Challenging Dogma - Fall 2007

...Using the social and behavioral sciences to improve the practice of public health.

Thursday, December 13, 2007

The Failure of the Minnesota ENABL Campaign – Monica Sawhney

In 1996 Congress passed The Personal Responsibility and Work Opportunities Reconciliation Act. While this act primarily concerned welfare reform, it also provided funding to states for abstinence only sexual education programs. These programs went on to be established through Title V of the Social Security Act. One such initiative created as a result of Title V was the ENABL (Education Now and Babies Later) campaign in Minnesota in 1998. It is a program targeted at youth and their parents or guardians throughout Minnesota. Its aims are to reduce adolescent pregnancy by reducing sexual activity and encouraging abstinence until marriage. The program teaches adolescents how to avoid involvement with sexual activity and how to open up the lines of communication with their parents (12).
The ENABL program in Minnesota focuses on teen pregnancy. Its initiative promotes the idea that abstinence is the best way to avoid teen pregnancy, using both a curriculum and family based approach. Youth are taught an in school curriculum revolving around the risk of teen pregnancy and STDs and are encouraged to use abstinence as their approach to these problems. The curriculum does not include information about the use of contraceptives. The ENABL campaign also aims at making parents more proactive. It provides resources and lessons for parents on how to discuss sex with their children. These resources are accessible online and in community centers (12).

Evaluation of ENABL
The ENABL campaign was evaluated in 2002, 4 years after the program was initiated. The analysis of the program was based on surveys determining attitudes toward sex and abstinence by students who had completed the curriculum. The results of the evaluation found that overall, the program had failed. The rate of students who were having sexual intercourse or those who said they would within the next 12 months almost doubled (9). The percentage of students who said they would talk to their partner about abstinence and avoid risky behavior fell. The rate of students who said they believed “sex was only something adults should do” also fell. The program did increase the frequency with which parents and children discussed sex. The analysis concludes with a recommendation that programs about sexual education would be more useful if they include information on both abstinence and safer sex (8).
Since the ENABL program was initiated, there has been no increase in the rates of teens abstaining from sex. An analysis of the program showed that the incidence of teen sex actually rose during this period of time. One of the biggest problems with this initiative is that it did not take many aspects of behavioral theory into account. The program did not take the Theory of Reasoned Action into account, neglecting to adequately address social norms and pressures adolescents may face. It also ignored Social Cognitive Theory by failing to address self-efficacy. These failures created a program that did not achieve the majority of its goals. By looking beyond the Health Behavior Model into other theories of behavior, the ENABL program may have been successful.

Failure of the Health Belief Model
A key problem with the ENABL program is that it is essentially based on the Health Belief Model. The Health Belief Model states that there are two conditions that must be met in order for a person to perform healthy behavior. The person has to believe they are susceptible to a problem that is severe, and that there are benefits to taking action against this problem without too many barriers (5). By teaching students that sex can lead to pregnancy and STDs, instructors assumed that teens would accurately assess the perceived susceptibility and severity of having sex. They also assumed that by teaching them to abstain from sex, teens would consider abstinence beneficial and free of many barriers. Even if youth were to perceive premarital sex in this way, research has shown that the Health Belief Model does not necessarily predict behavior (4). The statistics of the ENABL program speak for themselves. Even though adolescents were learning about the risks involved with having sex, the incidence of those who did engage in sex or said they would within one year nearly doubled. While the susceptibility and severity of pregnancy and STDs were presented to the teens as relevant to them, many did not perform the behavior.

Incorporating the Theory of Reasoned Action
The ENABL program did not account for the Theory of Reasoned Action, which may explain why the students did not respond to the curriculum. The Theory of Reasoned Action is based on the idea that a person’s intentions to carry out a behavior are based on their attitudes toward that behavior and their perception of subjective norms in regards to the behavior (5). Subjective norms are social standards in society that people see as prevalent and common. This idea of subjective norms is very important, especially when an initiative is directed at youth. Adolescents are also more susceptible to social norms than adults. They are less likely to perform a behavior if they are worried about how others will see them. They also have a stronger desire to fit in with their social groups, and therefore are more likely to adapt to these social norms. Norms are dictated not only by peers, but also the media. Both of these aspects have a strong influence on youth. These social norms often do not reinforce the idea of abstinence; many times they do the exact opposite.
Based on previous statistics, the idea of premarital sex has permeated throughout American society; it is therefore a social norm. Studies have shown that exposure to media with sexual content can result in an increase in sexual behavior. The perception of friends’ attitudes toward sex is also predictive of a teen’s own behavior (1). The ENABL program must focus on these subjective norms and attitudes toward behavior if it wants youth to practice abstinence. The approval of premarital sex is so widespread in the U.S. that it is hard to overcome these social norms. This campaign fails because it is unable to show adolescents that premarital sex is not a norm for teens in society. By changing the perceptions of the social norms, students may be able to change both their attitude and intention toward the behavior.
One study seems to have utilized the Theory of Reasoned Action in relation to HIV-risk reducing behavior in men who are HIV-positive. This experiment created an intervention in which men were educated and taught skills to reduce HIV-risk behavior in the context of social norms, self-efficacy, and communication in-group sessions. After the study, men who had participated in these sessions were more likely to use condoms with their sex partners. They were also more likely to divulge their HIV status and to inquire about a potential partner’s status. By addressing social norms and communication, this initiative was able to increase desired behavior (10). The ENABL campaign could have similar results if it was able to effectively change the way teens viewed the norms surrounding sex. If adolescents believed that many of their peers abstained from sexual activity, they may find it easier to do the same.

The Role of Self-Efficacy
Another problem with the ENABL campaign is that it does not address the issue of self-efficacy. Self-efficacy is a concept central to Social Cognitive Theory. It states that a person is not likely to change their behavior if they do not believe that they have the ability to do so. A person must have confidence in their capabilities to both do the behavior and to rise above challenges that may attempt to hinder the behavior (5). Recent studies reflect the pressures and realities faced by many youth today to engage in premarital sex. 47% of high schools students in the U.S. have had sexual intercourse by the time they graduate (13). It has been shown that by age 20, 75% of Americans have had premarital sex (6). While the ENABL program specifically targets youth, it is clear that sex before marriage is very prevalent in the U.S. today. Through the media, friends, and family, teens are constantly exposed to the idea of having premarital sex. In the face of this pervasiveness, youth may come to believe that premarital sex is the norm and in fact, unavoidable. If the ENABL program wishes to maintain its abstinence only policy, it must come up with effective ways to convince teens that they have the ability to abstain and to overcome the pressures not to abstain that frequently occur.
Numerous studies have shown that self-efficacy is a successful technique in helping people achieve a behavior. One such study involved predictors of condom use among African American college students. It found that self-efficacy was the most important factor related to condom use and safer sexual practices within the past six months. It was also related to an increasing frequency of condom use and overall lifetime condom use (2). Another study was done comparing the susceptibility to sexual risk-taking behavior and self-efficacy in Sierra Leonean students. It found that higher self-efficacy was related to rejecting sexual advances, which lead to significantly less sexual risk-taking behavior (3). These studies demonstrate the necessity for self-efficacy in order to deter risk-taking behavior. Teens who feel that they are actually able to abstain from sex will be much more likely to do so than those who feel like they cannot.

The Need for a Comprehensive Program
While the ENABL campaign is supposed to reach youth throughout Minnesota, it could also have had the effect of alienating certain adolescents in their programs. The initiative has one simple message, based on heterosexuality, and a curriculum built around that focus. The program has not been created in a way that addresses anything other than heterosexuality. Teens who may be homosexual, transgender, or of any other sexual orientation do not receive relevant information. They are not able to relate the messages in the curriculum to own their lives (11). An abstinence only initiative is also not relevant to teens who are already sexually active. Adolescents who have engaged in sexual behavior will not learn anything from the program since it does not apply to their actions or intentions. The program also does not teach youth methods for decreasing risks if they are engaging in sexual behavior. Teens who are sexually active may not be aware of the various options available to prevent the spread of STDs and lower the risk of pregnancy. As a result, they may continue to have sex but without proper protection (11).
Recent studies have shown that comprehensive sex education can be more effective than abstinence only education, especially with teens who are sexually active. One study compared results between an abstinence only program and a safer sex program in African American adolescents. The results showed that teens who were already sexually active engaged in less sexual intercourse after the program if they were in the safer sex group, as opposed to in the abstinence only group. Teens in the safer sex group were also more likely to use protection when they did have sex (7). By alienating certain groups of students from their program, the ENABL campaign could not reach all youth, as was its intention. By not adequately addressing the needs of all teens in its program, it may have even put them at a greater risk.

The ENABL campaign of Minnesota failed because it did not take certain behavioral concepts into account. If the campaign had utilized the Theory of Reasoned Action, it may have been more successful in changing teens’ views of social norms toward sex. If it had relied more on Social Cognitive Theory, it could have addressed the issue of self-efficacy. An emphasis on this concept could have enabled teens to believe that they were capable of abstaining from sex. The campaign also focused only on heterosexual adolescents who had not yet engaged in sexual activities. The curriculum did not address those who were already sexually active or not heterosexual, potentially missing a significant portion of teens. The curriculum’s focus was also strictly on abstinence, and not a comprehensive sex education course. If the campaign had taken these concepts into account, it may have been much more successful. Various studies have shown that social norms and self-efficacy play an important role in changing behavior. It is also more efficient for a campaign to be all encompassing, rather than focusing on particular groups of people that emphasizes one course of action. Taking these theories into account could have lead to ENABL’s success.


1. Brown, Jane D., and Kelly Ladin L'engle. "Sexy Media Matter: Exposure to Sexual
Content in Music, Movies, Television, and Magazines Predicts Black and White Adolescents' Sexual Behavior." PEDIATRICS 117 (2006): 1-18-1027. 10 Nov. 2007 .

2. Burns, Myron J., and Frank R. Dillon. "AIDS Health Locus of Control, Self-Efficacy forSafer Sexual Practices, and Future Time Orientation as Predictors of Condom Use in African American College Students." Journal of Black Psychology 31 (2005): 172-188.

3. Carter, Robert T. "The Effects of HIV/AIDS Knowledge, Sexual Self-Efficacy and
Susceptibility on Sexual Risk-Taking Behavior in Sierra Leonean Students of Higher Education (Immune Deficiency)." DigitalCommons@Columbia. 1997. Columbia University. 12 Nov. 2007

4. Choi, Kyung-Hee, Gust A. Yep, and Eugene Kumekawa. "HIV Prevention Among Asian and Pacific Islander Men Who Have Sex with Men." AIDS Education and Prevention 10 (1998): 19-30.

5. Edberg, Mark. Essentials of Health Behavior Social and Behavioral Theory in Public Health. Boston: Jones and Bartlett, 2007.

6. Finer, LB. "Trends in Premarital Sex in the United States, 1954-2003." PubMed. 2007. National Center for Biotechnology Information. 12 Nov. 2007 .

7. Jemmott, John B., Loretta Jemmott, and Geoffrey Fong. "Abstinence and Safer Sex HIV Risk-Reduction Interventions for African American Adolescents." Journal of the American Medical Association. 279 (1998): 1529-1536. 12 Nov. 2007 .

10. Randall, Lm, and Mk Lapinski. "Prevention Options for Positives: Evaluation of a Theoretically Based Prevention Intervention Targeted to HIV-Infected Men Who Have Sex with Men." Gateway. July 2003. National Library of Medicine. 12 Nov. 2007 .

11. Santelli, John, and Mary A. Ott. "Abstinence-Only Education Policies and Programs: a Position Paper of the Society for Adolescent Medicine." Journal of Adolescent Health 38 (2006): 83-87. 12 Nov. 2007 .

12. Say Not Yet! to Sex. 2003. Minnesota Education Now and Babies Later. 11 Nov. 2007 .

13. "Sexual Risk Behaviors." Healthy Youth! 22 May 2007. National Center for Chronic Disease Prevention and Health Promotion. 10 Nov. 2007 .

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