Friday, May 10, 2013

Theoretical Analysis: Why NYC’s Teen Pregnancy Prevention Campaign Misses the Mark, and How It Can Be Improved -- Katie Johnston, Spring 2013

Last month, the New York City Department of Health under Mayor Michael Bloomberg implemented a public intervention for teenage pregnancy called “The Real Cost of Teenage Pregnancy,” consisting of 4,000 printed subway and bus stop ads to reflect the “recent discourse on the issues of fatherhood, nonmarital births, marriage and poverty” (1). The series of posters displays titles like, “Think Being a Teen Parent Won’t Cost You?” with pictures of crying children addressing would-be parents with facts about decreased chances of children’s success and what financial outcomes teen parents will most likely face. Examples of these posters include a baby saying, “Honestly Mom… chances are he won’t stay with you. What happens to me?” and “I’m twice as likely not to graduate high school because you had me as a teen” (2). Other than the five poster prototypes, the Real Cost campaign includes an interactive texting game and a YouTube video PSA, which are not as pervasive and visible as the ads.
With this campaign, the New York City Human Resources Administration (HRA) had specific intent: unintended pregnancies are the highest in teens ages 15-19, and teen pregnancy has been proven to be a risk factor for children’s emotional and behavioral problems, lower performance in school, and poverty (1). Although it is a decrease from prior years, the pregnancy rate for teen girls was 72.6 pregnancies per 1,000 girls, higher than the national rate (1). With true aim, the HRA unfortunately attempted to curb this incidence by using persuasive methods based in theories commonly used in public health interventions known to be ineffective (3). While doing so, they employed a stigmatizing and shaming tone, which may have unintended consequences. There are ways to better use different persuasive theories that are known to work to reframe their campaign into more effective one, using theories based on proven results.

Critique Argument 1: Assumption of Rational Behavior

The print ads rely on statistics and facts of health risks associated with teenage pregnancy – each of the ads includes a fact about either an increase in poverty or a decrease of the child’s performance in school, presented as a statistic. This fact-based strategy is meant to, according to Mayor Bloomberg, make “very clear to young people that there’s a lot at stake when it comes to deciding to raise a child” (1). 
Although these statistics are true – each ad is cited on the website – this presentation of the facts to the teen demographic is futile on many levels. First, this campaign leans too much on the Health Belief Model to reach the goals it has set. The model states that people will balance the perceived costs and perceived benefits from an action, and this will directly reflect in their behaviors (4). The model hypothesizes that two variables determine what an individual’s behavior will be: 1) the desire to avoid the poor outcome, and 2) the belief that a specific health action will prevent this outcome (4).
This model has been found to not be sufficient in public health interventions because it assumes individuals do a thorough cost-benefit analysis with each behavior that may affect their health (5). In the Real Cost campaign, the HRA is making the case that the desire to avoid the outcome (teen pregnancy) should outweigh the benefits of sexual initiation and unprotected sexual intercourse. They then assume that the teenagers will change their behavior as a result because their desire to avoid teenage pregnancy will be increased.
While the teenagers will read and comprehend the statistics, they will not take any action to rationally apply these costs to their lives. The notion that people make rational choices about their health has been the downfall of many public health interventions simply because the reasoning is flawed: it has been found time and time again that people do not use rationality in their day-to-day health behavior choices (6). It is also known that sexual arousal is among the array of emotions that can further decrease rationality and increase risk taking in both adolescents and adults (7, 8). The HRA wrongly assumes that simply educating the teens of financial consequences that a child would have is going to trigger rational thinking in New York teenagers, let alone during a time of sexual arousal.
Similarly, this campaign also employs use of the Theory of Reasoned Action, but ineffectively.  The Theory of Reasoned Action states that intention and behavior are direct results of a balance of personal attitudes of outcome expectations and the perceived social norms (9). This linear progression from attitude to action assumes that behavior can be predicted by attitudes and intentions (5). Using this theory, these ads assume that the current attitudes of NY teens point to teenage pregnancy, and these attitudes can be changed by changing their perception of the social norms. These ads negatively portray not only the financial situations – “You’ll be paying to support me for the next 20 years” – but also social and emotional consequences: “Honestly Mom… chances are he won’t stay with you.” The HRA postulates that negatively portraying teen pregnancy will be enough to change perceptions of societal support for teen pregnancy and therefore change their intention and behavior.
The use of this theory has two major flaws. It again assumes rationality, which has already been discussed as incorrect with the Health Belief Model. However, this theory also is incorrect in thinking that teenagers did not already perceive the connection between teen pregnancy and health risks: the National Campaign to Prevent Teen Pregnancy has found that nearly all teens (97 percent of girls and 94 percent of boys) believe it is important to avoid getting pregnant or getting someone pregnant at this time in their lives (10). It is also seen that nearly all teens (92 percent) believe it is important for teens to be given a strong message from society that they should not have sex until they are at least out of high school (10). These numbers imply that this negative perception of teen pregnancy that the HRA is trying to create is already real and trying to “make clear,” as Bloomberg stated, something that is already obvious.
Both the Health Belief Model and the Theory of Reasoned Action depend on the fact that the individual will change their actions when they realize the outcomes linked to their behavior. One of the largest flaws in these theories is the assumption that there is going to be a behavior as a result of the intention the messages create. These theories incorrectly take into account that the individual already knows the best strategy to accomplish this, as well as how to access the means to do so. The NYC ads tell teens what they should not be doing – becoming pregnant – but it does not tell them how not to become pregnant. Although the interactive texting game accompanying the ads provides a 311 phone number for contraceptive information, the viewer will already have had to take action by texting the “NOTNOW” to the number on the ad. This is too removed from the messages already. These ads have a missing link between the intention they set – to not become pregnant – and how to accomplish this.

Critique Argument 2: Psychological Reactance Will Counteract Effect

Psychological reactance theory is found in all persuasive messages to some extent, and can be damaging to the intention of messages. The theory states that persuasive messages may evoke motivation to reject the advocacy, which is called reactance (3). The rationale behind this theory is that persuasive messages ask the viewer to act or think in some way, limiting their freedom to act or think in any other way they choose (3). The reactance is the sequential restoration of this freedom and can manifest in a range of ways, including indirect restoration (by derogating the source of the threat) and direct restoration (by doing the forbidden act) (3). For this reason, some public health interventions have found results that are opposite of their intent (3). Specific components of persuasive messages have been found to evoke reactance: for example, displayed dominance over the viewer has been found to increase reactance. The more controlling and dominant the persuasion is, the more reactance is felt by the viewer as a result (3).
This theory is vital to consider when attempting to delay the onset of teen sexual activity because of the role sexuality plays in teens at this developmental status. Many cognitive and psychosocial risk factors associated with reactance are likely lead to risky behaviors in adolescents, including resisting adult control and to engage in superficial oversimplified thinking, and to emulate adult behaviors without understanding consequences, to feel invincible, and to rebel against authority (11). Sexual activity is a prime example of a way teens often take control of their lives and display reactance. 
The Teen Pregnancy Prevention ad in New York did not keep these trends in mind when designing their campaign. In this case, freedom is restricted by the adversarial tone that is displayed in the ads. The question “Think being a teen parent won’t cost you?” is directly negatively confronting a person’s perception about teenage pregnancy in a condescending manner. This challenge to the viewer’s knowledge exercises logical dominance over the viewer, which will threaten the freedom of choice of behavior: it implies that the viewer would be senseless for not thinking about the financial risks before behavior. The campaign bluntly points this ignorance out, ignoring the fact that developmentally, teens are not taking the long term effects of their actions into account. Their knowledge is doubted, and teenage viewers may feel reactance toward this loss of freedom, and therefore reestablish their control and freedom in their choices. This reactance, mixed with the fact that sexual activity is found to be a clear mode to restore freedom, may cause this intervention to be ineffective with perhaps the opposite effect: teens may make riskier decisions.

Critique Argument 3: Too Little, Too Stereotypical, Too Late

The demographic that the Teen Pregnancy Prevention campaign intends to reach is adolescent girls and boys in New York who may or may not be engaging in sexual activity to convince them that having a child during teenage years is not in their best interests. However, the amount of people in this demographic is more limited than they think: teens who do not already feel it is very important to avoid pregnancy at this point in their lives make up less than 20 percent of the teen population (12). This seems to be a waste of assets: to try to reach this small population, especially with the possible unintended consequences.
And these unintended consequences are not unsubstantial: not only is there the possibility of psychological reactance, there is a possibility of stereotype susceptibility and shaming. The ads mainly feature large pictures of children of color. This decision may be to identify specific populations they are trying to reach: the National Campaign to Prevent Teen Pregnancy has found that the birth rate among Hispanic and non-Hispanic black teen girls was more than twice the birth rate among non-Hispanic white teen girls (13). However, the HRA is walking a fine line between playing into stereotypes and reaching populations that are most at risk. Although the epidemiology shows these populations are at the most risk for teen pregnancy, a commonly held stereotype of minorities, specifically women of color, centers on poverty and welfare (14).
These stereotypes do not only offer a social perception of certain populations, but they may affect individual behavior. The theory of Stereotype Threat, or stereotype susceptibility, finds that when individuals are reminded of commonly held opinions about groups of people that they belong to, they will show performance reflecting that stereotype.  It has been found in recent studies that “a performance in a domain is hindered when individuals feel that a sociocultural group to which they belong is negatively stereotyped in that domain” (15). This phenomenon is displayed in lower math test scores among women when before the test they are reminded that stereotypically, women have poor performance in math compared to men (15).
 The Real Cost intervention is not wrong for wanting to reach the groups of teens that will benefit the most from the campaign. However, due to the previously discussed shaming tone and frame the campaign displays, the ads further support the negative stereotypes about minority teen mothers. The HRA is claiming with these ads that the city Department of Health agrees with the negative stereotypes that exist about populations of color. As a result, the campaign may see a rise in stereotype susceptibility and will have the effect that is opposite than what they intended.
This theory also applies to teens at risk for subsequent births: one-quarter of all teen moms have a subsequent birth before the age of 20 (12).  Taking into account that every 1 in 5 teen girls in the United States is already a mother, this population is substantial (12). Since teen mothers are not able to change their motherhood situation, they are swept into the Teen Mother category already surrounded by perceptions of obstacles and failure in many cultures (16).  This stereotype of teen mothers continually facing financial, social, and parental obstacles is repeated back to them from the walls of bus stops and subway stations. This may lead to further psychological reactance, risky sexual decisions, and subsequent births. Public health funding should be used to support them, not further push them into stereotyped boxes.


The HRA intervention can easily remedy their missteps by making minor changes to change the framing of teen pregnancy and to add a strategy for teens to make better sexual health decisions. While some aspects of the campaign will be ineffective, there are some parts of the intervention that have been proven to work. To increase the use of these components would be ideal for the HRA. Also, implementation of other persuasion theories, like Prospect Theory and the Advertising and Marketing Theories, can be useful to jumpstart their message. Exemplified by other community-level campaigns that the National Campaign to Prevent Teen Pregnancy has evaluated and found to be effective, these theories can be adopted by the HRA in the next campaign.

Defense 1: Prospect Theory

In the current campaign, the tone in which the intervention is portrayed is problematic in many different aspects: the shame and stigma stereotypes it reinforces and the reactance it will trigger are both results in part by the way that the information is framed. A vast majority of this campaign centers on the losses that teens will experience should they be pregnant at this age. However, a simple reframing, or changing the meanings of actions in persuasive messages, could help this intervention be more effective. Reframing allows viewers to see a health choice differently than they had before, to consequently inspire change.
This reframing can be done based on the Prospect Theory, which states that when a person makes a decision under risk, the individual will make the decisions based on the gains rather than the losses (17). It has been found that when there are two similar choices that display equal outcomes, the individual will choose the one that lists the gains than the one that is expressed in potential losses (17).
The HRA can simply reframe the facts and ideas they are trying to sell to use the Prospect Theory to their advantage. One of the five posters in the campaign already employs it, stating, “If you finish high school, get a job, and get married before having children, you have a 98 percent chance of not being in poverty” (2). Since this poster is spelling out the gains of not having a child as a teenager, it is frames the intervention so teens can use it to their advantage. Another poster offers the same information: “Got a good job? I cost thousands of dollars each year.” However, the first poster will be more effective because it lists the gains of not having children, while the second poster lists the losses if a teen pregnancy occurs, making it less effective according to Prospect Theory. In a short-term improvement, the campaign can use this first poster more frequently than the other posters, to make sure the viewers see this ad more than the others. At the very least, the first poster can be coupled with another poster in the same area, so that both the gains and losses can be displayed at the same time, making the gains look more attractive (17). If only the negative aspects of teen pregnancy are listed, the campaign will fail.

Defense 2: Advertising and Marketing Theory

Another way this campaign can be reframed is based in common persuasion theories often used in advertising. Public health communication often relies upon the Health Belief Model because of the health nature of their messages (5). However, simply adopting the strategies marketing and advertising experts use in their everyday work will make the campaign read like an inspiring commercial instead of a dry, ineffective public service announcement.
The Advertising Theory is focused on the presence of a core value used to appeal to the target viewer. Successful core values used by major companies include control, freedom, and independence because these are salient, central values every individual holds close in order to feel fulfilled in their lives. The three aspects of the Advertising Theory -- the promise, support, and core value -- help build a platform for people to connect their actions to major values. Using core values can be a “unifying thread” between the campaign and the viewer: finding the values the messages have in common with the viewers can connect the intention of the campaign to the viewer on deeper levels (18). These values are found in every aspect of the campaigns: in the messaging, design, music, and implementation of the ads. Currently, the promise that is given to the viewers in the New York Teen Pregnancy Prevention campaign is that they will lose money and freedom if a teen pregnancy occurs.
This promise is supported by the statistics, and plays on the core value of freedom and control. Freedom and control are no doubt some of the strongest core values in advertising. However, this campaign establishes them negatively: the promise is one of perceived losses. In order to make the core values stronger, the campaign can establish ownership in the promise, increasing value of what is owned and increasing the value of these already strong freedom and control core values. In this case, the campaign can establish ownership by stating that their sexual health is their own to make decisions with, and the best way to own it is to delay pregnancy.
This ownership component is clearly used in the community-based campaign called “Be Proud! Be Responsible!” that proved to have improved contraceptive use among teen populations (19). The program was aimed toward teen males to reduce their risky sexual behavior. Simply the title framed their sexual health as an aspect of their lives that they can control and be proud of; responsibility also implies control and freedom in their sexual choices. However, they portray the best way to own their sexual health is to be in control of what occurs as a result of their sexual choices (19).
Also, the Marketing theory starts with the population that is targeted to find what core values are already present in the viewers’ wants and needs. Most public health interventions do the opposite: they ask “What should people do?” instead of “What do people want?” The Marketing theory connects their message to what is already present. As previously discussed, the majority of high school students already want to delay parenthood (Our Voice). To acknowledge this value in the campaign would make the intervention more effective because it will play off a desire that is already present. In this case, the intervention should not assume that teens do not want to delay pregnancy and try to convince them otherwise, as it currently does, but instead validate and support this desire.
This strategy instead supports freedom of choice and control, so possible psychological reactance is diminished. Also, since the campaigns will be evoking ownership and reaching already-deep core values, the susceptibility to stereotypes effect will be voided. The culturally adopted stereotypes are applied to individuals externally, and since the campaign could use a core value that is already owned by the individuals, the HRA can avoid damaging stereotype reinforcement.

Defense 3: How To Accomplish This Goal

The ads assume viewers will be rational in their thought as well as take action to change their behavior, which has already been established as a glaring flaw in this campaign. There is a lack of a self-efficacy component that will link the intention of avoiding teen pregnancy and the actions in order to do so: the HRA is telling teens to not become pregnant but does not offer concrete strategies to do so.
To better empower smart choices to avoid teen pregnancy, the campaign can encourage goal realization through Social Cognitive Theory. This theory states the four interrelated processes of motivation and behavior (self-efficacy, self-reaction, self-observation, and self-evaluation), proving that individuals “are contributors to their life circumstances, not just products of them” (20). By suggesting self-efficacious behaviors, the gap between the already-present intention to avoid teen pregnancy and the concrete behavior change to avoid it will become smaller. The Social Cognitive Theory can then be applied to the Real Cost campaign by providing a self-efficacious strategy, like using contraception or practicing abstinence.
However, the Social Cognitive Theory recognizes that choices do not happen in a vacuum: instead, a person’s personal and environmental factors affect behavioral factors (21). The environmental and behavioral factors include the fact that teens are not going to be thinking rationally during sexual activity, as well as access problems (7, 8). As a result, the suggested self-efficacious behaviors should not require rational thinking at the moment, such as condoms or other barrier methods that would need to be administered during sexual arousal. Instead, the choices should be encouraged outside of the context of incident sexual encounters but instead as a lifestyle choice, such as available long-acting reversible contraceptive techniques. These changes will add another personal and behavioral factor to the goal attainment of avoiding a teen pregnancy, avoid the assumption that rational thinking will occur, especially during sexual arousal, and will narrow the gap between intention and behavior.

1.    The City of New York Office of The Mayor.  Mayor Bloomberg, Deputy Mayor Gibbs and Human Resources Administration Commissioner Doar Announce New Campaign to Further Reduce Teen Pregnancy. New York, NY: The City of New York Office of The Mayor.  2013.
2.    Think Being a Teen Won’t Cost You? Real Cost of Teenage Pregnancy. New York: NYC Human Resources Administration. Department of Social Services.
3.    Dillard J and Chen C.  On the Nature of Reactance and its Role in Persuasive Health Communication. Communication Monographs 2005: 72(2): 144-168. 
4.    Janz N and Becker M. The Health Belief Model: A Decade Later. Health Education and Behavior 1984: 11(1): 1-47.
5.    Airhihenbuwa, C. An Assessment of Theories/Models Used in Health Communication for HIV/AIDS. Journal of Health Communication 2000. 5:5-15.
6.     Ariely, D. Predictably Irrational, The Hidden Forces That Shape Our Decisions. New York, NY: Harper Perennial, 2009.
7.    Pham, M. Emotion and Rationality: A Critical Review and Interpretation of Empirical Evidence. Review of General Psychology 2007: 11(2):155-178.  
8.    Elster J. Emotions and economic theory. Journal of Economic Literature 1998: 36(1): 47-74.
9.    Fishbein M and Ajzen I. Belief, Attitude, Intention, and Behavior: An Introduction to Theory and Research. Reading, MA: Addison-Wesley. 1975.
10. The National Campaign to Prevent Teen and Unplanned Pregnancy. American Opinion on Teen Pregnancy and Related Issues 2003. 2004.
11. Miller C, Burgoon M, Grandpre J, and Alvaro E. Identifying Principal Risk Factors for the Initiation of Adolescent Smoking Behaviors: The Significance of Psychological Reactance. Health Communication 2006: 19(3):241-252
12. Suellentrop K. The Odyssey Years: Preventing Teen Pregnancy among Older Teens. Washington, DC: The National Campaign to Prevent Teen and Unplanned Pregnancy 2010.
13. The National Campaign to Prevent Teen and Unplanned Pregnancy. Fast Facts: Teen Childbearing in the United States, Final 2010 Birth Data. 2012.
14. Ernst R. Localizing the "welfare queen" ten years later: race, gender, place, and welfare rights. Journal of Gender, Race and Justice 2008: 11(1)
15. Shih M, Pittinsky T, and Ambady N. Stereotype Susceptibility: Identity Salience and Shifts in Quantitative Performance. Psychological Science 1999. 10(1):80-83.
16. Herrman J. Adolescent Perceptions of Teen Births. Obstetric, Gynecologic, and Neonatal Nursing 2008: 37(1): 42-50.
17. Kahneman D, Tversky A.  Prospect Theory: An Analysis of Decision under Risk. Econometrica. 1979; 47(2):263-291.
18. Urde M. "Core value-based corporate brand building", European Journal of Marketing 2003: 37(7/8):1017 – 1040
19. The National Campaign to Prevent Teen and Unplanned Pregnancy. Program Description. Washington DC: The National Campaign to Prevent Teen and Unplanned Pregnancy.
20. Bandura, A. Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review 1977:  84(2): 191-215.
21. Bandura A., Adams N. and Beyer J. Cognitive processes mediating behavioral change.  Journal of Personality and Social Psychology 1977: 35(3): 125-139

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