Sunday, January 5, 2014

When Public Health Campaigns Hurt Instead of Heal: A Critique of New York City’s Teen Pregnancy Prevention Campaign- Kimberlynn Acevedo

Introduction of Current Intervention
The United States has long struggled with lowering teen pregnancy rates. There are several reasons why public health practitioners continue to prioritize teen pregnancy prevention initiatives. For one, the United States has the highest teen birth rate compared to other industrialized countries: 41.9 births per 1,000 teens between 15-19 years of age. Compare these to Switzerland (4.3) and The United Kingdom, ranked at number 2 (26.7) and it’s easy to comprehend severity of the problem. (1) The United States’ birth rate is approximately 10 times higher than Switzerland and nearly twice the rate of the United Kingdom—sounding the alarm for public health practitioners to step up and do something.
According to teen pregnancy research, the problems associated with teen pregnancies are far reaching and must be confronted. Unfortunately, efforts to address the problem have caused problems of their own. The latest teen pregnancy prevention effort in New York City proves that well-intentioned programs can have a negative impact. The New York City Human Resources Administration (HRA) is a government-sponsored agency that provides social services to over 3 million New Yorkers. (2) The reputable organization became the topic of conversation among many reproductive rights activists and anti-oppression groups in the city and around the country after unveiling their new teen pregnancy prevention effort. The city spent $400,000 and 2 years developing the campaign, which includes a few components such as an information-based text message program, videos, and public transportation advertisements. (3)
This paper will focus on the HRA’s advertisements that can be found at bus shelters and in subway cars.  Of the three component, this one is the farthest reaching as its does not require teens to voluntarily seek the information the HRA is providing. Rather, advertisements, like those used by big corporations, impose themselves upon an individual whether they want to see it or not. Ads are places strategically in public transportation locations because a lot of people, particularly teens frequent these locations. The purpose of the advertisements is to inspire teens to consider the greater implications associated with being a teen parent. The ads bring up issues of poverty and the social and financial price that teen parents must pay. The theory behind the campaign is simple: use frank ads to speak to youth about the realities of parenthood and to encourage responsibility. Commissioner Doar claims, "Teens giving birth before they are ready to provide emotional and financial support is not a good way to raise children." (4) While the overall message to teens may be true well meaning, the execution of the campaign’s advertising component was insensitive and damaging.
The forthcoming sections will discuss the shortcomings of the HRA’s teen pregnancy prevention campaign through a careful look at the behavioral model on which it relies, the reactions it provokes, and the deeper impact of running such a campaign. After the discussion of the campaign’s shortcoming, there will be recommendations through which to reshape the intervention and improve its overall effectiveness as a public health initiative.

Critique Argument 1: The ads will likely evoke psychological reactance
Psychological reactance theory asserts that when a person’s freedom is threatened, it forces them to cling tightly to whatever belief or behavior they associate with that freedom.  (5) In other words, certain approaches can cause individuals to do adopt or strengthen the opposite attitude or behavior a public health intervention aims to produce. This phenomenon is demonstrated in Driscoll’s study on the effect parental opinion of a partner has on the relationship. The study finds that couples that faced parental or external opposition experienced intensified feelings of love, or what Driscoll refers to as the Romeo and Juliet effect. (6)
Along these lines, the HRA’s teen pregnancy prevention ads are likely to trigger high levels of psychological reactance among teenagers because they directly threaten a number of freedoms teens perceive they have. These freedoms include having sex, whom they choose to date or have sex with, if they want to give birth or not, if they want to get married, if they will have a choice to not become poor.  Advertising captions like “Honestly Mom...chances are he won't stay with you. What happens to me?” and “I'm twice as likely not to graduate high school because you had me as a teen” can actually escalate teen pregnancy rates because teens might interpret them as a challenge to stay together with their partner after having a baby or make sure that their child graduates from high school to avoid being a statistic. (7)
Each ad presents a new issue related to being a teen parent (i.e. cost of raising a child, responsibility of paying child support, high probability that the father will leave the mother, and the increased chance of living in poverty as a result of having a child at a young age. While they each advertisement targets a different issue (high cost, disrupted education, high chance of poverty), the fact that they will likely evoke psychological reactants is a common thread that binds them together.

Critique Argument 2: The ads fail to use effective messengers to deliver a sensitive message           
Advertising theory takes psychological principles and applies them to its core advertising approach. That is to say that advertising theory considers what motivates people and uses this as their crux when communicating with their target audience. It uses, in part, psychological reactance theory to understand how messages, their delivery, and their content can influence behavior. Part of this principle relies heavily on the likability of the messenger. If the messenger is not someone that the receiver finds likable or relatable then there is a risk that teenagers might not take to it.
This idea helps highlight one the most obvious flaws in the Human Resources Administration’s advertisements campaign, which uses babies to delivery messages concerning teen pregnancy and parenting. All of the babies are approximately one year in age and are mostly babies of color. Using babies to communicate such a sensitive message breaks the rule of using subjects the target audience can identify with. For one, the likability of the messenger is nowhere to be found in these ads. While some people do indeed like babies, these babies are not ones that the HRA team wanted to be likeable. They are babies that teens are supposed to view as their own child. Teens are supposed to dislike these babies because they are representative of their future children if teens fail to take the precautions against becoming a parent at a young age.
Breaking this simple rule comes with a great cost to the administrators of this campaign. Ultimately, teens may have a hard time taking the message seriously because it evokes so many psychological reactance that drive teens to ignore authoritative advice especially when it comes from a baby.   

Critique Argument 3: The campaign perpetuate racist and stigmatizing ideologies about teens according to labeling theory
The campaign administrators understand that teen pregnancy rates are disproportionately affecting African American and Hispanic youth in New York City. Pregnancy rates among New York teenagers break down as follows: 37 per 1,000 White teens, 129 pregnancies per 1,000 African American teens, and 121 pregnancies per 1,000 Hispanic females. (5) Because those who are more likely to give birth as a teenager are teens of color, the HRA has clearly directed their advertisements to young women of color. The ads are a very clear indication that young women of color are the target audience, which can cause a negative effect according to labeling theory.
Labeling theory is the idea that labeling an individual or a group of people will have an effect on how that person or population is treated. For instance, professors treat students differently based on what they hear through the grape vine about specific students. They tend to base their first impressions as well as their semester long perception of a student based on whether they heard the student is an excellent or a weak student. (8)
In essence, labeling theory highlights the unwarranted but commonly made assumptions that are made about a person or group of people in everyday interactions and even in public health interventions. Understanding labeling theory lends itself to understanding the third flaw of the Human Resource Administration’s teen pregnancy prevention campaign. Only 1 of the 5 babies in the campaign’s ads is White. (7) This perpetuates the stereotype that most people of color will become teen parents. Further, the statistics that the ads choose to present make it clear that these campaigns label people of color as being more likely to be less educated, living in poverty and raising their children as single parents. These speculations, presented as mere facts, shape how people see and treat young people of color—especially girls who are more visible as teen parents.  
More devastatingly, however, is the fact that labeling theory comes with profound internal consequences that affect the labeled subject or in this case, teen parents. The effect can be understood through the results of a prosocial study that examined the effect a label has on helping behavior.  More specifically, the study explored whether or not individuals given a specific label would be more or less inclined to help another person in need. Researchers instructed participants to take a personality inventory. They did not look at the participants’ responses but instead blindly gave them a label, which was either intelligent or social. Upon receiving their label and leaving the room, participants exited through a hallway only to bump into an actor who was paid to drop all their notecards on the floor. The results were remarkable. Those who had been told they were “intelligent” were far less likely to help the actor pick up the notecards while those who were labeled “social” were more likely to help. (8)
While this study demonstrates that the effects of labeling may not always be negative, the use of labeling theory in the HRA’s campaign has deep implications for those being labeled. Those who are teen parents are left feeling stigmatized—causing them to internalize really harsh and harmful perceptions of themselves, teen parents, and people of color. Thus, the campaign helps elucidate two important effects supported by labeling theory:  those who see the campaign will internalize that teen parents are destined to live in poverty, lack an education or ever conform to the institution of marriage and will treat them accordingly. This means that teens of color may be subjected to personally mediated racism, institutional racism and internalized racism that is perpetuated by the very public shaming of minority youth. (9)
Like internalized racism, internalized shame has profound implications for health outcomes like stress, anxiety, and even high blood pressure among racial and ethnic minority populations—which are health issues that have each been understood as being triggered by knowing one’s position in the social hierarchy that favors Whites over Hispanics and African American individuals. (10) Shame also impacts whether or not an individual seeks resources (including reproductive services) and can play a major role in whether or not a young woman gets pregnant. Ultimately, the greatest paradox of this campaign flaw is that it ends up hurting the very people it intends to help: young people of color. Instead of inspiring youth to take precautions to not become a teen parent, it uses shame to explain to them why they shouldn’t become teen parents.


Proposed Intervention
The proposed intervention will also be an advertisement campaign that will be found in subway cars and bus shelters in each of the 5 boroughs of New York City. The goal of decreasing the rate at which teens become parents will remain the same but the way in which this campaign will work to achieve this goal will differ greatly. The campaign will be designed in a way that boosts morale among teens and fills them with excitement about the future, not fear or dread for what public health practitioners warn teens of color they are destined to become: less educated individuals living in poverty. It will show youth that there are several significant decisions that must be made and they have the power and control to make them. Instead of prescribing youth with a sense of fear or shame as a way to avoid becoming a teen parent, the campaign will advertisement real options that are proven methods of preventing pregnancy. While these ads will not include specific information about the use of and the effectiveness of each birth control method, it will certainly motivate teens to seek these resources by instilling in them a sense of power and confidence to seek resources and the sense of self-worth to advocate for themselves. Finally, the proposed intervention will learn from the mistakes made in the HRA’s ad campaign and will work to address each of the aforementioned flaws.

Selling the Freedom of Choice to Deflect Teens’ Psychological Reactance
The campaign will move away from using scary statistics as a way of influencing teenager’s behavior. Providing statistics or facts about a public health issue are proven to be ineffective ways of framing a message that is meant to influence behavior. Instead of implying what youth of color should do to avoid living in poverty for the rest of their lives, these ads will include a few very important ways teenagers can work towards their freedom. This campaign will operate with the understanding that teens are constantly being told what to do by parents, teachers, and even marketing campaigns that target youth to buy their products. With this in mind, and with knowing that teens assert their agency by not doing what they are told to do, the campaign will frame its message as selling freedom and not fear.
 The new intervention will achieve this by presenting options that give teenagers the illusion of control and will encourage them to really think about what options suit them the best (birth control, a pregnancy plan, or choosing abstinence). Illusion of control theory can be used to create a sense of control in the target audience (11). The illusion of control is rooted in perception and thus the campaign will work to manipulate teenagers’ perception of their independence. Specifically, the illusion of control will be used to inspire youth to choose which way they are going to avoid becoming a teen parent as a form of exercising their personal power and feeling their sense of control. It is argued that the sense of control is the illusion that one can exercise personal choice, plays a positive role in sustaining life and fostering mental health (12)
Thus, the goal of this new campaign will be to use illusion of control theory as a way of influencing healthy and protected sexual behavior among teenagers. Providing an array of birth control options (i.e. hormonal options, abstinence, or deciding on a plan if they become pregnant) through the advertisements will effectively restore the freedom that was threatened in the old campaign. The message moves away from telling youth what to do to dodge poverty and instead becomes about letting them see that they have control and can assert this control as a way of tasting freedom.   

Changing the Messenger: Teens Talking to Teens
The new advertisement campaign acknowledges how ineffective and insulting it was for the HRA to use babies to sell a message to teenagers. Teens are already bombarded by messages from all kinds of well meaning adults and adding babies to that list is downright unnecessary. The proposed intervention will work to decrease psychological reactance to the messenger by changing the person in charge of communicating the message of the campaign.
The advertisements will use real New York City teenagers to improve credibility and to reduce the likelihood that the message will fall on deaf ears. According to Silvia, increasing the credibility or attractiveness of a messenger can increase the positive force toward compliance. (13)
The intervention will specifically use young people of color to relay this message, as they will be role models with whom teens can identify. The campaign can work to highlight the stories of teenagers or young adults who have successfully avoided becoming teen parents through sharing the options and resources they used to successfully dodge becoming a teen parent. If teens can see someone who looks like them claiming their freedom through exercising their ability to choose how they are going to live their lives (by preventing becoming a teen parent), then they will know it is possible for them to do it, too.

Firing Shame and Stigma, Hiring Awareness and Empowerment
Finally, the proposed intervention will fight the stigma and shame perpetuated in the HRA’s campaign by implementing an element of awareness and empowerment. The advertisement campaign will be one that is rooted in hope and motivation and not in embarrassment or shame. It can and should inspire youth of color, those who are at risk of becoming teen parents, to have goals and dreams and stay focused on achieving them instead of scaring youth into focusing on not falling into the rut of teen parenthood.
The campaign will work to reverse stigma by adopting specific tactics that are influenced by the mental health community—another community that faces a great deal of stigma and shame. Mental health practitioners work with patients to minimize perceived stigma in their patients by providing insight. (14) This insight involves an honest evaluation of problematic stereotypes that people use to label individuals with mental illnesses as “other.” In assessing the negative expectations that people have about people who suffer with a mental illness, the patient becomes aware that the source of their negative self-perception has a lot to do with external forces. According to Byrne, “The patient needs to construct these stigmatizing experiences as part of a generalized prejudice in society, allowing the possibility of overcoming his or her own difficulties.” (14). This step is crucial and leads directly into the next step for fighting stigma: transforming the person from victim to the advocate.
The proposed intervention will address internalized shame and racism by promoting young people of color who learned to advocate for themselves and are successful despite social stigma they faced during their adolescence. Success can be defined as many things and include but are not limited to graduating from high school, getting a job, learning a new skill, or being the first person in their family to attend college. Portraying these images will go against the countless other negative images youth of color, especially women of color, encounter on a daily basis. Ultimately, the proposed intervention will turn the third HRA flaw on its back by using labeling theory to label people of color as resilient and resourceful individuals who are in control of their bodies, their confidence, and their futures.

Conclusion
This campaign is ultimately threatening teenagers’ freedom to make their own choices (choosing who they will date, when they will become sexually active, if they want to get married or not, etc.). The goal of this new campaign is to restore the freedom that was threatened in the old campaign by employing tactics such as using teenagers to present teens with options as a way of deflecting psychological reactance. The intervention will also address a critical health issue that many public health interventions fail to address: stigma and shame. By using an underlying tone of youth empowerment, the proposed intervention will help teens take control of their sexual behavior and become advocates for their health and for their lives.  

References:

1) "Teen Birth Rates: How Does the US Compare." The National Campaign. The National Campaign, n.d. Web. 30 Nov. 2013. <http://www.thenationalcampaign.org/resources/pdf/TBR_InternationalComparison.pdf>.
2) "HRA/DSS - About Human Resources Administration/Department of Social Services." HRA/DSS - About Human Resources Administration/Department of Social Services. N.p., n.d. Web. 30 Nov. 2013. <http://www.nyc.gov/html/hra/html/about/about.shtml>.
3) Taylor, Kate. "Posters on Teenage Pregnancy Draw Fire." The New York Times. N.p., 6 Mar. 2013. Web. 2 Dec. 2013. <http://www.nytimes.com/2013/03/07/nyregion/city-campaign-targeting-teenage-pregnancy-draws-criticism.html>.
4) Doar, Robert. "HRA Launches New Teen Pregnancy Campaign." nyc.gov. N.p., n.d. Web. 5 Dec. 2013. <http://www.nyc.gov/html/hra//downloads/pdf/news/internet_articles/2013/march_2013/Teen_Pregnancy_Prevention_Campaign_20
5)  Siegel, M. Lecture Notes. November 21, 2013.
6)Driscoll, R., Davis, K.E., & Lipetz, M.E. (1972). "Parental interference and romantic love: The Romeo & Juliet effect." Journal of Personality and Social Psychology, 24, 1-10
8) Siegel, M. Lecture Notes. December 12, 2013.
9) Jones CP. Levels of racism: A theoretic framework and a gardener’s tale. American Journal of Public Health 2000; 90:1212-1215.
10) Harburg W, Gleiberman L, Roeper P, Schork MA, Schull WJ. Skin color, ethnicity and blood pressure, I: Detroit blacks. American Journal of Public Health 1978; 68:1177-1183.11)
11) Siegel, M. Lecture Notes. December 5, 2013
12) Presson; Paul K., Benassi, Victor A. (1996). "Illusion of control: A meta-analytic review". Journal of Social Behavior & Personality 11 (3)
13) Silvia PJ. Deflecting reactance: The role of similarity in increasing compliance and reducing resistance.Basic and Applied Social Psychology 2005; 27:277-284.
14) Byrne, P. Advances in Psychiatric Treatment (2000) 6: 65-72 doi: 10.1192/apt.6.1.65.

                                       

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