Shifting the Paradigm to No Where: How the American College Health Association Failed Primary Prevention – Erin Williston

United States college students are increasingly threatened with violence on campus. One of the most pervasive forms of violence happens in a place students rarely anticipate. National studies have consistently found approximately 32% of college students experience domestic/ relationship violence (1). The overwhelming prevalence of violence against women on college campuses is well documented nationally. Women ages 16-24 are at the highest risk for rape and other forms of intimate partner violence (2). While the statistics are omnipresent, higher education has neglected to set their sights higher than simply responding to incidents of violence, a form of public health called tertiary prevention.

In April 2007, the American College Health Association stepped out with their, “Position Statement on Preventing Sexual Violence on College and University Campuses”. What followed was a document with a mission to “provide facts, ideas, strategies, conversation starters and resources to everyone on campus who cares about prevention of sexual violence” – the ACHA toolkit, Shifting the Paradigm: Primary Prevention of Sexual Violence. Primary prevention is a public health approach using environmental and system-level strategies, policies, and actions that prevent sexual violence from initially occurring. The problem with Shifting the Paradigm surrounds not its idea to use primary prevention to address the issue – but in the theories and interventions it encourages its audience to use. The interventions presented are deficient, archaic, and fail to speak the language of higher education as an organization.

Promoting a Deficient Tool – Opening Pandora’s Box

Shifting the Paradigm authors encourage screening for sexual violence in college health and wellness services. This tool could help identify survivors of sexual assault, provide client centered services in the health care setting and encourage reporting. While screening is widely debated and mildly supported in medical-based literature, it is not primary prevention (11).

What is most interesting in this proposed intervention is the missing critical piece. There is no mention on training medical care providers to ask the questions proposed in this intervention! There isn’t even an analysis of student health centers and their ability to train and implement an effective screening tool. The classic study Opening Pandora’s Box helps explain why it is vital to deliver training to providers who will implement these screening tools.

An analysis of interviews with physicians found exploring domestic violence in the clinical setting analogous to "opening Pandora's box." Their issues included lack of comfort, fear of offending, powerlessness, loss of control, and time constraints. This study revealed several barriers that physicians perceived as preventing them from comfortably intervening with domestic violence victims. These issues need to be addressed in training programs (3).

Student health centers are not equipped to respond to the answers these questions will bring. Questions such as:

• “Has someone ever touched you in a sexual manner against your will or without your consent?”
• “Have you ever recognized you had ‘unwanted’ sex while drunk or using drugs?”
• “Do you feel that you have control over your sexual relationships and your partner will respect your wishes if you say no to specific sexual activities?”

These questions don’t fit in to the 15 minute appointment providers have with students in a clinical setting; especially if the training or programs to support these questions doesn’t exist (3). Shifting the Paradigm misses the mark by calling this primary prevention and proposing it without mention of proper training for providers.

Revisiting Individual Models

Shifting the Paradigm makes several attempts to provide tangible primary prevention exercises for college health educators to use with their students. One of the first interventions is “[to] facilitate conversations about sex that focus on individual choices along the continuum of sexual activity… [to] identify and popularize healthy sexuality that respects gender, sexual orientation, and gender identity.” Another intervention encourages educators to distribute “10 ways young men can prevent sexual violence” to fraternities and other male dominated organizations on campus.

These are both classic examples of the Health Belief Model – an individualized public health model that assumes no social interaction, and demands rational behavior (4-5). This model and proposed intervention fails to understand one important issue in human behavior: people are not rational; they do not make decisions in silos and are easily influenced by unconscious factors.

Dan Ariely helps make this clear in his book Predictably Irrational: The Hidden Forces That Shape Our Decisions. Dr. Ariely conducted a study with Berkeley undergraduate students who underwent a variety of sessions in different orders answering questions about sexual and moral decisions. In one session students predicted their sexual and moral decisions while in a cold, dispassionate state. In another, they did the same but while in a hot, aroused state.

“In every case, our bright young participants answered the questions very differently when they were aroused from when they were in a ‘cold’ state….when participants were aroused they predicted that their desire to engage in a variety of somewhat odd sexual activities would be nearly twice as high as they had predicted when they were ‘cold’.” (6)

The results go on to demonstrate how in a cold, rational state, the men involved in this study respected women. They thought they understood themselves, their preferences and what actions they were capable of. These men, like many young college students, underestimated their reactions to arousal and the outside environment. It does not make these participants social deviants; it proves that human behavior is irrational.

This study is critical to understanding that college students do not make decisions in a vacuum; they are highly influenced in their vulnerable state of transition from high school to higher education. While Shifting the Paradigm encourages discussion about respecting gender and being aware of pop-cultures messages, the reality is college students are having good, bad and ugly sex without the influence of these conversations in the bedroom.

Could We Get a Little Buy In?

Contributing authors to Shifting the Paradigm express their hopes for primary prevention in the preface: “[primary prevention] must reach the same level of efficacy and adoptions as programs that respond to its consequences.”

Shifting the Paradigm authors makes 2 assumptions with this statement: 1. it assumes the reader is on a campus that is effectively responding to consequences of violence and 2. The reader understands the levels of public health prevention and the concept of moving upstream. These are erroneous assumptions considering many campuses are failing to make the basic responses to victimization work on campus. According to a 2005 National Institute of Justice report, of the nations institutions of higher education less than half listed a contact phone number for students who have been sexually assaulted that was accessible after “normal” business hours – when most assaults happen (7).

This demonstrates the lack of understanding Shifting the Paradigm authors have in regard to higher education organizations. If the authors had followed organizational development theory, they would have understood that one of the keys to mobilizing an organization is to know your community priorities. For example, by pairing a health issue with other priority issues you can maximize the potential for community action (8).

Shifting the Paradigm fails to speak the language of higher education and answer the questions critical to administrators in the organization. Administrators hold the keys to what college health professionals need – support from the institution: both financially and politically. Why should higher education administration care about sexual violence? How does it impact the organization and the students we serve? How much money will it save us if we invest in these programs? College health educators need to make the connection between health and academic success in order to speak the language of our stakeholders (9). Without this connection, administrators will fail to see the value in sexual violence prevention.

Moving Past Shifting the Paradigm

The authors and consultants for the ACHA toolkit neglected to produce a sound document for their intended audience. They sent out a grab bag of deficient, archaic and inconsistent tools for overburdened campus professionals to toss out at the end of the day. It is unfortunate that this opportunity to speak to higher education about primary prevention was wasted with the promotion of such tools as “discussion starters” and “screening interventions”. The lack of outcry from ACHA members isn’t surprising; many of them lost value in the document before reading it. In an effort to move forward and adopt a primary prevention approach to sexual violence, new theories must be brought to the table.

Smedley and Syme explain in their article Promoting Health: Intervention Strategies from Social and Behavioral Research, “It is unreasonable to expect that people will change their behavior easily when so many forces in the social, cultural and physical environment conspire against such change.” Smedley and Syme, along with many others in this field support the need for a social and behavioral approach to violence prevention (6,12-18). Shifting the Paradigm could benefit from considering two specific social science theories: Organizational Development (OD) and Fostering Healthy Norms (Norming) (8, 16-18, 20-21,). The finale of this post will provide empirical data and examples in support of using OD and Norming to address primary prevention of sexual violence on a college campus. It is vital to know these methods lend themselves concurrently however; creating an environment open to change from the top down should be the first step.

Stimulating Change

Community mobilization around a specific issue can be challenging. It requires much from the agent of change in order to move an organization toward a new behavior (16). ACHA members fit into the role of ‘agent of change’ and learning to speak the same language is a gateway to common ground. ACHA members would benefit by cultivating relationships with professional leaders on campus; one great approach is to appeal to the individual’s self-interest, showing how their participation in your cause can aid in achieving their own goals and objectives (23). Utilizing OD theory to foster shared goals and motivation among members of the institution will aid in the change process (16-18). Organizational Development theory encourages community and organizational change while taking into account the culture, organizational climate and capacity (16). Systematizing an institutional change utilizing the culture, climate and capacity is critical to avoid simply replicating what other schools do without evidence of an effective intervention.

To mobilize an institution to address sexual violence through primary prevention, three key issues should be addressed (17).

1. Define the community: Develop an understanding of the chain of command within the institution. Set up individual interviews with key players and learn who the movers and shakers behind decisions made on campus might be.
2. Assess and work with the community’s capacity for mobilization: Are their experienced professionals on campus who are researching or addressing sexual violence currently? What is the history of task forces or committees to address sexual violence appointed by upper administration? Look for current action within the institution and work with those players to assess the ability to move upstream in addressing sexual violence.
3. Understand the community agenda and select the right issue: ACHA members should look at the mission of the institution and assess how sexual violence might impact that mission. This could be done by reviewing national and local data regarding sexual violence. Sources may include the ACHA National College Health Assessment, Jeanne Clery Act Reports, local police and prosecutor’s office data and qualitative data from local organizations that work in the area of sexual violence. The impact sexual violence has on matriculation, retention, and graduation could be a critical piece of information for upper administration. Successfully selling primary prevention of sexual violence can be achieved if you pair the institution’s goals and objectives with your topic area goals and objectives.

Fostering Healthy Norms

There are 5 damaging norms that impact attitudes and beliefs about sexual violence (12). These norms are:

1. Women: limited roles for and objectification and oppression of women

2. Power: value placed on claiming and maintaining power (manifested in power over)

3. Violence: tolerance of aggression and attribution of blame to victims

4. Masculinity: traditional constructs of manhood, including domination, control and risk-taking

5. Privacy: notions of individual and family privacy that foster secrecy and silence.

ACHA members can address these norms by strategically promoting normalizing messages about positive female roles, egalitarian relationships, men standing up to aggression, downplaying negative risk-taking, and engaging citizens. The social norms approach provides tools for increasing perceived support to take action to address health and violence behaviors (20). The key is to create and sustain healthy norms within the institution and surrounding community (12).

We know that one of the critical places students’ receive and trust messages is from health care providers (26). A mandatory training with continuing education credit for all health care professionals on campus (in the student health center and otherwise) could help foster norms at an individual level. This curriculum would consist of trust building, using positive sexuality language and sharing healthy relationship guidance in a clinical setting (12-13). Providers would be expected to use the tools learned in this curriculum with patients to build trust and promote the health center as a safe, positive place to receive information and services. In order to implement this type of care, health care providers will need more time with patients. A critical role for ACHA members will be advocating for longer visits with providers and promoting efficiency in scheduling visits (3, 12).

The second component to this ‘Fostering Healthy Norms’ approach is to develop a marketing campaign that is interactive and promotes positive environmental change. Studies suggest that the social norms approach to sexual assault prevention is a promising practice that is worthy of further attention and research to determine its effectiveness (20). For example, at James Madison University a campaign designed to change men’s intimate behavior towards women was implemented. Data demonstrated significant increase in the percentage of men who indicated “stop the first time a date says no to sexual activity” and a significant decrease in the percentage of men who said “when I want to touch someone sexually, I try and see how they react.” (20). Other campaigns have demonstrated similar findings, making social norms marketing campaigns a promising practice in prevention of sexual violence.

No Substitute for Planning

The American College Health Association’s toolkit, Shifting the Paradigm: Primary Prevention of Sexual Violence would be a greater resource if the role of health and its impact in higher education was all ready established. However, without this critical collaboration, no campus is ready to implement tools that have not been grounded in research. The interventions fail to speak the language of higher education as an organization or foster change in the current climate.

In an effort to design a replicable toolkit, ACHA would have done well to offer planning and evaluation tools for primary prevention of sexual violence on college campuses. Saltz and DeJong’s comment in ‘In Reducing Alcohol Problems on Campus: A Guide to Planning and Evaluation’, “Simply replicating what other schools are doing is not a substitute for sound planning.” Utilizing Organizational Development theory to stimulate change from the top down, followed by a comprehensive implementation of Fostering Healthy Norms allows flexibility to accommodate the institution’s individuality and take research to practice.

References

1. Feminist Majority Foundation. Violence Against Women on College Campuses. 2005

2. Gross A.M., Winslett A., Roberts M., and Gohm C.L. An Examination of Sexual Violence Against College Women. Violence Against Women 2006; 12(3): 288.
3. Sugg NK, Inui T. Primary care physicians' response to domestic violence. Opening Pandora's Box. JAMA 1992; 267(23):3157-60.
4. Becker MH, ed. The health belief model and personal health behavior. Health Educ Monogr 1974; 2: Entire issue.

5. Janz NK, Becker MH. The health belief model: a decade later. Health Educ Q 1984; 11(1): 1-47

6. Ariely, D. The Influence of Arousal (pp. 89-108). In: Ariely, D. Predictably Irrational: The Hidden Forces That Shape Our Decisions. Harper Collins 2008

7. Kariane H.M., Fisher B. S., Cullen F. T. Sexual Assault on Campus: What Colleges and Universities Are Doing About It, U.S. Department of Justice Office of Justice Programs, December 2005, National Institute of Justice www.ojp.usdoj.gov/nij

8. Cummings, Worley. Organization Development and Change, 6^th ed. Boston, MA: South-Western; 1997

9. McNeil M., Grizzel J. Linking Student Health with Academic Success: American College Health Association Annual Meeting 2006.

10. American College Health Association. Shifting the Paradigm: Primary Prevention of Sexual Violence. www.acha.org/SexualViolence August 2008

11. PREVENT Program at University of North Carolina Injury Prevention Research Center. Prevent Provider Toolkit Module 1. January 2007

12. Davis R., Fujie-Parks L., Cohen L. Sexual Violence and the Spectrum of Prevention: Towards a Community Solution. National Sexual Violence Resource Center 2006.

13. Cohen L, Swift S. The spectrum of prevention: developing a comprehensive approach to injury prevention. Inj Prev. 1999; 5:203-207.

14. Smedley BD, Syme SL, A social environmental approach to health and health interventions. In: Promoting Health: Intervention Strategies from Social and Behavioral Research. Washington, D.C. National Academy Press 2000:4.

15. Banyard, V.L.; Plante, E.; and Moynihan, M. M. Bystander Education: Bringing a Broader Community Perspective to Sexual Violence Prevention. Journal of Community Psychology 2004 32: 61-79.

16. Steckler A., Goodman RM, Kogler MC. Mobilizing organizations for health enhancement: theories of organizational change. In: Glanz K, Rimer BK, Lewis FM, eds. Health Behavior and Health Education: Theory, Research and Practice, 3^rd ed. San Francisco, CA: Jossey-Bass; 2002.

17. Freire P. Pedagogy of the Oppressed. New York: Seabury Press; 1970.
18. Wendell L French; Cecil Bell (1973). Organization development: behavioral science interventions for organization improvement. Englewood Cliffs, N.J.: Prentice-Hall. chapter 8.
19. 
    
20. Berkowitz, A. Fostering Healthy Norms to Prevent Violence and Abuse: The Social Norms Approach. Preventing Sexual Violence and Exploitation: A Sourcebook. Wood and Barnes Publishers, 2007.

21. Berkowitz, A.; Jaffe, P.; Peacock, D.; Rosenbluth, B.; and Sousa, C. Young Men as Allies in Preventing Violence and Abuse: Building Effective Partnerships with Schools. San Francisco: The Family Violence Prevention Fund, undated. http://new.vawnet.org/Assoc_Files_VAWnet/YoungMenAllies.pdf

22. Morrison, S.; Hardison, J.; Anita Mathew, A.; and O’Neil, J. An Evidence-Based Review of Sexual Assault Preventive Intervention Programs. Research Triangle Park, N.C.: RTI International, 2004. http://www.ncjrs.gov/pdffiles1/nij/grants/207262.pdf

23. Langford L., DeJong W., Strategic Planning for Prevention Professionals on Campus, U.S. Department of Education, Office of Safe and Drug-Free Schools, Higher Education Center for Alcohol and Other Drug Abuse and Violence Prevention, Washington, D.C., 2008.

24. Bachar, K.J., and Koss, M.P. From Prevalence to Prevention: Closing the Gap Between What We Know About Rape and What We Do. In: Renzetti, C. M.; Bergen R. K.; and Edelson, J. L. eds Sourcebook on Violence Against Women, Thousand Oaks, Calif.: Sage Publications 2000.

25. Bartholomew, L.K.; Parcel, G.S.; Kok, G; and Gottlieb, N.H. Planning Health Promotion Programs: An Intervention Mapping Approach. 2^nd ed. San Francisco: Jossey-Bass, 2006.

26. American College Health Association. Publications and Reports. Baltimore, MD: American College Health Association. http://www.acha-ncha.org/pubs_rpts.html

27. Population Council. Yaari Dosti: A Training Manual. New Delhi, India. Population Council. , 2006.

Abstinence Only’s Alienation of Developmental Psychology, Social Psychology, and Public Health Basics - Joanna Matwiejczuk

Over the last several decades, sexual education has been incorporated into high school classrooms across the country. While policies over comprehensive sexual education versus abstinence only education vary state by state and classroom by classroom, it is also evident that the political climate over this distinction has been in the eye of controversy. The federal government fiscally supports an abstinence only curriculum for adolescents and due to various factors, many schools have accepted the money from the government to teach abstinence only and thus have adopted an abstinence curriculum while forsaking comprehensive sexual education. However, not only is an abstinence only curriculum a close minded approach to sexual health education, but it is also unrealistic for the target audience, as well as irresponsible from a public health perspective. From the 2007 Centers for Disease Control Youth Risk Behavior Surveillance System, it has been found that 48.7% of adolescents have self-reported to being sexually active (1). An abstinence only curriculum therefore is virtually lost on almost half of its target population, statistically speaking. You can’t tell me what to do! What developmental psychology has to say. It comes as no surprise to parents, teachers, the general public and even adolescents themselves that the teenage years have been classified from a behavioral science perspective as a time to rebel, to break rules, to push limits and to act in exactly the opposite way that society would like them to act. This is not to say that all teenagers disobey their parents or the law, but it is inherently natural for them to engage in risky behaviors, especially behaviors that they are told not to engage in. Rebellion is a tool used by adolescents to begin establishing a sense of self and to gain independence. According to Erik Erikson's work in developmental psychology, "adolescence is a period of time in which a young person can take time to explore identity so as to work out conflicts and establish a secure sense of self" (2). Abstinence only teachings rely only on highlighting all the negative aspects of sex, such as the risks of unwanted pregnancy, the risks of contracting sexually transmitted infections, as well as the emotional harm that could result when one begins having sexual contact before they are mentally ready. However, from a developmental perspective, "youth may view abstinence as a developmentally appropriate stage, which precedes the equally appropriate stage of becoming sexually active when they are 'ready'" (3). Abstinence only education does not teach safe sex nor does it point out resources where adolescents can turn to if they do indeed choose to have sex. This absolutist curriculum is unrealistic given what we know about the psychological development of young people. They are essentially being told "do not have sex" which could only further fuel the need to rebel and thus engage in sexual activity. Our country's "just say no" attitude towards adolescent risky behaviors including alcohol consumption, substance use, tobacco use, and sex has not changed the fact that youth across the United States experiment with substances AND with sex on a daily basis.
Adolescence is also a time when young people seek greater freedom and when they hone their abilities to make positive choices. However, oftentimes, young people make many negative choices before they realize what the "right" choice is, but from a developmental perspective, they must be allowed (within reasonable means) to make various choices and recognize the repercussions of their actions. This is what learning and growth is about and this is what teenagers need in order to grow into healthy, balanced adults. "Teenagers’ identification of themselves a people committed to abstinence could keep them from considering situation in which they might someday choose to engage in sexual behavior and from learning how they might then protect themselves against unwanted pregnancy and STDs" (4).
As educators of adolescents, schools as well as the federal government, should create an atmosphere of learning where young people can be presented with many options and receive explanations of the various consequences (positive and negative) of sex before making an educated decision about how they choose to proceed in their own sexual lives. This is similar to various parenting styles in psychology developed by Diana Baumrind, in which there is strong evidence to show that authoritative parenting where children are allowed more freedom and decision making leads to better youth development outcomes, as opposed to authoritarian parenting which demands strong adherence to set rules and stunts psychological development (5). "Strong abstinence intentions may be linked with a view of sexual behavior that minimizes the role of personal choice and agency in making sexual decisions" (6). Restrictive statements and scare tactics about sex education will not foster positive youth development nor will it equip young people with the personal negotiation skills they will need for the more difficult choices in their futures. "Young people...need to be prepared to negotiate and renegotiate...[and] be treated in ways that encourage meaningful decision-making including in relation to sexuality, from a much earlier age" (7).What about your friends? Will they be around? Perspectives from social psychology. A very important aspect that is neglected in abstinence only education is the influence and power of the social environment of adolescents. In general, society is very influenced by community, peers, the media, etc. (8). This influence is heightened for our society's very impressionable teenager. Abstinence only education fails to factor in the everyday environmental exposures into the classroom curriculum. It does not account for what is already out there in the world and merely preaches a single answer (no) to a very complex issue like sex. Many (47.8%) of youth are already engaging in sexual activity and while 52.2% may not be, they are in contact with their peers daily and oftentimes intimately. Abstinence only teachings do not address the power of peers and social groups as a teenager seeks social approval and engages in conformity. Personal and group attitudes towards sex can often be much stronger than messages to simply not have sex. Young people will not only encounter sex as an issue among their peer groups, but will also be confronted with it on a much more personal level in their intimate relationships. A curriculum that incorporates the possibility of such situations and provides tools to navigate such situations would be much more appropriate given the national statistics concerning sex and adolescents and the social climate that youth live in. "They live in a largely peer-defined world easily accessible through communication technologies" (7). Another extremely powerful influence on young people is the media. Sex is not only on television, but in movies, on the radio and in music, in magazines, billboards, advertisements, news, commercials, etc. countless times each day. "The mass media are an increasingly accessible way for people to learn about and see sexual behavior. The media may be especially important for young people as they are developing their own sexual beliefs and patterns of behavior, and as parents and schools remain reluctant to discuss sexual topics" (9, 10). Adolescents are heavily exposed to the media and while they view others (adults and their celebrity peers) engaging and negotiating sexual situations in their "on screen lives," it is unrealistic to expect them not to be considering it in their own lives. Abstinence only education fails to acknowledge all of the publicity sex is gaining in our society's media and instead chooses to voice the same message of simply saying no to sex before marriage. Instead of addressing and perhaps utilizing examples of sex in the media as an avenue for a lesson plan about safe sex, abstinence only delivers the same messages today as it did decades ago. Just as Trojan condom commercials can highlight the positive consequences from engaging in safe sex, sexual health education should be able to do the same. I didn’t do it because I thought you were…Well I didn’t because you were supposed to…A stance on public health and education responsibility As educators and public health professionals, we need to consider the repercussions of an abstinence only curriculum. While it may seem "best" to encourage young people to wait until marriage or a long term relationship to have sex, in reality many youth are not taking this course of action. However, even those who do choose to wait will eventually need information, resources, and support to inform their decisions and judgment about sex. Unfortunately, an abstinence only curriculum does not equip these youth for their "next step." Abstinence only education alienates the sexually active as well as the homosexual youth population. Since these groups have either started having sex, or may not see sex in a heterosexual framework (i.e. at risk for pregnancy or for intercourse), these young people are not included and given no resources to protect their own sexual health (11).
As a center of learning, schools should take responsibility for teaching their students about sex, about the risks and benefits, about safe and protected sex, and guide young people to resources that can be utilized to help make decisions, to facilitate safe sex, or resources to turn to in a time of need following sex. "Ironically, the very methods aimed at protecting children often contribute to their abuse...[by] underminding their potential of being aware, knowledgeable, and competnet individuals" (12). Indeed we are doing a disservice to young people by not sharing the facts with them and allowing them to develop and make healthy decisions based on their individual needs. It is disturbing to think that sex education has been forced to exist only outside the classroom for so many young people. As educators, there is an opportunity to shed light, accurately inform, and spread a message but, instead abstinence only educators are just saying no. "This approach captures only negative consequences of sexual activity, ignoring potentially positive aspects, such as developing a sense of intimacy, achieving social skills and goals, and experiencing sexual pleasure" (3). For the public health world, where disease prevention and health promotion are key goals, sex in and of itself is not the public health problem. Unsafe and unprotected sex is what causes of the spread of STDs and unwanted pregnancies. Of course abstinence would solve the issues, but since that is not realistic in the long term, the focus needs to remain on the promotion of safe sex to all those at risk, including and especially, adolescents. "Sex education is intended to serve a very practical public health purpose...[but] the growing prominence of the abstinence only approach will likely have serious unintended consequences by denying young people access to the information they need to protect themselves" (11). Ignoring the issue, as abstinence only education does in a way, will not eradicate the problems associated with unsafe sexual activity.
It is also dangerous to assume that those adolescents engaged in sex and those thinking about initiating sex are armed with the facts they need in order to do it safely. Their information may not come from parents or other educational sources, but rather the internet, media, and peers which can be much less reliable and send unclear, mixed, inaccurate messages. What abstinence only education has taught us
In conclusion, abstinence only education fails to deliver what adolescents need at this developmental stage in their lives and ill equips them for skills needed to engage in positive decision making. Adolescents will eventually, if they aren't already, become a part of the sexually active population and when they reach that point, they must have some information about safe sex, as well as options and resources to turn to. "Society must recognize that a majority of adolescents will become involved in sexual relationships during their teenage years" (13). Abstinence only education has failed to account for the dynamic influence of social environment, especially media and peer groups. Instead, it has focused on a static, close minded approach to address a complex and ever changing issue that faces our teens. Above all else, abstinence only education has failed the public health community by bypassing the real issue at the heart of sex which is the prevention of disease. By not taking the curriculum to the next level, the ignorance of safe sex can lead to very negative and unfortunate outcomes for our young people. Abstinence only supporters are failing our young people by not providing them with the information they need to protect their health and well being. So it's our responsibility, but what can we do?
Given all this information, we should start to consider what a more ideal approach to achieving safe sex amongst adolescents should actually look like. We have learned that abstaining from the abstinence only educational approach may prove to be beneficial if executed properly. A comprehensive sex education program needs to be developed in order to address the multifaceted issues that adolescent sexuality raises. And, not only developed but implemented and mandated by government as the most responsible approach to sexual health education. Although "comprehensive sex education" curricula are in place in schools across the country, we must examine what that really means. I do believe that a comprehensive approach is necessary, but there are crucial, key elements missing from many of the current comprehensive programs. We must specifically address what is known about adolescent psychological development and factor that into every feature of the program. We must also carefully consider adolescent psychology from a social perspective and be aware of the social climate of our society. Lastly, in order to address the issues outlined prior, we must always keep in mind that it is the duty of educators and public health professionals to design programs that effectively incorporate information and strategies specific to adolescents when considering the features of a comprehensive sex education curriculum.
Comprehensive sex education, unlike abstinence only education, acknowledges that adolescents may already be engaging in sexual activity, or may be considering beginning engagement in sexual activity. It incorporates abstinence into the curriculum, but does not solely focus on abstinence as the only option for preventing unwanted pregnancy or the transmission of STIs. It also points out and encourages safe sex practices, such as using birth control and condoms as well as teaches communication skills to assist adolescents in negotiating sexual activity. This education should ideally be happening in the classroom, either at the middle school or high school level when a large percentage of adolescents are starting to initiate sexual activity or thinking about it. I strongly believe that a classroom setting is the most effective way to reach many young people because school is mandatory. They have to attend. School is also where youth learn everything from math to science, and sexual health should be another course that they need to complete. As an epicenter of learning in their communities, schools must take on this responsibility and intentionally address sexual health in order to fully serve the students, as well as their parents, the community members, and society as a whole. It is a public health responsibility to teach complete (comprehensive) sex education that addresses all topics and considers all members of a population. This responsibility can be achieved very effectively in a classroom setting. It is harmful to employ an abstinence only education as it falls short of information dissemination. Information that is essential to making safe, healthy decisions.But, won't they just do what they want anyway?
In order to address the complexity of adolescent psychological development it is important to acknowledge that adolescent rebellion exists and that there may not be an effective way to combat it, nor should we try to. Comprehensive sex education would be charged with needing to work around this issue and find a way to successfully incorporate strategies that can work in such an atmosphere. The message of "no sex" as abstinence only education sets forth is very absolutist and casts a rule out for adolescents to follow. Not only would this be ineffective knowing what we know about adolescent rebellion, but it also would not allow for adolescents to naturally develop cognitively. Adolescents will be faced with difficult situations throughout their lives, and "no" will not always be the answer. From a youth development standpoint, comprehensive sex education needs to allow for healthy decision-making, both encouraging the navigation of options available and also equipping adolescents with skills to be able to critically think through a decision in order to make a positive one. I propose incorporating into the comprehensive sexual education curriculum a unit on healthy relationships and decision-making strategies. This may involve interactive lesson plans that allow youth to practice skills and also must include posing situations to them about sexual scenarios that they may need to navigate. Healthy relationships will need to cover everything from friendships, "hooking up," and dating, to long-term relationships, homosexual relationships and unhealthy (abusive, etc.) relationships. Some of these topics may be sensitive and it may be difficult for teachers to talk about, but creating an open environment where frank discussion is not only allowed but encouraged may make all the difference.
Comprehensive sex education needs to exist on a continuum. In other words, information dissemination is only the first step, other supports and reinforcements need to be in place in order for the information to be fully processed and utilized. I propose supplying "sex goody bags" during sex education which include resources and samples of many commonly used contraceptives. Items can include male and female condoms, spermicide, a condom carrying case, and tangible "dummy" examples of prescription contraceptives such as the vaginal ring, the patch, etc. as well as information accompanying each piece in the bag. The bag can also include a resource list of health centers, or a business card with important information that can be kept with them at all times. This way, adolescents have a chance to experiment with the various options they have and may more effectively find one that suits them. This approach factors in adolescent development because it allows for experimentation in a controlled environment and also acknowledges that not all young people may be comfortable approaching an adult with questions about sex. This way, youth have the chance to explore various methods to prevent unwanted pregnancy and STIs, and truly get a feel for their options.They won't listen...there's too much competition...
It is critical to realize that there are many societal influences upon young people. Comprehensive sex education may have to compete for attention. Or, there may be a way to utilize and incorporate social influences (peer and media especially) into sex education. Not only are communication skills necessary for adolescents, but a reliable medium of communication is necessary. As previously discussed, young people may not be comfortable enough to raise questions about their own sexual health. I propose the creation of a text message network ("Sext me!") that can provide resources, answers to questions and support for teens thinking about sex, experiencing the emotional aftermath of sex, or needing to know where to go for help. This two-way, anonymous form of communication could be a relatively easy, non-judgmental, non-confrontational way to get questions answered and resources supplied. It goes beyond just supplying information and text messaging is a medium that adolescents communicate through a lot. Such a network and program can be established through community resources, not necessarily exclusively schools. To address staffing issues, resources can pooled through the community, or city, county, state, etc. in order to create an extended network. Also, incorporating youth into the development of the "sext network" as well as employing young people in the infrastructure can add to the legitimacy as well as the approachability that other young people will experience when they consider sending a text message to obtain sex information.
It may seem nearly impossible to counteract with media influence in the lives of young people. And although it would be extremely difficult to monitor or change what is shown in the media about sex, there is a way to counteract the messages that are conveyed about sex. I propose that classroom curricula devote time to digesting and discussing the week's, for example, media activity. Whether it be the latest episode of a popular teen sitcom, or the release of a controversial song, teachers should intentionally designate classroom time to view, discuss, demystify, and engage young people in talking about any questions that could arise. It is also important to address details that may be missing from the staged situation, or address what follow up to a scene may look like in reality. Incorporating humor and open-mindedness into the classroom discussion is essential in order for this approach to be effective. Although this does not eliminate inaccurate, unrealistic information from reaching a very impressionable audience like teenagers, it does provide a solution so as to not ignore that this indeed does exist as a very real and powerful influence in their lives. This approach also grants an opportunity for educators to remain at the forefront of current youth sex culture and remain informed. This information and experience can also help mold their classroom curriculum to be more relevant, current and timely for teenagers.In conclusion, abstinence only education barely scratches the surface of what is a complex, involved, and multifaceted issue like adolescent sexual health. Comprehensive sexual education is a primary step in the right directions. There are obviously many other interventions that can be incorporated at an after school level, or within the community, or in a young person's home. However, I believe that sex education needs to heavily involve educators who spend day after day with the same young people and who are expected to teach. And they must teach. All the options and uncover all the resources that are available. Comprehensive sex education as laid out in this discussion must incorporate creative and current strategies in order to be effective. As times change, curricula must as well. However, three facts that will not change is that adolescent sex education is the responsibility of the public health and education community. Also, interwoven into all aspects of a comprehensive sex education curriculum, must be principles seeped in what is known about adolescent psychological development and what positive, healthy youth development looks like. And finally, educators must never ignore the strong effects of peer groups and the media on our society's young people. Education need not combat these effects, but rather find meaningful ways to use social psychology principles to create a strong, all encompassing curriculum that will reach adolescents and ultimately shape their decision-making skills and capacities.

REFERENCES
1. Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance System. Atlanta, GA: National Center for Chronic Disease Prevention and Health Promotion, Division of Adolescent and School Health, 2007.
2. Erikson, E. Identity: Youth and Crisis. London: W.W. Norton & Company, Inc., 1968.
3. Ott, MA, Pfeiffer, EJ, and Fortenberry, J. Perceptions of sexual abstinence among high-risk early and middle adolescents. Journal of Adolescent Health 2006; 39(2):192-198.
4. Masters, N, Beadnell, B, Morrison D, Hoppe, M, and Rogers Gilmore, M. The opposite of sex? Adolescents' thoughts about abstinence and sex, and their sexual behavior. Perspective on Sexual and Reproductive Health 2008; 40(2):87-93.
5. Baumrind, D. Parental disciplinary patterns and social competence in children. Youth and Society 1978; 9:238-276.
6. Fine, M. Sexuality, schooling, and adolescent females: the missing discourse of desire. Harvard Educational Review 1988; 58(1):29-53.
7. Lehr, V. Developing sexual agency: rethinking late nineteenth and early twentieth century theories for the twenty-first century. Sexuality & Culture 2008; 12:204-220.
8. Kirby, D. Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy, Washington, DC: National Campaign to Prevent Teen Pregnancy, 2001. 9. Brown, JD. Mass media influences on sexuality. Journal of Sex Research 2002; 39: 42-45.
10. Brown, JD, Steele, JR, and Walsh-Childers, K (eds.). Sexual Teens, Sexual Media: Investigating Media's Influence on Adolescent Sexuality. Mahwah, NJ: Lawrence Erlbaum Associates, 2002. 11. Collins, C, Alagiri, P, and Summers, T. Abstinence Only vs. Comprehensive Sex Education: What are the arguments? What is the evidence? Policy Monograph Series, 2002.
12. Robinson, KH. Childhood and sexuality: adult constructions and silenced children (pp. 66-78). In: J.Mason, J.Mason, & T. Fattore (eds.). Children taken seriously: Theory, practice, and policy. London: Jessica Kingsley Publishers, 2005. 13. Sexuality Information and Education Council of the United States. Adolescent Sexuality Fact Sheets. New York, NY: Sexuality Information and Education Council of the United States. www.siecus.org.

Abstinence-Only Education: The Failure of a National Forced Belief – Elizabeth Usaj

Introduction

Abstinence-only education (AOE) programs have been on the rise in the United States since 1996, when the federal government created a program called Title V – section 510 of the Social Security Act (1). Title V is a program that was passed as an attachment to a welfare reform law, and allowed for federal funding for AOE programs. President Bush’s 2009 budget designates $204 million for these AOE programs, which is a steep increase from the original $50 million in 1996 (1). To be eligible to receive these federal funds, a program must follow eight explicit characteristics, which require the programs to teach the physical, social, psychological and emotional consequences of early sexual experimentation and the value of sexual abstinence (2). The programs also must not include a discussion of contraception’s as protection against STDs or pregnancies, because the programs make the assumption that sex in a monogamous, married relationship is the expected standard of behavior (2).

Supporters of AOE programs typically believe that teaching abstinence is the only way to prevent unwanted teenage pregnancies and sexually transmitted diseases (STDs), not discussing safe sex practices and proper contraception use. Current statistics regarding teen pregnancy and STDs show that the issues are still of major significance to teenagers and that AOE programs have had little to no effect in reducing the overall rate of occurrence. The Centers for Disease Control and Prevention (CDC) has estimated that approximately 19 million new STD infections occur each year, and that almost half of them are among teens aged 15 to 24 (3). Teenage pregnancy is estimated at 757,000 a year among women aged 15-19 years of age (4). The U.S. has the highest rate of unwanted teenage pregnancies among developed countries (5), despite the hundreds of millions of dollars a year that are thrown at AOE programs aimed at preventing it. The failure of AOE programs can be attributed to the fact that they do not allow for self-efficacy, do not take into account social and environmental factors, and lack adequate understanding of how teenagers react when being told what to do.

Misleading with False Information and Claims of Morality

AOE programs are inherently coercive and provide misinformation and withhold information needed to make informed decisions (6). Information that is provided in 80% of the AOE curricula regarding reproductive health is false and distorted, claiming that “5-10% of women who have legal abortions become sterile” and that “the popular claim that ‘condoms help prevent the spread of STDs’ is not supported by data” (7). Statements such as these are often discussed as the facts in AOE programs and hinder teen’s ability to decide what is fact and what is fiction. Being provided with the wrong information removes a person’s ability to make an informed decision and infringes upon their self-efficacy. The belief that someone can carry out the desired behavior is affected by knowledge of steps necessary to avoid the risk (8). Teens who have information about reproductive health are more likely to use contraception than those without such information (9).

Albert Bandura, creator of the Social Learning Theory, uses the concept of self-efficacy as a main principle to achieve a desired outcome in his theory. Bandura states that self-efficacy is the conviction that one can successfully execute a specific behavior required to produce the desired outcomes (10). AOE programs fail to incorporate this key aspect of decision making into their structure and curriculum, removing a person’s belief that they have control over their own decisions. It has been shown that behavioral beliefs, self-efficacy, and other skills can reduce STD risk-associated sexual behavior among adolescents (11).

“Federal regulations for state abstinence education funding adopt a moral definition of abstinence, requiring that abstinence education teach that a mutually faithful monogamous relationship in the context of marriage is the expected standard of human sexual activity” (6). In AOE programs, the word abstinence is often defined in moral terms, using language such as “chaste” or “virgin”, and frames the activity of abstinence as an attitude or a commitment in addition to a behavior (6). Teenagers who have had sex or are contemplating sex may feel ashamed and embarrassed that they are performing immoral or unethical acts, and may try to hide their behaviors. This secrecy can lead them to avoid doctor’s visits that would prevent or treat STDs and pregnancies. The moral definition of abstinence programs is also discriminative against the gay, lesbian, bisexual, transgender and questioning youth because the definition of marriage is limited to heterosexual couples (6). Today, there is currently only one state that recognizes same-sex marriages, which helps to create a stigma around homosexuality as deviant and unnatural behavior (12). These youth may tend to feel isolated, lonely and immoral, increasing their risky behaviors and eliminating their ability to execute healthy behaviors.

Friends and Family Matter

AOE programs are based on the Health Belief Model (HBM) which focuses only on individual level factors and ignores many key aspects of a person’s life that influence decisions. “The HBM explicates the relationship between individual health beliefs associated with a disease or medical condition, and likelihood of engaging in preventive health actions” (13). The model assumes that individual decisions are made in a vacuum and that socioeconomic status, culture, race, social networks, media, and peer pressure do not play into one’s decision. For example, members of racial and ethnic minority groups are more likely to engage in behaviors that lead to early pregnancy, childbearing, and sexually transmitted infections (14). AOE programs are cookie cutter in design and focus on the general population of adolescents, not incorporating the other influential factors into their curriculum.

Peer pressure can play a large role in one’s decision to begin sexual activity. Teenagers with sexually active friends are more likely to engage in sexual activity themselves – they see sex as a “cool” thing to do (15). Even kids who believe, but don’t know for sure, that their peers are having sex, are more likely to engage in sex and feel that it will increase others’ respect for them (16). The same goes for condom usage and contraception methods. Teens who believe their friends do not use condoms are less likely to use them (17).

The relationship with one’s family influences one’s sexual behavior just as much as peer pressure can. Teens born from teenage mothers are more likely to start having sex at an early age and become teen parents themselves (9). Conversely, teens that come from families with two parents that are more educated and have higher incomes are “more likely to engage in positive reproductive behaviors than their peers who lack such backgrounds” (18). The expansion of a visible sexual culture including the increasingly sexually oriented media can also factor into a teens decision as to whether and when to engage in sexual behavior (19). The historical context and current environment of the teen can predict, to some degree, the likelihood that they will engage in risky sexual behaviors. The current AOE programs being designed around the HBM model fail to account for such factors, limiting the impact of the program.

Rational decision-making is another major flaw with the HBM. The model assumes that behaviors are always planned and rational. AOE programs follow this model and ignore the fact that behaviors can be impaired by other risky behaviors such as substance abuse. Teens that are already involved in other risky behaviors such as using alcohol and drugs are more likely to engage in risky sexual behaviors (20). Alcohol and drugs are known substances that blur one’s sense of judgment between right and wrong. Teenagers experimenting with alcohol and drug use could end up having unplanned sexual activity, where there is less of a chance of using protection. AOE programs, by not teaching or discussing information on contraception, do nothing to decrease the chance that these teens, while under the influence of alcohol and drugs, will use protection. 81% of teens want young people to receive more information about both abstinence and contraception (21). Including information regarding contraception options in AOE programs could possibly increase the chance of using them during unplanned and irrational sexual activity.

Don’t Means Do – Rebellious Teens

When a parent asks a teenager to do something, teens usually say no. It is not that they don’t want to help out; it is the mere fact that teens don’t like being told what to do (22). Teens want to figure things out for themselves and have the personal satisfaction of achieving it on their own. This ideology can be applied to AOE programs. Teens want the facts and then to be left to make their own educated decision (22). Smoking, risky sexual behavior and alcohol are all behaviors about which teens want to make their own decisions, and for which the government has set restrictions – in essence telling teens what not to do. Generally the methods used the Florida’s “Truth” campaign can be applied to the AOE programs, as teens generally feel the same way about sex as they do smoking. Research found that for the campaign to be successful the tone of “truth” could not preach and that “truth” needed a message other than “don’t” (22). Research also showed that teens were already well aquatinted with the negative effects of tobacco and despite this knowledge and awareness, teens still saw smoking as rebellious and self-identifying (23). “Using tobacco was a tool of rebellion for the teens, and was all about sending a signal to the world that the user made decisions for themselves” (22). Understanding this attitude, the “truth” campaign turned the focus from telling teens to stop smoking; to telling them it was actually the tobacco companies that were telling them what to do. This idea made the teens want to rebel out against the tobacco companies and the rates of smoking decreased.

The US has created an environment for teenagers to rebel out against the government’s forced beliefs and attitudes regarding sex. Comparing the US teenage pregnancy rates against other developed countries, the US tops the list (5). The situation is the UK, for example, is rather different in that “abstinence education has no support in public policy and receives no funding from government, although there is an expectation that sex educators in schools will emphasize the potential benefits of delaying or abstaining from sexual activity alongside providing information about contraception, sexual health services, sexuality and gender issues” (24). The U.K. government believes that encouraging a delay in the start of sexual activity has its place, but that fundamentally they must recognize the reality that people are able to make their own decisions about their sex lives (25).

Western and Northern European countries are beginning to accept the idea that teens will begin to have sex in their teenage years, certainly before marriage. Rather than trying to force abstinence beliefs upon their citizens, these countries “emphasize through their social institutions the provision of sex education and health care services aimed at equipping young people to avoid the negative consequences of sex” (26). These countries are going against the AOE programs by encouraging and expecting the teens to use contraceptives. This method has been proven effective by studies showing that rates of teenage pregnancy, childbirth and STDs are low in these countries (26).

Conclusion

AOE programs are fundamentally flawed in theory, design and message. Failure to allow for self-efficacy in the programs eliminates teen’s ability to feel that they are capable of postponing sex until they are married. The program curriculum provides false and misleading information. The curriculum also discriminates against the gay, lesbian, transgender and bisexual population by only considering marriage for heterosexuals. The program language also creates a sense that abstinence is the only moral decision for preventing pregnancies and STDs, forcing teens to feel embarrassed or ashamed of their sexual activity.

A teenager does not make a decision to have sex by only thinking about their individual susceptibility and severity. Teens tend to engage in risky sexual activity as a result of peer pressure, family circumstances, media attention, or even under the influence of alcohol and drugs. Their decisions are not always planned and are not always rational. AOE programs fail to account for these factors since the programs are designed off of the HBM. AOE programs also fail to account for the mentality of teenagers when it comes to being told what to do. Teens hate being told what to do and rebel out against this idea by any means that show they are in control. With the amount of money put into sexual education programs, it is only reasonable that they be expected to produce meaningful results. AOE programs have been proven ineffective, so now additional measures must be taken, including teaching safe sex practices and contraception use. These realistic programs, which do not insult the intelligence of their target audience, have been proven far more effective abroad, so it is time we started expanding them in the United States.

A Counter-Proposal to Abstinence Only Education Programs: Re-Framing Sex Education

With the United States ranking highest among industrialized countries in teenage pregnancy and the rates of STDs skyrocketing (3,5), the time for change is now. The current method of sexual education aimed at teens, abstinence only education (AOE), has not accomplished the goal of reducing teenage pregnancies and STDs. AOE education programs are based on the premise that teens should not engage in sexual intercourse until they are married (2), despite the fact that “few Americans remain abstinent until marriage, many do not or cannot marry, and most initiate sexual intercourse and other sexual behaviors as adolescents” (6). In order to create an environment where sexual education can make an impact on the rates of unwanted pregnancies and STDs, the United States needs to re-frame the way we think about sex. This new way to think about sex must address the key limitations of the AOE programs. AOE programs do not allow for self-efficacy, do not take into account social and environmental factors, and lack adequate understanding of how teenagers react when being told what to do.

Proposed Intervention

An intervention that would reduce the number of teenage pregnancies and STD infections would have to take a two-fold approach. The first step would be to re-frame the way the United States thinks about sex in an effort to create a social change. The second step would be to eliminate AOE programs because of their misguided framing of sex, and re-vamp the sexual education curriculum to include information on urging protection, based on social norms and the environment. To begin to re-frame the way the US thinks about sex is a difficult undertaking that may take a considerable investment of time to accomplish. “Frames are fundamentally about the relationship to the world and how people view it,” (27) they are unconscious, develop naturally, come into the public's mind through common use (28), and can be hard to change. The current frame used regarding sex is that sex before marriage is immoral and wrong, and that abstinence is the only way to protect oneself from unwanted pregnancy and STDs. Framing is a powerful tool to use to change peoples behavior. “The essence of social change is changing perceptions, which itself is the territory of framing” (27). People can often be expected to change their behavior solely based on the way something is framed or worded.

The proposed intervention would frame abstinence as being unrealistic and focus on the notion of “be real, be safe.” The frame would acknowledge that teens do engage in sexual activity, but that society doesn’t have to think it’s wrong and immoral. The message would no longer be “don’t have sex before marriage,” but “if a teen chooses to engage in sex, be safe and use protection.” The unconscious frame would no longer be “sex is wrong before marriage,” but “if you I’m going to have sex, I should be safe about it.” This key message would disseminate throughout all aspects of sexual education including the elimination of AOE programs. The basis for sex education for teens would now incorporate curriculum including contraception options, and the method of teaching would be based on the Social Learning Theory, including information on social factors and the environment.

The Social Learning Theory, created by Albert Bandura says that changing a behavior is based on three factors: “A person’s sense of self-efficacy about the behavior, the social/physical environment surrounding individuals, and the interactive process of reciprocal determinism, where a person acts based on individual factors and social/environmental cues, receives a response from that environment, adjusts behavior, and acts again” (29). The proposed programs are designed to incorporate the key message of how social factors and environmental factors can also affect a teen’s relationship with sex and contraception use, factors that AOE programs were lacking.

Knowing The Full Truth

The new intervention method of teaching teens about contraception provides them with the full range of options to prevent pregnancies and STDs. Teens will no longer be provided with false and misleading information regarding contraception, as was occurring under AOE programs (6). Teens will have access the full truth about prevention and will be able to make informed decisions for themselves. It has been shown that teens who do have information about prevention of STDs and pregnancy are more likely to use those contraception methods than those without such information (9). Self-efficacy, the ability to make informed decisions and the belief that one can successfully carry out the desired behavior to prevent STDs and pregnancy (10), will no longer be minimized in the new method of sexual discussions. Studies have also shown that self-efficacy can reduce STD risk-associated sexual behavior among teens (11).

The new frame for sex will no longer consider sex before marriage to be wrong or immoral. Teens that are engaging in sexual activity before marriage will no longer be compelled to hide their behavior or feel ashamed. The frame will encourage teens who choose to engage in sex to use protection. The gay, lesbian, bisexual, transgender and questioning youth will not be discriminated against under the new frame. AOE programs framed the moral standard of sex to be in a monogamous faithful marriage between a man and women (6). With the lack of states that recognize same-sex marriages, the stigma around homosexuality is that it is unnatural and immoral (12). Because the new frame will not place an emphasis on what constitutes a marriage, and will acknowledge that sex happens before marriage, the message will be pure – just be safe. The gay and lesbian population of teens will no longer need to feel isolated or immoral. They can have the confidence that their relationship or sexual activity is deemed normal and the frame of “be real, be safe” applies to them.

Accounting for “The Other” Factors

The new frame and updated sexual education materials will now account for external factors that play a part in teens decision-making process. The cookie cutter design of AOE programs can now be tailored to the specifics of the population in each classroom. Socioeconomic status, culture, race, social networks, media and peer pressure all play into the decision-making process, and information regarding these factors can be incorporated into the curriculum. Education around contraception usage among teens can be discussed and can be turned into the social norm. The knowledge of contraception can also increase use among teens; even when sexual behavior is unplanned or irrational. If teens believe their friends are using condoms, they are more likely to use condoms themselves (17). The old frame allowed teens to see sex as the “cool” thing to do if their friends were doing it (15). With the new frame, the “cool” thing is to use protection if having sex, and the teens will be armed with the appropriate information regarding contraception.

Once sex education classes are modeled around the Social Learning Theory and with the re-framing, factors such as a teen’s family, their history, and even the media will be included in discussions as to why it is good to use protection when having sex. The current media has dramatically expanded the visibility of a sexual culture, which plays into a teen’s decision to become sexually active (19). With the re-framing, acknowledging this fact can be used to the intervention’s advantage. The program could ensure that protection ads are run often, and through popular teen shows, demonstrate that it is “cool” to use protection.

Teen’s family and past history can also influence teen’s behaviors. Teens born from teenage mothers are more likely to start having sex at an early age and become teen parents themselves (9). These teens could have thought that since their mom was a teenage mom, that was normal. Since this lifestyle was all they had known, their environment was supporting that conclusion. Further, existing AOE programs were supporting the conclusion that teenage motherhood is acceptable so long as it is accompanied by a teenage marriage, and it is not too much of a stretch for a pregnant teen to accept the former without the latter. With re-framing the way society views sex, those teens may change their feeling about teenage pregnancy by seeing that the norm is not to be a teenage mom, but to use protection when having sex. Following the Social Learning Theory based curriculum, the media and family history are all part of a teen’s environment and will play into the teens decision making process about when to use protection.

A New View

Under the new proposal, society will no longer be telling teens not to have sex. The framing instead would be, society understands that teens will have sex, just be safe and smart about it - use protection. Teens hate being told what to do - they want to know the facts and then left alone to make their own educated decisions (22). A re-framing message has been proven effective in Florida’s anti-tobacco “Truth” campaign. Research conducted for the campaign found that for the campaign to be successful, the tone of “truth” could not be preachy and that “truth” needed a message other than “don’t” (26). To avoid the “don’t” message, the campaign re-framed the idea that society was telling teens not to smoke, to a frame that the tobacco companies were taking independence away from teens and that it was the tobacco companies that are now trying to tell teens what to do. The methods used in the anti-smoking campaign are applied to sexual behavior in the proposed intervention, as teens generally feel the same way about sex as they do smoking: they want to make up their own minds.

Re-framing sex and providing information regarding contraception is the method that most Western and Northern European countries are using to reduce pregnancies and STDs (24). These countries acknowledge that teens are going to have sex, so they put the emphasis on protection and contraception use. This method has been proven effective in reducing the rates of teenage pregnancy, childbirth, and STDs in these countries (26). The proposed intervention has taken into account what other countries are doing to reduce their rates, further proving that re-framing the idea of sex and providing information on contraception, family history, media and social norms can and will help reduce the rates of the US teen pregnancy and STDs.

Conclusion

AOE programs lack key elements that reduce their chances of achieving their desired goal of lowering the rates of teenage pregnancies and STDs. The proposed intervention accounts for these elements in two key ways: 1) by re-framing the way society views sex among teenagers 2) by basing the sexual education programs around the Social Learning Theory, incorporating teens’ social environments into programs promoting contraception use. Pregnancy and STD exposure are serious risks facing almost all teens. Ignoring the reality that teenagers will, despite all efforts, continue to be sexually active is not doing them any favors. Confronting these mature issues with tactics aimed at juveniles belittles both the issues and the audience. The proposed intervention seeks not only to reframe the way teenagers and Americans in general conceive of teen sexuality, but to empower teenagers with the knowledge to make informed choices and thereby the confidence to make the right decisions.

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26) Cohen S. Delayed Marriage and Abstinence-until-Marriage: On a Collision Course? The Guttmacher Report on Public Policy 2004; 7(2). http://www.guttmacher.org/pubs/tgr/07/2/gr070201.html. [Accessed 11/16/08]

27) American Medical Student Association. Introduction to Framing. http://www.amsa.org/uhc/FramingIntro.pdf. [Accessed 11/29/08]

28) Lakoff G. Simple Framing.

http://www.rockridgeinstitute.org/projects/strategic/simple_framing. [Accessed 11/29/2008]

29) Edberg M. Essentials of Health Behavior Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett, 2007.

Forgetting Your ABC's- Stephanie Gould

Forgetting Your ABC’s

Although reports of the numbers of people infected with AIDS and HIV vary and are often unreliable, it is clear that HIV/AIDS , along with other STDs, remain a significant problem for the United States. Since the first AIDS case was identified in 1981, about 1.7 million people in the US have become infected (9). Among these, it is estimated that about half occur in people aged younger than 25, and about a quarter are found among those who are between 13 and 22 years of age (17). Similar trends are seen for STDs in general – there are roughly 19 million new infections each year, and half of these are among adolescents and young adults. Teenagers and young adults are also disproportionately affected; while they account for around half of all new STD infections, they represent only 25% of the sexually active population in the United States overall (11).

As such, it is clear that interventions need to be aimed at teens to decrease their susceptibility to STDs and HIV/AIDS. One such proposal has been the ABC program. ABC stands for “Abstinence from sexual activity, Be faithful to a single partner, and use Condoms”, three behaviors which are believed to reduce STD and HIV/AIDS transmission. This program has been reported to have had significant success in other countries, most notably Uganda, where, after implementation of this program, overall AIDS prevalence fell from 15% to 6.5% in Uganda nationally (18).

However, implementation of the ABC program was not all that Uganda did. The Ugandan government also targeted the stigma attached to HIV/AIDS, created more comprehensive educational opportunities, advocated testing and counseling, and improved the status of women, among other things (4). This suggests that the ABC approach was not sufficient to explain the decrease in HIV/AIDS prevalence alone (12). Specifically, the ABC approach, by itself, has significant limitations. It is an individual level based model that does not promote self-efficacy and is framed in such a way as to ignore contextual differences and create very limited possibilities for change. These three deficits together make ABC a particularly inappropriate intervention for teenagers.

Problem 1: Individual Level Model

One of the most important problems with the ABC intervention is that it is an individual level model. It focuses on the individual and actions the individual should take. It assumes that individual decision-making is what will ultimately determine action. It thus fails to take into account anything beyond the individual, including the social environment, such as social or cultural norms and racial or ethnic disparities among teenagers (6). Perhaps most importantly, there is no room in the ABC for social exchanges regarding abstinence or safer sex, which can have very detrimental health consequences.

Sex, and more specifically safe sex, among teens is inherently social and socially determined. For example, adolescents who discuss sex either with their peers or with their parents are more likely to use condoms. There is also evidence that the interaction is reciprocal – teens’ perceptions of what other teens think of a behavior affects how they think of that behavior. For example, if teens think that their peers think that condom usage, or abstinence for that matter, is ‘cool’, they are more likely to use condoms or remain abstinent respectively. Among those who’ve already had sex, those who are able to discuss sex on a social level are more likely to have safer sex by using a condom, while those who are unable to discuss it are less likely to engage in safe sex (8). This shows how sex is socially constructed. If there is no place within the ABC model for some sort of social exchange regarding sexual behavior change, the ABC model will fail.

There is also the concept of social modeling, the idea that if you see someone like yourself succeed, you are more likely to believe that you can succeed and are therefore more likely to try the beneficial behavior (1). Again, there is no room for this in the ABC intervention program. Because there is no social discussion or interaction built into the model, there is no way social modeling can take place. The ABC model thereby ignores a potentially very effective way to encourage actions that will limit the transmission and spread of HIV/AIDS and STDs. The ABC model ignores the social context of the specific individual and doesn’t place teenagers in a social framework within which they can operate as a collective group and influence one another in potentially beneficial ways.

One’s social environment as a whole can also significantly affect behavior. The ABC program doesn’t allow an individual to place him or herself in context, but rather leaves the person alone to change as an individual. It has been shown in a study regarding smoking that whether or not those in your social network smoke affects whether or not you will smoke. The more those around you do a certain behavior, the more likely you are to engage in that behavior (3). These findings can certainly be extrapolated to abstinence, fidelity, or condom use. Moreover, behavior change tends to happen on a social level, such that entire social networks adopt a certain behavior at the same time (3). An individual level model cannot account for such a phenomenon. By ignoring this, the ABC model again ignores a potentially useful strategy in promoting the ends they want to attain.

Change needs to happen within a social framework for it to be successful. No change can happen in isolation, either by an individual him or herself or by ignoring one’s social surroundings. Moreover, it has been proven that change happens on a social level, involving entire social networks at a time (3) and that social interactions can have positive effects on influencing change in an individual (8). The ABC model simply does not address this issue, and leaves individuals as mere individuals, ignoring all the potential benefits of including one’s social group as part of the intervention. In sum, the individual level model fails because sex is so inherently social that change regarding sexual behavior cannot happen or be modified in isolation. Group-level dynamics need to be taken into account for true change to occur, and the ABC does not do this because it works only on the individual level.

Problem 2: Lack of Self-Efficacy

Self-efficacy is one’s belief in his or her personal capabilities to change. In other words, it is the belief that one can change effectively and control his or her actions. It has been shown that people are more likely to act, and thus more likely to actually change, if they have higher self-efficacy. In order to gain self efficacy, individuals need to either have had positive outcomes in the past, have an opportunity to engage in social modeling with their peers, or have social persuasion, where they are persuaded by their peers to believe in themselves and their abilities to act effectively (1). Having self efficacy can then change one’s behaviors. For example, a study has shown that feelings of self efficacy around saying no to sex was associated with higher condom use with both regular and casual partners (16), showing that self efficacy can have very positive effects on behavior change when it comes to sexual behavior.

As we have seen, however, the individual-level ABC model does not foster self efficacy in any way. It actually keeps teenagers from building self efficacy in the ways suggested. It doesn’t allow for the last two methods of gaining self efficacy to happen, as social discussions and environments are ignored, so no social modeling or social persuasion can happen. As for the first method of building self efficacy, the ABC attempts to preempt any sexual activity, so teens would not have had experiences in the past from which they can learn. Although one might gain self efficacy by saying no to a sexual encounter effectively, the ABC model does not explain how to do this, only that you should do it, so it is unlikely that this will increase self efficacy significantly. There is no place in the ABC model for self efficacy to occur and, without self efficacy, one is less likely to successfully engage in behavior change (1).

It has been found that most Americans initiate sexual behavior during their teen years. Specifically, the median age for first intercourse for females is 17.4, while it is 17.7 for men (17). The 2001 National Youth Risk Behavior Survey indicated that around half of all high school students reported engaging in sexual intercourse, and rates of safe sexual intercourse vary widely across location (8). Therefore, it is clear that interventions need to happen during teenage years. Moreover, it is critical that teens are allowed to build self efficacy during this time, so that they feel confident in doing what ABC suggests they do – be abstinent, be faithful, and use a condom. Sexual education programs usual occur throughout high school, but are clearly not being effective as defined by the ABC model given the high prevalence of sexual activity among teens and the varying rates of safe sex. This may be in part due to a lack of self efficacy. As will be discussed, sexual education programs tend to focus on abstinence only in the United States, making it nearly impossible to build self efficacy regarding sexual activity or to go beyond abstinence only. Youths do not consider abstinence and sexual activity to be opposing constructs (11), and as such, are not as dichotomous as the ABC model would suggest or hope that teenagers are. It is therefore particularly important that teens build self efficacy around all three aspects of the ABC model if they ABC model is to have any positive effect. However, the ABC model makes it nearly impossible to create self efficacy around any of the three behaviors at all.

When it comes to self efficacy, it is also clear that there are gender differences. Women are the fastest growing population group with HIV (15), accounting for 35% of the HIV population in 1985 and growing to 50% in 2007 (6). This may be due to the fact that females need to be specifically targeted to improve their self efficacy. Gender norms create imbalances in power between the sexes, often to the detriment of females. The power imbalances often lead to women having less say in their sexual activities than their male counterparts, in all three aspects of ABC (12). While the power imbalance is clear in instances of rape or sexual violence, it is similarly relevant in consensual sex (13). Social context needs to be taken into account – stereotypes reinforce the idea that males should always want to have sex and should be having sex as often as possible. Stereotypes for females, however, often place them in a coerced position, where they are more likely to have sex even if they don’t feel ready for it and are less likely to make their desires (such as saying no or using a condom) heard (13). The Theory of Gender and Power posits that gender-based inequalities pervade society, which leads to male control over most sexual encounters (15). It is possible that if females had more self efficacy, they could regain some control in their sexual relationships and feel more empowered in either saying no to sexual intercourse, asking for a monogamous relationship, or asking to use a condom.

It is clear that the ABC program does not foster self efficacy, as it does not mention how to effectively engage in any of the specific behaviors mentioned in its model but only the actions one should engage in. The ABC model may even inhibit one from building any self efficacy by preempting any sexual activity and ignoring the social dynamics of sex (1). It is also clear that this lack of self efficacy can have very detrimental effects, particularly to females who suffer from a social environment in which they may be expected to be subservient to males when it comes to sex (15). As such, the ABC model again fails. If teens do not feel empowered or like they can successful engage in behavior change, they will not change their behaviors and the ABC model will be ineffective.

Problem 3: Framing – Lack of Context

A final limitation of the ABC model is how it is framed. This limitation is manifested in several ways. First, it ignores geographical differences and social norms, which in turn ignores the fact that HIV/AIDS and STDs are spread in different ways in different areas. Secondly, the way the intervention itself is framed, particularly in the Unites States – Abstinence until married, Be faithful to one partner, use a Condom – makes it a very limited model.

The ABC model is theoretically meant to be applied in the same way in every country and in every location. One can easily see how this is not a very good idea. For example, HIV/AIDS spread is different in geographic areas where the population is stable and in areas where there is heavy migration. It thus stands to reason that an intervention to stop or slow the spread of HIV/AIDS needs to be different in these two locations. More specifically, the stable population would need to focus on individuals being faithful while the migratory population would need to focus more on using prevention, as it is harder to be monogamous when potential partners keep moving (6). Differences in social norms will also change the way in which the ABC model is received and operates. In places where teens are already having sex and frequent sexual activity is the norm, a focus on abstinence will not be very helpful. However, the ABC model makes no reference to these distinctions, and assumes that the same intervention plan will work everywhere. It is obvious from these examples that it will not.

As for the second manifestation of this framing issue, it may be helpful to focus on the United States. The United States reauthorized the President’s Emergency Plan for AIDS Relief (PEPFAR) in 2007. A component of this plan was to encourage the use of the ABC model worldwide (5). However, the United States itself has interpreted the ABC model in a very limited way – Abstinence until married, Be faithful once married, and use a Condom always (unless trying to have a baby in wedlock) (14). Thus, given that the median age of marriage in the United States is 25.3 years for women and 27.1 years for men (17), the United States has emphasized abstinence only education for teenagers. This seems to makes sense, except that we know that around half of all high school teenagers are engaging in sexual intercourse (8). Regardless, the federal government will only give money to state schools that are willing to provide exclusively abstinence only education. The federal definition of an abstinence only education plan includes teaching that: abstinence is the only way to avoid out-of-wedlock pregnancy and STDs; a faithful, monogamous relationship within marriage is the expected standard of human activity; abstinence is the expected standard for all teenage children; sexual activity outside of wedlock is likely to have harmful psychological and physical effects; and that bearing children outside of wedlock is likely to have harmful consequences for the child, the child’s parents and society at large. While there is no clear definition of abstinence that the government provides, it is clear that, implicit in its definition, is a moral component that frames abstinence not merely as an act, but as an attitude (17).

These education programs, ostensibly following the ABC model that the US has funded internationally, provides no way to help teenagers who have not adhered to strict abstinence from sexual activity. Considering that most teenagers do not find abstinence and sexual activity to be mutually exclusive (11), it seems fair to assume that these programs are not helpful to most teens, especially the 50% who reported to the Nation Youth Risk Behavior Survey in 2001 that they had already had sex (8). Most importantly, these abstinence only education programs have not been proven to be effective in delaying onset of sexually activity. Rather, these programs increase the likelihood of these teenagers having unsafe sex and not using contraception (7). Promoting abstinence only, or even abstinence and fidelity, presents only part of the picture and can actually endanger teens by not giving them important information about protecting themselves from HIV/AIDS and STDs (14).

The United States may have also derived its limited interpretation of the ABC model from the way that the ABC model is framed. It is framed as a series of behaviors that may be seen as being presented in a sequential order, as in abstinence being the most optimal or the first option, then being faithful, and only then using a condom. This would explain why the United States federal government has focused its sexual education programs primarily on abstinence, then on fidelity and only then on condom use, even though there is consistent evidence that comprehensive sexual education programs are just as effective in promoting abstinence while at the same time providing important information to those who do not choose abstinence (17).

The framing of the ABC model, while named quite cleverly, makes it a very limited model. It doesn’t allow for contextual differences among different populations, and it seems to present the different behaviors in preferential order. This limits the model as well as its effectiveness by ignoring differences and applying the same model to everyone without accounting for discrepancies in specific situations. Without better framing that doesn’t allow for placing one behavior over the other as well as framing that allows different manifestations of the intervention strategy for different situations, the ABC model cannot effectively produce change.

Conclusion

All three of the critiques interact to make the ABC model an ineffective model for changing teenagers’ sex behavior. By ignoring the group-level and social dynamics that are inherent in teenagers’ sexual relationships, the model denies teenagers the ability to build any self efficacy. Without self efficacy, change is unlikely to be successful (1). The framing of the model underscores how the model ignores contextual and social differences, as well as self efficacy, which limits the effectiveness of the model in almost any setting.

It is clear from the data presented on the high number of teenagers having sex that abstinence does not work for everyone. The ABC model, with the emphasis that the United States places on abstinence, therefore clearly won’t work as it stands now. Even if we place equal value on all three behaviors, without room to contextualize and open up the model from the limited interpretation we currently use, as well as simultaneously fostering self efficacy, there is no way the model will be effective for teenagers. In sum, the ABC model ignores social groups and interactions, doesn’t foster self efficacy and is framed in such a way so as to not contextualize for different individuals or settings. It is therefore that the ABC model intervention fails.

The Alternative Sexual Revolution Model

As was demonstrated above, the ABC campaign has had some moderate success (18). However, it is clear that the model has several limitations. Specifically, these limitations include the fact that it is an individual based model, that it has no place for self efficacy, and that it is framed in such a way as to not account for contextual differences. Therefore, changes need to be made to help the ABC intervention create more powerful change. While its basis is good, as has been shown by the reduction in HIV rates in countries that use this intervention, such as Uganda (18), improvements definitely need to be made.

The new intervention I propose, the Alternative Sexual Revolution intervention, will build off of the old ABC model in that all three components – abstinence, be faithful, and use condoms – will still be an important part of the model. However, the new model will be based on a combination of the Marketing Theory and the Social Networks Theory. These theories are group level theories. Rather than focusing on the individual, these theories focus on a group level and on influencing change among social groups (19, 20). By using these models, it will be easier for individuals to gain self efficacy and for the intervention itself to change according to contextual differences.

The basis of the Marketing Theory posits that one finds what an individual or group of individuals want – autonomy, freedom, independence, control – and sells it back to them through the behavior change. The idea is to sell the desire, not the behavior change itself. It is through the individual’s “buying” or adopting that desire that the behavior change will come. In general, people don’t value health in of itself. They value the freedom and independence that comes with good health. The key steps to marketing are first to define the product, then to determine the promise or the benefit that product will offer, followed by developing an image for the product and finally to provide support for that promise (20). In that way, people will “buy” your product and adopt the behavior change.

The Social Networks Theory emphasizes the importance of the relationships between individuals, and how those relationships influence behavior. By researching individuals within the context of their social network, one can learn a lot about that individual and about how to influence that individual to change. Since change often happens on a social, group level, researching the dynamics within a social group can help with getting individuals to change (19).

Using these two theories, a new intervention can be created. The idea is to target entire social networks at a time. This can be done by focusing on high schools and even specifically on cliques within high schools. The products – abstinence, being faithful and using condoms – then need to be marketed effectively throughout the school. The promises that these products will provide are freedom, independence and control over one’s sexual life. The key is that we want to market to teens not the behaviors, but what these behaviors will give them – the promises (20). Using television, the internet, and school posters as mediums, we can create ads that showcase these values. For example, with abstinence, we can show an ad with a young girl, saying how she is free, telling audiences that she says no when she wants to because she can. With being faithful, we can show a couple who tout their monogamous relationship as a way to be independent. Finally, with condoms, we can show teens who use condoms as a way to control their lives both now and in the future, by protecting themselves. These will be the images. Using teens as models, we can support the marketing promise through real world examples of teens who have successfully engaged in the behavior (or “bought” the product and experienced the promise), as shown in the ads. Thus, the four basic requirements of marketing successfully are met (20).

By calling this intervention the Alternative Sexual Revolution Campaign (ASR) rather than ABC, we don’t place an emphasis on any one element. Even though we use ‘sex’ in the title, we also call it an alternative revolution, which can easily include abstinence. The ambiguity in the title allows each teen to interpret the model as they want to – either as a way to be abstinent, be faithful, or to use condoms. It is also a slightly rebellious title, which can be yet another promise for teens when it comes to sexual behavior (20). The title of the model reframes the intervention in a way that is much more positive than ABC.

Running these ads and displaying these posters are a way to get teens to think about sex, and safe sex, in a different light. They won’t think about using the behaviors of the ABC model for the sake of doing the behaviors themselves, but rather to help them gain freedom, independence and control over their own lives, which are clearly desirable attributes for any teen. By specifically targeting each ad or poster to teens in general or even to specific cliques within a school, such as suggested by the Social Networks Theory (19), we can account for contextual differences and create a much larger amount of change. Because these ads happen on a social level, the impact again can be much larger than the impact from the ABC model.

Individual Level Model

The ABC is an individual level model, targeted at changing individual behavior (6). However, it is clear that sex is socially constructed and that dialogues between teens can help promote healthy sexual behaviors (8). It is thus crucial that the new intervention account for the social exchanges that happen on a group level. Both the Marketing Theory and Social Networks Theory are alternative theories that happen on a social level. They don’t account for individuals, but rather assume that change happens on a group level. The Marketing Theory directs ads at entire populations at a time (20), and the Social Networks Theory focuses on the interactions and relationships within a social group, not on the individual (19). The emphasis in the ASR model is not the individual, but on the social network, by having ads that target entire populations at a time and allowing for social exchanges to occur.

There is evidence that change happens at a social level. As one study reported, smokers tend to quit as an entire social group, and those who continued to smoke while the rest of the group quit were marginalized (3). This is a direct application of the Social Networks Theory. The ASR intervention accounts for this. The ads are targeted at entire schools, not at individuals. The ASR intervention also assumes that teens will talk to each other about the ads they see and will make the changes as a social group, which has been shown to happen (3, 8). By changing the social relationships within the teenager’s environment through the use of these ads and posters, social norms will change and more teens will be likely to adopt the behavior change (19).

In the ASR intervention, there is also room for social modeling, which has also been shown to influence behavior change (1). With the new intervention, teens can model after one another because the ads are displayed throughout the school and are meant to encourage change that happens within entire social networks simultaneously (19, 20). These ads will allow for discussions between teenagers and within social groups, which in turn will create an atmosphere for social modeling, which will lead to behavior change on both a social and individual level (1).

Sex is inherently social, especially among teens (8). The ABC failed because it had no room for the social implications of sex or for possible behavior changes on a social level. However, the ASR model does, by focusing on social networks rather than individuals and by advertising to entire schools, and not just telling individuals what to do. The emphasis in the ASR intervention is placed on social groups and their interactions, and it is by getting to them as a social network that behavior will change.

Self Efficacy

The ABC model has no component that includes self efficacy, which can be very important to behavior change (1). The ABC model doesn’t include self efficacy even though having self efficacy is related to engaging in healthier sexual behaviors (16). This is partly because the ABC model is an individual level model and partly because it simply never discussed the issue. The ARS model, on the other hand, has self efficacy in it inherently.

Bandura suggested that the ways to gain self efficacy are to have had positive outcomes in the past, to have an opportunity to engage in social modeling with one’s peers, or to have social persuasion, where one is persuaded by his or her peers to believe in themselves and their abilities to act effectively (1). The ASR model allows for social persuasion and modeling to occur, because the model takes place on a social level. There is room in the ASR model for social discussion, which will lead to these behaviors that encourage self efficacy, which in turn promotes behavior change (1). Because individuals can engage in social persuasion and social modeling, self efficacy is more likely to be gained.

Self efficacy in the ASR model will be furthered by the ads themselves through social modeling. The ads will show teens who have successfully engaged in a behavior – abstinence, being faithful, or using condoms – and who also have gained the promises of independence, control and freedom. Teens can use these ads to socially model themselves, and then socially model after one other. This allows not only for self efficacy to occur, but for it to occur throughout the entire social network on a group level.

Moreover, the Marketing Theory suggests that the some of the promises used in the model are autonomy, independence and control (20), all of which contribute to feelings of self efficacy (1). If an individual feels he or she has autonomy, independence and/or control, it is more likely that he or she will feel that she or he has self efficacy and is therefore likely to engage successfully in the behavior change. The ads that show the promises and support the promises will serve to advance an individual’s gaining self efficacy.

In the ABC model, it seemed that self efficacy, or lack thereof, specifically affected females in a negative way, making it harder for them to effectively negotiate sexual experiences (13, 15). The ASR model can take this into account by targeting females in their ads, using female examples of successes in the ads and targeting the ads to female consumers. By informing females of the gender discrepancies when it comes to sexual negotiations and by showing more females who successfully engaged in the behavior changes, females can begin to reverse the gender inequalities. Using ads that show how women can engage successfully in the behavior will help in giving power to women when it comes to sex (6). This will serve to increase females’ self efficacy as a social group overall, thereby improving their chances of successfully engaging in behavior change (1).

Framing – Lack of Context

With the ASR model, we have drastically changed the way the intervention is framed. The emphasis is no longer on the behavior itself, but on promises of what behavior change will bring – independence, freedom and control (20). These are considerably more appealing to teenagers than merely urging them to engage in behavior change. Using the Marketing Theory, we are promising the teenagers something they deeply desire, and backing that promise with an appealing image and support from personal success stories of other teens, to whom teens can relate. The frame of the intervention is thus totally different from the ABC model, and the reframing makes it more appealing to teens (20), who are therefore more likely to engage in the behavior change.

The ASR model also allows for contextual differences. The crux of the new model is the advertising campaign. It is easy to see how each ad would be changed or altered to fit a different environment or social context. Similarly, ads can be easily changed to target a different social network. In different parts of the world, and even within the US, different stresses should be put on the intervention depending on the contextual situation. For example, the ABC model made no differentiation between migratory populations and stable populations, even though it is quite clear that they should have (6). The ASR will be able to do so. More ads for condom usage can be put in places where populations are migratory, placing the emphasis on a behavior that will actually work given the situational context. Similarly, depending on social norms within a given social network, the ads can change accordingly. Since the ASR model can contextualize itself in this way, it will be much more effective than the ABC model.

Because the ASR model does not list specific behaviors in any specific order, it is unlikely than an emphasis will be placed on any one behavior. Because its title is ambiguous and somewhat rebellious (yet another promise that teens value (20)), teens can interpret it as they want and use it to back whatever choice they make. This is contrary to what the United States currently does, which is to place a significant emphasis on abstinence till marriage (14). The emphasis on abstinence-only education has been shown to be harmful by not giving teens complete information regarding STDs and HIV/AIDS (17). The new title of ASR will give the United States less justification for promoting abstinence-only education, especially given the dearth of evidence that abstinence-only education works and the proof that it may even be harmful (7, 17).

The framing of the ASR model, as well as its composition, make it a more open ended model that can be transformed and re-imagined appropriately in different situations. This is diametrically different from the ABC, which was limited and strict in its interpretation. Because the ASR model can be contextualized, it’s applications are much more far-reaching than the ABC model. We can thus expect it to have greater effects on positive behavior change.

Conclusion

The ASR model works for several reasons. It takes what it good about the ABC model – the behaviors themselves – and reframes them so that the intervention can actually work in the real world of teenagers today. Because it is based on group-level theories, change can happen on a larger scale and social phenomenon that have been noticed (3) can be accounted for. The composition of the Marketing Theory and the Social Networks Theory allow for self efficacy by promoting promises that encourage one to gain self efficacy (such as autonomy, control and freedom (20)) and by encouraging social exchanges and social modeling (1, 19). Finally, the framing and flexibility of the ASR ad campaigns permit differences in different social and geographical settings. Put together, these changes make the ASR a potentially very effective model.

In sum, the ASR campaign does what the ABC model could not. This is because it is based on group level theories, rather than individual theories. Sex is inherently social (8), and the ABC model simply could not account for that, which meant that it could not account for self efficacy or for reframing of the intervention in different situations. Due to the group level nature of the ASR model, these problems have been corrected. It is because of this that the ASR model exceeds over the ABC model, and brings about hope for real change among teenagers when it comes to STD and HIV/AIDS prevention.

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http://www.usaid.gov/our_work/global_health/aids/News/abcfactsheet.html

Additional References

19. Edberg, Mark. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA. Jones and Bartlett Publishers, 2007.

20. Siegel, Michael, Doner, Lynne. Marketing Public Health: Strategies to Promote Social Change. Gaithersburg, MD. Aspen Publishers, 1998.