Challenging Dogma

Tuesday, May 15, 2012

Same Old Song and Dance with CDC’s “Salt Matters” Effort – Doug Cowles

Dietary salt consumption is out of control in the United States and other developed nations around the globe primarily because of the proliferation of the processed foods industry over the last 40 years.  In the average persons diet within the United States, 77% of sodium intake comes from processed and restaurant foods.  Many processed foods contain 1000 mg of sodium or more per serving while typical restaurant meals contain 2300-4600 mg of sodium.  (1)   Compare these values with the fact that in 2005 the National Academy of Sciences established adequate dietary intake levels for sodium ranging between 1200-1500 mg/day and you are left with the sobering reality of the sodium consumption public health issue.  (2)   As a generality, processed food manufacturers use salt, among other food additives, to enhance the taste of and extend the shelf life of their products.  This practice is virtually ubiquitous amongst all processed food manufacturers and has led to our present day circumstances of having a population consuming, on average, upwards of two to three times the recommended as safe amounts of salt in their diets as the convenience and availability of processed foods is more the norm than the exception for meal options in developed countries.     The primary medical issue with salt intake is that it is directly related to hypertension, or more familiarly “high blood pressure”.   Hypertension is a leading cause of cardiovascular disease and is attributable for 8 million deaths per year worldwide.
As a part of a multi-faceted campaign to reduce sodium consumption in the US, the Centers for Disease Control  and Prevention (CDCP) released an educational  video entitled “Salt Matters: Preserving Choice, Protecting Health”.  The CDCP describes the video as “aiming to educate viewers on the staggering facts about the sodium in our food: where it comes from, how it affects our health, and what we can do about it”.  (1)   The video was made available in three version of varying length:  public service announcement (PSA) version (~2 minutes), a short version (~4 minutes) and finally, an extended version (~15 minutes).   To be fair, these videos were well produced and provided concise and accurate information about the issues involved with and causing the US dietary sodium consumption crisis we find ourselves faced with today.  The video provided several commentary segments from experienced national health policy leaders such as New York City Department of Health and Mental Hygiene Director Sonia Angell, MD, MPH, CDCP Director Thomas R. Frieden, MD, MPH, and Johns Hopkins University Assistant Professor Cheryl Anderson, PhD, MPH, MS who all lent credibility and a level of gravity to the issue and helped to communicate more effectively then the anonymous narrator used for the majority of the video.  Also, many graphical representations of statistical health data and dietary sodium contents in an average American’s diet were also effectively used to communicate the videos primary message areas. 
From an educational video perspective the CDCP hit all of their targets and really produced a well crafted video that is very informative to viewers.  From a social and behavioral sciences perspective however, the video really fell flat.  It is apparent that the production firm the CDCP used to produce the string of videos was not familiar with basic principles, theories, and techniques of social and behavioral sciences.  I will illustrate the three most glaring shortcomings of the CDCP video effort with this regard.   

Problem With the Use of the Health Belief Model
My first criticism of the video is that it rather rigidly follows the “Health Belief Model” (HBM) theory of influencing a behavior change in its viewership.  The HBM is a conceptual framework with which to follow in order to influence a particular behavior in an individual.  It originated in the design of public health programs developed in the 1950’s by the U.S. Public Health Service to screen citizens for tuberculosis.  It has a foundation upon the assumption that people will engage in healthy behavior if 1) they value the outcome (being healthy) related to the behavior, and 2) they think that the behavior is likely to result in that outcome.  (3)  The theory argues that a targeted population will be ready to make a health behavior change if the HBM based intervention hits upon these six theory constructs -
1.      Belief that they are susceptible to the condition (e.g. hypertension, cardiovascular disease)
2.      Belief that the condition has serious consequences
3.      Belief that taking action (adopting a low sodium diet) would reduce their susceptibility to the condition or its severity
4.      Belief that the costs (decreased enjoyment of meals / foods, time and energy spent analyzing food labels for low sodium options) of taking action are outweighed by the benefits
5.      They are exposed to factors that prompt action (the CDCP video)
6.      They are confident in their ability to successfully perform an action (self-efficacy)
Despite its popularity among public health practitioners, the HBM theory is flawed for a number of reasons.  The available evidence indicates that the HBM has only a weak predictive power in most areas of health related behavior.  This is in part a result of poor construct definition, a lack of combinatorial rules and weaknesses in the predictive validity of the HBM’s core psychological components.  (4)  The primary psychological weaknesses of the HBM is that human behavior is predicated by intentions and that we predominantly act rationally by deliberately balancing benefits against costs when electing to adopt or continue a particular behavior.  Dan Ariely, Professor of Psychology and Behavioral Economics at Duke University writes in his New York Times Best Seller, Predictably Irrational, “We are just pawns in a game whose forces we largely fail to comprehend.  We usually think of ourselves as sitting in the driver’s seat, with ultimate control over the decisions we make and the direction our life takes; but, alas, this perception has more to do with our desires – with how we want to view ourselves-than with reality”.  (5)  Arielly asserts in this book through the illustration of numerous psychological experiments involving human behavior and decision making that human behavior is not planned or reasoned but is automatic and responsive based upon numerous external and internal forces and engrained responsive human behaviors that are explicitly irrational. 

 Problem with the Message Framing
Throughout the video the viewer is bombarded with commentary, statistics, data, video imagery, graphical representations, and other forms of evidence supporting the videos core value of long term health promotion.  All of these elements contribute to the overall message frame being cast to compel a person to reject a high in sodium diet and the reason the video offers is “long term health”.   Message frames, or simply frames are the conceptual bedrocks for understanding anything.  People are only able to interpret words, images, actions, or text of any kind because their brains fit those texts into an existing conceptual system that gives them order and meaning.  Just a few cues, a word or an image, trigger whole frames that inspire certain interpretations in audiences.  (6)  Conceptually any message frame should consist of 5 component parts: a core position, a metaphor, a catch phrase, images or symbols, and finally an over arching core value which resonates with the target population the message is being developed for.  The central problem with the Salt Matters video was that the CDCP elected to use long term health as their core value in their message frame.  Long term health promotion is generally considered to be a poor core value to portray as a message frame to motivate a behavior change.  In terms of Maslow’s Hierarchy of Needs, long term health would generally rank as a higher level self-actualization need thus people generally hold it as important and idealistic yet are driven to act by lower level needs such as family, sexual intimacy, and personal security. (7)  An example of a frame using a personal security frame, a lower level need in Maslow’s hierarchy, would be to refer to a particular piece of legislation as a “job killer”.  Here “job killer” is being used as a metaphor, the catch phrase, and provides some symbolism for the frame.  Killer implies that someone is coming after you and that the situation is threatening, even dire.  Killers must be stopped.  They must be punished.  Their targets need immediate protection and defensive maneuvers.  The frame evokes these ideas before we have even an inkling of what the specific legislation is about. (6)            

 Ineffective Use of Social cognitive theory
Social cognitive theory posits that people gain knowledge by observing others within the context of social interactions and experiences as well as by outside media influences.  People do not learn new behaviors solely by trying them and either succeeding or failing, but instead, are dependent upon repeating the actions of others. (8)   The core determinants include knowledge of health risks and benefits of different health practices, perceived self-efficacy that one can exercise control over one’s health habits, outcome expectations about the expected costs and benefits for different health habits, the health goals people set for themselves and the concrete plans and strategies for realizing them, and the perceived facilitators and social and structural impediments to the changes they seek.  (9)  In this regard, one area where the Salt Matters video went wrong was with its selection of statistics and imagery that was depicted and the likelihood of them having the unintended consequence of reducing the viewership’s feeling of self efficacy.   
“The average American consumes twice the amount of salt then the recommended amount” – video narrator
“Very few people, if any at all, eat a low sodium diet” – Jeremiah Stamler, MD, Northwestern University
“I know what I’m supposed to do and yet I find it very challenging and difficult despite all the information that I have” – Sonia Angell, MD, MPH, New York City Department of Health and Mental Hygiene
“Better public health equals bland food can be a difficult message for consumers to accept.  You really do notice the difference.”  - Cheryl Anderson, PhD, MPH, MS, Johns Hopkins University
Listening to these quotes taken from the video makes a person feel that the idea of adopting a low sodium diet behavior change is too difficult and too undesirable to even attempt and the result will likely be that people won’t.   The second example I have of poor awareness to social expectations theory is in how the video described what the societal norms were toward sodium consumption.  Just looking at the same quotes I have provided above, gives  you a sense that you would be more an outlier than a conformer if you were to actually follow the advice of the video and adopt the behavior change being proposed.  In addition to the messages verbalized orally the video also uses imagery of foods which are high in sodium such as pizza, french fries, and canned soup to bolster key message points however the video depicted everyday people at eateries enjoying a lunch with friends and family which is easily relatable and can be identified as the norm.  People may deduce from these images and video footage that by adopting a low sodium diet they will not be able to enjoy their food and their personal relationships as they once did and again, would fall outside of the norm. 

Solution Offered to the Problems Expected with the Use of the Health Belief Model & Social Cognitive Theory
I would propose a social expectations theory based intervention rather than the HBM approach.  Instead of developing a video that is largely educational and health risk oriented I would focus in on these key message points in an alternative video -
§         Provide information as to the abundance of low sodium product and food choices and their wide spread availability
§         Identify where the products and food choices can be purchased
§         Offer  comparability in consumer price to higher salt content food choices
§         Inform the public of the imminent  legislation of process food manufacturers which would require them to reduce the sodium content in their marketed products as well as a call to action from political notaries from both major political parties
§         Present limited data and statistical information but ensure the information that is provided is provided in such a way as to describe the publics main stream adoption and support of the low sodium diet
These message points are intended to reshape the descriptive norms for the public around adopting a low sodium diet.  In essence you are simply identifying what is right with adopting the behavior and the current climate for low sodium products rather than what is wrong so that people get their social cues from the perceived norms portrayed.  Humans are not exactly lemmings, but they are easily influenced by the statements and deeds of others.  (8)  Having representation from each of the two major political parties should widen the appeal of the message and increase its reception by individuals who affiliate with one party or the other.  This would also reduce cognitive dissonance which has the potential to occur in this situation because in essence a freedom is being threatened by asking people to abstain from high sodium products.    I would also make an attempt to change the affective norm associated with the taste of low sodium products being perceived as bland in comparison to high sodium products.   Potentially I would portray a blind taste test scenario in a super market or sporting event where people were asked which particular product variation they preferred: the high sodium product choice or the low sodium product choice.  These portrayals would depict people voluntarily opting for the low sodium product choice so more and more the different taste was associated with being pleasant and desirable rather than bland.   In the 1950’s Solomon Asch conducted a series of experiments to gauge how susceptible people are to outside social influences by asking people to take a particularly easy test and report back the answers in a number of different contexts.  When the study participants reported back their responses individually and in private nearly everyone received perfect scores to the test however when the participants reported aloud and in front of the other participants in the study and an incorrect answer was read aloud by a study investigator nearly 1/3 of the participants changed their responses to reflect the incorrect response posed by the investigator.  People were responding to the decisions of strangers, whom they would probably never see again.  Conformity experiments have been replicated and extended in more than 130 experiments from seventeen countries with people confirming between 20-40% of the time. (8)  I think that my blind taste test portrayal would yield similar results.

Recommended Message Framing
A solution offered to the issues identified with the message framing of the Salt Matters video is to simply reframe the message to associate the core position with a core value that actually motivates people to adopt the desired behavior of adopting a low sodium diet.  Health messages can be framed either in terms of potential gains (i.e., advantages or benefits) or in terms of potential losses (i.e. disadvantages or costs). (10)  An example of a gain-framed message is “If you reduce your sodium intake by half, you will increase your chances of living a long and happy life”.  In contrast the Salt Matters video uses a loss-framed message of “If you do not reduce your sodium intake by half, you will increase your chances of dying early”.  A loss-framed message creates psychological reactance in a person because a particular freedom that the person had enjoyed (i.e. consuming a high sodium diet) is being threatened and nothing is being offered in return except for “long term health”, which we identified earlier as a weak core value which does not motivate behavior change and is deemed as lesser to the freedom being taken away.  People are averse to loss which creates an irrational response in people when a behavior that they identify with is threatened, and they have an irrational response to restore the freedom regardless of the information presented against it.  By reframing the message as a gain we are not taking away a freedom and triggering reactance, we are offering a benefit to people.  In a 1999 study performed to investigate the efficacy of different types of message framing on sunscreen use behavior, gain-framed messages were responsible for a 32% increase in sunscreen use when compared to that of loss framed messages amongst individuals in the study who had no initial plan to use sunscreen. (11)
I identified earlier in the paper that a frame fundamentally consists of 5 component parts: a core position, a metaphor, a catch phrase, images and symbols, and a core value.  For the Salt Matters campaign I would suggest “revolution” as the core value of the messaging.  The term “revolution” excites people to take action and has successfully been used in a number of other healthy diet / physical fitness campaigns such as the celebrity chef and television personality Jamie Oliver and his “Food Revolution” television show and web based endeavors.  The phrase “revolution” invokes a national pride in people to take their health back much like the country’s “forefathers” fought for and achieved freedoms during the American Revolution.  I would suggest portraying processed food companies as oppressors to which people need to revolt against by rejecting their products.  Symbols which would support this frame would include images of revolution which people would connect with: a raised, clinched fist or perhaps the Gadsden flag.  The Gadsden flag is a historical American flag with a yellow field depicting a rattlesnake coiled and ready to strike.  Positioned below the snake is the legendary “DON’T TREAD ON ME”.  The flag get’s it’s name from it’s designer, American general Christopher Gadsden and was the first flag ever carried into battle by the United States Marine Corps during the American Revolution.  (12)  In summary in terms of my frame construction I would recommend the following elements –
Core position – reject the consumption of high sodium processed foods
Metaphor – Revolution, War, Fighting against oppression
Catch Phrase – Don’t Tread on Me
 Images & Symbols – Gadsden flag + Raised, clinched fist
Core Value – Revolution

Creating Dissonance
Cognitive dissonance theory states that the possession of inconsistent cognitions creates psychological discomfort which motivates people to alter their cognitions to produce greater consistency.  (13)  People desire continuity and agreement in their beliefs and when it is not present, a feeling of disagreement or hypocrisy is invoked within the person and the person is motivated to resolve the dissonance by adopting the new belief.  The more public and overt the issue which is that is creating the dissonance the greater the discomfort created therefore I would propose a dissonance based component to the CDCP’s sodium reduction effort.  I believe that once the video and the messaging involved with the campaign itself is rebranded to reflect the frame outlined above that we would be able to create dissonance in people by issuing trinkets, t-shirts, bumper stickers, and other types of paraphernalia with the branding developed by the symbols used in the frame (Gadsden Flag, Clinched Fist).  By distributing these types of Salt Matters brand associated objects at public events such as concerts or sporting events we’d be disseminating the information amongst a wide swath of our targeted population.  When those individuals wore the t-shirt or adorned the bumper sticker on their vehicle they should feel a greater amount of compulsion to abide by the core positions made by the Salt Matters video and supporting messaging.  Dissonance would be created in those individuals that chose to continue to consume high sodium foods and over time a certain percentage of individuals would be compelled to resolve the dissonance by adjusting their behaviors to be more in alignment with the Salt Matters core positions.  
To address the flaws presented by the original Salt Matters educational video effort and campaign based upon the Health Beliefs Model, I proposed a campaign focused on initiating a behavior change in the public.  My proposals were focused on changing the norms around the acceptability of eating processed foods and the perceived accessibility and barriers associated with consuming a low-sodium diet,    reframing the topic all together so that people will feel a part of a larger movement against processed food manufacturers and changing the messages to gain-framed messages to reduce the potential for psychological reactance, and lastly to create dissonance in people to minimize the potentiality of the public ignoring the messaging and returning to their “normal” high sodium diet.   Similar to the formative research performed by the Florida “Truth” anti-smoking campaign, I feel that the public is well aware of the human health hazards posed by sodium therefore the educational HBM approach is bound to in effective.  My focus was on changing the behavior first upon the assumption that the beliefs would naturally evolve to conform which is another dissonance based approach to behavior change that I feel would be effective. 
1.)   Centers for Disease Control and Prevention, Salt Subject Page,
2.)   Havas, Stephen, The Urgent Need to Reduce Sodium Consumption, Journal of the American Medical Association, September 26, 2007, Volume 298, No.12
3.)   Edberg, Mark, Social and Behavioral Theory in Public Health, Essentials of Health Behavior, Jones and Bartlett Publishers, 2007.
4.)   Armitage, Christopher, Efficacy of the Theory of Planned Behavior: A meta-analytic review, British Journal of Social Psychology, 40, 471-499, 2001.
5.)   Ariely, Dan, Predictably Irrational, The Hidden Forces That Shape Our Decisions, Harper Collins Publishers, 2008. 
6.)   Dorfman, Lori, More Than a Message: Framing Public Health Advocacy to Change Corporate Practices, Health Education and Behavior, 32, 320-336, June 2005. 
7.)   Maslow, Abraham, A Theory of Human Motivation, Psychological Review, 50, 1943, 370-396.
8.)   Thaler RH, Nudge: Improving Decisions About Health, Wealth, and Happiness, Yale University Press, 2008, 53-71.
9.)   Bandura, Albert, Health Promotion by Social Cognitive Means, Health Education and Behavior, April 2004, 143-164. 
10.)                      Gallagher, Kristel, Health Message Framing Effects on Attitudes, Intentions, and Behavior: A Meta-analytic Review, Annals of Behavioral Medicine, 43, 101-116, 2012.
11.)                       Detweiler, Jerusha, Message Framing and Sunscreen Use: Gain Framed Messages Motivate Beach-Goers, Health Psychology, 18, 189-196, 1999.
12.)                       Early American Flags with Snake Motif, webpage,
13.)                       Stice, E, Dissonance-based Interventions for the Prevention of Eating Disorders: Using Persuasion Principles to Promote Health, Prevention Science, 9, 114-128, (2008). 
14.)                       Siegel, Michael, Effect of local restaurant smoking regulations on progression to established smoking among youths, Tobacco Control, 14, 300-306, 2005.
15.)                       Havas, Stephen, Reducing the Public Health Burden from Elevated Blood Pressure Levels in the United States by Lowering Intake of Dietary Sodium, American Journal of Public Health, January 2004, 94, 19-22.
16.)                       Mohan, Sailesh, Effective population-wide public health interventions to promote sodium reduction, CMAJ, 2009.
17.)                       Shadel, William, Uncovering the most effective active ingredients of antismoking public service announcements: The role of actor and message characteristics, Nicotine & Tobacco Research, 11, May 2009, 547-552.
18.)                       Hornik R, Effects of the national youth anti-drug media campaign on youths, American Journal of Public Health, 2008, 98, 2229-2236.
19.)                       Hicks JJ, The strategy behind Florida’s “truth” campaign, Tobacco Control, 2001, 10, 3-5.

Monday, May 7, 2012

The Failure of Gamification in Fitness Behavior Modification From The Perspective of Social-Cognitive Theory - James Henry Steinberg

1.       Emergence of Gamification
            Obesity and metabolic syndrome pose a crisis for the American health care system and its public, in terms of both cost and comorbidities. In the preceding quarter century, the entirety of the U.S. population weight distribution has shifted upward (1); today more than two thirds of the adult population is overweight or heavier (2). Diabetes Mellitus, the most prominent manifestation of metabolic syndrome, has increased in its proportion of U.S. adults from 3.7% in 1980 (age-adjusted) to 8.7% in 2010 (age-adjusted)(3).
            Behavioral approaches towards weight loss have thus far failed: over 80% of individuals return to pre-weight loss levels of body fat after otherwise successful regimens, from a variety of approaches(4). Due to this persistent failure, there has been an increased move away from an individual focus on obesity, to the examination of the “obesogenic environment” - the genetic and environmental factors that predispose people towards obesity (5,6).
            The most recent trend in fitness behavior modification involves “gamification” (7). Gamification involves the integration of game mechanics into marketing, health, web domains, etc. for the purpose of influencing and motivating groups of people. Gamification is built on the essential findings of behavioral biologists regarding operant conditioning. “Game” mechanisms are usually restricted to what are traditionally known as “role playing games” (RPGs). The role playing game genre is identified by incremental advances in game difficulty, coupled to incremental advances in the player’s efficacy (ability to overcame obstacles, exert his will, and achieve desired goals in the game), arriving in a predictable and systematic manner. Usually, the games are easy at first, with increasing effort required to achieve additional increments of efficacy later in the game.  These incremental increases in efficacy are colloquially termed “leveling,” as the in-game protagonist is assigned a “level” that indicates his efficacy. Games typically present a very simple sort of operant conditioning: perform action X (ordinarily “kill the monster”, although “record 5 push-ups” works just as well), and one receives positive reinforcement in the form of increased efficacy in one’s endeavors (increasing one’s “level”).
 A player’s belief in his ability to achieve his goals is ordinarily high in this context: action and achievement are linked in an obvious manner, entirely under the player’s control. Because the time and effort to achieve the next level are always readily apparent, it is a reward that can be considered “fixed” – there is no element of chance involved. The player knows exactly what he has to do, and how much of it, to achieve the next increase in game-efficacy (the equivalent of self-efficacy with regards to accomplishing in-game goals).
            RPGs also involve more complex conditioning mechanisms. Early behavioral biologists found that the schedule of reinforcement is important. If reinforcement ceases after a behavior has been linked to it, a behavior may be extinguished. Reinforcement can be spaced out (as “leveling” is in RPGs), though again – this can lead to extinction, if the reinforcement becomes too widely spaced relative to the positive value of the reinforcement. It has been found that the ideal schedule involves early fixed rewards, with decreasing frequency, and a transition into variable rewards. If the average number of awards over a unit of time is constant, but with large variance (meaning rather than 1 award every 5 minutes, there’s an average of 1 award of every 5 minutes, varying from every 1 minute to every 10 minutes), subjects are shown to be more strongly influenced by reinforcements that begin to arrive over long periods of time (8). Role playing games often incorporate this via in-game “items” for characters – game-efficacy increases in the symbolic form of clothing and armor for one’s in-game avatar. Some of these “items” are awarded in a fixed fashion, guaranteed on the completion of a certain in-game event. Others are variable: upon completing some in-game victory, a digital version of a die is rolled – giving high chances of a mediocre award, with smaller chances of correspondingly better awards. In some games, repeatedly completing these in-game events so as to roll and re-roll the die for chances at the best item becomes the entire point of the game. These awards are meaningful positive reinforcement because they are not cosmetic: they directly increase the player’s game-efficacy, enabling them to partake in more difficult challenges and explore more of the game.
            These increases in a player’s game-efficacy are directly tied into the standard mechanism for “reciprocal determinism” – the idea that a person is shaped by their environment and, likewise, shapes their environment. The challenges and obstacles in the game are distributed throughout discrete parts of the game that the player can access, avoid, and revisit at his desire. The positive reinforcement of the game comes through defeating challenges – finding some optimal ratio of challenge and victory. In the real game setting, the environment offers a gradient of difficulty, with cues to advance the player. The player, however, may opt not to follow such cues: if the advancement has grown too difficult, or some area holds a particular allure, the player may choose to dally there, increase his game-efficacy there (though at a slower pace than if he were seeking greater challenges), and move on later. This is ‘reciprocal’ in the sense that the game has a set of built-in environmental factors to manipulate the player’s progress and pleasure, yet at the same time the player has the ability to ignore these factors, increase his efficacy in an easier area, and then proceed. Proceeding into the new area later than one ought to have can entirely change the manner and pacing of obstacles presented. In effect, the player has changed his own game.
            Games have also begun to incorporate more social elements. “Achievements” are fixed events that, upon their completion in the game, usually are not linked to efficacy increases. Rather, they become visible over game-based social networks, showcasing one’s triumphs to their peers. In a dual role, it also serves to model to peers that the game in question is being played, and with some measure of dedication. This serves as a form of observational learning to encourage others to partake in the game in question.
            In short, the game-play mechanisms salient to driving user behavior include game-and-gamer reciprocal determinism; an optimal positive reinforcement schedule using both fixed- and variable-timing; meaningful positive reinforcements, in this context usually increasing the player’s game-efficacy; and social learning. The new trend of “gamification” has utilized these four mechanisms to attempt to manipulate user behavior, but has failed in regards to the first three.

2.      Examples of the Use of Gamification as a Public Health Intervention
            Gamification has attempted to incorporate each of these mechanisms. The most prominent example to date is the exercise gamification “Fitocracy.” The website involves a facebook-like social network, where users self-label as being interested in particular types of fitness activities (i.e., “powerlifters”). This serves to involve them in conversation with their cohort. The central function of the site, however, is the ability to record one’s workouts. Each exercise is worth points and these points add up to allow one to increase their “level.” One can also gain Achievements through particular routines (i.e. doing a bench press, a deadlift, and a squat press all in one week). One’s level and achievements are publicly displayed to one’s network. The leveling mechanism is thought to encourage exercise by providing a fixed positive reinforcement. To quote its creators, “what if fitness could be turned into a game? After all, both [Richard] and Brian understood how addictive it could be trying to get to that next level, beating that next boss, and completing that next quest… They also realized that the addiction that games create was the exact same addiction that drives their fitness efforts every day.” (9) The social components allow groups to act as models for observational learning, as well as incentivizing (one must gain the deadlift-squat-bench achievement not to be an outcast among powerlifters).
            Fitocracy serves as a prominent example, having been one of the first attempts to “gamify” public health, but it is hardly an anomaly. Design companies are now framing gamification as the “future of health care” (10). HopeLab hopes to combat child obesity with the “Zamzee”, a device students wear to track their physical activity. More active children get points, level up, show off on a social network, and purchase goods for “winning” (11). Zamzee’s approach is untenable however, in that creating tangible goods as a reward has worked in their limited (12-week, 350-subject) laboratory studies, but is something they are unable to scale for use with the general public. One of the largest has been the iPod-integrated Nike+, which uses a GPS sensor to track runners and later to upload their data, track statistics, join challenges, and connect (and compete) with other runners in the Nike network.
            Modern social gaming mechanics are attractive to those attempting to “hook” people into healthy activities. They seem to leverage the power of social influence (observational learning), as well as the various elements of reciprocal conditioning that have made otherwise-mindless games such as “Farmville” and “World of Warcraft” such runaway successes. If something as “boring” as Warcraft could be so addictive as to ruin lives (12), then why couldn’t such mechanisms be used to make fitness and health equally attractive?
3.      Flaws in the Use of Gamification as a Public Health Intervention
            Unfortunately, such “gamification” attempts take on the shape of cargo-cult science. Although they utilize the appearance of Social Cognitive Theory (SCT), they fail to implement the core mechanisms that actually drive behavioral change.
            3A. The Failure to Connect Game Mechanics to Intrinsically Valuable Awards
            The fundamental principle behind “leveling” is that it enhances both the player’s game-efficacy, as well as acting as positive reinforcement – improvement’s in a player’s efficacy also increase enjoyment of the play process. That is to say, that increasing “levels” in the game has no value in itself – it is valuable only as it empowers the player to accomplish other game actions that are pleasing. However, current gamification attempts have neglected the importance of linking levels to positive stimuli, and instead attempt positive reinforcement by awarding the “levels” themselves – in effect, offering to warm their participants with smoke instead of fire.
Fitocracy, for instance, provides points, levels, quests, and achievements, all tied into a social network. Theoretically one is driven to advance one’s exercise regime by chasing new quests and achievements, and stabilize it as a habit by chasing level advancement. It also takes advantage of the element of observational learning and social approval through the built-in social network: one’s achievements are broadcast to their peers while, simultaneously, one is constantly kept apprised of their peers’ achievements. However, the primary mechanism of positive reinforcement – the levels that one gains through physical activity – is entirely useless: there is precisely no difference at all between a level 30 individual (someone that has been actively fit for a significant period of time) and a level 3 individual (a novice). Advancing in levels offers no positive reinforcement aside from seeing that number creep upwards. Not only is the pleasure of watching a meaningless number increase minimal, but as the amount of exercise needed to increase levels grows larger with each successive level, the period between these “reinforcements” grows increasingly sparse, until extinction is more likely than actual reinforcement of the target behavior.
Much the same could be said of Zamzee, created by the non-profit HopeLabs with the explicit aim of helping children and teens manage their weight. It incorporates many of the standard gamification mechanisms, and it would seem to correct the primary deficit: points and levels ultimately lead to a “victory” condition that is connected with tangible rewards. However, where Fitocracy can handle essentially unlimited numbers of users, the non-profit Zamzee must now purchase and gift tangible goods. For their 350-subject test, they claim to have provided such rewards, without specifying what the rewards were. This is clearly an unscalable project, however: expanding this to teens en masse would require an enormously expensive outlay of products, or the cheapening of such rewards until they are no rewards at all. Although this nominally attempts to address the lack of intrinsic motivation, this positive reinforcement mechanism will not be deployable in a real-world setting: Zamzee essentially has no real positive reinforcement mechanism beyond points-keeping for its own sake.
Nike+ stands out slightly compared to the other two interventions, as it is more of an attempt at building brand loyalty than an active gamification program - although it has described itself as part of the “gamification” trend based on its Achievement program (akin to that used by Fitocracy), and the user statistic-tracking and sharing, which has given rise to a culture of achievement sharing and competition. Morever, it is relevant because of its emphasis on running: although it doesn’t seek to make people healthier, it does need its customers to continue running in order to build the brand-loyal social network Nike seeks. Nike+ has in fact been one of the few large corporations successful in using social networking to build brand loyalty, by using this approach (13). As such, its bottom line goal is still compatible with the other programs mentioned: drive people to continue performing a particular fitness activity through social-network based peer learning and positive reinforcement. However, Nike+ makes the same mistakes seen in Fitocracy and Zamzee: beyond the social value of being able to proclaim one has met some particular achievement, meeting the goals in the Nike+ “game” offer no real reinforcement that encourages sustained performance of the target activity. Between Fitocracy, Zamzee, and Nike+ one sees a cross-section of the largest current health-gamification efforts, both for- and non-profit, and yet the failure to use positive reinforcement consisting of actual positive stimuli rather than simple scorekeeping remains ubiquitous.
3B. Reinforcements Tend To Be On a Fixed, Not Variable, Schedule
The second major failing of current gamification attempts is the failure to use variable reinforcement as a supplement to fixed reinforcement schedules.  As Skinner showed, a rat will press a button endlessly if it is rewarded with a food pellet – but when those food pellets come too rarely, the rat will eventually stop pressing the button, in a phenomenon known as extinction. This is essentially fixed reinforcement: if the rat presses, then there will be a pellet, without doubt or variation. If, however, a food pellet is dropped every three presses on average, the rat will continue to press the button far longer – even as the average number of button presses for a food pellet increases. This is a variable reinforcement schedule: the rat doesn’t expect every press to result in a pellet but, rather, that enough presses will eventually produce a pellet.
Video games have successfully incorporated variable reinforcement (in the form of “items” awarded to one’s game avatar, with the quality of the awarded item being randomly determined), as a supplement to the fixed-schedule “level” system. Health gamification efforts, however, are strictly fixed: perform 20 pushups, get 40 points, 300 points needed for level 2. Fitocracy awards a constant number of points for each exercise which, when added up, award one with a new level. There is no unpredictability and no variation. This is fine for early levels, where working out for a few days can result in advancement, but once one has achieved “higher levels” and these achievements are few and far between (weeks or months apart), one is more likely to cause behavioral extinction than engagement. Zamzee awards points for activity in a likewise unvarying manner, which ultimately adds up to a prize. Nike+ awards achievements for certain runs (distance, time, calories, etc.) with no surprise achievements, variation, or other unexpected positive stimuli. Not only is the lack of a variable positive reinforcement not conducive to an optimal reinforcement schedule but, as the amount of time and effort between successive levels grows exceedingly long, the strictly fixed program may in fact result in extinction. The current lack of chance in reinforcement schedules is not only suboptimal – it may in fact be actively detrimental to the cultivation of the desired fitness behavior.
            3C. Lack of Reciprocal Determinism Fails to Cope with User Variety
The third major failing of current gamification efforts regards the absence of reciprocal determinism that is ordinarily found in a game setting. Reciprocal determinism in games is important in that one is dealing with an enormous variety of people of varying levels of skill, dedication, and time. If the challenges and reinforcements offered are not responsive to a person’s individual needs they are far less likely to be engaged. If a person is finding an average challenge, accompanied by average reward, overwhelmingly difficult that reward is unlikely to be sufficient positive reinforcement to encourage them to tackle additional ‘overwhelming’ challenges. Fitocracy, as a social network with an achievements and leveling system, offers challenges only in that it requires increasingly larger efforts in order to receive positive reinforcement. These rewards do not change the difficulty of any of a subject’s goals, nor does the subject have any ability to reshape his challenge environment. One cannot simply exercise further in an “easier” difficulty area, because there are no gradients in difficulty – one simply exercises, or one does not. And as there is no increase in game-efficacy (other than increased fitness), even “taking it easy” and advancing at a slower pace is without reward: the difficulty of challenges and goals is unresponsive to achievements and advancements (which ties back to the first point, that the achievements and advancements are merely numbers measuring engagement with the system, and not meaningful reinforcement). The player, having no ability to reshape his environment, cannot alter it to suit their particular needs or skill level. The same criticism holds for Zamzee and Nike+. Insofar as the only challenges introduced are the challenges of exercise, and a one-size-fits-all reinforcement schedule is applied, players are entirely unable to reshape their environment to produce an experience that is suitably positive to keep them engaged.
4.      Proposed Remedies for the Flaws of Gamification Theory to Promote Public Health
4A. Using Games, not Gamification, for User Interaction
The resolution to these problems is not to scrap the approach of gamification, but rather, to extend it to account for the elements of the Social Cognitive Theory model that are missing. The foremost necessity is to amend the lack of true incentives: “levels”, “points,” and so on cannot merely be metrics that take on the appearance of achievement and advancement.  One must also supplement the fixed leveling system with a variable system, to counter infrequent levels and possible extinction. Lastly, one must provide for some sort of reciprocal determinism, to allow players to create their own levels of difficulty.
The difficulty is posed by the fact that gamification platforms currently rely on only a single dimension of difficulty: physical exercise. The addition of an additional dimension – an actual game – would allow one to address the flaws in the current system. In this way, achieving “levels” in the health gamification, while not increasing one’s efficacy in the fitness-dimension, can be tied to in-game levels, allowing for increases in efficacy in the game-dimension. Such a change would turn the positive reinforcement of level gains into actual meaningful incentives. Additionally, fitness achievements could be linked to variable rewards in the game. Lastly, where reciprocal determinism is difficult to achieve in the fitness-dimension, one could do so in the game world. In brief, one could attach the health metric to an actual game that does fulfill the requirements of the Social Cognitive Theory, and rely on the game to drive behavioral change.
4B. Connecting Real-world Fitness to Games
There are multiple ways to attach the fitness behavior to a game. The most difficult approach would be to construct actual games, which receive information from a gamification platform and integrate it into the gaming experience. This would utilize all of the elements that actually created addictive video games to encourage fitness activities. In this case one would have a real game with all of the mechanisms of modern gaming built-in: social networks for observational learning and social outcome expectations, reciprocal determinism in the form of the game obstacles being faced, and variable reinforcement in-game coupled to the fixed advance of levels with one’s exercise.  Most importantly, leveling would now be tied to something positive and enjoyable: advancing in a fun game. This would be difficult to create wholesale, as creating long-lasting and successful video games is an extremely rare event, regularly achieved by only a handful of dedicated game companies.
On the other hand, licensing old and successful games that now exist in legacy but produce few sales for their parent company (e.g., Diablo 2, still engaging tens of thousands of players daily, a decade after release) could be a successful alternative, wherein the primary costs of development would become software engineering to link the in-game advancement-state to some health metric, and licensing costs. With such software engineering being a relatively simple feat (people create such programs as hobbies)(14), the only true stumbling block would be licensing fees. For games that produce little annual returns (i.e., Diablo 2 sales a decade after release) companies may be incentivized to ‘donate’ such licensing fees as a tax deduction or public relations maneuver. Player enrollment may even be increased if such health-game projects were released 6 months to 1 year prior to the release of a new sequel in the game series (i.e., the Diablo 2 Health game 18 months prior to the release of Diablo 3). As a form of marketing for both products, this may be even more attractive to the parent company.
4C. Partnering With Game Developers, not Games, to Avoid Obsolescence
            One could also attempt to remedy the failings in gamification platforms not by linking fitness metrics directly to a game, but by partnering with game platforms like facebook’s Rovio and Zynga, or  small “indie” game publishers that are currently creating armies of new games via platforms such as the iTunes App Store and Steam (15). Zynga, for example, offers in-game purchases using real-world money. However, insofar as these in-game items actually have unlimited supply, some small fraction of them could be “donated” to a public health program. Coupled to something like Fitocracy, some rewards may be achieved upon earning a level, with some others having a random chance of occurrence upon completion of achievements and quests (introducing our variable element). The game-external approach avoids the problem of games that become dated, as well as once more reintroducing the social elements, peer observational learning, and the other relevant elements of Social Cognitive Theory.
            4D. Using Games that already Cultivate SCT to Drive User Behavior
            The ideal situation is to engage with a game that already manipulates operant conditioning to create a Skinner Box effect, as well as the other components of the SCT model, and hook the gamified fitness platform into that ecology. For instance, Massively Multiplayer Online Games (MMOGs) are already built around the idea of addicting players with a combination of fixed positive reinforcement (leveling), variable positive reinforcement (item awards), observational learning of peers (in-game social networks, integrated with out-of-game social networks), reciprocal determinism (in-game difficulty scaling by choice of zoning and leveling rate), self-efficacy gains through repeat successes against incrementally difficult obstacles, collective efficacy (some obstacles must be faced with one’s in-game network), and incentives are provided primarily through the opportunity for item drops (an opportunity to roll the die on the variable reinforcement). These games often lack anything except these elements, arguably becoming not a game at all, and yet are wildly successful.
Through the integration of health metrics into such games one can make use of an already extent and extremely effective Skinner Box environment for addicting people into pursuing fitness. Mechanisms for convincing corporations to include such an element may be to encourage its use as a shield against litigation: game makers are already being sued for the dangers of their addictive games (16); a defense of keeping an eye on players’ well-being and encouraging public health may be a small investment towards deflecting significant costs in litigation.

5.      In Summation
The current trend towards gamification of health initiatives is based predominantly on the Social-Cognitive Theory of behavior, but fails to take into account the element of reciprocal determinism, does not provide for variable-schedule positive reinforcement to optimize reinforcement of target behaviors, and most crucially tends not to incorporate any real incentives – thus creating “positive reinforcement” with no positives. Gamification is lauded by marketing companies as using the adornment of games without the need for actual game-play, and yet in so doing misses out on what it is that actually causes behavioral repetition (17). The simplest method to address these short-comings is to look at extant games that have already successfully made use of these mechanisms, and target game developers and publishers for tying a fitness metric to these games. By taking full advantage of social cognitive theory, health initiatives will be able to draw upon successful methods for driving user behavior, rather than simply the cargo cult equivalent.

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Abstinence-Only Education: Why It Doesn’t Work And Should Be Replaced With Group-Based Comprehensive Education – Andrea Fantegrossi

Introduction: Abstinence-Only Education - Current Intervention

            Teen sex continues to create a number of ongoing concerns in our society.  Teen pregnancy and Sexually Transmitted Infections (STIs), such as HIV/AIDS, are prevalent concerns in many communities.  In fact “the United States ranks first among developed nations in rates of both teenage pregnancy and sexually transmitted diseases” (2).  Of note, 39% of all new HIV infections in 2009 were from people aged 13-29 (15).  Also importantly, “in 2010, 367,752 infants were born to women aged 15-19 years” (16). Many communities continue to use abstinence-only education programs to address these concerns.  Over 1.5 billion dollars have been invested in abstinence-only education programs since 1997 (22).  These existing programs encourage youth to refrain from sexual activity in general rather than outlining specific ways in which the risks can be minimized while engaging in this behavior, such as by using condoms (7).  The focus of abstinence-only programs is to “promote abstinence from sex…do not teach about contraception or condom use…cites sexually transmitted diseases and HIV as reasons to remain abstinent” (14). However, there is a growing body of evidence indicating that these abstinence-only programs are ineffective.  For instance, one study found that abstinence-only education has a positive correlation with teen pregnancy (2).  The ineffectiveness of abstinence-only education is particularly pronounced when it is compared to comprehensive education.  One study found that youths who received education on both abstinence and birth control were more likely to engage in healthy sexual behaviors, such as using condoms at sexual initiation, than their peers who received abstinence-only sexual education (3).  This study indicates that abstinence-only education is harmful to youth, as it does not provide the education necessary to lead to preventative measures.  While issues of teen pregnancy and STIs are ongoing concerns in our society, it is imperative that a more effective model be created in order to combat these issues.  In the following pages, I will explore the varying flaws with the abstinence-only approach and propose an intervention to address the existing flaws and improve upon sex education for youth.
Flaw #1: Abstinence-Only Education Is Likely to Invoke Psychological Reactance
            The abstinence-only education programs are reflective of the Health Belief Model, which dictates that people will base their behavior off of the perceived benefits/risks associated with a certain behavior (11).   As such, abstinence-only education does not entertain the reality that teens, among other people, are heavily influenced by the way in which the message is given – perhaps even more so than the message itself.  Part of the failure of abstinence-only education is likely due to psychological reactance, which is a phenomenon that exists when an individual feels that his or her freedom is being threatened and results in the individual ignoring the message being given.  One experiment that explored this phenomenon used a shopping website to track psychological reactance in users who received personalized shopping recommendations.  The study found that those consumers who were told that three types of personal data would be used when forming recommendations were less likely to use the recommendation services in comparison to those who were told that only one type of data would be used when forming recommendations (4).  As this experiment demonstrates, people did not want too much of their personal information to be used for recommendation purposes, as it limits the freedom of the consumer to receive a broader range of potential recommendations.  Instead, using too much personal data when creating recommendations results in a narrow snapshot of items the individual may like.  Another experiment studied participants who were given a text to read on how to conserve energy in a washing machine in comparison to participants who were given this text in addition to a picture of a robotic agent or film clip of a robotic agent.  The researchers hypothesized that, as robotic agents may be able to persuade people’s beliefs in the future, people would be more aversive in the picture and film clip conditions outlined above.  The researchers found that those participants who were in the film clip or picture conditions exhibited more psychological reactance than did the control group, which saw the text only (5).  Additionally, in one experiment, researchers tracking teen relationships found that the biggest predictor of relationship longevity was the degree to which the young people’s parents disapproved of the relationship.  Evidently, young people were much more likely to stay together when their parents were not in favor of the relationship (23).  Per the aforementioned experiments, people have an aversion to being controlled and will disregard the message being given if they feel that their freedoms are being threatened.
            These results have important implications regarding abstinence-only sex education.  As noted above, people who feel that their freedom is being threatened are less likely to be responsive to the message being given.  The abstinence-only curriculum indicates that youth should not be having sex in general, and the freedom to engage in new and exciting behaviors is being stripped from youth with this message.  Abstinence-only sex education does not give youth a choice regarding sexual decisions.  For instance, “”, a website that was created with the purpose of helping parents talk to their kids about sex, includes different approaches to talking to youth at difference ages and genders regarding avoiding sex.  When talking to a 13-15 year old girl, the website includes the dialogue, “Sex is a bad idea right now” (1).  This direct effort to manipulate youth into thinking a certain way has the strong potential to create huge levels of psychological reactance in young people.  Evidence has shown that youth have especially high levels of psychological reactance when they are being told not to do something by someone who has participated in the behavior themselves (23).  Bristol Palin, who gave birth as an unmarried teen, is an advocate for abstinence-only education.  Palin has been quoted as saying “…I do think it’s realistic.  It’s the hardest choice, but it’s the safest choice” (6).  Palin’s campaign to promote sexual abstinence is likely to contribute to the psychological reactance youth experience due to abstinence-only sex education.  Abstinence-only education is likely to create psychological reactance in young people due to the aforementioned factors, and it’s important that this reality be addressed in designing future sex education campaigns.
Flaw #2: Abstinence-Only Education makes the assumption that youth will accurately understand the risks associated with sex
            Abstinence-only education fails to teach students about different methods of contraception and safe sex, such as condom use.  Instead, these education programs simply encourage youth not to engage in sexual activity by educating youth on risks involved with sex, such as pregnancy and the transmission of STIs (7).  The Health Belief Model, on which abstinence-only education is based, posits that “the individual’s perceived susceptibility to a health threat” is one of the major factors in healthy behavior change and activity (11).   
            A study conducted by Henry A. Waxman found that the abstinence-only education curriculum was distorting data in order to scare youth into not having sex.  For instance, the Waxman study found that one curriculum advised students that “the typical failure rate for the male condom is 14 percent in preventing pregnancy”.  In reality, while “couples have a 15 percent chance of experiencing a condom failure over the course of the year” with typical use, the failure rate is 2-3 percent when condoms are consistently and perfectly used (7). 
            The scare tactics being used by abstinence-only educators may likely not be having the effect intended, as abstinence-only educators fail to take into account that people do not accurately assess the chance of bad things happening to them, which is called “optimistic bias”.  For instance, despite national efforts to educate the public on the dangers of smoking, one study that assessed smokers’ perceived risk of cancer and heart attack found that only 29 percent of participants felt that they had a higher chance of having a heart attack in their lifetime and only 40 percent of participants felt that they had a higher chance of having cancer in their lifetime than other people of the same age and sex (8).  One further study examines the attitudes of 11-14 year olds in their beliefs of what their chances are in developing skin cancer.  While more than half of the participants reported that they engage in tanning, most participants reported feeling that they are less likely than their peers to develop skin cancer later in life (9). 
            A further psychological construct, the Illusion of Control, provides additional evidence for the fact that people do not accurately assess risk.  As this construct dictates, people tend to think that they have more control over situations than they actually do.  One study hypothesized that participants would be more likely to bet more while engaging in a non-competitive task when the other participant (a confederate) appeared to be an awkward individual rather than a confident individual.   The researchers posited that, even though physiological responses, a non-competitive measure, were being tested, the degree to which the participants would bet against an awkward versus a confident confederate would be a reflection of the amount of control the participant felt he or she had versus the opponent. The results held true to the hypothesis, and participants on average betted more against the awkward confederate than the confident confederate (18).  This experiment demonstrates that humans tend to feel that they have more control over situations than they actually do.
            As the aforementioned studies demonstrate, those who engage in risky behaviors such as smoking and tanning do not fully appreciate and understand the negative consequences associated with these behaviors.  Youth who are having sex, in turn, are likely not to fully appreciate the risk involved with sexual behavior.  As such, outlining and underlining the risks associated with sexual behavior, as abstinence-only educators do, will not necessarily mean that young people will internalize these risks and understand the chances of these risks happening to them. Furthermore, young people may feel that they have more control over a situation than they actually do, further undermining interventions that underline the risks associated with certain behaviors, such sexual activity.
Flaw #3: Abstinence-Only Sex Education Fails to Acknowledge Social Expectations Which Dictate Human Behavior
            The Health Belief Model, on which abstinence-only curriculum is based, makes the assumption that individuals will make decisions on their own that will dictate their behavior, and does not take into account group behavior (11).  Abstinence-only sex education fails to take into account the extent to which teens are influenced by their peers, and are likely to emulate their behavior.  One study found that 1 and 3 boys between the ages of 15 and 19 feel pressured to have sex.  The same study indicates that, while 63% of participants reported that waiting to have sex is a good idea, most participants did not wait (10).  As this study demonstrates, the pressure to conform to the social norms as outlined by one’s peers can be more powerful than the will to act in accordance with one’s own beliefs.   Social Expectations Theory posits that people take into account the expectations of others when engaging in human behaviors.  The social nature of human behavior is likened to a baseball team, where “If each player simply decided what he or she wanted to do and acted independently, few games would be won” (13).  One study of sexual behavior in South Africa, where AIDS is particularly rampant, found that peer pressure experienced by both sexes played a role in sexual activity.  These results illustrate the reality that peer pressure minimizes the efforts to educate youth on the delay of sexual activity and abstinence from sex, among other messages (12). 
            Another study gave participants the task of identifying which line, of three, was the identical line to another line in question.  A number of confederates would voice their answers in advance of the subject’s answer.  When the confederates noted that a clearly different-sized line was identical to the line in question, the subject emulated the responses of the confederates over one third of the time.  In the control condition, the subjects did not hear the answers of confederates before giving an answer, and answered correctly in essentially every instance (17).  Thus, even when the behavior in question is discordant with the subject’s beliefs, people will continue to emulate the behavior of others. 
            Abstinence-only sex education intervenes at the individual level without taking into account the social aspects of behavioral change, which, as the research indicates, is an important aspect of human conduct.  Abstinence-only education does “not acknowledge that many teenagers will become sexually active” (14).  Through not acknowledging the evidence that teens will have sex in general, Abstinence-only educators in turn ignore the reality that teens are likely to be influenced by others having sex.  Through the failure to take the former reality (the prevalence of teen sex) into account, the existing education program cannot address the aforementioned latter reality (teens’ inclination to emulate the behavior of their peers).  This is harmful, as a meaningful and effective intervention should address the reality that social interactions do play a meaningful and lasting role in determining human behavior.
Intervention – Comprehensive Sex Education through TV
            I propose that the intervention be changed in order to address these flaws.  While current sex education takes place in schools, sex-education would more effectively be built into the plot lines of popular, youth-based TV shows.  In fact, data have indicated that “the average American child consumes more than six hours of media each day, combining and often multi-tasking with television, the internet, video games…” (25).  As such, creating a television-based campaign to address the issues associated with sexual activity would be an effective way to infiltrate the homes and minds of young people.
            Under the proposed intervention, existing TV shows with high youth viewership would be paid to infiltrate certain messages into their plot lines.  The TV shows in the proposed intervention would feature characters aged 13-19. Comprehensive sex education would be provided to viewers in part through the dialogue between the characters.  Additionally, the characters on the TV shows would attend sex education classes, where information would be provided to the characters, and thus the viewers, in greater depth.  For instance, the characters may put condoms on bananas in these classes in order to demonstrate how condoms are used.  The characters would also receive information regarding the prevalence and transmission of STIs such as HIV/AIDS, herpes, Chlamydia, and gonorrhea.  Viewers would be informed of the negatives and positives of different methods of contraception, or lack there of, through the experiences of the characters.  While some characters would use contraception and avoid certain negative consequences such as pregnancy and the spread of STIs, other characters would opt not to use protection when having sex, and still others would opt not to have sex at all.  The experiences of the characters would be reflective of the decisions they make regarding sexual activity and their methods of contraception and STI protection. Characters that don’t use contraception effectively, or at all, would address the consequences on the TV show.  For instance, a character that doesn’t use condoms may become HIV positive and/or pregnant.  Viewers would see, first hand, the risks involved with making certain decisions regarding sexual activity. 
            The TV shows would exemplify characters that make an array of decisions regarding sexual activity.  One qualitative research finding is that participants reported having less ideal virginity-loss experiences than are displayed in popular movies (19).  The proposed intervention would not seek to idealize sexual initiation.  In contrast, the intervention would provide well-researched plot-lines, depicting the realistic results of teen decisions regarding sex.  
Intervention Address Flaw #1: Deflecting Reactance
            While abstinence-only education is likely to create reactance, the proposed intervention would avoid this phenomenon.  Studies have shown that people are less likely to exhibit psychological reactance when the messenger is more similar to the person being persuaded.  One study found that participants who reviewed persuasive texts were more likely to agree with a communicator who was indicated as being more similar to the subject, such as by sharing a birthday with the subject, than a communicator who did not share any similarities.  This held true in both low and high threat conditions (20).  The messengers in the proposed TV shows in this intervention would be teens.  The teen characters would be weighing decisions regarding contraception use and whether or not to have sex.  The target audience, also teens, would not be prone to exhibit psychological reactance, as that the messengers would be similar to them.  This differs from conventional, classroom based sex education, where the messenger is typically an older individual than the teens.
            The TV shows in this intervention would further avoid creating psychological reactance because viewers would be shown that there are a number of options that one can make regarding sexual activity.  No option would be restricted, as is the case in abstinence-only education.  Rather, the potential consequences of these decisions would be thoroughly outlined in plot lines.  As previously noted, psychological reactance stems from people feeling as if their freedom is threatened.  As such, restoring choice is a way to combat this psychological construct.  Studies have shown that psychological reactance can be lowered or avoided when people are given a choice.  For instance, one study found that subjects will be more compliant with medical treatment when they perceive choice within the treatment setting (21).  The proposed intervention would give young people the freedom to make their own informed choices regarding sexual activity.
Intervention Address Flaw #2 – Acknowledging that youth may have sex and preparing them for it
               Given the evidence that people do not accurately assess risk, it’s important to acknowledge the reality that people will likely engage in risky behavior.  One study found that smokers believe that 42% of smokers in general will develop lung cancer, which is far higher than the true percentage of smokers who actually get this type of cancer.  The same population of smokers, however, reported that their own risk of developing lung cancer as compared to the rest of the population is 29% (23).  This result is reflective of the aforementioned optimistic bias.   This finding indicates that, even when people are aware of the risks involved with certain behaviors, they are not likely to understand their own risk.  As this intervention plans to teach comprehensive sex education through the characters’ experiences, it will address this flaw in the existing abstinence-only education programs by preparing youth for the inevitability that not all teens will abstain from sex.  Characters will use and discuss different methods of birth control such as condoms.  The pros and cons of different types of contraception will be worked into the dialogue of the television campaign so that youth become cognizant of their options.  For instance, an episode could include a character debating whether or not to use an intrauterine device (UTI) or condoms.  While the effectiveness of pregnancy prevention could be outlined for UTI use, the lack of prevention of STIs would be made evident to viewers, as well.
                        It has been documented that comprehensive sex education has resulted in declined rates of STIs and pregnancy, delayed sexual initiation, and increased use of contraceptives (22).  These results have been replicated in a number of trials.  For instance, a study found that group based comprehensive sex education “was found to be an effective strategy to reduce adolescent pregnancy, HIV, and STIs” (26).  Comprehensive sex education programs work because they acknowledge the reality that teens will often not entirely abstain from sex.  As humans do not always accurately understand the risk of certain behaviors to themselves, comprehensive sex education will provide young people with the tools to protect themselves if and when they do engage in sexual behavior.  
Intervention Address Flaw #3 – Shaping Social Expectations
                        The proposed intervention will address social change at a group level rather than an individual level.  As Social Expectations Theory dictates, people’s behavior is dictated by the expectations of others.  In one experiment that supports this theory, participants were asked what they felt the most important problem was for the country.  Participants were given five choices.  When participants were asked this question privately, only 12% responded to indicate that “subversive activities” were the leading threat to the country.  However, when asked in a group setting in which all other members of the group indicated that “subversive activities” were the biggest threat to the country, a whopping 48 percent of participants gave the same response (17).  As this study indicates, humans will conform.  Addressing this reality is important in designing an intervention.  Humans are likely to have their opinions, and thus, actions, shaped others.
                        Research has shown the television shows have been shown to shape societal attitudes.  In one such instance, British television shows, which make reference to the class-system on a regular basis, are noted as having influenced social attitudes regarding the class system in Slovakia once British television became popular in the country (24).  The proposed intervention would create television shows that would shape societal attitudes toward sexual behaviors, and certain behaviors would be normalized through this intervention, such as condom use.  In the proposed intervention, characters would typically use birth control and other forms of protection when they have sex.  As discussed previously, if the characters don’t use a condom, the negative results associated with this risky behavior would also be readily apparent.  One such example might be the characters’ contraction of HIV/AIDS.    In turn, young viewers would try to conform to the social expectations as dictated by this intervention.
Abstinence-only sex education in an unrealistic attempt to address sex with young people and should be replaced for a more progressive, group-based intervention.  Abstinence-only sex education creates psychological reactance in youth, makes inaccurate assumptions regarding one’s ability to accurately assess risk, and fails to address the issue at a group level.  In contrast, the proposed intervention addresses these flaws and is the superior campaign.  The more traditional models of sex education must be replaced with far-reaching campaigns that would prevent psychological reactance, provide youth with the tools and education needed to prevent pregnancy and the transmission of STIs, and alter social expectations.  The proposed television intervention will achieve these goals and create a realistic way for youth to understand their choices regarding sexual behavior through a compelling and enjoyable medium.

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