Challenging Dogma - Fall 2009

Thursday, December 17, 2009

Get Smart Before You Get Infected: A Critical Look at Boston sexED– Cristina M. Crespo

I. Introduction

Each year one out of every four sexually active teens contracts an STI in the United States (1). Studies show that compared to older adults, adolescents (10- to 19-year-olds) are at higher risk for acquiring STIs for a number of reasons, including limited access to preventive and regular healthcare services and physiologically increased susceptibility to infection (2).

About half (48%) of teens 12-17 say they want more information about sexual health from their health care providers. Among teens 15-17 who have had sex, only 6 in 10 had ever seen a health care provider about their sexual health (3). Many adolescents have limited access to sexual health care services, including contraception, STI testing, and counseling on sexual risk behaviors. Several factors influence teen access, including the ability to pay directly for services, laws that affect teens’ ability to seek certain services without parental consent (which vary by state) or the availability of free or low-cost, local family planning programs (4). Other barriers to care include limited access to transportation, lack of confidentiality, limited youth-friendly service delivery environments, fear about seeking care and lack of information about services available (5).

In Boston, the number of cases of STIs among young people has been rapidly rising. The Boston Public Health Commission has committed major funding for STI prevention exclusively targeting sexually active teens, specifically those between ages 15 and 19 who represent the highest percentage of new cases of Chlamydia and gonorrhea in Boston (5). In 2008, the incidence rate for Chlamydia among 15 –to-19 year-old females in Boston was 4,726 per 100,000, compared to 673 per 100,000 for women of other ages. In males ages 15-to-19, the incidence rate was 1,608 per 100,000 (5).

Statistics from the 2009 Health of Boston report show that 56 percent of Boston Public High School (BPHS) students have had sex, including 40 percent of those younger than 16; 24 percent of sexually active BPHS students had more than six partners. However, only 71 percent of sexually active students had used a condom during their last sexual contact. Referring to this statistic, Dr. Barry, director of the Infectious Disease Bureau at the Boston Public Health Commission, states that “we need to do a better job of educating teens about sexually transmitted infections,” She adds that “the costs of staying silent are too high” (5).

Students from the Boston Area Health Education Center (BAHEC) joined members of ‘We’re Educators - A Touch of Class’ (WEATOC), a youth development peer education program, in performing spontaneous skits about the dangers of STIs. The performances took place along the MBTA Orange Line, starting at the Forest Hill station in Jamaica Plain, where city officials announced the campaign.

As part of the campaign, the Boston Public Health Commission (BPHC) created a Facebook page chronicling campaign activities with YouTube videos created by BPHC. Fans of the page can anonymously post questions about sexual health that are answered by BPHC staff. Fans can also participate in opinion polls, get answers to frequently asked questions about sexually transmitted infections and/or obtain information about free STI testing sites in Boston.

In addition, the campaign features a one-minute video created by two Mattapan teens that is available on MTV, BET and FX, as well as Boston City TV. Campaign ads also are running on the MBTA, JAM’N 94.5 FM, and the Bay State Banner (African-American run Boston periodical) and El Planeta (Spanish-language Boston newspaper).

Mayor Thomas M. Menino states that “this campaign breaks new ground for the city of Boston in our efforts to reach young people wherever they are ---be it on Facebook or watching BET.” Dr. Barbara Ferrer, executive director of the Boston Public Health Commission that “it is critically important that we create an environment where young people can start to have a conversation about the fact that this behavior [not using protection] is not okay.”

In the spring of 2009 a student video contest, Get Reel: Check Yourself, ran on YouTube and was sponsored by Mayor Menino and the BPHC. Out of eleven submitted videos, the winning video, created by two teenagers in the Boston area, features a comedy skit set in a classroom where one student confuses STIs with the SAT, college entrance exam, and the teacher (also a teenager) educates the class on what the STIs are and how to avoid them. The message of the one-minute video to teens is to use condoms to reduce their risk of contracting an STI.

Out of that video came the campaign’s message: “A perfect score on the SATs might be hard, but preventing STIs isn’t. Do your homework. Protect yourself. Don’t get infected.”

As Boston’s first major effort exclusively targeting sexually active teens, Boston sexED aims for awareness and education about how to prevent STIs.

II. Critique of Boston sexED

Though the Boston sexED campaign incorporates innovative strategies such as having peers deliver messages not parents/adults as well as transmitting the campaign through popular internet media, it is flawed for three main reasons. First, the campaign does not incorporate the basic principles of marketing and advertising theory. Second, it assumes rational behavior. Third, it focuses on immediate social factors and conditions rather than corporate responsibility. The following section will use social science theory to explain each critique.

A. Selling Health, Education and Awareness

David Ogilvy, in Confessions of an Advertising Man, recaptures Dr. Johnson’s memorable statement: “promise, large promise is the soul of an advertisement.” (6) What pushes consumers to buy a product, he states, is the content of an advertisement, not its form. An advertiser’s most important job is to decide what he is going to say about his product, i.e. what benefit he is going to promise. (6) Indeed a great promise delivers its benefits by using strong support (i.e. stories, symbols, metaphors, images) that appeal to society’s core values. Furthermore, advertisements must be built around great ideas that do not bore people into buying the product rather lure people into it.

A great idea is also tagged to a great brand. Branding is a vital marketing strategy that links a product to a name, mark or symbol. The significance of a brand lies in the associations it represents and the resulting behavior that can be engendered such as buying a product and maintaining a relationship with a brand (7). Branding takes into account the relationship between consumer and product, the value added to a product and the exchange (cost and benefit) between product and consumer. It is much more than communication and persuasion. Branding positions objects in the lives of consumers in the larger social physical environments in which they live (9).

Successful brands provide aspirations - external ideas to which consumers can aspire. They deliver their message on the promise embodied in the ideal (8). Social modeling can also deliver this message. Psychologists have shown that social modeling plays a role in social learning and the formation of knowledge, attitudes and beliefs (9). It can be central in creating intended (and unintended) associations. For example, the Marlboro Man provides an appealing social model for the cigarette’s target audience. He is independent, confident and strong. These norms contribute to creating a social environment in which smoking is a socially desirable behavior. Formation of social imagery can promote aspiration towards that ideal which can play an important role in determining behaviors such as adolescent smoking (10, 11).

However, public health practitioners have failed to apply these basic principles of commercial branding and advertising to change health behaviors. Boston sexED is no exception. Public health has the unexploited potential to produce brands that can position health behaviors and the lifestyles they embody with the public and establish a long-term relationship that can be maintained beyond any individual campaign effort (8).

The brand object of a public health brand is the voluntary health-promoting behavior the individual is being asked to take up or maintain. To be successful, public health practitioners need to consider demand, competition and timing (12). Instead of deciding what they want the target audience to buy and attempting to sell a product that has little market demand, public health practitioners must find innovative ways of redefining, repackaging and reframing the “health product” so that it satisfies an existing demand among the target audience (13). Furthermore, public health campaigns must communicate an image that reinforces the most influential core values of the target audience through strong support.

Boston sexED sells health, awareness and education. It employs statistics and classroom education. First of all, the brand of the campaign is sexED, short for sexual education, which immediately places the context of the ad in a school setting. The fact that the ad was created by teenagers in the Boston area shows interesting insight into the psychology of these high school students. For the teenagers, talking about STIs takes place in a school setting, essentially in a sexual education class where no one is paying attention to the teacher. The teacher mocks a student for confusing the SATs (college entrance exam) with STIs and everyone laughs at her (student looks down in shame).

The teacher is portrayed as condescending. She uses the scare tactic to advise her students that “some STIs don’t show symptoms so you might be infected right now and not even know it.” One student looks up scared and possibly wondering what he might have contracted already. As soon as the teacher tells the students to use protection every time they engage in sexual intercourse, the ring bells and the students leave the classroom.

The scenario is a top-down imposition of ideas from teacher to student. Essentially the drama delivers the message that conversation about STIs takes place at school where usually an older woman (regardless of the role being played by a teenager) educates them about sexual education. At the end of the short ad, students leave the classroom without going into further conversation about what was taught. Discussion about sexual health does not leave the classroom setting.

Throughout the video, the high school students do not pay attention to the teacher; they are texting, flirting, lying back in their desks, laughing and behaving “cool”. Through their behavior, they are the ones that are depicted as cool, independent and rebellious – qualities that are desirable for teenagers. The teacher is depicted as strict as shown by her outfit and the way she addresses the students. She is condescending and prohibits the students from doing what they want. Additionally, even though the students use Ebonics, she does not.

Boston sexED uses weak support and does not appeal to the target audience’s core values of independence, control and rebellion. In its place, it appeals to student’s apparent desire for health by emphasizing prevention and protection. Even the branding fails to acknowledge teenagers core values. The target audience does not want to be reminded of school and education – they want to enjoy independence and control over their lives – not be further “schooled” about the dangers of unprotected sex.

Having a teacher talk about STIs and using protection fails to create a space where teenagers can engage in peer dialogue. Though part of the Boston sexED campaign uses Facebook as a resource for teenagers to ask questions (either publicly or anonymously) and obtain information about sexual health, answers are provided by an official of the BPHC staff – i.e. an adult. Doing so, the campaign fails to meet the principles of Psychological Reactance Theory which states that interpersonal similarity can reduce reactance by increasing compliance and by reducing resistance (17). Though this has been shown to be a great marketing technique, Boston sex ED fails to fully appreciate the potential of their campaign.

The promise that the advertising campaign makes is that by becoming aware of STIs and not confusing the term with the SATs that you will engage in protected sexual behavior. This promise does not fulfill the target audience’s deepest aspirations. The support – statistics, list of STIs, classroom setting, condescending and uncool teacher, shameful students – is weak and negative. The support does not compel the audience with strong images, metaphors, symbols and stories. Failing to incorporate the basic principles of advertising and marketing theory, the Boston sexED campaign is not branded and marketed in a way that will have long-term effects on teenager’s sexual behavior.

B. Assuming Rational Behavior

Boston sexED assumes that teenage sexual behavior is rational. It presumes that if people are educated about STIs, they will weigh the costs and benefits of preventing STIs and will use condoms the next time they have sexual intercourse. Even Mayor Thomas M. Menino says that “we know that with awareness comes changes in behavior, and that's what we are trying to achieve” with Boston sex ED. This statement clearly emphasizes the traditional public health belief that education fosters awareness which leads to positive changes in health behavior. However, by assuming rational behavior, most public health campaigns fail to consider the multifaceted environmental factors that affect individual decision-making.

Boston sexED is based on the Health Belief Model (HBM) – an individual level model that demonstrates that a person will weigh the perceived benefits of taking an action (using condoms) against the perceived barriers to taking that action (14). Perceived benefit is a function of a person’s perceived susceptibility to the health problem that the behavior will prevent (STIs) and the perceived severity of the health problem (14). The outcome of weighing barriers and benefits will dictate intention which dictates behavior.

Boston sexED has adolescent peers going along the MBTA lines addressing issues about STIs. YouTube videos recapture these outreach team efforts. Though this aspect of the campaign sounds innovative, the main focus of these outreach efforts is to present statistics, give out free condoms and T-shirts and have teenagers ask peers about what they want to know about sexual health education and whether they know where to get tested for STIs. This approach targets the campaign’s aim to create awareness and educate. It assumes that if teenagers learn about sexual health and know the benefits of using protecting they will act rationally and engage in protected sexual behavior.

Boston sexED assumes that teenagers engage in the HBM chain of thought. The slogan “get smart before you get infected” assumes that when people know the facts they will make rational decisions. However teenagers may not engage in protected sex for a number of reasons such as availability of condoms at times of sexual arousal and financial and transportation access to purchasing condoms. Moreover, due to the optimistic bias – phenomena that explains that people’s beliefs that negative events are less likely to happen to them than to others – teenagers are likely to underestimate susceptibility and severity (15). If a person thinks an event is controllable (using a condom when sexually aroused) then he or she is more likely to be influenced by the optimistic bias. As teenagers are likely to believe that their sexual emotions are controllable, they may be unrealistically optimistic that they will use condoms and prevent STIs.

The fact that the advertising’s setting is a classroom shows that Boston sexED wants to educate and create awareness of STIs. The students write in their notebooks the list of STIs on the board as if they needed to memorize the information for the next test. Because the situation takes place out of context – it fails to acknowledge real situations, social pressures, core values and “hot states” (16). In conclusion, the logic behind this campaign is that once you know the facts, you will remember to use condoms and behave rationally when a heightened sexual situation presents itself. It does not account for irrational behavior, uncontrollable conditions and the many social factors that play a role in health behavior decision-making.

C. No Corporate Blame

Public health research has focused its attention on risk factors that are relatively proximal causes of disease and social conditions that put people at risk of risks (18). Proximal causes of disease such as lack of condom use, poor sexual education and social risk factors such as access to important resources place an emphasis on the individual and the community in determining their health behavior and actions. These individually and socially-based models have failed to examine corporate practices as social determinants of health (19). Unlike the anti-tobacco smoking campaign, Truth, Boston sexED blames individual responsibility for unsafe sexual behavior rather than the companies that purposefully and un-purposefully market unsafe sex to teenagers.

Very little work in public health has focused on the cumulative impact of consumer exposures to corporate policies. Most of the research that has been conducted on corporate responsibility considers the consequences of a single product or corporate practice rather than patterns of behavior across a variety of industries.

It is important to understand how mass media images and messages about love, sex and relationships interact with what teens learn about sexuality at home, in school, and from their friends (20) because the media plays a big role in shaping adolescents' values, attitudes, and beliefs about sex. Studies have shown how issues of identity or teens' sense of themselves and others affects the media they like, how they interact with that media, and how they apply media matter in their everyday lives (21).

Sex sells. Engaging in sexual behavior is portrayed as desirable but seldom is pro-condom use and safe sexual behavior portrayed. Youth learn from the media and then form their identity based on what they see. If sex scenes skip the use of condoms, then young viewers may believe that the norm is not to use condoms and enjoy sex when sexual arousal ignites. Thus, the message is to follow your instinctual sensations at the moment rather than running to the store and buying a condom. When you return to your partner, you might not be aroused anymore!

Considering the amount of time and attention that young people give to mass media and popular culture provides an ideal opportunity for communicating about sexual health. Boston sexED has even realized the potential of spreading awareness through a diversity of social media such as popular social networking websites, radio stations, prime television channels and newspapers.

Though these means of reaching the youth sound promising, individuals will not be able to change unhealthy behavior unless policy and systematic changes support the desired behaviors. How much do the media make it cool to say “no” to sex, to practice safe sex, to negotiate condom use and to learn the ability to express oneself when “hot states” arise? How much are these messages marketed?

Some researchers argue that social structures and the distribution of wealth, power and knowledge are fundamental causes of disease, and that changes in these factors need to be addressed in order to achieve improvement in population health. (19).

Boston sexED focuses on individual behavior and does not take into account how power structures (e.g. the media) affect adolescent attitudes, knowledge and perception of sexual interactions.

III. Proposed Intervention

The following section will propose an intervention that addresses the three major critiques of the Boston sexED campaign: failure to incorporate the fundamentals of advertising and marketing theory, assumption of rational behavior and focus on immediate individual and social risk factors rather than corporate responsibility. Remodeling and repackaging the existing campaign in a way that takes into account irrational behavior, group level models and advertising and marketing theory can not only spread the information more effectively but it can also have a long-term effect in adolescent perceptions of sexual health.

A. Boston sexED should sell freedom, independence, control and rebellion NOT health

Boston sexED recognizes the multiple media venues with which adolescents interact and incorporates innovative ideas such as a YouTube video contest, peer street outreach and popular social networking websites to spread awareness about STIs. Having street outreach and passing out free condoms and T-shirts are excellent ways of getting attention. However, though these ideas take the modern adolescent into perspective, the campaign still fosters the traditional public health approach to health interventions: selling health and education.

The proposed intervention retains the basic idea of creating awareness about STI testing sites and contraception because there is demand for it (3) but it uses different marketing strategies to promote this awareness. Instead of selling health and education, Boston sexED should sell freedom, independence, control, identity and rebellion, the same core values promoted by the Truth campaign.

To make the campaign promise positive, public health practitioners can demonstrate that using condoms fulfills basic needs and desires and that not doing so conflicts with basic needs and desires. The way a product is defined should offer benefits that the target audience is seeking in a way that reinforces the audience’s core values. Adolescent core values of freedom, independence, control, identity and rebellion (13) should be the focus of Boston sexED. The current marketing campaign supports a negative promise (the student who confuses the SATs with the STIs is shamed for not knowing the difference) and negative support (classroom education). The student that is laughed at should feel empowered with knowledge not shamed for ignorance.

Choosing protection should be portrayed as empowering – as having power and control over your own body. Using condoms should be depicted as a thing the cool kids do. Rather than constraining, condoms should be a step towards independence from STIs and independence from problems that can harm your freedom and identity. Condoms could be marketed as a way to ensure positive liberty for the individual by keeping him in control of his future and allowing him, not an STI, to make his decisions (13).

Another advertising and marketing strategy is to use role model stories as was done by one of the AIDS Community Demonstration Projects in Long Beach, California to promote safe sex behaviors among women living in a low-income housing project. More than 200 role model stories were distributed in 175,000 flyers. These flyers told stories about people in the community who had taken positive steps toward consistent and correct condom use (22). Providing role models that are believable and similar to members of the audience incorporates the basic principles of the Psychological Reactance Theory (17) to ensure compliance through peer assimilation. Since most of the neighborhoods that are targeted by Boston sexED are African American, even using Obama as a role model could be effective at promoting social change.

Finally, the current campaign places too large a focus on the acronym confusion between STI and SAT. If you haven’t seen the video on TV or on YouTube then the posters on the MBTA bus and train lines make no sense. Public health campaigns should be clear in order to be effective. Else if the promise is not appealing and clear then the product (changes in health behavior) will not sell.

B. Boston sexED Should Assume Irrational Behavior

Boston sexED attempts to create an open space for the youth to ask questions and learn about STIs but it assumes that individuals make decisions in absence of environmental stimuli. The fact that the advertisement takes place in the context of a classroom has no basis in social reality.

By emphasizing education, specifically classroom education, this new campaign is in no way different from what teenagers hear at school through their sexual education courses. Seeing as this traditional teaching paradigm has obviously had no effect on the increased number of teens infected with STIs why perpetuate the approach.

Furthermore, Boston sexED should demonstrate that a person’s behavioral choices are not really free, that these decisions are influenced by economic, social and environmental constraints that do not allow for independence, control and autonomy. However, the Boston sexED campaign presents a false assumption of control – that by doing your homework you can protect yourself and not get infected. Instead it should mimic a real context where sexual pleasure and bodily desire take presence over controlled and rational behavior.

The fact that Boston sexED makes condoms available in street outreach programs is a good technique to promote safer sexual behavior. It was been shown that condom availability programs reduce the barriers—financial, logistical, and social—that deter sexually active teens from using condoms (23). These programs operate in locations (such as schools and teen clinics) where adolescents congregate; make condoms available at low or no cost to teens; and provide condoms in ways that minimize teens' discomfort about obtaining condoms. This approach recognizes that there are social factors outside adolescent control that affect decision-making. Research shows that financial accessibility is an important barrier for teenagers’ engagement in safe sexual behavior. This is especially true for teenagers in lower income communities. However, Boston sexED needs to make a stronger effort to make condoms available and information about testing sites clear, accessible and understandable. By doing so it recognizes the many factors that play a role in health behaviors and individual decision-making.

C. Boston sexED Should Induce a Teen Rebellion

Boston sexED should advocate for independence from the media’s influences and control over your own body and decisions. Condoms should be portrayed as tools that assert freedom and rebellion. Because the campaign will probably not have a long duration, it needs to be sustainable. This can be achieved through compelling marketing techniques that motivate a mass change at the group level. Boston sexED should reframe the issue of sexual health from education and awareness to revolution. Public health practitioners can show teenagers that the desired behavior change actually reinforces the core value of freedom and rebellion. This can be achieved by emphasizing how positive liberty will be conferred to the adolescent by using condoms, not by falling prey to the media’s depiction of unprotected sex.

Boston sexED should promote the idea that practicing safe sex yields huge benefits like feeling independence, control, autonomy and freedom to make your own decisions about your body. Teenagers should feel like they are part of a group of peers that is rebelling against power structures that constrain their liberty and independence.

IV. Conclusion

The Boston sexED campaign is unlikely to be effective and sustainable in affecting the sexual behaviors of the Boston youth. The campaign assumes rational behavior, blames individual and social factors rather than corporate responsibility and fails to take into account the fundamentals of marketing and advertising theory. Repackaging and reframing the public health issue such that it appeals to the target audience’s core values of independence, control and freedom the Boston sexED has the potential to go a long way towards minimizing the spread of STIs among Boston youth.


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