Monday, May 19, 2014

Baby Think It Over, Again A Critique of a Teen Pregnancy Prevention Program - Kelly McCue

Among developed nations, the United States has one of the highest rates of teen pregnancy, but this is not because teens in the US are having more sex (1). In fact, while European and US teens have similar rates of sexual activity, teens in Europe are more likely to use consistent and effective methods of contraception (1).  The teen pregnancy rates in 2008 were 68, 28, and 31 per 1,000 girls age 15-19 in the US, Canada, and Sweden, respectively (1). Clearly there are significant differences in teen pregnancy rates between these countries, but there are also huge disparities within demographic populations in the US.  For example, there were 117 pregnancies per 1,000 black girls age 15-19, 107 pregnancies among Hispanic/Latina girls, and 43 pregnancies among white non-Hispanic girls of the same ages in 2008 (1). The south and southwest have the highest rates of teen pregnancy (1), and approximately 60% of all teen pregnancies result in live births (2). Addressing teen pregnancy is important because of the health, social, and economic costs of teen births and teen parenting (2), in addition to health equity.   
Public health and school boards across the country have established a variety of teen pregnancy intervention strategies; among the most popular is the Baby Think It Over (BTIO) program. This model, developed in 1995, includes an eight-pound infant simulator equipped with internal microchip and sensor (3). The doll cries at various intervals and durations in the event of mishandling, incorrect positioning, neglect, hunger, and sleep, and the teen is responsible for reacting to these needs by aligning a sensor on a tamper-proof bracelet to the sensor on the doll (4, 5). Over the past decade, the technology and features of the doll have become more sophisticated, but the model of the program has remained the same. The BTIO program is modelled after the Health Belief Model (HBM), in which the desired outcome (changing teens’ sexual behavior) will result from providing teens with the opportunity of teen parenting for a few days (6). Following the HBM, the program assumes that experience with the infant simulator will enhance the teens’ perceived susceptibility to teen parenting, severity of teen parenting, benefits at stake if teen parenting is not avoided and, finally, the social and financial costs as a result of teen parenting (6, 7). The model presumes that several of these aspects will combine to influence the teens’ intention to change their sexual behavior and ultimately their actual behavior (7). The goal of this paper is to critique the Baby Think It Over model and call attention to why this program is not lowering teen pregnancy rates.  

It Takes Two to Tango
Baby Think It Over is offered to teenage girls and boys, but is predominantly utilized by girls, which is problematic because it encourages labeling and stereotyping of females and limits male accountability and involvement in safe sex. The program is offered through elective courses in middle schools and high schools across the US, which ultimately limits the number of students who can or will participate in the program. Most of the analyses of BTIO make note of small and predominantly female study samples (5, 8, 9, 10), which is a direct result of the program being offered in specific elective courses such as Home Economics or Family and Consumer Sciences (5). In other words, teenage girls are more likely to be exposed to the teen parenting simulation than are teenage boys because of where the program is offered within the school curriculum.
Excluding boys from this program, even unintentionally, further fuels the stereotype that teen parenting and behaviors to avoid it are a “girl’s issue” (9) because females literally carry the consequences of unprotected sex (11). Labeling theory explains what is known as a self-fulfilling prophecy, in that labeling these girls as solely responsible for contraception, avoiding teen pregnancy, and parenting actually encourages these girls to wear the label and live up to the expectations society gives them (12). Some reports that evaluated BTIO included no male subjects (13, 14) and several included only a very few male subjects, accounting for less than 25% of the studied population (5, 6, 9). This is indicative of the limited number of males who elect the courses and receive the BTIO simulation. One report commented that the boys that do enroll do not take the program seriously and do not perceive themselves at risk (9). Further, teen boys perceive the simulation to be unrealistic, as they believe it unlikely they would take care of a baby by themselves anyway (9). BTIO reinforces stereotypes, it does not change behaviors.
In general, females are more likely to want protected sex and specifically want the male to be protected, but this is highly dependent on the male’s willingness to use protection and his perceived dominance in a relationship (11).  An individual’s behavior will not determine or create safer and protected sexual intercourse; both partners must be involved in the decision and behavior (11). Environmental and societal factors also impact individual behavior, according to the social learning theory (15). These include social norms and roles as well as personal and social expectations (15). BTIO model does not discuss care-giving expectations or gender roles (9), but instead perpetuates the dogma that girls are expected to be responsible for avoiding teen pregnancy and fails to show that boys are equally accountable. Ultimately, the BTIO model creates an environment that encourages teen boys to deflect sexual responsibilities which is not conducive to a successful teen pregnancy intervention.  

Nothing Like the Real Thing, Baby
            Society and environment play an undeniable role in decision making (15). The BTIO model is limited because it does not allow for cultural or social adaptations to the program and it does not account for the influences these forces have on an individual. The program currently assumes the processes of decision-making and behavior-changing are completely dependent on the individual. Depending on school funding and curricula, the duration of BTIO simulation may be adjusted to between 3 and 7 days (6, 9, 13, 14), but reviews of BTIO have not expressed any culture-specific adjustments to the program. It is important to consider the community and the reality in which teens actually live, because these influences will directly impact the success of an intervention (15, 16).
Most of the studies evaluating BTIO were conducted at rural and urban white communities (10, 13). Studies that conducted surveys and focus groups among these communities report that many teens found the experience challenging and some teens explained that they will be more cautious in future sexual encounters (6). At least one evaluation of BTIO resulted in girls expressing the opposite reaction. This study was conducted at a predominantly Hispanic school in Denver (13). A survey of the girls before the BTIO simulation provided information about whether they had experience as babysitters and whether they expected the infant simulator to be easy due to their previous caregiving experience. Interestingly, many of these girls left the program agreeing that the infant simulator was challenging, but that a real baby is much easier (13). In some cases, girls finished the BTIO program with an even greater desire to become a teen parent (13). These examples support the powerful influence that environment has on decision making as well as exemplifies the irrationality of teens. BTIO highlights teen pregnancy as an undesired outcome and attempts to prove this with a noisy, fake doll. However, this is not a reality to girls (and boys) who have past experience caring for infants or come from families with young and capable mothers.  
In addition to social and cultural influences, girls that perceived real babies as easier and desired to be teen mothers after BTIO exposure may have experienced psychological reactance. The theory of psychological reactance explains why an individual will behave or act against a message that threatens the individual’s autonomy or freedom, especially when the message is delivered by an authoritative or dominant figure (17). Many health interventions elicit a psychological reactance from their target population simply because the intervention is perceived as a threat to something of value to the individual or population (17). Psychological reactance is a common phenomenon among adolescents and can be predictive of risky sexual behavior (18); telling youths that teen sex should be avoided not only motivates teens to reestablish their freedom to have sex, but actually increases the attractiveness of that behavior (18). Further, adolescents and emerging adults are particularly sensitive to messages that threaten their self-determination and near-adult freedoms (18). Perceiving these threats can stimulate the individual to perform the opposite of what is recommended (17, 18). BTIO is supposed to be difficult and is touted as such by teachers and students, sometimes including a comment that many participants will fail. While some students may accept this as a true fact, other adolescents may perceive this comment as a dare or a threat to their decision-making capacity. As BTIO instructors and participants highlight the challenges of teen parenting, psychological reactance may actually cause teens to prove this notion otherwise. The evaluation of BTIO from Denver is a case in point; the girls indicated that they thought parenting a real baby was easier and that teen parenting was an appropriate option for them (13). In summary, psychological reactance may cause the BTIO program to have the exact opposite effect as intended.

I’m Not Susceptible, Baby
            Baby Think It Over is designed to increase teens’ perceived susceptibility and vulnerability to becoming a teen parent by providing teens with an opportunity to role-play teen parenthood (6). BTIO utilizes the Health Belief Model in response to studies that showed teens’ lack of risk perception regarding pregnancy because of the personal fable, or the perception that teen pregnancy cannot happen to them (6, 13, 19, 20). The premise of BTIO is that teens will experience the hardships of teen parenting, internalize their susceptibility to teen pregnancy, and take the appropriate measures to avoid it. However, there is a clear disconnection between cause and effect, where teens are role-playing the effect (teen parenting), and not discussing the cause (unprotected sex). Teens are expected to think critically, to make the connection between effect and cause on their own, and to accept that they may be at risk.
            Expecting teens to recognize that they are susceptible means teens are expected to ignore the teen-mom or teen-parent stereotypes. BTIO focuses on teen parenting simulation, but underlying stereotypes will determine whether a teen participant recognizes their own personal risk. Neglecting to discuss the cause of teen parenting is a failure to break stereotypes and really show teens their susceptibility. Teen parent stereotypes may differ per community, but most will have some perceived indicators of what makes a teen parent, whether that includes race, poverty, IQ, or substance use. With these stereotypes in mind during the simulation, the participants may not assess their actual risk if they do not relate to the stereotype. The ‘representativeness heuristic’ is a certain kind of bias that leads people to draw certain conclusions about their risk, based on whether they perceive themselves as similar to the targeted population (21). The role a teen plays for a week is not real, but it is recognized as the reality of a teen that fits the stereotype and participated in risky activities. This model perpetuates stigma and stereotypes by not explicitly discussing how all males and females can be at equal risk if they do not practice safe sex. Allowing these stereotypes to continue deters many teens from assessing their risk. ‘Representativeness’ is a form of comparative optimism (21); in this case, teen girls who do not feel they fit the stereotypical teen-mom prototype will not be at risk for teen pregnancy. Key to this perspective is that teens participating in the BTIO program may understand the challenges that teen parents experience, as noted in many studies, but this does not translate into personal concern because the teens do not perceive their personal risk.
In lieu of the discussion of the causes of teen pregnancy, teens will determine their susceptibility by assessing their peers. According to a large study among adolescents, unprotected vaginal intercourse can be predicted by whether their friends are sexually active (16). This is supported by representativeness theory, as teens act like friends because they are similar and relatable (16, 21) and social learning theory, as teens are influenced by their peers and environment (15). Even though sexual intercourse can be directly influenced by friends and their perceived level of sexual activity, contraceptive use is not predicted in the same way. A form of optimistic bias, called the law of small numbers (22), continues to support why teens will not perceive their risk when they do not relate to the outcome. In schools that do not have an observable rate of teen pregnancy, BTIO may not successfully convince teens of their susceptibility because pregnancy is not the common outcome. Perceived personal risk can be determined by comparing oneself to someone with the desired outcome (22). BTIO expects that teens will connect their potential sexual behaviors to teen pregnancy, while teens determine their sexual outcomes by comparison of their peers who are not pregnant if that is the desired outcome of the teen, according to the law of small numbers. The combination of teens utilizing friends’ sexual activity as a standard, not connecting to the stereotype of a teen parent, and the apparent number of teen pregnancies in the school further encourages teens to continue their current behavior.  

A Proposition for Peer-Lead Pregnancy Prevention Task Force
            To effectively reduce teen pregnancy and teen parenting, the aforementioned issues overlooked by the BTIO program, male inclusion, cultural-adaptability, and identifiable risks, must be addressed. A teen-lead task force may prove to be an effective solution. Peer behaviors can be predictive of individual actions, especially among adolescents and in regards to risky behaviors, as previously discussed (16). The following intervention proposal for teen pregnancy prevention takes advantage of the power of labelling, peer pressure, and diffusion of innovation to change adolescent behavior in a positive way. A group of teens, selected via the existing student council, the captains of sports teams, or through elections, will be the promoters of safe sex. The peer group must also include key persons from the wide diversity of social cliques within a school system or neighborhood. Through events, anonymous condom-to-locker drop-offs (male and female condoms), and culturally appropriate counseling card dispersal (including information on benefits of abstinence, consensual sex, and linkages to health services) will be combined to lower the rates of teen pregnancy.     
            The task force is for teens and will be supported by teens. The first step to this campaign is to have teens choose the name of the task force, as this will increase their ownership of the program and utility of the services it offers. This concept is inspired by an article regarding the impact word association and imagery of various health messages has on adolescent behavior (23). In addition, allowing students and schools to choose the name will promote cultural adaptability. Not all schools and communities will have the exact same message, but they can follow the same guideline for promoting safe sex (including abstinence) through positive messages, not the negative outcomes as seen in the BTIO program. Several campaigns, including “The 84” (, “Crush” (, and “love Life” ( effectively use positive labels to reinforce positive behaviors and identities of individuals. “The 84” are proud to be the 84% of adolescents who do not smoke tobacco, “Crush” are tobacco-free lesbian, gay, bisexual and transgender persons (LGBTs) in the Las Vegas area, and “love Life” promotes teens and young adults to take control of their destiny and reproductive health through ‘sex positive’ messages. Positive labeling will result in teens living up to positive expectations, but in order to do so these teens must see value the label. Ownership of the label will ensure pride in the vision of the safe sex task force and result in positive behavior change.
            The task force will focus on positive messages that address how teens have sex, rather than the distant outcomes of teen pregnancy and teen parenting, as was the focus in BTIO. This will allow teens to assess the proximal risks they are aiming to avoid and provide teens with a tangible goal and message. While the goal of the task force is still to avoid teen pregnancy, the message must remain positive and proactive to decrease the negative stereotypes. The message should respect everyone’s choice and freedom to practice safe sex (including abstinence) and make this a value that teens want to own.
Election of task force members must include equal representation of males and females; this will also increase utilization of the services offered by the task force because of the familiarity and availability of their peers. The similarity of the task force to the teen audience will effectively reduce psychological reactance, thus increasing the likelihood that teens will follow the health messages promoted (24) while ensuring male involvement in the program. In combination with similarity, the use of reason and support without threats to autonomy or freedom will increase the credibility of the messengers and the health messages and promote compliance by the teens (24). Observing that the task force is supportive of safe sex (including abstinence) will encourage peers to practice safe sex as well. Strong peer support decreases negative health risks (25) and the more influential the peers, the greater improvements in behavior (26). “Following the herd”, a chapter in the book Humans and Econs, discusses the incredible power peer pressure has in influencing conformity and the motivation to do so (26). The task force takes advantage of the power of social influences and modelling of behaviors, observed in the social learning theory (15), and the predictive nature of adolescents as they look to peers for behavioral approval.
             The positive message and slogan of the task force, the similarity of the messengers to their peers, and sway the messengers have with influencing peer behavior supports the process of diffusion (27, 28). “Preventive diffusion” describes “an idea that an individual adopts at one point in time in order to lower the probability that some future unwanted event may occur” (29), communicated through channels in a social system (27). The task force intervention is a group-level, social model that will rely on the diffusion of the safe sex message, communicated by peers. According to diffusion theory, the peer-lead task force sets trends that will impact the behavior of the entire school population, not one individual at a time (28), thus creating behavior change at a much faster rate. As the innovative safe sex slogan spreads, the positive sexual behavior will become the norm, effecting behavior directly (28) and eliminating the need to focus on changing knowledge and attitudes first. Creating a safe sex norm within an entire school sets a new standard for teen boys and girls to follow, with pride, that will ultimately result in far fewer teen pregnancies than the Baby Think It Over model.

            Baby Think It Over is an individual-level model, which is costly in time, money and other resources. The model focuses on changing attitudes about teen parenting through a needy infant simulator, but it does not change teens’ behavior. Unfortunately, BTIO inadvertently encourages boys to assume girls are the only partner responsible for contraception and parenting, perpetuates stereotypes of teen moms and teen parents, and focuses on an outcome that is not explicit about the actual behavior to be avoided. The teen pregnancy prevention task force outlined in this proposal will likely not be ideal for every school situation, but will be more effective than BTIO. The proposed plan suggests a ‘safe sex’ campaign by diffusion, a model which should be adaptable in a variety of social situations, including abstinence-only schools, religious organizations, and other perspectives. The message should follow the guideline of being positive, tangible, and of value to teens. The task force model assumes that the school board will be supportive of a group of teens and promote their positive behavior without encouraging reactance from the task force and their peers. Notwithstanding, the group-level model will result in school-wide behavior change and the peer-based approach will ensure legitimacy of the message. This will result in fewer resources needed at a lower cost and a much more sustainable model. Think it over. Teens know about sex and they know about pregnancy, but teens do not always know where to access information or contraceptives in a comfortable setting. Preventing teen pregnancy should be a priority for all states and schools, and all teens deserve a foundation that will effectually support them in their surroundings and promote their behavior change.
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