Combating Teen Suicide: A Revolutionary Skill Building Intervention –Daniel Prevost

Introduction

This paper will propose a revolutionary skill building intervention addressing the deadly issue of teen suicide. This new intervention will be referred to as a Skill Building Intervention (SBI). SBI will directly address the flaws of screening teens for suicidal ideation pointed out in the attached paper, Survey Screening for Suicide is Suspect. The first section of the paper will outline a group level model and explain how it is more effective than the individual level model critiqued in the initial paper. The first section explains how this intervention will target specific groups of teens who are most in need. The second section of the paper will explain how SBI will proactively intervene with teens as opposed to the inefficient reactive method of screening. SBI will actively address reasons teens feel suicidal and teach them ways to deal with their feelings. This has the added benefit of helping teens who are depressed and in need of better coping skills but aren’t necessarily suicidal. The third section explains the ways SBI will address the barriers to treatment with a focus on reducing stigma. Throughout the paper, the terms teens and adolescents will refer to people in the age group 15-24.

A brief overview of the intervention

This Skill Building Intervention will focus on groups of adolescents known to be at risk for suicide. Using Marketing Theory, SBI will conduct interviews with members of at-risk groups to find out what they want most. After the interviews, their desires will be marketed back to them in a way that encourages them to join an after school club. Club members will engage in fun social activities that create a feeling of acceptance and teach important life skills. Each year the group will put on an event that is open to the public and aims to reduce the stigma surrounding mental health issues; it will also educate parents and fellow students about access to mental health care. The event will serve as a fundraiser and donations will be accepted to provide more funding for group activities and advertising. Fundraising will make this intervention more accessible to poorer communities. The following three sections will argue that SBI is significantly more effective than screening interventions.

A group intervention targeted toward at-risk groups of adolescents

This Skill Building Intervention (SBI) is superior to screening interventions because it intervenes at a group level as and it specifically targets at risk groups as opposed to simply targeting individual; SBI goes on to target at-risk groups instead of wasting recourses screening all teens. SBI is strongly supported by social network theory and Marketing. Social Network Theory states that people behave similarly in groups (2). This theory supports the premise that an effective intervention has to address a group or groups of people, not individuals. Individuals do not make decisions in a vacuum; outside factors including the behavior of their peers, shape an individuals behavior. Research has identified which groups of adolescents are at greatest risk for suicide. The following groups have been identified to be at an elevated risk for suicide: teens in special education classes, adolescents with substance abuse issues, and adolescents who isolate themselves from their peers (7,22,5). Marketing theory has outlined ways to change the behavior of a target group of people (6). SBI will target these at risks groups using this theory. Marketing theory seeks to identify the wants of the target population and then sells a desired behavior change back to the target population coupled with satisfaction of those wants (6). SBI will utilize focus interviews to identify the wants of the target population. Then advertising will be used to promote an after school group activity. Advertisements will be based on the results of the interviews. For example, a common want of the isolative group may be the need to feel accepted. In this case, advertisements would promise that if the targeted adolescents attended the SBI after school group, they will feel accepted. These advertisements would be supported by visual images. SBI will use marketing theory to combat teen suicide much like the successful Truth Campaign used marketing principles to reduce teen smoking in Florida (23). This intervention will be significantly more successful than screening interventions because it is based on proven social science theories and it targets groups of teens, specifically groups that are at high risk for suicide.

A new proactive intervention

This Skill Building Intervention (SBI) proactively teaches teens how to deal with feelings that lead to suicide making SBI far superior to an intervention that screens for suicide and only intervenes when a teen is already feeling suicidal and desperate. Screening for suicide is analogous to screening for lung cancer instead of basing an intervention on preventing people from smoking. It is far better to focus on teaching teens life skills that help them work through feelings of anxiety and depression. This will prevent them from feeling suicidal in the first place. Instead of wasting time and money screening teens for suicide, it is much better to invest time and money into this preventative after-school program that uses group activities and discussion to help teens deal with stressors that can lead to suicidal ideation. This program is likely to reduce the need for hospitalization and the number of teens who end up feeling so overwhelmed that they want to kill themselves.

SBI is proactive because it teaches teens how to deal with stressors that can lead to suicidal ideation. Some stressors that can lead to suicidal ideation and attempts are: a lack of interpersonal skills, a lack of problem solving skills, and feelings of hopelessness (24-25). Another stressor that can contribute to suicidal ideation is feeling isolated from one’s school environment (26). SBI will teach these skills through after school activities. These activities - for example, “save the world from toxic waste” - give members a challenging task that they have to work together to complete. These groups will give members the opportunity to practice problem solving and social skills. These activities will be designed to impart skills that will prevent teens from feeling suicidal. Activities will be followed by a group discussion to ensure maximum educational benefit from the activity.

The effectiveness of group activities to prevent teens from feeling suicidal is supported by Social Learning Theory. Social Learning Theory states that people learn to behave by observing the behavior of those around them (1). These group activities provide an atmosphere for adolescents to learn from one another. For example, if one member of the group has good social skills and poor problem solving skills, while another member has good problem solving skills and poor social skills, these individuals working together will learn from each other. These group activities would require participants to use social skills and problem solving skills to complete an activity. According to Social Learning Theory, teens participating in these groups will learn these skills by watching how other group members behave.

Reducing stigma and the barriers to getting help

This section of the paper is dedicated to explaining how this intervention will reduce the barriers to getting help for a mental disorder. The focus will be on reducing the stigma associated with mental disorders. Group members will have the challenge of planning an event that will increase awareness of mental disorders and promote the normalcy of seeking help and dealing with mental health issues. The key to this event is for it to be grand enough to attract media attention and a large number of students, parents, and community members. This event could last as long as a weekend and would include attractions like guest speakers, skits, information booths, and food. Each event would be designed by the group members and would be unique to the region, culture, and group organizing the event.


This event would use agenda setting theory to help reduce the stigma of mental illness. Agenda setting theory states that people’s views about what are important issues are shaped by the media (27). So if this event is broadcast by the media through TV, radio, and/or newspapers, it will influence people’s ideas about mental illness. This will reduce stigma by encouraging people to talk about mental health issues and by spreading the awareness promoted by the event.
This event would also make use of the Diffusions of Innovations Theory to reduce the stigma of mental disorders. Diffusions of innovations theory states that behavior changes in groups, in an S-shaped curve. The change happens slowly at first then catches on and there are mass amounts of people changing their behavior and then tapering off as most people have incorporated this behavior change (21). Guest speakers would talk about their past experiences with mental health issues. These speakers would share stories of how they opened up about their mental health issues and found support, treatment, and acceptance. According to the Diffusions of Innovations Theory, once the masses see a few people engaging in mental health seeking behavior it will catch on in the form of an s-shaped curve and the majority of people in need will take the initiative to get help.

This event would address additional barriers to treatment. For instance there will be a section of the event providing information about the accessibility of mental health care. The purpose will be to educate people that hospitals have to admit people who are suicidal regardless of their ability to pay for the hospitalization, and anyone who dials 911 and reports feeling suicidal will have an ambulance ride to the hospital, again, regardless of their ability to pay for the service. The event would also provide information about local support groups. Support groups are free and there are groups offering support for a variety of issues from substance abuse to depression. This event will also have a fundraising element. Attendees to the event can make donations that will provide additional funding for after school group activities and advertising. The fundraising component to these events will make this intervention more accessible in poorer communities. Planning this event is an example of a group project that will help members build self-esteem, develop social skills, and create a sense of belonging to their community. For all these reasons SBI significantly reduces stigma and other barriers to seeking help for mental health issues specifically suicidal ideation. SBI effectively addresses barriers to treatment using social science theories unlike screening interventions which do nothing to combat stigma or any other group level barriers.

Conclusion
This Skill Building Intervention (SBI) is superior to screening interventions because it considers group level factors, takes a proactive approach to suicide prevention, and it addresses barriers to getting help. Screening interventions have been abandoned due to their cost and impractical use of resources (10). SBI effectively uses resources by targeting high risk groups. Screening interventions react when a teen is at the point of desperation; SBI takes a preventative approach that teaches teens how to cope with feeling such as anxiety and depression while building social support for that teen. This approach has the potential to have a lasting impact on the community. While reducing the number of suicidal teens it can also help other teens lead more productive lives because they have learned effective coping skills. SBI addresses the epidemic of social stigma surrounding mental health in society. It uses social sciences to provide the necessary framework to reduce social stigma and reduce additional barriers that prevent people from seeking help for mental disorders. The use of research and the incorporation of social sciences has given SBI the potential to improve the lives of countless adolescents across the world in ways that screening interventions never could.








Survey Screening for Suicide is Suspect
Introduction
Suicide is the third leading cause of death for the adolescents (1). The numbers are astonishing and are under reported due to the shame associated with suicide (1). A current trend in public health is to screen adolescents to determine if they are at risk for attempting suicide. At a glance this may appear to be a good idea; however, there are some fundamental problems with this method of intervention. Social science theories and scientific research caution against this intervention. This intervention attempts to change behavior at an individual level which is ineffective for creating a complex behavior change. Complex behavior changes must be addressed at a group level and should be targeted to groups that are most at risk. The methods used to evaluate if an adolescent is at risk are flawed. The screening does not accurately assess if a person is at risk or not, it lacks racial consideration, and puts a dangerous label of “at risk for suicide” on many adolescents. Finally, this intervention does not address barriers to treatment. There are many obstacles to treatment for example access to health care, race, and ethnicity. The most important barrier that screening interventions fail to address is the social stigma associated with suicide.

Two of the better known screening interventions are Teen Screen and Signs of Suicide (SOS). Teen Screen is set up in schools and communities and the objective is to find out if an adolescent is at risk for attempting suicide. This is done by administering a questionnaire to the adolescent. If the questionnaire shows that the teen is at risk for suicide then they meet with a clinician to determine if they are truly in danger of attempting suicide. If they are deemed to be at risk by both questionnaire and counselor, then their parents are notified. Then the hope is that parents will seek treatment for their child. The SOS differs in two primary ways. The first is that it incorporates a psycho-educational component where adolescence are taught how to deal with friends who are suicidal and the second is that the screening process is self evaluated by the adolescents with the hope that this will encourage the adolescent to seek treatment on his or her own. This critique will focus on the general dangers and failures of screening for suicide in adolescence, not the dangers and failures of any one particular model. The research statistics presented in this paper that refer to adolescence will be representative of ages fifteen through twenty-four. Throughout the paper the terms adolescents and teen will be used interchangeably to refer to the same age group.

Failure at a Group Level

Screening interventions fail to target groups that are at a high risk for suicide; it focuses on promoting a behavior change in an individual not in a group of individuals. Social networking theory states that people behave in ways that are similar to the behaviors of those around them (2). This theory suggests that it is more effective to target an intervention towards a group of people as opposed to an individual, because people’s behavior is impacted by those around them. Using social network theory and research groups of people who are at high risk for suicide can and have been identified. Screening interventions are limited to individuals and treat all individuals as if they were at the same risk for suicide, which is false. Time and money would be better spent if this intervention were targeted and devoted to groups that are at a high risk for suicide. Some groups that are at high risk of suicide are adolescents that are in special education classes and adolescents with poor social skills. A major limitation to screening interventions is the failure to address the fact that people behave similarly in groups and the failure to focus on high risk groups.

Kids in school socialize in groups. Many typical classifications among adolescents are jocks, nerds, gangsters, preps, kids in special education classes, band geeks, popular people, druggies and outcasts. Adolescents with higher levels of social competence and the ability to maintain supportive friendships report that they have lower levels of behavior problems and increased levels of self-worth, motivation, leadership skills, and school performance (3-4). Another study that emphasizes the importance of social skills in relation to suicidal ideation is a study by Rich, Sherman & Fowler (5), found social withdrawal to be the most prevalent symptom in adolescents who complete suicide. Based on these studies targeting a group of people with poor social skills, for example outcasts, would lead to a stronger intervention. This intervention does not account for different groups of adolescents. It also does not consider which of those groups are at the highest risk for feelings of isolation and suicide. In order to have an effective intervention, different groups must be addressed in specific ways that are appealing to them. For example, advertising theory works to get at the heart of what a specific target population wants and then sells that idea back to them with a behavior change. In this case the target population might want social acceptance. Advertising for a support group in a way that promises social acceptance to a group of people who really want to be accepted is likely to create a behavior change for this group of people. (6).

Due to lower levels of emotional and cognitive functioning, adolescents in special education classes are not going to interpret and answer the screening questionnaire the same way as a person who is an honors student. So a questionnaire is not a wise intervention for this high risk group of teens. Special education kids in particular face challenges of isolation and a lack of social skills (7). Furthermore, they face difficult stressors of being bullied, antagonized and teased by peers, thus contributing to feelings of isolation. These factors put this group at higher risk for suicide.


Pablo, a special needs student, told interviewers, “When my grandpa died, (I was) very depressed and then when the kids teased me at school, that’s when I got more depressed…” (7). Another important consideration that is unique to this group is that they are at a higher risk for suicide due to cognitive defects and limited problem solving skills (8-9). Failing to consider the specific needs of different adolescent groups that are at high risk for suicidal ideation is a significant detriment to this intervention.

Screening Methods: Flaws and Detriments

Questionnaires used to evaluate adolescents’ risk of suicide have many drawbacks. A significant flaw is that the questionnaires consistently yield inaccurate results. Depending on the questionnaire used they tend to either yield false negatives or false positives. A false negative abandons a suicidal teen by considering him or her not to be at risk. A false positive tells a teen who is not at risk that he or she is at risk for suicide. The screening is even less accurate for non-white peoples; therefore, the intervention neglects this portion of the population. Finally, it subjects adolescences to the dangers of being labeled as suicidal.

There are a number of questionnaires available to screen for risk of suicide in teens. These questionnaires do not provide reliable results. The amount of times that the questionnaires predictions are wrong makes them impractical to use. Interventions like Teen Screen use questionnaires like the Columbia Suicide Screen (CSS), the Diagnostic Predictive Scales, (DPS), and the Suicide Risk Screen (SRS). The Signs of Suicide intervention uses the Columbia Depression Scale. Other examples include: the Risk of Suicide Questionnaire (RSQ), the Suicidal Ideation Questionnaire (SIQ), the Suicidal Ideation Questionnaire-JR (SIQ-JR) and the Suicide Probability Scale. (10) These questionnaires score youths a false negative for suicidal ideation, up to 52% of the time (11). This fails to identify half of the adolescents who are at risk suicide. Questionnaires that have fewer false negatives and higher false positives are more commonly recommended for school interventions (10). They are recommended for use in schools so that teens who are at risk for suicide do not go unidentified. These rates of false positives make implementing screening interventions in schools impractical (12). For example, in a study conducted by Halfors and colleagues utilizing the SRS, 37% of students were identified as at risk, but only about one out of every three of those was deemed to be at risk by clinicians. That means in a school with 1000 screened teens about 228 teens are falsely told that they are in danger of suicide. The time and cost of screening all these individuals have caused schools to abandon screening methods because they are impractical (12). Questionnaires either under or over identify at risk teens. The problems with under identifying are clear; teens in need do not get help. The problems for over identification are two fold. First, the high number of false positives makes screening too time consuming and costly. Second, it can be detrimental to falsely label a teen as being at risk for suicide.

Labeling an adolescent as suicidal has the potential to be deadly business. Any person who is labeled or put into a certain category is more likely to act in ways similar to others with this label (13). This increases the likelihood that a person who is suicidal might make an attempt after being labeled as at risk for suicide. Possibly even more dangerous, with the high number of false positives, this theory suggests that an adolescent who was not suicidal is at an increased risk of becoming suicidal as a result of this label. This theory is supported by the concept of self-fulfilling prophecy, introduced by social psychologist Robert Merton (1984). Self-fulfilling prophecy is when a person’s initially inaccurate expectations lead to actions that cause that expectation to come true (13).

Another significant flaw in the questionnaire is the lack of consideration for different racial groups. Manetta and Ormand caution that suicide screening questionnaires may not be appropriate for use with all racial and ethnic groups. Questionnaires have been developed and tested using whites as the majority of the sample population (14). The lack of testing for validity among non-white groups renders them useless for minority populations. Suicide rates among youth ages 15-24 is 11 in every 100,000 for whites and 7.9 in every 100,000 for non-whites (15). Although the rate of suicide completion is less for non-whites, they represent a significant proportion of the adolescents committing suicide. It is unethical to use a screening tool with a population that the tool has not been tested for. It is irresponsible of researchers to exclude non-whites in their research. Furthermore, it perpetuates a racial disadvantage to these ethnic groups who are already oppressed by many other socio-cultural factors. Due to the many flaws in the screening method: the lack of accurate questionnaire results, the lack of consideration for the non-white population, and the dangers of labeling adolescents as suicidal, screening interventions should be abandon.

Living Outside the Vacuum: Barriers to Treatment

Screening interventions do not address barriers that prevent adolescents from seeking treatment. Some of these barriers include: stigma, access to healthcare, family history, socio-economic status, culture, and ethnicity. The model hopes to give teens and parents an idea of whether they are suicidal or not. Then it hopes that parents and teens will act rationally and obtain professional help. However this logic is flawed because many times people do not act rationally (16). Behavior is much more complex. While this intervention fails to successfully address nearly every environmental barrier perhaps its largest failure is not addressing stigma. Stigma exists in social circles, among family, friends, and communities.

Fear of social stigma is a huge barrier to treatment for mental disorders. About two thirds of people with mental disorders do not seek treatment (17). For adolescents stigma can be a larger barrier that is more difficult to over come then it is for other age groups. Adolescents have to deal with forming their own identity in addition to forming their own ideas about mental disorders (18). They also must deal with their peers’ ideas regarding mental disorders. The majority of adolescents have a unique challenge because they are not in control of their access to treatment. For example, if a teen’s parents believe that being treated for a mental disorder is shameful and is associated with weak character then the parents may not allow their child to seek treatment. If a teen’s parents control access to transportation and access to medical coverage, then treatment can be virtually inaccessible to this adolescent. This intervention does nothing to break down the stigma of mental disorders within peer groups or with parents. One could argue that it reinforces the stigma because it secretly singles out teens as suicidal and out of the norm. This feedback can be detrimental to suicidal teens that commonly have issues with feeling socially isolated (19).

The stigma associated with mental disorders is deeply entrenched in society. It goes beyond the fact that many people lack education and understanding about mental disorders and their treatment. The idea that mental disorders are shameful and sinful has been past down through generations. There is also a lack of equality in the medical field between medical and psychological disorders. In many states it remains legal for insurance companies to reimburse physicians less for mental health services and to limit the amount they will spend on mental health services (20). A physician can spend the same amount of time diagnosing a patient and prescribing them medication and if the diagnosis is a mental illness as opposed to physical illness then most insurance companies will provide the physician with less compensation. This gives less credit and legitimacy to psychiatric disorders in the medical community and to the general public. This intervention does nothing to reduce the stigma of mental disorders in the community. Even if all suicidal teens in the U.S.A. were identified, there would not be a significant change in the number of teens seeking treatment so long as this stigma remains.
Diffusions of innovations theory proposes that behavior changes in groups, in an S-shaped curve. The change happens slowly at first then catches on and there are mass amounts of people changing their behavior and then tapering off as most people have incorporated this behavior change (21). This theory suggests that if stigma could be reduced and people were open about receiving mental health care it would break down the stigma and cause a major health behavior change. Given this change a huge barrier to people receiving mental health care would be removed. Of the people who complete suicide two thirds were not receiving mental health treatment at the time of their death and about half of them have never seen a mental health professional (17). Screening adolescence for depression or suicide does not work to reduce stigma which is a far greater obstacle for teens or anyone else who is in need a psychiatric treatment than identifying suicidal feelings.

Screening interventions focus on helping teens and their parents identify teens that are at risk for suicide. Most adolescence have learned in childhood how to identify feelings and emotions and have mastered the ability to communicate (1). By the onset of adolescence the average teen is able to identify and communicate that they have thoughts and feelings about killing themselves, therefore, identification is not the problem. The problem is that there are many barriers such as social stigma that prevent adolescents from communicating these feelings. This intervention has failed to address the barriers that could truly lead to saving teens lives.

Conclusion

This screening intervention is merely a diagnostic tool and it does a poor job at that. Its success is rooted in using questionnaires to increase health seeking behavior but it does not address the true barriers that prevent adolescents from seeking treatment. Focusing on the individual and failing to address the complexity of group dynamics is a huge flaw of this intervention. The intervention also neglects to address groups of people who are most at risk. The questionnaires are impractical to use because they yield too many false positives and/or false negatives. They also neglect the non-white population. This intervention does not account for the dangers of labeling an adolescent as at risk for suicide. Finally this intervention does not address external barriers that prevent teens from seeking help for suicidal ideation. The intervention assumes that suicidal teen needs to be identified, when the real barrier lays in stigma and other socio-cultural forces. Screening teens is ineffective, dangerous, and a waste of resources; this intervention has failed and should be discarded.

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Why Teens Couldn’t Live Above the Influence: Ineffectiveness of the National Youth Media Campaign to Prevent Substance Abuse in Teens-Chau Tran

Introduction

In 1998, Congress created and funded the National Youth Media Campaign led by the Office of National Drug Control Policy (ONDCP) in an effort to prevent and reduce drug use among youth. After five years and over $1.2 billion worth of media interventions and public relations efforts, evaluations by Westat Inc. and the University of Pennsylvania found the campaign ineffective in reducing youth drug use despite achieving high levels of media exposure (16, 7). More troubling was that evidence from University of Pennsylvania suggested the opposite: a possible increase in intended drug use among youth exposed to the campaign ads (7). As a result of the campaign’s ineffectiveness in both preventing initiation and curtailing current drug use, the U.S. Government Accountability Office has suggested reducing funds to the campaign until the ONDCP could provide evidence of an effective campaign (16). The ONDCP responded to these findings by noting that the campaign has undergone major changes by adjusting its advertisement messages to improve its effectiveness (4). The most current campaign, “Above the Influence,” based on elements of a combination of theories such as the theory of reasoned action and the social learning theory, may prove to be just as fruitless as their previous efforts.

The basic premise of the theory of reasoned action (TRA) is that behavioral intent is based on an individual’s attitudes about a behavior and their perception of the social norms associated with that behavior (5). Moreover the theory maintains that an individual’s intent will likely translate into behavior (5). Attitudes about a behavior are based on the individual’s expectation of the health-related outcome, and how strongly the individual feels about that outcome, while perception of social norms is believed to be a product of the individual’s belief of what others would think about the behavior and how important it is for that individual to conform to what others think (5). The theory of reasoned action assumes a rational thought process and that attitudes and social norms are weighted by each individual and then factored into the individual’s intention to do the behavior.

Social learning theory (SLT) is founded on the idea that individuals interact with their immediate environment (1). It is through this interaction that individuals learn by observing or modeling a certain behavior (1). Modeling a health behavior is thought to rely on four main components: 1. the ability to bring attention to the modeled behavior by making the behavior more attractive or the person doing the behavior more relatable to the observer, 2. the ability to aid in the retention of the modeled behavior through images and verbal descriptions, 3. the ability to allow for reproduction of the behavior through converting symbolic representations into the action, and 4. the observer must have a positive motivating factor in order to emulate the behavior (1).

Despite a well-intentioned effort to implement these theories as a way to prevent and curb drug use in the youth population, this campaign fails in several aspects. In many of its advertisements, it fails to recognize the limitations of the theory of reasoned action by assuming youth will make intended and calculated drug use/initiation decisions. Although the advertisements are regularly based on elements of the social learning theory, the models are hardly relatable to how youth think to impact behavior. Moreover, the campaign neglects and inappropriately addresses various social variables that may impact a large number of youth. Lastly, mixed messages from the campaign may both confuse and deter youth from adopting the intended behavior.

a. The Theory of Reasoned Action and misleading assumptions of adolescent attitudes and behavior.
In an effort to employ the theory of reasoned action, the National Youth Media Campaign created print ads such as “Lungs” which depict artwork of a lung in which two true/false questions are written on them asking, “ True or False, 1. When you smoke a joint you inhale four times as much tar as a cigarette, 2. A teenage marijuana user is twice as likely to drop out of school than a non-user. Answer: True, now get all the facts. Live above the influence” (9). Ads such as “Lungs” are targeting the adolescent expectations of the health and educational outcomes of smoking marijuana in an effort to change attitudes of the behavior. The idea is that by changing attitudes about the behavior, the ad would change the intention to perform the behavior and thus directly change the behavior itself (5). More over, by telling the adolescent to “Live above the influence,” ads are telling teens to neglect social norms and not smoke marijuana.

Ads employing the TRA such as “Lungs” make a few assumptions about adolescent attitudes and behavior. First, even if the ad was successful, as a limitation of the TRA, it assumes that intention will ultimately lead to behavior. While this may be true in theory, many of us may have similarly intended to do something but ended up not accomplishing our intended task due to a variety of factors. Psychological studies on adolescent deviant behaviors such as substance abuse add to this difficulty of accomplishing an intended behavior by suggesting common underlying causes in adolescent behavior such as difficulty in regulating negative emotions, emotionally driven behaviors during adolescence, poor impulse control, and sensation seeking behaviors (3). This inability for many teens to regulate emotions is noted to lead to emotional avoidance coping in which the teen avoids unpleasant feelings by further engaging in risky, sensation seeking behaviors that could temporarily alleviate these feelings (3).

Secondly, print ads such as “Lungs” assumes that factors such as the amount of tar or educational status are important enough for a teen to change their attitude towards marijuana. For example, if a teen’s family has positive perceptions of drug use, or if education or health is not important to a teen’s social network, it may be difficult for the teen to find issues such as health or education important enough to change attitudes about drug use. Moreover, although some teens may find these topics of value, there could be multiple factors in a young person’s life that play a larger role in decision-making, or that can overshadow the issues of health and education such as socioeconomic factors or family structure (11, 17). For example, recent studies have suggested that influential individuals such as siblings, cousins, and parents in the home and their views on drug use can determine marijuana use among teens (11, 17). Drug use can also serve a variety of different functions across different groups and subgroups of teens as ways to cope with a variety of environmental stressors such as poverty, oppression, or violence (17).

b. Social Learning Theory- using the wrong models
Although the campaign utilizes elements of social learning theory, many of the advertisements depict characters or situations that may be difficult for teens to relate to. One of the first components of social learning theory is to be able to bring attention to the modeled behavior or person doing the behavior so that it is attractive and relatable to the targeted observer. Television ads such as “Walk Yourself” or “Football” depict cartoon characters and/or situations that could never happen.

In “Walk Yourself” a cartoon boy is lying down smoking marijuana and his cartoon dog enters the room. The boy asks the dog, “Can’t you walk yourself?” while the dog walking away responds, “You disappoint me” (18). Neither the cartoon depiction nor the scenario of a dog talking to you exemplifies any real life situation that a teen may relate to or understand. By the ad’s inability to engage the viewer, any subsequent messages may be overlooked or scoffed at by the audience. Moreover, in this ad, the boy is happily smoking in his room and benefits by not having to do a chore with the only consequence of his dog being disappointed. What kind of message does this send to youth? That smoking may be beneficial because you don’t have to do your chores and the worst that can happen is that your dog tells you he/she is disappointed in you?

In “ Try Football,” a cartoon boy tells another cartoon boy walking his dog, “I smoke to impress the ladies”(13). The boy with the dog responds while walking away, “Try football.” The message here is “Football is an alternative to help get the ladies.” Although still well intentioned, the ad is still depicting cartoon characters and an unlikely conversation between two teens. Moreover, adolescents may not be swayed by this ad because although it offers an alternative, it does not show or prove the idea that football is any better than smoking marijuana.

c. Failure to address differences.

Addressing Cultural/Ethnic Differences
Despite ads that appear to be targeting non-white minority youth, the campaign may still be far from addressing ethnic/racial/cultural differences among the adolescent population. Searching through www.abovetheinfluence.com, some ads such as “Huggin the Block” and “Sent” seemed to be targeted towards African-American and Hispanic youth. “Huggin the Block” portrays an African-American girl as the narrator who raps about a boy named Trey who smokes marijuana and does nothing all day except sit on the steps with his friends (8). In “Sent,” a Hispanic young girl picks up the phone and says, “Hey girl, que pasa? My weekend was crazy, what I can remember” (12). She continues talking to her friend and finds out that an embarrassing picture was sent to all her friends from her “crazy weekend” (12). The scene ends with another girl flaunting a phone image to her circle of friends and a teen boy looking up at her from his phone in disapproval (12).

Although the campaign recognized the differences in racial and ethnic groups by creating ads that were intended to target African American, and Hispanic audiences, these ads only scratched the surface of creating a culturally sensitive intervention. According to Resniscow, et al. in the Journal of Community Psychology, cultural sensitivity consists of two dimensions, surface and deep structure (11). Surface structure is explained as matching an intervention to social and behavioral elements of the targeted population by using the people, places, foods, music, clothing familiar to that population (11). Surface structure is considered necessary for an intervention but is only a prerequisite, as it will only determine how receptive a population is to a message or intervention (11). Deep structure is noted as the factor that will impact an intervention and is explained as understanding how cultural, social, psychological, environmental, and historical factors affect a target population (11). With these elements in mind, one can try to understand how a population understands and perceives the problem and how a variation of these factors influences their behaviors. For example, it is noted that compared to Caucasians, African-Americans experience a greater number of stressful events, experience different types of stressors, and use different coping mechanisms to stressful events (11). The two ads “Huggin the Block” and “Sent,” failed to address any deep structure factors while only addressing a few surface structure elements such as inclusion of the people, clothing, music, and a bit of the language. Merely identifying ethnic/ racial/cultural differences and addressing surface structure may not be enough, in a complex problem such as teen drug use. It may require tailoring of interventions to address deep structures in a diverse adolescent population.

Addressing, gay, bisexual, lesbian differences
Another social factor that the campaign entirely fails to address are differences in lesbian, gay, and bisexual in adolescents, their cultural and social systems, and/or environmental stressors. Recent studies have shown that both prevalence and odds of lesbian, gay and bisexual youth substance abuse is higher than their heterosexual peers (10, 15). In a study, looking at bisexual young women compared to their heterosexual peers, it was found that bisexual young women were more likely to be solitary users, have pro-drug beliefs, and lower refusal efficacy, perceived greater parental approval, and had more exposure to substance using peers (15). These studies suggest that failure of the National Youth Media to address the right audiences in a culturally understanding and sensitive way may be a factor in its inability to prevent and curb drug usage among adolescents.

d. The “Boomerang Effect”- Reactance Theory

Another failure of the National Youth Media Campaign lies within its own slogan “Live Above the Influence.” While many of its ads such as “T-shirts” seem to be sending the message of being free, independent, and making one’s own choices, by constantly telling teens what to do to “Live above the influence” can be perceived as hypocritical and impinging the teen’s freedom to make one’s own choices (14). A possible consequence of these mixed messages could result in what is called reactance among teens that could prevent youth from adopting the intended behavior or even doing the opposite of the intended behavior coined the “Boomerang Effect” (2).The reactance theory derived from psychology posits that when individuals perceive that their freedom is threatened or restricted, they will emotionally react by directly contradicting the threat to regain or retain their behavioral freedoms (2). Reactance can also cause someone to adopt a stronger attitude towards the threatened behavior as well as increase resistance to future persuasion (2).

Florida’s successful “truth” campaign in 1998 understood this theory well. It found through interviews with youth, that they disliked anti-tobacco efforts that passed judgment on tobacco users and disliked even more so being told what to do (6). Yet, the National Youth Media Campaign continues to send hypocritical messages to youth who may be reacting to being told what to do.

Conclusion

The National Youth Media Campaign has the potential to improve the health and safety of many adolescents by preventing and curtailing substance abuse among this population. By understanding and getting into the minds of youth, the campaign can target interventions that address barriers, attitudes, and the true causes of behavior. Using more attractive and relatable models that teens would want and be inspired to emulate may help to bring attention and motivate teens to model the desired behaviors. Moreover, the adolescent population is a diverse population with different patterns of use, prevalence of use, and environmental and social factors that contribute to substance abuse. Although tailoring ads to different teen populations may be complex, such an intervention may be needed in solving such a complex problem. Finally, by carefully examining how a message is conveyed to the adolescent population, the campaign may be able to both capture the trust and attention of the adolescent population instead of deterring or pushing them in the opposite direction. By critically examining the flaws in their campaign and making a true effort to adjust them, the campaign can make a large impact in the lives of many teens.

An Intervention

Through the examination of the various flaws of the National Youth Media campaign, we may be able to construct an intervention that could better impact the teen drug decisions and outcomes. Accounting for these various flaws, the following four-pronged intervention is suggested as an improvement upon the current campaign. The first component of the intervention involves going beyond the focus group by accounting for various social, psychological, and developmental factors using field research and immersing interviewers into the world of various groups of adolescents. The second component of this intervention involves using an element of social learning theory, which involves winning the target population’s attention, and desire to emulate behavior using celebrities and real-life situations in ads. The third component of the intervention accounts for deep structure elements in ads targeting various groups and subgroups of teens. The last component of this intervention is to develop a message that keeps in mind the effects of psychological reactance in order prevent mixed messages towards teens on drug behavior.
The first component of this multilayered approach is to address various barriers to behavior such as psychological, developmental, and social factors that play a role in drug use through field research and directly talking to groups of teens representative of the target audience. Although the National Drug Youth Media Campaign used focus groups in their to better understand the target population, it may have been difficult to understand how these various factors, and their complexities truly influence teens without observing them within the context of their social environment (16). A possible component of the “truth” campaign’s success may have been contributed to the implementation of qualitative field research going beyond the interaction in a focus group (6). Interviewers in the “truth” campaign were dispersed into various youth environment and were made to act similar to their peers in order to build trust when gathering information (6). By immersing interviewers into the youth environment and gaining their trust, we may be able to receive a more complete understanding of how teens think and the complex factors that influence teen drug use decisions. Another goal of doing field research and talking to various groups of teens is to also understand the various differences across ethnic/racial/cultural groups and provide an opportunity to focus on deep structure elements such as how various cultural, social, psychological, environmental, and historical factors affect various groups and subgroups of teens (11).

This component of the intervention addresses a major limitation of the Theory of Reasoned Action (TRA) employed in many of the National Youth Media Campaign ads, which assumes that intention would directly lead to behavior. The previous ads neglected to account for factors that can cause behavior to deviate from intention such as psychological and emotional development (3). Moreover, while many of the ads illustrate the negative educational and health effects of smoking marijuana, studies have shown that there exist various social factors that may be relevant to address in anti-drug interventions (11,17). Evidence of these various factors as barriers to behavior suggest that merely addressing individual negative health and educational effects of drug use as shown in “Lungs” may be limiting and require a more critical examination. Moreover, evidence of the differences in psychological, historical, and cultural, barriers across different teen groups illustrates the complexity of the problem (11). By examining a fuller spectrum of barriers, differences, and groups, we could then account for and tailor ads and interventions that address these factors.

The next component of the intervention involves using popular celebrity teens in print and television ads portrayed in real-life situations that adolescents may face with drug use. This may be a better use of social learning theory because the people and situations may be more attractive and understandable to the adolescent viewer (1). The use of popular celebrity teens that many adolescents may already want emulate may better bring attention to the modeled behavior as well make the modeled behavior seem more attractive to the viewers. Unlike talking to a dog in “Walk Yourself,” using real life situations that adolescents encounter may increase the receptiveness of the ad because it pertains to something that they know and understand (1, 18). Moreover, using real-life situations may allow adolescents to more easily reproduce and emulate the desired behavior as described by social learning theory (1). Another important component of social learning theory is that observer must have a positive motivating factor in order to emulate the behavior (1). In “Walk Yourself,” the cartoon boy smoking marijuana avoided having to complete a chore with very little negative consequences besides the disappointment of his dog, which could be seen by many teens as a positive outcome (18). It may be important to note that using celebrities and real life situations may be ineffective if it fails to send the right message to the audience.

The third approach to this intervention is to not only target ads towrds different groups of teens of different cultures, ethnicities, races, and sexual orientations, but use ads that make a better attempt at addressing the deep structure elements of these groups. Although it may difficult to tailor ads to each group, it may be necessary and more effective than creating ads that inadequately address, or do not address these issues at all. Understanding deep structure elements such as the psychological, historical, social, environmental, and cultural context of each group can be accomplished through the first component of this intervention using field research (11). An example of an ad that might tailor to deep structure elements of a group may be to account for point used earlier of African-Americans experiencing a greater number of stressful events, different types of events, and different ways to cope (11). Using this historical, social, and psychological understanding one could create an ad that mirrors the types of stressful events that African American youth experience and identify a more positive coping mechanism that may be more understandable and acceptable for African American youth.

The last component of this intervention seeks to change the message of the campaign to decrease mixed messages as well avoid psychological reactance. The message can be tailored more towards sending a message promoting individual choice and self-efficacy instead of telling youth that they should not smoke and live above the influence. By understanding the idea behind psychological reactance and examining the approach of the “truth” campaign, sending a message that inspires and encourages youth towards the wanted behavior rather than telling youth what to do may be important to note in order to avoid deterring teens from the campaign (2, 6).

Although the current campaign has been very successful in achieving high amounts of media exposure, its various flaws limit and according to data, may prevent the campaign from achieving its goal in decreasing national adolescent drug use (16). Recognizing that achieving high exposure may do little to affect change, the proposed intervention seeks to improve upon the various flaws of the current campaign while maintaining this high exposure. By examining the various factors that affect youth decisions, we may be better able to develop interventions that address these elements. Using more attractive models in situations that adolescents can understand may help achieve more attention and desires to emulate modeled behavior. Tailoring ads to different cultural, ethnic, and racial groups by addressing deep structure elements although difficult may be key in approaching such a complex problem. Lastly, by creating a positive message that avoids a psychological reactance among teens, we may be better able to capture not only the attention but also the motivation of youth to establish the targeted behavior.

REFERENCES:
1. Bandura, A. Social Learning Theory. New York: General Learning Press, 1977.
2. Brehm, J. A theory of psychological reactance. New York: Academic Press, 1966.
3. Cooper, M. L., Wood, P. K., & Orcutt, H. K. Personality and the predisposition to engage in risky or problem behaviors during adolescence. Journal of Personality and Social Psychology 2003; 84(2):390-410.
4. Dotinga, R. Study: Federal Anti-Drug Campaign Didn’t Work.Washington, DC: Center for the Advancement of Health, 2008. http://www.cfah.org/hbns/getDocument.cfm?documentID=1796.
5. Edberg, M. Individual Health Behavior Theories (pp. 35-49). In: Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007.
6. Hicks, JJ. The strategy behind Florida’s “truth” campaign. Tobacco Control 2001; 10:3-5.
7. Hornik, R., et al. Effects of the National Youth Anti-Drug Media Campaign on Youths. American Journal of Public Health 2008; 98: 1-8.
8. “Huggin the Block”. The Ads. Washington, DC: Above the Influence, National Youth Anti-Drug Media Campaign. http://www.abovetheinfluence.com.
9. “Lungs”. The Ads. Washington, DC: Above the Influence, National Youth Anti-Drug Media Campaign. http://www.abovetheinfluence.com.
10. Marshal, M. P., Friedman, M. S., Stall, R., King, K. M., Miles, J., Gold, M. A., et al. (2008). Sexual orientation and adolescent substance use: A meta-analysis and methodological review. Addiction, 103(4), 546-556.
11. Resnicow, K., et al. Cultural Sensitivity in Substance Abuse Prevention. Journal of Community Psychology 2000; 28:271-290.
12. “Sent”. The Ads. Washington, DC: Above the Influence, National Youth Anti-Drug Media Campaign. http://www.abovetheinfluence.com.
13. “Try Football”. The Ads. Washington, DC: Above the Influence, National Youth Anti-Drug Media Campaign. http://www.abovetheinfluence.com.
14. “T-shirts”. The Ads. Washington, DC: Above the Influence, National Youth Anti-Drug Media Campaign. http://www.abovetheinfluence.com.
15. Tucker, J. Ellickson, P., & Klein, D. Understanding Differences in Substance Use Among Bisexual and Heterosexual Young Women. Women’s Health Issues 2008; 18:387-398.
16. United States Government Accountability Office. Contractor’s National Evaluation Did Not Find That the Youth Anti-Drug Media Campaign Was Effective in Reducing Youth Drug Use. Washington, DC:GAO 06-818, 2006.
17. Wagner, K. D., Ritt-Olson, A., Soto, D. W., & Unger, J. B. Variation in family structure among urban adolescents and its effects on drug use. Substance use & Misuse 2008; 43(7): 936-951.
18. “Walk Yourself”. The Ads. Washington, DC: Above the Influence, National Youth Anti-Drug Media Campaign. http://www.abovetheinfluence.com.

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.

REFERENCES

1. Tennessee District Attorneys General Conference. 2008. “What’s the Rush? Press Release”. Available at http://www.tennessee.gov/humanserv/cs/wtr/News_Release.pdf. Accessed November 10, 2008.

2. Tennessee District Attorneys General Conference. 2008. “What’s the Rush? Fact Sheet”. Available at http://www.state.tn.us/humanserv/cs/wtr/Media%20Fact%20Sheet%20-%20What's%20the%20Rush%20Campaign.pdf. Accessed November 10, 2008.

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