Oversimplification of a Complex Problem : A Critique of the Boston Public Health Commission’s New SexED Campaign

I. Introduction:
There are over two dozen infections and diseases that can be transmitted through sexual contact. (1) In the United States there are approximately 65 million people with one or more viral sexually transmitted infections (STI) and there are approximately 19 million new cases of STIs every year.(1,2) There are 56,000 new HIV infections each year and currently 1-1.2 million people in the United States live with HIV/AIDS. (1) In 2009, 56 percent of Boston Public High School students reported having sex and 40% of students younger than 16 reported being sexually active. (2) Only 71% of those reporting sexual activity indicated that they had used a condom during their previous sexual encounter. (2) One in two sexually active persons will contract an STI by the time they turn 25 (3) and nearly ½ of all STIs occur in people ages 15-24(4,2). A 2008 report indicated that 1 in 4 female teens has an STI/STD and half of all African American teen girls has an STD. (4) Condom use has been shown to significantly reduce the risk of many STIs. (3,5) Contrary to popular belief, being at higher risk for contacting an STI does not necessarily indicate risky behavior. The risk of contracting an STI increases in areas with high levels of poverty, unemployment, social and economic discrimination and poor access to healthcare. (1,6,7)
The Boston Public Health Commission (BPHC) has recognized the threat that STIs and teen pregnancies have on Boston youth. In an attempt to lower the STI incident rates in Boston teens, a new campaign called “SexED in Boston” has been introduced. (7) This is the first time major funding from BPHC has been spent to target STI prevention in sexually active teens. (2) The campaign includes print ads that can be seen in Massachusettes Bay Transportation Authority (MBTA) buses, trains and stations and in newspapers. (2) BPHC has produced TV ads that have run on local cable stations and can also be viewed on Youtube and on the SexED facebook page. (2,8,7)
The print ad consists of two teen girls leaning on a desk and the words “A prefect score on the SATs might be hard, but preventing STIs isn’t. Do your homework. Protect yourself. Don’t get infected”. (7) In the background is a chalkboard with the words “Mrs. Tinkleberry Health 101”. (7) A different ad simple says “Don’t confuse the SATs with STIs” (7) Below are examples of some of the print advertisements with Mrs. Tinkleberry in the glasses and Janay in the t-shirt.


The television commercial opens with a young teen pretending to be a strict and obnoxious teacher; Mrs. Tinkleberry. This teacher proceeds to ask the students what an STI is and no one answers. In an angry and accusing voice she calls on “Janay” and the student incorrectly answers that “Isn’t it that test you take when you want to get into college?”. (7) Everyone in the class laughs at her and Mrs. Tinkleberry explains in a condescending voice that that is the SATs. Mrs. Tinkleberry proceeds to explain what an STI is and that it may not cause symptoms and that to prevent this you should always wear protection and then she holds up a condom. The class is dismissed and Janay confronts “Jeffrey” who is clearly a teen girl dressed in drag pretending to be a teen boy. Janay says “Jeffrey you said we didn’t need no condoms”. He says “Ya but it was good though. It was worth it right?”. Janay says “No I didn’t know you were going to give me the SATs”. Mrs. Tinkleberry was listening and says in an exasperated voice as she rolls her eyes “STI Janay”. The commercial end and the words “Do your homework. Protect yourself. Don’t get infected” appear.
This critique is on the BPHC SexED campaign as a whole but focuses on the print and TV ads since they are the most prevalent part of this campaign. The second section of this paper outlines three fundamental flaws of this campaign. The third section of this paper focuses on what could be done to improve on this campaign and provides support for why these changes could improve the campaign’s success.
II. Critique of the Theories, and Lack of Theories, Used in the SexED Campaign.
There are three fundamental errors that the BPHC made when creating this campaign. The first is that they used the Theory of Planned Behavior to model a behavior that cannot be captured using this theory and ignored visceral influences. (9) The second critique is that BPHC did not follow any advertising or marketing theories when creating their advertisements. Instead, they relied on assumptions and guesswork which can be fatal to any campaign. (10) Finally, this paper will critique the BPHC for failing to consider important environmental and social factors that influence teen’s decision to have safe sex since research has shown these factors put a teen a greater risk for infection. (6)
A. BPHC Uses the Theory of Planned Behavior to Explain Irrational/Spontaneous Actions and Ignores Visceral Influences:
The BPHC clearly used the Theory of Planned Behavior to guide their campaign. The Theory of Planned Behavior says that before people change their behavior they weigh their attitudes and the importance of those attitudes and then weigh what people think and the importance of what those people think. This leads to an outcome expectancy and if they think they can do the behavior they will intend to and then they will follow through with the behavior. (9) When used to understand STI prevention the Theory of Planned Behavior would predict that to get teens to use condoms they must have negative attitudes about the outcomes and must strongly weigh the importance of that outcome. The teen must also consider what other people think and consider how important that person’s opinion is to them. Finally, this will lead the teen to develop an outcome expectancy. If the STI is considered very bad, they are deeply concerned about the negative consequences and the people they care most about think using condoms is good they will want to use condoms and practice safe sex. However, they must have self efficacy and really believe they can adopt that behavior. The teen would then decide they would intend to use condoms and then they would use condoms. (9,11,12,)
The BPHC uses this theory and attempts to influence the attitudes about condom use by giving facts. This is done both on the website, and in the TV ad. (7) This is an attempt to make teens understand that the outcomes for STIs can be very bad and very serious and that they are at risk. The BPHC uses the influence of what others think by using teens to deliver the message and using a Facebook page to show that their peers think using condoms is good. (7) The self efficacy is reinforced in the sexED slogan “A prefect score on the SATs might be hard, but preventing STIs isn’t”. (7) This slogan hopes to encourage teens to adopt the belief that they can do things to prevent STIs.
On the surface there doesn’t appear to be anything wrong with the message. However, in one study they found that 97% of adolescents had reported receiving STD education. (13) What can explain the high infection rates of teens if all they need are the facts? Theory of Planned Behavior is an individual level model that assumes the decision whether to use condoms is rational, it assumes this choice is also planned and that it is static. (9) Unfortunately, because of optimism bias – people’s tendency to feel that bad things are unlikely to happen to them and more likely to happen to other people, it may be easy to convince teens that STIs are dangerous and severe, but very hard to convince them that they will get one if they are not careful. (14)
It is also true that people often believe they are at risk, can do something to prevent that risk, fully intend to do it, but then do not follow through with the behavior. (15) There are many reasons that a teen might choose not to use a condom. There could be pressure from their partner to not use one. A condom might not be readily available in the heat of the moment. They may simply prefer not to use one because they feel it could interfere with pleasure. (15) At the moment when a condom is actually needed both parties involved are reacting to those visceral influences. A visceral influence is a natural human urge such as hunger, pain, thirst, sexual desire, etc. (15) When faced with these visceral factors people tend to ignore all else and their attentions and behaviors are focused at satiating that hunger, pain, sexual urge etc. (15) It makes people act in seemingly irrational manners. It has been found that people often will act against their own self-interest and fully know that they are doing so when visceral factors are involved. (15) Unfortunately, we underestimate the power of these visceral factors on both our behaviors and the behaviors of others. (15)
The Theory of Planned Behavior and other commonly used theories in public health do not take these natural human drives into account. In the case of condom use, teens are making a short-sighted tradeoff of sexual pleasure even though they know that it could lead to an STI tomorrow. This is an example of how visceral factors produce attention-narrowing.(15) These visceral factors also tend to make people selfish. (15) With that in mind, why would someone mention that they have an STI to their partner in the heat of the moment? The Theory of Reasoned Behavior would ignore these visceral factors and assume good information and good intentions would work. However, because of this very important issue, this campaign is missing the real problem entirely and setting the teens up for failure. The BPHC assumes condom use is a rational behavior when in fact it is irrational but in a predictable way. (16)
B. BPHC Violates Marketing and Advertisement Theories:
One of the most important rules that has been learned from research done on how to build a good campaign is that “The selection of the right promise is so vitally important that you should never rely on guesswork to decide it” (10) BPHC did do some research before embarking on the campaign but did not research the promise. In an interview with the Boston Globe Margaux Joffe, who was involved in the campaign, she said “They told us, ‘We don’t want some old 40-year-old woman telling us about sex and STIs…We laughed, but it makes sense. You may not trust the advice of an adult as much as you would someone in your peer group.’’(17)
The results from their research were easily explained by Reactance Theory. This theory outlines that using a communicator that is as similar to the target audience as possible can increase compliance and reduce resistance. (18) BPHC did take into account who would deliver the message but instead of an adult they used a teen dressed as “some old 40-year-old woman” named Mrs. Tinkleberry who acts condescending and scoffs at Janay’s stupidity. BPHC also made the fatal error of trying to sell health. Ogilvy was clear that a large promise that appeals to people’s core values is the key to any successful advertisement. (10) Although it may seem counterintuitive, health is not a core value. It has been shown that often the deepest distress that illness causes is due to loss of control and the loss of independence. (19) These core values can differ slightly by age and culture but for American teens some of the most powerful core values that they hold are freedom, rebellion, control, and independence. (19) These are the “products” that the teens want to buy into.
The ads done in the campaign were done by a 16 year old girl who had her video chosen out of submissions done by local students. (2) To me, it is clear that this is a better example of how we have failed the students than it is an example of an advertisement for condom use. The teen produced a scene that is an exaggeration of the way sexual education is taught in school. It was a groundbreaking idea for BPHC to have students give input and become involved because they have knowledge about Boston teens that no adult does. However, a successful campaign involves using advanced Psychology, Marketing and Advertisement theories that students at this age group could not be expected to know.
C. The BPHC Ignored Important Social and Environmental Factors
Teens in Boston are influenced by their peers, teachers, parents, the community, socioeconomic status, ethnicity/race, and many other external factors. These environmental and social factors have a tremendous impact on the likelihood of a teen becoming infected with an STI. In fact, socioeconomic status, race/ethnicity, unemployment and discrimination are risk factors for STIs. (1,6) While white Americans generally get STIs through risky sexual behaviors, black Americans tend to get them from both high and low risk sexual behaviors. (1) This can be attributed to the fact that the levels of infections are much higher in blacks. (1,6) The infections rates are also higher in areas with poverty, high unemployment, poor access to health care, and social and economic discrimination etc. (1,6) The simple fact is that many of Boston’s schools are in neighborhoods where these environmental and social factors are prevalent. The BPHC did not attempt to address any of these problems. The focus of the campaign was to relay information and impress upon them the importance of practicing safe sex or abstaining altogether.
It has long been understood that teenagers can succumb to peer pressure. One study investigating this notion found that females were more strongly influenced by peer pressure and that peer pressure influenced both males and females attitudes about sexual activity. (20) It is not trivial that it was females most affected by peer pressure. Condoms are worn my males and despite requests, it is the male who decides if he will wear one. Female condoms are available but they are more expensive and less well known. The BPHC uses females in their video and ads to promote condom use when it is males who must wear them and they must do so in that “hot” state and we have seen that people tend to be selfish in that state. (15) This gives the male the option of trying to pressure the woman into sex without condoms. There is the additional problem of being viewed negatively by your partner/peers if you have a condom because Social Outcome Expectancy could lead your partner to wonder why you were carrying one with you and wonder if you anticipated casual sex. (21) This could be particularly damaging for women who would carry a condom because wanting lots of sexual partners is seen as a “male trait” and women are viewed negatively if they appear to be promiscuous. (21)
III. Proposed Intervention
The first part of the intervention I propose is also the most controversial. I propose that condoms not only be readily available to teenagers free of charge but that there be a campaign to encourage teen boys to use condoms to masturbate. I have heard in popular culture of men using lubricated condoms for masturbation because it is pleasurable and convenient.(22) These would seem like something a teen boy might be curious about. This could be included on a “fun tips” card that comes with a condom goodie bag. It could also be made into print ads or TV ads but that must be carefully thought out, considered, studied and planned to avoid any unforeseen problems. If these advertisements were done tastefully and with tact, they could have the potential to be widely influence this behavior in teens.
In order for this to work condoms should be freely available in many places that teens go and can access privately. They could be in locker rooms, bathrooms, the nurse’s office, youth centers, etc. To make it more successful there might be variation with the type of condom that is provided. There are dozens on the market and each one promises a different pleasurable benefit.
The intervention would also need to create a better advertising and marketing campaign. My goal is to re-frame and re-package the “product” of sexual health. I would use teens as the communicators in all of the advertisements but while they would provide important insights, they would not write the actual advertisements. I would also attempt to use famous teens to support these ads in the hopes that they would be viewed as early adopters of the messages in the campaign and create a tipping point. (23) The overall messages would be simple. “I am in control”, “I am independent”. I would also backup these promises with stories, symbols, and images that reinforce the promise. (19)
I am impressed by BPHC’s use of a Facebook page. I would create a Facebook page and use it to build the brand and to better the chances that the campaign would reach that critical tipping point. (19,23)
The campaign that I would plan would also be particularly unusual because part of it would put a focus on programs not normally associated with lowering STIs. In addition to the free condoms, encouragement of condoms for masturbation, and ad campaigns with a big promise, I would try to improve the environment that the teens in Boston must live in. I would put aside money to pay for after school programs. One program would be an empowerment program designed to encourage teen girls to be active members of the community and go to college. The program would also encourage empowerment among all teens. I would also put an effort into literally cleaning up the neighborhood with a special focus of keeping the mile radius around the school very clean. The teens would be encouraged to help in this effort to help increase pride in the community.
Other social/environmental programs would include a course on how to improve on the SAT’s. These SAT preparation courses are currently offered but at a high cost at private tutoring centers. I would also offer courses that specialize in practical advice on how to get into college. They could receive help on their entrance essays, resumes, applications and with scholarship searches. The hope of this program is that it would lead to more students going to college and then getting jobs and lessening unemployment and poverty in the community.
i. Support For Using Visceral Influences
The purpose of encouraging condoms for masturbation is that it has been found that interventions done when in a “hot” state were more effective than an intervention done in a “cold” state. (16) If a teenage boy always reaches for a condom when he is in that hot state he would probably be more likely to associate that hot state with condoms and think of it when he was with a partner.(16) This is one way to actually provide an intervention when the teen is influenced by visceral factors. This is particularly important since males are the ones who must wear it. The Social Learning Theory (9) would predict that the teen would use a condom and if they have a positive reinforcement of a pleasurable experience they would be more likely to reach for a condom again. The environment would be conducive to acquiring a condom because they would be in many places free of charge. It would likely cause a buzz and if a teen thinks others might be trying or doing it he would be more likely to try it because people base many behaviors on social norms (Social Expectations Theory). (24) It is a simple step and since another partner is not involved they would have a great deal of self-efficacy. (9) The simple fact that the teen used it once for masturbation is in itself a reinforcement of the behavior and makes it more likely that he will use it again. (9)
This would do many things. It would mean that teen males might seek out condoms and possibly have condoms with them or in their room. This greater accessibility to condoms would mean that if in a hot state with a partner the condoms would already be there. This easy accessibility, even when visceral influences are at play, leads to, not perfect, but better condom use. (16) It allows for irrational behavior and creates a positive reinforcement between sexual pleasure and putting a condom on. It also gives teens experience with how to put a condom on. It can require some planning (getting the condom) but hopefully that will be less of an issue if they are free. (9)
ii. Support that investing in Marketing Theory and Advertising Theory pays off.
I do not pretend to know what slogan would resonate most with Boston youth but this is why I would invest heavily in research. This use of Advertising Theory, Marketing Theory and framing is a subtle but important difference in this campaign. It re-frames the issue so I am no longer selling health. (19) I am selling control and freedom. I would also work towards making images of condoms be closely associated with core values.
These core values in teens have been studied and teens care most deeply about are rebellion, control and independence. (19) The Truth campaign was hugely successful in re-framing a public health issue and creating a valuable brand. (22,23) The Truth campaign team did research and discovered that what teens valued most was rebellion. They then used this to encourage teens to rebel against the tobacco industry and they had amazing results. (25) In just two years current cigarette use dropped in teens from 18.5% to just 11.1%. (26) A 7.4% decrease is tremendous in such a short period of time. Although it is difficult to rebel against a disease it is easy to reframe sexual health to be about control and independence. I would use Advertising Theory and Marketing Theory and make those three core values as my big promise. (10,19) I would also try to use symbols and hopefully make condoms a symbol of rebellion, control and independence.
iii. Support for Social and Environmental Interventions:
My hope is that this project would extend beyond what traditionally would be thought of as a “sexual health intervention” but at the same time be uniquely successful. There is only so much that condom use can do. If a community has a high level of infected adults it puts everyone at risk, including those practicing low risk sexual behaviors. (1,6,21) The after school programs are aimed at making the community better and stronger as a whole. This should decrease poverty and unemployment which tend to lead to communities with higher STI rates. (6,21)
The Theory of Gender and Power postulates that inequalities between genders are due to divisions of power, labor, and the structure of cathexis. (6,21) Some of these disparities and inequalities produce certain exposures that increase women’s risk for diseases such as STIs. (6,21)
As discussed earlier, Black teens are more likely to become infected with an STI and also more likely to give in to pressure from peers. (1,20) Socioeconomic status, discrimination and unemployment are just a few more environmental factors that actually increase risk. (1,6) My program would address some of these problems with after school programs to encourage college educations. This is important because social and environmental issues are at the root of the problem and no amount of harping about condom use can influence these problems.
The Theory of Broken Windows would predict that garbage, graffiti, etc would create a general sense of disorder. (9) This method of cleaning up to prevent crime was used successfully in NYC subway stations. (9) The physical cleaning of the community should create a sense of order and stability. It should discourage the idea that “anything goes” and again, work towards the promotion of a healthy community and thus, healthy teens.
IV Conclusion:
One of the main strengths of the proposed intervention is that it is multifaceted and uses strategies that are rarely, if ever, used in STI/STD interventions. The new campaign avoids common pitfalls that the SexED campaign bought into and uses emerging theories based on the understanding that behaviors are not always, planned, static or even rational. This program has the ability to be tweaked and then implemented in other cities. The underlying issues outlined in this paper must be realized, understood and addressed before any progress can be made in the fight against STIs in teens.
References:
1. Guttmacher Institute. Washington, DC. Facts on Sexually Transmitted Infections in the United States. http://www.guttmacher.org/pubs/FIB_STI_US.html
2. The Boston Public Health Commission. Top Stories View. Boston, MA. http://www.bphc.org/Newsroom/Pages/TopStoriesView.aspx?ID=101
3. American Social Health Association. STD/STI Statistics > Fast Facts. Research Triangle Park, NC. http://www.ashastd.org/learn/learn_statistics.cfm
4. National Public Radio. Study: 25 Percent of Teens Have STDs : NPR. http://www.npr.org/templates/story/story.php?storyId=88140117
5. Crosby RA., DiClemente RJ., Wingood GM., Lang D., Harrington KF. Value of consistent condom use: A study of sexually transmitted disease prevention among African American adolescent females. American Journal of Public Health. 2003 Jun;93(6):901-902.
6. Wingood GM, DiClemente RA. The Theory of Gender and Power: A Social Structural Theory for Guiding Public Health Interventions. In: Emerging Theories in Health Promotion Practice and Research: Strategies for Improving Public Health. Jossey-Bass; 2002. p. 313-346.
7. Facebook. sexED in Boston | Facebook. http://www.facebook.com/bostonsexED
8. Youtube. Health 101: STIs. San Bruno, CA. http://www.youtube.com/watch?v=0JC8ijpW5iI&feature=youtube_gdata
9. Siegel, M. Class Lecture, Session 5. 2009 Oct 1;
10. Ogilvy D. Confessions of an Advertising Man. Revised. Atheneum; 1988.
11. Edberg M. Individual health behavior theories. In: Essentials of Health Behavior: Social and Behavorial Theory in Public Health. Jones and Bartlett; 2007. p. 35-49.
12. Theories and applications. In: Theory at a Glance. National Cancer Institute; 2005. p. 147-160.
13. Lane T. Despite having received relevant education, youth lack knowledge of STDs. Perspectives on Sexual and Reproductive Health. 2003 Feb;35(1):51-52.
14. Neil d. Weinstein. Unrealistic optimism about future life events. Journal of Personality and Social Psychology. 1980;39(5):806-820.
15. Loewenstein G. Out of control: Visceral influences on behavior. Organizational Behavior and Human Decision Processes. 1996;65(3):272-292.
16. Ariely D. Predictably Irrational: The Hidden Forces That Shape Our Decisions. 1st ed. HarperCollins; 2008.
17. Smith S. The Boston Globe. Cautions for and from teens. Boston, MA. http://www.boston.com/news/health/articles/2009/08/04/safer_sex_campaign_makes_use_of_peers_on_facebook_youtube_cable/
18. Silvia PJ. Deflecting reactance: The role of similarity in increasing compliance and reducing resistance. Basic and Applied Social Psychology. 2005;27(3):277.
19. Siegel M, M.D, Doner L. Marketing Public Health. Jones & Bartlett Publishers; 2004.
20. Brown BB. The extent and effects of peer pressure among high school students: A retrospective analysis. Journal of Youth and Adolescence. 1982 Apr 1;11(2):121-133.
21. Raj A. Class Lecture, The Theory of Gender and Power. 2009 Dec 3;
22. Hamburg J. I Love You Man. DreamWorks; 2009.
23. Gladwell M. Introduction. In: The Tipping Point. Back Bay; 2002. p. 3-14.
24. Siegel M. Class Lecture, Session 9. 2009 Oct 29;
25. Hicks JJ. The strategy behind Florida's “truth” campaign. Tobacco Control. 2001 Mar 1;10(1):3-5.
26. Bauer UE, Johnson TM, Hopkins RS, Brooks RG. Changes in youth cigarette use and intentions following implementation of a tobacco control program: findings from the Florida Youth Tobacco Survey, 1998-2000. JAMA. 2000 Aug 9;284(6):723-728.