Having Fun or Learning Some? A Critique of the Baby Think it Over Program Addressing Teen Pregnancy-Priya Sekar
It seems that recently there has been a surge of interest revolving around issues of teen pregnancy and teen parenthood, as evident by the creation of such TV programs as 16 and Pregnant and Teen Mom airing on MTV. These shows were created with hopes of showing teens the enormous responsibilities and struggles faced by being young parents and to deter them from the behavior that led to such a life: sex! With an increase in rates of teen pregnancy among young women, such efforts should be applauded, but are they the right strategy and are they effective?
Despite continued efforts to decrease teen sexual activity, more that half of U.S. teens have had sexual intercourse in their lifetime, and almost 1 in 10 have before the age of 13. In 1999, of those students who were sexually active, 42% reported that neither they nor their partner used a condom the last time they had sex (1). In 2005, the U.S. teen pregnancy rate reached its lowest point in more than 30 years, at 69.5 pregnancies per 1000 women, down 41% since its peak in 1991, at 116.9 pregnancies per 1000 women. But in 2006, the rate increased for the first time in a decade, rising 3 % to 71.5 pregnancies per 1000 women (2). For the first time since the 1990s, the overall rates of pregnancies and births among teens increased during the 2005-2006 year. Preliminary data on births from 2007 shows a further increase in birth rate among all women (2). Approximately 40% of all females will experience at least one pregnancy before the age of 20 (2). Teen pregnancy carries high costs in terms of both the social and economic health of mothers and their children. Teen mothers are less likely to receive prenatal care, and their children are more likely to be born before term, to have low birth-weights, and to have developmental delays. Teen mothers are also less likely to complete their education than mothers over 20 years of age (3). It is clear that there are devastating consequences of teen sexual activity, pregnancy, and motherhood and it should be a major public health concern.
In the last few decades, health professionals working with adolescents have increased their efforts at both designing and implementing interventions aimed at preventing teen pregnancy (4). Although there has been a recent downward trend in pregnancy rates in American teens, the U.S continues to have one of the highest of any Western industrialized nation. Most of the previous programs designed to prevent adolescent pregnancy focus on one of three approaches: sex education, encouraging sexual abstinence, or increasing the availability of contraception. None of these efforts alone seem to be effective however (5). In fact, some experts claim that the rise in teen pregnancy might be attributable to $150 million of federal financing per year spent on education that emphasizes abstinence until marriage, instead of focusing on and stressing the benefits of contraception and other methods of prevention. Fortunately, the Obama administration has moved away from this trend (6).
The National Campaign to Prevent Teen Pregnancy recently released a report reviewing various intervention approaches, finding that no single approach alone is fitting for attacking this problem. Programs advocating sexual abstinence, like the Postponing Sexual involvement Curriculum (PSI), aimed at American middle school students, often faired poorly (4). Another strategy shown to fail when used alone was the implementation of school-based clinics that provided a range of medical and counseling services to adolescents (5). Adolescent pregnancy is a complex problem and accordingly strategies of prevention should be multi-pronged. There should be a growth in the number and variety of programs, including education programs, family planning and contraceptive services, school-based health centers, youth development programs, and multi-component programs (7).
One intervention approach that has been tried is the Baby Think It Over (BTIO) Program. This is an infant simulation program that seeks to modify attitudes toward teen pregnancy and teen parenting. It is based on the theory that teens engage in unprotected sex because of a personal fable concerning pregnancy: the “It can’t happen to me” fable. It was expected that participation in the BTIO program, a form of role play, would encourage teens to acknowledge their own personal vulnerability to an unplanned pregnancy, and provide them with some insight into the experience of adolescent parenting (4). The program was originally created by nurses at the Teen Health Centre in Windsor, Canada in an attempt to decrease the high pregnancy rate among girls aged 19 years and younger (4). The program involves the use of infant-simulators, or lifelike dolls, that allows adolescents to role-play the responsibilities involved in parenting. The program is implemented in the parenting/sex education classes offered at the participating high schools as an option to fulfill a social science requirement (4).
Infant simulators are tools that encourage adolescents to contemplate the realities of parenting. Proponents argue that the use of simulators enable adolescents to understand the time and effort required in raising a child, thus convincing them to delay parenting and the behaviors that lead to becoming a parent (8). To make the experience more realistic, instead of using an egg or a bag of flour, Rick Jurmaine invented the Baby Think It Over infant simulator. These simulators were built to physically resemble real infants, weighing about 8 pounds and measuring about 20 inches long. The simulators are battery operated and are programmed to cry at random intervals every 2 to 4 hours requiring tending from the caregiver, which means inserting a magnetic probe into the dolls back and holding it in place for up to 35 minutes. The probe is attached to a tamper-proof hospital bracelet worn on the teen’s wrist (8; 4).
The BTIO Program has been used all over the U.S. and internationally by over 1 million students throughout school settings in the hopes of creating a lasting impression on both teen women and men of the personal sacrifice and challenges required of new parents (1). Though the BTIO Program was created with hopes of decreasing teen pregnancy rates and sexual activity, its impact on such behavior has yet to be proven conclusively (8) As Barnett concludes, the BTIO program “ended up being a cute gimmick that looked good to adults and became a silly game for the students.” There are many possible reasons responsible for the failure of this program. In analyzing the problem of teen pregnancy, creators used the Health Belief Model in implementing an intervention, which especially for teens, may not be ideal in persuading them to change their behavior. Secondly, the program focused only on a narrow target group. Lastly, the program did not account for the various levels of societal and environmental factors that influence behavior.
Critique Argument 1: Wrong Social-Behavioral Model Approach
The first issue with the creation and implementation of the BTIO Program is that it was developed through the perspective of the Health Belief Model, hoping to get teens to acknowledge their own vulnerability to an unplanned pregnancy. The Health Belief Model is the oldest of the individual behavior theories used in public health, originating from social psychologists Godfrey Hochbaum, Irwin Rosenstock, and Stephen Kegels in the 1950s (9). The model was originally created during research into why turnout for free TB screenings were so low. According to the model, health seeking and other health behaviors were thought to be motivated by an individual’s perceived susceptibility, perceived severity, perceived benefits of action, and perceived barriers to taking action (9). It is clear that the Health Belief Model is probably very useful in public health interventions targeting simple medical health related behaviors, like getting a vaccine. But changing adolescents’ sexual behavior is not comparable to convincing an individual to get a vaccine. The Health Belief Model does not address social and environmental factors (10), which play a large role on teen sexual behavior. Furthermore, this model does not take into account spontaneous activity that characterizes much of human behavior, like sex (10). The model assumes an acted behavior is the result of a cost/benefit analysis, of calculated rational thought devoid of emotion (10), which is untrue for sexual behavior.
The BTIO Program, in analyzing behavior in terms of the Health Belief Model, fails to frame the outcome of the intervention in a way relatable to teens. The Health Belief Model inherently frames the outcome of changing sexual behavior as preventing a negative outcome (a hard life of tough responsibility) instead of offering a positive one, like a future of freedom and autonomy. Perhaps reformulating the BTIO Program around a different social-behavioral model, that reframes the outcome in a positive manner, may make the program more effective. This idea of framing revolves around the idea that human choices are susceptible to the manner in which options are. The framing effect suggests that people incorporate a range of emotional information into the decision process, which the Health Belief Model fails to account for (11).
Critique Argument 2: Widen Target Population
In implementing the BTIO Program, proponents correctly took into account that early adolescents believe they are omnipotent and not vulnerable to becoming pregnant. This is in accordance with the Theory of Cognitive Development that describes adolescents reasoning and decision making as clouded by an imaginary audience (that thinks like adolescents) and a personal fable (8). But adolescents also underestimate the negative consequences that would follow if they did become pregnant and the difficulty involved in caring for a child. In fact, adolescents are more likely to believe that unlike most others, they could be perfect parents and still continue to lead normal teen lives, which the BTIO intervention failed to account for (8). So even after role-playing being a parent to a difficult baby, adolescents will still think they can be successful parents. Adolescents’ strong belief in the personal fable of omnipotence may cause them to simply overlook the negative aspects of any parenting experience they have (12). The BTIO Program was originally implemented through parenting and/or sex education classes, in which the students had the option of enrolling as a means to fulfill a social science requirement. It is quite possible that students enrolled in such classes were more interested in issues surrounding parenting to begin with (4), so they probably perceived parenthood to be more attractive than those students who did not enroll in such classes, and were less likely to be persuaded otherwise.
In choosing to implement the BTIO intervention in optional parenting classes, the implementers failed to account for the Cognitive-Behavioral Theories which propose that behavior is mediated by personal cognitions and vise versa; in other words, what people know and think affects how they act (13). In this case, the fact that the parenting classes were optional probably means that students registered in such classes were all alike, in that they all already viewed parenting in a positive light. So perhaps targeting a larger, less biased population would garner the BTIO program more effective.
Critique Argument 3: Doll Component Alone Unrealistic and Ineffective
It seems logical that to get adolescents to understand they are vulnerable to a difficult life if they become pregnant, they should be made to experience such a life. The Baby Think It Over Program has the right intention, but is a doll really effective in demonstrating the realities of raising a child? The purpose of the doll is to provide students with an understanding of the amount of time and effort involved in caring for an infant and how an infant’s needs might affect their daily lives and the lives of family and significant others (14). Though it was a valiant attempt at providing students with an understanding of the importance of postponing pregnancy, results showed that there were only minimal changes in attitudes and beliefs (14).
As the Ecological Perspective proposes, promoting certain behaviors involves more than just educating individuals about realities and right from wrong. It includes efforts to change organizational behavior, as well as the physical and social environments of communities (13). It is important to remember that behavior is affected by multiple levels of influence and the social environment, but the BTIO campaign failed to recognize this relationship.
The issues surrounding parenthood are much more complicated than just being able to deal with an infant’s unpredictable behavior (which the BTIO doll targeted) and such issues may be more relatable and applicable to adolescents. There are long term education, economic, and social consequences of teen parenting (4), that the BTIO Campaign does not even attempt to demonstrate. For example, caring for an infant requires a lot of money that takes away from future goals. Additionally, having another person to take care of 24 hours a day, 7 days a week, takes away time that would otherwise be spent in school, or hanging out with friends. There is also the issue of the social stigma surrounding teen pregnancy and single-parent families. Incorporating such influences and information into the campaign may help personalize both the short-term and long-term consequences of unplanned teen pregnancy (4).
While there are many flaws to the program critiqued, it is aiming in the right direction in attempting to show teens the harsh reality of trying to raise a child. The BTIO campaign has at its base the right components, but utilizing concepts from various social-behavioral and models and theories might help make the program more successful. First, the improved intervention should reframe the issue of teen pregnancy and parenthood as a hindrance to achieving future goals instead of as a guarantee to a difficult and tiring life. The idea of attaining future goals is more positive and would appeal more to teens. Associating a change in sexual behavior with personal motivations and goals relates more to adolescents than associating it with responsibilities of parenting. To sell safe sexual behavior as a method of attaining future goals, using components of the Advertising/Market Theory may be more appropriate than using the Health Belief Model.
Incorporating the campaign into a student-body wide mandatory health-education curriculum, which will cover all sorts of health behavior from smoking and alcohol, to sexual behavior, might also contribute to a greater success. Making the program school-wide will not only make the targeted group less biased and uniform, but it will also garner a greater influence of peer relationships that most adolescents are vulnerable to.
Furthermore, incorporating into the curriculum a section on the methods and positive outcomes of safe and smart behavior will help students understand the reasons to change their behavior and be personally motivated to do so. One method to consider using is a youth development/future career workshop that enlists guest speakers from various careers to talk about how they attained such goals. This addition gives students the chance to learn about the many career opportunities available and will help spark an interest in a future goal.
A workshop on the realities of teen pregnancy, including issues of money and social stigmas, should also be organized. These issues should be discussed as components in the sex education section of the health education curriculum, as negative consequences of unhealthy/unsafe behaviors. Including exercises like calculating the cost of raising a baby per week, month, or year may help teens understand the extremity of the situation as well.
Most importantly the sex education section of the course should teach all forms of prevention, from abstinence to contraceptive use, and offer various resources from which students can learn more information.
Defense of Intervention 1: Framing
The way in which a public health intervention and its potential outcomes are framed can greatly influence the success (or failure) of such an intervention. The original BTIO Program is framed negatively like a lot of other public health campaigns, showing the negative consequences of participating in unsafe sexual behavior, instead of the positive outcomes of not participating in such behavior. The original BTIO Program attempts to persuade adolescents to change their behavior using the Health Belief Model to show that even they are susceptible to the negative consequences of unsafe sexual behavior, framing the result of the intervention as avoiding a negative outcome.
Framing impacts people because it makes individuals view losses and gains differently, as the Prospect Theory suggests. The theory also proposes that a loss is more devastating than the equivalent gain is gratifying, so people will avoid risk if a positive frame is presented (15). So, if attaining career-goals is the equivalent gain to the devastating loss of a care free normal teen life (by the overwhelming responsibility to care for a child), then it makes sense that reframing the public health issue around this more positive idea will make the BTIO campaign more successful.
As mentioned in the proposed improved intervention, utilizing components of the Advertising or Marketing Theory (especially the idea of selling a positive desire) instead of the Health Belief Model would be more beneficial for reasons related to the idea of framing. As discussed in class, utilizing this component means selling the aimed behavior (prevention) as a means of fulfilling true needs and wants (16). In this case, prevention should be sold as a means of attaining freedom and autonomy-a way of attaining personal goals.
Defense of Intervention 2: A more universal target population
As mentioned previously, Cognitive-Behavioral Theories suggest that behavior is influenced by an individual’s cognitions and vise versa. So in the original BTIO Program, where only students who chose to enroll in parenting classes experienced the intervention, it was likely that such individuals were already pro-parenting and therefore less impressionable. Therefore, as mentioned in the intervention proposal, the campaign should target the entire high school student body through a required health education class instead of through an optional interest-geared class. By altering the target population in this way, it will be possible to prevent a self-selection bias, which may have existed before, from occurring (4).
Furthermore, peers are an important influence on individual behaviors (especially for high school students), as various social science theories suggest. The Social Learning Theory/Social Cognitive Theory suggests that people learn by watching what others do, and each behavior witnessed can change a person’s way of thinking (13). By targeting the entire student body, the wider issue of peer influence can be utilized. Teaching behavioral skills and changing perceptions of a portion of the peer group will eventually start to influence the rest of the peer group (3). Peer influence can be utilized to teach and spread the use of preventative measures. One example utilizing peer influence is virginity pledges. Studies actually show that students taking pledges delayed their first sexual experience by about 18 months (3). It is clear that utilizing peer influences can be effective in changing adolescent behavior.
Defense of Intervention 3: Taking a multi-pronged approach
As mentioned previously, health promotion involves more than simply educating individuals about right and wrong health practices. Changing behavior requires utilizing influences from the social and community environment as well. The Ecological Perspective emphasizes the interaction between, and interdependence of, factors within and across all levels of a health problem (13). This perspective emphasizes people’s interactions with their socio-cultural environments, stressing that behavior is affected by multiple levels of influence. Not only is behavior influenced by individual, intrapersonal, and interpersonal factors, but it is also affected by organizational and community factors.
This idea supports the proposal of including a youth-development type of component into the BTIO Campaign alongside educational sessions that influence individual knowledge, attitudes, and beliefs. Such programs focus on supporting and encouraging young people. Young people need opportunities to acquire a broad range of skills and to build connections within their community (7). Youth development programs take into account social networks which exist among individuals and groups (13). It has actually been shown that there is a strong relationship between educational and career plans and protection from adolescent pregnancy. Improving girls’ education and life options are correlated with reduced pregnancy rates (7). This multi-pronged approach also accounts for the influence of institutional factors, such as school regulations that many constrain or promote recommended behaviors. The proposed intervention suggests making information about resources for attaining contraceptives and other preventative measures available to all students, a recommendation that requires schools to change their regulations and policies. It is clear, that to best influence behavior change, it is important to take opportunity of all existing relationships between individuals, community, society, and organizations-allowing a public health concern to be attacked from all angles.
Though the original Baby Think It Over Program attempted to decrease teen pregnancy rates in a unique manner, its success rate was very low. The program tried to sell a change in behavior as a means to preventing negative consequences, instead of as a means of ensuring positive outcomes. Reframing and remarketing the outcome as something positive, in accordance with ideas of the Marketing Theory, will hopefully help make the new campaign more successful. Additionally, taking opportunity of the importance of peer influence by widening the target group to the entire student population will help utilize one of the main outlets of influence proposed in the ecological perspective. Adding in additional components of youth development programs (that utilize the influence of the community) and improved policies (that utilize the influence of institutions) will also help make the new campaign more successful in decreasing teen pregnancy rates. All in all, instead of focusing in on one social-behavioral theory, utilizing aspects of various theories might be helpful in making this campaign a success.
1. Somers, C.L, & Fahlman, M.M. Effectiveness of the Baby Think It Over Teen Pregnancy Prevention Program. Journal of School Health 2001 .
2. Guttmacher Institute. U.S. teenage pregnancies, births, and abortions: National and State trends and trends by race and ethnicity. www.guttmacher.org.
3. Solutions for America: Healthy Family and Children. Teenage Pregnancy Prevention. solutionsforamerica.org/healthyfam/teenage-pregnancy.html.
4. Out, J.W., & Out, K.D. (2001). Baby Think It Over: Using Role-Play to Prevent Teen Pregnancy. Adolescence 2001.
5. Kirby, D., Waszack, C., & Ziegler, J. Six school-based clinics: Their reproductive health services and impact on sexual behavior. Family Planning Perspectives 1991, 23, 6-16.
6. The New York Times. Lewin, T. After long decline, teen pregnancy rate rises (2010). http://www.nytimes.com/2010/01/27/us/27teen.html.
7. Kirby.D., et al. The impact of the Postponing Sexual Involvement Curriculum among youths in California. Family Planning Perspectives 1997, 29, 100-108.
8. Barnett, J.F., & Hurst, C.S. Do Adolescents take BTIO Seriously?
Adolescence 2004, 39.
9. Rosenstock IM. Historical origins of the health belief model. Health Education Monographs 1974; 2:328-335.
10. Individual health behavior theories (chapter 4). In: Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007, pp. 35-49.
11. DeMartino, B, Kumaran, D., Seymour B., Dolan, R.J. Frames, biases, and rational decision-making in the human brain. Science 2006: 313: 684-687.
12. Kralewski, J. & Stevens-Simon, C. Does Mothering a Doll Change Teens Thoughts about Pregnancy. Pediatrics 2004, 105, 30.
13. National Cancer Institute. Theory at a Glance: A Guide for Health Promotion Practice. Part 2. Bethesda, MD: National Cancer Institute, 2005, pp9-21 (NIH Publication NO. 05-3896). Available at: http://www.cancer.gov/PDF/481f5d53-63df-41bc-bfaf-5aa48ee1da4d/TAAG3.pdf.
14. Anda, D. BTIO: Evaluation of an Infant Simulation Intervention for Adolescent Pregnancy Prevention. Health and Social Work 2006.
15. Tversky, A. & Kahneman, D. The Framing of decisions and the psychology of choice. Science 1981, 211, 453-458.
16. Marketing public health-an opportunity for the public health practitioner (Chapter 6). In: Siegel M, Doner L. Marketing Public Health: Strategies to Promote Social Change (2nd edition). Sudbury, MA: Jones & Bartlett Publishers, Inc., 2007, pp 127-152.