The United States Government Should Stop Funding Abstinence Only Programs, Particularly the Choosing the Best Programs – Jen Jorgensen

Introduction

            In the United States, teen pregnancy and the rates of sexually transmitted infections among young persons aged 15-24 years remain as two important public health problems.  Although the teen birth rate has been on a general decline especially over the last several years, the rate remains high at 34.4 births per 1,000 (1).  This rate keeps U.S. teen birth rate as one of the highest rates among other industrialized nations (2).  Teen birth rates vary significantly across states (3) with rates highest in the South and Southeast (4).  Furthermore, disparities continue to exist as the teen birth rates for Hispanic and non-Hispanic black teenagers remain more than double that of white teenagers (3,5).  Fifty-nine percent of pregnancies in 15-19 year–olds in 2008 ended in birth and 26% in abortion (5).  Based on these statistics, there is not doubt that teen pregnancy remains as a public health problem especially when considering the elevated health risks for teen mothers and their infants.

            Similar to teen birth rates, rates of sexually transmitted infections (STIs) among U.S. adolescents are higher than in most other industrialized countries (6).  Despite accounting for only 25% of the sexually experienced population, young people aged 15-24 years will acquire nearly 50% (9.1 million) of the 18.9 million new cases of STIs each year (7).  Unlike teen pregnancy, the rates of STIs, particularly Chlamydia, gonorrhea, and syphilis, have increased in this population over the past several years (8).   Sexually transmitted infections not only have reproductive health sequelae, but they also affect the psychological health of those infected and present considerable economic burdens.  In light of these high rates and associated risks, the prevention of STIs among adolescents and young adults is an imperative public health matter.

            In attempts to reduce teen pregnancy rates and STIs rates among adolescents, U.S. public schools have instituted sex education programs.  Until recently, most programs used were those that taught abstinence-only and in fact many states mandate abstinence-only sex education for schools holding the belief that sex education including safe sexual practices sends a mixed message to students and promotes sexual activity (9).   The U.S. Federal Government, seemingly agreeing with this view, promoted abstinence-only education by placing restrictions and regulations of federal funding that allowed only for abstinence-only programs; specifically the government began several initiatives such as the Title V, Section 510 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (10).  When the federal funds for abstinence-only education expired in June 2009 and Congress approved a new evidenced-based Teen Pregnancy Prevention Initiative, advocates for removal of abstinence-only education began to think the federal government was finally moving in the right direction.  However, despite the overwhelming evidence that abstinence-only education programs are ineffective (11,12), the funding was restored and increased to include a mandatory $250 million abstinence-only fund in September of 2009, through an amendment of the Senate Finance Committee’s health-reform legislation (13).

            This paper will critically examine one of the most widely used sets of abstinence-only sex education programs, Choosing the Best.  We will examine three aspects of the program that will help to explain why this program is ineffective; many of the arguments we will make can be extrapolated to other programs and will also explain why the federal government should stop wasting taxpayer money on hopeless programs.   Next, we will provide alternatives and possible solutions for each aspect based on social behavior theories and prior research. 

Choosing the Best Programs

            Choosing the Best offers abstinence-centered sex education curricula through 3 different middle school programs for grades 6-8 and two high school programs for grades 9-10 and 11-12.  Each program consists of video vignettes, real life case studies, role-plays, interactive exercises and small-group discussions.  Discussions are lead by teachers. Programs range from 5 to 8 lessons long; a teacher using the provided materials conducts each lesson.   According to the founders, Choosing the Best programs are based on three learning theories: experiential learning theory, social learning theory and cognitive learning theory.  This paper will focus on the program for 8^th grade, Choosing the Best LIFE.  This is an 8-session curriculum that “helps communicate, dynamically and positively, the value of committing to abstinence.” The videos are intended to lead naturally to a discussion lead by the classroom teacher (14).

Criticism 1: Telling adolescents they should remain abstinent invokes reactance and leads to the opposite behavior

            The theory of psychological reactance posits that people have a set of actions or free behaviors that they are aware of, believe they have the ability to perform and feel they can engage in at the moment or in the future (15).  The ability to engage in sexual activity is one such free behavior for adolescents and adults alike.  If a person believes that a freedom is threatened, he will experience reactance, a motivational state aimed at restoring the threatened freedom, as a combination of anger and negative cognitions directed at the offending stimulus and/or it’s source (15, 16, 17).  When formulating the theory, Brehm observed that free behaviors could vary in significance and importance. Therefore, he hypothesized that the strength of psychological reactance is a function of the degree of threat directed at the perceived freedom and the level of importance that an individual assigns to the particular freedom (15).  By telling adolescents they must remain abstinent, Choosing the Best LIFE program is invoking psychological reactance.  Furthermore, the psychological reactance is likely to be extremely strong for two reasons: psychological reactance peaks during adolescence (18) and more importantly, freedom of sexual choices is highly valued among adolescents. 

            The theory of psychological reactance states that individuals experiencing reactance are motivated to restore their threatened freedom by performing the forbidden behavior or by resisting the behavior being advocated, a “boomerang effect” (19).  Not only are adolescents going to react with anger and negative perceptions to the abstinence-only message of the Choosing the Best LIFE, but also they will engage in the unwanted behavior, sex and completely reject abstinence.  The program does not address methods of safe sex, such as condom use; as a result, adolescents will engage in riskier sexual behavior when rebelling against the program to restore their freedom.  Psychological reactance has been shown to predict risky sexual behavior in young adults aged 18-25 (20); given that reactance peeks in adolescence, we can conjecture that reactance will also predict risky sexual behavior in adolescents.  Others have found that individuals will restore freedom through more indirect, vicarious forms such as performing an alternative but similar behavior to the one threatened or derogating the source (21).  Given this fact, adolescents may choose sexual activities, such as oral sex and mutual masturbation, other than sexual intercourse in order to rebel.  By not addressing these types of sexual activity as alternative options to sexual intercourse, Choosing the Best LIFE program may falsely lead adolescents to believe that there are no other options to sexual intercourse to quell their sexual urges.  Also, adolescents may think that there are no risks of sexually transmitted infections when engaging in these behaviors, as the program did not address them. 

Criticism 2: Videos used by the program focus on negative consequences of engaging in sexual activity

            An essential tool of the Choosing the Best LIFE is videos of teenagers or young adults discussing their experiences of the session’s topic; videos are described as focusing on the negative outcomes of sex.  For example, the “Sex, STDs and Honesty” session begins with a video that introduces students to the consequences of STDs, “Sex, Alcohol and Respect” session opens with a video of teens sharing their painful stories of mixing alcohol and sex and “Sex, Pregnancy, and Responsibility” focuses on a real-life teen couple’s struggles with unintended pregnancy.  This focus on negative consequences of sexual activity in flawed for two reasons. 

            First, by focusing on negative aspects the videos’ messages will instill fear and alarm in adolescents watching the video. Communication theory has found that using a fear-instilling message has the opposite effect of what it intends (22).  In other words, the receiver will be turned off from hearing the messages and accepting the content or advice.  When adolescents are watching the video discussing the struggles of unintended pregnancy, it is likely they will feel dread and in order to avoid that feeling, they will shut themselves off to hearing the underlying messages and advice.  The message of abstinence-only will not be received nor will any other advice the program has to offer.      Second, by focusing on the negative consequences of sexual intercourse, Choosing the Best LIFE is utilizing the Health Belief Model to change adolescents’ behavior.  According to the Health Belief Model (HBM), people examine their perceived susceptibility to a poor health outcome and the perceived severity of consequences.  Next, individuals weigh the benefits and risks of each option to rationally decide on which option is the best (22).  By examining the risks and negative consequences of sexual intercourse, the program is trying to provide students with information so that they may weigh the risks and logically choose abstinence. 

Reliance on the HBM to change adolescent sexual behavior is flawed for several reasons.  First, HBM assumes that all individuals highly value health (23).  Health is not as important to adolescents as is fitting in and being accepted by their peers.  Therefore, if their peers are engaging in sexual intercourse, adolescents are more likely to engage in sexual intercourse to fit in despite the potential risks.  Second, Choosing the Best LIFE relies on perceived susceptibility, as the HBM does, to push benefits and risks analysis to in favor of abstinence.  However, research of smokers has shown that people tend to rate their susceptibility of to disease lower than their peers’ susceptibility to disease (24).  People tend to over estimate the probability of good things happening to them while underestimating the probability that bad things will happen to them (25). 
Adolescents may watch the program’s videos thinking the whole time that will never happen to me and completely disregard the videos’ message.  Lastly, the HBM has been shown to poorly predict several behaviors such as sexual activities and addictive behaviors in which people often act irrationally.  HBM assumes that people act rationally; this is particularly not true with adolescents, as they often have not developed the cognitive ability to weigh risks and benefits.  

Criticism 3: Choosing the Best is incorrectly and ineffectively using Social Learning Theory

            According to their website, Choosing the Best LIFE utilizes social learning theory to develop the program’s tools and activities.  Unfortunately, they incorrectly and inefficiently implement the theory.  Social learning theory holds that there is an interactive triangle between individuals, their environment and their behavior and that modeling is an important component of the learning process (26).  Individuals observe a behavior taking place and then go out to adopt similar behavior, to simply put it.  One sessions of Choosing the Best LIFE is focused on choosing abstinence; again it begins with a video of teens sharing their reasons for choosing abstinence.  The video utilizes teens to provide peer role models that emulate the desired behavior.  An important factor in adopting modeled behavior is credibility of the model (27).  According to social learning theory, in order to be a credible role model the individual must have high status within the peer group (25).  The Choosing the Best LIFE abstinence video is using teens that are clearly not even in the peer group of the adolescents engaged in the program let along having high status within the group.  It is very possible that adolescents in the program might view these teens as unpopular or not cool.  Social learning theory states that in order to function as role models, adolescents would need to be able to observe peer role models practicing the healthy behavior (28).  If their peers are having sex, it is more likely that they will have sex regardless of watching a video with teens that choose to remain abstinent. 

            Furthermore, after watching the videos all discussions are led in some form by teachers.  To follow with social learning theory, the discussions should be led by adolescents within the group.  By using peers the program could reinforce the modeled behavior of abstinence from the video.  However, instead the program relies on teachers to facilitate discussion; adolescents will view the message as coming from their teacher and not a peer.  Anti-drug campaigns, such as D.A.R.E., have shown that using teachers led initiatives are ineffective (29).   Therefore, teacher led discussions on choosing abstinence are likely to be ineffective.

            Social learning theory is also used ineffectively when adolescents in the Choosing the Best LIFE program are asked to engage in role-play.  This role-play is meant to provide another model of behavior emulate as well as provide self-efficacy when making sexual behavior choices.  One may practice saying no to sex and it will likely be rather easy in a “cold” state, meaning a non-aroused state.  However, adolescents may find it difficult to use the skills learned in a “cold” state while in a sexually aroused or “hot” state.  In fact people in a “cold” state are more likely to believe they are in control of their behavior.  A study of sexual arousal found that men overestimate the degree to which they will be able to control their behavior (30).  By having adolescents engage in role-playing while in the cold state, Choosing the Best LIFE falsely leads adolescents to believe they will have greater control in the heat of the moment.  Replicating the intense feelings and sense of arousal at the time just before sexual behavior is difficult if not near impossible to do and is not appropriate for a school setting; therefore, role-playing may not be an effective way to increase abstinence among adolescents.

A Possible Solution: “Free to Be You”

            Aspects of social learning theory can be used to effectively teach sexual education to adolescents.  This paper will purpose a comprehensive sexual education program, Free to Be You, which incorporates aspects of social learning theory, social norms theory, and the sexual health model.  By using aspects of marketing theory, the program will extend outside of the classroom to a Free to Be You movement that promotes safe sex behavior and open discussion of sexuality and sex.  The ultimate goal of Free to Be You is to increase safe sex practices that would lead to decreased rates of teen pregnancy and sexual transmitted infections amongst adolescents.

            Prior to beginning, Free to Be You will conduct research be going into the field and interacting with adolescents.  Detailed information on the adolescent lifestyle, what they value and what they aim to achieve will be collected.  Data on the current sexual behaviors of adolescents will also be collected in order to establish current social norms.  It is commonly known that as soon to be adults, adolescents value autonomy and freedom; to start, Free To Be You will focus on these strong core values in its’ marketing campaign.  Lastly, observation of peer groups will help the program to identify peer-leaders and role models.

Defense 1: Comprehensive sexual education will provide adolescents with alternative sexual behaviors and using peers to discuss these behaviors will reduce psychological reactance

            As discussed, providing abstinence only education will lead adolescents to engaging in sexual intercourse or other sexual behaviors via attempts to restore their freedom and the “boomerang” effect.  As a comprehensive sexual education program, Free to Be You will present adolescents with information regarding several different types of sexual behaviors and safe ways to engage in those behaviors; this will include abstinence but will go far beyond that.  The sexual health model consists of ten components that are essential aspects of healthy human sexuality, many of which influence safe sex behaviors.  One component of the model focuses on normalizing masturbation and fantasy, which next to abstinence is the ultimate in safe sex (31). Free to Be You will incorporate this component to present adolescents with other safe ways to fulfill their sexual urges and desires.  By removing some of the stigma surrounding masturbation, masturbation can become a part of sexual behavior that can decrease the pressure to engage in sexual intercourse (31).   A study of African American women found a positive relationship between positive attitudes toward masturbation and positive attitudes toward condom use (31).  By presenting various sexual behaviors as different options, Free to Be You will provide adolescents with the ability to make their own choices and therefore, will evoke less psychological reactance as adolescents’ freedom and autonomy are not being threatened.

            Free to Be You may be perceived as telling adolescents what to do when making the point that condoms should be used during all sexual behaviors with penetration; adolescents may feel their freedom is being threatened and develop reactance as a result.  Studies have shown that people interpret threatening actions as less threatening when those actions come from similar people; in fact, similar people can persuade others to comply with a behavior even in the face of threats (32).  In order to decrease psychological reactance surrounding condom use, Free to Be You will use peer leaders, who use condoms themselves or understand the significance of using condoms, to lead discussions on the importance of condom use for safe sex (see defense 3 below for more on peer leaders).  Since these peer leaders will be adolescents themselves from the same school, adolescents in the program will feel very similar to and like the peer leaders and as a result, will be less threatened by messages to use condoms.

Defense #2: Focus on positive sexuality by creating a movement that adolescents will want to join

            Rather than focusing on the negative consequences that may result from sex, the Free to Be You will focus on the positive aspects of sexuality.  Two important components of the sexual health model are comfort in talking about sex and positive sexuality.  The model assumes that when people are more comfortable with their sexuality and can comfortably talk about sex they will be more able set appropriate boundaries for safer sex (31).  Free to Be You will focus on increasing adolescents’ comfort with discussing sex.  The program will encourage adolescents to explore and embrace their sexuality; this will encourage a positive view on different preferences rather than ignoring them as abstinence only programs do. The program will equip adolescents safe ways to explore their sexual desires that can lead to positive outcomes – such as mutual masturbation; this will help adolescents to realize that there is a way to satisfy their needs that does not have negative results.  By increasing adolescents’ comfort with speaking about sex and sexuality, Free to Be You will also increase their comfort with talking about safe sex boundaries.

Free to be You recognizes that adolescents may not value their health too highly and therefore, the health belief model may not be the best behavioral model to base the program on, as abstinence-only programs focusing on negative consequences are.  Adolescents strongly value autonomy, freedom and fitting in with social circles.  Therefore, the program will combine aspects of social norms theory and marketing theory with the program’s positive view of sexuality.  Social norms theory states that adolescents’ sexual behavior is influenced by their perceptions of the sexual behaviors of their peers.  These perceptions are often misconstrued with over emphasis of risky sexual behavior (33).  Therefore, if adolescents believe that their peers are having sex, then they will engage in sex.  If they believe their peers are using condoms, then they too will use condoms.  Free to Be You will use its research to determine what the current social norms are of the adolescents taking part in the program.  These social norms will be used to create a movement via a media campaign that highlights the positive and safe sexual practices of adolescents.  For example, the campaign may use a poster saying x% of your friends are using condoms – Join them!  By focusing on what adolescents are currently do, Free to Be You will work to change adolescents’ misperceptions of the sexual behaviors of their peers. Also, the campaign will encourage adolescents to join the rest of their peers, something that they value.  Marketing theory states that individuals are more likely to use a product or become part of movement if it offers a brand that promises something that they value strongly (34).  By allowing adolescents to become more like their peers, Free to Be You appeals to adolescents’ desire to fit into social circles.  Furthermore, providing options from which adolescents can choose provides freedom and autonomy. 

A second aspect of the media campaign and movement will include an interactive website.  The website will contain the current social norms of the group focused on safe sex behaviors and encourage students to become part of the movement.  There will also be a blog portion that highlights stories of different adolescents in the program that chose safer sex behaviors.  The stories will mainly focus on the success of the adolescents and the autonomy they have in choosing what they do in and outside of school – for instance, one might be the quarterback on the football team, another the class president.  These stories will incorporate how the adolescent engages in safe sexual behaviors – or even how they might be waiting for the right person – and how those behaviors allow him to maintain his freedom.  Adolescents will then be encouraged to share their own positive stories and post questions to others.  The ultimate goal of the media campaign is create a brand, Free to Be You, that is all about freedom of choice when it comes to safe sex practices.

Defense #3: Free to Be You will use social learning theory effectively by using credible role models as peer educators and leaders of the movement

            Social learning theory can be applied to sexual education by using peer educators to serve as role models.  Peer educators can talk about how they use condoms and other ways they practice safe sex becoming role models for others.  It is important that these peer educators be credible among their peer group as asserted by Social Learning Theory (26).  Free to Be You will observe the social dynamics of the adolescents who will partake in the program to identify and recruit individuals with a high status in the peer group; this will ensure that credible role models are obtained.  Prior studies have shown that popular-opinion leaders in communities were effective peer leaders because of their status within the community (28).  Similarly, Free to Be You believes that these high status individuals will be effective peer educators.  Also, by using peer educators from the adolescents’ actual social group it is more likely that these individuals will have similar or the same cultures as most other adolescents at a particular school. Cultural sensitivity is an important part of the sexual health model.  The sexual health model asserts that the cultural meaning of sexual behaviors should be taken into account because that meaning may drive unsafe or safe sex (31). Therefore, peer educators will help to incorporate specific cultural aspects of sexual behaviors into the program.

These high status individuals will be involved in the program from the beginning and will actually be the ones starting the Free to Be You movement.  They will be trained as peer educators and given the skills to speak about the current sexual practices and social norms of the group.  These individuals will be the initial stories featured on the blog portion of the website.  A flash mob of the school cafeteria done by the high status individuals will be used to raise awareness and start the movement.  The flash mob will dance and wear T-shirts with the movement name Free to Be You on it.  At the end, they will hold up posters with either facts of the current social norms (x% use condoms etc) or Free to Be You’s web address.

Conclusion 

            In closing, it is clear that abstinence-only sexual education programs are fraught with problems and challenges, only a few of which have been described here.  These programs do not adequately or effectively use behavioral theories to change the sexual behavior of adolescents.  The U.S. Federal Government should solely fund comprehensive sexual education programs and drop all funding for abstinence-only programs. Comprehensive sexual education programs that choose behavioral models applicable to sexual behavior and effectively incorporate those models do have the potential to significantly change the sexual behavior of adolescents.  Free to Be You as described here incorporates aspects of multiple behavioral models in order to develop a more encompassing program that promotes positive views of sexuality and safe sex.  It uses components of marketing theory to present the program in a way that is more inviting and attractive to adolescents.  Sexual education in the U.S. should move toward a similar program.

REFERENCES

1. Center for Disease Control and Prevention. Births: Preliminary Data for 2010. National Vital Statistics Report; Vol 60. No. 2. Hyattsville, MD: National Center for Health Statistics, 2011.

2. United Nations Statistics Division. Demographic yearbook 2009-2010. New York, NY: United Nations. http://www.thenationalcampaign.org/costs/pdf/counting-it-up/key-data.pdf

3. Center for Disease Control and Prevention. Birth Rates for U.S. Teenagers Reach Historic Lows for All Age and Ethnic Groups. NCHS Data Brief, No. 89 Hyattsville, MD: National Center for Health Statistics, 2012.

4. Center for Disease Control and Prevention. State disparities in teenage birth rates in the United States.  NCHS Data Brief, No. 46. Hyattsville, MD: National Center for Health Statistics, 2010.

5. Guttmacher Institute. U.S. Teenage Pregnancies, Births and Abortions: National and State Trends and Trends by Race and Ethnicity. New York, NY: Guttmacher Institute, 2010.

6.  Panchaud C. Singh S, Feivelson D, Darroch J. Sexually transmitted diseases among adolescents in developed countries. Family Planning Perspective 2000; 45:24-32.

7. Weinstock H, Berman S, Cates W Jr. Sexually transmitted diseases among American youth: incidence and prevalence estimates, 2000. Perspectives in Sexual and Reproductive Health 2004; 36:6-10.

            8. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2010.  Atlanta, GA: National Center for HIV/AIDS, Viral Hepatitis, STD, and TB prevention 2011.

            9. Stander-Hall SF, Hall DW. Abstinence-Only Education and Teen Pregnancy Rates: Why We Need Comprehensive Sex Education in the U.S. PLoS ONE 2011; 6:e24658.

            10. Advocates for Youth. The History of Federal Abstinence-Only Funding. Washington, DC: Advocates for Youth. http://www.advocatesforyouth.org/publications/429?task = view

            11. Santelli J, Ott MA, Lyon M, Rogers J, Summers D, Schleifer R. Abstinence and abstinence-only education: A review of U.S. policies and programs. Journal of Adolescent Health 2006; 38:72-81.

            12. Kohler PK, Manhart LE, Lafferty WE. Abstinence-Only and Comprehensive Sex Education and the Initiation of Sexual Activity and Teen Pregnancy. Journal of Adolescent Health 2008; 42: 344-351.

            13. Sexuality Information and Education Council of the United States. Statement of SIECUS President and CEO, Joseph DiNorcia, Jr., on Funding Opportunities for Evidence-Based, Comprehensive Sexuality Education and Title V Abstinence-Only Programs. SIECUS. http://www.siecus.org/index.cfm?fuseaction=Feature.showFeature&FeatureID=1914

            14. Choosing the Best. Choosing the Best LIFE. Atlanta GA: Choosing the Best. http://www.choosingthebest.org/index.html

            15.  Brehm JW. A Theory of Psychological Reactance. New York: Academic Press, 1966.

                16. Dillard JP, Shen L. On The Nature of Reactance and Its Role in Persuasive Health Communication. Communication Monographs 2005; 72:144–168.

                17. Quick BL, Stephenson MT. Further Evidence that Psychological Reactance Can Be Modeled as a Combination of Anger and Negative Cognitions. Communication Research 2007; 34:255–276.

            18. Arnett JJ. Adolescence and emerging adulthood: A cultural approach (2nd ed.). Englewood Cliffs, NJ: Prentice Hall 2004.

            19. Brehm JW, Cole A. Effect of a Favor, which Reduces Freedom. Journal of Personality and Social Psychology 1996; 4:420-426.

            20. Miller CH, Quick BL. Sensation Seeking and Psychological Reactance as Health Risk Predictors for an Emerging Adult Population. Health Communication 2010; 25:266-275.

20. Quick BL, Stephenson MT. The Reactance Restoration Scale (RRS): A Measure of Direct and Indirect Restoration. Communication Research Reports 2007; 24:131–138.

21. McGuire WJ. Input and Output Variables Currently Promising for Constructing Persuasive Communications. In Rice, R. & Atkin, C. (Ed.). Public Communication Campaigns. 3^rd Ed. 2001.

22. National Cancer Institute. Theory at a Glance: A Guide for Health Promotion Practice. Part 2. Bethesda, MD: National Cancer Institute 2005; 9-21.

23. Salazar MK. Comparison of Four Behavioral Theories. American Association of Occupational Health Nurses Journal 1991; 39:128-155.

24. Ayanian JZ, Cleary PD. Perceived Risks of Heart Disease and Cancer among Cigarette Smokers. Journal of the American Medical Association 1999; 281:1019-1021.

25. Weinstein ND. Unrealistic Optimism About Future Life Events. Journal of Personality and Social Psychology 1980; 39:806-820.

26. Bandura, A. Social Learning Theory. Englewood Cliffs, NJ: Prentice-Hall, 1977.

27.  Bandura A, Ross D, Ross S. Vicarious Reinforcement and Imitative Learning. Journal of Abnormal and Social Psychology 1963; 67:601–607.

            28.  Turner G, Shepher J. A Method in Search of a Theory: Peer Education and Health Promotion. Health Education Research 1999, 14:235-247

29. Ennet ST, Tobler NS, Ringwalt CL, Fleweling RL. How Effective is Drug Abuse Resistance Education? A Meta-Analysis of Project DARE Outcome Evaluations. American Journal of Public Health 1994; 84:1394-1401.

30.  Loewenstein G. Out of Control: Visceral Influences on Behavior. Organizational Behavior and Human Decision Processes 1996; 65:272-292.

31. Robinson BE, Bokting WO, Rosser BRS, Miner M, Coleman E. The sexual Health Model: Application of a Sexological Approach to HIV Prevention. Health Education Research 2002; 17:43-57.

32. Silvia PJ. Deflecting Reactance: The Role of Similarity in Increasing Compliance and Reducing Resistance. Basic and Applied Social Psychology 2005; 27:277-284.

33. Haines MP. Social Norms: A Wellness Model for Health Promotion in Higher Education. Wellness Management 1998;14:1-8.

            34. Evans WD, Hastings G. Public Health Branding: Recognition, Promise and Delivery of Healthy Lifestyles (3-24). In: Evans WD, Hastings G. eds. Public Health Branding: Applying Marketing for Social Change. Oxford University Press, 2008.