It Takes Two to Tango: A Critique of the Health Belief Model

INTRODUCTION

A sexually transmitted infection (STI) is a disease or infection spread from one person to another through direct or indirect sexual contact [examples include hepatitis B, syphilis, gonorrhea, Chlamydia, genital herpes, HIV, and AIDS] (1). Over the years, the frequency of sexually transmitted diseases has increased especially in adolescents. Each year, roughly 19 million STI’s are diagnosed of which almost half occur in young adults aged 15 to 24 (2). In 2006, individuals aged 13-24 accounted for 14 percent of newly diagnosed HIV/AIDS cases in the United States (2). Many sexually active young adults are inconsistent in their condom use putting them at risk for acquiring an array of STI’s. In 2007, it was reported that 39 percent of high school students did not use condoms during their sexual encounters (2). Throughout the years, public health practitioners have applied numerous approaches to address sexual practices in young adults. One such intervention employed the health belief model in improving condom use among adolescent females; however, improvements could be made to this intervention to make it more effective.

In the Orr et al intervention, researchers applied an intervention grounded in the health belief model. The intervention was designed to address the attitudes, beliefs, and skills of female individuals that influence male condom behaviors. Prior to the intervention, researchers assessed study participants using a questionnaire measuring their condom practices, sexual behavior, attitudes and beliefs, sociodemographics, motivation at enrollment and follow-up, and cognitive complexity (3). The intervention consisted of educating women on the seriousness of STI’s and their perception of vulnerability to them and in ways to negotiate condom use with their partners (3). Women were asked to return six months after the intervention to retake the questionnaire and to obtain Chlamydia cultures as means of testing the effectiveness of the intervention (3).

The health belief model is often used in public health interventions because it encompasses the attitudes and health beliefs that influence an individual’s behavior. In an attempt to better predict a person’s behavior, the model takes into account the individual’s perceived susceptibility to acquiring a disease, the severity of becoming ill, the benefits of altering the behavior, and the barriers associated with adopting the less risky behavior (4). Researchers can then use the information gathered from the model to create an intervention to illicit a behavior change. When the benefits of the behavior alteration outweigh the potential consequences of no change, it is more likely the purposed behavior change will occur (4). By assessing an individual’s attitudes and health beliefs with the model, researchers can create and implement an intervention framed in the health belief model that can result behavior change.

The Orr et al intervention utilizes the health belief model to tailor an educational intervention to increase condom use in females. The researchers focused on the beliefs, attitudes, and skills that influence male condom behavior, all of which are some of the key components of the health belief model. To understand these components, the investigators administered a questionnaire asking participants about their beliefs, attitudes, and perceived susceptibility to STI’s. The researchers assessed participants before and after the educational intervention to determine whether a behavior change took place by educating women in these particular areas of the health belief model instead of all its components.

While the health belief model is useful when applying interventions to certain populations and issues, it is not always the most appropriate model to use and is, in fact, unsuitable for some health outcomes. One problem with the model is its assumption that people think through what they are doing prior to actually doing it when oftentimes they think about it after the fact. Years of behavioral change research has revealed that belief formation does not always precede behavioral change and may actually follow it (5). Additional drawbacks of the model include its lack of consideration for the irrationality behind most decisions and its neglect in accounting for any spur of the moment decision making. Previous critiques of the model state its over-emphasis on people making planned, rational decisions (6). These critiques also state that people do not just weigh the risks and benefits associated with each decision when there are other conceivable reasons for making a decision other than these factors (6).

Another critique of the health belief model is that it overlooks the influence social norms and an individual’s morals and values have on a person behavior. Opponents of the health belief model state that when it comes to making healthy life choices, health beliefs are often in competition with other outside attitudes and beliefs that effect behavior (5). An additional downside to the health belief model is that it does not account for the effect a group can have on an individual’s behavior. These issues with the model focusing only on individuals and not groups and its lack of including the irrationality and external factors involved in decision making lend to the ineffectiveness of the Orr et al intervention.

CRITIQUE I

As previously mentioned, the health belief model does not take into account group relationships and since the Orr et al intervention uses this model, it is also a pitfall of this intervention. Generally, sexual encounters involve two people both of whom influence whether or not a condom when the moment of intimacy arises. The Orr et al intervention focused on increasing the use of male condoms during sexual encounters by applying an educational intervention to only females. The Orr et al intervention is not as effective because sex involves more than one person and is often riddled with power inequalities.

The health belief model is an individual level model but condom use involves both partners and not a single person. It is more appropriate to direct an educational intervention to both people involved in the behavior rather than just one. Targeting only one partner and expecting him/her to relay the information to the other person will not yield in a successful outcome. Various studies regarding adolescent sexual behavior and condom use have illustrated this inefficiency through revealing that a person may not push the topic of condom negotiation because of his/her partner’s reaction to the topic (7). If a person is already worried about how his/her partner will react to condom use, then it is highly unlikely that person will want to teach their partner about the sex education he/she received for fear of an adverse reaction. Therefore, to create a larger impact on condom use in young adults, interventions should be applied to both partners to deter negative reactions regarding prophylactic use in hopes of increasing the likelihood of condom use being discussed.

It is crucial to think of both people involved in the sexual relationship especially since young adults’ views on condom use change with the type of relationship in which they are involved. Relationships are no longer viewed as simply dating or not dating but instead seen as “steady, casual/friends, and ‘one-night stands’” (8). One common belief among adolescents is that if they are in a steady relationship then condoms are not needed (9). This view changes with the type of relationship adolescents are involved. To study perceived notions on condoms in relationships, adolescents were given questionnaires asking about their thoughts on condom use and sexual partner type. Results of the study disclosed that condoms are used more often during sexual encounters with anonymous partners, less often with casual partners/friends, and even less frequent with steady partners (8). It is important to consider the type of relationship and the number of partners when designing and applying a condom intervention because these often play a role in condoms being used.

Additionally, the intervention does not account for relationship inequalities that could affect condom negotiation. Relying on the female to use the intervention to negotiate condom use does not guarantee a condom will actually be used especially if the overall quality of the relationship is poor. Controlling behaviors and power inequalities within a relationship play a large role in condom negotiation (10). One study looked at the concept of relative power in adolescent sexual relationships and condom use. Researchers discovered that adolescents with more power were more inclined to get their way about condom use than those with less power (11). The study also reported that young men felt they had more emotional intimacy power over their partners and, thus, had more power when it came to decision-making in the relationship (11). The issue with power inequalities in relationships is further exacerbated when there is an age difference between partners, which can make condom negotiation more difficult. In these relationships oftentimes, the female relies on the male for economic support making the approach of the topic more difficult (12). To breach this gender inequality involved in condom negotiation and to ensure increased condom use in relationships with power struggles, the intervention needs to be applied to both partners.

Relying on a single individual to implement an intervention in a relationship is not the best approach to bring about a behavior change. When developing an intervention around condom use, it is not only crucial to take into account relationship complexities but to also target all sexual partners because they significantly influence the likelihood of the intervention being used appropriately.

CRITIQUE II

As Gilman et al stated the health behavior model exaggerates the likelihood of people making planned, rational decisions. The Orr et al intervention also makes this assumption and presumes that adolescents are rational in their thought processes. The intervention also assumes that adolescents do not understand the inherent risks associated with their behaviors and attempts to educate them accordingly. Research, on the other hand, has shown that humans are very irrational, especially when it comes to making decisions. Additionally, research has shown that adolescents are generally aware of the risks associated with a behavior prior to performing it. The Orr et al intervention is incorrect in assuming a rational choice will be made by predominantly irrational people and that these people are unaware of the risks associated with their choices.

Human beings by nature are not rational creatures and adolescents are by far even more irrational than adults. Young adults are commonly subject to “intense, combustible emotions and unpredictable behavior,” a side effect of the hormonal changes they undergo during puberty (13). To add to this intensity and unpredictable nature, adolescents’ brains also undergo significant changes during puberty, which often affect the areas of the brain that make them more responsible (13). The incomplete maturation of these areas of the brain contributes to the risky, irrational life choices teenagers make during this time (13). Taking these factors into account, asking adolescents to apply a condom intervention while they are engaging in a highly emotional and hormonal activity does not seem like the most effective way of changing a behavior. Therefore, when it comes to decision making and trying to elicit a behavior change, a successful condom intervention should take into account some degree of irrationality.

The intervention further assumes adolescents do not understand the potential risks that may result from not using a condom when in truth they do. One study compared the differences regarding HIV/AIDS knowledge among college students in 1990 to those in school in 2005. Results showed students in 2005 were more knowledgeable about their risks and about HIV/AIDS in general but still took part in higher rates of risky behavior [higher use of recreational drugs and higher rates of oral sex] (14).

Research has also shown that decreased condom use in sexual encounters is not due to misunderstandings about the risks but actually due to the way condoms feel during sex. Many adolescents admit to not using condoms because they believe they reduce pleasure felt during sex (7). In a study from the Bradley Hasboro Children’s Research Center, 1,410 adolescents were assessed on their condom use. Two-thirds of the participants reported not using a condom during their last sexual encounter stating loss of sensation as one of the main reasons (15). Concentrating on teaching individuals about STI’s when education is not needed is a waste of time and effort that could instead be spent teaching adolescents about the various styles of condoms and the way to choose proper sizes. Ensuring that adolescents are informed about the types and correct sizing of condoms improves condom use among this group, especially if the uncomfortable feeling of condoms is associated with them not fitting suitably in the first place.

The Orr et al intervention assumes a level of rationality behind decision making that does not always exist. To fix this issue, a successful condom intervention must include a degree of irrationality and should be grounded in a social science model that accounts for this. Additionally, Orr and colleagues believe adolescents do not know about their risk of acquiring STI’s. While addressing knowledge is an important aspect of creating a health intervention assuming ignorance when none exists results in an inefficient program. The outcome of the Orr et al intervention would be greatly improved if these factors were taken into account.

CRITIQUE III

As Campbell et al stated a major issue with the health belief model is in how it overlooks outside factors that influence healthy life decisions. The Orr et al intervention does not account for the numerous reasons, like parental views, religion, culture, affordability, and availability, for not using condoms that are not components in the health belief model. Adolescents do not only think about their perceived susceptibility to STI’s, the severity of STI’s, and the benefits and barriers of using condoms but an array of other factors also influence their decisions. These outside forces significantly influence the likelihood of adolescents using condoms.

Parents’ religion, culture, and views on contraceptive use considerably influence their children’s decision to use condoms. Children raised in very religious households are more likely to not use condoms because of these religious beliefs. One study looking at the association between religious affiliation and condom use showed decreased use with more conservative religions (16). Additionally, parents’ views influence adolescent condom use. Many adults do not condone the use of condoms and would rather enforce abstinence through punishment (9). This technique can either be very effective or scare adolescents into not using condoms during sex in fear of the ramifications. Additionally, some cultures place a stigma on females carrying condoms and will label them promiscuous for attempting to protect themselves (9). Women will not want to take responsibility for their sexual safety by using condoms when they know they will be negatively branded. Since many adolescents live with their parents, they are subjected to these views on a daily basis.

Oftentimes, parents’ religion, culture, and views on contraceptives make it difficult for adolescents to approach their parents and discuss sex because they are afraid of the repercussions that may result. This lack of communication can lead to feelings of urgency to have sex while parents are out of the house. Consequently when the opportunity for young adults to engage in sexual activities at home arises because the parents are not home, many young adults do not use condoms considering it is a “waste of precious time” (9). If parents were more willing to discuss sex with their children, safer sex techniques might be utilized more often. A successful condom intervention could look into educating parents on ways to talk to their children and adolescents on ways to discuss the topic with their parents to improve safe sex practices among this impressionable cohort.

Parents’ views, religion, and culture make it difficult for them to purchase condoms so adolescents are unable to rely on them to supply their condoms. The availability and affordability of condoms play a large factor in the likelihood of young adults utilizing them (9). Most young adults do not have a source of income and are unable to purchase condoms as a result. Additionally condoms may not be easily accessible in stores making it more difficult for these adolescents to acquire them. Thinking about these external factors could improve the outcome for the Orr et al intervention especially if the researchers handed out free condoms in addition to providing the STI education.

Condom use in relationships is complex because numerous external forces influence a couple’s decision to use them. To improve the overall outcome of the Orr et al intervention, these factors need to be identified and addressed. Only by managing the parental influences in addition to the power affordability and availability have on condom use will the outcome for Orr and colleagues intervention be improved.

IMPROVED INTERVENTION

While the health belief model is often used in sexual health and STI studies, it may not be the most appropriate for this intervention. To increase the overall effectiveness of the Orr et al intervention, it must be grounded in a social science model that incorporates educating both partners, the irrationality behind most decision making, and the external factors that influence choices. One approach that could be used is the social-ecological model; however, some adjustments must be made to it. This particular model looks at not only the individual but also his/her relationships, community, and society (17). In addition to assessing these areas in improving this intervention, it is also important to tweak the original social-ecological model so it includes irrationality. Incorporating these components in the creation of a new model, named the social-eco-not-always-logical model, allows for a more accurate prediction of an individual’s behavior, which will more successfully elicit behavior change.

The social-eco-not-always-logical model uses a multi-tiered approach similar to the social-ecological model. This new model will assess the knowledge, attitudes, and beliefs on the individual, relationship, community, and societal levels similar to the approach the social-ecological model takes (17). In addition to looking at these characteristics in the groups of people within each tier of the model, the social-eco-not-always-logical model will also include the irrationality that is seen at each level. Assessing all of these areas in this model, could aid Orr and his colleagues in creating a more appropriate intervention that could target more people and result in a much larger behavior change.

Grounding the Orr et al intervention in the social-eco-not-always-logical model could significantly improve condom use among adolescents. This new model does not just look at the individual but also those around him/her and the location in which he/she lives. Looking at all of these components allows for the intervention to be administered to a broader range of people causing behavior change on a much greater scale.

Using this model means applying the Orr et al intervention to both males and females instead of females alone. Intervening on both sexes will greatly influence condom use by providing the proper education to all of the individuals involved in decision to use or not use a condom. To do this, study participants will be asked to bring in their partners and both partners will be asked about their attitudes, beliefs, and perceived susceptibility to STI’s via questionnaire.

Participants and their partners will then receive the educational intervention and be asked to return in six months to retake the questionnaire. At this time, Chlamydia cultures will also be obtained as means of testing the effectiveness of the intervention similar to what was done initially. Targeting both individuals in a sexual relationship will hopefully increase discussion about condoms and address any relationship inequalities that may exist.

The Orr et al intervention may be improved further through the social-eco-not-always-logical model because it allows for irrationality. As previously stated adolescents are not rational beings especially when it comes to sex. Taking this into account permits the researchers to address this in the new intervention resulting in an increase in condom use. When providing the education, researchers should remind the couples that no matter how intense the moment gets there is always time for them to stop and use a condom. This concept should be stressed throughout the intervention so study participants remember the next they engage in sex. Constantly reminding both partners will help ensure that at least one of them will insist on using a condom.

The social-eco-not-always-logical model also looks at an individual’s relationships, community, and society and the affect they may have that person’s decision making. Accounting for influence outside factors, like cost, availability, parents, religion, and community, researchers can modify their intervention to address these additional issues. The education should include a list of local establishments in which adolescents can go to receive free condoms, like a local Planned Parenthood or nearby health clinics. Additionally, researchers need to continuously state the importance of protecting oneself from a STI no matter what parents, religion, and the community think.

Depending on the community in which this intervention is applied, the weight parents, religion, and social stigma play on an individual may be greater than expected. If this is the case, a separate education will be given to the community providing statistical data on the number of sexually active adolescents, the rate of STI’s among them, and the prevalence of condom use. This public intervention will focus on the importance of protecting adolescents from STI’s by supplying them with condoms should they choose to be sexually active. This intervention will receive plenty of negativity; however, it is important that those using the intervention remind parents and the community that some STI’s cause permanent injury or are incurable.

Researchers should also add that if adolescents decide to have sex, then it is better to provide them with the proper resources so they can at least be safe about their decisions. Educating the public will cause behavior change on the relationship, community, and societal level allowing for a wider acceptance of the intervention and helping to ease the influence parents have over adolescents condom use.

Grounding the Orr et al intervention in the newly invented social-eco-not-always-logical model allows for change to occur on multiple tiers simultaneously while also addressing a myriad of other factors that affect adolescents’ decision to use condoms. Accounting for these numerous influences by use of the model will result in behavior change among adolescents about condoms.

CONCLUSION

Overall, providing any educational intervention to adolescents at risk of making poor choices when it comes to condom use is better than not offering one. The Orr et al intervention is useful because it supplies some individuals with the right knowledge in hopes of them making a behavior change. However, the intervention is faulty because it is so heavily based on the health belief model. Using this model, people are only assessed on their beliefs, attitudes, and perceived susceptibility to STI’s and not on the various other factors that influence decision making like sexual partners, power inequalities, irrationality, parental views, religion, and culture, and the affordability and availability of condoms. Expanding the model the intervention is based on so that it assesses a wider array of potential influences will result in an even more successful outcome and reduction in the occurrence of STI’s in adolescents.

The Orr et al intervention could be improved through the application of the social-eco-not-always-logical model. This new model assesses the knowledge, attitudes, and beliefs of the individual and the people on the relationship, community, and societal levels that sway the individual’s decision making while also taking into account the irrationality that occurs on each tier. Looking at the potential influences the people on each of these levels contributes to the individual’s decision making would allow Orr and his colleagues to impact more adolescents with their intervention resulting in behavior change around condom use on a much larger scale.

REFERENCES

1. World Health Organization. Sexually Transmitted Infections. World Health Organization. http://www.who.int/topics/sexually_transmitted_infections/en/
2. Centers for Disease Control and Prevention. Sexual Risk Behaviors in Adolescents. Atlanta, GA: Center for Chronic Disease Prevention and Health Promotion, 2008. http://www.cdc.gov/HealthyYouth/sexualbehaviors/index.htm
3. Orr, D. et al. Behavioral Intervention to Increase Condom Use Among High-Risk Female Adolescents. The Journal of Pediatrics 1996; 128: 288-295.
4. Centers for Disease Control and Prevention. The Health Belief Model. Atlanta, GA: Center for Chronic Disease Prevention and Health Promotion, 2007. http://www.cdc.gov/std/Program/community/9-PGcommunity.htm#health
5. Campbell, C. Health Education Behavior Models and Theories – A Review of the Literature – Part I. Mississippi State University, 2001. http://msucares.com/health/health/appa1.htm
6. Gillam, S., et al. Understanding the Uptake of Cervical Cancer Screening: The Contribution of the Health Belief Model. British Journal of General Practice, 1991; 41:510-513.
7. Brown, L., et al. Condom Use Among High-Risk Adolescents: Anticipation of Partner Disapproval and Less Pleasure Associated with Not Using Condoms. Public Health Reports, 2008; 123: 601-607.
8. Ellen, J. et al. Types of Adolescents Sexual Relationships and Associated Perceptions About Condom Use. Journal of Adolescent Health, 1996; 18: 417-421.
9. MacPhail, C. et al. “I Think Condoms Are Good But, Aai, I Hate Those Things:” Condom Use Among Adolescents and Young People in A Southern African Township. Social Science & Medicine, 2001; 52: 1613-1627.
10. Manning, W. et al. Relationship Dynamics and Consistency of Condom Use
Among Adolescents. Perspectives on Sexual and Reproductive Health, 2009; 41: 181-190.
11. Tschann, J., et al. Relative Power Between Sexual Partners and Condom Use
Among Adolescents. Journal of Adolescent Health, 2002; 31: 17-25.
12. Longfield, K., et al. Relationships Between Older Men and Younger Women:
Implications for STI’s/HIV in Kenya. Studies in Family Planning, 2004; 35: 125-134.
13. Wallis, C., et al. What Makes Teens Tick: A Flood of Hormones, sure. But Also A Host of Structural Changes in the Brain. Can Those Explain the Behaviors that Make Adolescents So Exciting – and So Exasperating? Time Magazine, 2 May 2004. http://www.freewebs.com/ssterry/WhatMakesTeenagersTick.pdf
14. Teague, S. Perceptions of Vulnerability to HIV/AIDS: A Comparison of Two
College Cohorts, 1990 and 2005. AIDS Education and Prevention, 2009; 21: 526-537.
15. Lescano, C., et al. Condom Use with “Causal” and “Main” Partners: What’s in a
Name? Journal of Adolescent Health, 2006; 39: 443. e1-443. e7.
16. Agha, S., et al. The Effects of Religious Affiliation on Sexual Initiation and Condom Use in Zambia. Journal of Adolescent Health, 2006; 38: 550-555.
17. Bertrand J.T. Understanding Risk and Behavior: a Socio-Ecological Model. Baltimore, Maryland: Center for Communication Programs Johns Hopkins University.