches, schools and other pubic forums when issues of stigma are addressed. They produce and perform plays with anti-stigma themes. They conduct interviews to obtain evidence to inform policies which protect the rights of people living with HIV (25). They combat stigma within the health care system by serving on consumer advisory boards. While the continuing education section of the TOT toolkit includes one module which discusses the effects of stigma, it does not provide training in peer roles of advocacy and public speaking; including ideas for the contributions peers can make to reducing stigma within the community would provide an additional resource to organizations most impacted by this issue.
In rural areas, the problem of stigma is exacerbated by long distances between clients, health care facilities and other services. Clients often lack transportation to distant HIV health care facilities; they may be afraid to accept affordable transportation when it is offered for fear of being identified as HIV-positive by neighbors (26). The backbone of the peer-client intervention is face-to-face meetings; meetings are often coordinated to coincide with a client’s doctors appointments. The PEER Center could extend the reach of peers by including resources and peer training which provide ideas for alternative networking opportunities, such as regular phone meetings or computer-assisted peer interaction for clients with access to phone or computer.
FACTORS AT THE POLITICAL AND ENVIRONMENTAL LEVEL
Critique #4: Separate sources of funding lead to limitation in roles for which peers can be trained through the toolkit
Perhaps the biggest limitation of the PEER Center initiative occurs at the political level. The PEER Center and the three national centers are funded through the Minority AIDS Initiative which provides funds to HIV/AIDS service agencies to “improve HIV/AIDS-related health outcomes for racial and ethnic minority communities disproportionately affected by HIV/AIDS (27).” The initiative is administered through HRSA’s HIV/AIDS Bureau, which focuses on supporting care and support services to people infected with and affected by HIV/AIDS. As such, prevention efforts administered through HRSA are targeted to HIV-positive individuals, not to the larger community. Peer prevention initiatives targeting a broader community are separately funded and implemented by the Centers for Disease Control (CDC). Each of these organizations has its own procedures, reporting structures and evaluation mechanisms.
Yet increasingly there has been a call for closer integration between prevention and care among communities combating the disease. Last year for World AIDS Day, three staff members of the World Health Organization put out a joint statement that “linking treatment with prevention remains an overriding and critical public health challenge for the health sector (28).” In a recent article, Remien, Berkman et al. recommended a strategic approach to controlling the epidemic by supplementing increased testing with integration of HIV prevention into HIV care settings (29). This kind of integration of prevention and treatment takes place at the community level; community-based AIDS organizations may include outreach, prevention and consumer advocacy programs, and peers may play a part in all of these areas. At the funding level, however, these functions remain separate. Hence the TOT toolkit focuses on training peers for treatment adherence and linkage to care programs, but not for a role related to prevention within the community. Yet in the needs assessment which the PEER Center conducted, one community-based organization in South Carolina stated that they would like to use peers for “outreach, testing, prevention, helping clients with treatment adherence, and support and counseling.”(30) This organization will need to supplement the TOT toolkit in its current format with additional resources to meet all of its peer training needs.
Several of the training modules included in the TOT toolkit lend themselves to expanded peer roles of prevention and advocacy within the community. The harm reduction and “prevention for positives” modules, for example, include training in many prevention issues, such as negotiating use of condoms and reducing or eliminating risk behaviors. Modules on workplace issues address many factors that are common across roles, such as general communication skills, communication with coworkers and supervisors, adjusting to a professional work environment, and locating resources for further professional development.
A more holistic approach to fighting HIV/AIDS would involve peers at all levels of intervention. The presence of HIV-positive peers in the community who are willing to share their status and stories of how stigma has affected them empower others to put aside their fears, get tested, or seek treatment if they have been diagnosed with HIV. Peers serve as proponents of HIV-prevention efforts and are strong advocates for HIV testing. More testing leads to earlier detection of HIV disease, resulting in better outcomes. Having peers available to those individuals who are diagnosed with HIV and entering care or who are trying to return to care after having dropped out is another step in a continuum of interventions where peers may play a critical role. Restricting the TOT toolkit to a treatment-adherence peer role without recognizing the additional roles peers may play within an organization limits its usefulness. Organizations hoping to use it as a “one-stop-shopping” resource for training their peers will need to supplement it with additional resources.
CONCLUSION
Learning to live with HIV as a chronic disease is a complex behavior, requiring extensive support at many levels. Clients often require ongoing support from their network of family, friends, and health care and social service providers in order to stick to their regimens. Working as a peer is challenging as well, requiring extensive support from supervisors and others within an organization. Organizations themselves benefit from support and expertise to maintain a successful peer program. The peer initiative goes a long way to providing support at all these levels, either directly or indirectly. But the initiative generally and the TOT toolkit specifically could be improved by strengthening these supports through 1) increased recognition of the needs of the client’s support network as well as the unmet needs for support of isolated rural clients 2) a more tailored response to organizational needs with respect to peer programs through a closer examination of those organizations, and 3) an expansion of peer roles to include prevention and advocacy within the community. The TOT toolkit is in the early stages of development and testing. As organizations begin to apply it to their peer training programs, many of the ideas outlined here may well be incorporated as a result of feedback from those organizations.


SB721
Written Assignment 4
Dec. 11, 2008
Edi Ablavsky
Part II: Enhancing the peer intervention through use of Social Network Theory, Sociological and Anthropological Research Methods and Social Marketing
Introduction
To this point, I have identified four limitations of the peer initiative. They are 1) a lack of focus on the family and friends of people living with HIV as a source of support to clients 2) not addressing the issue of isolation and stigma among rural clients who may have limited access to peer support 3) the need to better understand the requirements of organizations wanting to implement or strengthen peer programs and 4) a limitation in the kinds of peer roles the initiative can address because the funding source limits the peer role to linkage to care and treatment.
Social Network Theory-based interventions to increase social support for people living with HIV
I would address the first two limitations—lack of focus on social network of people living with HIV, and the issue of clients in rural areas with limited access to peer support—using approaches based on the Social Network Theory. This theory posits that the people in a person’s social network have a profound influence on that person’s behavior. I see three ways in which this theory could be used to expand the reach of peers to serve remote clients:
1) Enlist the support of people in the social network of HIV clients by reaching out not only to people infected with HIV but to those affected by it: the network of family and friends surrounding the infected person. For clients who are willing to disclose their status to family and friends, establishing a peer-led support group to educate those members of the person’s network about HIV and how to best support people living with HIV would serve to strengthen the client’s adherence behavior. It would also serve the crucial role of reducing the stigma of the disease through a better understanding, thus changing the norms within the person’s social network and the community. In one recent study, in a majority of the participating families with an HIV-infected parent, family members expressed fears about the spread of HIV in the home (31). Clearly these families would benefit from additional support and education, as well as the client. While this intervention is beneficial to HIV-positive clients regardless of where they live, it would be particularly helpful to rural clients; if a client lives too far away to meet with a peer on a regular basis, enlisting the support of the client’s social network would provide many of the same support functions that a peer would.
2) Create a “buddy system” where two clients living in the same remote area could serve as peers to each other, providing each other with support and making sure they take their medication. This is a strategy being used in resource-limited settings with some success (32).
3) Expand the definition of “networking” to include the Web and other devices. Peers working with the three national education centers have reported using mobile phones to contact their clients with some success. Use of the Internet is more problematic, since less educated, economically disadvantaged and socially marginalized people are least likely to have access to a computer. Nevertheless, access is increasing, and for some rural clients, Web-based applications which provide some of the same kind of health education that peers offer may be a viable alternative (33). Communicating with peers via email or participating in social bulletin boards, such as those found on thebody.com (34), a popular website for information about HIV/AIDS, might be a source of support and connection for some remote clients.
Once these models of support for client networks and rural clients have been developed, the PEER Center training of trainers and capacity-building toolkits could be expanded to include modules to address these additional roles for peers, making them available to organizations who want to include them in their programs. The PEER Center could also use its knowledge of best practices in peer programs to develop interactive Internet-based programs to address some of the roles that peers play, particularly around HIV education.
Using sociological and anthropological methods to research organizations seeking to start peer programs—the first step in a social marketing campaign
In part I, I argued that a better understanding of the kinds of organizations who would benefit from starting or enhancing a peer program was needed in order to address the peer program requirements of these organizations. Researching such organizations is the first step in a social marketing approach. Social marketing techniques are effective for interventions—like the peer initiative— which encourage behavior change or an increase in program use, according to Nedra Kline Weinreich, author of Hands-On Social Marketing. To learn as much as possible about the target markets—such as the many freestanding clinics, clinics within hospitals, community-based organizations, AIDS Service organizations, state health programs, and faith-based organizations—I would turn to the research methods of sociology and cultural anthropology.
The PEER Center has already undertaken a portion of this work by conducting a needs assessment survey. This has yielded some important information about organizations in the South. The research has been limited to the organization’s potential use of peers, however, without regard for the broader context in which the organizations function. The next step would be to broaden the scope of investigation to include not only the South, but a representative sampling of various kinds of organizations throughout the U.S. Conducting focus groups, surveys, and in-depth, open-ended interviews would yield some important information on which to base a social marketing campaign: what constraints these organizations operate under, what their missions are, what populations they serve, how they are organized, what their problems and challenges are, what conferences they attend, what websites they visit, what newsletters they subscribe to, what organizations they partner with. By analyzing the quantitative and qualitative data this research would reveal, the marketing team would be able to uncover some common themes or patterns in different kinds of organizations with respect to the goals of their peer programs, the kinds of roles they expect peers to play, and their methods for recruiting and training peers. This information could be used to segment the target market more finely and develop resources and training modules to address the needs specific to these segments.
Using Social Marketing techniques to market peer programs to organizations
According to Kline Weinreich, “social marketing is the use of commercial marketing techniques to promote the adoption of a behavior that will improve the health or well-being of the target audience or of society as a whole.” (35) However, because we are marketing not to end-user consumers directly, but rather to organizations who will offer services to consumers, the commercial marketing techniques would be those used in “B2B” (business to business) marketing—those of a business offering its products or services for sale to another business. Just as B2B campaigns are used extensively in the business world, these same techniques can be used to market to organizations providing HIV/AIDS care to individuals. For example, we would establish a “customer advisory board” to provide feedback on various aspects of the mix as we develop them. Customer relationship management tools would be renamed as a “technical assistance log”, but the concept—keeping track of which “customers” you contacted when and what the follow up steps should be—would remain the same.
Below is the marketing mix consisting of the “four Ps” of the peer initiative marketing campaign (36):
Product: The product in this case is the idea of peer programs: encouraging organizations to include HIV-positive people in their programs for combating HIV/AIDS. To do this, we need to analyze the research we have conducted on our target organizations to identify the attributes and benefits that would resonate with each distinct segment. One way to do this is to articulate a problem that the organizations are trying to solve. For example, Ryan White-funded organizations are mandated to include consumer input into their programs—peer programs would be an excellent way to meet this requirement. Another is to identify what the competition is for peer programs within particular segments and demonstrate how using a peer program is different or better. For example, if case managers perform many of the functions of peers with HIV clients, we could demonstrate ways in which peers work together with case managers to complement their efforts and free them up to focus their energies on the higher level skills while the peers perform some of the lower level, more time- or labor-intensive tasks. Elements in the product mix would include resources to make it easier for the organization to implement a peer program—tools to make planning, organizational acceptance, hiring, training and supervision of peers, program evaluation, and other capacity-building activities simpler and more efficient. All of these would need to be continuously tested with the customer advisory boards as they are developed and refined.
Price: The price may be monetary—how much will it cost to fund a peer program—but since many of the organizations have already secured Ryan White funding, it is more likely to be the amount of effort an organization must undertake to implement and sustain a peer program. The needs assessment the PEER Center undertook reveals that peer programs are generally viewed as very labor-intensive to implement. The benefits of a peer program to the organization and the people it serves must outweigh these efforts. In addition to highlighting the many benefits of peer programs through promotion (described in more detail below), the peer intervention must demonstrate how the availability of best- practice guides, the many tools available, and the support of the peer education centers make it easier for organizations to implement a peer program. Once more, constant feedback from target organizations on which arguments resonate most with them will help to refine the way price is portrayed in the campaign.
Place: This refers to the distribution channel through which the organizations will receive support in implementing a peer program. The PEER
Center provides the product in part through its website. PEER Center staff increases its availability by conducting one-on-one capacity-building conversations over the phone, making presentations at conferences, and conducting webcasts 0n topics related to implementing peer programs. Place also pertains to the three national peer education centers which conduct outreach to their partners, make site visits, and conduct peer training and supervisor training for organizations who implement peer programs.
Place can also refer to the way a peer program is administered. Peer programs are generally managed and administered within the organizations providing care and services for people living with HIV/AIDS. Occasionally, however, peers may be outsourced to an organization and be administered by another local organization. In this latter case, the marketing mix would need to make sure that the local organization has everything it needs to provide the required support to make the peers successful within the organizations where they work.
Promotion: Promotion refers to making sure that the message about the peer intervention product reaches its intended audience. The purpose of the promotion is to motivate organizations to start or expand peer programs. Because the target audience in this case is relatively small, mass marketing campaigns are less useful than more personalized approaches. The national peer education centers have developed relationships with many of these target organizations and promote the implementation of peer programs through local seminar presentations, one-on-one consultations, site visits, and training opportunities. Drawing on the national peer educations centers’ local expertise, the PEER Center has created a brochure outlining the advantages of peer programs to link people living with HIV in care and treatment, regularly makes presentations at conferences such as the Ryan White All Grantee Annual Meeting. It also publishes an electronic newsletter highlighting successful peer programs and new resources available, conducts webcasts on topics of interest to organizations implementing peer programs. These efforts should be refined by identifying the different types of organizations the initiative is targeting and developing and testing materials with those audiences.
The above components are common to both commercial and social marketing campaigns. Kline Weinreich points out that there are some additional “Ps” specific to social marketing which need to be considered:

Publics: These are all the different audiences which the social marketing campaign must address in order to be successful. It includes not only the target audiences but all of the internal and external groups involved in the peer initiative. When developing a campaign, the team must continually communicate with these audiences to make sure they all understand and buy into the strategy. This would include all involved groups within the organizations which comprise the PEER Center, the three national education centers and their partnering organizations, any other contributing organizations with whom the initiative has partnerships, and the funding and administering government organizations.
Policy: In many cases, policy change is needed to increase the effectiveness of a social marketing campaign. In the case of the peer initiative, any policy that increases the stigma of HIV/AIDS or makes treatment adherence more difficult needs to be addressed at the organizational, local, state, or federal level. Examples of such policies might be laws which make the spread of HIV a crime, or Medicaid coverage for full-blown AIDS but not treatment following an HIV diagnosis. Because of their lived experience, peers can serve as a voice of authority in calling attention to such policy inequities and are sometimes trained as advocates within community-based organizations.
Purse Strings: Unlike business marketing campaigns, where funding generally comes from the marketing budget of the company selling a product, funding for social marketing programs comes from a wide range of sources ranging from government or foundation grants to individual or corporate donations. As outlined in Part I, one of the limitations of the peer initiative is that its funding has a profound impact on the types of roles the initiative can support, regardless of the needs of its target audiences. This issue can be addressed through partnerships as outlined below.
Partnerships: In the case of the peer initiative, partnerships-- the teaming up with other organizations to support the social marketing campaign and the behavior it is trying to encourage --are one of the most important parts of the marketing strategy. The peer initiative is a complex network of partnerships and relationships with other organizations. However, I would recommend one additional partnership: a collaboration between the Centers for Disease Control and Prevention (CDC) and the Health Resources and Services Administration (HRSA) with relation to the peer initiative. The CDC, with its focus on prevention, has several programs in place that provide capacity building to organizations to support a role for peers in testing and prevention. Programs such as the Mpowerment (37) project to prevent the spread of HIV among gay young men and Street Smart (38) to reduce the risk of HIV among runaway youth are completely separate from the peer initiative, which is funded through HRSA and focuses on access to care and treatment. Merging these programs to present a single set of training and capacity-building resources would eliminate administrative redundancies and simplify the task of starting a peer program for organizations who want to create a program which addresses HIV at several points, including HIV testing, linkage to care for newly diagnosed clients, outreach and prevention, advocacy and stigma reduction.
Such a collaboration is not unprecedented. In 2000 the CDC and HRSA partnered with state health departments and correctional facilities to create an initiative which integrated correctional and community-based health care services for prisoners. This initiative tested incoming inmates for HIV, provided linkage to care and treatment for those who tested positive, and provided HIV prevention services to all participants (39). This initiative was very beneficial to the prisons, who often struggle to provide health care and find funding for HIV testing and education. In the peer initiative, the onus currently falls on the organizations to cobble together from separate sources a coherent peer program that meets all their needs. Coordinating the many different ways that peers can be used to address HIV/AIDS at a higher level, rather than at the point of service, removes this burden from community organizations and clinics who are already stretched for resources and understaffed. The result would be an increase in the number and effectiveness of peer programs, resulting in more people being served better.
Conclusion
The peer initiative can be improved by studying the needs of organizations more closely and using this research to develop a marketing strategy to target those organizations with a product closely tailored to their needs. Part of this process would be to join forces at the top funding levels to create this product, as well as expanding the training of peers to include a variety of roles that reflect the needs of HIV/AIDS organizations and their clients.
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Abstinence Education: A Critique and Alternative Approaches for Improvement – Kathy Zheng

The United States spent about $1 billion dollars on abstinence education between 1998 and 2007 (1). The goal of this campaign, as promoted by President George W. Bush beginning in 2001, is to decrease the incidence of teenage pregnancy and sexually transmitted diseases through the promotion of abstinence among unmarried individuals. The Department of Health and Human Services established the website “4Parents.gov” as part of the campaign. Its main purpose is to provide information for parents about how to talk to their children about abstinence. However, despite the widespread efforts of the government and the vast funds that have been dedicated, the abstinence campaign has not been successful. Studies show that in areas where abstinence education is explicitly promoted in schools, the rate of sexual activity among teens increased after completion of the education program (2). The number of pregnancies among teens who participated in the abstinence only programs also increased (3). Thus, it is clear that abstinence-only education programs have fundamental flaws. While some of the flaws are rooted in the theoretical basis from which the program is designed, others are in reference to the audience in which the program is directed towards. Several criticisms of the approach, specifically the use of the 4Parents.gov website, as well as suggestions for the improvement of the intervention are presented here.
Criticism 1 – Theoretical Basis
It is evident that the abstinence-only education programs are based on several traditional models of health behavior. These models include the Theory of Reasoned Action (TRA) and the Health Belief Model (HBM). 4Parents.gov emphasizes the importance of parents communicating to their children their desire for them to abstain from sex until marriage (4). The argument is that children who understand their parents’ desire for them to abstain are more likely to do so. One of the facts that the website encourages parents to share is “Do you know that, according to one survey, two-thirds of teens who have had sexual intercourse wish they had waited?”
This approach is clearly modeled after the TRA because it aims to change a person’s attitudes towards a behavior and present abstinence as a socially desirable and acceptable behavior. One major criticism of this approach is that it is an individual level intervention. This is paramountly inappropriate for interventions dealing with teenage pregnancy and STDs because neither is individually acquired. Another argument to this approach is that it assumes that individuals will systematically weigh the benefits (100% prevention of pregnancy and STDs) and public perception and naturally arrive at a mathematical conclusion to abstain. Thus, 4Parents.gov is fundamentally arguing that is it a lack of knowledge and input that contributes to premarital sex. This is exceptionally unreasonable given the major emotional and hormonal input in a teenager’s decision to have sex.
Abstinence-only education is primarily a data based intervention. Proponents often cite statistics about the rate of STD transmission among the sexually active and unmarried (4). They frequently use data about the higher incidence of poverty among unmarried women who get pregnant as a tool to discourage sex before marriage. To its credit, 4Parents.gov presents some information about contraception other than abstinence. However, its merits are quickly abated when upon closer inspection, one notices that the failure rates of each form of contraception is prominently noted. This presentation clearly highlights the viewpoint of the website about abstinence rather than encourage the discussion of its alternatives.
The approach is also based on the HBM. The severity of the consequences of premarital sex and the susceptibility of a person to those consequences are presumed to be the main driving force behind the decision to abstain. Studies have shown that “knowledge of consequences” is the third most often cited reason for the use of abstinence education (5). Interventionists must trust that the teenager will view this information as dangerous enough to abstain from sex. However, it would not be prudent to assume that the teenager would then naturally make the rational decision. Adolescence is characterized by risk taking and rebellion (2). Therefore, a conscious effort by the teenager to act against the rational decision would be more likely. This model also creates an individual level intervention and this is inappropriate because sexual activity is generally not an individual level action. Furthermore, abstinence-only sex education assumes that the decision to have sex is made inside a vacuum, that is, without social or environmental determinants or influences. This is inappropriate because an adolescent’s decision to have sex is well-known to be influenced by the pressures or actions from others. Finally, abstinence-only education based on both the TRA and HBM assume that the adoption of abstinence is planned. This does not take into account the spontaneous nature of teenage activities, especially those sexual in nature (6).
One alternative model of health behavior that may explain the failure of abstinence-only education is Stigma or Labeling Theory. This theory argues that when people are labeled as a particular type of person, there is a self-fulfilling prophecy. If a teenager has already had sex and plans to continue having sex, the only advice the 4Parents.gov website gives to parents is to continue talking to the teenager and have her visit a health care provider. Although, there is information on the website about birth control, as mentioned, there is no information about how to speak to teenagers about using them. Thus, if the teenager is already sexually active, Labeling Theory suggests that teenagers may view themselves as being beyond the scope of abstinence-only education, and therefore may reject sex education altogether. The intervention does not comprehensively address the needs of this population and teenagers may continue with their unsafe sexual practices because there then appears to be no reasonable alternative. In fact, teenagers who find that they are unable to abstain may experience shame (2). This could lead to the teenagers being secretive about their sexual practices and discourage them from seeking out advice about ways to prevent pregnancy and STDs.
Criticism 2 – Contextual/Ecological Factors
As mentioned, abstinence-only education based on the traditional health behavior models is an individual level intervention. Despite the fact that actions to protect oneself from teenage pregnancy or STDs may be individual in nature to a certain extent, interventionists may not be able to act without knowing the context of the problem. There may be higher level factors that abstinence alone cannot reasonably address and they may be the fundamental causes of why a teenager is engaging in risky sexual practices.
One risk factor for such practices may be the community one interacts or lives within (7). For example, if the community is one where most residents are of low socioeconomic status, parents may work more than one job that requires long hours. 4Parents.gov assumes that parents have the time to maintain a continuous dialogue with their teenagers about the risks of sex. Their argument is that this dialogue is most influential for a teenager’s decision to abstain from sex. However, if the parents are unable to devote the time, 4Parents.gov does not offer an alternative solution to the problem.
Areas of low socioeconomic status may also be deprived of recreational activities associated with the community, church, or school for adolescents. Research shows that adolescents who participate in these activities are less likely to engage in risky sexual behavior (8). Abstinence-only education does not address the possibility of this deprivation of social activities and thus ignores the higher order contextual risk factors associated with the initiation of sex among adolescents.
The individual level intervention fails to address the influence of the media in a teenager’s decision to have sex. Images of sex are pervasive in the media and research shows that teenagers exposed to those images on television are more likely to have their first sexual experience sooner (9). However, the study also shows that the effect of sex in the media can be countered by parents watching television with their children and sharing their beliefs about safe sex. This would also assume that the parents can devote the time to partake in such activities. If this assumption is incorrect, then the influence of the media can be substantial.
Criticism 3 – Social and Cultural Factors
Abstinence-only education fails to address the social and cultural differences of teenagers and their families. A lack of understanding of these differences may lead to teenagers feeling marginalized and unworthy. In addition, an intervention that does not reasonably and comprehensively address alternatives to abstinence greatly limits the context in which the intervention can be presented, and context is of primary concern when approaching a subject that is culturally sensitive such as sexual activity.
There are cultures that practice family silence about topics relating to sex. For example, Choi et al states that “Asian families are not able to acknowledge sexual identity” (7). 4Parents.gov suggests that sexual abstinence by teenagers can be achieved mainly through dialogue with parents about the risks of sex. If sex is a taboo subject within a culture, then this dialogue is not possible. As a result, the underlying message propagated by the campaign would be inapplicable to the Asian population. Moreover, since the website does not comprehensively address alternatives to open discussions about abstinence and sex, teenagers may develop repressed sexual urges that may encourage them to seek out sex, safe or not (7).
In addition to racial differences, studies also show that there are gender differences with respect to adolescent attitudes about sex. Girls have more negative perceptions about the benefits of sex and less negative perceptions about pregnancy as compared to boys (10). 4Parents.gov does not address gender differences with their approach. The assumption is that both girls and boys would be equally receptive to the messages presented by the website. Since the research shows that there is a gender difference in sexual attitudes, the approach is unreasonable.
Abstinence-only education also fails to address the sexual practices of those for whom marriage may not be an option. The intervention operates under the assumption that its entire audience will eventually enter into a mutually faithful, monogamous relationship in the context of marriage (11). This approach discriminates against the gay, lesbian, and transgender youth (12). Marriage may not be possible for these individuals due to government policies. Therefore, abstinence-only education interventions either do not condone sexual activity for these people or they feel that this group is unworthy of safe sex intervention. The concept of worthiness is one that is often cited in support of sexual abstinence for teenagers (13). If teenagers who are gay, lesbian, or transgender do not abstain before marriage because marriage is unlikely, then they may develop a feeling of unworthiness if exposed to the abstinence message. In reference to Labeling Theory as discussed, this feeling may lead them to continue with unsafe sexual practices and may even exacerbate the problem.
As shown, there are many fundamental reasons for the failure of the abstinence-only campaign to fight pregnancy and the spread of STDs among adolescents. It is evident that the failure is unrelated to the lack of funding, but rather it can often be attributed to the lack of understanding of its audience. In addition, it can be seen that the traditional health behavior models inadequately address issues with significant social and emotional components that may also happen to be culturally sensitive. As a result, a more comprehensive and less contextually restrictive approach to the problem is warranted.
Alternative 1 – Predictable Irrationality and Alternative Health Theories
The abstinence-only campaign based on the traditional health belief models does not account for the irrationality of teenage behaviors and decisions. Therefore, an alternative intervention is suggested where there is no assumption of a rational decision on the part of the teenager to abstain from sexual activity and the basis for the intervention will be an alternative health behavior model. Studies show that among individuals aged 10 to 24 years old, 47.8% were sexually active in 2007 (14). About half of teenagers do not remain abstinent despite the 4Parents.gov campaign. Studies show that comprehensive sex education programs that include promoting methods of safe sex do better to reduce the number of partners, improve condom use, and reduce pregnancy among teenagers compared to abstinence-only education programs (15-16). These comprehensive programs are critical because they address the needs of teenagers who are already sexually active.
One suggested alternative health theory to use as a basis for an intervention is Marketing Theory or the Social Marketing approach (17-18). Unlike the TRA and HBM, Marketing Theory is a group level intervention because it does not seek to target each individual separately. The issue of preventing teenage pregnancy and STDs lends itself better to a group level intervention because of the social and peer influences associated with sexual decisions. Also unlike the TRA and HBM, this theory does not present the negative consequences of sex, but rather the positive outcomes of safe sex. Advertising Theory, which is a subset of Marketing Theory, argues that interventionists should first identify teenagers’ aspirations. The promise of a teenager’s fulfillment of those aspirations if they adopt safer sexual behaviors can be made through visual representations in the media.
Interventionists should look to the success of popular clothing brand campaigns for ways to market aspirations to teenagers. The television, billboard, or magazine advertisements for these clothing brands often do not even need to rely on a presentation of the product to be effective. Rather, the aspirations being presented may include teenagers being perceived as physically attractive, popular, independent, etc. Therefore, it is reasonable to assume that the same formula can be effective for a safe sex campaign. Commercials and print advertisements portraying attractive and popular teenagers in relatable yet glamorized settings could be presented along side messages promoting condom or contraception usage.
Alternative 2 - Addressing Higher Level Factors
As mentioned, the United States spent about $1 billion between 1998 and 2007 on abstinence education (1). There is clearly no lack of available funding for sex education. The issue is then to find better a way to utilize those resources to produce lower incidences of teenage pregnancy and STD infections. A criticism of the 4Parents.gov initiative is that it does not address the possibility of the deprivation of social activities within neighborhoods of low socioeconomic status. A lack of participation in recreational activities associated with the community, church, or school is a risk factor for engaging in risky sexual behavior among teenagers (8). Therefore, a successful intervention must do more than address the risk factors association with teenage pregnancy and STD transmission; it must also address the risk factors associated with risky sexual behaviors. The recommendation is to allocate some of the resources reserved for sex education towards funding for increased after-school activities or community recreational activities geared towards teenagers.
4Parents.gov also fails to address the influence of the media. However, an intervention based on Marketing Theory utilizes the influence to its advantage. If studies show that teenagers exposed to sex in the media are more likely to have their first sexual experience sooner, or media campaigns such as Florida’s “truth” initiative are able to decrease the incidence of teenage smoking by 7.4% in 30 days, then it is reasonable to believe that the media can also be a powerful tool to influence teenagers to adopt safer sexual practices (9, 19). Therefore, increased funding for recreational activities for teenagers in conjunction with the use of a Marketing Theory-based media intervention would have improved success over the 4Parents.gov campaign.
Alternative 3 – Cultural Competence and Social Awareness
In addition to community based programs to intervene where parental involvement may be limited, programs should also be established to provide support to parents who are able to take an active interest in their children’s sexual wellbeing. Addressing the social and cultural factors that limit the success of the 4Parents.gov campaign requires the establishment of such programs.
It is important to recognize culture as an important predictor of sexual initiation among teenagers. Although the relationship between culture and attitudes towards sex in the United States has not been fully explored in the literature, a study performed in the United Kingdom shows that an open dialogue about sex within Chinese families was uncommon often due to the language and cultural barriers between the UK-born teenagers and the China-born parents (20). Although abstinence-only education may seem inappropriate given that half of all United States teenagers have sex, it is important to note that the a generalized comprehensive sex education program may also be inappropriate for families of cultural backgrounds with conservative views about sex.
It is important for interventionists to recognize that some cultural views about sex may be more conservative than mainstream views (20). One approach would be to dedicate funds to establish community programs to teach parents how to overcome language, cultural, and generational barriers to effectively convey their own attitudes about sex. These programs should be led by individuals who have the same cultural backgrounds as those being served because there will be an intimate awareness of what is and is not appropriate. Another approach would be to produce television and print campaigns to air on foreign language channels and publications. These foreign language campaigns could show images of happy families and healthy teenagers with the message that effective culturally appropriate communication about sex could lead to these aspirations. In addition to comprehensive sex education programs directed towards teenagers who choose not to abstain, these approaches could show cultural groups how to give parental support to those teenagers who do abstain because of their own beliefs without feeling alienated by mainstream views.
The lesbian, gay, bisexual, and transgender (LGBT) community is one where abstinence education is inappropriate, for reasons described above. A feeling of worthiness should be reinforced within this community despite the fact that sexual activity occurs outside of marriage. Television and print campaigns, such as those previously suggested, can be tailored to present positive images of LGBT teenagers more prominently. Another direction campaigns geared toward LGBT’s can adopt is to make methods of safe sex provocative and fun. For example, there are condom commercials which show the sexual attractiveness of a man who has a condom to women. The same types of commercials can be produced showing LGBT couples.
Lastly, an important consideration for both the use of media and community programs for an intervention is gender differences. Studies have shown that girls and boys have differences in their perceptions about sex (10). As a result, interventionists should produce one set of media campaigns geared toward girls, such as portraying aspirations of being respected by peers for being sexually responsible, and another gears towards boys, such as portraying the independence one could have if one was not burdened by the responsibility of early fatherhood.
Ultimately, the use of the media as well as establishing community programs to address higher order societal risk factors for teenage pregnancy and STD transmission are improvements upon the current interventions adopted by the government. A government campaign to battle teenage pregnancy and STD transmission has the unique advantage of not being limited by funding, as public health initiatives tend to be. Public health professionals should look to successful marketing campaigns for commercial goods aimed at teenagers for inspiration on how to design a successful safe sex campaign. The funding is available for interventionists to purchase the same expensive air time slots as consumer product companies buy. Perhaps the unorthodox approach of marketing safe sex as a product rather than as a behavior is one that teenagers will finally respond to.
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