Rape Prevention Interventions: A Critique from a Social and Behavioral Sciences Perspective – Kelley Adams

Given the array of issues the field of public health addresses, there are a variety of interventions and prevention efforts currently in place. One issue of particular importance due to its dire consequences and adverse effects on health is rape and sexual assault. Current interventions in place to address the issue of rape include direct services for victims, management programs for convicted sex offenders, and education-based preventative programs. Because there is no consensus in the literature on what causes rape, the majority of programs in this area rely on secondary prevention efforts, and even those programs labeled preventative incorporate aspects of secondary prevention. Education-based rape prevention programs are typically directed at community groups, often either at groups of men in college settings who are at risk of perpetration (e.g. fraternity members and student athletes) (1-3) or at women who are at risk of victimization, simply by falling into certain demographic categories.(4,5 )The programs directed at women typically include or focus on teaching self-defense techniques. In this paper, I will analyze and critique education-based rape prevention programs aimed at women from a social and behavior sciences perspective, paying special attention to aspects of self-defense incorporated within these programs.

Intervening at the Individual Level

As previously mentioned, education-based rape prevention programs are often directed at the community at large, certain groups at risk of perpetration, and women. Programs directed at the latter group often incorporate aspects of self-defense into the curriculum, or otherwise are entirely focused on self-defense, and are marketed as self-defense programs. A program fitting this description was offered by the Boston University Police Department earlier this year, called the Rape Aggression Defense (RAD) program, and a mass email was sent to the Boston University community containing information about its availability to community members.(6 )This program is specifically aimed at women in the Boston University community, and its stated goal is to offer an accessible, educational, awareness-raising program that teaches self-defense techniques and tools for women to use in threatening situations.(6)While aiming to empower women to take responsibility for one’s own safety and how to take control of situations are admirable goals consistent with mainstream feminist ideologies,(5) the RAD program is “specifically for women who wish to physically protect themselves against rape and other forms of violence.”(6) This mildly inflammatory description of the target population implies that women who do not choose to participate in this program do not have an interest in protecting themselves or preventing violent attacks. In addition to taking an accusatory tone, this description reveals that this intervention is intended to create change at the individual level—the program aims to teach individual women to protect themselves in individual situations of risk—rather than on a larger scale. Although it could be argued that this is in fact a group-level intervention given that the class is not taught in a one-on-one manner but to groups of women, the goal of the program is to impart self-defense techniques to women so that they can protect themselves as individuals in individual situations.(6) This fact alone sets these types of programs up for failure in terms of creating significant change on a societal level.

While there is a lack of literature addressing education-based and self-defense rape prevention programs, reviews and criticisms of individual or social cognition models can be considered in light of and applied to these programs. Public health interventions that are based on models addressing individuals are often largely ineffective, or result in less than desirable amounts of change, as these models often ignore social conditions or societal factors that contribute to the problem at hand.(7- 10) An example of a classic individual-level model is the Health Belief Model, which dictates that individuals rationally weigh benefits and barriers, while considering their own susceptibility and the severity of consequences of the problem at hand, of performing the desired health-promoting behavior.(11) This model, like others at the individual level, has been criticized for ignoring the social and cultural context of the individuals that it targets, effectively attempting to analyze individual behavior in a vacuum.(7-10) It has also been criticized for assuming that all individuals considered using the model have equal access, resources, and information to perform the desired behavior.(7)

Given that self-defense classes offered for rape prevention are targeted at the individual level, these critiques are relevant. Programs like the Boston University Police Department’s RAD program, a program that is offered throughout the United States and Canada in various settings,(12) target women who “wish to protect themselves”(6) and do not explicitly consider issues of access, as enrollment costs money and the RAD program is only offered to Boston University women.(6) Similarly, the theoretical model underlying these classes places the responsibility for preventing instances of rape on potential victims rather than perpetrators, and theoretically attempts to end the problem of rape one attempted instance at a time—an unlikely feat considering it has recently been found that 1 in 6 women has been raped at some point in her lifetime.(13) Additionally, by offering self-defense training, these classes assume that self-defense skills are the tools needed to stop rape. In other words, there is no consideration of the fact that the vast majority of rapes are committed by offenders known to the victim, that rapes can take place within relationships and situations where factors other than physical force, such as coercion, are at play. These are examples of contextual factors that individual-level models, and subsequently, programs based on individual-level theoretical models, fail to take into account.

Branding of the Programs and Institutional Associations

Self-defense rape prevention programs, like the BUPD’s RAD program, are often offered in university settings and/or by law enforcement officials. While the involvement of law enforcement officials may offer a sense of security and trust in the skills taught in these classes for some, it may hinder the participation of others. Women involved in illegal activities or those fearful or distrustful of the police may not participate in these programs even though they “wish to physically protect themselves against rape and other forms of violence.”(6) This may be viewed as a failure on the part of those offering the programs to recognize how who delivers these programs matters, as the program’s association with law enforcement or even a more neutral, but still authoritative and powerful, institution like a university may be a deterrent for some. Psychological Reactance Theory (PRT), a theory originating in psychology, dictates that some may experience an emotional reaction to being told to do something, and react in the opposite way than is desired.(14-15) There is a body of literature on this subject that looks at how to prevent psychological reactance, and the general consensus is that having someone who is as similar as possible to the target audience deliver the intended message should successfully avoid this phenomenon.(14) This idea is also present in communications theory, specifically in McGuire’s Communication/Persuasion Matrix.(14) In terms of self-defense classes, this would mean that the instructors and institutions associated with the program should be similar to the women the program is intended for, and incorporating police involvement would dictate that those averse to law enforcement may in fact opt out of participating, even though they may have an interest in their own personal safety. This would undoubtedly be an unwanted effect, particularly given that this is an individual-level intervention seeking to instill change on a larger scale by reaching as many individuals as possible.

In addition to PRT, branding theory, largely used in advertising and marketing,(14) should be considered with regard to these programs. Although most people do not typically consider the brand created by institutions that provide public services like education and law enforcement, the values tied to the brands created by the police and universities matter. While universities can be seen as relatively benign institutions that simply offer schooling and educational resources to the general public, they can also be seen as political institutions with monetary interests and inherently authoritarian, hierarchical internal structures. Likewise, the police may be seen as well-meaning protectors of public safety by some, but as inherently political disciplinarians who work to promote the interests of the state or financial interests, rely heavily on authoritarianism, and abuse their power by others. Given the association with authoritarian and hierarchical institutions like police and universities, these self-defense programs are branded in a way that mirrors the values exhibited by the brands of these institutions,(14) which may be seen as positive or negative. The possibility of these brands being perceived as negative, or even simply as starkly different from the values that an individual holds, may effectively prevent people from participating in these programs not because they are averse to learning self-defense skills or preventing personal attacks, but because of how the program has been branded.

Assumptions Regarding Behavior

The underlying individual-level logic models that most rape prevention self-defense classes are built on assume that behavior is rational, planned, and that people have control over their behaviors. These classes aim to teach women self-defense skills so that, when presented with a threatening situation or in the case of an attack, the woman being victimized will be able to react and physically thwart her attacker’s attempts. The thinking is that if these women are trained in self-defense, they will be able to react in a rational way by drawing on their knowledge of self-defense and employing these techniques. It is also assumed that if this particular reaction is planned, that the individual will in fact react this way when faced with a situation requiring this response. Two core tenets of the social and behavioral sciences perspective assert that people behave irrationally, and that intention to perform a behavior does not necessarily lead to performance of that behavior.(7,16-17) These points are typically applied to relatively benign health behaviors like deciding to get a mammogram, in which case it might be theorized that someone would avoid getting a mammogram even though they are at risk for breast cancer because of fear of breast cancer or perhaps social norms dictate that getting a mammogram is not a socially acceptable behavior, and even though someone might intend to get a mammogram there are issues of access and resources that may prevent that person from getting one.(7) In contrast to these types of scenarios, rape and sexual assault are highly emotionally charged topics, and instances of attack or threats are wrought with emotion. Given this, it is even less likely that the person being victimized would be able to rationally recall self-defense techniques, think about how to adapt them to that particular situation, and successfully employ them. Therefore even though the victim may have intended to use these techniques and respond in a particular way, it may not be possible in such an emotionally intense situation. This is not to say that women with self-defense training are never able to use these techniques, but that it is easy to see how these techniques might fail in such situations and render these rape prevention programs less than useful.

Additionally, these programs assume that women will respond rationally and as they intend to in threatening situations because the hypothetical rape scenario these programs are created to prevent is oversimplified. If the typical instance of rape is the result of a sudden stranger attack, possibly with the involvement of a weapon, it would make sense to teach women self-defense techniques to ward off these attackers. However, in reality, between 75% and 95% of rape/sexual assault victims know their attackers,(18-20) revealing that rape often happens within more complex social relationships than the victim-stranger dyad that is typically thought of. Taking this into consideration, it becomes clear that women who go through these self-defense programs may find these techniques less than useful, as they may be more reluctant to hurt their attacker, may not perceive the situation as dangerous until physical resistance is no longer an option, or perceive resistance as futile or possibly detrimental to the relationship, if there is a social relationship in place. Sexual coercion, rather than forced rape is also omitted from this paradigm. Rape prevention self-defense programs assume that rape attempts can be prevented with physical self-defense techniques, assume that victims will be able and willing to use these techniques when faced with threatening situations, and assume that victims will be able to identifying situations as threatening in time to utilize these techniques.

In summary, self-defense programs as a form of rape prevention contain many flaws. They attempt to create societal change by working on an individual level, do not consider their possibly prohibitive association with law enforcement and institutions, and assume that behavior is rational, planned, and that intentions to perform a behavior lead to performance of that behavior. In addition, they place the responsibility of preventing rape on potential victims rather than potential perpetrators, do not address the fact that the vast majority of rapes are committed by attackers known to the victim, and fail to consider the role that coercion and social relationships play in instances of rape. Although it may beyond the scope of these programs, in attempting to prevent rape, these programs do not acknowledge that a sizable proportion of sexual abuse takes place when victims are in childhood, that males are victims of rape and sexual assault also, essentially contribute to the gendered assumptions about victims and perpetrators (i.e. that women are victims and men are perpetrators), and ignore the complexities around the dichotomous victim-perpetrator dyad (i.e. that victims can be perpetrators and vice versa). From a social and behavioral sciences perspective, these programs seem to be largely ineffective in contributing to the prevention and eradication of rape.

Moving Beyond Individual Responsibility: A Cultural Intervention for Rape Prevention

Taking into consideration the problematic aspects of self-defense classes as a form of rape prevention, my recommendation is to implement an intervention that goes beyond changing individual behavior or relying on individuals to prevent their own victimization, and addresses not only communities, but society as a whole. Although the forefront of rape prevention efforts have been moving towards utilizing a group-oriented bystander approach, where the entire community takes on the responsibility of preventing rape and everyone is trained in how to intervene in problematic situations,(21) this approach can still be viewed as addressing individuals, albeit in a collective manner, and attempting to change behavior one individual intervention attempt at a time. I propose to intervene long before reaching individual risky situations or relying on others to identify these situations and act.

There are currently an array of education-based programs conducted by rape crisis centers and offices of sexual assault prevention at various college campuses,(22-25) but these programs are typically disseminated to the public through single session groups, often to groups considered at risk for perpetration, like fraternity houses. I am not advocating for more of these types of programs, as there are many in existence despite an absence of empirically demonstrated efficacy, but rather for incorporating gender, sexuality, and sexual violence into general curriculums in elementary, middle, and high schools, so that they are not covered once, but are treated as themes throughout the year-long curriculum. This would not necessarily mean teaching sex education earlier, as gender issues and the concept of gender as a social construction can be incorporated into younger children’s education without explicit teachings about sex. The purpose of this would be to create an environment where gender and healthy visions of sexuality are often talked about rather than made taboo. Granted, school is only one of many sources of information available to children, and children should not be relied upon to be advocates of change, especially given their relatively powerless position in society. To compensate for this, a national media campaign would have to be launched concurrently espousing the same concepts and values to address adults and children not in school. This would potentially prevent concepts learned in school from being discarded as hypothetical and abstract, and allowing for application to daily life.

Research has shown hypermasculinity, harboring attitudes of hostility towards women, and power motivations to be risk factors for perpetration,(26) and this type of intervention is aimed at preventing the development of these attitudes and behaviors in childhood. Educational interventions with community involvement to prevent dating violence among teens have seen some success in reducing violence.(27) The Boston Area Rape Crisis Center (BARCC) conducts a training program with early childhood educators, that teaches identification of perpetration-like behaviors and solutions for dealing with them.(22) The intervention proposed here is building on these intervention models, but expanding it so that all school children are targeted, perpetration-like behaviors are not the only warning signs being looked for, and culture is examined as a risk factor or facilitator of sexual violence.

Beyond the Individual

Like many public health interventions, self-defense classes for rape prevention target individuals and aim to change individual behavior. The assumption is that if women can learn self-defense techniques, they will effectively thwart attackers’ efforts and prevent sexual assault, one averted incident at a time. This approach places the responsibility of prevention on potential victims, and is potentially cost-ineffective, given the amount of effort and resources spent to change individual behaviors. In contrast, the intervention proposed here addresses people on a larger group level, both in terms of the school-based intervention which addresses students and teachers, and in terms of the national media campaign. Notably, this removes any stereotype or label that can be inferred from the targeted group (e.g. potential victims or women who wish to protect themselves partake in self-defense classes). This model also attempts to change the beliefs and norms of a large societal group, and essentially works to change the societal consensus on topics like gender and sexuality, which is far removed from attempting to change how an individual conceptualizes gender, for example.

Models and theories of group change are numerous in social and behavior sciences, and are the preferred method for instituting change.(16) In contrast to traditional individual-level theories, these alternative theories recognize that people change in groups rather than as individuals, and that group dynamics are important in influencing how this change happens.(16) Specifically, advertising theory posits that if you make a promise to a group of people that provides them with benefits, reinforces the group’s core values, and is visibly supported, change can be instituted on a broad level using this singular intervention approach.(16,28) Similarly, social norms theory dictates that people change their behavior in groups, and individuals change as their social network changes, thereby reinforcing the importance of targeting groups rather than individuals.(16,29) In terms of the intervention presented here, the national media campaign would likely borrow concepts from advertising theory to communicate that certain attitudes around sexuality and violence are desired or undesired, respectively. This would work by promising people social currency through popularity upon adoption of these desired attitudes, while the desired attitudes would rely on core values like community and empathy, supported by imagery of people performing healthy visions of sexuality, for example. The educational component incorporates concepts from social norms theory as it attempts to change children’s social norms through educating them about desirable forms of sexuality and gender relations that would be disseminated through their social networks.

Branding and Associations

Self-defense programs are often operated by police departments or other authoritative and powerful institutions, which may be a participation deterrent for some. The intervention being presented here would address this by marketing itself as an initiative by multiple grassroots organizations that deal with sexual violence, domestic violence, and gender issues. By removing associations with institutions of authority, this intervention would be branded as sincere, working in the interest of the community, and instead of being conducted by authority figures, would be run by fellow community members. The incorporation of fellow community members in positions to disseminate this intervention is important, as Psychological Reactance Theory dictates that people may react poorly to being told what to do, and as communication theory stresses, especially if the person delivering the message is dissimilar from them.(14-15) For this intervention, the educational materials would be branded as having come from a collective of organizations, as would the media campaign materials. Similarly, special attention would be paid to who appears in the media advertisements, ensuring that people and values espoused in the ads reflect the groups targeted.

One concern may be that the educational component of this intervention will be less effective as it works through disseminating information in school, an institutional setting. However, this intervention would be implemented in school curricula as early as in elementary school, when teachers are not necessarily seen as authoritative adversaries, as they may be when students reach adolescence. The implementation of this program from a young age should instill the desired values and attitudes that are then carried with them into adolescence, so even though at initial implementation the program may not be as effective in adolescent groups as it is in younger groups, the program would still be instituted in these groups to provide consistency for those children who begin it at younger ages. Taking into account PRT and communications theory,(14-15) students themselves may be recruited to assist in teaching the educational component of this program at older ages to make its contents more salient.

Relying on Cultural Consciousness, Rather than Individual Behaviors

Self-defense classes rely on individuals to learn self-defense behaviors, accurately recall them in so-called risky situations (which they are assumed to be able to accurately identify), and effectively utilize them. This multitude of assumptions sets self-defense programs as a form of rape prevention up for failure. The intervention presented here, however, relies on the body of cultural knowledge around gender, sexuality, and sexual violence, rather than on individual actions, to prevent rape. It builds on the bystander approach’s emphasis on community responsibility for sexual assault prevention by attempting to achieve community responsibility for the collective cultural consciousness, or the shared knowledge about gender, sexuality, and sexual assault. The educational and media components of the program will theoretically change social norms by destigmatizing survivors of sexual violence, linking certain cultural attitudes to the facilitation of sexual assault and deeming those attitudes unacceptable, and really forcing people to critically think about gender, sexuality, and sexual violence, and how culture may facilitate sexual assault. These newly altered social norms should provide the impetus for people to take responsibility for the status of rape in that community, and therefore, would act as a form of primary prevention long before any individual instances of attempted sexual assault need to be thwarted.

Because this program aims to intervene long before individual risky scenarios are reached, it does not need to rely on the series of assumptions about the individual’s ability to remember information, analyze its applicability to the situation, and effectively utilize it, as in the case of self-defense programs. This program will not face the same branding issues as self-defense programs given its association with multiple smaller organizations rather than large institutions, it will avoid placing responsibility for prevention on potential victims, and it does not engage in or allow for victim-blaming. By instituting prevention on a level far removed from individual behaviors in certain situations, this approach inherently recognizes that most victims know their attackers, and acknowledges the role that coercion plays in sexual violence.

References

(1) Lisak D, Roth S. Motives and psychodynamics of self-reported, unincarcerated rapists. Am. J Orthopsychiatry. 1990:60(2):268-280.

(2) Garrett-Gooding J, Senter R. Attitudes and acts of sexual aggression on a university campus. Sociological Inquiry. 1987;59:348-371.

(3) Schaeffer AM, Nelson ES. Rape-supportive attitudes: Effects of on-campus residence and education. Journal of College Student Development. 1993;34:175-179.

(4) Koss MP, Gidycz CA, Wisniewski N. The scope of rape: Incidence and prevalence of sexual aggression and victimization in a national sample of higher education students. Journal of Consulting and Clinical Psychology. 1987;55(2):162-170.

(5) Brecklin LR, Ullman S. Self-defense or assertiveness training and women’s responses to sexual attacks. Journal of Interpersonal Violence. 2005;20:738.

(6) Boston University Medical Campus Corporate Communication (bumccorporatecomm@bu.edu). BUPD Offers Rape Aggression Defense Program [Internet]. To all BU medical campus staff and students. 2009 Jan 22. [cited 2009 Apr 5]. [4 paragraphs].

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

(8) Choi K, Yep GA, Kumekawa E. HIV prevention among Asian and Pacific Islander men who have sex with men: a critical review of theoretical models and directions for future research. AIDS Education and Prevention. 1998;10(Supplement A):19-30.

(9) Ogden J. Some problems with social cognition models: a pragmatic and conceptual analysis. Health Psychology. 2003;22:424-428.

(10) Thomas LW. A critical feminist perspective of the health belief model: implications for nursing theory, research, practice, and education. Journal of Professional Nursing. 1995;11:246-252.

(11) Rosenstock IM. Historical origins of the health belief model. Health Education Monographs. 1974;2:328-335.

(12) Boston University Police. RAD. [cited 2009 Apr 4]. Available at: http://www.bu.edu/police/services/RAD/

(13) Tjaden P, Thoennes N, for the National Institute of Justice, US Department of Justice. Full report of the prevalence, incidence, and consequences of violence against women: Findings from the National Violence Against Women Survey. Nov 2000. NCJ 183781.

(14) Siegel M. Developing Interventions: the rose of social and behavioral sciences models of individual behavior change: are they helping us or constraining us? IV [Lecture]. 2009 Feb 26. [cited 2009 Apr 5].

(15) Miller CH, Lane LT, Deatrick LM, Young AM, Potts KA. Psychological reactance and promotional health messages: the effects of controlling language, lexical concreteness, and the restoration of freedom. Human Communication Research. 2007;33(2):219-240.

(16) Siegel M. Developing Interventions: the rise of social and behavioral sciences models of individual behavior change: are they helping us or constraining us? III [Lecture]. 2009 Feb 19. [cited 2009 Apr 5].

(17) Ariely D. Predictably Irrational: the Hidden Forces that Shape Our Decisions. New York, NY: Harper Collins Publishers, 2008.

(18) U.S. Department of Justice, Bureau of Justice Statistics. National Crime Victimization Survey, 1995-2000: Violent victimization of college students. Washington, DC: 2003.

(19) Fisher BS, Cullen FT, Turner MT for the United States Department of Justice. The sexual victimization of college women. Washington, DC: 2000.

(20) Abbey A, Ross LT, McDuffie D, McAuslan P. Alcohol and dating risk factors for sexual assault among college women. Psychology of Women Quarterly.1996;20:147-169.

(21) Banyard VL, Plante EG, Moynihan MM. Rape prevention through bystander education: bringing a broader community perspective to sexual violence prevention. 2005 Feb. [cited 2009 Apr 26] US Department of Justice (unpublished). 208701. Available at: http://www.ncjrs.org/pdffiles1/nij/grants/208701.pdf

(22) Gopnik, Melissa. (Managing Director, Boston Area Rape Crisis Center). Email to: Kelley Adams. 2009 Apr 21.

(23) Boston Area Rape Crisis Center. BARCC services. [cited 2009 Apr 27] Available at: http://www.barcc.org/help/services/

(24) Harvard University, Office of Sexual Assault Prevention and Response. [cited 2009 Apr 27] Available at: http://www.fas.harvard.edu/~osapr/index.html

(25) Boston Area Rape Crisis Center (BARCC). Final Caps Training Descriptions. [cited 2009 Apr 27] Available at: http://barcc.org/assets/pdf/FINAL_caps_training_descriptions.pdf

(26) Lisak D, Roth S. Motives and psychodynamics of self-reported, unincarcerated rapists. Am. J Orthopsychiatry. 1990:60(2):268-280.

(27) Foshee VA, Bauman KE, Arriaga XB, Helms RW, Koch GG, Linder GF. An evaluation of Safe Dates, an adolescent dating violence prevention program. American Journal of Public Health. 1998;88(1):45-50.

(28) The Copy Workshop. Strategy seminar. [cited 2009 Apr 29]. Available at: http://www.adbuzz.com/OLD/Strategy.pdf

(29) Haines MP. Best practices: social norms. [cited 2009 Apr 29]. Available at: http://wch.uhs.wisc.edu/13-Eval/Tools/Resources/Social%20Norms.pdf

The Candie’s Foundation: An Example of a Flawed Public Health Campaign- Kelly O’Keefe

Why do public health interventions fail? The underlying goal of all public health interventions is to change the health behavior of a population from a detrimental behavior to a beneficial one, making us healthier and, presumably, happier. However, the message can easily be lost through an ineffectual intervention. The Candie’s Foundation campaign to reduce teenage pregnancy is flawed for three reasons: it relies too heavily on the (already defective) Health Belief Model, it promotes abstinence-only without alternative considerations, and its message is not being delivered by the most appropriate messengers in the most effectual venues.
According to the Candie’s Foundation, its mission is to “educate America’s youth about the devastating consequences of teen pregnancy” and the overall goal is to “raise awareness of this serious problem, and the consequences, bringing it into the national consciousness and to reduce teen pregnancy”(1). Indeed, teenage pregnancy is a growing public health issue in our society; teen parents are less likely to receive necessary prenatal care, and are more likely to smoke and have premature and/or low birth weight babies. Additionally, teen mothers are less likely to obtain a high school diploma and are more likely to be impoverished, straining our national economic resources and indirectly impacting the health of themselves and their families (2). However, the way in which the Candie’s Foundation attempts to decrease teenage pregnancy is unfortunately wrought with defects and weaknesses, making it an ineffective public health campaign.
To begin with, this intervention is ineffectual because it heavily relies on the assumptions of the Health Belief Model, which is flawed in many ways (fully discussed in Paper #1). The campaign relies on the idea that, given all the necessary facts, teens will make the right choice (which here means not having sex until they’re older). First of all, this assumption that teens are even capable of making a planned and rational decision about sex, weighing potential benefits and perceived barriers while factoring in perceived susceptibility and perceived severity, is laughable; as compared to adults, teens tend to be more driven by non-rational factors like hormones, rebellion, and peer acceptance, and are less likely to carefully consider facts before acting. Research has shown these anecdotal observations are supported by biology: along with the interplay of raging hormones, teens just don’t have the mental and neural capacity yet to make rational judgments or to exhibit mature behavior, and the brain isn’t adept at these tasks until about age 25, far past what society sees as the “teenage years” (3). Moreover, we know that even so-called ‘rational’ adults act in a predictably irrational way, and thus to assume otherwise is to have the intervention doomed to start with (4).
Even if teenagers were able to make rational decisions ahead of time, like the Health Belief Model asserts, the perceived susceptibility and severity in this particular situation may not be drastic enough to tip the scales in favor of abstaining from sex (especially given the potential benefits of sex, such as peer acceptance, physical pleasure, and so on). For one, statistically there is not a 1:1 correlation of sex to pregnancy; you do not get pregnant every single time you have sex, and teenagers experience this first-hand when they hear about all their friends having sex and not having babies each time, likely decreasing their perceived susceptibility of teenage pregnancy. Within those who do get pregnant, both in real life and on TV shows such as “Degrassi: The Next Generation”, abortions and morning after pills are common and even accepted, leading to a likely decrease of perceived severity of the situation (5). So assuming the Health Belief Model does in fact correctly model health behavior, in this particular situation given the circumstances, teenagers may not actually end up avoiding sex.
Additionally, this campaign does not take into consideration making these health decisions “in the heat of the moment”. Dan Ariely’s research on this topic has shown that sexual arousal has a strong impact on judgments, and furthermore that people are unable to predict the influence arousal will have on their behavior when they are in a non-aroused state (6). The Candie’s Foundation fails to address the fact that teenagers are likely to already be in an aroused state when they need to make a decision on whether to have sex, and does not provide any tools to assist with this “in the moment” choice. Also, the website gives a myriad of statistics on sex and pregnancy that teens are unlikely to recall at the moment of arousal, and no emotional factors associated with arousal or sex are even addressed; the act of sex is reduced to a series of facts and figures, which according to the Health Belief Model, helps to contribute to the rational individual weighing of these facts which leads to intention and subsequently leads to behavior (7). Unfortunately, we’ve already seen that teenagers are incapable of making rational decisions, and that emotions (stemming from increased hormone levels) tend to drive behavior (8), but the Health Belief Model does not account for these factors and thus is not an appropriate model to use for a teenage intervention.
Furthermore, the Health Belief Model is an individual level model that attempts to change behavior on an individual basis rather than overall groups of people. Given that teens are more likely to want to do what their peers are doing to “fit in”, it would make more sense to attempt to change all teens’ behavior at once (using an alternative model like Marketing Theory) rather than change them one at a time. Teens are more inclined to do what their peers are doing (and consequently, to do the opposite of what adults tell them to do), and so are less apt to make individual-only level decisions without considering what “everyone else” is doing; for example, analyses of teen smoking has shown the strong effects of peer pressure that help promote this behavior, despite the health risks (9). The Health Belief Model does not give any consideration to peer group mentality, a key aspect of teenagehood, and as such is missing a major avenue through which to reach this age group.
A second main reason the Candie’s Foundation’s message is inherently flawed is that it essentially promotes abstinence only, and does not give an alternative to the behavior it is trying to prevent. The campaign promotes abstinence exclusively as the only way to prevent teen pregnancy, and nowhere can be found a mention of any other options (condoms, birth control pill, family planning, etc). However, a recent study investigating teenagers’ attitudes towards abstinence shows that “they do not consider abstinence and sexual activity opposing constructs”; for them, abstinence does not simply mean the absence of sexual activity (10). In contrast, that’s exactly what abstinence means within this intervention, and as such there is a crucial discord between definitions and therefore a major disconnect between the intervention and the group the intervention is trying to reach.
Despite the popularity of abstinence-only education, we have seen that it just doesn’t work in reducing or eliminating teenage sex and pregnancy; a prime example is Governor Palin’s teenage daughter Bristol, who recently had a baby. In a recent interview with CNN, she stated that “abstinence for all teens is not realistic at all”, even though she still believes that the best option is abstinence based on her upbringing and spiritual beliefs (11). Going back to the Health Belief Model, this further demonstrates a major flaw that intention doesn’t necessarily directly lead to behavior, because as much as Bristol intended to remain abstinent (with much support from her family’s religious beliefs nonetheless), that intention clearly did not lead to the related behavior.
The way the Candie’s Foundation message is phrased is that teens have only two choices: have sex and therefore have a baby, or don’t have sex and escape not having a baby. Not only are other viable options to prevent teen pregnancy not explored at all- forcing teens to make a difficult dichotomous choice we already know their brains are not well-enough equipped to make-, but no tools are provided for teens to assist in making said difficult choice (for example, advice on how to counter strong sexual desires, ways in which to say “no” and walk away, and so on). This lack of alternatives and guidance may lead to a decrease in self-efficacy, which has been shown to be an important determinant of health outcomes for teenagers; a recent study investigating young adult sun protection habits found that self-efficacy predicted both intention and behavior, after controlling for all other variables contained within the Theory of Planned Behavior (12). Given this evidence, if a teen thinks they are unable to not give in to having sex in the first place, they will likely have a harder time not having sex.
A third reason the intervention is a failure is that the message of the campaign is not being delivered by the most appropriate messengers, and not in the most appropriate venues. Here, top celebrities are being used to promote abstinence for teens until adulthood. Unfortunately, many of these celebrities are much older than the teenagers the Foundation is targeting- like Fergie and Simple Plan-, some even with families of their own already; thus it is hard for teenagers to relate to them given that they are not in the same life stage, and might even want to rebel against the message because it is being delivered by “adults” (as we know, a core value for teenagers is rebellion against adults, in which case this intervention would be counterproductive). Teenagers are very susceptible to reactance, in that when they are told to do something (especially by adults), their inclination is to want to do the opposite because of a perceived threat to their freedom. Psychological Reactance Theory asserts that a good way to counter reactance is to ensure the messenger who delivers the message is as similar to the recipient as possible; unfortunately, this intervention does not take advantage of that solution, and instead may actually be exacerbating the potential reactance (13).
Also, celebrities may not be the best spokespeople for abstinence themselves, given their propensity for documented reckless behavior and the stereotype of “sex, drugs, and rock and roll” applied to all celebs (regardless of truth). Communications Theory tells us that the factors through which your message is conveyed are a crucial part of the message itself, and as such, the source of the message is very important to consider; if the source is not a reliable one, or is dissimilar to the message recipients, you may not be successful in getting your message across (14). This is perfectly highlighted within the Candie’s Foundation campaign in one notable PSA aired on the ABC Family Channel (15). Jenny McCarthy is the deliverer of the message in this PSA, interrupting two teenagers in the heat of the moment and telling them that they “obviously (are) not thinking about the consequences (of having sex)”. However, not too long ago, Jenny McCarthy was a major sex symbol herself, promoting sex for hot young singles on her game show “Singled Out” on MTV. How can a former promoter/seller of young sex now be championing the idea that you should wait to have sex until you’re older? This perceived hypocrisy isn’t something teenagers- or indeed, anyone- is going to respond well to, and again may even prove to be counterproductive.
Additionally, there are a myriad of racial and financial disparities involved in teen pregnancy that the messengers aren’t addressing. Minorities such as Hispanics and African Americans have a much higher rate of teen pregnancy than whites (2), but of the major celebrities involved in this campaign, only one is non-Caucasian (Ciara), which increases the dissimilarity between the messengers and the receivers (1). Also, minorities are more likely to be impoverished and subsequently less likely to have access to things like internet, cable TV, and expensive glamour magazines; in contrast, this campaign’s major three arenas of getting its message out are 1) its website, 2) the TV show The Secret Life of the American Teenager on ABC Family (a show on cable TV that revolves around white middle/upper-class teenagers), and 3) ads in magazines such as Seventeen. If those who are in the most need of this intervention don’t even have access to it, how can we expect to make a change in the first place?
The Candie’s Foundation has invested a lot of time, money, and effort to their campaign to reduce teenage pregnancy, and their intent is to help youth remain healthy. However, the ways in which they chose to spread their message and promote a behavior change in the teenage population are quite flawed. Basing its entire campaign too heavily on the defective Health Belief Model, promoting abstinence-only without alternative considerations, and delivering the message via inappropriate messengers through ineffective venues, are three main integral weaknesses in this intervention, and need to be ultimately addressed and modified in order to effect the health behavior change they originally set out to accomplish.

As we have seen, the Candie’s Foundation campaign to prevent teen pregnancy is flawed, and I propose a new, more effective campaign, focusing on early sexual education and promotion of condom use as a primary prevention tool. In middle school at about age 13, all students would complete a school-year-long seminar on sexual education, meeting once every few weeks for 2 hours during the school day (this would also be mandatory for all home-schooled students as well). This seminar would include topics specifically directed towards teenage pregnancy, such as the biology of puberty and fertilization, various pregnancy prevention methods, and what it’s like to be a teenage parent, but also would incorporate non-traditional but equally as relevant issues such as self-esteem, dating violence, inter-family relationships, and drug and alcohol use.
What makes this different from other sexual education/DARE-type programs already out there is that the students themselves will become the teachers. Each seminar, one of the students will be responsible for presenting one of the topics themselves, such that every student will get a chance to become the teacher and all topics will be covered by the end of the course. The moderator/teacher of the seminar will appropriately divide up the topics among the class at the beginning, and will assist the students in planning and implementing their seminar. However, the format will be untraditional in that it won’t only be students presenting a typical power-point lecture; each seminar must have at least one interactive piece, which can include guest speakers (for example, fellow teens who have already had a baby and are facing parenthood), demonstrations (practice putting on a condom with a banana), exercises (caring for a “baby” for a month), games (“Name That Menstrual Cycle”), coaching (how to recognize the signs of domestic/dating violence) and discussions (family issues as related to self-esteem). Each student would have a certain amount of freedom to be creative in designing their seminar and getting the main ideas about the issue across to their peers, but must include the various viewpoints involved with their topic instead of only one side of the story; for example, one seminar would be about abstinence, making sure to discuss both sides of the issue (weighing the pros and cons of each side). Additionally, all seminars must emphasize the options available to teenagers at that particular school or community that are a part of this program (relevant to each seminar’s topic), including easily-available free condoms, counseling, peer group discussions/support, family planning, and so on.
The concept of the intervention would be branded (16): a snazzy campaign title (that will have been created by the teens themselves and market tested) combined with an overall comprehensive image of the program as being really cool, interesting, relevant, and relatable could help attract positive feelings towards the program and make teens excited to be a part of it. Additionally, the idea of sex ed will be reframed from health (awkward/boring/lame) to sex (exciting/fun/cool/rebellious), to help shift the overall attitude towards the topic from negative to positive (17).
This intervention addresses the first major flaw of the Candie’s Foundation- relying entirely on the defective Health Belief Model-, by disregarding that individual model in favor of a combination of alternative health behavior change models (including Marketing Theory, Framing Theory, Communications Theory, and so on). It is clear that the principles of these alternative models fit nicely in concordance with what we know of teenage behavior. The ideas that groups are different from a simple collection of individuals, groups of individuals can be affected at the same time, behavior decisions are dynamic and can change in an instant, and behavior is predictably irrational, all seem to be custom-fit to help effect the most change in teenage health behaviors because they specifically reflect the teenage state of mind (18). The power of peer pressure and group mentality of teens (9), combined with unstable brain chemistry during the adolescent years (3) and the predilection to continue irrational behavior into adulthood (4), all lend themselves to the fact that the alternative models are much better choices to build an intervention with for teens, as compared to the individual level models such as the Health Belief Model for reasons already discussed above (7).
The second flaw in the Candie’s Foundation campaign that the new intervention corrects is that it doesn’t promote abstinence-only without alternative considerations. My new intervention is all about community support and education about choice, and will emphasize many different options for not becoming pregnant, instead of just one. As we have seen with Bristol Palin (11), while abstinence may work for some teens, abstinence for all teens just isn’t realistic, even when supported by a religious and family network. Abstinence will be discussed, of course, but other methods will also be given due consideration, since what safe sex option is right for one teen may not be right for another. But while all possible pregnancy prevention options will be discussed, in this particular intervention emphasis will be placed particularly on condom use as the cheapest and easiest way for a teen to help prevent pregnancy. Condom use will be destigmatized through the seminars (19), and free condoms will be made available to all students in an anonymous way (for example, a free vending machine in the boys and girls bathroom in both the middle and the high schools) so they will always have access to them.
The intervention will not only discuss specific birth control options as well as traditional contributors to teenage pregnancy (like lack of education on the basics of sexual biology and limited information on alternatives to abstinence), but will attempts to help address ancillary causes as well, such as deteriorating family relationships, drug and alcohol abuse, and failing self-esteem. Additionally, various seminars will focus on other important relevant topics such as “Making Decisions in the Heat of the Moment: Always Be Prepared”- helping to increase the amount of self-efficacy, which despite the flaws of individual-level behavior analysis, still may be an important predictor of eventual behavior in teens (12)- and “What Your Classmates Think About Teenage Sex: A Frank Discussion”- which could help address teens’ core values of belonging and conformity by encouraging them to imitate the positive behaviors and actions of their peers. Given the Diffusion of Innovations Theory, as soon as a certain number of teens have adopted the behavior of safe sex, the majority of the rest of the teen population of that school or community are likely to rapidly follow, so if we can reach that tipping point and change the sexual health behaviors of a number of teens, the behavior of (most of) the rest of the population may follow suit (20). Similarly, Social Networking Theory tells us that people exist in social networks and are likely to change our behaviors not as individuals but in groups; this is especially salient for teenagers, who have that core value of belonging and are quite likely to follow along and do what their group of peers are doing (21).
The third flaw in the previous campaign that the new intervention addresses is that its message is now being delivered by the most appropriate messengers in the most effectual venues. Rather than unattainable celebrities, people who have a conflicting or hypocritical background, or drastically older adults, the spokespeople of this intervention would be actual members of the peer group we’re trying to target. Normal, relatable, familiar, every-day classmates will be the ones primarily delivering the message of safe sex and education, and not only will these teens learn from their peers, but will be the ones to teach their peers as well when their turn comes. This again speaks to teenagers’ core value of acceptance and belonging; teens are highly likely to be influenced by their peers (9), so what better way to influence them than by using those peers as the messengers? Additionally, we will be able to help counter reactance against the perceived threat to freedom (13), because the spokespeople are indeed just like them by definition (in the same school/community, similar backgrounds, same age, and so on) and very much relatable. And of course, the benefit in having each student act as the teacher involves each student more deeply in the material, as well as helping get the message out more effectively to the rest of the class, because the teen creating the seminar has the unique understanding of the target audience’s psyche and can tailor the message appropriately (14).
Including this intervention within the usual curriculum of middle school helps not only strengthen the program by utilizing existing resources and structures (faculty, facilities, time/schedule, etc), but ensures that all school-going and home schooled teens will definitely have participated in this mandatory program in their early teenage years, and they will have done so together (further capitalizing on the idea of changing a group’s behavior together at once (21)). This eliminates the financial or other barriers the Candie’s Foundation fails to address, since these kids are required by law to attend school (public, private, or home school), so we know everyone of this age will have equal access to the program. Also, these kids will have gotten this intervention at a time when they are just starting to explore and understand sex better but before most have actually experimented, so the program can help set a positive tone for the upcoming teenage years.
Clearly, this new intervention has many advantages over the Candie’s Foundation campaign, including relying on alternative health behavior models instead of individual-level models, deemphasizing the sole focus on abstinence by introducing other viable safe sex choices such as condom use, and showcasing appropriate messengers in appropriate venues to effectively get the word of birth control out to the target group. Of course, teenage pregnancy is a difficult issue to deal with, and many past solutions to this public health problem have not yielded overwhelming results. But even given its limitations, I believe this new intervention will have a significant impact on reducing the amount of teenage pregnancy in our country, and at the very least will have a positive effect on the attitudes and behaviors of our nation’s youth.


REFERENCES
1. The Candie’s Foundation. The Candie’s Foundation: Home. The Candie’s Foundation. http://www.candiesfoundation.org.
2. Centers for Disease Control and Prevention. Adolescent Reproductive Health: Home. Washington, DC: Centers for Disease Control and Prevention. http://www.cdc.gov/Reproductivehealth/AdolescentReproHealth/index.htm.
3. Wallis C. What Makes Teens Tick (pp. 48-55). In: Time, June 2004.
4. Ariely D. Predictably Irrational: The Hidden Forces that Shape Our Decisions. New York: HarperCollins Publishers, 2008.
5. Kok D. Abortion Issue on Popular TV Show. In: The Interim, September 2004.
6. Ariely D, Lowenstein G. The Heat of the Moment: The Effect of Sexual Arousal on Sexual Decision Making. J. Behav. Dec. Making 2006; 19:87-98.
7. Edberg M. The Health Belief Model (pp. 35-38). In: Edberg M, Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers Inc, 2007.
8. Shen H, Gong Q, et al. Reversal of neurosteroid effects at x4B2g GABAA receptors triggers anxiety at puberty. Nature Neuroscience 2007; 10:469-477.
9. Beales J. Teenage smoking: fact and fiction. The American Enterprise 1994; 20:6.
10. Masters N, Beadnell B, et al. The opposite of sex? Adolescents’ thoughts about abstinence and sex, and their sexual behavior. Perspectives on Sexual and Reproductive Health 2008; 40.2:87.
11. CNN. Bristol Palin: Abstinence for all teens ‘not realistic’. CNN Politics. http://www.cnn.com/2009/POLITICS/02/17/bristol.palin.interview/.
12. Myers L, Horswill M. Social cognitive predictors of sun protection intention and behavior. Behavioral Medicine 2006; 32.2:57.
13. Miller C, Lane L, et al. Psychological reactance and promotional health messages: the effects of controlling language, lexical concreteness, and the restoration of freedom. Human Communication Research 2007; 33.2:219.
14. Edberg M. Communications Theory (pp. 65-69). In: Edberg M, Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers Inc, 2007.
15. The Candie’s Foundation. Video 1: Jenny McCarthy PSA. The Candie’s Foundation. http://www.candiesfoundation.org/psas.htm.
16. Huber F, Gutenberg J, Vogel J, Meyer F. When brands get branded. Marketing Theory 2009; 9:1:131-136.
17. Druckman J. On the Limits of Framing Effects: Who Can Frame? The Journal of Politics 2001; 63:1041-1066.
18. Siegel M. Alternative Models: Four Basic Premises of Alternative Health Behavior Models. In: class notes, 19 February 2009.
19. Link B, Phelan J. Stigma and its public health implications. The Lancet 2006; 367,9509:528-529.
20. Edberg M. Diffusion of Innovations (pp. 58-62). In: Edberg M, Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers Inc, 2007.
21. Edberg M. Social Network Theory (pp. 56-58). In: Edberg M, Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers Inc, 2007.