Summary of ReCAPP Forum:
"Reducing Sexual Risk Taking Behavior: Programs That Work"
December 2001

For two days in early December 2001, more than 150 researchers, program designers, and dedicated people working in organizations around the country and the world joined our on-line forum about Programs That Work. The wide-ranging discussion featured three guest moderators involved in the development and evaluations of these programs. The forum covered:

• What are "Programs That Work"?
  
  
• Defining effective programs: how do we know what works?
  
  
• The fidelity issue: adapting Programs That Work, including:
  • adapting curricula to specific populations, and
    
    
• Peer education

These topics — along with a list of resources and links mentioned by participants — are summarized below. Thanks again to all who contributed!

What exactly is a "Program That Works?" The U.S. Centers for Disease Control and Prevention (CDC) identified six Programs That Work (PTW) to reduce sexual risk taking among adolescents. These are:

• Reducing the Risk
• Get Real About AIDS (9-12 grade version)
• Be Proud! Be Responsible! (HIV/AIDS emphasis)
• Becoming A Responsible Teen
• Focus on Kids
• Safer Choices

The on-line forum's moderators, who included several of the designers of these curricula and programs, answered questions about each program's unique features and about what the Programs That Work have in common.

(For more detailed information about each of these programs and others mentioned during the forum, see ReCAPP's Evidence-Based Programs section and the Resources section of this summary.)

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• Expanding the List of Programs That Work
  Forum participants were eager to offer suggestions about other promising programs, in addition to the CDC's list of Programs That Work. (Note that some have evaluations underway, or have not been evaluated yet.) These included:
  
  
  • Making a Difference and Making Proud Choices — adaptations and extensions of the original Be Proud! Be Responsible! Curriculum. Loretta Sweet Jemmott, PhD, developer and researcher of these programs, offered the following descriptions:
    
    Making A Difference emphasizes that young adolescents should postpone sexual activity and that practicing abstinence is the only way to eliminate the risk for pregnancy and STDs, including HIV. It encourages positive attitudes and beliefs regarding abstinence, abstinence negotiation skills, and confidence in an adolescent's ability to abstain from sex.
    
    Making Proud Choices emphasizes that adolescents can reduce their risk for STDs, HIV, and pregnancy by using condoms, if they choose to have sex. It encourages positive attitudes towards condom use, skills, and confidence in an adolescent's ability to use condoms.
    
    
  • Children's Aid Society Carrera Program — a youth development approach used by one participant as a model for a comprehensive teen pregnancy prevention program and described in Emerging Answers as a program with strong evidence of success.
    
    
  • Our Whole Lives — Sexuality and Our Faith. This program, developed by the Unitarian Universalist Association and the United Church of Christ, drew praise for focusing on the entire life span (as its name suggests), from kindergarten through adulthood. As an Army health educator put it, "Great concept!"
    
    Moderator Konstance McCaffree, PhD, described Our Whole Lives as a wonderful curriculum and is hopeful that an upcoming evaluation will confirm the curriculum's benefits. "Though it doesn't completely fit the definition of comprehensive sexuality education program," she added, "it goes further in that direction. The facilitation includes involving students in discussions, with less direction toward one outcome — reducing pregnancy/disease. Participants learn about issues of gender, examine sexual orientation, body image, and more. It also has the spiritual component and manuals that help the facilitators lead the groups in this arena."
    
    (For more information on Our Whole Lives, try these web sites: ucc.org/justice/sexuality.htm and uua.org/owl/intro.html.)
    
    
  • Power Through Choices; Sexuality Education Curriculum for Youth in Foster, Group Care, and Other Out-of-Home Care Settings. ReCAPP Program Manager Lori Rolleri finds this curriculum, developed by the California Office of Family Planning, to be easy to use, with good content. (For more information, contact Mari Taylan, MPH, at the California Office of Family Planning, 916-654-6151).

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What's essential and what's optional in a Program That Works? The issue of fidelity — how closely a new program must resemble the model on which it is based — drew many comments from both moderators and participants.

• One part of the discussion focused on adapting the length or setting. For example, a participant from Wisconsin said, "It is next to impossible for classroom teachers to teach an entire program that may contain 6-16 lessons because of other demands on class time. Also, the veteran teachers who use these programs have years of experience. Teaching a program step-by-step stifles their creativity and doesn't take into consideration a teacher's understanding of their students and the school community."
  
  He continued, "Taking these concerns into consideration, we feel it is more important to emphasize what makes a program work than identifying programs that work. We want to provide teachers with the skills and knowledge to be able to develop a unit of instruction or curriculum that is based on what has been proven to be effective at preventing or reducing risky behaviors and promoting life-long health. We don't ignore PTW (in fact we sponsor PTW training) but we also don't promote them as the 'silver bullet' to reduce risky behaviors. I would like to know what the forum panel feels about program fidelity and is there any latitude to how these programs are implemented?"
  
  
  • In response, moderator Julie Taylor agreed that fidelity and length of program are ongoing issues as CDC tries to define and disseminate Programs That Work. For two of the featured curricula — Reducing the Risk and Get Real About AIDS — ETR has developed a practice profile. The profile is designed to give guidance to educators about three types of variation: best practice, acceptable practice, and unacceptable practice.
    
    
  • Moderator Karin Coyle, PhD, described some of her experiences reviewing variations in how Safer Choices has been implemented:
    
    "I agree that fidelity is a challenge," she said, "and the changes that are likely to occur span from dropping lessons to modifying approaches within classroom activities. I am not aware of any rigorous research on what happens to these longer programs when different combinations of lessons are taught, so I don't think we really know how program impact may change. (We can make some educated guesses, though)."
    
    "In the Safer Choices study," she continued, "we saw lots of variation in teaching style, philosophical emphasis, and comfort with discussing the topic. Because the teachers were part of the study, they were less likely to delete entire lessons, but they did often forget activities. The second year of the study, teachers were much more likely to adjust teaching strategies as they got more familiar and comfortable with the content. The impact we got with Safer Choices reflects these variations in fidelity."
    
    "I don't have any great solutions for handling the problem of ensuring fidelity, especially for longer programs," Dr. Coyle said, but she did offer some helpful suggestions. "Training regarding the importance of teaching with fidelity can help. Some districts with whom we work also have tried to prioritize lessons to give teachers guidance on what to keep if they can't teach the entire program. If this approach were used, one could use the research to guide the prioritization by focusing on lessons that address critical antecedents of sexual risk behavior."
    
    
  • Loretta Jemmott, developer of Making A Difference (MAD) and Making Proud Choices (MPC), offered to answer questions about "tweaking" these particular curricula:
    
    "I would say that there are key concepts and activities in MAD and MPC that are essential to the effectiveness of the curricula. However, there are items that can be adapted to meet community and/or cultural needs. Please contact me directly (215-898-6373) to discuss the ways in which you may need to tweak."
    
    Both of these curricula, she pointed out, are based on Be Proud! Be Responsible! A recent CDC study found that Be Proud! retained its effectiveness even after it was disseminated to community-based organizations and tailored to meet perceived local needs in five U.S. sites." Given that, Dr. Jemmott said, "I feel we will have the same success with MAD and MPC."
    
    For more information on CDC's study of the adaptation of Be Proud!, please see Kennedy MG, Mizuno Y, Hoffman R, Baume C, Strand J. (2000). The effects of tailoring a model HIV prevention program for local adolescent target audiences. AIDS Education and Prevention, 12 (3), 225-238.
    
    
• Another part of the discussion explored adapting curricula to specific populations.
  
  
  • Foster Care: In response to a question about programs for foster care youth, ReCAPP Program Manager Lori Rolleri offered this suggestion: "A curriculum titled Power through Choices: Sexuality Education Curriculum for Youth in Foster, Group Care and Other Out-of-Home Care Settings. The curriculum was funded by the California Office of Family Planning and revised in 2000. In my opinion, it's an easy-to-use curriculum with good content. There is an evaluation underway, but I do not think results are available yet. For more information, contact Mari Taylan, MPH, at the California Office of Family Planning at 916-654-6151."
    
    
  • Juvenile Justice: ETR Project Coordinator Alison Wakefield trains staff working within the juvenile justice system for the Survive Outside program, using the Be Proud! Be Responsible! curriculum because of its effectiveness among high-risk youth. "Survive Outside is a Centers for Disease Control-funded project to train Juvenile Justice (JJ) staff to implement HIV prevention strategies with incarcerated youth," she explained. "Survive Outside has been training JJ staff on the Be Proud! Be Responsible! curriculum for four years. We have found that JJ facilities have been very receptive to the curriculum, and a focus group we conducted with youth who had received the Be Proud! curriculum in Massachusetts showed similar results to those found by the Jemmotts in their research."
    
    Some foster care system staff have participated in this training as well. Ms. Wakefield offered to respond to specific questions directly and can be reached at 831-438-4060.
    
    
  • Teaching Abstinence in a Juvenile Justice Setting. A forum participant from Ohio asked for advice on "setting up an effective sex ed program for a juvenile justice system in a county that does not allow the promotion of contraception in its juvenile court programs."
    
    Moderator Julie Taylor offered these observations and suggestions: "It is our belief that youth in the juvenile justice setting are at high risk for a lot of things and need a harm reduction approach rather than an abstinence approach to sexual risk taking and/or alcohol and drug use."
    
    "Since to date, there is no credible research evidence that abstinence education reduces sexual risk taking among the general population or youth at high risk, we have decided not to use that approach in the programs we are using."
    
    "I ethically have trouble using an abstinence approach with youth who are very unlikely to be able to hear or apply the message," she explained. "For example, many girls in Juvenile Detention have been sexually abused. How does an abstinence message help them?"
    
    Later, she added: "I would try to educate the powers that be about the risks these kids take and the fact that some risks put their lives in jeopardy. I'm sure you have already tried that. Maybe it means doing some advocacy work — like finding a judge who will support your efforts, or lobbying with other decision makers."
    
    "We also work with the National Juvenile Detention Association," she said. "They work with policy makers and might have ideas about how to influence your local decision makers." Like other colleagues at ETR, Ms. Taylor offered to pursue this topic in person with those interested.
    
    
  • Latino/a Populations: In response to a question from a forum participant in Colombia, Lynette Gueitz, who worked on the Latino/a adaptation of Be Proud! For the National Council of La Raza and now works with Dr. Jemmott, offered to discuss key factors to keep in mind when working with acculturated versus non-acculturated Latino Youth. She can be reached at 215-898-0715.
    
    
  • Native American Populations: Forum participant Laurie Jensen-Wunder said that an adaptation of Be Proud! Be Responsible! for Native American populations is underway and should be available soon.

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A discussion on the role and value of peer education in sexuality education was sparked by a forum participant's question:

• "I was wondering what your professional thoughts are regarding peer education programs. Do you find that they are more effective than 'traditional' youth programming (adult facilitator)?"
  
  She went on to explain some of her concerns and reservations about this approach: "I personally have some concerns with the peer education model in that we place a lot of responsibility on children to educate their peers. I also feel that these programs take the responsibility off of adults. I think it's important that youth see adults discussing these sensitive issues, providing opportunities for meaningful exchange and opportunities for communicating accurate, non-threatening and non-moralizing information. As adults, we often feel that youth tune us out and only have interest in being with their peers. I feel that peer education tells youth that adults are uncomfortable talking with them about sex (for example) and that they should seek out their peers for information. As adults, I think it's important we educate ourselves first, get comfortable with the issue and show confidence in ourselves and our ability to educate our own children and in some professional cases other people's children (i.e., teachers, health educators, etc.) Comments?"
  
  
• Worthwhile, but labor-intensive. Moderator Konstance McCaffree, PhD, responded: "Peer education has great value, especially when social learning theory is the basis for the work." Dr. McCaffree cautioned, however, that putting an effective peer education program in place requires a lot of effort. "It is very labor-intensive," she explained, "because in order to train young people to implement sexuality education, you need to give them a great deal of training. You also need to monitor them well to provide help when they need it." She also observed that peer education "seems to work better for older age groups like the college programs. There are a number of high school peer education programs such as Hi-Tops in Princeton, NJ, but theirs is an on-going program where peers are recruited from the program they have grown up in. They also don't depend on a specific curriculum for implementation, which makes it easier for the peers and keeping them trained."
  
  
• Blending traditional and peer education approaches. Forum participant Cynthia Rosengard, PhD, a behavioral researcher at Brown University School of Medicine, added some insights from her own work: "My own experience would suggest that a blending of 'traditional' approaches and peer education really works the best. In the large-group interventions that we conducted with college-aged students, we had an 'adult' facilitator/health educator (usually a graduate student) and college-aged peer educators who ran small group discussions and participated in role-plays of sexual risk negotiation skills. This way, we had an 'expert' espousing safer-sex messages and providing information and facilitation, and we also had opinion leaders from their peer group who were pro-prevention as well. The two sources of information reinforced one another. I would imagine that, in younger age groups, it might be effective to have adults conduct some parts of the intervention and slightly older peers participate in other parts of the intervention."
  
  
• More support for blending approaches. Tim Bingham, Director of Ireland's YIELD program, echoed Dr. Rosengard's remarks: "YIELD has been working in the field of Peer Education for the past four years and has developed a programme that has seen positive results. We believe that both the 'traditional' methods of youth programming and peer education can be interlinked and should be."
  
  Responding to an earlier concern that a peer education emphasis may place an unfair burden on youth, he described YIELD's recruiting and training process: "If a young person is interested in becoming a peer educator, firstly they have to complete an application form and then go through an interview on why they want to go onto the programme. As part of the programme, we discuss why they want to become a peer educator, the values of an educator, i.e., should they smoke, drink or take illegal drugs. As the facilitator of the programmes, it is very important that my own views never come into the programme. Young people need to know what they believe, whether I agree or not. They need to have that firm foundation because they will be challenged by others and part of the programme is that they will be challenged by myself and others in the group. Peer education is all about empowering young people with information that can be passed onto others in their peer group."
  
  Deborah Wigely, a CCG Project Director in Northern California, also was enthusiastic: "We use a co-facilitation approach. College-age youth staff and adult staff team up to prepare, facilitate and debrief every educational session. We are using the Teen Outreach Program as our curriculum, in a community-based, after-school-program setting. We target 5th-8th grade youth in one time slot, and 9th-12th graders in another. Participants regularly report that the sessions are fun, our attendance has been quite consistent (last year 70% of the participants had 80% or better attendance throughout a 7-month intervention), the Youth Staff are growing at the speed of light, adult staff are able to 'stay current' through their interface with teen teammates, and maybe most important, participants see youth and adults working together as allies. All these things contribute to my conclusion that this approach is the best presentation methodology for this subject area."
  
  
• The Role of Adults. Christopher Kraus, a program manager in Ohio, offered these observations about the relative roles of peers and adults: "I like peer education and have managed a peer Ed sex Ed program for 12 years," he said. "But there is always an adult leader sitting in the back of the room during the lessons."
  
  "The role of the adult leader is key," he continued, "but it cannot upstage the role of the teen leader during the instruction. The adult's presence, though often silent, is important. The adult can answer questions that the teen cannot. But the adult must not censor the teen leader. Rather, the adult must be an active trainer of the teen leader, both before the lesson and after the lesson. The adult gives valuable feedback to the teen. The adult helps the teen develop as a leader. But the adult 'coach' must do this without taking away each peer educator's unique style. The peer must not become a mouthpiece for an adult. Each peer leader needs a certain kind of guidance to develop. It's different for each teen leader."
  
  For those interested in more information on his program, Mr. Kraus referred participants to the program's web site: www.cincinnatichildrens.org/psi.
  
  
• Peer Education in Safer Choices. In response to a question from moderator Julie Taylor, Karin Coyle described how peer educators are used in Safer Choices:
  
  "In Safer Choices, we used peer educators in two ways," she explained. "First, as part of the curriculum, we had students elect peer leaders within their classroom (6-8 youth, depending on the size of the class). These peer leaders assisted in the classroom with role play demonstrations, small group facilitation, etc. They did not teach but played a visible role. We included them in keeping with social cognitive theory on the benefits of positive role models."
  
  The second way was to establish peer clubs or peer teams at each intervention school. "This group of youth," she explained, "typically included from 10-18 students representing a variety of grade levels and subgroups on campus. These students were asked to design and implement six types of school-wide activities throughout the year. They also established a resource area on campus for HIV/STD and pregnancy prevention materials. The purpose of this peer component in Safer Choices was to help create a more positive school environment outside the classroom that reinforced and supported messages taught as part of the curriculum."
  
  "The peers were trained in different ways," Dr. Coyle added. "The classroom peer leaders had a brief two-hour training in which they essentially reviewed and practiced what they would be doing in the classroom."
  
  "The peer club members," she continued, "had a day-long training at the beginning of the year; met regularly with an adult coordinator, and had a brief refresher training at the beginning of second semester."
  
  "We continue to use the in-class peer leader model in some new research we are doing now with youth in alternative school settings," Dr. Coyle said. "It's been a great strategy for engaging youth in meaningful roles and for providing positive models in the classroom, and yet it doesn't require a lot of logistic planning."
  
  
• Comparing Peer Educators and Adult Facilitators. Loretta Jemmott, PhD, developer of Be Proud! Be Responsible!, Making a Difference, and Making Proud Choices, described results of a research study comparing 11th grade high school educators (selected by school counselors to serve as peer educators) and adult facilitators.
  
  "The peer educators received an intense five-day training on Peer Leadership and facilitation styles," she said. "They then received a two-day training on the curriculum. The adult facilitators also received this two-day training. The ability of both groups to effectively implement the curricula was evaluated."
  
  What did the researchers find? "We found that the adult facilitators and the peer educators were equally effective in implementing the curricula. The outcomes of the study were also the same (behavior change) for both groups (those taught by adults vs. those taught by peers)."
  
  Asked for recommendations regarding using peer educators, Dr. Jemmott said that the peer educators acted as co-facilitators during the implementation process. "The peers were liked better by youth," she said. "Clearly, this is something to keep in mind when implementing the program at a community level. It is also important during maintenance and follow-up."
  
  
• Talking About Sex: Peer Educators Can Help. Moderator Konstance McCaffree, PhD, noted that it's sometimes more difficult to help young people talk about sex than about drug and alcohol issues — the other area where peer education plays a significant role. In part, she said, this is "because we as a culture are relatively secretive and not very knowledgeable." When Dr. McCaffree works with parent groups, she said, "even though they want to be more comfortable talking with their children, they also realize that they don't have some of the knowledge that they need, and they definitely don't have the language. Even explaining to a young man about having wet dreams becomes difficult for many because they don't know much about it or there are lots of myths (and this is only a puberty issue)."
  
  "This is where peer education can be helpful to both young people and those of us in the healthy sexuality/harm reduction arena," Dr. McCaffree said. "Helping them learn how to talk about these issues, though labor-intensive to give them the skills and supervision, has many rewards down the line."
  
  
• Finding Out More About Peer Education. The May 1, 2002 edition of ReCAPP will focus on peer education. In the meantime, Karin Coyle and Lori Rolleri from ETR suggested these resources for those interested in finding out more:
  
  
  • Peer Potential: Making the Most of How Teens Influence Each Other by Peter Bearman, Hannah Bruckner, B. Bradford, Wendy Theobald and Susan Philliber. Published by the National Campaign to Prevent Teen Pregnancy. April, 1999. (www.teenpregnancy.org)
    
    Some of the key findings in this report include:
    
    • Creating a true support group requires more than putting adolescents together.
      
      
    • The composition of groups seems important for their success.
      
      
    • Peer leaders appear more successful in some situations than they are in others.
      
      
    • The use of peer leaders may have positive consequences for the leaders themselves.
      
      
    • There is some evidence that peer support groups produce positive outcomes for adolescents although we do not have any direct evidence that they can prevent teen pregnancy.

• Step by Step to Peer Health Education Programs: A Planning Guide by Malcolm Goldsmith and Sherri Reynolds. ETR Associates. 1997. (www.etr.org/pub/)
  
  
• Smith, M.U., DiClemente, R.J. STAND: A Peer Education Training Curricula for Sexual Risk Reduction in the Rural South. Preventive Medicine, 30, 441-449 (2000).
  
  
• Kirby, D., Korpi, M. Adivi, C. & Weissman, J. An Impact Evaluation of Project SNAPP: an AIDS and Pregnancy Prevention Middle School Program. AIDS Education and Prevention, 9 Supplement A, 44-61 (1997).

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On Curricula, Programs, and their Effectiveness

• Kirby, D. (2001) Emerging Answers: Research Findings on programs to Reduce Teen Pregnancy. Washington, DC: National Campaign to Prevent Teen Pregnancy.



• Power Through Choices: Sexuality education Curriculum for youth in Foster, Group Care, and other Out-of-Home Care Settings. (Contact Mari Taylan, MPH, California Office of Family Planning, 916-654-6151)



• Making a Difference: ReCAPP's Evidence-Based Programs
  
  
• Making Proud Choices: ReCAPP's Evidence-Based Programs
  


• Evaluation Fact Sheets on Safer Choices, Making a Difference, and Making Proud Choices: see individual curricula in ReCAPP's Evidence-Based Programs section



• Our Whole Lives: ucc.org/justice/sexuality.htm and uua.org/owl/intro.html



• Kennedy, M.G., Mizuno, Y., Hoffman, R., Baume, C., and Strand, J. (2000). The effects of tailoring a model HIV prevention program for local adolescent target audiences.
  
  
• Jemmott, J.B. III, Jemmott, L.S., & Fong, G.T. (1998). Abstinence and safer sex HIV risk-reduction interventions for African American Adolescents: A randomized controlled trial. JAMA, 279, 1529-1536.

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