Assessment on the effectiveness of the AIDS Risk Reduction Model - Paolo Chanes-Mora

The AIDS Risk Reduction Model (ARRM), an approach to reducing AIDS, is one of several social and behavioral models to reduce the ever growing impact of HIV/AIDS. ARRM is grounded in several health behavior theories including the, Theory of Planned Behavior, Health Belief Model and the Transtheoretical Model. These three theories are flawed because they treat problems as if they existed in a vacuum when in reality they are complex and multidimensional. As a result of being based on these three models ARRM suffers similar weaknesses. ARRM does not take into account that individuals will not change just because they are shown their susceptibility, and severity, of a health issue, that fact that planning to change a behavior does not always translate to behavior change, and it heavily depends of the use of arbitrary stages of change. ARRM is a weak model to target the HIV/AIDS population and several adjustments and changes would benefit this model.
The Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS) have created a pandemic that takes approximately 2 million lives a year, with nearly 3 million new infections yearly (1). HIV/AIDS impacts many demographic areas and it is important to develop a specific approach to truly make an impact in risk reduction. College campuses, state health officials, and grassroots programs are investing time and resources to implement effective models that will reduce the infections of HIV/AIDS. There are multiple available models, interventions and approaches to decrease HIV infections and improve awareness, some of which have been proven to work better than others. ARRM is one several models that can benefit from change in order to have a greater impact.
ARRM focuses on reducing the spread of AIDS. It aims to explain and predict the behavior change of individuals in relation to the sexual transmission of HIV/AIDS (2). The approach is based on the Health Belief Model (HBM), Theory of Planned Behavior (TPB) and the Transtheoretical Model (TTM). It is composed of three stages: 1) recognition and labeling of one's behavior as high risk, 2) making a commitment to reduce high-risk sexual contacts and to increase low-risk activities, and 3) taking action. The last stage, taking action, is broken into three more steps: 1) information seeking, 2) obtaining remedies and 3) enacting solutions (2).
In stage one of ARRM, the individual is supposed understand susceptibility through education about the severity of sexual activities associated with HIV transmission, believe that he/she is personally susceptible to contracting HIV, believe that having AIDS is undesirable and learn about social norms and networking (2).
Stage two examines the cost and benefits of risky behavior. It takes into consideration enjoyment, response efficacy, self-efficacy, knowledge of the value of good health and enjoyability of a sexual practice, as well as social factors (2).
Lastly, in stage three social networks and problem-solving choices come into play. It includes prior experiences with problems and solutions, level of self-esteem; resource requirements of acquiring help, ability to communicate verbally with sexual partners, and sexual partner's beliefs and behaviors (2).
The Health Belief Model is the fundamental theory driving the three stages of ARRM. The HBM, one of the oldest and most commonly used models in public health, is one of several individual based theories (3). It relies on perceived susceptibility, severity, benefits and actions, and barriers to taking the action. Also, It takes into consideration the degree to which a person feels at risk for a health problem, the degree to which a person believes the consequences of the health problem will be severe, the positive outcomes a person believes will result from the action, the negative outcomes from the action, an external event that motivates a person to act, and a person’s belief in his or her ability to take action (3). Exactly because of several of these approaches in the HBM, that exists in ARRM, make ARRM weak because not everyone who is aware of their risk to HIV/AIDS will want to change their behavior
The TPB is also a core theory of ARRM. Like the HBM, TPB focuses on rational decision-making, and planned behavior. This theory believes that a person’s attitude towards a specific behavior, and their perception of the subjective norms associated with that behavior are the driving force to initiating, or not initiating, a new behavior (4). The TPB extends on the HBM to include social norms and acceptance by others due to the change, or lack of change, in the behavior. Though, this theory is also not strong enough to make ARRM change a behavior and move from planning to actions. The TPB still does not allow for ARRM to be a successful approach to risk reduction due to that fact that planning to change a behavior does not always translate to behavior change.
The TTM proposes that individuals move through a series of motivational stages before achieving the desired behavior. For ARRM the desired behavior change is the risky behavior (5). The five stages of change are precontemplation, in which an individual shows no intention to adopt the health behavior; contemplation, in which an individual shows awareness of personal risk and the need to change; preparation, in which an individual expresses intention to change; action, in which an individual has actively adopted the behavior for a period of less than six months; and maintenance, in which the behavior is sustained for more than six months. At each stage emotional, cognitive, and behavioral processes promote moving to the next stage. Behavioral change can be made by the use of intervention strategies customized to an individual’s stage of readiness to change (6). In addition, a person can move in various ways through this model and do not need to follow a linear transition (5). However, when this theory is applied to the ARRM risk reduction is less likely to work because people don’t always directly fall into these categorized stages and would probably benefit more from individualized approaches
Stage one of ARRM which follows closely the beliefs of the HBM, require a person to understand knowledge of sexual activities associated with HIV transmission, believe that one is personally susceptible to contracting HIV, believe that having AIDS is undesirable and learn about social norms and networking. While in theory this knowledge would lead a person into stage two, weigh the health costs and benefits, it does not always work this way. If a person has multiple partners and is at a much higher risk of contracting HIV/AIDS but enjoys having unprotected sex, they are unlikely to be willing to change their behavior by just someone exposing them to the information. Salazar, in his literature review agrees that in multiple studies perceived severity was of low significance, particularly as it related to preventive health behaviors (7). In addition, it has been stated the HBM, in which ARRM is grounded in, has contributed to the limited understanding and the devaluation of individuals which can easily be applied to those seeing risk reduction practices (8). If an ARRM practitioner believes that based on such implications, as just spreading knowledge to a person, the individual will want to stop risky behavior, it can be seen how indeed the model does add to the limited understanding and devaluating individuals. It is not that simple, the individuals the ARRM is targeting are dynamic, and ever changing, not static and predictable as it is proposed by the model.
Also tied to the BHM, ARRM’s first stage, as Kyung-Hee describes it, is a stage of labeling (9). The risk reduction is meant to occur by labeling the risky behavior with the new information that has been presented regarding the health benefits. However, labeling can be different from individual to individual. There is not a set standard, nor can there be an assumption, that with labeling an action based on presented information it will lead to the desired behavior change.
The assumption in the TPB that planning behavior change leads to the desired behavior change makes ARRM weak. It assumes that behavior is a result of rational decision-making, and that behavior is done in a mechanistic order (6). It does not take into consideration instincts of sudden emotion, habits, income, education level, and other demographic characteristics (6). ARRM assumes that one’s intentions are an immediate determinant of behavior (7).
Further explaining the TPB, Kyung-Hee studies the connection made by ARRM in planning and actually changing behavior in his studies of Asian males who have sex with males (MSM). The subjects who did not practice safe sex, was not because they didn’t plan to use a condom, nor because they didn’t know about their risky behavior. The reasons included, not wanting to show their sexual status in order to avoid community stigma, bringing shame to the family and disappointing parents. MSM is a very high risk population because as explained, they are led by sexual urges and seek sex in a quick way that does not always allow them to use protection even if planned on it before hand (9). ARRM doesn’t take into consideration these outside influences that need to be targeted in the model to actually have significant risk reduction.
Stage three of ARRM, based on the TTM, reduces a person’s behavioral change into steps and heavily relies on the transitional stages, which makes the ARRM an ineffective model. People don’t always progress nor desire to progress in a straight line, as proposed by the ARRM, and can evolve a cyclical pattern of trying to stop, stopping and then beginning at another stage for several cycles (6). In addition, it is difficult to develop an arbitrary set of criteria to measure stages such as contemplation vs. maintenance, or maintenance vs. termination. Categorical placing can result in focusing on trying to figure out what stage the person is in rather than trying to focus on the intervention they should get (6).
West, R, adds that besides creating arbitrary categories and classifying individuals, the transtheoretical model ARRM is grounded on, presupposes coherent and stable plans will be made by the individual (10). Prior to engaging in risky sexual behavior one does not schedule a place and a time. People, who have multiple sex partners, do not always leave their homes scheduling appointments to have sex, nor whether or not they will be practicing safe sex. Many times it is spontaneous, impulsive, and a result of outside uncontrollable factors, and the TTM and ARRM leave no room for non-coherent and unstable plans.
The TTM is also heavily criticized as a type of scientific assessment used to appear capable of developing an intervention based on the needs of the individual (10). It is critiqued on the “soft” results it acquires, for example, going from precontemplation to contemplation, which according to West has no proven value (10). ARRM attempts to bring risk reduction in matter that fits its possible beneficiaries into boxes—stages they will most often not fit into.
To find the effectiveness of ARRM, and at the same time assess the HBM, TPB, and TTM that support the risk reduction model, an evaluation was created for both high risk seekers and low risk seekers. Risk seeking individuals were described as having impulsivity, disinhibition and engagement in problem behaviors. The study associated high risk seeking individuals with lower condom use, having multiple sexual partners, and not knowing their HIV status (11). The subjects in the study were asked to rank from 1 (strong disagree) to 4 (strongly agree), and answer yes/no questions to assess their risk level. The four main types of ranking questions asked were about perceived infection risk, AIDS knowledge, peer norms—mainly related to the HBM. Then there were yes/no questions asked about self-efficacy and intention to use condoms—TTM (11).
The results of the study showed that ARRM worked well for predicting condom use in both high and low risk seekers in this specific group of individuals. The two risk level groups achieved different levels of success depending on the ARRM stages of the study. For the high risk group, the leverage points were “prior condom use” and “self-efficacy.” Meaning stage two of ARRM, based on TPB, was not as useful to them. However, for the low risk seekers the leverage points were “previous condom use” and” intention to condom use,” and were the most important factors in their risk reduction. The low risk seekers leverage point demonstrates the importance of stage two for these individuals, and also further emphasizes how ARRM is not suitable for individuals of all risk levels (11).
As the results of Connor’s studies show, individuals in the ARRM do not always perfectly fit into the three stages of the model. Therefore, while a model might appear to be overall effective, it needs to be further analyzed and developed to find the stages that are relevant to the desired population. In ARRM specifically, and the three health belief theories need to be further developed to understand that knowledge of severity and susceptibility does not lead to behavior change, planning behaviors change does not always lead to action of the desired behavior change, and lastly that a person’s progress which is reduced into steps and heavily relies on the TTM stages might not apply and be effective to all people.
To improve these three main flaws in the health belief theories, and as a result in ARRM, there should be three major changes. First, the assumption in the HBM that perceived susceptibility and severity leads to behavior change needs to be dismissed. Rather, a new approach that show the benefits of engaging in good sexual practices needs to be developed; scare tactics usually don’t work. Second, environmental factors that can lead a person to change planned behavior, which are not included in the TPB, need to be addressed. Problems like not having access to condoms, cultural beliefs, income, and education level need to be addressed. Thirdly, a model that includes motivational progress, not one that will set a person in boxes as the TTM, will be most beneficial.
To dismiss the belief ARRM has that perceived susceptibility and severity leads to behavior change, safer sex practices should be made fun. For example, showing the individual who is about to engage in risky behavior and does not have a condom that there are multiple ways to still receive pleasure from a sexual activity that is less risky. Oral sex and several other methods of foreplay that do not involve sexual intercourse, and are still pleasurable, can reduce their risk level for contracting HIV/AIDS.
In addition to foreplay there are several “toys” such as dice, cards, and fun condoms that can be used in a campaign, or new approach, to show high risk users that being safe, even when caught in unprepared moments, can still be arousing and very pleasurable. This method of showing the positives will greatly steer away from ARRM’s way of showing scary statistics and information to try to show severity and individual’s susceptibility. As discussed in class with the childhood obesity campaign, showing parents the issue won’t change much. Better tactics are to show the positive outcome of the wanted behavior change.
In addition, by focusing on the positive results of safe sex practices, a new approach to stage one of ARRM, and the HBM, should be developed. The new approach should highlight that those who engage in low risk behavior have better communication skills. Partners who get tested for HIV prior to having intercourse, who talk about condoms usage, sexual transmitted diseases (STDs) and sexually transmitted infections (STIs) are able to have a healthier sexual relationship. These are the positive aspects risk reduction models like ARRM should focus on.
Secondly, as ARRM and the TPB wrongly assumes, planning behavior does not lead to change in risk reduction practices. A new successful approach would be to provide risk reduction opportunities. These opportunities should include established outreach programs that provide information about lubes, condoms, sexual health. Also the new approach to risk reduction should provide free HIV testing for couples and individuals who want to know their HIV status, and free STD/STI screenings.
Referrals to centers where women, and men, who want to engage in safer sex but are experiencing domestic violence, should also be available. Providing a support system will lead to higher chances of engaging in safer sex practices that will decrease their vulnerability to risky behavior. In addition, counseling should be provided for these individuals who do not have a say in the risky behavior they are involved in. If they need to leave an abusive partner temporary housing such as shelters should be available.
For individuals like the MSM discussed in Kyung-Hee’s study who were scared of their loved ones realizing their sexual conduct, there should be tactics such as group therapy to help them learn how to express their sexuality openly. Seminars and workshops to help those who have decided to change their behavior achieve it by providing the necessary skills to accomplish them would be a great environmentally inclusive as well as productive approach.
Lastly, to further be inclusive of environmental factors that can result in an individual who has planned to change their behavior carry out the change, cultural awareness and norms need to be considered. Since ARRM and the TPB do not consider these factors it has resulted in making them weak models. Cultural norms for many people define their behavior and if this important factor is ignored public health cannot expect planned behavior to result in actions that will reduce risky behavior.
To address the issue that ARRM, and the TTM, has with arbitrarily formed stages, new motivational and encouraging steps need to be formed. As mentioned by Edberg, people sometimes have a cyclical pattern, and can follow different steps in a non-sequential matter proposed by ARRM. Rather than trying to find what stage a person is in, ARRM and the TTM should develop a more individual approach to helping reduce risky behavior. Taking into consideration the environmental factors that make a person not follow through with their plans should be addressed. Another note made by West, is that “soft” results are not useful and steps such as precontemplation and contemplation need to be eliminated to develop an effective approach. Motivational and self-assessed changes are more successful than just trying to move someone from stage to stage (12).
These three recommendations would greatly benefit ARRM, and serve as a new approach to risk reduction. ARRM failed by being based on three models that were already flawed, that as a result made this risk reduction model even weaker. The model did not take into account that individuals participate in irrational behavior regardless of being shown the severity and susceptibility of the desired health change, that fact that planning to change a behavior does not always translate to behavior change, and it heavily depended on the use of the stages of change, which cannot be applied to all high risk individuals. HIV/AIDS interventions in general need to be more population and target specific and since HIV/AIDS does not occur in a vacuum and it involves relationships is should not solely be based on individual interventions. It is difficult to have strong model that tries to apply an approach surrounded only on the individual to a pandemic that is so complex. With a more population specific approach, a risk reduction program that includes the noted recommendations will be successful.

References


1. UNAIDS. AIDS epidemic update. 2009, November

2. Denison, Julie. Family Health International . 1996 . United States Agency for International Development., Web. 201Feb 2010. http://www.fhi.org/nr/rdonlyres/ei26vbslpsidmahhxc332vwo3g233xsqw22er3vofqvrfjvubwyzclvqjcbdgexyzl3msu4mn6xv5j/bccsummaryfourmajortheories.pdf

3. Beker MH, ed. The health belief model and personal behavior. Health education monographs.

4. Perloff. The dynamics of persuasion: communication and attitudes in the 21st century . 2nd. Mahwah, NY: Lawerence , 2003. Print.

5. Hacker, Karen Applying a transtheoretical behavioral change model to HIV/ STD and pregnancy prevention in adolescent clinics

6. Edberg M. Individual health behavior theories (chapter 4). In: Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007, pp. 35-49.

7. Salazar MK. Comparison of four behavioral theories. AAOHN Journal 1991; 39:128-135.

8. Thomas LW. A critical feminist perspective of the health belief model: implications for nursing theory, research, practice, and education. Journal of Professional Nursing 1995; 11:246-252.

9. Choi K, Yep GA, Kumekawa E. HIV prevention among Asian and Pacific Islander men who have sex with men: a critical review of theoretical models and directions for future research. AIDS Education and Prevention 1998; 10(Supplement A):19-30.

10. West R. Time for a change: Putting the Transtheoretical (Stages of Change) Model to rest. Addiction 2005; 100:1036-1039.

11. Connor, B. Are cognitive AIDS risk-reduction models equally applicable among high- and low-risk seekers? Personality and Individual Differences 2005; 38: 379–393

12. Adams, J. and White, M. (2003) Are activity promotion interventions based on the transtheoretical model effective? A critical review. British Journal of Sports Medicine, 37, 106–114.

Crash and Burn—A Critique of Anti-Tanning Public Service Announcements to Provide an Effective Melanoma Prevention Message-Susan Yanik

The haunting noises of clocks ticking, faint breathing and the sound of sizzling skin are some of the most provocative and memorable features of The Melanoma Foundation of New England’s video public service announcement titled “Tanning Is out, Your Skin Is In.” The ad features a young, white woman entering an indoor UV tanning bed lit like a carnival ride, and shows her skin beading with sweat, and the choppy shots of her body and the exterior of the tanning bed, which evokes a casket. Meanwhile, ominous statistics are flashed, stating the drastically increased risk of melanoma that results from indoor tanning, and the severity and growing threat of melanoma in teens and adults ages 15-29. The ad closes with the message “There is No Safe Tan—Tanning is Out, Your Skin Is In” [1]. If the purpose of this message was to nauseate and frighten viewers, this ad should be highly effective. However, it is clear that the Melanoma Foundation would want a multi-faceted advertisement, one that both discourages tanning and other risky behaviors, yet positively encourages safe sun practice, specifically sun-protection and early detection of melanoma. That said, the anti-tanning public service announcement by the Melanoma Foundation of New England (MFNE) and similar ones produced by the American Academy of Dermatology (AAD) [2] are flawed for a variety of reasons: the reliance on the Health Belief Model, a failure to target men and people of color, and it’s inability to deliver a positive message and practical solutions to combat the problem of melanoma.
To understand the need for effective sun protection messages, it is important to realize the dangers of early adulthood sun exposure and melanoma mortality. Melanoma is the most deadly form of skin cancer, and the most common form of cancer for Americans between the ages of 25-29 [3]. Melanoma is often fatal if allowed to spread, and approximately one American dies from melanoma every hour. However, if the melanoma is detected early, or before it spreads to the lymph nodes, the 5 year survival rate is about 99% [4]. Statistics from “Surveillance Epidemiology and End Results” (SEER) study from the National Cancer Institute state that the age adjusted incidence rate for melanoma was 20.1 cases per 100,000 men and women per year between 2003-2007 [5]. White men and women lead the annual incidence rates among the racial groups studied, with 29.7 per 100,000 men and 19.1 per 100,000 women, though blacks show about 1.0 incidence per 100,000 people, and incidences of melanoma among American Indians and Hispanics are about 3.9 per 100,000 people and 4.6 per 100,000 people, respectively. In addition, the trends in the rates of melanoma appear to be significantly increasing from 1975-2007 in men and women [6]. Studies have shown and overall worldwide increase in melanoma incidence, particularly in Australia and Western Europe, and often in the older male population in most countries [7]. Indeed, UV radiation is seen as a cause in at least 65% of melanoma cases [8] though other risk factors such as family history of melanoma, atypical mole syndrome (AMS) [9] and epigenetic factors, such as change in DNA methylation state [10] are proposed have a role in melanoma development.

Critique I: Use of the Health Belief Model

The anti-tanning public service announcements both serve to make viewers feel alarmed by the statistics presented and more aware of their vulnerability to melanoma. This design is part of the Heath Belief Model (HBM), used to explain and promote healthy, disease preventative behavior. The HBM was formulated in the 1950s by researchers from the U.S. Public Health Service, designed by breaking down health seeking behavior in four basic factors: 1) Perceived Susceptibility 2) Perceived Severity 3) Perceived Benefits of Taking an Action 4) Perceived barriers to taking an action [11]. The HBM has been in use since its creation, though over time various factors have been added to the model, such as “cues to action” (reformulated as the Social Learning Theory), and self-efficacy. The HBM was designed to confront the positive and negative forces in a person’s life, sway behaviors by encouraging steps away from negative decisions through emphasizing the perceived susceptibilities and seriousness of developing a condition in addition to the benefits of taking an action, while weighing the barriers to the action [12]. This model has been shown to be a relatively good predictor of individual level behaviors guided by an objective logical thought process [13].

While the model has been an effective tool in modeling behavior, its framework and attributes are not immune from criticism. The faults found in the HBM include its design as an individually-centered model, the assumption that health is a highly valued outcome among most people, its inability to account for spontaneous or irrational behaviors and reliance on likelihood and severity of beliefs as the only predictors of motivation [14]. Many studies have shown disadvantage of focusing on the individual, rather than the environment in model design, ignoring the social context and cultural norms of the society in which one functions [13, 15].Additionally, the HBM states that knowledge is considered to be gained only when an individual’s behavior has changed, which would fail to take into account the necessity for affective and cognitive portions of the learning process [16].
When the critiques of Health Belief Model are extended to the anti-tanning advertisements, many of the same problems still exist. The ads very effectively target two of the main HBM tenets, perceived susceptibility and severity, by describing the high incidence levels of deadly melanoma in the targeted age group. In the context of the model design, these are effective forces in pushing individuals away from a negative behavior towards a positive one. The trouble is, the positive benefits of not using a tanning bed are not explicitly stated. In addition, the perceived barriers to the behavior are also not mentioned in the public service announcements. While perhaps less applicable in a cessation message, barriers have been shown to be the most strongly associated variable in the model for sun protective practices, as shown in a study applying the HBM to relatives of melanoma patients [17]. Perhaps a more appropriate use of the HBM would be in a behavior adoption process, such as adoption of sun protective behaviors, whereby barriers to prevention and detection can be addressed.
Further addressing HBM use, an individually based anti-tanning model will appear less effective in a culture that praises tan skin, as shown by studies highlighting the importance of context and society on health behaviors [18]. Our current culture appears to place a high value on the appearance of tan skin, as evidenced by the approximately one million people visit who visit tanning beds on a given day [19], and about 28 million Americans have ever visited a tanning bed [20]. Sunbathing has been shown to be much more prevalent in adolescents whose social group, parents or friends also tan [21], a finding which may be harnessed in sunscreen adoption interventions.
Finally, the HBM is unable to account for spontaneous and irrational behaviors, including a spontaneous or infrequent desire to tan, which still may result in increased melanoma risk. People who tan for a special occasion or before going on vacation may not believe they are susceptible to an increased risk of melanoma, when a history of repeat (though potentially infrequent) sunburns and likeliness to burn is associated with developing melanoma as an adult [22, 23]. An example of irrational behavior is the finding that the majority of individuals who tan are those who have skin classified as “likely to burn”, but cite an appearance improvement as an impetus to tan [24].

Critique II: Failure to Target Men and Minorities

A meta-analysis examining 15 indoor tanning behavior studies in Europe and America found that girls are two to three times more likely to visit an indoor tanning bed than boys of the same age, and gender is a commonly controlled variable in studies of tanning bed users [21, 25]. A study reviewing melanoma epidemiology and trends found that in countries with high incidences of cutaneous melanoma, such as the US and Australia, the ratio of men and women developing melanoma is about equal, while in countries of low melanoma incidence, the rates of women diagnosed are higher than men [26]. Furthermore, the probability of men developing melanoma is 1:58, whereas the probability for women is 1:82, and men are approximately twice as likely to be diagnosed with melanoma between the ages of 60-79 [27]. A five year survival rate, calculated based upon relative survival in comparison to the general population showed a higher survival in women than men [6]. While melanoma development in men, especially in white men, is likely due to UV exposure, campaigns targeting UV exposure pathways other than tanning beds are needed to increase melanoma prevention and detection.
As previously stated, the melanoma incidence rates are higher for white men and women than Hispanic and Black minorities, but compared to Non-Hispanic whites, melanomas among minority populations are more likely to be detected at a later stage, and more metastatic, resulting in overall poorer health outcomes and decreased survival time [28]. Furthermore, the annual rate of increase among Hispanics in the US is 2.9%, nearly the same as the 3.0% increase seen in white non-Hispanics [6]. Many specific risk factors in non-white populations are still unknown, but research currently suggests that sun exposure may have less to do with melanoma in darker-skinned populations, due to the protective effects of increased skin melanin content, which is able to more efficiently scatter energy than lighter skin [29]. Additionally, high variation in DNA repair mechanisms within racial groups suggests the heterogeneous ability to control cellular mutations even within one race [30], while in vitro studies of melanocytes from blacks and whites showed that cellular melanin content can provide only partial protection from UV radiation [31]. Due to the different anatomical sites where primary melanoma tumors are found between minority populations and whites, in addition to potentially different exposure pathways to disease, melanoma has been seen as a heterogeneous cancer with potentially many underlying causes, one of which is UV radiation [29, 32].
However, as more studies are performed, understanding of behavioral and epidemiological risk factors for melanoma continues to increase. For example, it has been shown that African American men are four times as likely to develop melanoma than African American women [33], strikingly different than findings in whites. Additionally, a study of Hispanic high school students reported a perceived risk significantly lower than their white counterparts, and lower adherence to sun-protective behaviors [34], and Hispanics and blacks adults report full skin cancer screens less likely than non-Hispanic whites [35]. Together these findings suggest that the perceived risk for melanoma for Hispanics and blacks is lower among members in minority communities and health care providers.
Thus, because men and minorities are less likely to visit tanning beds, and because a large part of melanomas in minorities are found on areas of low sun-exposure, public service announcements focusing solely on the indoor tanning industry are flawed by missing a groups of people with increasing incidence rates of melanoma. By explicitly targeting the very specific demographic of tanning bed users (young, Caucasian women), the message may be lost on men and minorities, who arguably need the message as much as the white women. This failure to provide culturally and gender-specific messages about melanoma risk, prevention and detection is a major deficit in the anti-tanning melanoma prevention campaign.

Critique III: Failure to Promote Adoption of Preventative Behaviors and Melanoma Detection

In spite of previous sunscreen campaigns, and anti-tanning messages such the ones produced by the MFNE and AAD, one study showed that the rates of sunscreen usage among adolescents have only increased about 2% between the years of 1998-2004 [36], while melanoma incidences are increasing about 3% annually [6]. As previously discussed, the anti-tanning PSAs provide statistics to increase perceived risk and severity for their audience. Thus according to the message, the benefit to indoor tanning cessation is the potential to minimize mortality risk. While clearly important, it fails to remind viewers that there are other methods to decrease melanoma susceptibility, such use of sun screen and other sun protective practices, which should be utilized by all, not just indoor tanners.
Research shows that consistent sunscreen usage should be emphasized across genders and age groups. A study comparing daily sunscreen use with actual UV readings taken from personal monitoring devices found that women significantly applied sunscreen more frequently and on more high-risk days than males, while no difference was found in overall UV exposure between the genders [37]. The study also found that sunscreen was mainly used on days of high UV exposure, which is beneficial, but also implies that daily sunscreen use is may not be a common practice for many people. Sunscreen has been deemed an ideal sun protection measure, yet often times fail to protect against sunburn due to poor application practices [38], or sunscreen use before intentional suntan seeking behavior [39]. An effective melanoma prevention message ought to include encouragement not only for sun protective behaviors, such as use of protective clothing and limiting daytime sun exposure, but also include information on proper use of sunscreen.
Finally, the anti-tanning campaigns lack emphasis on early melanoma tumor detection and treatment, which are ultimately the most effective means in increasing survival time [40]. The ABCD mnemonic, a public health campaign developed in 1985 [41] is an effective tool used by both physicians and lay people in early detection of potential melanoma tumors and has since been augmented by the addition of “E” for evolving lesions [42]. However, physician performed or self performed skin evaluations are necessary to detect the tumors, though the exams are often unperformed by primary care physicians, due to lack of time or confidence in tumor diagnosis [43]. Approximately 24% of Caucasian adults in one study [44] performed a yearly self-skin evaluation, though this number is a far cry from ideal for a free, simple and life saving measure. A public service announcement attempting to decrease melanoma occurrence and increase survival time after diagnosis should surely mention sun protective behaviors and early detection practices, and the anti-tanning PSAs fail to do so.

Overview of Proposed Intervention: Advertising Theory

Tanning subgroups have been previously classified on the basis risk of developing melanoma after UV exposure, to better suit potential interventions [45]. For the purpose of this proposed intervention, three main groups at risk of melanoma will be targeted: the intentional tanners, the unintentionally exposed and the misinformed. The intervention will be guided by the principles used in the advertising theory. This model has been successfully used by marketers for decades, and is fit to replace the Health Behavior Model as a fresh way to appeal to the targeted groups, account for spontaneous decision making and effectively create a brand around healthy, protected skin. The foundations of the advertising theory lie in promises made to consumers, and assurance that the promises will be supported by the advertiser [46], or in this case, the melanoma prevention groups. The intervention builds upon the aforementioned flaws in the previous anti-tanning messages, and rather than addressing them in an outlined fashion, the intervention describes the new approaches needed for three distinct subgroups of the target population, and how this model enhances the former. The concept behind the proposed intervention lies on an overarching promise of healthy, beautiful and melanoma-free skin, and a disease free life. Instead creating a doom and gloom statistic-laden portrait of the tanning industry, the purpose of this intervention is to prevent melanoma by careful sun protection, and a behavioral shift away from tanning based on images of pure and natural beauty.

Intervention 1: Targeting Intentional Tanners

To maintain consistency with the originally anti-tanning messages, it is appropriate to focus on the same subgroup of people—those who intentionally tan and practice high-risk sun behaviors. Approximately 70% of the target audience would be Caucasian women in the 16-29 year old age group [47]. The intention is to brand the product of healthy, beautiful skin to these young girls, replacing the previous model of overly tanned skin. In public health branding, the relationship between consumer and public health sector is strongly valued [48], and in the proposed PSAs, the relationship between intentional tanner and the melanoma foundation should be more like one of mother-daughter or sister-sister, rather than a cold reading of didactic knowledge. The campaigns, which would be composed of a series of television and magazine ads would emphasize the true beauty that comes from natural skin. In this way, the campaign would also resemble the successful Green Movement in praising the natural, wholesome and peaceful [49]. These advertisements should feature photos and sketches of women of all skin tones, and relay the message that the most beautiful skin is healthy. The Skin Cancer Foundation provides a perfect example of a positive message with their “Go With Your Own Glow” campaign [50], using appealing images and endorsements by popular celebrities. A motto for this portion of the proposed intervention could read “Safe Skin is Sexy Skin”, in an effort to not only encourage protective behaviors, but also to attract the target audience to the ideals of beauty and appearance. Hopefully, with time and with enough social encouragement, the image of natural skin will be sold on the intentional tanners, and tanning bed use will become obsolete, especially in light of the added restrictions on tanning beds as recommended by the US FDA in March, 2010 [51]. This proposed intervention using advertising theory should be an improvement on the previous public service announcements constructed around the Health Belief Model through targeting of positive core values and lack of fear tactics in supporting the melanoma prevention message.

Intervention II: Targeting the Unintentionally Exposed

Selling sun safety to the general population, especially those who unknowingly experience UV radiation would be a huge step for the melanoma prevention program. Ideally, it would be advantageous to gather opinions from several groups at risk for melanoma, including adolescent males, adult males who appear to have the most rapidly increasing melanoma rates [6], and those who spend a large portion of their day outdoors. Ideally, these groups would provide feedback and elucidate the problems associated with sun protection and detection. The main intervention goal is to show sun protection as a current issue to maintain healthy skin in the present, rather than warn against the probability of future melanoma, which has reported as a barrier to motivation [45]. Not having feedback, it can be assumed that a main problem in sunscreen use arises from failure to apply adequate amount over a long enough time [38]. To counter the problem of sunscreen access, this section of the intervention would promote use of sunscreen in an affordable, easy to use and appealing vehicle. One possible idea would be to work with sunscreen manufacturers and produce sunscreen towelettes in age- and gender appropriate fragrances that can be purchased in a vending machine system at public beaches, outdoor concerts and festivals, where exposure to sun may be high. Also, to incorporate the core values of sexuality and attractiveness, the sunscreen adoption campaign could be advertised with pictures of adolescents applying sun screen to themselves and to others in a playful and engaging fashion. While this may not be the approach supported by family morality groups, it should definitely attract the attention of adolescent viewers. To target an older subset of the population, sunscreen use should still be emphasized in addition to advertisements showing fashionable sun protective clothing. It would be ideal for the melanoma foundation to partner with a clothing company to design appealing, wearable clothes that effectively block UV rays, and market them as sun-safe.
In this unintentionally exposed group, the message of detection is also extremely necessary. As mentioned in Critique III of the original intervention, rates of self-skin evaluations are not keeping pace with the melanoma incidence rate, and not helped by the failure of many primary care physicians in performing total body exams [43]. Therefore, a series of campaigns to promote self skin examinations (SSEs) are timely and could result in the detection of many pre-metastatic tumors. The American Academy of Dermatology coined the phrase “check your birthday suit on your birthday” [52], which is a clever and catchy message, though it does imply that checks should be performed only annually. It would be advantageous to design an advertisement extending the message of SSEs, and attempt to integrate them as part of a more frequent, monthly route, like paying rent and bills. Another example of a detection message could be targeted to people who spend recreation time outdoors, such as gardeners and golfers. One example of a slogan should show a picture of a gardener and state “If you leave no stone unturned, then why leave your skin unchecked?”

Intervention III: Dispel misconceptions and promote sun safe behavior in minority populations

Addressing a major criticism of the anti-tanning messages, culturally sensitive and specific messages are needed to dispel myths and provide African Americans and Hispanics with information regarding melanoma and preventative measures. As previously cited, Hispanic and black minorities have been shown to report a lower perceived risk of melanoma and are less likely to be screened for melanoma tumors at doctor’s office visits [34, 35]. The need for sun protective and early detection practices in minorities is more important than ever, with Hispanics becoming one of the fastest growing populations in the US [53], and in light with the increasing melanoma rates in the Hispanic populations [6]. An ideal campaign would be designed with feedback from members of the black and Hispanic communities, regarding approaches that are likely to appeal or repel the target audience. Without the input, a basic first step in designing melanoma prevention messages would use the format of embracing healthy natural skin, as shown in Intervention I. This proposed print/video public service announcement would show groups of people, including members of different ethnicities and genders, and promote the motto: “In all types of skin, healthy skin is the most beautiful.” This approach would target the core value of attractiveness and inclusion, and would help to raise awareness across racial groups. Furthermore, the unequal screen exams performed by physicians can be addressed with melanoma posters placed in doctor’s offices, reminding physicians to “Check all skin types at check-ins,” or a similar message to support total skin examinations in all patients. Finally, emphasis on culturally specific SSEs should be introduced, which would promote skin examinations of common anatomical tumor sites in darker skinned people, including arcral sites, such as feet and ankles. One static suggests that while 72% of melanomas are proximal the ankle in Caucasians, 90% are distal to the ankle in African-Americans [54]. Another potential intervention can show images of feet and stress the simplicity but importance in checking for potential tumors. These messages would be effective in dissolving misconceptions of no melanoma risk among minority populations, while giving a practical way to keep skin healthy.

References:

1. Melanoma Foundation of New England., Tanning Is Out, Your Skin Is In 2009. http://www.mfne.org/?page=mcpsas. Accessed 4/1/2010.
2. American Academy of Dermatology, Indoor Tanning is Out®, in Public Service Advertisements. 2010. http://www.aad.org/media/psa/index.html, accessed 4/1/2010/
3. American Academy of Dermatology Melanoma Fact Sheet. 2010 [cited 4/17/10]; Available from: http://www.aad.org/media/background/factsheets/fact_melanoma.html.
4. American Cancer Society., Cancer Facts and Figures. 2009: Atlanta, GA.
5. Altekruse, S. and e. al, SEER Cancer Statistics Review, 1975-2007. 2010 National Cancer Institute: Bethesda, MD.
6. SEER (2009) SEER Stat Fact Sheets--Melanoma of the Skin. Volume,
7. MacKie, R., et al., Melanoma incidence and mortality in Scotland 1979-2003. British Journal of Cancer, 2007. 96(11): p. 1772-1777.
8. Armstrong, B. and A. Kricker, How much melanoma is caused by sun exposure? . Melanoma Res., 1993: p. 395– 401
9. Haenssle, H.A., et al., Selection of patients for long-term surveillance with digital dermoscopy by assessment of melanoma risk factors. Arch Dermatol, 2010. 146(3): p. 257-64.
10. Rubinstein JC, et al., Genome-wide methylation and expression profiling identifies promoter characteristics affecting demethylation-induced gene up-regulation in melanoma. BMC Med Genomics, 2010 Feb(3): p. 4.
11. Edberg, M., Individual health behavior theories (Chapter 4), in Essentials of Health Behavior: Social and Behavioral Theory in Public Health. 2007, Jones and Bartlett Publishers: Sudbury, MA. p. 35-49.
12. Rosenstock, I., Historical Origins of the health belief model. Health Education Monographs, 1974. 2: p. 328-335.
13. Poss, J.E., Developing a new model for cross-cultural research: synthesizing the Health Belief Model and the Theory of Reasoned Action. ANS Adv Nurs Sci, 2001. 23(4): p. 1-15.
14. Salazar, M., Comparison of four behavioral theories. AAOHN Journal, 1991. 39: p. 128-135.
15. Choi, K.H., G.A. Yep, and E. Kumekawa, HIV prevention among Asian and Pacific Islander American men who have sex with men: a critical review of theoretical models and directions for future research. AIDS Educ Prev, 1998. 10(3 Suppl): p. 19-30.
16. Thomas, L.W., A critical feminist perspective of the health belief model: implications for nursing theory, research, practice, and education. J Prof Nurs, 1995. 11(4): p. 246-52.
17. Manne, S., et al., Sun protection and skin surveillance practices among relatives of patients with malignant melanoma: prevalence and predictors. Prev Med, 2004. 39(1): p. 36-47.
18. Marks, D., Health Psychology in Context. Journal of Health Psychology, 1996. 1: p. 7-21.
19. Whitmore, S.E., et al., Tanning salon exposure and molecular alterations. J Am Acad Dermatol, 2001. 44(5): p. 775-80.
20. American Academy of Dermatology., Facts about Indoor Tanning, Press Kit
American Academy of Dermatology, Editor. 1997, Schaumburg, IL.
21. Lazovich, D., et al., Characteristics associated with use or intention to use indoor tanning among adolescents. Arch Pediatr Adolesc Med, 2004. 158(9): p. 918-24.
22. Holly, E.A., et al., Cutaneous melanoma in women. I. Exposure to sunlight, ability to tan, and other risk factors related to ultraviolet light. Am J Epidemiol, 1995. 141(10): p. 923-33.
23. Whiteman, D.C., C.A. Whiteman, and A.C. Green, Childhood sun exposure as a risk factor for melanoma: a systematic review of epidemiologic studies. Cancer Causes Control, 2001. 12(1): p. 69-82.
24. Pagoto, S.L. and J. Hillhouse, Not all tanners are created equal: implications of tanning subtypes for skin cancer prevention. Arch Dermatol, 2008. 144(11): p. 1505-8.
25. Lazovich, D. and J. Forster, Indoor tanning by adolescents: prevalence, practices and policies. Eur J Cancer, 2005. 41(1): p. 20-7.
26. Garbe, C. and U. Leiter, Melanoma epidemiology and trends. Clin Dermatol, 2009. 27(1): p. 3-9.
27. Dao, H., Jr. and R.A. Kazin, Gender differences in skin: a review of the literature. Gend Med, 2007. 4(4): p. 308-28.
28. Byrd, K.M., et al., Advanced presentation of melanoma in African Americans. J Am Acad Dermatol, 2004. 50(1): p. 21-4; discussion 142-3.
29. Rouhani, P., S. Hu, and R.S. Kirsner, Melanoma in Hispanic and black Americans. Cancer Control, 2008. 15(3): p. 248-53.
30. Tadokoro, T., et al., UV-induced DNA damage and melanin content in human skin differing in racial/ethnic origin. Faseb J, 2003. 17(9): p. 1177-9.
31. Yohn, J.J., M.B. Lyons, and D.A. Norris, Cultured human melanocytes from black and white donors have different sunlight and ultraviolet A radiation sensitivities. J Invest Dermatol, 1992. 99(4): p. 454-9.
32. Curtin, J.A., et al., Distinct sets of genetic alterations in melanoma. N Engl J Med, 2005. 353(20): p. 2135-47.
33. Bellows, C.F., et al., Melanoma in African-Americans: trends in biological behavior and clinical characteristics over two decades. J Surg Oncol, 2001. 78(1): p. 10-6.
34. Ma, F., et al., Skin cancer awareness and sun protection behaviors in white Hispanic and white non-Hispanic high school students in Miami, Florida. Arch Dermatol, 2007. 143(8): p. 983-8.
35. Saraiya, M., et al., Skin cancer screening among U.S. adults from 1992, 1998, and 2000 National Health Interview Surveys. Prev Med, 2004. 39(2): p. 308-14.
36. Cokkinides, V., et al., Trends in sunburns, sun protection practices, and attitudes toward sun exposure protection and tanning among US adolescents, 1998-2004. Pediatrics, 2006. 118(3): p. 853-64.
37. Thieden, E., et al., Sunscreen use related to UV exposure, age, sex, and occupation based on personal dosimeter readings and sun-exposure behavior diaries. Arch Dermatol, 2005. 141(8): p. 967-73.
38. Diffey, Sunscreens: expectation and realization. Photodermatology, Photoimmunology & Photomedicine, 2009. 25: p. 233-236
39. Autier, P., M. Boniol, and J.F. Dore, Sunscreen use and increased duration of intentional sun exposure: still a burning issue. Int J Cancer, 2007. 121(1): p. 1-5.
40. Betti R, et al., Factors of delay in the diagnosis of melanoma. Eur J Dermatol, 2003. Mar-Apr;13(2): p. 183-8.
41. Friedman, R.J., D.S. Rigel, and A.W. Kopf, Early detection of malignant melanoma: the role of physician examination and self-examination of the skin. CA Cancer J Clin, 1985. 35(3): p. 130-51.
42. Abbasi, N.R., et al., Early diagnosis of cutaneous melanoma: revisiting the ABCD criteria. Jama, 2004. 292(22): p. 2771-6.
43. Torrens, R. and B.A. Swan, Promoting prevention and early recognition of malignant melanoma. Dermatol Nurs, 2009. 21(3): p. 115-22; quiz 123.
44. Kasparian, N.A., J.K. McLoone, and B. Meiser, Skin cancer-related prevention and screening behaviors: a review of the literature. J Behav Med, 2009. 32(5): p. 406-28.
45. Pagoto, S.L., et al., Sun protection motivational stages and behavior: skin cancer risk profiles. Am J Health Behav, 2004. 28(6): p. 531-41.
46. Ogilvy, D., How to Build Great Campaigns (Ch. 5), in Confessions of an Advertising Man. 1964, Atheneum: New York. p. 89-103.
47. Swerdlow, A.J. and M.A. Weinstock, Do tanning lamps cause melanoma? An epidemiologic assessment. J Am Acad Dermatol, 1998. 38(1): p. 89-98.
48. Evans, W. and G. Hastings, Public Health Branding: Recognition, promise and delivery of healthy lifestyles (Chapter 1), in Public Health Branding: Applying Marketing Skills for Social Change. 2008, Oxford University Press: Oxford. p. 3-24.
49. Galtung, J., The Green Movement: A Socio-Historical Exploration. International Sociology, 1986. 1(1): p. 75-90.
50. Skin Cancer Foundation, Go With Your Own Glow. 2010 [cited; Available from: www.skincancer.org/go-with-your-own-glow/.
51. Skin Cancer Foundation, FDA Advisory Committee Meeting to Review Tanning Bed Regulations, in For the Media. 2010, Skin Cancer Foundation: New York, New York
52. American Academy of Dermatology, Be Sun Smart (R) 2010 [cited 2010; Available from: http://www.aad.org/public/sun/smart.html.
53. Hu, S., et al., UV radiation, latitude, and melanoma in US Hispanics and blacks. Arch Dermatol, 2004. 140(7): p. 819-24.
54. Wanebo, H.J., J. Woodruff, and J.G. Fortner, Malignant melanoma of the extremities: a clinicopathologic study using levels of invasion (microstage). Cancer, 1975. 35(3): p. 666-76.

The Candie’s Foundation Campaign: A Flawed Approach – Sarah K. Clark

Overview:

Established in 2001, the Candie’s Foundation aims to educate teens about the devastating consequences of teenage pregnancy by promoting abstinence. All of the advertisements use celebrities and attempt to speak to teens on their own terms, with the hopes of influencing teen culture. Print advertisements have been placed in Seventeen, Vibe, The Source, Blender, Teen Vogue, J14, Elle, InStyle, and Cosmopolitan. Broadcast commercials have aired on ABC, NBC, CBS, Fox, ABC, and MTV. Candie’s has also made an appearance on a variety of websites, including AOL, MTV, The-N, MyYearbook.com, Seventeen.com, Black Planet, and perezhilton. The Candie’s Foundation has had more than 500 million media impressions in all major teen media outlets, but have they been effective? The following sections aim to prove that the campaign is greatly flawed and does not follow current public health theories, models and research.

Critique # 1: The Behavior Change Model/Theory

The first mistake made by the Candie’s Foundation is the use of the Health Belief Model to predict and influence their target audience’s behavior. The Health Belief Model is one of many rational belief models that assume human behavior is determined by an objective, logical thought process. It proposes that the likelihood that a person will take action concerning a health condition is determined by the person’s readiness to take action and by the perceived benefits of action weighed against the perceived costs or barriers (1). In the case of the Candie’s campaign, they hope to influence their target audience to rationally weigh the costs and benefits of having sex, ultimately deciding to choose abstinence.
Using this model, the individual must first determine how susceptible they are to getting pregnant. Since action will only occur if the individual believes they are highly susceptible, the Candie’s Foundation uses statistics such as, “more than 750,000 girls will become pregnant this year” and “more than 2,000 girls become pregnant each day”. Their hope is that by using large numbers, individuals will see themselves as being high risk.
Next, they want their audience to look at the severity of being a teen parent and how it would negatively impact their life. To demonstrate the severity, they show before and after images exemplifying how life as a teenager would change the minute one becomes a parent. In the new Bristol Palin commercial, they first show her nicely dressed, wearing pearls and in a well decorated, comfortable home. To demonstrate how life will change as a teen parent, they shift to a barren room, a disheveled looking Bristol Palin and the new baby playing on the floor. In the Teddy Geiger commercial, a brand new car transforms into a stroller, saying, “Not exactly what you had in mind for your first set of wheels, huh”. In another commercial with Ciara, a girl’s luxurious bedroom falls apart around her and becomes a baby’s crib after she partakes in sexual intercourse. Ciara then says, “Not really the way you pictured your first crib, huh”. The Candie’s Foundation wants the audience to perceive the results of becoming a teen parent as very severe and life altering.
According to the Health Belief Model, after determining susceptibility and severity, one determines the benefits of not having sex and then weighs these against the costs. This, however, is another area where the Candie’s campaign fails. It does not acknowledge the positive aspects of having sex or what one will lose by choosing abstinence. In a sense, it does not provide any costs, thus suggesting that abstinence should be a quick, no brainer decision. On the other hand, the campaign still suggests that the audience should make a rational weigh of costs and benefits, with the tagline, “pause before you play”. Ultimately, the idea is that if there is an intention to “pause”, it will lead to the desired behavior, abstinence.
There are a number of flaws in the Health Belief Model in general and in its use for the Candie’s campaign. For one, the Health Belief Model assumes that people always think rationally. This model “focuses on rational, intentional behavior and does not take into account the spontaneous activity that characterizes much of human behavior” (1). In the Candie’s campaign, it assumes people will weigh the costs and benefits of not having sex and then make the rational decision to “pause”. Humans, however, are not rational beings. Although a person may intend to do something, behavior does not always occur as planned, largely because of visceral and social influences. When it comes to abstinence, visceral influences may include the pleasure of sex, while social influences may include pressures from a significant other or feelings of embarrassment by saying “no”.
The absence of context is a large flaw of the Health Belief Model. Rosenthal stated that decision-making models, like the Health Belief Model, do not capture the essence of sexual risk-taking and that these behaviors need to be contextualized (2). This idea that we often forget about context and overestimate an individual’s knowledge and character has also been called the Fundamental Attribution Error. In addition, Thomas argues that the Health Belief Model views people as a collective group, depriving people of value and contextual meanings which are embedded in cultural practices, skills and languages. The model also lacks regard for sociopolitical and historical experiences (3). In terms of abstinence, this just shows that there are many variables that go into the decision of whether or not to have sex. The decision is not black or white, nor is it as easy as “pausing before you play”.
Finally, the last limitation of this model is the assumption that health is highly valued by most people and that when a “cue” about health occurs, individuals will likely act in a manner favorable to their health (1). In reality, other outcomes besides health may hold higher importance. In the field of public health, many people eat unhealthy foods because they enjoy the taste, despite that they know it is bad for them. In the case of sex, many teenagers partake in behaviors that they know are not in their best interest because of the pleasure, social acceptance or the emotions that come along with the physical action of having sex.

Critique #2: The Messages

A second error made by the Candie’s Foundation, is that the campaign uses negative statistics to tell their audience what not to do. On the print advertisements and television commercials, such statistics include, “more than 750,000 teenage girls will become pregnant this year”, “raising a baby can cost over $10,000 a year” and “almost every 2 hours for feeding time…if you choose to use formula, you’re looking at about $1,500 a year”. On the “Cry. Baby.” iPhone application, these include, “750,000 teen girls in America get pregnant each year – that’s more than 2,000 a day!”, “fewer than half of teen girls finish high school” and “the vast majority of teen parent couples don’t end up married – or even together!” These statements, although educating adolescents on the harsh realities of being a parent, do not connect with the audience on a more personal level. Instead, statistics are used to invoke fear appeals with the hopes of scaring adolescents away from having sex at a young age.
This strategy, although used by many public health professionals, is not effective. Evans and Hastings state, “One way that public health brands have in the past diluted themselves and lost trust is by delivering negative messages or invoking fear appeals about risky behaviors” (4). Most importantly, relying on negative statistics to elicit fear does not take optimistic bias into consideration. Weinstein (1980) describes optimistic bias as the idea that individuals rate the likelihood of an event happening compared to their peers, and thus believe that they are more likely to experience positive events and less likely to experience negative ones (5). Although the hope is that by using negative statistics and fear appeals, adolescents will decide to stay abstinent, in reality this will most likely lead to the thought, “a lot of teens get pregnant, but it won’t happen to me”. Instead of worrying that they are susceptible to an illness, or in this case may become pregnant, adolescents believe that they are somehow immune to an inclusion in the statistic. This optimistic bias or “perceived invulnerability” may result from distortions in assessing risk to self, a biased view of risk to others, or both (5).
In addition to the use of negative statistics, the campaign instructs the audience about what not to do. The message is clear, do not have sex or you may become pregnant. The campaign does not offer an alternative, just choose abstinence, period. This is evident from the print advertisements that state “sex can change everything”, to the branded t-shirts that state, “I’m sexy enough…to keep you waiting”. Other messages state, “be smart: you are too young to start” and “be sexy: it doesn’t mean you have to have sex”. The print advertisements state that the Candie’s Foundation is “providing information about the devastating consequences of teen pregnancy”, but when an interested viewer goes to the website for more information, and clicks on “learn”, they are just hit with a long list of facts and statistics. Like many other campaigns, the Candie’s Foundation spends so much time reiterating the “no sex” message that it fails to consider the perceived benefits of the behavior they are competing against – sex. The campaign does not offer any alternative behaviors, such as practicing safe sex with condoms or birth control, but instead attempts to elicit fear with an array of negative messages and statistics.

Critique #3: The Communicators

One of the most visible flaws in the Candie’s campaign is shown in who is delivering the message. All of the elements of the campaign appear to be directed towards the average teenage female. This is evident from everything including the hot pink/black look and feel, to the “Be Sexy” t-shirts, and all of the messages, images and statistics which aim to show what life is like as a teen mother. However, all of the commercials and print advertisements portray celebrities, most of which are no longer teenagers, only one which was pregnant as a teenager and a few that are even male. Celebrities include, Hayden Panettiere, Beyoncé, Fergie, Fall Out Boy, Ciara, Jenny McCarthy, Vanessa Minnillo, Ashley Tisdale, Hilary Duff, Ashlee Simpson, Usher, Rachel Bilson, and Teddy Geiger. These individuals live nothing like the audience they are speaking to and do not have any experience of what it is like to struggle as a teenage parent. They are speaking about something in which they have little to no knowledge and yet the Candie’s Foundation expects their target audience to listen. This choice in spokespeople contradicts social science theory which states that individuals have the best response to messages when they are delivered by people who are similar to them. Although celebrities may provide a recognizable face, the Candie’s Foundation did not choose their spokespeople appropriately if they wish to have their target audience respond favorably to the message.
One result that can occur from using a source that is so different than the target audience is psychological reactance. This theory, developed by Brehm and Brehm (1981), states that people believe they possess specific behavioral and cognitive freedoms and if those freedoms are threatened or eliminated, people experience psychological reactance, or the perception that the threatened behaviors or thoughts are more attractive and a desire to reestablish them (6). Silvia (2005, 2006a), who focused on the mechanics of threat, found interpersonal similarity between the communicator and target as a factor that mediates or even removes the effects of threat (and thus reactance). Similarly, when the person perceiving the threat is different from the person making the threat, reactance is more likely to occur (7).
Since advertisements are already intrusive by nature, it is important that the audience perceive the content within the advertisement as valuable. Only if the target audience perceives the content as valuable, will it be possible to keep their attention and increase the chances that they will retain the message. The less irritation and avoidance an advertisement elicits, the more value it will have. Ducoffe’s studies indicate that both information and entertainment are essential for communication exchanges between advertisers and consumers (8). Knowing that the Candie’s Foundation campaign interrupts regular viewing of television and print content, they should be making up for this interference with a spokesperson that the viewer can identify with and information that will be perceived as useful. Unfortunately, the Candie’s Foundation fails on both accounts and so has a strong chance of eliciting psychological reactance.

Intervention #1: The Behavior Change Model/Theory

The Health Belief Model, currently used by the Candie’s Foundation to influence behavior change, is flawed and outdated. This model assumes that people make rational decisions, plan their behavior in advance and operate only as individuals, without any influence from the outside world. In the Candie’s campaign, elements of susceptibility and severity are used to prove that the benefits of abstinence (not becoming a teen parent) outweigh the costs. The current campaign follows a traditional public health paradigm and attempts to appeal to the desire for health, or in this case not becoming a teen parent. However, as mentioned previously, this method is flawed. In order to improve the current intervention, a group model must be used. This allows for the opportunity to change the opinion of the masses, take visceral and social influences into consideration and use elements of irrationality.
Marketing theory, while originally developed for the consumption of products or services, can also be used to build brands for public health. In its original sense, Chisnall (1995) defined marketing as “the management process responsible for the identifying, anticipating and satisfying customer requirements according to the objectives of the organization'' (9). In public health, this means determining the deepest aspirations of the target audience, and then framing messages accordingly to influence healthy decisions. Similar to product brands, “public health brands can build relationships with audiences to encourage adoption and maintenance of preventive or health-promoting behaviors. Like commercial brands, they offer a brand promise, and typically ground their brand promotion in a ‘call to action’ that defines what the brand calls upon consumers to do” (4). In order to build a relationship, it is necessary to understand the target audience and then create a package that fulfills the audience’s wants and needs. In the Candie’s campaign, the target audience is teenage American girls. To appeal to this group’s core values, the campaign should focus on belonging, control and sex. It is recommended that through the use of these core values, the campaign move away from negative messages that tell the audience what NOT to do, to messages that empower girls to do what other girls their age are already doing: taking control of their own sex life. This leads to the ‘call to action’, which in this case is taking ownership for the purchasing, carrying, and using of condoms, for each and every sexual encounter. The recommended brand tagline, “Do It for You”, captures the essence of the brand promise: take control of your sex life and promise yourself a brilliant future.
Public health brands can also go beyond the immediate, practical benefits of the preventive or health-promoting behavior with an added value (4). Using the previous suggestions, messages can extend beyond the promotion of safe sex, with an added value that girls who buy condoms will be seen as confident and sexy. The hope is that over time, it will become a social norm for teenage girls to purchase and take ownership for the use of condoms.
Many campaigns have failed because they lost trust with the target audience (primarily adolescents, and secondarily their parents) because they failed to appreciate the perceived benefits of the behavior they were competing against, were generally negative and lacked emotional or graphic appeal, and failed to offer a viable behavioral alternative (4). The proposed intervention succeeds at each of these by acknowledging sex as a factor, providing positive and empowering messages, and proposing the use of condoms, rather than promoting a strict message of abstinence.

Intervention #2: The Messages

As discussed previously, using negative statistics and messages to promote a change in behavior is ineffective. Rather than use fear appeals to scare the target audience into action, it is recommended that elements of the group behavior models get put into play. Ownership and labeling theory are both elements of irrational behavior models that can be used to construct positive messages rather than negative ones.
Ownership, which describes how people are compelled to avoid loss, explains that people need to first own their behavior, before they can change it. However, in order to change a health behavior, such as practicing safe sex, the individual needs to find the offer compelling and immediate. Often this means that the offer is not health. In this intervention, the target audience needs to own their sex life by purchasing, carrying and using of condoms. The commercials and print advertisements will not include any statistics or messages that tell the audience what not to do, but instead images and phrases that empower teenage girls to take action. Images will include bright, vibrant teenage girls looking fearless, unlike the current commercials which show girls looking scared and alone. Messages will include the previously mentioned, “Do It for You”, as well as “Do It for Your Future”. Both the images and messages will reflect the idea of ownership, in this case, of your sex life.
A second element used in irrational behavior models is labeling theory. Originally developed by Howard Becker (1963) to explain deviant behavior, it has been used over the years to help explain how people are stereotyped based on their race, gender, ethnicity, socio-economic status, religion, or situation. A label is the product of group identifications and is created by the reactions of outsiders to a perceived social target-group (10).
When a person actually becomes that in which they are labeled, this is referred to as a ‘self-fulfilling prophecy’. Jussim (1990) and Merton (1976) stated that “when a self-fulfilling prophecy occurs, the target person’s behavior actually changes in ways consistent with the perceiver’s expectation” (10). Although this is usually thought of in terms of negative labels and behaviors, public health can use this idea to promote positive behavior. Such as, we can label teen girls as confident and expect that they will take ownership of their sex life, thus leading to a ‘self-fulfilling prophecy’ of girls actually participating in safe sex behaviors. Again, this idea of labeling theory ties into the suggested empowering, motivating messages that were explained earlier.
Cechaviciute and Kenny (2007) go on to explain that a label can only affect a person if that person does not possess a clear and confident conception of him/herself. Without a clear conception of self, people more easily internalize others’ perceptions and thus conform to the expectations, rather than convince perceivers to view them as they view themselves (10). Since teenagers are still defining who they are and do not yet have a clear conception of self, this element of irrational behavior will work very well for this target audience.

Intervention #3: The Communicators

In order to help avoid psychological reactance amongst the target audience, one must evaluate the current communicators of the abstinence message. As discussed in the critique, the current spokespeople are generally older and live very different lives as celebrities than the average American teenage girl. Only one of the spokespeople has gone through a pregnancy as a teenager, and the experience was one very different than it would have been if she didn’t have the same resources available to her. Bristol Palin does not have to worry if she has enough money to make ends meet, or if she has the support of her family. Instead she has to worry about being in the spotlight as a teen mother and how it will affect her life and that of her son.
Being told not to have sex by celebrities, who in the minds of teenagers, know nothing of what it is like to live as an average youth in America, can only lead to resistance. Although teenagers may look to celebrities for fashion tips, they need spokespeople they can relate to in order to truly grasp an important, life changing message. Schyns and Meindl stated that if an individual identifies with another person, then it is more likely that they will imitate the behaviors of that person (11). For this reason, it is highly suggested that the Candie’s Foundation use spokespeople that are peers to their target audience.
Generally, to keep with the positive, empowering tone, the television commercials and print advertisements should use everyday, bright, confident teenage girls to deliver these messages. However, in order to tell both sides of the story, the foundation’s website should include real life stories from teenage girls who became pregnant, in addition to stories and advice from spokespeople who practice safe sex. To keep with familiar faces, they should partner with MTV and ask teenage girls from the shows “16 and Pregnant”, as well as “Teen Mom” to share their stories. In each of these real-life shows, they follow a girl while they navigate adolescence, growing pains, rebellion, and coming of age; all while dealing with being pregnant, or having a new baby. Each girl's story offers a unique look into the wide variety of challenges faced by pregnant and new moms: marriage, adoption, religion, gossip, finances, rumors, graduating high school and getting/losing a job. Both the girls that practice safe sex and the girls that became pregnant can share their stories and give words of advice. These messages will take the place of the statistics which currently bombard the Candie’s Foundation website. These peer communicators will be a great improvement to the current spokespeople who promote a message that they cannot fully connect with.

Conclusion:

The Candie’s Foundation campaign to prevent teenage pregnancies is greatly flawed. The current behavior change model, messages to the audience, and communicators of the message must be changed in order to influence a change in behavior. In analyzing the current techniques used, a few main points became evident. For one, the organization should aim to promote safe sex, rather than abstinence. Not only is this goal more realistic, but research shows that people do not respond well when being told not to do something. Second, fear appeals and negative statistics should be eliminated and replaced by empowering, positive messages. Last, the communicators of the messages should be replaced by peers of the target audience, in this case, other teenage American girls. In making these changes, the goals of the Candie’s Foundation will be accomplished more successfully.

REFERENCES
1. Salazar M. Comparison of Four Behavioral Theories: A Literature Review. AAOHN Journal 1991; 39(3): 128-30.
2. Simon B. Health Psychology and Sexual Health Assessment. Nursing Standard 2006; 21.5: 35+.
3. Thomas L. A Critical Feminist Perspective of the Health Belief Model: Implications for Nursing Theory, Research, Practice, and Education. Journal of Professional Nursing 1995; 11(4): 247-49.
4. Evans W. and Hastings G. Public Health Branding: Applying Marketing for Social Change. New York, New York: Oxford University Press, 2008.
5. Whaley A. Differential Risk Perceptions for Unintended Pregnancy, STDs, and HIV/AIDS Among Urban Adolescents: Some Preliminary Findings. The Journal of Genetic Psychology 2000; 161(4): 436-7.
6. Donnell A., Thomas A. and Buboltz W. Psychological Reactance: Factor Structure and Internal Consistency of the Questionnaire for the Measurement of Psychological Reactance. The Journal of Social Psychology 2001; 141(5): 679-80.
7. Seeman A., et al. The Type of Threat Matters: Differences in Similar Magnitude Threats Elicit Differing Magnitudes of Psychological Reactance. North American Journal of Psychology 2008; 10.3: 583.
8. Edwards S., Li H. and Lee J. Forced Exposure and Psychological Reactance: Antecedents and Consequences of the Perceived Intrusiveness of Pop-Up Ads. Journal of Advertising 2002; 31(3): 83-85.
9. Tait R. and D. Walker. Marketing health and safety management expertise to small enterprises. Safety Science 2000; 36:96.
10. Haynes-Lawrence D. Home visitors' perceptions of teen mothers: Using qualitative research to explore labeling theory. Children and Youth Services Review 2008; 30: 1386-88.
11. Schyns, B. & Meindl, J. Implicit Leadership Theories: Essays and Explorations. Greenwich, CT: Information Age Publishing, Inc., 2005.

Having Fun or Learning Some? A Critique of the Baby Think it Over Program Addressing Teen Pregnancy-Priya Sekar

Introduction

It seems that recently there has been a surge of interest revolving around issues of teen pregnancy and teen parenthood, as evident by the creation of such TV programs as 16 and Pregnant and Teen Mom airing on MTV. These shows were created with hopes of showing teens the enormous responsibilities and struggles faced by being young parents and to deter them from the behavior that led to such a life: sex! With an increase in rates of teen pregnancy among young women, such efforts should be applauded, but are they the right strategy and are they effective?
Despite continued efforts to decrease teen sexual activity, more that half of U.S. teens have had sexual intercourse in their lifetime, and almost 1 in 10 have before the age of 13. In 1999, of those students who were sexually active, 42% reported that neither they nor their partner used a condom the last time they had sex (1). In 2005, the U.S. teen pregnancy rate reached its lowest point in more than 30 years, at 69.5 pregnancies per 1000 women, down 41% since its peak in 1991, at 116.9 pregnancies per 1000 women. But in 2006, the rate increased for the first time in a decade, rising 3 % to 71.5 pregnancies per 1000 women (2). For the first time since the 1990s, the overall rates of pregnancies and births among teens increased during the 2005-2006 year. Preliminary data on births from 2007 shows a further increase in birth rate among all women (2). Approximately 40% of all females will experience at least one pregnancy before the age of 20 (2). Teen pregnancy carries high costs in terms of both the social and economic health of mothers and their children. Teen mothers are less likely to receive prenatal care, and their children are more likely to be born before term, to have low birth-weights, and to have developmental delays. Teen mothers are also less likely to complete their education than mothers over 20 years of age (3). It is clear that there are devastating consequences of teen sexual activity, pregnancy, and motherhood and it should be a major public health concern.
In the last few decades, health professionals working with adolescents have increased their efforts at both designing and implementing interventions aimed at preventing teen pregnancy (4). Although there has been a recent downward trend in pregnancy rates in American teens, the U.S continues to have one of the highest of any Western industrialized nation. Most of the previous programs designed to prevent adolescent pregnancy focus on one of three approaches: sex education, encouraging sexual abstinence, or increasing the availability of contraception. None of these efforts alone seem to be effective however (5). In fact, some experts claim that the rise in teen pregnancy might be attributable to $150 million of federal financing per year spent on education that emphasizes abstinence until marriage, instead of focusing on and stressing the benefits of contraception and other methods of prevention. Fortunately, the Obama administration has moved away from this trend (6).
The National Campaign to Prevent Teen Pregnancy recently released a report reviewing various intervention approaches, finding that no single approach alone is fitting for attacking this problem. Programs advocating sexual abstinence, like the Postponing Sexual involvement Curriculum (PSI), aimed at American middle school students, often faired poorly (4). Another strategy shown to fail when used alone was the implementation of school-based clinics that provided a range of medical and counseling services to adolescents (5). Adolescent pregnancy is a complex problem and accordingly strategies of prevention should be multi-pronged. There should be a growth in the number and variety of programs, including education programs, family planning and contraceptive services, school-based health centers, youth development programs, and multi-component programs (7).
One intervention approach that has been tried is the Baby Think It Over (BTIO) Program. This is an infant simulation program that seeks to modify attitudes toward teen pregnancy and teen parenting. It is based on the theory that teens engage in unprotected sex because of a personal fable concerning pregnancy: the “It can’t happen to me” fable. It was expected that participation in the BTIO program, a form of role play, would encourage teens to acknowledge their own personal vulnerability to an unplanned pregnancy, and provide them with some insight into the experience of adolescent parenting (4). The program was originally created by nurses at the Teen Health Centre in Windsor, Canada in an attempt to decrease the high pregnancy rate among girls aged 19 years and younger (4). The program involves the use of infant-simulators, or lifelike dolls, that allows adolescents to role-play the responsibilities involved in parenting. The program is implemented in the parenting/sex education classes offered at the participating high schools as an option to fulfill a social science requirement (4).
Infant simulators are tools that encourage adolescents to contemplate the realities of parenting. Proponents argue that the use of simulators enable adolescents to understand the time and effort required in raising a child, thus convincing them to delay parenting and the behaviors that lead to becoming a parent (8). To make the experience more realistic, instead of using an egg or a bag of flour, Rick Jurmaine invented the Baby Think It Over infant simulator. These simulators were built to physically resemble real infants, weighing about 8 pounds and measuring about 20 inches long. The simulators are battery operated and are programmed to cry at random intervals every 2 to 4 hours requiring tending from the caregiver, which means inserting a magnetic probe into the dolls back and holding it in place for up to 35 minutes. The probe is attached to a tamper-proof hospital bracelet worn on the teen’s wrist (8; 4).
The BTIO Program has been used all over the U.S. and internationally by over 1 million students throughout school settings in the hopes of creating a lasting impression on both teen women and men of the personal sacrifice and challenges required of new parents (1). Though the BTIO Program was created with hopes of decreasing teen pregnancy rates and sexual activity, its impact on such behavior has yet to be proven conclusively (8) As Barnett concludes, the BTIO program “ended up being a cute gimmick that looked good to adults and became a silly game for the students.” There are many possible reasons responsible for the failure of this program. In analyzing the problem of teen pregnancy, creators used the Health Belief Model in implementing an intervention, which especially for teens, may not be ideal in persuading them to change their behavior. Secondly, the program focused only on a narrow target group. Lastly, the program did not account for the various levels of societal and environmental factors that influence behavior.

Critique Argument 1: Wrong Social-Behavioral Model Approach

The first issue with the creation and implementation of the BTIO Program is that it was developed through the perspective of the Health Belief Model, hoping to get teens to acknowledge their own vulnerability to an unplanned pregnancy. The Health Belief Model is the oldest of the individual behavior theories used in public health, originating from social psychologists Godfrey Hochbaum, Irwin Rosenstock, and Stephen Kegels in the 1950s (9). The model was originally created during research into why turnout for free TB screenings were so low. According to the model, health seeking and other health behaviors were thought to be motivated by an individual’s perceived susceptibility, perceived severity, perceived benefits of action, and perceived barriers to taking action (9). It is clear that the Health Belief Model is probably very useful in public health interventions targeting simple medical health related behaviors, like getting a vaccine. But changing adolescents’ sexual behavior is not comparable to convincing an individual to get a vaccine. The Health Belief Model does not address social and environmental factors (10), which play a large role on teen sexual behavior. Furthermore, this model does not take into account spontaneous activity that characterizes much of human behavior, like sex (10). The model assumes an acted behavior is the result of a cost/benefit analysis, of calculated rational thought devoid of emotion (10), which is untrue for sexual behavior.
The BTIO Program, in analyzing behavior in terms of the Health Belief Model, fails to frame the outcome of the intervention in a way relatable to teens. The Health Belief Model inherently frames the outcome of changing sexual behavior as preventing a negative outcome (a hard life of tough responsibility) instead of offering a positive one, like a future of freedom and autonomy. Perhaps reformulating the BTIO Program around a different social-behavioral model, that reframes the outcome in a positive manner, may make the program more effective. This idea of framing revolves around the idea that human choices are susceptible to the manner in which options are. The framing effect suggests that people incorporate a range of emotional information into the decision process, which the Health Belief Model fails to account for (11).

Critique Argument 2: Widen Target Population

In implementing the BTIO Program, proponents correctly took into account that early adolescents believe they are omnipotent and not vulnerable to becoming pregnant. This is in accordance with the Theory of Cognitive Development that describes adolescents reasoning and decision making as clouded by an imaginary audience (that thinks like adolescents) and a personal fable (8). But adolescents also underestimate the negative consequences that would follow if they did become pregnant and the difficulty involved in caring for a child. In fact, adolescents are more likely to believe that unlike most others, they could be perfect parents and still continue to lead normal teen lives, which the BTIO intervention failed to account for (8). So even after role-playing being a parent to a difficult baby, adolescents will still think they can be successful parents. Adolescents’ strong belief in the personal fable of omnipotence may cause them to simply overlook the negative aspects of any parenting experience they have (12). The BTIO Program was originally implemented through parenting and/or sex education classes, in which the students had the option of enrolling as a means to fulfill a social science requirement. It is quite possible that students enrolled in such classes were more interested in issues surrounding parenting to begin with (4), so they probably perceived parenthood to be more attractive than those students who did not enroll in such classes, and were less likely to be persuaded otherwise.
In choosing to implement the BTIO intervention in optional parenting classes, the implementers failed to account for the Cognitive-Behavioral Theories which propose that behavior is mediated by personal cognitions and vise versa; in other words, what people know and think affects how they act (13). In this case, the fact that the parenting classes were optional probably means that students registered in such classes were all alike, in that they all already viewed parenting in a positive light. So perhaps targeting a larger, less biased population would garner the BTIO program more effective.

Critique Argument 3: Doll Component Alone Unrealistic and Ineffective

It seems logical that to get adolescents to understand they are vulnerable to a difficult life if they become pregnant, they should be made to experience such a life. The Baby Think It Over Program has the right intention, but is a doll really effective in demonstrating the realities of raising a child? The purpose of the doll is to provide students with an understanding of the amount of time and effort involved in caring for an infant and how an infant’s needs might affect their daily lives and the lives of family and significant others (14). Though it was a valiant attempt at providing students with an understanding of the importance of postponing pregnancy, results showed that there were only minimal changes in attitudes and beliefs (14).
As the Ecological Perspective proposes, promoting certain behaviors involves more than just educating individuals about realities and right from wrong. It includes efforts to change organizational behavior, as well as the physical and social environments of communities (13). It is important to remember that behavior is affected by multiple levels of influence and the social environment, but the BTIO campaign failed to recognize this relationship.
The issues surrounding parenthood are much more complicated than just being able to deal with an infant’s unpredictable behavior (which the BTIO doll targeted) and such issues may be more relatable and applicable to adolescents. There are long term education, economic, and social consequences of teen parenting (4), that the BTIO Campaign does not even attempt to demonstrate. For example, caring for an infant requires a lot of money that takes away from future goals. Additionally, having another person to take care of 24 hours a day, 7 days a week, takes away time that would otherwise be spent in school, or hanging out with friends. There is also the issue of the social stigma surrounding teen pregnancy and single-parent families. Incorporating such influences and information into the campaign may help personalize both the short-term and long-term consequences of unplanned teen pregnancy (4).

Proposed Intervention:

While there are many flaws to the program critiqued, it is aiming in the right direction in attempting to show teens the harsh reality of trying to raise a child. The BTIO campaign has at its base the right components, but utilizing concepts from various social-behavioral and models and theories might help make the program more successful. First, the improved intervention should reframe the issue of teen pregnancy and parenthood as a hindrance to achieving future goals instead of as a guarantee to a difficult and tiring life. The idea of attaining future goals is more positive and would appeal more to teens. Associating a change in sexual behavior with personal motivations and goals relates more to adolescents than associating it with responsibilities of parenting. To sell safe sexual behavior as a method of attaining future goals, using components of the Advertising/Market Theory may be more appropriate than using the Health Belief Model.
Incorporating the campaign into a student-body wide mandatory health-education curriculum, which will cover all sorts of health behavior from smoking and alcohol, to sexual behavior, might also contribute to a greater success. Making the program school-wide will not only make the targeted group less biased and uniform, but it will also garner a greater influence of peer relationships that most adolescents are vulnerable to.
Furthermore, incorporating into the curriculum a section on the methods and positive outcomes of safe and smart behavior will help students understand the reasons to change their behavior and be personally motivated to do so. One method to consider using is a youth development/future career workshop that enlists guest speakers from various careers to talk about how they attained such goals. This addition gives students the chance to learn about the many career opportunities available and will help spark an interest in a future goal.
A workshop on the realities of teen pregnancy, including issues of money and social stigmas, should also be organized. These issues should be discussed as components in the sex education section of the health education curriculum, as negative consequences of unhealthy/unsafe behaviors. Including exercises like calculating the cost of raising a baby per week, month, or year may help teens understand the extremity of the situation as well.
Most importantly the sex education section of the course should teach all forms of prevention, from abstinence to contraceptive use, and offer various resources from which students can learn more information.

Defense of Intervention 1: Framing

The way in which a public health intervention and its potential outcomes are framed can greatly influence the success (or failure) of such an intervention. The original BTIO Program is framed negatively like a lot of other public health campaigns, showing the negative consequences of participating in unsafe sexual behavior, instead of the positive outcomes of not participating in such behavior. The original BTIO Program attempts to persuade adolescents to change their behavior using the Health Belief Model to show that even they are susceptible to the negative consequences of unsafe sexual behavior, framing the result of the intervention as avoiding a negative outcome.
Framing impacts people because it makes individuals view losses and gains differently, as the Prospect Theory suggests. The theory also proposes that a loss is more devastating than the equivalent gain is gratifying, so people will avoid risk if a positive frame is presented (15). So, if attaining career-goals is the equivalent gain to the devastating loss of a care free normal teen life (by the overwhelming responsibility to care for a child), then it makes sense that reframing the public health issue around this more positive idea will make the BTIO campaign more successful.
As mentioned in the proposed improved intervention, utilizing components of the Advertising or Marketing Theory (especially the idea of selling a positive desire) instead of the Health Belief Model would be more beneficial for reasons related to the idea of framing. As discussed in class, utilizing this component means selling the aimed behavior (prevention) as a means of fulfilling true needs and wants (16). In this case, prevention should be sold as a means of attaining freedom and autonomy-a way of attaining personal goals.

Defense of Intervention 2: A more universal target population

As mentioned previously, Cognitive-Behavioral Theories suggest that behavior is influenced by an individual’s cognitions and vise versa. So in the original BTIO Program, where only students who chose to enroll in parenting classes experienced the intervention, it was likely that such individuals were already pro-parenting and therefore less impressionable. Therefore, as mentioned in the intervention proposal, the campaign should target the entire high school student body through a required health education class instead of through an optional interest-geared class. By altering the target population in this way, it will be possible to prevent a self-selection bias, which may have existed before, from occurring (4).
Furthermore, peers are an important influence on individual behaviors (especially for high school students), as various social science theories suggest. The Social Learning Theory/Social Cognitive Theory suggests that people learn by watching what others do, and each behavior witnessed can change a person’s way of thinking (13). By targeting the entire student body, the wider issue of peer influence can be utilized. Teaching behavioral skills and changing perceptions of a portion of the peer group will eventually start to influence the rest of the peer group (3). Peer influence can be utilized to teach and spread the use of preventative measures. One example utilizing peer influence is virginity pledges. Studies actually show that students taking pledges delayed their first sexual experience by about 18 months (3). It is clear that utilizing peer influences can be effective in changing adolescent behavior.

Defense of Intervention 3: Taking a multi-pronged approach

As mentioned previously, health promotion involves more than simply educating individuals about right and wrong health practices. Changing behavior requires utilizing influences from the social and community environment as well. The Ecological Perspective emphasizes the interaction between, and interdependence of, factors within and across all levels of a health problem (13). This perspective emphasizes people’s interactions with their socio-cultural environments, stressing that behavior is affected by multiple levels of influence. Not only is behavior influenced by individual, intrapersonal, and interpersonal factors, but it is also affected by organizational and community factors.
This idea supports the proposal of including a youth-development type of component into the BTIO Campaign alongside educational sessions that influence individual knowledge, attitudes, and beliefs. Such programs focus on supporting and encouraging young people. Young people need opportunities to acquire a broad range of skills and to build connections within their community (7). Youth development programs take into account social networks which exist among individuals and groups (13). It has actually been shown that there is a strong relationship between educational and career plans and protection from adolescent pregnancy. Improving girls’ education and life options are correlated with reduced pregnancy rates (7). This multi-pronged approach also accounts for the influence of institutional factors, such as school regulations that many constrain or promote recommended behaviors. The proposed intervention suggests making information about resources for attaining contraceptives and other preventative measures available to all students, a recommendation that requires schools to change their regulations and policies. It is clear, that to best influence behavior change, it is important to take opportunity of all existing relationships between individuals, community, society, and organizations-allowing a public health concern to be attacked from all angles.

Conclusion:

Though the original Baby Think It Over Program attempted to decrease teen pregnancy rates in a unique manner, its success rate was very low. The program tried to sell a change in behavior as a means to preventing negative consequences, instead of as a means of ensuring positive outcomes. Reframing and remarketing the outcome as something positive, in accordance with ideas of the Marketing Theory, will hopefully help make the new campaign more successful. Additionally, taking opportunity of the importance of peer influence by widening the target group to the entire student population will help utilize one of the main outlets of influence proposed in the ecological perspective. Adding in additional components of youth development programs (that utilize the influence of the community) and improved policies (that utilize the influence of institutions) will also help make the new campaign more successful in decreasing teen pregnancy rates. All in all, instead of focusing in on one social-behavioral theory, utilizing aspects of various theories might be helpful in making this campaign a success.

REFERENCES:

1. Somers, C.L, & Fahlman, M.M. Effectiveness of the Baby Think It Over Teen Pregnancy Prevention Program. Journal of School Health 2001 .
2. Guttmacher Institute. U.S. teenage pregnancies, births, and abortions: National and State trends and trends by race and ethnicity. www.guttmacher.org.
3. Solutions for America: Healthy Family and Children. Teenage Pregnancy Prevention. solutionsforamerica.org/healthyfam/teenage-pregnancy.html.
4. Out, J.W., & Out, K.D. (2001). Baby Think It Over: Using Role-Play to Prevent Teen Pregnancy. Adolescence 2001.
5. Kirby, D., Waszack, C., & Ziegler, J. Six school-based clinics: Their reproductive health services and impact on sexual behavior. Family Planning Perspectives 1991, 23, 6-16.
6. The New York Times. Lewin, T. After long decline, teen pregnancy rate rises (2010). http://www.nytimes.com/2010/01/27/us/27teen.html.
7. Kirby.D., et al. The impact of the Postponing Sexual Involvement Curriculum among youths in California. Family Planning Perspectives 1997, 29, 100-108.
8. Barnett, J.F., & Hurst, C.S. Do Adolescents take BTIO Seriously?
Adolescence 2004, 39.
9. Rosenstock IM. Historical origins of the health belief model. Health Education Monographs 1974; 2:328-335.
10. Individual health behavior theories (chapter 4). In: Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007, pp. 35-49.
11. DeMartino, B, Kumaran, D., Seymour B., Dolan, R.J. Frames, biases, and rational decision-making in the human brain. Science 2006: 313: 684-687.
12. Kralewski, J. & Stevens-Simon, C. Does Mothering a Doll Change Teens Thoughts about Pregnancy. Pediatrics 2004, 105, 30.
13. National Cancer Institute. Theory at a Glance: A Guide for Health Promotion Practice. Part 2. Bethesda, MD: National Cancer Institute, 2005, pp9-21 (NIH Publication NO. 05-3896). Available at: http://www.cancer.gov/PDF/481f5d53-63df-41bc-bfaf-5aa48ee1da4d/TAAG3.pdf.
14. Anda, D. BTIO: Evaluation of an Infant Simulation Intervention for Adolescent Pregnancy Prevention. Health and Social Work 2006.
15. Tversky, A. & Kahneman, D. The Framing of decisions and the psychology of choice. Science 1981, 211, 453-458.
16. Marketing public health-an opportunity for the public health practitioner (Chapter 6). In: Siegel M, Doner L. Marketing Public Health: Strategies to Promote Social Change (2nd edition). Sudbury, MA: Jones & Bartlett Publishers, Inc., 2007, pp 127-152.