Tuesday, May 13, 2014

“Baby Think It Over” and Abstinence-Only Sexual Education Fail to Reduce Teen Pregnancy Rates –-Megan Scannell

            Despite a steady decline over the past 20 years (1), the teen birth rate in the United States remains the highest in the developed world with 3 in 10 American teenagers becoming pregnant before the age of 20 (2).  Sexual education in the United States is an extremely controversial topic, with persistent conflict between supporters of abstinence-only and supporters of comprehensive sexual education in schools. Abstinence-only programs teach students that abstinence from sexual activity is the only morally correct choice until marriage, and do not provide information about contraceptives (3).  In contrast, comprehensive sex education educates students about contraceptives and their ability to protect against STIs and pregnancy in addition to explaining that abstinence is the best form of birth control and STI protection (3). One popular public health intervention in abstinence-only education is the “Baby Think it Over” program, in which students must care for an electronic infant simulator. Realistic-looking dolls are given to high school students for an extended period of time, usually between three days and a week, to show them what life is like as a teen parent. The simulators cry for a variety of reasons, require diaper and clothing changes, regular feedings, and human contact. The device records data such as how long the baby cries for before being picked up and how often it is fed to ensure students are fully participating (4). The intention of the program is to show students how difficult caring for an infant is to discourage them from engaging in premarital sexual activity. Numerous studies have found the program to be ineffective (5,6,7), and others found the program to do more harm than good, with more girls wanting to become a teen parent after the intervention was complete (8).  It is no surprise that ‘Baby Think it Over” is not an effective means of teen pregnancy prevention as it does not consider the motives and influences that shape a teen’s decision-making process and behavior.
“Baby Think it Over” Does not Address Why Teens Get Pregnant
            Infant simulator programs are not an effective intervention to lower teen pregnancy rates because they do not properly engage with the reasons why teenagers have sex. Very few teenagers plan or attempt to get pregnant.  Optimism bias, or believing that one’s self is less likely to experience an event or develop a condition, is a well-documented phenomenon in humans (9).  People assume their risk for getting pregnant is lower than another person who is having the same amount of sex with the same amount of protection. Teens do not think their sexual activity will result in pregnancy, even if they are partaking in known risky, unprotected sex. As the Theory of Reasoned Action explains, a person’s behavior relies on their attitude toward the behavior, subjective norms, and behavioral intention (10). The students participating in “Baby Think it Over” already know that being a teen parent is not a desirable outcome. However, they do not think that a pregnancy will actually happen to them. Infant simulator programs are often used in areas and schools that experience little to no teen pregnancy. If the student does not see pregnancy as a valid threat it will not influence their sexual decisions. According to Psychological Reactance Theory, teens will prioritize their freedom to engage in sexual behavior over the threat of teen pregnancy (11). Since these teens underestimate their risk of pregnancy and do not realize how life changing it would be, they assume pregnancy is not a large threat toward their current freedoms and lifestyle. Their behavior will be determined to a greater degree by their desire to protect their sexual freedom then a fear to protect themselves from pregnancy.
            Despite the advice of parents, abstinence education in schools, and the influence of religious morality, 62% of American high school students will become sexually active before graduation (12). Several factors play a role in this statistic, including the influence of media and peer pressure. However, much of the decision to become sexually active can be based on physical and psychological need. Maslow’s hierarchy of human needs categorizes the factors that direct human behavior into a pyramid of needs (13). The bottom four levels of the pyramid are the deficiency needs, meaning a person must satisfy these needs before they can move on to fulfilling the top of the pyramid (13). These four categories are physiological, safety, belongingness and love, and esteem (13).  Sex is considered to be a basic physiological need in adult human bodies, along with the love of friendship and sexual intimacy, self-esteem, confidence, and respect from others (14). Teenagers have mature bodies and a physiological desire for sex. Their physical desire, paired with a basic need for sexual intimacy, guides many toward sexual relationships. In addition, self-esteem and confidence can often be improved through fulfilling sexual experiences. Many teens may also feel they are more respected by their peers or society once they are sexually active. Once their deficiency needs are met, a person can move on to growth needs like morality, problem solving, and acceptance of facts (13).  Teens are discouraged from sexual activity for moral reasons like religion as well as to reduce their risk for STIs and pregnancy. A person will not be able to make decisions based on morality or cultural disapproval while their deficiency needs are not being met.  Using an infant simulator to show teens the problem of how difficult teen parenting is will not prevent them from fulfilling their deficiency needs.
“Baby Think it Over” Fails to Provide Means to Avoid Pregnancy
            Abstinence-only programs try to reduce teen pregnancy by stressing abstinence as the only alternative to pregnancy. Abstinence is the only perfect method of birth control, yet students who receive abstinence-only sexual education have higher rates of teen pregnancy (15).  Students who were taught with abstinence-only programs will often not know how or why to use birth control properly if they do decide to have sex, increasing their risk for pregnancy.  As discussed above, the scare tactic of threatening teen parenting is not effective enough to keep teens from having sex. In order to reduce teen pregnancy, students must understand why pregnancy occurs and how to prevent it by effectively using contraceptives. Infant simulator programs do not acknowledge birth control or discuss how to prevent pregnancy with safe sex to students.
            According to the Theory of Planned Behavior, people’s control beliefs affect their decisions. A person believes it will be easy for them to perform a behavior when they can easily control or access the factors necessary to establish the behavior (10). Teenagers who have never learned about contraception will have a harder time reducing their risk of teen pregnancy. They do not know what types of contraceptives are the most effective and may not know how to use them or where to buy them.  If their only introduction to condoms are in the media and hearing friends talk about them, it will be embarrassing to ask how to use one. Media depictions of sexual activity do not usually discuss birth control; only the passion and pleasure are shown.  The teen’s idea of “normal” sex is what they have seen in media, and they will not consider it necessary or “normal” to use contraceptive. If the student thinks it will be hard or awkward to obtain contraceptives, they will not use them and increase their risk for pregnancy.
            In Social Cognitive Theory an intervention must address three factors in order to change a person’s behavior: self-efficacy, goals, and outcome expectancies (16). In order to prevent teen pregnancy, the students must feel that they have control over their sex lives, and are able to protect themselves from pregnancy. Students participating in an infant simulator program will be able to protect themselves with abstinence. Once they decide to have sex, they have no behavioral capability to control the safety of their encounter. Without the agency to properly use birth control, teens will continue to get pregnant. They have no observational learning from discussing how to have safe sex. If a model of a sexual relationship that used contraceptives is discussed in class, the students will be able to remember how to protect themselves while having sex because they can compare themselves to a realistic example of how to successfully avoid pregnancy.
“Baby Think it Over” Does Not Show the Real Experiences of a Teen Parent
            The strategy to infant simulators is that they will show students the hardships that accompany teen parenting, leading the teens to abstinence. Unfortunately, the simulated experience does not show life as a teen parent, it only inconveniences students for a few days. The student does not need to pay for diapers, clothes or food, does not go through the physical pain of pregnancy and childbirth, and does not need to worry about telling their family and friends they are becoming a parent. The simulators are not real, making it hard to associate the activity with an infant. The inconvenience, despite being a fraction of what teen parents experience, seems even less severe due to optimism bias and the Health Belief Model.  As a result of optimism bias, the participants will assume that even if they had a child, the experience would not be as hard as it seemed (9). Students will assume their child would never cry during the night or need to be changed at an inconvenient time. According to the Health Belief Model, a person’s behavior is the outcome of many factors including perceived severity, perceived benefits, and perceived barriers (10). Students caring for an infant simulator will not see the situation as severe as it really is while being affected by optimism bias. When a student is walking around with and caring for an infant simulator, they get attention from their peers, but often in a positive way. Many teenagers think it is funny to see their friends walking around with a doll, and will have fun pretending with them and joking around for a few days. Many of their peers will also be caring for a simulator, making it a social norm to carry a fake baby around. The participants can all give each other moral support and advice. The student’s parents often will help them with the project. Teachers of other classes know that students taking part in a simulation will have less free time and may offer extra help or homework extensions. These benefits do not exist for teen parents.  The situation will not create a fun opportunity for joking with friends, and it will not become an accepted norm to be a teen parent. Few or none of their friends will be able to relate to their situation or be able to offer support. Help from family and teachers will be less frequent as the parent will need assistance indefinitely. Communities often see teen parents as irresponsible, but students taking part in an infant simulator program are given positive attention. The student will also not experience many of the other barriers common in a teen parent’s life. The student will only need to give up free time and social activities for a few days. They will not be financially responsible, need to find a job or daycare, and can care for the simulator in their current living situation. Most teen parents will lose all of their free time to caring for their child and work and no longer be able to socialize with their peers. A baby is a significant financial burden that requires many teen parents to drop out of high school to find a job to pay for their child’s basic needs. The teen’s living situation may not allow them to stay there with a baby due to room or parental disapproval. These enormous stresses are not shown to students with infant simulators. When students assume the consequences of teen pregnancy are not severe, are given positive benefits and support from their community, and are not shown the harsh barriers that keep teen parents from living a comfortable and stress free life, they will not change their behavior to abstinence in order to avoid a teen pregnancy (10). The students do not believe the outcome of teen pregnancy is demanding as it truly is, and their behavior will reflect on this belief.
How Can Teen Pregnancy Be Reduced?
            In order to reduce teen pregnancy, infant simulator and abstinence-only sexual education programs must be replaced by mandatory comprehensive sexual education in schools. The state of California’s teen birth rate dropped 60% with mandatory comprehensive sexual education in schools (17). Comprehensive sexual education programs do not only instruct students how to use contraception. Teachers emphasize that abstinence is the only 100% effective contraceptive and students learn about STIs and their symptoms. In order to design an intervention that will reduce teen pregnancy rates as much as possible, comprehensive sexual education must be expanded to tackle the social and cultural dynamics that surround teenagers and sex. Learning about abstinence and proper use of contraceptives must be paired with frank discussions about why teens do not use birth control and how they can change the habit.  Conversations about why students decide to have sex and what a healthy sexual relationship looks like gives students a model of safe sexual behavior.  Showing students what life is like for teen parents in the most realistic way possible will help teens realize how large an impact a child would have on their life.
Discuss Why and How Students Have Sex
            According to Psychological Reactance Theory, a person’s behavior depends on their perceptions of how the behavior will threaten their freedom, and how important that freedom is to them (11). Many teenager sees their freedom to engage in sexual activity as much more important then the threat of becoming pregnant.  Asking that sexually active students use contraceptives instead of remaining abstinent is much more balanced with teens’ risk of pregnancy. Students will react to this intervention much more successfully, as the freedom to not use contraceptives is not nearly as vital to teenagers. When a population that would be engaging in unprotected sex begins to use contraceptives, the teen pregnancy rate will fall.
            Discussing the difference between healthy and unhealthy sexual relationships will also help students take control of their own reproductive health through Social Cognitive Theory. Conversations in class about why people choose to have sex and what makes a person feel ready to be intimate with a partner helps students have confidence in their decisions. Explaining what is bad or what is terrific about relationships displayed in the media can show students what to look for in a respectful, caring partner. Teaching students the importance of contraceptives in a healthy sexual relationship will help students normalize their use and associate them with a successful sexual encounter. Stressing the uniqueness and individuality of everybody’s own sexual existence prevents alienating students who are having sexual experiences outside of their peers’ norm. Communication and positive role models will help students find self-efficacy and feel confident in their sexual decisions (16). When a teen feels confident, they will more likely communicate with their partner to ensure they are being properly protected, or wait to become sexually active until they are ready (19).
Teach Proper Use of Contraceptive for Risk Reduction
            Helping students become confident users of birth control will ensure that they use it in all of their sexual encounters according to the Theory of Planned Behavior (10).  People will be more likely to change their behavior when they think it will be easy to do so. In order for more teenagers to have safe sex, it must become easier for them to use contraceptives. When students learn about their proper use in school, it will be easy for them to confidently use a condom or other method correctly. Increasing teenagers’ access to birth control is also necessary to decrease teen birth rates. Teen girls are unable to go on prescription birth control without going to a doctor first. Many of these students cannot pay for the extra prescription or feel awkward asking their parents’ permission to start medication. Anyone can purchase condoms from a variety of locations, but it can be an embarrassing and expensive experience. Providing condoms at school can be a great solution, but many parents, politicians, and community leaders object to the practice. Educating students where they can go to get free condoms or buy condoms in a more private environment will make it much easier for students to access contraception. Once the students feel comfortable accessing and using a birth control method, they will use it more often (10). The increased rates of birth control use will in turn lower the teen pregnancy rate.
            Teaching students to remain abstinent for moral or social reasons will be unsuccessful under Maslow’s hierarchy of human needs, as they must fulfill their basic deficit needs before growth needs like morality. Reframing the issue as a safety concern will allow teenagers to consider contraceptive use while considering sex, instead of after as a moral one (14).  Humans need to protect the security of their body, and both pregnancy and STIs will have negative effects on a person’s health. Talking to students about the realistic risks for harmful STIs like Chlamydia can help them to realize their health will be much safer with contraceptives. It is unrealistic to expect a teenager to take the time to consider moral obligations while in a sexual situation, but many will think about the importance of protecting their health before having sex, increasing the rate of birth control use and preventing what would have otherwise been an instance of unsafe sex.
Acknowledge the Struggle of Teen Parents
            It is impossible for a teenager to understand and experience the life of a teen parent without becoming one.  The novelty and fun of “Baby Think it Over” lead to inaccurate assumptions about life as a teen parent. However, a student’s perceptive can still be changed to a more realistic one through the Health Belief Model. The perceived benefits, severity, and barriers to a teen pregnancy are best shown through the everyday lives of teen parents. Unfortunately, it is hard to show students exactly what these lives are like. Teen parents that have turned into motivational or even cautionary speakers are outside the majority of teen parents in that they have usually received a high school or college degree and have a good-paying job. Over 50% of teen mothers do not graduate from high school, and less than 2% graduate college (18). 80% of teenage couples that become parents break up (18). Shows like “16 and Pregnant” and “Teen Mom” show the hardship these teenagers face, and have led to 5.7% reduction in teen births. Watching a few episodes or a documentary following the struggles of teenage parents and discussing how hard their lives are will help students realize the severity of their situation and how many barriers they face. When the students realize how hard life is for teen parent they will more likely use it as a consideration in their behavior.
            Teenage pregnancy is a public health crisis in the United States. Although well intentioned, abstinence only sexual education programs like “Baby Think it Over” do not provide the means to successfully reduce teen birth rates. What’s more, students are often taught to avoid premarital sex for moral reasons, are not introduced to any methods of contraception, and experience an incorrect representation of the life of a teen parent. Teenagers will continue to have sex, but will do so unprotected, continuing the high rates of teen pregnancy. Switching to a comprehensive sexual education program that addresses the reasons why teens have sex, how to use birth control, what a healthy sexual relationship is like, and what the life of a teen parent truly is will inspire much more change in behavior. As teens increase their use of birth control, the teen pregnancy rate will decrease to a more appropriate number.

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