Combatting the Spread of Sexually Transmitted Disease in Adolescents

Combatting the Spread of Sexually Transmitted Disease in Adolescents

Dr. Kimberly Brodie

Health Behavior Theory

MPH 515

Sara Quale

Dec. 7, 2013

Abstract

The prevalence of sexually transmitted diseases (STDs) among adolescents calls for an effective program to raise awareness of the problem and change attitudes toward sexual behaviors in teens. STDs can be life-threatening if not treated. They have the potential to diminish quality of life impacting not only the teen, but the teen’s family and future sexual partners emotionally, physically and financially. Current programs to address STDs in teens cover a mix of approaches including abstinence-only, abstinence and safe sex and self-efficacy in condom use and sexual practices. I introduce a program called “The Body of Power” that uses media, school-based instruction and home-based lessons to build knowledge and self-confidence toward healthy sexual behaviors and a teen’s power to decide what happens to his or her body.

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Chapter 1

Health challenge of sexually transmitted diseases

Sexually transmitted diseases (STDs) pose a significant health challenges in the United States. Twenty million new infections occur annually with half of those in people ages 15-24 (CDC Fact Sheet, 2011). Infections cause immediate and long-term health threats including increased risk of HIV infection and health complications such as reproductive health issues (CDC Fact Sheet, 2011). STDs cost the United States $16 million annually (CDC Fact Sheet, 2011).

Chlamydia, gonorrhea, syphilis, and HIV are some of the most commonly reported STDs in the country.Chlamydia is the most commonly reported STD and one of the most prevalent (Centers for Disease Control and Prevention, 2012). Infection in women can cause infertility, ectopic pregnancy and chronic pelvic pain. Gonorrhea is caused by a bacterium and grows in warm, moist areas of the reproductive tract and the mouth, throat, eyes and anus (CDC.gov, 2013). Syphilis is caused by a bacterium that can cause long-term complications and death. HIVis the virus that causes AIDS. All can be passed during oral, vaginal and anal sex and from mother to baby during birth (CDC.gov, 2013).

Epidemiological studies of STDs indicate that overall rates are higher among adolescents, females and blacks with some diseases increasing and some reducing slightly.The United States had 1.3 million cases of reported chlamydia in 2010 with a case rate of 426 per 100,000 (Stoner and Rother, 2012). Chlamydia rates are 2.5 times higher in females, possibly due to more widespread screening programs for females (Stoner and Rother, 2012). Rates are highest in the South and Midwest and much higher per 100,000 population in teens and young adult women (3,378.2 for women ages 15-19 and 3,407.9 for women ages 20-24) (Stoner and Rother, 2012). The rate for men ages 15-19 are 774.3, and for ages 20-24 are 1,187).Blacks and American Indians have the highest rates of chlamydia.

There were 309,341 cases of gonorrhea reported in the United States in 2010 (Stoner and Rother, 2012). The case rate was 100.8/100,000 with higher rates in females ages 15-24 (570.9). For men, the highest rate wasin 20-24-year-olds (421). Rates were highest in the South and Midwest. Blacks have a rate at four to five times higher than other race/ethnic groups.

The United States reported 13,774 cases of syphilis in 2010 with a rate of 4.5/100,000. Rates are high in urban areas and rural areas in the South. (Stoner and Rother, 2012). Case rates are highest in men ages 20-24 (21.9). Rates for women are low across age categories with the highest being 4.5 for women ages 20-24. Case rates are highest among blacks.

Cases of HIV remain high among adolescents ages 13-19 hitting black adolescents disproportionately hard. The U.S. population of 13-19 year olds in 2009 in 40 states was 23.3 million: 62% white, 17% black, 16% Hispanic. However, the diagnoses of HIV cases (N=2,056) were distributed with 73% black, 13% Hispanic and 12% white (Stoner and Rother, 2012).

Of the nearly 20 million new cases of STDs reported each year, young people ages 15-24, account for half of those case (CDC Fact Sheet, 2013).In survey estimates from 1999-2008, chlamydia prevalence in sexually active females ages 14-19 is 6.8% (CDC, 2012).Annually more than 820,000 people are estimated to contract the gonorrhea, but less than half of those cases are reported. It is estimated that more than 570,000 cases were among people ages 15-24 (CDC.gov, 2013).From 2004 to 2008, the rates of syphilis increased the most among men and women ages 15-24 (CDC.gov, 2013).

Chapter 2

The need for a public health program to address STDs

Public health programs on STDs should focus on adolescents to prevent them from acquiring life-long health problems and furthering the spread of STDs. This will improve the quality of life and life expectancy and reduce medical costs. Individuals who are infected with STDs are 2 to 5 times more likely than people who aren’t infected to acquire HIV if they become exposed to HIV during sex (CDC.gov, 2013).Gonorrhea left untreated in women may cause pelvic inflammatory disease (PID). In men, gonorrhea may result in health complications including infertility (CDC.gov, 2013).STDs are preventable by abstinence, fewer sex partners and effective condom use (CDC Fact Sheet, 2013). STD screening and prompt treatment is important for protection and prevention of spread (CDC Fact Sheet, 2013). Many STDs can be treated and cured if diagnosed early. Many people aren’t diagnosed earlybecause they don’t have symptoms or get screened (CDC Fact Sheet, 2013). CDC reports that young adults have a higher risk for contracting STDs because of a lack of access to health insurance, screening programs, treatments, and ability to pay for those services. The young adults also have a concern about confidentiality (CDC.gov, 2013).

MethodThe Theory of Planned Behavior (TBP) is a value-expectancy theory that weighs a person’s attitude, subjective norms, and beliefs about efficacy toward a health behavior to form intention on whether to adopt that health behavior.To form the construct of attitude, the person weighs personal beliefs about the costs and benefits of adopting the health behavior. The construct of subjective norms are the attitudes and beliefs held by one’s influencers. The person will consider what is socially acceptable about a health behavior.The last construct involves perceived behavioral control (DiClemente, Salazar and Crosby, 2013). TPB states that a person who has positive opinions about a health behavior and who experiences supportive normative beliefs will be more apt to adopt the behavior if they believe they have personal power to do so (DiClemente et al, 2013). To decide, the person will weigh facilitating factors, inhibiting factorsand personal knowledge and skill level.

The TPB can be applied to the issue of STDs in teens by focusing on attitude, subjective norms and personal control. To develop a positive attitude toward protective health behavior, teens must evaluate beliefs about having sex at a young age and the costs and benefits. The health program must recognize teens will consider:

• Having sex may make them feel liked, loved or more popular
• Having sex could lead to unintended consequences that can interfere with the future
• Having sex could result in infections/disease
• There’s nothing else to do for fun
• Asking boys to wear condoms is embarrassing.

Teens will evaluate the impact of the beliefs of their influencers about having sex at a young age and the cost and benefits, which creates the subjective norms:

• Parents would be disappointed
• Boyfriend/girlfriend wants to have sex
• Friends would be impressed if teen had sex
• Having sex at a young age is commonly accepted
• Boys don’t have to or want to wear condoms.

To build the construct of perceived behavioral control, teens must weigh facilitating factors against inhibiting factors related to the feasibility of abstaining from sex. They also must consider their own skill level in negotiating situations where they may be coerced into having sex. Finally, they must recognize whether they have the knowledge and skills needed to use condoms for protection. Points they will consider include:

• Lack of confidence or skill to resist pressure to have sex
• Lack of access and financial resources to medical care to be screened for STDs
• Lack of confidence to ask parents to see a doctor about STDs or condoms
• Lack of access, knowledge and skill about condoms
• Availability and accessibility of other activities to do for fun.

Chapter 3

Review of Existing Programs on Sexual Education for Teens

“Making Proud Choices! A safer sex approach to prevention of STDs, HIV and Teen Pregnancy (2007)” is a program by the Resource Center for Adolescent Pregnancy Prevention. It used the Social Cognitive Theory (SCT), the Theory of Reasoned Action (TRA) and the TPB.The program emphasize self-efficacy, goals, prevention attitudes, peer attitudes and partner beliefs. Itdiscusses consequences. Components address:

• Getting to know you and making your dreams come true
• The consequences of sex: pregnancy, STDs and HIV infection
• Attitudes and beliefs about HIV/AIDS and condom use
• Strategies for preventing HIV infection: Stop, think and act
• Developing and enhancing condom use skills and negotiation skills
• Community and family approach – how will the person’s actions and results of their actions affect the community

• Role of making responsible decisions and knowing the best prevention is abstinence

• Pride in making safe sex the right choice.

In a controlled trial, researchers found favorable results with participants who completed the curriculum reporting more consistent condom use and less unprotected sex in the three months after then intervention than did those in control group. Among students who were sexually experienced at the baseline, those in safer sex groups reported less sexual intercourse in the previous three months at the six- and 12-month follow-up than the people in the control group (Resource Center for Adolescent Pregnancy Prevention, 2007). The biggest challenge comes from communities where abstinence only education is the only supported curriculum.

In “Promoting Health Among Teens!-Abstinence Only Version,” educators use the SCT, TRA and TPB. This programpromotes abstinence as the best way to avoid pregnancy and HIV/STDs; that abstinence is a positive choice; and that teen pregnancy, HIV/AIDS and STDs are barriers to achieving goals. Finally, it teaches the skills necessary for a teen to respond confidently to pressures to have sex (Jemmott, L., and Jemmott, III, J., n.d.).

The program is structured similarly to “Making Proud Choices!”with curriculum that follows the same path, but omits discussion of condoms. More focus is on improving sexual choices and negotiation. Role play focuses on refusal and negotiation skills.

The program reported a reduction in the incidence of recent sexual intercourse at follow-up periods. It also reported delayed sexual experience among virgins (Jemmott, J.B., Jemmott, L.S. & Fong, G.T., 2009). However, abstinence-only programs have been criticized because they can be moralistic and discredit effectiveness of condoms. This program did not have statistically significant impact on condom use among participants compared to a control group (Jemmott et al, 2009). Abstinence-only education programs may be ineffective with youth who have already become sexually active or who are in committed relationships.

In “AIDS prevention for Adolescents in School,” educators use principles of the Health Belief Model (HBM). The lessons focus on skills in refusal, risk assessment and risk reduction. It aims to improve students’ knowledge, beliefs, self-efficacy and risk behaviors concerning HIV/AIDS (Walter and Vaughan, n.d.)

The program assisted students who were experienced sexually with increasing monogamy, reducing the number of drug-using sex partners and increasing condom use. However, it didnot have a significant effect on delaying the initiation of sex.

Chapter 4

Implementing “The Body of Power”

“The Body of Power” aims to impact the rate of STDs in adolescents by influencing attitudes toward teen sex, consequences of sex and skills needed to get out of tough situations. The program includes parents and guardians in the discussion to impact subjective norms.

“The Body of Power” program follows the TPB. Teens are asked to evaluate beliefs toward sex. They can visualize what it means to be a teen – beliefs about their favorite activities, goals and dreams for the future. They will discuss how or if sex fits into that picture and cover topics like monogamy, health risks, STDs and long-term health consequences.

The second construct of the program involves a review of subjective norms toward sex. Teens are asked about their parents attitudes towards teen sex. They consider the impacts of STDs on a person’s family and future relationships. The program buildsthe perception that peers respect someone who has control over the decision to abstain or to practice safe sex. It also aims to build parental/guardian involvement by increasing awareness of the issue in those groups.

The final construct of the TPB is beliefs of the individual about access, achievability and self-efficacy related to positive behaviors toward sex. This involves screening availability, health services and insurance coverage, negotiating skills as they relate to abstinence, monogamy and condom use, and knowledge of and access to condoms. The program will aim to increase education and accessibility of all areas.

“The Body of Power” has five goals: Reduce the number of teens who report onset of sexual activity; reduce the number of reports of teens with multiple sex partners; reduce the number of reports of teens who have unprotected sexual encounters; increase the number of teens who report that they are confident to say no to sexual encountersand increase the number of teens who report they are confident they can acquire and properly use condoms.To achieve these goals, the program will use formal and interpersonal communication channels with the Diffusion Theory. To visualize what it means to be a teen, in small groups participants will brainstorm and document favorite activities, responsibilities, dreams and goals to reach those dreams. The program will employ multiple communications channels to help teens and their parents understand the impacts of STDs. It will use classroom education from a medical provider as well as direct outreach to parents. To supplement that message, the program will use posters and electronic media in the community to reinforce the message, which also will include a testimonial from someone living with an STD. Again, small group sessions will be used for teens to brainstorm and visualize how their lives would change if they contracted an STD. Media spots can include teens talking with parents, peers and partners about positive sexual behaviors.

To improve a sense of efficacy, teens and parents will learn about access to screening clinics, medical insurance and care and how to practice safe sex by abstinence or the correct use of condoms. Classroom or small group sessions will help teens learn how to negotiate with friends and partners about safe sex and condom use.

A key to the success of this program will be in correctly addressing the concept of adopter categories and the S-Shaped Diffusion Curve. The goal will be to reach key opinion leaders as innovators and early adopters (DiClemente, et al, 2013). The message will be the importance of choosing healthy behaviors in order to pursue dreams and to convey the importance of self-confidence. Teens have power over their bodies. Early adopters can be identified on the microsystem level in schools or in a macrosystem environment as a member of the entertainment industry. Early adopters can influence the early and late majority. Important to remember here is that regardless of what stage teenagersare in during their sexual journey, they retain the power to change their behavior.

Summary “The Body of Power” has great potential to impact the culture surrounding sexual behavior in teens and the rate of STDs. It will provide accurate and balanced information on both abstinence and safe sex practices. It will be widely available in a classroom setting reaching a broader cross-section of children as opposed to at-home programs that have been limited demographically. The message across the classroom, small group and media presentations will be consistent and delivered in such a way that teens can relate to the characters and stories. The program will be presented through multiple communication channels over a period of time to allow for repetition and increased awareness of the messages. Finally, we will build the program to provide enough education about the risks involved, but on a level where teens can understand.

References

Advocates for Youth, (2012). Science and success, sex education and other programs that work to prevent teen pregnancy, HIV and sexually transmitted infections, Retrieved from