Why Teen Pregnancy Interventions Fail- Kari Cheng
Since 1991, the federal government and community organizations such as the National Campaign and Planned Parenthood have made similar efforts to prevent teen pregnancy. The main focus of these efforts is educating teens about contraceptives, promoting abstinence, and providing media messages that help raise teen awareness of the issue. As a result, the teen pregnancy rate has continued on a downward trend for more than a decade (1). However, despite these successful campaigns, teens account for about 80% of the approximately 3 million unplanned pregnancies annually (2). Furthermore, the National Center for Health Statistics reported in 2006 that the 14-year decline in the U.S. teen birth rate has reversed, and both the number of births to teens and the teen birth rate have risen (1). Although the teen birth rate grew only 3% between 2005 and 2006, experts are expressing reasonable concerns that the teen pregnancy rate will continue to increase in the upcoming years (1).
The tools that social organizations utilize (contraceptive education, media messages, and abstinence promotion) fall short of expectations, and this is likely due to the inappropriate application of the Social Cognitive Model in their intervention designs. Repeatedly, the concepts of self-efficacy and reciprocal determinism are under-addressed in many of the teen pregnancy prevention advertisements and education programs.
Social Cognitive Theory (SCT) explains that a behavior is constructed from the intricate interactions of an individual’s internal
world (self-efficacy), environmental influences (external factors), and interactive processes with others (reciprocal determinism) (3-5). Self-efficacy is an individual’s confidence and ability to overcome obstacles in order to pursue the behavior of interest (3-5). The level of self-efficacy can be influenced by factors such as the individual’s past experience in trying to accomplish the desired behavior, social persuasion, stress, and learning experiences (5). The more an individual believes in his or her ability to achieve a desired behavior, the more likely it is that it will be accomplished (3-4). The external environment, which includes both physical and social factors surrounding an individual, is important during the construction of the behavior, according to SCT, because during this process, individuals observe “rewarding” behaviors to learn or “emulate,” and “vicarious learning” takes place (4-5). Finally, a behavior is also heavily influenced by the reactions of the people with whom the individual interacts (3). Therefore, interventions fall short of expectations because organizations overemphasize the external learning factor of the SCT while undermining the importance of self-efficacy and reciprocal determinism.
Teen Pregnancy Interventions Put Too Much Emphasis on “Vicarious Learning”
When people shape their behavior by observing and emulating others in the environment (via positive or negative reinforcements), they are experiencing vicarious learning. Most of the teen pregnancy interventions are attempts to address the behavior as socially “rewarding” or socially “unacceptable.” For example, many abstinence campaigns employ famous and well liked celebrities, like winners of the Miss America pageant and Britney Spears, who take the abstinence pledge to set an example for teens and show them that abstinence is something “rewarding” to do (6). Conversely, abstinence campaigns may also have slogans that imply that sex prior to marriage has serious and unwanted consequences. For example, in 2007, the statewide Washington abstinence campaign slogan was ‘No Sex. No Problems” (7). Similar techniques are also used in contraceptive promotion advertisements. For example, the famous Zazoo commercial that was first aired in 2006 showed a wild, uncontrollable child creating an uproar in a supermarket and a meek, young father who simply did not know what to do about the situation. It ended with the message, “Use the condom” (8). The message was that having sex without contraceptives can bring results that are more than one can handle. A majority of the teen pregnancy interventions are structured in this way, with slogans and images trying to either encourage the good behavior (abstinence) or deter bad behaviors (sex without condoms). However, none of these interventions consider the importance of self-efficacy or reciprocal determinism, which may be especially relevant for interventions involving intimate relationships. Interventions devoid of these key components fail to value obstacles, such as an individual’s finances or power differences between the woman and the significant other that may deter individuals from accomplishing the desired behavior and understanding the consequences of having unprotected sex.
Teen Pregnancy Interventions Fail to Address Social Factors that May Lower Self-Efficacy
Studies have shown that the recent changes in public policies and mixed media messages may have provided additional barriers and kept teens from adhering to the desirable behavior (lowered self-efficacy). For example, starting in 2005, governmental funding for contraceptives or emergency contraceptives for teens has been falling. This decrease may put a higher financial burden on young teens and keep them from adhering to the desirable behavior (1). They may decide to have unprotected sex because they cannot afford condoms or pills on a long-term basis. Furthermore, the advertisements for “emergency contraception pills” may send a mixed message to teens: “If you messed up, it’s okay. You can just take a pill to fix it.” A recent randomized, controlled trial comparing the impact of direct access to emergency contraception through pharmacies and unintended pregnancies found that women are more likely to be negligent in engaging in unprotected sex when they know emergency contraceptives are an option (9). Other under-addressed self-efficacy issues are related to culture and language. One of the factors related to the recent increase in unprotected sex is large immigrant populations (1). While many of the teen pregnancy interventions provide powerful messages on educational Web sites, few are multi-lingual. If an immigrant does not speak English, it may be very difficult for her to comprehend the consequences of engaging in unprotected sex, and she may not be aware of resources for help. This may increase her sense of “helplessness.” She may feel that no one is there to explain available resources in the community, and there may be no counseling services to help with her emotional needs.
Therefore, additional approaches addressing the empowerment of teens and help them to think responsibly or boost their self-confidence are highly desirable if we want to help teens adhere to the desirable behavior (abstain from sex or use contraceptives when engaging in sexual behavior). Unfortunately, there are very few intervention slogans that focus on teen self confidence and empowerment. To make matters worse, many teen pregnancy campaigns target teen fears by sending a message that by acting irresponsibly, they will become social outcasts or undergo extreme stress. A recent UK anti-teen pregnancy campaign displays images of teen mothers who are social outcasts with nowhere to go and no one to help them. In addition, this commercial also shows that these young mothers are “frightened” and simply “helpless” (11). Although this commercial sends a powerful message, it may backfire, since “fear” may not deter teens from irresponsible sexual activities. Commercials like this one are telling teens that they will be “helpless.” Even though resources like Planned Parenthood are available to help teens through difficult situations, they may not bother to try to seek out help, believing the message in campaigns like the one detailed above.
Teen Pregnancy Interventions Failed to Address the Power Relationship
Most of the interventions focus on women and their emotions and the social consequences they will face if they are pregnant. However, very little study has been dedicated to understanding the behaviors of the men that lead to unplanned pregnancy. Statistics shows that 6 in 10 babies fathered by teen boys age 18-19 are unplanned and 52% of babies fathered by men between the ages of 20-24 are unplanned. Furthermore, Latino men between the ages of 15-44 are most likely to have unplanned children. Additionally, about one half of unmarried men under 24 do not use condoms while engaging in sexual activities (10). These statistics simply show that teen pregnancy interventions are ineffective in reaching males. These statistics also suggest that teen pregnancy interventions are only as effective as the number of males who follow the instructions. We must take into account the reciprocal determinism in interactions between the partners and recognize the power differences between men and women in a relationship. Oftentimes, women cave in to the desires of their male partners due to the power differences between them the power difference is especially clear when men are the financial providers, older, or have more social power than the female partner (12-14). Thus, in these inherently imbalanced relationships, most women do not want to offend or disappoint their partners. So far, none of the teen pregnancy interventions address the issue of teaching women to say “no” to unprotected sex or how to counter power differences. Power differentials in a relationship are more visibly portrayed in the anti-domestic violence campaigns, where oftentimes the messages are “say no” or “seek help” (13-14). Ironically, these are the types of messages that should be incorporated in the anti-teen pregnancy interventions. Providing teens with information about the consequences of sexual behaviors (babies, STDs) and the knowledge about where to access contraceptives is simply not enough. These tools need to be integrated successfully in the communications between two people in order for the messages to work.
Currently, most of the teen pregnancy campaigns focus on changing women’s behaviors. However, some messages should appeal to men. This is true because men have the power to convince their female partners to change their behaviors. After all, educating the less powerful side to convince the more powerful party to change a behavior is obviously not as effective as educating the powerful party to accept a behavioral change.
When considering powerful slogans to promote desirable behaviors, all components of SCT are equally important to the success of an intervention and should be addressed in equal proportions. Underweighting the importance of some aspects of the theory may reduce the overall effectiveness of the model. Interventions will not be successful when we fail to see that self-efficacy and power differentials in a relationship are also powerful characteristics that need to be considered in order for our interventions to work. We may have failed because even though we understand that teens change their behaviors by observing and emulating environmental models, we did not boost their confidence to achieve the behaviors (self-efficacy), or we targeted our interventions to the wrong population (should focus on behaviors of teen boys instead of teen girls). The results are, of course, compromised and diminished.
References
1. National Center for Health Statistics: Birth/Natality. http://www.cdc.gov/nchs/births.htm.
2. Proportion of All pregnancies that are Unplanned by Various Socio-Demographics, 2001. TheNationalCampaign.org. Visited: November 18, 2008.
3. Bandura A. Social Learning Theory. New York: General Learning Press, 1977.
4. Salazar MK. Comparison of four behavioral models. AAOHN. 1991; 39:128-135.
5. Bandura A. the self system in reciprocal determinism. Am Psychol. 1978; 33: 344-358.
6. How effective are abstinence pledges. News.bbc.co.uk. November 18, 2008.
7. Statewide abstinence campaign tells youth "No Sex. No Problems." http://www.doh.wa.gov/Publicat/2007_news/07-089.htm visited: November 18, 2008.
8. Zazoo condoms. http://www.zazoocondoms.com/
9. Raine TR, Harper CC, Rocca CH. Direct Access to Emergency Contraception Through Pharmacies and Effect on Unintended Pregnancy and STIs: a Randomized Controlled Trial. Jama. 2005; 293(1): 54-62.
10. Martinez GM, Chandra A, Abma JC, Jones J, and Mosher WD. Fertility, Contraception and Fatherhood: Data on Men and Women from Cycle 6 (2002) of the National Survey of Family Growth. National Center for health Statistics. Vital Health Stat; 23 (26).
11. Think about it. Think Contraception. http://www.thinkcontraception.ie/
12. Cleary BS, Keniston A. Havranek EP. Albert RK. Intimate partner violence in women hospitalized on an internal medicine service: prevalence and relationship to responses to the review of systems. Journal of Hospital Medicine. 2008; 3(4):299-307.
13. Antai DE, Antai JB. Attitudes of women toward intimate partner violence: a study of rural women in Nigeria. Rural & Remote Health. 2008; (3):996.
Teen Pregnancy Intervention Revisited: An Intervention That Works
Background
Since 1991, despite the combined efforts of both public and private institutions in lowering teen pregnancy, teen pregnancy still accounts for approximately 80% of the 3 million unplanned pregnancies annually (1). The failure of appropriately applying the principles of social cognitive theory is likely to be responsible for the inefficacies in many of the currently available interventions.
Social cognitive theory (SCT) explains that a behavior is constructed from the interactions of an individual’s internal world (self-efficacy), environmental influences (external factors, both physical and social), and interactive processes with others (reciprocal determinism) (2-4). These three primary components (self-efficacy, external factors, and reciprocal determinism) are often under addressed in teen pregnancy prevention campaigns, rendering them ineffective. The failures of currently available interventions call for a new effective intervention.
New Intervention
Old interventions have failed to account for factors in the following three areas: a) the overemphasis on promoting “vicarious learning” in teen pregnancy intervention campaign messages, b) the under evaluation of the physical environmental barriers to adherence of the targeted behavior, and c) the lack of focus in addressing both an individual’s self-confidence and his or her relationship to intimate partners. This new intervention proposes to increase the effectiveness of such interventions by coupling the fundamental underlying framework (SCT) with other theories in each of the problematic areas. The new intervention will be devised as follows. First, social marketing theory will be used to promote the desirable behavior. The desirable behavior (using condoms or abstinence) will be “dressed” up to encourage adolescents to emulate this behavior afterward, instead of using ineffective and bland campaign messages. Second, this new intervention will incorporate community mobilization theory to “mobilize” the available community resources to crack down on barriers that keep adolescents from adhering to the wanted behavior. The primary target of this focus is to provide adolescents with easy and increased access to the necessary contraceptives or emotional support. Finally, this intervention will use anthropology and social marketing theory to investigate both the individual’s self-efficacy and his or her relationships with partners in “context.” This approach aims to train the available support system (e.g., parents and counselors) to better associate with adolescents and their behavior norms depending on their social environment (social economic status, racial disparities, etc.) and attempt to encourage more males to practice safe sex with their partners.
Hence, this new intervention will be community based (since different communities have different compositions of needs, resources, income brackets, and ethnicities) and will utilize attractive advertisements via TV, radio, posters and pamphlets. In addition, it will mobilize the community to push for increased provisions of low-cost contraceptives and introduce local or mobile STD clinics that provide contraceptives, counseling, and testing services. Such services would involve training more culturally aware counselors from the community to convince male partners to practice safe sex and support adolescent women’s feeling empowered.
The arguments for the design of the intervention are further explained in the following sections:
A. Use social marketing theory in campaign advertisements: tailor the targeted behavior as desirable to the population
As the modern community becomes more diverse and interests are becoming more heterogeneous, implementing campaign slogans and employing “role models” who can uniformly reach all adolescents have become less effective (6,7). In dealing with fragmented adolescent populations, targeting them one community at a time may be a preferred strategy (6). Additionally, bare-bones campaign messages are rarely effective among adolescents; for example, the 2007 statewide Washington abstinence campaign slogan was “No Sex. No Problems,” which did not persuade a substantial number of adolescents to practice abstinence (8). Such slogans do not suggest an “attractive” behavior or target self-efficacy. Thus, applying the social marketing theory in campaign advertisements may seem a more suitable and effective strategy when attempting to sway adolescents. The social marketing theory is a specific approach that utilizes marketing principles to promote and generate changes in social behavior (9).
The theory consists of four components: product, price, place, and promotion (9). “Product” refers to the benefits that are associated with a desired behavior, which can change as the values of the target population change (9, 10, and 11). This means that the “product” or “desirable behavior” can be “dressed-up” and redefined as the adolescent’s definition of “cool” changes. “Price” refers to the physical or social cost or the sacrifice that is exchanged for a promised benefit within the target population (9). For example, an adolescent girl who wants to practice abstinence may have to face the social cost of dealing with pressure from her partner (11). “Place” refers to the issues of access and availability, such as the ways in which a certain behavior or product is distributed to the target population (9). For example, condoms would be placed in all convenience stores for easy accessibility for last-minute use (9). “Promotion” refers to strategies that are used to advertise, promote, and persuade a target population to “buy” or exchange its resources for the product (9). Through these four components, social marketing aims to increase the acceptability of a practice (desired behavior) among adolescents with the help of media to promote a product, idea, or attitude and assumes that the adolescents have unique attitudes and behaviors that are based on their own personal experiences (11). To support the claim that social marketing theory may be helpful in convincing adolescents to use contraceptives, a study has shown that adolescents are not likely to engage in safe sex practices unless they believe that the practice possesses “meaning” (12). Further, in the National Strategy Report, incorporating attractive messages using social marketing theory is highly recommended and proved successful in anti-teen pregnancy campaigns (7). Using social marketing strategy in media campaign messages is also adopted by various social organizations, such as Teen Pregnancy Prevention & Partnership and APAUSE (13, 14).
B. Incorporate community mobilization theory to “mobilize” the available community resources to crack down on barriers that keep adolescents from adhering to the wanted behavior
Since SCT theory failed to address many physical barriers for adolescents, such as having easy access to contraceptives or counseling services, more organized community-based efforts are needed to lower those barriers. Typically, the two primary environmental factors that prevent adolescents from adhering to safe sex practices are financial and local barriers to contraceptives or support. For instance, since 2005, governmental funding for contraceptives for adolescents has been falling (1, 15). This decrease may put a higher financial burden on younger adolescents and keep them from adhering to the desirable behavior (1, 15). Or the barriers can occur from the resources and culture of their communities. Adolescents of some communities may have to travel far to gain access to condoms. Additionally, some communities may not have convenient stores that stay open late, which may also serve as a deterrent for adolescents to practice safe sex. Thus, a community effort should push for late-hour licensing for some of the local convenience stores and encourage more funding for contraceptives or mobile clinics that provide condoms and STD testing services. Community actions involve the collective actions of community groups to increase awareness about the problem (16). Some successful and visible campaigns using such strategies include anti-alcoholism and anti-abortion movements (17, 18). In order to launch a successful community mobilization movement, one should first have a clear understanding of what type of community it is (Is it conservative or liberal? Does it have few or many resources?), choose the most feasible strategy to promote the agenda (e.g., create a budget for mobile clinics, extend stores’ hours, or apply for more funding), and gather information on powerful advocacy groups that can help strengthen the claim (15-18). For example, the Amherst Association for Healthy Adolescent Sexuality (AAHAS) is a grassroots community organization created in response to community concerns about adolescents’ sexual behavior and high pregnancy rates (19). This organization has been successful in promoting safe sex by incorporating local post-bachelor students to serve as community counselors and maintaining good relationships with local community board members. As such, frequent interactions were promoted between local parents and the organization via social meetings to sustain the empathy for “community feelings” and to involve everyone as part of the anti-teen pregnancy work. The AAHAS has been highly successful since its establishment (19).
C. Apply anthropology theory to create a nurturing counseling environment to help adolescents feel more empowered and address power differentials in relationships
Finally, many of the interventions fail to address the self-efficacy and reciprocal determinism components of the SCT. One way to help strengthen the application of this aspect is to combine anthropological and social marketing theories to help public health promoters stay focused on the issue. Cultural anthropology understands and explains health behavior as part of a pattern of living that integrates action with meanings, symbols, and values connected to a larger social structure (20, 21). It sees the behavior in context of the larger social context (20, 21). Therefore, to train and provide counselors from their own communities with sufficient understanding of the community’s background and structure, one can target an individual’s needs more successfully than a counselor that goes by the book. Both self-efficacy and reciprocal determinism target the internal and external influences on an individual. One focuses on an individual’s confidence when engaging in an activity, while the other explains how outside social influences can impact the individual’s behavior. The anthropology approach focuses on the social context that shapes an individual and their behaviors, which would include what structures their internal values and who has the most powerful influence on the individual. For example, if an adolescent is feeling helpless because of his or her race or social economic status, meeting with a counselor from a similar background who has experienced similar ideologies and values and has had a similar neighborhood experience would be much more empowering for that adolescent. Likewise, the anthropology approach can be enhanced by social marketing theory by applying it to the local boys to encourage them to practice safe sex. If an intervention can successfully induce adolescent boys to practice safe sex, adolescent girls will experience less reciprocal determinism (6).
In conclusion, although some components of the SCT may be difficult to apply, we can create interventions that combine other frameworks targeting each shortcoming to better address our public health problem. We should know that an effective strategy comes from a careful assessment of the culture, social, and environmental context of a community and tries to target our population and their behaviors within the context of that community. If we can first understand their cultural context, we can design a program incorporating the necessary frameworks and devise the most effective intervention.
References
1. National Center for Health Statistics: Birth/Natality. http://www.cdc.gov/nchs/births.htm.
2. Proportion of All pregnancies that are Unplanned by Various Socio-Demographics, 2001. TheNationalCampaign.org. Visited: November 18, 2008.
3. Bandura A. Social Learning Theory. New York: General Learning Press, 1977.
4. Salazar MK. Comparison of four behavioral models. AAOHN. 1991; 39:128-135.
5. Bandura A. the self system in reciprocal determinism. Am Psychol. 1978; 33: 344-358.
6. A National Strategy to Prevent Teen Pregnancy. US Department of Health Services. http://aspe.hhs.gov/hsp/teenp/ann-rpt00/
7. Kotler P, Roberto EL. Social Marketing strategies for changing Public Behavior. New York: Free Press; 1989
8. Statewide abstinence campaign tells youth "No Sex. No Problems." http://www.doh.wa.gov/Publicat/2007_news/07-089.htm visited: November 18, 2008.
9. Grier S, Bryant CA. Social Marketing in Public Health. Annu. Rev. Public Health. 2005; 26:319-39.
10. Kotler P. Marketing for Non-Profit Organizations. Englewood Cliffs, NJ: Prentice-Hall; 1975.
11. Walsh D, Champman Rudd RE, TW Maloney. Social Marketing for Public Health. Health Affairs. 1993. (summer); 104-119.
12. Koniak-Griffin D. Lesser J. Uman G. Nyamathi A. Teen pregnancy, motherhood, and unprotected sexual activity. Research in Nursing & Health. 26(1):4-19, 2003 Feb.
13. Teen Pregnancy Prevention and Partnership. http://www.teenpregnancy-stl.org/
14. Added Power and Understanding in Sex Education. http://www.apause.com
15. Martinez GM, Chandra A, Abma JC, Jones J, and Mosher WD. Fertility, Contraception and Fatherhood: Data on Men and Women from Cycle 6 (2002) of the National Survey of Family Growth. National Center for health Statistics. Vital Health Stat; 23 (26).
16. Beyer JM, Trice HM. Implementing Change: Alcoholism Policies in Work Organizations. New York: Free Press; 1978
17. Steckler A, Goodman RM, Kogler MC. Mobilizing organizations for health enhancement: theories of organizational change. In: Glanz K, Rimer BK, Lewis FM, eds. Health Behavior and Health Education: Theory, Research and Practice, 3rd ed. San Francisco, CA: Jossey-Bass; 2002.
18. Fullerton JT, Killian R, Gass PM. Outcomes of a community and home based intervention for safe motherhood and newborn care. Health Care Women Int. 2005; 26(7): 561—567
19. Joffres H, Langille D, Rigby J and Langille DB. Factors Related to Community Mobilization and Continued Involvement in a Community-Based Effort To Enhance Adolescents' Sexual Behaviour. The Qualitative Report. 2002; 7 (2).
20. Hahn, RA. Anthropology in Public Health: Bridging Differences in Culture and Society. New York: Oxford University Press. 1999.
21. Singer M. AIDS and the health crisis of the US urban poor: the perspective of critical medical anthropology. Soc Sci Med. 1994; 39(7) 931-948.
Appendix
Essay 3
Why Teen Pregnancy Interventions Fail
Since 1991, the federal government and community organizations such as the National Campaign and Planned Parenthood have made similar efforts to prevent teen pregnancy. The main focus of these efforts is educating teens about contraceptives, promoting abstinence, and providing media messages that help raise teen awareness of the issue. As a result, the teen pregnancy rate has continued on a downward trend for more than a decade (1). However, despite these successful campaigns, teens account for about 80% of the approximately 3 million unplanned pregnancies annually (2). Furthermore, the National Center for Health Statistics reported in 2006 that the 14-year decline in the U.S. teen birth rate has reversed, and both the number of births to teens and the teen birth rate have risen (1). Although the teen birth rate grew only 3% between 2005 and 2006, experts are expressing reasonable concerns that the teen pregnancy rate will continue to increase in the upcoming years (1).
The tools that social organizations utilize (contraceptive education, media messages, and abstinence promotion) fall short of expectations, and this is likely due to the inappropriate application of the Social Cognitive Model in their intervention designs. Repeatedly, the concepts of self-efficacy and reciprocal determinism are under-addressed in many of the teen pregnancy prevention advertisements and education programs.
Social Cognitive Theory (SCT) explains that a behavior is constructed from the intricate interactions of an individual’s internal world (self-efficacy), environmental influences (external factors), and interactive processes with others (reciprocal determinism) (3-5). Self-efficacy is an individual’s confidence and ability to overcome obstacles in order to pursue the behavior of interest (3-5). The level of self-efficacy can be influenced by factors such as the individual’s past experience in trying to accomplish the desired behavior, social persuasion, stress, and learning experiences (5). The more an individual believes in his or her ability to achieve a desired behavior, the more likely it is that it will be accomplished (3-4). The external environment, which includes both physical and social factors surrounding an individual, is important during the construction of the behavior, according to SCT, because during this process, individuals observe “rewarding” behaviors to learn or “emulate,” and “vicarious learning” takes place (4-5). Finally, a behavior is also heavily influenced by the reactions of the people with whom the individual interacts (3). Therefore, interventions fall short of expectations because organizations overemphasize the external learning factor of the SCT while undermining the importance of self-efficacy and reciprocal determinism.
Teen Pregnancy Interventions Put Too Much Emphasis on “Vicarious Learning”
When people shape their behavior by observing and emulating others in the environment (via positive or negative reinforcements), they are experiencing vicarious learning. Most of the teen pregnancy interventions are attempts to address the behavior as socially “rewarding” or socially “unacceptable.” For example, many abstinence campaigns employ famous and well liked celebrities, like winners of the Miss America pageant and Britney Spears, who take the abstinence pledge to set an example for teens and show them that abstinence is something “rewarding” to do (6). Conversely, abstinence campaigns may also have slogans that imply that sex prior to marriage has serious and unwanted consequences. For example, in 2007, the statewide Washington abstinence campaign slogan was ‘No Sex. No Problems” (7). Similar techniques are also used in contraceptive promotion advertisements. For example, the famous Zazoo commercial that was first aired in 2006 showed a wild, uncontrollable child creating an uproar in a supermarket and a meek, young father who simply did not know what to do about the situation. It ended with the message, “Use the condom” (8). The message was that having sex without contraceptives can bring results that are more than one can handle. A majority of the teen pregnancy interventions are structured in this way, with slogans and images trying to either encourage the good behavior (abstinence) or deter bad behaviors (sex without condoms). However, none of these interventions consider the importance of self-efficacy or reciprocal determinism, which may be especially relevant for interventions involving intimate relationships. Interventions devoid of these key components fail to value obstacles, such as an individual’s finances or power differences between the woman and the significant other that may deter individuals from accomplishing the desired behavior and understanding the consequences of having unprotected sex.
Teen Pregnancy Interventions Fail to Address Social Factors that May Lower Self-Efficacy
Studies have shown that the recent changes in public policies and mixed media messages may have provided additional barriers and kept teens from adhering to the desirable behavior (lowered self-efficacy). For example, starting in 2005, governmental funding for contraceptives or emergency contraceptives for teens has been falling. This decrease may put a higher financial burden on young teens and keep them from adhering to the desirable behavior (1). They may decide to have unprotected sex because they cannot afford condoms or pills on a long-term basis. Furthermore, the advertisements for “emergency contraception pills” may send a mixed message to teens: “If you messed up, it’s okay. You can just take a pill to fix it.” A recent randomized, controlled trial comparing the impact of direct access to emergency contraception through pharmacies and unintended pregnancies found that women are more likely to be negligent in engaging in unprotected sex when they know emergency contraceptives are an option (9). Other under-addressed self-efficacy issues are related to culture and language. One of the factors related to the recent increase in unprotected sex is large immigrant populations (1). While many of the teen pregnancy interventions provide powerful messages on educational Web sites, few are multi-lingual. If an immigrant does not speak English, it may be very difficult for her to comprehend the consequences of engaging in unprotected sex, and she may not be aware of resources for help. This may increase her sense of “helplessness.” She may feel that no one is there to explain available resources in the community, and there may be no counseling services to help with her emotional needs.
Therefore, additional approaches addressing the empowerment of teens and help them to think responsibly or boost their self-confidence are highly desirable if we want to help teens adhere to the desirable behavior (abstain from sex or use contraceptives when engaging in sexual behavior). Unfortunately, there are very few intervention slogans that focus on teen self confidence and empowerment. To make matters worse, many teen pregnancy campaigns target teen fears by sending a message that by acting irresponsibly, they will become social outcasts or undergo extreme stress. A recent UK anti-teen pregnancy campaign displays images of teen mothers who are social outcasts with nowhere to go and no one to help them. In addition, this commercial also shows that these young mothers are “frightened” and simply “helpless” (11). Although this commercial sends a powerful message, it may backfire, since “fear” may not deter teens from irresponsible sexual activities. Commercials like this one are telling teens that they will be “helpless.” Even though resources like Planned Parenthood are available to help teens through difficult situations, they may not bother to try to seek out help, believing the message in campaigns like the one detailed above.
Teen Pregnancy Interventions Failed to Address the Power Relationship
Most of the interventions focus on women and their emotions and the social consequences they will face if they are pregnant. However, very little study has been dedicated to understanding the behaviors of the men that lead to unplanned pregnancy. Statistics shows that 6 in 10 babies fathered by teen boys age 18-19 are unplanned and 52% of babies fathered by men between the ages of 20-24 are unplanned. Furthermore, Latino men between the ages of 15-44 are most likely to have unplanned children. Additionally, about one half of unmarried men under 24 do not use condoms while engaging in sexual activities (10). These statistics simply show that teen pregnancy interventions are ineffective in reaching males. These statistics also suggest that teen pregnancy interventions are only as effective as the number of males who follow the instructions. We must take into account the reciprocal determinism in interactions between the partners and recognize the power differences between men and women in a relationship. Oftentimes, women cave in to the desires of their male partners due to the power differences between them the power difference is especially clear when men are the financial providers, older, or have more social power than the female partner (12-14). Thus, in these inherently imbalanced relationships, most women do not want to offend or disappoint their partners. So far, none of the teen pregnancy interventions address the issue of teaching women to say “no” to unprotected sex or how to counter power differences. Power differentials in a relationship are more visibly portrayed in the anti-domestic violence campaigns, where oftentimes the messages are “say no” or “seek help” (13-14). Ironically, these are the types of messages that should be incorporated in the anti-teen pregnancy interventions. Providing teens with information about the consequences of sexual behaviors (babies, STDs) and the knowledge about where to access contraceptives is simply not enough. These tools need to be integrated successfully in the communications between two people in order for the messages to work.
Currently, most of the teen pregnancy campaigns focus on changing women’s behaviors. However, some messages should appeal to men. This is true because men have the power to convince their female partners to change their behaviors. After all, educating the less powerful side to convince the more powerful party to change a behavior is obviously not as effective as educating the powerful party to accept a behavioral change.
When considering powerful slogans to promote desirable behaviors, all components of SCT are equally important to the success of an intervention and should be addressed in equal proportions. Underweighting the importance of some aspects of the theory may reduce the overall effectiveness of the model. Interventions will not be successful when we fail to see that self-efficacy and power differentials in a relationship are also powerful characteristics that need to be considered in order for our interventions to work. We may have failed because even though we understand that teens change their behaviors by observing and emulating environmental models, we did not boost their confidence to achieve the behaviors (self-efficacy), or we targeted our interventions to the wrong population (should focus on behaviors of teen boys instead of teen girls). The results are, of course, compromised and diminished.
Reference
1. National Center for Health Statistics: Birth/Natality. http://www.cdc.gov/nchs/births.htm.
2. Proportion of All pregnancies that are Unplanned by Various Socio-Demographics, 2001. TheNationalCampaign.org. Visited: November 18, 2008.
3. Bandura A. Social Learning Theory. New York: General Learning Press, 1977.
4. Salazar MK. Comparison of four behavioral models. AAOHN. 1991; 39:128-135.
5. Bandura A. the self system in reciprocal determinism. Am Psychol. 1978; 33: 344-358.
6. How effective are abstinence pledges. News.bbc.co.uk. November 18, 2008.
7. Statewide abstinence campaign tells youth "No Sex. No Problems." http://www.doh.wa.gov/Publicat/2007_news/07-089.htm visited: November 18, 2008.
8. Zazoo condoms. http://www.zazoocondoms.com/
9. Raine TR, Harper CC, Rocca CH. Direct Access to Emergency Contraception Through Pharmacies and Effect on Unintended Pregnancy and STIs: a Randomized Controlled Trial. Jama. 2005; 293(1): 54-62.
10. Martinez GM, Chandra A, Abma JC, Jones J, and Mosher WD. Fertility, Contraception and Fatherhood: Data on Men and Women from Cycle 6 (2002) of the National Survey of Family Growth. National Center for health Statistics. Vital Health Stat; 23 (26).
11. Think about it. Think Contraception. http://www.thinkcontraception.ie/
12. Cleary BS, Keniston A. Havranek EP. Albert RK. Intimate partner violence in women hospitalized on an internal medicine service: prevalence and relationship to responses to the review of systems. Journal of Hospital Medicine. 2008; 3(4):299-307.
13. Antai DE, Antai JB. Attitudes of women toward intimate partner violence: a study of rural women in Nigeria. Rural & Remote Health. 2008; (3):996.
The tools that social organizations utilize (contraceptive education, media messages, and abstinence promotion) fall short of expectations, and this is likely due to the inappropriate application of the Social Cognitive Model in their intervention designs. Repeatedly, the concepts of self-efficacy and reciprocal determinism are under-addressed in many of the teen pregnancy prevention advertisements and education programs.
Social Cognitive Theory (SCT) explains that a behavior is constructed from the intricate interactions of an individual’s internal
world (self-efficacy), environmental influences (external factors), and interactive processes with others (reciprocal determinism) (3-5). Self-efficacy is an individual’s confidence and ability to overcome obstacles in order to pursue the behavior of interest (3-5). The level of self-efficacy can be influenced by factors such as the individual’s past experience in trying to accomplish the desired behavior, social persuasion, stress, and learning experiences (5). The more an individual believes in his or her ability to achieve a desired behavior, the more likely it is that it will be accomplished (3-4). The external environment, which includes both physical and social factors surrounding an individual, is important during the construction of the behavior, according to SCT, because during this process, individuals observe “rewarding” behaviors to learn or “emulate,” and “vicarious learning” takes place (4-5). Finally, a behavior is also heavily influenced by the reactions of the people with whom the individual interacts (3). Therefore, interventions fall short of expectations because organizations overemphasize the external learning factor of the SCT while undermining the importance of self-efficacy and reciprocal determinism.
Teen Pregnancy Interventions Put Too Much Emphasis on “Vicarious Learning”
When people shape their behavior by observing and emulating others in the environment (via positive or negative reinforcements), they are experiencing vicarious learning. Most of the teen pregnancy interventions are attempts to address the behavior as socially “rewarding” or socially “unacceptable.” For example, many abstinence campaigns employ famous and well liked celebrities, like winners of the Miss America pageant and Britney Spears, who take the abstinence pledge to set an example for teens and show them that abstinence is something “rewarding” to do (6). Conversely, abstinence campaigns may also have slogans that imply that sex prior to marriage has serious and unwanted consequences. For example, in 2007, the statewide Washington abstinence campaign slogan was ‘No Sex. No Problems” (7). Similar techniques are also used in contraceptive promotion advertisements. For example, the famous Zazoo commercial that was first aired in 2006 showed a wild, uncontrollable child creating an uproar in a supermarket and a meek, young father who simply did not know what to do about the situation. It ended with the message, “Use the condom” (8). The message was that having sex without contraceptives can bring results that are more than one can handle. A majority of the teen pregnancy interventions are structured in this way, with slogans and images trying to either encourage the good behavior (abstinence) or deter bad behaviors (sex without condoms). However, none of these interventions consider the importance of self-efficacy or reciprocal determinism, which may be especially relevant for interventions involving intimate relationships. Interventions devoid of these key components fail to value obstacles, such as an individual’s finances or power differences between the woman and the significant other that may deter individuals from accomplishing the desired behavior and understanding the consequences of having unprotected sex.
Teen Pregnancy Interventions Fail to Address Social Factors that May Lower Self-Efficacy
Studies have shown that the recent changes in public policies and mixed media messages may have provided additional barriers and kept teens from adhering to the desirable behavior (lowered self-efficacy). For example, starting in 2005, governmental funding for contraceptives or emergency contraceptives for teens has been falling. This decrease may put a higher financial burden on young teens and keep them from adhering to the desirable behavior (1). They may decide to have unprotected sex because they cannot afford condoms or pills on a long-term basis. Furthermore, the advertisements for “emergency contraception pills” may send a mixed message to teens: “If you messed up, it’s okay. You can just take a pill to fix it.” A recent randomized, controlled trial comparing the impact of direct access to emergency contraception through pharmacies and unintended pregnancies found that women are more likely to be negligent in engaging in unprotected sex when they know emergency contraceptives are an option (9). Other under-addressed self-efficacy issues are related to culture and language. One of the factors related to the recent increase in unprotected sex is large immigrant populations (1). While many of the teen pregnancy interventions provide powerful messages on educational Web sites, few are multi-lingual. If an immigrant does not speak English, it may be very difficult for her to comprehend the consequences of engaging in unprotected sex, and she may not be aware of resources for help. This may increase her sense of “helplessness.” She may feel that no one is there to explain available resources in the community, and there may be no counseling services to help with her emotional needs.
Therefore, additional approaches addressing the empowerment of teens and help them to think responsibly or boost their self-confidence are highly desirable if we want to help teens adhere to the desirable behavior (abstain from sex or use contraceptives when engaging in sexual behavior). Unfortunately, there are very few intervention slogans that focus on teen self confidence and empowerment. To make matters worse, many teen pregnancy campaigns target teen fears by sending a message that by acting irresponsibly, they will become social outcasts or undergo extreme stress. A recent UK anti-teen pregnancy campaign displays images of teen mothers who are social outcasts with nowhere to go and no one to help them. In addition, this commercial also shows that these young mothers are “frightened” and simply “helpless” (11). Although this commercial sends a powerful message, it may backfire, since “fear” may not deter teens from irresponsible sexual activities. Commercials like this one are telling teens that they will be “helpless.” Even though resources like Planned Parenthood are available to help teens through difficult situations, they may not bother to try to seek out help, believing the message in campaigns like the one detailed above.
Teen Pregnancy Interventions Failed to Address the Power Relationship
Most of the interventions focus on women and their emotions and the social consequences they will face if they are pregnant. However, very little study has been dedicated to understanding the behaviors of the men that lead to unplanned pregnancy. Statistics shows that 6 in 10 babies fathered by teen boys age 18-19 are unplanned and 52% of babies fathered by men between the ages of 20-24 are unplanned. Furthermore, Latino men between the ages of 15-44 are most likely to have unplanned children. Additionally, about one half of unmarried men under 24 do not use condoms while engaging in sexual activities (10). These statistics simply show that teen pregnancy interventions are ineffective in reaching males. These statistics also suggest that teen pregnancy interventions are only as effective as the number of males who follow the instructions. We must take into account the reciprocal determinism in interactions between the partners and recognize the power differences between men and women in a relationship. Oftentimes, women cave in to the desires of their male partners due to the power differences between them the power difference is especially clear when men are the financial providers, older, or have more social power than the female partner (12-14). Thus, in these inherently imbalanced relationships, most women do not want to offend or disappoint their partners. So far, none of the teen pregnancy interventions address the issue of teaching women to say “no” to unprotected sex or how to counter power differences. Power differentials in a relationship are more visibly portrayed in the anti-domestic violence campaigns, where oftentimes the messages are “say no” or “seek help” (13-14). Ironically, these are the types of messages that should be incorporated in the anti-teen pregnancy interventions. Providing teens with information about the consequences of sexual behaviors (babies, STDs) and the knowledge about where to access contraceptives is simply not enough. These tools need to be integrated successfully in the communications between two people in order for the messages to work.
Currently, most of the teen pregnancy campaigns focus on changing women’s behaviors. However, some messages should appeal to men. This is true because men have the power to convince their female partners to change their behaviors. After all, educating the less powerful side to convince the more powerful party to change a behavior is obviously not as effective as educating the powerful party to accept a behavioral change.
When considering powerful slogans to promote desirable behaviors, all components of SCT are equally important to the success of an intervention and should be addressed in equal proportions. Underweighting the importance of some aspects of the theory may reduce the overall effectiveness of the model. Interventions will not be successful when we fail to see that self-efficacy and power differentials in a relationship are also powerful characteristics that need to be considered in order for our interventions to work. We may have failed because even though we understand that teens change their behaviors by observing and emulating environmental models, we did not boost their confidence to achieve the behaviors (self-efficacy), or we targeted our interventions to the wrong population (should focus on behaviors of teen boys instead of teen girls). The results are, of course, compromised and diminished.
References
1. National Center for Health Statistics: Birth/Natality. http://www.cdc.gov/nchs/births.htm.
2. Proportion of All pregnancies that are Unplanned by Various Socio-Demographics, 2001. TheNationalCampaign.org. Visited: November 18, 2008.
3. Bandura A. Social Learning Theory. New York: General Learning Press, 1977.
4. Salazar MK. Comparison of four behavioral models. AAOHN. 1991; 39:128-135.
5. Bandura A. the self system in reciprocal determinism. Am Psychol. 1978; 33: 344-358.
6. How effective are abstinence pledges. News.bbc.co.uk. November 18, 2008.
7. Statewide abstinence campaign tells youth "No Sex. No Problems." http://www.doh.wa.gov/Publicat/2007_news/07-089.htm visited: November 18, 2008.
8. Zazoo condoms. http://www.zazoocondoms.com/
9. Raine TR, Harper CC, Rocca CH. Direct Access to Emergency Contraception Through Pharmacies and Effect on Unintended Pregnancy and STIs: a Randomized Controlled Trial. Jama. 2005; 293(1): 54-62.
10. Martinez GM, Chandra A, Abma JC, Jones J, and Mosher WD. Fertility, Contraception and Fatherhood: Data on Men and Women from Cycle 6 (2002) of the National Survey of Family Growth. National Center for health Statistics. Vital Health Stat; 23 (26).
11. Think about it. Think Contraception. http://www.thinkcontraception.ie/
12. Cleary BS, Keniston A. Havranek EP. Albert RK. Intimate partner violence in women hospitalized on an internal medicine service: prevalence and relationship to responses to the review of systems. Journal of Hospital Medicine. 2008; 3(4):299-307.
13. Antai DE, Antai JB. Attitudes of women toward intimate partner violence: a study of rural women in Nigeria. Rural & Remote Health. 2008; (3):996.
Teen Pregnancy Intervention Revisited: An Intervention That Works
Background
Since 1991, despite the combined efforts of both public and private institutions in lowering teen pregnancy, teen pregnancy still accounts for approximately 80% of the 3 million unplanned pregnancies annually (1). The failure of appropriately applying the principles of social cognitive theory is likely to be responsible for the inefficacies in many of the currently available interventions.
Social cognitive theory (SCT) explains that a behavior is constructed from the interactions of an individual’s internal world (self-efficacy), environmental influences (external factors, both physical and social), and interactive processes with others (reciprocal determinism) (2-4). These three primary components (self-efficacy, external factors, and reciprocal determinism) are often under addressed in teen pregnancy prevention campaigns, rendering them ineffective. The failures of currently available interventions call for a new effective intervention.
New Intervention
Old interventions have failed to account for factors in the following three areas: a) the overemphasis on promoting “vicarious learning” in teen pregnancy intervention campaign messages, b) the under evaluation of the physical environmental barriers to adherence of the targeted behavior, and c) the lack of focus in addressing both an individual’s self-confidence and his or her relationship to intimate partners. This new intervention proposes to increase the effectiveness of such interventions by coupling the fundamental underlying framework (SCT) with other theories in each of the problematic areas. The new intervention will be devised as follows. First, social marketing theory will be used to promote the desirable behavior. The desirable behavior (using condoms or abstinence) will be “dressed” up to encourage adolescents to emulate this behavior afterward, instead of using ineffective and bland campaign messages. Second, this new intervention will incorporate community mobilization theory to “mobilize” the available community resources to crack down on barriers that keep adolescents from adhering to the wanted behavior. The primary target of this focus is to provide adolescents with easy and increased access to the necessary contraceptives or emotional support. Finally, this intervention will use anthropology and social marketing theory to investigate both the individual’s self-efficacy and his or her relationships with partners in “context.” This approach aims to train the available support system (e.g., parents and counselors) to better associate with adolescents and their behavior norms depending on their social environment (social economic status, racial disparities, etc.) and attempt to encourage more males to practice safe sex with their partners.
Hence, this new intervention will be community based (since different communities have different compositions of needs, resources, income brackets, and ethnicities) and will utilize attractive advertisements via TV, radio, posters and pamphlets. In addition, it will mobilize the community to push for increased provisions of low-cost contraceptives and introduce local or mobile STD clinics that provide contraceptives, counseling, and testing services. Such services would involve training more culturally aware counselors from the community to convince male partners to practice safe sex and support adolescent women’s feeling empowered.
The arguments for the design of the intervention are further explained in the following sections:
A. Use social marketing theory in campaign advertisements: tailor the targeted behavior as desirable to the population
As the modern community becomes more diverse and interests are becoming more heterogeneous, implementing campaign slogans and employing “role models” who can uniformly reach all adolescents have become less effective (6,7). In dealing with fragmented adolescent populations, targeting them one community at a time may be a preferred strategy (6). Additionally, bare-bones campaign messages are rarely effective among adolescents; for example, the 2007 statewide Washington abstinence campaign slogan was “No Sex. No Problems,” which did not persuade a substantial number of adolescents to practice abstinence (8). Such slogans do not suggest an “attractive” behavior or target self-efficacy. Thus, applying the social marketing theory in campaign advertisements may seem a more suitable and effective strategy when attempting to sway adolescents. The social marketing theory is a specific approach that utilizes marketing principles to promote and generate changes in social behavior (9).
The theory consists of four components: product, price, place, and promotion (9). “Product” refers to the benefits that are associated with a desired behavior, which can change as the values of the target population change (9, 10, and 11). This means that the “product” or “desirable behavior” can be “dressed-up” and redefined as the adolescent’s definition of “cool” changes. “Price” refers to the physical or social cost or the sacrifice that is exchanged for a promised benefit within the target population (9). For example, an adolescent girl who wants to practice abstinence may have to face the social cost of dealing with pressure from her partner (11). “Place” refers to the issues of access and availability, such as the ways in which a certain behavior or product is distributed to the target population (9). For example, condoms would be placed in all convenience stores for easy accessibility for last-minute use (9). “Promotion” refers to strategies that are used to advertise, promote, and persuade a target population to “buy” or exchange its resources for the product (9). Through these four components, social marketing aims to increase the acceptability of a practice (desired behavior) among adolescents with the help of media to promote a product, idea, or attitude and assumes that the adolescents have unique attitudes and behaviors that are based on their own personal experiences (11). To support the claim that social marketing theory may be helpful in convincing adolescents to use contraceptives, a study has shown that adolescents are not likely to engage in safe sex practices unless they believe that the practice possesses “meaning” (12). Further, in the National Strategy Report, incorporating attractive messages using social marketing theory is highly recommended and proved successful in anti-teen pregnancy campaigns (7). Using social marketing strategy in media campaign messages is also adopted by various social organizations, such as Teen Pregnancy Prevention & Partnership and APAUSE (13, 14).
B. Incorporate community mobilization theory to “mobilize” the available community resources to crack down on barriers that keep adolescents from adhering to the wanted behavior
Since SCT theory failed to address many physical barriers for adolescents, such as having easy access to contraceptives or counseling services, more organized community-based efforts are needed to lower those barriers. Typically, the two primary environmental factors that prevent adolescents from adhering to safe sex practices are financial and local barriers to contraceptives or support. For instance, since 2005, governmental funding for contraceptives for adolescents has been falling (1, 15). This decrease may put a higher financial burden on younger adolescents and keep them from adhering to the desirable behavior (1, 15). Or the barriers can occur from the resources and culture of their communities. Adolescents of some communities may have to travel far to gain access to condoms. Additionally, some communities may not have convenient stores that stay open late, which may also serve as a deterrent for adolescents to practice safe sex. Thus, a community effort should push for late-hour licensing for some of the local convenience stores and encourage more funding for contraceptives or mobile clinics that provide condoms and STD testing services. Community actions involve the collective actions of community groups to increase awareness about the problem (16). Some successful and visible campaigns using such strategies include anti-alcoholism and anti-abortion movements (17, 18). In order to launch a successful community mobilization movement, one should first have a clear understanding of what type of community it is (Is it conservative or liberal? Does it have few or many resources?), choose the most feasible strategy to promote the agenda (e.g., create a budget for mobile clinics, extend stores’ hours, or apply for more funding), and gather information on powerful advocacy groups that can help strengthen the claim (15-18). For example, the Amherst Association for Healthy Adolescent Sexuality (AAHAS) is a grassroots community organization created in response to community concerns about adolescents’ sexual behavior and high pregnancy rates (19). This organization has been successful in promoting safe sex by incorporating local post-bachelor students to serve as community counselors and maintaining good relationships with local community board members. As such, frequent interactions were promoted between local parents and the organization via social meetings to sustain the empathy for “community feelings” and to involve everyone as part of the anti-teen pregnancy work. The AAHAS has been highly successful since its establishment (19).
C. Apply anthropology theory to create a nurturing counseling environment to help adolescents feel more empowered and address power differentials in relationships
Finally, many of the interventions fail to address the self-efficacy and reciprocal determinism components of the SCT. One way to help strengthen the application of this aspect is to combine anthropological and social marketing theories to help public health promoters stay focused on the issue. Cultural anthropology understands and explains health behavior as part of a pattern of living that integrates action with meanings, symbols, and values connected to a larger social structure (20, 21). It sees the behavior in context of the larger social context (20, 21). Therefore, to train and provide counselors from their own communities with sufficient understanding of the community’s background and structure, one can target an individual’s needs more successfully than a counselor that goes by the book. Both self-efficacy and reciprocal determinism target the internal and external influences on an individual. One focuses on an individual’s confidence when engaging in an activity, while the other explains how outside social influences can impact the individual’s behavior. The anthropology approach focuses on the social context that shapes an individual and their behaviors, which would include what structures their internal values and who has the most powerful influence on the individual. For example, if an adolescent is feeling helpless because of his or her race or social economic status, meeting with a counselor from a similar background who has experienced similar ideologies and values and has had a similar neighborhood experience would be much more empowering for that adolescent. Likewise, the anthropology approach can be enhanced by social marketing theory by applying it to the local boys to encourage them to practice safe sex. If an intervention can successfully induce adolescent boys to practice safe sex, adolescent girls will experience less reciprocal determinism (6).
In conclusion, although some components of the SCT may be difficult to apply, we can create interventions that combine other frameworks targeting each shortcoming to better address our public health problem. We should know that an effective strategy comes from a careful assessment of the culture, social, and environmental context of a community and tries to target our population and their behaviors within the context of that community. If we can first understand their cultural context, we can design a program incorporating the necessary frameworks and devise the most effective intervention.
References
1. National Center for Health Statistics: Birth/Natality. http://www.cdc.gov/nchs/births.htm.
2. Proportion of All pregnancies that are Unplanned by Various Socio-Demographics, 2001. TheNationalCampaign.org. Visited: November 18, 2008.
3. Bandura A. Social Learning Theory. New York: General Learning Press, 1977.
4. Salazar MK. Comparison of four behavioral models. AAOHN. 1991; 39:128-135.
5. Bandura A. the self system in reciprocal determinism. Am Psychol. 1978; 33: 344-358.
6. A National Strategy to Prevent Teen Pregnancy. US Department of Health Services. http://aspe.hhs.gov/hsp/teenp/ann-rpt00/
7. Kotler P, Roberto EL. Social Marketing strategies for changing Public Behavior. New York: Free Press; 1989
8. Statewide abstinence campaign tells youth "No Sex. No Problems." http://www.doh.wa.gov/Publicat/2007_news/07-089.htm visited: November 18, 2008.
9. Grier S, Bryant CA. Social Marketing in Public Health. Annu. Rev. Public Health. 2005; 26:319-39.
10. Kotler P. Marketing for Non-Profit Organizations. Englewood Cliffs, NJ: Prentice-Hall; 1975.
11. Walsh D, Champman Rudd RE, TW Maloney. Social Marketing for Public Health. Health Affairs. 1993. (summer); 104-119.
12. Koniak-Griffin D. Lesser J. Uman G. Nyamathi A. Teen pregnancy, motherhood, and unprotected sexual activity. Research in Nursing & Health. 26(1):4-19, 2003 Feb.
13. Teen Pregnancy Prevention and Partnership. http://www.teenpregnancy-stl.org/
14. Added Power and Understanding in Sex Education. http://www.apause.com
15. Martinez GM, Chandra A, Abma JC, Jones J, and Mosher WD. Fertility, Contraception and Fatherhood: Data on Men and Women from Cycle 6 (2002) of the National Survey of Family Growth. National Center for health Statistics. Vital Health Stat; 23 (26).
16. Beyer JM, Trice HM. Implementing Change: Alcoholism Policies in Work Organizations. New York: Free Press; 1978
17. Steckler A, Goodman RM, Kogler MC. Mobilizing organizations for health enhancement: theories of organizational change. In: Glanz K, Rimer BK, Lewis FM, eds. Health Behavior and Health Education: Theory, Research and Practice, 3rd ed. San Francisco, CA: Jossey-Bass; 2002.
18. Fullerton JT, Killian R, Gass PM. Outcomes of a community and home based intervention for safe motherhood and newborn care. Health Care Women Int. 2005; 26(7): 561—567
19. Joffres H, Langille D, Rigby J and Langille DB. Factors Related to Community Mobilization and Continued Involvement in a Community-Based Effort To Enhance Adolescents' Sexual Behaviour. The Qualitative Report. 2002; 7 (2).
20. Hahn, RA. Anthropology in Public Health: Bridging Differences in Culture and Society. New York: Oxford University Press. 1999.
21. Singer M. AIDS and the health crisis of the US urban poor: the perspective of critical medical anthropology. Soc Sci Med. 1994; 39(7) 931-948.
Appendix
Essay 3
Why Teen Pregnancy Interventions Fail
Since 1991, the federal government and community organizations such as the National Campaign and Planned Parenthood have made similar efforts to prevent teen pregnancy. The main focus of these efforts is educating teens about contraceptives, promoting abstinence, and providing media messages that help raise teen awareness of the issue. As a result, the teen pregnancy rate has continued on a downward trend for more than a decade (1). However, despite these successful campaigns, teens account for about 80% of the approximately 3 million unplanned pregnancies annually (2). Furthermore, the National Center for Health Statistics reported in 2006 that the 14-year decline in the U.S. teen birth rate has reversed, and both the number of births to teens and the teen birth rate have risen (1). Although the teen birth rate grew only 3% between 2005 and 2006, experts are expressing reasonable concerns that the teen pregnancy rate will continue to increase in the upcoming years (1).
The tools that social organizations utilize (contraceptive education, media messages, and abstinence promotion) fall short of expectations, and this is likely due to the inappropriate application of the Social Cognitive Model in their intervention designs. Repeatedly, the concepts of self-efficacy and reciprocal determinism are under-addressed in many of the teen pregnancy prevention advertisements and education programs.
Social Cognitive Theory (SCT) explains that a behavior is constructed from the intricate interactions of an individual’s internal world (self-efficacy), environmental influences (external factors), and interactive processes with others (reciprocal determinism) (3-5). Self-efficacy is an individual’s confidence and ability to overcome obstacles in order to pursue the behavior of interest (3-5). The level of self-efficacy can be influenced by factors such as the individual’s past experience in trying to accomplish the desired behavior, social persuasion, stress, and learning experiences (5). The more an individual believes in his or her ability to achieve a desired behavior, the more likely it is that it will be accomplished (3-4). The external environment, which includes both physical and social factors surrounding an individual, is important during the construction of the behavior, according to SCT, because during this process, individuals observe “rewarding” behaviors to learn or “emulate,” and “vicarious learning” takes place (4-5). Finally, a behavior is also heavily influenced by the reactions of the people with whom the individual interacts (3). Therefore, interventions fall short of expectations because organizations overemphasize the external learning factor of the SCT while undermining the importance of self-efficacy and reciprocal determinism.
Teen Pregnancy Interventions Put Too Much Emphasis on “Vicarious Learning”
When people shape their behavior by observing and emulating others in the environment (via positive or negative reinforcements), they are experiencing vicarious learning. Most of the teen pregnancy interventions are attempts to address the behavior as socially “rewarding” or socially “unacceptable.” For example, many abstinence campaigns employ famous and well liked celebrities, like winners of the Miss America pageant and Britney Spears, who take the abstinence pledge to set an example for teens and show them that abstinence is something “rewarding” to do (6). Conversely, abstinence campaigns may also have slogans that imply that sex prior to marriage has serious and unwanted consequences. For example, in 2007, the statewide Washington abstinence campaign slogan was ‘No Sex. No Problems” (7). Similar techniques are also used in contraceptive promotion advertisements. For example, the famous Zazoo commercial that was first aired in 2006 showed a wild, uncontrollable child creating an uproar in a supermarket and a meek, young father who simply did not know what to do about the situation. It ended with the message, “Use the condom” (8). The message was that having sex without contraceptives can bring results that are more than one can handle. A majority of the teen pregnancy interventions are structured in this way, with slogans and images trying to either encourage the good behavior (abstinence) or deter bad behaviors (sex without condoms). However, none of these interventions consider the importance of self-efficacy or reciprocal determinism, which may be especially relevant for interventions involving intimate relationships. Interventions devoid of these key components fail to value obstacles, such as an individual’s finances or power differences between the woman and the significant other that may deter individuals from accomplishing the desired behavior and understanding the consequences of having unprotected sex.
Teen Pregnancy Interventions Fail to Address Social Factors that May Lower Self-Efficacy
Studies have shown that the recent changes in public policies and mixed media messages may have provided additional barriers and kept teens from adhering to the desirable behavior (lowered self-efficacy). For example, starting in 2005, governmental funding for contraceptives or emergency contraceptives for teens has been falling. This decrease may put a higher financial burden on young teens and keep them from adhering to the desirable behavior (1). They may decide to have unprotected sex because they cannot afford condoms or pills on a long-term basis. Furthermore, the advertisements for “emergency contraception pills” may send a mixed message to teens: “If you messed up, it’s okay. You can just take a pill to fix it.” A recent randomized, controlled trial comparing the impact of direct access to emergency contraception through pharmacies and unintended pregnancies found that women are more likely to be negligent in engaging in unprotected sex when they know emergency contraceptives are an option (9). Other under-addressed self-efficacy issues are related to culture and language. One of the factors related to the recent increase in unprotected sex is large immigrant populations (1). While many of the teen pregnancy interventions provide powerful messages on educational Web sites, few are multi-lingual. If an immigrant does not speak English, it may be very difficult for her to comprehend the consequences of engaging in unprotected sex, and she may not be aware of resources for help. This may increase her sense of “helplessness.” She may feel that no one is there to explain available resources in the community, and there may be no counseling services to help with her emotional needs.
Therefore, additional approaches addressing the empowerment of teens and help them to think responsibly or boost their self-confidence are highly desirable if we want to help teens adhere to the desirable behavior (abstain from sex or use contraceptives when engaging in sexual behavior). Unfortunately, there are very few intervention slogans that focus on teen self confidence and empowerment. To make matters worse, many teen pregnancy campaigns target teen fears by sending a message that by acting irresponsibly, they will become social outcasts or undergo extreme stress. A recent UK anti-teen pregnancy campaign displays images of teen mothers who are social outcasts with nowhere to go and no one to help them. In addition, this commercial also shows that these young mothers are “frightened” and simply “helpless” (11). Although this commercial sends a powerful message, it may backfire, since “fear” may not deter teens from irresponsible sexual activities. Commercials like this one are telling teens that they will be “helpless.” Even though resources like Planned Parenthood are available to help teens through difficult situations, they may not bother to try to seek out help, believing the message in campaigns like the one detailed above.
Teen Pregnancy Interventions Failed to Address the Power Relationship
Most of the interventions focus on women and their emotions and the social consequences they will face if they are pregnant. However, very little study has been dedicated to understanding the behaviors of the men that lead to unplanned pregnancy. Statistics shows that 6 in 10 babies fathered by teen boys age 18-19 are unplanned and 52% of babies fathered by men between the ages of 20-24 are unplanned. Furthermore, Latino men between the ages of 15-44 are most likely to have unplanned children. Additionally, about one half of unmarried men under 24 do not use condoms while engaging in sexual activities (10). These statistics simply show that teen pregnancy interventions are ineffective in reaching males. These statistics also suggest that teen pregnancy interventions are only as effective as the number of males who follow the instructions. We must take into account the reciprocal determinism in interactions between the partners and recognize the power differences between men and women in a relationship. Oftentimes, women cave in to the desires of their male partners due to the power differences between them the power difference is especially clear when men are the financial providers, older, or have more social power than the female partner (12-14). Thus, in these inherently imbalanced relationships, most women do not want to offend or disappoint their partners. So far, none of the teen pregnancy interventions address the issue of teaching women to say “no” to unprotected sex or how to counter power differences. Power differentials in a relationship are more visibly portrayed in the anti-domestic violence campaigns, where oftentimes the messages are “say no” or “seek help” (13-14). Ironically, these are the types of messages that should be incorporated in the anti-teen pregnancy interventions. Providing teens with information about the consequences of sexual behaviors (babies, STDs) and the knowledge about where to access contraceptives is simply not enough. These tools need to be integrated successfully in the communications between two people in order for the messages to work.
Currently, most of the teen pregnancy campaigns focus on changing women’s behaviors. However, some messages should appeal to men. This is true because men have the power to convince their female partners to change their behaviors. After all, educating the less powerful side to convince the more powerful party to change a behavior is obviously not as effective as educating the powerful party to accept a behavioral change.
When considering powerful slogans to promote desirable behaviors, all components of SCT are equally important to the success of an intervention and should be addressed in equal proportions. Underweighting the importance of some aspects of the theory may reduce the overall effectiveness of the model. Interventions will not be successful when we fail to see that self-efficacy and power differentials in a relationship are also powerful characteristics that need to be considered in order for our interventions to work. We may have failed because even though we understand that teens change their behaviors by observing and emulating environmental models, we did not boost their confidence to achieve the behaviors (self-efficacy), or we targeted our interventions to the wrong population (should focus on behaviors of teen boys instead of teen girls). The results are, of course, compromised and diminished.
Reference
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6. How effective are abstinence pledges. News.bbc.co.uk. November 18, 2008.
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Labels: Adolescent Health, Orange, Sexual and Reproductive Health
posted by Danielle Lawrence @ 6:17 PM
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