Challenging Dogma


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

Monday, April 30, 2007

Public School Sex Education: The Failure of the Health Belief Model to Effectively Promote Abstinence Among Adolescents – Kelli Jarrett

Background

Since 1996, there has been a dramatic shift in the curriculum of sex education programs funded by the federal government. Section 510 of the 1996 Social Security Act, part of welfare reform, laid out 8 rules that now govern state programs on sex education that received federal funding (1). Beginning with this act, for states to receive federal funding for sex education programs, they must teach Abstinence Only Education (AOE), and the rules created by Section 510 specifically prohibit disseminating information on contraceptive services, sexual orientation and gender identity, and other aspects of human sexuality (1). This trend towards AOE continued with the creation of Community-Based Abstinence Education projects in 2000, which were funded through an earmark in the Maternal Child Health block grant entitled Special Projects of Regional and National Significance (SPRANS). SPRANS bypasses the earlier 1996 Section 510 rules for the state approval process, and makes grants directly available to community-based organizations, including faith-based organizations (2).

This dramatic shift away from comprehensive sex education for youth, towards Abstinence Only Education necessitates a critical look at the goals and underlying assumptions of these programs. No evidence currently exists on the effectiveness of these programs on delaying initiation of sexual activity in youths, or reducing teen pregnancy and Sexually Transmitted Disease rates. There is some evidence to show, however, that some of these programs decrease rates of contraceptive use among youth when they do initiate sexual activity (3). The failures of Abstinence Only Education can be explained in large part by its failure to employ valid Social and Behavioral Science models of health behaviors.

The Failure of the Health Belief Model in Abstinence Only Education

Abstinence Only Education is grounded in the Health Belief Model. The eight rules laid out in Section 510 of the Social Security Act of 1996 for Abstinence Only Education focus on emphasizing the dangers of premarital sex. The two most relevant of these eight rules are that schools receiving federal funding for sex education are required to teach: 1) Sexual activity outside of marriage is likely to have harmful psychological and physical effects, and 2) Bearing a child out of wedlock is likely to have harmful consequences for the child, its parents, and society (1). These two requirements for Abstinence Only Education focus on increasing youth’s perceived severity of the potential adverse consequences of sex before marriage. The Health Belief Model describes a rational decision making process where one’s perceived susceptibility to a health outcome and the perceived severity of that outcome is weighed against the perceived barriers to performing a certain health behavior, which ultimately leads to intention and then the health behavior (4). By focusing on the negative effects of sex before marriage and trying to scare adolescents by telling them what may happen if they engage in sexual activity before marriage, AOE is trying to build up the “perceived severity” block of the Health Belief Model, with the hope that this will lead youth to the intention of remaining abstinent, which will consequently result in them performing the desired “behavior,” which is remaining abstinent until marriage.

What the Health Belief Model fails to account for, however, is the outside influences that affect an adolescent’s decision to initiate sexual activity. The Health Belief Model is based solely on the idea that an individual rationally weighs the costs and benefits to come to a decision about the health behavior (4). One health behavior model that does account for some outside influence in the decision making process is the Theory of Reasoned Action, which includes the role of attitudes and perceived norms in forming intention and health behavior (5). By including one’s perceived norms, this health behavior model begins to take into account some of the social factors that affect the decision whether or not to have sex. In American society, it is clear that sex outside of marriage is the norm. Popular media promotes this stance, both in highly sexualized advertising and in popular television shows and movies that quite often depict individuals having sex outside of marital relationships. Even within their own home, many adolescents are exposed to intimate relationships that are not within marital ties. With the divorce rate in this country currently hovering around 50% (6), more than half of families at some point experience relationships outside of marital ties, and children in these families see their parents engaged in intimate relationships with new partners to whom they are not married.

With these outside influences informing their perceived norms, adolescents are much less likely (according to the Theory of Reasoned Action) to intend to remain abstinent. The Health Belief Model fails to take into account social norms and other influences outside of the individual rationally balancing the pros and cons, which is one reason that Abstinence Only Education, by relying on the health belief model, is failing to achieve its goals of delaying initiation of sexual activity and reducing rates of adolescent pregnancy.

Social Learning Theory and Abstinence Only Education

Another social science theory that can account for some of the failure of Abstinence Only Education is Social Learning Theory, which states that people have a tendency to model behavior they see in others (7). It is well known that adolescents are especially susceptible to outside influences, especially the behaviors they see others engaging in. Role modeling is especially important in this age group. Thus, when the role models that are most important to adolescents are highly sexualized individuals, adolescents tend to model this behavior rather than what they are taught through AOE.

One well known adolescent role model is Paris Hilton. She is a household name in the United States, especially in the world of adolescents. From media coverage, to her televisions show, to her infamous “sex tape,” she has become a prominent icon, and one that this generation of adolescents perceives as “cool.” She has become a role model for many teenage girls across the country, who model her clothing, hairstyle, as well as her highly sexualized behavior. The fact that Paris has engaged in premarital sex has been highly publicized, from the media reporting on her constantly changing boyfriends, to the aforementioned sex tape. Social Learning Theory states, then, that because she is a widely recognized role model, the health behaviors she engages in are likely to be modeled by adolescents. Abstinence Only Education, by focusing on individual decision making, does not take this modeling phenomenon into account. A focus on promoting better role models who are not highly sexualized would, according to Social Learning Theory, have a much greater impact on informing the decision of adolescents regarding their own sexual behavior than simply informing them of the risks of premarital sex.

Psychology, Adolescence, and Abstinence

Another model of health behavior from the social sciences that Abstinence Only Education fails to account for is Erikson’s Stages of Psychosocial Development (8). Adolescence is identified by Erikson as one of the psychosocial stages of development, which occurs between the ages of 11 and 18. During this period in ones life, the psychosocial crisis identified by Erikson is Identity versus Role Confusion (8). Adolescents are, for the first time, concerned with how they appear to others. Their central task during this time period is to identify peer groups and cliques, which comprise their significant relationships (8). This concern with how they are perceived by others has a strong influence on how susceptible adolescents are to peer pressure, which will have an effect on their decision making process concerning sexual activity and abstinence.

One important aspect of the theory that Erikson describes about adolescents’ concern with peers and how they appear to others is the importance of relationships with boyfriends and girlfriends, which are first developed in adolescent years. This is a specific element of the peer groups that Erikson describes, and thus adolescents tend to be very concerned about how they are perceived by their boyfriends and girlfriends. This has a clear impact on their decisions of whether or not to engage in sex. Concern for how their boyfriend or girlfriend will think of them, as well as what their peer groups think about sex and about people who have sex, plays an important role in determining whether or not adolescents will engage in this activity. Abstinence Only Education fails to address this factor at all. To effectively address it, one would have to find ways to change the perception of sex in adolescents as a group, instead of focusing on the decisions that an individual is making. Erikson’s stages of psychosocial development demonstrates the importance of the Theory of Reasoned Action and Social Learning Theory in predicting adolescent health behavior. Because in this stage of their lives adolescents are very concerned about their peer groups and how they appear to others, their perceived norms and the behaviors they see others engaging in have a much stronger influence on them than it might have on a different age group. If sex is acceptable to their peer groups, and tends to be the social “norm” that they see modeled for them, this is what they are likely to engage in. Abstinence Only Education focuses instead on the individual, as modeled by the Health Belief Model. It presumes that if you convince an individual of the risks of a certain behavior, they will weigh this out rationally and make a decision. As described by both Erikson’s Stages of Psychosocial Development and the other health behavior models described here, there are many factors outside of the individual that affect health behavior decision making, especially during the period of adolescence.

Conclusion

The failure of Abstinence Only Education stems from its focus on the individual’s decision making process, as modeled by the Health Belief Model. There are many factors outside of the individual that influence decision making regarding health behaviors, especially for adolescents. To achieve its goal of delaying the initiation of sexual activity and reducing the amount of adolescent pregnancy and STD infection, AOE programs must start to consider the social aspects of decision making, especially the unique aspects of adolescence and the effect that has on one’s decision making process. Using more appropriate social science models, such as Social Learning Theory or Erikson’s Stages of Psychosocial Development, would account for these interpersonal factors and lead to developing more effective programs to address the issue of teen sexual activity and its consequences.

References

1. Personal Responsibility and Work Opportunity Reconciliation Act of 1996, Pub. L. no. 104-193, 110 Stat 2105 (1996).

2. Maternal and Child Health Bureau. Womens Health USA 2003. Rockville, MD: Maternal and Child Health Bureau, 2003. http://mchb.hrsa.gov/pages/page_03.htm

3. Santelli J, Ott MA, Lyon M, Rogers J, Summers D, Schleifer R. Abstinence and abstinence-only education: A review of U.S. policies and programs. Journal of Adolescent Health 2006; 38: 72-81.

4. Rosenstock IM. Historical Origins of the Health Belief Model. Health Education Monographs 1974; 2: 328-335

5. Salazar MK. Comparison of four behavioral theories. AAOHN Journal 1991; 39: 128-135.

6. Centers for Disease Control and Prevention. Marriage and Divorce. Hyattsville, MD: National Center for Health Statistics. http://www.cdc.gov/nchs/faststats/divorce.htm

7. Bandura A. Social foundations of thought and action: A social cognitive theory. Englewood Cliffs, NJ: Prentice-Hall, 1986.

8. Erikson EH. Childhood and Society. New York, NY: Norton, 1950.

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