Challenging Dogma - Fall 2007

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

Sunday, December 9, 2007

Shut Up About the Baby, Already: The Ineffective Use of the Health Belief Model in the “Sex Has Consequences” Initiative - Katie Elliot

Any teenager who has held a babysitting job, spent an afternoon with a two year old cousin or sat behind a screaming infant on an airplane is probably not interested in having a baby any time soon. The same ninth grade girls who gush over the miniature clothing at Baby Gap cringe when they see a fellow mall-walker bogged down with a stroller and diaper bag. Sure, babies are cute, but most teens have seen enough Lifetime original movies and endured enough caustic threats from their parents to find the prospect of parenting equally shameful and terrifying (1). They get it: having a baby at fifteen, like, totally sucks. So why is the National Campaign to Prevent Teen and Unplanned Pregnancy, a major source of research in the field of teen sex behavior, still trying to drive this message home?

Each of the thirty-second “Sex Has Consequences” public service announcements created by the National Campaign presents a scenario in which a teen has to deal with the inconvenient, overwhelming, and sometimes tragic consequences of expecting or caring for a baby—followed by an ominous “Sex Has Consequences” warning. The National Campaign seems to assume that if young people only knew how awful it is to be a teen parent, they would stop having unprotected sex. Unfortunately, this intervention is guided by a prominent but fundamentally flawed theory of behavior change: the Health Belief Model (HBM). Under this model, individuals are assumed to rationally weigh the costs and benefits of their actions, determine whether they are susceptible to the possible negative consequences, and change their behavior accordingly (2). So, “Sex Has Consequences” uses classic scare tactic messages to highlight the high costs of teen pregnancy—and remind teens that one mistake can leave them with a two-month-old date on prom night. Although the National Campaign expects that this harrowing realization alone will cause teens to change their behavior, they fail to recognize that perceived barriers to action and social norms will often override teens’ better judgment when it comes to sexual attitudes and practices (3). By relying on the HBM, “Sex Has Consequences” offers ineffective threats instead of addressing the risk-reduction strategies and social factors that could more feasibly play a role in reducing teen pregnancy.

You Can’t Scare Them Out Of It

Most studies prove that teens do not respond well to scare tactics and threats, but the creators of “Sex Has Consequences” never got the memo (3). It is not that their commercials lack sufficiently frightening messages—in fact, several of the public service announcements are deeply unsettling. A particularly disturbing commercial begins with a teen girl screaming, “It’s my life!” at her disapproving mother before heading out to a raging high school party. The teen drinks beer as the narrator intones, “This was the night you were always going to remember.” Then, as the camera quickly cuts to the bedroom, the voice continues: “…because it’s the night you got pregnant.” Under the sounds of a deafening heartbeat, scenes flash between the teen’s bawling mother and her furious male sex partner—who slams the door and storms out after screaming, “I’m through!” At the end of the commercial the teen is left alone next to a baby crib, sobbing and rocking herself, as the camera flashes back to her initial declaration (“It’s my life!”) and the narrator warns viewers, “It’s your life—don’t mess it up with a pregnancy.” Blackout. “Sex Has Consequences” blazes across the screen.

If teens could be “scared” out of having unprotected sex, this commercial would do it; the desperation of this teen’s situation is heartbreaking. But what message does it have around which teens can mobilize? On their website, the National Campaign suggests that the public service announcements will spark discussion between teen sexual partners and among teens and their caregivers—presumably employing agenda-setting theory of behavior change, which asserts that the extent to which the media covers an issue will determine the public’s attention to and concern over that issue (4, 2). Few can argue, though, that teen pregnancy is not perceived as a problem in the United States. In fact, when US teen pregnancy rates peaked in the early 1990s, physicians and parents panicked, and, not surprisingly, the media followed suit with a host of documentaries and public service announcements eschewing the consequences of teen pregnancy (5). Teen pregnancy rates slowly began to decline. However, to what extent did media affect that outcome? And, if it did, is the success significant? The US still has the highest rate of teen pregnancy in the developed world (6). The media may be getting the message out there, but it is not getting the message right. And that is the problem.

“Your Life,” for example, sends scary but confusing messages to teens about risky behavior. Not only does it disparage unprotected sex, but also, presumably, teen drinking and drug use. The National Campaign has found that 25% of teens have engaged in unprotected sex while drinking alcohol or using drugs, and “Your Life” attempts to highlight the connection (4). Although alcohol consumption and drug use are arguably detrimental to teen development, and can certainly negatively affect teens’ sexual experiences, teens often associate these behaviors with desirable traits (7). By linking these activities to one girl’s ultimate sorry outcome, “Your Life” takes away all of the methods of teen rebellion without giving them new means by which to achieve the same feelings of excitement and maturity. The only thing that seemingly could have prevented this girl from winding up in a nursery is if she had never gone to the party in the first place. So the National Campaign throws in a last sucker-punch (remember the frowning mother at the beginning of the ad?): listen to your mom. Now, that message will go over well with teens.

It is highly likely that the negative consequences of sex captured in this and other “Sex Has Consequences” public service announcements will make teens realize that they do not want to get pregnant, but, as proven by a recent contraceptive-use study, awareness of negative outcomes alone will not change teens’ behavior (8). The National Campaign wants to remind teens that having a baby will ruin their lives, but—not surprisingly—most teens already knew that: in a 2007 poll, 84% of teens reported that being a teen parent would either delay or prevent them from reaching their future goals (4). Yet, many teens are still having unprotected sex (9). The problem with the approach of “Sex Has Consequences,” then, is its rigid adherence to the HBM: the creators fail to realize that teens’ behavior will not necessarily mirror their knowledge or intentions, especially when it comes to sexual practices (3). Teens don’t just need more information—they need methods and tools to initiate meaningful behavioral change.

They Get The Risk, Where’s The Reduction?

As expected, methods and tools to prevent pregnancy are sorely lacking in the “Sex Has Consequences” campaign. Although studies have found that comprehensive sex education methods are more desirable and more useful to teens than abstinence-only approaches, “Sex Has Consequences” remains committed to the HBM scheme of “consequence-awareness” (10, 12). That is not to say that there is no mention of contraception in this series—in fact, various contraceptives appear quite prominently in one of the public service announcements. However, this ad does more to undermine the effectiveness of contraception than promote its use. In the spirit of “Sex Has Consequences,” “Ticking Clock” begins with a distraught teen girl examining a pregnancy test, crying as she waits for the result. A large white clock is superimposed into the frame. Like “Your Life,” “Ticking Clock” proceeds in a flashback mode, showing a disappearing condom as the girl’s boyfriend whines, “It just doesn’t feel the same.” He continues, “Did you take your pill?” The phrase eerily repeats and echoes as the pill is shown mysteriously disappearing from the table surface, much the same as the condom, as the girl continues to cry and the clock continues to drone. An image of a steaming tea kettle is paired with the sounds of a crying infant, which gives way to another round of, “Did you take your pill?” As the pregnancy test flashes in front of the screen—its result indecipherable—her boyfriend says, “I’m sorry.” The last image juxtaposes the two teens’ solemn faces, as a single tear rolls down the miserable girl’s cheek.

Again, as with “Your Life,” what have teens learned? That condoms and birth control pills, when used correctly, can often effectively prevent pregnancy (6)? Or that contraceptives have the supernatural ability to appear and disappear at will? It is unclear as to whether the girl in “Ticking Clock” forgot to take her pill, took her pill according to her doctor’s directions, or never had a pill in the first place. However, by ignoring the option that an invisible bandit absconded with this birth control medication, it is clear that something went wrong in the process of pregnancy prevention. Instead of spelling out for teens what the problem was, and how to prevent or remedy such a situation, “Ticking Clock” leaves teens to guess.

There are many similarities between the “Sex Has Consequences” line of reasoning and the “Baby Think It Over ™” pregnancy prevention initiative, which supplies middle and high school students with infant simulators (that cry and need comforting, just like real babies) to show them the stark realities of teen parenting (13). Many students report having gained a better understanding of the struggles of teen parents, but as one student astutely observed, “That baby shows you what it’s like to have one, but it doesn’t show you how to prevent it” (13). Researchers who evaluated the effectiveness of this type of intervention agreed that it does not teach teens the skills needed to actually prevent a pregnancy such as refusal skills, contraceptive use, and communication skills (13). Likewise, in both “Your Life” and “Ticking Clock,” teens are asked to make too many jumps in logic between the initial behavior (unprotected or under-protected sex) and the ultimate outcome (a visit from the stork). To effectively connect teen pregnancy prevention to safe sex practices, teens need to have not only accurate and inclusive sex education, but also the confidence that they can achieve safe sex habits.

If teens (or people in general) do not believe that they are able to successfully execute a behavior, they are unlikely to try to perform that behavior (2). This is the theory of self-efficacy, which is largely ignored by the HBM but particularly relevant when discussing contraceptive use. At Bowling Green State University, four researchers found that adolescents who reported higher contraceptive self-efficacy were more likely to use condoms and other contraceptives during their sexual interactions, and suggest that self-efficacy is not only desirable but critical for behavior change (8). What often determines feelings of self-efficacy, other than instruction, is a teen’s social environment.

It’s A Group Thing

Although the HBM is arguably a poor choice of a model regardless of the program at hand, it is particularly inappropriate that this rational, individual-level theory of behavior should inform a teen pregnancy prevention initiative, namely because both adolescence and sexual behavior are rarely conducive to rational thought. More often, teens’ sexual practices are influenced by their social environment and the attitudes and actions of their peers—concepts which are entirely ignored by the HBM and therefore have no role in “Sex Has Consequences” (12). Both “Your Life” and “Ticking Clock” stress individual choice and personal responsibility but do not consider social and cultural issues that can affect teens’ choices about (and perceptions of) sexual experiences. Instead of making an attempt to change these norms on a mass level, “Sex Has Consequences” offers teens a stale “Just Say No” message, and remains focused on individual decision making (13).

Social Expectations Theory, which contends that individual behavior is based on accepted social standards and practices, can without doubt account for many of the outside influences that shape teens’ personal behavior (2). Although research at the National Campaign to Prevent Teen and Unplanned Pregnancy offers a variety of these factors (e.g. parental support, school environment), they are not well-used in this campaign (5). In addition, creators of “Sex Has Consequences” do not place these ads in the context of the social world of adolescence, specifically ignoring over-sexualized media content and its effect on teen sex choices (14). Finally, although some of these commercials include youth from diverse racial backgrounds, the campaign largely ignores the issue of teen pregnancy among non-white teens and does not ask teens to look meaningfully at their sexual behavior in terms of cultural factors. Without addressing these disparities, this campaign will not be able to help the groups of teens who may be most in need of pregnancy prevention skills (15).


Although its approach is ineffective, the National Campaign is of course justified in its concern over teen pregnancy. Numerous studies have shown that teen moms have poorer mental and physical health outcomes than their non-pregnant peers, and that they give birth to less healthy babies than do older women (4). Many teen parents do not complete high school (4). However, the National Campaign needs to move beyond a consequence-focused approach and integrate risk-reduction education and social critique into its future interventions.

A social marketing campaign with the resources and exposure level of “Sex Has Consequences” could have substantial and far-reaching effects on teens’ behavior, and perhaps even play a part in reducing teen pregnancy, but its ads are rendered unconvincing and useless because they rely on a method of health promotion that it is ineffective when it comes to inciting lasting behavioral change. The “shock value” of the ads may give teens nightmares, but it will not give them realistic birth control options. By relying on the Health Belief Model, the “Sex Has Consequences” advertising series underscores the (obvious) consequences of unprotected sex and teen pregnancy at the expense of providing effective strategies for behavior change among sexually active adolescents. Until this intervention addresses the underlying causes of teen sex behavior, its scary threats will remain scary, but empty.


1. Stevens-Simon C, Sheeder J, Harter S. “Teen Contraceptive Decisions: Childbearing Intentions Are the Tip of the Iceberg.” Women & Health. Haworth Press, Inc.2006.
2. Edberg, Mark. Essentials of Health Behavior. Jones and Bartlett Publishers: Boston, 2007.
3. Breinbauer C, Maddaleno M. Youth: Choices and Change, Promoting Healthy Behaviors in Adolescents. Pan American Health Organization: 2005.
4. National Campaign to Prevent Teen and Unplanned Pregnancy. 2007. 2 November 2007.
5. Kauffman, R. “The Decline In US Teen Pregnancy Rates, 1990-1995.” Journal of the American Academy of Pediatrics. November 1998; 102 (5): 1141-1147.
6. “US Teen Sexual Activity.” Kaiser Family Foundation. January 2005. 13 November 2007.
7. Benthin A, Slovic P, Moran P, Severson H, Mertz CK, Gerrard M. “Adolescent health-threatening and health-enhancing behaviors: A study of word association and imagery.” Journal of Adolescent Health. 1995; 17:143-52.
8. Longmore M, Manning W, Giordano P, Rudolph J. “Contraceptive Self-Efficacy: Does It Influence Adolescents’ Contraceptive Use?” Journal of Health and Social Behavior. March 2003; 44 (1): 45-60
9. Bartz, D, Shew M, Ofner S, Fortenberry J. “Pregnancy Intentions and Contraceptive Behaviors Among Adolescent Women: A Coital Event Level Analysis.” Journal of Adolescent Health. September 2007; 41 (3): 271-6.
10. Gahungu A, Pittman V. “Comprehensive Sexuality Education or Abstinence-Only Education, Which Is More Effective?” Journal Of Research For Education Leaders. 2006; 3 (1): 61-90.
11. Didion J, Gatzke H. “Baby Think It Over™ Experience to Prevent Teen Pregnancy: A Postintervention Evaluation.” Public Health Nursing. July 2004; 21 (4): 331-337.
12. Paluzzi P, Holmes S. “Providers, parents and communication: the keys to healthy teens and reducing teen pregnancy rates.” Contraception. 76 (1): 1-3
13. Whitaker DJ, Miller KS. “Parent-Adolescent Discussions About Sex and Condoms: Impact of Peer Influences on Sexual Risk.” Journal of Adolescent Research. 2000
14. Brown, J et al. “Sexy Media Matter: Exposure to Sexual Content in Music, Movies, Television, and Magazines Predicts Black and White Adolescents' Sexual Behavior.” American Journal of Pediatrics. April 2006; 117 (4): 1018-1027
15. Talashek M, Alba M, Patel A. “Untangling the Health Disparities of Teen Pregnancy.” Journal for Specialists in Pediatric Nursing. 2006; 11 (1): 14–27.

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  • At December 14, 2007 at 6:18 AM , Anonymous Jaffy said...

    Great arguments, and I like the way you used teenage language and sarcasm sometimes- it definitely evokes their state of mind.

  • At December 19, 2007 at 6:36 PM , Anonymous christelle said...

    I enjoyed reading your paper. Your paper was well written and arguments were clearly stated. I think this is an important issue because there are to many kids having kids.


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