Challenging Dogma - Spring 2011

Sunday, May 8, 2011

Why Public Health Campaigns Are Failing At Preventing Teen Pregnancy

Nearly half of adolescents (46%) between the ages of 15-19yrs in the United States report being sexually active at least once [1]. This rate of sexuality is fairly consistent in many different countries; however, the United States has the highest rate of teen pregnancy of all developed countries [2]. This in part can be attributed to the fact that it takes on average 13 months before a female adolescent discusses birth control options with a clinician after their sexual debut and an adolescent having unprotected sex for 1 year has a 90% chance of getting pregnant [3, 4].

Not surprisingly, eighty-five percent of the 750,000 teenage pregnancies per year in the United States are unintended [1]. Approximately half of teenage pregnancies end in the birth of a child; the remaining proportion end in either abortion (30%) or miscarriage (20%).

Teen pregnancy and subsequent parenthood has consequences for both the mother and child [3-5]. Teen mothers are less likely to complete high school and more likely to be a victim of intimate-partner violence, live in poverty and be dependent on public assistance programs. The children of these mothers also have more chance of having cognitive disorders and being neglected or abused. Daughters have higher rates of subsequent teenage pregnancies and sons have increased rates of incarceration. Thus, there are long-lasting effects of teenage pregnancy and birth.

Because of the lack of comprehensive sex education in a vast majority of schools in the United States [6] and less than 5% of high schools distributing condoms [7], public service campaigns are often the only “safe sex” messages that are heard amongst a highly-sexualized society [8]. The National Campaign to Prevent Teen and Unplanned Pregnancy is an organization based in Massachusetts that provides information and various press around safe-sex and teenage pregnancy.

They have a series of Public Service Announcements (PSA) that were created “by young people, for young people” and are located on a website entitled “Sex Has Consequences.” The PSAs in general are not effective for a variety of reasons and one in particular features a male adolescent going through the routine of getting ready in the morning—including turning off an alarm clock, taking a shower, brushing his teeth, getting dressed and making breakfast. However, each of these tasks is complicated by the fact that his right hand has been replaced with a baby doll. The end of this 30-second commercial has a statement appear on the screen that asks the question “Why complicate your life?” The commercial then ends with “Sex Has Consequences” on the screen and a website address for further information [9]. The video is available at:

There are three main reasons that this approach to preventing health issue unplanned teenage pregnancies is not effective.

Utilization of the Health Belief Model

The Health Belief Model is one of the original models utilized within public health [10]. In the arena of teenage pregnancy prevention, there are flaws to using this model which is based on the notion that adolescents will weigh the benefits and costs to avoiding pregnancy and adjust their behavior accordingly.

The health belief model assumes that adolescents will correctly perceive their susceptibility to pregnancy when they are sexually active. There has been evidence that this does not occur in young adults and you can assume that adolescent’s sense of invincibility only would exaggerate these results. A report published by the National Campaign to End Teen and Unplanned Pregnancy (the same organization that published this PSA) found that although a vast majority of young adults feel that pregnancy should be planned and avoiding pregnancy is very important to them now, almost 50% of those surveyed do not use contraception at all or consistently use contraception [11]. Additionally, one in five people surveyed admitted that it is extremely or very likely they will have unprotected sex in the next 3 months [11]. Therefore, despite the statistic that having unprotected sex for 1 year results in a 90% chance of pregnancy, a majority of sexual active adults do not utilize effective contraceptive methods. This disconnect between risk evaluation and behavior shakes the foundation of the health belief model itself.

Another component of the health belief model is that adolescents will understand the severity and consequences of teenage pregnancy and thus avoid it by practicing safe-sex. This is difficult to interpret in this commercial because of the lack of reality around the images used. Becoming pregnant or fathering a child does not lead to your hand becoming a baby doll and unusable. The message of this particular commercial centers around the idea of a baby being a complication to your life. However, the “complication” depicted in this commercial is having one less hand to use because the dexterity of the actors hand is lost when it is replaced by a baby doll. This results in a message that is unclear to understand for the viewer and somewhat confusing when trying to connect consequences with sexual behavior.

A final component of the health belief model is the assumption that intention leads to behavior. This tenant is complicated when it comes to sexual activity because few teenagers intend to get pregnant or contract a sexually transmitted infection. Instead, adolescents’ (or anyone for that matter) ability to control their behavior in the heat of the moment is limited. The immediate outcome and satisfaction from having sex is not linked to the behavior of safe sex in this commercial. This PSA also does not give any visual or literal idea to the viewer on how to control one’s behavior and incorporate safe sex into sexually activity. Instead, it just warns the viewer to not complicate their life with a baby.

Not Utilizing Modeling

This commercial and many commercials that focus around safe sex and avoiding pregnancy for adolescents do not utilize modeling as a component of the message. Instead, a vast majority of PSA’s often use images and scenarios centered on the outcome of pregnancy and fail to address the act that lead to that pregnancy. This commercial in particular attempts to scare the viewer into what their life may be like if they father a child but completely avoids addressing the activity of unprotected sex that lead to the fathering of a child. Furthermore, as discussed above, the images that are used are not realistic. Instead of giving adolescents actual models on how to change their behavior—there is a leap to the possible outcomes of that behavior.

Negotiating the use of a condom for example is not something that is commonly discussed with adolescents [12]. Instead of modeling the activity of a couple deciding to use a condom during sex and exactly how to use a condom correctly, that is all left to the viewer to figure out on their own.

The character in this PSA is a young male waking up in the morning and going through his routine. While it is important to include males in the conversation of unplanned pregnancy, it does not include a model of a couple that would be together making the decision to have protected sex. This sentiment is related to one of the five principles of the psychology of persuasion—communication theory [13, 14].

This principle is important in public health because who delivers the desired message is actually important. Instead of adolescents hearing a message about safe sex from an adult, it is ideal to hear that message from another adolescent. While this PSA does feature an adolescent, there really is not a way to connect with this character through the brief PSA in a way that makes the audience feel as if there is any commonality between them and the character pictured. Also, one could argue that this PSA would have very little connection to a female adolescent viewing it because throughout the entire PSA, there is no female pictured.

Utilization of Negative Labeling

This PSA utilizes negative labeling as a central tenant to the message it is conveying. It is not uncommon for PSA’s around sexual health, especially those geared towards adolescents, to use this sentiment. Again, however, the labeling is focused on the outcome of unprotected sex (pregnancy) and not the actual act of unprotected sex itself being the focus of the message.

Overall, there is a negative label that is associated with teen pregnancy in the United States [15]. Klein et al. describe this phenomenon as being related to the notion that pregnant adolescents are seen as not fulfilling their role as adolescents, failing to remain in school in some instances, failure to establish a stable family and failure to establish a vocation prior to starting a family and the parents often do not marry.

In this PSA, the negative label that is portrayed focuses on the outcome of a pregnancy leading to a “complicated life” when you have the responsibility of taking care of a child as a teenager is the message. This negative labeling of being an adolescent parent is focused solely on the change to one’s morning routine and not to some of the bigger-picture aspects of becoming a parent at a young age.

Again the labeling is around the outcome of pregnancy and there is no labeling—either positive or negative-around sexuality or the actual act of using appropriate contraception. It is almost like there is no connection to the activity that leads to the pregnancy because it is mostly ignored by this public health campaign.

There has been a lot of research around the association of labeling in adolescents in reference to delinquency [16], drug abuse [17] and mental health [18]. Overall, this research finds that poorer outcomes (i.e. repeat interactions with the justice system, failed abstinence from drug use, etc) were associated with instances when adolescents were labeled. While there hasn’t been published research around the concept of negative labeling and its association to teen sexuality and subsequent pregnancy per se, one could infer that previous research around other risk-taking behaviors has shown the use of negative labeling of adolescents is not beneficial.

Finally, the concept of ambivalence is not really addressed in this PSA and almost worsened by the negative labeling that is utilized. It has been noted in the literature that the lack of contraceptive use by adolescents can be somewhat attributed to their ambivalence to preventing pregnancy [19]. This lack of motivation is not helped by having a commercial make the claim that your life will be “complicated.” For some adolescents, the unrealistic complication depicted in this commercial of your hand being non-functional as you try and brush your teeth in the morning is not going to be powerful enough to overcome this sentiment of ambivalence.

Alternative Approach

Despite these critiques of current public health approaches, there are alternative approaches to the public health problem of teenage pregnancy in the United States. Once such program has been developed in San Antonio, TX and is entitled “ME NOW…baby later”[20]. This program is actually in alliance with the San Antonio Metropolitan Health District and their program entitled “Project W•O•R•T•H” and a non-profit organization called “The Healthy Futures Alliance: a community coalition to prevent teen and unplanned pregnancy.” Thus there is a lot of input from a variety of different sources and also legitimacy to the messages because of the alliances that have been created around this topic.

San Antonio has a high rate of teen pregnancy and birth compared to the nation as a whole. For example, according to 2007 data, the teen birth rate in Bexar County (where San Antonio is located) was 38.4 births/1000 females age 15-17 years old [21]. This birth rate is 73% higher than the nation as a whole. Therefore, there is a definitive need to address this problem within San Antonio and various organizations have come together to begin to effect change.

Utilization of Advertising Theory

Rather than approach the issue of teen pregnancy from the perspective of traditional health models that mainly focus on the individual and the assumption of rational behavior, advertising theory can be utilized [22]. When used within public health, advertising theory conveys a message that has mass appeal and consists of three tenants: a promise, support and core values

The first tenant is the promise and is considered the centerpiece of the advertisement. In the “ME NOW…baby later campaign” the video on the main page features a young female adolescent asking a group of diverse adolescents what “Me Now” means to them. Their answers range from finishing high school to attending medical school and all focus around the idea that concentrating on your time as an adolescent is important. Therefore, the promise of this campaign is that you can dream to accomplish anything as long as you focus on yourself now and wait to be a parent later. This promise is much different than the PSA from the National Campaign to End Teen and Unplanned Pregnancy which promised that your hand would turn into a baby doll if you got pregnant.

The second tenant of advertising theory is support which is provided through images and stories instead of solely based on statistics. For example, the opening video has various teenagers explaining their future goals and plans centered on the concept of delaying parenting. This is important because these teenagers are people you can believe and connect with-and their future aspirations are those that anyone in high school may have. The adolescents interviewed make the message of delaying parenting believable. It should also be noted that the background of this commercial appears to be a school classroom, which is another reminder to the goals given by the teenagers of completing high school and continuing on for further education.

Although not technically part of the concept of support within Advertising Theory, the website for this campaign is also very helpful in providing support for these two concepts. There is a section entitled “Baby Later” that actually gives you a brief overview of the options for contraception in order to not get pregnant. Additional links to medical clinics within San Antonio that specifically offer services to adolescents without parental notification, without insurance and without an appointment are listed. These characteristics for medical care are important to provide for adolescents who may desire to get contraception but are unable to do so for a variety of reasons. So, while this is not shown in the video through images or stories, there is further support on the website on how to make the promise happen.

The third tenant of advertising theory is the utilization of core values. The slogan for this campaign itself encompasses various core values such as youth, rebelliousness, independence, success, family and parenting. The video on the website further illustrates these core values by having the adolescents talk about what the slogan of the campaign means to them. By focusing on the idea of “Me Now” there is a theme of self-centeredness and entitlement that also works into the sense of rebellion that exists within adolescence.

Utilization of Modeling

The utilization of adolescents talking about delaying pregnancy is also important from a modeling perspective. Therefore, instead of telling adolescents what to do, we should show them what to do. For this campaign, the focus is on delaying pregnancy and the message is delivered by other teenagers that have made the decision to delay pregnancy and why that decision is important to them.

Another aspect of this campaign that is not only pertinent to San Antonio is the importance of diversity within modeling. As you can see from the video, there are a group of diverse adolescents answering the question of what “Me Now” means to them. Both genders are represented and there is more than one racial and ethnic background depicted through the adolescents that were chosen to participate. Additionally, there are photographs of adolescents on the website that represent a diverse group of adolescents.

A way to incorporate modeling into this campaign that is not currently a part of the “Me Now…baby later” campaign would be to also include images and stories of adolescents choosing various methods of birth control and how that decision was made. It would be even more interesting to include a video that portrayed a realistic conversation between two sexually active teenagers discussing their options for contraception.

Given the relative uncomfortable nature in the United States around sexuality, it would likely be difficult to include a very realistic conversation, for example one that occurs during foreplay. However, in media right now, there is a lot of depiction of sex and very little if any portion of those images involve a discussion or even utilization of contraception options [23]. Therefore, as public health officials we must use the same avenues that teenagers are exposed to and push the envelope to include safe-sex decisions and the use of contraception. The more modeling that can be depicted of sexually active adolescents actually making decisions around this concept, the more helpful that is to utilizing the concept of modeling.

Utilization of Positive Labeling

As mentioned earlier, the utilization of negative labeling can have impacts on adolescent behavior when it comes to other risk-taking behaviors. While most campaigns around teen pregnancy and safe sex rely on negative labeling and shame the outcome of pregnancy, the “Me Now…baby later” campaign does the opposite.

The catch phrase of this campaign “Me Now” sounds much more empowering and something that an adolescent would want to belong to instead of the last line of the previously discussed campaign—“Don’t Complicate Life.” This campaign from San Antonio is similar to the anti-smoking campaign targeted towards youth in Massachusetts entitled “The Eighty-Four” [24].

Using the same principals of positive labeling, the Eight-Four campaign approaches teen smoking by enticing them to be a part of the 84% of teenagers that don’t smoke. This is a campaign that makes adolescents feel empowered to be a part of it-the majority in fact. In addition, it is powerful to stand up as a group and say that you are not going to participate in a behavior like smoking. Often in adolescence there is a sense that everyone is smoking or everyone is having sex, and if you can dispel that myth and make adolescents feel like they are a part of something for not doing that behavior, it can be very effective.

The “Me Now…baby later” campaign also addresses the issue of adolescent ambivalence towards pregnancy prevention and thus subsequent contraception use. By giving a message of “Me Now” and having teenagers be a part of a larger movement-there is the opportunity to be a part of something and not feel alone in their decisions to focus on their achievements now and delay parenting.

Finally, and just as important, the “Me Now…baby later” campaign slogan incorporates the concept that these young adults will all have the opportunity and potential to be wonderful parents at some point of their life. By concentrating on themselves now, it will enable them to have the tools to be a parent later is a positive message and label applied to the targeted audience. It is also helpful in terms of making a connection between current actions and future consequences in a positive way rather than the negative approach that so often other campaigns around teen pregnancy utilize.


Teen pregnancy is a huge problem for the United States, as is evidenced by our high rates of teen pregnancy compared to similarly developed countries. However, by using the health belief model framework and negative labeling and not using modeling in these campaigns, we are not going to succeed. Instead, a new approach must be emphasized that takes into account the irrationality that often lies around the decision to have unprotected sex. Such alternatives include advertising theory, positive labeling and modeling. With a fresh approach to this public health issue, there is potential to make a genuine impact on this issue and effect change for society as a whole.


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