Sunday, May 5, 2013

Faults of the New York City Teen Pregnancy Prevention Campaign – Tif Wong

In spite of valiant efforts to reduce teen pregnancy, the U.S. still has the highest teen birth rate among comparable countries (5). Teen pregnancy and childbearing in the U.S. has steadily declined since the 1950s (33). A record low number of 329,797 babies were born to women aged 15-19 years in 2011 in the U.S., for a live birth rate of 31.3 per 1,000 women in this age group (4). Although this number is still high, it represents a drop of 8% from 2010 (4).
Teen pregnancy has immediate and long-term impacts on teen parents, their children, and society: about 50% of teen mothers receive a high school diploma by 22 years of age, compared to approximately 90% of their peers who did not give birth during adolescence (4); 43% of children of teenage mothers do not graduate high school by 19 years of age, compared to 20% of children if their mother was over 22 years of age when she gave birth (23); and around $11 billion per year is spent on teen pregnancy and childbirth related issues (4).
Many factors contribute to the complexity of teen pregnancy. Interventions targeting teenage pregnancy vary in their success for reducing rates of teen pregnancy. Effective programs are found to provide basic accurate information about the risks of unprotected intercourse and methods to avoid unprotected intercourse, provide clear options to avoid unprotected sex, and select teachers or peers who appeal to the target audience to disseminate information (9). An intervention that includes the aforementioned characteristics and increases levels of personal self-efficacy can have a positive impact on teens and reduce teen pregnancy rates.
New York City Reducing Teen Pregnancy Campaign
One intervention that aims to reduce teen pregnancy rates is Mayor Michael R. Bloomberg, Deputy Mayor for Health and Human services Linda I. Gibbs, and Human Resources Administration Commissioner Robert Doar’s New York City (NYC) Teen Pregnancy Prevention Campaign. The campaign features ads addressing the “real costs of teen pregnancy for teens and their children” (3) in subways, and bus shelters throughout the five boroughs, incorporates an interactive texting component, and a YouTube Public Service Announcement. The YouTube video said to be released in late March is currently unable to be found (2, 3).
The campaign has five print ads that feature children next to strong statements about the costs and negative consequences of being a teenage parent. The five statements are: “I’m twice as likely not to graduate high school because you had me as a teen.”, “Dad, you’ll be paying to support me for the next 20 years.”, Honestly Mom… chances are he won’t stay with you. What happens to me?”, “If you finish high school, get a job, and get married before having children, you have 98% chance of not being in poverty.”, and “ Got a good job? I cost thousands of dollars each year” (2, 3). The ads also ask viewers to text ‘NOTNOW’ to a short code to find out the “real price of teen pregnancy” (3). ­­Once viewers opt in to the campaign’s texting portion, they are sporadically texted facts of teen parenthood, benefits of delaying pregnancy, interactive games, and quizzes.
Criticism of Intervention 1: The Intervention Does Not Provide Information on Methods to Avoid Teen Pregnancy
Interventions that provide the audience factual information and methods to avoid unprotected intercourse are effective (9, 27). An intervention that is aimed at teens, but does not provide clear options to avoid the outcome of teen pregnancy is extremely inefficient (9). The intervention firstly assumes that teens will remember one of the campaigns ads, long enough to make an impact on their behavioural choices. Secondly, the intervention assumes that the teen will remember to either go to the campaigns website, or opt in to the campaigns texting program. Lastly, the intervention assumes that hard-hitting statements are enough to deter teens from engaging in sexual activities. Even if these assumptions are valid, teens that are impacted by these statements, but want to engage in protected sex are overlooked.
The campaign’s opt-in texting initiative focuses solely on the realities of teen parenthood and the benefits of delaying pregnancy; no information is provided on the use of contraceptives as a method to reduce teen pregnancy. The texting initiative assumes that the targeted teens are able to pay for the standard messaging rates. This may prevent two-thirds of the campaigns target audience from participating in the texting initiative, as pregnancy is both a cause and a consequence of teen pregnancy (1).
The HRA Teen Pregnancy page at also predominately focuses on the benefits of delaying pregnancy, only one out of the ten quick links explicitly provides information on contraceptives. The link to ‘Contraceptives Information’ is located at the very bottom of the quick links bar. This cumbersome process to obtain information on contraceptives is ineffective for teens that need information immediately, and for teens that do not have a smart phone to immediately access the page.
Key information on methods to avoid teen pregnancy is needed in order for this intervention to be effective in reducing teen pregnancy.
Criticism of Intervention 2: The Deliverer of the Message Does Not Match the Intended Audience
The deliverer of an intervention campaign’s message should be carefully selected as they represent the face of the intervention. The messenger is a model that usually appears along side the message, demonstrates behaviour, or provides a testimonial that a campaign promotes. The model is crucial in attracting attention, influencing perceived self-efficacy, personalising abstract concepts, bolstering belief formation due to source credibility, and facilitating retention due to memorability (7). The NYC Teen Pregnancy Prevention Campaign uses children as the messengers. Although these children appeal to viewers’ emotions, they are not the most effective models for a campaign targeting teens.
Messenger credibility is a crucial factor in public health campaigns (13). The messenger does not always have to be knowledgeable on a particular subject to be effective in promoting adolescent behaviour change (23). Children, as messengers, for a teen pregnancy prevention campaign are powerful as they represent the consequence of teen pregnancy. But, this is not the most important characteristic for an adolescent audience. Teens respond more positively to behaviour change programs with relatable messengers in a context that is familiar to adolescents (22, 28). Children messengers that carry hard-hitting statements would probably only serve to shock teens, and promote short-term behaviour change, but yield little long-term behavioural change (34).
Inappropriate selection of messengers is a common flaw in behaviour change campaigns (22). The current intervention prioritises shock, and initial emotional response over similarity. This is a poor choice for a behavioural change campaign, as teens relate better to similar individuals, and respond more positively to these individuals (9, 17, 22, 32). Supporters of this campaign may argue that toddlers are effective messengers because toddlers are often difficult to take care of, as they usually are only capable of saying few words, cry frequently, and require a lot of attention. However, teens with personal experience with younger siblings who have positive experiences with toddlers are excluded from the behavioural change campaign. Furthermore, toddlers are very different from teens, so it is unlikely that adolescents would remember the campaign ads (9, 22). Healthy, happy teens that are the children of a teen parent are at high-risk for being teen parents themselves (9, 24), but may also fail to identify with the campaign ad due to differences in personal experience.
Criticism of Intervention 3: The Intervention Creates Guilt, Fear, and Stigma in order to Change Behaviour
Interventions that utilise fear and shame as a method to illicit behavioural change are ineffective long-term, and usually create the opposite effect of the desired behavioural change (6, 10, 8, 34,). Even when fear arouses the interest of the audience, the desired health behavioural change may not occur (20). Strong statements that perpetuate stereotypes about teen parents and their children may do more harm than good. The intended audience may react to the statements with feelings of guilt, shame, or frustration (10, 11, 17, 18). Teen mothers or pregnant teens may feel these emotions more acutely as they cannot achieve the desired outcome of delaying parenthood (11, 17, 18). For these teens, the intervention may reinforce self-blame, and helplessness because the intervention does not also provide appropriate support networks or resources (11, 17-19). ‘Targets’ of the intervention may even hide their problems or not seek support due to feelings of shame and guilt (17, 19).
An unintended effect of this intervention is the label and stigma that it creates. The intervention utilises strongly worded statements accompanied by innocent looking toddlers that scare the intended audience about the potential hazards of teen pregnancy, and thus raise their motivation to avoid it (17, 19). This inadvertently creates a negative image of pregnant teens and teen mothers. Once stereotypes and stigmas are established, the teen mothers or pregnant teens may be ostracised, regarded as deviant, and even blamed for engaging in immoral behaviours that elicited the ‘punishment’ of their affliction (17, 18). This type of social climate within schools and in communities can be devastating for the vulnerable adolescents (18), as the teen years are a critical period of time for development (21, 26, 31).
Children of teen mothers may also experience feelings of shame and be stigmatised, as they are the messengers the NYC Teen Pregnancy Prevention Campaign. This may create an unintended effect of the child devaluing and undermining the parent-child relationship.  A campaign that instills guilt, fear, and stigma is inefficient for creating the desired behavioural change.
New Intervention Proposal: Utilise the Media to Provide Neutral Comprehensive Information with Methods to Achieve Behavioural Changes, and Shift Social Norms
An intervention that aims to reduce teen pregnancy must fulfill several objectives in order to be effective and successful. A new intervention that does not focus solely on negative aspects of teen pregnancy and motherhood, and rely on fear tactics will reach a larger audience, decrease stigma, and influence social norms. The intervention will utilise the existing framework of the current NYC Teen Pregnancy Prevention, but will be re-modeled. The re-modeled campaign will feature teens in the ads instead of children. The ads will be located in the same places they are now. The statement displayed next to the teens will be messages promoting the positive aspects of delaying future teen pregnancy. The ads will also contain a brief message regarding a website where teens can go for clear methods to delay future pregnancy, and where teen mothers can go to for help. The messages will have a neutral tone and encourage teens, pregnant teens, and teen mothers to all seek more information. The QR code located on the ad will bring the viewer directly to a website where the participant can click through to separate websites dedicated to teens, pregnant teens, and teen mothers. The mobile portion of the campaign will contain inspirational quotes for teens to prevent future teen pregnancy, offer clear methods on how to avoid future teen pregnancy, have interactive games and quizzes on the different types of methods to avoid future teen pregnancy, and direct teens to services that help prevent future teen pregnancy.
Short videos to be played during commercial breaks on television channels such as MTV, VH1, Bravo, and E!, will be used instead of a YouTube video. These short videos will feature teen characters discussing teen pregnancy prevention options in a setting familiar to teens. At the end of the segment a character will include a brief statement about where to obtain more information for teens, pregnant teens, and teen mothers, interested in learning more about future pregnancy prevention and methods to reduce pregnancy related stressors. Popular teen celebrities will also be featured in some of the short videos discussing methods to prevent teen pregnancy, explaining why teen pregnancy prevention is important, and promote future teen pregnancy prevention.
A new press release that highlights the positive aspects of future teen pregnancy prevention, clear methods to avoid teen pregnancy, and ways to alleviate stressors and obtain aid as a teen mother will be distributed to all state press outlets. The subsequent media attention will then attract more public attention and generate positive discussions about the new teen pregnancy prevention campaign.
Defense of New Intervention 1: Promotion of Options to Prevent Future Teen Pregnancy Prevention
Discussing multiple methods for preventing future teen pregnancy will allow teens to be aware of the various methods available. By also stating the campaign is to prevent ‘future’ teen pregnancy the campaign is including teens that are pregnant and teen mothers. The addition of the website to where teens may learn more information about preventing future pregnancy creates an easy and direct path to obtain comprehensive information.
Psychological Reactance Theory explains the behaviour of individuals who expect certain freedoms and who are then restricted in their free behaviours (29, 32) the individuals experience and unpleasant motivational arousal with the aim to restore their freedom and minimize future threats (29, 32). Persuasive messages in behavioural change campaigns implicitly or explicitly limits an audience’s freedom. (29). Messages that contain strong controlling language, that gives orders, focuses on denial, or offers proof of consequences have been found to elicit reactance (29). Behavioural change campaigns that cause reactance may undermine the effectiveness of a persuasive message, and have a significant negative impact on attitudes of the intended audience (29, 32).
The new intervention minimises psychological reactance theory by providing options for the teen, and utilising positive non-controlling language. By offering choices, teens realize that there are other alternatives to teen parenting, different methods to avoid teen parenting, and there are resources to help minimize the difficulty of teen parenting. This results in minimal reactance, as there is more freedom. Pregnant teens and teen mothers will not have feelings of anger, or shame because the new ads include them and offer help to them. The new ads seek to elicit feelings of hope and empowerment. By offering hope and empowerment instead of fear and shame, teens will react less negatively to the campaign. The short video also seeks to minimize reactance by use of narratives from teen peers and popular teen celebrities (29).
Agenda Setting Theory explains media influence on public opinion and politics. Increased media attention is believed to increase general population concern, and thus, awareness on a particular issue (14). The media is influential in shaping public opinion and priorities (25). This is especially true if the issue is presented in a positive atmosphere by respected and trusted media entities (25) By increasing public awareness about teen pregnancy and multiple methods to prevent teen pregnancy, public support and positive discussions surrounding teen pregnancy prevention will be improved.
Defense of New Intervention 2: Peers and Teen Celebrities are Effective Messengers for Adolescents
Peers and teen celebrities will be much more effective messengers for an adolescent behavioural change intervention. Teen peers help adolescents relate to the message, while popular teen celebrities reinforce to message of the campaign. Celebrity endorsed messages are found to be effective in influencing the behaviour of the intended audience (6). Having the intervention displayed on television will ensure that adolescents are exposed to regularly and repeatedly to the campaigns message (8).
Social Cognitive Theory explains the impact figures from the media and popular culture have on adolescents. The theory is largely based on observational learning, and an individual’s interaction with their environment (12). According to the theory, any single factor will not be sufficient for long-term behavioural change (27). Instead, reduction in teen pregnancy is most likely to occur when both environmental opportunities are presented and strong affirmative behavioural correlates exist (27). By presenting methods and resources to prevent teen pregnancy with relatable peers and popular teen celebrities, the intervention will be more effective. This is also the case for pregnant teens and teen mothers who wish to prevent future teen pregnancies.
Teen celebrities are effective for eliciting behavioural change as they provide cultural material for forming values and beliefs. They are ideal messengers for adolescent interventions as they are recognizable, well-liked, and perceived to be similar to teens. Adolescents form para-social relationships with media figures, and seek to apply the observed behaviour in their own lives (23). This is due to the teen feeling as if they know the figure as a friend (23). Using messengers that are relatable will increase the effectiveness of the intervention and produce behavioural changes.
The theory also explains that the primary and most direct facilitator of behavioural change is perceived efficacy (27). Self-efficacy has indirect effects on behaviour through outcome expectations, environmental perceptions, social modeling and social support (16). The intervention seeks to increase self-efficacy by creating simple steps to reduce teen pregnancy. By displaying the website on the ads and referencing a website in the short videos the intended audience will be able to go directly to the website to find methods to prevent teen pregnancy. Having the steps clearly stated will increase self-efficacy, as adolescents will know exactly what steps to take in order to avoid teen pregnancy. Increased self-efficacy has been shown repeatedly to increase health behavioural change.
The mobile portion of the campaign will also increase self-efficacy (15) as the texts provide inspirational quotes, neutral informational texts, and interactive games and quizzes that seek to increase knowledge and awareness about existing pregnancy prevention methods.
Defense of New Intervention 3: Positive Presentation of Will Facilitate Behavioural Change
Generation of positive discussion about the intervention will influence behavioural change. The discussion will likely shift social norms and make teen pregnancy prevention a more prominent topic and behaviour. The discussion will also benefit pregnant teens and teen mothers as the campaign has resources for them too. Social Norms Theory explains the comparison of an individual’s own behaviour to peer and social norms (30). Most people tend to adopt group attitudes and actions for social acceptance (35). An intervention that promotes discussion about preventing teen pregnancy, educates different methods to avoid future teen pregnancy and discusses the truth about teen pregnancy in a neutral manner, will likely promote behavioural changes. The campaign will create the perception that regular discussion about the teen pregnancy prevention and resources for teen mothers is standard adolescent behaviour. Featuring short videos on popular adolescent channels will enhance this perception and increase the effectiveness of the campaign (7). Shifting social norms to focus on the positive aspects of delaying pregnancy while positively supporting efforts to reduce the burden of already pregnant teens will help create a supportive environment for preventing future teen pregnancy.
The altered social norms will reduce the stigma associated with teen mothers and pregnant teens, and make the issue a standard topic of discussion. The media will also help alter social norms with frequent discussion on the topic. Negative stereotypes and misconceptions about teen mothers will be replaced by the knowledge portrayed in the campaign. The media will also focus on the extensive methods to avoid teen pregnancy and resources for teen mothers. The frequent media coverage on teen pregnancy prevention will create a positive feedback loop that generates even wider discussion about the topic and increase overall understanding about future teen pregnancy prevention. Increased discussion will also improve the likelihood of communities being more understanding and sympathetic to teen mothers, and increase the effectiveness of reducing teen pregnancy.
             Teen pregnancy prevention is a very difficult multi-factorial issue to address. Efforts to reduce teen pregnancy are commendable, but behavioural change interventions that have relatable figures presenting information, and provide basic accurate information about the risks of unprotected intercourse with clear methods of avoiding unprotected intercourse are proven to be more effective in eliciting behavioural changes than fear based campaigns (18). This modified intervention will reduce future teen pregnancy by giving adolescents the information and resources needed for the desired behaviour change.
(1) Teen Pregnancy Prevention. 2013; Available at: Accessed 05/25, 2013.
(2) The Real Cost of Teen Pregnancy. 2013; Available at: Accessed 05/23, 2013.
(3) HRA Launches New Teen Pregnancy Prevention Campaign. 2013; Available at: Accessed 05/23, 2013.
(4) About Teen Pregnancy. 2012; Available at: Accessed 05/25, 2012.
(5) Teen Birth Rates: How Does the United States Compare? 2012; Available at: Accessed 05/26, 2012.
(6) Agha S. The impact of a mass media campaign on personal risk perception, perceived self-efficacy and on other behavioural predictors. AIDS Care 2003 12/01; 2013/04;15(6):749-762.
(7) Bonnie RJ, O'Connell ME. Media Intervention Impact: Evidence and Promising Strategies. 2004.
(8) Brown JD, Witherspoon EM. The mass media and American adolescents’ health. Journal of Adolescent Health 2002;31(6):153-170.
(9) Card JJ. Teen pregnancy prevention: do any programs work? Annu Rev Public Health 1999;20(1):257-285.
(10) Chapple A, Ziebland S, McPherson A. Stigma, shame, and blame experienced by patients with lung cancer: qualitative study. BMJ 2004;328(7454):1470.
(11) Cho H, Salmon CT. Unintended Effects of Health Communication Campaigns. J Commun 2007;57(2):293-317.
(12) Dennis EA, Potter KL, Estabrooks PA, Davy BM. Weight gain prevention for college freshmen: comparing two social cognitive theory-based interventions with and without explicit self-regulation training. Journal of Obesity 2012;2012.
(13) Dorey E, McCool J. The role of the media in influencing children's nutritional perceptions. Qual Health Res 2009;19(5):645-654.
(14) Dunaway J, Branton RP, Abrajano MA. Agenda Setting, Public Opinion, and the Issue of Immigration Reform*. Social Science Quarterly 2010;91(2):359-378.
(15) Evans WD, Wallace JL, Snider J. Pilot evaluation of the text4baby mobile health program. BMC Public Health 2012;12(1):1031.
(16) Glanz K, Rimer BK, Viswanath K. Health behavior and health education: theory, research, and practice. : Jossey-Bass; 2008.
(17) Guttman N, Ressler WH. On being responsible: Ethical issues in appeals to personal responsibility in health campaigns. J Health Commun 2001;6(2):117-136.
(18) Guttman N, Salmon CT. Guilt, fear, stigma and knowledge gaps: ethical issues in public health communication interventions. Bioethics 2004;18(6):531-552.
(19) Guttman N, Zimmerman DR. Low-income mothers' views on breastfeeding. Soc Sci Med 2000;50(10):1457-1473.
(20) Hale JL, Dillard JP. Fear appeals in health promotion campaigns: Too much, too little, or just right? 1995.
(21) HERTZMAN C. The Biological Embedding of Early Experience and Its Effects on Health in Adulthood. Ann N Y Acad Sci 1999;896(1):85-95.
(22) Juarez P, Schlundt DG, Goldzweig I, Stinson N. A conceptual framework for reducing risky teen driving behaviors among minority youth. Injury Prevention 2006;12(suppl 1):i49-i55.
(23) Klepp K, Flisher AJ, Kaaya SF. Promoting adolescent sexual and reproductive health in East and Southern Africa. 2008.
(24) Maynard RA, Hoffman SD. The costs of adolescent childbearing. Kids having kids: Economic costs and social consequences of teen pregnancy 1997:257-284.
(25) Meraz S. Is there an elite hold? Traditional media to social media agenda setting influence in blog networks. Journal of ComputerMediated Communication 2009;14(3):682-707.
(26) MILLER–JOHNSON S, WINN D, COIE J, MAUMARY–GREMAUD A, HYMAN C, TERRY R, et al. Motherhood during the teen years: A developmental perspective on risk factors for childbearing. Dev Psychopathol 1999;11(01):85.
(27) Nehl EJ, Blanchard CM, Kupperman J, Sparling P, Rhodes R, Torabi MR, et al. Exploring Physical Activity by Ethnicity and Gender in College Students Using Social Cognitive Theory. ICHPER-SD Journal of Research 2012;7(2):11-17.
(28) Nitz K. Adolescent pregnancy prevention: a review of interventions and programs. Clin Psychol Rev 1999;19(4):457-471.
(29) Rains SA. The Nature of Psychological Reactance Revisited: A MetaAnalytic Review. Human Communication Research 2013;39(1):47-73.
(30) Reid AE, Cialdini RB, Aiken LS. Social norms and health behavior. Handbook of Behavioral Medicine: Springer; 2010. p. 263-274.
(31) Steinberg L. Cognitive and affective development in adolescence. Trends Cogn Sci (Regul Ed ) 2005;9(2):69-74.
(32) Steindl C, Jonas E. What Reasons Might the Other One Have?—Perspective Taking to Reduce Psychological Reactance in Individualists and Collectivists. Psychology 2012;3(12A):1153-1160.
(33) Ventura S, Hamilton B. US teenage birth rate resumes decline.NCHS data brief, no 58.Hyattsville, MD: National Center for Health Statistics.2011 .
(34) Wiley DC. The Ethics of Abstinence-Only and Abstinence-Plus Sexuality Education. J Sch Health 2002;72(4):164-167.
(35) Wolf MM, Dana A, Wolf MJ, Petrela EQ. A Case Study Examination of Social Norms Marketing Campaign to Improve Responsible Drinking. Journal of Food Distribution Reasearch 2012;43(1):96.

No comments:

Post a Comment