Critique of an STD/HIV Prevention Intervention: Safe in the City – Kristin B.

Introduction

            Sexually transmitted diseases (STDs), including Human Immunodeficiency Virus (HIV), are one of the biggest public health issues facing the United States today. Left untreated, STDs can pose serious and oftentimes irreversible health threats, and in the case of HIV, can lead to death. A 2011 Centers for Disease Control and Prevention (CDC) report estimated that there are 19 million new STD infections in the U.S. annually, of which half are among young people (1). STDs cost the health care system over 17 billion dollars a year (1). In addition, a March 2012 CDC report estimated that 1.2 million people in the U.S. are living with HIV and there are 50,000 new infections annually (2). Among these new infections, African American and Latinos are disproportionately affected (2). The same report also determined that one in five HIV-infected individuals is unaware of their status (2). Because STDs and HIV are transmitted overwhelming through sexual contact, getting tested and knowing one's status is imperative in reducing the number of new STD/HIV infections. Research shows that knowledge of one’s status increases the likelihood that infected individuals will decrease risky sexual behaviors (3).

            Abstaining from oral, vaginal, and anal sex, practicing monogamy with uninfected partners, reducing one’s number of sex partners, and using condoms correctly for every sexual encounter can reduce one’s risk of contracting STDs/HIV (4). Because using latex condoms is the most efficient way to reduce the risk of contracting an STD/HIV among those who do not abstain from sexual activity (5), many STD/HIV infection reduction interventions focus on giving people the knowledge and skills to use condoms effectively. Risk factors for not having protected sex include a lack of knowledge and perception of STD/HIV risk, negative attitudes about using condoms, a lack of knowledge about using condoms correctly, a lack of intentions to use condoms, a lack of self-efficacy and skills to get tested, and a lack of self-efficacy and skills for practicing safer sex, including acquiring condoms and negotiating their use. A majority of STD/HIV prevention interventions target these risk factors.

Overview of Safe in the City

            Safe in the City is a 23 minute video designed to reduce HIV and other STD infections by increasing condom use. The video is shown in public STD clinic waiting rooms and has no staff involvement and does not require any counseling or group facilitation – the video is simply shown on loop to those in the waiting room. The video’s goals are to increase STD/HIV knowledge, increase the perception of risk of getting HIV or another STD, promote knowledge of correct condom use and positive attitudes toward condom use, increase intentions to use condoms, build self-efficacy and skills for getting tested and facilitating partner testing, and build self-efficacy and skills for acquiring condoms, negotiating the use of condoms with their partner, and increase actual condom use (6). After watching the video, clients of the STD clinic are expected to use condoms correctly and consistently.

            The video is made up of five parts: three vignettes about negotiating condom use in various relationships and two animated portions about different types of condoms available and proper condom usage. As the video begins, the following words appear on the screen: “Remember, not having sex is the most reliable way to prevent getting an STD. Please talk to your healthcare provider for more information or if you have any questions.” The first story begins with Paul pressuring Jasmine to have sex without a condom, but Jasmine insists on using one. Later, Paul hooks up with an ex-girlfriend, Theresa, but only uses a condom for the end of the sexual encounter. Theresa calls Paul to tell him that she went to a clinic and was diagnosed with an STD and encourages Paul to get tested. Paul gets tested and decides to hold off on any further sex until his test results are back (7). An animated portion about properly putting on and removing a condom follows the story and emphasizes the fact that condoms should be used consistently and correctly for them to be effective (8). The next story shows Luis and Theresa beginning to get intimate and Theresa asking Luis if he has a condom, which he does not. He gets offended and Theresa explains that pulling out is not always effective and doesn’t protect against STDs, and that condoms make her feel safe and free. The scene ends with Luis running to a convenience store and returning to his apartment with a condom (9). The following animated segment is about different types of condoms and emphasizes the idea that there is a condom just right for everyone's needs (10). The final story picks up after Ruben has sex with Tim, who notes afterward that he had a condom with him but they got carried away and ended up not using it. Ruben later has sex with Christina and she finds out that he gave her an STD. The video ends with them going to the clinic together to get treatment for their STD (11).

Flaws of the Intervention

            Findings from the CDC's 2008 evaluation of Safe in the City show that the intervention did indeed significantly reduce new STD infections by 10% among patients attending the clinics where the intervention was provided (12). However, this reduction was seen only in males. Among females who viewed the video, there was neither a beneficial nor harmful outcome found which indicates that the intervention was ineffective among this population. Safe in the City, as the current intervention now stands, is not only flawed for the purpose of increasing condom use and reducing STD infections among females, but is also flawed as a standalone intervention that does not fully take into account social and behavioral science principles, theories, and research.

Critique #1 – Lack of Group-Level Component

            Safe in the City is an individual-level intervention that requires no contact or discussion with healthcare providers. The video is played in STD clinic waiting rooms where patients may choose to actively watch the video or not. In addition, the video is just over 20 minutes long, so the viewer might not have the chance to see the entire video or may only see the end of it. The viewer knows that the people in the video are actors and what is happening on the screen is not real even though it may depict real events. There is no opportunity for discussion or questions, though the video passively lets the viewer know that they should ask their healthcare provider if they have any questions. A short video cannot possibly cover all scenarios that are likely to come up, and because it is scripted, does not allow for spontaneous questions to lead to discussion. Most importantly, the video does not allow the viewer to practice the skills depicted.

            Simply watching a video intended to change behavior without being given the opportunity to practice the skills demonstrated or even discuss what was viewed is deemed less effective than pairing the video with another component (13, 14). In a study that examined the effectiveness of video-based patient education interventions on promoting condom use among men and women in public STD clinics in New York City, researchers looked at results from a control group, a group that only viewed the video, and a group that viewed the video and then participated in an interactive group session led by a trained facilitator (13). Subjects who participated in the interactive group session showed increased STD/HIV risk perceptions, greater self-efficacy, and higher rates of condom acquisition than the control group or the video-only group, however those in the video-only group demonstrated greater STD and condom knowledge and more positive attitudes about condom use (13). Another study, also conducted in public STD clinics in New York City, looked at the impact of a video-based educational intervention on condom acquisition among African American and Hispanic men and women (14). Findings show that compared to the control group and video-only group, subjects who experienced the video in conjunction with a group discussion were significantly more likely to acquire condoms (14).

            An important aspect of social cognitive theory, one of the theories Safe in the City is based on, is observational learning or modeling. Observational learning/modeling is the theory that people do what they see others do, not what people tell them to do (15). However, observational learning/modeling is not complete with just behavior imitation, it must also involve learning skills and retaining those learned skills for future use (16). This connection is made through aspects of the theory known as behavioral capability and self-efficacy, which emphasize the execution of observed skills and address performance and confidence barriers. Without also incorporating these other aspects, the social cognitive theory will come up short when put into practical use. While the stories portrayed in Safe in the City successfully show modeling by depicting bad outcomes occurring when one or one's partner does not wear a condom, the individual-level intervention does not take into account the importance of developing skills and collaborating on strategies for safer sex behaviors, which a group-level component could provide.

Critique #2 – Theoretical Basis in Rationality

            Safe in the City is theoretically based in the Information-Motivation-Behavioral Skills (IMB) Model, Social Cognitive Theory, and the Theory of Planned Behavior. The IMB Model holds that there are three fundamental determinants of risk reduction: information, motivation, and behavioral skills. Information, including facts about STD/HIV transmission and information regarding specific methods to prevention, is seen as the precursor to risk reduction behavior, then comes motivation to reduce risk, which entails attitudes toward prevention, social norms, and intentions to practice preventive behaviors, and finally behavioral skills are seen as needed in order to perform specific preventive acts (17). However, because this particular intervention does not develop behavioral skills, it is only based in the informational and motivational aspects of the model.

            Social Cognitive Theory is built on the understanding that behavior change is based on self-efficacy, goals, and outcome expectancies. It involves reciprocal determinism (the interaction between the individual, the behavior, and the environment), behavioral capability (the knowledge and skills to perform a behavior), expectations (anticipated outcomes of a particular behavior), self-efficacy (confidence in one's ability to take action), observational learning or modeling (deciding to perform a behavior based on watching someone else perform that behavior and seeing the outcome), and reinforcements (responses to the behavior that increase or decrease the likelihood of reoccurrence) (18).

            The Theory of Planned Behavior states that a person's attitude toward a specific behavior and that person's perception of the subjective norms (whether or not the behavior is likely to be approved or disapproved by one's social groups) associated with that specific behavior come together in an intention to perform a behavior (18). This behavioral intention is based on one's perceived behavioral control, which is made up of a person's self efficacy, or a belief in the ability to actually perform a behavior and a belief in the amount of power they have in actually performing the behavior (18).

            The assumption behind Social Cognitive Theory and the Theory of Planned Behavior is that people are rational decision-makers. However, these theories are flawed in that they overlook emotional variables, particularly those associated with sex, which tend to make individuals' behavior especially irrational. In Dan Ariely's book Predictably Irrational: The Hidden Forces That Shape Our Decisions, he discusses an experiment he conducted to demonstrate the influence of arousal. Male heterosexual participants in his study were asked to respond to questions while imagining how they would respond while sexually aroused. The first set of questions revolved around sexual preferences, the second revolved around the likelihood of engaging in sexually immoral behaviors, and the third set revolved around the likelihood of engaging in unprotected sex. Later on in the experiment, the participants were instructed to view arousing pictures and to masturbate while answering the same sets of questions as were originally asked. One of the findings of the study was that individuals were 25% more likely to predict that they would not use a condom in the aroused state than in the unaroused state (19).

            The theoretical basis of Safe in the City assumes that knowledge influences attitudes and that attitudes then influence behavior, yet this is not how actual behavior change seems to work. After watching Safe in the City, individuals may be of the mindset that they will always use a condom, but passion in the heat of the moment has been shown to say otherwise, particularly if one does not have the communication skills necessary for negotiation. While the IMB Model, Social Cognitive Theory, and the Theory of Planned Behavior may work well as a foundation for public health interventions that train in these types of skills, they do not sufficiently address how one can be expected to negotiate behavior, such as condom use, in an irrational or emotional state without training in a specific set of skills.

Critique #3 – Optimism Bias, Illusion of Control, and Stigma Theory Left Unaddressed            Because of the stigmatized nature of an STD/ HIV diagnosis, all public health interventions that aim to reduce new infections will have some of the same fundamental barriers. These barriers stem from Optimism Bias, the Illusion of Control, and the Stigma Theories.

            Optimism Bias is a bias that causes a person to believe that they are less likely to experience a negative event compared to others, yet more likely to experience a positive event (20). In fact, people who regard a disease as extremely serious are most likely to think that their likelihood of contracting that disease is less than average (21). Optimism Bias is the belief that contracting an STD/HIV could “never happen to me”, which leads people to engage in risky behaviors like having unprotected sex. Safe in the City does not address Optimism Bias, so even if an individual views the video, they may not think that the information pertains to them.

            The Illusion of Control is the tendency for people to overestimate their ability to control events, for instance to feel that they control outcomes that they actually have no influence over (22). Realistic control would be the use of condoms, because using a condom does provide actual protection, whereas illusory control would be asking about a partner's sexual history, where this does not provide actual protection, particularly if one's partner has never actually been tested (23). The Illusion of Control can be reinforced every time an individual has unprotected sex but does not get an STD, leading that individual to continue with that risky behavior (23). While realistic control is addressed in Safe in the City through the promotion of consistent condom use, all partners getting tested, and the omission of illusionary control, this may not transfer to the viewer in the clinic who has avoided STDs despite inconsistent protection. In addition, while the video does stress the importance of using a condom every time, Safe in the City does not stress the need to get tested after each unprotected sexual encounter and after each change in partner, particularly if there is not an understanding of mutual monogamy. Instead, the video assumes the viewer will never make a mistake and does not include this possibility in the scenarios.

            Stigma Theory is when an individual has an attribute and society discredits and rejects the individual because of that attribute (24). STDs, particularly HIV, are attributes affected by Stigma Theory and result in an individual being ostracized, rejected, avoided, and discriminated against by families, healthcare professionals, communities, and governments; violence against one who is perceived to have AIDS/HIV or who belongs to a high-risk group also occurs (25). Because Safe in the City is currently only implemented in public STD clinic waiting rooms, it does not address Stigma Theory adequately. The venue should not be exclusive and instead should reach those who are afraid of getting tested for fear of getting a positive result. In addition to Stigma Theory related to testing, some people may fear that using condoms, whether or not one is infected or not, may bring partner rejection (25). Safe in the City does not address how to proceed in a scenario in which one person attempts to negotiate condom use but has a partner that is resistant.

            Safe in the City, along with many other STD/HIV prevention interventions, does not provide ways to combat Optimism Bias, Illusion of Control, and Stigma Theory. A video may not be the best way to address these barriers since interaction with the individual is needed in order to determine their exact level of risk. The intervention’s venue is also problematic since those who are most at-risk for infection may not be successfully reached.

Proposed Intervention

            Safe in the City is not an entirely failed intervention. In fact, it is listed in the CDC's Compendium of Evidence-Based HIV Behavioral Interventions and is classified as a best-practice intervention due to positive evaluation findings (26). As a brief, video-based, individual-level intervention, Safe in the City is effective among males. As an intervention that is easy and inexpensive to implement and that can reach large numbers of STD clinic patients of different races/ethnicities and of different sexual orientations, it can be considered a success. For clinics that want to provide a STD/HIV prevention component but do not have the resources or funding for individual counseling or a group-level program, Safe in the City might even be the best option to make a meaningful impact. Moreover, research does show that implementing a lone video in a clinic is better than solely implementing standard clinic procedures (13, 14).

            A number of aspects of the intervention are good and should be incorporated into the modified intervention. Psychological reactance is the theory that when an individual is told that they cannot have something, there is more of a desire to get that particular something (27). While oftentimes public health interventions tell people what to do or not to do, Safe in the City instead empowers people by giving them choices while still insisting on condom use. There is an entire section of the video devoted to different styles of condoms that one can choose from, even ultra-sensitive ones for those who complain that they do not like the feeling of condoms. Communications theory and modeling call for a likeable, familiar, and similar person to deliver the message. Safe in the City successfully accomplishes this by using a young and racially/ethnically and sexually diverse cast of characters. Reciprocity is the idea that if someone does something for you, you feel like you want to do something for them (28). In the case of Safe in the City, the video drills into one's head that STD clinics have free condoms for the taking. Research has shown that when free condoms are visibly provided, about 80% of people take them, and of those that take them, almost 75% of people report using them (29). Finally, the video shows different reasons for using condoms including STD/HIV prevention, pregnancy prevention, and avoidance of long-term effects of STDs such as infertility, and the importance of using a condom for an entire sexual encounter from start to finish, waiting to know your status and your partner's status before having sex, standing your ground on using a condom even in the heat of the moment, and getting yourself and your partners tested (7, 9, 11).

            The proposed intervention will still involve the Safe in the City video in its full format, but it will also contain a group-level component led by a trained facilitator. This new component will involve group discussion, a skills-building session, STD/HIV and condom use information, and the distribution of free condoms. The following proposed modifications to the intervention will address the critiques detailed in the previous section in the hopes that with the new group-level component, Safe in the City could be an even more effective intervention in reducing rates of new STD/HIV infections.

Modification #1 – Addition of a Small Group Component

            The largest proposed modification to the Safe in the City intervention entails structural change. Instead of an entirely individually-based intervention, the proposed intervention would be a single session, small group-level intervention. This modification directly addresses the issue regarding the lack of opportunity for developing and practicing skill building. Specific aspects are pulled in part from a variety of similar video-based interventions that have an added counseling or group-level component, including RESPECT, Sisters Informing Sisters on Topics about AIDS (SISTA), and Video Opportunities for Innovative Condom Education & Safer Sex (VOICES/VOCES) (30, 31, 32, 33). To begin, small groups of about 4 to 8 individuals would be convened by gender and race/ethnicity, led by a trained facilitator of the same gender and race/ethnicity as the makeup of the group. The session would start with a viewing of the Safe in the City video in its entirety. Once the video was complete, the facilitator would begin the discussion by asking questions about the situations and characters in the video and encouraging participants to relate them to their own lives. The goal of this portion of the session is to increase the perception of personal risk of STD/HIV infection among the participants. Rather than providing general knowledge about STD/HIV, the discussion would focus on the behaviors that put people at risk for infection. The facilitator would also correct any misinformation about STD/HIV and condom use that is discussed.

            Following this discussion would be a skills-building session to work on developing and practicing skills needed for overcoming barriers to condom use. After the skills-building session, the facilitator would educate participants about the different types of condoms available for use. Before the group disbands, the facilitator would actively distribute, rather than passively provide, different types of condoms to participants based on what the participant identifies as needing. Throughout the intervention the facilitator would be available for questions and at the end would let participants know how to contact them if questions or concerns should arise after the session. It should be noted that depending on the needs of a particular group due to gender or culture, aspects of the session could be altered.

             An added group-level component allows participants to learn something through group interaction that they cannot learn from a video alone. Groups accomplish this by sharing common experiences, exposing one another to positive peer influence, increasing motivation to change, and providing support (34). The CenteringPregnancy program exemplifies this in another area of public health, prenatal care. While prenatal care is traditionally delivered individually, the CenteringPregnancy model is based on the theory that groups are effective in providing support and helping people reach goals and so is instead delivered in a group format by a healthcare provider to women in similar stages of pregnancy (34, 35). Evaluations of Centering Pregnancy show that compared to a one-on-one interaction, the group-level program increases social support, perceived empowerment, and exposure to useful skills and information (35). Adding this type of group-level component to Safe in the City will allow participants to learn from one another through discussion, social modeling and the aspects needed for modeling to be successful, behavioral capability and self efficacy, and will thus strengthen the existing intervention.

Modification #2 – Skills Building with Motivational Enhancement and Theory of Gender and Power

            The second modification addresses the flaw in basing a risk reduction intervention on theories that assume behaviors are rational, like Social Cognitive Theory and the Theory of Planned Behavior, while the original intervention is not built to give people the tools to make positive decisions in irrational states. The incorporation of a skills-building session however, complete with group practice and facilitator and group feedback on performance, allows a participant of the new intervention the ability and confidence to negotiate condom use even in an emotional state.

Under the guidance of the facilitator, participants of the new intervention would role-play, practice, and discuss communication skills like sexual assertiveness, which includes refusal skills, or the ability to refuse unwanted sexual contact, and condom negotiation. Training in these types of skills is effective in increasing the frequency of condom-protected sexual activity (36, 37). The skills would first be modeled by the facilitator and then practiced and discussed. The group would discuss problems they have encountered in trying to adopt safer-sex behaviors and develop and practice strategies for overcoming these problems. The IMB Model would now be used in full as a theoretical basis. This skills-building component is also founded in Motivational Enhancement, which promotes positive outcomes by actively involving participants in the behavior change process and in developing risk-reduction strategies that are suited to their own situations (38).

            While this sexual assertiveness skills-building aspect of the modified intervention would ideally address the fact that the original intervention is ineffective in increasing condom use among females, the group sessions would also have a component based on the Theory of Gender and Power. The Theory of Gender and Power is a social structure theory that posits that there is a sexual division of power that characterizes the gendered relationship of males and females, and that this division of power may explain non-condom use among women (39, 40). The modified intervention would address this power imbalance by correcting the misconception that a female asking her partner to use a condom use may imply infidelity or may compromise the relationship. SISTA, a peer-led HIV prevention program for African American women founded in the Theory of Gender and Power, has been shown effective in increasing consistent condom use, sexual behavior, self-control, sexual communication, and sexual assertiveness skills and in increasing partner adoption and support of consistent condom use (31). Borrowing from SISTA, facilitators of the new intervention for women would also use cultural- and gender-appropriate materials to encourage pride and enhance self-worth and teach verbal and nonverbal communication skills intended to reach partners hesitant to use condoms consistently or at all (31).

            Finally, by actively distributing condoms to the program participants and making sure they are aware that condoms are always available for free at the clinic, the message sent is that there is no reason to ever be without one. Because people have a tendency to forgo condoms in the heat of the moment if they are not readily available, making sure that condoms are indeed always available is a good step towards combating people's would-be irrational behavior.

Modification #3 – Personal Risk Assessments, Teachable Moments, Alternate Venues

            The modified intervention would address Optimism Bias through the personal risk assessments that occur after the viewing of the Safe in the City video. Relating the scenarios displayed in the video to ones in the participants' own lives, will make it clear that anyone can get an STD/HIV from unprotected sex, not just those who are stereotyped as “dirty”. This message will increase perception of risk of unprotected sex and reinforce the need for all individuals to use condoms (41). For participants who appear to underestimate their personal health risks, individual intensive counseling may be necessary to overcome Optimism Bias.

            The group-level component would also be able to address participants experiencing illusory control through teachable moments brought about by the personal risk assessment discussion. Teachable moments are situations that create an opportunity to influence behavior change (30). One way of accomplishing this is following the format used in a research study that used failure experiences as a way to undermine perceived invulnerability to HIV and reduce Optimism Bias, resulting in increased perceptions of personal risk for HIV and intentions to use condoms (42). In the study, the facilitator asked participants to write about a time when they had sex without a condom followed by a group discussion about why condoms are a necessity, an exercise which forced participants to remind themselves of a past failure while also simultaneously reminding themselves that condoms are essential in protecting oneself (42). Participants then individually judged whether individuals were HIV-positive or negative based on pictures and brief biographical and sexual experience information. The majority of participants performed at or below chance levels (42), also demonstrating failure.

            The sexual assertiveness skills-building portion of the group session and the component where the facilitator corrects misconceptions about what it means when one partner asks their partner to use a condom is intended to address the Stigma Theory critique. An additional way of addressing Stigma Theory is to hold the intervention in venues other than public STD clinics where other at-risk individuals can be found. These could include venues such as family planning centers, community health centers, schools, businesses, churches, drug rehabilitation clinics, and correctional facilities.

Conclusion

            Safe in the City is an individual-level, brief, single-session, video-based intervention designed to prevent new STD/HIV infections by encouraging increased condom use among clients in STD clinic waiting rooms. Because clients simply view the video, there is no development of skills necessary to successfully negotiate condom use with sexual partners and no discussion of common barriers to condom use or strategies to overcome these barriers. By encompassing the video within a small group component, the modified intervention would include gender- and culturally- appropriate segments on personal risk assessment, sexual assertiveness skills-building, overcoming barriers to condom use, accurate condom information, and condom distribution. These added segments aim to address issues related to the theoretical foundation of the original intervention, behavioral irrationality, Optimism Bias, the Illusion of Control, and Stigma Theory in the hopes that such modifications would transform the original intervention into a more effective intervention for increasing condom use and reducing rates of new STD/HIV infections.

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37. Sikkema, K.J., Winett, R.A., and Lombard, D.N. (1995). Development and education of an HIV-risk reduction program for female college students. AIDS Education and Prevention, 7(2), 145-159.

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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 1^st in the national in primary and secondary syphilis rates, 1^st in congenital syphilis rates, 2^nd in gonorrhea rates, and 3^rd 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.