Abstinence-Only vs. Comprehensive Sexual Education Efficacy in Reducing Teenage Pregnancy Rates in the United States—Lauren Dustin

Teenage Pregnancy Rates in the U.S.

Teenage pregnancy is a public health issue that affects every individual in a community. In 2006, 750,000 teenage girls, aged 15-19, became pregnant. Having a child during teenage years carries many emotional, physical, and financial costs to the parents and community. Teen childbearing costs $9 billion to taxpayers annually, and teen birth rates in the U.S. are up to 9 times higher than most other developed countries. (1) Teens get most information about sex and pregnancy prevention from their school curriculum. About 70% of school districts teach comprehensive sex education that includes information on the risks of sexually transmitted diseases, unintended pregnancies, contraception methods, and abstinence, while other schools teach abstinence-only curriculums. Between the years of 2006-2008, most teens had received information about most of these topics; however, about one-third of teens had not received any formal instruction about contraceptive methods and use. (2) In 2009, there were 39.1 births per 1,000 women aged 15-19, marking an historic low with a decline of 37% from the peak rate of 61.8 in 1991. (3) Although the rate of teenage pregnancy has been steadily declining, there is still a lot more work to be done in finding the most effective educational program.

How Teen Pregnancy is Currently Addressed

Sexual health education is handled in varying ways throughout our nation’s schools. About 35% of school districts in the U.S. believe in abstinence-only education that does not provide any additional information on other methods of prevention from STDs and pregnancy. Discussion of contraception is either prohibited completely, or only permitted in order to emphasize its ineffectiveness. The remaining school districts use comprehensive sex education programs sometimes referred to as abstinence-plus programs. These programs teach abstinence as the most effective method, but also include information and resources on other effective measures of prevention. There have been some shifts in which programs schools prefer, and the biggest change in sex education policies has been toward more schools using abstinence-plus policies. (4)
Abstinence-only education is based on the belief that young men and women are unable to develop committed, loving relationships, and that this leads to childbearing out-of-wedlock. These programs focus on how to develop loving and enduring relationships first before sexual activity. Supporters of abstinence-only programs argue that teaching teenagers about contraception implicitly encourages sexual activity. (5) So instead, abstinence-only education teaches that abstinence is the only way to avoid STDs and pregnancy, and every other method is ineffective. Most programs focus on instilling moral or religious values rather than providing accurate health information. Evaluation of abstinence-only programs found no delay in first sex and analysis of federally funded programs were even found to contain false, misleading, or inaccurate information about reproductive health. (6)

Supporters of comprehensive sex education or abstinence-plus programs say that it may not be reducing sexual activity in teens, but it is teaching them how to do it safely in order to prevent negative outcomes. About half of all teens ages 15-19 are sexually active, and a sexually active teen that does not use contraception has a 90% chance of becoming pregnant within one year. (2) This type of program recognizes the inevitability that most teens are going to be sexually active at some point during their adolescence, and their aim is to prepare them to make healthy and informed choices about contraception. A national survey revealed that 78% of parents of teenagers agree and believe that their children should learn about birth control and safer sex in school. Many medical organizations such as the Institute of Medicine, American Academy of Family Physicians, American College of Obstetricians and Gynecologists, and American Academy of Pediatrics also support the inclusion of contraceptive information with abstinence education to prevent teen pregnancy and STDs. (7)

There is no evidence to date that abstinence-only education delays teen sexual activity. However, research shows that abstinence-only strategies may deter contraceptive use and increase a teen’s risk of unintended pregnancies and STDs. (2) A study that compared abstinence-only and abstinence-plus education found that programs offering contraceptive education significantly influenced students’ knowledge and use of contraception methods. The study also found that abstinence-plus education led to increased contraception use by teens at follow-up compared to abstinence-only education. In addition, the use of abstinence-plus programs did not lead to an increase in sexual activity by teens, as mistakenly believed. (7) Evaluations of comprehensive sex education show that they do not increase rates of sexual initiation, they do not lower the age of first sex, and they do not increase the frequency of sexual activity or number of partners. In fact, teens who receive comprehensive sex education have a lower risk of pregnancy than those who receive abstinence-only or no sex education. (8)

New studies have shown that an increase in contraception use, not abstinence, is responsible for the decline in teenage pregnancy rates. According to the Guttmacher Institute, “86% of the decline can be attributed to the use of contraception, while only 14% can be attributed to abstinence.” (9) To reduce rates of teenage pregnancy, programs need to either improve contraceptive behaviors, reduce teen sexual activity, or both. Prohibiting contraceptive education in school-based programs keeps the very information that may have the greatest potential to decrease pregnancy rates from the people who need it the most. However, community attitudes towards teenage sexuality, rather than evidence-based interventions, greatly impact the acceptance of publicly funded school-based sex education programs. (7)

Government funding and policy-making by Congress, and individual state governments provide the basis for which type of education is used in certain school districts. In December 2009, Congress replaced the rigid Community-Based Abstinence Education Program with a new $114.5 million teen pregnancy prevention program to support evidence-based interventions and created the five-year Personal Responsibility Education Program (PREP). Its purpose is to educate adolescents on both abstinence and contraception, and to prepare them for adulthood by teaching subjects such as healthy relationships, financial literacy, and decision-making. Congress also renewed the Title V abstinence-only programs for another five years to provide funding to schools that choose to promote abstinence. (3)

Critique of Abstinence-Only Sexual Education Programs

Although abstinence-only education has not been proven to be effective or ineffective in preventing teen pregnancy in the United States, we can see how these programs have failed to apply social science theories correctly and are flawed in three fundamental ways.

The first major flaw in abstinence-only education programs is that it takes freedom and control away from teenagers when it comes to making decisions about sexual activity. Abstinence is stressed as the only effective method to prevent STDs and pregnancy, and teens are simply told to abstain. There is no information given about other methods of contraception so teens are not even given a choice to make, it is made for them. This type of program fails to consider the Theory of Psychological Reactance and how people react to their freedom being threatened or taken away. The theory says that when a person feels their freedom is being threatened, they experience reactance, a motivational state aimed at restoring the threatened freedom. (10, 11) In other words, they react by doing the negative behavior they are told not to do. When a teen is not given the freedom to make their own choices about sexual activity and contraception and they are simply told not to have sex, they will act out by doing the opposite of what they are told. Since abstinence-only programs do not provide information about contraception, these teens are at a greater risk for STDs and pregnancy because they are less likely to use any form of contraception when they do engage in sexual activity. (7)

Another flaw in abstinence-only education is the use of an improper communicator. These programs use adults, specifically teachers, to convey the message of abstinence as the only option. Teachers are the dominant player in the student-teacher relationship and their dominant and explicit messages can evoke increased psychological reactance. (11) Abstinence-only programs do not take into account the importance of similarity that is stressed in the Communication Theory, and that is also used as a way to reduce reactance and increase compliance. Teenagers who find it hard to relate to adults teaching them about abstinence will resist the very message. One of the most important aspects of the Communication Theory is the use of a messenger that is as similar as possible to the target audience. (12) The use of similarity has been found to reduce reactance and increase compliance. In a study done by Silvia, results showed that similarity increases liking and positive forces towards compliance while reducing negative forces toward resistance. Similarity also increases the communicator’s credibility and reduces the perceived threat to freedom. (10) Teachers and other adults may be the most practical communicator for school-based education, but in reality they are the least similar to the target audience and most likely to evoke reactance.

The last flaw of abstinence-only sex education is that providing inaccurate information or withholding information about contraception is morally and ethically wrong and unsafe. Abstinence is often presented as the moral choice for adolescents contemplating sexual activity. However, the current federal approach to supporting more funding for abstinence-only education raises serious human rights concerns. Access to complete and accurate sexual health information has been recognized as a basic human right and essential to make critical health decisions regarding sexual activity and the prevention of STDs and pregnancy. Abstinence-only programs are problematic because they withhold information and promote sometimes questionable and inaccurate opinions rather than facts. This threatens the fundamental human rights to health, information, and life. (13)

This flaw is a result of the incorrect usage of the Consumer Information Processing Model. This model explains that information is a necessary tool in health education; however, it is not sufficient for knowledge in general. Consumers, or students in this case, tend not to engage in extended searches for information. Therefore, if information about safe sex practices is not given to them in a structured way, they will most likely not seek it out themselves and this puts them in danger of contracting an STD or becoming pregnant if they do not know how to protect themselves. The Consumer Information Processing Model also states that before people will use health information it must be: available, seen as useful and new, and presented in a friendly format. This is where abstinence-only programs are flawed. They do not provide the new, useful, and necessary information in the first place, and the information they do provide, sometimes inaccurate, is not presented in a friendly way. (14)
Without complete and accurate information about sexual health and contraception, teens are unable to make a fully informed decision regarding sexual activity and STD and pregnancy prevention. In fact, teens who only receive abstinence messages face a greater risk of contracting an STD or becoming pregnant because they do not possess the necessary resources on other methods of contraception. (7)

Assessment

The actual causes of teenage pregnancy are not fully understood, but public health professionals would likely argue that a lack of information is a main reason. Teens that are not getting information about contraception and other prevention resources are at an increased risk for negative consequences because they are not informed or prepared to make these important decisions in a safe way. As discussed, abstinence-only sex education programs may be the least effective way to reduce teenage pregnancy rates because they are severely flawed. The explicit, forceful, and dominant messages portrayed by abstinence-only educators are the definition of what evokes psychological reactance in teens. When teenagers are told simply not to do something, they perceive their freedom to be threatened and they react to gain back that freedom by doing that behavior. This is the opposite of what abstinence-only programs want. Additionally, the use of a dissimilar communicator only heightens reactance and resistance to the abstinence-messages. People respond well and tend to comply with the beliefs and messages of a person who is most similar to them, often regardless of how threatening the message is. Lastly, the use of abstinence-only sex education in schools is morally and ethically wrong because they withhold crucial information that can be considered a basic human right in the context of making sexual health decisions. Teens need to be given the information that is new and useful to them because they are likely not going to seek out the information themselves. All of these flaws create inefficiencies that can severely hinder any possible progress made towards lowering the rate of teenage pregnancy.

New Theories

Using the social and behavioral theories previously discussed in the correct way along with several new theories will help to create a new and more effective sexual education intervention. These theories keep the target audience in mind and they recognize the need to reduce reactance in order to be successful. The new intervention will be comprehensive to include information not only about abstinence as the most effective method of STD and pregnancy prevention, but also additional information on other methods of contraception and how to use them.

Limiting Psychological Reactance & the Illusion of Control

Instead of using forceful abstinence-only messages, sex education programs should give the freedom of choice. Don’t tell teens what to do (abstain from sex), tell them what they can do instead (use protection if they become sexually active). Psychological Reactance can be a risk factor for initiation of the negative health behavior so it is important to limit reactance in order for an intervention to be successful in achieving its goal. One way to limit reactance to an intervention is to measure it before starting by finding out if the campaign would elicit reactance in the target audience. Public health professionals can do this through pilot studies or through questionnaires given to teens to assess their attitudes towards abstinence-only versus comprehensive abstinence-plus programs. To avoid reactance we need to know what elements can lead to it. Explicitness, dominance, and reason are three items that can influence reactance. The more explicit or forceful a message is, the more it evokes psychological reactance. When a communicator is perceived to have dominance over the message recipient, this increases reactance as well. However, when reason or support is given for the claim, this is likely to reduce perceived threats and reduce reactance. (11)

The Illusion of Control Theory explains that people value control over their lives or events that happen to them most when they have ownership over that behavior. If public health professionals were to use an intervention that sells control rather than takes it away, this would be accepted much more readily by our target audience. To give teen’s ownership over their sexual health decisions they will value their sexual health and choices they make much more, and this will lead to more informed choices about sex and contraception. The Illusion of Control Theory can also be used to decide when to intervene on a behavior. Intervening during the hot state (when someone is thinking about sexual activity or is already sexually active) will have the greatest effect on helping teens develop realistic plans for sexual activity and the use of contraception. (15)

Communication Theory & the Use of Similarity

The school setting is the most common place where teens learn about sex, both from their teachers and their peers. It is a logical strategy that the adults or teachers of the school system are the ones who educate teens about sex, but perhaps using a more similar messenger would have an additional impact on lowering the teen pregnancy rates. In addition to adults teaching sex education in the classroom, peers can be used to convey messages and information to other teens about contraception and pregnancy prevention in other settings through various forms of media. Interventions can use peers from the same school who are around the same age or even a celebrity who is of similar age.

The Communication Theory and study done by Silvia explains that the most important part of effective communication is to use a messenger that is similar, well-liked, and attractive to the target audience in order to increase compliance and reduce psychological reactance. The messenger should also deliver non-threatening information, unlike the messages in abstinence-only programs. (10, 12) Teens should be given the freedom of choice and control over their sexual health. Using similarity will help to balance positive and negative forces of compliance and reactance and give teens the confidence and freedom to make their own decisions about their sexual health. Providing the resources will enable them to make safer choices and help to decrease the teen pregnancy rate.

Bringing About Change with the Agenda Setting Theory

To learn from the flaws of abstinence-only programs and to eventually eliminate these programs all together I would propose using the Agenda Setting Theory. This theory is based on the idea that there is a public agenda, and it consists of what people are talking about and what people are interested in at that specific moment in history. If you can get people to think and talk about your issue, it will be a part of the public agenda and it will be much easier to have an impact on the public health issue. Public health professionals can use this theory to get people to realize the flaws with abstinence-only programs and why comprehensive programs can be more effective and safer for teens. This would tie in very well with the use of a media campaign targeting teens because often times the media dictates the public agenda. (12)

New Intervention

The first strategy towards creating a more effective sexual education intervention program that reduces the rate of teenage pregnancy in the U.S. would be to make all education programs comprehensive. I believe having comprehensive sex education as the primary form would be the most effective in increasing contraception use, and reducing STDs and pregnancy rates in teens age 15-19 as previously supported. (7) Information about safe sex and contraception is critical to teenagers who are faced with decisions about sexual activity. To withhold this information puts them at greater risk for negative consequences. The new intervention will offer control and freedom to the teenagers so as to not threaten them and evoke psychological reactance. Instead of explicitly stating that abstinence is the only way to go, the new intervention will feature other choices for contraception and prevention, in addition to abstinence. This has shown to be more effective in increasing the use of contraception, which in turn leads to a decrease in pregnancy rates. (9) The most effective curriculum-based programs have focused on a specific behavior, such as using contraception, and provide the basic information, not too much detail . They are age appropriate and based on theoretical approaches; they address peer pressure, and teach skills in problem-solving and decision-making to prepare students for difficult life choices they will encounter. Teaching basic life skills along with sex education has shown to be effective in increasing knowledge and changing attitudes and behavior towards contraception. (16, 17)

To give teens the freedom to choose how they handle their sexual health may not be enough to achieve the overall goal of reducing teen pregnancy. For this reason, the new intervention will also add another communicator to the program who is more similar to the target audience to deliver messages to teens. On top of the comprehensive school curriculum, the program will feature media ad campaigns emphasizing safe sex and “the choice is yours” type statements. The campaign will be marketed like a mass movement, urging teens to join the “Safe Sex” movement by choosing to abstain or use contraception, and realizing they have the freedom to choose and they have control over their sexual health decisions and the consequences of those decisions. By joining a movement, this will make the teens feel like they truly are in control and they will not feel threatened to obey abstinence-only messages. These messages will be delivered by someone who is familiar and similar to the target audience. Studies by Silvia show that similarity increases compliance and decreases resistance. This will have the greatest effect on getting teens to use contraception in order to reduce the teen pregnancy rates. (10, 12) Teens can relate to someone who is most similar to themselves, and this is not going to be the teachers or adults in a school. A peer-to-peer media campaigns will be a more effective element to the comprehensive sex education already in place.

The intervention will feature positive and freedom enforcing messages on posters throughout the schools, on computers, on school news broadcasts, on local television, and social networking websites. The campaign will say things like “Safe sex is sexy”, “The choice is yours, own it” and other positive, non-dominant messages. Teens say that they would prefer to get information about sex from their parents, but more than half of them report getting information about sex, birth control, and pregnancy from television shows, movies, and magazines. (18) Because teens most often learn about sex through these channels of communication, using magazines and local television would successfully reach the target audience. The messages will be created and delivered by peers and persons who are the most similar to the target audience such as students from the same school. The combination of control and the use of a similar communicator will greatly reduce reactance and increase compliance. (10)

Summary

Although many school-based and community interventions have been used to try to reduce the rate of teenage pregnancy in the U.S., most have been ineffective. The designs of abstinence-only programs are especially flawed because they evoke psychological reactance from the dominant and forceful messages they portray. They fail to provide the necessary information about contraception that teens need in order to make safe decisions about their sexual activity. Teens that do not receive information about contraception are at an increased risk for getting and STD or becoming pregnant. Educational programs that are comprehensive in nature and include information on both abstinence and other methods of prevention, as well as teach important life skills, are the most successful at increasing knowledge and changing attitudes and behavior. Teens respond best and tend to comply more with messages that use a communicator that is most similar to them. Interventions that take advantage of similarity effectively limit reactance while increasing compliance. This will have a positive effect on reducing the teen pregnancy rate in the U.S. The first step in creating a more effective sexual education program for all school districts to use is to get this issue on the public agenda through the use of the media. This intervention will depend on public support and community acceptance in order to be successful, and this will be the most difficult element to achieve.

References
1. Preventing teen pregnancy in the us. (2011, April 5). Retrieved from http://www.cdc.gov/vitalsigns/TeenPregnancy/index.html
2. Facts on american teens' sexual and reproductive health. (2011, August). Retrieved from http://www.guttmacher.org/pubs/FB-ATSRH.html
3. Facts on american teens' sources of information about sex. (2011, February). Retrieved from http://www.guttmacher.org/pubs/FB-Teen-Sex-Ed.html
4. Landry, D. J., Kaeser, L., & Richards, C. L. (1999). Abstinence promotion and the provision of information about contraception in public school district sexuality education policies. Family Planning Perspectives, 31(6), 280-286. Retrieved from http://www.jstor.org.ezproxy.bu.edu/stable/pdfplus/2991538.pdf?acceptTC=true
5. Rector, R. (2002, April 8). Effectiveness of abstinence education programs in reducing sexual activity among youth. Retrieved from http://www.heritage.org/research/reports/2002/04/the-effectiveness-of-abstinence-education-programs
6. The Content of Federally Funded Abstinence-Only Education Programs. (2004, December). Retrieved from http://www.apha.org/apha/PDFs/HIV/The_Waxman_Report.pdf
7. Bennett, S. E., & Assefi, N. P. (2005). School-based teenage pregnancy prevention programs: A systemcatic review of randomied controlled trials . Journal of Adolescent Health, 36(1), 72-81. Retrieved from http://www.sciencedirect.com.ezproxy.bu.edu/science/article/pii/S1054139X04001673
8. Kohler, P. K., Manhart, L. E., & Lafferty, W. E. (2008). Abstinence-only and comprehensive sex education and the initiation of sexual activity and teen pregnancy. Journal of Adolescent Health, 42(4), 344-351. Retrieved from http://www.sciencedirect.com.ezproxy.bu.edu/science/article/pii/S1054139X07004260
9. U.s. teenage pregnancies, births, and abortions: National and state trends and trends by race and ethnicity. (2010, January). Retrieved from http://www.guttmacher.org/pubs/USTPtrends.pdf
10. Silvia, P. J. (2005). Deflecting reactance: The role of similarity in increasing compliance and reducing resistance. Basic and Applied Social Psychology, 27(3), 277-284.
11. Dillard, J. P., & Shen, L. (2005). On the nature of reactance and its role in persuasive health communication. Communication Monographs, 72(2), 144-168. Retrieved from http://classweb.gmu.edu/gkreps/820/009.pdf
12. Shaw, E. F. (1979). Agenda-setting and mass communication theory. Retrieved from http://xa.yimg.com/kq/groups/22925642/1944236267/name/Shaw- Agenda-Setting and Mass Communication Theory.pdf
13. Santelli, J., Ott, M. A., Lyon, M., Rogers, J., Summers, D., & Schleifer, R. (2006). Abstinence and abstinence-only education: A review of u.s. policies and programs. Journal of Adolescent Health, 38(1), 72-81. Retrieved from http://www.sciencedirect.com.ezproxy.bu.edu/science/article/pii/S1054139X05004672
14. Campbell, C. (2001, August 21). Health education behavior models and theories: A review of the literature part i. Retrieved from http://msucares.com/health/health/appa1.htm
15. Langer, E. J. (1975). The illusion of control. Journal of Personality and Social Psychology, 32(2), 311-328.
16. Nitz, K. (1999). Adolescent pregnancy prevention: A review of interventions and programs. Clinical Psychology Review, 19(4), 457-471. Retrieved from http://www.sciencedirect.com.ezproxy.bu.edu/science/article/pii/S0272735898000877
17. Harris, M. B., & Allgood, J. G. (2009). Adolescent pregnancy prevention: Choosing an effective program that fits. Children and Youth Services Review, 31(12), 1314-1320. Retrieved from http://www.sciencedirect.com.ezproxy.bu.edu/science/article/pii/S0190740909001571
18. Brown, J. D., & Witherspoon, E. M. (2002). The mass media and american adolescents. Journal of Adolescent Health, 31(6), 153-170. Retrieved from http://www.sciencedirect.com.ezproxy.bu.edu/science/article/pii/S1054139X02005074

Why We Are Not Getting Through to Teens: A Critique of the ‘Every 15 Minutes’ Program — Sarah Baird

Whether it is realistic to expect teens to wait until they turn 21 to drink alcohol is debatable, but one thing is certain—some teens do drink. Teenage drinking is a risky behavior that 71% of high school seniors have participated in at least once and 41.2% report drinking within the last month (1). The prevalence of underage drinking combined with the fact that motor vehicle fatality is the leading cause of death amongst teens, has spurred many anti-drunk driving programs, some more successful than others (2). When I was in high school, my school chose the ‘Every 15 Minutes’ program to sell the “don’t drink and drive” message. ‘Every 15 Minutes’ is a worldwide, school based, anti-drunk driving intervention. The origins of the program date back to 1995 when the Chico Police Department developed this two-day intervention (3). The program’s name was coined from an early 1990’s statistic that someone in the United States dies every 15 minutes from an alcohol-related collision (3).

When a high school chooses to host this program, it involves the participation of community members such as law enforcement, paramedics, hospital staff, coroners, and funeral homes, in addition to actual high school students and staff members (4). Several students are chosen to participate in the intervention and on day one a “grim reaper” pulls one of the selected students out of class every fifteen minutes, their obituary is read, and they return to class as the “living dead” unable to communicate with their fellow classmates (4). A drunk driving collision is then simulated on school grounds with students watching. The simulation is intended to be as realistic as possible. Emergency response teams attempt to rescue injured students, some students are pronounced dead on scene and others are rushed away by ambulance, police officers administer sobriety tests to the drivers and they are booked on drunk driving charges (4). In order to simulate the separation from friends and family that occurs with death or jail time, the students who participate in the collision retreat to a hotel for the night (4). Day two involves an assembly with a video presentation of the previous day’s events and reflections from participants. The students who played a part in day one read letters addressed to their parents as if they actually died and parents read similar letters addressed to their children (4). A parent who actually lost a child in an alcohol-related collision will speak to the student body along with hospital staff and police officers (4). The program is intended to be dramatic and evoke strong emotions, provoking students to think about the consequences of their actions. A video showing this intervention in further detail can be seen on the ABC news program Good Morning America: Every 15 Minutes (5). Despite the widespread use of this intervention at high schools across the country, ‘Every 15 Minutes’ is flawed and unsuccessful in effecting change in teens’ behavior.

The Danger of Expectations
The expectation established by this intervention is one of the major downfalls of this program. The entire program is represented under the idea that a tragic death occurs every 15 minutes as a result of an alcohol-related crash. In reality, 10,839 deaths occurred in 2009 as a result of alcohol-impaired driving collisions, which translates to one death every 48 minutes (6). Alcohol-related driving fatalities have declined in recent years, but even when this program first began in 1995 there was one alcohol-related crash on average of every 30 minutes (7). From the start, the foundation of this intervention was based upon an incorrect statistic. While the ‘Every 15 Minutes’ website does acknowledge the number of individuals killed in alcohol-related crashes has decreased, an updated statistic is not referenced (4).

The inflated statistic is of concern for multiple reasons—one being that the ‘Every 15 Minutes’ message is increasing the perception of the prevalence of the problem. The message causes students to overestimate the norm of drinking and alcohol-related fatalities. Researches have linked the failure of the anti-drug campaign DARE to this same flaw, criticizing the program for making drugs seem too “normal” and misrepresenting the prevalence of drug use (8). Social norms are often a strong predictor of behavior and this correlation is explored by social norms theory, which is based on the principle that people incorrectly perceive the behaviors and attitudes of others to differ from their own (9). Perkins and Berkowitz first suggested what is now social norms theory in 1986 and have done extensive research of social norms relating to student alcohol use (9). Studies of this theory have shown individuals often overestimate the prevalence of risk behaviors and change their own behavior to conform to the perceived norm (10). Additionally, those who partake in risky behaviors use the misperceived norm to rationalize or justify their unhealthy behavior (10).

Applying social norms theory to ‘Every 15 Minutes’ suggests students will drink and drive and possibly justify their behavior because they misperceive their peers to be tolerant of and partaking in the behavior themselves. Social norms theory also implies students could feel uncomfortable speaking out against drinking and driving because they misperceive their peers to be drinking and driving at a greater rate than reality would dictate. Research has consistently found that students considerably overestimate the prevalence of heavy drinking and drunk driving (11). Perkins suggests interventions aimed at dispelling misperceptions can reduce problem drinking through empowering responsible students and restraining those who partake in the risk behavior (11). The ‘Every 15 Minutes’ program does the exact opposite, creating a negative cycle where risk behaviors are perpetuated and healthy behaviors are suppressed (10). Thus, the expectation of this intervention perpetuates an existing misperception, making the misperception reality.

Provoking Reactance
The overarching message of ‘Every 15 Minutes’ could be summarized as “don’t drink and drive or else.” Ideally teens would never choose to drink and drive, but the choice exists. This intervention removes that choice without offering much of an alternative. The program’s message is not only simplistic, but the domineering tone also threatens teens’ freedom.

The fear appeal structure of ‘Every 15 Minutes’ poses a threat to teens’ freedom. The standard fear appeal structure involves threat-to-health and threat-to-freedom components (12). The threat-to-health component is substantiated through the physical and emotional consequences, fake injuries and death, and statistics on alcohol-related fatalities. The threat-to-freedom component is validated through the staged prosecution and punishment, and idea that the only option is to abstain from drinking and driving. Health promotion messages that utilize strong threats to health and freedom have been associated with increased reactance (12). Under Brehm’s theory of psychological reactance, when free behaviors are threatened or eliminated, people experience a motivational state to reestablish those freedoms (12). Specifically, Brehm defines reestablishing freedoms as participating in the behavior that one has been told they cannot or should not participate in (13). Individuals will act to restore freedoms through any available means and their level of reactance is proportional to their value of the lost freedom (12). It is also of note that individuals may or may not be aware they are experiencing reactance (12).

Under the principles of the psychological reactance theory, telling teens ‘no’ could motivate them to say ‘yes’ and ‘Every 15 Minutes’ does just that. The program uses scare tactics to emphasize drinking and driving is a big problem with drastic consequences, which teens are at risk of, and in the face of this immense threat the underwhelming answer is—just do not drink and drive. Students walk away from this intervention knowing what they are not supposed to do, but not much else. The only solution offered up by the intervention is to act responsibly—a paternalistic message often hammered into teens. Looking back on our teen years we all know this is easier said than done. The “Just Say No” approach did not work for DARE and the equivalent message does not work here (8). Reactance is minimized when someone familiar and relatable delivers the message, which this intervention partly does, but the message is just too simple here to be effective (14). This theory also explains that those most likely to engage in the free behavior that is being threatened exhibit the highest degree of reactance (13). Thus, students that are most likely to drink and drive are also most likely to feel this intervention is trying to tell them what to do, motivating them to reestablish their control of the situation. By using threats, fear, and a paternalistic tone to persuade teens to adopt a responsible behavior this intervention just positions itself to provoke rebellion in those that are most at risk.
Failure to Overcome Teens’ Invincibility

‘Every 15 Minutes’ acknowledges that teens understand the dangers of drinking and driving, yet most believe it will never happen to them (3). In light of this knowledge, the program was designed to show teens they are not invincible (3). In terms of social science theories, teens believing they are invincible would be called optimistic bias, illusion of control, or restraint bias. Combating teens’ optimistic bias and illusion of control seems like an effective approach to address this public health problem; however, ‘Every 15 Minutes’ fails to do so.

Optimistic bias is the phenomenon that people tend to underestimate the risk of something bad happening to them and overestimate the risk of something good happening to them (15). People tend to underestimate the probability that bad things will happen to them even when they understand or overestimate the risk that bad things will happen to other people (15). For instance, 72% of drivers do not believe it is very likely that they will get caught drinking and driving and students have been shown to think their risk of developing a drinking problem is much lower than that of other students (15-16). Under the principles of optimistic bias, even if teens fully understood or overestimated the risks associated with drinking and driving, they would underestimate their own personal risk. According to Professor Siegel, optimistic bias tends to be highest in teenagers and when trying to overcome optimistic bias, telling stories about individuals is much more impactful than delivering public health messages via statistics. ‘Every 15 Minutes’ attempts to deliver the anti-drunk driving message through a story involving peers; however, this story is only a dramatization. The intervention takes the theatrics too far with fake blood, a grim reaper, and students playing dead, so it seems like a cheesy television show rather than a realistic situation. The fact that the events of the intervention are staged limits the believability and detracts from the effectiveness in overcoming the optimistic bias of the teen audience.

Illusion of control is the idea that people have an unrealistic sense of the extent to which they can control an event or the events that happen to them (17). Illusion of control and restraint bias are essentially one in the same, with restraint bias being the idea that people overestimate their ability to control their behavior, particularly as it relates to temptation (18). Applying these principles to the problem of teenage drinking and driving would imply teens overestimate their ability to control whether or not they would drink and drive in general or be involved in a drunk driving accident. In simple terms, these overestimations account for a sense of invincibility. In studies exploring temptation control under a hot versus cold state, individuals tend to overestimate their impulse control when in a cold state and be more realistic of their abilities when in a hot state (18). Since ‘Every 15 Minutes’ is delivered in the cold state (i.e. teens are sober), teenagers will tend to overestimate their ability to say no to driving after drinking or getting in a car with someone who has been drinking. Interventions delivered in the cold state are less effective and without effectively addressing how to handle the hot state, the impact of the program is limited by its delivery.

Conclusion
‘Every 15 Minutes’ is potentially an effective intervention for anti-drunk driving. The message is delivered in a story format, largely by peers, and relies more on appealing to emotions than persuasion via statistics and facts. The intervention’s website claims participants are satisfied with the program, but does this satisfaction translate into behavior changes? Unfortunately it does not. Research has shown this intervention changes teens’ attitudes for the short term, but not their behavior (19).
The failure of this program can be partially attributed to the aggressive dramatization of the intervention. The reality is the program aims at creating a sense of hysteria in order to scare teens into changing their behavior. Teens are often hormonal and emotional, so throwing some fake blood on their friends and rushing them away in ambulance will provoke a strong emotional reaction in some teens. However, at the end of the day, teens know this two-day intervention was staged and their friends and family are safe and sound. Students can rationalize the events of the intervention are just a tall tale and go back to relying on their optimistic bias and illusion of control. Without empowering students or giving them any sense of control ‘Every 15 Minutes’ is unsuccessful in effecting behavior change amongst teens. Once the shock of experiencing the intervention wears off, it seems as though the message does as well.

Proposed Intervention
In order to reach teens, we must understand them. Through comprehending where ‘Every 15 Minutes’ fails and the application of social science theories, a more effective school-based anti-drunk driving intervention can be developed. Based on the pitfalls of ‘Every 15 Minutes,’ a more successful intervention would dispel misperceptions, minimize reactance, and combat optimistic bias and illusion of control shared by teens.

Instead of focusing on a staged, dramatization of a drunk-driving collision, the new and improved intervention could focus on sharing a true story. An individual who has lived through an alcohol-related driving experience, preferably a recent alumnus of the target high school or a neighboring school, would share their story with the high school students. The individual could be someone who was charged with a DUI or in an alcohol-related collision. They would speak to the student body about the reality of being charged with a DUI and the effect it had on their life and their friends and family. Rather than telling students what not to do, the emphasis would be on what they learned from the experience, what they lost, and how it has changed them as a person. The speech would highlight the gravity of the situation with intent to inform rather than to scare the students. The tone would be serious, but not accusatory.

The speech would be coupled with educational and interactive components. The educational component would focus on dispelling myths about teen drinking habits, empowering teens with skills on how to deal with their decisions regarding alcohol use, and providing information on local designated driver services or who to call if they ever need a ride. There would be an anonymous question and answer session where students could safely voice any questions or concerns. The intervention would get parents and the community involved much like ‘Every 15 Minutes’ does, providing an opportunity to open up dialogue with parents about drinking. The success of the anti-drunk driving campaign would be maximized through community efforts to enforce laws and a no tolerance policy on selling alcohol to minors.
Using Expectations in Another Way

The new intervention would use expectations in another way than they are used in the ‘Every 15 Minutes’ program. Rather than representing the program under a negative, exaggerated statistic, the program would flip the statistics around. Focus would be placed on dispelling misperceptions related to teen alcohol use and drinking and driving, using social norms theory to impact teen behavior. The speaker would emphasize that they are the exception not the norm and encourage students not to share in their mistake. The program would highlight the positive side of teen trends, such as the fact that the majority of teens do not drink—a recent study found that almost 60% of teens surveyed did not have a drink within the last month (1). An even greater majority, almost 83%, of people age 12-20 are not binge drinkers (20). In 2009, 90% of teens had never driven a car or vehicle after they had been drinking and 72% of teens had never ridden in a car with a driver that had been drinking (21). Drawing attention to the good decisions teens make establishes positive rather than negative expectations.

As discussed early, expectations and perceived social norms are a powerful indicator of behavior. In particular, there have been many studies on how norms influence drinking amongst adolescents and how norms can be used to reduce alcohol consumption (9-11). Correcting misperceptions has been shown to reduce problematic behavior and encourage healthy behavior (10). Most students already believe their peers drink more than they actually do and perceive their peers to be more permissive in their drinking attitudes than they actually are (11). The expectations delivered by ‘Every 15 Minutes’ only add to the misperceptions already held by students. Setting the story straight on teens’ actual attitudes and behaviors as they relate to drinking and driving will help to correct these misperceptions. Empowered with the facts, teens can feel more comfortable abstaining from drinking, reducing their drinking, or voicing their opinion against drinking and driving.
Changing Words to Minimize Reactance

The new intervention will employ the principles of psychological reactance to increase acceptance of the message and effect change in teen behavior. ‘Every 15 Minutes’ focuses on pointing out teens’ bad decisions and telling them what not to do, the new intervention will remove the accusatory tone and focus on alternative options. Instead of a ‘just abstain from the behavior’ message, the new program will have a ‘be in control message’—reminding teens they are the one’s with the power. The speaker will incorporate messages such as “We know some of you will choose to drink. If you are going to drink, arrange a safe ride home. Figure your ride out before you start drinking. Have a cab’s number in your cell phone.” These messages are more neutral in tone and leave the option up to the student, making them feel in control and thus minimizing reactance. In preparation of the intervention, the school can send home flyers to parents encouraging parents to let their children know they can always call them for a ride, no questions asked. Of course not all parents will feel comfortable with this, but for those that are, it is important their teens know they have this option.

Research has shown the persuasiveness of anti-drinking campaigns is largely dependent on the level of reactance they create (22). Reactance is minimized when more gentle, subtle language is used and when someone familiar delivers a message (12,14). ‘Every 15 Minutes’ attempts to reduce psychological reactance by involving students in the intervention program. The new intervention will go a step further, using someone familiar and toning down the paternalistic message. Students will be able to relate to the speaker because they are close in age and from the same area, creating a sense of familiarity. Removing the graphic visualizations from the intervention and using positive statistics helps to reduce the threat-to-health aspect seen in ‘Every 15 Minutes.’ By giving teens freedom to choose from options, making them feel in control, and minimizing the perceived threats, the message is more likely to be accepted by a broader audience (12-14).

The Power of a True Story
‘Every 15 Minutes’ acknowledges that there is a sense of optimistic bias and illusion of control in teens, but solely relies on theatrics and fear to overcome these obstacles. In the proposed intervention, the speaker will share their story without any of the hysterics of ‘Every 15 Minutes,’ making the message more genuine and believable. Students can dismiss ‘Every 15 Minutes’ because it is fake, the raw honesty of an individual who has actually lived through a DUI arrest or alcohol-related collision is something students cannot deny. Students will walk away feeling moved by the personal story, but not scared by fake blood and mangled cars. People can understand probabilities and even overestimate them but still not grasp their own risk—telling stories about individuals will be a lot more impactful than probabilities (15).

The most realistic approach to combating illusion of control and restraint bias is empowering teens so the illusion is removed and they are in fact in control. Interventions delivered during the hot state tend to be more impactful because people are more realistic about the level of control they have over a given situation (18). This could be difficult to accomplish because this public health issue involves underage drinking and it would obviously be inappropriate to have teens drink before the intervention. However, the goggles that simulate vision when intoxicated could be used to illustrate to teens what their coordination and perception is like when they have been drinking. By empowering teens with information, whether it is the reality on teen drinking trends or what their options are when they find themselves in a situation involving alcohol, knowledge is power. The new intervention would remove the theatrics of ‘Every 15 Minutes’ and inform teens about the less dire consequences of a DUI such as the embarrassment of telling friends you do not have a drivers license, the nuisance of not being able to drive yourself anywhere, and the negative impact it has on your ability to get a job. These consequences that affect one’s independence and social life are more relatable and relevant to teens than killing a friend or going to jail, which just seem too farfetched for most teens to fully comprehend. Illusion of control and optimistic bias are difficult to overcome, but the new intervention aims to combat these tendencies by leaving teens with a more realistic grasp on the situation.

Conclusion
Whether a life is lost every 15 minutes or every 48 minutes, the point is a life is lost. The tragedy is a death from an alcohol-related collision is completely avoidable. As public health practitioners we are responsible for intervening and educating the public on this risky behavior. However, designing and implementing an effective public health intervention is no small feat. People are complex and irrational, but social science theories can help demystify the motivations, attitudes, and behaviors of individuals. Hopefully by using these theories to design and implement an anti-drunk driving intervention teens will be persuaded to maintain healthy behaviors and change unhealthy behaviors.

































REFERENCES

1. National Institute on Drug Abuse InfoFacts. High School and Youth Trends. Bethesda, MD: National Institute on Drug Abuse National Institutes of Health, 2011.
2. Miniño AM. Mortality Among Teenagers Aged 12–19 Years: United States, 1999–2006. NCHS Data Brief, no 37. Hyattsville, MD: National Center for Health Statistics, 2010.
3. Farrow JA. Every 15 Minutes Procedural Manual: A “How-To” Guide for Communities Dedicated to Reducing Teen Drinking and Driving. CA: State of California—California Highway Patrol, 2011.
4. The Every 15 Minutes Program. About Us. Lehigh Valley, PA: Every 15 Minutes Organization. http://www.every15minutes.com/aboutus/
5. Every 15 Minutes Channel. Good Morning America: Every 15 Minutes. San Bruno, CA: YouTube. http://www.youtube.com/user/Every15Min#p/a/u/2/nyBFkvW5D10
6. National Highway Traffic Safety Administration. Traffic Safety Facts 2009 Data Alcohol-Impaired Driving. Washington, DC: National Center for Statistics and Analysis, 2010.
7. National Highway Traffic Safety Administration. Traffic Safety Facts 1995 Alcohol. Washington, DC: National Center for Statistics and Analysis, 1994.
8. Reaves J. Just Say No to DARE. Time 2001.
9. Perkins HW, Berkowitz AD. Perceiving the community norms of alcohol use among students: some research implications for campus alcohol education programming. The International Journal of the Addictions 1986; 21:961-976.
10. Berkowitz AD. Applications of Social Norms Theory to Other Health and Social Justice Issues. In: Perkins HW, ed. The Social Norms Approach to School and College Aged Substance Abuse: A Handbook for Educators, Counselors, Clinicians. San Francisco, CA: Jossey-Bass, 2002.
11. Perkins HW. Social Norms and the Prevention of Alcohol Misuse in Collegiate Context. Journal of Studies on Alcohol and Drugs 2002; 14: 164-172.
12. Dillard JP, Shen L. On the Nature of Reactance and its Role in Persuasive Health Communication. Communication Monographs 2005; 72:144-168.
13. Brehm JW. A Theory of Psychological Reactance (pp. 377-390). In: Burke WW, ed. et al. Organization Change: A Comprehensive Reader. San Francisco, CA: Jossey-Bass, 2009.
14. Silvia PJ. Deflecting reactance: The role of similarity in increasing compliance and reducing resistance. Basic and Applied Social Psychology 2005; 27:277-284.
15. Weinstein ND. Unrealistic optimism about future life events. Journal of Personality and Social Psychology 1980; 39:806-820.
16. Beck KH, et al. A comparison of drivers with high versus low perceived risk of being caught and arrested for driving under the influence of alcohol. Traffic Injury Prevention 2009; 10:312-319.
17. Langer EJ. The illusion of control. Journal of Personality and Social Psychology 1975; 32:311-328.
18. Nordgren LF, et al. The Restraint Bias. Psychological Science 2009; 20:1523-1528.
19. Hover AR, et al. Measuring the effectiveness of a community-sponsored DWI for teens. American Journal of Health Studies 2000; 16:171-176.
20. Students Against Destructive Decisions. Statistics: Underage Drinking. Marlborough, MA: Students Against Destructive Decisions National. http://www.sadd.org/stats.htm
21. Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance – United States, 2009. Morbidity and Mortality Weekly Report 2010; 59:1-142.
22. Bensley LS, Wu R. The role of psychological reactance in drinking following alcohol prevention messages. Journal of Applied Social Psychology 1991; 21:1111-1124.

Canning Indoor Tanning: Evaluating The Current Public Health Approach And Offering Advantageous Changes To Be Made -Tara LePage

Introduction:

“Kiss by the Sun,” “Desert Sun,” and “Bermuda Bronze” are three clever names of tanning salons in south eastern Massachusetts, advertising to consumers a guaranteed healthy glow. What these consumers are not getting from these salon titles is the FDA’s perspective; advising that sunlamps and tanning beds promising consumers the bronzed body year-round, are posing serious health risks from the exposure to ultraviolet (UV) radiation (1). In addition to skin cancer, the most common of all cancers in the United States (2), the FDA warns about the associations of tanning with premature aging, immune suppression, eye damage, and allergic reactions (1). Despite empirical reports denouncing the use of indoor tanning beds, the indoor tanning industry continues to flourish. An article by Denise Woo and Melody Eide, “ Tanning beds, skin cancer, and vitamin D: an examination of the scientific evidence and public health implications” reports that as one of the fastest growing industries in the United States, indoor tanning businesses are accruing an estimated 5 billion dollars in annual revenue (2). The Skin Cancer Foundation estimates that nearly 30 million Americans tan annually at 50,000 U.S. tanning facilities; while the American Cancer Society estimates that there will be about 70,000 new cases of melanoma and about 9,000 melanoma related deaths this year (3). With projections like these, it is clear that tanning salons have successfully warranted demand across the country; however, unless meaningful intervention is in place soon, the latter of the above statistics will also continue rising, ultimately resulting in severe negative health consequences for the public.

Honing in on defining the scope of the problem of indoor tanning is rather alarming. While all age groups are victim to the advertisements and pressures of keeping up with a tan, vulnerable populations have been found as the most frequent users of the indoor tanning salons. “Persistent use of tanning facilities has become especially apparent within adolescent female populations” (4). Girls as young as eight years old are exposing their developing bodies to the dangers of indoor tanning, and according to some physicians, the risks are especially high for this population whose skin cells are both dividing and changing rapidly (4). The Center for Disease Control (CDC) reports that, “nearly 9% of teens aged 14-17 years old have used indoor tanning facilities, and girls aged 14 -17 years old were seven times more likely than boys within that age group to use the devices” (5). As part of the Healthy People 2020 cancer objectives, the goals include reducing the 14% of adolescents grades 9-12 who report using artificial sources of UV light for tanning as well as reducing the 13.7% of adults aged 18 or older who report using artificial sources of UV light for tanning (5). The statistics could not be more clear.

What does this mean for public health officials? Intervention is needed. Over the past decade, a variety of Public Health Campaigns have begun efforts to challenge the epidemic of indoor tanning. The general approach to combating indoor tanning has currently been derived from the traditional public health education of groups at risk, along with proposed legislative bans and misled ignorance of impactful social learning and modeling in today’s culture. It is clear from the numbers above, many of which have been reported within just the past two years, that these current approaches of intervention against the negative impacts of the indoor tanning industry have failed. Analyzing this public health problem with a more progressive perspective on social and behavioral health will yield great benefits towards the creation of new intervention approaches.

Flaw #1: Misuse of the Traditional Health Belief Model

The Health Belief Model has been a longstanding, traditional foundation for public health interventions, originating in the 1950’s from the work of social psychologists, Godfrey Hochbaum, Irwin Rosenstock, and Stephen Kegels (6). Basing its mechanism on the understanding that people weigh the scale of perceived benefits of practicing a behavior versus the opposing costs, there are six main principles influencing people’s decisions about whether or not to take action under the health belief model, including: “perceived susceptibility, are they at risk; perceived severity, are the consequences serious; perceived benefits, will taking action reduce risk and consequences; perceived barriers, are costs outweighed by benefits; cue to action, will intention prompt action; and self efficacy, is one confident in his or her ability to take action” (7). Assuming that individuals are rational in their evaluation of costs and benefits is a major limitation of the health belief model that directly ignores elements of external and social influence as well as disparities in knowledge among individuals (6).

Evidence of this model is manifested throughout the current approach working to defeat indoor tanning use. The Skin Cancer Foundation’s, “Go With Your Own Glow” campaign, published a variety of PSA announcements through the use of cartoon color print advertisements, along with libraries of educational videos explaining the process of UV radiation developing skin cancer (8). The CDC has supplemented their “Choose Your Cover” campaign with published educational brochures, posters, and print advertisements with the intention of emphasizing the statistics to stake their message (9). With these types of initiatives, public health officials from pristine agencies such as the CDC and The Skin Cancer Foundation are incorrectly assuming that by providing and explaining the risks and ultimate costs of exposure to indoor tanning UV radiation, that their target audiences, often young adolescent females, will rationally conclude with similar analysis of data that they should eliminate indoor tanning from their behavior cycle. Countering irrational mindsets with educated information alone has proven unlikely to be successful in many prior campaigns, and again in the case of diminishing the use of indoor tanning facilities.

Flaw #2: Legislative Bans Represent Heavy Hand Authority

Another major focus of anti-tanning campaigns has been their association with government intervention. A number of campaigns have teamed up with state lawmaking bodies, to propose and pass legislation concerning tanning restrictions for minors; the target audience for intervention. California is now banning the use of tanning beds for all minors under the age of 18; at least thirty one states regulate the use of tanning facilities by minors; and some counties are also involved in regulating the use of specific tanning devices (10). The International Agency for Research on Cancer has openly encouraged policy makers to “consider enacting measures, such as prohibiting minors and discouraging young adults from using indoor tanning facilities, to protect the general population from possible additional risk for melanoma” (10). While intervening on the macro level shows great initiative and responsibility, heavy handed authority is not always a successful route through which to take public health intervention, especially with a target audience at the adolescent development stage.

Turning to behavioral science for analysis of this approach, “psychological reactance was first defined in 1966 by Brehm, as the motivational state directed toward the reestablishment of a threatened or eliminated freedom” (11). The four elements that are fundamental to psychological reactance theory include freedom, threat to freedom, reactance, and restoration; which have each been researched extensively concerning their association with message rejection.

Described in the article by Rains and Turner, “Psychological Reactance and Persuasive Health Communication: A Test and Extension of the Intertwined Model”, interventions such as educational efforts, warnings, and legal restrictions have all produced boomerang effects largely consistent with the conditions necessary to, and responses predicted by, psychological reactance theory. Through limiting or threatening freedoms, health messages have the potential to elicit reactance and, as a result, lead individuals to ignore the message, perform the opposite of the behavior advocated, or otherwise attempt to restore their threatened or lost freedom (9).

As we concluded from the previously mentioned statistics, adolescents under the age of 18 were those most likely to be frequent consumers at indoor tanning facilities. Evaluating the restrictive bans in terms of Brehm’s theory, the passed legislation inadvertently added to the increasing profits of the tanning industry, as opposed to decreasing the number of individuals dangerously exposed to UV radiation through indoor tanning, the intended goal. While their health and well being were at the foundation of the age restrictive bans, the legislation directly threatens the freedom of this particular population. Taking psychological reactance into account before intervening on behalf of the public’s health is an important component for any intervention. In doing so, the challenge for public health officials is to initiate interventions that will avoid threatening individual freedoms. If the intervention fails, psychological reactance becomes an additional risk factor for the unhealthy behavior, specifically indoor tanning.

Flaw #3: Ignoring Social Learning and Modeling as a Major Impact of Current Society

It is interesting to uncover that the desirability of associating a tan with attractiveness was not adopted until early in the twentieth century. Historically, suntanned skin represented working-class farmers and outdoor laborers, whereas fair skin represented nobility and wealth. Shortly after sun tanned skin was utilized by clothing designers as a new fashion statement, the American culture also adopted the appearance as a popular beauty trend. Extending beyond physical appearance, a suntan was considered a sign of good health, wealth, and prestige. (12) These messages did not end with fashion shows. “The mass media is constantly changing and evolving, and over the last twenty years, different media has emerged including music videos, computer games, and the internet; thriving in popularity amongst adolescents” (13). Today, a suntan is advertised in magazines, television shows, movies, and more. “Effects of Media Images on Attitudes Toward Tanning,” a paper written by Mahler, Beckerley, Vogel, described experiments determining whether exposure to images in these types of media showing attractive models who do not have a tan, relative to those who do, might result in less favorable attitudes towards tanning (12). Ultimately, the results concluded, that as popular media revealed attractive models with a suntan, the favorability towards a tan increased (12).

What can be pulled from these data is that many decisions made by adolescents incorporate influence from the environment around them, often times media exposure. Overwhelmingly in the current approach to reach adolescents concerning the danger of indoor tanning, public health officials and organizations are targeting the individual for change. This approach misses a significant impact of the vulnerable adolescent lifestyle, their models. In understanding the Social Learning Theory/Social Cognitive Theory, individual behavior is part of a triangle; an interaction between an individual, his or her behaviors, and the environment (14). As one of the first traditional health belief models to include group level factors, “Bandura emphasizes, in the social learning theory, the importance of observing and modeling the behaviors, attitudes, and emotional reactions of others. He states that, “learning would be exceedingly laborious, if people had to rely solely on the effects of their own actions to inform them what to do;” (15) therefore they proceed by the examples of others. When creating interventions targeting adolescent behavior, it is important to take into consideration the impact of models on this specific population.

Changing the Approach:

From the examples provided above, it is clear that there is significant support behind the efforts put forward to decrease the danger of indoor tanning. That being said, the methods through which they have focused their approach have been ineffective. Altering the current approach will result in a world of difference concerning both the public’s perception and well being, as it is associated with indoor tanning. A more meaningful intervention will move away from dependence on the rational education of the traditional health belief model, and will divulge deeper than just statistics, to show the public impactful stories of individuals suffering from their decisions to choose to expose themselves to the dangers of indoor tanning. In addition, the intervention will also separate itself from the adoption of legislative bans, thus avoiding common psychological reactance occurrence in the target population. Lastly, this new approach will appreciate and incorporate the impact of social norms on societal decisions; selling the movement at a group intervention level will yield much more successful results. The role of communicating this public health message will be complex, and understanding these advances from the traditional approaches will only progress the success of public health initiatives in years to come.

Intervention #1: Moving Education away from Statistics

Educating the public on their health has been, and will continue to be an important role of public health officials and those who work on behalf of public health interventions. However, the traditional manner of presenting statistics is not always as successful as we would hope. In using the health belief model, the law of small numbers and optimistic bias are more progressive social behavioral principles addressing human irrationality that are directly ignored. The law of small numbers explains that humans have a distorted view of probability and without a proper perspective on statistics relating to risk, it is impossible to expect humans to be able to relate to the numbers. In public health, the truth is often used as support, highlighting statistics and probabilities, in an effort to convince the masses to change their behavior; however, the masses have this distorted understanding of numbers so much so that they are not impacted by the numbers provided. (16) Complementing this idea, “Optimistic bias means that people have the tendency to judge their own susceptibility for a disease or other negative outcome as lower than other’s susceptibility. People in general expect positive events in their futures even if there is no reason to assume this outcome” (17). Interestingly, while they underestimate risk and probability of negative outcomes in their own lives, individuals commonly overestimate risk and probability of negative outcomes in the lives of the general population.

Smoking studies have been another area of public health in which these phenomenons have been apparent. Smokers are able to define the negative health risks of smoking as much greater than the actual numbers in discussion of the smoking population overall. However, when asked about their personal risk, smokers feel inferior to those negative health outcomes, underestimating the personal probability (16). Specifically targeting adolescents, Richard Branstrom and Yvonne Brandberg concluded in their study “that adolescents have strong positive optimistic bias for several of the most important health risks, diminishing the importance of their individual health behavioral risk, while identifying these same risks as the most dangerous to other people’s health in the general population”(17). It is clear that this irrationality is programmed in humans; most likely a technique for avoiding depression, building self esteem, and coping.

Learning from the aforementioned studies, these concepts present a much different understanding of the impact of statistics; these biases are in effect and they simply are not acceptable. Rethinking the strategies of facts and statistics moves education in a new direction. Approaches that take advantage of this human quality of irrationality will likely result in positive change for the indoor tanning efforts. How to proceed? A new intervention will target one or two powerful examples of the negative effects of indoor tanning exposure rather than discuss the probabilities of hundreds in a mathematical format. Those at risk already understand the danger of the masses; we need a message that will strike the individual much more personally. Finding ways to utilize the media, the television, radio, and internet, to share the narrative of an individual suffering from skin cancer caused by excessive exposure to indoor tanning radiation, will be much more relatable for the adolescent population than numbers. This one compelling story, if employed in a manner that reaches the masses, will have a disproportionate effect on those targeted, one that is much different than their original inclinations of inferiority. Controlling for these factors, as well as understanding the need for and implications of this change, will be the first positive step in changing the intervention.

Intervention #2: Avoiding Psychological Reactance

Health communication researchers and practitioners are becoming increasingly aware of the risk of activating psychological reactance in the process of translating health awareness resulting in less effective or even counterproductive results (18). From what we have learned about the reactions to threatened freedom, it is necessary for public health officials to take caution in creating intervention approaches that avoid reactance from the target adolescent population. Three key techniques to focus on in avoiding psychological reactance are explicitness, dominance, and reason. In order to enhance persuasion over the developing adolescents, the message needs to be clear to the point where it does not make use of obvious manipulation. The message should also minimize the tone of dominance, or extent of highlighting that the source of the message is in control; and lastly, should strategize for significant support behind it’s reasoning in order to soften the perceptions of intrusiveness observed from the target population (19).

Working from these recommendations, it is clear why current interventions supporting the legislative bans against miners using indoor tanning facilities have backfired. Because adolescents are extremely perceptive in defending their freedom, it is important to frame any intervention goals at invoking their most prized core value of freedom, as opposed to taking it away. For a most effective approach, a message needs to project affirmation rather than contradiction towards individuals’ beliefs and attitudes in order to encourage behavior change. Incorporating similarities between the source and the recipient of the message is a common tool used to significantly decrease reactance. Also, in acknowledging these tendencies of young people, another study suggests that “health campaigns utilize slick production effects, hip music, lively camera work, and sharp editing techniques to produce messages effective at capturing the attention of the highly at risk target audiences” (20). Culminating these suggestions encourages an approach that emphasizes representativeness to the adolescent in the message we project. Of great importance will be choosing the right messengers to capture the attention of the target population in addition to investing creativity that matches the creativity and technology so familiar to today’s youth. Rather than telling them what choices to make, our message needs to covertly persuade them to believe our mission is already engrained in their own belief systems. Similar to smoking cessation programs, perhaps we can frame the tanning industry as the “bad guys” who are eliminating their future freedoms of life. In doing so, we can join forces with the target population to restore the threatened value and ultimately make advances in their health. Despite public health support of legislative actions targeted to protect the health of adolescents, it will be important to separate those initiatives from employed interventions. Adolescents need to know that our mission shares commonalities with their deepest values and beliefs, and each of these changes will develop relatable characteristics. We’re about what they’re about, and together we will continue to preserve their freedom to be healthy-- not destroy their freedom to make choices.

Intervention #3: Realizing the Group versus the Individual

Lastly, moving beyond the traditional Social Learning Theory, and progressing towards group level approaches can be much more impactful. Three basic premises of alternative models highlight the power of group level thinking that are not accounted for in traditional models of public health intervention. First, a group is more than just the sum of individuals; therefore, group behavior cannot be explained by models at the individual level because mob mentality takes over and negates the individual decision making. Second, groups of individuals can be affected at the same time, specifically influencing behavior change; and thirdly, behavior is in fact, often unplanned, out of our control and dynamic including visceral drives and aspects of environmental context that take a significant amount of human decisions out of immediate control. (21)

Components from the Social Expectations Theory, Social Network Theory, and the Diffusions of Innovation Theory all contribute a unique new twist of new ideas and the ability of understanding the parts of the current intervention that have been left out, until now. Social expectations theory states that much of people’s behavior is explained and dictated by their perception of how members of their social group behave; therefore, if harmful behavior is perceived as the standard in a social group, the social urge to conform will ultimately rule the decision making process of the individual group members (22). This message mirrors behaviors from inside the classroom to relationships across the country. Once the idea of social norms is grasped, diffusions of innovations theory models how behavior is picked up in a pattern overtime and eventually results in the change of those social norms. Tracking the percentage of the population adopting specific intervention practices overtime gives light to the period, also known as the point of inflection or tipping point, in which the ideas of the intervention take off and influence the population’s conformity (23). Lastly, social network theory, similar to the concepts of social norms, considers the specific network of family and friends that individuals associate and identify themselves with as the target for intervention. For adolescents this could be groups such as sports teams, extracurricular activity groups, student government, or simply just best friends.

Turning to our specific health focus, the dangers of indoor tanning, the current approaches have targeted individuals to motivate change. They have simply been missing a huge factor in the influence of the adolescent lifestyle; social norms and networks. Aside from the media impact mentioned earlier, direct environmental factors are also in effect on this population’s decision making. Perhaps the most powerful change of the new approach to this public health issue will result from the understanding of the dictation of social norms. We will be able to reframe the new intervention with an environmental approach that seeks to impact both social and cultural environments as the way to then influence individuals (22).

From the current numbers, we know that the practice of indoor tanning, especially among adolescents, is socially acceptable and even desirable. The job of the new approach is to change the social norm. We are surrounded by historic successes of this approach every day including the elimination of the deviant behavior of spitting in public, the acquired use of seatbelts in automobiles, all the way to the adoption of smoke free bars and restaurants across the country! It works. Without much studying, we know the peer effects that occur in the adolescent developmental stage. Rather than targeting each teen as before, it will be more beneficial to intervene at the group level, targeting the teen through his or her whole social network to relay our message. If this intervention has succeeded, behavior will begin to increasingly change in the direction of the intervention message across the population over time. Once the majority of the population has adopted the new norm, we too will reach the tipping point in popularity. With the technological advances of today’s world, there are a number of ways to target social networks including campaigns utilizing Facebook and Twitter, as well as professional networking sites such as Linked In. In these domains, our message not only reaches the masses, but the groups of those specific individuals who are at risk; influencing the herd mentality that ultimately negates individual decision making in a new way.

Conclusion:

Identified in this analysis are three of the major flaws in the current approach to the dangers of indoor tanning facilities, specifically targeting the adolescent population. Highlighting the imperfections has turned up the volume on the call for new intervention. It is clear that the support is present to fight for the health of this population. However, change is needed. Addressing each of these flaws with progressive theories and concepts of social and behavioral science will only lead to success. In this new intervention, the focus will control for the misuse of traditional health belief model’s educational use of statistics and rational decisions, reactance against threatened freedom, as well as the influence of social norms and networks on the developing adolescent. Powerful stories, invoking the core value of freedom, as well as taking a group level approach will combine together to steer the campaign against indoor tanning facilities in a new and more successful direction --ultimately attracting the adolescent population to join the movement against the use of indoor tanning facilities. Using this evaluation, the public health message will find a way to shine brighter in the eyes of the growing adolescents than the “Bermuda Bronze” and “Desert Sun” advertisements for unhealthy behavior.

References:

1) "Indoor Tanning: The Risks of Ultraviolet Rays." U S Department of Health and Human Services. US Food and Drug Administration, 8 Dec. 2011. Web. 12 Dec. 2011.

2) Woo, Denise, and Melody Eide. "Tanning Beds, Skin Cancer, and Vitamin D: an Examination of the Scientific Evidence and Public Health Implications." Dermatologic Therapy 23.1 (2010): 61-71. Web. .

3) Stellefson, Michael, and J. D. Chaney. "Determinants of Indoor Tanning Behavior Among Adolescent Females: A Systematic Review of the Literature." The Health Educator 38.1 (2006): 15-21.

4) Kravitz, Miriam. "Indoor Tanning, Skin Cancer, and Tanorexia Development of U.S. Indoor Tanning Policy." Journal of the Dermatology Nurses' Association 2.3 (2010): 110-15.

5) "Indoor Tanning - Skin Cancer." Centers for Disease Control and Prevention. 2 Nov. 2011. Web. 12 Dec. 2011. .

6) Edberg, M. "Individual Health Behavior Theories." Essential of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury: Jones and Bartlett, 2007. 35-49. Print.

7) Bethesda MD: National Cancer Institute. “Theory at a Glance: A Guide for Health Promotion Practice Part 2.” National Cancer Institute. 2005. 9-21. (NIH Publication No. 05-3896) Print.

8) "Go With Your Own Glow." The Skin Cancer Foundation - SkinCancer.org. Web. 9 Dec. 2011. .

9) "Cancer - Skin Cancer Publications." Centers for Disease Control and Prevention. 5 Apr. 2010. Web. 12 Dec. 2011. .

10) "Tanning Restrictions for Minors." NCSL Home. National Conference of State Legislatures, Oct. 2011. Web. 12 Dec. 2011. .

11) Rains, Stephen, and Monique M. Turner. "Psychological Reactance and Persuasive Health Communication: A Test and Extension of the Intertwined." Human Communication Research 33 (2007): 241-69. Web. .

12) Mahler, Heike, Shiloh Beckerley, and Michelle Vogel. "Effects of Media Images on Attitudes Toward Tanning." Basic and Applied Social Psychology 32.2 (2010): 118-227. Web. .

13) Bell, Beth, and Helgar Dittmar. "Does Media Type Matter? The Role of Identification in Adolescent Girls’ Media Consumption and the Impact of Different Thin-Ideal Media on Body Image." Sex Roles 65 (2011): 478-90. Web. .

14) Siegel, Michael. “Traditional Health Behavior Models.” SB721. Boston University, Boston. 6 Oct. 2011. Lecture.

15) "Social Learning Theory (A. Bandura)." Instructional Design. Web. 9 Dec. 2011. .

16) Siegel, Michael. “Social Network Theory, Maslow’s Hierarchy of Needs, the Law of Small Numbers, Optimistic Bias, and the Illusion of Control.” SB721. Boston University, Boston. 1 Dec. 2011. Lecture.

17) Branstrom, Richard, and Yvonne Brandberg. "Health Risk Perception, Optimistic Bias, and Personal Satisfaction." American Journal of Health Behavior 34.2 (2010): 197-205. Web. .

18) Shen, Lijiang. "Mitigating Psychological Reactance: The Role of Message-Induced Empathy in Persuasion." Human Communication Research 36.3 (2010): 397-422. Web. .

19) Siegel, Michael. “Psychological Reactance Theory.” SB721. Boston University, Boston. 7 Nov. 2011. Lecture.

20) Miller, Claude, and Brian Quick. "Sensation Seeking and Psychological Reactance as Health Risk Predictors for an Emerging Adult Population." Health Communication 25 (2010): 266-75. Web. .

21) Siegel, Michael. “Alternative Models.” SB721. Boston University, Boston. 13 Oct. 2011. Lecture.

22)"Best Practices Social Norms." Web. 9 Dec. 2011. .

23)Siegel, Michael. “Diffusions of Innovation Theory.” SB721. Boston University, Boston. 20 Oct. 2011. Lecture.