Challenging Dogma - Fall 2011

Sunday, December 18, 2011

Raising STD Awareness in Youth: The FaceIt Florida STD intervention – Mahima Mangla

To create an effective public health intervention against STD transmission, it is important to understand what motivates youth to engage in risky sexual behavior. Social influences from celebrities and social media, to the pressures of being accepted by their peers can serve as forces for youth to explore their sexuality. This exploration can often be both risky and unsafe many times. Abstinence-only interventions seem to be ineffective given the statistics of STD prevalence amongst younger populations. The goal to protect adolescents and teenagers from STDs through abstinence-only education or other harsher methods appear to be to no avail.

In 2005, the Kaiser Family Foundation came out with a report that found “Compared to older adults, sexually active teens and young adults are at higher risk for acquiring STIs, due to a combination of behavioral, biological and cultural factors. Though they make up 25% of the sexually active population, they account for nearly half of new STI cases (1).” The number of newly diagnosed STDs each year is approximated to be 19 million cases and half of the individuals diagnosed are 15-24 years of age. Furthermore, the rates of diagnosed Chlamydia, Gonorrhea, and Syphilis have all increased for men and women ages 15-19 from 2009 to 2010 (2). These figures suggest the need to introduce public health campaigns that address the issue of STD prevalence and transmission amongst youth.

One such intervention to raise STD awareness is the FaceIt Florida campaign founded by the Bureau of STD Prevention under the Department of Health in Florida (3). It is a web-automated human interaction website that serves as an interactive tool for adolescents and young adults to talk about their feelings and behaviors towards STDs. The goal of the intervention is for youth to consider the dangers of contracting STDs and to go through the journey of “self-evaluating their sexual behavior and decision- making” (4). The website is also a tool for parents to receive information about STDs and learn about how to handle a child who has been diagnosed with an STD. Although this intervention addresses a topic that clearly needs attention, the methods through which it interacts with youth seem problematic. By looking through a social and behavioral public health lens there are a few aspects of this intervention that need revision.

Critique One – The Pervasive Use of the Health Belief Model

The FaceIt Florida campaign relies too heavily on the use of the Health Belief Model to help youth make smarter decisions about sexual activity and STD transmission. The Health Belief Model is an individual level model and does not address the ability for adolescents and teenagers to be influenced by outside parties such as family and friends (5). The FaceIt Florida intervention requires individuals to enter an interactive website which effectively puts them into a personal vacuum of decision-making. What this intervention largely ignores is that engaging in sexual activity does not solely involve the person visiting website. FaceIt Florida suggests that all sexual behaviors like planning to use a condom, or not wanting to have sexual intercourse while at a friend’s party require a thought process that can or is always planned and reasoned (one of the tenets of the Health Belief Model). For example, when prompted on the website with the choice of clicking “Tell me why and how to wait” the screen shifts to two younger individuals who are engaged to be married to one another. The female is already infected with herpes. The two of them say that the best way for them to avoid STD transmission is to abstain from having sex until they are married to one another after which they will use condoms. Furthermore, they prompt the viewer with the opportunity to learn about “how to say no, or tell someone you want to wait” the female emphasizes how easy it actually is to transmit and receive STDs. She also proceeds to tell the viewer that the time to have the conversation with someone who you like is before you two have been involved in any intimate capacity. The woman tells the viewer to communicate to their partners that “there is nothing changing your mind.” The male follows up her comment and states “just don’t say anything that would suggest that you would change your mind.”

This approach to stay safe from getting an STD assumes that the viewer will be very mechanistic about their decision process. Meaning that through this intervention and listening to people who have STDs, youth will be able to determine the “perceived susceptibility” and “perceived severity” of getting an STD. Next, they will rationally weigh the “perceived barriers and benefits” of being risky or not, take the “cue to action” to avoid STDs, and will have the “self-efficacy” to make the “right choice (6).” This intervention assumes that being put in the situation where STD transmission is a risk, making only a one-time decision (often when the Health Belief Model is used) is required. A major flaw of FaceIt Florida is that it stipulates that the decision to engage in sexual activity is based purely on information and beliefs without regard to other outsides influences as effectors. In actuality, it is difficult to make choices about sex using the Health Belief Model (7). This intervention advocates that avoiding the transmission or receiving of an STD is by reaching a point of mental resolve that entails knowing the risks, not being too curious about sex, and understanding that STDs are best contained by waiting. This thought process parallels the methodical decision-making pathway of the Health Belief Model. This mechanism appears to be purely cognitive without any emotions or pressures (8). FaceIt Florida does not recognize that intention does not always lead to behavior.

FaceIt Florida fails to consider social norms by placing such a pronounced emphasis on the Health Belief Model. Adolescents or teenagers at a party enjoying themselves will likely not go through a cognitive decision-making process when faced with the opportunity to have sex. Especially given that sexual activity can possibly be one of the most emotionally-driven activities. When socializing in an atmosphere that includes various external influences, the Health Belief Model is not the most effective health model to implement in a STD intervention. Being able to look at the more complex web of influences on an adolescent’s life such as family, friends, peer pressure, and curiosity towards human sexuality will give a look into the more effective ways to approach an STD prevention intervention.

Critique Two: FaceIt Florida’s Approach is Likely to Induce Psychological Reactance

FaceIt Floridas efforts to foster a comfortable environment to explore how to prevent STD transmission has the potential to backfire. The intervention clearly tries to use elements like music and a party atmosphere to make those frequenting the website feel relaxed. However, it fails at actually providing a comfortable forum for youth to engage in an interactive discourse. Throughout the use of the interactive website when people are talking or one is browsing the options there is R&B music in the background. This music must have been chosen with the goal of making youth feel relaxed and open to hearing the message. However, more than the music choice, the problem lies with whom FaceIt Florida has chosen to deliver the intended messages (not to mention the messages themselves). When you enter the website, the first scene introduces an older and authoritative African American man who immediately says “we have all made mistakes, I know I have” and “sounds like you might be taking some risks (3).” At the start of this intervention a teenager or adolescent might already feel as though they have done something wrong or shameful. This man appears to be a condescending figure that is not relatable to a fifteen year old teenager. Having him serve as the first interaction young adults have during the intervention is an ineffective means to keep them engaged. The next person on the screen after this older figure is a doctor who talks about the risks of getting an STD even with the use of a condom. This makes fear the second emotion induced by the FaceIt Florida campaign after condescension.

If a condescending tone and inducement of fear is not enough, the interactive website opens up into a party scene in which everyone has an STD. Although this might be an effort to make those visiting the website feel more comfortable discussing STDs which can be stigmatized, the likely response is to feel uncomfortable and awkward. Looking into a party full of individuals with STDs is not the most relatable method of making a visitor feel at ease. In fact, all of following aspects of the FaceIt Florida campaign are likely to induce psychological reactance. If a teenager is told immediately that they are taking risks and that condoms are not completely efficacious, they might view it as an attack on their freedom to explore their sexuality (9). The effort to make a persuasive argument becomes increasingly difficult in the face of a threatened audience that wants to shut down. This reaction is addressed with the Psychological Reactance Theory. By telling youth that the best way to prevent as STD is to abstain from sexual activity, this direct attack on freedom can render the opposite response (10). In other words, the FaceIt Florida has the potential to induce negative reactance and elicit the opposite emotions than it actually seeks to render.

Another flawed aspect of the intervention is that much of the advice given to the viewer is delivered by an engaged couple. Most of the people frequenting this website are adolescents and teenagers who cannot relate closely to a couple that has decided to commit to one another. FaceIt Florida does a poor job of selecting individuals to deliver an anti-STD message that youth will react positively to. Relating to the person delivering a message is important in order to be less likely to induce reactants. A figure who is less likely to induce psychological reactance will generally be better at being persuasive and influential (11). For this reason, the FaceIt Florida program would benefit from having the intervention delivered to youth, by youth instead of a dominant and authoritative figure. Psychological reactance would be minimized if a friendly and supportive peer explicitly informed young adults about why they might be engaging in risky behavior and the reasons why that behavior is dangerous (12). FaceIt Florida could be more effective if the individuals presenting the information were more similar to those receiving the message. The more analogous the source and the recipient are the less likely an intervention will invoke psychological reactance. The present setup of having several adults and an engaged couple as the main speakers on the site creates a judgmental environment for youth who are sexually active. Further asserting that it is not a website that adolescent will likely want to spend a lot of time on.

Critique Three – Poor Development of a Catchy Program

A basic problem of the FaceIt Florida intervention is with its design. The intervention assumes that visitors will be engaged with this social media for a long duration of time. In general, the intervention would be more successful if it were enjoyable. However, FaceIt Florida takes far too long to convey the full message it seeks to deliver. There is ample opportunity for a young adult to tune out and feel as though they are attending a lecture instead of actually being on an interactive website. In a society where people are being constantly stimulated with new fast-paced technology and websites, the chance of wanting to stop and look at a website about STD prevention is unlikely. With this in mind, FaceIt Florida would benefit from creating a faster and catchier approach.

Overall, the intervention asks too much of the participator. FaceIt Florida requires around thirty minutes or more to thoroughly get an understanding of what it seeks for youth to take away regarding STD prevention. Not only does it present information, FaceIt Florida also necessitates viewers to interact with the website and type answers to questions. Writing about sexual activity and other personal matters regarding STD transmission is not the easiest task to complete on a public forum (especially when you do not know who is going to end up reading it).

On an even more basic level, this intervention assumes that most youth who need advice regarding safe sex and avoiding STDs will have a computer. Given that the rates of STDs are higher in minority populations with lower socioeconomic statuses, it is unrealistic to assume that these “more susceptible” individuals will have access to a computer for the purpose of doing an online intervention (2). The chance of using the school computer lab or family computer to answer these candid questions about sexual activity is doubtful. FaceIt Florida poses personal questions such as “how do you plan on protecting yourself from an STD?” or “share your STD story?” as if youth will be open to sharing their answers with an older African American man, a doctor, and an engaged couple. FaceIt Florida is not just going on an interactive website and learning about how to prevent STD transmission. It also requires youth to be honest about their sexual past which is a task that even adults have a hard time doing.

Developing a shorter more touching intervention would benefit FaceIt Florida. Often times, the slogans or ideas that stay in our minds are catchy and simple. For example sayings like “be cool, stay in school” or “you are what you eat” are catchy and distinctly remind us about the importance of education and staying healthy. This type of simplicity yet power needs to be incorporated into the FaceIt Florida program. The complicated nature of the website interaction and preachy quality of the speakers masks the clear and powerful message of making safe sex choices to prevent STD transmission.

Alternate Intervention – “We are the 100 Percent: Committed to Being STD-Free”

In Florida alone there are approximately 100,000 STD cases per year, 30% of which are derived from the adolescent and teenage populations (3). The goal of FaceIt Florida is important and tries to address the pervasive number of STDs cases amongst youth, but there are several ineffective components of the intervention. There is a need to account for the emotional aspects of decision-making and the environmental influences that push people to behave a certain way. FaceIt Florida fails to address the emotional aspect of decision-making and presents safe sex choices as very black and white decisions. However, the room for grey area especially when dealing with the subject of being sexual active is vast. Acknowledging these shades of grey as the emotions, social relationships, and cultural differences that drive youth to make particular decisions is important to design an effective intervention (13). An intervention or campaign should have clear and defined objectives of how to approach STD prevention.

An effective intervention against STD transmission and for safe sex would benefit from using Social Network Theory, subduing psychological reactance, and making it catchy and well-tailored to the lifestyle of a teenager or adolescent. This revised intervention would seek to create a welcoming environment for youth to learn about STD transmission and safe sex options. Titled “We Are the 10o Percent, this intervention would depict young adults who are all committed to being the 100% of individuals who are not infected with an STD and engage in safe and appropriate sexual activity. This would also be an interactive web-automated intervention and would feature young adults from different walks from life who are able to converse and relate to the visitors. This intervention would change how the message of preventing STDs and safe sex is delivered.

Point One of Intervention – Use of Social Network Theory

FaceIt Florida uses an individual-based model to talk about STD transmission and safe sex. It does not recognize that the decision to engage in risky behavior or be sexually active is not always an independent decision. It often takes more than one influence to make this kind of decision. We Are the 100 Percent addresses this flaw and uses the Social Network Theory in lieu of the Health Belief Model. The Social Network Theory is a group level model that accounts for the various spheres of influence that can affect a person’s decision-making process or lifestyle. This theory would do a better job of addressing the social pressures, norms, and emotions that drive young adults to resist or engage in risky sexual behavior. Unlike FaceIt Florida which suggests decisions about having or not having sex is a one-time decision, the Social Network Theory recognizes that networks and influences in one’s life are not static. Rather, along with personal beliefs, influential social actors contribute to an individual’s “insights, beliefs, and actions (14).” With this in mind, the interactive people on the website would be friendly, youthful, and accepting.

An important aspect of using the Social Network Theory is that visitors would have the opportunity to engage in a discourse with someone that is more similar to them. A flaw of using the Health Belief Model with FaceIt Florida is that it removes individuals from the environments they belong to and fails to address social norms. We are the 100% would reinsert those visiting the website into a more comfortable emotional space. Young adults would have the opportunity to talk to “the shy girl or guy,” “the class clown,” or “the first generation American” to name a few of the possible options (whoever the visitors relate most to) (15). While FaceIt Florida is a more generic and unemotional intervention, these various “youth representatives” could help online visitors comfortably talk about STDs. This more personalized delivery would offer a more realistic approach to how an adolescent or teenager would go through the decision-making process. For example, the question of when to have sex or not and whether or not to use condoms would become a more detailed and realistic discourse versus the more rigid “you must decide before you are put in the situation” approach of FaceIt Florida. In other words, the We are the 100%’s methodology of using Social Network Theory would be a way to include the external social influences that can often form our choices and behaviors.

Point Two of Intervention: Subdue the Presence of Psychological Reactance

The efforts to create a comfortable environment for youth to talk about sexual activity and STD prevention would benefit from decreasing the presence of psychological reactance. The chance to choose a youth representative one most relates to would be a method to reduce conformity and thereby assert the freedom for youth to be themselves. Contrary to the FaceIt Florida intervention which is very didactic, We are the 100% would be an intervention that seeks to be a more casual, yet meaningful conversation. This approach would allow the visitors to feel less threatened by the message. Within the first few moments on the FaceIt Florida website, visitors will likely told they are talking risks by an older individual and then will be referred to an online doctor who talks about the risks of getting STDs from sex. The final outcome from almost every prompt on the interactive intervention points to using condoms, having a monogamous partner, and/or abstaining from having sex until marriage as the solution to prevent STDs. Almost all of these choices are a threat to freedom and likely to induce psychological reactance. In place of stirring this reaction which often causes youth to become close-minded to the message, We are the 100% would be less restrictive in its messages (9). First by having the individuals delivering the message more relatable to the recipient of the information (as discussed in the first point of the alternate intervention), We are the 100% would be a less invasive and aggressive intervention.

The youth representatives on the interactive website would encourage a more comfortable conversation, posing questions like “Do you think about having sex and want to know what can happen by doing it? It’s cool to be curious, I am also. This is what I know…” This phrasing is far less abrasive and facilitates a more relaxed discussion versus more high-threat sentiments (16). We are the 100% would also address the gender differences associated with psychological reactance. Men seem to exhibit a greater degree of psychological reactance to threats to freedom than women do (12). Therefore, the female and male youth representatives will be designed to carefully deliver a message that is non-threatening to keep both sexes visiting the website equally engaged. Furthermore, We are the 100% would frame STDs as infections that cause threats to freedom or inability to be in control of oneself. Having a peer explain the detrimental implications of being sexually risky in a moment of freedom could be a way to use psychological reactance to the advantage of the intervention. FaceIt Florida induced psychological reactance in a negative light but We are the 100% would avoid inducing reactance or use it in covert manner to facilitate persuasion.

Point Three – We are the 100% - Effectively targeting youth to create a catchy and effective intervention

A major criticism of the FaceIt Florida intervention is that it requires visitors to be on the website for a long time engaging in an unwanted discourse. We are the 100% would remedy this flaw by being a more self-selected intervention. The more free form organization of the intervention will allow visitors to spend less time on the website and only listen to individuals they want to. FaceIt Florida forced visitors to listen to doctors and an engaged couple versus listening to the stories of young adults that are more relatable. Thus, with a softer goal of safe sex and STD prevention versus STD prevention by ways of abstinence, We are the 100% would be a less time consuming and tolerant intervention. It would be an intervention that youth might feel less ashamed to be on.

We are the 100% would be catchier than FaceIt Florida by instilling the feeling of being part of a bigger clique. The goal of being part of the 100% would be a way for the visitor to feel connected to something bigger and more supportive than just a one-time internet interaction. The We Are 100% would have live monthly forums with actual trained young adults on chats available to talk to visitors interested in learning about safe sex and STD prevention. Furthermore, this campaign would seek to get funding from larger safe sex organizations and use those funds towards creating giveaways for visitors. Having the opportunity to receive gift cards or We are the 100% paraphernalia could be an incentive to frequent the website. FaceIt Florida was not as successful at creating incentives or a website that young adults would want to remember and visit again. People would visit the We are the 100 % website more frequently if given the chance to receive these gifts from This incentive to regularly return to the website would inadvertently drive the message of being “sexually smart” and “STD aware” deeply into the minds of the viewers. Using giveaways would also be a clever and catchy way to brand the intervention. T-shirts and stickers printed with sayings like “Sticking To Deciding” (STD) would be a fun way to promote safe sex practices and STD prevention.

Overall, the FaceIt Florida campaign addresses an important issue. It has some positive elements like extensive information for youth and parents regarding STDs and a noticeable effort to create a comfortable atmosphere to learn about STD transmission. However, these positive steps are overshadowed by larger mistakes. The use of the Health Belief Model makes thinking about sexual activity a purely cognitive process. It is unrealistic to think youth will unemotionally approach this topic. Adolescents and teenagers have multiple spheres of influence that motivate their actions and beliefs and it is important to consider them. The use of the Social Network Theory would help address this problem.

Furthermore, the inducement of psychological reactance makes individuals less open to the message of STD prevention and safe sex. By being more neutral and friendly, the alternative intervention, We are the 100% would be more successful at maintaining an interested and calmer viewership. Furthermore, FaceIt Florida would benefit from creating a shorter more effective intervention versus this longer program that requires a lot of time. Creating a catchy or memorable slogan or branding image would certainly help shape the look of the intervention. While We are the 100% addresses the flaws of FaceIt Florida, it is important to recognize how difficult it is to create an open discourse about sex and STDs with young adults. Hopefully keeping open channels of communication through more effective interventions will potentially be a helpful step in the right direction. More generally, efforts to sensitively and effectively tackle this issue are essential to maintain a healthy youth population and future adult population.


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