A Critique of Abstinence-Only Education Programs in the U.S. – Amanda DiPaolo

Introduction

Adolescents and teens that are sexually active or engage in risky sexual behavior are at a high risk for unintended pregnancy, HIV and other sexually transmitted diseases (STDs). In 2011, nearly 330,000 babies (8.4% of all births) were born to teen mothers who were 15 -19 years of age, representing a birth rate of 31.3 births per 1,000 women in this age group (1,2).  Furthermore, nearly half of all reported STDs are among individuals aged 15-24 years (2).  In an effort to mitigate the social and economic impact of these outcomes, education-based interventions targeting young people are supported by the federal government. 

Multiple types of interventions have been implemented in schools around the country to help prevent or reduce risky sexual behavior among young people. In addition to comprehensive sexual education, some states receive funding for abstinence-only education under the Federal Title V Maternal and Child Health program. The current funding level for abstinence-only education under Title V is $50 million annually for FY2011 - FY2014 (2). Unfortunately, evaluations of abstinence-only courses and curriculums have failed to show evidence of reducing the likelihood for teens to become sexually active or use contraception (4 - 7). A prominent study conducted by Mathematica Policy Research Inc. concluded that abstinence-only program participants had just as many sexual partners as non-participants and had sex at the same median age as non-participants.  Contraception use was also just as likely among program participants compared to non-participants (4).

This intervention critique aims to highlight three basic weaknesses inherent in the general approaches of abstinence-only education programs funded under Title V.  At the core of these criticisms are three fundamental deficits.  First, these programs undermine the impact of societal messages about sex delivered via the media such as television/movies, music, the internet and magazines; this is important, as the media is a powerful tool for influencing youths’ beliefs (attitudes and subjective norms) about sex.  Second, while these approaches teach youth to avoid situations that can lead to sex, they are less likely to focus on the difficulties of making good decisions when they are already in a physical situation.  Finally, in many cases, educators and curriculum developers have neglected to consider that the use negative messaging (scare tactics and “slut-shaming”) to promote abstinence may cause adverse effects among youth. Such tactics may have little impact on teens that desire autonomy or to rebel against authority and can promote risky behavior.  In the same vein, these methods may be considered offensive and turn participants off to the entire program.

Critique argument 1: The impact of the media

The media plays a huge role in framing how people think about sex and offers an unrestrained resource for social learning. It serves as a “super peer” to   adolescents (especially young girls) by teaching them how to behave in romantic contexts and sexual situations (8,9). Essentially, the media provides young people with skewed perceptions of sex and normative sexual behavior – this may involve promoting overestimations of the frequency of sex and unrealistic expectations or scenarios (10).  The conclusions which youth draw about sex based on their exposure to the media are in line with the theory of cognitive heuristic availability.  This theory provides that individuals will often make judgments or generate biases about the frequency of events according to data that has limited validity (11).

Unfortunately, a review of abstinence-only education requirements does not show that these programs are directly required to address the impact of the media (12). While some programs have included education pieces that address the effects and inaccuracies of sexually driven media, many popular programs (FACTS,  Promoting Health Among Teens! Abstinence-Only,  Making a Difference) do not emphasize sex in the media leaving major gaps in the curriculum (13-15). 

Portrayals of sex and sexuality in the media are continuing to increase. In 1988, researchers estimated that teenagers viewed nearly 15,000 sexual references, innuendos or jokes on television alone (1).  More recently, the Kaiser Family Foundation estimated that the number of sex scenes on TV nearly doubled from 1998 to 2005 (17).  This influence is overwhelming when we also consider the impact of sex-related material on the internet and in magazines.  Research has shown that higher exposure to sexual media is directly correlated with more frequent sexual behavior and higher likelihood of teen pregnancy (18).   Since environmental factors are playing such a significant role in shaping youths’ beliefs about sex, abstinence-only programs that do not directly address this influence are pointless, to some extent.  To be effective, these programs must attack skewed perceptions about sex at their root cause.  Without ultimate control over what this “super peer” is teaching teens about sex, it is important that educators help teens become well-equipped to separate reality from the glamorized untruths projected by the media.

Critique argument 2: Decision-making in context

Many abstinence-only education programs have segments dedicated to decision-making; however, these portions of the programs do not address decision-making in context.  In fact, most of the discussion centered on decision-making is fact-based and describes the potential outcomes or consequences of making certain decisions. Some programs merely provide participants with a laundry list of statistics describing rates of STDs and unwanted pregnancies in hopes that this will help guide better decision-making (13). In a “cold” or rational state it is plausible that understanding “the facts” will help teens view abstinence as an important way to promote healthy future relationships and avoid unwanted pregnancy or disease. What this fails to do, however, is provide participants with practical tools for actually making tough decisions when they are in the “heat of the moment”, or “hot” states. This is especially important since research has shown that individuals are less inclined to think responsibly and rationally when aroused (19).  

Ariely’s concept of hot vs. cold is an important point to consider. In some cases, curricula will focus on making decisions to avoid sexual situations and advances, but less information is provided on decision-making in the “heat of the moment” a much more sensitive, yet relevant topic. This includes the decision to be prepared and use protection.  Of course, the goal of abstinence-only education is to promote abstaining from sex until marriage. However, statistics have shown that program participants are still engaging in sexual activity at similar rates compared to non-participants and they are doing so with little to no accurate knowledge of how to protect themselves (3, 20).  This lack of knowledge in conjunction with a lack of understanding of how hormones and emotions can inhibit one’s ability to make good judgments is a dangerous combination.  As a result, it is no surprise that numerous reports have cited abstinence-only states as having the highest rates of teen pregnancies and rising rates of STDs (21, 22).

Critique argument 3: The use of shame and scare tactics

Many abstinence-only education curricula tend to focus on the emotional drivers that influence teen sex such as the need to feel accepted or loved.  In addition to helping participants understand these feelings, programs use scare tactics or so-called “slut-shaming” methods to deter youth from wanting to have sex.  For example, a well-known abstinence-only lecturer, Pam Stenzel, admittedly employs negative messaging throughout her program in order to scare students about sex (23).  Other curricula include activities to portray how sexual promiscuity will cause an individual to lose value in the eyes of their future spouse.  The Choosing the best PATH curriculum has utilized the following activities:

“Mint for Marriage”

·      An unwrapped peppermint patty is passed from student to student. 

·      Each student is asked to hold it, examine it (maybe smell it) and then pass it to their neighbor.

·      After the patty is passed around the room, the instructor offers it to the class to see if anyone wants it.

·      The instructor asks the class “why is this peppermint patty no longer appealing?” invoking the response that “it’s gross and nobody wants it anymore.”

·      The instructor then ties the activity to the idea that “no one wants food that has been passed around and neither would you want your future husband or wife to have been passed around.”

 “A Rose with No Petals.”

·      The instructor holds up a rose and notes how beautiful it is, before passing it around to the class.

·      Each student is asked to pull a petal from the rose before passing it on to the next person.

·      When the rose is nothing more than a stem, it is passed back to the instructor.

·      The instructor then asks “how much value does the rose have now?”(24)

While meant to illustrate the value of virginity, it is hard to deny other ways of interpreting these activities.  A main concern would be encouraging feelings of shame which may inhibit sexually active teens from having conversations about safe sex or getting tested for STDs. 

There are two main issues with using negative messaging in abstinence-only education curricula. First, research has shown that scare tactics can have adverse effects by inducing rebellious behavior.   In a study of Scared Straight, an intervention designed to prevent youth from engaging in criminal activity, researchers found that the program was not effective at deterring criminal behavior, and in some cases, even promoted it by inducing rebellious actions (25). Secondly, “slut-shaming” can facilitate bullying or promote poor self-esteem (especially in young girls that have already been promiscuous) which may lead to further risky sexual behavior (26).  This tactic generally enforces the idea that individuals who have sex before marriage are bad, dirty people.  Students have publicly voiced complaints about the use of “slut-shaming” messages implied by motivational speakers aiming to promote abstinence (27).  Overall, negative messaging has been shown to work against the goals of abstinence-only education.

Proposed Alternative Interventions - Recommendations

The proposed intervention would be a focus on three core areas in order to boost the effectiveness of abstinence-only education programs.  Rather than designing an entirely novel intervention strategy, the proposed idea will build on and modify the existing approach. Therefore, the following guidelines should be incorporated into the existing requirements for approved programs under the Title V grant program.

1.    Each curriculum will have one segment dedicated solely to exploring the most important drivers of what shapes our beliefs and values about sex.  This can be in conjunction with modules regarding peer pressure; however, there must be particular and sufficient coverage on media literacy and the effects of sexual media.

2.   While abstaining from sex will continue to be the core message of abstinence-only education, further requirements should include that portions of each curriculum should address safe-sex practices. 

3.   Programs and instructors will be restricted from employing extreme tactics that could potentially inflict emotional harm and incite adverse reactions.

These recommendations will bolster abstinence-only education programs by ensuring that the curriculum addresses key facets of sexual behavioral learning.  Additionally, the programs will be more suited to meet the full needs of participants by taking a more realistic approach which considers a broader set of decisions teens will face regarding sex.  Moreover, the recommendations will ban harmful practices that have been linked to promoting bad self-esteem, poor learning outcomes and rebellious attitudes.

Articulation of the proposed intervention: Supporting argument 1

According to the Theory of Reasoned Action, both subjective norms and attitudes towards a behavior contribute to behavioral intention. Abstinence-only education has not been proven to change teens’ attitudes and values towards premarital sex; however, movies, music and other media have been shown to significantly influence these attitudes.  In order to address a major disparity in abstinence-only education, programs will be required to include modules on media literacy and the effects of sexual media.

A recent study of over 900 adolescents who underwent media literacy training provides sound evidence for this recommendation.  Pinkleton et al indicated that “participants who received media literacy training better understood that media influence teens' decision making about sex and were more likely to report that sexual depictions in the media are inaccurate and glamorized” (28). By helping teens recognize the sexual fallacies projected by the media, they will be less inclined to form distorted subjective norms about sex. Furthermore, the study cited that participants who took part in the training were more likely than the control group to believe that other teens practice abstinence.  The experimental group also reported a greater ability to resist peer pressure. Overall, the study provided solid evidence of how media literacy can positively influence teens’ beliefs about sex and logic-oriented decision-making process. 

In another study, a teen-led media literacy curriculum targeted primarily to middle school students was evaluated at 22 school and community sites.  The program helped to correct media-driven misperceptions that overestimated sexual activity among teens as the result of cognitive heuristic availability.  Participants were also less likely to expect social benefits from having sex or engaging in sexual behavior.  These results further enforce the promise of using media literacy training to influence or reshape adolescents’ attitudes and beliefs about sex. Requiring such training as part of abstinence-only education would provide participants with a “cognitive framework necessary to understand and resist the influence of media on their decision making concerning sex” (29).

Articulation of the proposed intervention: Supporting argument 2

Despite the overarching purpose to promote abstinence, programs need to include a safe-sex module.  The current model for abstinence-only education is unrealistic because it does not consider that irrational behavior will still occur and many teens will still choose to have sex.  It is essentially a Health Belief Model-based approach. Basically, by only focusing on decision-making as a means to prevent sexual activity, the approach ignores an entire portion of its audience – adolescents that will still have sex or are currently sexually active. It is important to remember that for multiple Title V abstinence-only programs, control and program group youth reported similar rates of sexual activity (4-7).  Therefore, a safe-sex module that covers the use of contraception and birth control should be required as part of approved curricula.  More importantly, this learning segment should also describe how emotional physical states affect our ability to make decisions. Specifically, participants should be exposed to the concept of hot vs. cold decision-making to further understand how their physiological responses to sexual stimuli will significantly impact their decision-making ability. 

Of course, it may take some persuading to include a “safe sex” module into an abstinence-only curriculum.  However, highlighting the scientific basis for irrational decision-making would help to make a strong case. Social Cognitive Theory is considered more advanced in comparison to the Health Belief Model because it considers irrational behavior as it contributes to irrational decision-making.  Requiring a safe sex component of the curricula will enable abstinence-only education programs to become better aligned with more modern (accurate) theories of social and behavioral processes.  

Articulation of the proposed intervention: Supporting argument 3

Based on the risks involved with negative messaging, programs that include scare tactics and so-called “slut-shaming” should not be funded under Title V. Instead, more evidence-based methods should be employed. One particular approach that has been correlated with the lowest risk for STDs is the promotion of self-efficacy. In fact, perceived self-efficacy, or a belief in one’s ability to exert control over his or her sexual behavior, has been identified as one of the best predictors of sexual risk-taking (30). At the risk of leaning towards a comprehensive strategy, self-efficacy skills should be taught for both abstinence and safe sex.  More specifically, sexual self-efficacy skills may include how to negotiate sexual activity and/or use contraception such as condoms or birth control (31).

By removing negative messaging from abstinence-only curriculums, a more conducive environment for promoting self-efficacy can be developed. Further research is needed to develop more concrete recommendations regarding which types of self-efficacy skills are most effective.

Conclusions

Abstinence-only education is not working and evidence highlighting its flaws far outweighs the evidence-base for supporting its effectiveness.  Upon applying well-known social behavioral theories, it is clear that gaps in abstinence-only education programs are creating barriers to preventing unwanted pregnancies and the transmission of STDs. Therefore, enhanced curriculum guidelines should include required media literacy training as this type of intervention has shown to directly influence adolescents’ attitudes and beliefs about sex. Additionally, ensuring that curriculums provide a broader approach to decision-making is critical. Learning about decision-making beyond the context of abstinence is important because teens are more likely to make irrational decisions in sexual situations. Also, restricting the use of negative messaging tactics is necessary to create a positive environment where more effective educational methods, such as self-efficacy training, can be implemented. 

Overall, applying these intervention strategies to the current framework for abstinence-0nly education will increase the effectiveness of these programs.

REFERENCES

1.    Martinez G, Copen CE, Abma JC. Teenagers in the United States: Sexual activity, contraceptive use, and childbearing, 2006–2010. National Survey of Family Growth. National Center for Health Statistics. National Vital Health Stat. 2011;23(31).

2.   Solomon-Fears C. Teenage Pregnancy Prevention: Statistics and Programs.  Congressional Research Service. April 15, 2013.

3.   Centers for Disease Control. Sexual Risk Behavior: HIV, STD, & Teen Pregnancy Prevention. Atlanta, GA : Centers for Disease Control and Prevention . Atlanta,GA. http://www.cdc.gov/HealthyYouth/sexualbehaviors/

4.   Trenholm C et al. Impacts of Four Title V, Section 510 Abstinence Education Programs (final report).  Mathematica Policy Research, Inc., April 2007.  

5.    Jemmott JB, Jemmott LS, Fong GT. Efficacy of a Theory-Based Abstinence-Only Intervention Over 24 Months. Archives of Pediatrics and Adolescent Medicine 2010; 164, no. 2:152-159.

6.   Kohler PK, Manhart LE, Lafferty WE.  Abstinence-Only and Comprehensive Sex Education and the Initiation of Sexual Activity and Teen Pregnancy. J Adolesc Health. 2008 Apr;42(4):344-51.

7.   Toledo, C. Abstinence-only education does not lead to abstinent behavior, UGA researchers find. UGA Today. November 29, 2011. http://news.uga.edu/releases/article/abstinence-only-education-does-not-lead-to-abstinent-behavior/

8.   Brown  J. D. , Halpern  C. T. , & L'Engle , K. L. Mass media as a sexual super peer for early maturing girls . Journal of Adolescent Health 2005; 36:420-427.

9.   Strasburger, VC. Adolescents and the Media: Medical and Psychological Impact. Developmental Clinical Psychology and Psychiatry, Volume 33.  Thousand Oaks, CA : Sage Publications, Inc. 1995.

10.             Bryant J and Oliver M.B. Media effects: Advances in theory and research. New York, NY: Routledge, 2009.

11.Tversky A and Kahneman D. Judgment under Uncertainty: Heuristics and Biases. Science, New Series 1974;185:1124-1131.

12.              Title V State Abstinence Education Grant Program Fact Sheet. Washington D.C.: Family and Youth Services Bureau. April 6, 2012. http://www.acf.hhs.gov/programs/fysb/resource/aegp-fact-sheet

13.             FACTS Curriculum. Portland, OR: Northwest Family Services. http://www.nwfs.org/empowering-youth/facts-curriculum.html

14.             Promoting Health Among Teens!-Abstinence Only Version (Overview). New York, NY: Select Media Inc. http://www.selectmedia.org/programs/phatab.html

15.Making A Difference! (Overview). New York, NY: Select Media Inc. http://www.selectmedia.org/programs/difference.html

16.             Harris L and Associates. Sexual Material on American Network Television During the 1987–88 Season. New York, NY: Planned Parenthood Federation of America, 1988.

17.             Kunkel D et al. Sex on TV 4. Washington D.C.: Kaiser Family Foundation. 2005. http://kff.org/other/event/sex-on-tv-4/

18.             Chandra A et al. Does Watching Sex on Television Predict Teen Pregnancy? Findings From a National Longitudinal Survey of Youth. Pediatrics 2008;122;1047-1054.

19.             Ariely D. Predictably Irrational : The Hidden Forces That Shape Our Decisions. New York, NY: Harper Collins Publishers. 2008.

20.              US House of Representatives Committee on Government Reforms – Minority Staff, Special Investigations Divisions. The Content of Federally Funded Abstinence-Only Education Programs. Washington, D.C. 2004. http://www.apha.org/apha/PDFs/HIV/The_Waxman_Report.pdf

21.             Ferguson D. States with ‘abstinence-only’ sex ed programs rank highest in teen pregnancies. The Raw Story. April 11, 2012. http://www.rawstory.com/rs/2012/04/11/states-with-abstinence-only-sex-ed-programs-rank-highest-in-teen-pregnancies/

22.             Nicholson, E. Faced With Rising Teen STD Rates, County Health Officials Lobbying DISD to Jettison Abstinence-Based Sex Ed. The Dallas Observer. March 19, 2004. http://blogs.dallasobserver.com/unfairpark/2013/03/teenagers_volatile_bundles_of.php

23.             Pam Stenzel: Review. Community Action Toolkit. http://www.communityactionkit.org/index.cfm?fuseaction=page.viewpage&pageid=1002

24.             Kempner M. They’re Baaaaaack: Abstinence-Only Programs Rely on Scare Tactics and Humiliation to Spread Misinformation. RH Reality Check. October 28, 2009.  http://rhrealitycheck.org/article/2009/10/28/they%E2%80%99re-baaaaaack-abstinenceonly-programs-rely-scare-tactics-and-humiliation-spread-misinformation/

25.             Petrosino A, Turpin-Petrosino C, Buehler J. “Scared Straight” and other juvenile awareness programs for preventing juvenile delinquency [Cochrane review]. In: The Cochrane Library. Issue 4. Chichester, United Kingdom: John Wiley & Sons, Ltd, 2004

26.             Ethier KA. Self-esteem, emotional distress and sexual behavior among adolescent females: Inter-relationships and temporal effects. Journal of Adolescent Health 38 (2006) 268–274.

27.             Owens E. High schoolers complain, tweet about slut-shaming during abstinence-only assembly. The Daily Caller. April 12, 2013. http://dailycaller.com/2013/04/12/high-schoolers-complain-tweet-about-slut-shaming-during-abstinence-only-assembly/

28.             Pinkleton B, Weintraub Austina E, Yi-Chun C, Cohenc M. The Role of Media Literacy in Shaping Adolescents' Understanding of and Responses to Sexual Portrayals in Mass Media. Journal of Health Communication: International Perspectives 2012;17:460-476.

29.              Pinkleton B, Weintraub Austina E, Yi-Chun C, Cohenc M,  Fitzgeraldd E. Effects of a Peer-Led Media Literacy Curriculum on Adolescents' Knowledge and Attitudes Toward Sexual Behavior and Media Portrayals of Sex. Health Communication 2008;23:462-472

30.             Bandura A. Self-efficacy beliefs of adolescents (pp. 307-337). In F. Pajares & T. C. Urdan (Eds.) Guide for constructing self-efficacy scales. Greenwich, CT: Information Age, 2006.

31.              Kali S. Van Campen  et al. “I Have What?”: How Sexual Self-Efficacy and Sexuality Education Are Associated with STD Risk in Adolescence. Francis McCelland Instisute. http://mcclellandinstitute.arizona.edu/sites/mcclellandinstitute.arizona.edu/files/I%20Have%20What%20How%20Sexual%20Selfefficacy%20and%20Sexualtiy%20Education%20are%20Associated_VanCampenToomey.pdf

Will Children in Alaska Get Out and Play Every Day? A Critique of an Overly Simplistic Public Health Campaign--Rebecca Song

Background

                  Since 1988, obesity rates in the United States have increased from 7.2% to 11.1% in children 2-5 years old; 11.3% to 18.8% in children 6-11 years old; and 10.5% to 18.2% in 12-19 year olds (1). Childhood obesity has become a wide-spread public health concern which has initiated several national as well as state-level interventions in response to this issue. A recent study published in the Journal of the American Medical Association that used a U.S. nationally representative sample, found that adolescent obesity has a significant association with severe obesity in adulthood with variations in race/ethnicity and sex (2). Therefore, it is crucial to direct efforts towards reducing childhood obesity to avoid or minimize health concerns in the future.

In the state of Alaska, the prevalence of childhood obesity exceeds the national average with 36% of children ages 5-18 above the normal weight. In an effort to reduce these rates in Alaska, the Alaska Division of Public Health launched the “Get Out and Play Every Day” campaign in 2012 to promote physical activity and raise public awareness of childhood obesity. The main goal of this campaign is to have every child complete at least 60 minutes of physical activity each day to “feel great and maintain a healthy weight.” (3) The campaign’s website and advertisements provide facts and statistics on obesity among Alaskan children, the number of hours spent in front of a television or computer and also the economic impact of the yearly obesity-related medical expenses of $459 million dollars. The daunting facts will hopefully encourage children and parents to engage in more physical activity and successfully meet the daily 60-minute goal.

Summary of Critique

            Although the “Get Out and Play Every Day” campaign provides important public health facts to raise awareness of childhood obesity and intends to encourage children to be active, it relies on components of the traditional Health Belief Model that will ultimately make this campaign unsuccessful. It assumes that individuals are in complete control of their health and they will easily change their behavior to meet the campaign’s 60 minute-goal (4). The campaign does not address important external factors that are potential barriers to achieving 60 minutes of physical activity a day nor does it provide alternative ways to stay healthy if physical activity is not possible due to either a disability or other constraints. Lastly, the campaign places the responsibility to be physically active not only on the individual child, but also on parents who may not model healthy lifestyles themselves and can trigger psychological reactance in their children.

Critique 1: Using the Health Belief Model as a foundation

            The “Get Out and Play Every Day” campaign is built on components of the Health Belief Model (also known as a value expectancy model) which focuses on the individual as the primary source of behavior change. It assumes that the targeted audience will engage in healthy behavior if they value the outcome and believe that the behavior is likely to result in that outcome. The Health Belief Model also hopes to change an individual’s behavior through rational decision-making to prevent the adverse outcomes, which in this case is obesity (4). The campaign assumes that all children and parents value health (good health) and therefore the presentation of statistics on childhood obesity and creating videos stating that the life expectancy of Alaskan children is declining will trigger a rational decision-making process to adopt a healthy lifestyle.  The answer to solving this problem is simple and viable in the campaign’s eyes – children just need to get out and play for 60 minutes every day. However, every Alaska resident does not place a value on health so the campaign’s strategy of simply presenting facts to raise awareness and preaching this one solution will not be effective. If there is little or no value placed on health, it will be difficult for children to fully comprehend the benefits of physical activity and how it will shape a healthy future for them. Though the tone of the campaign promotes a sense of urgency and the health consequences are severe, the individual must perceive the susceptibility to the health problem, the benefits of adopting a healthy lifestyle, and value the outcome in order to take action. For example, if a child’s friend does not engage in physical activity and his parents allow him to watch television all day, the child would not feel susceptible to a health problem or see a perceived benefit to physical activity because there is no immediate risk to him or his friend. Also, humans tend to act irrationally and are inclined to act on intuition or emotion so one cannot assume that shocking statistics will motivate an individual to change his or her behavior through rational-decision making (5). The campaign’s message is targeted directly to the individual without promoting confidence, success and empowerment.

The Health Belief Model only focuses on the individual and does not address the external social and environmental factors that contribute to childhood obesity. An individual is a product of his or her environment so one cannot expect to change an individual without changing the environment that surrounds him or her (6). The “Get Out and Play” campaign’s failure to address the multiple levels that influence a child’s values and behavior make it a weak and ineffective campaign. Studies suggest that health outcomes are associated with social and environmental factors and tend to be lower in less active communities (7). The lack of consideration of external factors that also influence a child’s behavior change weakens the “Get Out and Play Every Day” campaign and make it ineffective.

Critique 2: Barriers to Get Out and Play

            The “Get Out and Play Every Day” campaign fails to consider the physical, environmental and social barriers and limited access and resources for families. If barriers to affordable, safe, and achievable physical activity exist, the intervention will not be successful even if the individual intends to be healthy. Sallis and Glanz (2006) found that the recent changes in the “built environment,” such as the lack of sidewalks and long distances to schools, parks and recreational facilities, promote a sedentary lifestyle (8). For many Alaska residents, highways are the only roads that connect recreational facilities and schools, even in the largest city of Anchorage. Although Anchorage is the largest city in Alaska that holds half of the state’s population, it is not a densely populated city with a well-functioning public transportation system or sidewalks that connect neighborhoods which is a barrier to physical activity. Studies show that walking or commuter cities tend to have lower obesity rates but Alaska’s “built environment” discourages people to integrate this simple exercise into a daily routine and also establishes driving as the social norm (9). There is a social stigma against those who are seen walking, especially during the winter, because Alaska’s “built environment” caters to drivers. This social stigma will discourage people from walking because spectators may associate them with a lower socioeconomic status or someone without the means to buy a car.

            Alaska’s “built environment” as well as its natural environment can be unsafe for children to participate in outdoor activities. Alaska is a rural state that is not densely populated so a simple exercise such as walking around in the neighborhood may be a safety risk. There is a lack of local neighborhood parks or safe spaces for children to play because most funding and attention is placed on the National and State Parks. During the seven month long winter, Anchorage has an average of five hours of daylight with below zero temperatures. These weather conditions will discourage parents from letting their kids outside but instead allow them to watch television indoors because it is safer. The campaign’s website has announcements on local events to promote safe avenues of physical activity, however, they do not occur every day and several of these events require a fee to participate which may not be feasible for some families. This campaign focuses on the simplicity of exercising 60 minutes a day when in reality, there are many barriers to achieving this goal.

Critique 3: Dependence on Parental Involvement

            The campaign emphasizes the importance of parental involvement in a child’s level of physical activity and places responsibility on the parents to plan activities and motivate their children. They suggest that scheduling time for family exercise is just as important as scheduling a doctor’s appointment. The campaign’s message is based on the assumption that all parents have the time and capability to spend an hour a day to do family activities together. However, this campaign would not effectively change behavior of parents who work nights, multiple jobs, have busy schedules because their value is not in health and have other priorities such as, providing for the family financially. Parents simply may not know how to build in time for physical activity with the family because being active may be a new concept for them. The campaign does not adequately equip parents with the necessary tools or realistic examples of achievable activities or how they can motivate their children to exercise. Moreover, the emphasis on the simplicity of the goal has the potential to create feelings of failure among parents who cannot schedule time to be active together. Parents will lose confidence in their ability as caregivers and may give up on incorporating physical activity into the family routine.

If the campaign is placing responsibility on the parents, there must be behavior change in the child as well as in the parent’s behavior because the lifestyle of the parents is a determinant of a child’s health outcome. Agras et. al. (2003) assessed five independent risk factors for the development of overweight children and found that an overweight parent was the strongest risk factor (10). The findings in the study support the Social Learning Theory, which states that people learn new behaviors from modeling and observing in their environment. Children are more likely to learn through observational learning and if parents are adopting an inactive and unhealthy lifestyle themselves and do not promote health as value within the household, it will negatively impact the children’s behavior.

Parents that value health that attempt to instill that value in their children by scheduling family activities may trigger psychological reactance in the child and actually deter them from exercising or playing outside. Psychological reactance is a motivational state that people experience when there is a perceived threat to their freedom and autonomy and they try to restore it. Although parents are encouraging something positive for the best interest of the child, the child experiences a stronger force of reactance in an attempt to restore the threatened freedom and could create an issue that is more severe (11). For example, if a parent limits the number of hours that a child can spend watching television and tells them to play outside instead, it will trigger psychological reactance and children will do the opposite. Children’s resistant to physical activity will probably make parents give up easily if their schedules are already hectic as it is and relapse into their old ways. Using parents as a model and motivator for children can actually have a negative effect thus generating an ineffective campaign.

Shifting the Focus of the Intervention

            The Get Out and Play Every Day campaign must develop a framework based on theory-based interventions that use a multilevel approach. The campaign should broaden its strategy to a community level intervention and involve stakeholders that can contribute to combating childhood obesity in Alaska rather than placing all of the responsibility on the individual or parents. There should be a message of empowerment in the campaign to increase self-efficacy because it will build confidence in the children to believe they can achieve their goals. Lastly, the use of role models and community leaders that the children can identify with should be mobilized to deter psychological reactance and increase the likelihood of adopting a healthy lifestyle.

1. Individual to Community Level

            The Get Out and Play Every Day campaign places the burden of physical activity on the children and parents and does not address community involvement. If this initiative’s focus shifted from an individual to a community level campaign, there will be more positive reinforcements and accountability for individuals to remain active. A community level intervention would involve not only the family but educators, local government, health practitioners and even local business owners. Community-based programs use multiple interventions, targeting change among individuals, groups, and organizations, and they often incorporate strategies to create policy and environmental changes and this ecological approach will increase its success (12). Mittelmark, Hunt, Heath and Schmid (1993) explains that the key characteristics of successful community-based health promotion programs include mobilizing communities to actively participate in achieving program goals; implementing interventions in multiple community settings; using multiple individual-level intervention strategies; and developing environmental interventions (13). The Get Out and Play Campaign must engage the community as a whole in order to successfully reduce childhood obesity because it cannot rely on the individual alone, especially if they do not value health. If the community participates, there will be different avenues to achieve this goal and may the campaign may even expand beyond 60 minutes of physical activity but include things like nutrition and education with community participation. This will also display positive health behavior in the community that children will observe and learn from to adopt a healthy lifestyle. As the community actively participates in this campaign to fight childhood obesity in Alaska, the local government may respond by providing accessible and affordable spaces for safe physical activities such as neighborhood parks, after-school programs, and subsidized sports leagues.

2. Promoting Self-efficacy to Empower Children

            The intervention must adopt a strategy that will promote self-efficacy to build confidence and empowerment in order to be successful. Self-efficacy is an important factor that will affect the likelihood of a person to change his or her health behavior because it is built upon the idea than an individual’s perception on his or her ability to change will determine its success towards that behavior (14). An adoption of physical activity is largely a matter of individuals with stronger self-efficacy because they will expect to reap the benefits associated with being active and likely maintain a healthy lifestyle in the long run.  Children must be empowered to have personal expectations and have confidence to take action and overcome obesity. The goal cannot seem too overwhelming or the children will lack confidence if the goal does not seem achievable. Instead of emphasizing the 60 minutes a day, the campaign should first focus on small incremental steps that are surely attainable such as, walking up two flights of stairs at school or eating one vegetable a day. Parents should also be involved in having a formal contract or rewards for children and constantly give positive reinforcement which will increase a child’s likelihood that they will repeat the behavior. In a study by Andersen et al. (2010), they found that change in self-efficacy for physical activity was related to change in self-regulation which was found to be a potential mediator of the effect of self-efficacy on physical activity. Participants in a community level intervention who gained confidence in their abilities to be active engaged in more frequent goal setting, planning and monitoring behaviors, which led to increased physical activity so shifting the focus from the individual to the community will create a successful public health campaign.

3. The Use of Peer Role Models

            Replacing parents as the primary influencer in a child’s active lifestyle with role models that are identifiable and similar to the children will minimize psychological reactance. Silvia (2005) suggests that a strategy to deflect reactance is to utilize interpersonal similarity between the communicator and receiver of a particular message because it will increase the positive force toward compliance. In an experiment that matched people with a communicator with the same birthday, name, gender and year in school, they found a correlation between similarity of these characteristics and agreement. People tended to agree with the similar communicator when the threat was high and low which suggests that similarity is a strong force that will determine agreeability despite the threat level (16). Schunk (1987) found within existing educational research that peer models had beneficial effects compared with dissimilar-age models. Schunk also found that peer models can enhance children’s self-efficacy for learning better than adult models suggesting that model-observer similarity in age is an important factor for raising self-efficacy. Therefore, peers may be more influential when encountered with difficulties, such as not being able to exercise every day, and are uncertain about their capabilities (17).

The main mode of learning is through observation of other’s behavior according to the Social Learning Theory, so modeling is an important means of shaping a person’s behavior, attitude and beliefs. The use of age-similar role models will create a trust between the communicator so the children will not interpret the campaign’s message as a threat to their freedom and autonomy. Furthermore, humans influence other humans easily because they like to conform (18). If a youth role model frames health in a way that speaks to a child’s set of core values and can identify with the model, they will have a desire to adopt this value as their own and conform to the model’s behavior.  Based on this evidence, the campaign should utilize youth role models and match them with children two or three years younger to increase self-efficacy, effectively spread the campaign’s message and promote active lifestyles.

Conclusion

            The “Get Out and Play Every Day” campaign’s goal is to raise public awareness of childhood obesity and encourage children and families to perform at least 60 minutes of physical activity a day. Instead of aiming to change behavior on the individual level, the campaign should engage the community and broaden this campaign to a community level intervention. The participation of the community will create more opportunities to display positive health behavior that children can learn from and provide accountability to achieve this goal. The campaign should also focus on empowering the individuals to promote self-efficacy and make the individuals believe they can accomplish this health goal. The use of peer role models in addition to parental influence will create similarity among the children and increase the likelihood that children will adopt a healthy lifestyle for themselves. These interconnected interventions will complement each other and form an effective public health campaign to minimize childhood obesity in Alaska.

           

           

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