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” (http://the84.org/), “Crush” (http://socrush.com/about),
and “love Life” (http://www.lovelife.org.za/) 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.
Conclusion
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.
References
1. Finer, L. B., & Zolna, M. R. (2011). Unintended pregnancy in the United
States: incidence and disparities, 2006. Contraception, 84(5), 478–485. doi:10.1016/j.contraception.2011.07.013
2. CDC - About Teen
Pregnancy - Teen Pregnancy - Reproductive Health. Retrieved April 16, 2014,
fromhttp://www.cdc.gov/teenpregnancy/aboutteenpreg.htm
3.
Jurmaine,
R. 1994. Baby Think It Over ®. (Available
from Baby Think It Over ® Inc., 2709 Mondovi Road, Eau Claire, WI 54701).
4. Herrman, J. W.,
Waterhouse, J. K., & Chiquoine, J. (2011). Evaluation of an infant
simulator intervention for teen pregnancy prevention. Journal of obstetric, gynecologic,
and neonatal nursing: JOGNN / NAACOG, 40(3),
322–328. doi:10.1111/j.1552-6909.2011.01248.x
5. Somers, C., &
Fahlman, M. (2001). Effectiveness of the “Baby Think It Over” teen pregnancy
prevention program. The
Journal of school health, 71(5),
188–195.
6. Out, J., &
Lafreniere, K. (2001). Baby Think It Over: using role-play to prevent teen
pregnancy. Adolescence, 36(143), 571–582.
7.
Rosenstock,
I., Historical origins of the health belief model. Health Education
Monographs, 1974. 2: p. 328-335.
8. Borr ML (2009). Baby think it over: A weekend with an
infant simulator, Journal of
Family & Consumer Sciences Education, 27(2):45-55.
9. Didion, J., &
Gatzke, H. (2004). The Baby Think It Over experience to prevent teen pregnancy:
a postintervention evaluation. Public
health nursing (Boston, Mass.), 21(4),
331–337. doi:10.1111/j.0737-1209.2004.21406.x
10. Zuckerman, D. &
Becker, J. (2010). Dolls Are Not a Substitute for Babies | National Center For
Health Research. Retrieved April 25, 2014, from http://center4research.org/medical-care-for-adults/other-reproductive-sexual-health/dolls-are-not-a-substitute-for-babies/
11. Buysse, A. (1997).
`Appropriate’ male and female safer sexual behaviour in heterosexual
relationships. AIDS Care, 9(5), 549. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=pbh&AN=9710293705&site=ehost-live&scope=site
12.
Becker,
H. (1963). Outsiders: Studies in the
Sociology of Deviance. New York: Free Press.
13. Kralewski, J., &
Stevens-Simon, C. (2000). Does mothering a doll change teens’ thoughts about
pregnancy? Pediatrics, 105(3), E30.
14. Malinowski, A., &
Stamler, L. (2003). Adolescent girls’ personal experience with Baby Think It
Over infant simulator. MCN.
The American journal of maternal child nursing, 28(3), 205–211.
15.
Bandura,
A. (1977). Social learning theory.
New Jersey: Prentice-Hall.
16. Kim, C., Gebremariam,
A., Iwashyna, T., Dalton, V., & Lee, J. (2011). Longitudinal influences of
friends and parents upon unprotected vaginal intercourse in adolescents. Contraception, 83(2), 138–144. doi:10.1016/j.contraception.2010.06.019
17.
Brehm,
J. (1966). A theory of psychological
reactance. New York: Academic Press.
18.
Miller,
C. & Quick, B. (2010). Sensation seeking and psychological reactance as
health risk predictors for an emerging adult population. Health Communications, 25,
266-275. Doi: 10.1080/10410231003698945
19.
Saltz, E., Perry, A.,
& Cabral, R. (1994). Attacking
the personal fable: Role-play and its effect on teen attitudes toward sexual
abstinence. Youth and Society, 26 (2),
223-242.
20.
Stevens-Simon,
C. (1993). Working with the “personal fable.” Journal of Adolescent Health, 14, 349
21.
Shepperd, J., Carroll, P., Grace, J., & Terry, M. (2002).
Exploring the causes of comparative optimism. Psychologica
Belgica, 42(1-2), 65–98.
22. Tversky,
A., & Kahneman, D. (1971). Belief in the law of small numbers.Psychological
Bulletin, 76(2),
105–110.
23. Benthin, A., Slovic, P.,
Moran, P., Severson, H., Mertz, C. K., & Gerrard, M. (1995). Adolescent
health-threatening and health-enhancing behaviors: A study of word association
and imagery. Journal of
Adolescent Health,17(3), 143–152. doi:10.1016/1054-139X(95)00111-5
24. Silvia, P. (2005).
Deflecting reactance: The role of similarity in increasing compliance and
reducing resistance. Basic and Applied
Social Psychology; 27, 277-284.
25. Prinstein, M., Boergers,
J., & Spirito, A. (2001). Adolescents’ and Their Friends' Health-Risk
Behavior: Factors That Alter or Add to Peer Influence. Journal of Pediatric Psychology, 26(5), 287–298. doi:10.1093/jpepsy/26.5.287
26. Thaler, R., Sunstein, C.
(2008). Following the herd (Chapter 3). In: Thaler, R., Sunstein, C. Nudge: Improving Decisions About Health,
Wealth, and Happiness. New Haven, CT: Yale University Press,53-71.
27.
Rogers,
E. (1995). Diffusion of innovations (4th
ed.). New York: Free Press.
28. Bertrand, J. (2004).
Diffusion of Innovations and HIV/AIDS. Journal
of Health Communication, 9(sup1),
113–121. doi:10.1080/10810730490271575
Rogers, E. (2003). Diffusion of innovations (5th
ed.). New Y
