Tuesday, May 13, 2014

When a Public Health Intervention Fails to Connect with the Target Population: A Critique of New York City’s Teen Pregnancy Prevention Campaign --Jennifer Sun

Current Intervention
            Although the teenage pregnancy rate in New York City has declined by 27 percent over the last decade and roughly matches the national decline rate, there are still more than 20,000 teenage pregnancies in the city annually and nearly nine out of ten of them are unplanned (1)(2). The problems associated with teen pregnancies are well-known, far-reaching and must be confronted as a society. Unfortunately, efforts last year to address this problem in New York City have been controversial and giving rise to other problems. The primary reasons for the ineffectiveness of the well-intentioned intervention by NYC’s Human Resources Association (HRA) can be attributed to their failure to do comprehensive research on the social and economic determinants of teenage pregnancy and their failure to utilize popular social and behavioral theories to connect with targeted population and encourage positive behavioral changes.
            New York City’s HRA is the municipal agency that provides social services to over three million New Yorkers (3). This reputable organization has sparked fierce debate among reproductive rights activists, anti-oppression groups, anti-abortion groups, pro-choice groups, and anti-discrimination organizations in the city and nationwide after launching their new teenage pregnancy prevention campaign. The City of New York spent $400,000 and two years developing the campaign, which includes three components: public transportation advertisements, information-based text message program, and videos (4). This paper will focus on the advertisements that can be found at bus shelters and in subway cars because of the three elements of the intervention, this one is the farthest reaching. Like ads used by big corporations that impose themselves upon an individual, the five ads in this campaign are strategically placed in public transportation locations because a lot of people, particularly teenagers, frequent these locations. The primary purpose of the advertisements is to provocatively remind young people that there are great implications associated with raising a child as a teenager. The ads raise issues of poverty and the personal and financial price teenagers must pay, which are inherent components of child-rearing that parents must sacrifice.
The ad campaign is quite simple: use blunt and confrontational ads to convey to the youth of the city the realities and challenges of parenthood and to encourage responsible preventative behaviors. Representatives for the mayor, who is infamous for implementing other controversial public health campaigns, stated that NYC can no longer be “value neutral” about teenage pregnancy and that the city must “send a strong message that teen pregnancy has consequences — and those consequences are extremely negative, life-altering and most often disproportionately borne by young women” (5)(1). The forthcoming sections will discuss the shortcomings of the HRA’s teen pregnancy prevention campaign through a careful analysis of the behavioral model it uses, the reactions it provokes, and the deeper unintentional impact of the city’s intervention. Recommendations for an alternate intervention will be presented following discussion on critiques of the HRA campaign and how the city can utilize it to improve its public health initiative.

Critique Argument 1: The HRA institutionalizes racism in New York by perpetuating negative labels of Black and Latino populations
            Only one of the five babies used in the HRA ad campaign is white, while the rest are of Black, Latino or mixed ethnicity (6). Evidently, the primary target for the HRA ads are young people of color, particularly teenage women, as it should be considering that teenage pregnancy in New York City disproportionately occurs in the Black and Latino teenage population. In 2011, New York City’s pregnancy rates for Black and Latina women under the age of twenty were 26% and 39%, respectively, which accounted for nearly two-thirds of the teenage pregnancies that year (7).
            While the HRA is correct to target the Black and Latino youths of New York City for an intervention to reduce the teen pregnancy rate, they employed a negative use of labeling theory in their ads, which has profound and dangerous implications for the mental health of minority youths and for the racial dynamic of New York society. Given that humans have a natural biological capacity for predictably irrational behavior, labeling theory asserts that casting a label on an individual or a group of people will have an effect on how that person or population is treated. In one study example, labeling theory is supported with how the irrationality of teachers affects student performance. The study found that when elementary school teachers judged potential performance of children by being shown pictures of incoming students, the white children were consistently expected to do better than the black students based solely on their pictures (8).
Essentially, labeling theory illuminates the unwarranted but commonly made assumptions that are made about an individual or group of individuals in normal everyday interactions. With a clear understanding of labeling theory, it is evident that the use of predominantly babies of color in the HRA’s ads, commissioned by the City of New York, perpetuates the stereotype that most people of color will become teenage parents. The public display of this stereotype presented as a fact will consciously and subconsciously affect how the general population treat and view young minorities, particularly the young female teenagers.
In addition to the consequences in the larger society, the impact of negative labeling has profound effects on an individual’s internal psyche. The internalization effect can be understood through the results of a study that tested the effects of being stereotyped an Asian or a woman, where a sample of Asian women were given a math test with a prompt on race beforehand. The researchers discovered that when participants were given a prompt that reminded them that they were Asian, they achieved higher than average scores on the exam; however, when participants were given a prompt that reminded them that they were a woman, their scores were significantly lower. By being confronted with those stereotypes right before the exam, the participants internalized them and their behavior was subsequently affected (8).
Thus, the principles of labeling theory illuminate the deep racial implications for the people of New York City. Firstly, people who see the campaign will internalize that minority teenagers are mostly destined to be poor teenage parents, and will thus consciously and subconsciously treat them accordingly, which could potentially expose young minorities to more situations of institutionalized and personally-mediated racism. Secondly, the young teenagers of color will experience internalized racism from the stereotypes perpetuated in the ads, causing deflation in their self-esteem and accepting these negative perceptions of themselves. Internalized racism will trigger behaviors and practices of minority youth that contradict the literal message of the ads because they will believe and accept their pre-determined fate from the HRA’s deplorable and paradoxical application of labeling.

Critique Argument 2: The ads stigmatize teenage parents by ignoring the socioeconomic factors that contribute to teenage pregnancy
The HRA deftly uses framing theory to deliver a provocative and memorable message in their ad campaign by relying on the visual image of a baby to convey the core value of wealth and deliver strong catchphrases (e.g.“Got a good job? I cost thousands of dollars each year”) to drill their core position of having a baby as a teenage will be expensive and will likely result in a life of poverty. Provocative additional catchphrases such as, “Think being a parent won’t cost you? NY State law requires a parent to pay child support until a child is 21,” reinforce the HRA’s core position that teenage pregnancy leads to poverty. While the intense public debate that has ensued as a result of the campaign substantiates the degree of the frame’s power in appealing to the values of wealth and stability that people hold strongly, it also invokes anger and stigma, which the HRA did not anticipate. Although the public is well aware of the difficult challenges that teenage parents face, the ads’ effects of shaming and framing poverty as a result of teenage pregnancy only intensifies the level of stigma and shame that teenage parents already endure. The ads dehumanize teenage parents by referencing them as sad statistics and labeling them as forever doomed to a life of poverty for themselves and their children
. The HRA’s core position correctly recognizes the existence of a strong relationship between poverty and childbearing rates of teenagers. However, the causal association incorrectly identifies poverty as the outcome; when in fact, many studies, including a recent study by Kearney and Levine in 2012, found that teenage pregnancy is actually the outcome. The researchers concluded that the poorest people believe they have slim chances of economic mobility and therefore have children at a young age instead of attempting to improve their economic progress because they perceive limited possibilities in socioeconomic advancement. Moreover, the scientists emphasized that poor girls who bear children as teens do not suffer worse economic outcomes than similarly poor girls who have children later, which refutes the mainstream association of poverty and teenage pregnancy that the HRA propagates (9).
The use of framing theory in NYC’s print ad campaign has deep implications for teenage parents and young people with poor socioeconomic status. By only providing catchphrases and statistics on the ads which use a misleading frame, the HRA fails to inform the public on correct facts and provide more substantive information, like support programs that address the disparity of social and economic factors by assisting impoverished people in trying to lift themselves and their families out of poverty.

Critique Argument 3: The confrontational approach of the ad campaign will likely result in resistance and potentially more harmful effects
            Multiple research studies conclude that confrontational and provocative approaches such as the one taken by the HRA are ineffective in preventing or changing the risky behavior. The HRA incorrectly assumes that the confrontational tone of the ads will scare young people to practice behaviors that will prevent unplanned pregnancies. However, according to the psychological reactance theory, it is more likely that the harsh nature of the messages will trigger resistance among teens because they will feel that some of their perceived freedoms are being threatened. More specifically, the youth will have a rebellious reaction and adopt the opposite behavior of preventing teen childbearing to resist the threatening message pushed by the HRA campaign, which threaten their perceived freedoms of choice and independence in relation to their relationships, careers, sexual activity and family planning.
Driscoll’s study on parental opinions of a partner and its impact on that relationship found that when couples face external or parental opposition, they experience the Romeo and Juliet effect, that is, intensified feelings of love (10). This study validates the psychological reactance theory that people tend to cling more tightly to a behavior or belief they associate with a particular freedom whenever they feel that freedom is being threatened. In addition, a study on the use of confrontation as a form of substance abuse counseling found that utilizing a confrontational approach to counter a risky behavior actually evokes resistance in the individual or group being counseled, which subsequently prevents a positive behavioral change (11).
Thus, the confrontational captions like, “Honestly Mom…chances are he won’t stay with you. What happens to me? Are you ready to raise a child by yourself?” on the various issues of high costs, risk of poverty, child support, unfinished education will likely be perceived by teenagers as a challenge, thereby negating the purpose of the entire intervention.

Proposed Intervention
The proposed intervention will also be an advertisement campaign that will be found in subway cars and bus shelters in all five boroughs of New York City. While this ad campaign will target the same at-risk population, it will achieve the goal of reduced pregnancies in a much different manner. Instead of a confrontational approach that centers on shaming individuals and a segment of the population, it will utilize a positive, informative and relatable approach that seeks to empower minority youths, suggest alternative aspirations, offer the freedom to make their own choices, and provide information on how to access the tools and resources to improve economic mobility and work towards escaping poverty. This proposed campaign will display real teenagers of color from impoverished neighborhoods who share their uplifting stories of how they achieved considerable goals like going to college or getting a dream job. In addition, they will share information on how to access the resources and HRA social programs they used to achieve their goals. Moreover, some of the ads in the campaign will show the teens debunking common myths about contraception and birth control methods, and offer information on how to access them in New York City. This proposed intervention will learn from the critical mistakes made in the HRA’s ad campaign and will work to address each of the aforementioned flaws.

Defense 1: Overcoming Stereotypes and Empowering Young Minorities
Firstly, this proposed intervention will combat the racism perpetuated by the HRA’s use of labels that stereotype minority teenagers with the use of advertising theory. A major component of advertising is grounded in psychological reactance theory to understand how messages, their delivery, and their content can influence behavior. Success in the delivery of messages depends on the likability of the messenger. That is to say, 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 (12). Considering the importance of the messenger, this intervention will deliver its message through real New York City young adults who represent various racial backgrounds, but particularly Black and Latino people, as they will be relatable role models that the targeted population can identify with. The use of relatable real young adults will improve the credibility of the campaign and reduces 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). Moreover, by seeing the success stories of relatable young adults who avoided becoming teenage parents, the teenagers can internalize the positive label this intervention projects, and thus engage in the positive behaviors the intervention aims to promote, as exemplified in the study of the students who performed better on a test when reminded that they were Asian (8). Portraying images of successful young people of color is powerful for the psyche of the targeted population, where the definition of success is broad and encompasses but is not limited to graduating from high school, being the first person in their family to attend college, or getting a job. These positive labels counter the innumerable other negative labels of minority youth that are spewed daily and empowers them to believe they can achieve greatness.

Defense 2: Reframing Teenage Pregnancy as a Symptom of Poverty
The proposed intervention will reframe the HRA’s ads to dispel stigma and myths related to teenage childbearing, and promulgate the evidence-based concept that teenage pregnancy is a symptom of poverty, social inequality, and economic immobility that society must address using a positive approach. To counter the powerful damages on public perception of teenage pregnancy from the HRA ad campaign, this proposed intervention will reframe teenage pregnancy as a consequence of poverty using the same core value of wealth to support the core position that as a society, we have a social obligation to address the social and economic factors that lead to poverty and provide support and resources to those affected by poverty and inequality, and by doing so will contribute to the increased wealth of New York City as a whole. Using powerful images of minority teens overcoming poverty with the help of the city’s HRA social programs and using catchphrases that invoke feelings of community spirit, unity and mentorship will help the frame invoke the core values of wealth and community.
A key principle to reframing the previous intervention and making it successful in reducing the teenage pregnancy rate is Maslow’s hierarchy of needs. Maslow conceptualized that people are motivated to achieve certain needs and once a need is fulfilled, the individual seeks to fulfill the next one, and so forth. According to his model, physiological needs, like food and water, are the most basic and that people are not as motivated to fulfill their social needs of sexual intimacy, love and family because they are higher-level needs and not as vital to survival. Therefore in a public health setting, public health professionals must remember that health and sexual intimacy are higher-level needs for vulnerable and poor populations, which means that they are less of a priority for them (14). This intervention keeps implication in mind and therefore uses reframing to address the poverty of the targeted population in the hope that by providing information on how to access the city’s social programs and other non-profit services, the targeted population will be empowered to meet their basic physiological needs so that they can then make informed health and social decisions.

Defense 3: Offering Alternative Aspirations and the Freedom of Choice
The proposed intervention will work to decrease psychological reactance to the confrontational messages of the previous campaign by changing the message, tone and messenger of the campaign. As previously stated, specifically using young people of color to relay the public health message, will help the targeted population to identify with the young adult role models who have achieved accomplishments by avoiding becoming a teenage parent. By being exposed to someone who looks like them and who garnered freedom from poverty by exercising their ability to choose how they will live their lives, advocate for themselves and avoid being a teenage parent, then the targeted minority youth will believe it is possible for them to achieve similar goals. Keeping in mind that teenagers are often frustrated with constantly being told what to do by parents, teachers, and consumer goods marketing campaigns, and that teenagers have a tendency to react and rebel against these voices by doing what they are told not to do, this campaign will restore the freedoms that were previously threatened in the old campaign by ensuring that it is provides teenagers with options and information on choices that they can decide for themselves.
Time and time again, using statistics or facts about a public health issue have been proven to be ineffective ways of framing a message that is meant to influence behavior. The theory of optimistic bias, which is based on the relationship between irrationality and risk, asserts that people generally understand the risks of something in the general population, but will tend to underestimate that risk for themselves. For example, people who use mobile phones while driving tend to rationalize their unsafe behavior by reassuring themselves that unlike the 27% of people who get into motor vehicle accidents when using a mobile phone while driving, they will not crash because they believe they are a good driver” (15). Therefore, in order to combat optimistic bias and be more effective, campaigns should employ the use of powerful individual stories that are relatable to the target audience, rather than statistics. As opposed to using statistics that were the focus of the previous campaign, such as “If you finish high school, get a job, and get married before having children, you have a 98 percent chance of not being in poverty,” this ad campaign will present methods and resources that teenagers can utilize to work towards their freedom through a relatable messenger.

The failure of New York City’s HRA to conduct in-depth research into the true association between poverty and teenage childbearing and considering common social and behavioral theories of change prior to embarking on their mass advertising campaign is ineffective in achieving the intended outcome of the intervention: reducing teenage pregnancy. Instead, it is promulgating falsehoods on the association between poverty and teenage pregnancy; further stigmatizes teenage parents; causes psychological reactance in teenagers by threatening their perceived freedoms; fails to provide information or support for overcoming the socioeconomic inequities that drive teenage pregnancy rates; and perpetuates racism on the institutional, personally-mediated and internalized levels.
The goal of this new campaign is to restore the freedom that was threatened in the old campaign by empowering the teenagers to feel independent to make their own decisions; using accomplished minority young adults to present teens with options as a way of deflecting psychological reactance and minimizing optimistic bias; reframing poverty to reflect the real facts and providing information and support to address social and economic determinants of poverty; and ensuring that shame and stigma is removed from the campaign and that the positivity of youth empowerment will enable them to assert agency in their sexual behavior and education.

1.      Taylor K. (2013). “Posters on Teenage Pregnancy Draw Fire.” The New York Times. 6 Mar. 2013. Web. http://www.nytimes.com/2013/03/07/nyregion/city-campaign-targeting-teenage-pregnancy-draws-criticism.html
2.      King J. (2013). “New York City tries to chame its teens into not having babies.” Color Lines for Action. 6 Mar 2013. Web. http://colorlines.com/archives/2013/03/new_york_city_tries_to_shame_its_teens_into_not_having_babies.html
3.      Human Resources Administration Department of Social Services. (2014). HRA/DSS - About Human Resources Administration/Department of Social Services. http://www.nyc.gov/html/hra/html/about/about.shtml
4.      Szalavitz M. (2013). “Why New York’s Latest Campaign To Lower Teen Pregnancy Could Backfire.” Time. 28 Mar 2013. Web. http://healthland.time.com/2013/03/28/why-new-yorks-latest-campaign-to-lower-teen-pregnancy-could-backfire/
5.      United Nations Population Fund. (2013). “New York and Chicago Ad Campaigns Spur Debate and Controversy in Push to Prevent Adolescent Pregnancy.” UNFPA News.27 Oct 2013. http://www.unfpa.org/public/cache/offonce/home/news/pid/15478;jsessionid=19C6EE1C492BE62CF1433D3B3081263A.jahia02#sthash.6wgpmGC6.dpuf
6.      Racialicious – the intersection of race and pop culture. (2013). Controlling Portions, Controlling Pregnancies: Race And Class Panic In New York City Public Health Campaigns. 3 April 2013. http://www.racialicious.com/2013/04/03/controlling-portions-controlling-pregnancies-race-and-class-panic-in-new-york-city-public-health-campaigns/
7.      US Department of Health and Human Services. (2011). New York Adolescent Reproductive Health Facts. Office of Adolescent Health. http://www.hhs.gov/ash/oah/adolescent-health-topics/reproductive-health/states/ny.html
8.      Siegel, M. Lecture Notes. February 6, 2014.
9.      Kearney MS, Levine PB. (2012). Why is the teen birth rate in the United States so high and why does it matter? J Econ Perspect. 2012;26(2):141---166.
10.  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
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12.  Siegel, M. Lecture Notes. March 20, 2014.
13.  Silvia PJ.(2005). Deflecting reactance: The role of similarity in increasing compliance and reducing resistance. Basic and Applied Social Psychology 2005; 27:277-284.
14.  Simply Psychology. (2014). Maslow’s hierarchy of needs. Maslow. Web. http://www.simplypsychology.org/maslow.html
15.  Siegel, M. Lecture Notes. April 10, 2014.

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