Challenging Dogma - Spring 2008

...Using social sciences to improve the practice of public health

Sunday, April 20, 2008

“Don’t Do It”: Why the Use of the Health Belief Model in Abstinence-Only Sex Education Doesn’t Work for Adolescents – Laura Anatale

Although encouraging adolescents to abstain from intercourse for as long as possible is an important strategy for reducing the incidence of sexually transmitted infections, Human Immunodeficiency Virus (HIV), and teen pregnancy, recent approaches have pushed abstinence-only sex education on adolescents as their only source of information in school. This approach limits the information available to adolescents about contraceptives and impacts their ability to make informed decisions about their behavior. Abstinence-only sex education does not work for adolescents, because it relies heavily on the Health Belief Model and fails to account for the social context in which adolescents operate or the varying stages of psychological development in adolescence.
What is the Health Belief Model and Abstinence-Only Education?
The Health Belief Model, a model of explaining health behaviors that was created by Dr. Irwin Rosenstock of the University of Michigan in the 1950’s, focuses on a risk-benefit analysis within a person that leads to a readiness to act on a health behavior. The model is used to explain the process by which a person weighs whether or not to cease an unhealthy behavior to avoid a disease. Rosenstock believed that once someone weighs whether or not they may be susceptible to a disease (their perceived susceptibility), how severe the disease would be (perceived severity), and what sorts of barriers existed within the individual that would stop them from ceasing an unhealthy behavior (perceived barriers to action), then that leads to their intention to start or stop a behavior. The problem with this model is that it does not account for many factors that exist in the real world that could interrupt a person’s intention from leading to the actual behavior. In the case of abstinence-only education, the health belief model does not account for the differing cognitive stages of adolescence, the social context in which adolescents operate, or the influence of the media on adolescents’ ability to perceive how susceptible they would be to STIs or pregnancy.
The federal definition of abstinence-only education under the Social Security Act defines an abstinence-only education program as a program that:
· has as its exclusive purpose, teaching the social, psychological, and health gains to be realized by abstaining from sexual activity;
· teaches abstinence from sexual activity outside marriage as the expected standard for all school age children;
· teaches that abstinence from sexual activity is the only certain way to avoid out-of-wedlock pregnancy, sexually transmitted diseases, and other associated health problems;
· teaches that a mutually faithful monogamous relationship in context of marriage is the expected standard of human sexual activity;
· teaches that sexual activity outside of the context of marriage is likely to have harmful psychological and physical effects;
· teaches that bearing children out-of-wedlock is likely to have harmful consequences for the child, the child's parents, and society;
· teaches young people how to reject sexual advances and how alcohol and drug use increases vulnerability to sexual advances; and
· teaches the importance of attaining self-sufficiency before engaging in sexual activity.
Abstinence-only education employs the Health Belief Model by focusing on “scare tactics”, such as inflated condom failure rates and STI rates, emphasizing heavily the severity and susceptibility of sexual behavior. A 2007 report that analyzed federal abstinence-only education programs found that some programs claim that the chances of becoming pregnant when using a condom are one in six, and that condoms fail to prevent HIV in heterosexual couples 31% of the time (1).
Abstinence-only education also assumes that creating an intention in adolescents to abstain until marriage will lead to the behavior. In a recent review of abstinence-only sex education programs in Texas, the authors found that the most common methodological approach to abstinence-only education among the programs is to teach about the consequences of engaging in sexual activities before marriage, as opposed to using a peer modeling approach or a youth development approach that improves a youth’s self-efficacy (2).
Abstinence-Only Education Ignores the Developmental Stages of Adolescence
Abstinence-only education does not take into account the unique developmental needs of adolescents. Not only do adolescents develop at different rates physically, but they develop emotionally and cognitively at different rates as well. As adolescents grow, they develop the ability to think abstractly about who they are, about the long-term implications of their actions, and they no longer rely so heavily on their peer group as a source of identification (3). However, during the process of maturation, adolescents can be stuck mid-development in the “bullet proof” phase, where they do not understand the risks involved in engaging in certain behaviors. The gap between physical and emotional development can lead adolescents to engage in risky behaviors as well (4). As a result, abstinence-only education’s heavy focus on perceived severity and susceptibility, emphasizing the risks involved in sexual intercourse before marriage as a means to scare adolescents into abstaining, does not effectively convince adolescents to abstain.
The most effective approaches to reach out to adolescents and reduce risky sexual behaviors are those that provide factual information, include role-playing activities to model positive behaviors, and address the social pressures of adolescence (5). In addition, the most effective programs are grounded in alternative theoretical approaches that more accurately assess an individual’s motivation, such as the Theory of Reasoned Action, the Theory of Planned Behavior, Social Influence Theory, or Social Cognitive Theory (5). These theories identify the antecedents of risky behavior – such as the influence of parents’ behavior, the influence of the social context of adolescence, and the influence of peer pressure. By focusing specifically on an antecedent and trying to change the influence of that on an adolescent’s behavior, programs can be more effective than simply proscriptively insisting that adolescents abstain until marriage. Abstinence-Only Education Frames Abstaining as a Moral Issue
Abstinence-only education also frames abstaining as a moral issue, linking marriage and commitment with intercourse. One of the criteria for abstinence-only education programs is that the program must teach that “a mutually faithful monogamous relationship in context of marriage is the expected standard of human sexual activity.” By framing sexual intercourse as only being acceptable through the context of marriage, it does not account for adolescents who are in low-risk, committed, monogamous relationships who may not choose to abstain and need information about alternative methods to ensure they remain STI and pregnancy free. It also does not account for adolescents who are in lesbian, gay, or bisexual relationships, for whom “waiting until marriage” does not apply. Both of these groups of adolescents need access to sexual health information and family planning services, and abstinence-only education does not provide the tools to protect these adolescents from pregnancy or sexually transmitted infections. (6) A recent survey of adolescents by the Kaiser Family Foundation found that most adolescents are not being educated properly about the effectiveness of contraceptives – one sixth of those surveyed felt that having intercourse without a condom every once in awhile was “not a big deal” while one in five respondents thought that birth control pills offered protection against sexually transmitted infections. (7)
Abstinence-Only Education Ignores the Social Context of Adolescence
Abstinence-only education’s use of the Health Belief Model also does not take into account the societal pressures on adolescents to engage in risky sexual behaviors or the social context in which adolescents are trying to abstain. Adolescents are bombarded with media messages that sex before marriage is acceptable, but are told in the classroom that they must abstain. The conflicting messages affect their ability to assess their perceived susceptibility to disease and pregnancy since sex is treated so casually in the media and the consequences of risky behaviors are hardly ever shown. One study found that extramarital and premarital sex situations on television outnumbered sexual intercourse between spouses 24 to 1, and the appearance or discussion of contraceptives was rare (8). The conflicting messages interrupt adolescents’ intention to abstain from leading to the actual behavior of abstinence.
Adolescents cite their top sources of information about sex as their parents, friends, the media, and classroom education. Three in five adolescents say that while abstaining is a good idea in theory, “nobody really does” (7). Television programs such as Gossip Girl and The O.C. show teenage characters regularly engaging in sexual intercourse, and hardly ever acknowledge the use of contraceptives. These media messages keep adolescents from seeing themselves as susceptible to sexually transmitted infections or pregnancy, which is a hallmark of abstinence-only education. Conclusion
With the increasing popularity of an abstinence-only approach in the classroom, researchers are beginning to design studies analyzing the effectiveness of these approaches. One recent study by Mathematica Policy Research, which instituted abstinence-only curricula in classrooms across the United States, found that abstinence-only approaches made youth no more likely to abstain (9). This finding underlines the ineffectiveness of this approach in reaching out to youth and improving the health of adolescents in the United States. Future approaches to sex education for youth should focus on a youth development approach, improving youths’ sense of self-esteem and self-efficacy, providing factual information, and empowering youths to make the decision about whether or not to abstain.
1. Lee, C. Condom Information in Abstinence Programs Called Inaccurate. Washington Post, April 28, 2007. Retrieved on the web 3/15/08.
2. Goodson P et al. Is Abstinence Education Theory based? The Underlying Logic of Abstinence Education Programs in Texas. Health Education and Behavior 2006; 33: 252-271.
3. Christie D, Viner R. ABC of Adolescence: Adolescent Development. BMJ 2005; 330: 301-304.
4. Steinberg L. Cognitive and affective development in adolescence. Trends in Cognitive Sciences 2005; 9: 69-73.
5. Kirby D. Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy. Washington, D.C.: The National Campaign to Prevent Teen Pregnancy, 2001.
6. Santelli J et al. Abstinence and Abstinence-only Education: A Review of U.S. Policies and Programs. Journal of Adolescent Health 2006; 38: 72-81.
7. Hoff T, Greene L, Davis J. National Survey of Adolescents and Young Adults. Menlo Park, California: Henry J. Kaiser Family Foundation, 2003.
8. Chapin J. Adolescent Sex and Mass Media: A Development Approach. Adolescence 2000; 35: 799-811.
9. Trenholm C. Impacts of Four Title IV, Section 510 Abstinence Education Programs: Final Report. Princeton, NJ: Mathematica Policy Research, 2007.

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