Adoption and implementation characteristics for abstinence-plus curriculum.
Abstract: Background: Curriculum issues in sexuality exceed typical content scope and many individuals are involved in the adoption process. Purpose: This descriptive study investigates characteristics of individuals in school districts that do or do not implement a abstinence-plus sexuality education curriculum. Methods: Authors investigated characteristics of districts utilizing a web-based survey. Descriptive statistics and tests of association between implementation status and other characteristics were utilized. Results: A significantly larger proportion of those implementing reported teachers being most influential (39.4% compared to 8.5% not implementing). Discussion: Individuals involved in curricular adoption should be trained regarding factors influencing sexuality education, challenges and barriers.
Article Type: Survey
Subject: Teachers (Surveys)
Education (Curricula)
Sex education
School districts
Authors: Wilson, Kelly L.
Smith, Matthew Lee
Rosen, Brittany L.
Wiley, David C.
Pub Date: 03/22/2012
Publication: Name: American Journal of Health Studies Publisher: American Journal of Health Studies Audience: Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2012 American Journal of Health Studies ISSN: 1090-0500
Issue: Date: Spring, 2012 Source Volume: 27 Source Issue: 2
Accession Number: 308741504
Full Text: BACKGROUND

In 2009, the national average of high school students engaging in sexual intercourse was 46%, with 13.8% reporting four or more lifetime partners. Of those that were sexually active, 38.9% did not use a condom during their last sexual intercourse encounter (Centers for Disease Control and Prevention, 2010). In Texas, these rates are higher with approximately 52% of high school students reporting having engaged in sexual intercourse, 16.5% having four or more lifetime sexual partners, and 42.3% not using a condom during their last sexual intercourse encounter (Centers for Disease Control and Prevention, 2010). Considering these trends of adolescent risky sexual behavior, this evidence seems overlooked when public schools assess, select, and implement sexuality education curricula intended to protect youth from unplanned pregnancy and sexually transmitted infections (STI).

Despite the prevalence of high school students engaging in sexual activity, 94% of Texas school districts offer Abstinence-Only-Until-Marriage (AOUM) education curricula (Wiley & Wilson, 2009). At the national level, recent focus on teen pregnancy prevention has reinforced expectations of sexuality education professionals to educate adolescents about both abstinence and contraception to prevent pregnancy and STIs (Administration for Children and Families. U.S. Department of Health and Human Services, 2010). Thus, these statistics highlight disconnect between actual youth behaviors and the education provided in schools, which indicates the AOUM information provided in schools neither matches students' needs or provides them the knowledge necessary to protect themselves if they decide to have sex.

Nationally, the two most commonly used sexuality education curricula are AOUM and abstinence-plus (Kirby, 2007). AOUM sexuality education promotes and expects youth to remain abstinent from sexual activity until marriage. Abstinence-plus sexuality education also encourages abstinence as the safest method to avoid unplanned pregnancy and contracting STIs; however, these curricula additionally include medically accurate content about using condoms and other forms of contraception, should youth choose to engage in sexual activity (Kirby, 2007).

Despite widespread support for AOUM curricula, there is little empirical data suggesting that AOUM curriculum reduces risky sexual behaviors in youth (Kirby, 2007). Studies investigating the effectiveness of sexuality education determined AOUM curricula are not based on scientific theory (Goodson, Pruitt, Suther, Wilson, & Buhi, 2006), do not delay the initiation of sexual intercourse (Kirby, 2007; Santelli et al., 2006), and do not improve students' confidence to avert risky sexual situations (Borawski, Trapl, Lovegreen, Colabianchi, & Block, 2005). Further, AOUM curricula have been shown to omit topics including abortion, sexual abuse, and contraception (Wilson, Goodson, & Pruitt, 2005) and provide medical inaccuracies that withhold and distort health information (Santelli et al., 2006). Conversely, research on abstinence-plus curricula report these programs are effective in delaying students' sex initiation, reducing the number of sexual partners, and improving condom and contraceptive use (Bennett & Assefi, 2005; Kirby, 2007).

Acknowledging the national acceptance of AOUM sexuality programs and considering the majority of Texas school districts offer AOUM sexuality programs, it is important to consider the reasons for and factors associated with sexuality curriculum adoption and implementation. In studies investigating the determinants of adopting AOUM curricula, findings reveal that these curricula are more likely to be implemented in schools where decision makers were influenced by their own personal and professional beliefs and values (Wilson, Pruitt, & Goodson, 2008) and religiosity (Wilson et al., 2008; Wilson & Wiley, 2009). Other considerations for adopting sexuality curricula included funding constraints (Wilson et al., 2008) and the ease in which implementers could access curricula materials and associated resources (Wilson & Wiley, 2009).

PURPOSE

This descriptive study investigates the characteristics of individuals in school districts that implement or do not implement BIG DECISIONS, an abstinence-plus sexuality education curriculum. The purposes of this study were to: (1) identify the characteristics and perceptions of school district personnel implementing and not implementing BIG DECISIONS; (2) compare perceived support and challenges for implementing BIG DECISIONS based on implementation status; (3) identify the perceptions and implementation related experiences among those implementing BIG DECISIONS in their school district; and (4) assess challenges and barriers to implementing abstinence-plus curricula in the schools.

CURRICULUM DESCRIPTION

BIG DECISIONS is a free downloadable abstinence-plus sexuality education curriculum that may be accessed nationwide. The curriculum was designed to be appropriate for 7th-12th grade students, with ten total lessons containing up-to-date medically accurate information. It is also in compliance with Texas Education Code 28.004 (Texas Education Code 28.004). The curriculum contains three key messages for students that are reinforced throughout the curriculum: (1) engaging in sexual intercourse is a big decision; (2) abstinence is the healthiest choice; (3) teens who engage in sexual intercourse must use condoms and birth control consistently and correctly (Realini, 2009). In addition to the ten lessons used by instructors to educate students about human sexuality, BIG DECISIONS is offered in Spanish and the curriculum includes a parent session intended to educate parents about relevant issues surrounding sex and sexuality among school-aged youth (Realini, 2009). Even though school district personnel are able to download the curriculum from the BIG DECISIONS website free of charge, personnel who will be implementing the program are encouraged to attend a formal BIG DECISIONS training course to ensure implementation fidelity and maximize program effectiveness. Although not an evidence-based program, BIG DECISIONS yielded a "promising" initial evaluation, variables improved from baseline to post-test (e.g., abstinence, STI, condoms, self-efficacy, sexual pressure, condoms, and contraception) (Realini, Buzi, Smith, & Martinez, 2010). The curriculum was developed using a BDI logic model and meets Kirby's "17 Characteristics of Effective Programs" (Kirby, Laris, & Rolleri, 2006; Kirby, 2004)

In Texas, 11 independent and consolidated public school districts have formally announced (to the curriculum developers) adopting the BIG DECISIONS curriculum for use in classrooms. This represents six education service center regions and 14 counties in the state. Many community agencies are also using the curriculum. However, because the curriculum is made available online there may be school districts and other educational entities formally adopting and implementing BIG DECISIONS unbeknownst to program developers. For the purposes of this study, formal adoption included notifying the curriculum developer that a school district was using the curriculum.

METHODS

PARTICIPANTS AND PROCEDURES

Surveys were distributed through email invitation to 436 individuals that were part of a listserv maintained by the curriculum developer and the agency conducting BIG DECISIONS training during the 2009-2010 school year. The listserv consisted of all individuals who previously participated in training about and/or expressed interest in the BIG DECISIONS curriculum (e.g., signed up at professional conferences, registered on the website).

A reminder email was sent to the listserv approximately four days following the original recruitment message was sent. Data were collected over a two-week period. Of the 174 returned surveys (39.9% return rate), 148 had usable responses and comprised the final sample (overall response rate of 34.0%). Institutional Review Board approval was obtained at Texas State University-San Marcos.

INSTRUMENT

The data collection instrument was developed specifically for this exploratory study. The internet-based questionnaire consisted of 29 items and included Likert-type scales, yes/no, closed-response, and check-all-that-apply formats. The instrument assessed respondents' professional characteristics (e.g., Please identify your primary role in your school district); perceptions of professionals' roles in adoption and implementation (e.g., Who has/had the most influence to implement the BIG DECISIONS curriculum in your school?); perceptions of curriculum adoption and implementation (e.g., To what extent is your school/district implementing the BIG DECISIONS curriculum for teaching sexuality education?); and challenges to implementation of the curriculum (e.g., Have you faced any of the challenges listed below regarding the implementation of the BIG DECISIONS curriculum in your school/ district?). Completion of the survey instrument took approximately 15 minutes.

DATA ANALYSIS

All statistical analyses for this descriptive study were performed using SPSS (version 17). Frequencies were generated for all instrument items for all participants. Frequencies were also calculated independently for participants implementing BIG DECISIONS in their respective school districts and those who were not, where appropriate. Tests of association between participants' BIG DECISIONS implementation status and other characteristics were based on Pearson's chi-squared statistics. For the purposes of this study, [alpha] < 0.05 was used to identify statistically significant relationships.

RESULTS

Sample characteristics of study participants are presented in Table 1. Approximately 45% (n=66) of respondents reported BIG DECISIONS was being implemented in their local school districts. Over 33% of respondents reported their primary role in their school district to be a teacher, 10.1% as a school nurse, 7.4% as an administrator, 5.4% as a School Health Advisory Council (SHAC) member, and 43.9% as having a primary role of "other." Almost 30% of participants reported being SHAC members, although not their primary role in the district. With regard to BIG DECISIONS involvement, 68.9% of participants reported having attended BIG DECISIONS training, 25.6% reported having seen BIG DECISIONS' evaluation results, and 64.4% reported they would recommend others to implement BIG DECISIONS in their school districts.

When comparing these variables by implementation status, as seen in the bivariate relationships provided in this table, a significantly larger proportion of participants implementing BIG DECISIONS in their school district reported being teachers (47.0% compared to 22.0% of participants not implementing BIG DECISIONS in their school districts), having attended a BIG DECISIONS training (89.7% compared to 52.7% of participants not implementing BIG DECISIONS in their school districts), and having seen BIG DECISIONS' evaluation results (34.5% compared to 18.3% of participants not implementing BIG DECISIONS in their school districts). A significantly larger proportion of participants not implementing BIG DECISIONS in their school district reported not knowing BIG DECISIONS training existed (21.6% compared to 1.7% of participants implementing BIG DECISIONS in their school districts) and not having enough information to recommend others implement BIG DECISIONS in their school districts (24.3% compared to 3.4% of participants implementing BIG DECISIONS in their school districts).

Implementation characteristics reported among participants implementing BIG DECISIONS in their school districts are presented in Table 2. Among these participants, 87.9% reported the program was implemented during an in-school program, 47.0% reported implementing the program in grades 9 through 12, and 71.2% reported a teacher trained in health education and BIG DECISIONS were the implementers of the program. Approximately 32% of these participants reported using the full BIG DECISIONS curriculum as it is written and 51.7% reported using a majority of the BIG DECISIONS curriculum, but not the entire curriculum. Approximately 32% of participants reported using no other materials for teaching sexuality education other than the BIG DECISIONS curriculum. When asked to check-all-that-apply from a list of content areas where BIG DECISIONS was likely to be implemented, 84.8% reported health education, 9.1% reported health science technology education, 9.1% reported home economics education, 4.5% reported physical education, 4.5% reported science, and 3.0% reported an after-school program. When participants were asked to check-all-that-apply about complaints they had "heard of or been faced with" pertaining to the implementation of BIG DECISIONS, Approximately 26.3% reported hearing or being faced with one or more complaints. More specifically, 13.6% reported hearing of or being faced with a complaint from students, 15.3% from school district employees, 6.8% from parents, 6.8% from community groups, and 1.7% from other sexuality curricula creators.

Reasons why BIG DECISIONS is not being implemented in school districts reported among participants from a check-all-that-apply list are presented in Table 3. Among these participants, 29.3% reported BIG DECISIONS was not implemented in their school district because of perceived political controversy about sexuality education and 25.6% reported the school/district administrative acceptance of the curricular content. Additionally, 25.6% reported the curriculum is not being implemented because of a lack of school board support for curricular implementation, 23.2% reported the lack of SHAC champion curricular implementation, and 15.9% reported the lack of time to teach the curriculum.

All participants' perceptions of factors influencing BIG DECISIONS implementation in school districts are presented in Table 4. When asked to check-all-that-apply about whom has the most influence to implement BIG DECISIONS in their school district, 41.2% reported school administrators and 33.8% reported SHAC members. When asked to check-all-that-apply about who would support the decision to implement BIG DECISIONS in their school district, 49.2% reported SHAC members, 43.8% reported teachers, 43.4% reported students, and 33.3% reported school administrators. When asked to check-all-that-apply about challenges to implementing BIG DECISIONS in their school districts, 51.3% reported lack of time to teach the curriculum and 50.4% reported perceived political controversy about sexuality education.

When comparing these variables by implementation status, as seen in the bivariate relationships provided in this table, a significantly larger proportion of participants implementing BIG DECISIONS in their school district reported teachers having the most influence to implement BIG DECISIONS (39.4% compared to 8.5% of participants not implementing BIG DECISIONS in their school districts). A significantly larger proportion of participants implementing BIG DECISIONS reported SHAC members, teachers, school board members, school administrators, parents, and students would support the implementation of BIG DECISIONS in their school district, when compared to participants not implementing the curriculum, respectively. A significantly larger proportion of participants not implementing BIG DECISIONS in their school district reported challenges to implementing the curriculum in their school districts, when compared to participants implementing BIG DECISIONS in their school district. Specifically, significant challenges reported among those not implementing the curriculum included the lack of funding, inclusion of contraceptive information, student acceptance of content, political controversy about sexuality education, and acquiring parent permission, respectively.

DISCUSSION

Findings from this study identified characteristics and perceived support and challenges for implementing BIG DECISIONS among district personnel. Although focusing solely on the implementation of BIG DECISIONS in Texas, findings from this study have potential to provide general insights applicable to school districts implementing, or preparing to implement, sexuality education curricula in their local area. Findings from this study indicate that among school districts implementing BIG DECISIONS, the curriculum was primarily implemented in high schools (grades 9-12) and within health education classes. Participants reported the educator teaching the curriculum was trained in health education and BIG DECISIONS curriculum, and they typically used a majority of the 10 lessons included in the curriculum.

Among those both implementing and not implementing the curriculum in their district, one of the greatest perceived challenges to implementing BIG DECISIONS was the limited amount of classroom time available to teach the curriculum. This finding is consistent with previous research pertaining to time as a reported challenge when adopting and implementing sexuality curricula in schools (Wilson & Wiley, 2009). Further, given that teachers were reported as those most likely to implement the curriculum, this study reinforces the need for qualified, trained teachers who are comfortable teaching sensitive subjects, such as sexuality education (Kirby, 2007; Price, Kirchofer, Telljohann, & Dake, 2003). Teachers' views and values are important factors when implementing sexual health programs in the classroom. To receive high quality sexuality education, high quality teacher training is required and must be included in planning (Schaalma, Abraham, Gillmore, & Kok, 2004). Considering that implementation burden often falls on teachers to integrate newly adopted curricula while covering all existing course topics and remaining compliant with learning objectives and district expectations, strategies and protocols must be created to accommodate additional trainings and prep-time without detracting from their ability to be effective in the classroom. These considerations must be taken into account by school districts when selecting sexuality curricula and by curricula developers when attempting to 'market' their programs. Further, teachers' views and values should be solicited when districts select sexual health programs.

For participants within school districts that were not implementing BIG DECISIONS, the main reasons the curriculum was not being offered included the school administration acceptance of the curriculum, lack of SHAC recommendations and school board approval, and political controversy about sexuality education (Bowden, Lanning, Pippin, & Tanner, 2003). School administration and leadership play an important role in empowering teachers to support and adopt instructional strategies and policies related to curriculum implementation. Effective educational leadership is a central factor in the implementation of school practices (Harpell & Andrews, 2010). It is recommended that school administrators and SHAC members carefully reflect on teacher attitudes and empowerment when exploring the adoption of sexuality curricula. If teachers perceive they have the opportunity to participate in the curriculum adoption process (Harpell & Andrews, 2010), they may also perceive themselves to be involved in decision making and support integrating curricular practices.

When viewing perceptions of support by curriculum implementation status, those who reported implementing the curriculum perceived overwhelmingly higher support from a variety of potential decision makers, compared to their counterparts not implementing the curriculum. Among those who reported not implementing BIG DECISIONS in their district, SHAC members, teachers, and students were perceived as implementation decision supporters. As can be seen from these findings, it is no surprise that those implementing the curriculum perceive support from various levels. It is also important to recognize who they perceive to have the most influence over implementing the curriculum considering they have experienced the process of selecting this program for their district. Further, those not implementing the curriculum perceived differences in who has the most influence and support. Participants indicated school administrators had the most influence to implement BIG DECISIONS (43.9%), yet only 16.7% were perceived to support the implementation of the curriculum has widespread implications for sexuality curriculum adoption.

Rarely do school district policies state or imply that school administrators serve as "gatekeepers" for the selection of sexuality education curricula, nonetheless they may influence mandates and educational policies on school-based sexuality education (Eisenberg, Bernat, Bearinger, & Resnick, 2009). Therefore, they play a role in the adoption of sexuality programs and make decisions based on curricular characteristics. Personal beliefs and values (Wilson et al., 2008) as well as parental preferences (Eisenberg et al., 2009) are also considered in the development of curricula and programs offered to students. Training about their respective roles in the selection and implementation of curricula for SHACs, school administrators, and school board trustees would be beneficial for stakeholders to understand their role in the curriculum adoption process. It is counterproductive to have SHACs in an advisory role if school district administrators circumvent that process or if teachers perceive administrators will interfere with curriculum implementation (Wilson et al., 2008).

Research shows that sexuality education is overwhelmingly supported if it includes age and developmentally-appropriate information and such support should be used to implement quality sexuality education programs (Alton, Valois, Oldendick, & Drane, 2009; Dailard, 2001; Eisenberg, Bernat, Bearinger, & Resnick, 2008; Scripps Howard, 2004). Yet, over one-half of respondents reported "political controversy" as a challenge in implementing the curriculum. One purpose for having SHACs in an advisory role to school boards about health education matters is to reduce political controversy in the community. SHACs are required to include members that "represent community values." In theory, the views of these SHAC members should be represented in the SHACs' recommendations reducing perceived political controversy. School districts should carefully select SHAC members and facilitate the process of them being aware and trained in their roles and requirements in the adoption of evidence-based sexuality education programs (Chriqui & Chaloupka, 2011). This will better allow them to work with the community and school board to avoid or reduce controversy and strengthen policies related to sexuality education.

Participants reported evaluation results were identified as important, yet most had not seen evaluation studies about BIG DECISIONS. Evaluation results are easily accessible on the curriculum's website and discussed during training sessions, but only one-third of those implementing BIG DECISIONS were aware of the findings. As the fields of health and sexuality education increases its emphasis on evidence-based and promising programs, teachers and other curricula stakeholders must focus on assessing and utilizing evaluation results to justify program decisions. When making decisions to include a particular sexuality education curriculum in the public school classroom, it is important to be aware of the evidence of program effectiveness to ensure adopted curricula show promise and are appropriate for meeting district-specific objectives. Clearly, dissemination of evaluation results is the responsibility of the curriculum producer; however, it is important for teachers and other stakeholders to understand how to best utilize the data when selecting sexuality programs and curricula.

LIMITATIONS

While this exploratory study contributes to the understanding of BIG DECISIONS implementation, there are limitations that should be acknowledged. First, this study relied on self-reported data from a distribution list of individuals that were either trained in the BIG DECISIONS curriculum or expressed an interest or support of the curriculum. This may have introduced bias because individuals on this distribution listserv may have exhibited different perceptions toward sexuality education than those not on the listserv. Detailed sociodemographic and school district data were neither collected nor contained in the initial distribution listserv, which greatly hindered the ability to perform analyses to identify self-selection or response biases among survey responders and non-responders. Additionally, to maintain anonymity, survey responses of the 148 participants were not linked to email addresses or any other identifying information. This also restricted the ability to identify potential response biases. However, this study provides an interesting and justified focus because all participants expressed interest in this curriculum to be included on the listserv, yet not all represented school districts adopted BIG DECISIONS. Data were not collected to know the type of sexuality education curricula being implemented among participants indicating they were not using BIG DECISIONS. This information would have strengthened the existing comparisons made in this study. Second, data used in this study were cross-sectional, thus limiting the ability to perform analyses inferring causality. Future studies should attempt to collect longitudinal data using a pre-test/ post-test design (i.e., before they implemented the curriculum in their district and after the curriculum had been implemented). This would allow researchers to identify differences between initial perceptions of the curriculum and potential barriers/motivators/ enablers and perceptions of the curriculum, implementation characteristics, and benefits/barriers/supports/recommendations after the district had implemented the curriculum. Purposive sampling with stratification may have also been beneficial to ensure data were collected from individuals at all levels/ decision-making roles, and who also represented all districts where BIG DECISIONS was being implemented. Third, technology constraints (i.e. undeliverable emails, school district firewalls, and anti-spam filters) may have influenced response rates. The data collected with this instrument reflect a non-probability sample of individuals that expressed an interest in the BIG DECISIONS curriculum. Therefore, the actual response rate may have been higher than 34.0%. Further, because the curriculum is available to download for free on the BIG DECISIONS website, challenges arise pertaining to the documentation of formal adoption and implementation. Fourth, this descriptive study employed a cross-sectional survey design that described participants' current attitudes, beliefs, and practices related to the implementation of BIG DECISIONS with an instrument that was not pilot tested for validity and reliability. Finally, data pertaining to the participants' school district were not collected and prevented us from performing more complex analyses accounting for clustering by district. Thus, respondents from the same district may have been represented in the study sample.

TRANSLATIONTO HEALTHEDUCATION PRACTICE

The BIG DECISIONS curriculum is formally (with reports to the curriculum developer) and informally (through a free download with no report to the curriculum developer) adopted and implemented in diverse schools and districts across the state of Texas. This study suggests sexuality education, including abstinence-plus education, is a local decision associated with many facilitators and barriers. Just as BIG DECISIONS reinforces the message that having sex is a "big decision," making sexuality education curriculum adoption and implementation choices is a big decision as well. Individuals who influence the adoption and implementation of sexuality education should be trained and made aware of factors influencing age-appropriate, evidence-based programs, and sexuality education efforts. In addition, training school administrators and SHAC members and using the SHAC structure to support adoption and implementation of sexuality education curricula should be fully explored. Further investigation is needed to understand the impact individuals have on supporting best practices and advocating for the implementation and evaluation of sexuality education.

REFERENCES

Administration for Children and Families. U.S. Department of Health and Human Services. (2010). Teen pregnancy prevention program (TPP). Retrieved 11/24, 2010, from http://www.acf.hhs.gov/programs/ fysb/content/programs/tpp.htm

Alton, F. L., Valois, R. F., Oldendick, R., & Drane, J. W. (2009). Public opinion on school-based sex education in South Carolina. American Journal of Sexuality Education, 4(2), 116-138.

Bennett, S. E., & Assefi, N. P. (2005). School-based teenage pregnancy prevention programs: A systematic review of randomized controlled trials. Journal of Adolescent Health, 36, 72-81.

Borawski, E. A., Trapl, E. S., Lovegreen, L. D., Colabianchi, N., & Block, T. (2005). Effectiveness of abstinence-only intervention in middle school teens. American Journal of Health Behavior, 29(5), 423-434.

Bowden, R. G., Lanning, B. A., Pippin, G. R., & Tanner, J. F., Jr. (2003). Teacher's attitudes towards abstinence-only sex education curricula. Education, 123(4), 780-788.

Centers for Disease Control and Prevention (CDC). (2010). 1991-2009 high school youth risk behavior survey data. Retrieved 11/24, 2010, from http://apps.nccd.cdc.gov/youthonline/App/Default.aspx

Chriqui, J. F., & Chaloupka, F. J. (2011). Transparency and oversight in local wellness policies. The Journal of School Health, 81(2), 114-121.

Dailard, C. (2001). Sex education: Politicians, parents, teachers, and teens. Retrieved 11/18, 2010, from http:// www.guttmacher.org.lib-ezproxy.tamu.edu:2048/pubs/tgr/04/1/gr040109.pdf

Eisenberg, M., Bernat, D., Bearinger, L., & Resnick, M. (2009). Condom provision and education in Minnesota public schools: A telephone survey of parents. The Journal of School Health, 79(9), 416-424.

Eisenberg, M. E., Bernat, D. H., Bearinger, L. H., & Resnick, M. D. (2008). Support for comprehensive sexuality education: Perspectives from parents of school-age youth. Journal of Adolescent Health, 42(4), 352-359.

Goodson, P., Pruitt, B. E., Suther, S., Wilson, K., & Buhi, E. (2006). Is abstinence education theory based? the underlying logic of abstinence education programs in Texas. Health Education & Behavior, 33(2), 252-271.

Harpell, J. V., & Andrews, J. J. W. (2010). Administrative leadership in the age of inclusion: Promoting best practices and teacher empowerment. Journal of Educational Thought, 44(2), 189-210.

Kirby, D. (Ed.). (2007). Emerging answers 2007: Research findings on programs to reduce teen pregnancy and sexually transmitted disease. Washington, D.C.: National Campaign to Prevent Teen and Unplanned Pregnancy.

Kirby, D., Laris, B., & Rolleri, L. (2006). Sex and HIV education programs for youth: Their impact and important characteristics. Scotts Valley, CA: ETR Associates.

Kirby, D. (2004). BDI logic models: A useful tool for designing, strengthening and evaluating programs to reduce adolescent sexual risk-taking, pregnancy, HIV and other STDs. Retrieved June 20, 2009 from http://www. etr.org/recapp/documents/BDILOGICMODEL20030924.pdf

Price, J. H., Kirchofer, G., Telljohann, S. K., & Dake, J. A. (2003). Elementary school teachers' techniques of responding to student questions regarding sexuality issues. Journal of School Health, 73(1), 9.

Realini, J. (2009). BIG DECISIONS. Retrieved 9/5, 2010, from http://www.bigdecisions.org/

Realini, J. P., Buzi, R. S., Smith, P. B., & Martinez, M. (2010). Evaluation of "big decisions": An abstinence-plus sexuality curriculum. Journal of Sex & Marital Therapy, 36(4), 313-326.

Santelli, J., Ott, M. A., Lyon, M., Rogers, J., Summers, D., & Schleifer, R. (2006). Abstinence and abstinence-only education: A review of U.S. policies and programs. Journal of Adolescent Health, 38, 72-81.

Schaalma, H. P., Abraham, C., Gillmore, M., & Kok, G. (2004). Sex education as health promotion: What does it take? Archives of Sexual Behavior, 33(3), 259-269. Scripps Howard. (2004). August Scripps Howard Texas poll.

Texas Education Code 28.004. Local School Health Advisory Council and Health Education Instruction: Sections e-j, 74Cong. (1995).

Wiley, D., & Wilson, K. (2009). Just say don't know: Sexuality education in Texas public schools. Retrieved April 14, 2011from http://www.tfn.org/site/DocServer/SexEdRort09_web.pdf?docID=981

Wilson, K., Pruitt, B. E., & Goodson, P. (2008). The impact of middle school principals on adoption of abstinence-only-until-marriage programs in their school's curriculum. American Journal of Health Education, 39(5), 258-271.

Wilson, K. L., Goodson, P., & Pruitt, B. E. (2005). A review of 21 curricula for abstinence-only-until marriage programs. The Journal of School Health, 75(3), 90-98.

Wilson, K. L., & Wiley, D. C. (2009). Influence of materials on teacher adoption of abstinence-only-until marriage programs. The Journal of School Health, 79(12), 565-574.

Kelly L. Wilson, PhD, MCHES

Matthew Lee Smith, PhD, MPH, CHES

Brittany L. Rosen, MEd, CHES

David C. Wiley, PhD, MCHES

Kelly L. Wilson, PhD, MCHES, is affiliated with the Texas State University--San Marcos, 601 University Drive, San Marcos, TX 78666, 512-245-4373 (p) 512-245-8678 (f), kwilson@txstate.edu. Matthew Lee Smith, PhD, MPH, CHES, is affiliated with The University of Georgia, College of Public Health, Texas A&M Health Science Center, School of Rural Public Health. Brittany L. Rosen, MEd, CHES, is affiliated with Texas A&M University--College Station. David C. Wiley, PhD, MCHES. The corresponding author is Kelly L. Wilson
Table 1. Comparisions between Districts Implementing and
Not Implementing BIG DECISIONS

                Implement BIG DECISIONS

                  No           Yes          Total         [chi
                  (n=82)       (n=66)       (n=148)       square]

Primary Role in School District                           13.247 *
  Teacher         18 (22.0%)   31 (47.0%)   49 (33.1%)
  School Nurse    8 (9.8%)     7 (10.6%)    15 (10.1%)
  SHAC Member     4 (4.9%)     4 (6.1%)     8 (5.4%)
  Administrator   6 (7.3%)     5 (7.6%)     11 (7.4%)
  Other           46 (56.1%)   19 (28.8%)   65 (43.9%)

SHAC Member                                               0.950
  No              53 (67.1%)   47 (74.6%)   100 (70.4%)
  Yes             26 (32.9%)   16 (25.4%)   42 (29.6%)

Attended BIG DECISIONS Training                           21.638 **
  Yes             39 (52.7%)   52 (89.7%)   91 (68.9%)
  No              19 (25.7%)   5 (8.6%)     24 (18.2%)
  Didn't Know     16 (21.6%)   1 (1.7%)     17 (12.9%)
    Trainings
    Existed
Seen BIG DECISIONS' Evaluation Results                    7.084 *
  No              44 (62.0%)   34 (58.6%)   78 (60.5%)
  Yes             13 (18.3%)   20 (34.5%)   33 (25.6%)
  Not Sure        14 (19.7%)   4 (6.9%)     18 (14.0%)

Recommend Other Districts Implement BIG DECISIONS         11.495 **
  Absolutely      44 (59.5%)   41 (70.7%)   85 (64.4%)
  Probably        11 (14.9%)   14 (24.1%)   25 (18.9%)
  Probably Not    1 (1.4%)     1 (1.7%)     2 (1.5%)
  Don't Have      18 (24.3%)   2 (3.4%)     20 (15.2%)
    Enough
    Information

* P < 0.05; ** P < 0.01

Table 2. Among Only Those Implementing
BIG DECISIONS (n = 66)

                           n (%)

BIG DECISIONS is Implemented *

In-School Program        58 (87.9%)
After-School Program      3 (4.5%)

Grades that BIG DECISIONS

is Implemented *
  7th Grade                13 (19.7%)
  8th Grade                22 (33.3%)
  9th Grade                49 (74.2%)
  10th Grade               46 (69.7%)
  11th Grade               45 (68.2%)
  12th Grade               43 (65.2%)

Total Grades that BIG DECISIONS
is Implemented in

  8th Grade Only            5 (7.6%)
  Both Middle School        4 (6.1%)
    Grades (7-8)
  Al High School           31 (47.0%)
    Grades (9-12)
  All Middle and High       6 (9.1%)
    School Grades (7-12)

Implementors of BIG DECISIONS
in the District *

  Teacher trained in       47 (71.2%)
    health education
    and trained in
    BIG DECISIONS
  Teacher trained in       10 (15.2%)
    health education,
    but not trained in
    BIG DECISIONS
  Teacher not trained       4 (6.1%)
    in health education,
    but trained in
    BIG DECISIONS
  School nurse trained      4 (6.1%)
    in Big Decisions
  Outside speaker           4 (6.1%)
    trained in
  Big Decisions
  Other                     2 (3.0%)

Use Other Materials for Teaching
Sexuality Education

  Only (not using BIG       2 (3.0%)
    DECISIONS materials)
  A majority of the time   9 (13.6%)
  About half of the time   12 (18.2%)
  A small portion of       22 (33.3%)
    the time
  None (only BIG           21 (31.8%)
    DECISIONS materials)

Extent Use BIG DECISIONS Curriculum
for Teaching Sexuality Education

  Using full curriculum    19 (31.7%)
    as written
  Using a majority of      31 (51.7%)
    the curriculum, but
    not all
  Using about half of      6 (10.0%)
    the curriculum
  Using a small portion     4 (6.7%)
    of the curriculum

BIG DECISIONS is Likely to be
Implemented in *

  After-School Program      2 (3.0%)
  Health Education         56 (84.8%)
  Health Science            6 (9.1%)
    Technology Education
  Home Economics            6 (9.1%)
    Education
  Physical Education        3 (4.5%)
  Science                   3 (4.5%)

Complaints About the Implementation
of BIG DECISIONS From *

  Students                 8 (13.6%)
  School District          9 (15.3%)
    Employees
  Parents                   4 (6.8%)
  Community Groups          4 (6.8%)
  Other Sexuality           1 (1.7%)
    Curricula Creators

* Endorsed from a 'check-all-that-apply item

Table 3. Among Only Those Not Implementing
BIG DECISIONS (n = 82)

                                      n (%)

Why BIG DECISIONS is Not Being
Implemented *

  Lack of time to teach             13 (15.9%)
    curriculum
    Lack of funding                 13 (15.9%)
  Lack of training                  9 (11.0%)
    opportunities
  Inclusion of contraceptive        13 (15.9%)
  information
  School/district administrative    21 (25.6%)
    acceptance of
    curricular content
  Lack of SHAC recommendation       19 (23.2%)
    for curricular
    implementation
  Lack of School Board approval     21 (25.6%)
    for curricular
    implementation
  Political controversy about       24 (29.3%)
    sexuality education
  Acquiring parent permission        6 (7.3%)
  Other                             30 (36.6%)

* Endorsed from a 'check-all-that-apply' item

Table 4. Implementation Comparisions between
Districts Implementing and Not
Implementing BIG DECISIONS

                        Implement BIG DECISIONS

                              No          Yes
                            (n=82)       (n=66)

Who Has the Most Influence
to Implement
BIG DECISIONS ([yen])

  SHAC Members            23 (28.0%)   27 (40.9%)
  Teachers                 7 (8.5%)    26 (39.4%)
  Parents                  8 (9.8%)    12 (18.2%)
  School                  36 (43.9%)   25 (37.9%)
    Administrators
  Others                  29 (35.4%)   13 (19.7%)
  Would Support the

Decision to Implement
BIG DECISIONS ([paragraph])

  SHAC Members            23 (32.9%)   39 (69.6%)
  Teachers                21 (29.2%)   36 (62.1%)
  School Board            10 (14.1%)   28 (49.1%)
    Members
  School                  12 (16.7%)   32 (55.2%)
    Administrators
  Parents                 9 (12.3%)    27 (46.6%)
  Students                24 (33.3%)   32 (56.1%)

Challenges to
Implementing BIG
DECISIONS ([yen])

  Lack of time to         33 (52.4%)   28 (50.0%)
    teach curriculum
  Lack of funding         28 (45.2%)   9 (16.7%)
  Lack of training        25 (41.7%)   13 (24.5%)
    opportunities
  Inclusion of            37 (60.7%)   8 (15.4%)
    contraceptive
    information
  Student acceptance      15 (25.4%)    4 (7.5%)
    of content
  Political controversy   47 (68.1%)   16 (28.6%)
    about sexuality
    education
  Acquiring parent        24 (38.1%)   10 (18.2%)
    permission
                          Implement BIG DECISIONS

                            Total
                           (n=148)     [chi square]

Who Has the Most
Influence to Implement
BIG DECISIONS ([yen])

  SHAC Members            50 (33.8%)      2.703
  Teachers                33 (22.3%)    20.097 **
  Parents                 20 (13.5%)      2.221
  School                  61 (41.2%)      0.548
    Administrators
  Others                  42 (28.4%)     4.417 *

Would Support the
Decision to Implement
BIG DECISIONS ([paragraph])

  SHAC Members            62 (49.2%)    21.013 **
  Teachers                57 (43.8%)    21.753 **
  School Board            38 (29.7%)    41.377 **
    Members
  School                  44 (33.8%)    38.492 **
    Administrators
  Parents                 36 (27.5%)    32.671 **
  Students                56 (43.4%)    20.288 **

Challenges to
Implementing BIG
DECISIONS ([yen])

  Lack of time to         61 (51.3%)      0.067
      teach curriculum
  Lack of funding         37 (31.9%)    10.788 **
  Lack of training        38 (33.6%)      3.703
    opportunities
  Inclusion of            45 (39.8%)    24.007 **
    contraceptive
    information
  Student acceptance      19 (17.0%)     6.334 *
    of content
  Political controversy   63 (50.4%)    19.337 **
    about sexuality
    education
  Acquiring parent        34 (28.8%)     5.677 *
    permission

([yen]) Endorsed from a 'check-all-that-apply'
item ([paragraph]) Response choice: "Absolutely"
* P < 0.05; ** P < 0.01
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