Criteria-based development of a teen-directed abstinence-centered curriculum.
|Abstract:||As there are multiple teen sexual health programs showing mixed results, a standard for the design, implementation and evaluation of these programs should be adopted using the same criteria. Following the 17 criteria offered by Kirby et al. (2007), the Pure and Simple Choice (PSC) curriculum was developed, implemented and evaluated during the initial three years. Using a quasi-experimental, repeated measures design, participants' responses were more positive toward abstinence statements post participation. Results suggest the curriculum was able to instill or reinforce positive attitudes toward abstinence, and increase understanding of the possible consequences of risky behavior.|
Teenagers (Health aspects)
Youth (Sexual behavior)
Youth (Health aspects)
Medical research (Health aspects)
Medicine, Experimental (Health aspects)
Disease transmission (Health aspects)
Public health (Health aspects)
Sexually transmitted diseases (Health aspects)
Education (Health aspects)
Pickert, Sandra E.
Hart, Traci A.
Crowe, Robin E.
Theis, Lois M.
|Publication:||Name: American Journal of Health Studies Publisher: American Journal of Health Studies Audience: Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2009 American Journal of Health Studies ISSN: 1090-0500|
|Issue:||Date: Fall, 2009 Source Volume: 24 Source Issue: 4|
|Topic:||Canadian Subject Form: Teenage sexual behaviour|
|Product:||Product Code: E121930 Youth; 8000200 Medical Research; 9105220 Health Research Programs; 8000240 Epilepsy & Muscle Disease R&D; 8000120 Public Health Care; 9005200 Health Programs-Total Govt; 9105200 Health Programs NAICS Code: 54171 Research and Development in the Physical, Engineering, and Life Sciences; 92312 Administration of Public Health Programs; 62 Health Care and Social Assistance; 923 Administration of Human Resource Programs|
|Organization:||Government Agency: United States. Department of Health and Human Services|
BACKGROUND AND SIGNIFICANCE
Sexual activity among adolescents in the United States remains a public health concern. Recent estimates revealed nearly 19 million new diagnoses of sexually transmitted infections (STIs) in the United States in 2006, almost half of those among youth ages 15 to 24 years (Centers for Disease Control and Prevention [CDC], 2008). Specifically, a 2008 study estimated one in four teenaged women, or 3.2 million 14 to 19 year olds, has a STI, including chlamydia, herpes, trichomoniasis or human papillomavirus (Forhan, Gottlieb, Sternberg, Xu, Datta, Berman, et al., 2008). The most recent calculations also showed increases in the U.S. birth rate; teens aged 15 to 17 years increased 4.0% (22.2 per 1,000) and teens ages 18 to 19 years increased 6.0% (73.9 per 1,000) (Hamilton, Martin, & Ventura, 2009).
According to the Center for Disease Control and Prevention (CDC), "priority health-risk behaviors, which contribute to the leading causes of morbidity and mortality among youth and adults, often are established during childhood and adolescence, extend into adulthood, are interrelated, and are preventable" (Eaton, et al., 2006, June 9). Among high school students in 2007, nearly half (47.8%) reported having sexual intercourse, and more than one-third (33.9 %) reported having sexual intercourse with more than one person during the previous 3 months (Eaton, et al., 2008, June 6). Additionally, 22.5% reported drinking alcohol or using drugs before their last occurrence of sexual intercourse (Eaton, et al., 2008, June 6).
Healthy People 2010, Indicator 25 advocates responsible sexual behavior with a goal of increasing abstinence from sexual intercourse or the use of condoms for adolescents (U.S. Department of Health and Human Services, 2000). To reach this goal, Healthy People 2010 endorsed three protective behaviors to decrease the risk of STIs and unintended pregnancy: (1) abstinence from sexual activity during adolescence, (2) reverting to abstinence after having intercourse, and (3) at least using condoms consistently and correctly if regular intercourse is occurring. (U.S. Department of Health and Human Services, 2000). Therefore, educational programs aimed at preventing, delaying, or assisting teens to revert back to abstinence from sexual activity are central in influencing teen choices toward healthier lives.
ABSTINENCE EDUCATION INITIATIVES
PURE & SIMPLE LIFESTYLE PROJECT OF ABSTINENCE EDUCATION, INC.
Abstinence Education, Inc. (AE), a 501 (C) (3) organization based in Wichita, Kansas, is a faith- and community-based agency, that provides abstinence education to people of all ages, races, ethnicities, religions, and disabilities, without discrimination. The organization regularly serves a variety of youth including high-risk and special needs, youth from troubled families, unwed mothers, and youth in transition from detention centers. Active since 1997, the professional staff and volunteers of AE have served more than 15,000 youth and adults to address and educate the community on topics related to human sexuality.
PURE & SIMPLE CHOICE CURRICULUM DEVELOPMENT
Optimal lifelong sexual health is important to our youth and can be achieved most effectively by promoting (1) delayed sexual debut, (2) partner reduction, and (3) avoidance of risky sexual behaviors (Genuis & Genuis, 2004; Shtarkshall, Santelli & Hirsch, 2007). Kirby, Laris, & Rolleri (2007) and Marin, Kirby, Hudes, Coyle, & Gomez, (2006) emphasize that the key to sexual health includes the delay of adolescents' sexual debut.
To date, there is no research that demonstrates comprehensive sex education or abstinence-centered sex education intervention is superior in achieving the previously described adolescent sexual health goals. Rather, existing research about the impact of comprehensive sex education interventions and abstinence-centered interventions have shown varied results (Bruckner & Bearman, 2005; Bearman & Brucker, 2001; Caron, Godin, Otis, & Lambert, 2004; Coyle, Basen-Engquist, Kirby, Parcel, Banspach, Harrist, et al., 1999; Coyle, Kirby, Robin, Banspach, Baumler, & Glassman, 2006; DiCenso, Guyatt, Willan, & Griffith, 2002; DiClemente & Crosby, 2006; Kirby, Laris, & Rolleri, 2007; Manlove, Ryan, & Franzetta, 2003; Ott & Santelli, 2007; Rector, Johnson, & Marshall, 2004; Ross, Changalucha, Obasi, Todd, Plummer, CleophasMazige, et al., 2007; Santelli, Lindberg, Finer, & Singh, 2007; Santelli, Morrow, Anderson, & Lindberg, 2006; Scher, Maynard, & Stagner, 2006; Trenholm, Devaney, Fortson, Clark, Bridgespan, & Wheeler, 2008). Clearly, greater evidence is needed to reveal to which method is superior. The application of a criterion-based method to assess the content of adolescent sexual health curriculum could serve as a method to improve adolescent sexual health education.
CRITERION-BASED GUIDELINES TO ASSESS THE CHARACTERISTICS OF EFFECTIVE SEX AND STD/ HIV EDUCATION PROGRAMS
Because there are many different sexual health programs with mixed results, a standard for the design, implementation and evaluation should be adopted using the same guidelines and criteria. Moreover, Nagy (2002) advocates that theory pertinent to the topic should be used in curriculum development. Kirby, Laris, and Rolleri (2007) developed the Tool to Assess the Characteristics of Effective Sex and STD/ HIV Education Programs (TAC), based on an analysis of 83 articles detailing the characteristics of 19 successful curriculum-based programs in pregnancy, STD, and HIV prevention. The characteristics are divided into three categories: development, content, and implementation (Kirby, et al. 2007). Kirby's (2007) 17 TAC guidelines were followed to develop the Pure & Simple Choice curriculum.
THE PROCESS OF DEVELOPING THE CURRICULUM
CHARACTERISTIC 1: INVOLVED MULTIPLE PEOPLE WITH DIFFERENT BACKGROUNDS IN THEORY, RESEARCH, AND SEX AND STD/HIV EDUCATION TO DEVELOP THE CURRICULUM.
Experts in adolescent sexual health and development from a variety of disciplines collaborated in the development of the Pure & Simple Choice curriculum. Academicians from medicine, public health, and nursing guided the development of the curriculum. In addition, the design team had knowledge of health behavior theory, adolescent developmental models, and instructional and curriculum design, with extensive experience in conducting formative and impact evaluation. The cultural diversity of the Community Advisory Board and AE staff ensured a culturally sensitive curriculum for the various ethnic groups to be served.
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CHARACTERISTIC 2: ASSESSED RELEVANT NEEDS AND ASSETS OF TARGET GROUP.
In 2002, AE received a federal planning grant from the Department of Health and Human Services, Special Projects of Regional and National Significance (SPRANS) Division (Grant HIDMC00462-01). A structured interview study (N = 32) of 32 school personnel in rural and urban schools was conducted to assess attitudes and perceived needs of public and parochial school administrators and teachers regarding sexual health education. More specifically, the survey assessed attitudes toward current educational approaches for adolescent sex education and the eight legislative criteria (A-H) (Department of Health and Human Services Administration for Children and Families DHHS, [ACF], 2008) that define abstinence education.
Results suggested area schools used an abstinence based approach with middle school students while high school students were exposed to comprehensive sex education (Theis, Bahr, & Pickert, 2003). Responses from school administrators (63.6%) indicated agreement with the eight elements of the Title V, Section 510 abstinence definition (A-H definitions listed in Table 1). In addition, findings indicated that educators were aware a portion of their students had engaged in oral sex, mutual masturbation, and other infection transmitting sexual behaviors in addition to vaginal intercourse (Theis, Bahr & Pickert, 2003).
Two convenience sample surveys were conducted in 2002 (N=2,707) and 2003 (N=5,135) at the Kansas State Fair. The survey assessed adult and teen attitudes toward adolescent high-risk behaviors and the perceived effectiveness of primary prevention education aimed at reducing unhealthy behaviors. Results showed both youth and adult respondents' perceived unmarried sexual activity as unhealthy (65.0% and 80.1%, respectively). The majority of all respondents (69%) agreed Kansas middle and high schools should focus on abstinence as the only option to eliminate the risk of pregnancy and STIs (Theis, Bahr & Pickert, 2003).
CHARACTERISTIC 3: USED A LOGIC MODEL APPROACH TO DEVELOP THE CURRICULUM.
Logic models provide an organizing framework that induces program planners to incorporate research, theory, knowledge and professional experience to align risk and protective factors that influence behavior, and to incorporate these factors into the curriculum. Figure 1 displays the Logic Model for the Pure and Simple Choice Curriculum. Each of the eight curriculum episodes were linked to specific knowledge, attitudes, and belief determinants. Additionally, behavioral intentions, sexual activity behaviors, and health goals were aligned with the curriculum content. As a cornerstone for evidence based curriculum, three well recognized theories provide the basis for the eight curricular episodes: the Social Cognitive Theory Bandura (1969), Erikson's (1982) psychosocial developmental model, and the Whole Person Development Theory (McGraw, 2004).
Social Cognitive Theory (1969) (Bandura, 1969). A central construct of this theory is the development of self-efficacy, the individual's perceived confidence to perform a behavior, self-determine, or self-regulate behavior. To develop self-efficacy, the learner must have the capability to symbolize behavior, anticipate outcomes of behavior, learn by observing others' behavior, and possess the ability to reflect and analyze experiences. AE applied Bandura's model through the use of mentors (teen instructors and coaches), participants' examination of the consequences experienced by the four teen characters depicted in the curriculum episode presentations, and interactive activities associated with each episode.
Psychosocial Developmental Model. Erikson's (1982) psychosocial developmental model suggests that experimentation, rebellion, and self-doubt are potential behaviors exhibited during adolescence as teens struggle toward self-identity. During this phase of identity development, teens shift from their parents as a source of guidance to relying increasingly upon peer groups and mentors for inputs to guide behavior. Fidelity, the specific strength that emerges during adolescence, equates to having found one's place in the world, and equips the adolescent to contribute to society in a meaningful way. Fidelity requires the integration of life experience into a self-image that is acceptable to the teen and the community. The converse of fidelity development is role repudiation, the rejection of adult norms, and may be observed as diffidence or defiance (Erikson, 1982). Rather than having no identity, the adolescent acquires the social norms of the group with which they are experimenting. Teens may become involved in unhealthy activities such as drugs, alcohol, tobacco use or risky sexual behaviors at this stage.
Whole Person Development Theory. The Whole Person Development Theory (McGraw, 2004) applied specifically to abstinence education, postulates that sexuality impacts the whole person's cognitive, moral, emotional, and social domains. The core personal self must be recognized and respected to affirm the dignity of participants. The learning experience is a shared social "reality" to which each learner will have a psychological response. Programs that emphasize character development and abstinence from sexual activity until marriage teach a moral and social standard that is objectively seen as true and good, regardless of social norms and practices in the learner's community (McGraw, 2004).
CHARACTERISTIC 4: DESIGNED ACTIVITIES CONSISTENT WITH COMMUNITY VALUES AND AVAILABLE RESOURCES.
Initially funded through a 3-year Community Based Abstinence Education (CBAE) grant from the United States Department of Health and Human Services (Grant 90AE0085), the Pure & Simple Lifestyle (PSL) project provides primary prevention abstinence health messages. The program uses role modeling, teen dialogue and a focus on the relationship between decisions made today and their impact on the future. AE designed the PSL curriculum, Pure & Simple Choice, using the Federal A-H criteria (DHHS, ACF, 2008) to: (1) promote abstinence until marriage, (2) address positive aspects of character development, (3) promote positive goal-setting and decision-making skills, (4) increase respect for self and others, and (5) raise awareness of the negative consequences of teen sexual activity. The program, supported by parent action groups and community involvement, engages youth within their own surroundings and provides a comfortable, supportive atmosphere that instills program concepts and values. AE implemented the curriculum in a variety of settings: in-school and after-school programs, faith-based youth groups, and youth-serving, community organizations.
The PSL project was implemented through a community mobilization plan as recommended by the University of Kansas Work Group for Community Health and Development (2009) that engaged individuals, groups, and community leaders at the grassroots level in targeted geographical areas. As such, parents, community groups, and participants at all levels became more connected with the program, and exposure to its concepts and ideals were disseminated. The needs assessment was used to guide the construction of the evidence-based curriculum.
The dissemination plan was based upon geographical districts in both urban and rural communities, which were found to be natural boundaries for cultural sensitivity and communication with community leaders. PSL project coordinators, as members of each of the ethnic communities they represented, lived and worked within their districts. This strategy ensured close community relationships and collaborations through active participation in neighborhood advisory meetings, schools, community centers, faith-based organizations' activities, and youth organizations. As a result, community members embraced the PSL project message, goals, curriculum, made referrals for curriculum site presentations, and became volunteers in various project positions, including teen instructors and advisory board members.
CHARACTERISTIC 5: PILOT TESTED THE PROGRAM.
The finalized curriculum was initially implemented in five sites including three urban parochial middle schools, an urban Big Brothers/ Big Sisters organization, and a rural community church youth group. Project staff chose the locations based on willingness for curriculum implementation at the site. Initially, teen instructors acted out each playbook episode. Later playbook episodes were videotaped and incorporated to enhance live activity and discussion portions of the presentations. Formative and impact evaluation of the curriculum was initiated at the onset of implementation.
Within nine months of implementation, six focus groups were conducted to elicit feedback from teen curriculum participants about (1) the enrollment process, (2) program intervention and (3) initial impressions of the curriculum. Participants stated that they learned from the abstinence curriculum, and provided examples of how long-term consequences of behaviors reinforced their decision to choose abstinence. In addition, findings were used to improve the PSC curriculum and its delivery.
CHARACTERISTIC 6: FOCUSED ON CLEAR HEALTH GOALS--THE PREVENTION OF STDS, HIV, AND/ OR PREGNANCY.
Kirby et al. (2007) advocate that at least one of three sexual health goals be addressed in any program designed to prevent or reduce STIs, HIV or pregnancy. The health goals for the Pure & Simple Choice curriculum were: 1) reduce incidence of sexually transmitted diseases among youth aged 12-18 years; and 2) reduce incidence of out-of-wedlock births among youth aged 12-18 years. Throughout the eight curriculum episodes, clear consistent messages were articulated that teen sexual activity can result in STIs and out-of-wedlock pregnancy, and resulting negative consequences were discussed. PSC activities and discussions included emphasis on positive consequences of delaying sexual activity until marriage, such as increased likelihood of completing education, achieving goals, less likelihood of infertility due to STIs and better outcomes for parenting future children when teen out-of-wedlock pregnancy is avoided.
CHARACTERISTIC 7: FOCUSED NARROWLY ON SPECIFIC BEHAVIORS.
To achieve the health goals described previously, the curriculum designers specified two target health behaviors: 1) reduce the incidence of self-reported sexual activity among youth aged 12-18 years and 2) maintain or return to abstinent sexual practices. Program content and activities were tightly focused upon these two health behaviors, which were consistent with community values.
CHARACTERISTIC 8: ADDRESSED MULTIPLE SEXUAL PSYCHOSOCIAL RISK AND PROTECTIVE FACTORS AFFECTING SEXUAL BEHAVIORS.
Due to the potential risks to physical and mental health posed by premarital sex, programs aimed at preventing or delaying adolescent sexual activity are important. Advocates of primary prevention education promote optimum adolescent development by advocating refraining from all forms of unhealthy behaviors, including all forms of sexual activity until marriage (Eaton et al., 2006, June 9). According to Kirby (2007, pg 30), "effective programs identify and focus on specific psychosocial risk and protective factors and design multiple activities to address those specific factors." In an effort to improve and/or reinforce attitudes toward abstinence-until-marriage, the following content areas were addressed consistently within the eight episodes: 1) advantages of sexual abstinence after analyzing the consequences of sexual activity; 2) benefits of positive influences on the development of the whole person: physically, intellectually, creatively and emotionally; and psychosocial development; 3) the value of human fertility, motherhood, fatherhood and marital fidelity; 4) setting boundaries, behavioral expectations and character formation; and 5) development of sexual self-control, healthy decision making, and assertiveness with positive orientation toward the future. Moreover, the curriculum addressed 8 of 11 psychosocial risk and protective factors affecting sexual behavior among youth in the communities served as described by Kirby et al. (2007), including:
* Knowledge of sexual issues, STI and pregnancy prevention
* Personal values about sex and abstinence
* Perception of peer norms about sex and perception of peer sexual behavior
* Self-efficacy to refuse sex
* Intention to abstain from sex
* Communication with parents or other adults about sex
* Self-efficacy to avoid STI/HIV risk and risk behaviors
* Actual avoidance of places and situations that might lead to sex
The evaluation instrument assessed changes in knowledge, attitudes, beliefs and intentions associated with psychosocial risk and protective factors.
CHARACTERISTIC 9: CREATED A SAFE SOCIAL ENVIRONMENT FOR YOUTH TO PARTICIPATE.
To promote a safe social environment that enhances open, respectful dialogue among participants, program planners were thorough in the preparation of parents, young adults and teens to support the PSC curriculum delivery. In an unsafe social environment, participants may be less motivated to contribute to the discussion with questions or their views, but more importantly, may be less likely to internalize significant programmatic messages (Kirby, 2007). The program engaged youth within familiar surroundings, including school-based and after-school programs, faith-based youth groups, and youth-serving, community organizations. Teen instructors further fostered a comfortable, supportive atmosphere. Icebreakers and activities were used to assure comfort and engage all participants, aid in directed discussion, facilitate involvement, and provide positive reinforcement. Sites were required to have an adult present during PSC presentations to assist with classroom management.
CHARACTERISTIC 10: INCLUDED MULTIPLE ACTIVITIES TO CHANGE EACH OF THE TARGETED RISK AND PROTECTIVE FACTORS.
Through dialogue between the four main high school characters depicted in each episode, many relevant teen topics were discussed, including holistic adolescent development (physical, intellectual, creative, and emotional), understanding expectations of one's self and others, and setting boundaries. In addition, participants discussed the importance of demonstrating positive character traits and competency in life skills such as building a strong relationship, assertiveness techniques, resisting negative peer pressure, decision-making skills, and goal setting.
Participants discussed the pertinent risks and consequences of teen sexual activity, including STI transmission and prevalence of, out-of-wedlock teen pregnancy, emotional turmoil, increased vulnerability related to alcohol use, and how today's choices about sexual activity can impact the future. The anticipated result was for audience members to identify with and share in the experiences and decision-making of the characters in the PSC episodes.
Medically accurate data were woven throughout each 35- to 40- minute dramatic performance. In addition, an interactive activity, led by teen instructors or coaches, further illustrated the concepts within each episode. At each session, participants were given items to keep that emphasized concepts, summarized information, or encouraged making healthy choices, such as: bookmarks, bracelets, brochures, and t-shirts. To conclude each episode, teen instructors or coaches shared their personal story and decision to practice abstinence with the teen audience.
CHARACTERISTIC 11: EMPLOYED INSTRUCTIONALLY SOUND TEACHING METHODS THAT ACTIVELY INVOLVED THE PARTICIPANTS, THAT HELPED PARTICIPANTS PERSONALIZE THE INFORMATION, AND THAT WERE DESIGNED TO CHANGE EACH GROUP OF RISK AND PROTECTIVE FACTORS.
As a federal CBAE grant recipient, AE complied with the requirement to include the A-H criteria by applying the eight criteria as the basis of its curriculum development and delivery (Table 1). Each of the eight episodes uniquely incorporated the eight A-H guidelines (Department of Health and Human Services Administration for Children and Families DHHS, [ACF], 2008) sequentially, 1. e., Episode 1, "Advantages," explicitly addressed guideline "A," "has as its exclusive purpose teaching the social, psychological, and health gains to be realized by abstaining from sexual activity;" Episode 2, "Expectations" addressed guideline "B," "teaches abstinence from sexual activity outside of marriage is the expected standard for all school-age children," etc. Each episode also incorporated criteria other than the main criteria theme for that episode (Table 1).
AE sought to develop a curriculum that exceeded typical lecture and question and answer formats to incorporate the three applied behavioral theories by use of role modeling and dialogue. According to Soul City Institute for Health and Development Communication, dialogue is one of the critical 'intermediate' outcomes promoting behavior change or action (Goldstein, Usdin, Scheepers, & Japhet, 2005; Scheepers & Goldstein, 2007). AE's approach to abstinence education was consistent with other well known entertainment-education (EE) communication intervention designs (Singhal & Obregon, 1999) through its use of a "teen soap opera drama" to educate and inform. The series of eight episodes focused on the lives of four characters. The result was the Pure & Simple Choice curriculum, initially a playbook of dramatic "real life" episodes, accompanying companion interactive activities and discussion points. VHS/DVD videos of the episodes were produced and available for use in lieu of live actors.
AE produced the videos in conjunction with print curriculum materials within the context of an EE strategy (Singhal & Rogers, 1999), and was guided by parasocial interaction/identification (Horton & Wohl, 1956). As defined by Singhal and Rogers (2002), EE has been used to spread concepts to produce behavioral and social change. Social change is defined as the process in which an alteration occurs in the structure and function of a social system. Social change occurs at the individual, organizational, community or societal level. EE by itself sometimes brings about social change and, under certain conditions in combination with other influences, EE can create a climate for social change (Singhal & Obregon, 1999).
Predominately, EE has been used to improve health awareness, including HIV/AIDS awareness (Do & Kincaid, 2006), the empowerment of women with sexual and reproductive health and rights (Pillsbury & Mayer, 2005), and to measure the effect of media in health education (Farr, Witte, Jarato, & Menard, 2005; Keating, Meekers, & Adewuyi, 2006). Exposure, which helps measure EE effects, was positively associated with increased interpersonal communication between friends and family members and behavioral change at the individual and community level (Bouman, Maas, & Kok, 1998; Kane, Gueye, Speizer, Pacque-Margolis, & Baron, 1998). Internationally, researchers have found EE is associated with increased knowledge about program topics, positive changes in attitude, and increased self-efficacy (Davenport Sypher, McKinley, Ventsam, & Valdeavellano, 2002; Kane, et al., 1998; Valente, Kim, Lettenmaier, Glass, & Dibba, 1994; Yoder, Hornick, & Chirwa, 1996).
CHARACTERISTIC 12: EMPLOYED ACTIVITIES, INSTRUCTIONAL METHODS AND BEHAVIORAL MESSAGES THAT WERE APPROPRIATE TO THE YOUTHS' CULTURE, DEVELOPMENTAL AGE, AND SEXUAL EXPERIENCE.
After developing the content, AE sought alternative delivery styles to adapt the curriculum to any group or setting. For example, AE designed episodes for youth as young as 12 years but could be adapted for use with teens up to 18 years by adding additional activities and discussion appropriate for age and experience. In addition, AE designed the curriculum for an audience of both males and females. Curriculum dialogue, written with input from local teens, contained phrases in the local teenage vernacular. By presenting teen actors who modeled the decision to remain abstinent until marriage, AE attempted to provide adolescents with principles to reference in everyday life.
CHARACTERISTIC 13: COVERED TOPICS IN A LOGICAL SEQUENCE.
Through a variety of scenarios, the story of the lives of the four main high school characters, two boys and two girls, unfolds. Early in the series and throughout several scenes, a male and female couple articulates their decision to refrain from unhealthy behaviors including the use of illegal drugs, alcohol, and sexual activity before marriage. They verbalize their future goals and discuss possible consequences of high risk behaviors. Conversely, the other male and female couple chooses to become sexually active with one another. Consequences of their choices include the transmission of genital herpes, an unplanned pregnancy, alcohol abuse, and an unexpected teen death as a result of driving under the influence of alcohol.
In Episode 1 entitled "Advantages" teen actors/ instructors engaged the participants in understanding the social, psychological, and health advantages of abstaining from sexual activity until marriage, and developing as a whole, healthy person. Dialogue and activities were created to: (1) stimulate curiosity about the personal advantages of refraining from all sexual activity until marriage, (2) introduce the concept of personal holistic growth, and (3) form connections with persons of different ages and backgrounds. The intended long-term outcome from this episode was for participants to realize their self worth as a whole person and the social and psychological benefits of living a healthy, abstinent lifestyle.
Episode 2, "Expectations," demonstrated how youth can meet societal expectations to refrain from sexual activity until marriage. Additionally, group discussion incorporated a list of local services and support systems available to help teen participants meet their expectations. The goal of Episode 2 was for participants to experience connectedness to the community through friends, family, school, service, and/or faith-based groups and to develop a sense of being a part of something beyond themselves. The goal was for participants to appreciate that their sexual behavior outside of marriage had a lasting impact on the community in which they live.
Episode 3, "100% Pure & Simple," was written to confirm that positive personal freedom is the result of being abstinent until marriage. Moreover, abstinence is the only certain way to avoid STIs, out-of-wedlock pregnancy, and the emotional consequences of premarital sexual activity. Outcomes for this episode included participants' increased confidence to set standards for their own behavior and the ability to make choices that permit them to grow in a healthy, balanced way.
Episode 4, "Faithful Partners," incorporated the values of trust and faithfulness with the goal of empowering participants physically, psychologically, and emotionally for the long term, mutually monogamous commitment of marriage. In this episode, teen instructors explained the differences between love and infatuation, the meaning of trust, and helped participants identify important positive characteristics of a true friend and a marriage partner. The intended outcome of this episode was for participants to develop a sense of caring that extended to others and to be able to identify the important characteristics they desired in various relationships including peer friendships, dating partners, and a monogamous lifetime marital spouse.
In Episode 5, "Consequences" statistics and examples of out-of-wedlock birth and STIs were given to participants to emphasize the harmful psychological and physical effects of engaging in sexual activity before marriage. The "neglected heart" (Lickona, 1998) information was included with the episode to increase the participants' awareness of the possible effects of their partners' prior sexual activity and of their own choices. Participants learned about compassion for those who have made poor choices in the past.
Episode 6, "Out-of-Wedlock," taught teens about the responsibilities connected with parenting and to value the roles of motherhood and fatherhood. As an illustration of how personal decisions affect the child, parents, extended family, and society, teen actors/instructors discussed the adverse conditions associated with an out-of-wedlock pregnancy. The intended outcome of this episode was the recognition of the psychological, emotional, and physical effects of pregnancy.
In Episode 7, "Life Plan" teen actor/instructors demonstrated techniques of positive assertiveness and how to reject pressure to engage in sexual activity, violence, and the use of illegal substances, including alcohol and drugs. The intended outcome was for participants to experience, through the curriculum characters, a sense of self-efficacy in living their decision to be free from unhealthy choices. At the conclusion of this episode, participants could choose to defend their decision to refrain from all sexual activity until marriage and discuss how to further build their own foundation of healthy choices.
In the final episode, "Self Sufficient" teen instructors discussed integrating connectedness, caring, compassion, competence, and confidence into the participants' commitment to abstain from unhealthy choices. Emphasis was placed on gaining self-sufficiency while remaining in a loving, caring relationship. An additional component encouraged participants to write their short and long term life goals and confirm their decision to remain abstinent until marriage.
THE IMPLEMENTATION OF THE CURRICULUM
CHARACTERISTIC 14: SECURED AT LEAST MINIMAL SUPPORT FROM APPROPRIATE AUTHORITIES.
Program leadership invested significant time engaging sites for curriculum dissemination. Parental consent and adolescent assent were obtained prior to the start of any class. Additionally, parent information sessions were held at each site at times when parents were generally available (i.e. after school at pick-up time, immediately following a religious service, etc.). Parent phone calls regarding questions or concerns about the PSL project were encouraged.
Characteristic 15: Selected educators with desired characteristics, trained them, and provided monitoring, supervision, and support.
A two day training session was conducted for the project's adult coordinators and college aged coaches. Training consisted of the program staff describing the theoretical background of the curriculum, introducing the legislative A-H abstinence education criteria, presenting adolescent development and learning styles, and distributing epidemiologic information about STIs and teen pregnancy. In addition, staff divided training participants into eight groups to practice presenting one of the dramatic episodes and receive feedback and critiques.
A two-tiered peer educational program was designed to deliver the curriculum. Program staff selected coaches and teen instructors based on the following criteria: currently practicing abstinence from (1) sexual activity (if unmarried), (2) illegal drugs, alcohol, and tobacco; (3) the ability to relate to others of varying cultures and ethnicities; and (4) the willingness to attend practice sessions to adequately prepare for presentations.
College-age coaches served as mentors for volunteer high school teen instructors and assisted the instructors in preparation for each episode presentation. In addition, each coach and teen instructor developed a short personal testimony detailing their reasons for practicing abstinence. Theoretically, audiences of teen participants would model characteristics they observed in the presenters, especially when they related to the presenters (Erikson, 1982). Through sharing their personal testimony, the teen instructors and coaches developed leadership and communication skills, self-confidence, and deepened their sense of self-efficacy to make healthy choices. The presenters were monitored and supported by supervising AE staff.
CHARACTERISTIC 16: IMPLEMENTED ACTIVITIES TO RECRUIT AND RETAIN YOUTH AND OVERCOME BARRIERS TO THEIR INVOLVEMENT (E.G. PUBLICIZED THE PROGRAM, OFFERED FOOD, OBTAINED CONSENT).
The PSC curriculum was implemented at sites familiar to participants with safe, comfortable environments and at a time convenient for teen participants. To engage and retain participants, small incentives, such as candy, pencils and other teen appropriate incentives were given to participants. Parental consent and adolescent assent were obtained prior to the start of any class.
CHARACTERISTIC 17: IMPLEMENTED VIRTUALLY ALL ACTIVITIES WITH REASONABLE FIDELITY.
The Classroom Video Series, an edited edition of the original playbook scripts, was produced using local amateur teens and college-age young adult actors to play the character parts. The video series allowed for a consistent presentation across groups, and permitted time for preparation of discussion topics, interactive activities, and their abstinence testimonials.
A formative evaluation plan provided feedback to program planners. A curriculum evaluation committee, comprised of teens, college-aged adults, abstinence education experts, and community professionals, critiqued the full curriculum including scenarios, graphics, props, activities, and scripts. The assessment included scrutinizing content accuracy, information relevancy, educational methods, adherence to the A-H definition elements, and curriculum for intended teen audiences. Staff used feedback to improve the curriculum by incorporating language in the vernacular of and experiences relevant to today's teens.
A university-based evaluator was contracted to perform process and outcome assessment using a logic model approach. Staff and program stakeholders used results to adapt the intervention to enhance program effectiveness. Using a quasi-experimental, repeated measures design, changes in participant knowledge, attitudes, beliefs and intentions were assessed pre-intervention, post-intervention, and six months post-intervention. Previous research has documented the difficulty of evaluating teen's self report of sensitive topics (Bogart, Cecil, Wagstaff, Pinkerton, & Abramson, 2000), however others found success when confidentiality and anonymity were reinforced (Jaccard, McDonald, Wan, Dittus, & Quinlan, 2002). Therefore, the evaluation consisted of a self-administered, confidential, modified version of the Ohio Department of Health Abstinence Education survey.
Table 2 displays the demographic characteristics for all consented participants for each year of the evaluation period. The majority characteristics for participants (N=1,475) across the 3 years were predominantly female (56%), White/Caucasian (56%), lived with both parents (70%) and reported being "somewhat religious" or "very religious" (90%).
Survey items were categorized into four themes: sexual activity, drug/alcohol use, pregnancy and parenthood, and relationships and communication with parents. Paired sample t-test results indicated significant change in a positive direction in abstinent attitudes and intentions from pre-to-post-survey administration through the first three years of the evaluation (Table 3) for 22 of 27 items. These items indicated that participant's responses were more positive toward abstinence statements after participating in the PSC curriculum. Findings indicated the program was able to instill or reinforce positive attitudes toward abstinence, and increase understanding of the possible consequences of risky behavior. When resurveyed at six months post completion of the curriculum, the results suggested that most items with significant positive changes maintained positive movement over the pre-/post-/ follow-up timeframe. Minimal attitudinal decay occurred.
To obtain sufficient and accurate information for the program evaluation, various techniques were employed to improve the quantity and quality of the survey data received. For some participant groups, the survey was read to keep participants on task and to decrease distractions. For completion of the pre-intervention survey, small incentives, such as candy, were provided whereas a project t-shirt was given at the completion of the post-intervention survey. For the 6-month post-intervention survey, participants were rewarded with two movie tickets.
Attitudes and intentions are thought to be precursors of behavior, and as such, the initial program evaluation results suggest positive outcomes as a result of participation in the Pure & Simple Choice (PSC) curriculum. As abstinence education programs continue to develop, lessons learned from the PSC curriculum should be noted. The curriculum and role-play format provided teens with a relaxed, safe atmosphere in which to investigate and discuss the physical, emotional, and social benefits of abstinence-until-marriage. The supportive environment and presentations by peer role models permitted teens to ask questions, understand the consequences of actions, and acquire knowledge about the impact of sexual activity to physical, emotional, social, and spiritual health. In turn, teens were empowered to make good decisions regarding sexuality and high risk behaviors, resulting in freedom to build healthy relationships, seek life goals, and ultimately experience a stable marriage and raise healthy, happy children of their own.
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Sandra E. Pickert, RN, MPH, BSN, FNP, is the Executive Director of Abstinence Education, Inc. Ruth Wetta-Hall, RN, PhD, MPH, MSN, is a Assistant Professor of Department of Preventive Medicine and Public Health at University of Kansas School of Medicine-Wichita. Amy Chesser, PhD, is affiliated with University of Kansas School of Medicine-Wichita. Traci A. Hart, PhD(C), is a Human Factors PhD candidate in the Psychology Department at Wichita State University. Robin E. Crowe, MA, is affiliated with University of Kansas School of Medicine-Wichita. Lois M. Theis, RN, BSN, FCP, is the Founding President of Abstinence Education, Inc. Please address all correspondence to: Ruth Wetta-Hall, RN, PhD, MPH, MSN, University of Kansas School of Medicine-Wichita, 1010 North Kansas, Wichita, KS 67214-3199. Phone: 316-293-2627. Fax: 316-2932695. E-mail: email@example.com
Table 1: Curricula's Alignment with A-H Elements of the Federal Definition of Abstinence Education Program A-H Definitions Advantages Expectations A) The social, psychological, and health gains to be realized [check] [check] by abstaining from sexual activity B) Abstinence from sexual activity outside marriage as the expected standard [check] for all school-aged children C) Abstinence from sexual activity is the only certain way to avoid out-of-wedlock [check] [check] pregnancy, sexually transmitted diseases, and other associated health problems D) A mutually faithful monogamous relationship in the [check] [check] context of marriage is the standard for human sexuality E) Sexual activity outside of marriage is likely to [check] [check] have harmful psychological and physical effects F) Bearing children out-of- wedlock is likely to have harmful consequences for [check] [check] the child, the child's parents, and society G) Young people how to reject sexual advances and how alcohol and drug use increases vulnerability to sexual advances H) Importance of attaining self- sufficiency before engaging in [check] [check] sexual activity Episodes A-H Definitions 100% Pure Faithful & Simple Partners A) The social, psychological, and health gains to be realized [check] [check] by abstaining from sexual activity B) Abstinence from sexual activity outside marriage as the expected standard [check] for all school-aged children C) Abstinence from sexual activity is the only certain way to avoid out-of-wedlock [check] [check] pregnancy, sexually transmitted diseases, and other associated health problems D) A mutually faithful monogamous relationship in the [check] [check] context of marriage is the standard for human sexuality E) Sexual activity outside of marriage is likely to [check] [check] have harmful psychological and physical effects F) Bearing children out-of- wedlock is likely to have harmful consequences for [check] [check] the child, the child's parents, and society G) Young people how to reject sexual advances and how [check] [check] alcohol and drug use increases vulnerability to sexual advances H) Importance of attaining self- sufficiency before engaging in [check] [check] sexual activity A-H Definitions Consequences Out-of Life -wedlock Plan A) The social, psychological, and health gains to be realized [check] [check] [check] by abstaining from sexual activity B) Abstinence from sexual activity outside marriage as the expected standard for all school-aged children C) Abstinence from sexual activity is the only certain way to avoid out-of-wedlock [check] [check] [check] pregnancy, sexually transmitted diseases, and other associated health problems D) A mutually faithful monogamous relationship in the [check] [check] [check] context of marriage is the standard for human sexuality E) Sexual activity outside of marriage is likely to [check] [check] [check] have harmful psychological and physical effects F) Bearing children out-of- wedlock is likely to have harmful consequences for [check] [check] [check] the child, the child's parents, and society G) Young people how to reject sexual advances and how [check] [check] [check] alcohol and drug use increases vulnerability to sexual advances H) Importance of attaining self- sufficiency before engaging in [check] [check] [check] sexual activity A-H Definitions Self- Sufficient A) The social, psychological, and health gains to be realized [check] by abstaining from sexual activity B) Abstinence from sexual activity outside marriage as the expected standard for all school-aged children C) Abstinence from sexual activity is the only certain way to avoid out-of-wedlock [check] pregnancy, sexually transmitted diseases, and other associated health problems D) A mutually faithful monogamous relationship in the [check] context of marriage is the standard for human sexuality E) Sexual activity outside of marriage is likely to [check] have harmful psychological and physical effects F) Bearing children out-of- wedlock is likely to have harmful consequences for [check] the child, the child's parents, and society G) Young people how to reject sexual advances and how [check] alcohol and drug use increases vulnerability to sexual advances H) Importance of attaining self- sufficiency before engaging in [check] sexual activity A-H Definitions 13 Themes A) The social, psychological, Episode 1 Healthy person and health gains to be realized (spiritual, physical, by abstaining from sexual intellectual, creative, activity emotional development). B) Abstinence from sexual Episodes 2 and 3 offer activity outside marriage age appropriate teaching as the expected standard on return to practicing for all school-aged children abstinence after being sexually active C) Abstinence from sexual activity is the only certain Episodes 2, 3, 4 and 5 way to avoid out-of-wedlock instruct on the positive pregnancy, sexually transmitted health gains associated with diseases, and other associated abstinent lifestyle health problems D) A mutually faithful monogamous relationship in the context of marriage is the Episode 5, describes the standard for human sexuality value of abstinence and E) Sexual activity outside the direct links to dropouts, of marriage is likely to poverty, smoking, substance have harmful psychological abuse, violence and crime. and physical effects F) Bearing children out-of- Episodes 3 thru 8 wedlock is likely to have portray age appropriate harmful consequences for information about harmful the child, the child's consequences of unhealthy parents, and society decisions (sex and alcohol use) G) Young people how to reject Episodes 6 thru 8 emphasize sexual advances and how goal setting and future- alcohol and drug use increases oriented thinking vulnerability to sexual advances H) Importance of attaining self- sufficiency before engaging in sexual activity Table 2: Demographics Year 1 Year 2 Year 3 2005-2008 (n=308) (n=483) (n=684) (n=1,475) Characteristic % % % % Sex Female 63.5 53.6 53.6 55.7 Male 36.5 46.4 46.4 44.3 Race/Ethnicity * Caucasian/White 68.2 48.2 56.9 56.2 African American/Black 13.6 18.0 14.8 15.6 Hispanic/Latino 5.6 16.3 11.5 11.8 Bi-racial 5.0 5.7 6.7 6.0 Asian/Pacific Islander 3.3 5.3 4.9 4.7 Other 1.0 1.9 2.9 2.2 Live w/now Both Parents 74.8 65.1 72.3 70.4 One parent only 15.9 14.1 15.7 15.2 Parent and Step-parent 5.3 13.7 9.3 9.9 Grandparent(s) 2.0 3.0 1.5 2.1 Other person 0.7 1.3 1.1 1.1 Other relative 1.3 2.8 0.2 1.3 Self-reported religiosity Very religious 44.9 42.1 35.5 39.6 Somewhat religious 48.2 46.2 55.4 50.8 Somewhat non-religious 2.3 6.0 3.2 3.9 Very non-religious 2.0 1.7 1.5 1.7 Not sure 2.7 4.0 4.4 3.9 Note: Age was not collected the same in both survey versions and thus not comparable. * US Census Race/Ethnicity for Sedgwick County (all ages) are 84% White, 10% Hispanic/Latino, 9% Black, 4% Asian. Table 3: Pre-/Post-Administration Mean Scores: For 2005-2008 Participants (n=1,045) Item Item statement Pre Post 1 I feel I can go to my parent(s)/guardian(s) 3.58 3.69 with questions about sexual topics. 2 It is NOT ok for me to be sexually active 4.34 4.50 as a teenager. 3 Remaining sexually abstinent until marriage 4.32 4.53 shows respect for my boyfriend/girlfriend. 4 I plan to abstain from ALL sexual activity 4.16 4.34 until marriage. 5 I would say "no" if someone I cared about 4.23 4.31 wanted me to have sex. 6 I feel close to my parent(s)/guardian(s). 4.26 4.29 7 Babies born to teenagers are more likely 3.05 3.45 to be physically abused. 8 Most of my close friends are sexually abstinent. 4.01 4.03 9 My parent(s)/guardian(s) do care whether I am 4.49 4.56 sexually abstinent or not. 10 Teenage mothers and their children often 3.43 3.74 live in poverty. 11 Most of my close friends believe it is 3.66 3.90 important for teens to be sexually abstinent. 12 My parent(s)/guardian(s) set clear rules for me. 4.31 4.40 13 Babies born to teenagers are less likely to 3.76 3.90 grow up in homes with their fathers. 14 Remaining sexually abstinent until marriage 4.46 4.59 shows self-respect. 15 It is NOT okay to be sexually active with 4.01 4.30 someone you love before you get married. 16 I am satisfied with the way my parent(s) 3.60 3.74 /guardian(s) and I talk about sexual topics. 17 My parent(s)/guardian(s) would be disappointed 4.46 4.52 if I was sexually active. 18 If I got pregnant, OR got someone pregnant, 3.86 3.79 it would disappoint my parent(s)/ guardian(s). 19 I feel comfortable talking with my parent(s) 2.49 2.47 /guardian(s) about sexual topics. 20 Using drugs increases the chance a teen 3.79 4.18 will have sex before marriage. 21 Drinking alcohol increases the chances a 4.03 4.28 teen will have sex before marriage. 22 Teenage mothers are more likely to 4.06 4.36 drop out of school. 23 If his/her partner has an STD, a teen can 4.30 4.53 get an STD by having sexual activity one time. 24 I believe saving sexual activity until 4.44 4.57 marriage is the best choice. 25 Saying "no" to sexual activity as a teen 4.45 4.56 can help me reach my goals as an adult. 26 When you are in love, NOT having sexual 4.03 4.24 activity with your boyfriend/girlfriend is a good way to show how much you care. 27 If we had sexual activity, my partner 3.16 3.44 would NOT respect me. Item Change t p 1 0.11 -3.663 <.001 2 0.16 -6.073 <.001 3 0.21 -6.731 <.001 4 0.18 -5.379 <.001 5 0.08 -2.729 <.01 6 0.03 -0.907 NS 7 0.4 -11.601 <.001 8 0.02 -0.661 NS 9 0.07 -2.152 <.05 10 0.31 -9.160 <.001 11 0.24 -6.329 <.001 12 0.09 -3.226 .001 13 0.14 -3.724 <.001 14 0.13 -4.824 <.001 15 0.29 -9.383 <.001 16 0.14 -4.252 <.001 17 0.06 -1.721 NS 18 -0.07 1.827 NS 19 -0.02 0.305 NS 20 0.39 -11.514 <.001 21 0.25 -8.302 <.001 22 0.3 -10.342 <.001 23 0.23 -7.534 <.001 24 0.13 -4.926 <.001 25 0.11 -4.209 <.001 26 0.21 -6.992 <.001 27 0.28 -8.168 <.001
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