
==== Front
Health Educ Res
Health Educ Res
healed
Health Education Research
0268-1153
1465-3648
Oxford University Press US

38527293
10.1093/her/cyae012
cyae012
Original Article
AcademicSubjects/MED00860
Use of infant simulators as an aid in pregnancy and parenting educational interventions for school-aged students: a scoping review
Dinh Thi Thuy Ha School of Nursing, University of Tasmania, Newnham Campus, Newnham Drive, Newnham, Launceston, Tasmania 7248, Australia

Lees David B School of Nursing, University of Tasmania, Newnham Campus, Newnham Drive, Newnham, Launceston, Tasmania 7248, Australia

Van Dam Pieter J School of Nursing, University of Tasmania, Domain Campus, 71 Brooker Avenue, Glebe, Hobart, Tasmania 7001, Australia

https://orcid.org/0000-0001-8096-267X
McGarry Denise Elizabeth School of Nursing, University of Tasmania, Rozelle Campus, Corner of Church and Glover streets, Lilyfield, NSW 2039, Australia

*Correspondence to: D. E. McGarry. E-mail: denise.mcgarry@utas.edu.au
8 2024
25 3 2024
25 3 2024
39 4 351374
12 9 2023
02 3 2024
05 3 2024
04 3 2024
25 3 2024
© The Author(s) 2024. Published by Oxford University Press.
2023
https://creativecommons.org/licenses/by-nc/4.0/ This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (https://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site–for further information please contact journals.permissions@oup.com.

Abstract

Schools and school teachers often focus on content aimed at delaying sexual debut and preventing teenage pregnancy, and address the impacts of risky behaviours on infant health. Infant simulators are increasingly used in health education courses. However, it is unclear how effective this education is. In this review, we examined the evidence for the effectiveness and use of pregnancy/parenting education programmes for school-aged students using infant simulators. Infant simulators are lifelike replicas of human newborn babies that have electronic capacity to mimic a range of infant behaviours. These may include feeding, comfort needs and nappy changing. Responses to these replicated behaviours may be recorded to provide feedback of the adequacy of the response for educational purposes and provide feedback to prospective parents and caregivers. This review followed the guidelines for conducting a scoping review developed by Joanna Briggs Institute (JBI). After following the process as recommended by the JBI, 32 eligible articles were selected for inclusion. Eight themes emerged from the analysis and it was found that the use of infant simulators in terms of effectiveness was not conclusive. This may be due to lack of longitudinal studies examining the impact of the education provided. Furthermore, the literature did not address innovations of infant simulators that replicate infants with particular characteristics, those with fetal alcohol spectrum disorder, shaken baby syndrome or challenges from parental substance use. Further research is required to determine the long-term impact of using infant simulators on reducing risky behaviours. Given these challenges, it is important to support initiatives for sex, pregnancy and parenting education among all students.

Catholic Care Social Services Hunter-Manning Nil Catholic Care Social Services Hunter-Manning Nil
==== Body
pmcIntroduction

The World Health Organization (WHO, 2023) reports 21 million teenagers aged 15–19 years fall pregnant annually and at least 777 000 girls give birth when ≤15 years old [1, 4, 7, 22, 24, 48]. Not all teenage pregnancies are unintended or unwanted. In some communities, teenagers were themselves born to mothers who had early pregnancies [2]. Teenage pregnancies are associated with socio-economic disadvantage. Adolescent mothers are at higher risk of quitting school prematurely [3] and being unemployed [4]. Pregnant adolescents are also at higher risk of depression [5] and highly stressful lives [6]. Adolescent mothers also have a higher risk of domestic violence. Their babies have more health problems including lower birth weight and higher mortality and morbidity [7]. Adolescent mothers and their partners who are not prepared for parenting roles are more likely to present a risk of child neglect or abuse [6]. Maternal stress during the perinatal period is associated with postpartum challenges in caring for an infant [6].

School students can have little knowledge or understanding of the risks of unprotected sexual practices [8]. Sex education has been associated with improved knowledge in sexual and reproductive health and fewer risky practices that result in pregnancy and sexually transmitted infection (STI) [9]. Sex education initiatives for adolescents have been developed in schools but face challenges like: insufficient time allocated for the topics; teacher discomfort [10]; as well as lack of collaboration between parents and schools [11]. Schools often focus on content aimed at delaying sexual debut and preventing pregnancy, but do not address impacts of risky behaviours on infant health such as pregnancies with poor outcomes (Fetal Alcohol Spectrum Disorder [FASD], physical deformity, withdrawal syndromes). Given these challenges, it is important to support continued sex, pregnancy and parenting education among school students.

Infant simulators are increasingly used in health education courses including sex education, pregnancy and childcare [12, 13]. Historically, simulated experiences of caring for an infant involved approaches like caring for an egg or a sack of flour. Since infant simulators were developed commercially, associated sex and parenting education curricula have become available for educators. A frequently used infant simulator is the Baby-Think-It-Over (BTIO)™ marketed by RealityWorks®, first introduced in 1995 with a suggested curriculum [14–18]. This simulator replicates normal physical characteristics and some infant behaviours such as crying and burping. This creates more realistic experiential simulation so adolescents can play defined roles with responsibilities (feeding, comforting, changing diapers) that replicate parent reality. The simulator sensors can assess responsiveness to cues, handling and ability to meet the infant’s needs. Despite its increasing popularity, the use of BTIO™ is controversial due to lack of conclusive research supporting the effectiveness of interventions [12, 19, 20], considerable cost and lack of an effective instrument to measure programme-associated changes [21]. Other simulator types replicate anatomically abnormal characteristics of an infant, for example those born to mothers who use substances or alcohol (for example, drug affected or FASD infant simulators) or an infant who is shaken (shaken baby simulator). These infant simulators are designed for substance abuse and infant safety education for use in a variety of contexts including general sex education and parenting education for young people. These were developed following the introduction of the infant simulators such as BTIO™ by Realityworks® in the mid-1990s and their widespread uptake [22]. They add value in prevention of poor outcomes for pregnancies by improving knowledge, changes in attitude and behaviour intentions.

A preliminary search of PROSPERO, MEDLINE, the Cochrane Database of Systematic Reviews and Joanna Briggs Institute (JBI) Evidence Synthesis was conducted to check for any existing systematic reviews relating to the use of infant simulators in education for school-aged students. The authors of this current review have not identified any published or in-progress reviews despite an extensive search that examined the implementation, or evaluation of such programmes involving infant simulators for teaching pregnancy and infant care to school students. There is one systematic review about using simulators in teaching neonatal and infant resuscitation in medical education [23]; however, this was not the simulator of our interest. There is a contracted report collating evidence from 16 studies dated before 2009 using the Realcare® simulators [24]. In this report, no systematic search has been demonstrated along with a lack of defined inclusion or exclusion criteria, putting this document at risk of biased conclusions. The different infant simulators with varied curricula and teaching foci as well as the absence of rigorous evaluation of their use, supports the need for this scoping review of literature. The review findings will be helpful for educators, social and health workers, educational settings managers, parents and wider communities regarding optimal approaches for school students using an infant simulator.

In this review, the overarching question was ‘What evidence for the effectiveness and use of pregnancy/parenting education programmes for school-aged students using infant simulators has been documented in literature’?

This current review examined the following questions:

How have infant simulators been integrated with other content covered in pregnancy/parenting educational programmes for school-aged students?

How have these been delivered to school-aged students?

How have students engaged with infant simulators?

What outcomes have been measured as an evaluation of these programmes?

Methods

This review followed the guidelines for conducting a scoping review developed by JBI [25].

Inclusion and exclusion criteria

This review focused on papers reporting the development, piloting or implementation of programmes for school-aged students (grades 6–12). If the papers identified the participants as middle high school students, teenagers, adolescents or young adults, this was sufficient to meet the participant inclusion criteria. Any programmes delivered to participants outside this age range were excluded.

The programmes must have had content that targets students’ knowledge inclusive but not limited to sex education, teenage pregnancy prevention, pregnancy health or parenting skills (i.e infant care). These programmes must use an infant simulator as part of the teaching curriculum to demonstrate either pregnancy, the labour process, how to care for an infant, or to visualize infant health issues. An infant simulator is a device made in a human newborn form that can be of any type, material, demographic characteristic (e.g. skin tone) and function and attached technologies. The educational programmes could have been a mandated school-based curricula or an extra-curricular activity, and could be delivered in any teaching mode or a combination, such as face-to-face, group discussion, class teaching, virtual teaching or simulations, and could have occurred in any setting and any geographic location.

For this scoping review, studies considered used quantitative research design, such as experimental, quasi-experimental, mixed methods, cross-sectional and longitudinal studies, and qualitative research, or discussion papers.

Search strategy

The search strategy aimed to locate published primary studies, reviews, reports and opinion papers. Initial limited searches of Medline (EBSCO) and CINAHL (EBSCO) were undertaken to identify articles and key terms used to describe the articles. Key terms were matched to search for MeSH terms and keywords were used to search for titles, abstracts and keywords in Medline. The search strategy, including all identified keywords and indexed terms, were then adapted for each included information source. The reference lists of relevant systematic/scoping reviews and eligible articles were screened for additional papers. There was no restriction on language in the searches. It was planned that papers with an English language abstract and the main text in a language other than English would be collated into an appendix; however, the actual searches did not yield any papers as such. The review considered all studies published to date.

The databases searched included Medline (EBSCO), CINAHL (EBSCO), ERIC (EBSCO), Embase (Ovid), PsycINFO (Ovid) and Web of Science. Grey literature was sought on Google Scholar (20 first records), Trove, ProQuest dissertations and thesis database, and relevant websites such as http://www.vituralknowhow.com. Initial keywords to be used included pregnancy, parenting, infant care, adolescent, school students, teenagers, simulated baby and infant simulator.

Source of evidence selection

All identified records were uploaded into EndNote™ v.X9 (Clarivate Analytics, PA, USA) and duplicates removed. Titles and abstracts were screened by two independent reviewers (H.D and D.M) for assessment against the inclusion criteria for the review. The full texts of potentially relevant papers were reviewed against the inclusion criteria by two independent reviewers (H.D and D.M). Reasons for exclusion of full-text papers that did not meet the inclusion criteria were reported. Disagreements that arose between the reviewers at each stage of the selection process were resolved through discussion with all team members. Reference lists of selected studies and relevant systematic reviews were screened for further papers. If one study was available in various forms of a dissertation, a published research protocol, a media release or an original research publication, the latest was chosen. The results of the search were summarized using the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews (PRISMA-ScR) flow diagram.

Data extraction, analysis and presentation

Data from each paper were extracted independently by two reviewers and verified by a third reviewer. A data extraction tool was developed by the research team at the protocol development stage to collect specific details (author, year of publication, country of origin, aim, study population, setting, sample size, method, study design) and key findings related to the aim of this review (the content of teaching programme, mode of delivery, type of simulators, what outcomes were measured).

The results are presented in narrative texts, with supporting tables, which align with each research question of this scoping review. Characteristics of research studies were reported including the mode of teaching delivery, the content of the programme and which outcomes had been assessed.

Results

Study inclusion

A total of 1170 titles were found from 8 databases and 12 further titles have been hand searched from the Realityworks’® official website. After removing duplicate records, 1033 titles and abstracts were screened for potential inclusion. Forty-seven full-text articles were identified against selection criteria; 32 eligible articles were selected for this scoping review (see PRISMA flow chart—Fig. 1).

Fig. 1. PRISMA flow chart.

Characteristics of selected studies

Thirty-two studies were selected. These were published in the USA (n = 29), Sweden (n = 1), Australia (n = 1) and Scotland (n = 1). The design of these papers represented 21 original research papers, Masters’ theses (n = 5) and PhD theses (n = 6). Papers came from multiple disciplines including urban education (n = 1), applied technology (n = 1), education (n =1), science (n = 2), social work (n = 2), nursing (n = 2) and psychology (n = 2). Study designs included RCT (n = 1), longitudinal (n = 1), qualitative research (n = 2), mixed-method (n =1), survey (n = 1) and a majority employed a pre-/post-test design (n = 26). Studies were published after 1995, the year when simulators were first available commercially, and their popularity increased over the next 15 years; only three studies were published in the last 10 years. Most studies involved students of both genders (n = 24), while seven included only female students and one with males only. Students participated in a programme in year 6, ages 11–12 years (n = 2), year 7, ages 12–13 years (n = 1), year 8, ages 13–14 years (n = 6), year 9, ages 14–15 years (n = 4), year 10, ages 15–16 years (n = 8), year 11, ages 16–17 years (n = 7), year 12, ages 17–18 years (n = 2) and the study year was unspecified for some (n = 2).

The follow-up time-frame varied between studies and was grouped as (i) no follow-up period including those outcomes that were measured immediately or in a short time following the infant simulator exposure (n = 18) [13–15, 17, 20, 26–38]; (ii) a follow-up < 6 months (n = 7): at 2 weeks [39]; 4–6 weeks [40]; 6 weeks [41]; 6–10 weeks [42]; 10–12 weeks [18, 43] and 4 months [44]; (iii) a follow-up from 6 months to 1 year (n = 3), 8 months [45] and 9 months interview follow-up with a subgroup of students [27, 46] and (iv) follow-up after > 1 year (n = 4) including 1–2 years [47]; 2–4 years [16]; 4 years from 8th to 12th grade [48]; from participating time (13–15 years) until 20 years of age or the age they were first pregnant [12].

These studies involved 7939 students, excluding participants from three studies that did not provide an accurate number of participants [16, 28, 36]. The number who participated with infant simulators varied from six participants to a study with1829 participants from multiple sites. The intervention also varied from a single site to a cohort of 57 schools [12]. Among the interventions, one was delivered to adolescents who were committed by courts to a youth centre [31], and one specifically targeted adolescents with intellectual disabilities [13] (see Table I for characteristics of included studies).

Table I. Evidence table of articles

First author, year	Country	Participants	Sample size in numbers	Contents	Characteristics of simulators	Key results/findings	Recommendations for future work	
Barnett et al., 2006	USA	10th grade students	98	State-mandated health education course + BTIO™	Battery-operated, resemble real infant, cry randomly, one key to insert and turn to stop crying, electronic recording device to monitor how the BTIO™ is cared for (rough handling, neglect)	No significant differences were found in 4 outcomes between 2 groups, and before-after classes	Increased contact with baby simulator and more instructional activities are needed.	
Barnett et al., 2004	West Missouri, USA	8th and 10th grade	379	BTIO™ is integrated into the Part of the Life’s Walk sex education programme. 10th graders—this programme was run as an elective. Content includes pricing baby items and budgeting.	BTIO™ simulators mimic real infant, crying at intervals and participants utilize key to respond. Microprocessor to record the amount of crying and if it is roughly handled.	Survey responses show the value of the BTIO™ experience in helping students to recognize the difficulty of caring for an infant and to understand the importance of delaying parenthood	Future research needs to examine how BTIO™ can be used more effectively	
Borr, 2009	North Dakota State University, USA	Freshmen students aged between 14 and 16. Participants were randomly chosen from self-selected volunteers.	13	BTIO™ sat within a Family and Consumer Sciences course.	Resembles infant. The baby can set to 15 different schedules, cry when it needs feeding, rocking, burping or changing the diaper, have two ID for students and someone else, points deducted if babysitter ID is used frequently. The baby cry then being dropped, mishandled, shaken, head is not supported.	Ninth grade is an appropriate grade to take home the BTIO™ simulator, having this over a weekend rather than a night creates a more realistic experience. The project reinforced participants’ views about not becoming young parents.	Need more longitudinal studies around this to see long-term impact on teen pregnancies.	
Brinkman et al., 2016	Western Australia, Australia	Girls 13–15 years Years 9 or 10	1267	Western Australian adaptation of the US programme created by RealityWorks™ (Eau Claire, WI, USA) and often referred to as ‘Baby Think It Over’. Piloted and received well by participants, parents and teachers regarding health professionals delivering programme.	Comprising accessories as breastfeeding devices, nappies, clothing, wrist band identifier, baby sling, batteries.	The infant simulator-based VIP programme did not achieve its aim of reducing teenage pregnancy. Girls in the intervention group were more likely to experience a birth or an induced abortion than those in the control Schools in more than 89 countries currently use simulators. The results of this trial indicate that this intervention is likely to be an ineffective use of public resources aimed at teenage pregnancy prevention group before they reached 20 years of age.	Not given	
de Anda, 2006	Los Angeles, USA	Mandatory participation as part of compulsory unit of study. Mostly Grade 9, Latino	461	BTIO™ curriculum nested in mandatory health unit with preparatory work, group and individual discussion and additional support for those who found it difficult	Crying at intervals, can only silence by a key inserted in a slot at its back, the doll recorded data including time taken to care for the doll, dropping or hitting it.	Both the results of the data analyses and the adolescents’ own evaluation confirm the effectiveness of the BTIO™ intervention in changing perceptions regarding the time and effort involved in caring for an infant and in recognizing the significant effect having a baby has on all major aspects of one’s life.	A control who receives all of programme except use of simulation to refine understanding of valuable elements of programme.	
Didion et al., 2004	USA	Female 11th grade rural and urban	Not specify	Countrywide pregnancy intervention programme called ‘In Your Care’ using BTIO™ simulators	Resemble real infant, cry randomly, one key, electronic recording device to monitor how the BTIO™ is cared for	Student sample indicated that teen parenthood was essentially a negative experience and they intended to delay childbearing	Include experimental design	
Divine et al., 2001	USA	236 8th graders + 461 control comparison group	697	Students provided care to dolls over ‘several days’ that cried when hungry, needed a diaper change or needed attention	Programmed to cry, coo, burp on one of three schedules, life-size, realistic dolls	Students enhanced understanding about responsibilities and implications involved in parenting, with the effect that they would think more fully about the possible implications before engaging in sex, more so for females than males; control group felt less knowledgeable about care provision and judged care as less time consuming, difficult and expensive compared to intervention group	not discussed	
Douglas, 1996	USA	Female adolescents at risk of pregnancy were referred to by a community health clinic and a community centre; aged between 11 and 16 years	11	Three counselling sessions over 2–7 days at the clinic plus, instructions to care for the simulator, wearing a sympathy apron to simulate pregnancy; Study 2: the same lessons plus an advanced model of the BTIO™, the evaluation give students chance to ask questions about consequences of premarital sexual activity (pregnancy, STD, birth control info and services).	crying and need feeding by a probe attached, detect and record abuse, neglect	77.8% teens said the apron was uncomfortable and following the experience more rated not wanting to be a parent. Most teens agreed BTIO™ was not like caring for a baby although there was some burdensome to care for it.	increase sample size, developing comprehensive curricula with more real life situations, additional measures, conduct a follow up study, involve male adolescents repeated experiences, utilize schools, community centres, and teen clinics, obtain insurance for the dolls, involve parents; include confidential individual and group counselling.	
Frei, 2010	USA	12- to 14-year-old school students	100	To evaluate the 86 effectiveness of the BTIO™ experience on the adolescents’ perceptions of pregnancy and their intentions of future pregnancy.	Resemble real infant, cry randomly, one key, electronic recording device to monitor how the BTIO™ is cared for			
Freir, 2001	Scotland	14-year-old school pupils in Scotland	45	Unclear but use of BTIO™ dolls was part of the school’s ‘Healthy Relationships’ class	resemble real infant, cry randomly, one key, electronic recording device to monitor how the BTIO™ is cared for	little or no impact of the programme was confirmed		
Herrman et al., 2011	USA	14–18 years	79	Realcare Parenting programme (RealityWorks™) Curricula	Wireless technology ensuring allocated student cares for simulator, head & neck sensors to detect mishandling or abuse, life-like sounds. Infant cues require participant response (eg feeding, burping). Programmed for high irritability	No significant differences were found in the mean pre-/post-test scores or in correlations of the demographic data and mean scores. Two significant differences in pre/post-tests subscale scores were in the areas of friends and personal characteristics	The results of this study suggest that the effectiveness of using infant simulators to influence theperceptions of teens about the reality of teen parenting is minimal	
Hillman, 2000	USA	Female 8th grade	221	Parenting: Skills for Living programme	Assume Real Life Baby simulator as used by BTIO™ programme	Postponed age of first pregnancy for those who had the intervention. Co-curricular activity participation and criminal behaviours did not show any relationship, no significant differences were detected in regard to involvementin co-curricular activities, and no involvement in crime was self-reported	Model developed as guideline for implementing a pregnancy prevention programme in schools. NB 1997 Federal Law to provide abstinence education in public schools.	
Hooks, 2007	USA	12- to 19-year-old participants of mentorship programme sponsored by non-profit community organization	not specify	BTIO™ programme curriculum	Assume Real Life Baby simulator as used by BTIO™ programme	Proposal only	Proposal only	
Janeslatt et al., 2019	Sweden	17–20 years	6	One introduction session (using a card game) 5 topics about parenting & 2 sessions to introduce simulator. Three days of caring for simulator with a break/day care between 7 a.m. & 5 p.m. when students at school.	Cries and records interaction and timing of response. Closes down if ignored or treated roughly (shaking)	Use of Parenting ‘toolkit’ involving an infant simulator feasible among students with Intellectual disability.	Feasible for use with participants with Intellectual Disability.	
Jefson, 2003	USA	Grades 6, 7 & 8	372	Student participants exposed to one of 7 treatments ranging from infant simulator (1, 4 or 7 days), BTIO™ curriculum or combination. Convenience non-random selection.	resemble real infant, cry randomly, one key, electronic recording device to monitor how the BTIO™ is cared for	There is little evidence of the BTIO™ impact on participants feelings of self-efficacy	optimum length of BTIO™ exposure, the impact of gender and age are unclear and needs further studies.	
Kralewski et al., 2000	USA	6th and 8th female students in an urban middle school in a lower socioeconomic predominantly Hispanic	109	Students brough BTIO™ home for 3 days 2 nights	Crying at intervals, can only silence by a probe attached to caretakers’ wrist	Experience with BTIO™ didn’t make grade 6 students think it more difficult than infant care, grade 8 felt easier to care for BTIO™ than infant. Did not change student intention to be teen parents.	Future interventions to help adolescents to make future oriented goals than those discourage early parenthood.	
Malinowski, 2003	USA	11th grade girl students	9	Cared for the BTIO™ during an elective parenting course developed by their high school teacher. Students tended to the doll for 7 days. For half of the week, the participants cared for the girl doll. For the second half of the week, they switched to the boy doll, which was a newer model and required constant head support	Specific and record this quantitatively on its display panel. Internal sensors induce crying if the doll is placed in an incorrect position, mishandled, or wants to sleep. Located on the doll’s back is an electronic box designed to detect abuse, neglect, rough handling, or lack of head support,	3 themes: 1/ parenting journey incorporating intellectual, emotive and physical difficulties 2/recognizing the illusion Previously held about parenting a child 3/offering counselling to others based on BTIO™ experience	Develop quantitative instruments; including male experience; exploring alternative method to delay pregnancy (ie contraceptive)	
Mallery, 2002	USA	Male and female adolescents average 14 years old, range from 12 to 19	1829	health or family life course	cry in intervals, set in ‘cranky’ temperament, have a key at the back to stop crying after 30 min, recognizing abuse or neglect	The intervention group perceived that teen parenting is more difficult than the control group. Males perceived being teen parent is more problematic than females did.		
Marsh, 1999	USA	Adolescent males from 12 to 19 years committed by the courts to a juvenile correctional facility in a large rural area in New England	51	A parenting programme designed to provide the experience of parenting a real infant, parenting skills aimed at emotional responsibilities of parenthood. The adolescents received attachment parenting training before they experienced an infant simulator doll	the key to infant simulator was attached to each participant’s wrist that to be inserted into the back of the doll to stop it from crying	No difference in parenting score between two groups, no attachment to mother, to peers. Attachment to parent or peer score was not associated with parenting behaviour score. Age or cottage where the participants were residing did not associate with the parenting score.	A trend that older adolescents responding better to parenting role suggested future programmes aiming at older age. Father–child attachment should be explored to develop parenting training programmes aimed for male adolescents.	
McCowan et al., 2009	USA	students attending heath education classes from 9th to 12th grade from 7 schools across 4 states	309	BTIO™ and RealityWorks™ curriculum	A computerized monitoring unit produces reports that document how well students cared for the infant. The report shows how many times the infant was neglected, handled roughly and shaken, as well as how many times feeding, burping, rocking or changing were required	The treatment group had much higher scores on attitudes and cognitive achievement on the post-test and these differences were maintained on the follow up.		
Moody, 1999	USA	African American female adolescents from 11–15 yo living in an inner city. African American girls were selected as being the most at risk of having a baby in their teen years.	30	The BTIO™ pregnancy simulation programme plus SOS and the Next generation, a locally designed adolescent pregnancy prevention curriculum		No difference in attitude and knowledge score before and after the programme; however, compared to the control group, the experimental group had a higher realistic attitude toward teen pregnancy.	Future studies to evaluate parents’ observations of their child experience. More comparative groups like didactic only, dolls only, didactic and dolls, control group could be more effective.	
Out, 2001	USA	High school 11th grade students from 14 to 19 years, average 16.2 years	114	Parenting classes	Cry for several reasons (feeding or comforting), by applying a magnetic probe into the doll’s back and holding it for 35 min. Recording the number of times being rough handling, or neglect, of total time crying.	41.2% being sexually active; of them 83% had intercourse before age of 16 years. The intervention group was more likely to accurately assess the risk of unplanned pregnancy than the control group. The qualitative findings showed that the intervention group can depict examples of activities and consequences regarding child rearing than the control group	Involved more males; determine attitude in unplanned pregnancy, contraceptive use, teen parenting, abstinence from premarital sex. Content regarding consequences of teen pregnancy should be incorporated in other non-parenting courses as math, physical education, history, sociology etc.	
Price et al., 1999	USA	Three high schools in a rural country	220	One-week teen pregnancy prevention programme		Parents found having a baby had a positive effect (38%) and negative effect (37%) on family activities, and the baby taught their children involved a lot of responsibilities (85%), time-consuming (79%) and keeping them from achieving their goals in life (71%). Parents perceived increased conversation with their child in the effects of having a baby (72%), effects of being a parent (69%) and having sex (56%).	School programmes should minimize disruption to family activities; parent workshop for parents to give them hints on supporting children learning while minimizing negative effects on the family.	
Roberts et al., 2004	USA	Ranging from 14 to 18 years	236	New York parenting curriculum focusing on reflection-based parenting skills with childcare competencies	Cry, fed by bottle, a computerize monitoring unit reports how well the student cared for the infant (how many times the infant was neglected, handled roughly, and shaken, how many times feeding, burping, rocking, changing)	The infant simulator is effective for teaching childcare skills, enhancing student attitude toward sexuality, parenting issues.	Longer exposure with simulator may assist students understand long term implications of parenthood.	
Schmidt, 2010	USA	All 10th grade students in a high school	not specify	A health class with BTIO™ experience	Cry at intervals, students had a key to respond when the simulator required care	This is a proposal only		
Somers, 2006	USA	10th, 11th and 12th grade students of primarily while, middle class, suburban high school students, mean age = 15.8 and 16.6 years for the intervention/control group.	250	offered in a child development and health course	Students had to determine the reason for the baby distress by feeding it using a specially sensored-bottle, changing it sensored-diapers, holding it in an upright position and burping it in a cradled position. An internal computer monitors and records adolescents’ responses to the baby	No significant changes in both groups in age of onset of sexual intercourse, contraceptive use, frequency of oral sex, frequency of sexual intercourse. After the intervention, adolescents perceived that parents and friends would be less upset about them becoming pregnant as teenagers.	An experimental study with randomized participants, more gender and racial/economical diversity, more exposures with the babies and opportunity to use them in all aspects in life.	
Somers, 2001	USA	Primarily white, middle class, suburban high school students (mean age = 16.2 years); 9–12 years	213	Child development or health classes with exposure to the BTIO™		No significant differences between two groups at post-test	Educators to consider their intended goals for the BTIO™ and determine if the simulator has met those needs. Objective measures need to be developed including narrative data and qualitative studies.	
Somers, et al., 2001	USA	Grade 9–12	147	BTIO™ curriculum	Random crying controlled by insertion of a plug for varying periods. Actual simulation of baby care not required (changing nappies, feeding, burping, etc.).	Adoption & implementation of programme occurs with little research of effectiveness available, or evaluation of results planned.		
Space, 2000	USA	8th grade students	11	1/a weekly counselling with the mothers and their daughters (by school counsellor who was a teen mother) covering topics of transmitted disease to pregnancy, how to handle boys’ advances. 2/shadowing teen mothers in the high school to see how difficult it was to be a mother while attending classes 3/care for the BTIO™ for 1 week	A key to inserted at the back to stop the baby from crying	The baby simulator had more impression to participants over the counselling session, or the shadowing teen mothers. None of participants became pregnant during follow-up time warranting the change in their attitude.	Future studies to include boy participants	
Stelzel, 2009	USA	Male and female students aged 13–18	206	RealityWorks™ curriculum called ‘Understanding Shaken Baby Syndrome’—presents the clinical symptoms of SBS, education, discussion etc in a 50-min classroom session	The RealityWorks™ (2009) SBS Simulator™ is designed to demonstrate the result of violently shaking a baby or young child. It demonstrates the amount of force needed to permanently disable and or cause the death of a baby. Motion sensors in the simulator’s head, called accelerometers, measure the degree of acceleration. The simulator’s head is labelled with symbols that represent the functions lost when those areas of the brain are injured. The simulator’s head and face are clear so that the lighted LED’s are visible. When brain movement from shaking reaches levels that cause injury, those affected areas light up.		research needed to measure knowledge change and behaviour change over time. Attitude and self-efficacy could also be examined.	
Strachan, 1997	USA (one author Canadian)	48 High school students’ convenience sample, 2 city and one suburban high school. One intervention group and 2 control groups. 73% female, childless 16–18 yo 10th-12th grade	25	Life-space intervention (sponsor organization): BTIO™ curriculum Parenting in convenience sample Health or Home economics classes.	Programmed to cry every 45 min to 3 h. Responded to attention (insertion of a key). Recorded responses	Nonsignificant trend in expected direction (realistic parenting attitudes)	Longitudinal follow-up regarding pregnancy	
Tingle, 2002	North Carolina randomly selected counties, USA	Average age 15.5 years 86.3% female. 61% ‘white’	431	BTIO™ programme	Included chip that recorded interaction between student and simulator including tampering and total time simulator cried without intervention.	Minimal changes reported or found on any dimension.	State-wide study suggests no advantage for this intervention.	

There were a variety of infant simulators used in the programmes. Three different versions of the Baby-Think-It-Over (BTIO™, RealityWorks®) were used, Ready-or-not-tots (Nasco™) and Shaken Baby Syndrome simulator (RealityWorks®). See Table II for characteristics of these infant simulators.

Table II. Infant simulators

Infant simulator type	Characteristics of the infant simulator	Citations	Number of citations	
Baby-Think-It-Over—key operated
(RealityWorks®)	The infant simulator cries randomly and requires the student to insert a key at the infant simulator’s back. The electronic device records the amount of crying, rough handling, or neglect in a set time period.	[14–16, 18, 26, 27, 30–32, 36–38, 40, 41, 45, 49]	16	
Baby-Think-it-Over—probe operated
(RealityWorks®)	The infant simulator cries when it needs feeding or comforting and that requires the student to insert a probe into infant simulator’s back. The computerized monitoring unit records the number of times the infant simulator is neglected, handled roughly, or shaken, and how many times it needs feeding, burping, rocking or diaper changes.	[29, 33–35]	4	
Realcare baby
(RealityWorks®)	Students have to determine the reasons for infant simulator’s crying by feeding it using a specially sensored bottle, changing it with sensored diapers, holding it in an upright position and burping it in a cradled position. Other accessories provided with the infant simulator include a stroller, infant care seat, nappy bag, clothes, baby wipes, blanket, feeding bottle and journal.	[12, 13, 17, 20, 28, 39, 43, 44, 46, 48]	10	
Ready-or-not-tots (Nasco manufacturer)	Cry, coo, burp, care is provided by inserting 4 keys (attention, diaper, feed, burp) at the back of the infant simulator. Sensors detected mishandling and tampering with the controls.	[47]	1	
Shaken Baby Syndrome simulator.
(RealityWorks®)	Motion sensors in the simulator’s head, called accelerometers, measure the degree of acceleration. The simulator’s head is labelled with symbols that represent the functions lost when those areas of the brain are injured. The simulator’s head and face are transparent so that the lighted LEDs are visible. When brain movement from shaking reaches levels that cause injury, those affected areas light up.	[37]	1	

Teaching content

Most of the programmes (30/32 programmes or 94%) introduced students to infant simulators in structured educational sessions. Some used the provider’s curriculum, some adapted the provider’s curriculum, others utilized their own curriculum and two introduced the BTIO™ simulator without any known lesson plans. Nine others used the available curriculum provided by RealityWorks’® [12, 15, 18, 20, 28, 38, 40, 44, 46]. Fourteen programmes used the BTIO™ with adapted health education classes on parenting, family life and child development [13, 14, 17, 18, 26, 27, 30, 31, 33, 35, 36, 39, 43, 48]. Five others adopted the RealityWorks’® curriculum with a focus on the topics of adolescent pregnancy prevention/sex education [16, 32, 34, 45, 49]. One study used the RealityWorks® Shaken Baby Syndrome simulator to demonstrate the impact of shaking an infant on its brain together with content from the ‘Understanding Shaken Baby Syndrome’ curriculum (RealityWorks® [37];).

Delivery of programmes

Class lectures and instructions

Programmes integrated infant simulators with other content concerning pregnancy prevention or parenting skills, delivered in class instructions [12, 32, 35]. Brinkman et al. (2016) described 4 sessions (groups of 4–5 girls) covering a range of health concerns including contraception, STIs, drug use, nutrition, immunization, pregnancy choices and parenting skills. In another programme, the experimental group was assigned to a parenting curriculum [35] or a locally designed adolescent pregnancy prevention curriculum [32]; but, content was not specified. With the Shaken Baby Syndrome infant simulator, students learned the clinical consequences of a severe shaking, the situations in which caregivers may lose control and ways to ease the frustration, anger and stress that can occur when caring for an infant [37]. Another programme combined lectures and demonstrations in a project targeting African American girls and using edu-dramas, a teaching technique that uses a dramatic story telling manner [32].

Workbook. Brinkman et al. (2016) used an enhanced version of the workbook endorsed by the manufacturer, covering topics of simulator care and pregnancy-related topics (nutrition, exercise, immunization, prevention of injury, smoking, alcohol and illicit drugs, Sudden Infant Death Syndrome, breast feeding, etc.) which students completed and kept for later reference.

Classroom simulation

Students were taught how the BTIO™ infant simulator was operated [12, 26, 27, 31, 35, 37, 49]. Students observed and participated in demonstrations with the only case of Shaken Baby Syndrome infant simulator use [37].

Videos. Brinkman et al. (2016) introduced four documentaries of teenage mothers talking about their own experiences, including the public’s reaction to their pregnancy and practical implications of being a teenage mother. This programme also had a 10-min video of a simulated preconception visit to a GP [12]. Didion (2004) used a video about responsibilities of parenting but no further details were described.

Coaching & counselling

Students had weekly meetings with a nurse practitioner, who read their journals, and supported the ongoing emotional and social needs of the adolescent participants; this relationship becoming fundamental to the intervention [20]. Another programme employed a counsellor to have weekly sessions with mothers and daughters about safe sex and pregnancy issues, with the counsellor being a teenage mother herself [45]. The strategy of having both the mothers and the daughters in the educational sessions was based on earlier research and a pilot study by the same researcher, which showed that girls who became pregnant were distant from their mothers, while girls who had managed to avoid pregnancy had close relationships with their mothers [45].

Student engagement and reflection

Programmes facilitated students in group discussions regarding their experience of participation [15, 16, 38, 40]. Peer support within such groups was an important factor in shaping perceptions of the programme [20].

In some programmes, students were asked to individually reflect on their experience. In other programmes, individual reflection involved less structured approaches such as journaling to record thoughts and feelings about the experiences [48]. Other programmes prompted more structured individual reflection and analysis in the form of essay writing about what participants had learnt, liked or disliked about the experience [47]. Some programmes featured a more comprehensive approach where students recorded aspects of their experience such as the times the infant simulator cried or demonstrated other actions, what the teenager did at the time, and how they felt about it [16, 20, 26, 39, 47].

Students’ involvement with the infant simulators

In most programmes, students took an infant simulator home for between 1 and 7 days. Typically, the students tended the infant simulator over a weekend (3 days 2 nights) [16, 18, 20, 27, 29, 30, 32–36, 38, 39, 43, 49]. Other programmes had varied length of exposure to the infant simulator. One programme tested three different time exposures with the BTIO™ for 24, 48 and 72 h [26]. Barnett (2004) had two groups of students: 8th graders who cared the infant simulator for 48 h during the school week; and 10th graders who cared for the simulator for 72 h during a weekend. The longest exposure was observed for 7 days inclusive of school time [17, 45]. An exception was the use of the Shaken Baby Syndrome infant simulator that students only had opportunity to observe and participate with in a classroom demonstration [37].

Several programmes required students to care for the infant simulator at home and during class time [13, 40, 45, 48], so students could understand the disruption to their academic study. Most programmes requested students to be the sole caregiver, with the key/probe attached to their wristband, while others allowed an alternate carer to assist with caring using a ‘babysitter ID’, and times caregivers attended the infant simulator were recorded [39].

Infant simulators were distributed randomly according to gender, except for one study in which students had half a week to care for a female infant simulator then for the second half of the week switched to a male infant simulator (which was a newer model requiring constant head support) [17], or students decided in a pair who would have the male or female infant simulator [27].

Other activities were designed to help students experience parenting roles. Students were required to simulate purchasing necessary newborn items [32], or had to make a budget for having a newborn [49]. In one study, participants ‘shadowed’ teenage mothers in a high school for a day to observe the difficulties in balancing schooling with child rearing, and from which they developed expectations of the care and responsibilities before they tended the simulator [45].

Self-reported outcomes

Student-reported outcomes have been mostly assessed using surveys, but some used interviews or self-reflection. These outcomes were categorized (see Table III). Four studies measured at least one knowledge outcome relating to health issues, sex knowledge or impact of having a child on students’ academic and social life [14, 15, 32, 37]. Eight studies measured insights of being young parents, having a child, and caring for the simulated infant [15, 18, 20, 29–31, 39, 40]. Attitudes regarding sexuality, pregnancy, parenting and social acceptance were evaluated in 13 studies [13, 14, 16, 18, 26, 32, 33, 35, 38, 43, 46, 47, 49]. Self-efficacy for parenting was measured in two studies using two different scales [13, 44]. Specific sexual behaviours, parenting behaviours toward the simulated infant and communication between parents and teens were assessed in eight studies [13, 14, 18, 31, 33, 43, 47, 49].

Table III. Self-reported outcomes and measurements

Outcome categories	Outcomes	Measurements and citation	
Knowledge	Knowledge of preconception health issues, infant mortality/morbidity, safe sex practices	SOS pre-/post-test (12 multi-choice questions) [32]	
Sex knowledge	Self-developed instrument (15 True/False, multichoice items) [14]	
Impact of having a child or newborn infant (on students’ academic and social life, on family members, emotional risks, family and cultural values)	BTIO™-1 (25 Likert-scale items) [15]	
Knowledge of Shaken Baby Syndrome	Understanding Shaken Baby Syndrome-12 (12 items) [37]	
Perception	Perceptions toward being young parents	Interviews and affect cards (printed words prompting students’ comments) [39]	
Perception of having child at teenager ages	14 Likert-scale items [30]	
Perceptions toward teenager parenthood	19 Likert-scale items [40]	
Perception about age that they wanted to have the first child	Open questions [29]	
Perception about when they wanted to have the first child	A multiple-choice question [15]	
Perceptions about 1/contraceptive/sexual attitudes and behaviours, 2/ desire to achieve/avoid pregnancy, 3/understanding of the responsibilities of child-rearing, 4/appreciation of the impact of childbearing on their lives/future, 5/attitudes toward premarital sex.	Survey [42]	
Perception regarding costs and rewards associated with parenting	Thoughts on Teen Parenting Survey [20]	
Perception about caring for the BTIO™	A 4-scoring 10-item scale [29]	
Perception of how caring for the BTIO™ changed their thoughts	BTIO™-2 [15]	
Perception about similarity between doll care to infant care	A 4-scoring 8-item scale [29]	
Perception of how well parents and peers serve as a source of psychological security	Survey [31]	
Attitude toward sexuality, sex and pregnancy prevention	Attitude toward teenage sexuality	4-scoring 12-item scale [14]	
Attitude toward sexuality and pregnancy	25 attitudinal items in 5-point Likert scale [46]	
Attitude toward abstinence and contraceptive use	Attitudes concerning abstinence from premarital sex and toward the use of contraceptives [33].	
Attitude toward teen pregnancy and contraception; sexual experience; Attitude toward parenting	Health Belief Model Approach to Adolescents’ Fertility Control (35 items, 6 subscales) [33]	
Attitude toward parenting, pregnancy, birth control, sexual behaviours	Infant simulator impact scale (38 items, 15 demographic and 23 attitudinal items) [35]	
Attitude toward parenting, sexuality, having and caring for infants	9 Likert-scale items [47]	
Attitude toward BTIO™, parenting and sex	Data from BTIO™ and surveys [49]	
Attitude toward teen pregnancy and its impact	Attitude about teen pregnancy	Survey [16]	
Attitude toward discomfort of pregnancy	Sympathy Apron Post-test [26]	
Attitude toward the impact of teen pregnancy	8 items in the BTIO™ test [32]	
Attitude toward future orientation, realism about responsibilities of child rearing, personal intentions regarding sexual intercourse and childbearing, self-efficacy to resist risky situations.	Teen Attitude pregnancy scale [18, 43]	
Attitude toward parenting	Attitude toward parenting	BTIO™ pre-/post-test and additional questions [26]	
Attitude toward parenting	Parenting attitude scale (10 item) [38]	
Attitude/expectations regarding parenting	Single item requiring response [33]	
Attitude toward parenthood	Infant Simulator Attitude Scale (Strongly agree–Strongly disagree) [13]	
Attitude toward social acceptance	Teen attitude about other people’s acceptance of teen pregnancy and premarital sex	Additional subscales attached to Teen Pregnancy Attitude Test [43]	
Student’s self-efficacy	Self-efficacy regarding parenting	General Self-efficacy Scale [13]	
Self-efficacy regarding parenting	Infant Care survey [44]	
Sexual behaviours	Sexual behaviours (specific behaviours listed)	5-scoring 11-item scale [14]	
Sexual behaviours (kissing, petting, oral sex, sexual intercourse)	Sex Knowledge and Attitude Test [43]	
Sexual experience and use of contraceptives	Sexual/Contraceptive Behaviours Questionnaire [33]	
Sexual behaviours (10 sexual behaviours divided in ‘sexual communication’ and ‘sexual activity’)	Self-reported frequency [18]	
Sexual behaviours (amount of sexual intercourse)	Self-reported frequency at one month after programme [49]	
Perceived parent-teen communication	Communication with parent following intervention	4 scoring 12-item scale [14]	
Behaviours toward infant simulators	Parenting behaviour via caring for the BTIO™	Data from BTIO™ (frequency of attendance, neglect, rough handling, head not supported) [13]	
Parenting behaviour via caring for the BTIO™	Student Response Sheets (written) [47]	
Parenting behaviour via caring for the BTIO™	Data from BTIO™ (neglect = 1, abuse = 5) [31]	

Pregnancy-related outcomes

Two programmes (a longitudinal and a Random Controlled Trial (RCT) study) tracked participants until their first pregnancy.

Hillman et al. (2000) followed 221 female students from 8th to 12th grade to determine whether and when pregnancies occurred and found those exposed to infant simulators had a postponed onset of pregnancy following this intervention (mean= 3 years 2 months) compared to those who did not (mean = 2 years 2.5 months). Although delayed pregnancies were observed following the intervention, most of the pregnancies that occurred were during 11–12th grade [48]. Summertime and holiday seasons marked the times of the year when many pregnancies began. The data were self-reported and verified with school records when possible.

Brinkman et al. (2016) followed 1267 girls in the intervention and 1567 girls in a control group for over 3 years and found a higher risk of pregnancy in girls participating in the intervention (exposure to the BTIO™ curriculum) than with the control group. The data were determined by tracking participants through a data linkage system which recorded all births in the region, but no reliable data regarding miscarriage and induced abortion was available.

Programme evaluations by students, parents and teachers

Schmidt et al. (2010) explored effects of the programme on students’ academic and social life, family members, emotional risks and family and cultural values using a survey tool offered by the RealityWorks’® manufacturer (a 25-item scale). Somers (2006) asked students questions about how the BTIO™ programme affected them, how realistic the simulator was and the level of engagement in the programme. Focus groups explored the benefits of the BTIO™ programme and whether the programme should continue [16]. Divine et al. (2001) used several items in a survey to examine students’ evaluation.

Five studies reported at least one outcome from parents or teachers. Parents were asked about their perceptions of the programme on family activities, their child, parent–child communication and technical aspects of the programme [34]. In a similar manner, Tingle et al. (2002) sought responses from teachers and parents regarding participant changes in attitude to parenting, impact on family life and how feasible the programme was to implement [40]. A further study reported that teachers felt the BTIO™ infant simulator was a valuable addition to their subject [27].

Somers, Gleason [42] sought teachers’ insights regarding the reasons for teenage pregnancy. They hypothesized that parents not being home during the day (55%) and peer pressure (67.2%) were factors related to teenage pregnancy; with 10% attributing pregnancy to schools not addressing sex education issues. Overall, 84% of the teachers recommended the programme to other schools and 86% supported the programme being implemented in their school annually.

More recently, the BTIO™ was used to teach parenting to adolescents with intellectual disability, and teachers found the programme was feasible; however, only six participants joined this pilot programme [13].

Discussion

This scoping review has found that studies addressing the use of infant simulators as an aid in pregnancy and parenting educational interventions for school-aged students were mainly from the USA (29/32 studies). Eligible publications confirmed it was a popular research focus during 1995–2005, and only three studies have been published in the past 10 years. Three countries other than the USA (Sweden, Australia, Scotland) each had one study, identifying that it is unknown how well-received the infant simulators are outside the USA.

RealityWorks® simulators were the leading products, and their infant simulators were used in 31 of the 32 studies. The use of RealityWorks® infant simulators varied between studies. Teaching content and delivery were diverse and implementation of the Baby-Think-It-Over (BTIO™) curriculum also varied. This curriculum has the objective to help teenagers understand challenges of raising an infant, the ramifications on academic achievement, social life and future goals, postponement of sexual activity and use of contraception. It might be suggested that content may prepare teenagers for the reality of parenthood independent of a resolve to delay parenthood. The outcomes of the curriculum may also be influenced, by the way in which the educator interprets and delivers it.

It was striking that the assessment of the outcomes of the curricula was primarily pre-/post-test surveys of student reactions to their experience. Some studies also included feedback from families and teachers which was also largely survey based. Only two studies were found that tracked outcomes until first pregnancy [12, 48], which limits the evaluation of the effectiveness of this intervention. Hillman et al. (2000) reported postponed age at first pregnancy for those who had participated in the intervention [48]. However, Brinkman et al. (2016) reported that there was a higher risk of pregnancy, birth or abortion among girls who participated. They suggested that the limitations of the study may partially explain this finding, in particular the low participation rate of students (50% in control schools, 58% in intervention schools) the lack of information about students who declined participation and the higher socioeconomic level of control group (although this discrepancy was controlled). No measure for miscarriage (spontaneous abortion) was included as reliable sources do not exist. Sample size limited capacity to investigate whether the intervention group was more likely to seek termination—but this was not the aim of the research which was to examine whether the intervention reduced pregnancy rates before 20 years of age [12]. No studies were located that focussed on measuring the quality of parenting. Some measures regarding rough handling of the infant simulator or time to care, could serve as quality proxies. But this measure risks a reductionism avoided by examining the better understanding of the demands of parenting as an outcome of the intervention, the learning of which could provide a deeper and more nuanced measure of parenting quality. It is clear from these findings that studies will be needed to examine the quality of parenting.

The five studies that had a comparative design [14, 18, 33, 38, 40] did not find any differences in pre-/post-test measures between the teenagers who participated in sessions with the infant simulator compared to those who received usual classes. There were positive comments about the efficacy of infant simulators from both parents (for example, ‘I think it would prevent a lot of teens from having kids too early, it should be included in all sex education classes’) [36] or from students ‘It would be hard to study at school during the day because I was so tired from taking care of the baby’ [31], demonstrating that students understood the hardship of having a baby. However, the measure of effectiveness requires empirical data.

It has become clear that the lack of differences in pre-/post-test could have caused by limitations in study design. Barnett [14] argued that the lack of delayed follow-up could have impacted the post results, as programmes require time to influence thinking and behaviour. Barnett [14] also articulated that the evaluation instrument did not measure some of the outcomes. Somers and Fahlman [18] identified the issue of short periods of exposure to the mannequins and this might have impacted the postsurvey results, by demonstrating no changes in behaviour and thinking. Tingle [40] believed that the lack of a true control group and the absence of a specific intervention protocol for teachers could have affected the results. The latter meant that it was at the teachers’ discretion to what was taught in the intervention and therefore different teaching strategies might have been employed. Strachan and Gorey [38] noted that a small sample size and a convenience selection could have explained to why there was no difference found between a pre- and post-test. The study cohort could have been students who already had knowledge in the area and therefore the postsurvey did not reveal changes. Out and Lafreniere [33] mentioned that the lack of controlled exposure could have influenced the results, as students in the intervention group attended classes with students in the comparison group, potentially influencing the survey results. Segregating the comparison groups and intervention groups was recommended by using different schools.

Overall, the results of the identified studies were mixed, showing only provisional support for the impact of BTIO™ and the Realityworks® infant simulators in change in attitudes and behaviours or intentions. Only two longitudinal follow-up studies existed and demonstrated limited efficacy of these programmes reducing teenage pregnancies, and there is no conclusive evidence of the effectiveness of the intervention on this outcome, especially in contexts outside of the USA and in relation to other recent versions of the simulators (displaying infant variation). Study outcomes are influenced by accompanying resources, curricula, facilitator input, and perhaps most confoundingly, the impact of the specific student and their social context. Given the diversity in the study designs and outcomes measured, further work would be warranted to examine the impact of these interventions on pregnancy prevention and/or parenting skills.

Limitations

Despite a comprehensive and wide search of literature, the scarcity of publications outside USA might reflect that many similar programmes might not have been evaluated, had results published, or have results which are not publicly available. This review could have missed such unpublished sources, which could have further evidence not examined in this review. There is some suggestion that despite of their expense the infant simulators have been adopted across schools in 89 countries [12]. Such adoption suggests that it is not limited to high resource countries as USA and Australia.

Conclusion

Literature did not address innovations that replicate infants with fetal alcohol spectrum disorder, Shaken Baby Syndrome or challenges from parental substance use. The development of these variations in infant simulators opens new learning objectives beyond basic pregnancy and parenting educational interventions.

The significant number of studies using infant simulators for pregnancy prevention and parenting education warrants a systematic review of effectiveness to explore the efficiency of this teaching approach. In addition, as no evidence has been reported on the use of the more recent infant simulators that replicate infants with particular characteristics, research on the use of these infant simulators is essential. In this instance, the outcomes would emphasize healthy pregnancy outcomes rather than prevention or delay of pregnancy alone.

Acknowledgements

We thank Sara Evans, Nikki Reece and Kate Blythe of CatholicCare Social Services Hunter Manning and Kathryn Sweeger formerly of CatholicCare Social Services Hunter Manning for their contribution in discussion of this scoping review.

Author contributions

Thi Thuy Ha Dinh (Project Conceptualization, Database Search, Study Selection, Data Extraction, Data Synthesis, Manuscript Draft), David B. Lees (Project Conceptualization, Data Extraction, Data Synthesis, Manuscript Draft), Pieter J. Van Dam (Project Conceptualization; Data Synthesis, Manuscript Draft), Denise Elizabeth McGarry (Project Conceptualization, Study Selection, Data Extraction, Data Synthesis, Manuscript draft).

Funding

This work was supported by the CatholicCare Social Services Hunter Manning.

Conflict of interest statement

None declared.
==== Refs
References

1. World Health Organization . Adolescent pregnancy 2023. Available at: https://www.who.int/news-room/fact-sheets/detail/adolescent-pregnancy#:∼:text=Every%20year%2C%20an%20estimated%2021,per%201000%20women%20in%202023. Accessed: 23 June 2023.
2. Mann  L, Bateson  D, Black  K. Teenage pregnancy. Aust J Gen Pract  2020; 49 : 310–6.32464731
3. Cruz  E, Cozman  FG, Souza  W  et al . The impact of teenage pregnancy on school dropout in Brazil: a Bayesian network approach. BMC Public Health  2021; 21 : 1–8.33388037
4. World Health Organization . Adolescent pregnancy 2023. 2023 Available at: https://www.who.int/news-room/fact-sheets/detail/adolescent-pregnancy#:∼:text=Every%20year%2C%20an%20estimated%2021,per%201000%20women%20in%202023. Accessed: 23 June 2023.
5. Osok  J, Kigamwa  P, Stoep  AV  et al . Depression and its psychosocial risk factors in pregnant Kenyan adolescents: a cross-sectional study in a community health centre of Nairobi. BMC Psychiatry  2018; 18 : 1–10.29304757
6. Scorza  P, Merz  EC, Spann  M  et al.  Pregnancy-specific stress and sensitive caregiving during the transition to motherhood in adolescents. BMC Pregnancy Childbirth  2021; 21 : 1–8.33388035
7. Faulks  F, Shafiei  T, McLachlan  H. Perinatal outcomes of socially disadvantaged women in Australia: A population-based retrospective cohort study. BJOG: An International Journal of Obstetrics & Gynaecology. 2023; 11 : 1380–93.
8. Keto  T, Tilahun  A, Mamo  A. Knowledge, attitude and practice towards risky sexual behaviors among secondary and preparatory students of Metu town, south western Ethiopia. BMC Public Health  2020; 20 : 1394.
9. Mark  NDE, Wu  LL. More comprehensive sex education reduced teen births: quasi-experimental evidence. Proc Natl Acad Sci USA  2022; 119 : e2113144119.
10. Rose  ID, Boyce  L, Murray  CC  et al.  Key factors influencing comfort in delivering and receiving sexual health education: middle school student and teacher perspectives. Am J Sex Educ  2018; 14 : 466–89.33897308
11. Robinson  KH, Smith  E, Davies  C. Responsibilities, tensions and ways forward: parents’ perspectives on children’s sexuality education. Sex Educ  2017; 17 : 333–47.
12. Brinkman  SA, Johnson  SE, Codde  JP  et al.  Efficacy of infant simulator programmes to prevent teenage pregnancy: a school-based cluster randomised controlled trial in Western Australia. Lancet  2016; 388 : 2264–71.27570178
13. Janeslatt  G, Larsson  M, Wickstrom  M  et al . An intervention using the parenting toolkit “Children-What does it involve?” and the Real-Care-Baby simulator among students with intellectual disability-a feasibility study. J Appl Res Intellect Disabil  2019; 32 : 380–9.30353612
14. Barnett  JE . Evaluating “baby think it over” infant simulators: a comparison group study. Adolescence  2006; 41 : 103–10.16689444
15. de Anda  D . Baby think it over: evaluation of an infant simulation intervention for adolescent pregnancy prevention. Health Social Work  2006; 31 : 26–35.16550845
16. Didion  J, Gatzke  H. The baby think it over experience to prevent teen pregnancy: a postintervention evaluation. Public Health Nursing  2004; 21 : 331–7.15260838
17. Malinowski  A, Stamler  LL. Adolescent girls’ personal experience with baby think it over infant simulator. MCN  2003; 28 : 205–11.
18. Somers  CL, Fahlman  MM. Effectiveness of the “baby think it over” teen pregnancy prevention program. J Sch Health  2001; 71 : 188–95.11393931
19. Pérez-Gaxiola  G . An infant simulator programme did not reduce teenage pregnancy. Arch Dis Child Educ Pract Ed  2017; 102 : 168.
20. Herrman  JW, Waterhouse  JK, Chiquoine  J. Evaluation of an infant simulator intervention for teen pregnancy prevention. J Obste Gynecol Neonatal Nursing  2011; 40 : 322–8.
21. Somers  CL . Effects of infant simulators on urban, minority, middle school students. Health Promot Pract  2014; 15 : 35–43.23475524
22. Realityworks® . Eau Claire, Wisconsin, USA2020. Available at: https://www.realityworks.com/blog/realityworks-announces-the-25th-birthday-of-realcare-baby-the-worlds-most-advanced-infant-simulator/?v=6cc98ba2045f. Accessed: 23 June 2023.
23. Mileder  LP, Urlesberger  B, Szyld  EG  et al . Simulation-based neonatal and infant resuscitation teaching: a systematic review of randomized controlled trials. Klin Padiatr  2014; 226 : 259–67.25153910
24. Wang  MQ . The Realcare Baby Program Evidence of Efficacy. A Realityworks White Paper (nd) Available at: https://www.virtualknowhow.com.au/realcarewhitepaper-evidenceofefficacy.pdf. Accessed: 20 April 2023.
25. Peters  MDJ, Marnie  C, Tricco  AC  et al.  Updated methodological guidance for the conduct of scoping reviews. JBI Evidence Synth  2020; 18 : 2119–26.
26. Douglas  JL . An evaluation of a teen pregnancy prevention program: baby think it over [M.S.S.W.]. Ann Arbor: The University of Texas at Arlington; 1996.
27. Freir  V . The validity of using a simulated baby as part of a sex education programme [D.Clin.Psy.]. Ann Arbor: The University of Edinburgh United Kingdom, 2001.
28. Hooks  NJ . Teenage motherhood: can we think it over? [M.S.W.]. Ann Arbor: California State University, Long Beach, 2007.
29. Kralewski  J, Stevens-Simon  C. Does mothering a doll change teens’ thoughts about pregnancy?. Pediatrics  2000; 105 : e30.
30. Mallery  JG . Practicing parenting? Effects of computerized infant simulators on teenage attitudes toward early parenthood. J Early Educ Fam Rev  2002; 9 : 18–28.
31. Marsh  LB . Impact of attachment training on male adolescents’ responses to infant simulator dolls [Psy.D.]. Ann Arbor: Antioch New England Graduate School, 1999.
32. Moody  LB . The effects of role-play and simulation as pregnancy prevention strategies on knowledge and attitude of African-American adolescents in an urban community [M.S.N.]. Ann Arbor: Grand Valley State University, 1999.
33. Out  JW, Lafreniere  KD. Baby think it over: using role-play to prevent teen pregnancy. Adolescence  2001; 36 : 571–82.11817637
34. Price  JH, Robinson  KL, Thompson  C  et al . Rural parents’ perceptions of the baby think it over program—A pilot study. Am J Health Stud  1999; 15 : 149.
35. Roberts  SW, McCowan  RJ. The effectiveness of infant simulators. Adolescence  2004; 39 : 475–87.15673224
36. Schmidt  LM . Impact of an infant simulation program on prevention of adolecent pregancy. 2010.
37. Stelzel  MK . Is a school-based educational program effective in changing knowledge regarding the prevention of shaken baby syndrome?  [Ph.D.]. Ann Arbor: Marquette University, 2009.
38. Strachan  W, Gorey  KM. Infant simulator lifespace intervention: pilot investigation of an adolescent pregnancy prevention program. Child Adolesc Social Work J  1997; 14 : 171–80.
39. Borr  ML . Baby think it over: a weekend with an infant simulator. J Fam Consum Sci Educ  2009; 27 : 45–55.
40. Tingle  LR . Evaluation of the North Carolina “Baby think it over” project. J Sch Health  2002; 72 : 178–83.12109172
41. Frei  AM . The impact of an infant simulation intervention program on the perceptions of pregnancy and infant care in adolescents. 2010.
42. Somers  CL, Gleason  JH, Johnson  SA  et al . Adolescents’ and teachers’ perceptions of a teen pregnancy prevention program. Am Secondary Educ  2001; April 1 : 51–66.
43. Somers  CL . Teenage pregnancy prevention and adolescents’ sexual outcomes: an experiential approach. Am Secondary Educ  2006; 34 : 4–24.
44. Jefson  CA . The impact of RealCare® Baby and the baby think it over curriculum on urban middle school students’ perceptions of parenting and self-efficacy. [Ph.D.]. Ann Arbor: The University of Wisconsin - Milwaukee, 2003.
45. Space  MR . Adolescent pregnancy: strategies to encourage the delay of parenthood among adolescents [Ed.D.]. Ann Arbor: The University of New Mexico, 2000.
46. McCowan  RJ, Roberts  SW, Slaughter  J. Using infant simulation to reduce pregnancy among high school students. Health Educ  2009; 41 : 35–41.
47. Divine  JH, Cobbs  G. The effects of infant simulators on early adolescents. Adolescence  2001; 36 : 593–600.11817639
48. Hillman  CB . The Effectiveness of an Infant Simulator as a Deterrent to Teen Pregnancy among Middle School Students. University of North Texas, 2000.
49. Barnett  JE, Hurst  CS. Do adolescents take “baby think it over” seriously?. Adolescence  2004; 39 : 65–75.15230066
