Saturday, December 15, 2012

The Failure of Choosing the Best, an Abstinence Program Educating Adolescent Students –Kathleen Grueter

Introduction –Current Speculation Over Abstinence Education 
Sexual activity amongst uneducated adolescents has remained a highly publicized issue in the United States for decades. According to the Centers for Disease Control and Prevention in 2011, 47% of all U.S. teenagers have had sexual intercourse and 16% of all U.S. teenagers were never taught in school about HIV or AIDS infection (1). In 2012, the U.S. Department of Health and Human Services (HHS) stated that one-third of new HIV infections come from people ages 13-29, the larges of any age group (2). Federally funded sex education is utilized in the United States as a primary prevention tool to address numerous public health concerns. Sex education seeks to decrease unplanned adolescent pregnancy and the development of sexually transmitted infections, as well as to promote safe and healthy relationships (3).
The United States has funded more than $1.5 billion abstinence-only education programs since 1997 and until 2010 it was the only form federally funded (4, 7).  As the U.S. Department of HHS states, “Abstinence education is an important preventive component of an overarching federal strategy designed to protect youth from the physical, psychological and economic consequences associated with teenage sexual activity and non-marital childbearing” (3).  However, the Obama Administration made the politically controversial decision in 2010 to defund abstinence-only educational program and began funneling money towards “proven effective” comprehensive sex education programs (4). While comprehensive programs promote safe sex and the use of contraceptives, abstinence programs value the moral importance of saying “no” to the temptation of sexual intercourse prior to marriage.
One abstinence program still federally funded is Choosing the Best. This program was established in 1993 and reaches over four million students across the nation. This program believes “abstinence is the only way to eliminate physical and emotional risk associated with premarital sex” (5). Choosing the Best has adapted courses for students ranging from middle school through high school to touch upon the various challenges and pressures adolescents face at each stage of life. This program believes it is effective due to the following five keys: Choosing the Best provides current information on health consequences of sex, instills confidence against peer pressure, involves parents, creates a motivational classroom environment, and builds strong moral character in teenagers (5).
Choosing the Best has the potential to have a deeper impact and reach a wider range of adolescences, however drastic changes must be made towards their intervention technique. This paper critiques three aspects of Choosing the Best as a public health approach to educate adolescent students on sexual education, in particular its use of the individual level theory, the Health Belief Model. Furthermore, this paper provides an alternative intervention that addresses the three crucial flaws of Choosing the Best.
Critique #1: Choosing the Best: Influenced by the Health Belief Model
            One of the five keys to effectiveness of Choosing the Best is that provides current information on the health consequences of sex. Choosing the Best, like all abstinence education programs, is based around the idea that public health officials will positively influence adolescent students if they intervene early and inform students of the risks of premarital sex as well as the benefits of abstinence. For example, Choosing the Best Path, which is aimed grade seven students, teaches that “one in five Americans aged twelve and up contract genital herpes. Assertiveness training in these eight lessons engage students in learning how to say “NO” to premarital sex and “YES” to health relationships” (5). Choosing the Best assumes that once students understand the perceived risks of having sex, such as out-of-wedlock pregnancy and the contraction of a sexually transmitted infection (STI) like genital herpes, the adolescents will choose abstinence; these students value their health and will rationally deter from the psychological, physical, and financial repercussions that can extent from premarital sex. This assumption that we, as human beings, rationally follow a value expectancy model when making decisions is based on the oldest and most popular individual behavior theory, the Health Belief Model (HBM) (10).
The HBM was created in the 1950s due to the research of the U.S. Public Health Service (USPHS) social psychologists, Godfrey Hochbaum, Irwin Rosenstock, and Stephen Kegels (8).  USPHS offered free tuberculosis screenings to citizens through mobile clinics; the social psychologists sought to understand the reasoning behind the decision of the majority of the citizens to not take advantage of the mobile clinics (8,9). Through their research, they determined that all of the citizens performed a cost-benefit analysis and only a few actually believed the perceived benefits outweighed the perceived costs and took action.  This analysis was based upon their perceived susceptibility of becoming diseased, the perceived severity of this disease, the perceived benefits of taking action, and the perceived barriers of taking action. After weighing their costs against the benefits, those intent on preventing and screening for tuberculosis waited for the “cue to action”. Their attendance at the screening was determined by their “self-efficacy” and ability to successfully follow through with action (9).
Over the years, there has been speculation over the HBM and if all human being decision-making can be based upon this value expectancy model. Studies have questioned whether we, as human beings, choose to engage in healthy behavior simply because we value the outcome and understand that a certain behavior will lead to this outcome (8, 11). As Day, Dort, and Tay-Teo suggest, one of the flaws of utilizing the HBM is that model “does not have the power to predict behaviors consistently”. The HBM is often times successful at predicting certain linear human behaviors, such as choosing to take part in a tuberculosis screening. However, the HBM cannot always predict more complex behaviors that involve external pressures, such as adolescents engaging in sex (11).  
Dan Ariely furthers this thought that human behavior is not always simple to determine in his book, Predictably Irrational. In Chapter 5: The Influence of Arousal, a study is performed on decision-making and sexual arousal “to understand the degree to which rational, intelligent people can predict how their attitudes will change when they are in an impassioned state” (12, pg. 89). The study compared participants’ answers on the topics of prevention, protection, conservatism and morality first when they were in a hot aroused state, then in a cold state (12, pg. 97). The results demonstrated that we as human beings are completely irrational at times and a model, such as the HBM, cannot predict this irrationality. For example, on the five questions on immoral activity the participants were 136% more likely to engage in immoral activity when in a hot state compared to a cold state (12, pg. 136). This study castes doubt that informed adolescent children enrolled in Choosing the Best will always weigh the costs and benefits and choose abstinence. Although in a cold state a teenager may understand the repercussions associated with premarital sex, they will not always make the rational choice depending on their emotional state. Furthermore, this study suggests that Choosing the Best and other abstinence education programs are not the most suitable form of sexual education for adolescent children; teenagers need to be informed about contraceptives due to the fact their behavior is not always rational.
Critique #2: Choosing the Best: A Trigger for Psychological Reactants
The second key to effectiveness of Choosing the Best is that this program instills confidence against peer pressure. According to the Psychological Reactants Theory, this aforementioned ability to combat against peer pressure is highly unlikely. Adolescent children enrolled in this program are taught that abstinence is the only way to truly remove the risk of the physical, psychological, and financial risks associated with premarital sex. As Jack W. Brehm suggests, “Freedom of behavior is a pervasive and important aspect of human” (13). This abstinence or nothing attitude leads to freedom feeling threatened. A sense of control has been taken away from these teenagers. As Paul J. Silvia state, “One way to bolster a threatened freedom is to exercise the freedom—people thus seek censored activities, show “boomerang effects” in response to threatening messages” (14). Rather than adhere to the guidelines of abstinence, adolescences are likely to respond to peer pressure and engage in sexual promiscuity because it is a freedom that they have not been provided. 
Studies have yet to prove the long-term effectiveness of abstinence programs, such as Choosing the Best, which suggest that adolescences are indeed experiencing reactants and the “boomerang effect” is occurring. Title V of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 was established and began funneling $50 million into abstinence education annually.   In one study, Congress authorized a multi-year evaluation of effectiveness of four abstinence-only programs funded by Title V. The study demonstrated that the abstinence education programs had no impact on the rate of sexual activity or rate of unprotected sex of the adolescences (15).  As Advocates for Youth states, “No abstinence-only program has yet been proven through rigorous evaluation to help youth delay sex for a significant period of time, help youth decrease their number of sex partners, or reduce STI or pregnancy rates among teens” (4).  Rather than threatening the adolescents’ freedom and triggering psychological reactants, Choosing the Best ought to establish autonomy by informing them of all of their options, including contraceptives.
The third key to effectiveness of Choosing the Best is that the program promotes parent involvement and participation at home. According to an experiment performed in Deflecting Reactance: The Role of Similarity in Increasing Compliance and Reducing Resistance, when participants lack similarities with a communicator, threats to freedom decrease the likelihood that the participants will agreement with the communicator (14).  Moreover, when the communicator was similar to the participants in characteristics, such as age or year in school, these similarities had a great effect on agreement. As Silvia states, “it was predicted that interpersonal similarity can reduce reactance by increasing compliance and by reducing resistance” (14). Therefore, according to the Psychological Reactants Theory, it would be best to not use parents as a communicator on a topic as sensitive as sexual activity. The adolescents could feel threats to freedom due their dissimilarities with the communicator and the “boomerang effect” could occur (14). According to this experiment, it would be most effective to use a communicator that is both likable and similar to the adolescent students (14).
Critique #3: Choosing the Best: Limiting Health as the Core Argument
Choosing the Best’s fourth keys to effectiveness is creating a motivational classroom environment. As their website states, “The philosophy of Choosing the Best is that abstinence education is about health for our teens” (5). This program is centered on the core value of health; it could gain more enthusiastic support in the classroom if it honed in on a more compelling core value, like opportunity or freedom (18). As stated in The Power of a Frame: Analysis of Newspaper Coverage of Tobacco Issue—United States, 1985-1996, “the concept and symbolic importance of individual freedoms are deeply ingrained in American myth, culture, and law” (18). Americans are intrinsically drawn to the idea of freedom.  Therefore Choosing the Best does not utilize the most effective means of attracting teenagers or creating a motivational classroom environment. Rather than emphasizing health, Choosing the Best ought to focus on this educational program providing adolescence the opportunity and freedom to a better future. If Choosing the Best reframes their core values it will emotionally appeal to a greater audience.
The final key to effectiveness is building strong moral character in teenagers. To better achieve this goal, they need to better connect with their audience by promoting their brand as a desirable service that teenagers strive to be apart of. According to Leonard L. Berry, “Strong-brand service companies consciously pursue distinctiveness in performing and communication the service, use branding to define their reason for being, connect emotionally with customers, and internalize the brand for service providers” (16). Choosing the Best strives to build strong character in adolescents so it needs to better communicate its goal to attract and emotionally connect to the masses of youth. Rather than simply branding itself as an education resource for healthy, moral teens, Choosing the Best could brand itself as company that develops confident, knowledgeable young adults with the world at their fingertips.
New Intervention: Comprehensive Sex Education with the Use of Mass Communication

            In spite of its flaws, Choosing the Best has the right intentions of educating the American youth on the risks associated with premarital sex. Moreover, this program has an enormous platform and reaches four million students. If Choosing the Best utilizes the following radical intervention, it will be able to reach an even greater number of adolescents and have a deeper impact.
First, Choosing the Best must begin providing comprehensive sex education.  Adolescence must understand the types of contraception and correct precautions to take if and when they decide to engage in sexual activity. With more and more evidence available on the ineffectiveness of abstinence education, it is time for the restructuring and redirection of this form of education program. The Obama Administration decided in 2010 to begin funneling money into comprehensive sex education because unlike abstinence education, there is evidence to demonstrate that comprehensive education delays the onset of sexual activity in youth and increases condom and contraceptive use (17).
Second, each school that is enrolled in Choosing the Best, must begin a peer-mentoring program. Previously, Choosing the Best provided video vignettes of teens, classroom discussions with teachers, and conversations with parents, however these methods were insufficient as a means of communication with vulnerable adolescents. One study in particular demonstrated that students enjoyed peer-led education compared to teacher-led education (21). Through the peer-mentoring, adolescent students can communicate with each other on topics that are difficult to discuss with adults and receive advice. This program would allow upperclassmen students to act as mentors to their younger peers and provide valuable guidance due to the fact they recently experienced similar circumstance. The mentors not only relate to the mentees in age, but the mentors are also can relate in terms socially and economically as they are from the same region (14).
Third, the brand of Choosing the Best must be transformed.  Previously, Choosing the Best was branded as a program that focused on the core values of teen health and morality. Now that Choosing the Best provides comprehensive sex education, it will be branded as a program that provides youth the freedom to make their own autonomous decisions (18). The American youth are now choosing the best decision for themselves. The slogan will be “Knowledge is Power”.
Fourth, Choosing the Best will utilize the media to extend their influence throughout the nation and create a movement around the catch phrase “Knowledge is Power”. Choosing the Best will send a press release to the media announcing the transformation of the program. The press release will state that Choosing the Best will be holding a rally in Times Square in New York City to announce the exact changes to the curriculum, including the “Knowledge is Power” movement (20). Speakers at the rally include young actors, singers, and athletes in support of the movement (14, 19). After the rally, Choosing the Best will broadcast commercials on typical youth television stations and buy advertisements on social media websites and teen magazines. These advertisements will include positive stories from teens as well as celebrities (19). The American youth will be even more attracted to the “Knowledge is Power” movement and more likely to seek Choosing the Best educational programs at their schools when they see that popular young celebrities in support the program.
The overall purpose of Choosing the Best’s “Knowledge is Power” movement is to empower the youth of American to seek comprehensive sex education. We all deserve the right to make an informed decision about our bodies and our future.   
Defense of New Intervention 1:
            Under the new intervention, Choosing the Best utilizes comprehensive sex education. This form of education greatly reduces the flaws associated with abstinence-only education. Abstinence education is based off of the Health Belief Model and makes assumptions about human behavior. It assumes that we weigh the perceived threats associated with an action against the perceived benefits and make an informed decision. While these assumptions are true when evaluating certain human behaviors, they do not predict accurately the complex and emotional nature of sexual activity. Teaching comprehensive education and informing adolescent students about all forms of contraception prepares these teenagers for all circumstances. We, as human beings, are irrational and ought to be informed and prepared to handle any circumstance.
Defense of New Intervention 2:
            The new intervention greatly reduces the occurrence of psychological reactants. These students do not feel their freedom has been taken away because they are no longer threatened by ultimatum of abstinence or nothing. There is very little likelihood of the “boomerang effect” occurring under this intervention because the students are now informed and free to make whatever decision they wish (14). Rather than feeling threatened, the students feel autonomous.
            Moreover, this intervention significantly decreases the probability that students will experience reactants when in the presence of a communicator. Previously, students were taught in a classroom setting with discussion and video vignettes, as well as discussion with parents at home. By establishing a peer-mentoring program, the students are now learning from communicators that are similar to them and more susceptible to agree with their message (14, 19). Secondly, the use of a young celebrity to deliver the message of joining Choosing the Best will likely increase the support and popularity of the program. As Silvia states, “Liking another person increases the tendency to like objects that the other person likes” (14). Not only is the celebrity similar in age, they are also extremely likable.  
Defense of New Intervention 3:

            Rather than simply addressing the public health concern of sex education through a traditional individual level model, the new intervention utilizes multiple alternative models to better persuade American adolescents on the group level.  These models address the fact that we as human beings do not always make rational decisions.
            First, the new intervention brands Choosing the Best in a way that does not immediately associate this sex education program with health. Now this program is associated with the phrase “Knowledge is Power”. When people think of Choosing the Best, it evokes feelings of confidence and autonomy because it provides students the freedom and power to make decisions for themselves (18).
            Second, the new intervention utilizes agenda setting theory. This program uses numerous sources of media including the press release, the rally, television commercials, and social media to get the message of “Knowledge is power” on the public agenda. This program hopes to change human behavior by changing what is discussed in the media (20).
            Lastly, the new intervention utilizes modeling theory. As stated in The Effects of Mass Communication, “[The media] provide symbolic modeling of almost every conceivable form of behavior. A rich literature has shown that both children and adults acquire attitudes, emotional responses, and new styles of conduct from all the media, and especially from films and television” (19.) If Choosing the Best advertises their new brand through media sources they will have the capability of changing behavior on the group level. The youth of America will see celebrities and teenagers spreading the message of “Knowledge is Power” and want to join the movement.

(1) Centers for Disease Control and Prevention. Youth Online: High School YRBS, Atlanta, Georgia: Centers for Disease Control and Prevention.
(2)Presidential Advisory Council on HIV/AIDS. Resolution: Support Comprehensive Sex Education for Our Nation’s Youth. Washington, D.C.: Presidential Advisory Council on HIV/AIDS, 2012.
(3)U.S. Department of Health and Human Services. DHHS Abstinence Education Program, Washington, D.C.: U.S. Department of Health and Human Services.
(4)Advocates for Youth. Comprehensive Sex Education: Research and Results. Washington, D.C.: Advocates for Youth.
(5) Choosing the Best. Curricula. Atlanta, GA: Choosing the Best.
(6)Advocates for Youth. The History of Federal Abstinence-Only Funding. Washington, D.C.: Advocates for Youth.
(7)National Public Radio. Proven Sex-Ed Programs Get a Boost From Obama. Washington, D.C.: National Public Radio.
(8)Individual health behavior theories (chapter 4). In: Edberg M. Essentials of Health Behavior: Social and Behavior Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007, pp. 35-49.
(9)National Cancer Institute. Theory at a Glance: A Guide for Health Promotion Practice. Part 2. Bethesda, MD: National Cancer Institute, 2005, pp. 9-21 (NIH Publication No. 05-3896). Available at:
(10)  Janz, N.K. and M.H. Becker. The Health Belief Model: A Decade Later. Health Education Quarterly; Spring 1984: 1-47. Available at:
(11)  Day, Susan. Social Cognition Models: A Review of Their Relevance for Understanding Participation in Cancer Screening. Victorian Cytology Service 2007; 2-28. Available at:
(12)Chapter 5: The Influence of Arousal (pp. 89-108). In: Ariely, Dan. Predictably Irrational: The Hidden Forces that Shape Our Decisions.  New York, HarperCollins, 2008.
(13)Brehm, Jack W. Chapter 22: A Theory of Psychological Reactance (pp.377-387). In: Burke, Warner. Organization Change: A Comprehensive Reader. San Francisco, CA: Jossey-Bass, 2009.
(14)Silvia PJ. Deflecting reactance: The role of similarity in increasing compliance and reducing resistance. Basic and Applied Social Psychology 2005; 27: 277-284. 
(15) Mathematica Policy Research. Impacts of Four Title V, Section 510 Abstinence Education Programs. Princeton, NJ: Mathematica Policy Research, 2007. Available at:
(16)Berry, Leonard. Cultivating service brand equity. Journal of the Academy of Marketing Science 2000; Issue 1, pp. 128-137. Available at:
(17)Advocates for Youth. Science and Success: Sex Education and Other Programs that Work to Prevent Teen Pregnancy, HIV, and STIS.  Washington, D.C.: Advocates for Youth, 2012. Available at:

(18)Menashe CL, Siegel M. The power of a frame: an analysis of newspaper coverage of tobacco issues—United States, 1985-1996. Journal of Health Communication 1998; 3(4): 307-325.
(19)Defleur ML, Ball-Rokeach SJ. Theories of Mass Communication (5th edition), Chapter 8 (Socialization and Theories of Indirect Influence), pp. 202-227. White Plains, NY: Longman Inc., 1989.
(20)Prologue: “The Game Is Afoot”. In: McCombs, M. Communication and Dem0cracy. Mahwah, New Jersey: Lawrence Erlbaum Associates, 1997.
(21)Forrest, S. A Comparison of Student’s Evaluations of a Peer-delivered Sex Education Programme and Teacher-led Provision. Sex Education. Oxfordshire, United Kingdom, Academic Search Premier, 2002. 

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