Challenging Dogma - Fall 2011

Saturday, December 24, 2011

Thinking First Before Using “ThinkFirst for Teens” – Malindi Thompson


Head and spinal cord injury bears a substantial burden on society, especially among certain higher-risk populations (1). Most head and spinal cord injury-related morbidities are the result of motor vehicle and traffic-related accidents, in which injury may have been avoided had safer driving behaviors and proper precautionary measures been taken beforehand (2). This paper will address the important potential impact that injury prevention programs have in preventing head and spinal cord injury among populations who are affected most. However, in addressing a health issue that relies heavily on the behavior and actions of individuals within a population, complexities arise which mediate the effectiveness of prevention programs. Carefully examining health behavior theory is necessary in order to effectively target health choices in the context of a person's environment, and meeting the public health goal of making safer behaviors also the easier behaviors to achieve. Critical evaluation of ThinkFirst for Teens (TFFT), a program of the National Injury Prevention Foundation, will demonstrate that often prevention programs overlook fundamental behavioral influences and create assumptions to explain certain risk-taking behaviors. This review will identify weaknesses to TFFT, as well as suggest alternative approaches that may provide stronger influence for adolescents to make safer driving decisions before injury occurs.

HEALTH PROBLEM: Head and spinal cord injury among adolescents

Motor vehicle crashes cause over one out of three deaths among teenagers in the U.S., the leading cause of death for this age group (1). Additionally, millions of drivers and passengers are treated each year for injury as a result of motor vehicle crashes, most of which are teenagers and young adults (3). Nearly half of all traumatic head and spinal cord injuries are caused by motor vehicle accidents, 50-70% of patients between the ages of 15 and 35 years old (4). Among all age groups, males are approximately 1.4 times more likely than females to sustain a traumatic brain injury (5); teenage males are nearly twice as likely to die of a motor vehicle accident than teenage females (1). The economic burden of lifetime costs of fatal and nonfatal head and spinal cord injuries in medical care, treatment, rehabilitation, and lost work productivity costs accumulates to an estimated $99 billion annually in the U.S. (6).

Many current injury prevention programs aim to increase driver and passenger safety by addressing risky driving behaviors widespread among adolescents. Active approaches to reduce head and spinal cord injuries are promoting the consistent use of safety belts and increasing driver safety. Seat belts are the most effective intervention for protecting motor vehicle occupants, reducing the risk of serious injuries from motor vehicle crashes by approximately half (7). However, teenagers, especially males, are least likely to wear seat belts (8). Other safety measures include leaving adequate headway between vehicles, not speeding, and not driving while intoxicated (2).

CURRENT APPROACH: “Use your mind to protect your body” (9)

ThinkFirst for Teens (TFFT) is an educational injury prevention program that is nationally and internationally recognized as a leader in injury prevention through education, research, and policy (10). The program's goal is to decrease the prevalence of preventable head and spinal cord injury among teens by reducing associated high-risk behaviors, and encouraging safer choices toward safety belt usage and safe driving behavior (9,10,11). The program, which focuses on good decision making skills and the consequences of risk taking, aims to reduce risk-taking among youth by educating middle and high school students on the dangers of risk taking and increasing their understanding of their risk of possibly fatal injury from motor vehicle accident (11).

TFFT is implemented in a middle/high-school assembly environment, and consists of a short video, lecture, guest speaker, and discussion (10,11). The video shows clips of youth who have been affected by a head or spinal cord injury: details about how the injury occurred, how the injury has permanently changed their life, and how it could have been prevented. The guest speaker, a young person who has sustained a head or spinal cord injury, gives a personal testimony about their experiences and challenges since the accident. Together, the program elements present real people who have lived to tell their real experiences. Consistent throughout each program component, emphasis is placed on the devastating and irreversible consequences that may occur as a result of a brain or spinal cord injury, and how, through risk-reduction, these consequences may be avoided (10).

Despite positive reviews on ThinkFirst's national website, several evaluation studies have produced results which question the effectiveness of TFFT in actually changing behaviors among adolescents exposed to the program. One evaluation of TFFT by Wright et al. (1995) found no significant changes in attitude scores between pre- and post-test assessments in schools that had implemented TFFT (12). Results showed a significant increase in knowledge among middle school students, but not high school students, and no significant impact was observed for seat belt use among all age groups (12). The evaluation further measured that self-reported behavior had significantly changed in the direction toward unsafe behavior after intervention, rather than safer behavior, for eight out of nine schools in the study (12). Similar findings from an evaluation of TFFT in Oregon reinforce the conclusion that students exposed show changes in knowledge, but no change in self-reported seat belt use (13).

Based on the findings of these evaluation studies, TFFT's program effectiveness may be legitimately questioned. Several arguments arise, which provide possible explanations as to why the program is flawed, according to the previous studies. Foremost, TFFT is based on the Health Belief Model (HBM) (11). The HBM theorizes that a person's value and expectancy beliefs guide their behavior (14). TFFT rests on the idea that increasing student knowledge of the serious effects of brain and spinal cord injuries and actual likelihood of sustaining such an injury will induce behavioral change toward less risky driving-related activities. Review of behavioral literature supports a challenge to this theory, arguing that the HBM is not an effective strategy for injury prevention among youth (14).

Relying on assumptions of human behavior such as those associated with the HBM and similar behavioral health theories (Theory of Reasoned Action and Theory of Planned Behavior) creates barriers to the effectiveness of health programs such as the TFFT. Three main critiques of TFFT will identify larger themes that often persist in other health behavior programs: 1) TFFT is individually-focused; 2) TFFT assumes that adolescents think and act rationally; and 3) TFFT uses ineffective motivators to produce behavior change.

RECOMMENDATION: Modify approaches

Elements that are required for a health program to be successful include comprehensiveness, social and cultural-sensitivity, appropriate timing, incorporation of varied techniques, having a sufficient dosage, ensuring positive relationships with its patients, and using theory-driven methods (15). Overall, TFFT has good intentions and meets most programmatic standards, but has a weak approach. TFFT lacks appropriate theories that explain adolescent behavior and their decision-making processes. Modifying the approaches used by TFFT to overcome challenges of injury prevention among adolescents through behavioral change may be done in three ways: 1) Use a social-ecological model; 2) Recognize that knowledge alone will not produce behavior change; and 3) Evaluate what motivates adolescents to influence behavior. Strategically incorporating these recommendations into a new head and spinal cord injury prevention program for youth, based off of TFFT, will likely result in a much more effective intervention.

CRITIQUE 1: ThinkFirst for Teens is individually focused

The HBM, the theory that TFFT is based on, is individually focused and does not address interpersonal, social, or overall contextual factors surrounding behavior (14). TFFT aims to change beliefs each teenager has toward his or her own susceptibility to injury from vehicle crash, so that in the future when placed in a risky situation, the teen will make the right decision and “think first” before acting. By framing the issue so that the decision to be safe or not is up to the teenager alone limits the program’s scope of influence to only intrapersonal mediators, such as knowledge. Because people actually behave and react within the context of their broader socio-cultural environment, TFFT ignores many powerful external influences which may affect the program’s ultimate effectiveness (16).

Research supports the theory that contextual social factors strongly influence adolescents’ likelihood of engaging in high-risk behaviors. In general, teens are more likely than older drivers to drive recklessly (speeding and allowing shorter headways), but in the presence of other passengers this behavior is shifted (17). Peer influences, whether intentional or unintentional, act as either risk or protective factors toward driving behavior, depending on the way that the driver perceives that the passenger views the driving behavior as desirable or expected (17). In the presence of a male teenage passenger, teen drivers typically engage in more risky driving than the general traffic; in the presence of a female, teens drive more carefully by allowing greater headway in-between cars (17). Across all teenagers of both genders, safety belt use has been found to decrease as the number of passengers increases (18).

Lastly, assuming that behavior is determined by only individual beliefs and values implies that decision making is a static process which occurs, under any circumstance, as a simple “right” or “wrong” decision. In reality, not all situations that adolescents find themselves in contribute equally to the likelihood of risky driving (19). Strong emotional responses to certain stimuli may make the application of concrete decision-making and good driving skills extremely difficult when caught in the moment.

HOW TO STRENGTHEN 1: Use a social-ecological approach

Social-ecological models of behavior are comprehensive behavioral theories that emphasize the interactions between individuals and their family, organizations, communities, and society as a whole in understanding the multiple levels of influence of a health behavior (14). Evidence supports the concept that in order for health programs to be successful in helping people adopt, change, and maintain a positive behavior, programs must be multifaceted and address socio-structural determinants of health as well as personal determinants (16,20). Adolescents are highly influential, particularly to strong social influences from peer groups, and behave in ways that they perceive to be expected by their peers, based on social norms that they are exposed to in their external environment (21,22). Incorporating social influences into injury prevention theory addresses not only teenagers’ perceptions of their own driving skills and risks which contribute to their behavior, but equally addressing the importance of the perceptions they have toward passengers they ride with.

Patterns of adolescent risk behaviors reinforce the theory that ecological models are useful in systematically targeting group-level trends of behavior. Teens that have been exposed to one risky driving behavior have likely been exposed to others (23). Approaching risky-driving behavior from a group-level perspective may provide a more useful method of targeting the health problem of head and spinal cord injury than from an individual-level perspective.

CRITIQUE 2: Thinking first is not rational

The premise of ThinkFirst for Teens is that by teaching teens to rationally “think first” before engaging in risky behavior, they will be able to avoid serious harm. This mentality in itself is not rational. People in general, even those equipped with rational decision-making skills, often act irrationally (24). Adolescents face many environmental and developmental hurdles that affect the activities they decide to engage in on a daily basis, but no solid evidence is found which supports the suspicion that adolescents are at a particular cognitive disadvantage in understanding the risk and consequences of risk taking behavior, compared to adults (25). Therefore, rather than view irrational behavior as a flaw of adolescent mentality, irrationality must be recognized as a common human characteristic. Injury prevention programs that rely only on decisions made from a well-reasoned weighing of positive and negative outcomes, such as TFFT, will encounter difficulties due to a limited scope of behavioral explanation (26).

A weakness of traditional theory that emphasizes rational decision processes is that rational behavior often is missing the important behavioral element of emotion. Emotions, whether positive or negative, directly affect attitudes, values, beliefs, coping mechanisms, and the ultimately the behaviors that produce a health outcome (14). Emotional involvement is a strong contextual influencer of how an individual responds to a given situation, and may be effectively utilized to further promote adolescent behavior after a health program’s educational component proves insufficient (27).

A second challenge of thinking that adolescents will always make safe and rational choices after increasing knowledge and risk-awareness is that gaps may persist between increased knowledge, intention, and behavior change. Consistent with the findings of the Wright et al. (1995) evaluation previously mentioned, increased favorable attitudes and behavioral intentions as a result of a risk-prevention program do not always translate into actual behavioral change (28).

HOW TO STRENGTHEN 2: Knowledge is not enough

Broadening TFFT’s mechanism of influence to encompass intrapersonal emotions and habitual modes of thinking will produce lasting and internalized behavioral outcomes (29). Rather than influencing behavior by increasing knowledge and awareness of injury, a new approach must capitalize on emotional and contextual factors common to teen drivers. Emotional engagement in a non-threatening manner will ensure that improvements in beliefs, attitudes, and intentions then lead to actual behavioral change. Successes of other youth prevention programs, such as anti-tobacco campaigns, may be attributable to the creative ways in which health-effects information is presented that emotionally engages and mobilizes viewers (30).

CRITIQUE 3: ThinkFirst for Teens uses ineffective motivations

A final critique of TFFT’s approach is that the mechanism of motivation which is thought to produce a positive reaction may be inappropriate for youth. The video and guest lecture in all TFFT school assemblies uses scare tactics to emphasize what could happen to teens if they continue to choose risky diving behaviors (i.e. Paralysis due to head or spinal cord injury). Terror management creates a negative reaction to the behavior that causes an unwanted outcome, and in theory it is the role of this aroused fear that activates behavioral change (31). This threatening strategy is usually ineffective at reducing risk-taking behaviors, except among audiences who are unaware of the problem and its associated behaviors (31,32). Lack of knowledge of motor vehicle accidents is typically not an issue among adolescents of driving-age.

Although the benefits to utilizing emotions to produce an intrinsic response were discussed previously, this method must be approached cautiously. Health messages that are overly aggressive and threatening, communicated through personal testimonies and graphic depictions of negative health effects, may cause an over-reaction among adolescent viewers and result in more risky behavior (30). This over-reaction is demonstrated through the Wright et al. (1995) evaluation of TFFT, which showed changes in self-reported behavior among exposed adolescents toward the direction of increased risk-taking (12).

HOW TO STRENGTHEN 3: Frame risky behavior differently

Rather than framing the problem of risky driving behavior as a character flaw shared by most adolescents, intervention strategies should counteract negative outlooks. Blaming adolescents for the reckless behaviors that they engage in, such as risky driving, will produce negative labels. Instead, highlight adolescence as a period of growth and development, and identify true motivators as positive gains. Behavioral persuasion that is communicated through gain-framed appeals is found to be statistically significantly more persuasive than loss-framed appeals (33). Emphasizing positive goals is a recognized strategy for simultaneously optimizing health and counteracting negativity, which works well in the context of injury prevention among youth (29).


To summarize, ThinkFirst for Teens is a well established educational injury prevention program aimed at reducing head and spinal cord injury among adolescents by building on health decision-making skills and reducing risky behaviors. However, many challenges arise in the implementation of a program based on the Health Belief Model due to individual, rational and negatively focused motivations, which often prove to be ineffective. This report addressed weaknesses of the ThinkFirst for Teens program and proposed recommendations to broaden its approaches toward successful behavioral change. Incorporating a social-ecological model that includes external influences, in addition to knowledge-based change, and framing the issue in a manner that highlights positive gain will more effectively persuade adolescents to alter their risky-driving behaviors.


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