Challenging Dogma - Spring 2008

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

Tuesday, April 22, 2008

The Ineffectiveness of Fear: A Critique Interventions Targeting Adolescent Sexual Behavior – Miriam Drapkin

Adolescence is widely, and correctly, acknowledged as a time of important psychosocial development in which long-term health behaviors are adopted (1). Public health activists often target adolescents for interventions to promote positive health behaviors and reduce negative ones; sexual behaviors are some of the most commonly addressed aspects of adolescent health. Because unprotected sex and many sex partners are strongly associated with negative health outcomes such as teen pregnancy and contraction of STDs, interventions generally aim to reduce these behaviors (2). However, these interventions often emphasize the dangers and negative risks associated with sexual behavior, indicating a reliance on theoretical models such as the Health Belief Model and the Theory of Reasoned Action. These models are unproven or insufficient in positively influencing adolescent sexual behavior, and may even have a negative effect. Exploring the developmental aspects of adolescent behavior and decision-making and alternative models of health behavior may result in more efficacious interventions for improving adolescents’ sexual health.

Risk Perception and Adolescent Behavior
Sexual behavior interventions often fail to impact adolescents’ behaviors because they misconceive the link between risk perception and action. Interventions targeting adolescent sexual behavior often focus on risk awareness, or the degree to which adolescents acknowledge and believe themselves to be susceptible to negative consequences associated with high risk behavior (3). Millstein notes that “risk perceptions play a fundamental role in behavioral intervention programs, which try to get adolescents to recognize and acknowledge their own vulnerability to negative outcomes” (3). This approach is based on the belief that low levels of perceived vulnerability lead adolescents to engage in risky behaviors that they would otherwise avoid. However, the underlying assumption of the relationship between the perceived risk, vulnerability, and protective health behaviors in adolescents is surprisingly unsupported in social and behavioral science literature.
Contrary to the popular belief that adolescents perceive themselves as invincible and at low risk for negative health outcomes, adolescents experience relatively high levels of anxiety regarding nearly every aspect of daily life, including sexual health (3). Furthermore, adolescents are more than aware of the risk of negative outcomes and even overestimate their own vulnerability (3). In light of such evidence, one would expect lower levels of risk behavior among adolescents to correspond with higher levels of risk perception; however, the literature indicates that this is not the case (1). Sexual behavior interventions that are grounded in the belief that engaging in high risk behavior is due to adolescents’ lack of perception of the risks and consequences, therefore, appear counterintuitive.
This suggests that the link between perceived vulnerability and adoption of a health promoting behavior that is so essential to the Health Belief Model and Theory of Reasoned Action is unexpectedly weak. The effectiveness of employing interventions that further inflate the anxiety that adolescents feel about sexual health risks by focusing on the dangerous consequences of sexual behavior should, therefore, be questioned. Not only does it stand to reason that an intervention based on such a model might have a lower positive impact, but it may even have a negative impact on adolescents with already high levels of anxiety.
An alternative model for health behaviors and cognitive functioning may better explain the negative association between risk perception and sexual risk behavior in adolescents. Rather than viewing health decisions as made on an individual basis by a fully developed person, Knauth suggests a “framework in which the family, rather than the individual, is viewed as the emotional unit,” and that health decisions are made in the context of the developmental process of differentiation (4). In this theory, chronic anxiety is posited as the mechanism that hinders effective decision making with regard to risk behaviors; social problem solving aids individuals in managing anxiety and taking a healthy approach to decisions about health behaviors. Research has shown that higher levels of differentiation initiate and encourage the development of social problem solving skills, which are associated with lowered levels of chronic anxiety, which are in turn associated with decreases in risk behavior in adolescents (4).
The Differentiation of Self Model not only provides insight into mediating factors in adolescent decision making, but sheds light on how interventions based on individual-level behavior models focused on enhancing perceived risk might be not only ineffective but potentially harmful. By taking into consideration the context of anxiety that adolescents experience during the process of social cognitive development, the Differentiation of Self Model explores the negative effects that chronic anxiety has on the ability to solve social problems such as decisions about sexual behavior. This suggests that increased levels of fear and anxiety may actually hinder adolescents’ ability to avoid risky behaviors and adopt protective ones. Therefore, employing interventions that “emphasize the likelihood of negative outcomes seems counterproductive if young people already feel a sense of heightened vulnerability, particularly in view of the inhibiting effects of excessive anxiety on preventive health behaviors” (3). All this evidence suggests the inadequacy of traditional health behavior models, and that public health activists should examine alternative models in devising interventions for reducing risky sexual behaviors among adolescents.

Self-Efficacy and Autonomy in Adolescent Behavior
The Health Belief Model and the Theory of Reasoned Action are often criticized for failing to acknowledge the role of self-efficacy in the adoption or avoidance of various health behaviors. The same criticism applies in the case of interventions to reduce risky sexual behaviors in adolescents that focus on the negative consequences of such behaviors. Many interventions that are grounded in traditional health behavior models “assume that sexual activity and related behaviors, such as condom use, are controlled by an individual who makes a decision to take a risk or not” (5). However, decisions to engage in risky sexual behavior nearly always involve another person, and therefore cannot be evaluated solely in terms of the beliefs and values of an individual. The ability to make a health decision regarding sexual activity and the subsequent risk of that activity is influenced by the characteristics of an intimate relationship, including “unequal power dynamics with older partners, pressured or forced sex, communication difficulties, limited partner selection, and influence on condom use” (5).
By failing to consider the impact that a partner may have on an adolescent’s capacity to adopt protective health behaviors or avoid negative ones, traditional health behavior models bypass a potentially key component of the decision making process. Just as chronic anxiety has been shown to be negatively correlated with the adoption of healthy sexual behaviors, self-efficacy is positively correlated with them (5). Whitten has studied adolescents’ emotional responses to sexual activity as a variable in risk status, and finds that individuals who report discomfort or dissatisfaction when they have sex are significantly more likely to have an STD (5). In this evidence, Whitten finds support for the applicability of the Social Cognitive Theory, in that “negative reactions to intercourse might indicate a low level of self-efficacy for refusing unwanted sex” (5). Therefore, interventions that focus on encouraging individuals’ desires to adopt a protective health behavior without addressing whether they have the ability to engage in that behavior in the context of their relationships are inadequate for adolescents with lower levels of self-efficacy. Given the high rates of social susceptibility during the highly impressionable period of adolescent development, it is possible that interventions based on traditional health behavior models are, therefore, ineffective for a large proportion of adolescents.
Linked with self-efficacy (as well as differentiation) is the principle of autonomy. Autonomy is of key importance in adolescents’ cognitive development. The “importance of the relationship between cognitive processes (judgment and decision-making), social influences such as peer and parent influences, the development of autonomy, and how these factors relate to health behaviors during adolescence” cannot be overstated (6). However, the development of autonomy is omitted from traditional health behavior models, leaving a critical void in interventions that target adolescents, particularly those related to risk behaviors. Because adolescents “see risk-taking as a way to achieve identity and autonomy,” ignoring these contributing factors to adolescent behavior may reduce the efficacy of a given intervention (6).
Developing a health behavior model that takes into account adolescents’ desire for autonomy could go a long way towards understanding the types of interventions that positively affect sexual behavior in adolescents. Instead of viewing autonomy as a negative influence on adolescents’ behavior, it should be recognized as an asset. Spear notes that “when adolescents have the freedom to make autonomous choices and exercise independent personal responsibility, they are more likely to avoid negative health behavior such as smoking and practice health-promoting behavior” (6). The traditional, fear-inspiring sexual behavior intervention may actually have a negative effect on autonomy (as well as self-efficacy) because it increases the perception of danger from the environment, and reduces an individual’s sense of control over potential outcomes. Rather than relying on models that encourage an irrational level of fear and anxiety in adolescents, public health activists should focus on interventions that are grounded in models of autonomy, self-efficacy, and social problem solving to reduce high risk sexual behaviors.

Traditional health behavior models, specifically the Health Belief Model and the Theory of Reasoned Action are inadequate for devising interventions that target sexual behavior in adolescents. There is evidence that the emphasis these interventions place on the risks and negative consequences of sexual activity is not only redundant, but counterproductive in that it contributes to a generalized sense of anxiety that inhibits adolescents from adopting protective health behaviors. Furthermore, adolescents may be more influenced by social and developmental factors such as relationships with their partner and the extent of their independence that directly contribute to self-efficacy in adopting or avoiding certain sexual behaviors. Alternative models that consider the social and developmental context of adolescents are necessary in formulating efficacious interventions for adolescent sexual activity.

1. Wells SA. The Health Beliefs, Values, and Practices of Gay Adolescents. Clinical Nurse Specialist 1999; 12(2):69-73.
2. Dolan Mullen P et al. Meta-analysis of the Effects of Behavioral HIV Prevention Interventions on the Sexual Risk Behavior of Sexually Experienced Adolescents in Controlled Studies in the United States. Journal of Acquired Immune Deficiency Syndromes 2002;30:S94-105.
3. Millstein SG et al. Perceptions of Risk and Vulnerability. Journal of Adolescent Health 2002; 31S:10-27.
4. Knauth DG et al. Effect of Differentiation of Self on Adolescent Risk Behavior: Test of the Theoretical Model. Nursing Research 2006; 55(5):336-345.
5. Whitten KL et al. The Emotional Experience of Intercourse and Sexually Transmitted Diseases: A Decision-Tree Analysis. Sexually Transmitted Diseases 2003; 30(4):348-356.
6. Spear HJ et al. Autonomy and Adolescence: A Concept Analysis. Public Health Nursing 2004; 21(2):144-152.

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