Teen pregnancy prevention is a national concern. While we have seen dramatic declines, the US continues to have one of the highest teen childbearing rates among industrialized nations 1. Approximately 750,000 teens become pregnant each year 2. Sexuality education interventions that incorporate infant simulators are sometimes used to educate adolescents about parenting as a strategy to decrease teen pregnancy. These interventions, often called “Baby Think It Over” (BTIO), are generally tailored to meet the needs of specific populations based on time, space and resources available. Just as BTIO interventions vary widely, methods for evaluating the effectiveness of these interventions also vary. The purpose of this research was to evaluate the effectiveness of a BTIO intervention in changing the perceptions of high school students regarding the costs of teen parenting.

The BTIO intervention evaluated in this research was developed and presented by educators from the Children’s Home Society. Adapted from the Realityworks^© curriculum, this intervention was tailored to meet the needs of students while following the guidelines of the county school board. This BTIO intervention, presented annually since 2000 with increasing numbers of participants (> 1000/year) each year, is popular among students and teachers and assumed to be effective as teen pregnancy rates in the county have steadily declined during that time period. Since the onset of the program, BTIO has grown from two classroom presentations in two high schools to over 21 classroom presentations in all six county high schools. During these 13 years the county has dropped from 28^th to 47^th in the rate of teen births 3. While many initiatives are in place, it is possible that BTIO may have had an influence on these decreased rates. Prior to this research, the intervention had been evaluated using a brief survey assessing student satisfaction, which was consistently very positive. After conducting the program for a number of years the educators determined it was time for a more systematic evaluation to examine the effectiveness and to identify changes in order to strengthen the intervention.

Teen pregnancy is an important public health concern often resulting in hardships for teen parents and their children, and contributing to poverty 4. Children who are born to teen parents usually pay the greatest price for teen pregnancy. These children are more likely to have problems at birth, chronic health problems, and difficulty in school 5. They are at greater risk for abuse or neglect and less likely to achieve their full potential due to poor school performance 4, difficulty sustaining employment, and criminal involvements 6

The Theory of Adolescent Sexual Decision Making Influencing Teen Pregnancy provides theoretical support for this BTIO intervention 7. According to this theory, if adolescents appreciate positive input from others, desire future success and believe in themselves, they are more likely to avoid risky situations that could lead to risky choices resulting in teen pregnancy.

Baby Think It Over (BTIO) interventions are used in a variety of settings to discourage teen pregnancy. Interventions are structured in different ways, but most include teens borrowing infant simulators, so they can experience “realistic” teen parenting. The simulators are programmed to cry, indicating a need for attention such as feeding and changing diapers. Simulators cry randomly with increasing intensity until corrective actions are taken and they are designed to automatically turn off if mishandled or neglected, to prevent damage to the simulator. When returned, printable logs from simulator software can be used to evaluate care and stimulate discussions about the challenges of teen parenting.

Some researchers have reported a lack of support for the efficacy of BTIO interventions. Barnett 8 found no significant change in knowledge, attitudes, or parent-adolescent communication about sex or sexual behavior in either experimental or control group participants. Other researchers 910 reported no change in knowledge, attitudes, or intentions about teen parenting. In a large statewide BTIO intervention, while parents and teachers reported increased communication about parenting, no changes in students’ beliefs and attitudes could be detected 11. Unique weekend BTIO intervention structuring was not found to be effective either 12.

Other researchers have reported more positive outcomes. In a funded longitudinal study with experimental and control groups of urban, minority middle school students, Somers found a BTIO intervention helpful for control group participants to realize they were not ready for parenthood. Following another BTIO intervention the participants became more aware of the challenges of parenting and the negative impact teen parenting would have on education, career goals, social life and relationships 13. Roberts and 14 reported increased childcare skills and reinforced awareness of the challenges of childrearing, and importance of promoting abstinence in adolescents following their BTIO intervention. Adolescent females, in a phenomenological study, reported less idealized views of parenting 15 and college students reported increased anxiety due to simulator crying following BTIO simulator experiences 16.

Interventions incorporating infant simulators may have positive effects that require time to mature in order to influence adolescent decision-making 8. Years after a BTIO intervention, participants in a qualitative study reported continued awareness of the challenges of parenting and half postponed intercourse as a result 17. They also believed the intervention should be mandatory for high school students.

Infant simulators can capture the attention of adolescents and promote their engagement. Perhaps the key to success is the quality of the educational component that accompanies simulator use. According to Chavaudra 18, unless a comprehensive educational program that includes financial, emotional, relationship, and future achievement consequences accompanies simulator use, negative rather than positive outcomes might result. Positive outcomes were reported by Kuhn 19 in Milwaukee, Wisconsin where simulators were a component of a large city-wide effort to lower the teen pregnancy rate.

Our BTIO intervention was unique in that the educational component was the primary focus of the intervention and the simulators, since limited in number, were secondary. Simulators were given to only 27% of the participants at the conclusion of the week-long in-class intervention. Student interest and engagement was increased by the possibility of taking home a simulator, or having a friend take one home. The intervention was presented to 18 to 35 students daily from Monday to Friday during a 50 minute health class. Data were collected in 21 different classes from seven to 19 students in each class. Students returned simulators on the following Monday.

This intervention was designed to help students appreciate the social, financial, and emotional costs of having a baby as a teen. Each student was given a unique life scenario card (randomly distributed) with age (ranging from 16 to 28), educational level (9^th grade to PhD), marital status (single or married), and number of children (one or two) designated for the exercise. During the intervention, students had to find housing and jobs, based on the stipulated scenario, and complete a one month budget to pay for all of their children’s and their living expenses using only the amount of money the job they chose provided. Students were provided a book of relevant information in the form of newspaper ads including: employment opportunities (job titles/descriptions) with educational requirements and salary; housing (apartments, houses, mobile homes, student housing, and living with parents (for 16 year-old only) with monthly costs; child care, (had to decide which center—each with a different hourly rate—fit their schedule); utilities based on size of house, (electric, heat, water, sewer, garbage, recycling, telephone, and cable); laundry for number of people in the home; food and meals based on number of adults in the home (purchasing groceries and eating out if possible); transportation to and from work (purchase car, bus pass, taxi, ride share, or carpool; purchasing a car included paying for repairs and gas). They had to juggle their schedules between work, school, and daycare, because not all daycare centers were open during weekends and the bus did not run on weekends. The book also had price lists for insurance (home, car and medical), health and beauty items, clothing, household supplies, pets, miscellaneous items, and infant supplies. The students had to choose where to purchase items since discount stores, department stores and specialty stores all had different prices. They also had to include entertainment, gifts and charity expenses. All items had to be included in the budget that was calculated on a three page worksheet. As time allowed, discussion of prepared budgets (anonymously) was held during class, and students were given opportunities to make revisions if needed. The intervention also included discussions about the challenges of parenting including videos about Shaken Baby and Sudden Infant Death Syndrome.

On the final day of the week, students, selected by their teachers, were given infant simulators to take home for the weekend. Most teachers chose students based on the order in which they returned their permission slips. Students returned borrowed simulators the following Monday. After returning their simulators, each student was given a print-out of the "care" of the simulated baby and participated in a final discussion about the “parenting” experiences with classmates. At the conclusion of the intervention, teachers graded the students on their participation.

BTIO interventions vary widely because they are tailored for different populations and evaluated in different ways, often with instruments developed by researchers. The BTIO intervention evaluated in this research likewise is unique, but the evaluation was conducted with a standardized measure that can be used by other researchers in the future.

Female and male students from a South Florida public high school completed a pre-test and two post-tests to determine the initial effectiveness of this BTIO intervention in changing high school students’ perceptions of the costs of teen parenting. Responses from 236 students who completed all three surveys (pre-test and post-tests one and two) were utilized for this evaluation. Ages ranged from 14 to 17 with a mean age of 14.78 years. The demographics of these students appear in Table 1. Due to the limited number of simulators available, only 64 (27%) of the participants took home simulators during the final weekend of the intervention.

The Thoughts on Teen Parenting Survey© (TTPS) was used to evaluate the effectiveness of this BTIO intervention. The TTPS is a valid reliable instrument developed to determine the views of adolescents about teen parenting (Herrman, Waterhouse, & Chiquoine, 2011). This survey has been used in a variety of settings including other BTIO intervention evaluations (Herrman, et al.). The TTPS has three parts. Part A is designed to collect demographic data and was completed by students only during the pre-test. Part B, the 44-item Perceptions of Teen Parenting Scale (PTPS) was created to collect participants’ perceptions of the cost or impact of teen parenting on relationships, finances, education, future career, personal characteristics, and life in general. The PTPS has an alpha reliability of .89 and yields a composite score of participants’ perceptions of costs and rewards of teen parenting that allows for measurement of intervention effectiveness through pre- and post-testing. The lower the cumulative score, the higher the costs and lower the rewards associated with teen parenting. Part C of the survey has 31 items addressing beliefs and attitudes about sexual activity, teen pregnancy and related support systems. Parts B and C are answered using a 5-part Likert scale ranging from “strongly disagree” to “strongly agree”.

The Children's Home Society (CHS) provides BTIO interventions in the public high schools in the county where this research was conducted. This evaluation took place in the high school with the greatest number of participants. CHS administrators and educators scheduled and implemented this BTIO intervention. Prior to beginning the project, teachers sent letters to parents/guardians explaining the intervention and requesting consent for students to take infant simulators home for a weekend. This was an “opt out” program, so students who did not return consent forms participated in the educational component of the program, but were not eligible to take home an infant simulator. If a parent/guardian opted-out, their child was provided an alternative activity. Following approval by the Institutional Review Board of the sponsoring university and the local school board, information about the research and an additional parental consent for the evaluation component were included with the other BTIO information sent to parents. Students who returned intervention consent forms, but not research consent forms, participated in the BTIO program, but not this evaluation.

After signing adolescent consent forms, eligible students completed the Thoughts on Teen Parenting Survey (TTPS) prior to the onset and at the conclusion of the intervention. The participants completed the TTPS a third time at the end of the semester. Due to the scheduling of the BTIO intervention, this final evaluation was conducted from one to four months later. To assure confidentiality, no personal data were collected. All surveys were coded to facilitate matching pre and post-tests.

Data from the Thoughts on Teen Parenting Survey at pre and post-tests were analyzed using SSPS software. Internal consistency reliability for Part B using Cronbach’s alpha was assessed via SPSS at each point (i.e., pretest, posttest 1 and posttest 2). Repeated-measures ANOVA was used to determine whether participants reported significant changes between time points for each item on Part B and Part C, as well as for the total score of Part B. Additionally, a two-way mixed ANOVA was used to determine whether students who took simulators home experienced different trajectory changes compared to those who did not.

While this research provides some helpful information, some limitations could have affected the project outcomes. All of the participants were from a single high school, and no control or comparison groups were used, which limits the generalizability of the results. Initially, most students were enthusiastic, hoping to get an infant simulator at the conclusion, which may have influenced their interest in the pre-test. By the final day, enthusiasm for the program had waned and some participants were not interested in repeating the TTPS. Also, disappointment at not being chosen to take home an infant simulator may have influenced post-test answers. Some students who did not return consent forms were interested in the surveys and wanted to assist their classmates, despite begin asked to work alone. Six teachers selected the students from their classes who took home infant simulators. This could have biased the comparisons between those who took home simulators and those who did not. Social desirability could have influenced the responses of some participants. However the large number of participants and repeated measures were used to minimize this effect.

The costs of teen pregnancy are enormous and impact the nation, individual states, and communities, as well as teens and their children. BTIO interventions also require significant investments of limited resources. Teen pregnancy is a concern to school health professionals because it can result in disruption of education and student loss. A significant number of participants in this study recognized that teen pregnancy often derails academic plans and future success. Interventions that engage students and increase their awareness of the costs of teen parenting are a good investment if effective in preventing pregnancy.

Discussing evidence-based pregnancy prevention methods, such as correct use of condoms and other contraceptive methods, within schools can be challenging and is prohibited in many communities. BTIO interventions provide an alternative pregnancy prevention strategy by helping adolescents appreciate the costs of teen parenting. However, combining BTIO interventions with open discussions about safe-sex pregnancy prevention strategies could be even more effective.