Why Emergency Contraception has Failed to Decrease Unintended Pregnancy Rates – Is There a Better Solution? – Danielle Roncari

Introduction

Unintended pregnancies, including those that are mistimed, are a significant maternal and child health problem and comprise 49% of all pregnancies in the United States (1). Women with unintended pregnancies are more likely to recognize their pregnancies late, delay the start of prenatal care, and have unhealthy behaviors during their pregnancy (2). Consequences may also extend to the woman’s own health and socioeconomic status and to that of her family. To this end, family planning public health professionals have piloted many interventions to decrease the rate of unintended pregnancy. Programs ranging from comprehensive sexual education, in-depth contraceptive counseling, availability of emergency contraception (EC), increased contraceptive availability and increased use of long-acting reversible contraceptives (LARC) have all been advocated as potential solutions. Success, however, has been mixed. In particular, improved access to EC including over the counter status and advanced provision, has had little effect on decreasing rates of unintended pregnancy. While increasing the use of LARC may be a promising intervention to decrease these rates. Current use of LARC is extremely low and an effective public health intervention to increase use has yet been proposed.

In understanding why EC has met with such little success, it is important to understand how the method works. There are currently two methods of EC available in the United States, levonorgestrel and ulipristal acetate. Each method works most likely by preventing ovulation. As such, these medications are extremely time sensitive. If they are taken too remote from an episode of unprotected intercourse or after ovulation has already occurred, the potential window to prevent a pregnancy is lost. The levonorgestrel method is most effective within 72 hours of unprotected intercourse, but can be used up to 120 hours and ulipristal acetate can be used up to 120 hours (3 and 4).

In attempting to decrease unintended pregnancies, public health and medical professionals have developed many interventions to increase the use of emergency contraception. Among these interventions, have been advanced provision of emergency contraception and a policy change allowing the levonorgestrel method to be available over the counter to people age 17 and over with a picture ID. Both of these interventions have potentially increased access to the medication but have done little to actually decrease unintended pregnancy rates.

In a Cochrane Review of 11 randomized controlled trials of advanced provision of EC, pregnancy rates were unchanged with the intervention (5). While these results are disappointing, it is interesting to note that these studies did not show an increase in STI rates or frequency of unprotected intercourse among participants who had advanced provision of EC.

Emergency Contraception and the Health Belief Model

So why has improved EC access not decreased unintended pregnancy rates? The methods are effective, with efficacy ranging from 60% to 94% depending on when in the cycle it’s taken (3). One reason for its lack of effect is that EC was never designed to be a long-term method of birth control. It was intended to be a “back-up” method, something to be used for those times when a primary method either wasn’t available or had failed. Public health and family planning experts believed that EC could be a solution to a large number of unplanned pregnancies. However, in order for EC to prevent a large percentage of unintended pregnancies, improved access was necessary because of the time sensitive nature of the medication. Past efforts to improve this access have focused on obtaining over the counter status for EC as well as “advanced prescription” - providing patients with prescriptions or actual boxes of the medication at routine annual exams so it’s available “just in case.” The idea behind these interventions was that it was a lack of access that was preventing the widespread use of EC and hampering its ability to decrease unintended pregnancy rates.

Policies and programs to improve EC access can be attributed to adoption of the health belief model. At the core of the health belief model are the following principles: 1. An individual has a perceived susceptibility to a condition 2. An individual has a perceived severity of a condition and its potential consequences 3. There are perceived barriers by the individual to adopting a particular health behavior 4. There are perceived benefits for the individual to adopt a certain health behavior 5. The individual has confidence in his or her ability to take action and 6. The individual is exposed to factors that prompt action (6). Underlying these principles is the assumption that people behave rationally and are able to weigh the costs and benefits of a behavior in order to choose the appropriate course of action. For EC, this would mean that an individual would understand the negative consequences of unprotected intercourse, would understand the benefit of using EC and the minimal cost to using such a medication and would therefore choose to take the medication. The model also assumes that the individual after using EC would recognize that unprotected intercourse can lead to unintended pregnancy and thus after using EC would obtain more reliable contraception or abstain in the future to avoid this consequence.

We know, however, that EC has not had an effect on unintended pregnancy. It would appear that individuals have not used EC when needed and/or they have not followed up its use with a more long-acting method of contraception. There may be several reasons for this failure, both medical and behavioral. Focusing on behavioral patterns, the health belief model may be a poor choice to determine decision-making surrounding EC and may help explain why improved access interventions have not led to the desired outcomes.

The primary reason that the health belief model has poorly influenced EC use is people are not rational and do not make rational decisions, particularly when it comes to sexual intercourse. Inherent to this model, the individual must understand herself to be at risk of unintended pregnancy. Traditionally, unintended pregnancies are those that are unwanted or mistimed while intended pregnancies refer to those that occur at the “right time” or later than desired (7). These pregnancies, therefore, are caused by a behavior, sexual intercourse that by its very nature is often an unplanned, unintended, or unexpected event. Surveys of college and adolescent students corroborate this view.

College students report a high incidence of unplanned intercourse. In a survey of college students in 1991, 40.9% used either no contraception or withdrawal at first intercourse with 10.1% reporting they did not use contraception because they were not prepared (8). Results among adolescents are similar with 30-38% of adolescents reporting inconsistent contraceptive use (9). Furthermore, we know that 40% of unintended pregnancies are a result of inconsistent or incorrect use of a contraceptive method (10).

These results affirm that intercourse is often unplanned and to expect that people will plan to prevent the outcome of a very behavior that was not intended is unrealistic. And what we know about EC is that it only works if taken immediately after intercourse (or at the very least up to 120 hours after unprotected intercourse). EC is also only effective for a single act of unprotected intercourse; multiple acts will not be prevented by a single course of EC. Some degree of planning is therefore needed even with EC.

A second reason why the health belief model has not been an appropriate model for EC is the individual may have a perceived susceptibility to becoming pregnant that is not in line with scientific principles - the idea that “it won’t happen to me.” We know that EC only works for a single episode of unprotected intercourse. In reality, in a given cycle people may have many such episodes. However, the individual may take EC for one of those episodes and think that they are either protected or not susceptible with subsequent acts. They never follow through after the first episode and obtain more reliable contraception because they do not see the need or the risk in not doing so. In a randomized controlled trial of advanced provision of emergency contraception compared to no advanced provision, adolescent mothers in the intervention group were no more likely to begin another more effective method of birth control at 6 or 12 months (11).

Another reason that the health belief model has failed to be a successful model to predict behavior regarding use of EC is that while unintended pregnancy is something to be avoided by most public health professionals, individuals may not see avoiding this as a beneficial outcome. We know that for some people unintended pregnancy does not mean unwanted and about half of women with an unintended pregnancy choose to continue the pregnancy. Results from the NSFG report that among women who had an unintended pregnancy due to a contraceptive failure, 59% were unhappy or very unhappy about the pregnancy while 25% were happy or very happy (12). Trussell et al suggests that for some women: 1. Planning or intending to become pregnant may be different than wanting to be pregnant: 2. The concept of planning pregnancy may not have the same meaning for all women: and 3. Ambivalence towards pregnancy may lead to contraceptive failure (13).

And while finally, certainly improved access has decreased barriers to EC use, Many individuals may still perceive barriers to using it properly particularly because it has such a short window of action. For example, teenagers under age 17 still need a prescription to obtain EC, an individual may use her one pack of advanced provision and then never keep a second pack available and many pharmacies may refuse on moral objections to stock a medicine despite its over the counter status (14).

In summary, EC has failed as a public health intervention to decrease unintended pregnancies. There are many reasons for this failure and in particular, trying to promote the use of EC with the health belief model is particularly flawed because of the following faulty assumptions:

1. Sexual intercourse is a planned event and done rationally.

2. People have only 1 episode of unprotected sex per cycle and if they have greater than 1 episode, they will begin more effective contraception after using EC.

3. People recognize the negative health consequences of unprotected intercourse and because of these health consequences and their perceived susceptibility to pregnancy make the decision to take EC.

4. With over the counter status and advanced provision policies, individuals no longer face barriers to appropriate use.

Alternative Model to Decrease Unintended Pregnancy

Given that we know sexual intercourse to be an inherently irrational, unplanned behavior, an acceptable model to change behavior would not rely on the rationality of individuals. It would also make use of technologies that don’t require planning with each act of intercourse. LARC, in particular the Mirena and Paragard intrauterine contraceptives (IUCs) and the Implanon contraceptive implant, provide highly effective, temporary birth control that is not coitally dependent and is safe for most users. While technology has developed these highly effective, safe methods of birth control, they have not been widely accepted. New policies need to be developed to promote their use. Social network theory can provide a framework for improving utilization of these devices. Such an intervention based on this theory could use new social media such as Facebook and Twitter along with carefully designed advertisements tailored to at-risk populations that air both during network television shows that are popular with young adults and are printed in magazines read by young adults. This is in stark contrast to current media around these devices which typically depict women in their mid 30s with a family, certainly not the demographic most at risk of unintended pregnancy. These concerted media and online efforts would help spread the message through various social networks that these methods are safe and effective. As a result, use of LARC would increase.

Why hasn’t LARC been widely accepted? According to the National Survey of Family Growth, only 4.9% of reproductive aged women were using an IUC and only 0.08% of women were using an implant (15). Yet LARC is an excellent method of birth control in that it’s safe, doesn’t require the user to remember anything, and has very few contraindications.

In part, this low rate of use is secondary to myths surrounding these methods. Many reproductive aged women or their family members still remember an earlier IUC, the Dalkon Shield, which had higher failure rates than some of its predecessors, unacceptably high rates of septic abortion, hospitalization from severe pelvic inflammatory disease, resultant sterility and even death (16). Implanon conjures up images of Norplant, the preceding long-acting contraceptive implant that was introduced in the early 1990s. Norplant was immediately targeted to low-income women through the work of the Norplant Foundation, which provided 2.8 million Norplant devices a year to these women. Many states targeted low-income women and offered them financial incentives to use Norplant. In Kentucky, women were given $500 and an additional $50 a year for each year they continued to use Norplant. Louisiana paid women $100 per year to use the device. At the same time, women were not told about all of the side effects of the drug (17).

In order to combat some of the myths and fears surrounding LARC and gain more widespread acceptance, social networking theory may be an appropriate behavioral model to frame public health interventions. The theory takes advantage of the interconnectedness of individuals on many levels. In 1954, J.A. Barnes first proposed the concept of the “social network, ” which he described as patterns of connection including bounded groups (e.g. families, tribes) and social categories (e.g. race/ethnicity, gender) (18). This theory has been used to explain many behaviors including contraceptive use, alcohol consumption, obesity, and smoking. In a study assessing the prevalence of smoking of a 30+ year period among Framingham Heart Study participants, smoking cessation appeared relevant to one’s social network with smoking behaviors found more commonly among subjects interconnected by both close and distant social relationships. Furthermore, smoking cessation was more common among participants who had a sibling, spouse, friend, or coworker who had also quit smoking (19).

Today these connections have expanded to include online media such as Facebook, Twitter and MySpace, which have proven to be powerful tools to promulgate ideas and promote behaviors and products. Healthcare is just starting to use this media as well. As an example, one primary care practice in Brooklyn, called Hello Health, uses social media to take the place of many traditional health care roles. Patients can IM a question to the doctor, get an online “visit” for a problem and even read the physicians’ biographies on Facebook (20). In addition, peer-peer education is already occurring on many of these social networking sites. One study on the number of breast cancer groups on Facebook found 620 such groups with activities related to fundraising, awareness, service promotion, and patient/caregiver support. The support groups were the most popular sites on Facebook with the greatest number of posts (21). There remains tremendous opportunity to capitalize on the success of these media outlets to promote health behaviors.

Contraceptive use is particularly prone to influence by one’s social network. Often misconceptions, misperceptions as well as personal stories, dissatisfaction or satisfaction with a particular method are shared among people in the same social network (22). In some social networks, individuals may consider the advice regarding contraceptive effectiveness, side effects, safety and instructions for use to be more reliable coming from those in their network than from health care professionals. In a qualitative study of Latina females on their concerns about contraceptive side effects, women in the focus groups tended to value anecdotal information from peers over that of providers (23). In another qualitative study among a group of postpartum African American and Latina young women, the authors similarly found that the social network played a large role in family planning decision-making. Women often reported that while providers gave accurate information, the stories and experiences of women in their social circle had a more direct impact on their contraceptive choice (22). However, this information from their social network was also used in a positive way to encourage women to choose a more reliable method.

Given the influence that one’s social network has on contraceptive use and knowledge, this network could be exploited by public health professionals to increase use of LARC. If LARC were more commonly used, many of the reasons that improved EC access failed to decrease unintended pregnancy rates could be avoided. First, sexual intercourse is unplanned and often done irrationally. LARC, however, because it is long-acting does not require an individual to plan for each act of intercourse. It’s already in place even during unexpected sexual encounters. Second, EC only works with a single episode of unprotected intercourse. LARC is good for multiple acts without requiring any additional effort on the part of the user. Third, many people perhaps do not use EC because they do not believe in their own susceptibility to pregnancy or do not believe in the negative health consequences of unintended pregnancy. Likely, women’s belief in their susceptibility to pregnancy and their feelings regarding how a pregnancy may positively or negatively affect their lives may change several times during their reproductive life. With LARC, an individual needs to only recognize at one point in time that she is at risk of an unintended pregnancy and that this is not a desired outcome and subsequently visit a provider for a device. After this initial insertion, she needs to then consciously make a decision that an unintended pregnancy would not be a negative consequence and visit a health care professional for removal. In fact, in a study looking at interest in intrauterine contraception among seekers of emergency contraception or pregnancy testing, presumably a population that at the time of their clinic visit recognized the importance of avoiding pregnancy, 85% reported an interest in same-day insertion of an IUC (24). The challenge thus is to capture this group of patients at their most vulnerable time. And finally as compared to EC, while LARC may have a high upfront cost, once the device is inserted or implanted, there are no additional barriers. An individual does not need to visit a pharmacy, see a health care provider or pay any additional cost for effective contraception. In a research setting that eliminated many of these barriers to use of more effective methods, including provider misinformation and cost, 67% of subjects chose a LARC device (25).

LARC has many inherent advantages as a contraceptive method to decrease unintended pregnancy rates. It is safe, highly effective, doesn’t require repeated effort once in place and has no additional barriers to use once it is inserted. This is in contrast to EC, which is user-dependent and less effective. LARC, however, is infrequently used in the United States. The challenge to public health professionals is to develop innovative ways to increase utilization of these methods. Given the inherent unpredictability of sexual intercourse, constantly changing attitudes and emotions surrounding pregnancy, and a lack of understanding of the negative health consequences of unintended pregnancy, an intervention for increasing utilization based on the health belief model would be ineffectual. Furthermore, given that beliefs about fertility, childbearing and contraception are often tied to one’s cultural and social beliefs, social network theory may provide a more appropriate framework for an intervention to improve LARC uptake among at risk populations which would and thus decrease unintended pregnancy rates.

References

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The Socio-cognitive Approach of the “Healthy Relationships” Intervention: A Critique of the Current System – Lali Reddy

Introduction

HIV is a rapidly spreading sexually transmitted disease that has implications on both the individual and societal levels. An example of an intervention that specifically addresses AIDS is Healthy Relationships, which is funded by the CDC’s Replicating Effective Programs (REP) Project (1). The aim of this intervention is to reduce the transmission of HIV in HIV positive individuals by targeting their behavioral patterns using the social cognitive theory. With the application of this theory in their intervention, Healthy Relationships concentrates on enhancing the individual’s perceived self efficacy and outcome expectations of his or her actions, modeling after a social worker to build behavioral skills, and using the individual’s own personal objectives to manage HIV. Although these objectives are well intentioned, there are better ways to approach HIV positive individuals who want to have control over their disease as well as reducing its further transmission. For example, the Healthy Relationships intervention needs to focus more on instilling positive behavioral patterns, avoiding deviant sexual behavior, and clearly defining both safe and unsafe sexual behavior. This can be done by certain revised intervention methods that include creating small groups of about four people (ideally two couples) who can all share their experiences with HIV to form a social structure of support for each other. Another method involves creating a blog or forum online where the participants can discuss his or her own personal progress and can see how their peers are developing their safe sexual behavioral patterns. This will play a huge impact in redefining the norms of safe sex and promote such positive behavior among HIV positive individuals. [1]

Overview of “Healthy Relationships”

Healthy Relationships is an individual-level public health intervention, which was evaluated through a randomized clinical trial and whose goal is to reduce HIV-transmission risk behaviors in men and women living with HIV by incorporating the use of small social support groups to discuss the problem as well as how best to deal with it (1). This is accomplished through group discussion, role-play, and skill-building exercises to help these individuals cope with HIV-related stressors and learn the skills to maintain safe sex practices. There were 328 HIV-positive participants in this study who were randomly assigned to either the intervention group (n=185) or the comparison group (n=143). The intervention group consisted of small group discussions, informational videos, and personalized evaluations to help them create strategies to reduce risky sexual behavior. On the other hand, the comparison group consisted of social support groups that provided basic information about HIV and how to properly manage this disease through the use of personalized health maintenance plans. (5)

Outcome expectancies and self-efficacy

Although this intervention is well developed in terms of providing the HIV-positive individual with the opportunities for change, it does not consider the fact that an individual alone may not have the adequate decision making process skills to assess his or her problem and then use the given resources to create a solution. The flaw here is that this intervention has the pre-conceived notion that planning out the proper behavior of these individuals will lead to them accurately abiding by the plan and leaves no room for failed attempts or other modes of improvement. As a result, a flawed assumption of Healthy Relationships is that the participant will be able to watch HIV videos and listen to lectures on safe sex practices and automatically be able to follow such pre-planned behaviors, like increased condom use. This is where two principles of the social cognitive theory arise, which are outcome expectancies and self-efficacy. These concepts work together to fully define the planned behavioral process that this intervention wants these individuals to follow. Self-efficacy is based on the idea that the individual believes he or she has the capability to assess a situation and then evaluate its consequences in terms of how he or she should behave accordingly (2). This refers to beliefs in one’s capabilities to coordinate and undertake actions required to attain certain goals which involve regulating one’s own motivation, thought processes, and behavior patterns depending on which aspects of life one wants to control (2). The main idea is that the individual has the capacity to prioritize his or her goals and take the necessary steps to reach these goals alone. This is also exemplified in the objectives of the Healthy Relationships intervention as they use visual aids such as video demonstrations to communicate the message of safe sex and let the individual assess the content of the video while supposedly building certain skill sets simultaneously.

Outcome expectancies are simply the perceived consequences of these situations or actions that are solely based on what the individual perceives (3). As a result, the person is given full authority to not only realize that there is a problem in the first place, but also to comprehend the implications of this problem and find out ways to appropriately handle the situation. Through these ideas, the individuals are given false beliefs that if they simply follow the planned behavior that is taught to them, they will be able to create their own personalized self-care plans and adhere to these practices.

In order to go through this whole process alone, this intervention requires that one must completely understand the consequences of his or her actions. For example, a participant of the Healthy Relationships intervention group would need a well-rounded understanding of HIV and how it is spread as well as a comprehension of the possible results of their practice of unsafe sex, including the transmission of infection to not only themselves but also their respective partners. This is one of the main outcome expectancies that Healthy Relationships should instill in its participants—HIV is a sexually transmitted disease that also has the potential to be spread throughout society due to unsafe sexual behaviors. It is a disease that is highly dependent upon the behavior patterns of the individual and whether or not they themselves fully understand the social implications that are involved with this life-threatening disease (6). This is exemplified in a prospective cohort study that analyzed an HIV-positive individual’s network dynamic and found that this particular individual is on the periphery of a rather normal population (about 3600 people), but is in the center of a population consisting of injecting drug users near Brooklyn, NY (6). This shows that social network structure and dynamics of network change have great impact on an understanding of HIV transmission (6). Rather, this intervention falsely assumes that by educating and talking to these HIV-positive individuals about unsafe practices, they will foresee the previously mentioned outcome expectancy and refuse to participate in unsafe sex altogether. An example of this would be the HIV-positive individual self-evaluating his or her lack of condom use as a satisfying and pleasurable experience rather than a preventative measure, as was indicative of a study using HIV-positive gay and bisexual men (3).

An alternative approach to this intervention that would build on their existing skills would involve creating small interactive discussion groups where individuals can feel comfortable sharing their experiences with HIV. The group as a whole would be able to give suggestions as to how they would change not only their own behavior but what the other members of the group could do to practice positive behavior. This concept is called reciprocal peer learning where individuals in a particular group or cohort act as both teachers and learners (7). As a result, not only will the group members be able to teach their peers about their personal experiences with HIV, but they will also have the opportunity to learn from others’ stories. This group would be more effective if it consisted of two couples so that each partner can directly talk to their counterpart and discuss the underlying issues that result in their practicing unsafe sex. By using this intimate group-based intervention, one of the key components of a successful public health intervention will be fulfilled, which involves enhancement of skills by providing the opportunities for guided practice and corrective feedback (1). As a result, as the couples individually discuss their disease management strategies, they will also have the chance to give each other feedback, in turn, strengthening their own relationship with each other. This will also apply in the case that couples are not used because individuals will be able to both bond with and support each other as they share their experiences living with HIV.

There are two key areas that this revised intervention will address and that is a clear understanding of HIV as well the proper social supports to promote behavioral change. In a study done by Bandura using HIV-positive individuals, it was shown that people achieve self-directed change when they clearly understand how their personal habits affect their well being, and this change occurs within a network of social and interpersonal influences (1). It is these unbreakable interpersonal influences within the individual’s social network that plays a crucial role in claiming a strong regulatory function in terms of behavior assessment (1). Referring back to the social cognitive theory, instead of assuming that through an individual’s self-efficacy he or she will be able to easily comprehend and adhere to the planned behavior is erroneous. As a result, in order to receive a positive response from the intervention participants, it is important to show them through interactive groups that they are not alone in this struggle. It is crucial to use instructive methods such as reciprocal peer learning to illustrate the idea that this behavior is not planned but rather a collaborative effort in order to attain the ultimate goal of reduced HIV transmission. Also, the necessary feature of this intervention should be providing the opportunities for these individuals to use their social support systems to go through the right decision making process, instead of relying solely on their own perceived self-efficacy. This continues to hold true because what we see through our own eyes may not be what others see through their own eyes. Consequently, to achieve the best outcome expectations, the aspect of HIV management should be viewed not on an individual and planned level, but rather on a social standard of improvement.

Modeling as a method of disease management

Modeling is used in the Healthy Relationships intervention as an observational method for the participants in order to exemplify the right behavior to portray (1). A social worker or counselor is the one modeling the behavior in a small group setting, and the participant is the observer who is supposed to watch the behavior being done and act accordingly. Although this method seems practical, not all people learn via modeling, and this may even lead to reluctance to learning the correct behavior (8). In other words, when these HIV-positive individuals are shown the right way to practice safe sex they may feel overwhelmed that they may never reach that point. According to the flow theory, the perceived challenges that an individual faces in a particular situation are closely in tune with the person’s perceived skills (8). This would indicate that while the individuals are taught to model after the social worker, they might feel like they do not have the skill set to do so. Consequently, they will act in accordance with what they feel and when they feel capable of doing it (8). This exemplifies self-determination theory which concludes that intrinsic motivation is the satisfaction of human needs, such as competence, and motivation still varies with the individual and his or her interests (8). Consequently, if the participant in this intervention has no interest or motivation to learn the desired behavior like the social worker has modeled, then it is important to nurture a connection with the individual that will increase their motivation. The idea that someone who does not have HIV, such as a social worker, is showing them how to practice safe sex is not relatable to their situation.

This concept is illustrated in the social cognitive theory whose component involves the need for guidance on how to translate doubts and concerns about a particular behavior into efficacious actions (1). This would be representative of the social worker being the source of guidance and the efficacious actions would be the participants’ practice of safe sex. Another assumption of this theory that is also revealed in the Healthy Relationships intervention is the perceived value of utilizing social modeling. It is believed that the individual’s ability to learn via social modeling provides a highly effective way for not only increasing knowledge and skills, but also simultaneously transmitting these attributes to people through media such as videotape modeling (1). As a result, when these methods are applied to AIDS prevention, they would primarily focus on managing one’s own personal behavior as well as interpersonal situations (1). The aspect of this concept that is flawed is the idea that by showing the individual what the right thing to do is, the individual will make his or her own decision to follow this advice and immediately develop the accepted behavioral pattern.

Another scenario that is being used in AIDS interventions and is actually considered the “future” of these interventions is the application of computer technology to the prevention of HIV transmission. Schinke and Orlandi are developing interactive computer programs that will serve as the vehicle for instructing individuals on how to manage unsafe sexual activity by role-playing with computer characters on what they would say and do in particular risky situations (1). What is interesting to note here that is these scientists are simply assuming that when people watch these “cartoon characters” doing right thing by avoiding risk, that somehow this will translate into individuals doing the exact same thing. Consequently, the conclusion that is being drawn here is that people model after computer programmed characters. This is definitely an invalid conclusion since people are sometimes reluctant to model after real social workers, let alone computer generated ones.

The improved intervention that should be implemented into Healthy Relationships should be one that asks the HIV-positive individuals to model after their own peers. Implementing the notion of self-regulation with peer modeling will lead to more successful results (9). Self- regulation is the willingness of the individual to direct or manage his or her own learning process, and this can be further enhanced through peer modeling (9). The results of a study done at the University of Texas at San Antonio showed that self-regulation can be taught and that peer models can be an effective means of doing so (9). With respect to the Healthy Relationships intervention, this would mean having a peer member who currently has HIV and also practices safe sex illustrate the correct behavior that should be followed. What this does is it directly relates the participant to the peer leader so that a first-hand relationship is automatically made because they can both share in their experiences of living with HIV. Another way to best address this situation would be to help the individuals understand why they are even at the intervention in the first place and what can be done to change their lives for the better. In other words, it is crucial for this intervention to clearly define its goals for the individuals and the motivating factors that will be implemented to help them achieve these goals. In fact, goals are viewed as direct and sometimes sufficient predictors of behavior (3).

A perspective that can be taken to clearly establish the goal of the intervention is the use of the cognitive evaluation theory, which states that all external events have both a controlling aspect and an informational or feedback aspect (4). A controlling environmental aspect is one that puts pressure on the individual to reach some behavioral outcome or attempting to coerce the individual into acting in a particular manner, which decreases their intrinsic motivation for goal attainment (4). On the other hand, an informational environmental aspect provides the individual with beneficial information in the absence of that particular pressure to reach the behavioral outcome, and this is when there is heightened intrinsic motivation to attain that goal (4). Applying this theory to the Healthy Relationships intervention, it is clear that this intervention has certain practices that would enable the controlling aspect of this cognitive evaluation theory. For example, the use of social workers to model the correct safe sexual behavior would decrease the individuals’ motivation because now they are under pressure to reach this high level of success.

Conversely, approaching the concept of disease management using the informational aspect of the cognitive evaluation theory will produce better results because the individual is not pressured to reach a particular behavioral outcome. For example, instead of the individual modeling after a social worker, it would be more applicable to have the individual model after a peer who has succeeded in their own AIDS management and is willing to share his or her story. In this way there is no internal strain for the participants to accomplish such high standards of behavior because now they can self-evaluate themselves in terms of what their own personal goals are and how people just like them are able to achieve these aspirations. This improved intervention would provide ample support and guidance for participants to feel like they themselves have the capability to overcome any obstacles that this disease may present and have the capacity to take the necessary steps to alter their risky behavior. The main objective of this intervention is the participant and bringing them to the realization via peer leader modeling of what they see wrong with their life and what this intervention will do to positively change it.

The role of environment

Society and social media itself play major roles on both individual and group-level behavioral patterns (1). How people interact with each other and how they deal with their own personal issues are both part of a major network of personal and societal relationships. In the social cognitive theory that is applied in the Healthy Relationships intervention, normative influences regulate behavior through two systems—social sanctions and self-sanctions (1). Social sanctions are demonstrated in the notion that social norms convey standards of conduct and people behave in ways that give them self-satisfaction and refrain from ways that violate these norms because that will bring self-censure (1). With respect to the intervention, participants will act according to the unspoken norms that are present among the other HIV positive participants of the group. As a result, no matter how many instructional videos and social worker-led seminars they attend, their individual actions will always be a reflection of the group’s actions. Another interesting point that also arose in the previous sections of this paper was the idea of interpersonal relationships. It is these interpersonal influences operating within one’s immediate social network that have a stronger regulatory function than when simple general norms are considered (1). In other words, if everyone in the small group discussion had friends or family who feel that practicing safe sex is a good idea and should be promoted, then each individual within their respective social network will act in accordance with this belief. This idea was also illustrated in a study done among drug-dependent women in which it was shown that the more their friends use and regard condoms positively, the stronger the women’s beliefs in overcoming interpersonal barriers to safer sex practices (1). As a result, the Healthy Relationships campaign should focus more on influencing the masses and the social networks that these individuals are immersed in on a daily basis in order to persuade each individual’s behavior and attitude toward safe sex.

Dzewaltowski states that there are four main environmental factors that have an impact on health behavior, and these are feelings of connection between people, feelings of autonomy, skill-building opportunities, and healthy norms that refer to group norms (3). Even though the Healthy Relationships intervention touches on these four factors in some way, it needs to redirect its methods to clearly address each factor individually and then assess the potential impact of the desired results. One way to modify the current intervention would be to redefine the group norms among HIV-positive individuals in order to promote healthy behavior. In a study among HIV-positive adolescents in Zambia, the researchers created an innovative behavioral intervention called the value utilization/norm change model (VUNC) in order to reduce HIV transmission among this highly sexually active group (10). The basic elements of this model, which borrow concepts from the Theory of Reasoned Action, are ethnographic fieldwork, domain and consensus analysis, strategic planning, and peer leader training (10). These various steps are integrated into one cohesive behavioral structure and have been beneficial in redefining social norms about sexual behavior and instilling healthy behavior (10). A model like this could be applied to the Healthy Relationships intervention in order to bring a new perspective to the evaluation of social norms among HIV-positive individuals. By instituting safe sexual behavior as the norm among this group of people, the rates of HIV transmission have the potential to be reduced.

Conclusion

In conclusion, the Healthy Relationships intervention uses the social cognitive theory to focus their approach on the individual’s perceived self-efficacy leading to positive outcome expectations, modeling using social workers, and personal objectives. Although this approach has certain constructive themes, this intervention would be more effective if there were changes made in its core concepts. As a result, more benefits for the participants would result if the focus of the Healthy Relationships intervention was geared toward fostering interpersonal relationships, modeling after peer leaders who are appropriately managing living with HIV, and emphasizing more on the role of the participant’s environment. These modifications would lead to better health outcomes as well as safer sex practices among the participants of this intervention. Overall, the proper management of a life-threatening disease such as HIV requires strong social support and the implementation of strong behavioral patterns, which are both provided in revisions to the current system.

References:

1. Bandura, A. (1998). Health promotion from the perspective of social cognitive theory.

Psychology and Health, 13, 623-649.

2. Bandura, A. (1994). Social cognitive theory and exercise of control over HIV infection. In R. J. DiClemente and J. L. Peterson (Eds.), Preventing AIDS: Theories and methods of behavioral interventions (pp. 25-59). New York: Plenum.

3. Luszczynska, A. & Schwarzer, R. (2005). Predicting Health Behaviour: Research and Practice with Social Cognition Models. Social Cognitive Theory (pp. 127-169). Open University Press: New York.

4. Ryan, Richard M. (1982). Control and Information in the Intrapersonal Sphere: An Extension of Cognitive Evaluation Theory. Journal of Personality and Social Psychology. Vol. 43. No. 3: 450-461.

5. Information on Healthy Relationships from CDC website: http://www.cdc.gov/hiv/topics/research/prs/resources/factsheets/healthy-relationship.htm

6. Rothenberg, Richard B., Potterat, John J, Woodhouse, Donald E., et. al. (1998). Social Network Dynamics and HIV Transmission. AIDS 12: 1529-1536.

7. Boud, David, Cohen, Ruth, & Sampson, Jane (1999). Peer Learning and Assessment. Assessment and Evaluation in Higher Education. Vol. 24. No. 4: 413-426.

8. Turner, Julianne C. Using Context to Enrich and Challenge our Understanding of Motivational Theory (Chapter 5). Motivation in learning contexts: theoretical and methodological implications. (2001). pp. 85-104.

9. Orange, Carolyn (1999). Using Peer Modeling to Teach Self-Regulation. The Journal of Experimental Education. 68 (1): 21-39.

10. Feldman, Douglas A., O’Hara, Peggy, & Baboo, K.S., et. al (1997). HIV Prevention among Zambian Adolescents: Developing a Value Utilization/Norm Change Model. Soc. Sci. Med. Vol. 44, No. 4: 455-468.

Critique of an Australian Binge Drinking Awareness Campaign in New South Wales

Public health campaigns are an important part of a community’s pursuit to better its citizens’ health. Whether the aim is simply to increase knowledge or to encourage behavior change, public health campaigns use social/behavioral theories to try to construct the most effective message possible. Unfortunately, not all social/behavioral theories are made equal, which means that not all public health campaigns are equally successful in different situations. The Australian “Know When to Say When” binge drinking awareness campaign is a perfect example. According to the campaign’s producers, the New South Wales (NSW) Government, it aims to challenge the community “to consider the amount of alcohol they consume, by placing the spotlight on behaviour that our society erroneously accepts as 'normal' when people drink too much” (13). While certainly an admirable goal, the campaign has some major failings. This paper will examine three major problems behind the “Know When to Say When” campaign and suggest more appropriate methods for each, based on alternative social/behavioral models.

Critique One -The Slogan

The first flaw stems from the campaign’s main slogan of ‘When have you had enough?” That simple phrase is enough to derail any chance of getting the campaign’s message across to its intended audience. While it might seem innocuous on the surface, the slogan has a strong paternalistic, judgmental overtone attached to it. Add in the various follow-ups that NSW has devised: ‘when you get a little silly,’ ‘when you get a little stupid,’ and ‘when you make a mess” with its accompanying “when you just turn in to one,” and the campaign is sure to engender an adverse reaction (13).

This response is explained by Psychological Reactance Theory (PRT). According to this theory, first described by Brehm in 1966, people respond to perceived threats to their freedom by trying to regain control through adverse actions (11). In this sense, freedom is not just a physical reality; it also includes actions, emotions, and attitudes (2). Reactance (opposite reaction) can take many forms, from simply ignoring the message, to belittling or disparaging the source that produced the message, all the way to increasingly engaging in the exact behavior that the message was intended to prevent (12).

One way to elicit psychological reactance is by choice of tone. Using aggressive, dogmatic language gives off a tone of authority that makes the audience feel like children being lectured by their parents (5). This directly threatens freedom of attitude and may be especially detrimental in the case of NSW’s binge drinking awareness campaign because the action that the campaign addresses is already considered socially rebellious. So much research has been done on programs designed to prevent alcohol abuse that authors attempting to review the relevant literature rely on meta-analyses and comprehensive reviews (6; 7). This is pertinent because, despite such a wealth of investment (both mental and financial) into the subject, those in charge of designing new public health campaigns continue to rely on inappropriate social/behavioral theories that continue to elicit this ‘boomerang’ effect of psychological reactance (6).

Alternative Intervention(s)

There is an alternative way to deal with this issue while still using the principles of psychological reactance theory; avoid engendering psychological reactance by toning down the message. Binge drinking may be a dangerous activity and an emotional topic, but presenting it in that way to people already engaging in the activity on a regular basis will not help NSW accomplish its goals. Instead, a better approach would be to generalize the message so that it becomes less accusatory toward the people whose behavior the campaign is targeting. Making sure that the people delivering the message are as similar as possible to the message recipients will greatly reduce the antagonistic tone of the message (8). In addition, telling people something similar to their pre-held beliefs will have positive results and reaffirm their values (8). For example, a more appropriate slogan might be, “You know when you’ve had too much. But do you know what to do about it?” This acknowledges that people are generally smart enough to have a decent idea of their alcohol tolerance, especially if they are frequent (i.e. binge) drinkers. The problem is not that people are unaware of how drunk they can get, it is that they either do not see it as a problem or do not feel they have the power to change their behavior. Altering the tone of the campaign to a subtle, non-accusatory acknowledgement that there might be a control problem, rather than a lack of awareness, not only allows the message to reach a wider audience (for example, those who sit at home alone and get drunk and thus are not featured in the campaign’s social- and family-centered examples), but also presents the opportunity for message recipients to ‘take back control’ of the situation – a central tenet of psychological reactance theory.

Critique Two – Sensationalized Outcomes

The campaign’s second flaw is that it misrepresents and sensationalizes drinking outcomes in both the television advertisement and on the campaign’s informational website. The goal is to convey shameful, socially-inappropriate drunken actions in an attempt to guilt viewers into changing their faulty behavior. The problem is that the negative reactions of others fail to stand out in comparison to the actions of the drinkers. In fact, the television advertisement accomplishes the opposite of its intention; its portrayal of people who have had too much to drink is more fun and amusing than sad and pitiful. It’s easy to overlook any angry, judgmental faces in the background because people watching the advertisement who identify with the scenes are more likely to bemusedly recall a similar episode they had than to feel contrite about that episode.

The television advertisement depicts 10 different scenes intended to showcase common occurrences for people who frequently over-drink, but the majority of these scenes are highly dramatized and hard to take seriously. This is especially true when considering the cohort of society that usually experiences the highest rates of binge drinking: young adult males. These vignettes – particularly the scenes in which a woman falls down while holding a wine bottle, a woman knocks over people’s glasses at a table as she walks by, someone vomits in a cab, and a man runs into a garbage can on the sidewalk and then kicks it loudly – are likely to be misinterpreted. Instead of eliciting feelings of derision or embarrassment, these scenes are likely to be seen as either funny or, worse, something to which to aspire for people of that gender and age group.

The campaign’s website fares no better, also falling prey to over-dramatization. For example, the page titled, “The numbers behind what we drink” is loaded with all sorts of statistics that are portrayed in a duplicitous way, so as to look more extreme than they truly are. NSW achieves this by leaving out the denominators in many of their statistics. One statistic claims that “There are over 3,000 deaths from alcohol in Australia every year” but it does not include the total number of deaths the country experiences for comparison (13). NSW also tries to make some drinking outcomes seem more severe than they are in reality. When the site states that “70% of the population reported experiencing one of 14 'harms' from a stranger within the last 12 months,” they include in this definition such events as avoiding intoxicated people and places, being annoyed by vomit, and urination or littering (13).While none of those actions or outcomes are pleasant, their inclusion in a list of true harms inflicted by binge drinkers as if they are really that critical to people’s safety and overall well-being is highly suspect. It seems more likely that they added these actions in as a way to increase the acknowledgment of ‘harms’ all the way up to 70% to make the effects of binge drinking on others seem more severe.

Alternative Intervention

Rather than try to scare or shame binge drinkers into lessening their alcohol consumption, NSW should focus on subtle education. Dramatizing statistics and potential consequences of persistent drunkenness will only prompt inattention and/or resistance. Instead, NSW should utilize a tactic proven to counter the undesirable outcomes of both Psychological Reactance Theory and the Theory of Optimistic Bias: similarity. PRT has already been described above. The Theory of Optimistic Bias postulates that individuals tend to incorrectly assume that they are more likely than their peers to experience positive events and – importantly for this paper – less likely than their peers to experience negative events (10). In other words, a person’s perception of his/her own risk differs relative to that of others. A central issue of this theory is the perception of control (just as with PRT), in that the amount of control a person considers himself/herself to have over a behavior directly influences the amount of optimistic bias attached to the behavior (10). Similarity is important to both of these theories because its use has been shown to increase perception of control and lessen the effects of the unwanted behaviors, in this case, reactance and bias (4; 8).

For this campaign, NSW should utilize the concept of similarity by either using real people in their campaigns or at least hiring actors that look more like “real” people. The current cast of characters in the television advertisement is too glamorous, amusing, and good-looking for most people to identify with. While some binge drinkers are likely to resemble the actors in the advertisement, the majority of people are unlikely to conform to such standards. In addition, using true stories of unfortunate or undesirable outcomes resulting from binge drinking will be more likely to elicit a positive response to the campaign than using dramatized, stereotypical situations. When a real person relates a story, the audience is able to see and hear the regret in that person’s face and voice. In the current campaign, the actions are depicted as they happen, with few consequences shown. Seeing five seconds worth of a couple of disappointed children’s faces is not sufficient to convince people that their actions are truly detrimental to those around them. NSW needs to focus its efforts on giving binge drinkers stories and people that they can identify with. Not only will this tactic be more likely to get drinkers’ attention, it also provides a potential sign of hope for those who do not think they are able to stop drinking.

Critique Three – Choice versus Compulsion

The third major flaw of NSW’s “Know When to Say When” Campaign is its framing of the issue. Despite the admirable intention to both increase awareness of and educate about the prevalence of binge drinking in Australia, at no point in either the television advertisement or on the website does NSW address the possibility that parts of their target audience could have an abuse problem that is out of the individual’s personal control. The television advertisement frames binge drinking solely as a personal, planned decision and fails to mention any ways to get help if it becomes more than that. The campaign website fares slightly better through its inclusion of a page of “helpful contacts” that lists numbers for agencies such as regional Alcohol and Drug Information Services and various informational websites. Still, there is no mention of possible compulsion or addiction, even in the description of these resources. If as many Australians engage in binge drinking as NSW claims, there are sure to be a good number of citizens with a true substance abuse problem. This campaign focuses on the hurt drinking inflicts on others around the drinker, but it would behoove the NSW Government to consider the hurt binge drinking inflicts on the drinkers, as well. Alcoholism takes victims on both sides of the battlefield.

Although not explicitly stated, NSW seems to have based its campaign on the Theory of Reasoned Action. This is demonstrated by the campaign’s assumption that 1) binge drinking is an action that can be changed simply by personal intent and 2) that social norms have enough influence to incite change to a person’s behavior. In this social/behavioral theory model, emphasis is placed on attitudes, subjective norms, intentions, and behaviors that are directed at something specific; in this case, binge drinking (1). Intention is the best predictor of behavior and is based on perceived control over that behavior (14). In the case of NSW’s campaign, social norms are displayed through the audience’s negative reaction to the inebriated people in each of the video vignettes. If intention is the best predictor of behavior, then this campaign’s failure to appropriately depict negative social reactions, as explained above, makes it unlikely to provoke an intention to change one’s ways.

Alternative Intervention

In order to address this problem, NSW needs acknowledge that addiction is a potential part of the problem it seeks to address and that intention and social norms are not always sufficient to cause a person to change his/her ways. In this respect, the campaign’s approach is not wrong; it is insufficient. Combining the current method with a second social/behavioral theory would enable to campaign to reach a broader range of ‘offenders.’

For those who find limiting themselves to a few drinks or remaining sober more difficult than the current campaign envisions, the Illusion of Control Theory might be appropriate. The problem with this cohort of drinkers is that they actually do not possess control over their drinking habits. Whether these people already know this or have yet to become aware of it because they have not yet tried to stop binge drinking, this theory focuses on returning a sense of control to those without it.

The Illusion of Control theory is based on the concept that humans desire to find a relationship between behaviors and events and, through manipulation of that relationship, believe they can obtain control over their environment. Conversely, humans detest the loss of this relationship and associated control over their environment and experience negative affects when faced with either the perceived or actual loss of that control (3). In other words, if one already worries that s/he lacks control over a situation – for instance, binge drinking – then attempting to control that behavior and failing will have negative repercussions. This is important, not only because it shows that NSW’s campaign could result in depressive or other ‘negative repercussion’ outcomes for the cohort not in control of its drinking habits, but also because it offers a way of addressing the core problem. The campaign needs to devise ways to give those people back the feeling of control over their addiction. According to Thompson, a good way to increase the perception of control over a situation is to use positive feedback, which emphasizes success, rather than failure (9). This could range from simply encouraging people to seek help and praising those that do, to including actual stories of real people who never thought they had a binge drinking problem until they attempted to stop and what they did to overcome their addiction. As with the other two suggested interventions, the concept of similarity when delivering this message is likely to increase positive reaction to the message because it also imparts a sense of control on the individual receiving the message. Proof that enhancing the illusion of control is beneficial was demonstrated in a study conducted on college students by Alloy and Clements. Results showed that student exhibiting greater feelings of control over the test situation were less likely to experience such severe negative repercussions or become discouraged when the outcome did not develop as they had intended, compared to students exhibiting less feelings of control over the situation (9). Effectively combining the current tactic, which relies on the Theory of Reasoned Action, with aspects of the Illusion of Control Theory would be a much more comprehensive way of addressing this important national issue.

Conclusion

Designing appropriate, effective public health campaigns is something that governments and organizations struggle with the world over. Often, the people in charge of designing these campaigns rely on outdated, inappropriate social/behavioral theory models to frame their products. Sometimes, they do not consult any theories at all. Marketing companies and successful businesses, including such unsavory but persistent public health foes as Phillip Morris, are proof that campaigns based on social/behavioral theories can be wildly successful; they just need to be well-researched and well-targeted.

The key to making NSW’s message an effective one is to make it realistic and palatable for its target audience. This includes not passing judgment on popular behavior, appropriately portraying the reality of unhealthy situations by not over-dramatizing them, and understanding that the target audience is not a single entity that will completely respond to a single message.

The third critique is especially important because, as public health professionals, it is not simply our job to educate; it is our job to help those unable to help themselves. While frequent social binge drinking surely does cause harm to those who engage in it on a regular basis, the majority of offenders will likely grow out of the habit, eventually. It is those who cannot move past the drinking that need the help and the hope the most. All three suggested interventions are likely to speak to alcoholics better than the current campaign, if for no other reason than increasing similarity between the campaign and its audience is likely to heighten awareness of the problem. In addition, by positively educating without judgment and depicting more accurate drinking situations, it is possible that people may begin to identify others in their social circles with a binge drinking problem. Even that circuitous route could engender some positive results through interventions and increased emotional support.

The bottom line is that people are not rational beings and the use of any theory, model, or general assumption that employs the assumption that we are is sure to fail. The NSW Government has the proper intentions but clearly views people as rational enough to view its campaign, absorb the message, and act accordingly. This is not a likely scenario and, until NSW is able and willing to integrate interventions that accept people’s inherent irrationality, its campaigns are sure to fail.

REFERENCES

Journal Articles:

1. Blue C. The Predictive Capacity of the Theory of Reasoned Action and the Theory of Planned Behavior in Exercise Research: An Integrated Literature Review. Research in Nursing & Health 1995; 18.2: 105-21.

2. Dillard J and Shen L. On the Nature of Reactance and Its Role in Persuasive Health Communication. Communication Monographs 2005; 72.2: 144-68.

3. Heckhausen J. and Schulz R. A Life-span Theory of Control. Psychological Review 1995; 102.2: 284-304.

4. Helweg-Larsen M. and Shepperd J. Do Moderators of the Optimistic Bias Affect Personal or Target Risk Estimates? A Review of the Literature. Personality and Social Psychology Review 2001; 5.1: 74-95.

5. Quick B. L. and Stephenson M. T. Further Evidence That Psychological Reactance Can Be Modeled as a Combination of Anger and Negative Cognitions. Communication Research 2007; 34.3: 255-76.

6. Ringold D. Boomerang Effects in Response to Public Health Interventions: Some Unintended Consequences in the Alcoholic Beverage Market. Journal of Consumer Policy 2002; 25: 27–63.

7. Sheppard B. H., Hartwick J., and Warshaw P. R. The Theory of Reasoned Action: A Meta-Analysis of Past Research with Recommendations for Modifications and Future Research. Journal of Consumer Research 1998; 15.3: 325.

8. Silvia P. Deflecting Reactance: The Role of Similarity in Increasing Compliance and Reducing Resistance. Basic and Applied Social Psychology 2005; 27.3: 277-84.

9. Thompson S. C. Illusions of Control: How We Overestimate Our Personal Influence. Current Directions in Psychological Science 1999; 8.6: 187-90.

10. Weinstein N. D. Unrealistic Optimism about Future Life Events. Journal of Personality and Social Psychology 1980; 39.5: 806-20.

Books:

11.Brehm J. A Theory of Psychological Reactance. New York: Academic, 1966.

12. Burgoon M, Alvaro E, Grandpre J, and Voulodakis M. Revisiting the Theory of Psychological Reactance. In Dillard J.P. and Pfau M (Eds), The Persuasion Handbook: Developments in Theory and Practice. Thousand Oaks, CA: Sage Publications, 2002.

Websites:

13. New South Wales Government. Know When to Say When. New South Wales, Australia. http://www.whentosaywhen.com.au/index.php

14. University of Twente. Theory of Planned Behavior/Reasoned Action. Enschede, The Netherlands. University of Twente. file:///F:/721%20Paper%20B/Theory%20of%20 Reasoned%20Action_ %20U_Twente.htm.