The “It’s Your Sex life” Campaign: False Belief in the Health Belief Model – Sergey Rekhtman
The Centers for Disease Control (CDC) and Prevention estimates that individuals under 25 years old account for two-thirds of the estimated 19 million newly diagnosed sexually transmitted infections (STIs) in the United States (7). According to the “It’s Your Sex life” (IYSL) Campaign, one out of two people will get an STI by the age of 25 and most won’t know it (1). Since STIs are often life-long infections, and since the majority of these infections are acquired before the age of 25, targeting the youth for public health interventions is a sound principle. The difficulty lies in devising strategies to effectively increase safe sexual practices such as condom usage and testing for STIs.
Many public health interventions designed to combat sexual health focus on providing factual data about the scope of this problem and hope that their message alters behavior (11). This type of strategy weakly uses the resources allotted for public health interventions. For the past few decades, public health interventions focused on the health belief model. This may explain why many prior interventions are modeled to provide factual data. IYSL is no different, and it largely follows this train of thought. Although some aspects of this intervention are successful, it has the funding and the publicity to achieve much greater results than are currently realized (4).
The Health Belief Model: Introduction and Limitations
This psychosocial model was initially developed to explain “the widespread failure of people to accept diseases preventatives or screening tests for the early detection of asymptomatic disease” (3). Based on this theory, health behavior is influenced by two major variables. The first is the desire to avoid illness, or if ill, to get well, and the second is the belief that a particular health action will prevent disease or lessen disease burden (3). Health behaviors are then motivated by perceived susceptibility of illness, perceived severity, perceived benefits of action, and perceived barriers to taking that action (8). Once an intention is formed, cues to action motivate the person to act and action then depends on self-efficacy, or the person’s belief in their ability to take action (8). This process is a conscious tug-of-war and the winning side leads to a particular health behavior, be it a positive or negative behavior.
Several limitations exist which lead this theory to be a poor choice to model health behaviors. Many different factors influence behavior and this theory and a major one such as social norms is not addressed (12). This is particularly important in decision-making especially in teenagers who constantly stride to be more like their peers. There are also different types of decisions to be made. Some decisions must be made consistently and are involved in coping and these are the ones most ignored by this theory (12). Most health behaviors require constant reiteration before they are adapted making this a serious limitation. Also, many decisions that are made are irrational, and the health belief model completely ignores this fact (5). Significant limitations exist when using the health belief model to understand human behavior.
IYSL: Brief Introduction
IYSL is an intervention developed to target the youth to promote good sexual practices in order to decrease the spread of STIs and unwanted teenage pregnancies. The key to this intervention is the highly colorful and simple-to-use website. This website is clearly designed to target the youth by using hip terms and fragmented sentences; language typically used when teens communicate with one another (1). After spending several minutes surfing this site, a teen would be exposed to the majority of messages that are intended to be seen. These messages typically describe factual information about STI contraction as well helpful hints of how to talk to one’s significant other about sexual health (1). Interactive features include a discussion board where confused or scared teens may ask for help and a handy locator where one may input their zip code to determine the nearest location which tests for STIs (1). After testing this zip code feature, I found that there are testing sites within walking distance from my location, which may be very useful to a teenager.
Although the website appears helpful, it is only useful when visited. The majority of visitors tend to hear of the site through word of mouth, or through the major intervention tool, a TV show which airs on music television known as “16 and pregnant” (1). This show attempts to illustrate how difficult it is to be a teen mother due to an unintended pregnancy. Further supplementation of public health messages in the form of commercials are presented during intermissions of the show. These messages tend to be factual often relating to the likelihood of acquiring STIs, similar to the ones seen on the website (1).
IYSL and the Health Belief Model
When examining IYSL, it is clear that the intervention is established to follow the health belief model. The health belief model asserts that when an individual understands the risks involved with a bad health behavior, they will intend to do a good health behavior in its place (3). Many of the IYSL interventions are meant to educate the youth as to what happens when sexual health is not addressed. For instance, one section of the website addresses talking with your significant other about sexual health includes, “But, if you are confident about your facts” (1). This implies that if you know the facts behind good sexual health, you will know enough to be able to change current health behaviors, and this greatly demonstrates the dependence on the health belief model. IYSL’s confidence in health belief model makes it susceptible to the same limitations the model is subject to.
IYSL Does Not Address Social Norms
Intentions are acts determining mentally upon some action or result (9). This implies that there is an action or result that follows the formulation of an intention. The health belief model asserts that once an intention is formulated, the likelihood of it becoming an action depends on cues to action (12). Unfortunately, even when a cue is provided, this is not always the case. Many factors have been shown to be important in converting an intention to an action (10). IYSL provides information on why to be sexually healthy which addresses perceived susceptibility and severity of negative health behaviors. IYSL then also provides the cues to action with the use of its TV show and the advice giving style of the website. These cues, according to the health belief model would translate intentions into activities, but many factors are ignored. Among these factors, social norms may extremely significant.
Teenagers are constantly exposed to peer pressure, which may lead to negative health behaviors. This stems from the fact that a feeling of group membership is comforting in contrast to an adolescent’s uncertain sense of self (13). Individuals in their teenage years are often faced with many decisions, and due to the comfort of group membership, they may find themselves conforming to the ideas of their peers. IYSL prides itself on providing many reasons why individuals should be sexually healthy and prevent STI contraction. It does not even address that negative stigmas exist which may prevent one of the most efficient ways to reduce STIs, condom usage. For instance, condoms may label an individual as being strong and independent, but at the same time promiscuous, inappropriate, and a poor friend (15). Few teens want to be labeled promiscuous. Another study found that a big factor involved with decreased condom usage was the acceptability of condom use (14). These studies imply that considerable stigmas exist about positive sexual behaviors, and social norms must be changed for interventions to be successful. It almost seems as if IYSL does not address such negative stigmas so as not to incept these ideas in unaware individuals. IYSL appears to follow the strategy of “just ignore it and it will go away.”
IYSL and the Assumption of Rationality
The health belief model asserts that once an individual understands they should do a health behavior, and there are no factors standing in their way, they will do the health behavior (12). This clearly assumes that human behavior is rational and that behavior is a consequence of only rational thinking. IYSL consequently also makes this assumption. By providing considerable information of why good sexual habits are necessary, IYSL assumes that teenagers that know this information will finally understand how dangerous it is to have poor sexual habits. Unfortunately, human behavior is not rational (5).
A false assumption of rationality makes IYSL particularly weak from the standpoint of a health behavior intervention. Health behaviors are typically constant decisions that must be reiterated to be adapted. The health belief model is strong when predicting behavior that is rational and intentional (12). Since most health behaviors are quite the opposite, and are often spontaneous, and irrational, application of this theory is weakened from a health perspective (12). Many health behaviors also often require coping and are gradual lifestyle changes. Although individuals often make spontaneous decisions to change their health behavior, there is no guarantee that such changes will persist or be rational. Without a clear understanding of the irrationality of human health behaviors, interventions are unlikely to succeed.
IYSL Induces Psychological Reactance Theory
Interventions such as IYSL focus on describing the negative aspects of withholding good health behaviors, and this may be counterintuitive. Psychological reactance theory states that the reaction of individuals who have perceived to a loss of a freedom will often react to regain that freedom (16). This is particularly true when an individual is told to do something, or not to do it because such an act relinquishes their freedom. This has been shown extensively in the literature. In one instance, it was shown that consumers were more likely to want products which were scarcer and government regulations making products unavailable further induced this want (17). Another example is a study of pop-up ads on websites which showed that individuals were more likely to avoid intrusive ads that interrupted web page access than ads which appeared after a webpage had been closed (18). Public health interventions are no different and are subject to psychological reactance. Additionally, nearly every public health message attempts to decrease an individual’s freedom by forcing a change in behavior. Although the intentions are to initiate a positive behavior, most public health messages consistently invoking psychological reactance theory. When such events occur, individuals are apt on either ignoring the message, or doing the opposite of what they’re told (16).
IYSL is guilty of having the potential to greatly evoke psychological reactance. Virtually all of the messages in this campaign are orders to get tested for STIs, talk to significant others about STI testing, and to wear condoms. The catch phrase of the campaign seems a very likely part of the intervention to invoke psychological reactance, “GET YOURSELF TALKING GET YOURSELF TESTED” (1). Being in all capital letters, this phrase furthermore sounds like an order from a higher authority. With teenagers, such authoritative statements will likely evoke psychological reactance and lead to worse sexual health behaviors. The only method of minimizing psychological reactance in IYSL is through the use of language. Since the language on the website is made up of fragmented sentences and slang words used by teenagers, any teenager that explores the site will feel a sense of similarity, and this may mitigate some psychological reactance (1, 6). Psychological reactance is a dangerous threat to public health campaigns, and only by being cautious of it, may we create more efficient interventions.
Conclusions about IYSL
Traditionally most public health interventions were modeled based on the health belief model. In such cases the inherent flaws of the model are extrapolated to the interventions. IYSL is no different and carries some of these same flaws. Teenagers often look to their peers for guidance, and social norms are not addressed whatsoever in this intervention or in the health belief model. Rational behavior which is unlikely to be seen when attempting to change health behavior is the basis of a major assumption of both the theory and the intervention. Additionally, the invocation of psychological reactance makes this intervention not only less powerful, but also dangerous since it may increase the possibility of a negative behavior. This intervention had great potential with the significant partnerships, a TV show on primetime MTV, and significant funding. Had IYSL been modeled after a more theory of human behavior, these significant opportunities may have been better utilized.
Designing a Better Intervention
Health interventions based on the health belief model and other psychosocial models have been traditionally used for years, but have often come short of their goals. For instance the evaluation of an intervention of condom usage found that participants who received the health belief model intervention used condoms more, but since the resultant condom usage was inconsistent, there were no difference in outcomes of acquiring Chlamydia (19). We live in a computerized social era where we need to use a different type of strategy to reach out to young individuals. Dependence on a single theory is unlikely to be very successful, because although theories are useful, human behavior is very complex and extremely challenging to predict. To broaden our chances of success, I propose using aspects of several different theories to model human behavior. “In some cases, elements of different theories and even the theories themselves can be combined to get the best results” (12). I would model my intervention on two major social theories: marketing theory and labeling theory.
The “Be Yourself, Be Cool, Be Unique” Campaign (BYCU)
The BYCU campaign is meant to target teenagers that are sexually active or that will be in the near future. Major aspects of this intervention include a TV show on a major teen network such as MTV, public service announcements in the form of advertisements during commercial breaks of the TV show, social events, and an interactive website which may become a social network for teenagers. Using mass media, professional athletes, and movie stars to support this intervention, it could potentially reach a nation-wide level.
Marketing theory will be the basis for many different aspects of this intervention. Using marketing theory to model public health interventions first requires the determination of the needs and wants of the audience. Teenagers have been shown to have particular core values such as control, freedom, and acceptance (24). In order to successfully market to them, we must not market health (24), but rather repackage health to sell these core values. One such public service announcement in the BYCU campaign may be a commercial:
“It starts with a story of a girl playing soccer for her team. She has to sit out of a play in order to run back to the bench to take 10 tablets of HIV medication. Next, she would look at the screen and say, “I have HIV, but now there is medication to treat it. The only problem is it gets in the way of my game.” She then would finish by saying, “you're in control; don’t change that” as she runs back to the soccer game.”
Rather than selling the health that a teenager would get from good sexual health, this type of announcement would sell control that a girl has lost in her life. Other commercials may concentrate on selling freedom and acceptance as well.
BYCU Addresses Social Norms
Many different social stigmas exist, and these may determine such things as health, employment, and social rejection (20, 22). Negative stigmas may be due to negative labels put on individuals. Labeling theory states that there are both outsiders to groups and people who are labeled outsiders regardless of them conforming to the behaviors of a group (21). Due to some sort of similarity between the outsider and the one “labeled” an outsider, the labeled individual is often assumed guilty of the same discordance the outsider is guilty of (21). This is a description of negative labeling, but positive labeling of an individual for going against the behaviors of the group because the group’s behaviors are negative, has great potential to be used in public health. By labeling these “deviant” individuals, others in the group may conform as well (21). Additionally, once individuals have these “positive” labels, they are likely to change their behavior just because of the label (23). BYCU will label individuals as either “cool” or “unique.” “Cool” is already often used as a positive label to describe deviants in society that others strive to be. By associating a health behavior as being “cool,” BYCU would be using positive labeling to its advantage, and make it more likely that the behavior will be performed.
Aside from labeling activities, many positive messages will come from the TV show BYCU will create. This show will be a reality show on a primetime network (such as “16 and pregnant” with the IYSL campaign) and it will follow 10 young adults in their early 20’s. These individuals will have drama-stricken lives which will attract viewers and their lives will revolve around social events involving alcohol. Rather than creating a message that social drinking and sexual activity is bad, this show will differ from the IYSL show and concentrate on how to live “normal” lives but to be safe about it. The individuals in this program will encounter difficult decisions which could affect their health and they will portray positive behaviors such as using condoms in the hope that viewers will be convinced this is the social norm. This primetime showing will also allow additional public health commercials to air during commercial breaks, further moving the campaign along.
BYCU Does Not Assume Rationality
Unlike the health belief model, marketing theory does not assume individuals to be rational. Since BYCU is modeled on marketing theory, it does not fall weakness to this same assumption. Quite the opposite actually occurs where marketing often depends on individuals making irrational choices to buy products (5). In no way, does marketing theory expect individuals to make the “right” decision, but to make decisions that are most similar to their wants and needs. Marketing theory repackages these core values and sells them based on their appeal to certain groups. BYCU is no different and it will expect teenagers to engage in better sexual health practices by offering core values such as control, freedom, and acceptance. Rather than tell teenagers the health behavior they should participate in, BYCU will give them something they already had, but often feel they are lacking. In no way is this rational, but it gives marketing theory the advantage of overcoming irrational thought.
Marketing theory also addresses the complex irrationality of groups. Groups are are more than just a collection of individuals. It is unlikely that the behavior of a group may be predicted by the behavior of one individual (25). Group behavior is largely irrational, unplanned, and dynamic (2). This behavior is largely explained by herding theory which goes into great detail describing this phenomenon. The non-rational view on herding theory is that individuals follow each other without performing rational analysis (26). Marketing theory is a group level model in which core values may be sold to entire groups. The irrationality of groups makes marketing even stronger since it allows marketing to reach a larger number of people all at once. Marketing theory not only assumes humans irrationality, but it depends on it.
BYCU Minimizes Psychological Reactance
Psychological reactance occurs whenever an individual feels their freedom is threatened (16). Most health messages order individuals to conduct a new behavior, and this often induces psychological reactance. Since BYCU is well aware of this possibility, this intervention has taken several steps in reducing reactance. Factors that may affect psychological reactance include deflection of the source of a message and similarity of the recipient of the message to the communicator (6).
Deflection of the source is the major method by which BYCU attempts to minimize reactance. BYCU will take no pride in telling everyone they are responsible for the intervention, and they would prefer not to be implicated with major portions of the intervention such as the TV show and public health commercials. The website would also have very little mention of the intervention and it would mostly consist of a social networking site for teenagers to discuss their problems, thoughts, and opinions about sexual health. One tab in the site would be labeled, “sexual health information,” and this would link to a sister site which is the main information hub of BYCU. Individuals who want to read information on how to be sexually healthy and why would scan this site. Other than this sister site, it would be difficult to determine the source of this intervention, and this would deflect some psychological reactance.
Similarity is another major method of decreasing psychological reactance. When the communicator of a message is highly similar to the recipient, the recipient is more likely to agree with the message regardless of how significant the threat to freedom is (6). The website would be designed in such a way as to appear to be created by teenagers. Common slang and abbreviations teenagers use to communicate would be evident throughout the site. Also, a panel of teenagers would be recruited as part of this intervention to help design the website and give a real perspective to it. Also, in all of the messages during the public health commercials, teenagers would be giving the message, and not a single adult would be utilized as a main character in one of these. These methods will decrease psychological reactance and this is essential for a health message to be accepted.
Health interventions are modeled after social science models of human behavior. When attempting to understand human behavior, it is important to consider the social norms of society, the irrationality of human behavior, and the potential psychological reactance that ensues from feelings of deprivation of freedom. The health belief model does not predict human behavior based on these principles and interventions such as IYSL are weakened as a result. Future interventions, such as BYCU must take in account that these factors are important in predicting human behavior, and may use marketing theory, labeling theory, and herding theory to model and understand human behavior. Only by truly understanding the complexity of human thought, may we attempt to address negative health behaviors.
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