England’s Maternal Prenatal Smoking Cessation-Robbie Frank

There are a number of successful smoking cessation interventions based on behavioral theories. Even though many smoking cessation interventions are deemed successful, none of the interventions are without flaws (12). In England, there is a smoking cessation intervention targeting pregnant women. This intervention is based on the theory of planned behavior (TPB). An intervention based on the TPB model is a fundamentally flawed approach to maternal prenatal smoking cessation because it is an individual level based intervention, it asserts that perceived behavioral control is a predictor of actual behavioral control, and assumes that human behavior is the output of rational, linear decision making process.
Intervention
The England Department of Health launched a smoking cessation ad campaign based on the TPB model targeting pregnant women (20). The ad shows an obviously pregnant woman smoking a cigarette. The campaign then goes on to provide information on how cigarette smoke “restricts the essential oxygen supply to an unborn baby, so that their tiny heart has to beat harder every time a pregnant woman smokes.” The campaign reinforces the message that cigarette smoking harms unborn babies, and that stopping smoking is the right thing to do (social norms say smoking when pregnant is bad). The ad also goes on to inform the reader that smoking cessation –no matter how far long the pregnancy is−will immediately benefit the woman and her baby (control belief—the belief in the ability to control the improvement of the health of mother and child will make it easier for the mother to participate in smoking cessation). It then offers information on how pregnant women can take the situation into their own hands and receive professional support to assist them in smoking cessation (perceived power). The offer of assistance in smoking cessation is meant to turn intentions into the desired behavior. This ad presents smoking cessation as a positive, desirable behavior that one can control.
Theoretical Framework of Intervention
To contextualize the flaws of the England smoking cessation intervention, it is important to understand the health behavior model upon which the intervention is fashioned. The TPB model was proposed by Icek Ajzen in 1985 as an extension of the theory of reasoned action (TRA). TRA is an individual level theory based on the concept that individuals go through complex cognitive assessments before making decisions on behavioral intentions. This is then followed by the rational movement from assessment to behavior (15). A person’s intent to perform (or to not perform) a behavior is viewed as the instant determinant of the action (13). TRA includes two determinants to intention: personal (attitude) and social (subjective norm). An attitude is described as a negative or positive evaluation of performing or not performing a desired behavior. Subjective norm indicates a person’s perception of the social pressure exerted by others who think that a given behavior should or should not be performed. This theory lacked because a person can go through the process of assessment and have a behavioral intention, but still not be able to do the behavior (13). To address this issue, a new element called perceived behavioral control was added to TRA. Perceived behavioral control refers to the degree to which someone believes they have control over whether they can take the action (control belief) and the strength of that belief (perceived power). This new element reformulated TRA to TPB. It attempts to explain the relationship between people’s attitudes and their behaviors, based on people’s perceived behavioral control and perceived power (13).
Flaws of Intervention
Individual Level Intervention

The ultimate goal of the ad intervention is to reach a broad target audience of maternal prenatal smokers and convince them to change to the desired health behavior of smoking cessation. This smoking cessation intervention is based on the TPB model. Due to such, this intervention has inherit flaws of the TPB model, one of which being that this intervention functions on the individual level. The ultimate goal of an individual level intervention is to change the knowledge, awareness, and skills of an individual. These types of campaigns focus on changing a specific aspect of an individual’s attitude, belief, and/ or cognition (27). This is a drawback in an attempting to change the health related behavior of a target audience because the enactment or non-enactment of the target audience’s behavior is likely a result of personal individual-level processes that precede the behavior. Because maternal prenatal smokers are not a homogenous group, different women will have different reasons for participating or not participating in the desired health behavior of smoking cessation. England’s individual level smoking cessation interventions does not take into account that being healthy and giving birth to a healthy baby is not a core value for all women. Due to such, a smoking cessation intervention must be able to find a common ground amongst pregnant women and impact those core values in order to effectively promote the behavior change of smoking cessation.
The individual level approach to maternal prenatal smoking cessation is unable to address the social factors that may influence the behavior of continued smoking. Research shows that tobacco use (or non-use) results from a complex mix of influences that range from factors that are directly tied to tobacco use (e.g., beliefs about the consequences of smoking) to those that appear to have little to do with tobacco use (e.g., parenting styles and school characteristics) (22). Thus, there are a number of social factors that attribute to why women continue to smoke during pregnancy. Some women have cited a socio-economic burden as a barrier to smoking cessation. These women are unable to fund smoking cessation aids such as cigarette modification products, thought changing products, and stop smoking educational products (22). In a study conducted by Greaves, research found that some women use cigarettes to “organize” their social interactions in order to build and bond pleasant social and work relationships (24). In other studies, pregnant women cited smoking as a tool of self definition. Continued smoking projected a personal image perceived by the smoker as cool, tough, defiant, adventurous, sexy, young, and slim. Smoking was also cited as a means through which pregnant women are able to suppress emotions or dissipate feelings of fear or pain in preference to expressing negative emotions openly. The behavior of continued maternal prenatal smoking was also influenced by the smoking habits of husbands, partners, family members, and friends. These factors can contribute to the difficulty of smoking cessation (2). An individual-level model is inappropriate in shaping a smoking cessation intervention for pregnant women because it neglects to acknowledge that the decision of smoking cessation is not necessarily made on and individual level and that there are a number of social factors that impact decisions related to health behaviors.
Perceived Behavioral Control is a predictor of Actual Behavioral Control
A fundamental defect of a maternal prenatal smoking cessation intervention based on the TPB is the assumption that perceived behavioral control is a predictor of actual behavioral control. It is postulated that perceived behavioral control serves as a proxy for actual behavioral control, therefore having a direct influence on both intention and the actual behavior (1). On the contrary, perceived behavioral control is fundamentally different from actual behavioral control. Perceived behavioral control is a strong predictor of the strength of a person’s intention to participate in a certain behavior (25), not a substitute or predictor for the actual behavioral control that a person possesses. Actual behavioral control refers to the extent to which a person has the skills, resources, and other prerequisites needed to perform a given behavior (19). Due to the conceptual difference between perceived behavioral control and actual behavioral control, it is inaccurate to assume that perceived behavioral control can predict or impact a person’s actual behavioral control. Whether or not a person perceives that he/she has full control over his/her ability to perform a behavior and also the strength to do so, does not necessarily lead to the person performing the desired behavior (25). The TPB model does not accurately predict how people move from intention to behavior because it inaccurately asserts that perceived behavioral control is a predictor of actual behavioral control.
In a study conducted on the influence of perceived behavioral control, research revealed that perceived behavioral control impacts behavior only through the prediction of a person’s behavioral intentions (8). Perceived behavioral control is a strong predictor of the intent to do a behavior, but not a predictor of the actual behavioral control a person possesses (25). The fulfillment of many health behaviors do not coincide with attitudes towards, or intentions regarding a specific behavior. The England’s maternal prenatal smoking cessation intervention possesses the ability to convince a pregnant woman to develop a strong belief that she has control and power over her ability to stop smoking. However, strong perceived power and control beliefs do not lead to actual behavioral control, which is necessary to act on the desired behavior intention. Strong perceived power and control beliefs lead to strong intentions to do the desired behavior. Strong intentions is not sufficient enough to illicit the execution of a desired behavior. Pregnant women must possess actual behavioral control in order to perform the intended behavior (19). The assertion that the belief of perceived behavioral control is linked to pregnant women’s ability to act on the intention to participate in smoking cessation is inaccurate. Actual behavioral control must be present in order for a person to act upon his/her perceived behavioral control. Without actual behavioral control, the pregnant woman does not possess the skills and resources necessary to enable her to exercise the intended behavior of maternal prenatal smoking cessation. It is therefore difficult to assess how the construct of perceived behavioral control impacts behavior modification without first understanding the role that actual behavioral control plays in the human decision making process.
Human Behavior is Rational and Linear
Due to the fact that this intervention is rooted in the TPB model, its design oversight assumes that behavior is the output of rational, linear cognitive decision making processes (15). Many behavioral theorists and social scientists argue that human behavior is complex and irrational, therefore difficult to predict (18). Irrationality is defined as the tendency that humans possess to behave, express emotions, and think in ways that are inflexible, unrealistic, absolutist and self- and social-defeating and destructive (16). In light of the irrational nature of human behavior, it cannot feasibly be asserted that decision making is a linear, planned process. Human behavior is affected by the broad social or cultural environment surrounding the behavior, the immediate social situation or context in which the behavior occurs, the characteristics or disposition of the person performing the behavior, the behavior itself and closely related behaviors, and the interaction of all these conditions (22). There are a number of factors that can cause a person not to carry out their planned behavior. In smoking cessation, the decision to use or not to use tobacco is linked with a range of factors, some of which have little or not relation with actual tobacco usage (22). The human decision making process is the result of a complex interplay between cognitive, emotional, social, personal, and environmental influences (16) that can often time lead to irrational, self defeating unplanned behavior.
Today, most pregnant women seem to be aware of the health risks associated with maternal prenatal smoking, however, awareness alone is not sufficient enough to prompt women to stop smoking (9.). Studies show that maternal prenatal smoking is not solely the result of a lack of knowledge of health risks associated with the behavior. It is instead the result of the human decision making process which is shaped by external factors that can persuade women to deviate from the planned, desired behavior of smoking cessation (7). The assumption that decision making is a linear process neglects to consider the extraneous factors that might influence the target audience’s behavior. In a study of women’s attitudes toward smoking, it was found that although most of the women in a focus group considered themselves addicted and dislike smoking itself, they liked the social, psycho-logic, and physical effects of the cigarettes (23). Some reasons given by women for maternal prenatal smoking included those related to an inability to cope with psychological issues (i.e., depression, anxiety, irritability, etc.) and their physical addiction to nicotine (the appearance of characteristic withdrawal symptoms when the use of nicotine is suddenly discontinued) (3). Other factors associated with smoking cessation for pregnant women are their level of education and their race. Research reveals that smoking cessation among pregnant women increases as their level of education increases (5.). In 1991, 45.4 percent (±10.5) of women with 16 or more years of education quit smoking during pregnancy. This finding is consistent with previously published studies (6, 11.). Studies also showed that the percentage of smokers who reported having quit smoking for at least one week during their pregnancy was higher among American Indian mothers (64 percent) than among white mothers (57 percent) or black mothers (49 percent) (26). The factors that impact the decision to participate in maternal prenatal smoking cessation are not all rational, nor are they part of a linear decision making process. The previously stated research helps to illustrate the fundamental flaw of a maternal prenatal smoking cessation intervention based on the TPB model because it demonstrates that the human decision making process is irrational and unplanned (10), thus completely contradicts the functioning of the TPB model.
Conclusion
Due to the inherent flaws and shortcomings of all health behavioral theories, there is no one theory able to adequately and accurately predict human behavior. Human behavior is complex and influenced by a number of intrinsic and extrinsic factors (12). When attempting to predict human behavior, it is important to examine behavior decisions in the context of the target audience’s needs, preferences, social and environmental networks, and core values. In regards to such, public health practitioners must design and utilize health behavior modification interventions based on appropriate health behavior models in order to continue to advocate for healthier behavior.
Introduction
In assignment #3, the fundamental flaws of a maternal prenatal smoking cessation intervention based on the theory of planned behavior (TPB) approach was highlighted. This paper addresses the fundamental flaws highlighted in assignment #3 by offering an alternative approach to the maternal prenatal smoking cessation intervention. To address the fundamental flaws of the TPB approach, the new approach is based on the framing theory. Framing theory asserts that an issue can be viewed from a number of different perspectives . These different vantage points can be interpreted as having implications for multiple deeply ingrained core values of a population. Framing refers to the process by which people develop a particular conceptualization of an issue or organize their opinions about an issue (30). Thus, framing theory redefines, repackages, repositions, and reframes behavior modification interventions in a way that addresses the fundamental core values and needs among the target audience (33). The framing theory approach improves upon the flaws of the TPB approach in assignment #3 because it functions on a community level, takes advantage of the fact that human behavior is irrational and decision making can be non-linear, and it understands that perceived behavioral control is not a predictor of actual behavior control because there are external factors that can impact whether or not a person performs a desired behavior.
Functions on Community Level
Unlike the TPB approach, the framing theory functions on a community level by addressing the wide-spread core values of the target audience. This theory does so by speaking to the packaging and positioning of a public health intervention to appeal to deeply ingrained, widely shared core values held by the target audience (33). A community level smoking cessation intervention must be able to address the common ground amongst pregnant women and impact those core values in order to effectively promote the behavior change of smoking cessation. Literature shows that health is generally important to individuals because it impacts their core values by garnering the fundamental need and desire to have a certain degree of personal freedom, independence, autonomy, and control over their lives (33). To market changes in health behavior, public health must redefine, repackage, reposition, and reframe the health behavior intervention in a way that satisfies an existing demand among the target audience (33). By redefining the problem, framing also suggest a new solution to the problem (35). Framing theory moves the maternal prenatal smoking cessation intervention from the individual level to the community level because this approach equips the intervention with the capacity to appeal to the core values of the general public (34).
While the underlying model in assignment #3 tries to change current health behaviors to fit with the suggested health behaviors, the framing theory recognizes that the target audience will only take action when they believe that the suggested behavior aligns with the core values of their community. Thus, the framing theory focuses on appealing to its audience’s widely accepted core values and not the health value of the public health practice (33). For example, if public health practitioners were trying to market a framing theory approach of smoking cessation to pregnant teenaged girls, the intervention should address the core values of this target audience. Research shows that continued smoking during pregnancy projects a personal image perceived by the smoker as cool, tough, defiant, adventurous, and sexy (29). The framing theory approach could use these core values to create an intervention that sends the message that not smoking during pregnancy is cool, tough, defiant, adventurous, and sexy. This repackaging and repositioning of teenaged maternal prenatal smoking cessation speaks to the core values of a large community of people, thus having appeal beyond the individual level.
Takes Advantage of Irrational Human Behavior and Non-Linear Decision Making

The framing theory takes advantage of the fact that human behavior is irrational and that decision making can be non-linear. This theory addresses the flaws from assignment #3 by using irrational human behavior and spontaneous decision making as means through which it can change the perception of a suggested behavior while ultimately changing the audience’s perception of self interest. It does so by altering the relationship between the perception of the behavior and the audience’s self interest. Framing theory does not assume the need to change its audience’s health behaviors to conform to the suggest health behavior. This model redefines the suggested behavior so that it is perceived as being in the audience’s self interest and addresses the audience’s core values (33). This will encourage the audience to participate in the suggested behavior. This is achieved by demonstrating that the intervention will help the audiences to fulfill its fundamental needs and desires.
For example, a maternal prenatal smoking cessation campaign based on the framing theory can use a group of core values; such as freedom, independence, and control, to frame an intervention. Instead of defining a smoking cessation intervention as a behavior that will improve a person’s health, it can be redefined to be perceived as a behavior that will offer smokers freedom from the tobacco industry’s manipulation, independence from the addiction of nicotine, and control over the fate of their lives. In this smoking cessation campaign, the solution to the problem of loss of freedom, independence, and personal control is smoking cessation. The irrational behavior and non-linear nature of human decision making enables the relationship between the perception of the audience’s behavior and the perception of the audience’s self interest to be altered by repackaging and repositioning a smoking cessation campaign to be about empowerment within the target community.
Perceived behavioral control is not a predictor of actual behavior control because there are external factors that can impact a person’s ability to perform a desired behavior

The framing theory accounts for the fact that perception of control over one’s ability to complete a behavior (perceived behavioral control) does not necessarily lead to actually having the power or control to practice that behavior (actual behavioral control). Perceived behavioral control does not lead to actual behavioral control because there are external factors that can limit a person’s ability to perform a behavior in which he/she might have perceived control over (13). Whether or not a person perceives that he/she has full control over his/her ability to perform a behavior and also the strength to do so, does not necessarily lead to the person performing the desired behavior (25). Research shows that tobacco use (or non-use) results from a complex mix of influences that range from factors that are directly tied to tobacco use (e.g., beliefs about the consequences of smoking) to those that appear to have little to do with tobacco use (e.g., parenting styles and school characteristics). Thus, there are a number of social factors that attribute to why women continue to smoke during pregnancy (22).
The TPB approach does not accurately predict how people move from intention to behavior because it inaccurately asserts that perceived behavioral control is a predictor of actual behavioral control. It does not consider the impact of external factors in a person’s ability to have actual behavioral control. The framing theory addresses this flaw by redefining, repackaging, repositioning, and reframing the health behavior intervention in a way that satisfies an existing demand or need within the lives of the target audience, thus, addressing the external needs and desires of the audience to enable them to participate in the desired behavior (33). For example, a group of pregnant women have the desire to stop smoking are offered an opportunity to participate in a free program that will assist them with smoking cessation (perceived behavioral control). Unfortunately, many of the women are unable to attend the weekly program due to transportation issues, lack of appropriate child care, work, etc. This means that these women do not possess actual behavior control to carry out their desired behavior of smoking cessation. A framing theory approach would restructure the health behavior intervention in ways that would satisfy the demands and needs within these women’s lives in order to give them actual behavior control to participate in smoking cessation.
Conclusion
Maternal prenatal smoking is a complex behavior that is influenced by a number of factors. The framing theory is able to addresses the different ways in which situational and personal factors influence a woman’s decision to participate in smoking cessation. The framing theory provides public health practitioners with a means through which they can define, position, and package a smoking cessation intervention in ways that address pregnant women’s core values and help to them to quit smoking.





Works Cited

References
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2.) Brosky, G. Why do pregnant women smoke and can we help them quit? Canadian Medical Association Journal Jan. 15, 1995; 152(2): 163–166.
3.) Draper, E. and Haslam, C. A qualitative study of smoking during pregnancy.
Psychology Health & Medicine 2001; 6, 95−99.
4.) Dutta-Bergman, M. Theory and Practice in Health Communication Campaigns: A Critical Interrogation. Health Communication 2005; 18 (2); 103–122.
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pregnancy. American Journal of Public Health 1990; 80 (5):541–4.
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Health Sept. 1989; 103 (5): 337-43.
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The Gardasil Campaign: Merck, Take a Look at it from a Public Health Perspective – Maithili Jha

In 2008, the American Cancer Society (ACS) estimated that 11,070 women in the United States were diagnosed with invasive cervical cancer, and 3,870 women died of cervical cancer (4). A leading cause of cervical cancer is human papillomavirus (HPV) that is passed sexually from one person to another (1). In response to both the rate of cervical cancer and the cause of cervical cancer, pharmaceutical companies have been racing to find a vaccine against HPV. One such pharmaceutical company, Merck claims that they have succeeded in finding a vaccine against HPV called Gardasil. Merck’s marketing approach to promote the drug was to lobby for mandatory vaccinations for 11 year-old girls in junior high, and infiltrate the media with the “One less” advertisement. The Food and Drug Administration and the Center for Disease Control have approved and recommended Gardasil, for women between the ages of 9 and 26. The FDA and the CDC also convey the message that women who are already infected with HPV will not be protected by the vaccine (5). While some may see the importance in vaccinating a female before potential exposure to HPV, others have seen Merck’s lobbying of mandatory vaccination of young girls in schools as a point of controversy and the “One Less” campaign as misleading. This paper will review and evaluate the means with which Merck has promoted the Gardasil vaccine, from a public health perspective.
The Premature Promotion of Gardasil, Merck could have used HBM
The FDA approved Gardasil for marketing and sale in 2006. Soon after, Merck began lobbying for mandated vaccinations in schools (14). The lobbying campaign ended in February 2007, but the opposition and views against compulsory vaccinations for a sexually transmitted virus still linger for two reasons. First, the vaccine was marketed and promoted before the entire public even knew what HPV was or that HPV may lead to cervical cancer. And, second, because representatives in at least 24 states and DC have initiated legislation to require vaccination in schools (9).
Rick Perry, the Governor of Texas, issued an executive order requiring Texan schoolgirls to be vaccinated against HPV. The conclusion that "the governor of Texas provided a solution to a problem before many were even aware of the problem. Educating the public after the fact is much harder” (11) remains even though three months after Rick Perry issued the order, he passed a bill undoing the mandate. Rather than using policy to market the vaccine, the promoters of Gardasil would have benefited from the use of traditional health behavior models such as the Health Belief Model. To an unaware public, education relaying the risks associated with HPV, marketing the benefits of preventing HPV, and addressing the perceived barriers to getting the vaccine may have muffled the backlash against expedited vaccinations.
In 2004, Holcomb, Bailey, Crawford and Ruffin conducted a study assessing adults’ knowledge of HPV. They concluded that adults seen in a physician’s office have a limited knowledge of HPV (7). In 2008, Gerend and Magloire conducted a similar study, and found that awareness of HPV was relatively high and increasing amongst sexually active individuals. They then went on to say that “With the release of Gardasil, Merck has since initiated its ‘One Less’ marketing campaign, which has received regular television airplay. High levels of awareness observed in the present study, coupled with the fact that television, radio, and magazines were cited as the most common sources of HPV information, provide some evidence for the effectiveness of these campaigns” (6). However, even though Gerend and Magloire’s study found that the awareness of HPV among sexually active individuals was relatively high, women who may have benefited the most from the vaccine, namely those who are not yet sexually active, were more likely to communicate the least interest in getting vaccinated (6). Had the campaign addressed the perceived risks of being sexually active and getting HPV, and the perceived benefits of being vaccinated, then maybe the parents or guardians of the eleven-year-old school girls and women who are not yet sexually active would be more receptive to the idea of endorsing and using Gardasil, and feel like they are at risk.
The perceived barriers associated with implementing mandatory vaccinations are multi-faceted. The monetary cost of Gardasil may be too high for some women, and calculating the return on the investment of being vaccinated may be difficult. The Gardasil vaccine costs $125 per dose, and $375 for the full series consisting of three vaccinations. While some health insurance companies may cover the costs being vaccinated, others may not (8). If a young girl is required to be vaccinated against the virus, and she does not have adequate health insurance then her parents or guardians would be forced to pay on their own. Once approached with a bill for a vaccine against a sexually transmitted virus, the parents and/or guardians may question why they should pay for a vaccine, if there is a chance their child may not get HPV. A parent’s acceptance of the idea of their child being sexually active is variable. As a writer for the National Health Federation states, “…many parents are opposed to making the vaccine mandatory, and in some states, like Massachusetts, the efforts have stalled. Some parents are opposed to mandatory vaccination on moral grounds, believing that vaccinating their daughters against a sexually transmitted disease sends the message that sexual activity at such a young age, or even prior to marriage, is acceptable. Others simply believe that the government has no right to usurp parental authority by mandating a vaccine for a disease that is not spread through casual contact” (2). Religious views, conservative values, education, and socio-economic status are all examples of what may affect how willing a parent is to consider the risks of their child being sexually active, even if their daughter will not be sexually active until she is older.
Mandatory vaccination of 11-year-old girls does not provide the parents and guardians with a sense of self-efficacy. Along with the vaccination, the lobbyists have not proposed a method for the parents to approach their daughters with the topic of sexual activity and consequences thereof. The mandate does not provide HPV education for the parents and children, leaving the parents and children to learn about the causes and effects of the virus on their own. Incorporating educational materials administered by the schools for the parents and children into the mandate may ease the transition into having children be vaccinated.
Social Cognitive Theory says, “Don’t just look at the 11 year-old, look at her environment too”
The Gardasil campaign failed to consider the individuals environment, when proposing mandatory vaccinations, and could have better incorporated how an individual responds to cues from the environment and visa versa, or reciprocal determinism into the campaign. In the 1960s, Albert Bandura proposed a behavioral theory that looked beyond the individual, and into the individual’s environment (3). He suggested that behavioral change is dependent on three constructs: individual characteristics, environmental factors, and reciprocal determinism (3).
Environmental factors like social norms, culture, and religion, affect an individual’s decisions. Before educating the public with the “One less” campaign or lobbying for mandatory vaccinations, the Gardasil campaign should have taken into account that the vaccine is to guard against the result of a behavior – sexual activity. In conservative groups, religious or political for example, the reception of learning about sexual behavior differs. A conservative Muslim woman may not be open to talking about her sexual behavior, or may not consider herself at risk for HPV, because of her conservative background and the understanding that she only has one partner. Yet, that Muslim woman is as much at risk of getting HPV as anyone else, simply because the virus is sexually transmitted. Merck should have borrowed from Bandura’s theory, evaluated the situations in which HPV occurs, and the perceptions of those situations within a social group by the individuals themselves (3).
Follow the Communications Theory, Avoid a False Sense of Security
As stated earlier, the Gardasil vaccine was the fasted drug to be approved and endorsed by the FDA and CDC. Because of this, the drug was prematurely marketed as a cervical cancer vaccine and not an HPV vaccine for certain strains. And, Merck’s marketing department and the lobbyists petitioning for mandatory vaccinations unsuccessfully communicated the vaccine’s purpose and benefits, while providing a false sense of security to the public (10). Previous public health campaigns had similar shortcomings until they started utilizing theories like the Communications Theory (CT). It is unknown as to whether Merck’s marketing department followed the CT when promoting Gardasil. But, it is apparent that when applying CT to the Gardasil campaign, weaknesses in Merck’s marketing approach begin to surface.
The Communications Theory states that one must consider the source of the message, the message itself, the channel by which the message is communicated, the receivers of the message, as well as feedback and understanding from the receiver (3). The Gardasil campaign is vulnerable to criticism, because it did not consider the message, the receiver, or whether there is feedback and understanding from the receiver.
Within the constructs of CT, the sources of the Gardasil campaign are Merck, lobbyists, and the policy makers in favor of mandatory vaccination. The message that Merck conveys in its “One less” campaign is that Gardasil is a vaccine against cervical cancer and that women should make the decision on their own, without the influence of policy to be vaccinated. The lobbyists say that schools should implement mandatory vaccinations. The lobbyists are sending a message that the vaccine will be effective if made mandatory by policy makers for grade schools, and this message is incongruent with Merck’s ad campaign highlighting personal initiative. Merck used media (television, print ads, news channels) and policy as the channels to convey their messages. In the “One less” campaign, the receivers of the message are the women receiving the vaccine, and the policy makers who could implement mandatory vaccinations. And, to the lobbyists, the receivers are the policy makers and other people able to influence whether the vaccine becomes a requirement for eleven-year-old school girls.
Either Merck should have enlisted the aid of public health organizations to formulate its message and educate the receivers that Gardasil is a vaccine against the strains of HPV that are the leading cause of cervical cancer, or they should have incorporated that education into their own advertisements. “One less,” that is, “one less woman with cervical cancer” does not relay why women should take Gardasil, a vaccine against HPV, resulting in a false sense of security against the cancer. The lobbyists and some policy makers have endorsed the idea of mandatory vaccinations of eleven year-old girls. Their proposals should include education plans for schools, physicians and parents about HPV, how it relates to cervical cancer, and behaviors leading HPV, instead of just proposing vaccinations.
Merck’s advertisements use young women and mothers as subjects. However, young women and mothers are not the only receivers in the campaign. On the one had, the lobbyists are saying that it is best to implement mandatory vaccinations for girls who are eleven and twelve years old before they are sexually active. And, on the other hand, Merck is not using eleven and twelve year olds as the subjects for their advertising, but young women making decisions on their own. Both the lobbyists and Merck’s advertising team are not taking into consideration other receivers of their message: the parents of eleven and twelve year old female students, those families and young women who cannot afford the vaccine for their children or themselves, the sexual partners of the women who are not infected with HPV yet, but could be in the future, religious and conservative groups, and physicians. Again, advertisements directed to parents of the children who would be vaccinated, as well as education programs for all the receivers of the message should be integrated into the campaign.
While it is difficult to gauge understanding of a concept, it is important for Merck and the lobbyists to continue market research on whether all the receivers know what HPV is, and what Gardasil does. Even if the eleven year olds do not fully understand why they are receiving the vaccine, the parents and guardians of the children should understand why they must vaccinate their children against a sexually transmitted virus.
Bridging Private and Public Domains
While this has not been a critique of Gardasil, the vaccine, but it has been a critique of Merck’s approach to promoting the vaccine. Public health is still developing and improving upon its models for influencing behavioral change, private companies such as Merck would benefit from utilizing established traditional and non-traditional health behavior models in their marketing campaigns, and promotions of therapeutics. By learning from the Gardasil campaign, one hopes that in the future private industry, and public health will be able to form a liaison and prevent the educational holes in the public’s awareness of pharmaceutical effectiveness.
Two-Step Marketing, a New Approach to Vaccine Promotion
When Merck used marketing techniques in combination with policy promotion for the Gardasil campaign, they had the potential to positively impact a wide population. However, Merck fell short of its potential. Instead of focusing on ways to limit controversy surrounding the nature of the virus, or barriers to receiving the vaccine, they rushed to have the vaccine approved and promoted by the FDA and the CDC, and lobbied for mandatory vaccinations of girls in grade school. This section will propose an alternative approach to promoting the vaccine, addressing the three previously stated arguments for why Merck’s Gardasil campaign failed, while staying within Merck’s constructs of coupling marketing and public policy. This new two-stage approach would allow Merck to use policy to influence its advertising schemes, and would allow policy to steer Merck’s advertising schemes as well, splitting the marketing efforts into two phases: education (Stage I), and product promotion (Stage II).
Premature Promotion of Gardasil Leading to an Uneducated Public : Stage I
Merck marketed the Gardasil vaccine using the “One Less” advertisement, before the entire public knew what HPV was or that it may lead to cervical cancer, resulting in the misconception that Gardasil prevents cervical cancer. To thwart this reaction, State and Federal lawmakers should propose legislation requiring the pharmaceutical company producing the vaccine to advertise their product in two stages. First, in Stage I they would need to use market research techniques to gauge the public’s knowledge about HPV and cervical cancer, and release a preliminary set of educational advertisements. Then, Stage II of advertising would be for the drug itself.
With a policy in place requiring pharmaceutical companies to assess the knowledge of the public about the product, Merck would need to find out how much people know about HPV, cervical cancer, and their relationships to sexual activity. Asking questions like: ‘Do you know what the vaccine guards against?’ ‘Do you know the causes of HPV?’ ‘Are you comfortable talking to your children who are under the age of twelve about sex, and the risks involved with sexual behavior?’ would provide insight as to whether the “One Less” campaign is informative or misleading. And, asking these questions would lead to the first stage of advertising involving education in HPV, not Gardasil. The ads may involve mothers and fathers talking to their daughters about HPV, or could be in the form of educational pamphlets and web-based seminars for health care providers
In return, Merck would not just lobby for mandatory vaccinations, but for vaccinations and HPV/vaccine education in grade schools. The education in the school systems would involve informing the parents and guardians of the children about the benefits of the vaccine, thereby minimizing the impact of addressing sexual behavior with children. Merck would be able to incorporate finding out when parents and guardians are comfortable with learning about HPV vaccinations into their market research efforts for Stage I. Thus, Merck would be able to determine how much time parents need to be educated in the subject, and lobby for the amount of parental education necessary.

Does one Ad Apply to Everyone, Everywhere? : Stage II
For Stage II, Merck would use all of the information gathered during the market research phase, and determine how answers to their questions may vary according to race, ethnicity, age, gender, culture, and socio-economic status amongst other variables. Currently, there are not many variations to the “One Less” advertisements. Merck, has not marketed to conservative groups, transgender individuals, immigrants, or partners of those getting the vaccine. By performing the necessary market research for Stage I, Merck’s marketing directors would understand the challenges faced with being from a conservative culture and bringing up the topic of sexual behavior with children, and the impact of a partner asking their loved one to be vaccinated.
In one example of a Gardasil commercial there are eight different women individually, in the form of a soliloquy saying they want to be “One Less.” And they are saying everything during the commercial in perfect English, and with “American” mannerisms. It is not until the last ten seconds of the ad do they show a group of young girls, jump roping, saying “O-N-E-L-E-S-S,” appealing to a group of people who collectively agree that one should be vaccinated with Gardasil. There is not a single example of a mother saying the importance of talking to their daughter(s) about HPV, a partner talking to another partner, be it a heterosexual or a homosexual relationship, about getting vaccinated, or an example of a religiously conservative person expressing the importance of the vaccine (12). By going through the steps of Stage I, Merck would have known that a Muslim mother still may not feel comfortable talking to their husband or boyfriend about being vaccinated or having their daughters vaccinated, after seeing the advertisement described above. And, Merck would understand that some cultures are more community oriented, and the opinions of others matter more than their own individual opinion. After doing the research, and learning about the different educational requirements for each culture, Merck might have benefited from including a group of ethnic women who do not speak perfect English, sitting together, discussing HPV in their ads.
Avoid a False Sense of Security, a Riled Up Crowd : Stage I & Stage II
On June 9, 2006, Gardasil was approved by the FDA. And, on November 23, 2006 Merck launched its print, online and television advertising campaign for the vaccine (13). By February of 2007, Merck had already started lobbying for mandatory vaccinations in schools. They had only been marketing the vaccine for two months with advertisements like the one involving eight women mentioned earlier. In that same ad, one woman says “Gardasil will not treat cervical cancer,” and the woman right after her says, “Ask your doctor about getting vaccinated with the only cervical cancer vaccine” (12). Merck prematurely marketed the vaccine as one that prevents cervical cancer to a public that, in two months of advertising, had not been educated in HPV, the causes of cervical cancer, the fact that HPV is not the only cause of cervical cancer, and that even if one is vaccinated they still might end up with the cancer. Once Merck started lobbying for mandatory vaccinations, the public knew two things: that Gardasil is a cervical cancer vaccine, and that HPV is related to sexual activity. Gardasil is not a cervical cancer vaccine, so the public was misinformed and had a false sense of security in the vaccine. And, even though HPV is caused by sexual activity, they were not ready to be introduced to a mandatory vaccine for a controversial topic: sexual activity.
Had Merck followed a two-stage process for promoting the vaccine, and included a broader educational portfolio into their marketing campaign, their lobbying attempts and advertisements may not have caused such a great sense of distrust in a FDA approved vaccine. Instead of releasing the Gardasil ads five months after approval, Merck could have waited, done the research for Stage I of advertising, and been more effective by gaining the trust of the public. The two-stage approach of educating and then promoting the vaccine would force Merck to fully inform the public in HPV, and then push for mandatory vaccinations. By the time the lobbying efforts would be known to the different communities, the individual people making up the communities would be more accepting to the idea of having their daughters vaccinated, and they would have understood the value in having mandatory vaccinations in schools.
Conclusion : Money was not Discussed, and it won’t be
The two-stage approach to promoting a vaccine discussed in this paper, does not take into consideration the monetary impact of having twice as many marketing campaigns. However, one would hope that for FDA approved vaccines, and products affecting a person’s health, pharmaceutical companies will be able to fabricate, and re-organize their Research and Development and Marketing budgets to allow for better education of the public, and find value in equating education and product promotion. And, one would hope that lawmakers would see the benefit in aiding pharmaceutical companies in providing more information on the vaccines and the viruses. Maybe, one day it will become common practice to conduct Stage I type activities while doing clinical trials for the vaccine or drug at the same time. But, until education and product promotion have equal weight in the public and private sectors, we will continue to have vaccines quickly marketed to an ignorant public, and public opposition to effective vaccines.
References
"Cervical Cancer Basic Information." Centers for Disease Control and
Prevention: Your Online Source for Credible Health Information. 22 Dec. 2008. Department of Health and Human Services. 27 Mar. 2009.
2."Efforts to Make Gardasil Mandatory Stall in Some States." The National Health Federation: A Not-For-Profit Health-Freedom Organization. 24 Apr. 2008. National Health Federation. 4 Apr. 2009.
Edberg, Mark. Essentials of Health Behavior: Social and Behavioral
Theory in Public Health. Boston: Jones and Bertlett, 2007
4. "Facts about Cervical Cancer." Michigan Cancer Consortium. Feb. 2009. Michigan Department of Community Health. 4 Apr. 2009.
5. "FDA Licenses New Vaccine for Prevention of Cervical Cancer and Other Diseases in Females Caused by Human Papillomavirus." U.S. Food and Drug Administration. 8 June 2006. U.S. Department of Health & Human Services. 27 Mar. 2009.
6. Gerend, Mary A., and Zita F. Magloire. "Awareness. Knowledge, and Beliefs about Human Papillomavirus in a Racially Diverse Sample of Young Adults." Journal of Adolescent Health 42 (2008): 237-42.
7. Halcomb, Bryan, Joanne M. Bailey, Kathleen Crawford, and Mack T. Ruffin IV. "Adults' KNowledge and Behaviors Related to Human Papillomavirus Infection." Journal of the American Board of Family Medicine 17 (2004): 26-31.
8. "HPV Vaccination Information for Young Women." Centers for Disease Control and Prevention. 26 June 2008. Department of Health and Human Services. 27 Mar. 2009.
9. "HPV Vaccine." National Conference of State Legislatures: The Forum for America's Ideas. Apr. 2009. 4 Apr. 2009.
10. Jones, Bethany. "Gardasil Marketing Campaign for Cervical Cancer Misses the Mark." Associated Content: Information from the Source. 10 Oct. 2007. 27 Mar. 2009.
11. "Mandatory Vaccination with Merck's Gardasil Raises Eyebrows." Seeking
Alpha. 7 Feb. 2009. 23 Mar. 2009.
12. Merck. "Gardasil Commercial." YouTube. Nov. 2006. .
13. "Merck Launches National Advertising Campaign For GARDASIL, Merck's
New Cervical Cancer Vaccine." Medical News Today. 23 Nov. 2006. 27
Apr. 2009 .
14. "Merck lobbying States to mandate Gardasil for school girls." News-Medical.Net-Medical and Health News Headlines. 30 Jan. 2007. 4 Apr. 2009.

Failure Of The Healthy Futures Program-Grace Thiongo

Introduction
Federal support for “abstinence-only” education programs has expanded rapidly. The federal government spends approximately $170 million on abstinence-only education programs. However, states are limited to spending the money on abstinence-education programs only. As a result abstinence-only education, which promotes abstinence from sexual activity without teaching basic facts about contraception, now reaches millions of children and adolescents each year in the United States. In contrast, comprehensive sex education encourages both abstinence and effective contraceptive use, which have been shown in many studies to delay sex, reduce the frequency of sex, and increase the use of condoms and other contraceptives. In addition, the abstinence-education programs, which promote sex after marriage, do not take the lesbians, gays, bisexuals and transgenders into account, who cannot get married in 49 of the 50 states. Massachusetts is among one of the states that promote the abstinence-only education curricula. Governor Mitt Romney announced in April 2006 that the state will funnel nearly $1 million in federal funds to a faith-based organization to teach abstinence to public middle school students in a dozen communities across the state [1]. This faith based organization is known as Healthy Futures.

A 2005 Youth Risk Behavior Survey [2] indicates that among Massachusetts high school students 45% ever had sexual intercourse, 34% had sexual intercourse during the past three months, 35% did not use a condom during their last sexual intercourse and 75% did not use birth control pills during their last sexual intercourse. CDC recommends better health education. A 2004 School Health Profiles indicated that among Massachusetts middle/junior and senior high schools that taught health education, 59% of them required students to take two or more health education courses, 94% taught abstinence as the most effective method to avoid STDs and 50% taught how to correctly use a condom and 40% taught the basic prevention methods of STDs.

Healthy Futures is a state- and federally-funded health program that bases its curricula on educating teens in the areas of sexuality, healthy relationships, and self-respect through arguably “medically-accurate” information and interactive skits and demonstrations. Further, it empowers teens to avoid the social, psychological and health consequences of early sexual activity and provides the skills necessary to attain abstinence before marriage [3]. Supporters of abstinence-only programs argue that they are an effective way of reducing pregnancies and reducing the spread of sexually transmitted diseases. The group, the largest of its kind in Massachusetts, was formed in September 2002 by A Woman's Concern, a pregnancy health services agency that lists its guiding principles on its website as the importance of the gospel, the sanctity of human life, and the soundness of sexual purity, marriage, and family [4]. The Healthy Futures program, a Boston-based agency, runs abstinence programs in several dozen schools across the state. The program, free to the school districts, is available to schools in 12 communities with high numbers of teen births, including Boston, Lawrence, Lowell, and Lynn [3].

Opponents of abstinence-only programs counter that teens are going to have sex anyway, and that such programs, by not teaching the merits of condoms and other contraception, increase the risk of pregnancy and disease.” The problem here is not the abstinence," said Angus McQuilken, director of public relations and governmental affairs for the Planned Parenthood League of Massachusetts, a leading provider of comprehensive sex education in the public schools [5]. ''We're doing them a disservice if we deny them medically accurate information about how to protect themselves" she says.

Healthy Futures And The Gay Community
Despite the nearly 15000 lesbian and gay teenagers in Massachusetts public high schools [6], and the growing visibility of gays and lesbians in the broader culture, few educators are willing to address homosexuality in the classroom. Advocates assert that including gay issues in sexuality education could help address heightened health risks faced by gays and lesbians due to misinformation and lack of information about safe-sex practices; emotional isolation that contributes to high suicide and dropout rates among gay teens; and widespread harassment of gay and lesbian students by their peers and teachers [7].

In a society that generally shuns from the idea of homosexual relationships and marriages, curricula that reject the idea of sexual intimacy among homosexuals ignore their need for critical information about protecting themselves from sexually transmitted diseases. The program’s objective of reducing the number of pregnancies and STDs among teens cannot be effective if a large number of teens who are vulnerable to these practices are excluded from the curricula. This ultimately undermines efforts to educate teens about protecting their health and also creates a hostile environment for gays and lesbian teens.

Stacy Weibley, a sexuality educator and public policy associate, states that teens face increased health risks, largely because of fear and ignorance [7]. In 1995, a study based on Minnesota teens published in the Journal of Adolescent Health found that lesbian and bisexual girls were more likely to become pregnant and more likely to have multiple pregnancies than heterosexual girls. In addition to the health risks, these teens can become suicidal as well. A 1995 report from the Centers for Disease Control and the Massachusetts Department of Education found that lesbian and gay youth are four times more likely than non-lesbian and gay teens to attempt suicide. And the U.S. Department of Health and Human Services has reported that gays and lesbians account for 30 percent of all teen suicides [7].

Including information about homosexuality, remains highly controversial among parents, school administrators and teachers. About 1 in 12 high school health teachers taught their classes that homosexuality is wrong in 1995, according to a survey of 211 U.S. school districts published in the Journal of School Health. LAMBDA reports that 77 percent of prospective teachers would not encourage a class discussion on homosexuality and 85 percent oppose integrating gay and lesbian themes into their existing curriculums [7].

Healthy Futures And Self-Efficacy
The curriculum teaches the adolescents and teens that abstinence from sexual activity until marriage is the expected social norm and the only manner in which to avoid sexually transmitted diseases and unwanted pregnancy. Healthy Futures plainly state in their curriculum that “sex is wonderful in the context of a faithful, lifelong relationship, which is marriage, but that there are physical and emotional risks outside of the context”. They also misrepresent the effectiveness of condoms in preventing sexually transmitted diseases and pregnancy. The curriculum teaches that the claim that condoms help prevent the spread of STDs, is not supported by the data; it also states that in heterosexual sex, condoms fail to prevent HIV approximately 31% of the time; and that a pregnancy occurs one out of every seven times that couples use condoms [3]. Abstinence-only program educators are not permitted to discuss the proper use of contraception, including condoms, as a way to reduce risk of contracting HIV or other sexually transmitted diseases.

The concept of self-efficacy based on Albert Bandura’s social cognitive theory assumes that human beings by means of self-esteem, exercise control over their thoughts, feelings and actions. This theory is rooted in a view that individuals are engaged in their own development and can make things happen by their actions [8]. Based on this ideology, the Healthy Futures curricula believe that teens and adolescents will not have sex before marriage because they are told that they should wait is being unrealistic. The virginity pledge program, strongly emphasized by Healthy Futures, encourages students to make a pledge to abstain from sex until marriage. However a study by Bearman et. al [9] found that while in limited circumstances virginity-pledgers may delay first intercourse, they still have sex before marriage and are less likely than non-pledgers to use contraceptives at first intercourse or even get tested for STDs when they do become sexually active.

Healthy Futures And Contraceptives
With only two-thirds of teens in the United States having had sexual intercourse by the time they are 18, it is vital to provide them with information to protect them [10]. Such discussions must include information on methods of reducing risks, including use of condoms and other birth control methods. While abstinence-only programs may delay sexual activity and reduce the number of sexual partners over a lifetime, abstinence-only education curricula that do not discuss contraceptive methods are placing the teens in danger of unwanted pregnancies and being infected with sexually transmitted diseases.

A study by Kirby [11] found that there is enough evidence to show that abstinence-education programs coupled with comprehensive sexual education, delay sex and reduce sexual risk among teens. It is disheartening that abstinence-only programs do not include comprehensive sex education in their curricula. According to Duberstein et. al [12] between 1995 and 2002, the proportion of adolescents who had received any formal instruction about methods of birth control declined substantially, and by 2002, one-third of adolescents had not received any advice on contraception.

Undoubtedly, the Healthy Futures abstinence-only education program presents information about pregnancy prevention and testing and treatment of STDs. However, they do so incompletely and inaccurately. For instance, a 2004 congressional report [13] concluded that many federally-funded abstinence-only curricula misrepresent the effectiveness of condoms in preventing STDs and pregnancies by exaggerating the failure rates. In particular, the Healthy Future program presents data on the effectiveness of latex condoms by using data from a 2000 workshop by the National Institutes of Health panel [14]. This program concludes that the NIH determined that there is insufficient evidence whether condoms can prevent STDs. However, looking at data from the NIH panel, they determined that the relative risk of acquiring STDs or getting pregnant decreases as condom usage increases from a relative risk of 0.006 of using a condom which then breaks, to using a condom with no break or leak at a relative risk of 0.0.

A vast majority of parents, teachers and health practitioners have been in recent years at a consensus that teens should receive complete and accurate information about abstinence and contraceptives. In a nationwide poll conducted by Kaiser Family Foundation, National Public Radio and Kennedy School of government [15], researchers found out that the majority of parents wish to a have comprehensive-based sex education curricula that cover topics such as condom use, sexual orientation and options such as abortion and adoption.

In addition, a national survey by Darroch et. al [16] that was carried out in 1999 among 7th-12th grade teachers found that 93.4% believed that sexuality education courses should cover birth control methods, 89% believed that curricula should cover factual information about abortion, 88.8% believed that the curricula should include where to go for birth control, 82% proposed that curricula should include correct ways to use a condom, and 77.8% believed that curricula should be geared towards other sexual orientations other than heterosexuals.

Conclusion
It is undoubtedly true that abstinence-only education programs aim to reduce the spread of STDs and unwanted pregnancies among teens. However, curricula need to further help them by giving them complete and accurate information about STDs and use of contraceptives effectively. In addition, lesbians and gays need to be taken into account as well, keeping in mind that they too are a vulnerable population and therefore their health needs to be protected as well. Lastly, the social cognitive theory only goes as far as a person’s will and strength takes them. Believing that teens will not engage in sexual practices until they are married is unrealistic particularly because of the influence of media and social networks as well.

REFERENCES
1. http://www.boston.com/news/local/massachusetts/articles/2006/04/21/state
_widens_teaching_of_abstinence/
2. http://www.cdc.gov/HealthyYouth/sexualbehaviors/state-facts.htm
3. http://www.healthy-futures.org/choose.htm
4. http://www.awomansconcern.org
5. http://www.plannedparenthood.org/ma/
6. http://www.boston.com/bostonglobe/magazine/articles/2007/11/11/easy_out/
7. http://www.womensenews.org/article.cfm/dyn/aid/811/context/cover/
8. Bandura, A. Self-efficacy: The exercise of control. New York. WH Freeman and Company. 2001.
9. Peter S. Bearman & Hannah Bruckner. Promising the Future: Virginity Pledges as they Affect Transition to First Intercourse 35 (2000); see also Hannah Bruckner & Peter Bearman, After the Promise: the STD Consequences of Adolescent Virginity Pledges, 36 J. Adolescent Health 271 (2005).
10. Hatcher RA et. al. Contraceptive technology, 18th rev. ed. New York: Ardent Media, 2004.
11. Douglas Kirby. Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy 16 (2001)
12. Laura Duberstein et al., Changes in Formal Sex Education: 1995-2002, 38 Persp. Sex. & Reprod. Health 182, 184 (2006).
13. United States House of Representatives Committee on Government Reform – Minority Staff Special Investigations Division, The Content of Federally Funded Abstinence-Only Education Programs (2004) (hereinafter House Committee Report) Christopher Trenholm et al. Impacts of Four Title V, Section 510 Abstinence Education Programs (2007).
14. http://www3.niad.nih.gov/research/topics/STI/pdf/condomreport.pdf
15. National Public Radio et al., Sex Education in America, General Public/Parents Survey (2004), available at http://www.npr.org/programs/morning/features/2004/jan/kaiserpoll/publicfinal.pdf
16. Jacqueline E. Darroch et al. Changing Emphases in Sexuality Education in U.S. Public Secondary Schools,1988-1999, 32 Fam. Plan. Persp. 204, 206 (2000).

The Failure of Abstinence-Only Sexual Education in Schools in Reducing the Rates of STD’s and Pregnancy in the Adolescent Population – Katelyn Spada

Abstinence-only sexual education has failed in reducing the rates of STD’s and pregnancy in teens because those implementing the program neglected to frame the issue to teens in a relatable manner. The main focus of this paper is to address the need for abstinence-only sexual education programs to incorporate the social and behavioral sciences, such as psychology and sociology, in order to reframe abstinence-only sexual education so that it appeals to teens. Current abstinence-only sexual education programs fail to incorporate concepts that play important roles in teenagers’ lives. These programs neglect to address the importance of the messages about sex that are displayed by the mass media and accepted by society. Also, many abstinence-only educators fail to realize that teens are in the process of establishing their own sense of autonomy and may not abstain in order to prove that they can make their own decisions about sex (1). Although many teens intend to abstain from sex until marriage, there are few who are able to maintain this commitment (2). Abstinence-only sexual education fails to inform teens about contraceptives and birth control that could protect them should they choose to have sex. By incorporating the social and behavioral sciences, these programs would be able to address these issues and be more effective in lowering the rates of pregnancy and STD’s in the adolescent population.
About Abstinence-Only Sexual Education
Abstinence-only sexual education exclusively promotes the importance of abstaining from sexual intercourse until marriage and typically includes no discussion of contraceptives, birth control, or abortion. The abstinence-only curriculum emphasizes that abstinence is the expected social standard for school-aged children and teaches children that pre-marital sex leads to STD’s, teen pregnancy, and social stigma (3).
The federal government largely funds abstinence-only sexual education in public schools through Title V of the 1996 Welfare Reform Act and through Community-Based Abstinence Education. Title V of the Welfare Reform Act allows the government to allocate grants to states whose public schools teach abstinence-only sexual education (3). The government outlines strict curriculum criteria that must be met in order for the state to receive federal funding. The programs funded by this act are able to discuss contraceptives, but are allowed only to give examples of their failures. These programs do not educate teens on the benefits of contraceptive use (4). A large amount of money has been allocated to fund abstinence-only education programs. From 1996-2006, the federal government has given over 1 billion dollars to state-run abstinence-only programs through Title V of the Welfare Reform Act. Abstinence-only sexual education programs also receive funding through Community-Based Abstinence Education (CBAE), which began in 2000. CBAE is the largest federal abstinence-only funding source, giving 115 million dollars in grants in 2006. These grants bypass state governments and are awarded directly to state and local organizations that teach abstinence-only sexual education. Many grantees are faith-based or small non-profit organizations that service local private and public schools and other organizations in their area (3).
The Importance of Recognizing Teen Autonomy
Current abstinence-only sexual education programs fail to engage teens and educate them about the dangers of promiscuity because the curriculum does not take into account the fact that teens are in the process of establishing their own sense of autonomy. Proponents of abstinence-only programs argue that teens must be taught abstinence in order to guide them away from promiscuity, but they fail to recognize that many teens are mature enough to know the difference between acceptable and unacceptable behavior. According to psychological theory, teens aim to be independent, self-governing individuals who make their own decisions and live by their own rules of morality (3). Programs aimed at educating teens about sexual behavior should incorporate this theory in order to help teens create their own set of morals without the values of others being forced upon them.
Studies have shown that sexuality is especially associated to freedom and control during adolescence. While parents and teachers should be involved in the surveillance and control of teen behaviors to ensure their safety, teens should be in charge of creating their own morals and making their own decisions. Battles over right and wrong behavior are often fought between adult and child, but the more important struggles are within the teens themselves (5). Sexual education programs should not emphasize the beliefs of those in charge of presenting the material, but should present information on all of the ways to practice safe sex.
The Impact of the Mass Media and Societal Norms
Society as a whole regards sex as normal and acceptable. This conflicts with the message that “sex is immoral and wrong” that is being presented by abstinence-only educators. Oftentimes, teens feel pressured to do what everyone else is doing in order to fit in with their peers (6). By not taking into account the role of social norms and the messages presented by the media, abstinence-only educators are setting their programs up for failure. Teens are exposed to the “sex sells” message sent out by the media on a daily basis. Media outlets, such as television, radio, and magazines, are constantly presenting teens with sexual images and lyrics that are contradictory to the message taught by abstinence-only programs (7).
Media sources are important life-lesson educators for teens and teens often use media sources to gain information about sexuality (7). Bandura’s Observational Learning Theory is based on the idea that learning results from observing the behavior of some other person or model (7). This theory can be applied to suggest that teens can learn the mechanics, motives, and consequences of sexuality from the media and store such knowledge for use in their own personal circumstances. Teens often use this information like a script that outlines what behaviors are expected of them in sexual situations (7). For example, many articles in teen magazines say that girls should not kiss their dates until they have had a second date with them to avoid giving off the wrong impression, and studies have shown that many girls take this advice (8). In this way, the media plays a crucial role in educating teens on the “right” way to act according to societal norms.
While parents and the community may have some influence on the decisions teens make, studies have shown that the mass media and peer influence have the most impact on teen decision-making processes (9). These studies have also shown that families have little to no influence on adolescents’ self-evaluation of sexuality when compared to the influence of the media and peers (9, 10). The information that teens gather about sexuality from the media and from their peers plays an important role in the development of their own sexual behavior (10).
Intent Does Not Always Lead to Behavior
Abstinence-only sexual education programs have failed in reducing the rate of pregnancy and the incidence of STD’s in the adolescent population because these programs have relied too heavily on the idea that if teens intend to abstain from sexual intercourse until marriage, they will uphold that commitment (2). In reality, intentions to abstain from sexual intercourse until marriage may not determine whether or not teens actually do abstain (2). Many external factors may interrupt the intention-behavior continuum.
A recent study presented at the 2003 annual meeting of the American Psychological Society found that over 60% of college students who had pledged virginity during their middle or high school years had broken their vow to remain abstinent until marriage (2). While many of these students may have intended to uphold their vows to abstain from sexual intercourse until marriage, their behavior did not follow their intentions.
There are many situations in which adolescents choose to have sexual intercourse even if they had previously intended to abstain. Teenage romance often evokes strong emotions. Studies have shown that when involved in a serious relationship, teenagers who may have intended to abstain from sexual intercourse before marriage choose to have sex for a number of reasons (11). Most commonly, teens who once intended to remain abstinent have had sex in order to make their relationship feel more adult and to feel more intimate with their partner (11).
Teens also choose to engage in sexual intercourse when under the influence of alcohol or drugs. An estimated 50% of American teenagers have experimented with alcohol and/or drugs at least once (12). Alcohol and drug use has been proven to cause individuals to engage in behaviors that they would not have engaged in otherwise (12). For this reason, intentions to abstain from sexual intercourse until marriage do not accurately predict one’s actual behavior.
Correcting Abstinence-Only Sexual Education Programs’ Failures
Today’s abstinence-only sexual education programs neglect many issues that affect how teens view sexuality. Those developing these programs must realize that social norms and peer pressure, in conjunction with a teen’s developing sense of autonomy, have a strong influence on sexual behaviors. It is also important for these programs to provide teens who choose not to abstain from sex with information on ways to protect themselves. In order to be more effective in reducing the rates of pregnancy and STD’s in America’s adolescent population, these ideas must be incorporated into abstinence-only education programs.
Social norms must be modified in order to make abstinence a more acceptable option in today’s society (13). Abstinence-only sexual education proponents must work with the media in order to incorporate more examples of behaviors that are in accordance with abstinence-only program values. By making abstinence a social norm, these programs will be more relatable, and therefore more successful, in increasing the number of teens who choose to abstain (13).
Abstinence-only sexual education programs need to be restructured in order to be effective in reducing the rates of pregnancy and STD’s in teens (14). While abstinence should remain the focus of these programs, information regarding contraceptives and birth control should also be included. Many proponents of abstinence-only education may be unwilling to accept the need for information about contraception and birth control in abstinence-only programs, but this information is important for those who choose to have sex to know in order to protect themselves from STD’s and to prevent unplanned pregnancies. Studies have shown that programs that focus on abstinence but include information regarding contraceptives have been the most successful in reducing pregnancy and STD’s in adolescents (14). Since abstinence-only sexual education is taught in many public schools and students do not have a choice to enroll in other sexual education programs, including information regarding safe sex is important for all students – especially those who do not agree with the abstinence-only sexual education programs’ goals.
Involving teens in the development and the presentation of the abstinence-only sexual education curriculum would also have a positive impact on abstinence-only programs. Peer influence plays a major role in decision-making processes during adolescence (6). By involving teens in the development and the delivery of the abstinence-only sexual education curriculum, these programs would be able to increase the social acceptance of abstinence among the adolescent population (13).
Conclusion
Current abstinence-only sexual education programs have failed to reduce the rate of pregnancy and incidence of STD’s in the adolescent population. This failure is a result of the fact that those implementing the programs have not framed the issue in a way that is relatable to teens. Abstinence-only sexual education program creators neglect to consider the fact that teens are in the process of establishing their own sense of autonomy and may rebel against the messages being taught to them by their instructors (1). They also fail to acknowledge that the messages about sex received by teens through the mass media and social norms conflict with the values being promoted by abstinence-only programs (7). Lastly, abstinence-only sexual education programs are based on the idea that intent directly governs behavior. This is not always true; there are many external factors that influence whether or not an individual’s behavior reflects their intentions (2).
Addressing the failure of current abstinence-only sexual education programs is an important public health matter because of the high rates of pregnancy and STD’s in the American adolescent population. In order for these programs to have an impact on teen sexuality, social norms must be altered to make abstinence more commonplace and information about contraceptives needs to be included in these programs.

REFERENCES
1. Huebner, Angela. Adolescent Growth and Development. Virginia Cooperative Extension: Virginia Polytechnic Institute and State University; 2000. Publication 350-850.
2. Dailard, C. Understanding 'Abstinence': Implications for Individuals, Programs and Policies. The Guttmacher Report on Public Policy: Guttmacher Institute 2003.
3. Howell, M. "The History of Federal Abstinence-Only Funding." July 2007. Advocates for Youth. http://www.advocatesforyouth.org/publications/factsheet/fshistoryabonly.htm
4. United States House of Representatives Committee on Government Reform –Minority Staff Special Investigations Division. The Content of Federally Funded Abstinence-Only Education Programs. Washington D.C.: U.S. House of Representatives, 2004.
5. Griffin, C. Troubled teens: Managing Disorders of Transition and Consumption. Feminist Review 1997; 55:4-21.
6. Brown, B. The Extent and Effects of Peer Pressure Among High School Students: A Retrospective Analysis. The Journal of Youth and Adolescence 1982; 11:121-133.
7. Donnerstein, E., Huston, A., Wartella, E. Measuring the Effects of Sexual Content in the Media: A Report to the Kaiser Family Foundation. Menlo Park, CA: Kaiser Family Foundation; 1998.
8. Adams, S., Garner, A., Sterk, H.M. Narrative Analysis of Sexual Etiquette in Teenage Magazines. Journal of Communication 1998; 48:59–78.
9. Baran, S.J., Courtright, J.A. The Acquisition of Sexual Information by Young People. Journalism Quarterly 1980; 57:107-114.
10. Brown, J., Guo, G., Jackson, C., Kenneavy, K., L’Engle, K., Pardun, C. Sexy Media Matter: Exposure to Sexual Content in Music, Movies, Television, and Magazines Predicts Black and White Adolescents’ Sexual Behavior. Pediatrics 2006; 117:1018-1027.
11. Ott, M. Media May Prompt Teen Sex. Perspectives on Sexual and Reproductive Health 2006; 38:84-89.
12. Califano Jr., J., Foster, S., Foster, W., Vaughan, R. Alcohol Consumption and Expenditures for Underage Drinking and Adult Excessive Drinking. JAMA 2003; 289:989-995.
13. Bersamin, M., et al. Promising to Wait: Virginity Pledges and Adolescent Sexual Behavior. Journal of Adolescent Health 2005; 36:428-436.
14. DeJoy, S., Perrin, K. Abstinence-Only Education: How We Got Here and Where We're Going. Journal of Public Health Policy 2003; 24:445-459

100% Effective? The Unintended Consequences of Federal Abstinence-Only Education – Kristin Semancik

Significant declines in teenage pregnancy rates occurred during the 1990s. The Centers for Disease Control and Prevention (CDC) attributed half of this decline to decreased sexual experience and half to improved contraceptive use, conservatively estimating contraception effectiveness (1). A combination of abstinence and safe sex practices education proves most effective for preventing teen pregnancy and STI-contraction (2, 3). Despite evidence of the value of teaching contraception (2), federal funding continues to support only abstinence-only education, a controversial subject that extends beyond health terms into moral territory.
Abstinence-only education drastically expanded under the Bush presidency. The federal government provided $170 million in 2005 to programs that promoted abstinence from all sexual activities until marriage, twice the amount issued in 2001 (4). According to federal guidelines, abstinence-only education programs must teach abstinence as the only certain method to prevent pregnancy and sexually-transmitted infections (STIs) (4). Programs must focus on specific concepts including the social, psychological, and health gains of abstinence; the harmful psychological and physical effects of sex outside of marriage including depression and STIs; and the detrimental ramifications of teen pregnancy for the child, the child’s parents, and society (4). Programs also must stress abstinence as the expected standard for all school age children, and marriage as the expected standard of human sexual activity (4).
On June 21, 2007, the US Department of Health and Human Services (HHS) launched its Parents, Speak Up! Campaign, an abstinence-only educational program that combines public service announcements with online resources to encourage parents to talk with their children about abstaining from sex until marriage (5). However, the Parents, Speak Up! Campaign only focuses on one influence on teenage sexual actions, parental advice. The program ignores vital influences on teen sexual behaviors and neglects significant subsets of the teenage population. The Parents, Speak Up! Campaign fails to prevent, and may actually increase the incidence of, risky adolescent sexual behavior.
Peer Influence on Teenage Sexuality
The Parents, Speak Up! Campaign encourages parents to talk to their teenagers about sex and tell them to wait to have sex until marriage (6). The federal program assumes teenagers will abstain from sex if their parents instruct them. However, most individuals first engage in sex as teenagers before marriage; for American women, the median age of the first sexual experience is 17.4 years, but is 25.3 years for the first marriage (7). Parental conversations alone do not stop teenage sexual activity (8). Although parents provide much of the education, adolescents receive information regarding sexual behavior from other sources, notably from their peers (9).
Both parents and peers impact adolescent sexual behavior (10). Current sexual education programs focus mainly on the role of parents and often neglect peer impact (10). Teenagers converse with friends about sex: almost 50% of 13-to-15-year-olds talk about sexual intercourse with their friends (11). These conversations convey perceived adolescent norms. These norms, viewed as typical behavior, guide teenage sexual decision-making. Adolescents that believe that their friends are having sex are significantly more likely to become sexually active (9, 12, 13). Friend approval correlates with increased teenage sexual activity (10). For teenagers, friends’ perceived opinions greatly influence sexual decisions and oppose parental advice.
Achieving social status, respect from one’s social group and peers, encourages adolescent sexual initiation and continuing behaviors. Adolescents that value popularity are significantly more likely to have sex at an earlier age (14). High self-esteem and good peer relations, characteristics associated with more popular adolescent groups, correlate with engaging in sex at a younger age (15). Teenage males used sex to achieve social status, because increased experience equates to “coolness” (10). Adolescents who moved often, thus lacking permanent social connections, have sex more frequently and use sex as a tool to develop friendships (14). Other ambitions and goals propagated by peer groups sometimes override the desires for popularity. Teenagers who had academically-high-achieving-peers initiated sex at an older age (14).
Adolescent sexual initiation extends beyond peer pressure. Teenage girls seek love, approval, and a sense of maturity through sexual behaviors (10). A committed relationship is a significant sexual intercourse risk factor (16). Both emotional and physical desires surround adolescent sex. Eighty-percent of females and 66% of males have sex, because they love their boyfriend/girlfriend, and eighty-two-percent of females and 89% of males have sex for pleasure (17). Peer influences diminish somewhat as the adolescents age (12); however, peer approval remains a strong factor affecting sexual behavior into adulthood (10). The federal program ignores adolescent norms by only addressing parents. Peer leaders succeed more in changing adolescent norms and attitudes about sex than adults (18). Interventions for teenage populations cannot ignore these impacts on behavior choices. Teenage sexual behavior is complex. Social conditions and teenage desires work counter abstinence-only messages by pressuring adolescents to initiate sex, limiting the effectiveness of the Parents, Speak Up! Campaign.
Ignoring Vulnerable Populations
In addition to inadequately addressing all sources of sexual information for teenagers, the Parents, Speak Up! Campaign also ignores two teenage population subsets, individuals who have had sex and homosexuals, by instructing adolescents to have sex only when married and purporting sex in the context of marriage as the only acceptable standard. Due to their inability to live up to all the standards, these groups will lack self-efficacy and consequently, will most likely reject the program in its entirety.
Firstly, the campaign does not address adolescents who have already had sex. The campaign commercials portray the child as innocent, as a parent’s “muffinhead” or “cuddlebug” (6) and fails t0 frame the conversation for parents whose children are sexually active. Parents, Speak Up! Campaign ignores a large portion of teenagers. Over ½ of teens have sex before their 18th birthday and over 80% of people in the US have sex before marriage (9). According to the campaign commercials, “success comes for those who wait”; waiting insures having an education, family, career, and happiness (6). These goals seem unattainable for teens that choose not to wait. Teenagers may not practice safe sex if they have already failed to abstain. The campaign framing ignores a large subset of the teenage population, those who have had sex, and fails to educate them about safe practices. Sexually-active teens need information regarding safe sex practices not provided by abstinence-only education (7).
Secondly, the message of abstaining from sex until marriage ignores homosexual adolescents by implying heterosexuality, further isolating them and potentially encouraging riskier behavior. About three-percent of high school students identify as gay, lesbian, bisexual, transgender, or questioning (GLBTQ) (7). Many psychological and physical consequences of sex that the federal programs seek to prevent are of particular concern for this teenage subset, including depression and STIs, but the program, to its detriment, ignores the population.
Although teen pregnancy, a focus of abstinence-only education, may not be a factor for much of the GLBTQ population, STIs, another component of abstinence-only programs, affect this population and can be transmitted through various sexual activities including oral and anal sex (6). To prevent the transmission of STI infections, successful intervention for sexual behavior change must address the particular needs of the homosexual population (19). For example, many adolescents, especially the GLBTQ population, view AIDS as a chronic condition due to recent medication improvements. This can lead to unsafe sexual practices (9); federal efforts do not address these dangerous beliefs. No component of the campaign is tailored to specifically address GLBTQ needs.
The program also has emotional ramifications for the GLBTQ teenagers. The emphasis on marriage can further stigmatize homosexuality, detrimentally impacting the GLBTQ population (7). The program fails to acknowledge the legitimacy of committed relationships within the GLBTQ population (19). GLBTQ teens already encounter social difficulties; teenagers may feel more isolated due to a perceived dearth of parental support. GLBTQ adolescents’ resulting low self-esteem leads to risk-taking, particularly unsafe sexual practices and depression (20). Education programs should not further stigmatize a vulnerable group.
The blanket message of “wait until marriage to have sex” will not accomplish the range of federal goals for the sexual activity of a diverse teenage population. Both teenagers who have already had sex and GLBTQ are especially vulnerable populations to the negative consequences of sex abstinence-only education seeks to prevent, yet the federal program ignores and further stigmatizes them.
Unsafe Sexual Activities & Abstinence
Abstinence-only education not only fails to address certain subsets of the population, but also adversely affects the sexual behavior of the targeted population. According to President Bush, abstinence is “the surest way, and the only completely effective way, to prevent unwanted pregnancies and sexually transmitted disease” (21). Abstinence is 100% effective when used perfectly, but like all methods of birth control, its actual use, everyday application, is lower than perfect use. The Parents, Speak Up! Campaign biases effectiveness by comparing perfect use of abstinence to actual use of other contraception methods (6). Research lacks a measure of typical use of abstinence.
Consistently maintaining abstinence is very difficult, especially for teenagers (21). Intention to abstain from sex does not directly lead to behavior, and teenagers often have unplanned sex even when they have pledged abstinence (7). An abstinence-only education fails to provide adolescents with tools for safe sex. The majority of teenagers have sex even when they plan on abstaining (16). Those with abstinence-only education exhibited more risky sexual behaviors than those who received comprehensive sexual education due to a lack of information on protecting themselves when engaging in sex (16). As a result, the highest rates of teen pregnancy in 2000 in the US occurred in states that focused on abstinence-only education and the lowest rates occurred in states that provided information on both contraception and abstinence (9).
Various definitions of “abstinence” further complicate educational effectiveness. The federal program aims to teach abstinence from all sexual activities (6). Many adolescents who identify as virgins define abstinence as refraining solely from vaginal intercourse, not refraining from oral and anal sex (22). The Kaiser Foundation, a reputable health organization, and Seventeen magazine, an entertainment and social information source for many teens, found that half of 15-to-17-year-olds think that virgins can have oral sex (21). In an urban high school, 35% of students who said they were virgins had engaged in mutual masturbation, oral sex, and/or anal sex (23). Older populations exhibited similar beliefs: 55% of self-reported college virgins reported having oral sex (21).
Lacking knowledge about safe sex due to a focus on abstinence-only educations, teenagers often engage in oral and anal sex without protection from STIs. Tenth graders not only reported having oral sex more frequently than vaginal intercourse, but also had more oral sex partners and used protection less frequently than with vaginal sex (9). Only 6% of self-reported teenage virgins who had oral sex always used a condom and 86% never used one (24). Although individuals will not become pregnant, STIs can be transmitted through oral sex and anal sex. Unprotected anal sex increases the risk of STI-transmission compared to vaginal intercourse (21). Oral sex spreads many STIs including herpes, hepatitis, gonorrhea, syphilis, Chlamydia, chancroid, and human papillomavirus (22). However, for some STIs, the risk of the infection declines for oral sex in comparison to vaginal intercourse transmission. The HIV virus, for instance, is rarely transmitted through oral sex, because saliva inactivates the virus (22). Although pregnancy does not occur with oral and anal sex, many of the other problems that the abstinence-only education, particularly the psychological and physical repercussions of teenage sexual activity can occur. By ignoring teens’ definitions, the program intends to teach abstinence from all sexual activities, but adolescents interpret abstinence as only pertaining to vaginal sex.
In addition to problems regarding definitions, teens frequently break abstinence vows. Abstinence-only programs therefore delay teenage sexual intercourse, not prevent it. By college, 60% of students who pledged virginity broke their pledges (7), illustrating the difficulty of maintaining virginity until marriage. Abstinence-only education typically affects adolescents’ short-term attitudes, but not long-term behavior (3). As a result, most teenagers who pledge abstinence engage in premarital sex and when they have intercourse, are less likely to use condoms and receive STI treatment (16). Abstinence-only education programs do not provide the resources for sexually-active adolescents. Teaching both abstinence and safe sex practices better equips teenagers to cope with pressures of adolescence.
Conclusion and Implications
The Parents, Speak Up! Campaign, an abstinence-only educational program, neglects important factors that impact teenage decisions and ignores entire subsets of the teenage population. The program fails to contextualize current adolescent behaviors and beliefs about sexual behaviors into its intervention. Economic, educational, familial, and social factors impact teenage sexual activity (9). Programs need careful design to address the unique, complex nature of a diverse teenage population’s sexual behaviors. Marketing solely to parents to talk to their children about abstinence is not the best use of limited federal funds
The sexual education agenda needs change. Recently, programs strongly focus on abstinence-only education, but only 15% of parents solely want abstinence taught in schools (7). However, due to the moral implications of sexual education, a small group of vocal abstinence-only education proponents can push an agenda that many do not support. They succeed, because the opposition lacks the drive to fight back. All teens face pressure to engage in sexual relations during their adolescence. The issue affects anyone who has children, who is an adolescent, and according to the government, society as a whole, which must cope with the ramifications of sexual decisions.
In 2002, abstinence-only education programs did not make the CDC’s list of “Programs That Work” to reduce adolescent risky sexual behavior (9). Federal policy should include a mix of proven effective methods, not concentrate solely on abstinence, which sounds great in theory, but lacks results in reality. From 1991 to 2003, pregnancy rates declined 27% for women ages 15-19; 86% of this decline was due to increased contraception use and 14% was due to refraining from sexual activity (2). The contraception use accounts for 100% of the decline for ages 18-19 (2). Sexual education programs that combine abstinence education with safe sex instruction do not increase sexual activity and teen pregnancy rates, and abstinence-only education has not been proven to prevent initiation of sexual activity (23). Society cannot pretend that all teenagers are abstaining from sex; teenagers need to be educated to protect themselves and others from unplanned pregnancies and unwanted STIs.
Programs that teach only abstinence fail to effectively address any and all risky teenage sexual behavior. According to 2/3 of US teens, solely teaching abstinence-only sexual education is ineffective in preventing the onset of sexual behaviors (9). Limited federal pecuniary resources should be allotted to proven comprehensive sexual education to help protect vulnerable populations and society as a whole. Compared to other developed nations, the US has the highest teen pregnancy and STI rates, rates that are declining slower than other nations (9). Other countries are more successful, and the US must look to them for guidance. The future for federal sexual education efforts remains unclear, but the 2008 elections provide an opportunity for federal policy improvements to better utilize the millions of sexual education dollars.
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