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.
Proposed
Intervention:
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.
Conclusion:
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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