Abstinence Has a Ring to It, But Is It the Answer? A Critique of the Silver Ring Thing Campaign– Christine Vanderheiden

Introduction

Let's talk about sex for now to the people at home or in the crowd
It keeps coming up anyhow
Don't decoy, avoid, or make void the topic
Cuz that ain't gonna stop it
-Salt ‘n’ Pepa (1)

Let’s talk about sex. As lyrically stated in the early 90’s song, “Let’s Talk About Sex”, Salt ‘n’ Pepa revealed the taboo subject of sex to the media. Acknowledging that teenagers have, and will, have sex is realistic. Providing said teenagers with information regarding sexual safety is smart. With nearly half of fifteen to nineteen year olds sexually active in the U.S., it would be irresponsible not to teach teenagers about safe sex (2). As it turns out, that is exactly what abstinence campaigns, such as the Silver Ring Thing, are promoting.
The Silver Ring Thing is a movement toward abstinence. This movement is aimed at Christian teens across the country and in England to encourage chastity by using Christian teachings and morals to avoid sex until marriage (3). This campaign does not promote the teachings of safe sex; in fact, it asserts that teaching safe sex is wrong, as it encourages teenagers to have sex before marriage (3). The Silver Ring Thing uses youth oriented methods to deliver their message to teen audiences. They travel to a number of different cities where they have seminars and shows including talks, lessons, sketches, and music. Teenagers follow these shows, take an abstinence pledge, and pay $12 for an abstinence pack, which includes a Bible, Abstinence Bible, and a silver ring. The ring, contains a verse from the Bible, “God wants you to be holy, so you should keep clear of all sexual sin. Then each of you will control your body and live in holiness and honour.” –Thessalonians 4:3-4 (3). This is a religious-based program with only one goal in mind; to stop all individuals from having sex before marriage.
A 2002 study done by the National Survey of Family Growth, asked 40,000 people ages 15-44 about their sexual behavior. Of those interviewed, 95% reported that they had had premarital sex. That leaves 5% of people who had abstained from sex until marriage (4). Also, studies have shown that adolescents who take virginity pledges are no less sexually active than those who do not take pledges (5). In fact, one study done by Columba University showed that of 12,000 teens aged 12-18, 88% of pledgers had sex before marriage (6). It is obvious that either the abstinence program is not as effective as it is meant to be or that it is unrealistic to believe that people will choose to abstain from sex until marriage.
Abstinence is the only sure protection against STDs and unwanted pregnancy, but with so many sexually active individuals, is it realistic? The above-mentioned study showed that while 88% of the pledgers had sex within two years of making the pledge, they also had similar rates of STDs and were less likely to use contraception (6). With the abstinence-only teachings, the use of contraceptives is not encouraged or taught. How does that make sense knowing that about 95% of people will engage in sexual activity before sex? Is depriving information regarding sexual safety really part of the plan to ultimately prevent STDs and unwanted pregnancy? Is this not the goal of abstinence teaching?
These questions may be addressed directly to the government, whose spending for abstinence-only programs has increased significantly over the past decade. Funding increased from $73 million a year in 2001 to $204 million in 2008. That is a total of $1.5 billion in federal money (7). These programs teach abstinence only methods and completely disregard actual safety information concerning contraceptives. Cecile Richards of Planned Parenthood stated that abstinence-only education was "an experiment gone awry. We spent $1.5 billion and can't point to a single study that says this helps. If it doesn't help, why fund it?" (7).
Critique 1: Societal Influence
Denny Pattyn, president and founder of Silver Ring Thing, discusses the main goal in his campaign in video highlighting entitled, “Get It On.” Pattyn explains that what they are trying to do is create a culture shift in America where abstinence becomes the norm again, instead of the exception (8). He asks two important questions to pastors; “Do you have an abstinence program that you use in your church and is it working?” He notes that if there is a current program, “it does not seem to be working all that well because teenagers continue to get hammered by a culture that is dead set on getting them to be sexually active” (8).
It is socially acceptable for people to have sex before marriage. It is a personal choice that takes into account individual’s morals and perceptions of social norms. Both are important and influential in making decisions, as social norms are a primary determinant of behavior. A big part in what causes attitudes and behavior and how they are spread is the social network theory. A social network is any social relationship that one may have, such as a friendship, a kinship, common beliefs, sexual relationships, etc (9). These networks play a critical role in determining values of society and actions taken as a result of those values. As you will see later, the United States shows to have different values and, as a result, different sexual outcomes as compared to other countries used in the study.
One study found that adolescents considered abstinence to be “not so much a health choice, or even a moral choice, as a stage of life that was naturally followed by a sexually active life stage.” Also found in the study, “’Readiness’ for sex also appeared to play a role in a survey that investigated young women’s reasons for having or not having sexual intercourse; beliefs and values were cited as reasons for not only abstaining from sex, but also engaging in sexual activity.” (10). Teens have certain values about sex and do not view it as a negative choice. Not only teens, but Gloucester Superintendent, Christopher Farmer, was forced to take a hard look at the problem of teen pregnancy, and even he realized that, “abstinence is one course of action, [but] we recognize that in the real world that doesn’t always happen.” (11). Society understands the reality of sex before marriage, so why should we follow a campaign that fights that?
In fact, creating a negative connotation about sex may actually be more harmful than helpful. In the article titled, “Can More Progress Be Made? Teenage Sexual and Reproductive Behavior in Developed Countries,” five countries, Sweden, France, Great Britain, Canada, and the U.S., were studied regarding sexual behavior. Out of the five countries, the U.S. showed higher levels of adolescent pregnancy, less contraceptive use, and higher prevalence of infection and STDs than the other countries. This article showed how positive attitudes about sexuality and clear expectations for behavior in sexual relationships contribute to responsible sexual behavior (12). In countries such as France and Sweden, sexuality is seen as normal and positive, and the expectation is that sex will take place in a committed relationship (not necessarily marriage), and those involved will use protection (12). In the U.S., adults are more concerned about whether young people are having sex and close relationships are viewed as worrisome because they may lead to intercourse. Talk about contraception is avoided for fear that such discussion may lead to sexual activity (12). This negative attitude reflects poorly on the country and is most likely to blame for such high pregnancy and STD rates.
Having positive values and intentions regarding sexual activity is important. This critique is not merely putting down the value of abstinence, but it is pointing out reality. It is easy to flip through your Abstinence Bible, slip on a ring and pledge not to have sex before marriage. But is it easy to ignore the human instinct of sexual desire? What about a night alone with your boyfriend/girlfriend, when the atmosphere is just perfect to get a little closer to each other? What about the hot state?
The Silver Ring Thing completely disregards the Illusion of Control Theory and Restraint Bias. The Illusion of Control theory illustrates that people believe that they have more control than they actually have once they decide to do something. Similarly, restraint Bias is the tendency to overestimate one's ability to show restraint in the face of temptation (13). People tend to believe that if they choose something, they have more control over it. If a teenager chooses to be abstinent, they do so in a cold state, where people most likely overestimate their sense of control. However, in a hot state, you have a much more realistic idea of control, and you may have less than you think. Self-restraint may not be enough to fight the influence of society and sexual instinct, and that is something this campaign needs to tackle.
Critique 2: Promoting to a Small Target Market
One clear criticism is that this campaign has pigeonholed itself to appeal to a small population of unwed individuals. What about those who are not religious? What about the population of gay/lesbian teens? What about those who are already sexually active?
According to statistics of 15-44 year old sexually active, unmarried individuals, this campaign only applies to about 5% of the population. This is also assuming that those 5% are Christian following the teachings of God. This religious aspect of the campaign is also stated in the Mission of the Silver Ring Thing, “How can a student give their life to God if they are giving their body to someone else? Think about it… They can’t. You can’t move in two directions at once, yet every week our students are falling into the traps of a sex-obsessed culture.” (14). In this program, teens are taught to understand that abstinence until marriage is God’s plan. What about teens who do not believe in God? What about teens who do not live the lifestyle of God’s teachings?
Approximately 2-5% of adolescents around the country describe themselves has being homosexual. Another 4% are unsure in high school. A national survey of approximately 1,700 college students found that 48% of self-identified gay and bisexual college students became aware of their sexual preference in high school, while 26% found their true sexuality in college. Of these gay, lesbian, bisexual individuals, about 44% of the sexually experienced reported using no use of contraception and about 12% used ineffective methods (15). It is understandable that the Silver Ring Thing wants to avoid sexual behavior by delaying sex until marriage, but how are gays, lesbians, and bisexuals going to follow a program that frowns upon their sexual orientation?
The goal of this campaign is to create a culture shift where abstinence becomes the norm again and not the exception (14). How can you change an entire culture by using such a rigid foundation that is geared toward only a portion of the population? Janet Rosenbaum, of the Johns Hopkins Bloomberg School of Public Health, noted that, “somebody who decides to take a virginity pledge tends to be different from the average American teenager. The pledgers tend to be more religious. They tend to be more conservative. They tend to be less positive about sex.” (16). Also, Rosenbaum noted that pledgers do not seem to be internalizing the pledge because it does not seem to be motivating them to change their behavior.
In studies, she conducted comparing teens that made a purity pledge and teens that had not. Results showed that 82% of pledgers not only retracted their promises, but denied ever having made them (5). This study shows that some teens are giving the purity ring a shot, but most of them are not following through. What is the next step for those who retracted their pledge? What about the teens who do not feel like a purity ring is meant for them at all? This program risks alienating youth by promoting a “one size fits all” image of adolescence that really only matches the true experience of a minority of youth (17 page ii).
This campaign disregards the Marketing Theory and the importance of creating a realistic target market. This theory stresses the importance of identifying and understanding the needs and wants of the target audience, then designing a product to benefit the target audience (18). Research is necessary in finding out what people want, and then market that product to fill the void. In this case, the campaign was designed before assessing the realistic needs and wants of the target audience. If more research had been done, the Silver Ring Thing would have taken into account 95% of unwed people that are already sexually active, or the percentage of gay, lesbian, bisexual individuals, or those who are not religious. These groups would have been factored into the target audience and the product would have been designed for them, as well. With such a small target audience, it is nearly impossible for this campaign to be a success.
Critique 3: Limited Information with Abstinence Only Education
The Silver Ring Thing was created in 1996 as a response to the escalating numbers of teen pregnancies (14). The founders of this program saw the only solution to this problem was abstinence. They saw abstinence as the only way to avoid the “harmful physical and emotional effects of premarital sex.” (14). They recognized that teaching the practices of safe sex and distributing condoms will not ensure the protection from the problems arising from sexual activity (14). So, they do not teach it. Many people see this as a negative approach to solving this issue. Medical professional organizations criticize abstinence for leaving out potentially lifesaving information (19). Abstinence-only programs “are inherently coercive by withholding information needed to make informed choices,” the American Public Health Association said in a statement (19).
In a study comparing the sexual activity of pledgers and non-pledgers, findings showed that both groups are just as likely to engage in premarital sex, but the pledgers are less likely to protect themselves from pregnancy and disease (5). This is because their abstinence-only education does not acknowledge that teens will become sexually active, so they are not taught about contraception or condom use. Discussions of abortion are avoided completely. Information about sexually transmitted diseases and HIV is given strictly as a reason to remain abstinent, instead of to inform teens of the dangers of these diseases and how to use protection against them (17).
Even adults agree that students should be informed as to how to protect themselves. In a survey asking whether or not people who are sexually active should be given information to protect themselves, 84% agreed that they should and 10% thought that telling young people about birth control and sexually transmitted diseases would only encourage them to have sex (17 page 3). Most parents believe that their children need to learn about sex and how to protect themselves. They need to learn about HIV/AIDS and other STDs. They need to learn how to use condoms. They need to learn about how to obtain and use birth control. They need to have homosexuality addressed in sexuality education. (17, page3).
This campaign failed to take into account the Psychological Reactance Theory. This theory suggests that when people feel that their perceived freedom is being threatened, they experience reactance. Reactance is a motivational state that restores the threatened freedom, usually by rebelling (20). Rebellion is expected during teenage years, but this campaign may push teens to rebel even more. To have, or not to have, sex is ultimately the individual’s decision. When a teenager is following a program that is focusing so much on the “Do Not’s” and the “No’s” it is more likely that the individual will feel that their freedom is threatened. Social influence is more successful when it does not threaten freedom (20). This message needs to be delivered in a way that does not seem like teens are being told what to do.
“Like it or not, sexual activity is a reality for teens in America, and it is hard to imagine a school-based intervention which will magically undo the media pressures and natural hormonal urges that young people experience. Facing up to this reality means implementing responsible programming that truly meets the test of science and the real world needs of the youth. “ (17 page 19).
Intervention 1: Create a Value Neutral Approach
One of the biggest problems with abstinence-only education is that it raises concerns for gay and lesbian teens. Not only does abstinence-only education disregard the homosexual population, but it goes so far as creating hostile environment for gay and lesbian teens. Many of these programs stigmatize homosexuality and discriminate against gay and lesbian students (21). In a society that does not allow gays and lesbians to get married, efforts to educate teens about protecting their health are undermined. Some people do not even view same sex relationships an “adequate means of achieving a genuine physical relationship with another human being because this type of ‘union’ is contrary to the laws of nature.” (21). With such hostility toward homosexual relationships, it is obvious that sexual health programs need to address homosexuality in a positive light to have an impact.
An obvious approach to creating a more positive image for sexuality is to create a curriculum in schools that addresses a broader base beliefs and values. SIECUS is an example of a comprehensive school-based sexuality education that respects the diversity of students and understands that students have different values and beliefs (17 p. 14). When dealing with a school wide initiative to end unwanted pregnancy and the spread of STDs, it is important to acknowledge and address all values and beliefs, so that there is not an adverse effect. Effective sexual education should not only address a range of topics, but should be appropriate for all students, regardless of their sexual orientation. It should also encourage health attitudes concerning not only sex, but adolescent growth and development to encourage positive attitudes about gender roles, sexual orientation, dating, marriage, and family. Any religious connotation should be left out of the curriculum, so not to offend anyone or create bias of any information being taught in the school (22).
Intervention 2: Make Contraceptives More Attainable for Teens
The Silver Ring Thing blatantly ignores the use of contraception. The program believes that offering contraception will only encourage sexual behavior. Studies have actually shown that pregnancy and STD rates are lower in countries where contraceptive services are part of an integrated medical plan and easier to obtain. In the U.S., clinic visits and prescriptions are usually costly and difficult to obtain (12). The most important thing for teenagers is to have easy access to information and services, to receive confidential, non judgmental care, and to be able to afford it. While most government funding is going straight to abstinence only education, it should be directed toward encouraging contraceptive use to those teens that are sexually active and unprotected.
The reason why it is so important to provide easily accessible contraception is partly because of the tendency of teens to have optimistic bias (17). Interviews have shown that although young people are concerned about AIDS, they do not perceive themselves to be personally at risk (17). This is mostly due to the fact that they are simply not informed about contraception. Some 21% of teens mistakenly believe that birth control pills are effective in HIV protection (17). There may not be a way around the optimistic bias, but at least teens can protect themselves even though they believe they will not be affected by their behavior.
Statistics show that the majority of sexually experienced teens (74% of females and 82% of males) used contraceptives the first time they had sex (23). At most recent sex, 83% of teen females and 91% of males used contraceptives. These 2002 numbers showed a vast improvement since 1995 when only 71% of teen females and 82% of males had used contraceptives at last sex (23). With emphasis on teaching the use of contraception and making it easily attainable, these statistics should rise, and in effect, the STD and pregnancy statistics should decrease.
Intervention 3: Use Education, not Scare Tactic
There seems to be a concerning disconnect between politicians, teachers, parents, and students regarding their thoughts on sexual education. Politicians are eager to promote abstinence-only education, while teachers, parents and students believe that more information should be taught. An overwhelming 90% of teachers believe that students should be taught more in their sexual education. They believe sexual education should include how to obtain birth control, information about abortion, the correct way to use a condom, and sexual orientation. But, few teachers actually teach what they believe should be taught. One in four teachers are told not to teach grades 7-12 about contraception (24). This is mainly due to state and local policy mandating sexual education and using funding on abstinence only education, rather than comprehensive sexual education. Even if teachers were allowed to cover these topics, about one-third may avoid them due to fear of adverse community reaction (24).
The Silver Ring Thing campaign is promoting a healthy objective, but it is simply not realistic. Abstinence based programs should still be taught in school, but in conjunction with a more comprehensive education. According to a study from the Archives of Pediatrics & Adolescent Medicine, abstinence programs were proven to be more effective in lower grades, such as sixth and seventh (19). It makes sense to focus on abstinence education geared toward younger teens, as they are not as sexually active as older teens. Asking teens to delay sex until they are ready, rather than until they are married, is a more realistic approach and it portrays sex in a more positive light.
Studies have shown that there are lower pregnancy rates in countries that emphasize comprehensive sexuality education. In countries such as Canada, France, Sweden, and Great Britain, comprehensive sexuality education is mandated in schools. These school programs teach the importance of prevention of disease and pregnancy, contraception use, and respect and responsibility with relationships. Programs like this are not funded in the U.S. State and federal funding is directed toward abstinence-only education, but not comprehensive sexual education (12). Teens need to be informed and need to feel like they own their decisions. When they are not given the opportunity to make informed decisions, they will not make informed decisions. Sex should be framed as something they can own and something they can protect, rather than make it a forbidden subject.
Conclusion
The Silver Ring Thing was created to stop unwanted teen pregnancy. Instead, it has stopped the teaching of safe sex to sexually active teens. The purity pledge to God deprives teens of crucial sexual education and knowledge they need to protect themselves. One positive aspect of the campaign was that it may have delayed teens’ first sexual experience by a year or two. But, overall, teens that were taught the importance of abstinence were not told the importance of protection.
It seemed to be that the founder, Mr. Pattyn, was missing the point entirely on preventing unwanted pregnancy and disease. In a world where teenagers share the same religious based values and they are not influenced by society, this program may have been a success. However, they did not take into account their target audience and did not realize the illusion of control that people think they have. People may not make rational decisions all the time, but at least if they are provided with information, they can make informed decisions.

REFERENCES
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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.

The Candie’s Foundation, Brittney, And Bristol: Sending The Wrong Message About Teen Pregnancy - Sue D'Onymous

INTRODUCTION

Unwanted pregnancy is a huge burden, not only on the individuals but on society as well. This is especially pressing for the United States, as it has the highest teen pregnancy rates of all similarly situated countries (1). This rate is ten times more than Japan and almost double the rate of Great Britain (1). The vast majority of these pregnancies, roughly 85% of them, are unintended and not planned (2). Teen pregnancy spiked in the 1980’s and has decreased over the 1990’s (2). The teen pregnancy rate has continued to decrease throughout the 2000’s, until 2006 (3). In 2005 there were around 70 pregnancies per 1000 female teenagers, but in 2006, the rates realized a 3% increase (3). Further, from 2005-2007, the rate increased 5% (4). Experts attribute this change in pregnancy rates to an increase in sexual activity and a decrease in the use of contraceptives (4). Additional factors that might be contributory is a change in attitude towards the risks of contracting HIV/AIDS (4). Showing a marked change in attitude, only 6% of 18-29 year olds, in 2007, believe that HIV/AIDS is the most pressing health concern, whereas in 1995 44% of respondents marked this as the most pressing health problem (4). Other factors that might contribute include a refocus on abstinence-only education, lack of education on contraceptives and lack of access to contraceptives, interventions largely focusing on younger teens (where, there has been an increase in birth rates for older teens), and the cultural attitudes that Americans have adopted (4).

This last part, the change in social norms and the societal attitude towards sex and pregnancy is very interesting. In an article put out by the National Campaign to Prevent Teen and Unplanned Pregnancies, they speak out about how recent celebrity teen pregnancies have been almost lauded (4). The article states, “…the high-profile teen pregnancies of Bristol Palin and Jamie Lynn Spears were largely greeted as the latest in a long line of celebrity baby bumps. Perhaps such trends and factors help shape the social script for teens, suggesting that getting pregnant and starting a family in the teen years as a single teen who may not have even finished high school is simply not that big a deal.” (4).

This bring me to discuss the Candie’s Foundation campaign. This campaign is currently being headed up by Bristol Palin. For those not aware of her status, she is a single mom, daughter of Sarah Palin. Bristol’s pregnancy was announced shortly after her mother was nominated to be John McCain’s vice presidential running mate.

It helps to understand who Candie’s is and what they do. Candie’s is a brand of popular teenage clothing, shoes, and undergarments. They have had many different famous faces for their clothing advertisements. Recently Hayden Panettiere was the face of Candie’s, but the current poster-woman is none other than Brittney Spears (5) Without going further into it, as it is not the focus of this paper, is it interesting to note that the advertisements and their current website are obviously using the core value of sex to sell their products. What is ironic is that the Candie’s Foundation’s sole purpose is trying to promote the reduction of teen pregnancies, something intimately (no pun intended) tied to sex. In a recent editorial in the New York Times, Gail Collins draws this same conclusion, “Palin is not in any way to be confused with the new Candie’s brand spokesperson, Britney Spears. Bristol is the one endorsing abstinence; Britney is the one promoting ‘hot bottoms.’” (6) Now, let us turn to a critique of the Candie’s Foundation media campaign to reduce teen pregnancy.

Critique 1: Who is your spokesperson? Don’t pick someone who sends the wrong message or waffles.

Originally, Bristol Palin spoke out against abstinence-only education to prevent teens becoming sexually active. Lately, she’s switched teams, saying “I just want to go out there and promote abstinence and say this is the safest choice.” (6) She was also quoted saying, "Regardless of what I did personally, I just think that abstinence is the only ... 100 percent foolproof way to prevent pregnancy." (7) So which is it Bristol? Is abstinence unrealistic or not? Please clarify. Where you have a spokesperson who waffles, it sends a confusing message and conjures questions of if this person is being paid to state what the organization backing them wants them to state. This completely undermines the credibility of the spokesperson.

Also, the current video ad on their website is not something that most teens can relate to. For an intervention to be effective, people must be able to relate to it. How many teens who are at risk for pregnancy can relate to Bristol? She comes from a supportive family, a wealthy family, and because of her pregnancy she has received a lot of recognition, including being asked to be the face of this campaign.

The video she stars in, with her son, starts out with her all dressed up. She then says, “What if I didn’t come from a famous family? What if I didn’t have all their support? What if I didn’t have all these opportunities? Believe me it would be pretty….Pause, before you play.” As she’s speaking, she loses her dressed up look and the furnishings in the room. In the end, she is in a room with just her son, a crib, a couch and she is dressed in plain jeans and a t-shirt. Is she implying that if your parents are supportive and have money, it’s a joy-ride having a kid? So, maybe only poor people or others with unsupportive families shouldn’t get pregnant as a teen. Perhaps that’s not the intended message, but it’s certainly what comes across. Most of American teens simply can’t relate to what she’s going through. Her family is famous and wealthy, so Bristol doesn’t come across to many teens as someone they can relate to. If a teen can’t relate, why would they listen the message?

Social Expectation Theory would teach us that this promotion and exaltation of being a single mom, in Bristol’s case, reinforces a social norm that it’s ok to get pregnant, perhaps even something cool (8). Babies are the new “thing to have” instead of a purse or pair of shoes. Everyone who is anyone has one, including Bristol Palin (and Jamie Lynn Spears). Using a success story as your poster child undermines changing the societal view of teen pregnancy. Bristol Palin has had relatively few consequences of being a single mom. She graduated from high school and has a supportive family to help her through the tough times. Yes, she may stay up at night with her son and be changing stinky diapers, but she’s far from being destitute and she isn’t facing a tough decision between having the child, giving it up for adoption, or having an abortion. These are real choices that the vast majority of teens who become pregnant deal with and struggle with. Having a little rich girl tell them, perhaps condescendingly, that without her wonderful silver-spoon life, “it wouldn’t be pretty” doesn’t speak to the vast majority of teens, who don’t have the privileged life that Bristol is lucky to have. Holding someone like Bristol Palin on a pedestal is not the way to change societal norms and views about teen pregnancy.

Critique 2: Make a campaign that will reach different groups, not just white teens.

Young teens who are Hispanic and African American are the most at-risk groups for teen pregnancy (9). As a group, white teenage females roughly 20% will get pregnant before they are twenty years of age (9). In comparison, about 51% of Black teens will become pregnant before their twentieth birthday (9). Similarly, 53% of Hispanic teens will conceive a child prior to turning twenty (9). These are alarmingly different figures, yet if you look at the Candie’s Foundation Campaign to reduce teenage pregnancies, the ads are far more appealing to white teens.

Perhaps Malia and Sasha Obama can relate to Bristol Palin, since their family is similarly situated: wealthy, in the political spotlight, etc. While Bristol’s particular ad isn’t one that many teens can relate to, the Candie’s campaign in general may not be something that a young Black or Latina teen can relate to. Candie’s does have two token minority celebrities in the campaign. Ciara has both a print spot and a video spot and Vanessa Mannillo has one print spot. Ciara is featured in one out of four videos and one out of eight print advertisements. While I commend Candie’s for including these two women in the campaign, there are many minorities that aren’t represented, for instance, Latinas have no celebrity representation.

Where minorities are the most at-risk groups, an effective campaign to reduce teen pregnancies should be more focused on these groups. I could speculate if this was intentional, but this certainly hints to institutionalized racism. This may not have been a conscious decision, but it represents the systematic difference in how a public health problem is approached (10): with a prominent focus on whites. Although the majority of the population is white, there is a disproportionality of the teen pregnancies in the minority populations and interventions and campaigns must take this into account in order to be successful.

Critique 3: Societal Intervention Should be the Focus, Not Individual

Marketing Theory and Advertising Theory are very poignant examples of how behavior can be changed on the group level. These two theories operate by finding out what the target audience wants out of life, then packages its product to sell them their hopes, dreams, desires, needs and wants (11). Looking at just the Bristol Palin video, it’s difficult to figure out what the campaign is selling; in strong advertising campaigns, you know exactly what they are selling and I’m not referring to the product. Each campaign sells a “core value” – something that the target audience wants. It could be power, wealth, attractiveness, sex, etc. Candie’s gets this process. All you have to do is look at their new advertisements featuring Brittney Spears and you’ll know that it’s “sex” that the brand is selling, not clothes, shoes, or underwear. In fact, Candie’s has come under fire for this, according to the New York Times (6) and shortly after it, The Candie’s Foundation was established. If I were Neil Cole, head of Iconix (which owns Candie’s) and really wanted to run an effective campaign against teen pregnancy, I would use “sex” as the core value in the prevention advertisements. (This will be discussed in a subsequent section.)

There are a lot of other elements of marketing and advertising theory put into practice in this campaign, but they seem to miss the heart of effective advertising and marketing: selling a strong core value that appeals to your target demographic. What is positive is that they use branding with a slogan of “pause before you play” and they use a catch color scheme of black and hot pink. The images draw you in, too. These are all great things, but if you don’t have a solid core value or promise to sell, no teen will buy into it.

Additionally, if you look at Social Expectations Theory you want to change the social norms and this is done on a group-level, not an individual-level (8). This campaign targets the teens themselves. This is not necessarily a bad thing; any successful campaign should target the teen demographics in particular. That being said, teens are not the only audience to target. To fully change societal norms, you need to target the media and, most importantly, the entertainment industry.

The entertainment industry’s norms and portrayal of (and acceptance of, perhaps for the sake of drama,) sex and teen pregnancy needs to be changed if you want societal norms to change. If sex is portrayed as a right of passage or a normal activity that everyone is participating in, who would wait to have sex and miss out on sowing their wild oats? Even if you just wanted to peddle the societal norm of using prophylactics each and every time you have sex, then this needs to be portrayed in movies, on the television, and through effective advertisement campaigns.

If you look at practically any mainstream show on television that teens watch, everyone is having sex and protection/contraception is not necessarily tied to that activity: Gossip Girl, Private Practice, Ugly Betty, etc. All the popular and cool characters are having sex and not necessarily in a discriminate approach to the activity. In a recent episode of Gray’s Anatomy, one of the characters discussed with another character that the third date is the “sex” date, especially if your date cooks you dinner. In almost all mainstream entertainment shows, (Desperate Housewives, Grays Anatomy, Gossip Girl, to name a few) there are multiple characters that have sex on the first date (sometimes there isn’t even a date) or if they are trying to be “good” they might wait for the third or fourth date. I have never seen a show where there is a character who wants to wait for sex (and these are very few) and doesn’t end up caving (i.e. the character of Joey Potter on Dawson’s Creek, or the Character of Grace Bowman on Secret Life of the American Teenager). This is the social norm we much change and we should change it to the message that: not everyone is having sex, those who do only enter into it with seriousness, and those who do always use contraception and protection.

Proposed Alteration to this Campaign

The Candie’s Foundation campaign does have some very good attributes. As discussed before, the branding of the website and the advertisements is done well. It also has tank tops that support the cause and help with branding, that say: “I’m SEXY enough to keep you waiting…”, “Be SEXY. It doesn’t mean you have to have sex.” Additionally, the color and the lay-out of the website is eye-catching, in black and hot pink.

Some of the messages and print ads are purposeful and might be effective and influential. For instance, there are several print ads where you see a celebrity’s face on one page and on the other pages is a baby stroller with the caption “Not what you had in mind for your first set of wheels, huh?” Other print ads have a similar format, but depict a baby bottle with the caption, “You think being in school sucks?” Last, there are ads that have a baby’s crib with the caption, “Not really what you pictured for your first crib, huh?” I think these tie in nicely with the campaign’s key tag-line, “Pause, before you play.” These all send the message to think about the consequences of having sex.

That being said, the messages are negatively depicting parenthood and having a child. There is a better way to go about this. The core values that this campaign should be reframed to “sell” are the core values of either independence/freedom or sex. It’s obvious by the number of teen pregnancies that many American teens are interested in sex, so why not repackage it and sell it in a way that makes sense? Why not package it along with freedom and independence, which are two core values that appeal to teens?

Instead of focusing on the consequences of pregnancy, this campaign could focus on how being smart about sex, by either waiting or using contraceptives, teens are empowered and provided with independence and freedom. For instance, instead of just having the baby crib, the campaign could show two “cribs”: one baby crib, and one nice apartment with young, college kids enjoying a dinner party. Perhaps, the new tag-line should be something like, “What do you want your first crib to look like?” Then, instead of only focusing on the consequences, you can “sell” the teens the alternative of living a fun life in college or as a young professional without a baby. The same goes for the baby carriage; the carriage could be opposite a picture of a teen purchasing his or her first car (or receiving the keys to the car). Also, the tag-line that runs with these advertisements could be, “What do you want for your first set of wheels?” These ads wouldn’t totally focus on the consequences, but would remind teens that this is a choice and that they are the ones who control the choice between being a teen father/mother or having independence in their young life.

Additionally, while refocusing the messages could solve part of the problem with this campaign, it really needs to select someone who is an appropriate spokesperson. The spokesperson should be someone who is believable, likeable, and to whom teens can relate. Perhaps they could bring on teen mothers who don’t have the support of their families, who aren’t wealthy, and who live with very tough choices each day; this might be especially effective if they couple it with those mothers promoting a message that while having a child can be wonderful, it’s not something that should happen in your teens year and not until you are ready (financially, emotional, etc.).

Alternatively, they don’t need to have just one spokesperson and these people don’t need to be single parents. I think selecting celebrities who have been responsible and who, themselves, haven’t participated in shows/music videos/etc. that feed into the “everyone is having sex” mentality. Celebrities such as Hayden Panettiere, Alicia Keys, Hilary Duff, etc. fit the criteria. I’m sure there are many others out there who also could be great spokespersons.

There are two other issues that Candie’s needs to consider when choosing spokers persons: First, that there should be more representation of minorities, since minorities are disproportionately at risk for teen pregnancy. Second, for the Candie’s Foundation campaign to be successful, they cannot undo their work by using a poster-child for promiscuity and/or bad decisions.

Reaching out to celebrities or other spokespersons of color is key to run an effective campaign. Teens of color must have something in the campaign that they can relate to, in order to boost efficacy. Starting with Alicia Keys, Raven Symone, or America Ferrera would be a great starting point for respectable stars who set a great example (or at least stay out of the tabloids) for teens. Alicia Keys would be great especially since she started her career in music so young. Having her in the campaign can talk about how her success wouldn’t have been possible if she had gotten pregnant. This provides teens with a positive role model to whom they can relate and shows the positive side of waiting or using effective contraception: they too can achieve their goals and become successful. Also, Raven Symone is a fabulous role model for young girls. She is young, successful and has been acting since she was very young. She has appeared in many teen roles, including her own show “That’s So Raven.” Her continued success can be tied in with positive, affirmative messages for teens to make responsible, good choices. Additionally, America Ferrera has been acting since she was young. She could use this platform to encourage kids to pursue their dreams and not compromise by making a bad or risky decision. More spokespersons of color should be added, whether famous or not.

As previously stated, if the Candie’s Foundation wants to run a successful campaign, it cannot use a poster-child for promiscuity and/or bad decisions in its advertising. If the Candie’s company uses, for instance their current spokeswomen, Brittany Spears for as the face of their clothing line, what message does that send to teens? Teens are probably more likely to see a Candie’s campaign before they see the Foundation’s ads. Candie’s is a brand and it should be a united front between the Foundation and the apparel line: both should promote strong women who make good life choices and aren’t the subject of tabloid fodder. Brittany Spears is no role model for a teenage girl. Alternatively, Candie’s should be applauded for bringing on Hayden Panettiere and should bring in more women like her. They should strive to bring in celebrities with a positive image and should also bring in more celebrities of color to be the cover of the apparel line. Any of the beautiful women of color mentioned in the previous paragraph would be excellent choices.

To address the last issue of societal norm changing, the Candie’s Foundation campaign should not just target teens. It should put social pressures on the entertainment industry to provide decent entertainment which would include more characters who either wait to have sex and/or use contraception properly (and every time they have sex). Both television and movies can change societal norms because they reach the vast majority of Americans, many of them on a daily basis. The Foundation should lobby for less focus on sex as a story-line and if there is a sex story-line, that it is one that doesn’t promote an “everybody is doing it” and/or “everyone has sex on the first, second or third date” mentality. Teens need positive role models and reinforcement of and support for the courageous decision to either wait on sex or demand that contraception be used.

Candie’s could put together a consistent message through coupling the Foundation’s brand with the apparel brand. They should include more persons of color as representatives and role models and should focus their messages on empowerment, rather than consequences. That would be a good start. To really be most effective, they must put pressure on society to change our norms and acceptance of teens having sex so young and/or without proper contraceptive means. Only then will we see a larger and prominent change.

References:

1. Kaiser Family Foundation, National Campaign to Prevent Teen Pregnancy: The More You Know About Teen Pregnancy, found at http://www.kff.org/youthhivstds/1360-teensstat.cfm, last accessed on 4/16/10
2. American Medical Student Association, 1998-99 National Initiative on Teenage Pregnancy, found at http://www.amsa.org/AMSA/Libraries/Committee_Docs/teen_pregnancy.sflb.ashx, last accessed on 4/16/10
3. The National Campaign to Prevent Teen and Unplanned Pregnancies, Teen Pregnancies in the United States, 1988-2006. Also found at http://www.thenationalcampaign.org/resources/pdf/Briefly_TeenPregRates_1988-2006.pdf, last accessed on 4/16/10.
4. The National Campaign to Prevent Teen and Unplanned Pregnancies, Why are the Teen Pregnancy and Birth Rates Increasing?, January, 2010. Also found at http://www.thenationalcampaign.org/resources/pdf/Briefly_Why-Are-the-Rates-Increasing.pdf
5. See, http://www.candies.com/
6. New York Times, Bristol Palin’s New Gig, May, 2009. Also found at, http://www.nytimes.com/2009/05/07/opinion/07collins.html?_r=1, last accessed on 4/16/10
7. ABC, Good Morning America, Teen Mom Bristol Palin: The New Fact of Abstinence, May, 2009. Also found at: http://abcnews.go.com/GMA/story?id=7510385&page=1, last accessed on 4/16/10
8. For discussion of Social Expectation Theory and how media works to pass on social norms. DeFleur ML, Ball-Rokeach SJ. Theories of Mass Communication (5^th edition), Chapter 8 (Socialization and Theories of Indirect Influence), pp. 202-227. White Plains, NY: Longman Inc., 1989).
9. The National Campaign to Prevent Teen and Unplanned Pregnancies, Policy Brief: Racial and Ethnic Disparities in Teen Pregnancies, 2008. Also found at http://www.thenationalcampaign.org/resources/pdf/Briefly_PolicyBrief_RacialEthnicDisparities.pdf, last accessed on 4/16/10.
10. Jones, CP. Levels of racism: A theoretical framework and a gardener’s tale. American Journal of Public Health 2000; 90:1212-1215.
11. How to build great campaigns (Chapter 5). In: Ogilvy D., Confessions of an Advertising Man. New York: Antheneum, 1964, pp. 89-103.

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

INTRODUCTION

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

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

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

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

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

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

CRITIQUE I

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

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

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

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

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

CRITIQUE II

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

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

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

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

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

CRITIQUE III

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

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

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

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

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

IMPROVED INTERVENTION

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

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

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

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

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

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

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

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

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

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

CONCLUSION

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

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

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