Challenging Dogma - Spring 2008

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

Friday, April 18, 2008

TeenPEP: How It Fails To Rally Teens To Healthy Sex Behaviors - Kelly Diringer

Recent research suggests that adolescents are becoming sexually active at ever younger ages, with nearly 20% having had sex by the age of 15 (1). About a quarter of all new sexually transmitted disease (STD) cases occur in teens 15-19 years old, and two-thirds of cases occur in people ages 15-24 (2). A recent study conducted by the Centers for Disease Control (CDC) of STD incidence among American teenagers found that at least one in four teenage American girls has an STD, and among teens who actually admitted to having sexual intercourse (3), the rate jumped to a disturbing 40% (4). According to an Atlantic County Public Health Officer, these estimates are consistent with rates observed in New Jersey (4). New Jersey has the 16th highest pregnancy rate and the highest abortion rate among girls less than 20 years of age (5).
That sexual activity initiated during adolescence is associated with early pregnancy, STDs (some of which can lead to infertility and cancer), substance abuse and delinquent behaviors (6) is compelling evidence of the need for effective interventions to change sexual health behaviors among adolescents. Addressing unhealthy behaviors in adolescence would reduce the overall burden of disease and, thus, decrease associated economic costs (7).
The New Jersey Teen Prevention Education Program (Teen PEP) is a statewide peer education and sexual health promotion initiative for New Jersey high schools. The program trains teenagers for the roles of peer sexual health educator who are meant to be role models for sexuality related issues and to teach the importance of safer sex, including the use of condoms and birth control to prevent pregnancy and STDs, making good sexual health decisions and the consequences of unwise ones. In addition to their work among peers, peer educators lead workshops for parents and other family members to help improve communication, decision-making, negotiation, and self-management skills (8).
However, I will argue that there are limitations to TeenPEP that inhibit its success in enabling high school students to make healthy decisions. Specifically, I will argue that TeenPEP trains the wrong individuals to the role of peer educator, that there are socioeconomic disparities limiting parental involvement, and that the intervention is not designed to effectively reach the target population.
Wrong Students Trained as Peer Educators
According to social cognitive theory, behaviors are learned through the observation of others engaged in a behavior and the subsequent modeling of the behavior, with direct influences of parents and peers considered primary social references (9). With regard to the effectiveness of peer education approaches, observational learning presents the greatest impact when the peer educator is considered to be similar to the target population with respect to age, interest, behavior, experience, status, and social and cultural backgrounds (10, 11). The greater the assumed similarity, the more persuasive are the models' successes and failures (11).
However, the fact that interested ninth-graders are essentially self-selected to the role of peer educator via a voluntary application process and appointment by teachers based on qualities such as reliability, leadership, and ethics, guarantees that they will be different from the broader high school population. In fact, peer education programs like TeenPEP have found that peer educators are different demographically from the students to whom they deliver the sex education. Peer educators compared to program recipients were more likely to be slightly older, white (12, 13), female (14- 12, 13), high academic achievers (14-12, 13), and come from socially more advantaged families (12). If the target population sees the peer educator as very different from themselves, then their perceived self-efficacy is not much influenced by the models' behavior and the results they produce (11).
Social Network Theory focuses on the interdependence of individuals within a social system (kids in a classroom, a neighborhood, etc) and postulates that these individuals interact with each other and serve as references to each others’ decision-making. Like Social Learning Theory, Social Network Theory emphasizes the importance of “friendship homophily”, or the similarity between youths, with sex, age, academic interest, and participation in school activities acting as “filters for friendship selection” and peer group formation. An important predictor of the outcomes is thought to be an individual’s position in the social system, with close-knit group members experiencing a greater pressure to conform to behaviors than peripheral individuals (9).
Socioeconomic Disparities Limit Parental Involvement
Parental involvement and communication have been correlated to healthy behaviors in teenage children, thereby preventing teen pregnancy and sexually transmitted diseases (15, 16, 17, 18). Some data show that, in general, males are more affected by conversations with peers, while females are more affected by conversations with their parents (11). Other studies suggest that parents’ impact on adolescents’ health behaviors is greater than that of peers (16) with parent-teen communication having a protective effect that can extend well into teens’ college years (19). Taken together these data indicate that TeenPEP is justified in incorporating a parent-teen component into the health initiative. However, it fails to recognizes, and therefore fails to address, socioeconomic disparities in parental involvement that puts the most at-risk teens at a disadvantage to the benefit of parent involvement.
Minority and impoverished teens (18) and teens whose parents are unemployed and less educated (1, 20) are at a higher risk for initiating sexual intercourse, unsafe sex behaviors and acquiring STDs. The parents of these high-risk individuals are also the most underrepresented among the ranks of parents involved with the school-based activities (15). Parent socioeconomic status (SES), marital status, employment status, spoken language, and education have consistently predicted their level involvement or non-involvement in intervention programs (21). Common parent involvement barriers include changing work schedules, childcare and transportation problems, language barriers and conflicting family responsibilities (22) and are likely to be disproportionately experienced by individuals of lower socioeconomic status. Lareau and McNeal demonstrated that middle class parents may feel more welcome at schools than lower or working class parents, indicating that discrimination and intimidation may be an additional barrier unique to minority and lower SES parents (22, 15, 23).
Without addressing the barriers to parental involvement, particularly for those of lower socioeconomic status parent, the effectiveness of TeenPEP is limited.
Failure to Reach the Target Population
Black adolescents are more than twice as likely to be living in families with incomes at or below 200% of the federal poverty level (24). Relative to Whites, pregnancy rates and the prevalence of STDs are disproportionately high among African-American teens (20). SES has been shown to account for as much as 50% of the racial disparities in adolescent health (24). Williams and Collins identified residential segregation as “a central determinant of the creation and perpetuation of racial differences in SES” by limiting the housing options of black Americans to the least desirable residential neighborhood (25).
The Theory of Collective Socialization states that neighborhood role models and monitoring are important to a child’s socialization and can influence behavior, attitudes, values and opportunities (26). The number of affluent, high occupational status, stable adults has been found to play a significant role in healthy positive outcomes for youths (26, 27). Adults in disadvantaged neighborhoods negatively influence youths because of joblessness and undesirable activities (27). The affects of neighborhood persist even after accounting for the socioeconomic characteristics of families. In fact, simulations by Brooks-Gun et al. predicted that placing an adolescent white girl in the environment in which black adolescents are raised (holding family structure and resources constant), would result in a 2-fold increase in the rate of white teen pregnancy (26).
Interestingly, TeenPEP programs are more likely to be implemented in schools in counties with per capita incomes greater than the NJ median, with only 17 of 47 TeenPEP programs being in counties with per capita incomes less than $40ooo (Reference 800). This past March, a United Nations committee reviewing compliance with the International Convention on the Elimination of All Forms of Racial Discrimination (ICERD) criticized US for the racial discrimination in reproductive healthcare and recommended that comprehensive sex education programs aimed at prevention of STDs and teen pregnancy be implemented in neighborhoods with high proportions of African Americans (28).
TeenPEP is unlikely to successfully enable at-risk high school students to make healthy decisions about sex because the wrong individuals are trained to be peer educators, there are socioeconomic disparities limiting parental involvement, and the intervention is not designed to effectively reach those individuals most at-risk for negative sexual health outcomes.
Evaluations of peer education programs have consistently found that the only benefits were to the peer educators themselves, and despite an apparent increase in knowledge, sexual behaviors among program recipients did not change (12). This realization should motivate development of a revised intervention based on social/behavioral theories that do not rely on the assumption that knowledge equals action.
To increase effectiveness TeenPEP would need to expand to all school districts, particularly those in the poorest communities. The program should incorporate a system of nomination in which the target students are involved in the selection of future peer educators, which may result in a models for behavior that are more representative of the at-risk students. Lastly, schools should work to increase parental involvement and should recognize that a parent’s involvement is informed by their background (social class, race, prior education and experiences).
1. Rose A, Koo HP, Bhaskar B, Anderson K, White G, Jenkin J. The influence of primary caregivers on the sexual behavior of early adolescents. Journal of Adolescent Health 2005; 37:135-144.
2. Fox HB, McManus MA, Zarit M, Fairbrother G, Cassedy AE, Bethell CD, Read D. Fact Sheet No. 1. Racial and Ethnic Disparities in Adolescent Health Care and Access to Care. Incenter Strategies: For the Advancement of Adolescent Health. January 2007.
3. Nationally representative CDC study finds 1 in 4 teenage girls has a sexually transmitted disease. Chicago, Illinois: 2008 National STD Prevention Conference – Press Release, March 11, 2008.
4. Study finds 1-in-4 teen girls has a sexually transmitted disease. The Press of Atlantic City: Life One Page At A Time. March 12, 2008.
5. Guttmacher Institute. US Teenage Pregnancy Statistics National and State Trends and Trends by Race and Ethnicity. New York, NY: Guttmacher Institute, 2006.
6. Baker JG, Rosenthal SL, Leonhardt D, Kollar LM, Succop PA, Burklow KA, Biro FM. Relationship between perceived parental monitoring and young adolescent girls’ sexual and substance use behaviors. Journal of Pediatric Adolescent Gynecology 1999; 12:17-22.
7. American Social Health Association for Kaiser Family Foundation. Sexually Transmitted Diseases in the US: How many and at what cost? Research Triangle Park, NC: American Social Health Association, 1998.
8. Princeton Center for Leadership Training. New Jersey Teen Prevention Program (Teen PEP). Princeton, NJ: Center for Leadership Training.
9. Kobus K. Peers and adolescent smoking. Addiction 2003; 98(Suppl 1):37-55.
10. Strange V, Forrest S, Oakley A and The RIPPLE Study Team. What influences peer-led sex education in the classroom? A view from the peer educators. Health Education Research Theory & Practice 2002; 17(3):339-349.
11. Pan American Health Organization. Youth: Choices and Change Promoting Healthy Behaviors in Adolescents. Scientific and Technical Publication No. 594. Washington, DC: Pan American health Organization, 2005.
12. Borgin P, Marinacc C, Schifano P, Perucci CA. Is peer education the best approach for HIV prevention in schools? Findings from a randomized control trial. Journal of Adolescent Health 2005; 36:508-516.
13. Strange V, Forrest S, Oakley A and The RIPPLE Study Team. Peer-led sex education-characteristics of peer educators and their perceptions of the impact on them of participation. Health Education Research Theory & Practice 2002; 17(3):339-349.
14. Baskett-Milburn K, Wilson S. Understanding peer education: insights from a process evaluation. Health Education Research Theory & Practice 2002; 15(1):85-96.
15. McNeal RB. Differential effects of parental involvement on cognitive and behavioral outcomes by socioeconomic status. Journal of Socio-economics 2001; 30:171-179.
16. Green HH, Documet PI. Parent peer education: Lessons learned from a community based initiative for teen pregnancy prevention. Journal of Adolescent Health 2005; 37:S100-S107.
17. Nagy S. Barriers to parent involvement in middle school health education. American Journal of Health Studies 2000.
18. DiIorio C, Dudley WN, Soet JE, McCarty F. Sexual possibility situations and sexual behaviors among young adolescents: the moderating role of protective factors. Journal of Adolescent Health 2004; 35(6):258e11-258e20.
19. DiIorio C Dudley WN Lehr S Soet JE. Correlates of safer sex communication among college students. Journal of Advanced Nursing 2000;32(3):658-665.
20. Santelli JS, Lowry R, Brener ND, Robin L. The association of sexual behaviors with socioeconomic status, family structure and race/ethnicity among US adolescents. American Journal of Public Health 2000; 90:1582-1588.
21. Spoth R, Redmond C, Hockaday C, Shin CY. Barriers to participation in family skills preventative interventions and their evaluations: a replication and extension. Family Relations 1996; 45:247-254.
22. Lareau A. Social class differences in family-school relationsips: the importance of cultural capitol. Sociology of Education 1987; 60:73-85.
23. McKay MM, Atkins MS, Hawkins T, Brown L, Lynn CJ. Inner city African American parental involvement in children’s schooling: Racial socialization and social support from parent community. American Journal of Community Psychology 2003; 32(1/2): 107-114.
24. Fox HB, McManus MA, Zarit M, Fairbrother G, Cassedy AE, Bethell CD, Read D. Racial and ethnic disparities in adolescent health and access to care. Incenter Strategies for the Advancement of Adolescent Health Fact Sheet No 1. 2007.
25. Williams DR and Collins C. Racial residential segregation: a fundamental cause of racial disparities in health. Public Health Reports 2001; 116:411-416.
26. Brooks-Gunn J, Duncan GJ, Klebanov PK, Sealand N. Do neighborhoods influence child and adolescent development? American Journal of Sociology 1993; 99(2):353-395.
27. Moore MR. Socially isolated? How parents and neighborhood adults influence youth behavior in disadvantaged communities. Ethnic and Racial Studies 2003; 26(6):988-1005.
28. Soohoo C and Anderson K. US Falls short on racial disparities in health. RH Reality Check: Information and Analysis for Reproductive Health.

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  • At April 24, 2008 at 11:13 AM , Anonymous Jackie said...

    "In fact, peer education programs like TeenPEP have found that peer educators are different demographically from the students to whom they deliver the sex education"

    I completely agree. I think the last person that I would want to hear a talk about safe sex from would be some high-achieving kid that may just be doing the program so that s/he can put it on a college application. As a student receiving the lecture, I'd feel that s/he had no idea where I was coming from.

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