Friday, January 23, 2015

A Solid Effort Falls Short in Addressing Youth Sexual Risk in Ottawa, Canada – Julia Bond

According to the Public Health Department in the city of Ottawa, Canada, the rates of sexually transmitted infections (STIs) such as chlamydia, gonorrhea, and HIV are on the rise among Ottawa’s young people. In an attempt to address this, Ottawa Public Health launched an intervention titled “Sex it Smart” (1). This program allows Ottawa residents to order 1 package of condoms to be mailed to their home address free of charge. The program website also contains a condom locator, which provides the addresses of locations where residents can pick up free condoms. This list includes health clinics, non-profit organizations, and some private businesses. Additionally, the website contains educational messaging around STIs. Though this intervention has many positive aspects that increase its chances of success, including being effectively branded with a logo, there are nonetheless aspects that need improvement.
A Distanced Tone Invites Psychological Reactance and Modeling Behavior
The “Sex It Smart” campaign homepage states, “Not using a condom is the top risk factor among individuals diagnosed with an STI...That’s why we launched Sex It Smart, a new condom campaign for youth.” There is also a scrolling banner at the bottom of the homepage that states “Think of all the qualities you want in a partner….is one of them Chlamydia?” These statements contribute to a feeling of significant separation between the “we” behind the campaign and the “you” to whom it is addressed that pervades the campaign’s website (1). Creating this distinction in the campaign’s messaging could result in 2 specific negative responses from young people when they engage with the campaign, which would significantly decrease its chances of success.
First, the separation between the public health workers who created the campaign and the young people they are trying to reach could incite psychological reactance. Psychological reactance is a phenomenon described by J.W. Brehm (2) in which people faced with a threat to their freedom respond by immediately taking steps to restore that freedom. A relevant example would be a parent forbidding their teenager from attending a party, and the teenager subsequently reasserting their freedom by sneaking out to the party that night. Studies have demonstrated that when it comes to messages that contain a threat to freedom (eg you must always use condoms), similarity of the messenger to the recipient of the message can significantly decrease reactance compared to a dissimilar messenger (3). The disparity between the messenger and the young people being addressed in the “Sex It Smart” campaign website could result in psychological reactance because young people will be made to feel as if their freedom to choose not to use condoms is being threatened. This will undermine the effectiveness of the campaign, as youth will subsequently seek to reassert their freedom to ignore the free condoms.
Secondly, the distanced tone of the campaign may influence youth behavior in an unintended way through social modeling. The campaign’s homepage references the following statistics about sexual health in Ottawa: “About a third of sexually active 15-29 year olds in Ottawa did not use a condom the last time they had sex.  Fifteen to 29 year olds account for approximately three-quarters of 2013 chlamydia and gonorrhea diagnoses in Ottawa” (1). Social modeling theory posits that one way people adopt new behaviors is by mirroring behaviors observed in others in response to certain situations (4). Because the campaign has set up a distinction between the “us” behind the campaign and the “you” engaging with it, emphasizing the fact that a full third of youths did not use a condom while having sex could backfire and normalize the lack of condom use. If young people who are interested in having sex but who are naïve or inexperienced happen upon the site, instead of focusing on sexual health risks they may instead choose to focus on the fact that a large number of their peers who are successfully having sex are doing so without a condom. This in turn may influence their decision-making when they are faced with the opportunity to have sex. If, due to the perceived prevalence of not using a condom, they successfully have sex without a condom for the first time, social modeling behavior theory suggests that they will make the connection between not using a condom and effectively having sex, and they will likely continue to abstain from condom use (4). One examination of a failed youth-targeted anti-marijuana campaign that ran in the United States from September 1998 to June 2004 suggests this very phenomenon as one possibility for its failure. Hornik et al (5) state that exposure to the campaign messaging may have inadvertently implied that marijuana use was commonplace, thereby increasing the likelihood that young people exposed to the campaign would try it. The “Sex It Smart” campaign runs the risk of eliciting a similar boomerang affect by communicating to youths that many of their peers are having sex without condoms.
Optimistic Bias Compounded by the Power of Partner Selection
The above statistics referenced by the “Sex It Smart” campaign do demonstrate that there is a need to address youth sexual practices in Ottawa and attempt to rectify the large number of young people contracting STIs. Unfortunately, studies have demonstrated that people consistently underestimate the likelihood of negative outcomes happening to them. This phenomenon is known as optimistic bias, and has been demonstrated in a variety of populations, including active smokers (6, 7). Thus even though the statistics revealing the high risk of STIs among 15-29 year olds in Ottawa are compelling, it is likely that an individual reading them will underestimate their own personal risk. Additionally, studies have demonstrated that perceived controllability of a behavior increases the optimistic bias associated with that behavior (6). In the case of STI risk, people likely feel a large measure of control over their risk because they are the ultimate arbiters of their own sexual experience. Feeling that they control who their partners are will contribute to a sense of confidence that they are at less risk than other people. When optimistic bias is taken into consideration, the decision to highlight statistics on the homepage of the “Sex It Smart” campaign is a strategy that has the potential to undermine the campaign. If people don’t think that they personally are at risk, it is unlikely that they will seek out free condoms.
The fallacy of rational decision making in the heat of the moment
              The “Sex It Smart” campaign improves upon the often-criticized health belief model because it acknowledges that everyone does not have equal access to condoms, and attempts to rectify that by providing them free of charge (8). Unfortunately, the campaign ends its efforts at getting condoms into the hands of young people, which suggests that the people who designed it believed that once people had condoms, they would then choose use them in the moment. This presumes that health-related decision making and behavior is the result of a rational, considered decision-making process, an assumption which has been demonstrated to be faulty in many situations (8). Designing the campaign to end with getting condoms to young people reduces its chance of being successful for a few reasons.
            Firstly, it has been demonstrated that sexual arousal significantly affects decision-making. Especially relevant to this campaign, one study of college-aged males demonstrated that self-reported willingness to engage in unsafe sex was significantly higher when males were sexually aroused as compared to when they were nonaroused. Of particular importance is that fact that subjects were unable to predict the effect that being aroused would have on their own tolerance for unprotected sex (9). This study indicates that even if the “Sex It Smart” campaign were successful in getting a nonaroused person to obtain condoms, this does not mean that in an aroused state they would use them.
            Further, a 2001 self-report study of almost 10,000 high school students across Canada revealed that alcohol use was an independent risk factor for inconsistent condom use (10). Alcohol has been demonstrated to affect women’s sexual decision making by increasing their perceptions of a situation as having sexual potential and increasing sexual interest, as well as potentially influencing women to focus more on the positive aspect of risk-taking behavior (11). Once again, in this context simply having condoms would not be sufficient to enable positive behavioral change. In order to be effective, this campaign needs to address the discrepancies between the initiative to obtain condoms and the drive to use them in the heat of the moment.
            Secondly, the “Sex It Smart” campaign fails to address the role of gender in sexual decision making. In her astute criticism of the health belief model, L. Thomas decries the “…model’s inability to allow for the inclusion of the relationship between health status and historical, social, and political structures” (12).  This lack of insight into the role gender of in sexual risk is present in the “Sex It Smart” communications. A recent study examining 15 Australian women who engage in non-romantic sex concluded that though these women may be partaking in “non-traditional sexual behavior,” (eg having sex outside of a committed relationship), they were nonetheless still constrained by traditional gender roles, and thus had limited sexual agency. The authors suggest that this is in part due to the limited availability of a social script that promotes empowered female sexual agency (13). These conclusions are borne out by an evaluation of the sexual attitudes of 161 women that demonstrated that despite initial assertiveness about condom use, even minor prompting from a male partner against condom use substantially reduced a woman’s likelihood to use a condom (11). In a survey of 24 English women between the ages of 16 and 20 who were about to have or had recently had an abortion, the women cited, among other reasons, a desire “not to break the spell” and pressure from a male partner, as reasons why they did not use condoms (14).
            When it comes to condom use, providing women with condoms is not sufficient to overcome the complex dynamics present in heterosexual sexual activity. These data suggest that despite being cognizant of the risks of unprotected sex, women often go along without using a condom, in part to please male partners. In order to more effectively increase condom usage among young women, initiatives need to empower women as sexual decision makers, and increase their perceptions of self-efficacy in sexual negotiation (15). Unfortunately, the “Sex It Smart” lacks compelling messaging addressing these issues.
            Clearly, an initiative that provides condoms with the assumption that they will be used when young people are in the midst of a complex sexual negotiation is erroneous. The calm, level-headed person who orders the condoms from the “Sex It Smart” campaign website thinks differently than the aroused person who will subsequently opt not to use them. In order to truly be effective, the “Sex It Smart” campaign needs to take pains to go beyond providing condoms and attempt to exert some influence over decision making during sexual activity.
Introducing We Sex It Smart – Uniting Youth for Healthier Sex
            In order to address the above flaws in the “Sex It Smart” campaign, a new campaign called “We Sex It Smart” could utilize the existing framework of free condom distribution but add components that would increase its chances of success. “We Sex It Smart” would be a youth-directed movement designed by young people themselves, and feedback from the target audience would be frequently solicited. “We Sex It Smart” would be branded as a movement to promote better, healthier sex, as opposed to being limited to reducing STI transmission. “We Sex It Smart” would house personal stories on its website, highlighting people brave enough to be open about their own experience with STIs.
To increase relevance during sexual activity, “We Sex It Smart” would add a ritualistic component to the free condoms. Condoms would come with stickers that could be gifted to partners or placed in sticker books that would come with orders of condoms. There would be a variety of stickers to encourage a “collect them all” attitude. Partners would be encouraged to create a joint sticker book, thereby providing a level of camaraderie in sexual decision making.
Finally, “We Sex It Smart” would host forums, discussion boards, and branded informational material on its website that would directly address the reality of sexual decision-making for young people. These areas would be called “We Ladies Sex It Smart,” and “If you sip, don’t slip,” and would be branded as distinct components of the “We Sex It Smart” campaign to increase memorability and impact. These message boards would openly acknowledge the fact that young people are often making sexual decisions while under the influence of alcohol, and would allow young people to share their own experiences.  There would also be educational material addressing female sexual agency and healthy decision-making even while drinking.
Striking the right tone for youth behavioral change
To address the issues associated with the current tone of “Sex It Smart,” “We Sex It Smart” would engage with youths from its conception to ensure that the tone of the campaign does not invite psychological reactance. As demonstrated by Silvia, similarities between the messenger and the audience reduce the risk of psychological reactance to messages that could be perceived as limiting freedom (3). To that end, using young people themselves to communicate the about the risk of STI transmission during unprotected sex will decrease the chance that other young people will react negatively to the information. Additionally, it has been demonstrated that designing public health campaigns with youth input and featuring youth leadership is exceptionally effective in inciting behavioral change. As described by Bauer, the “Truth” campaign in Florida had a significant effect in reducing youth smoking in the state. The hallmark of this campaign is that it is led by young people and relies heavily on the input of young people who are peers of the target audience (16). “We Sex It Smart” will borrow from this model, and thereby seek to put youth front and center in the quest to increase healthy sexual decision-making. The rebrand of the campaign to encompass healthy sexuality, as opposed to simply addressing STI risk, is also an effort to increase youth engagement. People are generally not moved by messaging and campaigns that only focus on health. Rebranding this campaign to focus on broader themes like autonomy, intimacy, and pleasure will help keep young people interested and engaged (17).
Making young people the face of the “We Sex It Smart” campaign will also address any concern with social modeling behavior. The campaign will no longer center on unhealthy adolescent sexual behavior, but rather will celebrate healthy sexual decisions. This will encourage youths looking to the campaign for information on sexual behavior to associate condom use with positive sexual outcomes (4).
Personal Stories as an Antidote to Optimistic Bias
“We Sex It Smart” will focus on the voices of young people – even those who have made risky sexual decisions in the past. According to “the law of small numbers,” people tend to be biased towards remembering and relating to individual stories as opposed to broad statistics (18). Additionally, it has been demonstrated that messages that are emotionally evocative and tell compelling personal stories are the most impactful, and have the most potential to incite behavioral change despite optimistic bias (19). To this end, “We Sex It Smart” will leverage the law of small numbers by highlighting the emotionally charged stories of people who have been affected by STIs in the past to encourage youth to recognize that anyone can be affected by them.
Due to the sensitive nature of STI status, “We Sex It Smart” could use the stories of adults who have since overcome their battles with STIs such as chlamydia and gonorrhea. Adult women who have had fertility struggles due to contracting these STIs in their youth would be particularly compelling for the campaign. These women could share emotional stories that would drive home the fact that despite perceived control over sexual decisions, it is impossible to know who has an STI. It would also help dispel any stereotypes that youths have as to who contracts STIs, as it has been demonstrated that in addition to perceived control, an existing stereotype of who is at risk is associated with optimistic bias (3).
Rituals and Empowerment to Encourage Relevancy in the Moment
Bridging the gap from the acquisition of condoms in a cold state to the actual use of condoms in an aroused state is likely the biggest challenge facing the “We Sex It Smart” campaign. This challenge is compounded by the addition of alcohol and gender dynamics into the equation. The “We Sex It Smart” campaign will have 2 components that will work together to attempt to address this issue.
Firstly, the addition of a ritual can make a behavior more likely to be adopted (18). To capitalize on this, the “We Sex It Smart” campaign will add a ritual to condom use to make it easier to remember, even in a state of arousal. Condoms obtained through the “We Sex It Smart” campaign will come with stickers attached to them. These stickers will be branded to match the campaign. The promotional messaging on the campaign website will encourage participants to use these stickers in one of a few recommended ways: 1) post it in public to show support for your campaign, 2) share them with friends or partners, or 3) put them in sticker booklets that are provided with orders of condoms. As a variety of stickers will be produced, these sticker booklets could encourage condom usage by making a game out of collecting the stickers. The option to choose which activity to do with your sticker would provide another layer of ownership over the ritual, which could increase individual investment (18). The sticker booklet will come emblazoned with promotional messaging encouraging participants to share stickers with their partner. This will attempt to make condom use a joint activity, which may deflect some of the gendered tension that has been reported in heterosexual sexual activity (13-15).
Secondly, “We Sex It Smart” will add forums and informational material that will help youth accurately address their sexual realities. For one thing, the role of alcohol in sexual decision-making is completely absent from the “Sex It Smart” messaging (1). “We Sex It Smart” will address alcohol as a component of young peoples’ lives, and contextualize healthy sexual decision-making within a social life that includes alcohol use. This aspect of the campaign will have its own brand, called “If you sip, don’t slip.” Branding can make a public health campaign more effective and memorable, and a critical component of branding is to acknowledge the reality of the target audience (20). “If you sip, don’t slip” will openly address the fact that adolescents sometimes make sexual decisions under the influence of alcohol (10), and would provide information on how alcohol affects sexual decision-making and suggestions for making healthy sexual decisions even in a state of inebriation.
“We Ladies Sex It Smart” would be another branded component of the “We Sex It Smart” campaign. This effort would focus entirely on young girls and empowering them to have sexual agency. It would openly acknowledge that oftentimes girls report feeling more embarrassed than boys purchasing condoms, and this directly impacts their usage patterns (21), and also that girls react to the influence of male partners when it comes to condom usage (11). “We Ladies Sex It Smart” would provide empowering messages to young girls around their ability to influence sexual decisions and speak up for their desires. It would also provide a forum where young women could share their experiences and encourage each other to speak up for healthy sexual experiences. This could contribute to positive modeling behavior. If young girls are exposed to women who have advocated for healthy sexual behavior in their own lives, it could create new social norms that empower girls to push for condom use if they want, even against the wishes of their male partner. Since women are reported to be struggling from the absence of a positive social script that ascribes them sexual agency (13), it will be up to “Ladies Sex It Smart” to create it.
The “Sex It Smart” campaign is strong start for an effective public health initiative. It strives to address one of the crucial problems in public health: access. By providing condoms to anyone in Ottawa who fills out an online form, it makes a laudable attempt to eliminate barriers to sexual health in a community that needs it.
Regardless, the campaign has many aspects that should be improved to maximize its efficacy and reach. For one thing, effective public health campaigns must work with their target audience, not speak down to them. Harnessing the energy and voice of Canadian youth would be a boon to this effort. Secondly, the use of statistics is not a compelling way to encourage change. Instead, this effort should use individual stories to make its message more relevant. Finally, the assumption that improving condom access is sufficient to improve condom usage misses much of the reality of sexual decision making. The addition of a fun ritual, as well as the open acknowledgement of some of the realities of adolescent sexual life in Canada, would make this campaign far more relevant, engaging, and effective.
1.     Ottawa Public Health. Sex It Smart Campaign. Ottawa, Canada. Ottawa Public Health.
2.     Brehm J. A Theory of Psychological Reactance (pp. 277-290). In: Burke W, Lake DG, and Paine JW, ed. Organization Change: A Comprehensive Reader. San Francisco, CA: Jossey-Bass, 2009.
3.     Silvia PJ. Deflecting reactance: The role of similarity in increasing compliance and reducing resistance. Basic and Applied Social Psychology 2005; 27:277-284.
4.     DeFleur ML, Ball-Rokeach SJ. Theories of Mass Communication (5th edition), Chapter 5 (Socialization and Theories of Indirect Influence), pp. 202-227. White Plains, NY: Longman Inc., 1989.
5.     Hornik R, Jacobsohn L, Orwin R, Piesse A, Kalton G. Effects of the national youth anti-drug media campaign on youths. American Journal of Public Health 2008; 98:2229-2236.
6.     Weinstein ND. Unrealistic optimism about future life events. Journal of Personality and Social Psychology. 1980; 39:806-820.
7.     Ayanian JZ, Cleary PD. Perceived risks of heart disease and cancer among cigarette smokers. JAMA 1999; 281:1019-1021.
8.    Individual health behavior theories (chapter 4). In: Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007, pp. 35-49.
9.     Ariely D and Loewenstein G. The heat of the moment: the effect of sexual arousal on sexual decision making. Journal of Behavioral Decision Making. 2006; 19(2):87-98.
10. Poulain C and Graham L. The association between substance use, unplanned sexual intercourse and other sexual behaviours among adolescent students. Addiction. 2001; 96(4):607-621.
11.   Norris J, Stoner SA, Hessler DM, et al. Cognitive mediation of alcohol's effects on women's in-the-moment sexual decision making. Health Psychology. 2009; 28(1):20-28.
12.  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.
13.  Moran C and Lee C. Women’s constructions of heterosexual non-romantic sex and the implications for sexual health. Psychology & Sexuality. 2014; 5(2):161-182.
14.  Brown S and Guthrie K. Why don't teenagers use contraception? A qualitative interview study. Eur J Contracept Reprod Health Care. 2010; 15(3):197-204.
15.  Pearson J. Personal Control, Self-Efficacy in Sexual Negotiation, and Contraceptive Risk among Adolescents: The Role of Gender. Sex Roles. 2006; 54(9-10):615-625.
16.  Bauer UE, Johnson TM, Hopkins RS, Brooks, RG. Changes in youth cigarette use and intentions following implementation of a tobacco control program: Findings from the Florida Youth Tobacco Survey, 1998-2000. JAMA 2000; 284:723-728.
17.  Siegel, Michael. “Social and Behavioral Sciences SB271 – Session 2.” Boston University. SB712. Fall 2014. September 11, 2014.
18.  Siegel, Michael. “Social and Behavioral Sciences SB271 – Session 13.” Boston University. SB712. Fall 2014. December 4, 2014.
19.  Durkin SJ, Biener L, Wakefield MA. Effects of different types of antismoking ads on reducing disparities in smoking cessation among socioeconomic subgroups. Am J Public Health. 2009; 99(12):2217-2223.
20. Siegel, Michael. “Social and Behavioral Sciences SB271 – Session 9.” Boston University. SB712. Fall 2014. October 30, 2014.

21.   Moore SG, Dahl DW, Gorn GJ, Weinberg CB. Coping with condom embarrassment. Psychology, Health & Medicine. 2006; 11(1):70-79.

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