Challenging Dogma - Fall 2007

...Using the social and behavioral sciences to improve the practice of public health.

Monday, December 10, 2007

Stay Alive: A Family Based Deterrent or Determinant in the Spread of HIV/AIDS? – Kami Power

Despite overwhelming evidence of the ineffectiveness of abstinence only programs, many faith-based organizations still employ this model to push their religious agendas under the guise of public health and community empowerment. As Jonathan Cohen of Human Rights Watch said, “Abstinence-only programs are a triumph of ideology over public health.” (1) The Stay Alive program established by United Families International is no exception. With the mantra of “Live a Long, Loving Life,” the program teaches African children ages 9-14 that practicing abstinence until marriage is the only method to prevent the spread of HIV/AIDS and to be accepted by your family and your peers as an individual of worth.

While using this approach may be effective for some children, for many others and their communities it has set them up for failure. Despite their best intentions, the organization has failed to fully analayze the crucial long-term outcomes of this intervention. What the founders of this program have failed to take into consideration is the unintended sociological implications for individuals who are unable to translate the information taught into action or to follow through with the desired behavior. In fact, research has shown that abstinence-only interventions often have the opposite effect on behaviors, increasing risk. (2,3,9) These effects are brought on by the Stay Alive program's three major flaws: reliance on the Health Belief model, reliance on individual self-efficacy to achieve the desired behavior, and use of an inappropriate normative/re-educative sociological perspective.

Theory vs. Reality

Even the best intentions, if not based in reality, will fail as often intention does not directly correlate with behavior. The Stay Alive curriculum, which is based directly on the Health Belief Model, assumes that in addition to directly translating intention into behavior, participants will be able to accurately weigh a lifetime of health risks and benefits and make rational decisions based on this analysis.

First, the model assumes that participants have accurate information on which to base their decisions and are able to rationalize both short-term and long-term risks and benefits. However, studies show that most abstinence only programs, such as the Stay Alive program exported to Africa through United Families International, inaccurately portray and often exaggerate the risks of sexual behavior and STD transmission. (4)

Secondly, the Stay Alive program, in following the Health Belief Model, assumes that youth will rationalize this misinformation to support their intention to abstain and turn that intention directly into behavior. This final link determines the success of the intervention. Research shows however, that despite increased knowledge levels and improved attitudes and intentions, abstinence-only education did not translate from information into behavior. (2,5,6,9) If this is a difficult task for youth in economically and politically stable high-income countries, how much more difficult is it for a child in a developing country afflicted by conflict and disease?

Self-Efficacy: What happens next?

In addition to relying on an ineffective model for health behavior, the program also heavily relies on the concept of self-efficacy: the belief by an individual that they are able to perform the desired behavior. To be successful, Stay Alive program participants must believe that they are able to remain abstinent until marriage. This does not take into account the outside environmental factors which children may know to be beyond their control. For example, it is not uncommon in low-income countries for women and children to gain income from selling their bodies for sex. If a child believes that they will never be able to remain abstinent, then they may never even try for even a short time.

Additionally, youth may see HIV transmission as inevitable and therefore never attempt the behavior to begin with. Research shows that if an individual believes he/she will contract disease regardless of changing health behavior, they will not try to emulate the behavior at all. Rather there is acceptance of the inevitable and increased rates of risky behavior. (7)

Furthermore, it is not only the behavior that may seem unattainable for participants, but also the final life outcome. Examine this excerpt from the Stay Alive Program lesson number 2: “Now envision a house for your future family, a home where you live together with your husband or wife and your children. Envision some happy times with them in this house: washing the new babies and dressing them in clean clothing, stirring delicious food in a pot, mending the roof, sweeping the floor clean, talking and laughing together.” (8) For many participants this may seem like an unrealistic expectation even if the health behavior is exemplified. Thus we must ask the question, what is the benefit to avoiding risk and remaining abstinent until marriage if the final life outcome (the reward) is unattainable even under the most ideal circumstances.

When changing social norms only serves to separate social outcasts

Even under the most ideal circumstances, public health interventions are never 100 percent successful thus making it crucial to provide alternative methods for behavior modification. By using an all or nothing approach to sexual abstinence before marriage, the Stay Alive Program, alienates those unable to follow the program by providing no alternatives. Research shows that abstinence only programs are ineffective at achieving long-term behavior changes and fail to provide alternatives for those unable to perform the behavior.

In addition to not providing alternatives, abstinence only progreams may negatively impact long-term health. Studies show that all or nothing approaches to abstinence create social and psychological barriers to health education and access. (2) For example, those who engage in sexual activity before marriage may be more likely to avoid treatment (6). By discouraging open dialogue about health concerns and treatment, those unable to abstain are relegated to a life of guilt and shame.

Without providing education and rational alternatives for prevention of HIV/AIDS, the change in social norms will be a negative one which creates outcasts of anyone who is unable to remain abstinent until marriage, whether it is under their control or not.

Conclusion

The objective of this paper is not to condemn abstinence as an alternative for HIV risk reduction. Instead it is a critique of the approach employed by the Stay Alive program. By applying a sociological perspective, we can see that the current normative/re-educative model is ineffective and should be replaced with the rational/empirical model.

Alternatively, the Stay Alive program would be more successful using an abstinence-plus approach. Abstinence-plus provides a pyramid of options with abstinence at the top. This alternative approach addresses the fatal weaknesses in reliance on the Health Belief Model, self-efficacy and the persuasive nature of the current program. Instead it provides accurate information on a wide range of alternatives in an inclusive manner which is more appropriate for topic and the target audience. (10)

As shown throughout this paper, the Stay Alive program is flawed in its reliance on the Health Belief model and individual self-efficacy and its use of an inappropriate normative/re-educative sociological perspective. If the Stay Alive program continues to use this ineffective program, the implications for the target population will be hugely negative.

References

1. Human Rights Watch. Uganda: 'Abstinence-Only' Programs Hijack AIDS Success Story. March 2005. http://hrw.org/english/docs/2005/03/30/uganda10380.htm.

2. Borawski EA, et. al. Effectiveness of Abstinence-Only Interventions in Middle School Teens. American Journal of Health Behavior 2005; 29(5): 423-434.

3. Medscape Today. Abstinence-Only Programs May Not Affect Risk for HIV Infection. Medscape Today 2007.

4. U.S. House of Representative Committee on Government Reform - Minority Staff Special Investigations Division. The Content of Federally Funded Abstinence Programs 2004. http://oversight.house.gov/documents/20041201102153-50247.pdf

5. Advocates for Youth. Five Years of Abstinence-Only-Until-Marriage Education: Assessing the Impact. http://www.advocatesforyouth.org/publications/stateevaluations/index.htm.

6. Bruckner H. and Bearman P. After the Promise: the STD Consequences of Adolescent Virginity Pledges. Journal of Adolescent Health 2005; 36: 271-278.

7. Siegel M. The Importance of Formative Research in Public Health Campaigns: an Example From the Area of HIV Prevention Among Gay Men (Appendix 3-A), pp. 66-69. In: Siegel M. Doner L. Marketing Public Health : Strategies to PRomote Social Change. Sudbury, MA: Jones and Bartlett Publishers, 2004.

8. Stay Alive Program. Stay Alive I Supplements. Lesson 2: “A Loving Family Can Bring Happiness.” http://www.stayalive.org/stayalive/Lesson_Two.cfm.

9. Dworkin, S. and Santelli, J. PLoS Medicine. Do Abstinence-Plus Interventions Reduce Sexual Risk Behavior Among Youth 2007. PLoS Medicine. http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371% 2Fjournal.pmed.0040276&ct=1.

10. Underhill, K, et. al. Sexual Abstinence Only Programs to Prevent HIV Infections in High-Income Countries: Systematic Review. British Medical Journal Online 2007. http://www.bmj.com/cgi/reprint/bmj.39245.446586.BEv1.

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