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My Take

Seeing Relationships: Best Next Steps in STD/HIV/Pregnancy Prevention

Karin Coyle, PhD

Teen pregnancy rates have dropped by over half in the past 20 years. More teens today are waiting to have sex and using contraception when they do have sex. Evidence-based interventions for sexual and reproductive health (SRH) have played a role in these encouraging trends.

At ETR, we’re big supporters of evidence-based programs, and our Research and Evaluation team has carried out some of the important studies that prove such programs can be effective. But we also know our work isn’t done.

Our team is testing some exciting new programs that ask middle and high school students to consider the ways romantic relationships influence their sexual choices and risks. We call this “contextualizing” sexual and reproductive health education—that is, using the context of relationships to build health-promoting information, attitudes and behaviors.

When we re-cast the focal points in SRH programs from an individual to an individual within a relationship or friendship, we see richer classroom discussions, greater engagement among students, and more student excitement about the content and the lessons.

Why Focus on Romantic Relationships?

There are compelling reasons to bring more focus to a relationship context in SRH education. For example:

  1. Romantic relationships are central in young people’s lives. By middle adolescence (ages 12 to 14), most young people have had at least one romantic relationship. In a recent analysis of data from the National Longitudinal Study of Adolescent Health (Add Health), 3 out of 4 respondents reported having a romantic relationship in the previous 18 months.
  2. Most youth experience sexual pressures and risks within romantic relationships. When the focus of SRH education is on the individual, students are often learning content and skills outside the context where they are actually most likely to need them.
  3. Relationship factors are determinants of sexual risk. Our recent middle school study found that a number of elements, including length of relationship, involvement with an older partner, and going out as a couple rather than with a group, are determinants of sexual risks. We also found other sexual behaviors such as touching private parts and oral sex were related to having vaginal intercourse. 
  4. Youth master key developmental tasks through romantic relationships. Relationships help young people engage in deeper learning about emotional intimacy, personal identity and autonomy. These are features that also play a significant role in attitudes and commitments about sexual risks.
  5. Youth find relationships intrinsically interesting. Students care about romantic relationships. They’re interested in their own and their friends’ relationships, and are often fascinated by fictional relationships in movies, TV, books and other media. This draws them into the content and conversations during the program.
  6. Relationship patterns learned in adolescence can influence future relationships. We set the groundwork for healthier future relationships when we help youth distinguish between healthy and unhealthy relationships, give them opportunities to practice how to express personal wishes and set limits, and support learning about how to build trust and intimacy without compromising personal boundaries. This kind of learning has the potential to reduce sexual risk and relationship violence as well as enhance overall emotional health.

Changing to a Relationship Focus: Some Examples

What does it look like if we shift from our existing individual focus to a contextual, relationship-based focus? Here are some examples from common activities in popular and respected SRH programs; we discuss other examples in a recent paper on this topic. In many cases, the individually focused activities provide foundational skills. Adding contextual activities enriches the learning and provides students with more practical skills for real-life situations.

Activity Individual Focal Points Contextual Focal Points
Condom negotiation Students practice “condom comebacks” they can use if a partner pressures them to have unsafe sex. They roleplay refusal skills. Students discuss social and relationship factors that influence condom use, including trust, intimacy (dropping condom use represents a point of greater intimacy), and relationship duration; they practice negotiating condom use in these situations.
Sticking with sexual limits/personal boundaries Students perform roleplays in which they practice skills for sticking with their sexual limits; for example, they may learn about using alternative actions (“Let’s go to a movie”). Students perform roleplays with more context—relationship length, individual vs. group dating, being with an older partner, prior sexual behavior within this or other relationships; they also learn to recognize and navigate different limits in a relationship (e.g., going with the safest limit rather than convincing the other person to change a limit).

The Power of Stories

We’re testing this approach to SRH education in a number of ways. One of the most exciting and promising is through storytelling. Stories are a powerful and engaging way to illustrate the contextualized elements of relationships and address a range of determinants in a natural, “non-clunky” way.

For lessons in a high school curriculum, we developed a series of characters and relationships, then interwove their stories across the curriculum. In each lesson, students hear the latest “installment” of the tales, almost like a soap opera. We worked with focus groups of high school students to develop these stories, and used youth experiences as the foundation for the events described to lend credibility to the stories.

The youth in our focus groups were also upfront about their frustration with adults discounting the value, meaning and legitimacy of their relationships. Bringing attention to these relationship-based stories affirms for students that the emotional experiences they have in relationships are powerful and meaningful, and that educators recognize and respect this.

The students who took part in the pilot test really liked the story-based approach.  They identified with the characters and were able to see real-life experiences of their friends and peers reflected in the unfolding dramas. Students even asked to take turns reading the stories each day.

What the Future Looks Like

Students have received HIV/STI and pregnancy prevention programs for decades, many of which share similar elements and approaches. We have an opportunity to use new avenues to offer dynamic, fresh content, and broaden the sexual health topics we provide for youth. Storytelling and using the context of relationships in the learning are two promising approaches for doing this. 

Karin Coyle, PhD, is a senior research scientist at ETR who specializes in the development and evaluation of health prevention programs, particularly HIV, other STD and pregnancy prevention.