Monday, May 20, 2013

Real Cost of (Ineffective) Teen Pregnancy Prevention: A critique of New York’s Teen Pregnancy Prevention Program--Caroline Kimberly

Introduction & Background
On March 3, 2013 Mayor Bloomberg, the Deputy Mayor for Health and Human Services announced the roll out of a new campaign with the goal of further reducing teenage pregnancy rates in New York City.  The campaign consists of posters in subway and bus terminals asking the question, “Think being a teen parent won’t cost you?” and of toddlers and young children saying things such as, “Honestly, mom… chances are he won’t stay with you. What happens to me?” and “Dad, you’ll be paying to support me for the next 20 years. “One depicts a toddler crying with the text, “I’m twice as likely not to graduate high school because you had me as a teen.” (1).
 The second component to the intervention is a text-based initiative in which the public can participate in learning the “real cost of teen pregnancy” through games and quizzes via text message (1). Many of the texts are just as harsh as the posters, where if you choose to follow a pregnant teenage girl, her friends call her fat at prom, she loses her best friend, and her parents kick her out of the house. New York has seen a steady increase in teenage pregnancy over the past few years and mayor Bloomberg believes that these harsh advertisements are the best way to further prevent teen pregnancy. The press release launching the new campaign outlines how the approach is meant to, “Address the issue from both an economic and social perspective, the message focuses on responsibility and the impact employment, family, education and the emotional and financial support of both parents have on a child’s well-being.” (2).
Incorporating texting and technology familiar to teens is increasingly being incorporated into public health interventions in addition to traditional methods in order to meet adolescents at a point they understand. Unfortunately most social media programs use Social Cognitive Theory, Theory of Reasoned Action and the Theory of Planned Behavior to reach teens and fail to realize important flaws in their design (3). New York’s new Teen Pregnancy Prevention Program falls into the same trap as most public health interventions. Specifically, the program incorrectly assumes that teens believe they are at risk of becoming pregnant and fails to acknowledge positive choices teens make by stereotyping the period of adolescence as one where you make bad choices. Finally, the intervention invokes psychological reactance in teens. By defining pre-marital sex as costly, inappropriate and shameful the intervention effectively encourages teens to take risks sexually out of defiance.

Flaw #1: Assumes teens accurately perceive risk
The intervention assumes that teens believe they are at risk of becoming pregnant, and that if they believe they are at risk, they will change their behavior. The assumption that adolescents believe they are at risk of pregnancy completely discounts the overwhelming research that teens tend to feel a sense of invincibility, which lowers perceived risk, in the realm of long-term health outcomes. Wickman, Anderson and Greenburg (2008) sought out to understand adolescent perceptions on what invincibility meant to them. As one teen put it, “somehow I think that it can never happen to me because it is (only) other people who have bad things happen….”(7).
 Almost all teens know that if they have unprotected sex, there is a chance they will become pregnant. However, as Kershaw et al (2003) write, sexual risk is not accurately perceived among adolescents, leading them to engage in what they believe is a minimal risk activity, unprotected sex. In a sample of adolescent females who had engaged in unprotected sex with more than one partner (i.e. high-risk behavior for STI infection), 65% believed that their behavior was only slightly or not at all risky (4).  Underestimation of perceived risk only increases as an individual engages in an increased number of risky interactions (6). In other words, as frequency of risky acts increases, real risk also increases, however perceived risk decreases, leaving those at the greatest risk with the greatest sense of false safety.  Those at the greatest risk therefore are the least likely to recognize these posters of crying babies as something to pay attention to. The posters are hung in very public and busy spaces, where passersby are likely to ignore the message, assuming it does not pertain to them. The texting aspect of the campaign must be subscribed to, and since many teens do not see themselves as needing a pregnancy prevention program, they will not subscribe.

Flaw #2: Stereotypes perpetuate behavior, not change it.
Society has effectively stereotyped adolescence as an emotionally taxing, physically awkward and challenging time in our lives. We are all taught that teens make bad choices, take unnecessary risks and disregard what parents tell them to do. While some of these characteristics can be accurate to some degree, the negative image placed on teenagers is detrimental to their health behavior. When we apply overarching stereotypes to any group, they are more likely to live up to, or down to, that stereotype. For example, the stereotypes exist that Asian Americans are particularly intelligent in math and science and that women are not as gifted in those subjects. After two separate groups of Asian American females were reminded of each of these stereotypes, and given an exam, participants scored relative to the stereotype they were reminded of (8). Those that had gender inequalities on their mind had lower scores than those that had ethnic differences on their minds. This simple experiment has important implications for the Teen Pregnancy Prevention Program. Constantly reminding teens of their risky health behavior stereotype may lead them to fulfill that stereotype. As one teen describes, “media focuses on the negative behaviors of teenagers and that because of an established negative stereotype, teens do not have the chance to prove themselves.” (7).
In addition, the intervention fails to address the reality that our society has effectively sexualized almost every aspect of our lives. Advertisements crowd airwaves and websites with overly sexual commercials advertising everything from deodorant to alcohol to clothing. Mass media has a large role in socialization processes of teens and has been referred to as “a sexual super-peer” in influencing teen behavioral practices and exposure to hypersexual media has a strong association with earlier initiation of sex among teens (5). The media’s role and the messages sent by the public health community are conflicting yet both shed a negative light on adolescents. Media constantly appeals to teens using sexual ads as they try to adapt to the changes in their body physically and mentally, and encourages teens to experience their sexual freedom.  At the same time adults, and public health interventions such as this remind teens of the risky decisions they make. The intervention does nothing to support teens in defining themselves as sexual beings in a healthy and supportive way, which would help them make better decisions and change stereotypes.

Flaw #3: Threatens teens’ freedom by stigmatizing deviant and ‘risky’ behaviors
The Teen Pregnancy Prevention Program paints a harsh portrait of teen mothers, accusing them of meaningfully putting children into an environment in which it is near impossible to thrive. The posters have an authoritative tone to them, stigmatizing teen parents as bad people. However the research shows that this preachy and negative stereotype approach to sharing information in reality completely shuts down teens’ willingness to listen. Negative stereotypes foster a hostile relationship between adolescents and adults, and create an “’us-against-them’” mentality (7). Hostile atmospheres in which adults try to tell teens what to do invoke strong psychological reactance in adolescents. Psychological reactance results in rebellion and pushes teens to experiment with their sexuality in an unhealthy context. Teens exhibit psychological reactance often through an, “No one can stop me,” or “I don't have to listen to anyone,” attitude, leading them to make risky choices (7).
  When the public health community victimizes and shames teen parents, we are only promoting stigmatization of adolescent sexual intercourse. Stigmatization effectively defines adolescent sex as a ‘deviant’ behavior and subsequently limits teen’s feeling of sexual autonomy. Psychological reactance theory describes how when we limit one’s behavior and remove their freedoms they are actually more likely to engage in that behavior. Psychological reactance has been shown to be an effective predictor of engaging in risky sexual behavior, more predictive than sensation seeking or consumption of alcohol or drugs (6).  Therefore it is essential to include a prevention method of reactance in public health interventions, something this campaign certainly does not do.

Proposed Alternative Intervention
Interventions to prevent teen pregnancy must be focused on the present, not the consequences that are to come down the road. We must also work to change the negative stereotypes surrounding teenagers and the choices they make by changing the discourse of how we approach understanding how adolescents make choices. Finally, we must not foster the “us-against-them” culture that ignites the desire to make the unhealthy choice. Therefore I propose a community action-based intervention that involves former teen parents, facilitates discussion and promotes a culture of empowerment and changing stereotypes. Community based interventions have shown promise in addressing health disparities in at risk populations (12).
The texting component of the NYC Teen Pregnancy Prevention Program is not a terrible idea, however it must be implemented in a less authoritative and accusatory way.  Text-based interventions allow teens to ask questions anonymously at anytime that is convenient to them. Therefore my intervention would have a component in which teens are provided with a phone number they can text any question they may have concerning sexual or health in general.

Focus on the here and now
Adolescents, and many adults are unable to act in logical ways in the present to protect from outcomes in the future. They simply do not recognize that becoming pregnant could really happen to them (8). Therefore it is essential to meet teens where they are rather than forcing them to think about a future they cannot envision. Showing teens the immediate implications, both positive and negative, of their actions allows them to contextualize the action. For example, Wickman et al (2011) found that telling adolescents not to smoke because their lungs will turn black in ten years elicits no behavior change, yet an intervention that tells teens their crush won’t want to kiss them because they smell bad will (7).

Change the discourse, creating a safe environment
Adolescents will likely conform to stereotypes even if they are shifted from negative to positive. Changing the discourse of the conversations about choices teens make eliminates that negative environment and provides adolescents an opportunity to prove adults wrong. Rather than behaviors being risky, it may be helpful to promote “exploratory or experimental” behavior within a safe context. Rather then telling teens their sexual desires are ‘bad’, change the discourse to trying to understand where they are coming from. Shifting vocabulary however must be accompanied by a shift in attitude by parents, community members and educators. Adults must be open to creating a supportive environment in which teens can learn and take calculated, educated risks within the context of a safe environment.
Safe environments in which to take risks greatly decreases the negative health outcomes associated with those risky behaviors. For example, participation in needle exchange programs as an injection drug user significantly decreases one’s risk of HIV infection (10). By eliminating a risk factor an creating a culture of measured risk we can greatly decrease teen pregnancy rates.

Young women must be empowered and encouraged to take control of their sexuality. My proposed intervention discards telling teens what to do and instead creates a community of teens who choose to have safe sex and are comfortable in their sexuality. Goal oriented, inclusive and constructive programs reframe teen pregnancy prevention and are essential to reaching the most at-risk populations (11).  Young women must be included in discussions and accept their desire to be recognized as sexual beings. Education programs telling them what to do will not change behavior, therefore programs that include information about relationships and sexual desire and empower them to take control of those relationships and desires will have the greatest effect. “By empowering teens—especially teenage girls whose desire is often denied or stigmatized—to recognize and take control of their own desire, they will be more in control of their sexual behaviors.” (Sisson, 2011).

Overall the Teen Pregnancy Prevention Program is an ineffective public health intervention. The program fails to acknowledge some of the most basic characteristics and personality traits of adolescents by assuming accurate perception of risk of pregnancy, promoting negative stereotypes and disseminating information with an authoritative tone. As public health professionals we must address these faults to insure that young men and women have a safe environment in which they can make educated decisions are supported by their community in taking control over becoming sexual beings and accurately perceive risk in the short term.

(1) HRA- Teen Pregnancy Prevention. “Think being a Teen Parent won't Cost you?” NYC Human Resource Administration Department of Human Services.  28 April 2013.
(3)Kylene Guse, M.A., Deb Levine, M.A., Summer Martins, M.P.H., Andrea Lira, M.H.S., Jenna Gaarde, Whitney Westmorland, Melissa Gilliam, M.D., M.P.H. “Interventions Using New Digital Media to Improve Adolescent Sexual Health: A Systematic Review.” Journal of Adolescent Health, Volume 51, Issue 6, December 2012, Pages 535–543
(4)Kershaw, Trace S., Kathleen A. Ethier, Linda M. Niccolai, Jessica B. Lewis, and Jeannette R. Ickovics. 2003. “Misperceived Risk Among Female Adolescents: Social and Psychological Factors Associated with Sexual Risk Accuracy.” Health Psychology 22 (5) (September): 523–532. doi:10.1037/0278-6133.22.5.523.
(5) L’Engle, Kelly Ladin, and Christine Jackson. 2008. “Socialization Influences on Early Adolescents’ Cognitive Susceptibility and Transition to Sexual Intercourse.” Journal of Research on Adolescence 18 (2): 353–378. doi:10.1111/j.1532-7795.2008.00563.x.
(6)Miller, Claude H., and Brian L. Quick. 2010. “Sensation Seeking and Psychological Reactance as Health Risk Predictors for an Emerging Adult Population.” Health Communication 25 (3) (April): 266–275. doi:10.1080/10410231003698945.
(7)Wickman, Anderson & Greenburg. Mary E. Wickman, PhD, RN, Nancy Lois Ruth Anderson, PhD, RN, FAAN, Cindy Smith Greenberg, DNSc, RN, CPNP. “The Adolescent Perception of Invincibility and Its Influence on Teen Acceptance of Health Promotion Strategies”. Journal of Pediatric Nursing, Volume 23, Issue 6, December 2008, Pages 460–468 .
(8)Weinstein, Neil D. 1984. “Why It Won’t Happen to Me: Perceptions of Risk Factors and Susceptibility.” Health Psychology 3 (5): 431–457. doi:10.1037/0278-6133.3.5.431.
(9)Ariely, Dan. Predictably Irrational: The Hidden Forces That Shape Our Decisions. New York, NY: HarperCollins, 2008.
(10)                 Don C Des Jarlais, PhD, Michael Marmor, PhD, Denise Paone, EdD, Stephen Titus, MPhil, Qiuhu Shi, MS, Theresa Perlis, MS, Benny Jose, PhD, Samuel R Friedman, PhD. “HIV incidence among injecting drug users in New York City syringe-exchange programmes.” The Lancet, Volume 348, Issue 9033, 12 October 1996, Pages 987–991
(11)                 Sisson, Gretchen. “Finding a way to Offer Something More: Reframing teen Pregnancy Prevention.” Sexuality Research and Social Policy. Springer Science. 2 May 2011.
(12)                 Heidi Hauser Green, M.S., M.L.I.S., Patricia I. Documét, M.D., Dr.P.H..”Parent peer education: Lessons learned from a community-based initiative for teen pregnancy prevention.” Journal of Adolescent Health, Volume 37, Issue 3, Supplement, September 2005, Pages S100–S107

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