Challenging Dogma - Fall 2008

Wednesday, December 17, 2008

Use of Health Belief Model and Ineffective Marketing to Prevent Teen Pregnancy: A Critique of Tennessee’s New Initiative- Jessica Long

On September 9, 2008, the Tennessee District Attorneys General Conference officially announced the launching of a new campaign, coined “What’s the Rush” (1). The goal of this campaign, which is supported by the Tennessee Department of Human Services, is to reduce teenage pregnancy by showing high school students the social, financial, and legal consequences of adolescent pregnancy. Teen pregnancy is a nationwide problem that is gaining prevalence in some states, including Tennessee (2). In 2002, 12% of all pregnancies in the United States were in adolescents between the ages of 15-19 (3). Adolescents that give birth are more likely to deliver premature and low birth weight babies than older women, and perinatal death is more common (4). If an adolescent has more than one baby while still in their teenage years, the incidence of these adverse outcomes increases almost threefold (2,4). Premature birth and low birth weight can result in a myriad of problems, including mental disabilities, blindness, deafness, and cerebral palsy (2). Adolescents are also more likely to smoke during pregnancy and belong to a lower socioeconomic status (SES) (4).

This problem is of particular concern in Tennessee, where there were 13,000 cases of adolescent pregnancy in 2006 (3). This campaign focuses on many of the negative social aspects and outcomes of teen pregnancy by distributing a video and advertisements to high schools across the state. The campaign focuses on the effects of teen pregnancy on the teenage mother and father, as well as the baby. It lists statistics concerning drop out rates for teen moms, legal and financial responsibilities of the father, and the likelihood that the child will end up in prison (5). These issues are demonstrated through facts listed in the brochure and stories from actual adolescent mothers and fathers in the video (5).

This intervention is based primarily on the Health Belief Model. This model suggests that in order to cause change in an individual, the perceived susceptibility and severity of a problem must be targeted, and weighed against the perceived barriers of solving the problem (6). In this example, the severity is targeted by showing how hard life is after having a child, through statistics and personal stories in the video. The susceptibility is targeted by showing that every teen parent is affected by this, and there are consequences that cannot be avoided. According to this model, by addressing these issues the intention of the students should change, and therefore cause a behavioral change. However, this model has many limitations, and has since been replaced by theories that provide a more thorough examination of behavior and therefore lead to more successful interventions (7). By basing “What’s the Rush” solely on the Health Belief Model, the campaign has inherent flaws that will lead to an ineffective use of time and resources. The campaign relies on the premise from the Health Belief model that intention leads to a change in behavior, which is not always true. It does not effectively reach its audience and cause the changes it intends because it does not consider environmental factors and how they influence behavior. Finally, it solely targets severity and susceptibility in its marketing and advertising, ignoring strategies on how to effectively reach the intended audience.

Assumption that Intention Leads to Behavior

One of the main flaws of the Health Belief Model, as well as other models such as the Theory of Reasoned Action, is the assumption that intention leads to behavior (6,8). According to this theory, if the intervention successfully makes the individual feel that the problem is something that they are susceptible to, and that it is a severe problem, then the change should occur because the person wants the change. While this may be true for one time events, such as deciding whether or not to be immunized, an individual may face barriers moving from intended behavior to actual behavior for bigger issues. There are a number of factors that could potentially interfere with an action being taken despite the intention being present. Lack of knowledge or education, lack of resources or not knowing how to take the next step are all problems that interfere with a change in behavior. Critics of the Health Belief Model believe that one main aspect that it is missing is a cue to action (9). This cue to action could be either an event in the individual’s life or external interactions with others, or a change in personal feelings about an issue.

In the context of the “What’s the Rush” campaign, the cue to action would be knowledge and resources regarding teenage pregnancy. One major flaw in this campaign is the complete lack of knowledge or resources in reference to pregnancy prevention. The campaign provides a myriad of facts and statistics focused on what life will be like with a baby, the legal and financial burden on the father, and the risk factors of the child (2). However the initiative completely fails to address safe sex, birth control or even abstinence. The campaign tells the students that they should not get pregnant but does not provide the knowledge or resources to help them reach this goal. In order to successfully prevent teen pregnancy, the campaign should be teaching about condom use and birth control pills. Along with the posters and videos, the campaign should provide funding for free condoms to be distributed in schools. The campaign could even work with schools toward allowing access to birth control or counseling within the school itself. All of these steps would provide the cue to action that the students would need to successfully prevent pregnancy. In order for this campaign to be successful, it must provide information, resources and guidance concerning how to prevent the pregnancy from occurring instead of simply focusing on how bad it will be once it happens.

Fails to Address Environmental Role on Behavior

Tennessee is a large state, compromising approximately 3 million people in 95 counties (10). As expected in such a large area, there is a great deal of diversity in race, income, education, SES and many other factors that play a role in health. These differences can be found within each region, but there are also large differences among counties across the state (11). In 2006 the Tennessee Institute of Public Health published an assessment of health in Tennessee divided by county. One of the assessments it used was health determinants, including socioeconomic status, access to health care, and the physical environment. This study found that there are significant differences in resource availability throughout the state, with dramatic differences from county to county (11). In addition, census information for the state shows that different regions in the state vary dramatically in racial diversity, as well as median household income and educational levels (10).

These differences are important when considering a public health intervention. When targeting an individual, it is important to address environmental factors that affect the behavior of that person. The Health Belief Model does not address environmental influences on behavior, or anything else that could be considered group influences (7). According to this model, and the basis of “What’s the Rush”, behavior is determined at the individual level. However behavior is linked to groups and it is known that such factors as race, culture and SES can strongly influence behavior (12). A different model, such as the Social Cognitive Theory, could be used to compare how some of these factors could be addressed. The Social Cognitive Theory focuses on the importance of the immediate social context of the individual, and how the environment affects the behavior (13). This theory addresses how many important influences on behavior, such as self-efficacy, expectancies, and behavioral capability are directly linked to the environmental situation of that individual (13). One aspect that holds particular importance is the situation of the individual, which includes all the factors of that person’s social life and environment. This includes the individual’s race, religion, SES and built environment. Interventions that follow the Social Cognitive Theory are successful because they research and address environmental aspects that are unique to the target audience, so that the reasons for behavior are better understood (13). However, this by necessity means that regions that are significantly different are targeted in a specialized way. An intervention that targets the situation of a middle class white suburban youth will not be as effective in an inner-city school with a high population of African American or Latino students who are of a lower SES. The reason for this is because in order to change behavior, influences on behavior must be understood and directly addressed (13).

“What’s the Rush?” is a uniform campaign that is distributed to counties throughout the state, with no regard to the demographics of that particular county (14). The campaign does not address the fact that teenagers may be coming from all different backgrounds, with different financial burdens or views toward pregnancy. The focus of the campaign on the high cost of child support may not hold much weight for a boy from an affluent neighborhood. Similarly, the data provided concerning the low percentage of pregnant mothers who attend college may be meaningless to a girl who was never expected to make it that far in her education. These are just two examples of how failing to account for variances in the target audience could negatively affect the outcome of the campaign. This campaign does not consider the environmental context of the target audience, and therefore alienates any individual who deviates from norms that this campaign is based on.

Statistics and Negative Imaging are Ineffective Marketing Tools

Public Health interventions often rely on advertisements to relay a message to the target audience and try to induce a change. Many interventions have relied on advertisements following the Health Belief Model, focusing on susceptibility and severity of the change. Brochures and advertisements dealing with public health issues often list statistics to try and educate the public. By depending on statistics and focusing on the negative aspects of a behavior, this form of advertising assumes that people value their health, can control their behavior, and that intentions will lead to behavioral change; these are all limitations of the Health Belief Model (6).

Due to these limitations, new ideas emerged on more effective means of reaching the target audience. The Framing Theory suggests that people do not respond to the facts, they respond to the way a situation is framed (15). It is not enough to just present the information about a behavior, there must be some sort of angle or context in order to change their perception. Other theories have emerged that borrow ideas from other disciplines, such as the Advertising Theory. This theory suggests that in order to change behavior, you have to try to sell a promise of what the individual really wants (16). This theory suggests that using visual images that are appealing to what the person truly wants is a more effective tool than simply listing facts. This theory is a subset of an overall Marketing Theory, which suggests that the change being offered has to be presented as attractive (17,18). According to this theory, instead of focusing on the negative aspects of the behavior, you must focus on the positive aspects of change. The advertisement should suggest that the correct behavior is not very costly and would have positive benefits on the lives of the individual (17,18).

The way in which this campaign targets teenagers is through poster advertisements, a brochure and a video. The poster advertisements present a situation that a normal student would be in and interject phrases that are intended to show the reality of teen pregnancy. For example, the posters show a picture of a bus, with a line stating “The school bus doesn’t stop at daycare” (5). Another poster shows a cafeteria, with a line that states “Strained peas and baby formula are not on the school cafeteria menu” (5). The brochure highlights various facts about teen pregnancy, focusing mainly on the social and financial burden of a child. It presents the information as a fact sheet, listing the information in small paragraphs. The video shows the burden of teen pregnancy by following the lives of girls who became pregnant at young ages (5).

These advertisements rely on scare tactics, statistics, and negative imagery to relay a message. These approaches have all been proven to be ineffective means of changing behavior. They rely on ideas from the Health Belief Model, suggesting that these statistics will show the students how severe a burden a child would be and therefore that student will not get pregnant. These advertisements are not framed in a way that would effectively reach the students; they are simply presented with facts. The ads do not show any positive aspects of not getting pregnant, or how easy and beneficial it is to prevent pregnancy. Finally, there are no techniques used in these advertisements that target the true aspirations and beliefs of these differing adolescent groups. These ads did not use any of the ideas that Framing Theory, Advertising Theory, and Marketing Theory have proven are effective means of reaching an audience.

Conclusion: Why This Campaign is Flawed

This campaign is based on a flawed public health model that has since been replaced with much more effective theories and approaches. The Social Cognitive Theory, as mentioned above, is just one of the methods of approaching a public health problem that considers various dimensions of behavior and the factors influencing it, rather than just focusing on one area. By basing the campaign on advertisements that follow the Health Belief Model, the campaign is missing important factors needed to change individual’s beliefs and ideas, as well as those factors that are important to changing the final behavior. In addition, the campaign uses ineffective marketing and advertising strategies that have been proven to have very little effect. For this campaign to be successful, it would have to make three major changes. It must rework the advertising to target what the audience wants to do with their lives, and demonstrate how they can achieve it by changing their behavior. It would have to use images and reframe how teen pregnancy is prevented. The information used in the campaign would also have to change, and would have to be more specialized to different regions. The campaign must consider the environment and culture of the specific audience it is targeting. Finally, this campaign would have to offer information and resources on how to prevent teenage pregnancy, instead of simply preaching that it is bad. Behavioral change is not always a direct result of a change of intention, and a conscious effort must be made to facilitate this movement to action.

The Next Step: A New Intervention

In order to address the high prevalence of adolescent pregnancy in Tennessee, the General Attorney’s office would have to focus on correcting these flaws to create a more successful intervention. While “What’s the Rush” does have some strong points, some important changes need to be made in order to successfully target the intended audience. The way that this could be done is to stop using the Health Belief Model as the basis for the intervention. As mentioned above, the Health Belief Model addresses susceptibility and severity, but does not address the many other influences on behavior (9). It also makes the assumption that behavior will follow intention, ignoring important factors that may be barriers to an actual change in behavior. Because the intervention is based on this model, the marketing of the campaign is ineffective and relies on tactics that have been proven to have little impact on the public. In order to truly effect change in the teenage population in Tennessee, the intervention should instead be based on a model that addresses a broader range of influences on behavior, such as the Social Cognitive Theory.

As previously discussed, the Social Cognitive Theory could be used to correct some of the fallacies of the “What’s the Rush?” campaign. This theory includes many environmental and social factors that influence behavior, as well as addressing individual factors, and how behavior can actually change as a result of this intention (13). If this theory was used, an intervention could be created that that considers the social and contextual situation of the audience being targeted. It would also target the step from intention to actual behavior change, and facilitate students in making that change. With the Social Cognitive theory as a basis, more effective advertising techniques could be used in conjunction with the Marketing Theory to create a successful campaign. This campaign would include education and counseling as well as providing resources so that adolescents have the means to change their behavior. It would consider the environmental context of different counties and adjust the campaign appropriately to different portions of the state. The Marketing Theory could then use these individual factors as a basis to create effective advertising. Together these factors could use the resources the Tennessee Attorney General’s Office have put together to create a more effective campaign.

“What’s the Rush?” was flawed because it did not take the appropriate steps to change the behavior of the students it targeted. The campaign used the Health Belief Model to try and show teenagers how severe pregnancy can be at such a young age, but the intervention stopped there. There was no mention to the adolescents about how they can prevent unwanted pregnancies from occurring. The Social Cognitive Theory suggests that once an intention is in place, behavior can be changed using reciprocal determination. This is a process in which the individuals’ ideas about a behavior are targeted by using social and environmental cues to show what should be done (13). The individual then responds to these cues and adjusts their behavior. This is a continuous cycle, with cues and adjustment occurring over time. This process could be used to make the step from intention to behavior in a campaign against teenage pregnancy. Throughout the campaign, the individuals’ ideas about teen pregnancy are targeted in a way that creates an intention to prevent teenage pregnancy. Once this is established, this new intervention would include the social and environmental cues to help the students achieve this goal. This could be done by offering sex education and counseling within the school. In order to prevent pregnancy, teenagers must understand not only that pregnancy is bad, but the steps that they must take to prevent it. Resources such as condoms and birth control pills could be provided by the school nurse, and confidential counseling could be offered as well. Classes, either separately or within health education classes, should be provided that teach about proper contraceptive use. These resources and education would provide the cues which could then lead to an adjustment of behavior. By providing the education and resources necessary to change their behavior, this campaign allows teenagers to take decisive action and actually change their behavior, instead of simply having the intention to do so.

The “What’s the Rush” campaign was also flawed because it failed to address the environmental issues that come into play in teen pregnancy. The Social Cognitive Theory could be used to address this part of the intervention as well. This theory focuses on how the environment can affect the behavior of an individual. This theory recognizes that people can be influenced by their surroundings, and if individuals come from markedly different backgrounds they can view behavior in very different ways. The Social Cognitive Theory therefore takes into account the situation of an individual, or the unique environment in which their behavior takes place (13). For teenagers this environment would be their home, school, and community. However, teenagers from an affluent suburban town and those from a lower SES urban neighborhood are going to have very different situations, and therefore their behavior will be affected differently. Another environmental factor that this theory considers is vicarious learning. Observing behaviors of others and how that affects that person can influence an individual (13). This is another factor that is relevant to this issue because adolescents may be more affected by seeing the effects of unwanted pregnancy than reading statistics.

The intervention can directly target these two factors. First, the situation of the individual can be targeted by recognizing that Tennessee is not a homogeneous state. Different counties vary greatly in average income levels, educational status, and ethnicity (10). These could all affect the situation of an individual in drastic ways. A campaign must be specialized to the cultural and socioeconomic norms of that particular town. This can be done by using data found easily online to assess these factors and the distribution across the state. Then separate campaigns with the same message but different approaches can be developed. It may be as simple as having two campaigns, one targeting inner city teenagers while another targets suburban or rural teenagers. They could each focus on things that are more relevant to that particular group. For example, in a more affluent county, the campaign can target the difficulty of attending college when you have a baby. Meanwhile the urban campaign can focus more on the legal responsibilities and costs of having a child. Additional factors could be assessed using state statistics and epidemiological data as well. If certain areas seem to have higher levels of teen pregnancy than others, then it could be assessed by that local government to determine if there may be cultural influences affecting that high prevalence, and the town could specialize their campaign to address those issues.

Another environmental factor that could be utilized is vicarious learning. The “What’s the Rush” campaign did attempt to target this by distributing a video that follows the lives of teenage mothers, but this could be further targeted by actually bringing in teenage mothers as guest speakers. This could be accomplished within a class as mentioned above that focuses on sexual health. Teenage mothers would be invited to come in and talk about their experience in their own words, as well as answer questions from the students. Local health and social workers who have experience working with pregnant mothers could also be brought in. This would provide a personal experience for the students, because instead of simply watching it on a video they could see and interact with someone in that situation.

Finally, the Social Cognitive Theory could be used together with the Marketing and Framing theories to run a more effective advertising campaign. As noted above, the Marketing Theory states that successful campaigns focus on the positive aspects of change, and use visual imagery instead of statistics to portray this image (17). This theory suggests that you should try to sell your pitch to the audience by portraying it as fulfilling their desires. The Framing Theory states that the perception of an individual can be changed by simply putting the behavior in a different light (15). The “What’s the Rush” campaign was not able to follow these theories because the basis of the campaign was showing the negative effects of the behavior. However, the Social Cognitive Theory works well with these two methods of marketing. The Social Cognitive Theory identifies characteristics of an individual that affect their behavior. Self-efficacy, expectations and expectancies are all considered in the Social Cognitive Theory (13). Self-efficacy refers to how confident a person is that they can perform a task, while expectancies refers to if a person thinks the expected outcome is good or rewarding. Expectations refer to what a person thinks will happen if they change their behavior. All of these concepts can be combined using these theories of advertising (13).

Instead of using negative imagery and statistics in the teen pregnancy campaign, the intervention should include advertisements in schools, community centers and on the television that are positive and upbeat. These images can show happy, beautiful, well adjusted teenagers doing fun activities such as hanging out with friends or scoring the winning goal in the big game. Instead of framing the issue to show all the negative ways pregnancy would affect them, the advertisements can show the positive aspects of using contraceptives and therefore avoiding unwanted pregnancy. The advertisements, as the Marketing Theory suggests, do not necessarily have to be entirely realistic; it may not be true that you will be popular or find love simply because you are not pregnant. They just have to show positive images and ideas that are appealing to teenagers, to show that these things are more likely to happen if you are not pregnant or have a child to take care of. This will then provide a correlation between changing the unwanted behavior and achieving the things you desire.


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