Interventions Directed at Adolescent Sexuality Issues in Developed and Developing Countries: Evidence of What Works

1. Interventions Directed at Adolescent Sexuality Issues in Developed and Developing Countries: Evidence of What Works Douglas Kirby, Ph.D., ETR Associates March, 2003 * Some of these slides are based upon material in Emerging Answers, published by the National Campaign to Prevent Teen Pregnancy. You can obtain a free copy of the Executive Summary of Emerging Answers from dougk@etr.org. If you are from a developing country, you can obtain a free copy of the full volume from that same e-mail address. Some of these slides are also based on material in Advancing Young Adult Reproductive Health: Actions for the Next Decade published by Pathfinder International.

2. Sex and HIV/AIDS Education Programs for Adolescents

3. Sexuality & HIV/AIDS programs have multiple goals: • Decrease unintended pregnancy • Decrease STD including HIV/AIDS • Improve sexual health in other ways

4. Can sex and HIV/AIDS education programs reduce adolescent sexual risk-taking?

5. Study Criteria • Programs: • Targeted youth 11-19 years old • Were implemented in groups in schools or community settings • Were implemented in U.S., Canada, or developing countries • Studies: • Employed experimental or quasi-experimental design • Had a sample size of 100 or larger • Measured impact upon behavior

6. The Number of Programs with Different Effects on Sexual and Contraceptive Behaviors

7. The Number of Programs with Different Effects on Sexual and Contraceptive Behaviors(Continued)

8. Studies with Special Importance • Safer Choices: Preventing HIV, Other STD and Pregnancy • Reduced unprotected sex for 31 months or more • Reducing the Risk: Building Skills to Prevent Pregnancy, STD & HIV • Was independently evaluated 3 times in 3 different states in the U.S. and each time it delayed the initiation of sex; • In 2 of 3 states it increased condom or contraceptive use

9. Characteristics of Programs that Did Not Change Behavior • Focused mostly on increasing knowledge • Only taught generic decision-making or communication skills (not skills specifically about sexual behavior) • Did not give a clear message about sexual behavior • Were too short to include many activities

10. Characteristics of Effective Programs • Focus on reducing sexual risk-taking behavior • Are based on psychosocial theories that identified psychosocial sexual risk and protective factors • Give a clear message about avoiding unprotected sex (i.e., avoiding sexual intercourse or always using condoms or contraception) • Provide basic accurate information about risks of unprotected intercourse and methods of avoiding intercourse or using condoms or contraception • Address social pressures on sexual behavior

11. Theories identified important sexual psychosocial factors related to sexual behavior: • Knowledge about STD/HIV transmission and method of protection • Personal values about adolescents having sex • Attitudes about condoms and contraception • Perception of peer norms or family values about sex and condoms or contraception • Self-efficacy to refuse unwanted sex or to insist on condom or contraceptive use

12. Characteristics of Effective Programs continued • Provide modeling of and practice in communication and refusal skills • Use teaching methods to involve participants and help them personalize information • Incorporate behavioral goals, teaching methods, and materials that are appropriate to the age, sexual experience and culture of the students • Last a sufficient number of sessions to complete important activities • Select teachers or peers who believe in the program and then provide training for those individuals

13. Conclusions about the Impact of Sex/HIV Education Programs • Not all curricula are effective • Knowledge is not enough • Generic skills are not enough • Effective curricula have the ten characteristics summarized

14. Conclusions about the Impact of Sex/HIV Education Programs continued • Sex/HIV education programs • Do not increase sexual activity • Sex/HIV education programs may: • Delay initiation of intercourse • Reduce number of sexual partners • Increase use of condoms and contraception • Emphases upon abstinence and contraception are compatible, not conflicting

15. Conclusions about the Impact of Sex/HIV Education Programs continued • Programs are quite robust; they are effective with multiple groups: • Males and females • All major ethnic groups • Sexually experienced and inexperienced • Youth in advantaged and disadvantaged communities • Programs may be especially effective with higher risk youth in disadvantaged communities

16. Conclusions about the Impact of Sex/HIV Education Programs continued • Sex/HIV education programs: • Are not a complete solution • Can be an effective component in a more comprehensive initiative involving families, health services and communities more broadly

17. Implications for Policy • Should encourage the implementation of sex/HIV education programs demonstrated to be effective with similar populations • Should encourage the implementation of sex/HIV education programs with common characteristics of effective programs

18. Implications for Policy continued • Should provide adequate time in the classroom or in youth serving organizations for these programs • Should provide adequate training to teachers or staff so that programs are implemented with fidelity • Should encourage implementation with fidelity in other ways

19. One-On-One Sex Education/Counseling in the Clinic Setting • Clinics changed their protocols for working with adolescent clients • Multiple studies found a significant increase in condom or other contraceptive use • Provided more than routine information • Asked questions about adolescents’ sexual behavior and barriers to abstaining from sex or using protection • Did role plays refusing sex or using condoms • Gave a clear message about avoiding unprotected sex

20. Implications for Policy • Clinics should implement clinician-patient protocols found to be effective • Youth-serving agencies should refer youth to health services with effective protocols • Other agencies can use similar protocols in other settings

21. Integrated Sex Education and Youth Development Programs • Children’s Aid Society Carrera Program • Included many components (e.g., help with school, job club, sex education, health and mental health services, art and sports) • Reduced pregnancy by half for 3 years • Some youth development programs without a good sexuality education program did not reduce teen pregnancy or childbearing

22. Conclusions • Some sex and STD/HIV education programs and some clinic programs address sexual risk and protective factors and can delay sex or increase condom or contraceptive use • Some programs combine a good sex education program and a good youth development program and have the greatest impact • Effective programs give a clear message about avoiding unprotected sex and involve youth interactively so that they personalize the message

23. Overall Implications for Policy Policies should: • Support the implementation of specific programs demonstrated to be effective with similar populations • Support the implementation of programs with the characteristics of effective programs • The 10 characteristics of effective programs • Support multiple types of effective programs, both sex and HIV education and youth development programs, as resources warrant