REP Adult Secondary HIV Prevention Interventions: Their Failure to Address Sexual Risk Taking Among HIV- Infected Population- Jessica Ripton

Approximately 33% of HIV-infected individuals from diverse populations across the U.S. continue to engage in unprotected sexual intercourse (1). Nationally, unprotected sexual intercourse with an infected partner continues to be the leading transmission category among men who have sex with men (MSM) at 67% and unprotected heterosexual contact accounts for 80% of all infections among women (2). In response to continued sexual risk taking, HIV prevention strategies have expanded to include secondary prevention interventions, which are prevention interventions aimed at reducing transmission risk behavior among HIV positive individuals. Researchers, local health providers and government agencies recognize the need to quickly implement interventions that have shown effectiveness in reducing transmission risk behavior in randomized controlled trials. Such interventions are commonly referred to as evidence-based. The goal of the Center for Disease Control (CDC) Replicating Effective Programs (REP) is to package evidence-based behavioral interventions in an accessible language and format to be used to guide prevention providers in replicating effective risk-reduction programs in their own settings and communities (3). Three of the thirteen evidence-based behavioral interventions currently included in the CDC’s REP focus on reducing sexual risk behavior among HIV-infected populations. Two of the interventions focus on adult populations, while the third focuses on HIV-infected youth. This paper will concentrate on the REP behavioral intervention designed for HIV-infected adults, as the issues specific to HIV-infected youth merit a separate investigation.

The secondary prevention behavioral interventions included in REP for adults have contributed significantly to the field of HIV prevention; however, several limitations will impact the effective replication of these interventions in HIV-positive communities throughout the nation. Both interventions focus on either providing individuals with information on how to reduce sexual risk taking or building skills and strategies to reduce sexual risk taking. Yet neither intervention attempts to uncover the complex reasons why the sexual risk taking continues. This paper will address the following fundamental limitations of the REP secondary prevention interventions: 1) Social Cognitive Theory’s emphasis on skill and education-based behavior change doesn’t address the root cause(s) of continued sexual risk; 2) the interventions fail to assess how multiple psychosocial issues such as limited access to care, lack of stable housing and lack of social support impact sexual risk taking and; 3) despite strong evidence that HIV infected population experience high level of psychological distress, neither intervention addresses underlying mental health issues which may have initially put these individuals at greater risk of HIV infection and will likely continue to impact their sexual risk behavior.

REP & Evidence-Based Secondary Prevention Interventions
The CDC’s Division of HIV/AIDS Prevention (DHAP) has been working to make research–based HIV/AIDS prevention interventions available to communities since 1996 through technical assistance programs such as REP (4). Briefly, REP works in partnership with two other technology transfer projects in DHAP: Prevention Research Synthesis (PRS) and Diffusion of Effective Behavioral Interventions (DEBI). The programs work to identify evidence based interventions and prepare packages of materials for dissemination to HIV prevention agencies and providers (4). As noted previously, two of the thirteen REP programs focus on HIV-infected adults: Healthy Relationships and Partnership for Health. The following section will briefly describe the initial intervention studies where efficacy was determined.

Healthy Relationships is a behavioral intervention grounded in Social Cognitive Theory designed to assist people living with HIV to reduce HIV- transmission risk behavior through group sessions emphasizing the importance of building behavioral skills, enhancing self-efficacy for practicing risk reduction behaviors, promoting intentions to change risk behaviors, and developing strategies for behavior change. This study involved a randomized clinical trial design with a study population that included 230 HIV-positive men and 98 HIV-positive women from diverse backgrounds recruited from AIDS services and Infection Disease Clinics in Atlanta, Georgia. The study found significantly less unprotected intercourse and greater condom use at 6 month follow-up for the intervention arm (5).

In contrast, Partnership for Health is a behavioral intervention based on a social cognitive model that used brief provider-delivered counseling using either a gain-framed message (emphasizing the positive consequences) or a loss-framed message (emphasizing the negative consequences) on issues to reduce sexual risk taking among females and males at six large HIV clinics in California (6). The randomized controlled evaluation study found that at follow-up (up to 7 months after the intervention) the patients who reported two or more partners at baseline unprotected anal and vaginal intercourse (UAV) was reduced by 38% for those patients who received the loss-framed message counseling, but no significant changes were seen in those who received the gain-framed messages (6).

Limitations of Social Cognitive Theory
Both interventions are based on Social Cognitive Theory (SCT). SCT is rooted in an earlier theory of Albert Bandura’s called Social Learning Theory, which was based in behaviorism and was focused on how individuals learn through experience (7). SCT evolved when Bandura began to shift his focus to the concept of self efficacy and the role it plays in the process of behavior change. In addition to individual characteristics like self-efficacy, SCT also proposes that behavior change is a function of environmental factors and the interactive process between an individual’s behavior based on internal and external cues and the response the behavior elicits from society (7). While SCT clearly considers the individual’s interaction with environmental factors, it remains largely focused on the individual’s capacity to enact behavior change through self-efficacy. SCT, however, arguably does not expressly consider how self-efficacy can be limited by environmental factors, such as lack of affordable housing, access to care, ability to pay for medication, and other socioeconomic factors. Moreover, SCT seems to lend itself to interventions that are designed to provide individuals with information and skills or strategies to enact behavior change without addressing underlying issues that impact individual’s ability to negotiate sexual risk reduction. In their article on HIV prevention among Asian Pacific Islander (API) MSM, Choi et al. (8) argue that existing social cognitive theories have limited use in addressing the larger environmental factors affecting HIV risk because they are individual-focused models that ignore the individual’s wider social context. Choi et al. referenced how API MSM’s negative experience with cultural expectations, parent and family silence about sex, stigmatization and racism make it harder to practice safe sex (8). These issues could be considered “fundamental causes” of unsafe sexual behavior much in the way Link and Phelan (9) attributed social conditions as fundamental causes of major diseases. Link and Phelan argued that in order to understand risk factors we must contextualize the risk and examine how individuals come to be exposed to the risk (9). HIV prevention programs that fail to contextualize risk factors, assess the wider social environment, and identify the fundamental causes of sexual risk taking may be largely ineffective in the long term.

SCT in the context of both Healthy Relationships and Partnership for Health, leads to a reliance on individual based behavior change strategies. In Healthy Relationships, the intervention focused on increasing self-efficacy through targeted skill-building around issues of serostatus disclosure and negotiating sexual risk reductions. The intervention was administered in small groups and relied heavily on skill-based behavioral change (5). The brief provider messages used in the intervention for Partnership for Health were based on information regarding the health benefits of safer sex or health disadvantages of continued sexual risk taking. The brief provider messages were delivered at all visits except those that dealt with acute illness (6). Both interventions were successful at decreasing transmission risk behavior, but it can’t be determined if that decrease will be sustained. Information and skill-building interventions among HIV-infected populations undoubtedly impact behavior, but that impact is only as great as the individual’s ability to use the information or skill. An individual’s ability to use the information or the skill is not solely based on self-efficacy and secondary behavioral interventions need to do a better job identifying the fundamental causes of continued sexual risk taking.

Lack of Assessment of Multiple Psychosocial Issues
This paper uses the term psychosocial issues to broadly define a variety of psychological, social and economic issues impacting HIV-infected individuals such as mental health concern, socioeconomic concerns and lack of social support. In their article, Reif et al (10) state that HIV infected populations often experience multiple psychosocial needs and stressors, but often these needs are not met and HIV-infected individual are without the needed financial assistance, psychiatric care and social support (10). In multivariate logistic regression analyses, the author found that unmet needs in terms of benefits (Social Security, health insurance and prescription drug plan) and social support were associated with being less likely to be taking any HIV medication (10). The article suggests that those HIV infected individuals with unmet psychosocial needs may have worse health outcomes than those whose psychosocial needs are met. While there is no mention of a connection between unmet psychosocial needs and increased HIV transmission risk behavior, it may be that a similar relationship exists between numerous unmet psychosocial needs and increased transmission risk behavior. Using multivariate logistic regression models, Stall et al (11) found that a greater number of psychosocial health problems among MSM (polydrug use, depression, childhood sexual abuse (CSA), partner violence) were significantly and positively associated with high-risk sexual behavior and HIV infection indicating HIV prevention program need to address broader health concerns. The research of both Reif et al and Stall et al strongly suggest that reliance on traditional intervention models that focus solely on sexual risk may be unable to fully explain and address continued sexual risk taking in HIV-infected individuals.

There is little direct research on how psychosocial issues may impact transmission risk behavior among HIV-infected population; however, there is certainly evidence to suggest that such a connection is possible and merits investigation. Secondary prevention interventions like Healthy Relationships and Partnership for Health tend to be so focused on sexual risk taking that they de-emphasis other issues that are important to HIV-infected populations. Both interventions would benefit from taking a more holistic approach to sexual risk taking. A holistic approach would provide information and skill-building, as in Healthy Relationships and Partnership for Health, but would also include a thorough assessment of barriers to using the information or the skills.

Lack of Assessment of Underlying Mental Health Issues
Numerous studies have examined posttraumatic stress disorder (PTSD) and depression rates among HIV-infected populations and found them to be higher than rates among the general population and higher than individuals suffering from other chronic diseases (12; 13; 14). Within HIV infected sub-groups, MSM and minority women are at increased risk for PTSD (13), which may be attributable to both higher rates of stressful life events and childhood sexual abuse in these groups (14). Despite the strong evidence to support interventions aimed at assessing and treating mental health issues within HIV-infected populations, neither Health Relationships or Partnership for Health incorporated mental health assessment and referrals into the intervention. Given what is known about the prevalence of mental health disorders in HIV infected populations, this omission seems almost unbelievable. Prevention information and skill-building may have little impact on the sexual risk behavior of an HIV infected individual suffering from untreated anxiety disorder. It could be argued that the assessment of mental health status should be the first step in all secondary prevention programs. HIV-infected individuals with untreated mental health disorders may not be able to fully use the brief provider messages on risk reduction or the skill-building on risk reduction to enact sustained behavior change. An intervention that focuses solely on transmission risk behavior dismisses the important and complex role mental health disorders play in sexual risk taking and overall HIV disease progression.

Incorporating Mental Health Assessment in Interventions
In Healthy Relationships, the intervention would have benefited from having some individual counseling where the patient could discuss issues specific to their experience. Prior to the individual counseling session, patients could be asked to complete a brief mental health screening assessment. The counselor could use the results of the mental health screening assessment to inform the individual counseling sessions and when appropriate provide referrals for follow-up mental health services. Partnership for Health included brief provider message at all non-acute medical visits. However, it may have been more effective for providers to use some of the visits to address other issues that may impact the lives of their HIV-infected patients. Several of the brief interventions could have focused on assessing unmet mental health needs and developing a plan to access appropriate treatment services. By making small adjustments to overall interventions, both Healthy Relationships and Partnership for Health could address the mental health concerns of the patients, which may decrease their sexual risk taking and improve their overall health outcomes.

Conclusion
The critique of the REP behavioral interventions is not intended to be dismissive of their innovation or importance; rather, the intention is to illuminate areas that require further research. As the quest for a biomedical intervention (i.e. microbicides, vaccine, and post-exposure prophylaxis) suffers considerable set backs in clinical trials, the need for effective, targeted and diverse behavioral interventions is urgent. Moreover, these needed interventions must make an impact on the sexual risk taking in those groups most impacted by the epidemic. To accomplish this within high risk HIV-infected sub-groups (i.e. communities of color and MSM), research must tailor behavioral interventions to address major factors impacting continued transmission risk behavior. Interventions that fail to consider the complex social realities of HIV-infected populations will fail to develop holistic approaches and may run the risk of dismissing important issues that impact overall health. It may be that HIV prevention within infected populations requires multiple interventions to address the root causes of continued sexual risk taking. Researchers have begun to call for a more diverse array of prevention intervention within an integrated approach that considers and equally emphasizes social, psychological, medical and economic realities of HIV-infected individuals.

In their article assessing secondary HIV prevention interventions, Gordon et al note that the vast majority of the interventions have been limited to variants SCT, which typically highlight cognitive behavioral skill-building without incorporating contextual factors (15). Further, the authors argue that interventions should target multiple levels of prevention and calls for researchers to shift secondary HIV prevention towards a more complex social-ecological model (15). The ecological model of health promotion offers three advantages over the individualistically-orientated behavior change models as summarized by Choi et al: 1) deemphasizes the importance of the individual on behavior change, 2) examines both individual and environmental influences for unhealthy behavior, and 3) promotes the use of environmental approaches in prevention programs (8). The ecological model would involve the assessment of risk on multiple levels and would be better equipped to determine the fundamental causes of continued sexual risk taking.

HIV continues to disproportionably impact communities of color and MSM (3). Research must be committed to determining how and why HIV impacts those communities and exploring how HIV prevention programs may address multiple levels of risk. This critique of the REP secondary prevention interventions suggests that risk is impacted by a variety of individual and environmental factors that are not adequately addressed by interventions based on SCT. Examining those communities most affected by HIV forces us to confront how poverty, racism and homophobia contribute to increased HIV risk and will likely continue to impact transmission risk behavior. By replicating evidence-based interventions in MSM or communities of color that fail to account for poverty, racism and homophobia, researchers will find it difficult to initiate and sustain healthy behavior change. To better combat the transmission of HIV, research must focus on a new generation of secondary prevention interventions largely based on the ecological model.

References
1. Kalichman SC, Rompa D, Cage M. Sexually transmitted infections among HIV seropositive men and women. Sex Transm Infect. 2000 Oct;76(5):350-4.
2. CDC. CDC HIV/AIDS fact sheet: A glance at HIV/AIDS among men who have sex with men. November, 2007. Available at: http://www.cdc.gov/hiv/resources/factsheets/PDF/MSM_Glance.pdf
3. CDC, Replicating Effective Programs Plus. Atlanta, GA: US Department of Health and Human Services. Accessed November, 2007. Available at: http://www.cdc.gov/hiv/topics/prev_prog/rep/index.htm
4. Eke AN, Neumann MS, Wilkes AL, Jones PL. Preparing effective behavioral interventions to be used by prevention providers: the role of researchers during HIV Prevention Research Trials. AIDS Educ Prev. 2006 Aug;18(4 Suppl A):44-58.
5. Kalichman, S.C., Rompa, D., Cage, M., DiFonzo, K., Simpson, D., Austin, J., Luke, W., Buckles, J., Kyomugisha, F., Benotsch, E., Pinkerton, S., and Graham, J. (2001). Effectiveness of an intervention to reduce HIV transmission risks in HIV-positive people. American Journal of Preventive Medicine 21(2), 84-92.
6. Richardson J.L., Milam J., McCutchan A., Stoyanoff S., Bolan R., Weiss J., Kemper C., Larsen R.A., Hollander H., Weismuller P., Chou C.P., and Marks G. Effect of brief provider safer-sex counseling of HIV-1 seropositive patients: A multi-clinic assessment. AIDS 2004;18:1179-1186.
7. Mark Edberg. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007.
8. Choi K, Yep GA, Kumekawa E. HIV prevention among Asian and Pacific Islander men who have sex with men: a critical review of theoretical models and directions for future research. AIDS Education and Prevention 1998; 10(Supplement A):19-30.
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10. Reif S, Whetten K, Lowe K, Ostermann J. Association of unmet needs for support services with medication use and adherence among HIV-infected individuals in the southeastern United States. AIDS Care. 2006 May;18(4):277-83.
11. Stall R, Mills TC, Williamson J, Hart T, Greenwood G, Paul J, Pollack L, Binson D, Osmond D, Catania JA. Association of co-occurring psychosocial health problems and increased vulnerability to HIV/AIDS among urban men who have sex with men. Am J Public Health. 2003 Jun;93(6):939-42.
12. Koopman C, Gore-Felton C, Azimi N, O'Shea K, Ashton E, Power R, De Maria S, Israelski D, Spiegel D. Acute stress reactions to recent life events among women and men living with HIV/AIDS. Int J Psychiatry Med. 2002;32(4):361-78.
13. Kelly B, Raphael B, Judd F, Perdices M, Kernutt G, Burnett P, Dunne M, Burrows G. Posttraumatic stress disorder in response to HIV infection. Gen Hosp Psychiatry. 1998 Nov;20(6):345-52.
14. Kimerling R, Calhoun KS, Forehand R, Armistead L, Morse E, Morse P, Clark R, Clark L. Traumatic stress in HIV-infected women. AIDS Educ Prev. 1999 Aug;11(4):321-30.
15. Gordon CM, Forsyth AD, Stall R, Cheever LW. Prevention interventions with persons living with HIV/AIDS: state of the science and future directions. AIDS Educ Prev. 2005 Feb;17(1 Suppl A):6-20.

The Failure of the Minnesota ENABL Campaign – Monica Sawhney

Introduction
In 1996 Congress passed The Personal Responsibility and Work Opportunities Reconciliation Act. While this act primarily concerned welfare reform, it also provided funding to states for abstinence only sexual education programs. These programs went on to be established through Title V of the Social Security Act. One such initiative created as a result of Title V was the ENABL (Education Now and Babies Later) campaign in Minnesota in 1998. It is a program targeted at youth and their parents or guardians throughout Minnesota. Its aims are to reduce adolescent pregnancy by reducing sexual activity and encouraging abstinence until marriage. The program teaches adolescents how to avoid involvement with sexual activity and how to open up the lines of communication with their parents (12).
The ENABL program in Minnesota focuses on teen pregnancy. Its initiative promotes the idea that abstinence is the best way to avoid teen pregnancy, using both a curriculum and family based approach. Youth are taught an in school curriculum revolving around the risk of teen pregnancy and STDs and are encouraged to use abstinence as their approach to these problems. The curriculum does not include information about the use of contraceptives. The ENABL campaign also aims at making parents more proactive. It provides resources and lessons for parents on how to discuss sex with their children. These resources are accessible online and in community centers (12).

Evaluation of ENABL
The ENABL campaign was evaluated in 2002, 4 years after the program was initiated. The analysis of the program was based on surveys determining attitudes toward sex and abstinence by students who had completed the curriculum. The results of the evaluation found that overall, the program had failed. The rate of students who were having sexual intercourse or those who said they would within the next 12 months almost doubled (9). The percentage of students who said they would talk to their partner about abstinence and avoid risky behavior fell. The rate of students who said they believed “sex was only something adults should do” also fell. The program did increase the frequency with which parents and children discussed sex. The analysis concludes with a recommendation that programs about sexual education would be more useful if they include information on both abstinence and safer sex (8).
Since the ENABL program was initiated, there has been no increase in the rates of teens abstaining from sex. An analysis of the program showed that the incidence of teen sex actually rose during this period of time. One of the biggest problems with this initiative is that it did not take many aspects of behavioral theory into account. The program did not take the Theory of Reasoned Action into account, neglecting to adequately address social norms and pressures adolescents may face. It also ignored Social Cognitive Theory by failing to address self-efficacy. These failures created a program that did not achieve the majority of its goals. By looking beyond the Health Behavior Model into other theories of behavior, the ENABL program may have been successful.

Failure of the Health Belief Model
A key problem with the ENABL program is that it is essentially based on the Health Belief Model. The Health Belief Model states that there are two conditions that must be met in order for a person to perform healthy behavior. The person has to believe they are susceptible to a problem that is severe, and that there are benefits to taking action against this problem without too many barriers (5). By teaching students that sex can lead to pregnancy and STDs, instructors assumed that teens would accurately assess the perceived susceptibility and severity of having sex. They also assumed that by teaching them to abstain from sex, teens would consider abstinence beneficial and free of many barriers. Even if youth were to perceive premarital sex in this way, research has shown that the Health Belief Model does not necessarily predict behavior (4). The statistics of the ENABL program speak for themselves. Even though adolescents were learning about the risks involved with having sex, the incidence of those who did engage in sex or said they would within one year nearly doubled. While the susceptibility and severity of pregnancy and STDs were presented to the teens as relevant to them, many did not perform the behavior.

Incorporating the Theory of Reasoned Action
The ENABL program did not account for the Theory of Reasoned Action, which may explain why the students did not respond to the curriculum. The Theory of Reasoned Action is based on the idea that a person’s intentions to carry out a behavior are based on their attitudes toward that behavior and their perception of subjective norms in regards to the behavior (5). Subjective norms are social standards in society that people see as prevalent and common. This idea of subjective norms is very important, especially when an initiative is directed at youth. Adolescents are also more susceptible to social norms than adults. They are less likely to perform a behavior if they are worried about how others will see them. They also have a stronger desire to fit in with their social groups, and therefore are more likely to adapt to these social norms. Norms are dictated not only by peers, but also the media. Both of these aspects have a strong influence on youth. These social norms often do not reinforce the idea of abstinence; many times they do the exact opposite.
Based on previous statistics, the idea of premarital sex has permeated throughout American society; it is therefore a social norm. Studies have shown that exposure to media with sexual content can result in an increase in sexual behavior. The perception of friends’ attitudes toward sex is also predictive of a teen’s own behavior (1). The ENABL program must focus on these subjective norms and attitudes toward behavior if it wants youth to practice abstinence. The approval of premarital sex is so widespread in the U.S. that it is hard to overcome these social norms. This campaign fails because it is unable to show adolescents that premarital sex is not a norm for teens in society. By changing the perceptions of the social norms, students may be able to change both their attitude and intention toward the behavior.
One study seems to have utilized the Theory of Reasoned Action in relation to HIV-risk reducing behavior in men who are HIV-positive. This experiment created an intervention in which men were educated and taught skills to reduce HIV-risk behavior in the context of social norms, self-efficacy, and communication in-group sessions. After the study, men who had participated in these sessions were more likely to use condoms with their sex partners. They were also more likely to divulge their HIV status and to inquire about a potential partner’s status. By addressing social norms and communication, this initiative was able to increase desired behavior (10). The ENABL campaign could have similar results if it was able to effectively change the way teens viewed the norms surrounding sex. If adolescents believed that many of their peers abstained from sexual activity, they may find it easier to do the same.

The Role of Self-Efficacy
Another problem with the ENABL campaign is that it does not address the issue of self-efficacy. Self-efficacy is a concept central to Social Cognitive Theory. It states that a person is not likely to change their behavior if they do not believe that they have the ability to do so. A person must have confidence in their capabilities to both do the behavior and to rise above challenges that may attempt to hinder the behavior (5). Recent studies reflect the pressures and realities faced by many youth today to engage in premarital sex. 47% of high schools students in the U.S. have had sexual intercourse by the time they graduate (13). It has been shown that by age 20, 75% of Americans have had premarital sex (6). While the ENABL program specifically targets youth, it is clear that sex before marriage is very prevalent in the U.S. today. Through the media, friends, and family, teens are constantly exposed to the idea of having premarital sex. In the face of this pervasiveness, youth may come to believe that premarital sex is the norm and in fact, unavoidable. If the ENABL program wishes to maintain its abstinence only policy, it must come up with effective ways to convince teens that they have the ability to abstain and to overcome the pressures not to abstain that frequently occur.
Numerous studies have shown that self-efficacy is a successful technique in helping people achieve a behavior. One such study involved predictors of condom use among African American college students. It found that self-efficacy was the most important factor related to condom use and safer sexual practices within the past six months. It was also related to an increasing frequency of condom use and overall lifetime condom use (2). Another study was done comparing the susceptibility to sexual risk-taking behavior and self-efficacy in Sierra Leonean students. It found that higher self-efficacy was related to rejecting sexual advances, which lead to significantly less sexual risk-taking behavior (3). These studies demonstrate the necessity for self-efficacy in order to deter risk-taking behavior. Teens who feel that they are actually able to abstain from sex will be much more likely to do so than those who feel like they cannot.

The Need for a Comprehensive Program
While the ENABL campaign is supposed to reach youth throughout Minnesota, it could also have had the effect of alienating certain adolescents in their programs. The initiative has one simple message, based on heterosexuality, and a curriculum built around that focus. The program has not been created in a way that addresses anything other than heterosexuality. Teens who may be homosexual, transgender, or of any other sexual orientation do not receive relevant information. They are not able to relate the messages in the curriculum to own their lives (11). An abstinence only initiative is also not relevant to teens who are already sexually active. Adolescents who have engaged in sexual behavior will not learn anything from the program since it does not apply to their actions or intentions. The program also does not teach youth methods for decreasing risks if they are engaging in sexual behavior. Teens who are sexually active may not be aware of the various options available to prevent the spread of STDs and lower the risk of pregnancy. As a result, they may continue to have sex but without proper protection (11).
Recent studies have shown that comprehensive sex education can be more effective than abstinence only education, especially with teens who are sexually active. One study compared results between an abstinence only program and a safer sex program in African American adolescents. The results showed that teens who were already sexually active engaged in less sexual intercourse after the program if they were in the safer sex group, as opposed to in the abstinence only group. Teens in the safer sex group were also more likely to use protection when they did have sex (7). By alienating certain groups of students from their program, the ENABL campaign could not reach all youth, as was its intention. By not adequately addressing the needs of all teens in its program, it may have even put them at a greater risk.

Conclusion
The ENABL campaign of Minnesota failed because it did not take certain behavioral concepts into account. If the campaign had utilized the Theory of Reasoned Action, it may have been more successful in changing teens’ views of social norms toward sex. If it had relied more on Social Cognitive Theory, it could have addressed the issue of self-efficacy. An emphasis on this concept could have enabled teens to believe that they were capable of abstaining from sex. The campaign also focused only on heterosexual adolescents who had not yet engaged in sexual activities. The curriculum did not address those who were already sexually active or not heterosexual, potentially missing a significant portion of teens. The curriculum’s focus was also strictly on abstinence, and not a comprehensive sex education course. If the campaign had taken these concepts into account, it may have been much more successful. Various studies have shown that social norms and self-efficacy play an important role in changing behavior. It is also more efficient for a campaign to be all encompassing, rather than focusing on particular groups of people that emphasizes one course of action. Taking these theories into account could have lead to ENABL’s success.

References

1. Brown, Jane D., and Kelly Ladin L'engle. "Sexy Media Matter: Exposure to Sexual
Content in Music, Movies, Television, and Magazines Predicts Black and White Adolescents' Sexual Behavior." PEDIATRICS 117 (2006): 1-18-1027. 10 Nov. 2007 .

2. Burns, Myron J., and Frank R. Dillon. "AIDS Health Locus of Control, Self-Efficacy forSafer Sexual Practices, and Future Time Orientation as Predictors of Condom Use in African American College Students." Journal of Black Psychology 31 (2005): 172-188.

3. Carter, Robert T. "The Effects of HIV/AIDS Knowledge, Sexual Self-Efficacy and
Susceptibility on Sexual Risk-Taking Behavior in Sierra Leonean Students of Higher Education (Immune Deficiency)." DigitalCommons@Columbia. 1997. Columbia University. 12 Nov. 2007
.

4. Choi, Kyung-Hee, Gust A. Yep, and Eugene Kumekawa. "HIV Prevention Among Asian and Pacific Islander Men Who Have Sex with Men." AIDS Education and Prevention 10 (1998): 19-30.

5. Edberg, Mark. Essentials of Health Behavior Social and Behavioral Theory in Public Health. Boston: Jones and Bartlett, 2007.

6. Finer, LB. "Trends in Premarital Sex in the United States, 1954-2003." PubMed. 2007. National Center for Biotechnology Information. 12 Nov. 2007 .

7. Jemmott, John B., Loretta Jemmott, and Geoffrey Fong. "Abstinence and Safer Sex HIV Risk-Reduction Interventions for African American Adolescents." Journal of the American Medical Association. 279 (1998): 1529-1536. 12 Nov. 2007 .

10. Randall, Lm, and Mk Lapinski. "Prevention Options for Positives: Evaluation of a Theoretically Based Prevention Intervention Targeted to HIV-Infected Men Who Have Sex with Men." Gateway. July 2003. National Library of Medicine. 12 Nov. 2007 .

11. Santelli, John, and Mary A. Ott. "Abstinence-Only Education Policies and Programs: a Position Paper of the Society for Adolescent Medicine." Journal of Adolescent Health 38 (2006): 83-87. 12 Nov. 2007 .

12. Say Not Yet! to Sex. 2003. Minnesota Education Now and Babies Later. 11 Nov. 2007 .

13. "Sexual Risk Behaviors." Healthy Youth! 22 May 2007. National Center for Chronic Disease Prevention and Health Promotion. 10 Nov. 2007 .

Advance Provision of Emergency Contraception and its effects on Prevention of Unintended Pregnancies- Diego Martinez-Vasquez,M.D

Modern contraceptive methods represent more than a technical advance: they are the instrument of a true social revolution—the "first reproductive revolution" in the history of humanity, an achievement of the second part of the 20th century, when modern, effective methods became available. Today a great diversity of techniques have been made available and—thanks to them, fertility rates have decreased from 5.1 in 1950 to 3.7 in 1990. As a consequence, the growth of human population that had more than tripled, from 1.8 to more than 6 billion in just one century, is today being brought under control (1).

The most recent cycle of the National Survey of Family Growth demonstrates that, despite a reduction in unintended pregnancies among adolescents, college-educated, and higher-income women, 49% of all pregnancies in 2001 (3.1 million) were unintended. Of these unintended pregnancies, 42% ended in abortion. Furthermore, 48% of unintended pregnancies occurred in women who were using contraception during the month of conception (2, 3).

Unintended and teenage pregnancies (49%) are major public health concerns in the United States (see above). Emergency contraception (EC) is used to prevent pregnancy after failure of a contraceptive method or after unprotected intercourse. EC can prevent pregnancy when taken within 120 hours of unprotected intercourse (4). Several types of EC regimens exist, including an estrogen-progestin combination (sometimes called "combined regimen" or "Yuzpe regimen"), levonorgestrel alone (plan B), and mifepristone.

Some clinical trials have been studied the benefits of providing EC in and advance manner (AEC) to facilitate females in their use (4). The idea begin was to determine if when giving AEC can reduce the rates of unintended pregnancy when compared to regular EC. These clinical trials did not showed any benefit in reducing unintended pregnancies in females who received AEC compared to EC.

Contraceptive counseling. A Healthy People 2010 objective is to increase the rate of intended pregnancy to at least 70% of all pregnancies (5). One approach to reducing rates of unintended pregnancy is providing contraceptive counseling during primary care visits. The National Survey of Family Growth defines birth control counseling as “counseling about whether to use birth control methods, how to get them, information about different methods, and how they are used.

EC for a woman, who has unprotected intercourse, requires several steps to reduce the risk of unintended pregnancy. She must perceive that her risk of pregnancy is real and must be motivated to prevent it. She must be aware that a post-coital contraceptive method exists that could reduce her risk of conception. She also must have specific knowledge about how to obtain it and time its administration. She must have access to it, including a place to get it, a way to pay for it, and the time to invest in getting it. Any of those steps can be barriers to actually using emergency contraception after unprotected sex.

One of the current and likely been a very significant barrier to making EC part of routine contraceptive counseling is that providers are unlikely to initiate discussions regarding EC or offer an advance prescription (AEC). One particular barrier to the provision of EC information may be lack of a standardized manner in which to deliver information and the option for EC. Major health organizations and groups, such as the World Health Organization, American College of Obstetrics and Gynecology and the International Consortium for Emergency Contraception, have guidelines regarding key points to be included in EC counseling. However, despite increases, knowledge is still limited and EC provision does not occur in a majority of visits(6).

Contraceptive counseling is defined as a form of interpersonal (as opposed to public) communication. It includes information-giving as well as opportunities for clients (patients) to express their concerns, values, and preferences and to ask questions. Information may be provided through multiple communication channels, and using multiple channels may have a synergistic impact, with written or video material reinforcing oral communication. In health care settings, counseling may include face-to-face discussions between the patient and her provider; group discussions; peer counseling; telephone hot lines or information resource lines; print or video materials made available in information kiosks or resource centers; and telephone or mail follow-ups or reminders. In the case of contraceptive counseling, the goal is to empower women to prevent unintended pregnancy (1, 2, 6).

Counseling is conceived as having three dimensions: 1) exposure refers to whether or not any counseling occurs through any communication channels; 2) content refers to the information imparted during counseling; and 3) personalization refers to the degree to which women’s needs and preferences are addressed. Little research on U.S. populations has addressed the relationship between counseling and contraceptive adoption or continued use (7).

The plausibility of the hypothesis that counseling is associated with contraceptive use is supported by evidence that provider counseling influences women’s use of other preventive tests and interventions. Studies of mammography screening find that one of the most common reasons reported by older women for not obtaining mammograms is that their physicians did not recommend it.

Theories of health behavior attempt to explain how individuals adopt or fail to adopt health-promoting behaviors (e.g., exercise, smoking cessation, use of screening mammography) or maintain those behaviors over time. Theories such as the health belief model, the theory of planned behavior, and the transtheoretical model provide a basis for examining the relationship between contraceptive counseling in the health care setting and contraceptive behavior. These theories recognize that knowledge alone is not sufficient to motivate individuals to adopt health-promoting behaviors and that factors such as values, expectations, and social influences also are important determinants of health behaviors. In addition, these theories draw attention to intervening steps between the acquisition of information and health-promoting behavior, such as building self-efficacy and forming behavioral intent.

The function of counseling in the health care setting can provide information and help clarify the options available to the individual, thus empowering individuals to make informed decisions with respect to their health. Counseling can help alleviate fears about specific options or reduce anxiety about social consequences of options, thus addressing some of the nonrational components of health decision making. Providing information and enabling individuals to cope with their concerns help build self-efficacy for behavior change. Counseling also can help individuals move from one stage of behavior change to another—for example, from the precontemplation stage, in which there is no intent to take action, to the contemplation stage, when an intent is formed to change behavior in the near future—or to maintain a health behavior once adopted.

Increase risky sexual behavior, increasing the risk of pregnancy or sexually transmitted diseases. Several studies have looked into AEC in effort to circumvent some of these obstacles. (8, 9). The studies showed that there is no evidence that suggests that providing AEC causes adolescents to have more unprotected intercourse or less consistent contraceptive use. Indeed, contrary to many health care providers and the public's views, the AEC group participants reported significantly higher condom use. The problem with this studies is that these studies failed to showed reduction in unintended pregnancies when compared to standard access situations (defined as routine contraceptive counseling, provision of information on emergency contraception, or emergency contraception on request) (4).

These trials share a common weakness. Reported information on use of emergency contraception, frequency of unprotected intercourse, and changes in contraceptive patterns was of unknown validity. Since these self reports lacked objective verification, this information should be viewed with caution. Objective evidence indicates that self reports on use of contraceptives other medications are inaccurate, and that self-report of unprotected intercourse is inferior to other ascertainment methods. Some degree of underreporting of pregnancies may have occurred in both the advance provision and control groups in these trials, particularly those trials using only self-reported data. Unintended pregnancies terminated by induced abortion are routinely underreported. However, results from the trials relying on pregnancy testing were consistent with results from the trials using self-reports of pregnancy(4).

None of the adequately powered trials showed difference in pregnancy rates, despite increased use, multiple use and faster use of AEC (4).

This conclusion conflicts with earlier optimistic projections of the potential public health impact of improved access. This intervention could have failed because the way women perceives pregnancy risk or because concerns about side effects, and inconvenience(10, 11).

Health care coverage or insurance. Although men and women have some similar challenges with regard to health insurance, women face unique barriers to becoming insured. More significantly, women have greater difficulty affording health care services even once they are insured. On average, women have lower incomes than men and therefore have greater difficulty paying premiums. Women also are less likely than men to have coverage through their own employer and more likely to obtain coverage through their spouses; are more likely than men to have higher out-of-pocket health care expenses; and use more healthcare services than men and consequently are in greater need of comprehensive coverage. Moreover some females don’t have coverage of prescription contraceptives. The direct medical costs of unintended pregnancies were US$5 billion in 2002 and direct medical cost savings due to contraceptive use were US$19 billion (12, 13).

In summary, advance provision of emergency contraception does not decrease unintended pregnancies nor increase sexual risking behaviors or sexual transmitted diseases. In order to decrease unintended pregnancies using advance provision of emergency contraception, routine and consistent counseling by health providers (physicians, pharmacists, nurse practitioners and physician assistant) in emergency contraception has to be provide to any female who is sexually active. Health behavior models like the health belief model, the theory of planned behavior, the transtheoretical have to be use in combination to assess the specific needs of each patient. Health coverage and insurance has to be taken in account when prescribing or recommending AEC. Overall not having access to medical coverage directly impacts the availability of physicians and health care providers. Moreover new programs have to be implemented to increase access of this population to health care.

Finally more studies need to be performed to asses the use of advance provision of emergency contraception. These studies need to be conducted looking at counseling and behavior model as described above. Nevertheless new programs that facilitated easy access to AEC for uninsured sexually active females have to be implemented through out the federal or state level.

References:

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3. Martinez GM, Chandra A, Abma JC, Jones J, Mosher WD. Fertility, contraception, and fatherhood: data on men and women from cycle 6 (2002) of the 2002 National Survey of Family Growth. Vital Health Stat 23 2006(26):1-142.

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