Term project

Running head: SEXUALLY TRANSMITTED INFECTIONS IN YOUTH

Sexually Transmitted Infections in Youth: With a Close Look at Females B00529042 Debbie Martin, PhD Health Promotion Theory 2110 Dalhousie University April 4, 2011

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Sexually Transmitted Infections in Youth: With a Close Look at Females The fact is that the rates of sexually transmitted infections (STI) are increasing at an alarming rate; although there has been much effort put into reducing the prevalence of STI in Canada (Public Health Agency of Canada, 2007). Education is the foundation of which health promotion is built on. Learning throughout life is possible when it is “facilitated in school, home, work and community settings” (Ottawa Charter for Health Promotion, 1986, p.3). More public schools are integrating sexual health into their own teaching curriculums. “Schools are one of the key organizations for providing sexual health education” (Public Health Agency of Canada, 2008, p.19). The hope is that by educating students to increase positive sexual health outcomes it reduces negative sexual health outcomes (Public Health Agency of Canada, 2008). Also, in most communities there are an increasing number of sexual health clinics, services and programs in addition to the growing online help available in Canada. The Public Health Agency of Canada states that, “the different sources of sexual health education work together along with related health, clinical and social services to increase the impact of sexual health education” (2008, p.

21).

Females are the most affected population with STIs; therefore this report will be focusing on females between the ages of 15 to 24. In 2004, the Canadian Sexually Transmitted Infections Surveillance Report showed that the male to female ratio for genital Chlamydia was 1:2. Females accounted for two- thirds of the reported cases and females aged 15 to 24 were the most affected age group, they make up 73% of the cases reported. Chlamydia is the most commonly reported infectious disease in Canada. In 2004, Chlamydia made up 49% of all reported STIs (Public Health Agency of Canada, 2007).

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As a future health promoter I can see the effects of certain STIs having a dramatic impact on our female population. As stated earlier Chlamydia is the most reported STI in Canada, however in most cases it is asymptomatic and goes untreated. This ongoing pattern allows for Canadians to be largely unaware of the seriousness of this infectious disease, causing a domino effect leading to small populations being tested and treated for Chlamydia. It is “estimated that less than 10% of infections” have been reported (Public Health Agency of Canada, 2007, p. 12).

If Chlamydia is left untreated it posses many health threats; some of these include the, “pelvic inflammatory disease (PID), chronic pelvic pain, ectopic pregnancy and other adverse pregnancy outcomes, and infertility” (Public Health Agency of Canada, 2007, p. 13).

I see the need for better sexual health resources, in particular prevention and control of these health issues. My aim is to help provide information to the general public about the importance of safe sex and to decrease the negative outcomes related to sexual health; especially in different ethnic groups in Canada. I hope that I can support and guide individuals to make healthy decisions that lead to a healthy lifestyle. My goals directly aligns with the Ottawa Charter’s (1986) definition of health promotion, it states that “health promotion is the process by which people increase control over and improve their health” (Ottawa Charter for Health Promotion, 1986). The lack of information the population has concerning STIs and the preventative methods are putting them at risk. As a health promoter it is my duty to give people the tools to achieve their fullest health potential. As well, it is important to take into account the populations’ culture, race, gender and socioeconomic status.

For this report, I have chosen to use the Health Belief Model (HBM) as the individuallevel behaviour change perspective and the Diffusion of Innovation Theory (DIT) as the community-level health perspective to apply to this health issue.

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The Health Belief Model (HBM) The HBM is a psychological model made up of four major components, they are: (1) Perceived susceptibility to problem, (2) perceived seriousness of consequences of problem, (3) perceived benefits of specific action and (4) perceived barriers to taking action. The first two major components to this model are linked to the perceived threat and the last two major components are connected to the outcomes expectations. Studies have identified the “perceived barriers as the most influential variable for predicting and explaining health-related behaviors” (as cited in Denison, 1996). All of these elements connect to the individuals’ perceived ability to attain a certain goal, also known as self-efficacy. This model has been adapted over the years to fit individual health behaviour change to promote health (Denison, 1996; Nutbeam, Harris, & Wise, 2010).

To better understand the connection between this health issue and the HBM, I will be using a case study to describe how the HBM helps to change unhealthy behaviours.

Case Study Shannon is a 19 year old university student. Shannon does not have a steady boyfriend at the moment, but she is taking preventative actions when it comes to unplanned pregnancies.

Shannon likes to go out and party, in the past six months Shannon has had three unplanned onenight-stands, and two out of the three times no condom was worn. Shannon is rethinking her decisions after her best friend contracted Chlamydia.

Shannon now realizes that she can contract an STI knowing that her best friend is being treated for one. Knowing that her best friend has an STI puts things in perspective for Shannon because before she did not know anyone who had an STI and believed that they were very rare.

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Although most STIs are curable, some if left untreated can cause serious harm and could lead to death. Shannon researches STI after finding out about her best friend and what she finds out is alarming to her; she could have an STI and not even know it. Shannon is only 19 years old and has already had five sexual partners in her lifetime. She has thought about her future and she wants to have children someday. She now realizes that by having unsafe sex is putting her at risk of infections that can lead to infertility, which scares her.

Shannon thinks back to those two one- night- stands when a condom was not used. She thought that being on birth control was enough of a reason not to use a condom that protecting herself from an unplanned pregnancy was all she needed to worry about. Then she thought about the one-night-stand when a condom was used. Shannon could not see any benefits from not using a condom that both situations were virtually the same in regards to the outcome. Shannon then thinks why a condom was not used and she realized it was never discussed in the two times a condom was not used. During the time a condom was used her sexual partner asked if a condom should be used and Shannon without really thinking about it replied “sure”. Shannon questions whether or not the two other sexual partners had condoms but since she never asked they just assumed it did not matter. Shannon knows now if they had of asked she would have said “yes”.

Consequently, Shannon now realizes the dangers of having unsafe sex and becomes aware that the risks outweigh the benefit of not using a condom. This connects to the HBM because it shows that Shannon perceptions have changed about the seriousness of unprotected sex; thus changing her actions and increasing her control. In the end Shannon decides to go get tested at her community sexual health clinic to see if she has contracted anything and she also decides to practice safe sex from now on. With Shannon’s new knowledge about sexual health she feels empowered and has a boost in confidence. Which again relates back to the HBM when

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she has developed self-efficacy and is confident in her ability to make healthy decisions regarding her sex life.

Diffusion of Innovation Theory (DIT) New ideas are the foundation which the DIT is based upon and how different populations or communities adopt these new ideas is how the DIT works. These ideas could involve adopting new technology like the “IPad 2”or health behaviour practices such as deciding to receive the “Gardasil” vaccine or in the this case to adopt condom use. DIT is defined as “the process by which an innovation is communicated through certain channels over time among members of social systems” (as cited in Nutbeam, Harris, & Wise, 2010, p.24).

There are certain factors that must be considered to fully understand the DIT and they are: “the characteristics of the potential adopters; the rate of adoption; the nature of the social system; the characteristics of the innovation; and the characteristics of change agents” (Nutbeam, Harris, & Wise, 2010, p.24). Consequently, due to these factors they produce a variety of different outcomes in different individuals. These groups of individuals were given specific names; listed in order from the individuals who are the first to adopt the new idea to the individuals who are last or never adopt the new ideas are the, innovators, early adopters, early majority, late majority and the laggards (Nutbeam, Harris, & Wise, 2010). The breakdown of percentages for each group usually is as follows: two to three percent are the innovators, ten to 15 percent are the early adopters, 30 to 35 percent are the early majority, 30 to 35 percent are the late majority and the laggards account for ten to 20 percent of the population (Nutbeam, Harris, & Wise, 2010).

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Although, condoms have been around for well over a century it can still be considered a new idea. This is true because “if it is new to an individual, then it is an innovation” (Nutbeam, Harris, & Wise, 2010, p.24). In today’s society, many young people who are engaged in sexual activities choose not to use condoms (Denny-Smith, Bairan & Page, 2006). Ever since hormone contraceptives (most commonly referred to as “The Pill”) have been available condoms usage has decreased (McEvoy & Coupey, 2002). Moreover, another contributing factor is the abstinence-only educational programs taught in schools. The students coming out of high schools teaching such programs are “naïve about the risks of STIs” (Downing-Matibag & Geisinger, 2009, p. 1207) and thus do not adopt the use of condoms and are then labelled as laggards.

North American culture is not as open to talking about sexuality and sexual health as much as other cultures such as Dutch and Icelandic. Due to the attitudes and perceived beliefs associated with sex it causes “a natural barrier between young people and health professionals” (Barron, 2005, p.39). Youth do not generally feel comfortable when talking about safe sex practices and again causing individuals to slowly realizing the benefits of condoms or knowing how to access condoms (McEvoy & Coupey, 2002). Plus, they usually tend to think that they are above getting an STI, which is referred to as “magical thinking” (as cited in Barron, 2005, p.40).

As Barron (2005) points out that it is “similar to Piaget's (1972) suggestion that adolescents enter a stage of egocentrism (selfcentred) when young people believe that they are above mundane risks and demands” (p.40). However, in order to trigger behaviour change there first must be prompt such as an intervention (as cited in Barron, 2005).

In regards to screening and testing for STIs there are plenty of negative psychological and social consequences including the “shame, anxiety, embarrassment, isolation, fear of rejection, and fear of being less sexually desirable” regardless if the tests come back positive or negative

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(as cited in Foster & Byers, 2008, p.193). The negative stigma that accompanies STIs are so powerful in our society that that alone could be reason enough for a young woman not to get tested for fear of “feeling dirty and not discussing their STI for fear of others' negative reactions” (as cited in Foster & Byers, 2008, p. 193). Furthermore, the stigma relating to STIs as described by Foster and Byers (2008), Based on the perception that STIs are the consequence of choosing to engage in behaviour that is contrary to traditional cultural values. Specifically, individuals may assume that a person who contracts a STI has participated in sexual behaviour that they view as immoral such as unprotected sex, sex with multiple partners, or sex with immoral partners (p. 194) All the stigma and perceptions linked to having an STI are disincentives and barriers for young female not to get tested or screened and consequently they become the laggards. The importance “of de-stigmatizing STIs in order to increase access to STI care” is one of the goals of many health professionals (as cited in Foster, & Byers, 2008, p.194).

Health Promotion Initiative An effective health promotion initiative aimed at increasing the use of condoms and reducing the prevalence of STIs would be to increase the accessibility to condoms and health services including anonymous screening and education. The delivery of the initiative would come in the form of a public health campaign which would use the Social Marketing Theory (SMT). It would incorporate a variety of different Medias including posters, pamphlets, commercial advertising, radio announcements, online advertisements and a school-based curriculum just to name a few. Of course this would be an ongoing, long-term initiative in order

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to yield the best possible outcomes and hopefully not seen as “a ‘quick fix’ to much larger issues [sic issue]” (Gagnon, Jacob, & Holmes, 2010, p. 254).

In today’s society health has moved toward a shared responsibility to both the individual and the health professionals and not just the health professional as it did in the past (Browes, 2006; Gagnon, Jacob, & Holmes, 2010), and “prevention campaign emphasizes ‘the notion of individual choice (. . .) and draws attention to the fact that [public health] makes people feel responsible and culpable for their health status” (as cited in Gagnon, Jacob, & Holmes, 2010, p.

252). The SMT uses the concept that the individual is the consumer and the product is the “public health message and prescribed behaviors” (Gagnon, Jacob, & Holmes, 2010, p.253). It is said that “advertising in the mass media is an effective means of propaganda, able to persuade audiences to take up a desired behavior” (as cited in Gagnon, Jacob, & Holmes, 2010, p. 254) As mentioned above, the health services would include anonymous screening and education; however, it is clear that “different groups in society, such as teenagers, may require care to be delivered in a different way” (Barron, 2005, p. 38). It seems as though school-based health clinics could offer the best accessibility to students and the ability to reach a large population of the youth including the individuals at high risk (McEvoy, & Coupey, 2002). The aim for anonymous screening would be to increase and promote it amongst the youth. Studies have shown that “increasing anonymous testing and its advertisement would provide one means of providing population-sensitive care and could thus increase the screening rates of individuals (O'Byrne, & Holmes, 2005, p.523).

The education aspect of the initiative would be integrated into all public high schools as a requirement in their curriculum across Canada starting in grade nine. Therefore, it would not

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discriminate against lower economic areas, rural areas or any other factor. This is important because studies have shown “that the two determinants of income/social status and education are implicated in sexual practices that result in higher STI rates” (O'Byrne, & Holmes, 2005, p.525).

The curriculum would incorporate information about STIs, how they are contracted with a special emphasis on the fact that an individual can contract an STI from performing or receiving oral sex, the symptoms of different STIs with an emphasis that many STIs are often asymptomatic especially in females, different treatments for STIs, and how to practice safe sex including how to negotiate sex with your partner, discuss all the barriers that hinder the youth not to use a condom , how to use a male condom and female condom (dental dam) properly and clearly explaining that hormonal contraceptives do not protect against any STIs including HIV. Moreover, incorporating evidence of the prevalence in their specific area would increase the students’ perceived threat for contracting a STI (Downing-Matibag, & Geisinger, 2009) which links to the HBM. Education alone will not be an effective strategy, “the informational approach assumes that increasing peoples' knowledge should increase their level of condom use. However, the results of information campaigns have not led to a reduction of risky sexual behaviours” (Martin, 2006, p. 31). Increasing the accessibility of condoms would be an effective and efficient way to decrease STIs. We would do this by installing condom dispensers in the privacy of both the male and female bathrooms in shopping centers, religious institutions, recreational centres, community centers, clubs/bars, restaurants, and in all colleges, universities and high schools; the distribution of condoms in schools “have been found to be an effective strategy for the prevention of STIs despite the controversy surrounding them” (as cited in McEvoy, & Coupey, 2002, p. 467). By

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making condoms more accessible it can increase individuals’ perceived self-efficacy, which connects back to the HBM (Downing-Matibag, & Geisinger, 2009).

All of these strategies would increase their perceived susceptibility for STIs, perceived seriousness of contracting an STI and the consequences attached, youth would realise the benefits of using a condom or getting STI screening, and by taking about all the barriers helps find solutions and breakdown these barriers lets students take control of their sexual health.

The DIT is embedded into this initiative because it will increase condom use and STI screenings by reaching the populations that are the “late majority” and some of the” laggards”.

They are reached because the campaigned targeted areas where young people will most likely be or the areas where they are known to visit often. In addition, it was able to reach the high risk population (the people who are likely never to adopt condom use and STI screening) by being intergraded into all school curriculums in Canada starting at an early enough age.

Reflection The two main theories that I used for this report on STIs in youth were the HBM and the DIT. I found these theories to be very different and I soon realized that because of the differences between these two theories it left me confused about how I looked at the same health issue in the same light. The HBM tries to determine how individuals think about certain health decisions and taking it a step further by going step by step and taking an in depth look into the decision making process of each individual. The HBM also focus at an individual level and I find it is not ideal to apply it to a large population. It also tries to predict people’s actions based on their perceptions, however some of the time when people weigh out the benefits of adopting the new health action or behaviour against the costs they are not always rational thinkers or decision-makers.

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Although, the HBM helps me to realize and understand the chances that youth, and in particular females will engage in safe sexual practices, I find this model easy to use and very practical. I like how it takes into account factors that influence the individuals’ decision-making process including factors such as our own personal characteristics and social norms.

I see the HBM by viewing the countless factors all being stacked on a scale to see which end will be heavier the side that will choose the health behaviour or the side that will reject the health behaviour. Sometimes, even if it is more heavily weighted on the benefits side to adopt the health behaviour not everyone will think rationally and choose the obvious choice. In this fact not all HBM when applied to individuals make sense from the outside looking in you really must be in the person’s shoes to understand their frame of thinking and decision making-process.

The DIT does not attempt to understand or explain human behaviour like the HBM; instead it categorizes populations into groups who are at different stages of accepting a new idea.

I do not find that this theory tells me much information only percentages of the prevalence of innovation and acceptances of the new practice, new technology, or what have you. Unlike technology such as cellar phones; when they first come out hardly anyone had one, only a select few with the money and need for such a device. Over time however, people began to see the need and luxury of having a portable phone on you at all times and as time pass they became more affordable. The only problem that I see with the theory, you cannot use it much in health promotion because it does not show you factors that are influencing the late majority or the laggards. But while health practices and behaviours are hard to change this theory can be applied to a very large population however only to describe the adoption of new ideas.

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Although I did ample research many studies tell the same stories over and over again saying that condoms use has decrease, the problem with the DIT is that it does not take into account the retrograde diffusion. I am talking about once the excitement wears off when newer better ideas come along. There is no graph depicting the percentages when that happens or is it just the same as this one? In this case, condom usage was down due to the invention of hormonal contraceptives; however the males are to use the condom while females are to take “The Pill�.

This would cause confusion in this theory, I think. In the end, the DIT only provides an overview of what happens over time. It does not provide an exact percentage specific to a health issue or topic, just like the 20/80 rule that I use in everyday life, but when it comes to health promotion I like to see the true numbers.

Although, I did apply both theories to the same health issue, I did it in separate parts which I found very easy to comprehend, however once I needed to think of them working together for the same initiate I found it a bit challenging. I think you need to think outside the box and apply critical thinking and theoretical thinking when discussing theories. It was interesting how one theory could co-exist with the other; it came to me when I saw that the DIT was embedded all along without ever having to do one thing, except for point it out. I did not realise until asked how these two theories made me look at the same health issue with different eyes.

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References Barron, S. (2005). Sexual health of adolescents. Primary Health Care, 15(5), 37-41.

Browes, S. (2006). Health psychology and sexual health assessment. Nursing Standard, 21(5), 35-39.

Denison, J. (1996). Behavior Change -- A Summary of Four Major Theories. Control and Prevention (AIDSCAP): Behavioral Research Unit. Retrieved from http://www.fhi.org Denny-Smith, T., Bairan, A., & Page, M. (2006). A survey of female nursing students' knowledge, health beliefs, perceptions of risk, and risk behaviors regarding human papillomavirus and cervical cancer. Journal of the American Academy of Nurse Practitioners, 18(2), 62-69.

Downing-Matibag, T., & Geisinger, B. (2009). Hooking up and sexual risk taking among college students: a health belief model perspective. Qualitative Health Research, 19(9), 1196-1209.

Foster, L., & Byers, S. (2008). Predictors of stigma and shame related to sexually transmitted infections: attitudes, education, and knowledge. Canadian Journal of Human Sexuality, 17(4), 193-202.

Gagnon, M., Jacob, J., & Holmes, D. (2010). Governing through (in)security: a critical analysis of a fear-based public health campaign. Critical Public Health, 20(2), 245-256. doi:10.1080/09581590903314092 Martin, A. (2006). Risk taking behaviours within sexual health. Primary Health Care, 16(10), 31-34.

McEvoy, M. & Coupey, S.M., (2002). Sexually transmitted infection: A challenge for nurses working with adolescents. The Nursing Clinics of North America. (37) 461–474.

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O'Byrne, P., & Holmes, D. (2005). Re-evaluating current public health policy: alternative public health nursing approaches to sexually transmitted infection testing for teens and males who have sex with males [corrected]. Public Health Nursing, 22(6), 523-528.

Ottawa Charter for Health Promotion (1986) First International Conference on Health Promotion. Retrevied from www.who.int/ Public Health Agency of Canada (2007). Canadian Sexually Transmitted Infections Surveillance Report. Canada Communicable Disease Report (CCDR), 33S1, 1-69.

Public Health Agency of Canada (2008). Canadian Guidelines for Sexual Health Education.

Retrieved from www.phac-aspc.gc.ca.

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