Sunday, January 5, 2014

New York City’s Teen Pregnancy Prevention Campaign: A Closer Look at a Flawed Intervention – Christine Zakhour


Introduction
Over the last two decades, the United States has seen a steep decrease in teen pregnancies; however, the rates continue to tower above those in peer countries in the developed world (1). In early 2013, the New York City Human Resources Administration (HRA) released a new campaign in an effort to reduce teen pregnancy rates in New York City. Mayor Michael Bloomberg along with Deputy Mayor for Health and Human Services (HHS) Linda Gibbs and HRA Commissioner Robert Doar announced the new campaign in a Press Release on March 3, 2013. The focus of this health initiative is to warn teenagers of what is at stake if they choose to become a teen parent. Mayor Bloomberg supports the campaign, stating that it “makes it very clear to young people that there’s a lot at stake when it comes to deciding to raise a child” (2).
The New York City Teen Pregnancy Prevention campaign consists of four components. The first component is an info-graphic, which users access through a link on the campaign’s homepage within the HRA website. The infographic focuses on females ages fifteen to nineteen years old and lists statistics about the number of teen pregnancies in New York City divided by neighborhood, New York City’s rates of pregnancy compared to the United States, and several other relevant factors, including costs of pregnancy and raising a child. In addition, the graphic includes national statistics about teen moms, including high school and college graduation rates and the likelihood of teen dads marrying the mother of their child. The second component of the campaign is a series of short videos featuring young women and men who were teen parents. The third and largest component of the campaign is print ads, displayed on bus shelters and in subways throughout New York City. These ads show pictures of babies, some of which are crying, with hard-hitting facts and statistics about teen pregnancy. All of these ads feature the last, interactive texting component of the campaign. Each ad instructs pedestrians and commuters to text “NOTNOW” to a specified number and those who text are presented with a teen parenting scenario and subsequently sent statistics about teen pregnancy.
While New York City’s campaign has admirable goals and emphasizes the continued need for public health intervention in the realm of teen pregnancy prevention, there are several flaws that limit its effectiveness in reducing teen pregnancy. This critique will explore three primary faults in the New York City Teen Pregnancy Prevention Campaign, including the overemphasis on risk communication and long-term consequences, use of ineffective messengers, and focus on fear tactics, contributing to the stigmatization of teen pregnancy.
Critique Argument 1: Focuses too heavily on risks and long-term consequences, without accounting for adolescents’ reactions

            Health campaigns geared toward the adolescent population must appropriately address that specific population in order to be effective. The first flaw in the campaign is that it focuses too heavily on risks and long-term consequences, without anticipating youth’s innate reactions that include optimistic bias and illusion of control. Many studies indicate that health campaigns can be effective in creating awareness, but “have had little impact on adolescent behaviors” (3). This campaign focuses on messages about the long-term risks and consequences of teen pregnancy. Thus, the core value of the messages in this campaign is freedom and how freedom will be taken away at a later date if teens were to get pregnant. While freedom is a strong frame for this campaign, there is no educational component that teaches and prepares teenagers how to exercise their freedom in the short-term. The ads simply imply that teenagers should avoid getting pregnant in order to keep their freedom and avoid the negative consequences of pregnancy and raising a child as a teenager. Without a preparation component on information about access to contraception, the campaign is incomplete. “The ultimate goal of any framed message is to promote a particular behavior”, however, it is unclear whether that behavior is condom-use, abstinence, or some other preventative measure (4). A critical flaw in the Teen Pregnancy Prevention campaign is the focus on long-term consequences, like raising a child, rather than short-term prevention measures, like safe sex.
            The Teen Pregnancy Prevention Campaign assumes that simply stating the facts will resonate with teenagers and promote better decision-making, however, it fails to account for inherent responses, such as optimistic bias, among this population. Optimistic bias is a phenomenon in which individuals feel that they are less likely to experience negative events and more likely to experience positive events than others (5). Thus, despite the warnings of teen pregnancy conveyed through New York City’s new ad campaign, optimistic bias indicates that many teenagers will be unaffected by these messages and perceive their chance of becoming pregnant as lower than their peers. Research has shown that adolescents are often aware of risky behaviors, however, they choose not to alter their behaviors simply because they personally feel less at risk (6). The level of risk-taking is possibly exacerbated among this age group due to adolescent information processing and the adolescents’ current state of cognitive development (6). The Teen Pregnancy Prevention Campaign may promote hard-hitting and effective messages about teen pregnancy, but those messages will not resonate with the targeted age group if the campaign does not account for optimistic bias and the resulting rationalization of risky behavior.
            Many studies have found that for individuals, “the greater the perceived control over the outcome of an event, the greater the optimistic bias for that event” (7). This can become a cyclic process, where control may make a person feel like they will only have positive outcomes or will avoid negative ones, and positive outcomes may make a person feel more in control. Additionally, people often overestimate their self-control when it comes to decision-making, a thought process similar to optimistic bias. Illusion of control is a theoretical idea, which explains the extent of control that people believe they have over their lives, even in chance situations (8). When combined with optimistic bias in this campaign, the illusion of control indicates that adolescents are likely to feel that they have a great amount of self-control and will abstain from unprotected sex, or that the odds for avoiding pregnancy will work in their favor if they do have unprotected sex. Ariely et al. looked further into the combination of optimistic bias and illusion of control and conducted a study in which they measured the effects of sexual arousal in decision-making among college-aged male students and found that sexual arousal “seems to decrease the relative importance of other considerations such as behaving ethically toward a potential sexual partner or protecting oneself against unwanted pregnancy” (9). Based on this study, it is clear that health campaigns that tell teens to simply avoid risks that may lead to unintended consequences are misguided and will be ineffective. Many researchers have explored the hot-cold empathy gap, which explains how when people are in a cold state, they do not accurately predict the decision that they’ll make when they are in a hot or aroused state (10). The campaign does not adequately equip teenagers to make an informed decision in this hot state and essentially has no educational component. In order to promote safe sex among teenagers, it is necessary to teach them either how to avoid temptation or be prepared if or when they succumb to that temptation (10). The Teen Pregnancy Prevention Campaign is sorely lacking in these areas and does not teach teenagers about how to overcome the illusion of control and be prepared in situations in which they must make a decision in a hot state of mind rather than a cold, rational one.  
Critique Argument 2: Uses ineffective messengers
            Of critical importance in any public health campaign is the use of effective messengers to convey the health message. The messenger is a key component in determining the success of a campaign, as each messenger can draw attention to it and strengthen the audience’s beliefs through their perceived credibility (11). For a message to be effective, the audience must like the messenger. Messengers enhance a campaign and draw the target audience by “being engaging (attractiveness, likability), credible (trustworthiness, expertise), and relevant to the audience (similarity, familiarity)” (12). Regarding the Teen Pregnancy Prevention Campaign, messengers that are similar to the audience (teenagers) would convey the message best. Peer models are the most effective messengers for youth and minorities because they are perceived as more trustworthy than other conventional sources (13). Models are incredibly important for the success of a public health campaign because with ineffective messengers, a program can lose credibility among its target audience.
New York’s Teen Pregnancy Prevention campaign fails to employ effective messengers. The target audience for the campaign is teenagers, however, the campaign uses babies and older young adults who had babies as teens as messengers. The print ads, the most visible part of the campaign, highlight images of crying babies. Babies and children are not effective messengers for the Teen Pregnancy Prevention Campaign because they are distant consequence of unprotected sex and dissimilar to teenagers, the targeted audience. The print ads, however, are not the only visible medium with ill-suited messengers. Additionally, the campaign’s main webpage features a series of short videos showcasing young adults who were teen parents. The advocates in the video appear to no longer be teenagers. In the videos, each parent talks about his or her own story, including costs of his or her child, the importance of pregnancy prevention, and the loss of adolescence as a result of parenting. Both victims and ordinary people who convey negative health outcomes from personal experience can be effective messengers (13). In this case, however, because they are already parents and seem to no longer be teens, they become less credible to the target population. While the messages are meaningful, these young adult messengers are simply unable to capture the attention of teens effectively because there is no level of similarity that exists.
Therefore, one of the campaign’s major flaws is that the campaign materials do not account for the prevalence and importance of peer influence among teens. Peer influence is an important factor in “adolescent risk-taking”, and research has shown that teens who participate in risky behaviors felt validated by friends who also partake in similar behaviors (14). The campaign loses efficacy when there is no peer role model for the target audience to engage with and be influenced by.
Critique Argument 3: Uses Fear as motivation and stigmatizes teen pregnancy

            Another critical flaw in the Teen Pregnancy Prevention Campaign is that the majority of the messages are harsh and negative, creating a stigma around teens who become pregnant. Much of the content of each component of the campaign focuses on the negative consequences of teen pregnancy. The infographic, for example, displays warning statistics such as “8 out of 10 teen dads don’t marry the mother of their child” and “more than half of teen mothers never graduate from high school” (15). In addition, the print ads on bus shelters and in subways around the New York City deliver the aforementioned statistics through harsh messages such as “I’m twice as likely not to graduate high school because you had me as a teen” or “Honestly Mom… chances are he won’t stay with you. What happens to me?” (16). The texting component of the campaign, which has been under fire in the media as of late, includes a hypothetical situation involving a teen who is ostracized by her parents, friends, and boyfriend for getting pregnant, with her best friend calling her a “loser” at prom (17). Teen pregnancy interventions should be focused on education and prevention, rather than isolating and stigmatizing pregnant teenagers or teenagers raising children.
These negatively framed and harshly stated facts are not helpful for teens and stigmatize much of the campaign’s targeted population. Teens dealing with poverty already may feel isolated and stigmatized and tend to be more at risk for teen pregnancy. In reality, and as stated in the infographic, the majority of teenagers who had unintended pregnancies in New York City were living in poverty, and teen pregnancy rates were over 2.5 times higher in high poverty neighborhoods compared with low poverty neighborhoods (15). Many studies have shown that pregnant teens already feel stigmatized by their pregnancy and experience feelings of isolation and despair (18). A campaign that reinforces negative feelings through negative messaging is unlikely to effectively communicate with youth.   
The Teen Pregnancy Prevention Campaign’s messages, based on fear tactics, and, perhaps unintentionally, stigma around teen pregnancy, also have the possibility of evoking defense mechanisms among high-risk teens. The terror management theory (TMT) explains the potentially defensive reaction among teens. TMT provides that mortality and negative thoughts can negatively influence behaviors (19). In campaign, as teens are bombarded with negative thoughts and threats of pregnancy, they could react by doing the exact behavior they are being warned against. According to TMT, teens could perceive the campaign’s messages as threatening as well as anxiety-inducing, and as a result, they could employ this defense tactic (20).
Feelings of fear and degradation from the campaign’s harsh messages can also provoke reactance among teenagers. Reactance is a state in which people feel motivated to cling to a belief or behavior when they feel that their freedom is threatened (21). As mentioned previously, the core value of the teen pregnancy prevention campaign is freedom. The ads imply that teen pregnancy will take away a teen’s freedom. The campaign is unclear regarding whether it wants students to use contraceptives or abstain from sex altogether, but at a minimum, it is implying that adolescents should avoid unprotected sex. According to Silvia, “when a communicator delivers a message that contains a threat to freedom, the message creates a positive force to comply as well as a stronger force to react” (21). By employing values and messages that threaten teens’ freedom, the campaign may actually create a paradoxical effect, possibly encouraging the behavior it is trying to warn against (22). For instance, instead of adopting safer sex behaviors, teens may feel more inclined to take risks. The psychological reactance theory addresses the potential for riskier behavior among teens and can provide health campaigns with a framework for understanding adolescents’ responses to health campaigns (22). However, it is clear that this specific campaign does not address the theory of psychological reactance.
Proposed Intervention
New York City’s Teen Pregnancy Prevention campaign must be revised to account for several social and behavioral constructs in order to succeed and not meet the fate of many other failed public health campaigns. The campaign can be an effective intervention in teen pregnancy prevention in New York City by following a framework that is more heavily based on theories of mass communication and, specifically, advertising theory. By taking an approach similar to Florida’s anti-smoking “truth” campaign, a peer-led “movement”, the Teen Pregnancy Prevention Campaign can create better awareness of the consequences of teen pregnancy through media (23). Advertising theory and social marketing focus on the audience and attractively selling the social product (12). The Teen Pregnancy Prevention Campaign should continue to use each component of the campaign, including the texting, print ads, infographic, and videos, but should alter them significantly. The campaign should more heavily focus on selling the concept of freedom to teenagers. Consequently, the campaign should make the promise of freedom appealing to teenagers by suggesting, for example, that if teenagers have safe sex, they are more likely to be successful in life and achieve their dreams. Each component of the ad should highlight this concept.
Simple changes, such as retitling the campaign to “Join the Safer Sex Movement: The Freedom to Live your Life,” can make the campaign much more appealing to the target audience. With this simple change to the title, the campaign uses key words such as “join” and “your” to create feelings of ownership among youth. A key component of the improved campaign should involve a peer-led movement, with campaign messengers being teens themselves. A peer-led campaign can contribute to better feeling of control among the targeted teenagers. Framing the core value of the campaign as preserving freedom, rather than taking it away can also help make teenagers feel more empowered. With peer teenagers being the primary messengers in the campaign, the print ads should no longer feature pictures of the babies and the videos should be led primarily by teens. The campaign can feature a couple videos about pregnant teens, but they should still be around the same age as the target audience. Pregnancy is more of an immediate threat to teenagers rather than the longer-term consequence of actually raising the child. Additionally, according to the law of small numbers theory, people are more likely to believe in small samples and numbers rather than statistics based on a larger population that is less tangible (24). Thus, featuring pregnant teens in some of the videos that are similar and familiar to the audience may make the consequences more believable.
The Teen Pregnancy Prevention Campaign should continue to employ risk messaging, but to compliment adjusting the core value of freedom, the messages should similarly be framed in a more positive way. For example, instead of the accusatory tone that many of the print ads and negatively framed statistics currently employ, the campaign should focus more on positive statistics, like its one positive message: “If you finish high school, get a job, and get married before having children, you have a 98% chance of not being in poverty” (16). Instead of asking the disdainful questions at the bottom of each ad, such as “think being a teen parent won’t cost you?” or “are you ready to raise a child by yourself?”, the ad should highlight the safer sex movement and how safe sex offers freedom to teenagers (16).
After changing the messaging to focus on safe sex, the campaign should offer teenagers a venue to learn more about preventing teen pregnancy. The campaign should offer options and advice on how to avoid pregnancy, such as through using birth control or being abstinent. The campaign should have a texting option that refers teenagers to information about where they can access free condoms, contraceptive care, and nearby health centers in their city, instead of the current texting scenario that only involves stories and statistics. In addition, the campaign should include such information should be included online so teenagers are better informed about how measures that prevent unintended pregnancies are the key to freedom.
To solve the faults of the current campaign, there are several specific interventions that this paper will discuss more in depth below. For the Teen Pregnancy Prevention Campaign to succeed, it must account for optimistic bias, focus on short-term consequences and prevention measures, use effective messengers, and deflect psychological reactance through anticipating innate behaviors.
Intervention 1: Anticipate optimistic bias and focus on the now
There are several ways that risk messages can be conveyed in a more effective way in order to create less negative reactions. This includes anticipating these reactions initiated by innate behaviors such as the illusion of control and optimistic bias, and offering teenagers an educational component to help them understand how to protect themselves in the moment. Creating an educational component to the campaign would also allow it to place more emphasis on more short-term solutions for teenagers, rather than focusing too heavily on the long-term consequences. While it is important to convey negative consequences that go along with a behavior, it is necessary to do so in a more immediate, plain sight way.
In order to overcome the illusion of control, the campaign must offer ways for teenagers to feel more control over their lives. Thus, the campaign should frame its messages around giving teens freedom and promoting preventative measures as a source of freedom. Creating an educational component to the campaign will allow teenagers to understand and implement preventative practices and ultimately have safe sex if they choose to do so. In addition, offering teens a variety of information sources concerning how teens can control their decisions, including information about local clinics and contraception, can help teens to embrace their feeling of control. 
Teenagers perceive themselves as being able to make choices and are less aware of their judgmental limitations (22). Thus, it is important that through this unintended pregnancy prevention campaign, teens are taught how to understand how decisions in a hot state differ from decisions in a cold state and how to be prepared to practice safe sex in either state (10). This may help the campaign overcome optimistic bias. In addition, implementing the law of small numbers theory through the use of peer messengers and videos featuring peers could help teenagers overcome optimistic bias. Teenagers may be less likely to dismiss the message if their peers, who are similar to them, share individual stories about their experience with unprotected sex or unintended pregnancies. This is likely to be more impactful than the current messengers, who are babies and young parents.
Intervention 2: Use effective messengers
            The Teen Pregnancy Prevention Campaign can employ more effective messengers by using the peer-leadership model. Studies have demonstrated the positive effect of peer education on interventions of risky sexual behaviors, including resisting peer pressure and having unprotected sex (25). Peers as messengers can elicit a more positive response among the target audience, as they can be thought of as more credible and personal (12). In addition, having an effective messenger can break down barriers and help in avoiding optimistic bias, as mentioned in Intervention 1. The improved Teen Pregnancy Prevention Campaign should use teenagers who are from New York and live in the same neighborhoods as the target population. Additionally, the new messengers should vary in terms of race, gender, and background to make the campaign inclusive, without being too broad. This will help teenagers better grasp messages when people just like them say, “I’m like you. It can happen to you because it happened to me” (3). Peer pressure should not be undervalued in public health campaigns directed at teenagers, as it can be both a negative and positive force.
Intervention 3: Empower teenagers to make good decisions
            Adolescents will experience psychological reactance if they feel that they are being told what to do by forms of authoritative control (22). This is another reason why peer-led movements can enhance this campaign and reduce unintended consequences such as psychological reactance. Research has proven that reactance can occur when people perceive their freedom as being threatened (21). Thus, framing the campaign in a way that offers teenagers freedom, rather than taking away their freedom, will help to reduce reactance. The message should be that preventing unwanted pregnancies by having safe sex gives teenagers freedom to live their lives without having to give up their youth.
            Additionally, using peer messengers reduces the likelihood of psychological reactance among the teenagers. Those who communicate messages are more likely to be successful and get the audience to comply if they are perceived as credible and similar (21). Additionally, peer messengers are likely to reduce dominance. This, paired with the information about where to access clinics and safe sex tips will also provide support to teenagers, further reducing likelihood of reactance.
            In conclusion, in order to truly achieve change among teenagers at risk for unintended pregnancy, it is essential to consider social and innate responses that factor into decision-making among this population. By critically evaluating and implementing social theories, as well as identifying key pieces in campaigns that have worked in the past, the Teen Pregnancy Prevention Campaign can be successful. Without these changes, however, this campaign will fail to make a lasting impact on teenagers.



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