Issues and Strategies in STD Prevention and Control: A View from Clinical, Public Health and Community Settings
Rekart, Michael L., The Canadian Journal of Human Sexuality
Abstract: Canada's goals for STD control must be considered in the context of the social, economic, political and personal environment. Key issues include behavioural determinants of STD risk, access to clinical services, social supports, reducing discrimination, expanding life opportunities, resource maintenance, life skills and self-esteem, social marketing, school health curricula and political impediments. Successful strategies to reduce sexually transmitted diseases will depend on our ability to change the behaviour of Canadian society with respect to populations at greatest risk, including youth. It will rely on changing our own attitudes as well
A recent issue of this journal (CJHS, 6) was dedicated to delineating the current situation with respect to sexually transmitted diseases (STDs) and to charting a course for Canada through the next decade (Alary, 1997; Fisher, 1997; Lytwyn & Sellors, 1997; Maticka-Tyndale, 1997; MacDonald & Brunham, 1997; Patrick, 1997a; Patrick, 1997b; Romanowski, 1997; Steben & Sacks, 1997; Tepper & Gully, 1997). The surveillance, research, program and policy needs were clearly spelled out, an achievable control strategies in screening, prevention and case management were specifically noted. meticulous and thoughtful work of these authors led to the "Proposed STD Control Goals for Canada" (Patrick, 1997a). This commentary presents the view from frontline STD control programs and highlights important considerations in implementing the strategies necessary to achieve these goals.
Several general issues will play a crucial role in making progress against STDs and achieving the STD Control Goals for Canada.
1. Determinants of Behaviour The behaviours which lead to STD transmission and acquisition have been known for some time. The STD control discourse has already taken the logical next step to focus on changing the risky behaviours and supporting the safer ones. Effectiveness in promoting behaviour change is dependent on understanding why specific behaviours occur. For this, STD control programs need to involve behavioural scientists, qualitative researchers and ethnographers in conducting the necessary studies, asking the right questions, and helping us to understand how their work contributes to STD prevention. Why an 18 year old boy decides not to use a condom can have many answers: some can be. deduced logically (e.g., he is embarassed to buy one), but some others are known only to that boy (e.g., he has a mild latex allergy). In the latter instance, no amount of condom promotion or free distribution will be as immediately successful as identifying the allergy and providing access to polyurethane condoms. Multidisciplinary research can, in many cases, help us to better understand the varied and complex pathways to STD prevention behaviour.
2. Youth Fifteen to twenty-four year olds bear the major burden of STDs. Rates in excess of five times the national average are not uncommon in this group. Any hope of making significant inroads into STD incidence over the next 10-20 years will rely heavily on changing behaviour in teenagers and young adults. It is now clear that to be effective, behaviour change interventions must first occur before young people become sexually active.
3. Special Populations People come in various shapes, sizes and colours, they come from various backgrounds and cultures, and they live in different social millieux. STDs take refuge in core transmitter groups and marginalized populations behind the walls of poverty, discrimination and inequality. For example, locally transmitted gonorrhea, endemic congenital syphilis and cervical cancer can never be eliminated until Canadian society moves beyond the assurance of basic human rights to the provision of basic human needs: education, nutrition, shelter, freedom from discrimination, good health and equal opportunity. The poor, the homeless, the outcast have more important things to deal with than dysuria and discharge. …