Introduction and Background:
In an effort to continue a trend that has led to a 27% reduction in teenage pregnancies over the past ten years, Mayor Michael Bloomberg and the New York City Department of Public Health have aimed to further curtail the current rate of 72.6 teen pregnancies per 1,000 girls with a controversial advertising campaign titled the “Real Cost” (1). The campaign has been running since March of 2013 and features several different advertisements posted on trains and bus shelters all around New York City. The advertisements depict a sad or crying toddler of minority race commenting on the real life monetary costs of teenage pregnancy by stating things such as, “Dad you’ll be paying to support me for the next 20 years”, “Got a good job? I cost thousands of dollars each year”, and “Honestly mom, he probably won’t stay with you. What happens to me?” (2). The aim of the advertisements is to show teenagers the enormity of the cost that raising a child can actually have and ideally convince them to wait until they are financially stable before having children.
The emotionally provocative advertisements are only one component of the “Real Cost” campaign, which also includes an interactive choose your own destiny text messaging game (2). When the message “NOTNOW” is sent to the number listed at the bottom of the advertisements, the sender is able to choose whether they would rather talk to a pregnant Hispanic teen or the baby’s father, also of Hispanic descent. In the story line of the pregnant teen, her best friend calls her a “fat loser” at prom, the baby’s father begins to ignore her, and her parents have a strong negative reaction. In contrast, the male character addresses the financial aspect of teenage pregnancy by discussing the burden of paying child support and further reinforcing that teenage fathers often do not remain a part of the child’s life. The “Real Cost” campaign uses shock value from the facts and messages presented in the advertisements to shame teenagers into being more cautious with their sexual behaviors.
Overview of Critique:
The “Real Cost” campaign has done an excellent job of identifying the long-term financial consequences of having a baby during adolescence, rather than following the futile and unsuccessful efforts of other campaigns by preaching abstinence to teenagers who clearly don’t want to hear it (3). In addition, this program actually does make a solid effort to connect with its target audience via the texting component that it offers. That being said there are still many issues surrounding the ability of this campaign to affectively change teenage behaviors, mostly related to flaws in the design of the program.
Firstly, the advertisements seem to stigmatize teenagers who are already parents by ostracizing them, rather than helping to find ways of successfully fitting into society. In addition, by creating a stigma around adolescent sexual behavior it threatens the freedom of teenagers, ultimately leading them to defy the anti-sex message of the advertisements (4). Secondly, the campaign fails to invoke risk perception theories, as it assumes teenagers accurately and rationally understand their individual risk of pregnancy. The last flaw to be discussed deals with the use of individual level models, such as the Theory of Reasoned Action and the Theory of Planned Behavior, to combat an issue with many systemic and group level implications (5). The campaign assumes that teenagers make a conscious decision to become pregnant, when in reality the large majority, more than 75%, of teenage pregnancies are considered unplanned and occur as the result of many environmental factors such as poverty, violence, and underage alcohol use (5).
Flaw #1: Stigmatizes teenage mothers and adolescent sexual behaviors
The messages printed on the advertisements convey the message that teenage mothers are awful people because they willingly brought a child into the world that they knew would be starting at a huge disadvantage in many aspects of life. By portraying teenage mothers in this light to the general public, the campaign perpetuates the stereotype that adolescents who have a child should be ostracized for making poor decisions. This aspect of the campaign lends itself to Labeling Theory, or Societal Reaction Perspective, which is the idea that people will act in accordance to a stereotype they have been labeled with, regardless of whether they view themselves as fulfilling that role (6). In addition, when a campaign places the blame for an issue on one specific group, in this case teenage parents, it forces the rest of the community to make harsh judgments about that group. The label cast by the advertisements creates a stigma surrounding teen moms that forces them into a feeling of exclusion and social isolation (7).
One study analyzing the perceptions of teenage pregnancy in the UK, conducted by Whitehead et al, concluded that teenagers who decide to go through with having a baby are greatly affected by the attitudes and opinions of their friends and family (7). If the reaction of their support network is negative, this forces teen moms to experience a feeling of “social death” and can have severe negative health consequences for both the mother and the baby (7). Another study on a sample of 925 pregnant low-income adolescents, conducted by Wiemann et al, found that at least 2 out of every 5 teenage mothers felt stigmatized, and suggests that shame campaigns make pregnant teens less likely to speak with their parents about the pregnancy or to seek the proper medical care (5). Teenage mothers who experience this feeling of social isolation are much more at risk for physical or mental health problems due to constant stress and this can have a drastic impact on an already disadvantaged child. Therefore, by further isolating teen moms this campaign is ensuring that they will not be able to easily assimilate back into the social structure of society, further compounding the issues associated with teen pregnancy. Teen moms will need to overcome a strong stigma of their self-identity, social norms, and the public’s hostile attitude towards teen pregnancy.
A second important stigma created by the “Real Cost” campaign places a negative connotation on adolescent sexual behavior. The advertisements use a very pedagogical tone where it is widely known that teens do not respond positively to authoritative messages. According to one study on the relationship between the psychological reactance theory and initiation of smoking, threats to freedom invoked a “boomerang effect” where subjects actually went on to participate in the risky behavior more often (8). Similarly, by placing a negative connotation on pre-marital sex, the campaign appears to contextualize adolescent sexual intercourse as unacceptable, shameful behavior and in turn threaten the freedom of teens. Therefore, it creates a fortuitous psychological reactance where the threat causes them to cling to their beliefs more tightly. Moreover, this is likely to result in increased risky adolescent sexual behavior as teenagers aim to defy the messages of the campaign in order to preserve their personal liberties (8). The design of this campaign does not include any methods to mitigate reactance as evidenced by the harsh stigmatization of both teenage mothers and adolescent sexual behaviors.
Flaw #2: Assumes teenagers correctly understand their personal risk
The “Real Cost” campaign makes a huge assumption that teenagers accurately perceive their own individual risk of becoming pregnant and that they consciously decide to take their chances even though they correctly understand the risk. The program also assumes that teenagers will make changes in their behavior based a fear of the outcome happening to them. According to risk perception theories, however, the Law of Optimistic Bias states that people of all ages tend to underestimate their own personal risk for negative outcomes while greatly overestimating the risk of the general population (9). For example, when smokers were asked to comment on perceived risk of lung cancer they undershot their own individual risk, while greatly overshooting the risk of the general smoker population (9). 60% of adolescents in the study believed “they could smoke for a few more years and then quit”, which perfectly embodies the irrational risk assessment of both teen and adults alike (9). Teenagers won’t view their individual risk for a behavior as being exceptionally high if they don’t believe there are immediate consequences they will experience.
According to a study on adolescent risk perception, “Participants reported greater knowledge of the risks from the activities they perform, less fear of those risks, greater benefits relative to those risks, less seriousness of effects, more personal control over the risks…and higher perceived participation rates by peers” (10). Therefore, for teenagers who have engaged in unprotected sexual activity the scathing risks conveyed by the advertisements are already marginally less effective since their perceived risk from unprotected sex has already begun to diminish. This means that the campaign is not effectively reaching its target audience since those most at risk for teen pregnancy are desensitized to the reality of the messages presented to them. The study also suggests “participants in high risk activities thought they could control their risks but at the same time believed they were unable to avoid the activity” (10). This finding highlights that since teenagers choose to engage in risky behavior they feel an illusion of control over the impending risks that they face. The study also suggests a significant influence from peer pressure that seems to mitigate much of the risks teenagers may perceive as they strive to live up to social pressures. This combination of decreased perceived risk and increasing peer pressure raises many important questions about the efficacy of a program such as “Real Cost”, which is designed to discourage adolescents from engaging in risky behavior.
Flaw #3: Uses Individual level models for a group level issue
One of the main flaws in this campaign is that by focusing on the outcomes of teenage pregnancy, the designers of “Real Cost” chose to ignore many factors that are significantly associated with the real causes of the issue. When observing the issue from the outcome standpoint it appears as though teen pregnancy is simply a problem of individual decision-making. Under these circumstances it would be understandable to employ the Theory of Reasoned Action or the Theory of Planned behavior because these are individual level models that assume a reasoned and planned intention leads to performing a behavior (11). However, when the issue is examined more closely it appears that there is a complex interplay of many factors and covariates that lead to an increased risk for teenage pregnancy, including socioeconomic status, family structure, substance abuse, and violence (5).
One study of teenage mothers tested the effectiveness of various different social constructs in successfully changing the behavior of teens to use contraception. The statistical analyses of the study revealed that, “…constructs from Social Cognitive Theory and Theory of Planned Behavior have limited usefulness in predicting unprotected sex of adolescent mothers from vulnerable ethnic or racial groups” (12). By putting the focus on individual choice rather than systemic group level changes to improve the lives of the most disadvantaged, the campaign does not raise any debate about methods to address the underlying causes of teen pregnancy. When asked about the methods employed in this program, the Vice President of education and training at Planned Parenthood of New York brilliantly stated, “These ads are saying—falsely—that teen pregnancy is going to make you poor and keep you poor, but we know that poverty keeps you poor” (1). Therefore, in order for the campaign to successfully change the behavior of its target audience it must take into consideration ways to diminish the health and economic disparity of these vulnerable ethnic and racial groups.
In addition, the text-messaging component of the campaign is a well-intentioned effort to connect with the teenage generation but it won’t be effective in convincing teens not to engage in risky behavior. Similarly to the advertisements, the texting simulation attempts to invoke shame in teenage girls by sending the message that if they get pregnant their boyfriend will leave them and they will lose their friends (2). The texting simulation also attempts to use aspects of the Theory of Reasoned Action/Theory of Planned Behavior, that suggest people weigh the importance of the attitudes of their family and friends before they make behavioral changes (13). The story line of the texting simulation implies that the negative responses and opinions of the pregnant teen’s friends, family, and boyfriend have enough weight to force a behavioral change away from risk. Again, the intervention ignores social determinants in assuming that engaging or not engaging in risky sexual behavior is a simple decision.
The primary strategy of the “Real Cost” campaign is to portray victimized children who are predetermined for failure because they were born to an adolescent mother. However, in choosing to focus specifically on the behavior of teenagers the campaign completely neglects the idea that the surrounding environment has a large impact on shaping the individual (14). Research has shown that three common characteristics associated with most unplanned teenage pregnancies are aversion to school, poverty, and low expectations for their future career prospects (14). Although addressing these three issues head on does not exactly cut to the root of their causes, when combined with community based participatory research these methods can have profound effects on reducing teenage pregnancy rates. In addition, the “Real Cost” campaign does not seem to educate teens about important topics such as how to avoid teen pregnancy, how to handle risky situations, or the importance of contraceptives.
Therefore I propose a new intervention to reduce unplanned teen pregnancies, which aims to generate interest in school from a young age and provide vocational job training to teens in an effort to raise career aspirations. The new intervention will reframe the issue of teen pregnancy by having advertisements with pictures of teenagers who make statements about the positive outcomes associated with waiting to have children, rather than using shame tactics to fortify old stereotypes. In addition, there will be a community based participatory research component, which aims to forge bonds between teenage mothers and the community. These bonds will help to foster discussions about underlying social issues that are associated with teenage pregnancy and what can be done to ameliorate these disparities. Another necessary component of the campaign is continued and increased education on sexual health to ensure that teens are equipped with the proper knowledge to handle risky situations. In conjunction with increased education, there must be free clinics in neighborhoods and schools where teens can go to have personal questions answered as well as to acquire contraceptives such as condoms or birth control.
Finally, the new intervention will also make use of a texting component but it will not be used to tell teenagers negative life events they may experience if they become pregnant. Instead, the phone number will be a sexual education hotline to provide answers to questions teens may be too scared or embarrassed to ask an adult. Studies show that there is a severe disconnect in the communication between parents and their teens about important sexual topics such as initiating sex, contraceptives, and risk of sexually transmitted diseases (15). Teens that have poor communication with their parents about these topics must turn to their peers for the answers, where they may receive false information and are also heavily influenced by the pressures of peer norms (15). Therefore it is crucial to establish an open line of communication between teenagers and sexual education, which can be accomplished through both the free clinics and the texting hotline.
Reframe the Issue
Reframing the teen pregnancy issue as a systematic problem rather than an individual behavioral problem will change the public view of teen pregnancy and ultimately move the conversation into a greater social context. By using frame theory to reframe the issue in terms of socioeconomics and other health determinants, it will put an end to the social isolation that accompanies teen pregnancy. In turn, this allows teenage mothers to become an important part of the conversation regarding how to avoid unplanned pregnancies, through community based participatory research. Community based participatory research combines education and social action to improve health by involving the members of the community who are actually experiencing these disadvantages (16). Using advertisements that create labels and stigma for teenage mothers, has led to families that are becoming stuck in a loop of repeating the same behaviors. As studies suggest, pregnant teenagers are more likely to have a mother who had a teenage pregnancy than non-pregnant teenagers (17). In addition, removing the stigma on teen moms could reduce the stress created by strained social relationships and have positive health effects for both the mother and the child.
The secondary stigma against pre-marital sex can also be reframed to not threaten the freedoms of teenagers or induce psychological reactance towards performing risky behaviors. Teenagers do not respond well to a lecture based approach and therefore the new intervention will use a strategy that includes positive advertisements as well as free clinics at public schools where teens can get information on sexual health, acquire contraceptives, and be given anonymous referrals. Instead of pushing teens towards risky behavior through shame, the new intervention will aim to educate teens on how to make the right decisions and how to mitigate risk if they decide to engage in sexual activity. Research studies have shown the great importance of sexual health education by suggesting, “adolescents who received comprehensive sex education had a lower risk of pregnancy than adolescents who received abstinence-only or no sex education” (18). Thus, by giving teens answers to their questions about sexual health through education we can avoid the boomerang effect that results from the previous shaming frame. Finally, teens who are educated and understand the true risks of their behavior will be less influenced by peers to initiate risky behavior that could result in teenage pregnancy.
Create a sense of control from the health perspective:
The advertisements used in the “Real Cost” campaign simply cannot be effective in the long term because teenagers do not accurately understand the risk of they themselves actually getting pregnant after engaging in risky behavior (9). It is essential to convey the message that teenagers have much less control than they actually realize when they don’t use contraceptives.
In order to combat issues with risk perception, the new campaign must establish that the only way to achieve control over the risk is through becoming educated and taking the proper precautions to minimize the chance of pregnancy as much as possible. In addition, people struggle to understand the impact that an event may have years down the line and for that reason scare tactics appealing to people with “low self efficacy” are usually not successful in changing behavior (19). In order to combat this issue, the new campaign must shift the focus away from outcomes that may occur in the future and towards getting people to talk about the more important questions of; what are the underlying causes of teenage pregnancy? And, how can they be dealt with? The new intervention must avoid stigmatizing so that it does not recreate the same flaws of the “Real Cost” campaign. By sending an overall positive message about adolescent sexual behavior through education and use of safe sex practices, teenagers will be more in tune with the message and hopefully gain a better understanding of how to actually control their own risks.
Shift to group level social models:
The roots of teenage pregnancy go well beyond a personal decision to use protection and are highly correlated with many social factors (5). Therefore, individual level social models cannot be effective in the long term and group models must be applied. As previously discussed, three important similarities for pregnant teens include lack of interest in school, poor socioeconomic status, and lack of optimism about the future.
The intervention must begin to generate interest in school by starting with kids at a very young age. Teens have already established that they do not enjoy school and therefore it will be especially difficult to change their opinions at such a late point in development. The intervention must institute childhood development programs to ensure that impoverished children become active in school through both the classroom and extracurricular activities. Influencing children at a young age to have a positive emotional response about school greatly increases the likelihood that this will carry over into their teenage years (14). The new campaign can work to do this by employing aspects of the Social Network Theory in aiming to reach out to the most popular kids and getting them more involved. Kids generally follow trends set by those with the most connections and therefore if the most popular adolescents change their attitudes about school many others are likely to do the same.
Although poor socioeconomic status is not an issue that can be remedied through health campaigns, the new intervention can provide school counseling for teens with a history of having a bad childhood as well as other factors associated with growing up in poverty (14). Lastly, by providing vocational job training the new intervention will boost the future career prospects of impoverished teens. The fact that teens don’t enjoy school only aggravates the issue of not having promising occupational goals. Research has suggested that self-esteem issues are highly correlated with sexual risk taking, in turn leading to increased teenage pregnancy (20). This positive change in perceived future prospects will lead to a rise in teenage self-esteem and indirectly a reduction of unplanned teenage pregnancies.
The “Real Cost” teenage pregnancy prevention program is ineffective in changing risky behaviors because it makes too many assumptions about the target audience. The intervention fails to realize that teens have a very skewed view of their own personal risk and therefore many of them will feel as though the campaign does not apply to them. In addition, the campaign fails to address the underlying social causes that lead to increased rates of teenage pregnancy and therefore cannot have lasting impacts. Finally, the use of shame is often not an effective strategy and should not be used to promote stereotypes about teenage moms. It is essential for public health practitioners to shift the focus of interventions and create a greater emphasis on resolving issues with social determinants that lead to increased risk of teenage pregnancy.
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