Challenging Dogma - Fall 2007

...Using the social and behavioral sciences to improve the practice of public health.

Monday, December 10, 2007

Stupid, Dirty, and Cheap: An Analysis of the National Campaign to Prevent Teen and Unplanned Pregnancy – Victoria Churchill

Each year 750,000 15-19 year-olds become pregnant (1). Approximately 34% of teenage pregnancies end in abortion (1). Between 1991 and 2004 teenage mothers were responsible for 6 million births and it was recently reported that teenage pregnancies cost the United States $9 billion annually (2-3). Compared to older women, teenage pregnancy is often associated with poorer health outcomes. Teen mothers are at an increased risk of having a baby who is premature, has a low-weight birth weight, or dies within the first year of life; these risks remain even when controlling for marital status, appropriate maternal education level, and adequacy of prenatal care (4). From this data, it is clear that public health programs aimed at minimizing the number of pregnancies among teenagers, especially those who are unmarried or undereducated, serve legitimate public interests.

One of the most prominent campaigns to emerge from this public health problem is the National Campaign to Prevent Teen and Unplanned Pregnancy (NCPTUP), which began in 1996. Their mission, as stated on their web site is “to promote values, behavior and policies that reduce both teen pregnancy and unplanned pregnancy among young adults. By increasing the proportion of children born into welcoming, intact families who are prepared to take on the demanding task of raising the next generation, our efforts will improve the well-being of children and strengthen the nation.” (5)

Despite the campaign’s sincere interest in minimizing unplanned pregnancies, the means they use to achieve their goal are badly chosen. The NCPTUP relies heavily on the Health Belief Model and the Stigma theory to instill fear and shame into teenagers instead of providing them with the resources and support they need, therefore decreasing their sense of self-efficacy to not engage in unprotected sexual behaviors.

Stigma Theory and Labeling

Stigma was originally defined as an attribute that diminishes the target person “from a whole and usual person to a tainted, discounted one.” (6) The NCPTUP both labels and stigmatizes teenagers who do not conform to the campaign’s goal of preventing teenage pregnancy. One way the campaign does this is with their Stay Teen Print Ads (7). The ads feature seven different advertisements each focusing on an individual teen. The featured teenagers consist of two black males, two white males, one black female, and two white females. The compositions of the photographs give the viewer a clear indication in what social groups each teenager belongs. Additionally, the campaign labels each teenager with his or her own phrase. One Black male is a football player (“Stay alpha; Stay untouchable; Stay in the zone”) while the other is aggressively posed in front of a chain-link fence (“Stay up; Stay real; Stay a poet.”). The campaign is reinforcing stereotypes against black male teenagers. They are being labeled as aggressive and strong: a message that does not directly correlate with an anti-pregnancy campaign. They are being told to be aggressive, but to also to respect women and to not have premarital sex. This is not to say that black males cannot be displayed as both strong and respectful. However, the NCPTUP does not seem to take into account how black males are portrayed as aggressive in the media already, and the negative consequences because of it. Research has shown that black couples have higher rates of male-female sexual aggression than other races (8). By continuing the labeling and stigmatizing black teenage males as aggressive and “alpha” the NCPTUP is doing a disservice to those they are trying to help.

The labeling and stereotyping does not end with the black males. One white male is on a skateboard, the other is playing a video game (“Stay airborne; stay off the grid; stay punk” and “Stay focused; stay alive; stay a slacker.”) These images show white teenage boys as unmotivated and uninterested in education. Yet, they are expected to read the campaign and understand how to practice safe sex. Furthermore, research demonstrates that teenage boys who have low SES, high aggression, and low academic performance combined show the highest proportion of teenage fatherhood (9). The NCPTUP illustrates these three risk factors in their campaign, but does very little to challenge the labels.

For the female teens the slogans are less racially discriminating, but they definitely express gender stereotypes. The slogans for the female teenagers are: “Stay cliquey; stay self-centered; stay in demand”, “Stay bratty; stay opinionated; stay an over achiever”, “Stay a princess, stay strong, stay diva.” These labels suggest that a strong, educated woman is self-centered, bratty, and a diva. By qualifying what it means to be a powerful woman with stereotypical and negative descriptions, the NCPTUP is stigmatizing the image of an empowered woman. The NCPTUP stereotyping ad campaigns very likely lead the teenagers to adopt the self-fulfilling disempowered prophecies presented to them, rather than make educated and informed decisions about their sexual behaviors.

In their latest ad campaign the NCPTUP continues with its tactics of labeling and stigmatizing teenagers who do not conform to the abstinent/condom every time message. Like the previous campaign, this once again disempowers teenagers. They feature six separate photos of teenagers, each standing alone and each with a large, red-lettered word across the photo. The much smaller, vertical print on the left of the photo is meant to qualify the word in red, but the main message being the six teenagers are described with the negative words. In this advertisement racial diversity is slightly more apparent than the prior print campaign, yet does not seem to properly reflect the actual rates of teenage pregnancy among white, black, and Hispanic teens. Black teenagers have the highest rate, followed by Hispanic and white teens (1). It seems NCPTUP is only grazing its target audience by addressing the majority of the population and not the majority of those at risk. For the four adolescent females, the words used to describe them are “Cheap” (“Condoms are cheap. If we’d used one I wouldn’t have to tell my parents I’m pregnant.”); “Dirty” (“I want to be out with my friends. Instead, I’m changing dirty diapers at home.”); “Nobody” (“Now that I’m home with a baby, nobody calls me anymore.”); “Reject” (“I had sex so my boyfriend wouldn’t reject me. Now, I have a baby. And no boyfriends.”) (10). The message being portrayed is that these four teenage girls had sex while young and unmarried and are now cheap, dirty, nobodies, and rejects. The NCPTUP gratuitously stigmatizes adolescent girls who have premarital sex in order to prevent other adolescents from engaging in unprotected sex. However, these are inappropriate means to achieve their goal. It has been shown that stigmatization can often lead to a decrease in healthy behaviors, especially behaviors related to sexual health (11). By stigmatizing the young women NCPTUP is disempowering them.

Health Belief Model—Self efficacy

The NCPTUP also relies heavily on the health belief model (HBM). The model asserts that intention is directly linked to behavior. Therefore, in order to get someone to change their behavior, they just have to want to change. Criticisms of the HBM argue that there are other factors that influence whether or not a person’s intention will actually lead to the completion of the desired behavior (12). In addition, the HBM does not address the concept of self-efficacy. Self-efficacy is the individual’s belief that s/he can accomplish the desired behavior (12). It has been shown that teenagers that have higher self-efficacy in regards to delaying sex have a higher likelihood of later onset of sexual activity (13). Higher self-efficacy positively correlates with rates of condom use (13). Furthermore, evidence has shown that people with higher general self-efficacy are less likely to experience helplessness (14).The NCPTUP explicitly states only two options to prevent pregnancy: use a condom every time or remain abstinent. This is an over-simplification of the spectrum of teenage sexual behaviors. It also assumes that every teenager can use a condom every time or abstain from sex. Teenagers do not always feel they have the ability to do either of those activities, which forms a lack of self-efficacy. Furthermore, teenagers reading the site may not even know what risky sexual behaviors are; the NCPTUP does not provide a definition of what “sex” is and are therefore relying on what the teenager already knows about sexual behaviors. In one study less than 25% of teenagers included oral sex in their definition of “having sex” (15). While oral sex does not directly result in pregnancy, it is a behavior that can lead to unplanned intercourse, and therefore should be addressed in a pregnancy-prevention campaign.

Health Belief—Perceived severity

Another way the NCPTUP fails using the HBM is by the use of fear appeals. The HBM theorizes that an individual’s perception of the severity of the consequences of not engaging in the behavior impacts whether or not they engage in that behavior (12). If not doing the behavior surpasses the individual’s threshold of discomfort, then it is more likely they will comply with the behavior, according to the HBM. Fear-arousing is used in many health promotion campaigns, but it is often done so without taking into account other factors needed to make a fear appeal an effective campaign (i.e. vulnerability) (16). The NCPTUP website focuses heavily on the consequences of having sex; not only to the mother and father, but also to the child and society as a whole. One document available from the NCPTUP titled Playing Catch-up: How Children Born to Teen Mothers Fare claims that children born to teenage mothers are less developed socially, cognitively, physically, and verbally, compared to children born to older mothers (17). This is a fear appeal applied by the NCPTUP to prevent teenagers from becoming parents. Fear appeals are only effective when they also provide solutions that “are both easy to perform and effective.”(18) It has been also shown that fear appeals do not work for every circumstance and audience, so it is especially important to take into account the age of the target audience (18). Adolescents do not respond well to fear appeals that emphasize long-term health risks; and while having a baby is a fairly immediate risk the NCPTUP warns teenagers about, the real fears highlighted on the website (namely the negative health outcomes of a child born to young parents) are long-term (19). Clearly, trying to scare teenagers to not have sex is ineffective and inappropriate.

The NCPTUP is attacking the problem of teenage pregnancy in the wrong ways. There are enormous negative implications that will result if the NCPTUP continues using the stigma/labeling and health belief model, focusing on perceived severity, to change the behaviors of adolescents. Youth may become disempowered and frustrated. They may also feel unmotivated to change their behavior if they put themselves at risk by having unprotected sex already.

It is clear that the National Campaign to Prevent Teen and Unplanned Pregnancy has a legitimate and sincere interest in minimizing pregnancies to adolescent and unmarried parents. However, instead of finding ways to empower teenagers to make well-informed decisions about their sexual behaviors, they are authoritarian, letting teenagers know exactly the consequences of unplanned pregnancies. Furthermore, in attempts to speak on the same level as the teenagers they insult, stigmatize, and marginalize the very teenagers who are at-risk and disempowered. This not only takes away the remaining self-efficacy these teenagers have to make their own healthy decisions, but also stigmatizes them if they are not able to follow the abstinence-or-condom mandate by the NCPTUP.

A very recent report from the Center for Disease Control found that rates of teenage pregnancy in the U.S. went up for the first time in fifteen years (20). The main reasons for this increase were the focus on abstinence-only education, increased sexual activity and decreased condom use (20). If the United States wants to continue seeing a decrease in teenage pregnancies, we must address the topic in a way that allows teenagers to feel in control of their own health behavior decision-making. By using threats and not taking the time to consider the obstacles teenagers face in deciding to practice safe-sex we only end up with rebellious and disempowered teenagers, perpetuating the prevalence of unplanned and teenage pregnancies.

REFERENCES

1. Guttmacher Institute. U.S. Teenage Pregnancy Statistics: National and State Trends and Trends by Race and Ethnicity. New York, NY: Guttmacher Institute, 2006.

2. The National Campaign to Prevent Teen Pregnancy. Why it Matters: Linking Teen Pregnancy Prevention to Other Critical Social Issues. Washington DC: The National Campaign, date unknown.

3. The National Campaign to Prevent Teen Pregnancy. Why it Matters: The Costs of Teen Childbearing. Washington DC: The National Campaign, date unknown.

4. Fraser A, Brockert J, Ward R. Associations of Young Maternal Age with Adverse Reproductive Outcomes. The New England Journal of Medicine 1995;332:1113-1117.

5. The National Campaign to Prevent Teen and Unplanned Pregnancy. Mission and Goal. Washington, DC: The National Campaign. http://www.teenpregnancy.org/about/atc.asp.

6. Yang LH. Application of Mental Illness Stigma Theory to Chinese Societies: Synthesis and New Directions. Singapore Medical Journal 2007;48:977-985.

7. Stay Teen. Stay Teen Print Ads. Washington, DC: The National Campaign to Prevent Teen and Unplanned Pregnancy. http://www.stayteen.org/print/default.html.

8. Ramisetty-Mekler S, Caetano R, McGrath C. Sexual Aggression Among White, Black, and Hispanic Couples in the U.S.: Alcohol Use, Physical Assault, and Psychological Aggression as Correlates. The American Journal of Drug and Alcohol Abuse 2007;33:31-43.

9. Xie H, Cairns BD, Cairns RB. Predicting Teen Motherhood and Teen Fatherhood: Individual Characteristics and Peer Affiliations. Social Development 2001;10:488-511.

10. Teenage Pregnancy. Our Latest Ad Campaigns for Teens. Washington, DC: The National Campaign to Prevent Teen and Unplanned Pregnancy. http://www.teenpregnancy.org/resources/audiovisual/psa/labels/default.asp

11. Rao D, Kekwaletswe TC, Hosek S, Martinez J, Rodriguez F. Stigma and Social Barriers to Medication Adherence with Urban Youth Living with HIV. AIDS Care 2007;19:28-33.

12. Salazar MK. Comparison of Four Behavioral Theories: A Literature Review. AAOHN Journal 1991;39:128-135.

13. Carjaval SC, Parcel G, Basen-Engquist K. Psychosocial Predictors of Delay of First Sexual Intercourse by Adolescents. Health Psychology 1999;18:443-452.

14. Lightsey OWJ, Barnes PW. Discrimination, Attributional Tendencies, Generalized Self-Efficacy, and Assertiveness as Predictors of Psychological Distress Among African Americans. Journal of Black Psychology 2007;33:27-50.

15. Randall H, Byers E. What is Sex? Students’ Definitions of Having Sex, Sexual Partner, and Unfaithful Sexual Behavior. The Canadian Journal of Human Sexuality 2003;12:87-96.

16. de Hoog N, Stroebe W, de Wit JBF. The Impact of Vulnerability to and Severity of a Health Risk on Processing and Acceptance of Fear-Arousing Communications: A Meta-Analysis. Review of General Psychology 2007;11:258-285.

17. Terry-Humen E, Malove J, Moore K. Playing Catch-up: How Children Born to Teen Mothers Fare. Washington, DC: The National Campaign to Prevent Teen and Unplanned Pregnancy, 2005.

18. Hale JL, Dillard JP. Fear Appeals in Health Promotion Campaigns (pp. 65-80). In: Maibach E. & Parrott R. L., eds. Designing Health Messages: Approaches from communication theory and public health practice, 1997.

19. Smith KH, Stutts MA. Effects of Short-Term Cosmetic Versus Long-Term Health Fear Appeals in Anti-Smoking Advertisements on the Smoking Behaviour of Adolescents. Journal of Consumer Behaviour 2003;3:157-177.

20. CNN. Teen Births Up for the First Time in 15 Years. December 5, 2007.

http://www.cnn.com/2007/HEALTH/12/05/teen.births.ap/index.html.

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2 Comments:

  • At December 14, 2007 at 9:51 AM , Anonymous Deinera said...

    And I thought my campaign was bad! Was any thought given to those women who had already become pregnant during their teens, or were currently pregnant? The labels of dirty and cheap are so offensive, and certainly wouldn't inspire any one to change their behavior in the future.

     
  • At December 14, 2007 at 11:22 AM , Blogger Read said...

    WOW. So I'm thinking about the kind of people creating and implementing this campaign. Do you think they saw themselves as "nothings, rejects, brats, etc" when they were teenagers? I think the fear technique works if they're your kids and you keep them locked up in their rooms until they turn 25...

     

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