Friday, December 21, 2012

Abstinence-only Education: A Naïve, Flawed and Ineffective Intervention - Megan Heffernan


For years, both parents and teachers have tiptoed around conversations about sex with teenagers and ignored the serious issues stemming from unsafe sexual behavior; public health interventions, especially through governmental funding, have focused on teaching abstinence instead of promoting safe sex.   Youths having unprotected sex leads to unplanned pregnancies and higher rates of HIV and STDs.  In Louisiana, this problem is magnified, yet the state government still refuses to permit comprehensive sex education in public schools.  
Nationwide since 2006, the number of diagnoses among youths aged 13-24 has been steadily increasing, accounting for almost a quarter of all new cases (1). According to the most recent CDC HIV Surveillance Report, Louisiana ranked fourth in the country in terms of AIDS case rates.  In terms of other STDs, Louisiana continues to rank among the worst states in the country.  In 2010, it ranked 1st in the national in primary and secondary syphilis rates, 1st in congenital syphilis rates, 2nd in gonorrhea rates, and 3rd in chlamydia rates (2).  Finally, the U.S. teen birth rate for women ages 15-19 in 2010 was 34.5 per 1,000, but the Louisiana teen birth rate was 47.7 per 1,000, which included 8,974 total births (3).   Although the teen birth rate has decreased since 2007, Louisiana continues to have rates above average.  These are major health concerns for the state and southern region as a whole, yet the majorly funded intervention continues to be abstinence-only education. 
In order to analyze abstinence-only education, the first place to look is the legislation; Louisiana state law currently reads:
The major emphasis of any sex education instruction offered in public schools of this state shall be to encourage sexual abstinence between unmarried persons and any such instruction shall:
a) Emphasize abstinence from sexual activity outside of marriage as the expected standard for all school-age children.
b) Emphasize that abstinence from sexual activity is a way to avoid unwanted pregnancy, sexually transmitted diseases, including acquired immune deficiency syndrome, and other associated health problems. 
c) Emphasize that each student has the power to control personal behavior and to encourage students to base action on reasoning, self-esteem, and respect for others.  (4)

Even within the text of the law, major flaws can be seen.  The law mentions basing behavior on “reasoning, self-esteem, and respect for others,” showing reliance on the Health Belief Model and an inaccurate assumption that adolescents’ behavior is reasoned and rational.   Secondly, by using teachers as implementers, the intervention violates Communications Theory, which stresses the importance of specific characteristics of both the message and messenger.  Finally, abstinence-only education induces significant psychological reactance, most likely resulting in an increase in sexual behavior, the opposite of the intended result. 
Critique #1: Adolescent Behavior is Not Reasoned and Rational: Flaw of the Health Belief Model
  The abstinence-only campaign assumes that adolescents make decisions, specifically regarding their health, in a rational and reasoned manner.   In congruence with the Health Belief Model, which focuses on perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action and self-efficacy, abstinence-only education stresses the importance of weighing the positive and negative consequences of every decision.  “The HBM is known as a value expectancy model, which basically refers to the assumption that people will engage in healthy behavior if 1) they value the outcome (being healthy) related to the behavior, and 2) they think that the behavior is likely to result in that outcome.” (5)  The abstinence curriculum attempts to inform students of the severity of HIV and other sexually transmitted infections, in an attempt to sway the balance towards perceived risks.  The message, “If you don’t have sex, you won’t get HIV or get pregnant,” stresses the perceived benefits of remaining sexually inactive.   Finally, supporters believe promoting self-esteem and respect for yourself and others will provide adolescents with the self-efficacy necessary to make the appropriate decision regarding sex. 
If students rationalized their decisions about whether to have sex using the thought process portrayed in the Health Belief Model, then perhaps the risk would in fact outweigh the benefits.  In this circumstance, however, the Health Belief Model and the abstinence-only campaign do not account for two extremely important influences on adolescents’ decision-making process.   First, in the moment when a young boy or girl is thinking about whether to have sex or not, most likely the abstinence-only education they received in school is not the highest influence on their decision.  Sex is a behavior driven by emotion, not a rational thought process.   For adolescents, having sex is similar to smoking, in that “a youth’s reason for using tobacco had everything to do with emotion and nothing to do with rational decision making.” (6) Second, the Health Belief Model does not account for social norms or peer pressure.   In terms of decisions about sex, significant pressure may come from a partner, friends or peers that could change the opinion or behavior of an adolescent.  A student may have decided after their abstinence-only class that they wanted to wait to have sex to avoid the risks associated with the behavior, however the social pressure to conform may dictate the final choice.  “If you care about what other people think about you…then you might go along with the crowd to avoid their wrath or curry their favor.” (7) Ultimately, adolescents’ lives are complicated, easily manipulated, and void of rational decision-making, which all contribute to the flawed nature of abstinence-only education and its foundation in the Health Belief Model.

Critique #2: Ignores Communications Theory

Abstinence-only education, taught by teachers to youth, ignores communications theory, which says the source of a public health message should be someone who is likable, familiar, and similar.  According to McGuire, messenger credibility is enhanced by power, perceived expertise, perceived honest, attractiveness and being similar to the target audience.  Additionally, the message must be realistic and use an appropriate tone for the audience (8).  Most likely, teachers are not the most effective messengers of abstinence-only education for teenagers.  Students listen to their teachers throughout the day, every day of the week, and the abstinence-only message most likely gets lost with everything else.  Furthermore, teachers lack similarity to their students, which reduces their reliability. 
In their study, Lloyd et. al discussed sex education with a number of focus groups, predominately concentrating on African American youth.  According to the students, the type of sex education they received in school varied from a movie about diseases, to signing a piece of paper saying you’ll stay abstinent, to nothing at all.  “One male youth insisted, ‘I would never listen to a teacher [providing sex education].’  Youth expressed a desire to learn from health professionals (e.g. physicians, nurses, health educators), role models (e.g. coaches) or people living with HIV/AIDS rather than teachers, whom they perceived as uncomfortable teaching sexual health and unable to relate to the everyday experiences of youth.” (9) Although this study was performed in rural North Carolina, African American students in New Orleans most likely have similar opinions on their current sex education.  These specific complaints from students follow the communications theory, in that they look for expertise, honesty or similarity.  Although a doctor may not be the most similar to the students, when the message comes from an expert, it is likely to be more seriously received.  Students mentioned wanting the message to come from a role model, which would be a person that could relate better to the students’ lives.  Ultimately, in New Orleans, students receive either no sex education at all or limited abstinence-only education with their teachers as messengers, which has been shown to be extremely ineffective. 

Critique #3: Induces Psychological Reactance
Finally, the current sex education intervention for adolescents induces psychological reactance, and may in fact persuade them to have sex instead of promoting abstinence.  Telling a teenager what to do threatens their control, forcing them to find a way to restore their freedom, often by doing the opposite of the suggested behavior.  This backlash, known as psychological reactance, is a response to threats to perceived behavioral freedoms (10).  “One way to bolster a threatened freedom is to exercise that freedom – people thus seek censored activities, show ‘boomerang effects’ in response to threatening messages, and choose forbidden decision alternatives.” (11) For teenagers, having sex is considered a personal freedom, and when that freedom is compromised, they will most likely respond by participating in risky sexual behavior.   Additionally, a threat to one freedom often induces a fear of threats to other freedoms, a phenomenon associated with psychological reactance known as implication theory (12).   Therefore, when a teacher deprives a student of their sexual freedom, the individual may perceive it as a threat to further freedoms, inducing a stronger force to react.   Because freedoms are constantly limited in a teenager’s life, they seek any behavior that can restore their control, and sex is often first on the list. 
In youths, the psychological reactance can materialize as rebellion: rebellion against their teachers, rebellion against their parents, and rebellion against society.  As mentioned previously, anti-smoking campaigns have had similar effects on youths: by telling them they should not smoke, it actually encourages it.  “Like piercing an ear or dying hair, using tobacco was a tool of rebellion and all about sending a signal to the world that the user made decisions for themselves.” (6) Similar effects have been studied in college students and drinking, as Bensley and Wu indicated that dogmatic alcohol prevention materials might have counterproductive effects for some college students due to psychological reactance (13).   Like smoking and drinking, for sexual behavior, the results are similar.  Miller and Quick found that psychological reactance was predictive of risky sexual behavior in emerging adults (14).  “Human nature being what it is, there are always tendencies toward deviant behavior.  People transgress norms; they fail to play roles according to expectations; they defy the wishes or orders of the powerful, or they fail to recognize the status of those who enjoy social honor.” (15) Teenagers use their sexual behavior as an outlet to rebel and to maintain a sense of control over their lives.  For this reason, promoting abstinence ignores the innate nature of adolescents, and consequently is bound to fail.
Finally, as mentioned in terms of communications theory, the abstinence-only education campaign ignores the importance of similarity in delivering a behavior-changing message.  By using teachers as the vector for delivering the message, the campaign increases the reactance among adolescents.  Although a threat to freedom will always cause some negative reactance, certain techniques, such as interpersonal similarity, can reduce the negative force to improve compliance (11).  According to Silvia, similarity can “increase the positive force toward compliance by increasing liking for the communicator.  Second, similarity can reduce the negative force toward resistance by fostering positive interpretations of the communicator’s actions, particularly the degree of threat in the message.” (11) Clearly, current abstinence-only education does not take advantage of the theory of similarity, but instead continues using communicators who trigger significant negative reactance against the intended message. 

Let’s Talk about SEX
In April 2012, the CDC published a report about HIV, other STD, and pregnancy prevention education in public secondary schools between 2008-2010, specifically looking at the 45 states that had information available.   Not surprisingly, Louisiana was one of 5 states not represented in the report (16). Clearly, Louisiana is behind the curve in terms of the trend across the country, and it does not appear changes will be occurring anytime soon.  Most recently, in May 2012, a bill requiring the teaching of sex education in Louisiana public schools failed (17). Because interventions cannot be implemented through the public school system, a campaign that reaches students outside of school must be utilized.  Although the current model is ineffective, education in terms of sex, HIV and pregnancy is important, but it must exist with the appropriate message, messengers and circumstances.  A more effective intervention would take advantage of social marketing to promote the program: “Let’s talk about SEX.”    In small groups, led by young adults, teenagers would be encouraged to talk about sex, specifically how to protect themselves without reducing pleasure.  The program would glamorize condoms, in an attempt to change the attitudes of the students regarding condom use.  Although education about HIV, STDs and pregnancy would be a part of the intervention, it would not be the focus.  Therefore, the intervention is not based on rational decision-making process in accordance with the Health Belief Model, a flaw of abstinence-only education.  By using peer discussion and facilitation by young adults, the program will follow communications theory.  Finally, by talking about sex instead of forbidding it, the negative psychological reactance will be eliminated.

Decision-making is Irrational
Public health campaigns must acknowledge and remember that an adolescent’s decision-making process does not follow a rational, risk-weighing procedure, but conversely is influenced several outside factors.  In the “Let’s talk about SEX” program, the goal will be not only promoting conversations about sex, but also increasing the appeal and “sexiness” of condoms.   Remembering the flaws of the Health Belief Model, and that in the heat of the moment a person may not weigh the risks and benefits of using a condom, this program will instead appeal to innate human drives, such as pleasure.  By talking about the benefits of condoms in terms of sexual pleasure instead of avoiding disease and pregnancy, the goal is to create a desire instead of an obligation to use condoms.  The message is not, “When you are having sex, you should remember that not protecting yourself can lead to serious disease and pregnancy, and therefore use a condom,” but instead, “Sex with a condom is fun, sexy and gives you control.  Everyone is doing it!”  By normalizing and glamorizing condom use, the hope is that teens will actually be pressured INTO using condoms by their peers, because it is the cool, sexy, fun thing to do.  

Using Young Adults as Facilitators
One of the major flaws with the abstinence-only campaign is the use of teachers as messengers, and the fact they are not the most compelling people to be sending the message according to Communications Theory.  McGuire discussed the importance of attractiveness and similarity of a messenger, in addition to using a realistic message.  By using young adults, possibly recent high school graduates, as the facilitators of these discussions about sex, the teenagers will be more likely to appreciate the message.  Additionally, telling students to abstain from sex until marriage is not realistic, and therefore ineffective.  However, promoting the appeal of condoms is realistic and the students can relate, specifically when the message comes from possible role models and people they admire.  Finally, because older, more mature, but still “cool” young adults would be promoting the “sexiness” of condoms, the younger students would take their opinion seriously, therefore having a stronger impact on their current beliefs. 

Avoiding Psychological Reactance by Promoting Sex
Telling teenagers not to have sex threatens their freedom, which then results in the opposite action, where they have sex in order to restore control.  Instead of limiting adolescents’ options to abstinence, the “Let’s talk about SEX” program promotes conversations, specifically about sex, pleasure, and condoms, in order to reduce the psychological reactance associated with the topic.  By talking about different types of condoms and how they can be used in fun ways, the intervention does not deprive freedom, but instead gives them more choices and control.  Control is extremely important to adolescents, and in terms of sexual behavior, by promoting condoms as a form of control, they become more appealing than if they are merely a form of protection.  The goal is the same as safer sex education programs that strive to convince youth to use condoms in order to protect themselves from disease and pregnancy, however the mechanism is different.  Instead of stressing the importance of protection, the focus is pleasure, control and fun: values that resonate more strongly with youth.  Instead of inducing psychological reactance by instructing youth on what they must do, the “Let’s talk about SEX” campaign frames condom usage as something youth WANT to do.

Conclusion
In New Orleans, people wonder why the rates of HIV, sexually transmitted diseases, and pregnancy are higher than the national average, but fail to recognize the root cause is the continued fear of alternative sex education interventions.   According to a study conducted at Tulane University, evidence from across the United States indicates a correlation between the type of sex education and sexual health outcomes.  Therefore, the researchers conclude sex education must be redefined as a public health issue that should be subject to quantitative metrics and quality review standards.  “Low-income communities in Louisiana rely heavily on public schools; thus this has potential to help address socioeconomic health disparities in a population demonstrated to be at particularly high risk for HIV and other negative sexual health outcomes.”  (18) Until sex educations in public schools improve, alternative interventions must attempt to combat the health disparities in the region that lead to high rates of HIV, STDs and teen pregnancy.  Interventions, like “Let’s talk about SEX,” must push the envelope to ensure positive response from adolescents.  In a changing landscape of public health, interventions can no longer follow the strict thinking of the Health Belief Model, but must rely on alternative theories that complement the irrationality of human behavior. 

REFERENCES

(1)   Center for Disease Control and Prevention.  HIV among Youth. http://www.cdc.gov/hiv/youth/index.htm
(2)   State of Louisiana Department of Health and Hospitals.  2010 STD/HIV Program Report.  http://new.dhh.louisiana.gov/assets/oph/Center-PHCH/Center-PH/hiv-aids/2010/2010SHPProgramReportFinal.pdf
(3)   U.S. Teen Birth Rates. http://www.cdc.gov/nchs/data/databriefs/db89_tables.pdf
(4)   Louisiana State Legisltaure.  http://www.legis.state.la.us/lss/lss.asp?doc=80423
(5)   Edberg M. Individual Health Behavior Theories (pp. 191-204). In: Edberg, M, ed. Essentials of Health Behavior. Sudbury, MA: Jones and Bartlett, 2007.
(6)   Hicks, J. The strategy behind Florida’s “truth” campaign. Tobacco Control 2001; 10:3-5.
(7)   Thaler, RH & Sunstein, CR. Following the herd (pp. 53-71). In: Thaler, RH & Sunstein CR, ed. Nudge: Improving Decisions About Health, Wealth, and Happiness. New Haven, CT: Yale University Press, 2008.
(8)   McGuire, WJ. Input and Output Variables Currently Promising for Constructing Persuasive Communications. In: Rice, R & Atkin C, ed. Public Communication Campaigns.  Thousand Oaks, CA: Sage Publications, 2001. 
(9)   Lloyd, SW, et. al. The role of public schools in HIV prevention: perspectives from African Americans in the rural south. AIDS Educ Prev. 2012; 24(1): 41-53.
(10)       Brehm, JW. A Theory of Psychological Reactance. New York, NY: Academic Press, 1966.
(11)       Silvia, PJ. Deflecting reactance: the role of similarity in increasing compliance and reducing resistance. Basic and Applied Social Psychology. 2005; 27(3), 277-284.
(12)       Brehm, JW. Psychological Reactance: Theory and Applications. In: Srull, TK, ed. Advances in Consumer Research Volume 16, 1989. 
(13)       Bensley, LS & Wu, R. The role of psychological reactance in drinking following alcohol prevention messages. Journal of Applied Social Psychology. 1991; 21: 1111-1124.
(14) Miller CH & Quick BL.  Sensation seeking and psychological reactance as health risk predictors for an emerging population. Health Commun, 2010; 25(3): 266-75.
(15)  DeFleur, ML & Ball-Rokeach, SJ. Socialization and theories of indirect influence (pp. 203-227). In: DeFleur, ML & Ball-Rokeach, SJ, ed. Theories of Mass Communication. New York, NY: Longman, 1989. 
(16) MMWR Report. HIV, other STD, and pregnancy prevention education in public secondary schools – 45 states, 2008-2010.  2012. 61(13): 222-228. 
(17) HIV infections among young black New Orleanians traced to abstinence only sex education, 2012 http://www.nola.com/education/index.ssf/2012/08/hiv_infections_among_young_bla.html
(18)  Jham, M, Elliot, L, & Dery, M. Reducing sexual health disparities among adolescent youth: making an evidence-based case for comprehensive sexual health education in Louisiana public schools. AIDS 2012 conference abstract.

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1 Comments:

At May 16, 2013 at 12:03 AM , Blogger Kazi Rahim Ullah Rahi said...

It is a good idea to choice an abstinence program. Abstinence has a lot of benefits. One of them is You will be able to tell your future children that you waited for sex until marriage. Isn't it a thing to be pride in???
Benefits of Abstinence

 

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