Challenging Dogma - Spring 2009

Thursday, April 30, 2009

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.

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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.

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