Sunday, January 5, 2014

NYC’s “Not Now” Teen Pregnancy Campaign Not Effective – Laura DelloStritto

Introduction
Between 2007 and 2011, teen birth rates in the United States have decreased a stunning 25% overall. This decrease was noted across all races and ethnicities, although rates of Hispanic and Black women remain highest due to the disparities that remain between populations.  (3) This decrease continues a trend of decline of live births to adolescents that began in 1991. (9) Teen pregnancy rates, measuring pregnancies that not only end in live birth but also attempt to account for abortions/miscarriages, has also seen a drastic decrease in the last 20 years: a decline of 42%. (9)  Increased percentages of usage of contraceptives by adolescents as well as a desire to wait to have sexual intercourse have been implicated as potential contributors to this decline.3
However, 82% of U.S. teen pregnancies remain unplanned, and the United States still has significantly higher levels of teen pregnancy than most other developed nations, according to the Alan Guttmacher Institute for advancing sexual and reproductive health worldwide. (4) The level of sexual activity does not vary considerably among teenagers in the United States, Great Britain, Canada, France, and Sweden; however, researchers have noted several factors that may contribute to a higher rate of U.S. teen pregnancy. Teenagers in the United States are more likely to initiate intercourse before age 15 than other study nations. (4) In addition, U.S. teenagers are less likely than teens in other nations to use contraceptives, particularly hormonal methods that have the highest use-effectiveness rates. (4) The Guttmacher institute concludes that the ease of access to contraceptives and reproductive health services providers may be a contributor to less effective contraceptive use among U.S. teens. (4)
The U.S. Department of Health & Human Services name engagement in school and extracurricular activities, maternal level of education, living with biological parents during early adolescence, an living in wealthier neighborhoods with high employment levels as protective factors against U.S. teen pregnancy.(9) The Guttmacher institute’s international report emphasizes the importance of social and economic equality in noting that both lower teen pregnancy rates and birth rates are linked to economic inequality. (4) U.S. teens are more likely than those in comparable nations to have grown up in disadvantaged circumstances, which put them at higher risk for teen pregnancy than their international peers. (4) Within the United States, New York has the 11th highest rate of teen pregnancy, with 77 pregnancies for every 1,000 teenage girls as of 2005. (7) New York teens in the Youth Risk Behavior Survey were also less likely to have used a condom in their last sexual encounter than the overall rate for the US. (1)  To further decrease rates of teen pregnancy specifically in New York, Mayor Michael Bloomberg and the NYC Human Resources Administration/Department of Social Services have developed a public health campaign focusing on teen pregnancy entitled “Not Now.” The campaign, featuring a series of advertisements, a video, and an interactive text message game, attempts to illustrate the cost of teen pregnancy for parents and their children. According to the campaign website, it claims to feature “ads with hard-hitting facts about the money and time costs of parenting, and the negative consequences of having a child before you are ready.” (7)
The primary component of the campaign, the ads themselves, feature images of distressed babies delivering such “hard-hitting facts” about teen pregnancy. (8) A crying baby boy states, “I’m twice as likely not to graduate high school because you had me as a teen” and an inquisitive baby girl questions “Honestly mom… chances are he won’t stay with you. What happens to me?” (2) Two other babies note “Dad, you’ll be paying to support me for the next 20 years” and “Got a good job? I cost thousands of dollars each year.” (3) Beneath these questions, these facts are restated in more neutral language, such as “kids of teen moms are twice as likely not to graduate than kids whose moms were over age 22.” (2) Listed on each advertisement is a number to text to participate in an interactive “game” that takes you through the life of a teenager who found out she was pregnant, allowing the user to make decisions for her such as finish her math homework or sleep. At the conclusion of the short game, the user is awarded a numerical place based on success of choices made in the game and is given a yearly cost of raising a child and NY law about paying child support.
Numerous voices have opposed these ads citing fear tactics and emotional shaming. (10) In addition to the shame that these ads may incite, they also fail to effectively employ behavioral science theory to achieve their desired result of lowering teen pregnancy rates in New York.

Critique 1: No Clear Behavior Promoted
NYC’s “Not Now” campaign, consciously or not, relies in part on a foundational model for predicting social behavior. According to the Health Belief Model (HBM,) an individual uses their perceived susceptibility of a negative outcome and severity of that outcome to determine what perceived benefit they would gain by performing a suggested behavior. The individual then weighs this perceived benefit against the perceived cost of performing the behavior in order to make a decision, which then informs whether the behavior they perform is in concert with or against the behavior suggested by the intervention. (5)
NYC’s ad campaign follows this model in that it presents facts about the severity of the outcome of teen pregnancy in an attempt to lead their audience to the decision of avoiding risky actions that could lead to teen pregnancy. Even before accounting for the flaws in the HBM itself, NYC’s campaign has failed to stringently adhere to the health belief model. Yes, it does provide knowledge of the severity of the outcome of teen pregnancy; however, knowledge of severity is essentially all it provides. Further information on their website provides a few statistics that may or may not inform their audience to their perceived susceptibility of becoming pregnant as a teenager due to the optimism bias most possess that states ‘Sure, these are the statistics, but that won’t happen to me.’ (12)
Most importantly, the NYC campaign does not actually offer a clear behavior to perform. Clarity is essential in transmission of a message, (6) but in this case while it is clear that NYC does not want teenagers to become pregnant, the campaign does not persuade its audience to perform any behaviors that will prevent this outcome. The overemphasis on outcome without any suggested behaviors to prevent it is a fatal flaw of these advertisements. Even if viewers of the ads decided that the benefits of not being pregnant as a teen outweighed the cost, they may not know how to put their decision into action.
Finally, the HBM’s internal flaws weaken NYC’s strategy. The HBM has been proven particularly weak as it ignores all social and environmental factors in the decision-making process, assuming that all decisions are rationally made within a vacuum. (5) This model may be effective for one-time decisions such as immunizations, but are not adequate for a decision to avoiding teen pregnancy, which has been shown to be heavily linked to level of neighborhood poverty, something that adolescents in particular cannot control. (4)

Critique 2: Reduces, Rather than Promotes Self-Efficacy
Similar to the Health Belief Model, the Theory of Planned Behavior (TPB) states that individuals weigh their own perceptions concerning a behavior to determine their action; in addition, according the TPB, individuals also account for perceived social norms and what others would want them to do. (12) This is an improvement from the HBM as it accounts for some social factors. Another key component of the TPB is that making a decision does not directly lead to a behavior change; instead, individuals need self-efficacy. Self-efficacy, introduced by psychologist Albert Bandura, is defined as our belief that we are capable of performing the suggested behavior. (12)
NYC’s campaign can be seen as in alignment with the TPB in its attempt to illustrate what behavior one’s future children would want them to perform, i.e. avoid getting pregnant as a teenager to enhance their future child’s well-being. The depiction of the child itself is a flaw in the campaign, as to effectively persuade it is important to use a credible and/or relatable messenger to deliver information. A future child is neither credible nor relatable to teenagers and thus the message is much more likely to be discredited and even laughable. (6)
In addition to an ineffective messenger, the NYC teen pregnancy campaign does not promote self-efficacy in order to convert the decision to avoid teen pregnancy into the actual behavior. In fact, the ads drastically reduce self-efficacy with their disparaging messages: “Honestly mom… chances are he won’t stay with you.” “Got a good job? I cost thousands of dollars each year.” (2) These messages are likely to reduce self-esteem in general for teens that are not in stable relationships and/or jobs. While the ads may make teens realize they are not equipped to be parents, these negative messages are also likely to instill a sense of inevitability, hopelessness, and failure in teens instead of encouraging them to take action to prevent teen pregnancy.
In combination with the attack on self-esteem and subsequent stress that the ads may incite, one of the most critical flaws with the NYC campaign is that there are no strategies offered to improve self-efficacy and avoid teen pregnancy. Although involvement in extracurricular activities is shown to prevent teen pregnancy, none are suggested. (3) Even more egregiously, not only do the ads fail to mention locations to obtain contraceptives, using contraception is never even mentioned as a tool to avoid the outcome they aim to prevent. This lack of tools to promote self-efficacy to avoid teen pregnancy paired with disparaging messages is likely to further reduce the effectiveness of the campaign.

Critique #3: Counterproductive Core Value and Framing
The core value, or guiding factor in the creation and execution of NYC’s teen pregnancy campaign is clearly fear. With the attempt to instill fear in mind, these ads were designed to force teens to face their distraught future child holding them accountable for their actions. However, fear can be disempowering, making it less effective and in fact counterproductive. The disparaging messages delivered by the children in the campaign can lead to a sense of hopelessness and low-self worth. The stress is exacerbated as the campaign relies almost entirely on how much money it costs to raise a child.
We know that adolescents most at risk are those from disadvantaged economic backgrounds, (4) meaning that they are likely already at some level of daily stress hoping that they will be able to find a job or finish school. A campaign focused almost entirely on money and costs will likely just lead to more stress. It is possible that adolescents may actually turn to sex and romantic relationships as a stress reliever when confronted with constant reminders of their disadvantaged background and now advertisements of their possible future.
Instead of proposing a strategy to reduce teen pregnancy, by conflating a risk factor for teen pregnancy with the actual outcome, these ads could serve as a bleak reminder of the current financial state of their target demographic. Instead of inspiring a change in behavior it incites stress or defiance that may lead to an increase in a behavior that may lead to the outcome it aims to prevent.

Proposed Intervention:
The NYC teen pregnancy prevention campaign needs a drastic overhaul. The following changes should be made in order to improve efficacy and persuasiveness of the campaign: define a behavior, not a state, to promote or abstain from. Practicing safe sex is a more definitive strategy to reduce teen pregnancy rather than simply making the “decision” not to become pregnant as a teenager. Statistics show that 82% of teen pregnancies are unplanned, illustrating that it is not truly a “decision” to become pregnant and should not be erroneously branded as such. (9) Secondly, change the messenger to a relatable peer rather than an imagined toddler to enhance credibility and provide tools to improve self-efficacy after removing the messages that decrease it. Finally, reframe the entire campaign with an empowering core value of freedom rather than the disempowering value of fear.

Defense #1: State a Clear Behavioral Change
The NYC teen pregnancy advertisements as they currently stand appear to rely on the Health Belief Model, in which an individual weighs perceived susceptibility and severity of outcome to determine the perceived benefit gained by performing an encouraged behavior. (5) If the perceived benefit is greater than cost, the individual will theoretically then choose to implement the behavior. (5) However, by shaming the state of teen pregnancy without clearly stating a behavior to encourage or discourage, the current advertisements provide an ineffective message. Even if teens choose to avoid teen pregnancy, they may not know how. By encouraging safe sex as a behavior and tying the campaign to teen pregnancy through personal stories, the campaign will likely be immensely more successful in achieving its goal of decreasing teen pregnancy rates in NYC.

Defense #2: Add Tools to Build Self-Efficacy
The “Not Now” ads are somewhat in alignment with the Theory of Planned Behavior, stating that individuals compare their perceptions of a behavior as well as what social norms would support in order to determine how they act in response to the suggestion. (14) However, in their current state, the ads use a highly unrelatable messenger to relay the information and mimic a social force that should influence the decision to risk teen pregnancy: a distraught unborn child. Improved ads will change this messenger to an attractive person in the age group of the target demographic to improve relatability and acceptance of the message, or a well-liked celebrity that falls within the age group. (6)
In addition, the TBP relies heavily on the idea that making a decision alone is not enough to lead to a behavior change. (14) Self-efficacy, the belief we are capable of performing a suggested action, is required in order to convert a decision into a behavior. (14) At present, the advertisements do not present any tools to improve self-efficacy, as they do not illustrate any strategies whatsoever to avoid teen pregnancy. No tools presented to the audience and the messaging used in the ads my actually decrease self-efficacy. “Dad, you’ll be paying me child support for the next 20 years” (2) and similar phrasings that attempt to mimic the feeling of failing your child may actually lead the target demographic to thinking that they are hopeless and have already failed if they do not have steady income or a successful relationship. To improve this, revamped advertisements should list locations where free contraceptives or health screenings can be accessed in order to empower teens to act out their decision to practice safe sex.

Defense #3: Reframe Campaign with Empowering Core Value and Supports
The “Not Now” campaign currently employs a core value of fear in order to convey its message, supported almost entirely by financial messages of the cost of raising a child. As youth most at risk for teen pregnancy are primarily already from disadvantaged backgrounds, (4) these ads may increase stress and in fact lead the target audience to turn to sex and romantic relationships to forget about their current financial woes, leading to a counterproductive conclusion.
A reframed campaign with a core value of freedom will be empowering rather than disparaging to the target audience. Using marketing theory, which identifies what people want before creating a tailored package to fulfill those needs, (13) this frame can be created with a focus on encouraging safe sex. Sex is nearly universally appealing, and accessible contraception may help many people achieve that end. Supports for the frame will come in the form of personal stories depicting relatable adolescents conveying messages such as “I practice safe sex because I want to make sure I can focus on my passion for music.” This support echoes the core value of freedom from additional responsibility and freedom to pursue one’s passion, a message that will ring particularly true for most adolescents. It also implies ownership of the behavior, a factor that is noted to help behaviors stick. (11) Adolescents involved in extracurricular activities, another protective factor against teen pregnancy, should also be featured. (9)
Conclusion:
Although the rate of teen pregnancy has been decreasing in the United States over the last 20 years, it remains higher than similar developed nations. (4,9) New York has the 11th highest teen pregnancy rate in the U.S., with 77 pregnancies per 1,000 adolescents. (7)  NYC’s current “Not Now” teen pregnancy prevention campaign aims to decrease this rate, but it does not properly define a behavior to promote, it educes self-efficacy to perform a suggested behavior instead of improving it, and it relies on a disempowering and possibly counterproductive core-value of fear.
In order to improve this campaign, it is highly recommended to define safe-sex as a behavior to promote, especially as condom use is lower in New York than the U.S. as a whole according to the Youth Risk Behavior Survey.1 In addition, including tools to promote self-efficacy to perform safe sex, such as listing the locations of free contraception, will improve the efficacy of the campaign. Finally, reframing the campaign with an empowering core value of freedom and delivering the message with relatable peers instead of fictitious children will correct the current flaws in the existing campaign to create a much more effective public health message.




References:
1.    Apps.nccd.cdc.gov. CDC-Youth Online-High School YRBS T-Test New York 2011 Results. [Online] Available from: http://apps.nccd.cdc.gov/youthonline/App/Results.aspx?TT=A&OUT=0&SID=HS&QID=QQ&LID=NY&YID=2011&LID2=&YID2=&COL=S&ROW1=&ROW2=&HT=4&LCT=&FS=&FR=1&FG=1&FSL=&FRL=&FGL=&PV=&TST=True&C1=7&C2=8&QP=G&DP=1&VA=CI&CS=Y&SYID=&EYID=&SC=DEFAULT&SO=ASC [Accessed 12 Dec 2013].
Cbsnews.com. - New York's teen pregnancy PSAs - Pictures - CBS News. [Online]
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6.   Nyc.gov. Teen Link - Teen Pregnancy Prevention - Teen Pregnancy in New York. [Online] Available from: http://www.nyc.gov/html/hra/teenlink/html/prevention/new_york.shtml [Accessed 10 Dec 2013].
7.   Nyc.gov. HRA/DSS - Campaigns - Teen Pregnancy Prevention. [Online] Available from: http://www.nyc.gov/html/hra/html/news/teen_pregnancy_prevention.shtml [Accessed 10 Dec 2013].
8.   Office of Adolescent Health. The Office of Adolescent Health, U.S. Department of Health and Human Services. [Online] Available from: http://www.hhs.gov/ash/oah/adolescent-health-topics/reproductive-health/teen-pregnancy/trends.html [Accessed 10 Dec 2013].
9.   Powell M. In Fighting Teenage Pregnancy, the Folly of Shame and Blame. The New York Times. [Online] March 11th. 2013 Available from: http://www.nytimes.com/2013/03/12/nyregion/in-fighting-teenage-pregnancy-bloomberg-errs-by-playing-shame-game.html?_r=0 [Accessed 10 Dec 2013].
10.                  PsyBlog. 6 Quirks of Ownership: How Possessions Bend Our Perceptions. [Online] Available from: http://www.spring.org.uk/2008/04/6-quirks-of-ownership-how-possessions.php [Accessed 12 Dec 2013].

11.Sharot, Tali.The Optimism Bias. [Online] May 28th 2011. Available from: http://content.time.com/time/health/article/0,8599,2074067,00.html [Accessed 10 Dec 2013].

12.                  Small Business - Chron.com. Examples of Marketing Theory. [Online] Available from: http://smallbusiness.chron.com/examples-marketing-theory-21058.html [Accessed 10 Dec 2013].
13.                  Utwente.nl. Theory of Planned Behavior/ Reasoned Action. [Online] Available from: http://www.utwente.nl/cw/theorieenoverzicht/Theory%20Clusters/Health%20Communication/theory_planned_behavior/ [Accessed 10 Dec 2013].


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