The Prevalence of Unhealthy Bodies: A critique on addressing childhood obesity in the Primary Care Setting-Krishna Chokshi

Introduction

Recently, the problem of unhealthy bodies has almost become an epidemic in America. Overweight adults seem to be a big public health concern since this group has a considerably increased risk of diseases such as diabetes, and even cancer (13). To address this issue, some researchers planned interventions to decrease childhood obesity within the primary care setting. Researchers believed that taking a “preventive” approach would be effective, since the probability of an obese child becoming an obese adult is 50% after the age of 6 (13). Though addressing a relevant issue, this approach has many flaws. Many interventions taking this approach did not succeed in achieving their desired outcome. Evidence from researchers, the social sciences, as well as the effectiveness of different behavior change models provide us with evidence as to why these interventions were not effective. First, these interventions were largely based on individual level models. Parts of the interventions were aimed at parents, and not children, or vice versa. Individual behavior within social networks was not given consideration. Second of all, these interventions failed to take into consideration environmental factors that could influence a child’s health. Finally, these interventions failed because they did not sell to kids what they want. Instead, what was being sold was mainly the doctor’s interest.

Individual level models are not effective

Behavior change models that target individuals instead of that individual’s social network tend not to be effective. Many traditional behavior change models are based on the individual level. Some examples of these include the Health Belief Model, the Theory of Reasoned Action, and the Theory of Planned Behavior (2, 4, 6). The interventions aimed at addressing childhood obesity within the primary care setting mirror one or more of these models.

For instance, in a study done by Schwartz, Hamre, Dietz et al in 2007, physicians attempted to deliver obesity prevention intervention using motivational interviewing strategies. Their study group was a group of 91 children within the ages of 3-7 who were overweight or at risk. In addition to talking with the children about diet and exercise, they physicians provided the children with tips from the CDC on healthy eating and activity. The researchers observed no significant differences in BMI at the end of the study. In fact, the control group did better than the intervention group on healthy snacking, and loss to follow up was high. This intervention was similar to the Health Belief Model in that the doctors tried to persuade the children that unhealthy eating habits would cost them in the long run and that there were benefits to their health in changing their behavior (13).

In another study done by Kubik, Story et al in 2008, researchers chose a group of 117 parents of 5-10 year olds to test whether counseling them would be effective in changing their children’s eating habits. The researchers found that in general, parents did not regard take-home messages they received from counseling about weight, physical activity and eating practices as relevant. This intervention was also somewhat based on the Health Belief Model, except that it was even more indirect. The physicians hoped that if the parents could see the perceived benefits of having their children eat healthy and exercise, they might be able to influence their kids. They did not succeed (13).

The main argument against these traditional behavior change models is that they emphasize individual behavior change process and pay little attention to other influences on behavior. Models based on individual behavior change cannot be effective when that individual is a part of a larger social network. Social Sciences say that the most effective interventions occur on multiple levels. Intrapersonal as well as interpersonal and group factors must be considered when developing an effective model of behavior change. These interventions that simultaneously influence multiple levels may be expected to lead to greater and longer lasting changes as well as maintenance of health promoting habits (5).

In contrast to some traditional models of behavior change, social network theory argues that what dictates a person’s behavior depends on the behavior of the social network (1). Social network theory views social relationships in terms of nodes and ties. Nodes are the individual actors within the networks, and ties are the relationships between the actors. In contrast to traditional theories, social network theory says that attributed views of individuals are less important than their relationships and ties with other actors in the network. This approach has been useful in explaining many real world phenomena.

Further evidence in the social sciences suggests that behavior which appears to be individual may be viewed as social behavior. Individual behavior is largely the result of the expectations of others (6). This social scientist proposes that in creating an intervention, we have to ask ourselves “how do groups change their behavior?” rather than “how do individuals change their behavior?”

Consequently, we see that unless we take entire social networks into account, interventions aimed at producing behavior change in the individual will not be effective. Persuading children to eat nutritiously or convincing parents that their kids should be more active will not produce healthier children. Instead, there has to be an analysis of the social networks these children make decisions in order for interventions to be effective.

Failure to Consider Environmental Factors

Another big flaw of these interventions is that they fail to account for societal and community factors that could influence kid’s health. In the studies done by Schwartz, Hamre, Dietz et al as well as Kubik, Story et al, individuals were counseled as to how much and what types of foods the kids should eat, and what type of physical activity was necessary. These counseling methods were not effective because there are a variety of other variables which could influence a child or parent’s ability to follow these guidelines.

It is very possible that parents did not have access to or did not know how to cook the foods the physicians suggested were appropriate for their kids. In fact, other studies confirm the fact that some parents simply do not know how cook and sometimes part of a more effective intervention requires them to be taught how to (13). It is also possible that eating habits and types of foods can vary amongst cultures. “Leafy greens,” as prescribed by many of these interventions, is not a staple part of every culture’s diet.

Another environmental factor these interventions fail to account for is socioeconomic status. As we found through class activities, socioeconomic status is closely linked with the kinds of foods available as well as the opportunities to engage in physical activity. Those in lower socioeconomic status groups do not always have access to the wholesome, organic foods as those in higher socioeconomic areas. People in lower income neighborhoods cannot always afford gym memberships and cannot always rely on the safety of a local park for physical exercise.

One study done by Yeong Sook Yoon actually tested the relationship between socioeconomic status and obesity. Adjusting for confounders, they concluded that there was a statistically significant relationship between low income and obesity in the population of Korean men they studied (14.). In anther report published in the Sage journal, researchers found that low-income populations have an elevated risk of obesity as well as chronic diseases. Environmental factors influence health behaviors that contribute to obesity. These researchers propose that in order to address the issue of obesity in these neighborhoods, specific interventions must be designed to help these communities make use of the specific resources available to them (ex. produce stands, walking trails, etc.). Overly generalized interventions encouraging children to engage in physical activity are not effective without considering these factors (7).

The school environment was also left out of these intervention models. Children spend a significant time at school, and the environment of the school can have a significant impact on their daily food intake as well as their physical activity. As an example, in a study in Vienna, researchers found that 60% of the snacks available in vending machines were unhealthy. Also, 75% of the schools had at least one food facility in the direct neighborhood of the school. These researchers recognized the importance of developing an integrated multisectoral approach and policy to address children’s eating habits. They discussed that a child is a part of the environment and that effective interventions must include different sectors: local authorities, schools, community, as well as parents. They say that if we are to move forward in preventing obesity, there must be a more balanced food selection at school, not just at home (11).

There is also scientific evidence why effective interventions must take into account environmental factors. A neural network in our bodies has been identified s the control system for the regulation of food intake. However, another extensive neural system that processes appetite and rewarding aspects of food intake is mainly interacting with the external world. This system is constantly attacked by signals from the environment, ultimately resulting in increased energy intake. Because of this, these scientists recognize that the changing environment and its associated lifestyle are primary causes of obesity in the large majority of the population (3).

Another environmental factor these interventions in the primary care setting failed to address is the fact that kids are easily influenced by the advertisements of unhealthy foods and snacks. Research conducted by psychologists with expertise in child development, cognitive psychology, and social psychology shows that children under the age of eight are unable to critically comprehend messages they see on television and are more prone to accept them as truthful, accurate, and unbiased. This can led to unhealthy eating habits as evidenced by our obesity epidemic in young people today. Some psychologists even suggest that advertising targeted at children under the age of eight be restricted. The Task Force, appointed by the American Psychologists Association, conducted a lengthy review of the literature in area of advertising media. Advertisers spend more that $12 billion a year on advertising messaged aimed at the youth market. Additionally, the average child watches more than 40,000 television commercials per year (8).

Interventions are not giving kids what they want

Perhaps the most essential reason as to why these interventions aimed at curbing childhood obesity within the primary care setting failed is because these physicians and researchers were not selling to kids what they really wanted. If kids were not getting what they wanted or what they found appealing out of these interventions, they were bound to fail.

Since these interventions were based on some traditional public health models, the importance of the “consumer’s wants” was not taken into account. However, recent theories emphasize the importance and effectiveness of getting an audience to believe that what they are buying into is actually extremely appealing. Marketing theory is one technique used by public health organizations to get people to change behavior. These organizations first ask themselves “what do the people want?” They take the answer to this question and try to sell it back to their audience instead of asking themselves “what do we want them to do and how are we going to get them to do it?” Instead of directly trying to sell their product, they sell an “idea” that people like. The reason why marketing theory is so effective is because it uses the “5 Ps.” These include 1.Product 2. Price 3. Place 4. Promotion and 5. Positioning. The product refers to the behavior or the idea that is being sold. The price of the product refers to the monetary as well as the non-monetary cost of a product. These can include psychological, social, or convenience costs. The place refers to the site where the product is distributed. Promotion refers to the way in which the audience is made aware of the product. Positioning refers to the psychological "image" of the product (10).

In the interventions at the primary care setting, kids were advised to eat certain foods like “whole grains, fruits, and vegetables.” Plainly seeing these items listed on paper were neither appealing nor what kids wanted. Children were encouraged to watch less television, and to get physical activity. This method did not work because the “product” (losing weight) was not something these kids absolutely wanted in the first place. It came with a price since it meant they had to watch less TV, cut down on the foods they liked, and eat more vegetables. The kids received counseling sessions at their doctor’s offices, and so the “place” was not one they associate with having fun at all. Though the physicians may have tried to promote healthy eating, it was not done in a way that the kids found appealing, nor was it associated with something that was enjoyable or “cool.”

Kids are obviously influenced by what they see on TV. If it is marketed to them in the right way, they are likely to buy into what they have to do. Advertising theory is another effective, less traditional public health method used to homogenously control a group of consumers at the same time. Advertisers sell their product by making consumers a promise and supporting that promise through visual images (9). As affirmed by Kunkel, kids tend to believe what they see. These interventions in primary care did not advertise healthy eating habits in way that is proven to work effectively on children. Instead, they tried to talk to kids and gave them pamphlets and guidelines as to how they were to change their behavior. These methods were not effective. They did not assure kids with a “promise” of something they wanted, nor did they support their intervention with images that were visually appealing to them. Psychologists have done extensive research in what methods are effective in creating behavior change in children. Simply talking to kids and proving them with papers are not effective methods.

Finally, the creators of these interventions clearly did not have in mind what the kids actually wanted because they did not give kids a reason to stay with the program. Kids want to have fun, be with friends, and do the things they are used to doing. Instead, the basic premise of these studies was to target children who were already categorized as “obese.” The primary goal of these studies was not to produce happy, active children, but instead to specifically reduce their BMI. Instead of giving children a way to enjoy being active in a more natural, assuring way, they automatically stigmatized them as “overweight.” Stigma theory says that when people are labeled, once they self-identify with that label, they become that label (15). Kids who were picked to participate in this study automatically had this label put on them. Already, their self-esteem was lowered, and they may not have been happy to be a part of this program. Furthermore, since the investigators’ goal was to specifically reduce BMI in overweight children, they gave other children who were not categorized as “overweight” no reason to be active and eat healthier. The investigator’s methods were flawed because in failing to see what would attract kids to be healthier, they set themselves up for poor compliance, loss to follow up, and disinterest in the study all together.

A New Approach

These interventions aimed at reducing childhood obesity through the primary care setting have many flaws. They are largely based on the individual level, fail to account for environmental factors, and do not sell to kids what they wanted. With this in mind, I am proposing an intervention in which the US Department of Agriculture (USDA), with its “My Pyramid” dietary and activity guideline would provide kids with an incentive to be healthy. Through an online site, the USDA would allow kids, in teams, to document points they earn by participating in various healthy habits (outlined below). When the team earns a certain amount of points, it will win a gift certificate to Old Country Buffet. Through this program, the USDA would encourage parents, schools, as well as the community to get involved in kids’ health. To promote the program, the USDA would air commercials during television programs kids between the ages of 6-11 normally watch. In this new approach, there is a large emphasis on social networks as well as environmental factors that influence a child’s behavior. This new method also keeps the children’s interests in mind and provides a fun way for them to make healthy decisions.

Social Networks: Involving Parents and Friends

The interventions aimed at reducing childhood obesity through the primary care setting did not focus on the child-parent relationship nor did they account for the fact that children make decisions with their friends. Social scientists say that in order for longer lasting changes as well as maintenance of health promoting habits, an effective intervention must occur on multiple levels and consider group factors (5.) Social network theory argues that what dictates a person’s behavior depends on the behavior of the social network (1) and that individual behavior is largely the result of the expectations of others (6). Therefore, in creating this new intervention, we ask ourselves “how do groups change their behavior” instead of “how do individuals change their behavior?”

To answer this, we must first get children’s most important social network, their families, on the same page. By involving parents, the aim is to ensure that kids receive uniform messages and encouragement as to how to be healthy. Children will be able to log points for things like accompanying their parents to the super-market, assisting them with preparing a meal, and engaging in 30 minutes of daily physical activity. To validate these points, parents must sign off on their children’s daily logs (parents can sign on to their kids’ logs with their own passwords). This way, parents are forced to learn more about healthy habits and stay very involved in their children’s daily activities.

Kids also tend to make decisions based on their friends’ behavior. In this new intervention, children pick 3 friends to join their team. Instead of individually working towards a goal, the kids in the team pool their points towards the prize. Through this method, kids do not feel like they are the only ones participating in the program. Furthermore, working in teams helps friends encourage each other to do what will earn them the most points.

Accounting for Environmental Factors: Schools and the Community

Another substantial flaw in the interventions aimed at curbing childhood obesity in the primary care setting was that they failed to take environmental factors into account. Previous studies prove that there are strong ties between low income and obesity (14) Scientific evidence also shows that our brains are constantly attacked with signals from the outside world which often encourage people to consume more food than they should (3). One way researchers propose to keep lower income families from being at risk of obesity is to encourage them to become familiar with the recourses available in their particular communities (7).

To address this issue, a main focus of this intervention will be to encourage families to learn more about and make use of the resources in their neighborhoods. Another way for kids to earn points is to go with their parents to “discover health” in their community. If kids accompany their parents and discover a new grocery store, stall, or stand where fresh produce is available to them, they can document this online. Kids can also get points by finding a new bike path, walking trail, or park in their community. Of course, the kids will then receive points for making use of these recourses.

Another issue that some of these interventions through the primary care setting failed to account for was that not all people eat the same foods. The investigators in those interventions may have been under the impression that giving examples of certain “green” foods (like fruits and skim milk which the kids should eat “lots” of) and “red” foods (like cream cheese, soda, and potato chips that the kids should limit) would make it easy for the kids to follow dietary guidelines. However, these foods may not be common in every child’s diet. This new intervention will use “My Pyramid” instead as a guideline for how much food from the different food groups kids should include in their diet. “My Pyramid” guidelines are more adaptable to families who eat and cook different foods. Instead of generalizing which kinds of foods kids should eat and not eat, kids receive their own “My Pyramid Plan” based on their age, height, weight, and activity levels. Kids will earn points if they meet the requirements of their individual “My Pyramid Plan” daily (16).

Researchers also say that if we are to move forward in preventing obesity, there must be a more balanced food selection at school, not just at home (11). In order to make sure kids can keep their “My Pyramid Plan” in mind while at school, schools can help kids by labeling the cafeteria’s different food choices according to which food group(s) they fall under. This way, instead of unrealistically forcing schools to only offer “healthy” food choices, kids might be more likely to choose foods wisely depending on their individual plans. The kids can save the labels from the food they eat at school to make it easier to document when they get home.

Another environmental factor these interventions in the primary care setting failed to address is the fact that kids watch and are easily influenced by how foods are advertised on television (8). The USDA can make it a point to work with advertisers to also tell kids which food group(s) their products fall under. Again, it is not realistic that this new intervention will stop advertising of “unhealthy” foods. However, if kids discuss with their parents and are aware of what types of foods fit into their own “My Pyramid Plans”, they will be more conscious of which foods they eat so as to earn more points for themselves as well as their team.

Selling Kids What they Want

Finally, interventions aimed at preventing childhood obesity at the primary care level did not sell kids what they want. First of all, kids do not want to be stigmatized as “obese” (15) This new intervention sells a message to all kids that this program is something fun for everyone. This is crucial because it is important for all kids to know that a healthy lifestyle is not only something for people while they are trying to lose weight. Here, our end goal is not to reduce children’s BMI, but rather to get all kids to start making healthy choices. This will make kids more likely to join and less likely to drop out. There is no “limit” to being healthy, whereas a goal like reducing BMI can only work for certain kids, and only to a certain point.

Using media theory and its 5 Ps: Product, Price, Place, Promotion, and Positioning, this intervention sells a product that kids want: a fun “game” with a prize at the end (10). Kids like working in teams and being with their friends. They enjoy working hard earning points with an incentive in mind. Giving kids an incentive to engage in healthy behavior motivates them as well as reinforces the idea that its ok to go out and enjoy a meal with their family and friends once in a while. Being healthy does not mean going to one extreme or another, but being able to make good choices. Other than what the child’s family may already spend on purchasing groceries, the kids can obtain this “product” at virtually no cost. There is also no limit as to the place where kids can participate in this program. In fact, they are encouraged to get involved within their families, friends, schools, as well as their communities. A way in which this intervention can be promoted is through popular actors and actresses that the kids recognize. In between television shows that kids normally watch, young actors and actresses can advertise this new program in a way in which kids feel it is easy, fun, and socially accepted. Through this method, kids will have a positive “image” of the program and will add to effective positioning of the product. We know that kids watch a lot of TV and are influenced by what they see. Advertising theory focuses on making consumers a promise and supporting that promise through visual images (9). Through using the TV as a medium to market this product, we can effectively get a message across to kids while they are doing something they already enjoy doing.

Finally, kids recently enjoy spending a lot of time online. Kids are more likely to keep up with their “My Pyramid Plans” and document their points if they are doing so through a fun, interactive site online rather than on a separate piece of paper or in a book. They can also share their status with their teammates online. Recognizing that all children may not have access to televisions or computers at home, it is crucial that schools cooperate with the USDA to make children aware of this program and help them participate.

Conclusion

In developing effective interventions to address the problem of unhealthy bodies, we must at the very least take social networks and environmental factors into account. Furthermore, unless we present an intervention in an appealing method, kids are unlikely to follow any program. This new intervention addresses these flaws and offers an inventive approach to being healthy. With approaches like this, we can successfully convey the message that living a healthy lifestyle is for all people.

References

1.) Barnes, J. “Introduction to Social Network Theory.” http://home.earthlink.net/~ckadushin/Texts/Basic%20Network%20Concepts.pdf

2.) Bandura, A. (1977). Self efficacy: Toward a unifying theory of behavioral change. Psychological Review, 84, 191-215.

3.) Berthoud, Hans-Rudolf. “Homeostatic and Non-homeostatic Pathways Involved in the Control of Food Intake and Energy Balance” Obesity Journal (2006) 14, 197S–200S; doi: 10.1038/oby.2006.308

4.) Fishbein M. & Azjen. I. (1975). Beliefs, attitudes, intentions, and behavior. Boston: Addison-Wesley.

5.) Grizzel, James. “Behavior Change Theories and Models” From US Surgeon General's Report on Physical Activity and Health, Chapter 6 - Understanding and Promoting Physical Activityhttp://www.csupomona.edu/~jvgrizzell/best_practices/bctheory.html

6.) Hornick, Robert. “Alternative Models of Behavior Change Annenburg School for Communication, Working Paper 131, 1990, p 5/6: Theory Summary.

7.) Jilcott, Stephanie B. et al. “A guide for Developing Intervention Tools Addressing Environmental Factors to Improve Diet and Physical Activity.” Health promotion Practice, Vol. 8, No. 2, 192-204 (2007). http://hpp.sagepub.com/cgi/content/abstract/8/2/192?rss=1

8.) Kunkel, Dale. “TELEVISION ADVERTISING LEADS TO UNHEALTHY HABITS IN CHILDREN; SAYS APA TASK FORCE.” American Psychological Organization

http://www.apa.org/releases/childrenads.html

9.) Marshfield, David. “Advertising Theory.” http://www.ciadvertising.org/SA/fall_02/adv382j/dan02/proj3/theory.htm

10.) Meischke, Hendrika “Social Marketing Theory.” http://depts.washington.edu/obesity/DocReview/Hendrika/basedoc.html

11.) Middelbeek, Lideke. “Environmental factors related to

diet, physical activity and overweight in secondary schools.” National Institute for Public Health and the Environment.”

12.) Rosenstock, I.M (1974). The health belief model and preventive health behavior. Health Education Monograph, 354-386.

13.) Wright, Julie. PhD. Slides and Interview on “Childhood Obesity and the Primary Care Setting” Including Studies by Schwartz, Hamre, Dietz et al and Kubik, Story et al

14.) Yoon, Yeong Sook et al. “Socioeconomic Status in Relation to Obesity and Abdominal Obesity in Korean Adults: A Focus on Sex Differences. (2006) The Obesity Journal. 14, 909–919; doi: 10.1038/oby.2006.105http://www.nature.com/oby/journal/v14/n5/full/oby2006105a.html

15.) Link, Bruce. “Stigma as a Barrier to Recovery: The Consequences of Stigma for the Self-Esteem of People With Mental Illnesses.” Psychiatric Services 52:1621-1626, December 2001 © 2001 American Psychiatric Association

16.) My Pyramid.gov. United States Department of Agriculture Home.

Knowledge is Power: Government Funded Abstinence-Only Programs Omit Crucial Information on Sexual Health -Diana Theriault

“Vows of abstinence break more easily than latex condoms (1).” Yet America is still taught to abstain from sex. Education is important. How can anyone make an informed decision when much of the information is not provided? Abstinence-only education is ineffective at preventing many teens from engaging in sex before marriage and only hurts those who do have sex without the knowledge of how to do so safely.
When you think of the word sex, what comes to mind? For many there is a negative connotation that comes along with that word. In America, people don’t talk about sex openly. We keep that part of our lives a secret. It is almost like you have to hide it. Sex should be a topic that everyone is comfortable talking about. This is the first step in having a safe and healthy sexuality. Communication is key in this area. If the only thing we tell the children of America is, “don’t do it,” then what happens if and when they do? Are we just supposed to say, “I told you not to?” No. We should be promoting abstinence, but saying “in the event you do have sex, here is how to protect yourself.” Because when it is all said and done, teenagers are going to have sex whether or not you tell them to.
The data shows that people do have sex before marriage. “The average age of first intercourse is 16.9 for boys and 17.4 for girls (2).” Yet the “average age of first marriage continues to rise. for women the average age is 25.6 and for men it is 27.5 in 2007 (3).” This is a major drawback of these types of programs. We can see that the programs don’t work, that people are still having sex anyway, and many are just ignorant to the way contraception works and how it can protect them. Still, abstinence-only education is valuable right? The following studies show otherwise.
Abstinence-Only Education: More harmful than helpful?
If you think about it, almost everything that we engage in, such as driving a car, jumping on a trampoline, smoking cigarettes, taking prescriptions, swimming in pools and many more, have safety guidelines to abide by. Also in case of an emergency, there are steps to take to prevent any further harm. But why is it that when it comes to sex, we fail to teach those safety guidelines? It’s like throwing someone in the driver’s seat of a car and saying go! If you don’t know how to drive, you don’t know the rules of the road, how to be safe and what to do incase of an emergency, do you really want that person to be behind the wheel? I surely don’t. “In 2005, 37.2 percent of sexually active high school students and 44.6 percent of sexually active twelfth grade students did not use a condom during their last sexual intercourse (4).” Many of them ‘got behind that wheel’ without learning about safety. Unprotected sex can lead to unintended pregnancies and sexually transmitted infections which can lead to other complications. Even more distressing is that, “One-quarter of sexually active adolescents nationwide have an STD, and many STDs are lifelong viral infections with no cure (4).”
A survey from the Kaiser Family Foundation found that young adults want to learn. “They want to know more about how to use condoms, how to recognize the signs of STD and HIV infection, what STD and HIV testing involves, and where they can get tested. They also want more instruction on communicating effectively with partners about sensitive sexual concerns and relationship issues (5).”
Abstinence-only education programs have been funded by the government for many years, however, comprehensive sex education programs have suffered from new restrictions on what can be taught to receive funding. Essentially any program that teaches about contraception has been limited in the funding they can receive under the Bush administration. This allows for more programs that refuse to teach about contraception and safety. If teens want to learn about safety and healthy sexual relationships, shouldn’t we give them guidance?
A study done following over 2000 students from elementary school to middle school and through high school that had abstinence-only education failed to prove that this education is valuable. The study found that there was no difference between those who participated in abstinence-only education versus those who did not. This study confirmed what other studies have already shown. "The most effective programs are those that say abstinence is the best choice but birth control and protection are also worth knowing about (6)." Yet abstinence is still funded heavily by the government. I like the way one woman, Martha Kempner, put it when she said,”Abstinence-only was an experiment and it failed (6)." Failed experiments should not be continued and especially not funded with tax payers dollars.
These programs have not taught our kids properly. Some adolescents even believe they are being safe by using contraception, but they may be using it in correctly. I believe that this proves the point: “One in five young people believe that birth control pills offer protection from STDs and HIV/AIDS. The same amount of people believe that condoms are not effective in preventing the transmission of STDs and HIV/AIDS (5).” If people believe they are protecting themselves or that using condoms won’t protect them from contracting diseases this is a serious misconception. The lack of knowledge about sexual behavior and protection is astounding. I do believe that abstinence is an important thing to teach the young people of America. Children need to develop feelings of self-confidence, independence, and all in all, just grow and mature to make these complicated sexual decisions. But abstinence taught alone leaves people with the knowledge of the dangers of sex but no way to prevent the dangerous consequences.
Not only do these programs fail to educate, but they give out false and misleading information. A report put out by the House of Representatives actually proves that 80% of the curriculum guarantees to contain false, misleading, or distorted information about reproductive health. This false information includes the effectiveness of contraceptives, the risks of abortion, and even scientific errors such as the number of chromosomes that an individual has (7). These things are important. Everyone should know the true facts. How can you make an important judgement like this without having all of the correct information? The same report states that, “youth who pledge abstinence are significantly less likely to make informed choices about precautions when they do have sex (7).”
Community Influence on the Development of Sexuality
Abstinence-only programs teach an ideological view. We set the bar very high when we expect everyone to abstain from sex until marriage. Although this may prevent a few sexual encounters out-of-wedlock, it certainly does not apply to everyone. As kids, we are taught values and morals to live by. As we get older, we discover our own morals and values that we wish to live by. However, when society pushes virginity as the only option, it makes it seem like sex is a bad thing. Therefore, if you have sex, you are bad. This can have social and emotional implications.
Abstinence-only education is an example of the Health Belief Model applied in practice. The Health Belief Model is a theory that suggests that an individual will make a rational decision based on perceived benefits weighed against perceived barriers. It also implies that if a person feels susceptible and that the consequence is severe enough, a person would take action to avoid that behavior (8). Abstinence-only educators believe that if one is taught the severity of consequences and how easily susceptible they are to pregnancy and disease that everyone will abstain. They portray it in such a way that the barriers greatly outweigh the benefits. Even the governments definition of abstinence-only education includes “teaching the social, psychological, and health gains to be realized by abstaining from sexual activity its exclusive purpose (4).” They are trying to prove the benefits of abstinence. These benefits are real, however, we know that decisions are not only based on the individual level alone and so these benefits may not be as important as the beliefs of others for example.
“ ASRH (Adolescent Sexual and Reproductive Health) programming should be approached from an ecological perspective, with the belief that individual behaviors and decisions are not made or practiced in a vacuum, and that social norms and institutions often determine the choices available to most individuals (9).”
There is a large factor of social influence that abstinence only programs come along with. Social norms stereotype men and women as well as heterosexual and homosexuals into different categories. These stereotypes portray “girls as naturally chaste and boys as constantly struggling to control their rampant sexuality and raging hormones (10).” Sexist views put gender roles on men and women. In education like this these stereotypes are taught as facts. The are biological sciences that makes men and women act differently towards sex. This teaches women that if they do express desires and wish to talk about sex, they may be found as promiscuous where men are just generally curious because they have testosterone and it is natural for them to feel these desires (10). This conservative thinking heeds much guilt for women and leaves both sexes uneducated about safety and communication among adolescents. Although gender stereotypes have an enormous impact on teens, stigmas of sexual orientation have an even greater impact. Abstinence-only education programs do not even bring up the subject of homosexuality. This is deliberately left out because programs like these are actually “required by the federal funding guidelines to instruct students that heterosexual marriage is the ‘expected standard’ (10).” Since gay marriage is not recognized nationally in the United States as legal, it is easy to see why the government would leave this discussion out of the program. Because how can you stay abstinent until marriage if you can’t even get married? And we already know that sex out-of-wedlock can be a burden on society so those who do not follow the ‘expected standard’ must also be a burden, right? That is what these programs teach us. It almost allows for discrimination and increases homophobic beliefs which is not right. In society today, everyone should be treated equal regardless of gender, sexual orientation or any other differences we have between us.
As we can see, society and our surrounding communities can greatly influence our views and what we consider social norms. We must adopt a culture open to communication and discussing all sexualities. Teaching teens about contraceptive options, physical differences between men and women, and sexual orientation does not encourage adolescents to go explore what they just learned. We are just providing the facts and allowing them to make an informed decision on their sexuality and bringing about safe options while doing so.
A Violation of Basic Human Rights
Abstinence-only education fails to allow access to basic health information. To educate our children we must provide the full spectrum of options and information. When you hear questions like: “You can’t get pregnant the first time right? Isn’t everyone having sex? Can you get pregnant if you use birth control (11)?,” you know there is much more that teens have to learn before having sex. A person who is in the contemplating stages of having sex should first know their beliefs and feelings about sex. If they feel that they are ready then the next question to ask would be “in what kind of sexual relationship would sexual involvement be comfortable or OK for me (12)?” And when someone is ready to have sexual intercourse they need to be prepared for all of the consequences with that decision including emotional feelings. If kids are not taught the full spectrum of sexual responsibility they can not make informed decisions. Leaving information out or distorting truthful information is harmful to all. Health information should be freely provided and true. By giving out wrong information, these programs are violating our human right to education and information about sexual health.
“Individuals who lack information about sexual and reproductive health care thus also lack the ability to protect themselves from STIs, including HIV/AIDS, and unplanned pregnancy (10).” It is everyone’s right to seek out truthful information. This is why it is not only important for educators to teach the facts, but for parents to divulge all pertinent information as well. Most teens are influenced by many factors when making decisions about health. Parents, peers, and school education are at the top of the list for influencing children on sex. If your peers are taught the same as you, then they are most likely going to base their decisions on the same information you received which does not promote anything but continued misinformation. However, if parents step in, they may be able to influence the child and teach them the right things. Many adults however do not know everything about sex. Even the parent has the right to information and education. That is why it is up to the educators who are supposed to have up to date information on sex and sexual consequences to teach the future of America. Children only learn what they are taught, that is why it is our job to teach, and their right to learn health education.
“Major human rights documents discourage states from limiting access to contraceptives, and other means of maintaining sexual and reproductive health, from censoring, withholding, or intentionally misrepresenting health-related information, including sexual education, as well as from preventing people’s participation in health-related matters, or allowing third parties to do so (10).”
Abstinence-only education violates these rights which has a negative effect mostly on those who do not receive the knowledge. It puts those who do have sex at greater risk for health consequences that they do not even know about, or for that matter, how to prevent negative health effects and unintended pregnancies. Abstinence only education violates the rights of all humans, but has an even greater potential risk in LGBT (lesbian, gay, bi-sexual, and transgendered) individuals and their families by failing to provide “useful and appropriate sexual health information (10).” Men who have sex with men have the highest risk for developing HIV/AIDS (13). These statistics need to be known. Even for those who do not consider themselves gay when they are younger, may realize later in life that they are homosexual or bisexual and should have the facts on both homosexual and heterosexual encounters.
Final Thoughts on Abstinence-Only Education Programs
“The communities should provide access to education about sexual health and responsible sexual behavior that is thorough, wide-ranging, begins early, and continues throughout the lifespan” (14). Such education should give them knowledge about pregnancy, STD's, contraceptives and responsible choices. Abstinence-only education cannot provide this comprehensive education. It should be taught as part of an education program but not as the only program.
A New Perspective
“Comprehensive sex education teaches about abstinence as the best method for avoiding STIs and unintended pregnancy, but also teaches about condoms and contraception to reduce the risk of unintended pregnancy and of infection with STIs, including HIV. It also teaches interpersonal and communication skills and helps young people explore their own values, goals, and options (15).” This type of sex education is important for teenagers to get the full spectrum of knowledge on this topic. Comprehensive sex education have been proven to work (16). Mandates prohibiting educating the youth about the benefits of condoms and contraception make these programs ineligible for federal funding (17). Teens need to learn about all aspects of sexual health to protect them from the dangers of infection and pregnancy. This is something that abstinence-only education cannot provide.
Does Comprehensive Sex Education Provide Benefits?
A concern of many with comprehensive sex education is that it will encourage teenagers to want to have sex at a younger age than they would have had they had abstinence-only education. Research however shows that this is not the case. “Evaluations of comprehensive sex education and HIV/ STI prevention programs show that they do not increase rates of sexual initiation, do not lower the age at which youth initiate sex, and do not increase the frequency of sex or the number of sex partners among sexually active youth (15).” Knowing that these programs do not have an influence on increasing sexual activity of teenagers, we can say that they are not harmful. How though do these programs provide a benefit?
Findings put out by the National Campaign to Prevent Teen and Unplanned Pregnancy, stated that almost all of the comprehensive sex education programs they evaluated had a positive effect on the behavior of teenagers. “In particular, they improved factors such as knowledge about risks and consequences of pregnancy and STD; values and attitudes about having sex and using condoms or contraception; perception of peer norms about sex and contraception; confidence in the ability to say ‘no’ to unwanted sex...communication with parents or other adults about these topics.(18).” Comprehensive sex education is teaching teenagers responsibility, giving them confidence and teaching self-esteem. Not only this but this education is teaching them about risks and prevention. The APA stated, “Based on over 15 years of research, the evidence shows that comprehensive sexuality education programs for youth that encourage abstinence, promote appropriate condom use, and teach sexual communication skills reduce HIV-risk behavior and also delay the onset of sexual intercourse(19).” With all of the evidence shown, it is clear that comprehensive sex education has many benefits and proves to be the superior method to teach teenagers about sexuality.
Influence on Development of Sexuality
Comprehensive education also plays off of the Health Belief Model, although it includes other tools to educate as well. “Rather than trying to deter or frighten young people away from having sex, effective sex education includes work on attitudes and beliefs, coupled with skills development, that enables young people to choose whether or not to have a sexual relationship taking into account the potential risks of any sexual activity (20).” Teenagers need the opportunity to form their own opinions on this subject matter. Have they been taught the consequences of their actions? Have they been taught how to handle such consequences? Do they know where to get support? If one does become pregnant, do they know all the options? Are they emotionally prepared for such consequences? Also, can they communicate with parents and other adults from whom they are educated? There are so many more questions that need to be asked and answered pertaining to sex and the development of sexuality. These questions cannot be answered in an abstinence-only classroom. “Programs designed to prevent pregnancy need to give young women information about pregnancy and opportunities to discuss the topic so that they form opinions. Furthermore, programs should emphasize positive attitudes toward contraception, because effective contraceptive use is shaped by such attitudes and is strongly associated with reduction of pregnancy risk (21).”
Pregnancy is not the only topic discussed in comprehensive sex education. Sexual development, such as physiological, anatomical and emotional changes in puberty are also discussed. For this education to be comprehensive in all aspects it must also include discussions on healthy relationships. “In terms of information about relationships they need to know about what kinds of relationships there are, about love and commitment, marriage and partnership and the law relating to sexual behavior and relationships as well as the range of religious and cultural views on sex and sexuality and sexual diversity (20).” Like I said before, teenagers are going to have sex whether you tell them to or not. Given the tools, teenagers will make the right choice for themselves, and learn about their own sexuality armed with knowledge on how to be safe. The right attitudes and beliefs on sexuality and the known dangers of what sex can be without protection being taught to teenagers is great. Abstinence-only education may be able to provide these things. However, comprehensive sex education goes beyond the concepts in the Health Belief model and brings in the tools needed to develop a healthy sexuality and be safe when engaging in these activities.
Right to Information and a Right to Equality
America has always prided itself on freedom. We are the land of the free. Though many people do not feel this way. Shouldn’t all Americans have the right to decide if and when they want to engage in sexual activity? Abstinence-only education teaches teenagers that this is not a right. One must not engage in such activities until marriage. Well if one doesn’t have that right, than can’t they choose with whom they would like to engage in this activity with? According to abstinence-only education, that too is not a right. By definition marriage is between a man and a woman (22). Which leaves lesbian, gay. bisexual and transgendered teens to believe they do not have the same rights. So if one cannot decide with whom, or when to have sexual encounters, than at least the information on how to be protected and have safe sex is given, right? Wrong again. Contraceptives and other methods of protection are not taught in abstinence-only education programs because teenagers shouldn’t be having sex anyway (23). So when a teenager gets older and maybe does wait until marriage to have sex, do they know how to protect themselves? If never given the information to learn how to fully prepare for sex and the consequences that come with it, physically and emotionally, than no matter how old you get you still are not prepared. Comprehensive sex education prepares you for all of what is to come. You are given the knowledge and information needed to make the right decisions, so when it comes down to it, you can decide if, when and with whom you want to engage in sexual activity with knowing how to stay protected when that decision comes. “State parties must ensure that children have the ability to acquire the knowledge and skills to protect themselves and others as they begin to express their sexuality (23).” These are the rights and freedoms Americans are entitled to.
Culminating Thoughts
Given all of the information about abstinence-only education programs and comprehensive sex education programs, one is clearly able to see the benefits that comprehensive education provides over abstinence-only education. I believe that abstinence is necessary to teach and to instill core values and morals in teenagers. I also believe though that teenagers are rebellious in nature and because they are told not to do something they are more apt to do so. So when educating teens about sex, one should also be taught about contraceptives and how to respect one another’s choices. Whether those choices are to have sex or not, or whom they may choose as a partner, or even how to handle the event of an unintended pregnancy. Developing their own attitudes and beliefs about sexuality is essential. With comprehensive education, one can make an educated decision and learn about sexuality. Comprehensive sex education should be available to all teenagers, it is a right of Americans. Therefore, comprehensive sex education should be funded by the government instead of abstinence-only education. It is important that the children of America have the freedom to make their own choices when it comes to sexuality and they should be guided on how to make the right choices.
REFERENCES
1. Elders, Joycelyn M. “Vows of Abstinence Break More Easily Than Latex Condoms.” Rethinking Schools Online. 2002. Milwaukee, WI. 20 November 2008 <http://www.rethinkingschools.org/sex/elders.shtml>.
2. Guttmacher Instutute. In Their Own Right: Addressing the Sexual and Reproductive Health Needs of American Men. 2002.
3. U.S.Census Bureau. Estimated Median Age at First Marriage, by Sex: 1890 to the Present. 2007.
4. Trenholm C. et al. Impact of Four Title V Section 510 Abstinence Education Programs. Final Report. Princeton: Mathematica Policy Research; 2007. http://www.mathematica-mpr.com/publications/pdfs/impactabstinence.pdf
5. The Henry J. Kaiser Family Foundation. (2003). National Survey of Adolescents and Young Adults: Sexual Health Knowledge and Experiences. http://www.kff.org/youthhivstds/upload/National-Survey-of-Adolescents-and-Young-Adults.pdf
6. Stepp, Laura Sessions. “Study Casts Doubt on Abstinence-Only Programs.” Washington Post. April 14, 2007. http://www.washingtonpost.com/wp-dyn/content/article/2007/04/13/AR2007041301003.html
7. UNITED STATES HOUSE OF REPRESENTATIVES COMMITTEE ON GOVERNMENT REFORM — MINORITY STAFF SPECIAL INVESTIGATIONS DIVISION. “The Content of Federally Funded Abstinence-Only Education Programs: Prepared for Rep. Henry A. Waxman.” December 2004. http://oversight.house.gov/documents/20041201102153-50247.pdf
8. Rosenstock, I. M. (1974). Historical Origins of the Health Belief Model. Health Education Monographs. Vol. 2, No. 4. 328 – 335.
9. Community Pathways to Improved Adolescent Sexual and Reproductive Health: A Conceptual Framework and Suggested Out come Indicators. December 2007. Washington, DC and New York, NY: Inter-Agency Working Group (IAWG) on the Role of Community Involvement in ASRH. http://www.advocatesforyouth.org/publications/iawg.pdf
10. Kay J.K., Jackson A. Sex, Lies and Stereotypes. How Abstinence-Only Programs Harm Women and Girls. Legal Momentum; 2008
11. “Facts & Stats.” The National Campaign To Prevent Teen Pregnancy. 2002. Washington, D.C. 20 November 2008. <http://www.teenpregnancy.org/resources/teens/facts/default.asp>
12. “Sexual Responsibility.” Olin Health Center. 2002. Michigan State University, MI. <http://www.healthed.msu.edu/fact/sexual_responsibility_1.shtml>
13. Centers for Disease Control and Prevention. “A Glance at HIV/AIDS among Men Who Have Sex with Men.” January 2006.
14. “The Surgeon General's Call to Action to Promote Sexual Health and Responsible Sexual Behavior: At a Glance: Vision for the Future.” U.S. Department of Health & Human Services. July 2004. Washington, D.C. <http://www.surgeongeneral.gov/library/sexualhealth/glancetable.htm>
15. Advocates for Youth. “Sex Education Programs: Definitions & Point-by Point Comparison.” Accessed on December 6, 2008. http://www.advocatesforyouth.org/rrr/definitions.pdf
16. Kirby D. Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy. Washington, DC: National Campaign to Prevent Teen Pregnancy, 2001.
17. American Foundation for AIDS Research. Assessing the Efficacy of Abstinence-Only Programs for HIV Prevention among Young People. [Issue Brief, no. 2] Washington, DC: Author, 2005.
18. Kirby D, Emerging Answers 2007: Research Findings on Programs to Reduce Teen Pregnancy and Sexually Transmitted Diseases, Washington, DC: The National Campaign to Prevent Teen and Unplanned Pregnancy, 2007, p. 4, Accessed Dec. 6, 2008. http://www.thenationalcampaign.org/EA2007/EA2007_full.pdf
19. American Psychological Association (APA). (Feb. 2005). “Comprehensive Sex Education is More Effective at Stopping the Spread of HIV Infection.” Accessed December 8, 2008. http://www.apa.org/releases/sexeducation.html
20. Avert: AVERTing HIV and AIDS.“Sex Education that Works.” Accessed on December 8, 2008. http://www.avert.org/sexedu.htm
21. Perspectives on Sexual and Reproductive Health, Vol. 36, No. 6, Findings from Add Health (Nov. - Dec., 2004), pp. 248-257 http://www.jstor.org/stable/1520257 Accessed Dec. 10, 2008
22. "Marriage." Merriam-Webster Online Dictionary. 2008.Merriam-Webster Online. Accessed December 10, 2008 <http://www.merriam-webster.com/dictionary/marriage>
23. Santelli, John S., MD, MPH, Schleifer, Rebecca, JD, MPH, and Lande, Lila J., MPH. “Abstinence and U.S. Abstinence-Only Education Policies: Ethical and Human Rights Concerns.” Accessed on December 10, 2008. http://www.protectchoice.org/downloads/Reproductive%20Justice%20Briefing%20Book.pdf

Connecticut “Make Healthy Fish Choices” Campaign-Amanda DeLoureiro

On October 16, 2008, the Connecticut Department of Public Health and the Connecticut Food Association began publicizing a statewide campaign entitled “Make Healthy Fish Choices” (1). This campaign is geared towards women and children, and its purpose is to educate people about the health benefits and dangers of consuming different varieties of local and store-bought fish (1). This has involved the publication in English and Spanish of take-home cards entitled “Healthy Fish Choices for You and Your Family”, which are being distributed in participating supermarkets and grocery stores statewide (1). The cards contain information specific to pregnant women, nursing women, women of child-bearing age, and young children about the health merits and dangers of eating fish, and suggestions about how often different types of fish should be consumed (2).
Problems of the “Make Health Fish Choices” Campaign
The “Make Healthy Fish Choices” campaign is a clear example of an intervention that follows the Health Belief Model. This model is based on the idea that an individual’s perceptions regarding health behavior are rational, and an intervention can be used to alter the attitudes of the individual (3). This particular health behavior intervention focuses on changing how individuals view their perceived susceptibility, or the degree to which they think they are at risk of getting sick from the toxins found in many fish (4- 37). There are three main problems with this type of an intervention based on the Health Belief Model, in addition to a major problem with how the issue of fish contamination is being framed through this campaign. First, this intervention focuses on individual-level decision-making, and does not take into account the fact that there are environmental factors that can also affect decisions that people make about the consumption of fish (4-38). Secondly, this campaign assumes that everyone in Connecticut will have equal access to the information provided in the guides, which is untrue because of the large segment of the population that is not literate in English or Spanish, and will not understand all of the vocabulary presented in the document (4-38). Thirdly, this intervention assumes that those affected by the campaign will make rational decisions about their consumption of fish, and in doing so discounts the impact of cultural norms on choices regarding fish consumption (4-38). Lastly, this campaign frames the issue of contaminated fish in such a way that it ignores the root cause of this problem, pollution, and instead focuses on what the consumer can do to decrease the health risks associated with consuming this fish. The “Make Healthy Fish Choices” campaign should have done two major things differently: 1) it should have been modeled after a different type of health model that was more community-based, in order to address the influence of outside impacts like culture on behavior, and 2) it should have framed the issue in such a way as to address the root causes of fish contamination in Connecticut.
Individual-level decision-making ignores outside influences on behavior
A major problem with the “Make Healthy Fish Choices” intervention is that it is targeted at the individual, and was not developed to address social and environmental influences on behavior related to health. This campaign involved only a handout that was read by an individual person, instead of a more community-based effort that would address outside influences on diet, such as cultural norms. The focus on the individual person that is used in this campaign, like the example set forth in other interventions based on the ideas of individual-level models like the Health Belief Model and the Theory of Reasoned Action, reflects the value that North American and Western European cultures place on individualism (5). These societies are very focused on the concept that individuals have complete control over their behavior and decision-making, and in doing so tend to overstate the influence of personal behavior on health (5). Most of the original behavioral health models were built on various assumptions, such as 1) the individual is the key decision maker, 2) individuals value good health and will change their behavior in order to attain positive health outcomes, and 3) cognitive predisposition, like beliefs, attitudes, and perceptions, are a major driving force of health behavior (6-5). All of these assumptions are not inherently correct, because they ignore other influences that may impact individual decision-making and make people choose unhealthy habits, like consuming large amounts of contaminated fish. This intervention ignores the extent to which pre-existing beliefs, attitudes, and perceptions regarding fish consumption may counteract the information being put forth in the pamphlet.
In recent decades, researchers have begun to question the validity of relying solely on health behavior models that are based on individual-level decision-making in achieving substantive and sustainable changes to health behavior (6-6). It is thought that many individual-level models, like the Health Belief Model, do not lead to large-scale behavioral change because they are focused on changing the behavior of individuals. More recently developed models have focused on community-based campaigns, through which it is hopeful that norms within an entire community of people will be changed to encourage more healthy behaviors (6-6). Whereas the “Make Healthy Fish Choices” campaign focuses on changing individual perceptions of the health risks involved with fish consumption, community-based initiatives would prioritize changing the perception of an entire population regarding these health risks. Instead of focusing solely on the individual, health behavior campaigns should recognize the impact that factors like community, living and working conditions, and socioeconomic, cultural, and environmental impacts have on decisions people make about their health (5). It is doubtful that this intervention, based on the Health Belief Model, will be adequate to initiate widespread behavioral change in this case because the change for which the campaign is advocating ignores contextual meanings that are entrenched in group qualities, for example cultural practices, skills, and languages (3). Instead, the campaign would have been wise to take into account the outside influences that can significantly impact the choices that people make regarding fish consumption.
Lack of access of information to low literacy populations
Another major problem with this campaign is that the information about healthy consumption of fish is only offered in the form of a written handout. There are two major problems with this document that may inhibit access to the information provided: 1) it is available in only English and Spanish and 2) it makes use of scientific vocabulary. The availability in only two languages is of concern because in Connecticut, 12.9% of the population is foreign born and this number is predicted to rise in the coming decades (7). The large proportion of immigrants contributes greatly to the percentage of the adult population of Connecticut that is not literate in English. In 2001, 16% of Connecticut’s adult population was in the lowest of five literacy levels, which means that this group of people will be unable to understand the information as it is currently being presented (8). This segment of the population will not fully comprehend the suggestions being made, nor are they apt to know the different types of fish that are listed.
Populations with low literacy face various problems properly understanding health risks, including inadequate comprehension of available health education material, social networks that are not well-informed regarding health problems, and inadequate access to health services (9). A previous intervention geared at addressing the health needs of low literacy populations designed a book which promoted understanding through color coding, graphic symbols, simple language, and clear type (9). The “Make Healthy Fish Choices” intervention did not follow this example, and instead presented health-related information using extensive vocabulary, including words like “PCBs” and “omega-3 fatty acids”, in a manner that was not very clear (2). Low levels of literacy in a large proportion of Connecticut’s population, coupled with low understanding of scientific concepts, means that this intervention provides information in a way that many Connecticut residents will not fully comprehend.
Assumes people will make rational decisions without considering cultural practices
Another major problem with the “Make Healthy Fish Choices” campaign is that it assumes that people will make rational decisions without considering other factors that may have a significant impact on fish consumption, such as cultural practices. The Health Belief Model is known to ignore these outside impacts and instead focus on affecting how the individual makes decisions related to health (4). However, there are many groups of immigrants in Connecticut whose diet is composed of a large quantity of fish that may not, even given the information, choose to change their dietary habits. For example, between 2000 and 2006, the Brazilian population of Connecticut grew 82%, from 10,379 to 18,871 (7). Due to its large coastline, vast rivers, and the influence of Portuguese conquistadors who brought their dietary practices to the new world, the diet of many Brazilians includes a large amount of fish (10). Although the diet of this population may be altered due to the influence of living in the United States, diets of particularly the new immigrants cannot be expected to change dramatically with an individual-based intervention like the “Make Healthy Fish Choices” campaign. This intervention provides information that goes against the Brazilian’s cultural norms of consuming large quantities of fish, and yet it is questionable whether this information will be strong enough to change people’s perception of the health risks related to consuming fish. Many immigrant populations, particularly recent immigrants, tend to live in communities that have large populations of others from their country, as well as markets with food from their country. In order to change dietary norms for groups such as this, it would be necessary to create an intervention to address an entire population of people like the recent Brazilian immigrants.
Downstream approach that ignores the cause of the pollution
Another key problem with the “Make Healthy Fish Choices Campaign” is that it focuses on providing information to fish consumers about the dangers of fish consumption, instead of framing the issue in such a way that it places blame on the companies that contribute to the pollution of Connecticut’s fish. In Connecticut, 75% of fish samples taken have mercury levels that exceed the safe limit for women (0.13 ppm), with an average of 0.42 ppm (11). Sampling in Connecticut waters of specific fish species, such as smallmouth bass and certain predator fish, have found that 100% of fish exceed the safe mercury levels for women (11). Much of this mercury comes from businesses along the rivers of Connecticut, such as power plants. In order to reduce mercury pollution in the rivers of Connecticut, the state passed a law in 2003 that limited emissions to 0.6 pounds of mercury per trillion Btu, or 90% efficiency (11). However, the pollutants in Connecticut rivers do not originate solely in the state of Connecticut, as the Connecticut River estuary includes parts of the states of Massachusetts, Vermont, and New Hampshire.
The intervention as it currently stands does not address the underlying causes of pollution of fish from sources like coal fired power plants, and instead focuses on putting the responsibility of healthy fish consumption on the individual consumer. Institutional framing is the way that public health practitioners can social construct risk (12). In this case, the issue should be framed in such a way that people see the corporations from throughout New England that they are polluting their fish and their water as an enemy, so that they become angry with this group and hopefully work to initiate change. The Connecticut Department of Public Health should make use of the frame-alignment process, which involves linking individuals and social movement organizations with the same set of interests, values, and beliefs (12). In framing the issue in this way, the department could help to initiate a movement for change that would ultimately affect all people who consume fish from the waters of Connecticut.
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Alternative intervention
An appropriate alternative intervention will need to address the problems associated with the Health Belief Model, as well as the root cause of water pollution that is resulting in the contamination of fish. The proposed intervention would provide educational programming to people throughout Connecticut, which would teach them about the dangers of consuming certain types and amounts of fish, and also about the causes of water and subsequent fish contamination. The education programs would be advertised in and provided in local libraries, schools, and religious organizations, in order to reach a large segment of the population. The information would need to be provided in such a way that it addresses the needs of individual communities, consequently there would be a need for flexibility so that each presentation of the information would be designed for people of different backgrounds and cultures. The intervention would also provide people with a form to send to their government representatives about the environmental hazards associated with water pollution and its effects on fish. It is hopeful that this would cause a significant change in policy, and encourage the government to properly address the root cause of fish contamination.
This intervention would address the major problems associated with the Health Belief Model that have been previously outlined. Firstly, it is a community-based intervention that is aimed at changing the behavior of a population, not specific individuals. Secondly, the intervention would educate low-literacy groups of people because the information would be provided verbally. Finally, this intervention would address the need for information to be presented in a culturally sensitive manner, by altering the presentation to speak to the cultural dietary norms of each represented population.
It is also hopeful that, by providing information about the causes of water pollution, and by giving people forms to send to their representatives, they will bond together in order to fight major contributors to water pollution. This intervention would be much more successful than the “Make Healthy Fish Choices” campaign because it 1) deals with the problems associated with the Health Belief Model and 2) properly frames the issue in such a way that the root cause of fish contamination is addressed.
Group-level intervention addresses outside influences on behavior
One major problem with the “Make Healthy Fish Choices” intervention is that it focuses on changing the behavior of individual people and ignores the influence of groups on behavior. Some of the more recently developed behavioral theories have emphasized that groups are different than simply a collection of individuals, and that groups of individuals can be affected at the same time (13). One example of how the emphasis in social behavior models has been altered to address the needs of groups is seen in the Social Expectations Theory, which states that people act in mass based on the prevailing social norms (13). Thus, interventions based in the Social Expectations Theory attempt to alter the social norms of an entire group of people (13). For example, an intervention in Finland that made smoking in the workplace illegal was found to be successful at changing social norms, so that non-smoking at work is now seen as normal behavior in this nation (14).
The proposed intervention can be similarly productive because it addresses behavior change at the level of the community instead of at the level of the individual by having members of a population learn about and discuss the causes and implications of fish contamination. It is hopeful that, though discussions in the education programs and follow-up conversations with their peers, citizens of Connecticut will come to see the consumption of reduced amounts of fish as a societal norm.
Provides information to low literacy populations
Another major problem with the “Make Healthy Fish Choices” campaign is that it assumes that people will have equal access to the information provided in the pamphlets, when in reality low literacy populations will be unable to adequately understand the suggestions being put forth. One study of functionally illiterate populations made the suggestion that preexisting health literature should be extensively reviewed by assessing readability and comprehensibility, editing written material, and evaluating the effectiveness of less complex written documents (15). The researchers found changing the educational intervention so that used less complex language and an easy to read format made it more effective in addressing the needs of low literacy readers (15).
The proposed intervention goes even further than the previous example, as it properly addresses the difficulties in comprehension associated with low literacy populations by educating people through verbal presentations. These presentations will be made in different languages depending on the needs of individual populations, and will provide universal access to the information to all people who attend the education sessions.
Considers cultural practices
Another problem with the “Make Healthy Fish Choices” campaign is that it assumes that an individual’s intention to reduce fish consumption, as a result of an educational intervention, will actually result in behavior change. However, this ignores the impact that cultural norms have on diet, such as the example of Brazilian immigrants discussed in a previous section. The proposed intervention addresses the needs of people of very different cultures by encouraging public health professionals to be flexible in how material is presented based on the needs of varying communities. The results of a previous study that looked at the effects of socio-cultural factors on food selection practices suggest that in order to provide information about food in a culturally sensitive manner, public health professionals need to 1) incorporate cultural information into education approaches, and 2) incorporate the entire household in educational programs (16).
The proposed intervention is designed in a way that will be sensitive to the dietary norms of different cultural groups, even recent immigrant populations, by including cultural information in the programming and by encouraging all members of a household to attend. For example, if public health practitioners wanted to address fish consumption in the growing Brazilian population in Hartford, they might teach people how to incorporate other types of meat into recipes that traditionally have fish. In this way, the behavior of a population that has distinct cultural norms regarding food can be changed by encouraging slightly altered behavior that is sensitive to that population.
Addresses cause of pollution
The final strength of the new intervention is that it deals with the issues associated with the consumption of contaminated fish by addressing the root cause of this problem, which is water pollution from industrial waste. It does this by giving participants of the education programs the opportunity to fill out a form to be sent to their governmental representative, which would outline the problem and the changes that would be necessary to reduce fish contamination. This method makes use of framing theory, which states that an issue can be seen from many perspectives and can be viewed as having implications for many considerations (17). Interventions of this kind use framing to reorient how people think about a certain issue (17). Framing theory has been successful in many public health interventions, the most notable being the anti-tobacco Truth campaign. This intervention frames tobacco smoking in such a way that it encourages young smokers to have anti-industry attitudes towards producers of cigarettes (18). A study in 2004 found statistically significant increases in anti-industry attitudes among youth since the Truth campaign was introduced (18).
The proposed intervention is similar to the Truth campaign in that it encourages the general public to speak out against producers of fish pollutants. It frames the issue in such a way that contaminated fish are not simply a food that they should avoid, but also a problem that they can work to prevent.
Conclusion
The “Make Healthy Fish Choices” campaign of informational handouts regarding the benefits and health risks related to fish consumption is not efficient in relaying this information to the general public of Connecticut. This intervention, which is based on the Health Belief Model, is poor because it is based on an individual-level model of decision-making, ignores problems that people may face in accessing the information, and assumes that citizens will make rational decisions about fish consumption once provided with information. Additionally, this intervention ignores the root cause of the need for the campaign, which is water pollution, and instead focuses on changing consumer behaviors.
In order to be a more effective intervention, the Connecticut Department of Public Health needs a campaign that addresses the significant problems associated with the Health Belief Model in a way that encourages Connecticut residents from all backgrounds to want change from corporations polluting local bodies of water. The proposed intervention would address the flaws of the existing campaign by creating a community-based initiative to address the needs of Connecticut’s diverse population in a linguistically and culturally sensitive manner, while also addressing the underlying cause of the fish pollution.
Works Cited
(1) Connecticut Department of Public Health. Connecticut’s Fish Consumption Advisory and the Safe Eating of Fish Caught in Connecticut. 7 Nov 2008. http://www.ct.gov/dph/cwp/view.asp?a=3140&q=387460&dphNav_GID=1828&d phPNavCtr=#47464.
(2) Connecticut Department of Public Health. State Health Department “Reels-In” Fish Eaters. 16 Oct 2008. http://www.ct.gov/dph/cwp/view.asp?A=3294&Q=425142.
(3) Thomas, Linda W. A Critical Feminist Perspective of the Health Belief Model: Implications for Nursing Theory, Research, Practice, and Education. Journal of Professionalism 1995; 11(4): 246-252.
(4) Edberg, Mark. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Boston: Jones and Bartlett Publishers, 2007.
(5) Marks, David F. Health Psychology in Context. Journal of Health Psychology 1996; 1(1): 7-21.
(6) DiClemente, R., Corsby and R., Kealer, M., Eds. Emerging Theories in Health Promotion Practice and Research. San Francisco: Jossey-Bass, 2002.
(7) Mejia, Rafael and Canny, Priscilla. Immigration in Connecticut: A Growing Opportunity. Connecticut Voices for Children. Oct 2007.
(8) Gelb, Jennifer. Summary of Connecticut Plan for Adult Education and Family Literacy. OLR Research Report. 16 February, 2001.
http://www.cga.ct.gov/2001/rpt/olr/htm/2001-r-0198.htm.
(9) Berger, David, Moira Inkelas, Sonya Myhre, and Alanna, Mishler. Developing Health Education Materials for Inner-City Low Literacy Parents. Public Health Reports 1994; 109(2): 168-172.
(10) Fish, Warren R. Changing Food Use Patterns in Brazil. Luso-Brazilian Review 1978; 15(1): 69-89.
(11) US Public Research Group Education Fund. Reel Danger: Power Plant Mercury Pollution and the Fish We Eat. Aug 2004.
(12) Zavestoski, Stephen, Kate Agnello, Frank Mignano, and Francine Darroch. Issue Framing and Citizen Apathy Toward Local Environmental Contamination. Sociological Forum 2004; 19(2): 255-283.
(13) Siegel, Michael. SB 721 Class Lecture. 9 October 2008.
(14) Heloma, Antero and Jaakkola, Maritta S. Four-year follow-up of smoke exposure, attitudes and smoking behavior following enactment of Finland’s national smoke- free work-place law. Addiction 2003; 98: 1111-1117.
(15) Horner, Sharon D, Dawn Surratt and Sarah Juliusson. Improving Readability of Patient Education Materials. Journal of Community Health Nursing 2000; 17(1): 15- 23.
(16) Gittelsohn, Joel and Vastine, Amy E. Sociocultural and Household Factors Impacting on the Selection, Allocation and Consumption of Animal Source Foods: Current Knowledge and Application. Constraints on Animal Source Food Consumption 2003; 4036S-4041S.
(17) Chong, Dennis and Druckman, James N. Framing Theory. Annual Review of Political Science 2007; 10: 103-126. (18) Thrasher, JF, J Niederdeppe, MC Farrelly, KC Davis, KM Ribisl, and ML Haviland. The impact of anti-tobacco industry prevention message in tobacco producing regions: evidence from the US truth campaign. Tobacco Control 2004; 13: 283-288.

A Critique of Abstinence-Only Policy’s Culturally Biased Messages – Jenna Sandler

Despite overwhelming evidence discounting its success, Abstinence-Only education programs still receive high levels of federal funding in the United States. In the 2007 federal budget, $204 million were allocated to institutions implementing abstinence-only programming and the funds are expected to rise in the 2009 budget. (1) Additionally, states that accept these funds are required to match them by 75%. (2) Thus, an enormous sum of taxpayer dollars is being wasted on ineffective programs and would be better spent on programs that address social and behavioral contexts of sexual risk taking. In our culture, sexual activity is a topic carrying with it widespread and heated controversy. However, the reality is that nearly half of adolescents in grades nine through twelve are sexually active, (3) and one out of four teens has a sexually transmitted infection. (4) Given these statistics, 97% of Americans agree that conversations about sex must be considered a necessary part of a child’s education. (5) How such topics are taught, however, is not quite so unanimous. Fervent supporters of Abstinence-Only education represent a conservative constituency that does not realize the public health threats such programs pose to the adolescent population. (6)
To be eligible for federal funding, programs must follow the A-H abstinence education guidelines, which require the contextualization of sex within a monogamous heterosexual marriage.(4) Abstinence-only programs are deterred from teaching the use of or giving access to contraception, emphasizing instead that abstinence is the only way to protect oneself from sexually transmitted infections (STIs) and teen pregnancy. (7) The results from the Mathematica report, which conducted a federally-mandated evaluation of four Abstinence-Only programs, indicated that youth in such programs were not more likely to abstain from sex or less likely to engage in unprotected sex, as its proponents would hope. Instead, adolescents seem to be confused about the efficacy of contraception in protecting from health risks. For example, 23% of the youth who participated in the Abstinence-Only programs reviewed in the Mathematica report believed that condoms do not protect against HPV and herpes, as compared to 15% in the comparison group. (4) Such programs seem to offer no benefits in terms of sexual risk taking and critics argue that its flawed methodology may even produce harmful effects for teens.
Due to the implications of sex in the sectors of religion and morality, resistance to simply adapting new sex education paradigms to adjust for failures of current programs remains a huge barrier. Public health professionals must, however, analyze the reasons behind Abstinence-Only’s failure rather than merely repeatedly displaying statistics of teen pregnancy and STI rates to the public. The lack of cultural and social context, the over-reliance on the Health Belief Model, and the disregard of self-efficacy all contribute to adolescents ignoring the messages of Abstinence-Only.
“My mom was a teen mother and proud of it”: Abstinence-Only neglects the role of cultural and social context
The fundamental premise of abstinence-only programming, as delineated in the A-H characteristics is the promotion of sex as a behavior for heterosexual, married couples. It decries having children out of wedlock and thus, disparages single parents. (4) This strategy is likely to marginalize those who come from single parent homes, which represent 35% of children born in 2004. (2) The following excerpt from Sex, Lies, and Stereotypes, a report from Legal Momentum whose mission is to advocate for the rights of women, demonstrates the stereotypes engendered by abstinence only programs:
“The strong ideological bent of the groups designing abstinence-only programs often leads them to disseminate scientifically inaccurate and misleading information about contraceptives, STIs, and abortion in order to promote dangerous gender stereotypes, and frequently to rely on scare tactics and homophobic sentiments to convey their message.” (2)
Premarital sex is labeled as “wrong” which may decrease compassion for teens who do get pregnant or live with STI’s. (2) There is an especially significant risk for teen girls, who must live with visible consequences (pregnancy) of sexual activity and the ubiquitous social stigma perpetuated by Abstinence-Only programs. (2) Fathers of children born to teen girls are likely to be a few years older (8) and are unlikely to pay child support, and teen mothers are at an increased risk off dropping out of school and needing to be on welfare. (9) In fact, Title V, section 510 which created federal funding for Abstinence-Only programs was born out of the Temporary Assistance for Needy Families Act as a part of welfare reform, and the amount of funding for each state was determined by its prevalence of low-income children. (6) Rather than eliminating the need for welfare, Abstinence-Only programs have only perpetuated the cycle of poverty. In fact, 60% of teen mothers were already living in poverty before they got pregnant. (10) Furthermore, schools with the least resources often use Abstinence-Only programming because it is backed so heavily by U.S. government funding when the immediate support they may need is access to contraception.
For religious, white, Christian adolescents, abstinence only programs reinforce the values learned in the home and may be effective. However, for youth for whom abstinence until marriage and two parent households are not the norm, it conveys a very different message. These are the adolescents most at risk and as a result of the negligence of schools in providing contraceptive information, they are slipping through the cracks. Statistics show that 95% of Americans have had premarital sex by the age of 44, (2) demonstrating that the goal of abstinence until marriage is unrealistic and does not represent a value of the majority.
Along with adolescents from low socioeconomic status communities, African-Americans and Latinos report higher rates of teen pregnancy and STI’s. (11) The assumption that norms of marriage and sex are universal across cultures is a misconception that contributes heavily to the failure of abstinence only programs. Traditionally, in paternalistic cultures, women were not granted control of their own sex lives and were confined to abstinence whereas men were free of consequences from premarital sex. The availability of contraceptives gives women control over their own sexual risk-reduction. Dismissing condoms as an acceptable alternative represents a setback from progress and re-institutes gender inequality. (2)
Abstinence-Only programs also miss the mark for gay, lesbian, bisexual, and transgender youth (GLBT). The fundamental message promoted by such programs is abstinence until marriage, which in and of itself represents a dilemma for this youth constituency. When marriage is not a viable option for most of these adolescents, neither is abstinence. Additionally, GLBT lifestyles are condemned, with teachers required to encourage only heterosexual marriage per the federal funding guidelines. Junior high and high schools already pose problematic environments for youth exploring sexual identity, with a lack of tolerance and an unacceptability of differences, especially in this realm. By reinforcing conservative, narrow-minded thinking, abstinence-only programs arguably violate basic human rights. (2)
“Don’t have sex or else”: Abstinence-only is rooted in the Health Belief Model
Perhaps the biggest flaw characteristic of the Abstinence-Only movement is its over-reliance on the Health Belief Model. The Health Belief Model attempts to predict behavior by suggesting that perceived severity and perceived susceptibility of an outcome in combination with perceived barriers will lead to an intention that correlates with actual behavioral output. (12,22) Perceived severity refers to the individual’s beliefs about the seriousness of the consequences of a health behavior, and perceived susceptibility refers to the level at which one rates individual risk of an outcome. (12) Guided by the false assumptions of this behavior change model, programs utilize scare tactics by showing pictures of disease, by exaggerating the effects of sexual activity, and by using shame and guilt as strategies to ostracize sexually active adolescents. They teach the perception that all STI’s are life-threatening and incurable, and portray an inaccurate and misleading picture of the effectiveness of contraceptives. (2) These tactics may elicit a visceral, intense response among participants, but the effects are short-term. It sacrifices scientific rigor in an attempt to create ideological persuasive messages. (2) Furthermore, Abstinence-Only programs assume that adolescent behavior is planned and rational. It considers a scenario in which a teen is presented with the opportunity to engage in sexual activity, and relies on the teen’s ability to weigh the possible consequences of a decision and decide analytically whether or not to engage in said behavior. The reality of adolescent sexual intercourse, however, is that it occurs sporadically and inconsistently. (13) Decisions are made impulsively and, especially with sex, are influenced by emotion and physical desire in addition to cognition. Abstinence until marriage requires a long commitment of withstanding from a behavior that is an inherent act of human nature, and an intention in high school to remain abstinent until marriage is not likely to be upheld far into the future. Developmentally, the prefrontal cortex of the early adolescent brain is not fully wired for making rational decisions and as a result, behavioral decisions are overwhelmingly based on emotion. Teenagers are therefore ill-equipped to evaluate risk and reward. (14) Moreover, the choice to become sexually active is not solely an individual one -the decision involves another person. Thus, peer pressure is a strong influence on adolescent sexuality. The peer group is a fairly accurate predictor of whether one will choose to remain abstinent. (15) As such, the focus should shift toward changing social norms. By contrast, relying on the Health Belief Model confines interventions to a focus on individual processes of change. It ignores any element of social influence in behavioral decisions. (12)
The methodology of Abstinence-Only programming aims to increase students’ knowledge of the consequences of sexual activity as a vehicle for increased perceived susceptibility and severity. One study comparing a group exposed to a health belief model abstinence program to a control group found that there was no increase in abstaining from sex and no decrease in unprotected sex, additionally finding that females in the control group were better at using contraception than females in the program group. These data indicate a harmful effect of Abstinence-Only programs. (16) Even if a program communicates the negative consequences of STI’s and the challenges of teen pregnancy convincingly, perceived severity and susceptibility is of sex generally rather than unprotected sex. This is an unreasonable behavioral expectation, and once adolescents leave the classroom, they are bombarded by thousands of sexualized messages from the media and peers. During one hour of television viewing, an adolescent will see about 11 sexual acts. (6) These mixed messages create a confusing framework for decision-making. Again, the link between intention and behavior relied upon by the Health Belief Model will likely be interrupted by these clashing expectations.
“Can I do it?”: The disregard of self-efficacy
Self-efficacy has been shown to serve an important role in successful public health interventions. (23) Self-efficacy refers to “individuals' expectations about whether they can execute specific activities, which reflect their personal control over a situation.” (17) Self-efficacy of abstinence until marriage is challenging to assess because the time between adolescence and marriage is an ever increasing number of years. (18) During this period, adolescents are constructing their own moral beliefs and are undergoing monumental physical and emotional changes. The ability to abstain from sexual activity is not easy, especially for hormonally raging adolescents. By age 19, 70% are engaging in sexual intercourse. (19)
The ultimate goal of this intervention is to prevent teen pregnancy and decrease the incidence of STI’s. It is true that abstinence is the only way to 100% ensure a zero risk of these outcomes, but the lack of alternatives for those who do choose to become sexually active reduces self-efficacy dramatically. Bandura, the psychologist who developed the concept of self-efficacy, explained that self-efficacy is attained through practicing protective behaviors. Practicing sex communication with peers and parents, for instance, is a good predictor of good communication in sexual relationships.(20) Abstinence-Only programs are counterproductive to this finding, because they create a taboo around sex, causing teens to be uncomfortable talking about it.
As has been laid out in this paper, abstinence is an unreasonable goal for the majority of adolescents. Self-efficacy of protected sex, however, can be promoted through the specific instruction on how to use a condom. Coyle et al in 2001 found that “students exposed to activities that strengthen beliefs in their ability to use condoms were more likely to have protected sex.” (17) Interestingly, adolescents who are less involved in religion are more likely to use protection, most likely due to misconceptions about condom use in Abstinence-Only programs. (17) Statistics show that if condoms are used correctly every time, they work in preventing pregnancy 97% of the time but if they are used inconsistently, they fail about 10-14% of the time. (2) Abstinence-Only programs fail to explicitly teach teenagers how to correctly and consistently use a condom during every sexual encounter, and self-efficacy deflates as a result.
Conclusion
In conclusion, Abstinence-Only programs have yet to produce sound research findings that demonstrate a public health impact. With the goal of eliminating teen pregnancy and STI’s, Abstinence-Only creators were well-intentioned but created a behavior change program based on their own ideological drives rather than scientific fact. By relying on an unreasonable behavioral promise, to refrain from sex until marriage, Abstinence-Only programs not only fail to elicit behavior change but also neglect the impact of cultural and social context on sexual behavior and encourage harmful stereotypes. Definitions of marriage and sex are not universal across cultural groups, socioeconomic groups, genders, or races, and youth are likely to disregard a message that contradicts their own beliefs. In addition to its fundamental flaws, Abstinence-Only programs often implement these lessons through a combination of scare tactics and guilt and shame. Although the U.S.’s teen birth rate has followed a decreasing trend in recent years, STI rates continue to rise and the teen birth rate still remains at the top for developed nations. (2) Spending federal dollars on Abstinence-Only programs is only setting us back in improving adolescent health. Behaviors that develop in adolescence are likely to become embedded lifetime habits, so successful prevention is critical. As such, future policies should recognize the abstinence but drop the only.
Graduate and Celebrate: A Social Sciences Based Approach to Sexual Education
In recognition of the flaws embedded in the Abstinence-Only approach to teen pregnancy and STI prevention, I would argue for a policy-wide switch to a comprehensive sexual education program that gives information about sex and its consequences but also focuses on relationship communication. According to STI and teen pregnancy intervention reviews by Doug Kirby, characteristics of successful programs include an accurate portrayal of risk, opportunities to practice communication skills, staff that believe in the efficacy of the program, discussion of peer pressure, and perhaps most importantly “incorporation of behavioral goals, teaching methods and materials that are appropriate to the age, sexual experience and culture of the students.” (24)
The following proposal is based on comprehensive sexual education programs that have elicited decreases in rates of unprotected sex and teen pregnancy, and is guided by Kirby’s “10 Characteristics of Successful Programs.” (24,25) Rooted in Framing Theory, which suggests that the specific way a health behavior is presented impacts people’s choices, (26) it primarily aims to frame graduation as a high achievement (especially in schools where this might not be current perception), and to frame condom use as an important safer sex practice (instead of disparaging already sexually active teens). It would be implemented in both middle and high schools, and would include three components: education, media coverage, and celebration of graduation. This policy specifically requests that education begin in early middle school, before adolescents are making sexual decisions. (27) The education piece can be broken down further into a teacher training component, a peer education component, and a behavioral skills training component. The curriculum would include creating a teen task force of students from the area who demonstrate leadership qualities and a passion for effecting positive change. After being appointed, they would then be trained as peer educators. Teen task force students would hold weekly after-school forums where other students can express opinions, share experiences, or ask personal questions. In addition, teachers would receive additional training so that they may serve as mentors and role models to the students around the clock and be available and willing to discuss sexual health issues.
While emphasizing that abstinence is the only true way to ensure 100% protection, contraception will also be taught as an alternative. Specifically how to use contraception and where to access it will be delineated in the lessons. Students will learn about adult resources and access to appropriate care. The curriculum will utilize role-playing, interactive discussion, activities, and games. In addition to the education piece, the media will highlight the efforts being undertaken by the schools. Third, because of the inextricable link between teen pregnancy and high school dropout, graduation will be framed as a highly celebrated, momentous, and highly prized accomplishment. Schools will be encouraged to institute annual graduation celebration blowouts to reward students for their achievement.
Social and cultural context
Ignoring differences in culture within a single classroom is a fatal limitation of Abstinence-Only programming that requires awareness. The first step is to recognize that perpetuating the social norm of sex only within the context of a heterosexual marriage may be a violation of human rights. According to labeling theory, already sexually active adolescents or adolescents of single parents will be labeled as “immoral” by the existing curriculum. Once labeled as such, learned helplessness sets in and motivation to engage in protected sexual intercourse or to stop engaging in sex is diminished. As a result, these individuals become disproportionately infected with STIs or become pregnant. In order to avoid sweeping generalizations that may result in a self-fulfilling prophecy, sex must not necessarily be framed as a negative occurrence but as something that one must be prepared for. Allowing all students to feel comfortable talking about sex rather than reinforcing its current taboo status will help avoid this harmful cultural bias.
By the same token, Erikson’s psychosocial theory states that this age is the critical period for developing sexual identity. (28) Understanding that experimentation with sex is an appropriate developmental tendency, it is a public health responsibility to provide alternatives and create an environment by which risk-takers are protected from lifelong consequences. Moreover, emphasizing relationship communication and redefining relationships to include more than just heterosexual norms will decrease any stigma attached to LGBT youth while still teaching the ability to discuss safe sexual practices with a partner.
In order to delve into the cultural and social context of each community, it is important to first conduct focus groups with teens to determine the social determinants of sexual risk behaviors. (29) The teen task force is the heart of developing culturally appropriate lessons. Aside from being delivered by trusted peers who come from the same background and are part of the social network, the messages will be specific and relevant to neighborhoods and social groups. Teens will be equipped not only with a solid theoretical understanding of sexual intercourse and its consequences but of actual places within the community where condoms are available, where STI testing is done, what the policies are on emergency contraception and abortion, and who to go to if questions should arise.
Departing from the Health Belief Model
Instead of relying on individual intentions, which do not always lead to behavior change, this program addresses the social context of adolescent sexual behavior. Recognizing that not all individuals have the same values, opportunities, and experiences, the education part of the program addresses alternatives to abstinence and emphasizes relationship skill building. It aims to transform the framing of sex as negative and immoral and focus more on protection from teen pregnancy and sexually transmitted infections. By transforming the social norms surrounding high school graduation, making it highly desirable and presenting the challenges that teen mothers face, it takes advantage of the highly peer-influenced nature of adolescent behavior. (30) Ultimately, the hope is that high school graduation becomes such a desirable and expected norm that it becomes an internalized reason to avoid unintended pregnancy and a host of other risky health behaviors.
Furthermore, by taking into account the irrationality of human behavior and discrepancy between intention and behavior, this intervention program recognizes that individual beliefs about sex will change over time. Accepting abstinence until marriage as an intention at age 13 has little predictive value of behaviors at 18 or 20. Again, assessing the social context of the increasing gap between early puberty and late marriage age leads to the assumption that providing alternatives, should goals change, is imperative. Instead of utilizing the scare tactics in accordance with the Health Belief Model, this policy change would include giving accurate portrayals of risk and accurate means of protection.
The use of the media is an essential piece of this program that allows it to affect teen pregnancy and STI rates on a population wide scale. Challenging social norms within schools throughout the nation and sharing the efforts of schools within and between communities nationwide will begin to spark dialogue about teen sexual health issues. In accordance with agenda-setting theory, which suggests that the volume of media exposure on a topic increases its pervasiveness in social perceptions, the continued review of these programs in the media will begin to shift the attitudes toward both high school graduation and sexual behavior.
Self-efficacy
According to Social Cognitive Theory, self-efficacy is “a person’s confidence that he or she can perform a behavior.” (31) Solely giving students the behavioral goals is not enough. The goals must be realistic in taking into account the context of adolescents’ lives and they must be given the means to reach those goals. Instead of the unrealistic goal of abstinence, I argue that the aim for students should be to successfully graduate from high school. This is an attainable, near future, specific benchmark that employs a positive youth development approach. While not directly targeting teen pregnancy and STI infection, it does take into account the abysmal dropout rates of teenage mothers and considers the holistic context of the adolescent life. (32) Part of the intervention will include changing the social norms around high school graduation. Huge celebrations will be thrown in honor of graduates each year, with appealing advertisements around schools and communities heightening anticipation for the event. Media attention highlighting graduation and honoring graduates will accompany the celebrations.
Additionally, by giving students alternatives to abstinence, we are at least increasing their self-efficacy of consistent protection. Making condoms available and teaching students how to use them properly will increase the rates of protected sex among those engaging in sexual activity. Behavioral training, namely role playing and practicing responding to scenarios that may present themselves in real life also increases the level of self-efficacy. Having students practice discussing sex with one another will shift the connotation of sex as a taboo subject, and especially having girls practice voicing their relationship expectations will decrease the gender norms attached to sexual relationships. Actually practicing speaking the words will help students articulate their own wishes when an actual situation arises. As simple and obvious as it may seem, we would be remiss in telling students to “just say no” without having them practice. (20) Also, having them assess and evaluate their own opinions rather than just imposing one on them will empower them with the ownership of their own goals.
Conclusion
In summary, the objectives of the proposed intervention are to provide an accurate assessment of risk for STI’s and unintended pregnancy, to encourage abstinence but give adolescents resources and knowledge about contraception as an alternative, to create a teen task force of students to serve as peer educators, to institute weekly after-school teen forums facilitated by peer educators, to provide additional teacher training, to conduct culturally-appropriate lessons about self-efficacy and healthy relationships, to promote high school graduation as an extraordinary achievement, and to use media access to encourage dialogue about sexual health among and within communities. By addressing the central flaws of the Abstinence-Only approach and changing the framing of high school graduation and contraception, the enactment of this prevention program as policy will not only decrease rates of unintended pregnancy and STI’s but level the playing field for all adolescents rather than exacerbating the already remarkable disparities.


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