Challenging Dogma

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

Saturday, April 21, 2007

Why the current approach to sexual health education for adolescents misses the mark – Wendy Moore

In 2005, the Center for Disease Control and Prevention (CDC) found that 46.8% of high school students had sexual intercourse and 33.9% were currently sexually active (1). In fact, in 2004 the CDC determined that three million new cases of sexually transmitted infections occur in U.S. adolescents every year, and more than half of all new cases of HIV infections occur in people under 25 (2). Noting that adolescents account for such a large amount of sexual health issues, public health officials and policy makers have backed efforts to educate them about the consequences of early sexual activity. Many states have adopted school-based sexual health education programs in order to address the three leading sexual health issues affecting adolescents today: AIDS/HIV, STDs, and teen pregnancy (3). Many of these interventions are based on the Health Belief Model. However, these interventions fall short because the Health Belief Model does not account for the realities of adolescents’ sexual activity and decision-making. The Health Belief Model wrongly assumes that adolescents are rational decision-makers; it ignores other internal and external factors effecting adolescents and promotes a negative, fear-based approach to school-based sexual health education. Using this model, public health interventions restrict and reduce their efficacy with adolescents.

Health Belief Model

The Health Belief Model states that individuals decide their behavior by weighing the perceived risks and severity of these risks, against the perceived benefits resulting in an intention to act. According to this model, the intention to act is followed by a corresponding behavior (4-5). The Health Belief Model makes several assumptions about human behavior. First, it assumes that human behavior is always rational. Second, it assumes that people’s intention to act equates to their corresponding behavior. Third, it believes equipping people with the right information will definitely lead them to choose the correct behavior (5).

Rational Decision-Making

Traditional models like the Health Belief Model have long promoted the idea that all people make decisions in a rational, health promoting manner. It is also believed that even when persons are participating in unhealthy behavior, they will stop or change their behavior once they become aware of its unhealthy consequences. One common assumption is that adolescents taking part in risky behavior simply are not aware of the risks and severity of their actions. However, research actually shows that risk-taking adolescents over-estimate their risk of getting negative health consequences at a significantly higher rate than those not participating in risky behavior (6). Moreover, adolescents weigh their short-term gains more heavily than their long-term consequences. Based on this mentality, the benefits of short-term gains overshadow the full consideration of many long-term consequences (7).

Second, adolescents are more prone to irrational decision making when they find themselves in new and unfamiliar environments. For example, many adolescents noted that often they did not expect to have sexual intercourse or unintentionally went “too far” (8, 9). The unexpected circumstances prevented these adolescents from planning in advance or following suggested interventions (9). This impulsive decision-making leaves younger adolescents even more susceptible to irrational decision-making and risky situations because they are less physically, emotionally, and socially mature.

In fact, adolescents who take risks are more prone to participate in various forms of risk-taking behavior than non risk-taking peers. Studies show that adolescents who use drugs and alcohol are more sexually active than non-substance using adolescents (10). In 2005, the CDC found that 23% of adolescents admitted to using drugs or drinking alcohol before their last sexual intercourse (1). This relationship show a correlation between risk-taking youth and more irrational thought processes.

Because rational decision-making and adolescent behavior is not one in the same, the Health Belief Model should not be categorically applied to adolescent public health interventions. Future programs should consider how adolescents approach decision making and how to better equip them for unexpected situations.

Other Critical Factors Effecting Adolescent Decision-Making

Dependence on the Health Belief Model with its rational approach has prevented public health educators from considering other essential factors that influence adolescent behavior. These factors include critical developmental, environmental, and social influences, which combined with decision-making, may affect people’s intentions and actions.


The first point to consider when developing public health interventions for adolescents is their brain maturity. Science shows that the human brain continues to develop well past age twenty, ipso facto; an eleven year old brain is neurologically less developed than that of an eighteen year old. By inference, younger adolescents are less equipped to fully comprehend the ramifications of their actions (7). Therefore, delaying or reducing risky behavior with younger adolescents is a better approach, while a more cognitive, reason-based approach may have greater efficacy with older, more mature adolescents. Nevertheless, considering developmental factors is essential to understand adolescents’ decision-making capabilities.


The second point to consider regarding adolescents’ decision-making is how environmental factors influence adolescent behavior. Adolescents’ exposure to sexually-explicit media is one example, which is believed to have a significant effect on 21st century adolescents. Sexual themes are common in much of the main-stream music listened to by adolescents today. On average, adolescents listen to approximately 1.5-2.5 hours of music a day (11). Consequently, modern media appears to influence adolescents’ decision-making skills and reinforce perceived short-term benefits of sexual activity. One example comes from a focus group where pregnant teen moms noted that the consequences of having sex were positive according to media models – people feel good, they feel loved. Good things not bad things happen when one has intercourse according to television or radio songs (8). Therefore, public health interventions designed for adolescents should evaluate and determine the role of environmental factors such as media on adolescents’ decision-making and find ways to include these factors into their health curricula.


The third point in understanding adolescents’ decision-making is the influence of social factors, namely, peer pressure and modeling. Adolescents are more susceptible to peer pressure and rely more heavily on social approval than adults (12). Researchers have found that adolescents are more likely to participate in risky, irrational behavior when in the presence of their peers versus when they are alone. The younger the adolescents the more their behaviors were influenced by their peers. In addition, these same adolescents came to better, more mature decisions by themselves then when they were in the company of others (12). Thus, if adolescents are surrounded by peers, risky situations and poorer judgments are more likely to occur.

Modeling is another important construct, which shapes adolescent behavior. In focus groups with teen mothers, many teen moms came from social settings where their friends also had babies. Additionally, the parents of these teen moms were supportive, doting grandparents (8). Hacker et al. found that sexually active adolescents were more likely, than abstinent adolescents, to have mothers who had their first child at 17 years or younger (9). In both cases, adolescents’ social environments can shape their values and behavior. Because the Health Belief Model assumes that everyone has the same sense of right and wrong, this model cannot address the various social values, which adolescents hold.

Ultimately, the Health Belief Model assumes a one-size fits all approach to adolescent behavior. In so doing, it over looks critical developmental, environmental, and social factors present in the daily lives of adolescents. These factors play an enormous role in shaping adolescent behavior and must considered when developing public health interventions.

Beyond a Negative Approach

The current school-based sexual health education programs use a very negative, fear-based approach to discuss sexual activity and sexual health. Relying on the Health Belief Model, educators repeatedly stress the enormous risks and compounding severity of adolescent sexual activity. The message becomes a list of “dos and don’ts” intended to persuade adolescents to avoid certain risky behaviors. Although, fear appeals tactics can be effective, messages characterized predominantly by fear can be off putting and deter an audience from its intended suggestion. Fear appeal tactics, therefore, should be carefully placed and should not be the only technique employed in public health interventions. Public health interventions should encourage new, creative ways to broach topics such as adolescent sexual health and sexual activity.

Fear appeal tactics

Fear appeal tactics are persuasive messages used to evoke an emotional response to a threat expressing or implying some sort of danger. There are two important components of fear appeal tactics. The first is to list the various consequences, which should arouse fear and motivate a person towards a solution. The second is a list of recommended solutions to reduce this fear (13). Fear appeal tactics are used in many public health interventions because of their proximity to the Health Belief Model, but these tactics are not always effective. In fact, Bennet found that high-level fear appeal tactics, such as correlating AIDS and death, were only effective with low self-esteem subjects (14). Researchers explain this relationship through the terror management theory (15). This theory states that self-esteem and world views act as buffer to manage intense fear, such as death. When world views are challenged, individuals react by rejecting the new ideas and perceiving these opposing views as counter to their own (15). In school-based sexual health education programs, for example, fear appeal tactics are often used to repeat severe sexual health consequences. Over time, adolescents gain knowledge and self-esteem about this subject, which may lead them to reject continuous fear appeal tactics, perceiving these as threats to their own world views versus solutions to impeding danger. The terror management theory challenges the Health Belief Model by illustrating how self-esteem and world views affect decision-making skills. If this is true, the current school-based sexual health education programs may not only be ineffective, but could discourage the adoption of their suggested solutions.

Beyond fear

By limiting school-based sexual health education programs to fear appeal tactics, programs are inundated by negativity. They are restricted from incorporating new methods such as general sexual health information or humor into their health curricula. As Witte and Morrison noted in their research of adolescent sexual behavior, low threat groups had more positive attitudes towards monogamy than high threat groups (15). Therefore, health curricula containing general sexual health education could provide adolescents with useful information on their human physiology and emotions without simply reiterating harmful consequences of sexual activity. Second, how a message is communicated is just as important as what is being communicated. In Beaudoin’s communication research, he notes that youth respond best to short-term messages versus long-term ones and humor versus fear (16). In fact, a 1998 FAME anti-smoking campaign which incorporated sleek and funny advertising was so successful that 92% of Florida adolescents surveyed were familiar with the campaign (17). This campaign suggests that public health interventions can benefit from creative and thoughtful approaches to some of the most serious health issues.

The current school-based sexual health programs for adolescents are largely negative, because they are rooted in fear appeal tactics. Since fear appeal tactics work sparingly and in certain groups, determining when and how to use them is important. Certainly, it does not imply that public health interventions must depend on them. In fact, researchers suggest that other methods such as short-term messages and humor are more effective techniques with adolescents.


Although the Health Belief Model is being strongly critiqued, it is not an inherently poor model. Clearly, many social scientists and public health interventions depend on its logic. The main goal of this paper is to identify the weaknesses associated with using this model as the corner stone of public health interventions especially those developed for adolescents such as school-based sexual health education programs. Public health interventions do need behavioral models but the correct model should be identified and carefully scrutinized.

In the case of school-based sexual health education programs, the Health Belief Model with its strict rational approach often ignores many critical developmental, environmental and social factors affecting adolescents and their decision-making abilities. The take home message of this intervention is based in fear. This method not only provides ineffective solutions but also inhibits public health from adopting new, more creative approaches to adolescent sexual health issues. For these reasons, a new model ought to be considered for developing school-based sexual health education programs for adolescents. Interventions aimed at a more holistic, positive approach towards sexual health education; ones that recognize the strengths and weaknesses of decision-making adolescents, and seek to teach them better ways of avoiding risky, unexpected situations. A new approach to school-based sexual health education programs would give the current curricula a refreshing face lift.


1. Center for Disease Control and Prevention, Youth Risk Behavior Surveillance 2005.
2. Center for Disease Control and Prevention. Youth Risk Behavior Surveillance, U.S., Morbidity and Mortality Weekly Report 2003, 53 (SS02), 1-96
3. Forrest, J. & Silverman, J. What Public Health Teachers Teach About Preventing Pregnancy, AIDS and Sexually Transmitted Diseases, Family Planning Perpectives 1989; 12 (2) 65-72
4. Wikipedia. http;//
5. Seigel, M. Health Belief Model, SB721-A2 Class Notes: 3-22-07 and 3-29-07.
6. Johnson, R. et al. Risk Involvement and Risk Perception Among Adolescents and Young Adults, Journal of Behavioral Medicine 2002; 25 (1): 67 -82
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11. Martino, S. et al. Exposure to Degrading versus Nondegrading Music Lyrics and Sexual Behavior Among Youth, Pediatrics 2006; 118: 430-441
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13. Hunt, D. & Shehryar, O. The nature of fear arousal and segmentation of target audiences in fear appeals, American Marketing Association 2002; 13: 51-59
14. Bennet, R. The effects of horrific fear appeals on public attitudes towards AIDS, The International Journal of Advertising 1996; 15: 183-202
15. Witte, K & Morrison, K. Using scare tactics to promote safer sex among juvenile detention and high school youth, Journal of Applied Communication Research, 1995; 23: 128-42
16. Beaudoin, C. Exploring Anti-Smoking Ads: Appeals, Themes, and Consequences, Journal of Health Communications 2002; 7: 123-137
17. Zucher, D. et al. Florida’s Truth Campaign: A Counter-Marketing, Anti-Tobacco Media Campaign, Journal of Public Health Management Practice 2000; 6(3): 1-6

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