Takeaways from Boston’s Games for Health Conference

Several Danya employees from Atlanta, GA, and Silver Spring, MD, attended the Games for Health Conference in Boston, MA, in late June. As I outlined in a recent Danya blog post, serious games and games for health are growing fields and are showing great potential for behavior change and improved health outcomes. After attending the conference, I was further convinced that games can be a powerful (and fun!) tool for both public health and health care professionals. People are currently creating games for nearly every health issue from chronic diseases to behavioral health and for various purposes from personal health improvement and treatment adherence to workforce training. Right now, the possibilities seem unlimited. Here are my five takeaways from the Games for Health Conference.

1. Serious games need to be seriously fun. As a health communicator with a public health background, I immediately think about the outcome the game is designed to achieve when I think about games for health. Games designed to improve health need to be effective, but the very premise of a game is to have fun. If a game isn’t fun, people won’t play it.

Depending on the audience of your game, fun may be even more vital. As Michael Fergusson, game designer at Ayogo explained, “A child’s illness and treatment is serious, but kids seriously need to have fun.” So, while serious games absolutely need to be designed around sound theory and accurate health information, it is just as important that they are also built to be engaging and entertaining to the targeted player.

2. Games can change the world. One of the most interesting sessions I went to discussed two games that use crowdsourcing to tackle huge public health challenges. The first is a game to help identify malaria cases called Malaria Spot. According to CDC, in 2010 there were about 219 million cases of malaria around the world and 660,000 deaths due to malaria. Currently, the process for correctly identifying a malaria case involves a certified health professional counting parasites in a blood sample, which can take up to 30 minutes. Since there are millions of cases, you can imagine the backlog in even identifying cases, let alone getting people treatment. The Malaria Spot concept, designed by Spanish scientist Miguel Luengo-Oroz, transforms this identification process into a game where players hunt real malaria parasites in a blood sample uploaded to the Internet. Luengo-Oroz has done the math and when 13 players hunt the same blood sample for 1 minute, the accuracy of identifying a malaria case is the same as an expert. He has also calculated that only 1% of current video game play time is all that it would take to identify all the cases of malaria worldwide! While there are still several questions to address by way of legality and ethics before this game can be fully implemented, this game could seriously change the world! To help support this creative solution and hunt malaria, visit the Malaria Spot website.

A similar idea was presented by Amy Carton of Cancer Research UK. The country’s leading cancer research center has a huge amount of data about cancer. While some data can be analyzed by computers, much of the data needs to be analyzed by human eyes; with limited human resources, they’ve got more data than they can analyze. To help solve this big data problem, Cancer Research UK is currently developing a game where players will be helping to analyze their data. The catch is, they want to create such a fun and engaging game that you will want to play it for fun’s sake, and you may never even know you’re helping their scientists unlock invaluable scientific findings.

3. The best games aren’t always digital. Another session I attended that really had me leaning forward was about non-digital games. Yes, you heard me right; board games and games like charades are not completely a thing of the past—who knew? The game developer Max Seidman, who works at Dartmouth’s Tiltfactor Lab, described a game called RePlay Health, which is a real-life strategy game designed to help people learn about the health care system. Through a guided role-playing game, players balance physical activities and their character’s health. Through different choices players must make that depend on their health, they can learn how all of the different pieces of a health care system work together. This game was designed not only to improve understanding of our (often confusing) health care system, but also to foster empathy among players.

So, while our world is undoubtedly becoming more and more digital, it is important to remember that mobile games aren’t the only option. In fact, one game created by Tiltfactor Lab found that their board game version had significantly better outcomes than their mobile version. The value of face-to-face interaction during a game is something that can’t quite be replicated in a digital game. While digital games often rely on feedback systems using complex formulas, the real-life interaction in non-digital games allows for a game to be fully understood by players, teaching systems thinking and potentially leading to richer outcomes.

4. Games are about an experience. An idea that was mentioned throughout the conference was that games are about creating and sharing experiences. This was most clearly communicated during the keynote presentation by Palmer Luckey of Oculus VR (i.e., “virtual reality” for all you non-gamers). Luckey created a cutting-edge virtual reality (VR) headset that is more lightweight and affordable than previous VR systems and helps draw the player even farther into the simulated environment created by the game. The realm of VR is pretty remarkable; it has the potential to achieve immersion, sensations, and even emotions unlike any other media platform. For example, a VR game can create a falling experience like no other video game. The players feel as if they themselves are falling, not an avatar representing them, and this can elicit a real falling sensation and even the emotional response of fear.

To me, a health communicator and inexperienced gamer, video games aren’t always very interesting because they can seem unrealistic. As Luckey describes VR, this “ultimate medium” has huge potential to achieve behavior change because it can engage a wider range of players with the reality factor and it has the potential to elicit emotions, a powerful behavior change tool. Visit the Oculus VR website for more information on the new headset and the growing realm of virtual reality.

5. Developing a good game takes a team, maybe even an army. While playing some games may be relatively easy, I learned that creating a game is certainly not simple. Especially in the serious games space, creating a game that aims to change behavior and impact health is quite complicated. Not only do you need an experienced game developer, as well as subject matter and behavior change experts in the specific health topic being addressed, but some of the most successful health games also gather substantial input from their target populations.

The creators of Remission2, the recently released update of a game designed to help kids adhere to cancer treatment, spent a significant amount of time talking to children with cancer about how they view cancer, how they view chemotherapy, what they would want to do to cancer, and more to create a game that correctly aligns with player beliefs and desires. While the first version of the game did achieve positive biological outcomes, including increased antibiotics and chemotherapy in the patient’s blood, Remission2 is already performing better in the areas of positive emotions, self-efficacy, and shifts in attitudes, thanks to user input.

Similarly, PlayForward, created by Yale’s Play2Prevent Initiative, is a game to prevent HIV in high-risk youth populations. The creators of the game discussed with teens in depth about their goals, community, and interests. As a result, this game has been shown to effectively improve protective factors among players.

The Games for Health Conference was certainly an enlightening one for our team members, and we’re excited to continue our own research and development within the games and health field. What are some of your favorite serious games? How are they fun, changing the world, or non-digital, and what type of experience do they provide you on your path to better health?

By Katie Mooney

Interactive Customized Advertisements for Health

How many advertisements do you see every day? Some researchers estimate that the average person sees as many as 5,000 advertisements per day, while others report that exposure is probably closer to 250 ads daily. Regardless of the actual number of ads you’re seeing, Bauer and Greyser suggest that most of us only really connect with a select few out of the hundreds we’re presented. Public health agencies seeking to stand out from the crowd with innovative, out-of-the-box campaigns should strongly consider developing an interactive custom ad for a real impact on their target audiences.

With the help of social sharing and advancing technologies, more and more brands are using technology to create interactive ads that deliver these enhanced, real-impact experiences. These types of ads engage through two-way communication. Some draw people in by soliciting a direct response, requesting some type of action from the participant, while other forms inspire engagement through personalized and localized elements. The following interactive ads are some of our favorites here at Danya that we think have been successful because creators utilized unique materials, chose unusual locations, or took advantage of new technologies to make a unique connection with their viewer:

Lenticular Printing by ANAR Foundation

The Aid to Children and Adolescents at Risk (ANAR) Foundation used lenticular printing to show different anti-child-abuse messages to viewers of different heights. This technology allows different images to be seen depending on the vantage point. The billboard is designed to show the message “If somebody hurts you, phone us and we’ll help you” along with the ANAR Foundation’s telephone number when viewed by individuals (children) less than 1.3 meters (approximately 4 feet 3 inches). The message to adults reads, “Sometimes child abuse is only visible to the child suffering it.”

Worms Eating Dough Show “Crack Consumes”

The Brazilian alliance of Partnership for a Drug Free America’s posted several billboards made of dough at “Galeria do Rock,” a popular place for youth. As observers walked by, they saw worms eat through the advertisement, illustrating the point that “Crack Consumes.”

Interactive Long Film

The Australian Air Force used an interactive long film. On the site, users can click on almost any object in the video to receive more information.

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Coca-Cola’s “Small World Machines”

“Small World Machines” invited Indians and Pakistanis to interact by completing simple tasks like waving, touching hands, drawing a peace sign, or doing a dance to receive a Coke. Participants could watch each other complete the engagement because of 3D touchscreen technology that projected and captured a streaming live video feed onto the vending machine screen.

Volkswagen’s “Slowmercial”

DDB Brussels illustrates a new concept, the slowmercial, a form of television advertisement where the action on the screen has little to no movement. The creators of the commercial are trying to develop a solution that counteracts the fast-forwarding that is now common for DVR television users. Because of the static nature of the slowmercial, even when viewers fast-forwarded the commercial, they will still see the ad as if it were developed for print.


 HeartRescue Simulates Cardiac Arrest

The HeartRescue Project, funded by the Medtronic Foundation, has developed an interactive online video that gives viewers a choice about what actions to take to progress the video and save a life. The creators are illustrating to viewers the steps they should take if faced with a sudden cardiac arrest situation.

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Obviously, some of these ads were very risky (did you see the worms in the Partnership for America ad?). However, perhaps the message to public health is to take some risk. Interactive ads are a rich medium that allow designers to be inventive and to think about the unexpected. Although risky may not always translate into an effective message delivery, these ads do prove that more often than not, interactive ads can create buzz, catalyze interaction, and provide opportunities for creative solutions that reach audiences in new ways. These elements are crucial in the competitive world of message delivery, and public health should take advantage.

By Tracye Poole

NPIN Hosts First Bilingual Twitter Chat for HIV/AIDS Prevention

As part of its monthly Twitter chats, CDC’s National Prevention Information Network (NPIN) hosted its first bilingual Twitter chat on June 20, focusing on HIV prevention in the Latino/Hispanic communities, with support services from Danya team members. NPIN uses its Twitter chats to share messages with and connect its numerous followers to ways in which to implement structured interventions at the ground level around HIV/AIDS, viral hepatitis, STDs, and tuberculosis. For this chat, that meant connecting key partners who can have the greatest influence within the Latino/Hispanic community—one of the cultures hardest hit by HIV/AIDS, according to CDC.

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In 2010, Latinos accounted for 21 percent of all new HIV infections. With this in mind, NPIN worked closely with key partners like the AIDS Project Los Angeles, Latino Commission on AIDS, and the CDC Division of HIV/AIDS Capacity Building Branch and Office of Health Equity to discuss HIV prevention successes and challenges in Latino/Hispanic communities, integrating HIV prevention messages with other public health messages, understanding risk groups, and highlighting the upcoming National HIV Testing Day. The chat also highlighted the new CDC Reasons/Razones campaign, which is a national bilingual AIDS prevention campaign for Hispanic/Latino gay and bisexual men.

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Overall, the bilingual chat was successful in drawing attention to the impact of HIV/AIDS in Latino/Hispanic communities and helped a variety of state and local organizations hear the best practices and strategies used by prevention partners across the country.  The chat had more than 80 participants, 764 posts, and a potential reach of more than 3.3 million.

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From a structural perspective, Twitter chats like these have the capacity to connect, engage, and teach partners from across the country in ways that other tactics cannot. Unlike a formal meeting or costly conference, participants can contribute from the comfort of their offices and walk away with invaluable best practices, lessons learned, and new strategies that can help in their future program planning. In many ways, Twitter chats provide an opportunity to learn from others, save time and resources by hearing others’ stories, and create a culture sharing around a topic that affects so many.

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It is imperative that we continue to raise HIV/AIDS awareness and promote prevention with social media, especially within communities at risk. As we recognize National HIV Testing Day this Thursday (June 27), let us remember our due diligence to share prevention messages, get tested for HIV, and encourage others to do so. This year’s theme is “Take the Test, Take Control.” It can only be effective and have true impact if WE ALL take responsibility for our own health.

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Save the date for our next NPIN Twitter chat (#NPINChat), July 18 at 2 p.m. EST, and follow up with @CDCNPIN for more details to come!

By Carlos Chapman

Summer Homework: Play Video Games (for Health!)

School is out and summer is here! For many kids, this means replacing 6 hours of school with 6 hours of video games. Although a utopia for many teenage boys and even many teen girls (97% of teens age 12–17 play video games), this extra time spent in front of a screen is often viewed by public health practitioners and parents as a tragedy. However, a new type of game has emerged—games with purpose beyond entertainment or “serious” games—and, with more evidence surfacing every day about their effectiveness, we can now actually encourage our kids to play games. With increasing awareness of the childhood obesity epidemic and the growing innovation behind games designed to improve health, it may not be so difficult to get our kids active during summer break!

Health behaviors, especially physical activity, can be very difficult to change. These behaviors are learned over a lifetime and are influenced by a range of factors, including environment, family, social norms, awareness, and more. To overcome such barriers, public health practitioners are partnering with gaming experts and behavioral scientists. Together, they are developing new, innovative strategies to increase physical activity and improve health through games—and it’s working!

Zamzee, created by HopeLab to combat childhood obesity and prevent chronic disease, is one such game making significant strides in increasing children’s physical activity levels. Zamzee is a small device that kids carry with them throughout the day to measure their physical activity. The device then communicates with a gamified website that displays the child’s physical activity data, provides points based on the amount of movement, and allows kids to select rewards. HopeLab, in partnership with the Robert Wood Johnson Foundation, completed a dozen scientific studies on Zamzee and found that the game increased physical activity by 59 percent and improved risk factors associated with chronic diseases.

Zamzee Tracker
Zamzee Tracker
Zamzee Web site
Zamzee Web site

 

 

 

 

 

 

 

 

 

So, how does it work? HopeLab explains the outcomes through their focus on both extrinsic and intrinsic rewards. The extrinsic rewards, points and gift cards, help motivate kids to initiate physical activity, while the intrinsic rewards, the positive experiences children gain through physical activity and participation in Zamzee, help sustain the behavior change over time. In other words, these rewards work to increase perceived benefits and reduce perceived barriers—determinants of behavior change in the Health Belief Model, a behavior change theory widely used in the public health field. The extrinsic rewards and intrinsic rewards, such as successfully becoming more active (mastery), achieving goals (purpose), and interacting with similar users (relatedness) increase the perceived benefits of physical activity. Other intrinsic rewards, like feeling confident in one’s abilities (competence) and gaining independence (autonomy) reduce the perceived barriers to physical activity. Together, these rewards increase the likelihood that the user will engage in a preventive health behavior, physical activity in this case.

In a study on exergames conducted by Georgetown University and sponsored by the Robert Wood Johnson Foundation, scientists found similarly encouraging results. Exergames, which have become quite popular, are a category of video games like Nintendo’s Wii EA Sports Active that require physical activity to play. The study examined health impacts in overweight and obese high school students who regularly participated in exergames. Results showed that students who engaged in cooperative exergames lost an average of 3.6 pounds over the 20-week study period versus the control group, which gained an average of 1.9 pounds.

Exergames
Exergames

Again, these results can be explained through the constructs of behavior change theory. The Theory of Planned Behavior, another behavior change model popular in public health work, identifies intention as the predecessor to action. The theory outlines three determinants of intention, including an individual’s beliefs about the actual behavior, what they perceive other people believe about the behavior (subjective norm), and their perceived ability to perform the behavior. Students in this study gained self-efficacy through successfully becoming more active, and peer support by participating in cooperative games as opposed to competitive games. These factors improved perceived behavior control and the subjective norm, respectively. Together, these changes influenced the students’ intention, which ultimately determined their behavior.

Games increasing physical activity in children are only the beginning; many other audiences and health issues are the target of games currently in the market. Lumosity, a game created for all ages to promote brain health, has been shown to improve brain functions, such as cognition and memory, among others. Re-Mission, another game created and extensively studied by HopeLab, is a game that improves childhood cancer outcomes by helping kids adhere to their treatment plans. A 2008 randomized control trial of Re-Mission showed increases in both knowledge and self-efficacy by playing the game, and a recent 2012 brain-imaging study showed increased neural responses that are typically associated with reward and positive motivation. And one of my favorites, Zombies, Run!, motivates players to run, in real life, as they try to escape a quickly approaching, virtual zombie attack.

Lumosity
Lumosity
Re-Mission
Re-Mission
Zombies, Run!
Zombies, Run!

 

 

 

 

 

 

 

The field of serious games has great potential to impact public health, especially with the current vast adoption of mobile, self-tracking, and movement-sensing technologies. To successfully create a game that achieves behavior change and impacts health status, evidence-based behavior change models must inform its design. The serious games movement is demonstrating how the difficulties of behavior change can be overcome through creative application of theory and innovation in an already successful field. So before we ban our kids from video games during the summer months, let’s look into what games might keep them entertained while also improving their health!

Our mission here at Danya is to provide innovative solutions for social impact. We work to provide products and services that meet user needs and expectations and operate with technology already in use. As the field of serious games continues to expand, Danya will certainly be looking for opportunities to incorporate this innovative solution to achieve meaningful, public health impact.

By Katie Mooney

The Silent Crisis

Men take pride in many things. Fixing stuff. Lifting heavy objects. Eating large quantities of food. Growing beards. But too often, men take pride in their ability to avoid the doctor.

Coughing up a lung? It’ll pass.

Broken leg? Walk it off.

Mysterious growth has gained sentience? You can never have too many friends.

It’s as though men think the number of doctor visits is inversely related to toughness. Avoiding the doctor doesn’t result in a merit badge of manliness. It results in increased mortality rates.

June is Men’s Health Month, a time to heighten the awareness of preventable health problems and encourage early detection and treatment of disease among men and boys. According to the Centers for Disease Control and Prevention (CDC), men are half as likely as women to see a doctor or health professional for preventive services. In 2011, CDC found that U.S. women’s life expectancy is nearly 5 years longer than men’s. Men are more likely than women to die from many of the leading causes of death, including heart disease, cancer, chronic lower respiratory disease, diabetes, and HIV.

This disparity in men’s health is often referred to as the “silent crisis” due to men’s tendency to procrastinate when it comes to their health and not seek care until it is too late. Many men won’t speak up about health issues or will outright deny symptoms with the misguided belief that if they just tough it out, then their health will get better on its own. What these men don’t realize is that avoiding the doctor is a selfish act because it’s not only their health that they’re jeopardizing, but also the happiness and well-being of their family members and loved ones who will watch them get sick.

There are several campaigns working to raise awareness of men’s health issues and encourage men to take a more active role in their health. The successful Movember campaign has not only resulted in millions of mustaches being grown, but also millions of dollars raised for prostate and testicular cancer initiatives. Men’s Health Network’s Wear Blue campaign provides a number of helpful tools and resources for those looking to increase awareness of men’s health issues.

Danya has worked on several government initiatives to improve men’s health, specifically, as it relates to HIV and STD testing and prevention. For example, Danya provides marketing support for CDC’s Testing Makes Us Stronger campaign, which is designed to promote HIV testing among black gay and bisexual men and to demonstrate that knowing one’s HIV status is important and empowering information. Danya also manages CDC’s National Prevention Information Network, which provides HIV, STD, viral hepatitis, and TB prevention information and campaign resources for men in addition to other populations.

These organizations are doing their part to encourage men to take a more active role in their health and visit their doctor for preventive care. What about you? What are some ways that you can help end the silent crisis?

By Jeff Slutz

National Skin Cancer Awareness Month: Time for the Truth about Tanning

Ah, the merry month of May—time for prom, the beach, and Memorial Day, that long, sun-filled weekend that kicks off the summer.

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It’s no coincidence that May is National Skin Cancer Awareness Month. The National Council for Skin Cancer Prevention campaign this year is all about sunburns.

But everyone—especially teens—needs to hear a bigger message, too: There is no safe tan, contrary to what your local tanning salon wants you to believe. Did you know that many metro areas now have more tanning salons per square mile than Starbucks or McDonald’s? So there are plenty of opportunities to fry all year round, with a discount for frequent tanners. Researchers have even documented a trend of mother/daughter bonding through tanning bed visits!

tanning 2Teens, in particular, are vulnerable to the media mania promoting sun-kissed skin. And so, melanoma, the most serious skin cancer, is becoming more and more common among young people. The United States Cancer Statistics (USCS) 1999–2009 Cancer Incidence and Mortality Web-based Report shows that melanoma is the second most common cancer among young people age 15 to 29. And teens just keep on tanning—about one in three young white women under 25 tans indoors. Having sunburns early in life is equally dangerous.

Getting the no-tan message across to teens is a challenge. After all, it’s hard for teenagers—just like the rest of us—to connect what we do today to health outcomes down the road.tanning 3

 

To help with this task, Danya was pleased to develop The Truth about Tanning infographic for CDC’s Division of Cancer Prevention and Control as part of the NPIN contract. (You’ll see images from the infographic here, and you can download The Truth about Tanning for your website, social network, or blog!) Based on behavioral interventions that have been successful in reducing intentional tanning, the infographic dispels common myths about tanning with a focus on appearance-related themes, which are definitely top-of-mind for young women.

My personal favorite image from the infographic plays up the “yuck factor” with the risk of picking up skin infections from tanning beds that haven’t been cleaned properly—or at all! More and more dorms and apartment complexes are offering tanning facilities as a perk to attract residents . . . but who’s doing the cleaning?

PrintCDC also recommends these easy ways to avoid sunburn:

  • Schedule outdoor activities before 10 or after 4 when UV rays are less intense.
  • Stay in the shade.
  • Wear sunglasses to protect your eyes.
  • Wear a hat with a wide brim.
  • Use sunscreen with at least 15 SPF even on cloudy days. Put it on again every 2 hours and after swimming or sweating.

As a life-long sun lover, I admit it’s tempting to ignore the facts (just this once, I tell myself—I’ll cover up next time). But the mirror doesn’t lie. The truth is, we pay a price for tanning, regardless of the source, sunlight or tanning bed. Melanoma is just not worth the tan it takes to get there.

By Madeline Barrow

May is Teen Pregnancy Prevention Month

Image credit -- CDC's Vital Signs: Preventing Repeat Teen Births
Image credit — CDC’s Vital Signs: Preventing Repeat Teen Births

I hesitate to admit this on a work-related blog, but since May is National Teen Pregnancy Prevention Month, here goes: I watch MTV’s Teen Mom 2 almost every week. Almost every week, I find myself criticizing the moms on the show for being so immature, and then reminding myself that I need to have more empathy because the moms are still kids, too.

Inevitably, that leads me to wonder what it would have been like had I become a mom at 16. Would I have finished high school, much less college? Would I have ever been able to leave my hometown (and the help of family members)? Could I have raised a healthy, successful child?

The honest answer to my questions is maybe, maybe not.

There are a lot of statistics out in the world about teen moms. According to CDC, they are less likely to finish high school – only about 50% of teen moms receive a high school diploma by 22 years of age (compared to 90% of women who did not give birth during adolescence).

There are also a lot of statistics about babies born to teen moms. They are more likely to have fewer skills and be less prepared for kindergarten, be incarcerated at some time during adolescence, drop out of high school, give birth as a teenager, and be unemployed or underemployed as a young adult.

But teen pregnancies can be prevented. That’s why it’s one of CDC’s Winnable Battle areas. And that’s just one of the reasons Danya is proud to provide assistance to CDC’s Division of Reproductive Health through an NPIN Task Order.

Over the past two decades, teen pregnancy rates have fallen in the United States. Still, according to CDC, in 2011, 329,797 babies were born to teen mothers (age 15–19). Perhaps this is even more surprising: In an April 2013 issue of Vital Signs, CDC’s Division of Reproductive Health announced that nearly one in five teen births is a repeat birth, meaning that the mother has had two or more pregnancies that resulted in live birth before age 20. That’s about 183 repeat teen births a day in the United States.

There are disparities in teen birth rates, with non-Hispanic black youth, Hispanic/Latino youth, and socioeconomically disadvantaged youth of any race or ethnicity experiencing the highest rates of teen pregnancy and childbirth. Additionally, American Indian and Alaska Natives, Hispanics, and black teens are about 1.5 times more likely to have a repeat teen birth, compared to white teens.

Repeat births pose additional risks to teen moms and their babies. For moms, it further tightens resources and education and employment opportunities. For babies, rates of preterm and low birth rate are higher in teens with a repeat birth, as compared to first births.

What can we do to prevent teen pregnancies – and teen repeat pregnancies? And how do we talk about teen pregnancy prevention without criticizing and disparaging teens who are parents? These are difficult questions to answer because teen pregnancy is such a controversial topic. But it’s important and ignoring it won’t make it go away.

In Vital Signs, CDC suggests that all teens, including teen parents, can:

  • Choose not to have sex.
  • Use birth control correctly every time if they are having sex. They should also use condoms every time they have sex to prevent disease.
  • Discuss sexual health issues with their parents, partner, health care professionals, and other adults and friends they trust.
  • Visit www.hhs.gov/opa to find a family planning clinic near them for birth control if they choose to be sexually active.

Although there are lots of statistics about teen parents and their babies, being a teen parent is about so much more than numbers. Don’t we all think we are going to beat the statistics anyway, especially as teenagers? Sometimes, we do. That’s a little bit of what I hope we get to see on Teen Mom 2.

By Stacy Fentress