Winning the War against STIs: Why Public Health Interventions have failed to reduce STI rates among Adolescents- Oluwakemi Olukoya

Sexually transmitted diseases (STDs) remain a major public health problem in the United States. The CDC estimates that approximately 19 million new infections occur each year and almost half of the infections occur among young people 15-24 years of age. Though several public health campaigns have been conducted to curb the spread of sexually transmitted diseases (STD) among adolescents, the rate of STDs continues to soar. The failure of these campaigns can be linked to their reliance on traditional health behavior models which have limited ability to change behavior. The traditional health models are limited by their individualistic approach to change behaviors and by their assumption that individuals have mastery and control over decision making and behavior change.

An example of a public health campaign which is based on traditional health behavior models is the It’s Your (Sex) Life (IYSL) national campaign. IYSL is an ongoing partnership of MTV and the Kaiser Family Foundation to help young people make responsible decisions about their sexual health (1). IYSL campaign has distinguished itself from other public health campaigns by winning the Emmy and Peabody award for public information campaign on HIV/AIDS, other sexually transmitted diseases and related sexual health issues. In addition, the recent extension of IYSL partnership with Planned Parenthood Federation of America to promote the GYT (Get Yourself Tested) campaign- aimed at removing the taboos surrounding STD testing- through celebrities seems promising. Despite the above strengths of the IYSL campaign, its’ message, based on traditional health behavior change models (Health Belief Model and Social Learning Theory), has limited ability to change adolescents risky sexual behaviors to preventive behaviors. This article critically reviews the It’s Your (Sex) Life national campaign and presents three arguments which explain the limitations of the IYSL from the perspective of social and behavioral sciences.

I.) Health Belief Model
By using the Health Belief Model, It’s Your (Sex) Life campaign presumes that by promoting ads which emphasize on the consequences and statistics of sexually transmitted diseases, an individual will perceive his susceptibility to acquiring STD and perceive the severity of STD on his life; thus he would rationally weigh the benefits of not engaging in risky sexual behaviors to barriers which leads to intention and safe sex practices. For example, one ad featured a lady instructing a “teenage girl” to break up immediately with her boyfriend who refused to use a condom because she is at risk of contracting HIV.

Though the ad provides factual information, studies have shown that early prevention efforts that involved providing factual information about HIV/AIDS to promote safer sexual practices among adolescents and young adults were not strongly correlated with preventive behaviors(2). Thus, knowledge is necessary but not sufficient for HIV/AIDS risk reduction (2; 3). In addition, findings from various studies(4) that applied the HBM to promote preventive sexual behaviors among heterosexual college students have been inconsistent and provided only partial support for the model. Overall, perceived barriers (to condom use) received the most consistent support as a significant predictor of engaging in preventive behaviors (5). The fact that the extension components of the HBM did not significantly increase the prediction of condom use among college students may reflect the limitations of the HBM in promoting protective behaviors (5).

Furthermore, there is a wider social context within which individuals must circulate such as families and communities, which in turn affect the individuals’ decisions and behavior. HBM does not account for such social and environmental factors. (6) The HBM focus on individual-level factors and its’ reliance on the individual’s ability to make rational decisions and develop intention (7) to engage in protective behaviors constitute a major weakness of this approach. Intention does not always lead to behavior and human actions are mostly irrational. Also, HBM does not take into account the spontaneous activity that characterizes much of human behavior (7)

II.) Self-efficacy versus Self-control
IYSL draws from SLT by promoting self-efficacy. The IYSL campaign assumes that by instructing adolescents to take charge of their sex life by being in control and making smart choices, adolescents will be empowered and thus develop self-efficacy to practice safer sex. However, this assumption is false because individuals lack self-control over their actions due to other influences.

Studies indicate that patterns of social cognitive development in adolescence vary as a function of the content under consideration and the emotional and social context in which the reasoning occurs (8). Adolescents’ reasoning about real-life problems is not as advanced as their reasoning about hypothetical dilemmas (9) (e.g. a female practicing negotiation of condom use in a non-aroused state versus an aroused state). Adolescents’ when faced with a logical argument are more likely to accept faulty reasoning or shaky evidence when they agree with the substance of the argument than when they do not. (10-11). In other words, adolescents’ social reasoning, like that of adults, is influenced not only by their basic intellectual abilities, but by their desires, motives and interests (12).

Behavioral data have made it appear as though adolescents are poor decision-makers (i.e. their high-rates of participation in dangerous activities, automobile accidents, drug use and unprotected sex) however, there is substantial evidence that adolescents engage in dangerous activities despite knowing and understanding the risks involved (13-15). Thus, in real-life situations, adolescents do not simply rationally weigh the relative risks and consequences of their behavior – their actions are largely influenced by feelings and social influences (16). In addition, research has shown that sexual motivation can distort judgments on the risk of contracting sexually transmitted disease (17). Results from a study suggests that arousal does not change an individual’s general knowledge about the risks of unprotected sex, but when it comes to concrete steps involving condoms, sexual arousal changes one’s perceptions of the tradeoffs between benefits and disadvantages in a fashion that decreases the tendency to use them. (18)

III.) Social Determinants
IYSL campaign fails to account for diverse array of factors influencing adolescents’ risk taking behavior (Figure 1). Such factors include familial characteristics such as parental support, peer influence, school environment, community, socioeconomic status, racial disparities and societal factors such as media exposure (19). IYSL campaign may have no influence on adolescents who do not belong to a stable and supportive family system. Families provide role models, shape sexual attitudes, set standards for sexual conduct, control and monitor adolescents’ behaviors. Parental monitoring is associated with older ages of sexual initiation, smaller numbers of sexual partners and more consistent contraceptive use, all of which suggest lower STD risk (20). Thus how will the IYSL campaign account for teenagers, particularly homeless teens, who do not have family support and are predisposed to engage in risky behaviors?

In addition, though IYSL campaign used teenagers to promote its’ message to other teens, the campaign failed to recognize the power of group dynamics in shaping an adolescent decision with regards to which norms to abide to. Peer norms surrounding sexual behaviors and condom use have been shown to be major influences on both risky and protective sexual behavior. When adolescents perceive that friends and similar-aged teens engage in risky sexual behavior, even if their perception is skewed, then they are more likely to adopt those same behaviors (19). IYSL campaign needs to be more strategic in using teenagers in its’ ads in promoting safe sex practices rather than showing teenagers who are willing to adopt condom use because of the consequences of acquiring STDs.

The IYSL campaign failed to take full advantage of the effect of school environment on sexual risk taking behaviors. In one ad, a Professor told a group students that “there is hardly any healthy sexual relations…… they should learn to stop and have a conversation” about sex. Through this ad, IYSL campaign assumes that students have self-control and schools are a good place to let adolescents know they can take charge of their sex life. Though schools play a vital role in sex education, how does IYSL account for other aspects of school social environment associated with risky sexual behaviors? School structural attributes affect norms and attitudes about dating practices and sexual behaviors (21). Studies of the effects of school characteristics on sexual risk-taking behaviors found that racial composition and school type (public or private) are associated with age at first intercourse and number of sexual partners (22). Compared to private schools, teenagers in public schools have a higher STD risk. (21-22).

In addition, IYSL campaign failed to take into consideration racial differences in an ad which lead to counterproductive responses from adolescents. In the commercial, a white teenage girl refused to have sex with a black teenage boy because he did not have a condom to use. Though the ad was trying to tell adolescent females to be firm in their decision of practicing safe sex, the public interpreted it as her being a racist as illustrated by several comments on You Tube. This commercial also failed to use effective communication principles by ensuring a similar group was used as the source of message to the receiving group. The media plays a significant role in socialization of adolescents and therefore impacts their sexual risk and protective behavior. For example, studies have found that greater exposure to rap music videos and X-rated movies were associated with having multiple sex partners, more frequent sexual intercourse, and testing positive for an STD (23, 24). It is ironic that MTV, partners of IYSL campaign, hopes to promote protective sexual behaviors while they show more of music videos promoting sexual activity.

Overall, we cannot hope to optimize changes in adolescents’ sexual behavior without addressing the broad range of factors that influence adolescents’ decision-making process and, in turn, their likelihood of engaging in risky sexual behavior (24).


COnclusion
In order to achieve greater success, “It’s Your (Sex) Life” campaign must move beyond the traditional health behavior models- focused on individual level factors. Merely examining individual-level determinants in isolation provides a limited perspective on a complex issue and, furthermore, precludes a more in-depth understanding of how higher-level variables (e.g., family, peers, school, community, and society) may be independently associated with STD risk behaviors in the presence of other individual-level factors (19). Thus, while efficacious in promoting the adoption of STD/HIV-preventive behaviors in the near-term, individual-level interventions appear to be insufficient in sustaining newly adopted preventive behavior changes over protracted periods of time (19). What is needed is a complementary approach that addresses these multiple spheres of influence and adopts alternative health behavior change models capable of changing people’s behavior en masse to the desired or protective health behavior.

Section 2
To address the problem of rising STD’s rates among adolescents, I propose an intervention/strategy that promotes condom use at a group level by utilizing the following alternative health behavior models: marketing (social marketing) and framing theories.

Marketing is defined by the American Marketing Association as the activity, set of institutions, and processes for creating, communicating, delivering, and exchanging offerings that have value for customers, clients, partners, and society at large. Social marketing is the systematic application of marketing strategies along with other concepts and techniques to achieve specific behavioral goals for a social good. Social marketing seeks to influence social behaviors and to benefit the target audience, the general society and not the marketer.(26)
The defining features of social marketing emanate from marketing’s conceptual framework and includes exchange theory, audience segmentation, competition, “the marketing mix,” consumer orientation and continuous monitoring. (27)
Framing comes from cognitive science, which defines a frame as a conceptual structure involved with thinking.(28) Frames are a composition of elements—visuals, values, stereotypes, messengers— which together trigger an existing idea. Frames tell us what a communication message is about. They signal to us what to pay attention to (and what not to), and they set up a pattern of reasoning that influences decision. Framing, therefore, is a translation process between incoming information and the pictures in our heads (29)

Intervention: Ignite Campaign- bringing out the fire in you

This intervention builds on the growing evidence which indicate that promoting pleasure in condom use, alongside safer sex messaging, can increase the consistent use of condoms and the practice of safer sex.(30) Ignite campaign aims to reduce STD’s rate by increasing the consistent use of condoms among sexually active adolescents. It aims to achieve this by reframing the use of condoms as being pleasurable rather than a just a protection “tool” from sexually transmitted diseases; also by using effective marketing strategies to spread its’ message.

Components of the Intervention

1) Form partnership with a condom manufacturing company in order to make Ignite pleasure condoms.

2) Use strategic adverts to reframe condoms as being pleasurable. I created two commercials which use pleasurable activities (dancing, and going to the beach) to appeal to core values (such as attractiveness, pleasure, vitality, sex) which adolescents value more than health.


Commercial One:
Several teens are gathered in an arena to watch a Salsa dance competition (illustrated by showing contestants (adolescents) with their partners (male and female) wearing salsa dance costumes)
Scene: Presenter of the show: Let’s welcome our final contestants for the night
(The crowd cheers)
Two teams come on stage and as the salsa music plays both teams start dancing.
Team 2: The female partner suddenly stops dancing…..she tells her partner “I can’t continue dancing…..my wrist hurts severely”. Her partner smiles and brings out a pack of Ignite condom (she smiles), he opens the condom pack and ties it around her wrist. Immediately vibrant salsa music plays, team 2 does amazing dance steps and wins the competition. At the end of the commercial, Ignite condom- bringing out the fire in you is displayed.

Commercial two:
Four teenage boys sitting on the beach suddenly get excited when four attractive females walk up to them. The boys stare so hard that “fire” comes out of their eyes. Each of the girls show the boys a box of ignite condom…..strangely the boxes become “alive”, grow so big and each female enters the box. Happily each boy grasps one Ignite condom box.

The two commercials use the power of visual imagery to frame the message. Imagery in brand marketing helps to create the external ideal (e.g. a figure, image or symbol that embodies socially desirable characteristics). Thus an individual will aspire to close the gap between his or her own self image and the idealized external image (e.g. Ignite condom brands).

3) Spread the message via a multi-channel approach by using a combination of traditional media channels, including TV, radio, print (billboards, celebrity, sports and other youth magazines), and new media such as internet websites (blogs, download materials, videos, games, celebrity and Ignites’ own website), E-mail services, Social networks (Facebook, Myspace), Youtube, Desktop agents, mobile phone texting and placing ads on other hand held computing devices.

4) Organize community based events such as concerts, cultural festivals, fairs where free Ignite condoms can be distributed. Distribution can be extended to recreational centers, school health centers, summer camps, hair salons etc. Flyers that have the logo of Ignite and the picture of the star couple in the Salsa dance ad will be distributed. Also, members of the community will be engaged in advocacy for the provision of sufficient resources (e.g. comprehensive adolescent health centers) for adolescent health.

5) Regular evaluation of the campaign to gauge the responses of the target audience to all aspects of the intervention, from the broad marketing strategy to specific messages and materials.

Argument: Why the Ignite campaign is better than It’s Your (Sex) Life campaign
1.) Strength of the alternative health theories over the health belief model
Unlike the HBM that relies completely on individual level factors to change behavior, the alternative health models utilize the group phenomenon to change people’s behaviors en masse. Groups are not just a collection of individuals; they have certain characteristics which individuals tend to adopt. For example, though an adolescent may not want to engage in risky sexual behaviors, when he/she perceives that friends and similar-aged teens engage in risky sexual behavior, then he/she is more likely to adopt those same behaviors (19). The alternative health theories do not focus on predicting individual behavior rather they take advantage of the predictable group “mentality” (the herd mentality) to change an entire group at the same time. The Ignite campaign uses effectively two alternate health theories (Framing and Marketing) which have been proven to yield desirable results in the commercial and political sector. There is substantial evidence that social marketing is effective in changing health behaviors on a population level (31). The VERB campaign, It’s what you do, promoted by the CDC is a good example of how social marketing can change health behavior at a group level. Marketing alters the environment to make the recommended health behavior more advantageous than the unhealthy behavior it is designed to replace (27).

The Ignite campaign uses the framing theory to appeal to other core values (sex, attractiveness, pleasure) more compelling to adolescents than health as used by the IYSL and other public health campaigns. Framing an issue on core values more important to individuals (level 1) is vital because they are the ones that connect to individuals in the deepest way (29) which can trigger the ‘jolt’ necessary for instantaneous behavior change. According to Lakoff (1996), people’s support or rejection of an issue will largely be determined by whether they can identify and connect with the Level 1 values rather than the minute details of issues (e.g. statistics of sexually transmitted diseases) which may “crowd’ level 1 core values and make the campaign message ineffective. The national Truth campaign used the framing theory to appeal to the rebellious core value of adolescents. By successfully framing non-smoking as being rebellious and promoting a teen focused “counter marketing” brand, Truth campaign was able to account for 22 percent of the decline in adolescent smoking prevalence from 25.3% to 18.0% from 200-2002. (32)



2.) Self control
Unlike the IYSL campaign which assumes that adolescents have self control over their actions and can take charge of their sex life, the Ignite campaign takes cognizance of the fact that people have difficulty with self control and their social reasoning is influenced not only by their basic intellectual abilities, but by their desires, motives and interests (12). In addition, the alternative health models used in the Ignite campaign take advantage of the fact that human behavior is influenced by expectations, predictably irrational and not planned. For example, there are “seasons” in the stock market when investors (skilled and unskilled) “rush” to buy a particular stock at unreasonable high prices because such companies have strategically raised the expectations of consumers (via branding, framing and marketing theories) and taken advantage of the predictable irrational “herd” mentality. Similarly, by successfully associating the Ignite condom brands with the core values (sex, attractiveness and pleasure) that appeal to adolescents, the Ignite campaign can take advantage of adolescents lack of self control (which contributes to risky behaviors) and predictable irrational behavior in order to increase the use of Ignite condoms. Trust campaign, conducted by the U.S.-based Population Services International (PSI) promoted an HIV/AIDS prevention social marketing campaign that was effective in reaching adolescents and young adults in Kenya. The Trust campaign promoted the social desirability of condom use by making condom use seem cool. Studies show that the campaign increased adolescents and young adult awareness of the Trust condom brand and increased condom use among those with repeated exposure to the brand. (33)

It is important to note that while the commercial marketing strategies benefit the marketer, the social marketing strategy used by Ignite campaign benefits the target audience and the society at large by reducing STD rates and its consequences. In addition, by actually making pleasurable condom packs, Ignite campaign is not deceiving the target audience.

3.) Social Determinants



Though the Ignite campaign may not be able to address all the societal factors that influence adolescents’ behaviors, it offers a more comprehensive approach for addressing these factors than the IYSL campaign. Firstly, because adolescents are increasingly less subject to parental influence and more subject to peer and media influence (31), there is a dire need for public health professionals to promote media campaigns that can influence adolescents. Campaigns that appeal to the core values of adolescents are more influential than campaigns which emphasize on the negative consequences of acquiring STD’s. The use of negative messaging (“don’t do this behavior”) counters the rebellious core value of adolescents. Adolescents rebel against external restrictions on their independence and self-control (31), thus they develop opposing reactions to negative — “don’t do it” —messages. For example adolescent boys who associate displeasure strongly with condom use are likely to rebel against outside forces who try to “impose” condom use on them without offering them an immediate, tangible, gratifying and valuable exchange that will not make them feel a loss. Thus by reframing condom use as pleasurable and using ads that do not counter the rebellious nature of adolescents and appeals to their other core values (pleasure, attractiveness, sex), the Ignite campaign has superiority in using the media to influence adolescents’ behaviors than the IYSL campaign. The success of the Trust campaign in increasing condom use by framing condom use as being cool, illustrates the power of branded messages that convey positive behavioral alternatives for young people (33).

Secondly, through the extensive use of multi-channels by the Ignite campaign, the campaign is capable of fighting the “battle” against other media and marketing exposures that can promote risky health behaviors. The VERB campaign, It’s what you do, is an excellent example of a public health campaign that used several multi channels to reach its target population. The VERB advertising and promotions reached “tweens” in their homes, schools, and in their communities. The primary vehicle was paid advertising in the general market and in ethnic media channels. The VERB made use of TV, radio channels, print advertising in dozens of youth publications, websites, social networks (Facebook, MySpace) and other media agents such as text messages. Evaluation of the VERB campaign showed that as these same children became more aware of VERB, they engaged in more free-time physical activity sessions. The average 9-to 10-year old youth who were aware of VERB engaged in 34 percent more free-time physical activity sessions per week than did 9- to 10-year-old youths who were unaware of the campaign. (31)

Thirdly, the Ignite campaign also offers a comprehensive approach to promoting preventive behaviors through its outreach to the communities and school based centers. In addition, by involving community members in advocacy for provision of comprehensive adolescent centers, the Ignite campaign takes advantage of the “power” of social marketing in affecting policy makers through the media to frame public debate in support of enacting health policies; thus by influencing policy makers, they can address the broader social and environmental determinants of health (27).

Conclusion
The alternative health behavior models (Framing and Social Marketing Theories) used by the Ignite campaign have the potential to promote preventive sexual behaviors among adolescents; and thus reduce STD rates. Public health professionals need to abandon the “myth” that using such strategies to promote healthy behaviors is manipulative and unethical. It is time for public health campaigns/interventions to look beyond the traditional health models which have failed to curb STD rates among adolescents. The Ignite campaign provides a strong model that can be used to win the war against sexually transmitted diseases.

REFERENCES
1.) Music television channel (MTV).IT’S YOUR SEX LIFE. http://itsyoursexlife.com/iysl
2.) Johnson E. H, Gant L, Hinkle Y. A., Gilbert D, Willis C, Hoopwood T. Do African American men and women differ in their knowledge about AIDS, attitudes about condoms and sexual behaviors? Journal of National Medical Association.1992; 84(1):49-64.
3.) DiClemente R. J, Forrest K. A, Mickler S. College students’ knowledge and attitudes about AIDS and changes in HIV-preventive behaviors. AIDS Education and Prevention. 1990; 2(3): 201-212
4.) Lollis C. M, Johnson E. H, Antoni M. H.The efficacy of the Health Belief Model for predicting condom usage and risky sexual practices in university students. AIDS Education and Prevention. 1997; 9(6): 551-563.
Sands T, Archer J, Puleo S. Prevention of health-risk behaviors inn college students: Evaluating seven variables. Journal of College Student Development. 1998; 39(4): 331-342. Steers W. N, Elliott E, Nemiro J, Ditman D, Oskamp S. Health beliefs as predictors of HIV-preventive behavior and ethnic differences in prediction. Journal of Social Psychology. 1996; 136(1): 99-110.
5.) Evelyn B. Winfield and Arthur L. Whaley A Comprehensive Test of the Health Belief Model in the Prediction of Condom Use Among African American College Students. Journal of Black Psychology. 2002; 28(4):330-346
6.) Kyung-Hee Choi; Gust A. Yep; Eugene K. HIV Prevention Among Asian and Pacific Islander American Men Who Have Sex with Men: A Critical Review of Theoretical Models and Directions for Future Research. AIDS Education and Prevention. 1998; 10(A): 19-30.
7.) Mary K. Salazar MN, COHN. Comparison of four behavioral theories. AAOHN Journal. 1991; 39(3):128-135.
8.) Eisenberg N, Morris A. Moral cognitions and pro-social responding in adolescence (pp. 155–188). In: Lerner R. and Steinberg L ed. Handbook of Adolescent Psychology. Wiley, 2004
9.) Sobesky W. The effects of situational factors on moral judgments. Child Dev. 1983;
54:575–58
10.) Klaczynski P.A. Bias in adolescents’ everyday reasoning and its relationships with intellectual ability, personal theories, and self serving motivation. Dev. Psychol. 1997; 33:273–283
11.) Klaczynski P, Gordon D. Everyday statistical reasoning during adolescence and young adulthood: Motivational, general ability, and developmental influences. Child Dev. 1996; 67: 2873–2891
12.) Laurence Steinberg. Cognitive and affective development in adolescence. Trends in Cognitive Sciences. 2005; 9(2 ):69-74
13.) Benthin A. Adolescent health-threatening and health enhancing behaviors: A study of word association and imagery. J. Adolesc. Health. 1995; 17:143–152
14.) Cauffman, E. and Steinberg, L.The cognitive and affective influences on adolescent decision-making. Temple Law Rev. 1995; 68:1763–1789
15.) Slovic, P. What does it mean to know a cumulative risk? Adolescent’s perceptions of short-term and long-term consequences of smoking. J. Behav. Decis. Making. 2000; 13:259-266
16.) Steinberg, L. Risk-taking in adolescence: What changes, and why? Ann. N. Y. Acad. Sci. 2004; 1021: 51–58
17.) Blanton H, Gerrard M. Effect of sexual motivation on men’s risk perception for sexually transmitted disease there must be 50 ways to justify a lover. Health Psychology. 1997; 16:374–37
18.) Dan Ariely, George Loewenstein. The Heat of the Moment: The Effect of Sexual Arousal on Sexual Decision Making. Journal of Behavioral Decision Making. 2006; 19: 87–98
19.) DiClemente R.J, PhD, Salazar L.F, PhD, Crosby R.A, PhD. A Review of STD/HIV Preventive Interventions for Adolescents: Sustaining Effects Using an Ecological Approach. Journal of Pediatric Psychology. 2007; 32(8):888-906
20.) Hogben M, PHD, Leichliter J.S, PHD. Social Determinants and Sexually Transmitted Disease Disparities. Sexually Transmitted Diseases. 2008; 35(12):S13–S18.
21.) Upchurch D.M, Mason W.M, Kusunoki.Y, Johnson M. Social and Behavioral Determinants of Self-Reported STD Among Adolescents. Perspectives on Sexual and Reproductive Health.2004;36 (6):276–287
22.) Teitler JO and Weiss CC. Effects of neighborhood and school environments on transitions to first sexual intercourse. Sociology of Education. 2000; 73(2):112–132
23.) Wingood GM, DiClemente RJ, Bernhardt JM, Harrington K, Davies SL, Robillard A. A prospective study of exposure to rap music videos and African American female adolescents’ health. American Journal of Public Health. 2003; 93(3):437–439
24.) Wingood GM, DiClemente RJ, Harrington K, Davies S, Hook EW. Exposure to X-rated movies and adolescents’ sexual and contraceptive-related attitudes and behaviors. Pediatrics. 2001; 107(5):1116–1119
25.) Maton K. Making a difference: The social ecology of social transformation. American Journal of Community Psychology .2000; 28(1):25–57
26.) Kotler P, Andreasen A. Strategic Marketing for Nonprofit Organizations.
New York: Prentice Hall, 1996.
27.) Grier S, Bryant A.C. Social marketing in public health. Annu. Rev. Public Health. 2005; 26:319–39
28.) Lakoff, G. Don’t Think of an Elephant! Know Your Values and Frame the Debate. Chelsea Green: White River Junction, 2004
29.) Dorfman L, Wallack L, Woodruff K. More than a message: Framing public health advocacy to change corporate practices. Health Education & Behavior. 2005 ; 32 (3): 320-336
30.) Philpott A, Knerr W, Boydell V. Pleasure and Prevention: When Good Sex Is Safer Sex. Reproductive Health Matters. 2006; 14(28):23–31
31.) National Institute for health care management. Recommended Adolescent Health Care Utilization: How Social Marketing Can Help. NIHCM Foundation Issue Brief March 2009.
http://www.nihcm.org/pdf/NIHCM-SocialMarketing-FINAL.pdf
32.) Farrelly MC, Davis KC, Haviland ML, Messeri P and Healton CG. Evidence of a Dose-Response Relationship Between ‘truth’ Antismoking Ads and Youth Smoking. American Journal of Public Health. 2005; 95(3):425–431.
33.) Agha S. The Impact of a Mass Media Campaign on Personal Risk Perception, Perceived Self-Efficacy and on Other Behavioral Predictors. Aids Care. 2003; 15(6):749–62