Scientific Papers

Agenda-setting in policies related to high-risk sexual behaviours, stimulants, and alcohol abuse in Iranian adolescents | Health Research Policy and Systems


Agenda-setting

The present research results, which were mainly the results of interviewing the key people and analysing the documents, were presented based on the Kingdon model (Table 2).

Table 2 Kingdon’s agenda-setting streams

Problem stream

According to Kingdon, policy-makers are drawn to problems through three mechanisms: indicators, events and feedback. These factors capture the policy-makers’ attention and prompt them to take action. The following matters have been explained in this context.

Indicators

One of the factors that contributed to the formation of a problem stream in this domain was the availability of various indicators and reports related to the prevalence of high-risk behaviours, social harms and deaths resulting from them in adolescents and adults. A significant portion of these incidents could have been prevented. As a result, high-level decision-making positions in Iran became sensitized and attentive to this issue. This led to the formation of supportive positions and interventions to control these issues throughout the country. The most important sources that made this problem stream significant among policy-makers were various studies, such as reports related to human immunodeficiency virus (HIV) from the Ministry of Health, forensic medicine reports, prevalence studies of drug and stimulant abuse, monitoring of the status of social harms ordered by Iran’s supreme leader and reports from the Expediency Council. An interviewee stated that “a strong research team was responsible for monitoring the social harms ordered by the supreme leader, and their findings were presented in reports. The results of their research indicated that the conditions were very poor.” (I23).

Another factor that contributed to the creation of the problem stream was the status of HIV and sexually transmitted diseases in Iran. Sexual transmission is one of the ways in which HIV can be transmitted, and the number of cases has been increasing in recent years. The Third National Strategic Plan of AIDS Control in Iran highlighted that the sexual behaviours of adolescents and young people could potentially lead to the sexual transmission of HIV in the population if no action is taken [79]. The population of Iran is predominantly young, and recent studies have shown a significant prevalence of high-risk sexual behaviours among youngsters. There has been an increase in the number of identified cases of sexual transmission, which has raised serious concerns about the start of the third epidemic wave, i.e., HIV sexual transmission. However, sexual behaviour outside the framework of marriage is considered unacceptable in Iran and is punishable by law, which means that these behaviours often occur secretly in society. One interviewee said:

“…The situation is very serious, and it is believed that punishment alone will deter individuals from engaging in high-risk behaviours. However, this approach may not be effective, particularly among adolescents and young people of this generation.” (I21).

Regarding drug abuse, studies conducted by the University of Welfare and Rehabilitation Sciences in 2004 and 2007 in the form of rapid situation assessments revealed that the age of addiction in Iran has decreased. Additionally, the consumption pattern of opioids, stimulants and psychedelics has also increased. [80, 81]. Furthermore, the University of Welfare and Rehabilitation Sciences conducted a study on the prevalence of high-risk behaviours among individuals aged 15–25 years. The study found that adolescents who consume drugs have a higher prevalence of engaging in other high-risk behaviours compared with their peers [82]. The results of this study led to an increased level of sensitivity within the Ministry of Health and Welfare Organization towards the issue of high-risk behaviours.

Due to the fact that alcohol abuse is considered taboo in Iran and is punishable by law, there are no authentic published statistics available on this issue. In some cases, officials in this field have announced paradoxical statistics. Despite the lack of accurate statistics on alcohol consumption, it has been noted that there has been an increase in its use in Iran, which is a cause for concern. One interviewee mentioned:

There are many problems like this where statistics are not available, and suddenly after several years, they are revealed as big uncontrollable issues. I have always maintained that the statistics we have or hear about are only the tip of the iceberg that is out of the water, and we only see the iceberg when we hit it like the Titanic.” (I26).

Focusing events

Several focusing events caused attention to be drawn towards high-risk behaviours and social harm in the general public, particularly among adolescents. These events included Iranian officials’ visits to the slums of Mashhad, instances of large-scale alcohol poisoning in the cities of Sirjan and Rafsanjan (located in Kerman Province), an increase in adolescent offences, such as the murder of an Afghan female child by an Iranian adolescent and the broadcasting of programs on social harms by the Islamic Republic of Iran Broadcasting.

One event that brought more attention to the issue of social harm was the visit of Iran’s supreme leader to the slums of Mashhad. During this visit, he demanded an improvement in the situation of marginalization and an examination of social harm. This event garnered the attention of policy-makers and brought the issue into focus, resulting in the promotion of the Social Council of the Country to the Social Affairs Organization. The Social Council of the Country was established in 2001 to develop policies related to the prediction, prevention and resistance against social problems and harms, as well as to coordinate with other organizations.

In 2016, the supreme leader delegated the presidency of the Social Council of the Country to the president, and the council was promoted to the Social Affairs Organization with the aim of preventing social harm. This organization then reached out to several entities, including the Welfare Organization, Ministry of Health, Anti-narcotics Headquarters, Education Organization and Judiciary, to collaborate on designing and implementing effective policies and programs to address high-risk behaviours and social harm among adolescents and young adults in Iran.

“We cannot say that attention was not paid to social harm, but after the supreme leader’s visit, it became very important. He ordered to organize this situation and asked for reports; in this way, the harm were brought into focus. Many senior managers visited there, and the topic of harm prevention became hot.” (I29).

“The visit of the supreme leader brought attention to the issue, and as a result, the Social Council of the Country was promoted to the Social Affairs Organization, which took charge of coordinating and examining the matter. The organization encouraged all related organizations to propose programs and solutions to tackle the problem, and subsequently, various plans were suggested by the Ministry of Health, Education Organization, and other entities….” (I27).

The large-scale alcohol poisoning incidents in Rafsanjan and Sirjan cities in Kerman Province were the focusing events that brought attention to alcohol abuse in Iran. In 2013, 298 people were poisoned with alcohol in Rafsanjan, resulting in the death of 4 people. In 2017, a similar incident occurred in Sirjan, which led to the poisoning of 114 people and the death of 5 people. These incidents received widespread media coverage and raised awareness about the issue of alcohol abuse. Policy-makers began to pay more attention to this issue, which had previously been overlooked.

“It made the policy-makers realize that the alcohol problem cannot be solved by whipping and fines alone, and that the number of cases is not limited. Therefore, they needed to take serious measures. For instance, how many people are living in Rafsanjan and Sirjan, and how many of them consume alcohol? Now, imagine a city like Tehran. This incident compelled policy-makers to think seriously about the problem.” (I5).

According to statistics provided by the Judiciary, offences committed by adolescents have increased significantly, and this has been occasionally mentioned in the media. However, two high-profile crimes on Gandi Street – the murder committed by two male and female adolescents in a love story – and the murder of an Afghan female child by an Iranian male adolescent after raping her, brought the issue of adolescents to the attention of policy-makers more than ever before.

“The story of Gandi Street, which occurred in 1996, was a wake-up call that our adolescents need help, despite some who still deny it. At that time, some blamed the influence of cultural invasion from satellite television in their homes. Then, in 2016, the tragic story of the Afghan child who was raped and murdered by an Iranian male adolescent highlighted the fact that we have not adequately trained our adolescents to manage their instincts. We also perpetuate taboos by telling them to keep silent about sensitive issues….” (I6).

Another event that brought attention to social harm was the broadcasting of programs and documentaries on the subject. After years of neglect, television networks began to focus on social harm, and their coverage attracted the attention of the public and policy-makers alike.

“In the 1990s, we had very good documentaries on social harm, such as Hell but Cold and Days without Calendars. These programs won prizes, but they were never broadcast on TV. They addressed issues such as adolescents, child labor, divorce, addiction, etc.; however, they were not aired on TV. In 2000, the media atmosphere improved, and as social problems continued to increase, a documentary called Shock was broadcast on TV. It was then understood that people must be made aware of these issues, demand change, and even help policymakers.” (I9).

Feedback

Regarding feedback, we can mention two points. The first one is that the feedback proposed about the Education Organization in different meetings, including the shared meetings with the Ministry of Health and the Social Council of the Country, showed a lack of satisfaction with the performance of the Education Organization in preventing the harm. An interviewee stated:

“The representative of Judiciary told him (the Education Organization) that their performance is satisfactory, but he did not know why their Correctional centreFootnote 1 and prisons are exploding!” (I11).

The second issue in this regard is the feedback provided by organizations to higher officials. Most of the interviewees believed that one of the reasons for the worsening problems in adolescents is the secrecy and censorship of events by organizations, as they are concerned about being accused of negligence. “one of the reasons for worsening problems in adolescents is the secrecy and censorship of events by organizations. These organizations are often concerned about being accused of negligence, so they only report their successes to upstream officials and withhold information about problems. As a result, problems continue to grow secretly and unchecked, until they become too big to ignore.” (I19).

Policy stream

The policy stream refers to policy solutions and alternatives for solving significant problems. Generally, the policy stream about these behaviours and other social harms, from the beginning of the Iranian revolution until now, included two approaches: denial and acceptance.

During the denial period, policy-makers denied the existence of the problem and attributed all social harms and events to cultural invasion. Therefore, policy-makers considered the occurrence of these behaviours to be the consequence of western culture. The policies during this period were based on emphasizing the religious aspects of behaviours, resisting the prevalence of anomalous behavioural patterns, showing the negative effects of western vulgar non-ethical culture, promoting abstinence and emphasizing the legal and religious obligation to consider chastity and avoid ethical corruption.

During the acceptance period, different programs and solutions were proposed by various organizations to address the issue of social harms. Despite the range of programs proposed, all focused on life skills, social empowerment, parenting styles and increasing awareness among parents and education staff regarding high-risk behaviours. Fear messages targeting those over 15 years of age were also employed to prevent high-risk behaviours such as drug and alcohol abuse, and in cases where adolescents were struggling with substance abuse, they would be referred to a psychiatry centre for withdrawal. In the case of high-risk sexual behaviours, the abstinence approach was the dominant strategy adopted. Although the Ministry of Health proposed policy to provide training about sexual issues and pregnancy health in schools, it was not well received. “We deny the existence of sexual topics greatly. The truth is that there are many instances of sexual relationships before marriage. In a study that has not yet been published, the numbers regarding sexual behaviours before marriage were quite high; however, we believe that the numbers are even higher in reality because it was a self-declaration study. In the general public, we think that the statistics are even higher, but we do not talk about it, and we haven’t talked about it for years. For instance, we have observed a changing pattern of HIV transmission from drug injection to sexual transmission, while some days ago, I heard on TV that HIV transmission in Iran only happens through drug injection. Denying the existence of this issue is a big mistake….” (I36).

The interviewees suggested that there is no distinct boundary between denial and acceptance in Iran’s approach towards high-risk behaviours. They emphasized that this issue is significantly impacted by the political party in power during each period. Some parties acknowledge the problem and implement policies based on acceptance and problem-solving, while others choose to deny the issue and implement policies based on denial. “We cannot definitively say that we have moved past the denial period. While the situation has improved compared to the past, it still heavily depends on the political party in power in Iran. It’s like a cycle; sometimes we deny and keep the problems hidden, and then the issues are brought to the forefront by a political shift, and we enter an acceptance period.” (I42).

Politics stream

The global attention towards non-communicable diseases and high-risk behaviours, along with their significant impact on community health, has led to officials of the Ministry of Health seeking solutions to address these issues. Furthermore, the special attention given by organizations such as the United Nations Children’s Emergency Fund (UNICEF), WHO, and the United Nations Program on HIV/AIDS (UNAIDS) to the changing pattern of AIDS transmission in Iran, with signs of an increase in HIV sexual transmission, has caused serious concerns for the Ministry of Health officials. This has led to fears of the beginning of the third epidemic wave, i.e., the HIV sexual transmission epidemic in Iran. On the other hand, Iran’s supreme leader proposed a national division plan to the Ministry of Interior in the domain of social harm management. He determined five priorities to solve the problems, among which addiction, drug abuse and ethical corruption were mentioned. He demanded all organizations try an organized, scientific and integrated way to prevent social harm. The order of the supreme leader, as the highest political position in Iran, caused an appropriate opportunity for all relevant organizations to be more involved in reducing social harm. Some involved organizations in this regard included the Education Organization, Welfare Organization, Judiciary, Anti-Narcotics Headquarters, police force and Ministry of Health.

In 2013, the Ministry of Interior, in collaboration with the Ministry of Health and other organizations involved in the prevention, therapy and reduction of alcohol harm, established the National Committee for Prevention and Control of Alcohol. This committee played a vital role in creating the National Document of Prevention, Therapy, Reduction and Rehabilitation of Alcohol Harms, which provided a framework for actions against alcohol abuse and defined the roles and responsibilities of various organizations involved in addressing this issue. The Ministry of Health, Ministry of Education, Anti-narcotics Headquarters and Judiciary were the main policy entrepreneurs that benefited from this framework and set policies primarily focused on prevention.



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