HIV, Sexual & Reproductive Health Position Statements

ETR was established in 1981 as a training organization for teachers implementing sexuality education in California. Since then, our work in the area of HIV/AIDS and sexual and reproductive health has expanded to include research, program development and evaluation, organizational and individual capacity building, and dissemination on a national scale.

ETR's Sexual and Reproductive Health Charter—an internal, multidisciplinary team—adopted five focal areas that aim to promote the sexual health and well-being of communities and youth and to reduce disparities in HIV/AIDS, unintended pregnancy and sexually transmitted infection (STI). ETR’s position statements describe our agency values and beliefs in the area of sexual and reproductive health, organized around these five focal areas that align with our Health Equity Framework.

Community & School Context | Relationships & Connectedness | Education, Treatment & Prevention |
Developmental Neuroscience | Implementation Science

 

Community and School Context


ETR believes that everyone deserves to live in a community that is economically, socially and physically healthy, where individuals and families have access to quality, affordable sexual and reproductive health care and education across the lifespan.

Community and School Context is concerned with how place—where a person lives, works and/or goes to school—influences sexual and reproductive health. We know that educational and employment opportunities, access to health and social services, and local policies shape the choices people make about their health and relationships. For example:

  • Opportunities to finish high school and go to college improve the health of individuals and the future health and well-being of their children and families.[1],[2]
  • When people have better access to sexual and reproductive health care, there are fewer unintended and teen pregnancies.[3]
  • The presence of caring and trusting relationships and opportunities for meaningful engagement in the school and community are known to influence sexual behavior choices and outcomes.[4], [5] These factors also impact other outcomes, such as substance use, mental health and academic achievement.[6], [7], [8]

ETR’s work in this area aims to:

  1. Address community- and school-level social drivers of inequities that affect sexual and reproductive health through developing and/or evaluating programs, practices and policies that support growth on multiple outcomes.
  2. Build the capacity of community and school leaders to assess, improve and evaluate structures that promote healthy behaviors, caring relationships and safer environments.
  3. Disseminate research findings and best practices on population-level strategies that work to reduce inequity and improve sexual and reproductive health.

 

Relationships & Connectedness


ETR believes that creating positive and safe relationships is essential to improving health outcomes. Sexual and reproductive health programs should address consent and communication within partnerships, and cultivate child/youth connectedness with parents and other trusted adults.

Relationships & Connectedness focuses on how relationships with partners, peers and parents—healthy or unhealthy—impact sexual and reproductive outcomes. Sexual behavior most often occurs within the context of a relationship and is influenced by connectedness to families and peers. For example:

  • Relationship patterns learned in adolescence can impact future relationships.[9] Individuals bring forth a history of sexual and relationship experiences that can impact successive relationships, [10] highlighting the importance of addressing unhealthy patterns and promoting healthy ones early on. 
  • Dating violence or intimate partner violence victimization is associated with increased risk for low self-esteem. [11] Young people who experience victimization are more likely to report poor emotional well-being, suicidal thoughts and attempts, risky sexual behaviors, pregnancy, cigarette smoking and disordered eating.[12],[13] Teaching strategies that promote healthy relationships during adolescence are key to preventing dating violence patterns that can carry into adulthood.
  • While peers are important, young people say their parents most influence their decisions about sex.[14] Connectedness between parents/caregivers and young people is protective of a range of risk behaviors.[15]

ETR’s work in this area focuses on:

  1. Developing and/or evaluating programs that use relationships as a central theme for increasing sexual health.
  2. Addressing the role of exposure to violence, human trafficking and other trauma on sexual health outcomes through research and collaboration with community-based partners.

 

Education, Treatment & Prevention


ETR believes that education, treatment and prevention strategies should be inclusive of all communities, including “invisible” populations, such as LGBT, homeless and system-involved youth. Health education and services should be designed and implemented with the acknowledgment of the social and structural factors that create inequities in our workplaces, health and school systems.

Education, Treatment & Prevention concerns the direct role of health education and services in modifying knowledge, attitudes, skills and behaviors related to preventing unintended and teen pregnancy, STIs and HIV/AIDS. Communities, families and individuals, including young people, are healthier when they have accurate information about their sexual health and rights, and have access to reliable and inclusive services. For example:

  • Evidence shows that prevention programs are effective at reducing sexual risk behaviors among youth.[16], [17]
  • Education plays a critical role in reducing the incidence of HIV, as well as advancing linkage to and retention in care. [18]
  • Major reductions in unintended pregnancy are possible when health services are affordable, universally available and accessible.[19], [20]
  • Positive behaviors and outcomes are more likely to be sustained if health education and services address social and structural factors affecting sexual decision making.[1], [21]

ETR’s work in this area involves:

  1. Building the capacity of communities, schools, organizations and individuals to implement and sustain programs to reduce disparities in unintended pregnancy, STIs and HIV/AIDS.
  2. Evaluating promising programs and strategies, with a particular focus on hard-to-reach populations (e.g. system-involved youth, young adults, special education, etc.).
  3. Providing materials and other resources to support education, treatment and prevention efforts nationally and internationally.

 

Developmental Neuroscience


ETR believes that using developmental neuroscience literature provides an opportunity to strengthen sexual and reproductive health programs and practices, leading to greater impact and reduced disparities. ETR frames its study of neuroscience and sexual health in the context of how environmental factors—such as trauma—influence decision making and behaviors.

Developmental Neuroscience relates to how brain development and functioning influence decision making and behavior, specifically in adolescents. Due to the complexity in sexual decision making for adolescents and young people, the sexual and reproductive health field can learn from this emerging area of research. For example:

  • Adolescence is a time of increased neuroplasticity, meaning that there is potential for the brain to change and adapt based on experience. This makes adolescence a critical period for helping young people develop important life skills and healthy behaviors.[22]
  • Developmental changes in social and emotional brain structures are associated with increased risk taking from childhood to adolescence.[23], [24]
  • Risk taking declines from adolescence to adulthood with the maturation of cognitive control systems in the brain that help to regulate impulsive behavior.[23], [24]
  • Experiences of chronic stress or trauma can inhibit the growth of brain structures that are important for self-regulation and decision making.[25]
  • There is a need to create social contexts that provide the appropriate support to adolescents in order to develop their skills of self-control.[26]

ETR’s work in this area includes:

  1. Engaging with experts in the field of neuroscience to discuss, disseminate and apply research to sexual health program development and implementation.
  2. Translating research to support capacity building and wider use of the research.
  3. Partnering with organizations and funders to develop and evaluate innovative interventions and programs that incorporate findings from the neuroscience field.

 

Implementation Science


ETR believes that empowering people to use programs in their community is critical for increasing the scale, sustainability and impact of programs. As the only organization in the sexual health field who develops, trains on, evaluates and disseminates interventions to scale, we aim to bridge the gap between research environments and the context of practice.

Implementation Science concerns not just what outcomes are achieved by an intervention but how interventions achieved that change. Numerous program evaluations have reported changes in sexual risk behaviors, unintended pregnancy, STIs, and HIV/AIDS. Implementation research allows us to identify the components, messages and factors that are most effective in modifying attitudes, skills and behaviors that lead to positive health outcomes. Through implementation science, we can also examine the influence of other factors in program implementation, such as facilitator characteristics, training and support, implementation schedules, and organizational readiness.

  • Fidelity to core components is fundamental for outcomes, and adaptations are both a practical reality and important factor for increasing contextual fit and acceptance.[27]
  • Organizational readiness, facilitator training and implementation support are critical for achieving behavior and health outcomes.[27], [28], [29]
  • Evaluation and the development of more sensitive measures contribute to the understanding of when, how and in what context interventions are effective, accepted and cost efficient. Ongoing efficacy, effectiveness, process and replication evaluations are essential to this body of knowledge.[31]

ETR’s work in this area centers on:

  1. Identifying and testing core components of existing and new interventions as well as factors that influence implementation.
  2. Conducting rigorous evaluations of training and implementation support to increase the efficiency and effectiveness of professional development.
  3. Building the capacity of implementers to assess, select and customize programs for different communities.

Notes

[1] Viner, R. M., Ozer, E. M., Denny, S., Marmot, M., Resnick, M., Fatusi, A. & Currie, C. Adolescence and the social determinants of health. Lancet, 2012; 379: 1641–1652.

[2] Gakidou, E., Cowling, K., Lozano, R., & Murray, C. J. Increased educational attainment and its effect on child mortality in 175 countries between 1970 and 2009: A systematic analysis. Lancet, 2010; 376: 959–974.

[3] Frost, J. J., Frohwirth, L., & Zolna, M. R. Contraceptive Needs and Services. Guttmacher Insitute. Accessed September 2015: http://www.guttmacher.org/pubs/win/contraceptive-needs-2013.pdf

[4] Markham, C. M., Lormand,  D., Gloppen, K. M., et al. Connectedness as a predictor of sexual and reproductive health outcomes for youth. J Adolesc Health, 2010; 46: S23–41.

[5] Patton, G. C., Bon, L., Carlin, J. B., Thomas, L., Butler, H., Glover, S., Catalano, R., & Bowes, G. Promoting social inclusion in schools: A group-randomized trial of effects on student health risk behavior and well-being. Am J Public Health, 2006; 96: 1582–1587.

[6] Fletcher, A., Bonell, C., & Hargreaves, J. (2008) School effects on young people's drug use: A systematic review of intervention and observational studies. J Adolesc Health, 2008; 42(3): 209–220.

[7] Resnick, M. D., et al. Protecting adolescents from harm: Findings from the National Longitudinal Study on Adolescent Health. JAMA, 1997; 278: 823–832.

[8] Wells, J., Barlow, J., & Stewart-Brown, S. A systematic review of universal approaches to mental health promotion in schools. Health Education, 2003; 103(4): 197–220.

[9] Sorensen, S. (2007). Adolescent romantic relationships: Research facts and findings. ACT for Youth Center of Excellence. Accessed July 2016: http://www.actforyouth.net/resources/rf/rf_romantic_0707.pdf

[10] Furman, W., and Wehner, E. A. (1994). Romantic views: Toward a theory of adolescent romantic relationships. In R. Montemayer, G. R. Adams, and G. P. Gullota (eds.), Advances in Adolescent Development, Vol. 6: Relationships During Adolescence. Thousand Oaks, CA: Sage.

[11] Silverman, J. G., Raj, A., & Clements, K. Dating violence and associated sexual risk and pregnancy among adolescent girls in the United States. Pediatrics, 2004; 114(2): e220–225.

[12] Ackard, D. M., and Neumark-Sztainer, D. Date violence and date rape among adolescents: associations with disordered eating behaviors and psychological health. Child Abuse and Neglect, 2002; 26, 455–473.

[13] Ackard, D. M., Eisenberg, M. E., & Neumark-Sztainer, D. Long-term impact of adolescent dating violence on the behavioral and psychological health of male and female youth. The Journal of Pediatrics, 2007; 151( 5): 476–481.

[14] Albert B. (2012). With one voice: America’s adults and teens sound off about teen pregnancy. Washington, DC: The National Campaign to Prevent Teen and Unplanned Pregnancy. Accessed February 2014: http://thenationalcampaign.org/ resource/one-voice-2012

[15] Lezin, N., Rolleri, L. A., Bean, S. and Taylor, J. (2004). Parent-Child Connectedness: Implications for Research, Interventions and Positive Impacts on Adolescent Health. Santa Cruz, CA; ETR Associates.

[16] Kirby, D. (2007). Emerging Answers 2007: Research Findings on Programs to Reduce Teen Pregnancy and Sexually Transmitted Diseases. Washington, DC: National Campaign to Prevent Teen and Unplanned Pregnancy.

[17] U.S. Department of Health and Human Services. Teen Pregnancy Prevention Evidence Review. Accessed July 2016: http://tppevidencereview.aspe.hhs.gov

[18] Jukes, M., and Desai, K. (2005). Education and HIV/AIDS. UNESCO. Accessed July 2016: http://unesdoc.unesco.org/images/0014/001460/146012e.pdf

[19] Birgisson, N. E., Zhao, Q., Secura, G. M., Madden, T., & Peipert, J. F. Preventing unintended pregnancy: The Contraceptive CHOICE Project in review. Journal of Women’s Health, 2015; 24(5): 349–53.

[20] Ricketts, S., Kingler, G. & Schwalberg, R. Game change in Colorado: Widespread use of long-acting reversible contraceptives and rapid decline in births among young, low-income women. Perspecitve on Sexual and Reproductive Health, 2014; 46(3).

[21] DiClemente, R., Salazar, L. F., & Crosby, R. A. A review of STD/HIV preventive interventions for adolescents: Sustaining effects using an ecological approach. J Pediatr Psychol, 2007; 32(8): 888–906.

[22] Lenroot, R., & Giedd, J. N. Brain development in children and adolescents: Insights from anatomical magnetic resonance imaging. Neuroscience and Biobehavioral Reviews, 2006; 30: 718–729.

[23] Steinberg, L. A social neuroscience perspective on adolescent risk-taking. Developmental Research, 2008; 28(1): 78–106.

[24] Casey, B. J., Jones, R. M., & Somerville, L. H. Braking and accelerating of the adolescent brain. Journal of Research on Adolescence, 2011; 21(1): 21–33.

[25] Romeo, R. D., & McEwen, B. S. Stress and the adolescent brain. Annals of New York Academy of Sciences, 2006; 1094: 202–214.

[26] Dahl, R. Adolescent brain development: a period of vulnerabilities and opportunities. Annals of New York Academy of Sciences, 2004; 1021: 1–22.

[27] Berkel, C., Mauricio, A. M., Schoenfelder, E. & Sandler, I. N. Putting the pieces together: An integrated model of program implementation. Prev Sci, 2011; 12: 23–33.

[28] Lauer, P. A., Christopher, D. E., Firpo-Triplett, R., & Buchting, F. The impact of short-term professional development of participant outcomes: A review of the literature. Professional Development in Education, 2014; 40(2): 207–227.

[29] Kelsey, M., & Layzer, J. Implementing three evidence-based program models: Early lessons from the Teen Pregnancy Prevention Replication Study. J. Adolesc Health, 2014, 54: S45–S52.

[30] Valentine, J. C., Biglan, A., Boruch, R. F., Gonzalez Castro, F., Collins, L. M., Flay, B. R., Kellam, S., Moscicki, E. K., & Schinke, S. P. Replication in prevention science. Prev Sci, 2011; 12: 103–117.