A Social and Behavioral Critique on the Above the Influnce Campaign- Bianca Di Chiaro

Introduction:

The use of marijuana in adolescents is a public health problem of national importance because the number of smokers has been on the rise since the 1990s (1).  The National Youth Risk Behavior Survey (YRBS), which is conducted every two years providing data from 9^th through 12^th grade students, showed that some drug trends have begun to increase. The survey showed that more students have used marijuana one or more times, have used marijuana on school property one or more times, and have been offered, sold or been given drugs on school property between 2009 and 2011. (2) The rising use of marijuana amongst peers can be linked to adolescents decrease in perceived risk of using the drug. (3) It is imperative that there is a public health focus on marijuana use in adolescents since their age group is more susceptible to addiction. (4)

            In response to the increased drug use by adolescents in the United States, the National Youth Anti-Drug Media Campaign was funded. (5) From 1998 to 2004 the United States Congress spent over one billion dollars towards the campaign. (6) The main focus of the campaign was to decrease drug use by educating, decreasing initiation, and convincing users to stop.  (7) The current campaign is called Above the Influence, which targets adolescents with national messaging through television, print, and the internet. Much of the campaign focuses on commercials against the use of marijuana. One of the most frequently aired Above the Influence commercials is a thirty second commercial in which an adolescent who is high on marijuana is greeted in their kitchen by their dog. The dog tells the adolescent how they wish they didn’t smoke pot and that they are not the same when they are high.   

            While the National Youth Anti Drug Media Campaign was able achieve high levels of media coverage the intended message did not reach the targeted youths. Instead, many of the youths created parodies of the commercial which can been seen all over the internet. Not only did the message have the intended effect, the amount of coverage caused the opposite to occur. The exposure decreased the youth’s intentions to stay away from marijuana and decreased the antidrug social norms affiliated with marijuana (6). Had the campaign focused on the social and behavior effects the commercial would evoke, the overall goals of the campaign would have been more successful. In the subsequent paragraphs the main problems with the commercial used during this campaign will be discussed.

Critique: Ineffective use of the Health Belief Model

            The health belief model is a psychological model developed to predict health behaviors in individuals. The model first came about when a doctor wanted to better understand why many people were not taking advantage of free tuberculosis testing that was available to them. The Health Belief Model is used as a predictive tool for behaviors such as life style behaviors, life style behaviors in relation to health, and compliance with medication. An assumption that this model makes is that individuals will engage in specific health behaviors if the outcome is favorable to them. (8)

There are six components of the health belief model, which were not effectively used  to create behavioral change in the targeted youth of the Above the Influence campaign. The first component of the model is perceived susceptibility, which demonstrates an individual’s perception of their risk of developing the health issue. (8) In the commercial, the use of marijuana is not displayed as a health risk. Not displaying the health risks results in the targeted youths believing that marijuana is not a major cause of health problems. The second component is perceived severity, which demonstrates an individuals belief of the level of harm the health issue would cause if the individual were to develop it. (8) Many youths do not perceive marijuana use as harmful (3) and the commercial does not demonstrate the health risks involved with smoking marijuana to achieve the behavioral change. The next component is the perceived benefits. This component focuses on how changing an individuals habits would have a health benefit to them. (8) While the goal of the campaign is to show the benefits of not using or stopping the use of marijuana, the campaign falls short because the commercial demonstrates that if a person gets high they will have the benefit of talking to their dog. The forth component is the perceived barriers, here the model focuses on the obstacles an individual would face to maintain the beneficial health outcome. The commercial does not display the negative outcome of using marijuana only the positive outcome of communicating with their dog. The fifth component of the theory are the cues to action. This component is based on continual stimulation to increase the likelihood that the healthier choice would be made. Continual exposure to the commercial makes marijuana seem like the common social norm cuing the viewer into action to partake in drug use. The last component focuses on self-efficacy, an individual’s confidence in their ability to demonstrate the change. While a youth has the self-efficacy to decide to take action, not taking drugs may not be the action that they are willing to take. (9)

            The three main goals of the campaign are to decrease drug use by educating, decreasing initiation of those who have never smoked, and convincing youths who do smoke marijuana to stop (7). Instead of reaching these goals to deliver a healthy drug free message the commercial sends the message that if a person gets high they will be able to have communications with their pet dog. It can be expected that many youths with pets would want the opportunity to speak with their dog. The commercial could have been more successful in translating their message into a behavior if they had examined the effects of social and behavioral models.

Critique: The Psychological Reactance Theory

The psychological reactance theory is a psychological theory developed to explain the reaction that occurs when an individuals  freedom of behavior is threatened or eliminated. The theory describes that an individual has a set of behaviors that they can display at any moment within the realm of possibilities.  In preparation of choosing their next behavior, an individual takes in their internal and external surroundings. After taking in their surroundings, the individual weighs which behavior would bring them the most satisfaction in that moment. When one of their behaviors is threatened or eliminated the individual feels the loss of their freedom. The perceived loss of freedom causes reactance in the individual. Reactance is the reaction that occurs due to this loss causing the individual to attempt to reestablish their freedom of choice. (10) The Above the Influence commercial created by the National Youth Anti-Drug Campaign causes reactance in the targeted youth because the commercial threatens a behavior. The message of the Above the Influence commercial is to not smoke marijuana and to those who do smoke, to stop smoking marijuana.  The message is thus eliminating this behavior choice.

One of the main goals of the campaign is to focus on the youth that are already participating in smoking marijuana and convincing them to stop. Those that are already actively smoking marijuana or have previously smoked will feel the most reactance towards the message of commercial. The magnitude of reactance that is felt by an individual depends on the worth of the behavior to the individual. The greater the behavior is to the individual the greater the magnitude of reactance. The youths that are actively participating in smoking marijuana will have the greatest reactance towards the Above the Influence commercial.  A smaller magnitude of reactance will occur in those who have not smoked marijuana or have only smoked a small number of times. The youth may not feel the reactance right away but when they feel their freedom of choice challenged they will have an even stronger will to reestablish their freedom. The reestablishing of their freedom occurs when they partake in the behavior that was threatened or partaking in a similar behavior such as smoking cigarettes. (10) The youths will be pushed towards the behavior that was threatened. This means that youths who have never smoked may start and those who do smoke will smoke more. The campaign is creating the opposite effect then the desired behavioral change.

Another aspect that plays a role in the magnitude of reactance is similarity.  When there is similarity between the individual and what the individual is observing, studies have shown a decrease in the negative force of reactance and an increase in the positive force of compliance. (11) In the commercial, a dog delivers the main message of the National Youth Anti-Drug Campaign. A dog and adolescent are not similar. Having a dog deliver the main message only increases the negative force of reactance in the youth. In this aspect the commercial pushes the targeted population further away from compliance with the main message of the campaign.

The psychological reactance theory creates a motivational state (10), where the youth may not have thought about wanting to try marijuana but the ad brings the behavior into their mind. This behavior is then threatened or eliminated from, in turn motivating them to take action against the commercial. The commercial makes the targeted youth believe that their peers are using marijuana, which increases the  increases the likelihood that they should also smoke marijuana (6) Here a youth who may have never considered smoking marijuana may now have the intent to do so. The more times the youth is exposed to the commercial the more reactance they will feel. The psychological reactance theory may be able to explain why the intent to stay away from marijuana decreased during the time after the Above the Influence commercial campaign. (12)

Critique: The Social Cognitive Theory

The social cognitive theory is a psychological theory that was developed to explain how environmental factors, personal factors, and human behavior interact. The theory is used to describe how an individual gains knowledge through direct observation.  The media plays an important outlet where individuals can observe and learn different behaviors. Through the media, individuals can observe both an action and the consequences while maintaining the sequence of events that led to behavior and outcome. Observations can motivate an individual to act despite whether there is a positive or negative reaction following the behavior. Through the Above the Influence commercial, the targeted youth observe someone their age who is high from smoking marijuana. The youth gains knowledge of the behavior and learns the outcome, which in the commercial is hearing their dog talk to them. Observing the commercial motivates the targeted youth to perform the behavior instead of avoiding the behavior. (8)

             There are three core determinants of the social cognitive theory that can effect an individuals behavior. The first determinant is based on an individuals understanding of the expected outcome. The individual develops an expected outcome through gaining knowledge of the risk related to the behavior. This knowledge can then create the condition for change. (8) In the Above the Influence commercial, the behavior that changed was not the goal of the campaign since a study found that youths were less likely to stay away from marijuana following the message. (12) The youth watching the commercial observes someone around their age, who is high and listening to their dog talk to them. The youth then understands that if they act the behavior of smoking marijuana their expected outcome is to talk to their dog.  The second determinant is perceived self- efficacy and the third determinant is goals. This describes that an individual must have the skills necessary for change and believe they can make the change. Roles models can be factor that effects these determinants. Applying these two determinants to the commercial, the youth see someone their age, high and realize that they have the ability to get high and obtain the same outcome. (8)

            There are key concepts to the social cognitive theory that can effect the main factors responsible for change. The first concept is expectations; the anticipated outcome of the behavior. In the commercial the only focus is on the outcome of smoking marijuana instead of focusing on the benefits of not smoking. Another concept is behavioral capability; having the skills to perform a behavior. With the widespread reach of the Above the Influence campaign, many youths observe others their age getting high. The observation creates the illusion that if their peers can get smoke marijuana then they also have the ability to smoke marijuana. Another concept of this theory is reinforcement, which is demonstrated by the wide spread media campaign. The commercial creates the idea that smoking marijuana is more common among youth and their peers increasing the likelihood of the behavior (12). Two other concepts of this theory is modeling and observational learning. In the Above the Influence commercial the targeted youth observes someone their age getting high. The youth gains knowledge of what it looks like to be high as well as gaining of knowledge from someone within their age group. Many of the concepts that effect behavior, as described through the social cognitive theory, caused an opposite effect of the main goals of the Above the Influence campaign. (8)

Proposed Intervention:

Changing the Above the Influence campaign to include social and behavioral theory will increase compliance of the National Youth Anti-Drug Campaigns message. The main media source for the message would remain on television since this outlet creates observation learning with high sensation-value contexts. Studies show that messages geared towards older teenagers and young adults are most persuasive through television. (1) A commercial that shows a group of youths lead by a celebrity refusing to smoke marijuana, the commercial then shows the group off having fun playing soccer while the individual who offered the drugs is alone with anxiety. The use of a celebrity is critical because the use of someone famous has been shown to increase compliance with the health message. (14) The use of a similarly aged group as the targeted youth is used since adolescents are more likely to demonstrate behaviors similar to their peers (15). Instead of just stating the smoking marijuana is bad, the commercial shows the risks creating a larger impact (12) and demonstrating the benefits of saying no.

Solution: Health Belief model

The first critique of the Above the Influence commercial addressed social and behavioral problems explained through the health belief model. This theory describes that if there is a serious enough threat to someone’s health, that person will avoid the action. (8) In the Above the Influence commercial there is no threat to the youths health even though the main message is to not smoke marijuana. A better direction to take the commercial is to develop media that shows the health risk and severity that can be relatable to the youths. (16) A successful campaign that targeted youths to stop smoking cigarettes was the “truth” campaign. This campaign showed that the risks described to youths to cause change had to be relatable to their everyday lives such as pregnancy and divorce. The campaign demonstrated that everyday risk factors had a larger impact then long term risk factors. They found that youths had no reaction toward the risk of death because to them the scary facts were not seen as a big deal. The “truth” campaign also realized that they needed to use a message other then “don’t”. (17) The “truth” campaign shows that more can be achieved through showing why not to do something instead of saying “don’t” do something. The message of the serious risks of smoking marijuana, such as losing friends or anxiety (13), should be delivered by someone relatable to the youth instead of using a dog.

At the beginning of the paper, the different components of the health belief model were discussed in relation to the negative effects caused by the Above the Influence commercial.  Here, the components will be discussed in relation to delivering the National Youth Anti-Drug message to achieve behavioral change in the targeted youths. To achieve perceived susceptibility, marijuana should be reintroduced as harmful to strengthen the social norm that drugs are not good. To achieve perceived severity, the commercial should focus on the commonality of the risk factors associated with smoking marijuana. To achieve perceived benefits, the focus should not be on avoiding health risks but on a positive outcome. A benefit must be something relatable, unlike talking to a dog. This could be spending time outside with friends, playing rigorous sports, or participating in other group activities. (11)  To show that there are no barriers, the commercial should focus on groups of students staying away from drugs. Self-efficacy can be achieved through reaching youths through the campaign, verbal reinforcement and showing peers working together in the commercial to stay away from marijuana. The goal of the campaign can be met through a commercial, if the commercial uses the health benefit model to its advantage by studying the social and behavioral components associated with the model.

Solution: The Psychological Reactance Theory

              The second critique that was made about the Above the Influence commercial focuses on the psychological reactance theory. This theory is used to describe the reaction of an individual if their freedom of behavior is threatened or eliminated. In the commercial, the goal of the dog is to relay the message of not smoking marijuana. The campaign would have been more successful at delivering this message if the message did not threaten the freedom of behavior.  This problem can be solved without changing the main message of the National Youth Anti-Drug Campaign. In changing the commercial, the goal is to deflect reactance and increase compliance. When a message threatens freedom of choice, there is a positive force to comply and a negative force to react. In many cases of reactance, the negative force is the more powerful force causing the reaction. The goal of the commercial should be to reduce the negative force so that it is equal or less then the positive force. Achieving this will increase compliance. (11)

              The reduction of the negative force of smoking marijuana can be achieved through using similarity. Delivering the message by someone who the targeted youths relate too will increase the positive force to comply and decrease the negative force to react. In the current commercial, a dog delivers the message, which is not similar to the targeted youth. This difference increases the negative force to react and decreases the positive force to comply. (11) The commercial instead should have an adolescent who is similar to the targeted youth deliver the message because adolescents are influenced by their peers (15). This similarity would increase the positive force to comply while decreasing the negative force to react. (11) To create even more compliance, a person that many adolescents look up to such as a celebrity should be used. A celebrity that is around the age of the targeted youth from a band, movie or television show would further increase the positive force and decrease the negative force of reactance. (14) Using a celebrity would increase the positive force and decrease the negative force by influencing the perception of the magnitude of the threat to freedom. Making a few changes to the Above the Influence commercial, following the psychological reactance theory would create a higher rate of compliance among the targeted youth.

Solution: The Social Cognitive Theory

              The third critique that was made about the Above the Influence commercial focuses on the social cognitive theory. This theory describes how different factors can cause behavioral change in an individual. The three core determinants of this theory were discussed above and will now be applied to make constructive changes to the campaign commercial. The first determinant is outcome expectancies (8). In the current commercial the outcome described is using marijuana to talk to a dog. Instead, the commercial should be changed to highlight the real effects of smoking marijuana. For example, the commercial could show that marijuana causes anxiety and loss of friends (13) creating the condition for change. The second and third determinant is perceived self-efficacy and goals. This part of the commercial should highlight the mechanism by which the goal of not smoking is achieved. The goal of not smoking marijuana should be delivered by a group of people that the targeted youth can relate to as to demonstrate that the youth can do it too. Using these determinants properly through a commercial can have a large effect on implementing change in an individual’s health practice (8).

              Changing the commercial to include some of the key concepts of the social cognitive theory can have a large impact on behavioral change. The first concept is expectations. Instead of the expectation of getting high and talking with their dog, the youth should understand the negative expectations associated with smoking marijuana. Another concept is behavioral capability. In the commercial the targeted youth observes someone who is similar to them being high. This demonstrates that they have the ability to get high too. Instead, the commercial should focus on someone who is similar to the youth not getting high. The commercial could demonstrate other activities with the person refusing to get high. The message of not smoking would be able to reach the youth because they would know they have the ability to refuse to smoke marijuana. Having the same widespread media impact as the Above the Influence campaign already has would create reinforcements of the positive message. The two other concepts of this theory are modeling and observational learning. Using someone his or her age to model refusing to smoke marijuana is more relatable then using a dog to deliver the campaigns message. This also gives the opportunity for the targeted youth to learn through observation. Making small changes based on the concepts and core determinants of the social cognitive theory would have a large impact on the compliance of the targeted youth.  (8)

References:

1. Palmgreen P, Donohew L, Lorch E, Hoyle R, Stephenson M. Television campaigns and adolescent marjijuana use: tests of sensation seeking targeting. American Journal of Public Health. 2001; 91(2):292-296

2. Centers for Disease Control. Trends in the Prevalence of Marijuana, Cocaine, and Other Illegal Drug Use National YRBS. Washington, DC: Centers for Disease Control

3. National Institute on Drug Abuse. DrugFacts: High School and Youth Trends. National Institute of Health. http://www.drugabuse.gov/publications/drugfacts/high-school-youth-trends

4. Chambers RA, Taylor JR, Potenza MN. Developmental neurocircuitry of motivation in adolescences: a critical period of addiction vulnerability. American Journal of Psychiatry 2003; 16(6):1041-1052

5. Office of National Drug Control Policy. National Youth Anti-Drug Media Campaign. Washington, DC: The White House. http://www.whitehouse.gov/ondcp/anti-drug-media-campaign

6. Hornick 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(12): 2229-2236

7. Office of National Drug Control Policy. Above the Influence Factsheet. Washington, DC: The White House. http://www.whitehouse.gov/sites/default/files/page/files/ ati_fact_sheet_6-26-12.pdf

8. Theories and Applications (pp14) In: Theory at a glance: A guide for health promotion practice. National Cancer Institute, 2005

9.  Behavioral Change Models. The Health Belief Model. Boston, MA: Boston University. http://sphweb.bumc.bu.edu/otlt/MPH-Modules/SB/SB721-Models/SB721-Models2.html

10. Burke W, Lake DG, Paine JW. Organization Change: A Comprehensive Reader.  San Francisco, CA. 2009

11. Silvia PJ. Deflecting Reactance: The Role of Similarity in Increasing Compliance and Reducing Resistance (pp227-284) In: Silvia PJ. Basic and Applied Social Psychology. Greensboro, NC: Lawrence Erlbaum Associates, Inc., 2005.

12. Hornik R, Yanovitzky I. Using Theory to Design Evaluations of Communication Campaigns: The Case of the National Youth Anti-Drug Media Campaign. University of Pennsylvania ScholarylyCommons 2003.  

13. National Institute on Drug Abuse. Marijuana: Facts Parents Need to Know. National Institute of Health. http://www.drugabuse.gov/publications/marijuana-facts-parents-need-to-know/want-to-know-more-some-faqs-about-marijuana

14. Cram P, Fendrick M, Inadomi J, Cowen M, Carpenter D, Vijan S. The Impact of a Celebrity Promotional Campaign on the Use of Colon Cancer Screening. Arch Internal Medicine. 2003; 163(13): 1601-1605.

15. Gardner M, Steinberg L. Peer Influence on Risk Taking, Risk Preference, and Risky Decision Making in Adolescence and Adulthood: An Experimental Study. Developmental Psychology. 2005; 41(4)625-635

16. Edberg M. Individual health behavior theories (pp35-38) In: Edberg M. Essentials of health behavior: Social and Behavioral Theory in public health. Sudbury, MA: Jones and Bartlett publishers, 2007.

17. Hicks JJ. Tobacco Control. The strategy behind Florida’s “truth” campaign. Miami, FL: Crispin, Porter, and Bogusky, 2001.

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.

Conclusion

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.

References

1.     Ottawa Public Health. Sex It Smart Campaign. Ottawa, Canada. Ottawa Public Health. www.sexitsmart.ca.

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 (5^th 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.

Critique of the “Don’t Be a Lab Rat” Campaign-Xiaohui Cao

Introduction

The “Don’t Be a Lab Rat” campaign, launched August 2014, is a marijuana-education campaign focusing on teens in Colorado. The $2 million campaign is created by the state of Colorado and the city of Denver, and founded by legal settlements with pharmaceutical companies.
The “Don’t Be a Lab Rat” campaign includes a website, interactive theater ads and TV commercials. Besides, 12-foot-long, 8-foot-high rat cages are used at the corner of street in Denver to raise teens’ attention on marijuana use. The campaign’s online website has a lot of statistics on adverse effects of using marijuana in teens. The TV commercials also suggest that marijuana impairs teens’ brain and causes long-term mental problems. By using disputed facts, the campaign want to warn the teens not to be a lab rat in finding the adverse health effects of the drug.

Marijuana use by adolescents has been a problem in the US for a long time. According to the National Institute on Drug Abuse (1), marijuana use among teens has been increasing since the mid-to-late 2000s. In 2013, 7.0 percent of 8th graders, 18.0 percent of 10th graders, and 22.7 percent of 12th graders used marijuana in the past month. Also, studies have shown that drug abuse could lead to other problem behaviors such as fighting, stealing, vandalism, and early sexual activity. Therefore, effective anti-drug campaigns targeting on adolescents are important to decrease the prevalence of drug use in this population. However, the “Don’t Be a Lab Rat” campaign has been controversial since it was created. In this paper, the flaws of this campaign will be discussed and new intervention will be proposed.

Part One: Critique Arguments

Argument one: Scare tactics do not work well on teens
The most obvious flaw the “Don’t Be a Lab Rat” campaign makes is that the campaign relies heavily on scare tactics such as fear-based statistics. On the website of the campaign dontbealabrat.com, there are a lot of scary statistics from research that connect marijuana use to high risk of certain disease such as schizophrenia, depression, stroke, heart attack and etc. The website also emphasizes the negative effects of the drug on the teens’ brain, saying that marijuana could shrink parts of the teenage brain and that teen marijuana users may lose an IQ of 8 points permanently. In addition to the scary statistics, the campaign also put giant human-sized “lab rat cages” all over Colorado, trying to warn teens to stay away from experimenting such adverse health risks. However, it is shown that teens are less likely to believe the message and tend to discredit the messenger when exaggerated dangers, false information are delivered (2).

These threatening statistics and “lab rat cages” are used by the campaign with regard of the Health Belief Model. Health Belief Model, developed in the 1950s, argues that individuals are ready to change their health behavior if they believe that they are susceptible to the condition and the condition has serious consequences (3). By using the model, the campaign is intending to raise the teens’ awareness of severity of the outcomes and simply assuming that the teens will realize the terrible consequences of smoking drug and thereby stay away from it. However, the Health Belief Model may not work very well on teens because its limitations under the condition.
One assumption the campaign makes is that teens are rational so that they will weigh their degree of risk and analyze the cost-benefit of their behavior and make the right decision to stay away from drugs (4). However, the reality is that individuals may not be rational thinking when making decisions (5).  This is especially true when it comes to teens. For example, one study shows that “a youth’s reason for using tobacco had everything to do with emotion and nothing to do with rational decision making” (6). In the campaign, teens may be aware of all the adverse effects of marijuana might have on their health but still use the drug. One theory that might suitable for this case is the Optimistic Bias Theory. According to optimistic bias theory, individuals tend to underestimate their own risk of having a bad outcome in the future (7).  For example, one study shows that optimistic bias is linked to sexual risk taking in youth (8). In the “Don’t be a lab rat” campaign, teens may think they are invulnerable to the adverse effects, and such optimistic expectations make the fear-based statistics ineffective.

Also, health may not be a strong core value appealing to teens. The “Don’t Be a Lab Rat” campaign focuses on raising the teens’ awareness of adverse health effects of using marijuana. It emphasizes the relationship between teenage marijuana use and risks of many serious diseases such as schizophrenia, depression, stroke, and heart attack. Unfortunately, teens may in fact have less care about their health. In other words, health is not a strong core value for this particular population. In advertising theory, it is important to know what your target audiences really want and need. If health is not the most important value teens have been seeking, it is less likely that raising awareness of health would work in the campaign.

Argument two: Psychological reactance is created among the teens
Another reason why the “Don’t Be a Lab Rat” campaign is flawed is that it may introduce psychological reactance among the teens through wrong messages and wrong messagers. According to psychological reactance theory (9), when people are told to do something or not to do something, they think their freedom is threatened or lost. As a result, they will experience a motivating pressure towards reestablishing their threatened freedom by doing the things that they are told not to do (10). When teens see the slogan of the campaign “Don’t be a lab rat”, they may think their freedom is being taken away because they are asked not to use the drug. In order to reform their freedom, teens will instead begin to use marijuana, which is the opposite of behavior that the campaign suggests. Therefore, exposing to the campaign may in fact motivate their willingness to initiate using of marijuana rather than keeping them away from the drug.

Also, the campaign incorrectly uses “researchers” as their messagers to deliver the message that using drug is bad for teens. Psychological reactance could arise because such authoritative messagers have little in common with the teens and therefore are less persuasive. This disconnection between teens and messagers would make it hard for messagers to successfully persuade teens to stay away from marijuana.

Argument three: Failing to account for social norms
The third reason why the campaign is considered flawed is that it only focuses on the change of individual teens’ behaviors to using marijuana rather than taking into account the effect of social norms, which is another limitation of the Health Belief Model (4). Health Belief Model is most suitable for one time decision such as getting a flu shot. When coming to the decision of quitting from drug, HBM may not work in such a complex condition where other factors involved. Instead, drug use is the outcome of the interaction between intrapersonal factors and social factors such as influence from peers and parents (5). In this situation, social norms theory is more proper to use since it emphasizes the importance of understanding environment and interpersonal influences in changing behaviors in teens.

According to the Social Norms Theory (11,12), misperceptions of how peers think and act will influence teens’ behavior. When information on peer group norms is incorrectly present, teens are more likely to overestimate or underestimate the prevalence of the behavior among their peers. Usually, they overestimate the value of problem behaviors and underestimate healthy behaviors, tending to adopt the problem behavior (12). Studies have shown that American students usually misperceived the norms of their peers by perceiving considerably exaggerated drug use as typical at their school (13). This perceived norm is that the typical student is a much more frequent user than the self-reports indicated. Therefore, it is quite likely that in the “Don’t Be a Lab Rat” campaign, teens may incorrectly perceive a higher prevalence of marijuana use among their peers and thereby initiate using of the drug. In addition, if their peers who use the drug seem to be some cool guys, their likelihood of engaging in the drug may increase further. Based on the report of the National Survey On American Attitudes On Substance Abuse Xvii: Teens (2012), 47% of teens who have seen pictures of their peers partying with alcohol or marijuana on social networking site such as Facebook and MySpace said that it seemed like the teens in the pictures were having a good time (14).

Part Two: Proposed Intervention
The “Don’t Be a Lab Rat” campaign seems to be flawed and ineffective because of the above reasons. Therefore, a more effective campaign that may be needed to reduce the prevalence of drug use among teens in Colorado. Three more effective approaches that address the above problems in the campaign are discussed below.

First, to address the problem that teens do not concern much on health risks presented in the scary statistics, the campaign should use personal stories and focus on core values that are more important to teens. Second, in order to avoid or reduce psychological reactance, use similar messagers and positive message to make the messagers more persuasive and to make the message more compelling. Third, using Social Norms Theory instead of Social Belief model to account for environmental and interpersonal influences.

Defense one: Using stories instead of scare tactics
The first approach for the proposed intervention is to use personal stories instead of scary statistics. Based on the Optimistic Bias Theory, teens are likely to think their own risks of getting disease are lower than the present risks in the general population. Therefore, instead of using statistics that show risks of disease among the general population, the campaign could use personal stories to raise awareness. For example, put stories of their peers on the website and create videos with images and music. One thing need to be aware is that using health as a core value in the story seems to be ineffective. The campaign should do research and find values that their target audiences really want and use that value in their stories. For example, since most teens regard independence and freedom as important values, the story could be a peer losing independence because of using drug.

Defense two: Using similar communicators and positive messages
In order to avoid psychological reactance, the campaign should change their message to a more positive one and use communicators who are familiar and similar to the teens. For example, using peers, especially the most popular ones in school to deliver the message could better make the message persuasive. Popular peers are similar to and welcomed in the teens, and thereby will be more persuasive than researchers. Research suggests that similarity can increase the positive force toward compliance and decrease the negative force toward resistance (15). Also, studies show that similarity increases the likelihood of compliance by increasing liking for the communicators (16). In addition to change of communicators, the campaign should also change their message to one that makes teen feel their freedom is ensured rather than threatened.

Defense three: Telling the truth and creating sense of belonging
To address the problem where teens are likely to overestimate the prevalence of marijuana use in their peers and engage in using the drug, correction of misperception is needed. Studies have shown that correction of the misperception could reduce prevalence of certain problem behavior (17). One possible way to correct the misperception is to let individuals know the actual healthier norms. This is based on the power of the Social Norms Theory, which indicates that social norms could influence people in both unhealthy and healthy ways (12). When individuals have a perception that most people do not use drugs, they will also less likely to use drugs. Therefore, rather than presenting a lot of unreliable information on potential dangers of marijuana and unintentionally making them perceive an overestimated prevalence of drug use, the campaign should show teens the truth -- accurate information about the actual healthier norms among their peers. For example, the campaign could do surveys to find out the teens’ perceived prevalence of marijuana use among peers and the actual normative prevalence, and then show these figures to the teens.

Another approach to account for peer influence on drug use among teens is to create sense of association and belonging. This could be done through branding and creating an identical logo for the campaign. In order to make the teens join and embrace in their campaign, the Florida’s “truth” campaign make “truth” a brand, successfully gaining wide awareness (6). The “Don’t Be a Lab Rat” campaign could also make their own brand similar to “truth” and create a cute and identical logo to let more teens join their campaign. Based on the Social Norms Theory, since teens are likely to be influenced by their peers, the campaign could also create sense of belonging through their online website and social networking site such as Facebook. Teens could join their peer group online, share their positive experience and stories, and get positive feedbacks from their peers. If they see a majority of their peers are living a positive and healthy lifestyle, they will less likely to engage in an unhealthy behavior such as using drugs. Researchers have analyzed studies on college students’ binge drinking and found that web-based feedback could have a positive effect on the problem (18).


References
1. National Institute on Drug Abuse. DrugFacts: High School and Youth Trends. http://www.drugabuse.gov/publications/drugfacts/high-school-youth-trends

2. Botvin GJ, Malgady RG, Griffin KW, Scheier LM, Epstein JA. (). Alcohol and marijuana use among rural youth: Interaction of social and intrapersonal influences. Addictive Behaviors 1998; 23: 379–387.

3. National Cancer Institute. Theory at a glance: a guide for health promotion practice. (2nd ed.) NIH Publication 2005; 05- 3896

4. Edberg M. Individual health behavior theories (pp. 35-49). In: Essentials of Health Behavior: Social jand Behavioral Theory in Public Health. Jones and Bartlett Publishers, 2007.

5. Dan A. Predictably Irrational: The Hidden Forces that Shape our Decisions. New York: HarperCollins Publishers, 2008.

6. Hicks JJ. The strategy behind Florida’s “truth” campaign. Tobacco Control 2001; 10:3-5.

7. Weinstein ND. Unrealistic optimism about future life events. Journal of Personality and Social Psychology 1980; 39:806-820.

8. Chapin J. It Won't Happen to Me: The Role of Optimistic Bias in African-American Teens' Risky Sexual Practices. Howard journal of Communications 2001; 12; 1: 49-59.

9. Brehm, JW. A Theory of Psychological Reactance. New York Academic Press, 1966. 


10. Grandpre J, Alvaro EM, Burgoon M, Miller CH, Hall JR. Adolescent reactance and anti-smoking campaigns: a theoretical approach. Health Commun 2003;15; 3:349-66.

11. Berkowitz AD, Perkins HW. Problem drinking among college students: A review of recent literature. Journal of American College Health 1986; 35: 21-28.

12. Berkowitz AD. The Social Norms Approach: Theory, Research and Annotated Bibliography. Trumansburg, NY, 2003.

13. Bruce EC, Beth RH, Cynthia AG. Adolescent Development: Pathways and Processes of Risk and Resilience. Annual Review of Psychology 1995; 46: 265-293.

14. Perkins HW, Meilman PW, Leichliter JS, Cashin MA, Presley CA. Misperceptions of the Norms for the Frequency of Alcohol and Other Drug Use on College Campuses. Journal of American College Health 1999, 47:253-258.

15. National survey on american attitudes on substance abuse xvii: teens. http://www.casacolumbia.org/addiction-research/reports/national-survey-american-attitudes-substance-abuse-teens-2012

16. Silvia PJ. Deflecting reactance: The role of similarity in increasing compliance and reducing resistance. Basic and Applied Social Psychology 2005; 27:277-284.

17. Byrne D. An overview of research and theory within the attraction paradigm. Journal of Social and Personal Relationships 1997; 14: 417–431.

18. Moreira MT, Smith LA, Foxcroft D. Social norms interventions to reduce alcohol misuse in university or college students. Cochrane Database of Systematic Reviews 2009; 3.

Primary Violence Prevention And Asking The Right Questions: Why School-based Interventions Fail To Change Behaviors – Sylvie Hundley

1.0 Introduction

On an average day in the United States, sixty-five people die and more than 6,000 people are physically injured from interpersonal/intimate partner violence (9). In recent years this violence seems to be occurring with greater frequency and severity in our society (2-3,9,15-17). Intimate partner violence (IPV), generally termed to encompass physical, sexual, or psychological harm by a current or former partner or spouse, (14) is a growing public health concern that affects billions globally (2-3,9,15-17).

1.1 Public Health, Psychopathology and Intimate Partner Violence

Integrating the public health model for IPV prevention has caused a shift in the way we respond to violence from a reactive approach to a preventative approach (2-3,6,9-10,12-13,15-17). Additionally, research on developmental psychopathology, supported by the National Institute of Health, has expanded our understanding of violence. Psychopathology studies have shown that adolescent and adult violent behavior almost always can be traced back to origins in early life. They have demonstrated with statistical accuracy that adolescent violence can be predicted from indicators demonstrated as early as five years of age (3). Public health and psychopathology studies indicate that the development of violent behavior is an interaction between cultural forces and failures in development. These studies support the popular belief that youth violence prevention is the most effective way to end IPV (3,9).

1.2 Forming Prevention Programs: Focus On Youth Prevention

In the past two decades youth violence rates have stabilized suggesting that the problem is no longer an epidemic but instead has become endemic to our society (3). In response, scores of IPV intervention programs have been haphazardly assembled to squelch violent behavior. Many prevention programs focus on interrupting the development of violent behavioral in youth before violence begins. (3,9). To capitalize on the adolescent “window of opportunity” for learning and early intervention efforts, most primary prevention programs are conducted in middle school to high-school settings. While there is no universal model for IPV prevention, given the social and (usually) gendered nature of the problem most youth programs appear to be loosely based on social learning theory and feminist theory (3,6,11,15-17).

1.3 Program Evaluation

In an attempt to find the cure-all program that can be implemented to end IPV, violence interventions have been rigorously analyzed for efficacy. Unfortunately Meta analysis of IPV prevention programs report that the overwhelming majority cannot demonstrate measurable outcomes (11,15-17). The few programs that do manage to document statistical significance report slight changes in in knowledge and attitudes among the intervention group. However, knowledge and attitudes are easier to change than behaviors (3) and there remain few effective adolescent IPV preventions available (11). Additionally, among some interventions the change in attitude was documented in the undesired direction (16,17).

1.4 Asking “Why?”

This lack of efficacy is not surprising, given that IPV is not only pervasive in many communities, but also vastly underreported and often construed as a normal part of immature relationships (2-3,6,9-10,12-13,15-17). Despite the fact that our approach to eliminating IPV from society is broadening in scope under the public health lens, our response is still too reactionary and too focused on the violent outcome.  This is demonstrated by the overwhelming attention placed on measuring program effectiveness instead of measuring the mediators of behavior change. It is crucial that programs measure the skills that intervention strategies intend to change in order to determine which changes in specific skills ultimately lead to changes in behavior. The goal should not only be determining which programs work, but to understand why (17).  Public health has provided a bridge between conceptualization of how chronic violence develops and application of how prevention programs can interrupt that development. But in order to accurately implement prevention programs that work in the real world, their needs to be another bridge connecting the sciences, social theories and preventions to the public at large (3).

2.0 Criticisms

            There are three main elements of consideration that have not been properly evaluated in IPV primary prevention programs that inhibit substantial measures of behavior change.    

2.1 Missing The Critical Components Of Social Learning And Cognitive-behavioral Theories

Almost all youth IPV prevention programs employ feminist and social learning theories as a basis for intervention. However, the extent to which interventions use critical components of these theories is unclear, especially social learning theory. Social learning and cognitive-behavioral theories emphasize the importance of identifying potential factors that influence the development of new skills in the adoption of new behaviors. However, few interventions examine the acquisition of previously absent behaviors as part of their intervention (11).

2.1.1 Limited Setting and Social Learning Theory

It is clear that violence is a learned behavior any exposure to violence in early age is highly predictive of entering a violent relationship later in life (2-3,6,9-10,12-13,15-17). Social learning theory acknowledging that learning does not happen in isolation of ones environment; stressing the importance of external influences on various internal processes. The theory postulates that a large contribution to behavioral development is the product of observing and then emulating the actions of others within an individual’s community (1). This is known as modeling. Modeling behavior is common among adolescents given the overwhelming need to attain peer acceptance and “fit in” with a group (1-3,6-7,11,14-17). School programs that focus on changing the nature of violence among peer-group interactions and peer-group norms can be extremely influential in behavior modification but programs of this nature are less common than individual approaches (2). Furthermore, just as peers and schools exert their own influence on behavior, so too do the other environments children inhabit and confront on a daily basis (2,11). For this reason, school-based IPV intervention programs that apply social learning theory in a “microenvironment” are inherently flaw. School-based programs for IPV interventions are isolating the school environment from the home environment and so create unrealistic circumstances that fail to address real-world situations, and fail to produce real-world results. Without connecting school-life and home-life school-based interventions are putting youth in opposition with their origin and limiting potential to influence behavior. It is important that school interventions do not come at the expense of parent-teen communication, mistrust, or conflict.

2.1.2 Social Ecological Model and Excluded Populations

As youth might observe violence in their home, they may also look to the larger community to teach them about healthy relationships (8). To account for the multiple ways the environment influences youth behavior, the CDC utilizes the social ecological model as a basis for IPV prevention initiatives. Similar to social learning theory, the social ecological model identifies the interactions between external and internal processes in the development of behaviors. The social ecological model conceives of relationships as operating on different levels: interpersonal, community, and society level (13). School interventions largely ignore community or population level interactions by focusing instead on individual choices (3,11,15-17). The social ecological model proposes that there are multiple levels at which behaviors can be influenced. School-based interventions focusing on only one level of the model may be overlooking whole segments of the population.

Additionally, some students, especially those most at risk may not be accessible by schools (17) Many students may lack school engagement and/or have difficulty getting involved in school-related activities. Many school-based interventions systems use a messy, one-classroom-at-a-time educational approach to IPV prevention. They usually bring in a speaker from outside of the community who addresses a class with an isolated, presentation about IPV (17). This approach can evoke strong psychological reactants. This has been demonstrated in some programs that reported a “backlash” among the male population who developed attitudes in opposition to program messages (16,17).

2.1.3 Family Environment

Social learning theory suggests that through teaching and shaping their children’s behavior, parents dramatically affect acceptance or rejection of acceptable behaviors (1) yet family venues have received relatively little attention in IPV prevention programs (17). This is surprising given the mounting evidence for the intergenerational predictors of violence. The popular notion of a cycle of violence suggests that witnessing partner violence or experiencing family violence at a young age is strongly associated with increased risk for children to develop attitudes, beliefs, and behaviors that lead to their own involvement in violent relationships (1-4,6-9,11-13,15-17).

2.2 Universal Interventions and Limited Theoretical Approach.

School-based interventions appear to be advantageous for many reasons. They can easily reach large numbers of students in a short time, create safe environments, promote learning, and affect social interactions and peer modeling behavior. Most IPV interventions are universal, that is, they are directed towards one or only a few targeted skills, contexts, or persons without regard for risk or personal factors (3,11,15-17). Although universal interventions are an excellent way to provide basic information to a large population, different people experience IPV in different ways (3,8-9,11,15-17).

Studies show that IPV is a multidimensional problem that spans across a constellation of risks factors (2-4,6-9,11-13,15-17). Risks do not exist in isolation from one another; each uniquely contributes to the development of violent behavior and outcomes (3,17). The complexity of IPV require interventions to either focus simultaneously on multiple risk factors or target specific prevention efforts to specific children (3). Selective interventions allow for targeting of specific at-risk populations or environments, and thus the content of those interventions can directly address whatever risk factors are believed to lead to partner violence.  Ultimately, the development of selective interventions requires a solid theoretical framework in order to identify the vulnerable population to target interventions (16,17).

2.2.1 Narrow Focus On Theories

The majority of IPV programs represent a fairly limited range of theoretical approaches (15,17).  The background-situation model of courtship aggression developed by Riggs & Oleary, attachment theory, social expectations theory, and the social ecological model are all important behavioral theories that are largely underutilized by school intervention programs (3,11,15-17).

2.2.1a Background-Situational model

The background-situation model of courtship aggression takes into account the interaction background factors that may affect an individual’s tendency to be generally aggressive, and situational factors that result in the expression of partner violence. Background factors include modeling of antagonism by parents, parent–child aggression, prior use of violence, arousability, and certain personality factors. Situational factors include relationships conflict, stress, alcohol use, and partner aggression. In essence, background factors explain who might be involved with partner violence and situational factors explain when partner violence might occur (17). The background-situational model may be important for identifying specific variables as predictors of IPV.

2.2.1b Attachment Theory

Attachment theory focuses on cognitive formations of relationship processes. Attachment theory proposes that children conceptualize relationships based on their history with significant caregivers. The theory suggests that this cognitive-affective understanding of relationship elements, (the relationship, the self, and the other) functions both as a prototype and template for developing future relationships. Although cognition develops and changes over time, internal working models, which operate outside of awareness, are thought to remain generally consistent (16). Studies suggest that power, reciprocity, and intimacy are developmentally important for adolescents, their development of intimate relationships and violence within those relationships ( 2-4,6-9,11-13,15-17). Thus focusing on the role of coercive interactional processes in the development of IPV using Attachment theory may be beneficial.

2.3 Multiple Risk Factors And The Lack Of Generalizability

Studies show that dating violence begins in middle school and disproportionately affects minority groups yet there are minimal interventions that target this demographic (11,17). Two school-interventions such as Safe Dates and fourth R: Skills for youth Relationship (fourth R) programs have been shown to produce significant behavioral effects: both reduced dating violence perpetration or victimization. However, these programs may not be as effective in ethnic-minority middle school youths because they were developed for and evaluated in older, predominantly White youths (11).

There are a number of factors that contribute to keeping the interpersonal pattern of violence and aggressive behavior consistent over time. The emerging conceptualization is that chronic violent behavior results from life-course developmental experiences (3). The life-course perspective (18) helps to understand how the combination of early programing experiences at critical/sensitive life stages and the cumulative effect of lifetime exposure to IPV impacts individual’s risk and protective factors. Studies suggest that the source of violent behavior resides at the intersection of the individual and the culture interacting over time.

2.3.1. Intergenerational cycles of IPV

The social learning model would predict that those who witness violence in their upbringing would be more likely to repeat behavior in their own relationships (1). Supporting the concept of modeling, several studies have documented a relationship between witnessing violence in the home and increased risk of being both a victim and a perpetrator of violence. Family risk factors, particularly those associated with parental behavior and the home environment are highly associated with IPV risk (1-4,6-9,11-13,15-17). Youth who experience IPV report witnessing their parents exhibiting acceptance of abuse or engaging in violent relationships and perceive the abuse to be normal because they, “grew up in an environment where that’s what they see people do.”(7, p.568). 

2.3.2 Cultural Competence

Studies suggest that abuse is as a learned behavior in which cultural norms played an important role. Often parental acceptance or downplay of adolescent IPV was attributed to cultural beliefs that supported traditional gender roles and permissive attitudes toward violence. Supporting feminist theory, studies find that adherence to traditional sex roles is among the most powerful predictor of attitudes supporting tolerance of IPV (7,17). The importance of underlying attitudes about sex roles, power, and control are strongly influenced by culture (2,4,7,8). Studies show that across many Latino communities “gender roles not only serve as a justification for abuse, but they also increase women’s vulnerability to abuse by keeping them isolated, subservient to male partners, and self-sacrificing to community and family” (7, p.568). Additionally, In some cultures abuse is not viewed as an issue. If the child is brought up in an environment where abuse is normal and the community says the abuse is within what they consider normal, then it becomes difficult, and possibly insulting to label their relationships as “undesirable.”

2.3.3 Adolescence

The adolescent life stage is a period of heightened risk for IPV given the developmentally distinct ways they experience violence (4,7). Adolescents are highly susceptible to modeling behavior and tend to conform to rigid gender stereotypes and social norms. Adolescence is a period of value and identity formation as well as a time when youth are creating their ideas of love and attachment (2-4,6-9,11-13,15-17). Additionally, pubertal development and social influences aid in the formation of romantic interests and sexual motivations increasing sensation seeking, risk taking and reckless behavior. Taken together, the reorganization of regulatory systems that occurs in adolescents’ development and social influences shape the adolescent life stage as a critical period, tangled with both risks and opportunities (14).

            It may also be important to consider whether partner violence is merely one component of the characteristic risk-seeking behaviors that occur in adolescence. It may be that adolescent are “hard wired” to take risks of this nature because their brain is not fully developed (16,17). In this instance it is important for interventions to work on building an environments that are as safe as possible for adolescents to take risks.

3.0 Conclusion: Bridging The Gaps

IPV prevention programs are still in early development, but are likely to be an important component of prevention strategies (2,3,6,9,11-13,15-17).  Current primary prevention efforts for partner violence consist almost exclusively of universal, school-based, dating violence prevention programs that target individual-level factors. These programs show little variability with regard to theoretical foundations, intervention strategies, or targeted populations. Additionally, prevention programs fail to incorporate key components of the few models they do use by limiting interventions to school venues (3,11,15-17). School-based interventions need to find a community outlet (8) and incorporate a more accurate use of social learning theory (11) that acknowledges the differences between the home and school environments. More work is needed regarding program development to expand the theoretical basis for interventions, and to develop targeted and culturally sensitive interventions that understand the complex interactions of youth development and environmental influences. Interventions that utilize these theories must be culturally competent and address the different ways that people may experience or be predisposed to violence.

4.0 Proposed Intervention: Making IPV Prevention Programs “Sexy”

            Given the nature of IPV, it is essential the intervention happen early. School-based interventions accomplish this goal, but they must have a structured curriculum that is supported by behavioral theories/models along with community-based activities. In order to yield the best overall outcomes for families impacted by IPV prevention programs must utilize a combination of outreach and collaborative strategies that are rooted in the community and connect to personal values. This can be accomplished with effective use of social marketing theory and advertising theory.

4.1 Social Marketing And Advertising

Social marketing and advertising theory have been growing in popularity within the public health arena (5). Social marketing theory is a way to create and package intervention programs so that it fulfills the needs of a target population’s wants. There are certain basic cultural values that are held in common and have a strong impact within community networks (5,7,17). Social marketing and advertising theory are able to create mass universal appeal for a product by offering desirable benefits that grab the attention of communities of interest. Programs that properly utilize these theories have been proven to facilitate the acceptance, rejection, modification, abandonment, or maintenance of particular behaviors by groups of individuals (5). Once a target population has been identified a combination of advertising theory, social expectations theory, and social networking theory can be used to effectively seed a campaign.

4.1.1 Using Social Networks To Insert Desirable Behaviors

Social expectations theory states that people will follow societal norms. Adolescents are especially susceptible to following cultural norms and so can be more easily persuaded using advertising theory. Social Expectations theory evaluates behavior on a population level, targeting social norms, as a predictor of how whole groups might behave. Social networking theory works as a means to focus interventions by mapping out out networks within groups. Understanding the social norms within one cluster of a social network and targeting that population with an effective use of advertising theory can effectively seed behavior changes that increase positive peer modeling, community endorsement of acceptable dating behavior, and social support for IPV prevention.

In order to effectively package and sell anti-violence, IPV programs must conduct extensive marketing research with youth, their parents, and other influencers inside and outside school compounds (5). The social-ecological model can be used to better understand violence and the effect of potential prevention strategies. In considering the complex interplay between individual, relationship, community, and societal factors the social ecological model helps to address the dynamics that put people at risk for experiencing or perpetrating violence (13).

4.2 The Notion Of Exchange

IPV intervention programs need to address deep desires, inspirations and aspirations of their young audience. Most programs assume that freedom from violence is a big enough promise to catch interests however, as adolescents is a time when many youth are still forming their ideas of love violence may not be a deterring factor for them. In fact, many service providers report that they found it difficult to get some youth to see that they were being abused in a relationship (7). Some adolescents may be so focused on “being in love” and belonging to someone that jealousy and possessive behaviors are often misinterpreted as signs of affection (2-4,7,11,15-17). Programs to target youth and their communities need to utilize advertising theory to create mass universal appeal for IPV prevention initiatives. This may involve celebrity endorsement or social media, which highlights the attractiveness of strong women and caring men.

4.3 Researched Based Preventions, Targeting Interventions To Appeal To Core Values

It is important that vulnerable populations receive IPV prevention services specific to the unique way they perceive violence (2-9,11,15-17). This means evaluating core values specific to cultural identities to convey messages that will be well received by the target population (5). School-based universal interventions are missing their mark by assuming that education leads to prevention (5,17). The educational model believes that creating awareness is the best way to create behavior change. However, knowledge is not as strong of a core value as love and acceptance. The educational model works best works when the benefits of the behavior change are inherently attractive, immediate, and obvious and costs are low (i.e. SIDS campaign, educating parents to put baby to sleep on it’s back to prevent sudden infant death syndrome). In contrast, marketing is the most effective strategy when program goals are not directly consistent with self-internalized beliefs because it offers alternative choices that invite voluntary behavior exchange. Programs need to have a greater focus on selective interventions that allow for targeting of specific at-risk populations or environments. The content of those interventions can then directly address whatever risk factors are believed to lead to partner violence.

4.3.1 Enforcing Freedom

It is important not to over generalize and apply labels. Message should reinforce freedom not take it away. In these way, IPV intervention programs need to give out positive stereotypes, avoid psychological reactants, and construct messages in a way that reinforces freedom not box people into categories. Using marketing gives IPV programs a brand, reinforces core values, and ensures sustained intervention (5). Marketing and advertising theory would ensure that messages are applicable to real-world environments and are delivered effectively.

4.4 Taking Control

Studies on IPV prevention have found that the community must take responsibility for ongoing program activities, and advertising theory is a way to get the communities interested in a campaign (5). Furthermore, the community must assume ownership of their campaign (8). This involves giving youth the ability to develop their own campaigns, create advertisements for their campaign, develop social networks, and ultimately enhance executive functioning and subconsciously change behaviors.

5.0 Conclusion: A Call to Action

            For an IPV prevention campaign to be successful, it must consist of a promise that provides a solution to issues that the target population considers important and offer a benefit they truly value. Promotional strategies must carefully design a specific message using appropriate communication techniques that resonate within communities. Community-based preventions that utilize marketing theory have the potential to harness community strengths by facilitating mobilization, empowerment, and participation, balances power differentials which ultimately benefit social changes (5).

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