Reducing Adolescent Sexual Risk: A Theoretical - ETR Associates

Reducing AdolescentSexual RiskA Theoretical Guidefor Developingand AdaptingCurriculum-BasedProgramsKnowledgePerceived RiskVideosMini-LectureRoleplayClinic VisitAttitudesPerceivedNormsTeenSexualBehaviorGamesSkillsDouglas KirbyETR AssociatesKarin CoyleETR AssociatesForrest AltonSouth Carolina Campaignto Prevent Teen PregnancyLori RolleriEngenderHealthLeah RobinDivision of Adolescentand School Health, CDCIntentionsParent-ChildCommunication

Reducing AdolescentSexual RiskA Theoretical Guide forDeveloping and AdaptingCurriculum-Based ProgramsDouglas KirbyETR AssociateswithKarin CoyleETR AssociatesForrest AltonSouth Carolina Campaign to Prevent Teen PregnancyLori RolleriEngenderHealthLeah RobinDivision of Adolescent and School Health, CDC

ETR Associates (Education, Training and Research) is anonprofit organization committed to fostering the health,well-being and cultural diversity of individuals, families, schoolsand communities. The publishing program of ETR Associatesprovides books and materials that empower young people andadults with the skills to make positive health choices. Weinvite health professionals to learn more about our high-qualitypublishing, training and research programs by contacting us at4 Carbonero Way, Scotts Valley, CA 95066, 1-800-321-4407,www.etr.org.The South Carolina Campaign to Prevent Teen Pregnancy(SC Campaign) works in all of the state’s 46 counties to preventadolescent pregnancy through education, technical assistance,public awareness, advocacy and research. Since its inceptionin 1994, the SC Campaign has established itself as the leaderand quality resource in South Carolina for comprehensive,medically accurate, age-appropriate, science-based approachesand evidence-based programs to prevent teen pregnancy.For more information, visit www.teenpregnancysc.org orwww.carolinateenhealth.org.© 2011 ETR Associates. All rights reserved.Published by ETR Associates4 Carbonero WayScotts Valley, California 95066Printed in the United States of America10 9 8 7 6 5 4 3 2 1Title No. A063ISBN 978-1-56071-704-1

DedicationThis volume is dedicated to Guy Parcel, Ph.D.,Professor of Health Promotion and BehavioralHealth, University of Texas School of PublicHealth, Austin Regional Campus, formerDean of the School of Public Health at theUniversity of Texas Health Science Center atHouston and former director of the Center forHealth Promotion and Prevention Research.Guy has been an incredibly productive andprolific leader in the fields of health educationand public health more generally. His manyaccomplishments include helping to develop andpromote intervention mapping, a very rigorousand systematic approach to designing effectiveprograms. In our joint work together, I learneda great deal from Guy about approaches toeffective curriculum design, as well as programevaluation and project management. Much ofthe foundation of this book was stimulated byhis approach and ideas.Douglas KirbyReducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programsiii

AcknowledgmentsThis book evolved out of a series of all-day trainings thatwere jointly conceived by the South Carolina Campaign toPrevent Teen Pregnancy and myself and that I conductedover several years for the SC Campaign. Each trainingfocused on two or three risk and protective factors (and/orbackground topics) that became the basis for the chapters inthis book. I want to thank Suzan Boyd, former ExecutiveDirector of the SC Campaign; Forrest Alton, currentExecutive Director of the SC Campaign; and others at theCampaign for their intellectual, administrative and financialsupport for those trainings and, ultimately, this volume.I especially want to thank my co-authors—Karin Coyle,Forrest Alton, Lori Rolleri and Leah Robin—for theircontributions to this book. They helped conceptualize thebook, review and edit each chapter, summarize activities asexamples, arrange focus groups to review the entire volumeand obtain funding. Karin Coyle also wrote parts of twochapters and provided particularly helpful guidance on theremaining chapters. I also want to thank Lisa Romero forcreating the resource section and reviewing the volume.The book was strengthened by the reviews of numerousexperts in the field, including Bill Bacon, Patricia Dittus,Joyce Fetro, Ericka Gordon, Angie Hinzey, Chris Markam,Susan Milstein, Leslie Pridgen, Mary Prince, Nicole Ressa,Stacy Sirois and Antonia Vilarruel. Without question, thisbook benefitted from their innumerable suggestions.This book was partially supported by funding from theDivision of Adolescent and School Health, National Centerfor Chronic Disease Prevention and Health Promotion,Centers for Disease Control and Prevention (CDC)(Contract # 200-2002-00800), and Cooperative Agreementnumber 5U65DP424971-05. The findings and conclusionsin this report are those of the authors and do not necessarilyrepresent the views of CDC.ivReducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

ContentsDedication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iiiAcknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . iivActivities, Boxes and Figures . . . . . . . . . . . . . . . . viTables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Creating a Logic Model andLearning Objectives . . . . . . . . . . . . . . . . . . . . . 93 Increasing Knowledge . . . . . . . . . . . . . . . . . . 334 Improving Perceptions of Risks—Both Susceptibility and Severity. . . . . . . . . . . 435 Addressing Attitudes, Values and Beliefs . . . . 556 Correcting Perceptions of Peer Norms . . . . . . 757 Increasing Self-Efficacy and Skills . . . . . . . . . 838 Improving Intentions . . . . . . . . . . . . . . . . . . . 999 Increasing Parent-ChildCommunication About Sex . . . . . . . . . . . . . 10710 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . 119Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programsv

Activities, Boxes and FiguresActivity 4-1 Pregnancy Risk Activity and Follow-UpActivities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50Activity 4-2 STD Handshake . . . . . . . . . . . . . . . . . . . . . . . 52Activity 4-3 STD Risks . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53Activity 5-1 Reasons to Not Have Sex . . . . . . . . . . . . . . . . 70Activity 5-2 Dreams, Goals and Values . . . . . . . . . . . . . . . 71Activity 5-3 Sexual Values Line . . . . . . . . . . . . . . . . . . . . . 72Activity 5-4 “Dear Abby” . . . . . . . . . . . . . . . . . . . . . . . . . . 73Activity 5-5 Addressing Barriers to Using Condoms . . . . . 74Activity 6-1 Conducting In-Class Surveys to ChangePerceptions of Peer Norms . . . . . . . . . . . . . . . . . . . . . . . . . . . 82Activity 7-1 Lines That People Use to Pressure Someoneto Have Sex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91Activity 7-2 Situations That May Lead to Unwantedor Unintended Sex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92Activity 7-3 Roleplaying to Enhance Refusal Skills . . . . . . 94Activity 7-4 Condom Line-Up . . . . . . . . . . . . . . . . . . . . . . 96Activity 7-5 Using Condoms Correctly . . . . . . . . . . . . . . . . 97Activity 8-1 Creating Personal Sexual Limits . . . . . . . . . . 104Activity 8-2 Creating a Plan to Stick to Their Limits . . . . 105Activity 9-1 Homework Assignment to Talk with Parents.115Activity 9-2 Relay Race for Parent-Child Programs . . . . . 116Activity 9-3 Human Sexuality Board Game forParent-Child Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117Activity 9-4 “Dear Abby” for Parent-Child Programs . . . 118Box 2-1 Tips for Developing Logic Models . . . . . . . . . . . . . 11Box 2-2 Criteria for Assessing Logic Models andTheir Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Box 3-1 Types of Activities to Increase Knowledge inEffective Pregnancy and STD/HIV Prevention Curricula . . 36Box 3-2 Important Topic Areas to Cover in Pregnancy andSTD/HIV Prevention Curricula . . . . . . . . . . . . . . . . . . . . . . 42Box 10-1 Potential Pilot Test Probes . . . . . . . . . . . . . . . . . 123Figure 1-1 Possible Logic Model of Psychosocial FactorsAffecting Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Figure 2-1 Basic Elements in a Logic Model That Forms theBasis of This Book . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Figure 2-2 Steps for Developing and UnderstandingLogic Models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Figure 2-3 An Example of a Logic Model to ReducePregnancy and Sexually Transmitted Disease byImplementing a Sexuality Education Curriculum . . . . . . . . . 15Figure 5-1 Peripheral Route—Central Route . . . . . . . . . . . 57Figure 10-1 Assessing Factors in Curricula . . . . . . . . . . . . 121viReducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

TablesTable 1-1 The Number of Curriculum-Based Sex EducationPrograms with Indicated Effects on Sexual Behaviors . . . . . . 4Table 1-2 The 17 Characteristics of Effective Programs . . . . 5Table 2-1 Bloom’s Revised Taxonomy of Learning—Cognitive Processing Domain . . . . . . . . . . . . . . . . . . . . . . . . 13Table 2-2 Learning Objectives to Reduce Sexual Activity . 23Table 2-3 Learning Objectives to Increase Condom Use . . 25Table 2-4 Learning Objectives to Increase HormonalContraceptive Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27Table 2-5 Learning Objectives to Increase STDVaccinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29Table 2-6 Learning Objectives to Increase Pregnancy andSTD Testing and Treatment . . . . . . . . . . . . . . . . . . . . . . . . . 30Table 3-1 Number of Studies Reporting Effects ofKnowledge on Sexual Behavior . . . . . . . . . . . . . . . . . . . . . . . 35Table 3-2 Number of Studies Reporting Effects ofKnowledge on Condom or Contraceptive Use . . . . . . . . . . . . 35Table 3-3 Number of Programs Having Effects on DifferentKnowledge Topics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35Table 4-1 Number of Studies Reporting Effects ofPerceptions of Risks of Pregnancy or STD/HIVon Initiation of Sex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45Table 4-2 Number of Studies Reporting Effects ofPerceptions of Consequences of Pregnancy and ConcernAbout Pregnancy on Contraceptive Use . . . . . . . . . . . . . . . . 45Table 4-3 Number of Studies Reporting Effects of OverallConcern About Risks of STD/HIV on Condom Use . . . . . . 45Table 4-4 Number of Programs Having Effects onPerceptions of Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46Table 4-5 Examples of Items That Have Been Used toMeasure Perceptions of Risk . . . . . . . . . . . . . . . . . . . . . . . . . 49Table 5-1 Number of Studies Reporting Effects of AttitudesAbout Abstaining on Teens’ Own Sexual Behavior . . . . . . . . 61Table 5-2 Number of Studies Reporting Effects ofAttitudes About Condom/Contraceptive Use on Teens’Own Condom/Contraceptive Use . . . . . . . . . . . . . . . . . . . . . 62Table 5-3 Number of Programs Having Effects onAttitudes Toward Sex and Condom/Contraceptive Use . . . . 63Table 5-4 Examples of Survey Items from Research Studiesof Attitudes, Values and Beliefs in Different Domains . . . . . 67Table 6-1 Number of Studies Reporting Effects ofPeer Norms About Sex on Teens’ Own Sexual Behavior . . . . 77Table 6-2 Number of Studies Reporting Effects ofPeer Norms About Condom/Contraceptive Use onTeens’ Own Condom/Contraceptive Use . . . . . . . . . . . . . . . 77Table 6-3 Number of Programs Having Effects onPerceptions of Peer Norms or Behavior . . . . . . . . . . . . . . . . . 78Table 6-4 Examples of Items That Have Been Used toMeasure Perceptions of Peer Norms . . . . . . . . . . . . . . . . . . . . 81Table 7-1 Number of Studies Reporting Effects ofSelf-Efficacy to Refrain from Sex on Teens’ OwnSexual Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85Table 7-2 Number of Studies Reporting Effects ofSelf-Efficacy to Insist on Condom/Contraceptive Use onTeens’ Own Condom/Contraceptive Use . . . . . . . . . . . . . . . 85Table 7-3 Number of Studies Reporting Effects ofSelf-Efficacy to Actually Use Condoms or Contraceptiveson Teens’ Own Condom or Contraceptive Use . . . . . . . . . . . 86Table 7-4 Number of Programs Having Effects onSelf-Efficacy and Skills to Perform Protective Behaviors . . . 86Table 7-5 Examples of Items That Have Been Usedto Measure Self-Efficacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89Table 8-1 Number of Studies Reporting Effects ofIntentions on Initiation of Sex . . . . . . . . . . . . . . . . . . . . . . . 101Table 8-2 Number of Studies Reporting Effects ofIntentions on Condom or Contraceptive Use . . . . . . . . . . . . 101Table 8-3 Number of Programs Having Effectson Intentions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101Table 8-4 Examples of Items That Have Been Usedto Measure Intentions to Have Sex or Use Condoms orContraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102Table 9-1 Number of Studies Reporting an AssociationBetween Parent-Child Communication About Sexand Teens’ Initiation of Sex . . . . . . . . . . . . . . . . . . . . . . . . . 109Table 9-2 Number of Studies Reporting Effects ofParent-Child Communication About Sex on Teens’Subsequent Initiation of Sex . . . . . . . . . . . . . . . . . . . . . . . . . 109Table 9-3 Number of Studies Reporting Effectsof Parent-Child Communication About Sex onTeens’ Condom or Other Contraceptive Use . . . . . . . . . . . . 109Table 9-4 Number of Programs for Teens HavingEffects on Parent-Child Communication About Sex . . . . . 111Table 9-5 Number of Programs for Parents andTeens Having Effects on Parent-Child CommunicationAbout Sex and Teen Sexual Behavior. . . . . . . . . . . . . . . . . . 111Table 9-6 Number of Programs for Only Parents HavingEffects on Parent-Child Communication About Sex . . . . . 113Table 9-7 Examples of Items That Have Been Used toMeasure Parent-Child Communication About Sexuality . . 114Table 10-1 Instructional Principles Importantfor Each Factor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programsvii

1 IntroductionThis book was created tohelp others design or adapttheir own curricula.Overview of This BookUnintended pregnancy and sexually transmitted diseases(STDs), including HIV, continue to be importantproblems among young people in the UnitedStates. These problems can be addressed effectively ifyoung people reduce their sexual risk behaviors—forexample, if they initiate sexual activity later, havesex (meaning vaginal, anal and oral sexual activity)less frequently, have fewer sexual partners anduse condoms or contraception more consistently.However, programs designed to address unintendedpregnancy and STDs cannot directly control thesexual risk behavior of young people; rather, theycan only affect various risk and protective factorsthat, in turn, affect decision making and behavioramong young people.Risk and protective factors include biological factorssuch as age or maturation, community factors suchas economic opportunities or crime rates, and familyfactors such as strong families and monitoring ofchildren.However, a very important group of risk and protectivefactors is “sexual psychosocial” factors. Theseinclude knowledge, perceptions of risk, attitudes,perceptions of norms, self-efficacy and intentions.These are particularly important because 1) theyhave a very strong impact on sexual decision makingand behavior and 2) educational programs, eitherin school or out of school, can significantly improveeach of them, if curricula include the right kinds ofactivities that incorporate important instructionalprinciples.Although it is relatively easy to increase knowledge,it is not easy to markedly improve all ofthese factors. If curriculum activities fail to includeimportant instructional principles, they may fail toimprove these factors and may fail to have an impacton behavior. On the other hand, there is considerableevidence that all of these factors are amenableto change when appropriate instructional techniquesare used. Thus, these principles are important toachieve behavior change.This book is not a curriculum itself. Instead, it isdesigned to help reproductive health professionals,educators, curricula selection committees and othersdesign or adapt curricula so that they focus on riskand protective factors that are related to sexual riskbehavior and use instructional principles most likelyto improve the targeted factors. It can also be usedto select curricula that incorporate these features,Chapter 1 Introduction 1

ut it does not focus on other important criteria forselecting curricula.We have structured the book around risk andprotective factors most likely to be changed by acurriculum-based program. Each chapter focuseson a different risk or protective factor, summarizingthe available evidence showing that the factor affectssexual behavior and discussing relevant behaviorchange theory and important instructional principlesfor improving the factor.Although most of the examples in this book comefrom activities used primarily with middle or highschool-aged youth, it also can be useful for peopledesigning curricula for younger or older youth.Finally, even though all the examples involve sexuality,the risk and protective factors, the theories andthe pedagogical principles may apply to many healthbehaviors other than sexual risk, such as eatingnutritiously, exercising and preventing substanceabuse. However, theories and research on the factorsaffecting these other behaviors should be thoroughlyreviewed before applying the instructional principlesdiscussed.Sexual Risk Behaviorand Its ConsequencesIn the United States, young people engage in considerablesexual risk behavior prior to or outside ofmarriage. For example:• Roughly half of all high school students reporthaving had sex at least once and close to twothirdsreport having sex before they graduatefrom high school (Centers for Disease Controland Prevention 2010b).• Although 80 to 90 percent of teens report usingcontraception during their most recent act ofsexual intercourse, many teenagers do not usecontraceptives correctly and consistently. Among15- to 19-year-old women relying upon oral contraceptives,only 70 percent take a pill every day(Abma et al. 1997). Among never-married men15-19 who had sex in the previous year, only47 percent used a condom every time they had sexin that year (Abma 2004).As a result, pregnancy rates and birth rates amongU.S. young adults remain very high relative to otherdeveloped countries.• In 2004, the latest year for which data are published,the rate of unplanned pregnancy was highestamong women 18-19 and 20-24 years of age.In these age groups, more than one unplannedpregnancy occurred for every 10 women, a ratetwice that for women overall (Finer and Henshaw2006; Ventura, Abma et al. 2008).• Among 15- to 19-year-old teens, about 72 ofevery 1,000 women became pregnant in 2006(the last year for which data are available)(Guttmacher Institute 2010). This means thatcumulatively, more than 30 percent of teenagewomen in the United States became pregnant atleast once by the age of 20.• These rates were much higher for Hispanics(127 per 1,000 women) and blacks (126 per1,000 women) than for non-Hispanic whites(44 per 1,000 women).• In absolute numbers, about 750,000 womenunder age 20 become pregnant each year(Guttmacher Institute 2010).• More than 80 percent of these pregnancies areunplanned (Finer and Henshaw 2006).• Among young women ages 20-24, each year1.7 million pregnancies occur, 58 percent ofwhich are unplanned. Among unmarried women20-24, 72 percent of their pregnancies areunplanned (Connor 2008).These unintended pregnancies have negative effectson the young adults involved, their children andsociety at large.• Teenage mothers are less likely to completeschool, less likely to go to college, more likely tohave large families and more likely to be singlethan their peers who are not teenage mothers,increasing the likelihood that they and their childrenwill live in poverty. Negative consequencesare particularly severe for younger mothers andtheir children (Hoffman 2006).2 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

• Children of teenage mothers are likely to haveless supportive and stimulating home environments,lower cognitive development, less education,more behavior problems and higher ratesof both incarceration (for boys) and adolescentchildbearing than children of non-teenage mothers(Hoffman 2006).STDs are also a large problem. Compared to olderadults, sexually active adolescents and young adultsages 24 and younger are at higher risk for acquiringSTDs. For example:• The most common STDs among young peopleare human papillomavirus (HPV), trichomoniasisand chlamydia. Although young adults (24 andunder) represent only 25% of the sexually activepopulation, they account for nearly half (48 percent)of the new STD cases every year. In 2004,there were more than nine million cases of STDreported in this age group (Weinstock, Berman etal. 2004).• In addition, more than 7,000 young adults 24 andunder were diagnosed with HIV in 2008 (Centersfor Disease Control and Prevention 2010a).• The prevalence of STDs are typically muchhigher among African-American young peoplethan non-Hispanic whites (Centers for DiseaseControl and Prevention 2008a). In 2006,for example, the rates of gonorrhea amongAfrican-American 15- to 19-year-old womenwere 15 times greater than those for white womenin the same age group. The rate for African-American men ages 15-19 was 39 times higherthan for 15- to 19-year-old white men (Centersfor Disease Control and Prevention 2008).Impact of Curriculum-BasedSex and STD/HIV EducationProgramsIn response to these high rates of unintended pregnancyand STDs, many people concerned aboutadolescent reproductive health have implementeda wide variety of programs to reduce sexual risk.Aside from contraceptive services, STD testing andtreatment and other reproductive health servicesprovided in clinics, the most commonly implementedtypes of prevention programs are curriculum-basedsex and STD/HIV education programs.These programs are based on a written curriculumand are implemented among groups of youth. Theyare in contrast to one-on-one peer programs; healthfairs; youth development programs and other kindsof programs that also have an impact on adolescentsexual behavior. They are commonly implemented inschools where very large numbers of young peoplecan be reached before and after they have initiatedsexual activity. However, curriculum-based sexand STD/HIV education programs also have beenimplemented effectively after school and in nonschoolsettings such as clinics, community centers,housing projects and elsewhere.Multiple reviews of sex and STD/HIV educationprograms have been conducted in the United Statesand elsewhere (Johnson, Carey et al. 2003; Robin,Dittus et al. 2004; Kirby 2007; Underhill, Operarioet al. 2007, UNESCO 2009). They consistently supportthe following conclusions (see Table 1-1):1. Sex and STD/HIV education programs do notincrease sexual behavior, even when they encouragesexually active young people to use condomsor other forms of contraception.2. Some programs delay the onset of sexual intercourse,reduce the frequency of sex, reduce thenumber of sexual partners, increase condom use,increase other contraceptive use, and/or reducesexual risk.3. Not all programs are effective at changingbehavior. According to one review (Kirby 2008),about two-thirds of the programs had a positivesignificant impact on one or more sexual behaviorsamong the entire sample or among importantsub-groups within the sample (e.g., males orfemales). About one-third did not. And one-thirdof the programs improved two or more behaviors;the remainder did not.4. Numerous characteristics distinguish theeffective programs from the ineffective ones(Kirby 2007). For example, the effective programsChapter 1 Introduction 3

used psychological theory and research to identifythe cognitive risk and protective factors that affectbehavior and then developed program activities tochange those factors, gave clear messages aboutbehavior and taught skills to avoid undesired andunprotected sexual activity. Table 1-2 lists all thedistinguishing characteristics.5. Some programs for parents also have been foundto be effective at increasing communicationbetween parents and their adolescents and atreducing adolescent sexual risk behavior(Kirby 2007).Identifying and ImprovingImportant Risk andProtective FactorsAs stated above, curriculum-based sex andSTD/HIV programs, as well as other programs,cannot directly control whether young peopleengage in sexual activity or whether they useprotection; instead, young people make their owndecisions about sexual behavior and use of protection.Thus, to be effective, programs must markedlyimprove those risk and protective factors that havean important impact on youths’ decision makingabout sexual behavior.Logically, if programs correctly identify the factorsthat have a clear impact on behavior and if programactivities markedly change those factors, then theprogram will have an impact on behavior. However,if programs identify factors that only weakly affectbehavior or fail to change the factors sufficiently,then they may not affect behavior. Consequently,it is critical both to identify the important factorsaffecting behavior and to implement programsdesigned to change those factors.Factors that have a large impact on behavior includeinternal cognitive factors (such as knowledge, attitudes,skills and intentions) and external factors suchas access to adolescent-friendly reproductive healthservices. Curriculum-based programs, especiallythose in schools, typically focus on internal cognitivefactors. These factors are very proximal (closelyTable1-1The Number of Curriculum-Based SexEducation Programs with IndicatedEffects on Sexual BehaviorsUnitedStates(N=47)OtherDevelopedCountries(N=11)DevelopingCountries(N=29)AllCountriesin the World(N=87)Initiation of Sex➤ Delayed initiation 15 2 6 23➤ Had no significant impact 17 7 16 40➤ Hastened initiation 0 0 0 0Frequency of Sex➤ Decreased frequency 6 0 4 10➤ Had no significant impact 15 1 5 21➤ Increased frequency 0 1 0 1Number of Sex Partners➤ Decreased number 11 0 5 16➤ Had no significant impact 12 0 8 20➤ Increased number 0 0 0 0Use of Condoms➤ Increased use 14 2 7 23➤ Had no significant impact 17 4 14 35➤ Decreased use 0 0 0 0Use of Contraception➤ Increased use 4 1 1 6➤ Had no significant impact 4 1 3 8➤ Decreased use 1 0 0 1Sexual Risk-Taking➤ Reduced risk 15 0 1 16➤ Had no significant impact 9 1 3 13➤ Increased risk 0 0 1 1linked to behavior conceptually) and are related tobehavior.Previous studies of curriculum-based sex and STD/HIV education programs have demonstrated thatthose programs that effectively delayed the initiationof sex, reduced the frequency of sex, or reduced thenumber of sexual partners sometimes focused onand improved the following cognitive factors (Kirby2007):1. Knowledge, including knowledge of sexual issues,pregnancy, HIV and other STDs (includingmethods of prevention)2. Perception of pregnancy risk, HIV risk, and otherSTD risk3. Personal values about sexuality and abstinence4. Perception of peer norms and behavior about sex5. Self-efficacy to refuse sexual activity and to usecondoms and contraception4 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

Table1-2 The 17 Characteristics of Effective Programs*The Process of Developingthe CurriculumThe Contents of the Curriculum ItselfThe Process of Implementingthe Curriculum1.Involved multiple peoplewith different backgroundsin theory, research and sexand STD/HIV education todevelop the curriculum2. Assessed relevant needs andassets of target group3. Used a logic model approachto develop the curriculumthat specified the healthgoals, the behaviors affectingthose health goals, therisk and protective factorsaffecting those behaviorsand the activities addressingthose risk and protectivefactors4. Designed activities consistentwith community valuesand available resources (e.g.,staff time, staff skills, facilityspace and supplies)5. Pilot-tested the program*Curriculum Goals and Objectives16. Focused on clear health goals—the prevention ofpregnancy and/or STD/HIV17. Focused narrowly on specific behaviors leading to thesehealth goals (e.g., abstaining from sex or using condomsor other contraceptives), gave clear messages aboutthese behaviors and addressed situations that mightlead to them and how to avoid them18. Addressed multiple sexual psychosocial risk and protectivefactors affecting sexual behavior (e.g., knowledge,perceived risks, values, attitudes, perceived norms andself-efficacy)Activities and Teaching Methodologies19. Created a safe social environment for youth toparticipate10. Included multiple activities to change each of thetargeted risk and protective factors11. Employed instructionally sound teaching methods thatactively involved the participants, that helped participantspersonalize the information and that weredesigned to change each group of risk and protectivefactors12. Employed activities, instructional methods and behavioralmessages that were appropriate to the youths’culture, developmental age and sexual experience13. Covered topics in a logical sequence14. Secured at least minimalsupport from appropriateauthorities such as departmentsof health, schooldistricts or communityorganizations15. Selected educators withdesired characteristics(whenever possible),trained them and providedmonitoring, supervisionand support16. If needed, implementedactivities to recruit andretain youth and overcomebarriers to their involvement,e.g., publicized theprogram, offered food orobtained consent17. Implemented virtually allactivities with reasonablefidelityKirby, D. B. (2007). Emerging Answers 2007: Research Findings on Programs to Reduce Teen Pregnancy and Sexually Transmitted Diseases.Washington, DC: National Campaign to Prevent Teen and Unwanted Pregnancy.6. Intention to abstain from sexual activity, restrictsexual activity or decrease the number of sexualpartners7. Communication with parents or other adultsabout sexuality, condoms or contraception1Similarly, those programs that effectively increasedcondom or contraceptive use sometimes focused onand improved the following factors (Kirby 2007):1. Knowledge, including knowledge of sexual issues,pregnancy, HIV and other STDs (includingmethods of prevention)1 Communication with parents or other adults is not a cognitivesexual psychosocial factor. However, it is a factor that many programsaddressed and improved and that in turn changed behavior.2. Attitudes toward risky sexual behavior andprotection3. Attitudes toward condoms4. Perceived effectiveness of condoms to preventSTD/HIV5. Perceptions of barriers to condom use6. Self-efficacy to obtain condoms7. Self-efficacy to use condoms8. Intention to use a condom9. Communication with parents or other adultsabout sex, condoms, or contraceptionBoth theory and numerous empirical studies havedemonstrated that these factors, in turn, have animpact on adolescent sexual decision making andChapter 1 Introduction 5

ehavior (Kirby and Lepore 2007). These factors areamong the most important concepts in widely usedeffective psychosocial theories of health behaviorchange, such as social cognitive theory, theory ofreasoned action, theory of planned behavior, andthe information-motivation-behavioral skills model(Fishbein and Ajzen 1975; Ajzen 1985; Bandura1986; Fisher and Fisher 1992).In sum, there is considerable evidence that effectivesex and STD/HIV education programs actuallychanged behavior by first having an impact on thesefactors, which, in turn, positively affected youngpeople’s sexual behavior.Although there is evidence that all of these factorsaffect behavior, some of them affect each otherand only indirectly affect behavior. For example,it is commonly believed that intentions to performa behavior most directly affect that behavior. Inturn, relevant attitudes, perceptions of norms andself-efficacy affect intentions. Further, other factors(e.g., knowledge) may affect attitudes, perceptionsof norms and self-efficacy. Figure 1-1 provides anexample of how these factors may be related.Finally, although intentions to perform a behaviortend to be good predictors of whether or notthe behavior is then performed, many things candisrupt (or moderate) the intention–behavior link.For example, environmental constraints or habitsmay affect whether intentions translate into behavior,so even intentions do not completely determinebehavior.Organization of This BookThe organization of this book follows the frameworkof logic models, which are described in greater detailin Chapter 2.The primary health goals addressed in this bookare to reduce unintended pregnancy and STDs. Toreduce unintended pregnancy, young people need todelay sex or reduce the frequency of sex and increasethe consistent and correct use of effective contraception.To reduce STD transmission, young peopleneed to delay sexual activity, have sex less frequently,have fewer sexual partners, avoid concurrent sexualpartners, increase condom use, increase the timeperiod between sexual partners, be tested (andtreated if necessary) for STDs and be vaccinatedagainst human papilloma virus (HPV) and hepatitisB (Kirby 2007). Logic models for some of thesebehaviors are presented in the next chapter.Figure1-1Possible Logic Model of Psychosocial Factors Affecting BehaviorEnvironmentKey Risk and Protective Factors(Sexual Psychological Factors)Sexual BehaviorsHealth GoalsSex andSTD/HIVEducationParent-childcommunicationSupport fromenvironmentPerceptionof riskKnowledgeActualbehavioralcontrol(self-efficacy)AttitudestowardbehaviorsPerceivednormsPerceivedbehavioralcontrol(self-efficacy)Strength ofintention toperform eachsexual behavior• Delay onset of sex• Decreasefrequency of sex• Decrease numberof partners• Avoid concurrentpartners• Increase timebetween partners• Increase use ofcondoms or birthcontrol• Increase STDtesting andtreatmentDecreaserates of teenpregnancy,STD and HIV6 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

Each of the following chapters focuses on an importantrisk and protective factor that affects thosebehaviors and can be changed by curriculum-basedsex and STD/HIV education programs. Withineach chapter, we:• Identify a risk or protective factor that has animpact on these sexual risk behaviors• Identify important theories that address eachfactor• Summarize the evidence for the impact of thatfactor on the sexual behaviors 2• Summarize the evidence for the ability of programsto change the factor3• Specify important instructional principles foreffectively changing each factor• Summarize examples of activities that have beenused in curricula that effectively changed eachfactor• Provide references to more detailed descriptionsof those activities in effective curricula• Provide a sampling of items used in studies tomeasure each factor (These items simply providemore detail about some of the concepts in eachfactor.)Consequently, this book can be used to help developcompletely new curricula, to add new activities toexisting curricula that may not have sufficientlypowerful activities to change particular factors,to improve the effectiveness of existing activitiesalready in curricula and to critically review curriculaactivities for possible adoption. When adaptingcurricula that have strong evidence of impact,all changes should be consistent with guidelinesfor adapting those curricula (Rolleri, Fuller et al.,unpublished).Reading this book from cover to cover may be challenging.Thus, readers may wish to:1. Read the first two chapters to obtain an overviewof the book, logic models and behavioralobjectives.2. Read and apply those chapters addressing thespecific factors that are in their own logic models.3. Read the final chapter and apply the principles totheir curricula.2 In each chapter, the evidence assessing the relationship betweenthe factor discussed in that chapter and sexual behavior is based ontabulations of the studies summarized in Sexual risk and protectivefactors: Factors affecting teen sexual behavior, pregnancy, childbearing andsexually transmitted disease: Which are important? Which can you change?(Kirby and Lepore 2007).3 In each chapter, the evidence assessing the impact of curriculumbasedprograms on the factor discussed in the chapter is based largelyon tables in Emerging answers 2007: Research findings on programs toreduce teen pregnancy and sexually transmitted diseases (Kirby 2007).Chapter 1 Introduction 7

2Creatinga Logic Modeland Learning ObjectivesKeys to Creating a Logic ModelComplete the following four steps in order: Identify 1) thehealth goal(s) to be achieved; 2) the behaviors that directlyaffect that health goal(s); 3) the factors that affect eachof those behaviors and that can be modified; and 4) theintervention components or activities that will improve thosefactors.Keys to Creating LearningObjectivesIdentify the precise behaviors to be implemented to avoidunprotected sexual activity and the particular knowledge,facts, beliefs, attitudes, peer norms and skills needed tohave the intentions and ability to conduct those behaviors.BackgroundMost, if not all, programs that have led to sexualbehavior change have either explicitly or implicitlydeveloped logic models. Their development is one ofthe 17 characteristics of effective curriculum-basedsex education programs. Creating a detailed logicmodel is a very important first step in the processof creating a new program or improving or adaptingan existing program. It provides the frameworkor roadmap specifying which activities affect whichfactors that, in turn, change behavior and achievehealth goals.A foundation of this book is a particular logic modelthat assumes that specific curriculum activities canaffect selected sexual psychosocial factors that, inturn, reduce sexual risk behavior and potentiallyreduce unintended pregnancy and STDs (see Figure2-1). This chapter briefly describes a process forcreating logic models and provides a very detailedexample of one logic model that is consistent withthe subsequent chapters in this book and the manyprinciples therein.This chapter continues with a discussion of learningobjectives, because a critical step in developingcurriculum-based intervention activities is creatinglearning objectives to focus the instruction andensure it will produce learning that is related to thebehavioral goals specified in the logic model.Types of Logic ModelsAlthough many logic models include these fourcomponents, they sometimes use different wordsto describe them. Some may use the conceptsabove, while others may refer to “interventions,”Figure2-1Basic Elements in a Logic Model That Forms the Basis of This BookSpecifiedCurriculumActivitiesAffectChosen Risk andProtective FactorsThatAffectImportantSexual BehaviorsWhich,in Turn,ReduceTeen Pregnancy,STD and HIVChapter 2 Creating a Logic Model and Learning Objectives 9

“determinants,” “behaviors,” and “health goals,”or “activities,” “short-term objectives” and “longtermoutcomes,” or “processes,” “outcomes,” and“impacts,” respectively.There are also other variations among logic models.Some include only these four minimum components,while others may provide more informationon inputs or specify far more complex causal models,with some determinants of behavior affecting otherdeterminants or with reciprocal causality acknowledged(e.g., determinants affecting behaviors andvice versa).Steps for Developinga Logic ModelCreating a logic model consistent with the goalsof this book involves completing at least four basicsteps:1. Identify possible health goals and select thehealth goal(s) to be achieved. For the purposesof this book, those health goals are reducingunintended pregnancy and STDs among youngpeople. These are listed on the far right side of thelogic model (see Figure 2-1).2. Identify potentially important behaviors thataffect the selected health goal and then select theparticular behaviors to be targeted. Key behaviorsfor sexual risk-taking are specified in Chapter 1.Specifically, to reduce unwanted pregnancy,young people need to delay sex or reduce the frequencyof sex and increase consistent and correctuse of effective contraception. To reduce STDtransmission, young people need to delay sex,have sex less frequently, have fewer sexual partners,avoid concurrent sexual partners, increasecondom use, increase the time period betweensexual partners, be tested (and treated if necessary)for STDs and be vaccinated against HPVand hepatitis B.3. Identify potentially important risk and protectivefactors of the selected behaviors and selectthose factors that can be changed and are to betargeted. This book highlights selected sexualpsychosocial factors affecting sexual behavior andparent-child communication about sexual behavior.Multiple studies demonstrate that these factorscan be changed by curriculum-based activitiesand can, in turn, affect sexual risk behavior.4. Identify or create possible interventions or activitiesthat have sufficient strength to improve eachselected risk and protective factor and select thosethat are most effective. The following chaptersprovide examples of many effective activities anddescribe theory-based instructional practices forincreasing their effectiveness.These four steps are summarized in Figure 2-2.Box 2-1 provides additional tips for developinglogic models, and Box 2-2 provides criteria forFigure2-2Steps for Developing and Understanding Logic ModelsThe order of the steps for developing the logic model:Step 4 Identify andselect interventioncomponentsStep 3 Identify andselect importantrisk and protectivefactorsStep 2 Identify andselect importantbehaviorsStep 1 Identify andselect healthgoal(s)The causal order of the components of the completed logic model:SpecifiedInterventionComponentsand ActivitiesAffectChosen Risk andProtective FactorsThatAffectImportantSexual BehaviorsWhich,in Turn,ReduceTeen Pregnancy,STD and HIV10 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

assessing logic models. Logic models are describedmuch more fully in Kirby (2004). An on-linecourse on these models also is available free ofcharge at: http://www.etr.org/recapp/documents/logicmodelcourse/index.htm. Intervention Mapping(Bartholomew, Parcel et al. 2006) describes morecomprehensive approaches that involve logic modelsand that are effective.A Detailed Example ofa Logic ModelFigure 2-3 provides a very detailed example of alogic model that incorporates activities from curriculathat have been effective at improving sexualpsychosocial factors and behavior. The figure illustrateshow to read a logic model and how a givencurriculum would reduce sexual risk behaviors. Italso provides a frame of reference for the remainderof this book. Indeed, Chapters 3 to 9 focus onthe risk and protective factors that are in this logicBox2-1 Tips for Developing Logic Models• Choose your target. Remember that logic models aregraphic depictions that show clearly and concisely thecausal steps through which specific interventions canaffect behavior and thereby achieve a health goal.They can be applied to any health goal or to any goalthat is affected by the behavior of individuals or thepolicies and programs of organizations.• Be comprehensive. Consider all reasonable possibilitiesat each stage, all health goals of interest, all behaviorsaffecting a selected health goal, all factors affectingeach behavior, and all activities or interventions thatmay affect each factor.• Be thorough. Consider both positive and negativebehaviors and both risk and protective factors thataffect those behaviors.• Be strategic. Focus on the goals, behaviors, risk andprotective factors, and intervention strategies that aremost important and that you can change; the mostimportant health goal in the community that yourorganization wishes to achieve (and can), the mostimportant behaviors that have the greatest impact onthat health goal and that you can change, the mostimportant factors that affect each behavior and thatyou can change, and the activities or interventionsthat most strongly affect each factor and that you canimplement.• Be realistic. Assess the impact of each activity or interventionon each factor, the impact of each factor oneach behavior and the impact of each behavior on thehealth goal. Select only those that have the greatestimpact.• Consider the evidence. Review research when assessingwhich activities, risk and protective factors andbehaviors are most important in addressing a healthgoal.• Be very specific. For example, when choosing a healthgoal, specify the particular health outcome and thepopulation to be targeted (e.g., a particular agegroup in a particular geographic area). When choosingbehaviors, identify the specific behavior, not abroader behavior. (For example, do not specify “reducingunprotected sex” as a behavior. Instead, break itdown into abstaining, using condoms, having mutuallymonogamous partners, using contraception, etc.)When choosing activities, describe them sufficiently sothat readers can understand how they will affect theirtargeted factors.• Call for back-up. Identify multiple activities to changeeach important risk or protective factor. (Create amatrix to help with this as described in Chapter 10.)• Know your target. Complete all of these activities witha thorough knowledge of the particular population ofyoung people, their community, their culture and theircharacteristics always in mind.• Widen your perspective. Involve multiple people inthe development of your logic model. Include peoplewith different areas of expertise, such as knowledgeabout adolescent sexual behavior, psychosocialtheories of behavior change, factors affecting sexualbehavior, effective instructional strategies, youth culture,community values and research on sex educationprograms.• Use the logic model as a tool. Use your logic modelnot only to develop an effective program, but toexplain it to other stakeholders and to train staff whoimplement it.• Monitor progress. Over time, conduct evaluations toassess your logic model and program, using the datato update and improve them.Chapter 2 Creating a Logic Model and Learning Objectives 11

model, provide evidence regarding how these riskand protective factors affect behavior, provide evidencethat curriculum activities can improve themand describe the theory behind these psychosocialfactors, as well as the instructional principles forshaping curriculum activities to improve them.Learning Objectives:Becoming More SpecificAfter creating a logic model, the next important stepin developing curriculum-based intervention activitiesis creating learning objectives. The elements inlearning objectives are typically more precise thanthose in logic models and therefore further focus theinstruction. If prepared properly, these objectivesshould convey what students will be able to do as aresult of the lesson(s).Box2-2 Criteria for Assessing Logic Models and Their Development 4Criteria for Assessing the Model• Can the selected factors be modified markedly bypotential interventions?Overall• Are all factors that affect behavior and can be• Does the model make sense? Do the goals, behaviors,risk and protective factors and interventionchanged by feasible interventions included?approaches reflect the understanding of the group?Program Components• Are all items in the correct columns?• Can the activities and components in combinationhave a marked impact upon each of the selected• Are all the relationships causal (as opposed to correlational)?factors? Do multiple activities or components addresseach factor?Goals• Is there strong evidence from research or elsewhere• Is the stated goal a priority?that the intervention strategies can improve the• Is it well defined?factors?• Are the populations defined well enough (e.g., by age, • Is it feasible to implement each of the interventionsex, income level, location)?components? Are the necessary organizational• Does your organization have the capacity to addressrequirements in place? Do staff have the neededthis goal?skills? Are there sufficient financial resources? Is therenecessary political or policy support? Is there sufficientBehaviorscommunity support?• Are all the important and relevant behaviors that have• Given the purposes of the model, were the interventioncomponents described in sufficient detail?a marked impact upon the health goal identified andselected? If not, are there good reasons provided forexcluding some of the behaviors?Criteria for Assessing the Development of• Are the behaviors defined precisely?the Model• Do they directly and strongly affect the health goal?• Were people with different views involved in the• Are they measurable?development of the model? Were youth involved inRisk and Protective Factorsthe development of the model? Were people with programexperience involved? Were researchers involved?• Were risk and protective factors in different domainsidentified (e.g., media, community, school, family,• Is a process described for actually using the modelpeer, and individual)? If not, were good reasonsonce it is developed (e.g., using it to create a curriculum,train educators, inform stakeholders or facilitateprovided for excluding some of the factors?• Are both risk and protective factors included?grant writing)?• Do selected factors have a strong causal impact upon• Is a process described for periodically assessing andone or more behaviors?updating the model?4 These are criteria for assessing logic models in general, not only logic models specifically designed for curriculum-based programs.12 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

For example, not having sex at a particular time orwith a particular person may involve: deciding notto have sex, communicating personal limits aboutsex, suggesting alternative activities to sex, avoidingsituations that might lead to sex and refusing to havesex. Similarly, using condoms may involve: makingthe decision to use condoms, buying or obtainingcondoms, carrying condoms, negotiating their useand using condoms.Associated with each of these more specific behaviorsare multiple learning objectives that will affectstudents’ intention and ability to perform thesebehaviors. Because there are learning objectivesassociated with each of the sexual psychosocial factorsdiscussed in the following chapters, examplesof learning objectives are presented in a matrix withthe specific behaviors down the left-hand side andthe psychosexual factors across the top. (See Tables2-2 to 2-6.)Taxonomies of learning (Bloom, Englehatt et al.1956; Krathwohl, Bloom et al. 1964; Anderson andKrathwohl 2001) are among the most well-usedtools to help shape objectives and reflect a continuumof learning ranging from lower levels (e.g.,remembering key facts) to actually synthesizing andconstructing new learning. There are taxonomies forthe cognitive, affective, and psychomotor domains,descriptions of which are available on the Internet.These taxonomies also have lists of “learning verbs”associated with each level to help developers shapeobjectives. (See examples for the cognitive processingdomain in Table 2-1.) Ideally, students shouldbe challenged to reach higher levels of learning (e.g.,applying, analyzing, evaluating or creating) ratherthan just recalling information. Indeed, researchhas shown that students who work with content athigher levels of a taxonomy retain more than thoseworking only at lower levels (Garavalia, Hummel etal. 1999). For example, students who learn strategiesTable2-1 Bloom’s Revised Taxonomy of Learning—Cognitive Processing Domain *LowerLevelRevisedTaxonomyLevelBrief Decription of Level*Examples of Learning VerbsExamples of Behavioral ObjectivesRememberRecall facts or bits ofinformationList, memorize, identify,cite, recallStudents will be able to list 5 factsabout HIV transmission.UnderstandConstruct meaning from theinformation rememberedExplain, describe, illustrate,clarify, restate, discussStudents will be able to describe howcondoms protect against HIV.ApplyUse the information in agiven situationApply, use, demonstrate,show, practiceStudents will be able to use refusalskills correctly when faced withpressure to have sex.AnalyzeBreak material into smallerparts and see how the partsrelate to each other and thebigger pictureAnalyze, examine, compare,contrast, debate, appraiseStudents will be able to compareand contrast the pros and cons ofhaving sex.EvaluateMake judgments based onthe informationEvaluate, judge, decide,appraise, recommendStudents will be able to decide onthe most effective form of protection(abstinence and contraception) for3 pairs of students in relationships.HigherLevelCreateSynthesize the information andput it together to apply it in anew wayCreate, design, construct,present, compose, hypothesize,generate* Note: Details regarding the revised taxonomy can be found in Anderson and Krathwohl 2001.Students will be able to composea response to an anonymous callerseeking advice on what to do aboutsome STD symptoms he/she isexperiencing.Chapter 2 Creating a Logic Model and Learning Objectives 13

to avoid unwanted sex and then synthesize themand apply them to other situations will rememberand use them more than those students who simplyreiterate the strategies.Once the learning objectives have been established,it is essential to ensure the planned activities and theobjectives are in alignment. If an activity is includedin the curriculum but really does not support studentsin meeting the stated objectives, then it shouldbe modified or replaced. If an existing program doesnot have clearly stated objectives, they should becreated.Tables 2-2 to 2-6 include examples of behavioralobjectives for the key behaviors specified in the logicmodel in Figure 2-3. These tables are not exhaustive,but provide a range of examples of the types ofobjectives that could be included in a curriculum toaddress abstinence, sexual partners, contraceptiveuse, condom use, STD testing and treatment, andvaccinations.14 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

Figure2-3 An Example of a Logic Model to Reduce Pregnancy and Sexually Transmitted Diseaseby Implementing a Sexuality Education CurriculumIndividual Risk andCurriculum Activities Protective Factors Behaviors Goals• Provide accurate information about the risks of pregnancy• Implement simulation activities in which teens see that with each passing month,more teens get pregnant if they have unprotected sex, but don’t get pregnant ifthey abstain• Have students write down what they would have to do in the next 48 hours if theyjust found out they were pregnant• Have students write down activities they wish to do in coming years, and then markwhich ones would be difficult or impossible if they had a child• Show video clips of teen parents who talk about how they wish they had waiteduntil they were older to become parents• Provide accurate information about the risks of STDs (including HIV)• Implement simulation activities in which adolescents can see how STDs can spreadrapidly in people engaging in unprotected sex with multiple partners• Show video clips of teens who contracted herpes or other incurable STDs and whodescribe the consequencesIncrease knowledge andperception of risks andconsequences of pregnancy andchildbearing if sexually activeIncrease knowledge andperception of risks andconsequences of contracting anSTD, including HIV, if sexuallyactive• Delay initiation ofsex• Reduce frequencyof sex amongsexually active• Reduce number ofpartners• Avoid concurrentpartners• Increase timebetween partners• Have only longterm,mutuallyfaithful partners ifhaving sex• Reduce teenpregnancy• Reduce STD• Provide accurate information about the additional risks of having multiple partners,concurrent partners and short periods of time between partners• Implement simulations showing the huge impact on the size of sexual networks ofsmall increases in number of partners• Conduct simulations demonstrating the impact of concurrent versus sequentialsexual partners on the spread of STDsIncrease knowledge and perceptionof risks of the impactof multiple partners, concurrentpartners, and gap of timebetween sexual partners on contractingan STD, including HIV• Have peer leaders lead group discussions in which students discuss the advantagesand disadvantages of engaging in sex, and emphasize benefits of abstaining fromsex or having only one long term faithful partner if having sex• Identify peers who are popular among different groups of adolescents and whoare willing to publicly support abstinence or having only one long-term, faithfulpartner if having sex• Have groups of peers plan and implement school-wide activities such as assemblies,contests, media materials and small group discussions, all of which promoteavoiding unprotected sex by abstaining from sex• Conduct school-wide polls and report results showing support for adolescentsavoiding unprotected sex; provide individual stories to personalize results of thepolls• Collect survey data from students and report results showing that most studentsabstain from sex or support only one long-term, faithful partner if having sex• Implement roleplays in which adolescents successfully resist sexIncrease perception that peersare not sexually active andsupport abstinence or long‐termfaithful partners(Continued)Chapter 2 Creating a Logic Model and Learning Objectives 15

Figure2-3 An Example of a Logic Model to Reduce Pregnancy and Sexually Transmitted Diseaseby Implementing a Sexuality Education Curriculum (Continued)Individual Risk andCurriculum Activities Protective Factors Behaviors Goals• Lead group discussions in which students discuss the advantages and disadvantagesof engaging in sex; emphasize that abstinence is the only 100% effective methodof avoiding pregnancy and STD, and may reduce some emotional negativeoutcomes; and emphasize that some advantages of sex are short-term while somedisadvantages can be long-term• Discuss methods of showing you care about someone without engaging in sex• Create materials for parents to help them explore, understand, and express theirvalues about sexuality, love and relationships• Assign homework activities in which students ask their parents several questionsabout their values about sexuality, love and relationships• Through class discussions and help from peer leaders, identify and describe thetypes of situations which might lead to undesired sex, and identify multiplestrategies for avoiding each situation• Provide demonstration and practice of skills to refrain from sex when pressured tohave sex• Have teachers or peer leaders demonstrate effective strategies for saying no toundesired sex through scripted roleplays• Have students divide into small groups and practice roleplays by reading scripts• Repeat roleplays with increasingly challenging situations and less scripting,allowing students to use their own skills in more difficult contextsDecrease permissive attitudesabout sex and increase attitudesfavoring abstinence or longterm,faithful relationships ifhaving sexIncrease belief that parents/family have conservativevalues about sex and supportabstinence or long-term,faithful relationships if havingsexIncrease self-efficacy and skillsto abstain from undesired orunprotected sex• Delay initiation ofsex• Reduce frequencyof sex amongsexually active• Reduce number ofpartners• Avoid concurrentpartners• Increase timebetween partners• Have only longterm,mutuallyfaithful partners ifhaving sex• Reduce teenpregnancy• Reduce STD• Have students think clearly about what is the right choice for them in terms of sexand number of partners• Have them think about what circumstances or events might challenge their choiceto abstain from sex or limit sex to one faithful partner• Have them create a personal plan to avoid those circumstances or events orovercome themIncrease intention to abstainfrom sex or to abstain from sexoutside of long-term, faithfulrelationships if having sex(Continued)16 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

Figure2-3 An Example of a Logic Model to Reduce Pregnancy and Sexually Transmitted Diseaseby Implementing a Sexuality Education Curriculum (Continued)Individual Risk andCurriculum Activities Protective Factors Behaviors Goals• Provide accurate information about the risks of pregnancy (see above)• Implement simulation activities in which teens see that with each passing month,more teens get pregnant if they have unprotected sex, but don’t get pregnant ifthey abstain (see above)Increase perceived susceptibilityto pregnancyIncrease correct andconsistent use ofcontraceptionReduce teenpregnancy• Have students write down what they would have to do in the next 48 hours if theyjust found out they were pregnant (see above)• Have students write down activities they wish to do in coming years, and then markwhich ones would be difficult or impossible if they had a child (see above)Increase perceived consequencesof pregnancy and childbearing(greater importance ofavoiding pregnancy)• Provide accurate information about the different types contraception commonlyused by adolescents; indicate which protect against both pregnancy and STD;discuss advantages and disadvantages of each; discuss side effects, both positiveand negativeIncrease knowledge about contraception,including the recognitionof positive side effectsof hormonal contraceptives (aswell as negative side effects)• Provide parents with accurate information about adolescent sexual behavior,pregnancy and STD• Give students homework assignments in which they should talk with their parentsor other trusted adults about abstaining from sex, condom use and contraceptionuseIncrease belief that parents/family support contraceptiveuse if sexually active• Provide accurate information about the different types contraception commonlyused by adolescents; state their effectiveness if used correctly; indicate whichprotect against STD; discuss advantages and disadvantages of each; discuss sideeffects, both positive and negative (see above)• Have students identify the ways in which using condoms may reduce pleasure (e.g.,disrupts love making) and identify ways to avoid this (e.g., have a condom ready)(see below)• Identify ways that using condoms and other forms of contraception can make sexmore pleasurableIncrease intention to abstainfrom sex or to abstain from sexoutside of long-term, faithfulrelationships if having sex(Continued)Chapter 2 Creating a Logic Model and Learning Objectives 17

Figure2-3 An Example of a Logic Model to Reduce Pregnancy and Sexually Transmitted Diseaseby Implementing a Sexuality Education Curriculum (Continued)Individual Risk andCurriculum Activities Protective Factors Behaviors Goals• Identify peers who are popular among different groups of adolescents and who arewilling to publicly support a message against having unprotected sex and for usingcondoms or other contraceptives• Have groups of peers plan and implement school-wide activities such as assemblies,contests, media materials and small group discussions, all of which promoteavoiding unprotected sex by abstaining from sex and using contraception if havingsex• Conduct school-wide polls and report results showing support for adolescentsavoiding unprotected sex; provide individual stories to personalize results of thepolls• Collect survey data from students and report results showing that most studentsabstain from sex or use condoms or other forms of contraception• Implement plays in which adolescents successfully resist sex or always usecontraceptionIncrease belief that peers usecontraception, if having sexIncrease belief thatpeers support the use ofcontraception, if having sexIncrease correct andconsistent use ofcontraceptionReduce teenpregnancy• Through class discussions and help from peer leaders, identify and describe thetypes of situations that might lead to unprotected sex, and identify multiplestrategies for avoiding each situation• Provide demonstration and practice in using skills to avoid unprotected sex• Have teachers or peer leaders demonstrate effective strategies for saying no tounprotected sex through scripted roleplays and have students practice roleplays• Repeat roleplays in which students insist upon the use of contraceptionIncrease self-efficacy to say noto unprotected sex and to insiston using contraception• Identify places where adolescents can obtain affordable contraception withoutembarrassment• Provide demonstration and practice in how to use condoms properlyIncrease self-efficacy and skill toobtain and use contraception• Have students identify possible situations or changes in their lives that might causethem to forget to take birth control pills and brainstorm ways to overcome thosesituationsIncrease skill to usecontraception consistently• Have students think clearly about what is the right choice for them in terms of sexand condom and contraception use• Have them identify what circumstances or events might challenge that choice• Have them create a plan to avoid those circumstances or events or overcome them• If their choice is to use contraception, have them create a specific plan to obtainand use contraception consistently and correctlyIncrease intentions to usecontraception(Continued)18 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

Figure2-3 An Example of a Logic Model to Reduce Pregnancy and Sexually Transmitted Diseaseby Implementing a Sexuality Education Curriculum (Continued)Individual Risk andCurriculum Activities Protective Factors Behaviors Goals• Provide accurate information about the risks of STDs (including HIV) (see above)• Implement simulation activities in which adolescents can see how STDs can spreadrapidly in people engaging in unprotected sex with multiple partners (see above)• Have people who are HIV positive talk about the impact that HIV has had upontheir livesIncrease knowledge andperception of risks andconsequences of contracting anSTD (including HIV) if engagingin sex without condomsIncrease correct andconsistent use ofcondomsReduce STD• Provide accurate information on the effectiveness of condoms in preventingpregnancy and STDs, if used consistently and correctlyIncrease knowledge of effectivenessof condoms in preventingpregnancy and STD• Brainstorm ways to have condoms available and ready when needed• Brainstorm ways to make condom use more sensual rather than less sensual• Provide accurate information on how different types of condoms (correct size,lubricated, etc.) can both reduce breakage and slippage and increase pleasureImprove attitudes about condomuse: Decrease attitude thatcondoms are a hassle, interruptthe mood, reduce pleasure, indicatea lack of trust, etc.• Provide parents with accurate information about adolescent sexual behavior,pregnancy, STDs, and the effectiveness of condoms• Give students homework assignments in which they talk with their parents or othertrusted adults about abstaining from sex and condom useIncrease communication withparents about condom use andsupport for use if sexually active• Identify peers who are popular among different groups of adolescents and who arewilling to publicly support a message about avoiding unprotected sex• Have groups of peers plan and implement school-wide activities such as assemblies,contests, small media materials and small group discussions, all of which promoteavoiding unprotected sex by abstaining from sex and using condoms if having sex• Conduct school-wide polls and report results showing support for adolescentsavoiding unprotected sex and using condoms if having sex; provide individualstories to personalize results of the polls• Collect survey data from students and report results showing that most studentsabstain from sex or use condoms• Implement plays in which adolescents successfully resist sex or always use condomsIncrease perception that peerssupport the use of condoms ifsexually active• Have groups of students go to different places where condoms are available andassess how easily and comfortably teens could obtain condoms there• Have students go to one or more places where condoms are available and assess thetypes of condoms available and their costIncrease self-efficacy to obtaincondoms(Continued)Chapter 2 Creating a Logic Model and Learning Objectives 19

Figure2-3 An Example of a Logic Model to Reduce Pregnancy and Sexually Transmitted Diseaseby Implementing a Sexuality Education Curriculum (Continued)Individual Risk andCurriculum Activities Protective Factors Behaviors Goals• Have teachers or peer leaders demonstrate effective strategies for refusing toengage in unprotected sex through scripted roleplays and have students practiceroleplays• Repeat roleplays in which students insist upon the use of condomsIncrease self-efficacy to insist onusing condomsIncrease correct andconsistent use ofcondomsReduce STD• Provide demonstration and practice in how to use condoms properlyIncrease self-efficacy to usecondoms correctly• Have students think clearly about what is the right choice for them in terms of sex,condom or other contraceptive use• Have them identify what circumstances or events might challenge that choice• Have them create a plan to avoid those circumstances or events or overcome them• If their choice is to use condoms, have them create a specific plan to obtain and usecondomsIncrease intentions to usecondoms• Provide research data on the high prevalence of HPV among young women• Describe how some varieties of HPV lead to cervical warts and some varieties leadto cervical cancer and death• Provide research data on the relative number of deaths due to cervical cancer andAIDS among women in the last 40 years• Provide research data on the prevalence of Hepatitis B and its consequencesIncrease perception of risks ofHPV and Hepatitis BIncrease vaccinationsfor HPV andHepatitis BReduce STD• Provide research data on the effectiveness of HPV and Hepatitis B vaccines• Provide information on where to obtain vaccinations and the costs of the vaccinesto young people• Have a speaker from a clinic talk about the vaccines and procedures for obtaining itIncrease knowledge ofeffectiveness of HPV andHepatitis B vaccines and placesto obtain vaccinations• Provide research data showing the increases in the percentages of young womenwho are being vaccinated for HPV• Provide role model stories promoting the benefits of vaccination and suggesting itswider use• Collect survey data showing that classroom peers would like to avoid HPV andHepatitis B and support vaccinationIncrease belief that peers arebeing vaccinated for HPV orsupport vaccination• Send information hope to parents with factual information about HPV, cervicalcancer, and the HPV vaccine• Include as part of a homework assignment to talk with parents about beingvaccinated for HPV if femaleIncrease communication withparents about being vaccinatedfor HPV(Continued)20 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

Figure2-3 An Example of a Logic Model to Reduce Pregnancy and Sexually Transmitted Diseaseby Implementing a Sexuality Education Curriculum (Continued)Individual Risk andCurriculum Activities Protective Factors Behaviors Goals• Provide accurate information about the risks and consequences of STDs (includingHIV) (see above)• Implement simulation activities in which adolescents can see how STDs can spreadrapidly in people engaging in unprotected sex with multiple partners (see above)• Provide accurate information on how some STDs can be cured, how the physicalsymptoms of other viral STDs can be reduced, and how the infectivity of their viralSTDs can be reducedIncrease knowledge of the risksof contracting an STD and theconsequences of undiagnosedSTDsIncrease testing andtreatment of STDReduce STD• Have a guest speaker from a clinic explain the testing and treatment process andwhere testing and treatment services are available• Have students obtain accurate information about the availability of confidentialand low-cost STD testing and treatment services in the local community (see above)and have them assess each service• Have students call or visit a clinic and obtain information about itIncrease knowledge of theavailability of confidential andlow-cost STD testing and treatmentservices• Provide accurate information about STD tests and treatment, emphasizing that STDtests need not be painful• Brainstorm ways to make teens more comfortable going to a clinic for testing (e.g.,go with a friend)Increase positive attitudesand comfort being tested andtreated for STDs• Have students divide into groups and research different STDs and their symptoms;have them create posters or pamphlets showing the common symptoms thatwarrant being checked for STDs• Have students identify other situations that might warrant being tested for STDs(e.g., being tested before stopping condom use and using hormonal contraceptionin a long-term, mutually faithful relationship)Increase self-efficacy to knowwhen to visit a clinic and betested and treated• Show a video on teens and STD testing, clarifying the process of going to a clinic,being tested, notifying partners, etc.• Have students identify the names and locations of the nearest health services thatprovide confidential and low-cost STD testing and treatment services• Have students develop a feasible plan for arranging and getting to those healthservices• Have students call or visit a clinic and obtain information about itIncrease self-efficacy to visit aclinic and be tested and treatedChapter 2 Creating a Logic Model and Learning Objectives 21

Table2-2Learning Objectives to Reduce Sexual Activity: Delaying Initiation of Sex, Reducing Frequency of Sex Among Sexually Active, Reducing Number ofPartners, Avoiding Concurrent Partners, Increasing Time Between Partners and Having Only Long-Term, Mutually Faithful Partners, if Having Sex *Specific BehaviorsStudents will beable to:Knowledge andPerceptions of RiskStudents will beable to:Attitudes, Valuesand BeliefsStudents will beable to:Perceptions ofPeer NormsStudents will beable to:Skills andSelf-efficacyStudents will beable to:IntentionsStudents will beable to:Parent-ChildCommunicationStudents will beable to:Decide to not havesex, either at all atthat point in theirlives or unless in along-term, mutuallymonogamouscaring relationship(LTMMCR)• Explain the function of the male and femalereproductive systems and how they work.• Characterize different types of sex.• Assess the risk of pregnancy or STD if havingunprotected sex.• Evaluate the consequences of unintendedteen pregnancy and childbearing.• Predict how (or reconstruct how)unintended pregnancy and childbearing mayimpact their lives.• Assess the risk of STD if having unprotectedsex.• Evaluate the symptoms and consequences ofdifferent STDs, including incurable STDs suchas herpes and HIV.• Assess the impact of having an incurable STDon their lives.• Analyze the impact of small increases innumbers of sexual partners on the increasedsize of sexual networks and risk of STDtransmission.• Compare and contrast the risk of havingconcurrent sexual partners instead ofsequential sexual partners.• Conclude that the only 100% effective wayof avoiding STDs, including HIV, or gettingpregnant is to not have sex.• Appraise how LTMMCRs can reduce STD risk.• Define characteristics of a LTMMCR.• Assess the emotional and socialconsequences of having sex or casual sex.• Evaluate the most important reasons for nothaving sex or for having sex only within aLTMMCR.• Assess the pressures/influences (social, peer,partner, media) to have and not have sex.• Conclude that people should always havethe choice to not have sex.• Generate ways to show love and affectionwithout having sex, and choose theirfavorites.• Internalize the beliefthat it’s important torespect oneself andthat they are worthyof respect.• Internalize the beliefthat not having sexor having sex withinLTMMCR is consistentwith respectingoneself.• Value a decisionto not have sex orto have sex withinLTMMCR.• Believe that makingthe decision to nothave sex will reducerisk of getting STDs(including HIV) orbecoming pregnantand having sex onlywithin a LTMMCRwill reduce risk ofSTD/HIV.• View taking responsibilityfor sexualbehavior favorably.• Value not gettingpregnant or gettingsomeone pregnant,or acquiring anSTD/HIV.• Internalize the beliefthat most youngpeople their agehave not had sex (ordid not have sex lastmonth) if true.• Internalize the beliefthat most youngpeople their agesupport the decisionto not have sex.• Internalize the beliefthat friends approveand respect theirdecision to not havesex.• Identify peers whowill support theirdecision to not havesex.• Internalize the beliefthat most youngpeople their agesupport the decisionto have sex onlywithin a LTMMCR, ifhaving sex.• Internalize the beliefthat friends approveand respect theirdecision to only havesex within LTMMCR,if having sex.• Make a decisionto not have sexwith confidence.• Commit to nothaving sex atthis time in theirlives or to havesex only within aLTMMCR.• Communicate withparents and otheradults and evaluatehow parents andother adults feelabout younger teenshaving sex.• Identify parents andother adults who willsupport their decisionto not have sex.• Communicate withparents and otheradults and internalizethe belief that mostparents and otheradults feel it’s importantfor people tohave sex only withina LTMMCR, if they dohave sex.(Continued)22 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

Table2-2Learning Objectives to Reduce Sexual Activity (Continued)Specific BehaviorsStudents will beable to:Knowledge andPerceptions of RiskStudents will beable to:Attitudes, Valuesand BeliefsStudents will beable to:Communicate theirpersonal limitsregarding sex andintimate behaviors.• Describe what a personallimit is.• Generate ways tocommunicate personal limitsto friends/partners.• Select and/or state theirpersonal limits regarding sexand intimate behaviors.• Make a case for why it’simportant to communicatepersonal limits to friends/partners.• View favorably thebenefits of communicatingpersonal limitto not have sex.• Demonstratefavorable attitudestoward talking aboutsexual limits.• Hold the belief thatcommunicating personalintentions andlimits will decreaserisk of pregnancyand HIV/STD.• Hold the belief thatcommunicating personallimits will leadto a better relationshipwith partner.Suggest alternativeactivities to sex withtheir partners.• Generate alternate activitiesto having sex.• Propose different waysto suggest or bring upalternative activities.• Appraise which alternativeactivities are most viable fortheir use.• Make a case for whya healthy relationshipis not predicatedon sexual activity.• See the value in suggestingalternativeactivities to sex as away to strengtheninterpersonal relationships.Avoid situationswhere they couldhave sex.• Analyze situations (places,peers, times) that may makeit hard to refuse sexualpressures.• Develop strategies for avoidingsituations where theymay face sexual pressures.• Have desire to avoidsituations that maymake it hard torefuse or handlesexual pressures.• Believe that avoidinga high-risk situationwill help themkeep from havingunwanted or unprotectedsex.Perceptions ofPeer NormsStudents will beable to:• Acknowledge that teenscommunicate their personallimits to friends.• Believe that teens communicatetheir personal limitsregarding sex to partners.• Recognize that people mayhave different personallimits regarding differentbehaviors.• Internalize the belief thatfriends approve of themcommunicating personallimits.• Internalize the belief thatpartners approve of themcommunicating their limits.• Identify friends whocan help them stick withand communicate theirpersonal limits.• Summarize the beliefs ofothers regarding the use ofalternate activities to sex.• Identify friends/ peerswho will support alternateactivities.• Form the belief thatsignificant others approveand respect their decisionto avoid situations thatmay make it hard to refusesex.• Identify friends/peerswho will support them inavoiding and/or identifyingrisky situations.Skills andSelf-efficacyStudents will beable to:• Demonstratethe ability tocommunicate theirpersonal limits tofriends or partners.• Communicate theirlimits to friendsor partners withconfidence.• Demonstrate abilityto suggest or bringup an appropriatealternative activity tosex.• Recommend analternative activity tosex with confidence.• Demonstrate howto identify signsand situations thatmay make it hard toresist or refuse sexualpressures.• Develop confidencein their ability to identifysigns and situationsthat may make ithard to say no to sex.IntentionsStudents will beable to:• Form intentionsto share personallimits with friends/partners.• Plan to suggestalternativeactivities to sexwith partners.• Plan to avoidsituations thatcould lead to sex.Parent-ChildCommunicationStudents will beable to:• Identify parents andother adults who canhelp them establishand communicatetheir personal intentionsand limits.• Internalize the beliefthat parents wantthem to communicatetheir sexual limits tofriends/partners.• Identify adults whowill support alternateactivities.• Identify adultswho will supportthem in identifyingand avoiding riskysituations.(Continued)Chapter 2 Creating a Logic Model and Learning Objectives 23

Table2-2Learning Objectives to Reduce Sexual Activity (Continued)Specific BehaviorsStudents will beable to:Knowledge andPerceptions of RiskStudents will beable to:Attitudes, Valuesand BeliefsStudents will beable to:Perceptions ofPeer NormsStudents will beable to:Skills andSelf-efficacyStudents will beable to:IntentionsStudents will beable to:Avoid situationswhere they couldhave sex.• Detect signs that let them knowit may be hard to refuse/handlesexual pressures (feeling out ofcontrol, lack of adult supervision;feeling pressured to do somethingthat does not feel right).• Develop strategies for handlingsigns that may make it difficult torefuse sexual pressures.• Demonstrate howto avoid thesesituations (e.g.,physically avoidssituation; userefusal/negotiationskills).Refuse to have sex. • Compose a list of signs and situationsthat may make it difficult torefuse sexual pressures.• Demonstrate characteristics ofclear refusal skills (e.g., clear no,delay tactics, alternative actions).• Value the importanceof not having sexor having sex onlyin a LTMMCR. Holdthe belief that usingappropriate refusalskills will lead to successfullyabstainingwithout jeopardizinginterpersonalrelationships.• Hold the belief thatusing refusal skillswill reduce the risk ofgetting HIV, STD orbecoming pregnant.• Internalize the beliefthat most young peopletheir age do not havesex or only have sexwithin a LTMMCR.• Believe that their closefriends approve andrespect their decisionto not have sex or tohave sex only within aLTMMCR.• Demonstratethe ability to usedifferent refusalskills in multiplesituations.• Appraise therange of refusalstrategies andidentify thosemost comfortableand relevant fortheir use.• Use refusal skillsin a variety ofsituations with ahigh degree ofconfidence.• Form intentionsto refuse sex.* Tables 2-2 to 2-6 are based largely on matrices of learning objectives developed by Chris Markham, Susan Tortolero, Melissa F. Peskin and Ross Shegog for It’s Your Game: Keep ItReal. An HIV/STI and Pregnancy Prevention Curriculum for Middle School Youth. Copyright, 2006. The University of Texas Health Science Center, Houston, Texas.Parent-ChildCommunicationStudents will beable to:• Identify adults who willsupport their use ofrefusal strategies to nothave sex or to have sexonly within a LTMMCR.• Talk about differentapproaches to refusingsexual pressures withparents or other adults.• Believe that most parentsfeel it’s important topractice refusal strategiesto not have sex.24 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

Table2-3Learning Objectives to Increase Condom UseSpecific BehaviorsStudents will beable to:Knowledge andPerceptions of RiskStudents will beable to:Make the decision touse condoms.• Explain the function of the male andfemale reproductive systems and howthey work.• Describe transmission and symptomsof HIV/STD.• Evaluate the consequences of notusing a condom during sex.• Illustrate how using condoms whenhaving sex will reduce the riskof getting STD/HIV or becomingpregnant.• Assess the short-term and long-termimpact of having an STD (including anincurable STDs such as herpes or HIV).• Assess the short-term and long-termimpact of becoming a parent at thistime in their lives.• Evaluate the pressures/influences(peer, media, social) of using and notusing a condom.• Explain the difference betweenunprotected and protected sex.Buy or obtain a freecondom.• Summarize teens’ legal rights to buycondoms.• List places to obtain or buy condoms.• Analyze the different types of condomsand the relative advantages/disadvantages of each type.• Generate ways to approach and askfor condoms.• Describe common barriers to obtainingand using condoms.• Propose ways to overcome or reduceeach of these barriers.Carry condoms. • Summarize different ways to carry andprotect condoms when carrying them.• Identify times when a person mayneed to carry a condom.Attitudes, Valuesand BeliefsStudents will beable to:• Hold favorable viewsabout taking responsibilityfor sexualbehavior by makingthe decision to usecondoms.• Value not gettingpregnant or acquiringan STD/HIV.• Hold the opinionthat deciding to usea condom is highlyimportant for peoplewho are having sex.• Conclude that thebenefits of usingcondoms outweighthe risks of not usingcondoms.• Express favorableattitudes towardbuying or obtaininga condom, if havingsex.• Express favorableattitudes towardscarrying condoms.• View carrying acondom as a matureand responsible stepto take.Perceptions ofPeer NormsStudents will beable to:• Internalize the beliefthat most young peopletheir age use a condom,if they have sex.• Internalize the view thatmost young people theirage believe it’s importantto use condoms, ifhaving sex.• Summarize peer supportfor their decision to usecondoms.• Deduce that most sexuallyactive teens buy orobtain free condoms.• Identify people whowould assist them inbuying or obtaining afree condom.• Conclude that sexuallyactive teens carrycondoms.• Internalize belief thatmost sexually activeteens feel it’s importantto carry condoms.Skills andSelf-efficacyStudents will beable to:• Make a decisionto use condoms,if having sex.• Locate where tobuy or obtain afree condom.• Approachand ask forcondoms.• Demonstratethe ability tocarry a condom.IntentionsStudents will beable to:• Intend to usecondoms, ifhaving sex.• Intend to buyor obtain afree condom, ifhaving sex.• Intend to carrya condom, ifhaving sex.Parent-ChildCommunicationStudents will beable to:• Communicate with parentsand/or other adultsabout their decision touse condoms, if havingsex.• Identify parents or otherpeople who supporttheir decision to usecondoms.• Communicate withparents and/or otheradults about obtainingcondoms.• Identify parents or otherpeople who supporttheir decision to obtaincondoms.• Identify parents or otherpeople who supporttheir decision to carry acondom.(Continued)Chapter 2 Creating a Logic Model and Learning Objectives 25

Table2-3Learning Objectives to Increase Condom Use (Continued)Specific BehaviorsStudents will beable to:Knowledge andPerceptions of RiskStudents will beable to:Attitudes, Valuesand BeliefsStudents will beable to:Effectively negotiatethe use of condomswith every partnerevery time, if havingsex.• Demonstrate steps to negotiatecondom use.• Plan ways to avoid having sex ifnegotiation of condom use fails.• View taking responsibilityfor sexualbehavior by negotiatingcondom usefavorably.• Personalize the valueof not having sexunless a condom isused.Establish intention touse a condom withpartner.• Demonstrate ways to communicateyour intentions to usecondoms to partner.• Generate personal decision to usecondoms.• Present reasons why it’s importantto communicate decision to usecondoms to your partner.• Analyze the benefits of communicatingdecisions to use condomswith a partner.• Demonstrate techniques for elicitingand hearing partners’ intentionsto use condoms.• Value the importanceof communicatingintentions to usecondoms to partners.• View talking aboutusing condoms withpartners favorably.• View willingness touse condoms as away of respectingeach other.Use a condomcorrectly.• Compose a list of steps for propercondom use.• Evaluate the condition of a condom.• Demonstrate how to correctlyapply a condom.• Demonstrate how to safelyremove a condom.• Compose a list ofbeliefs supportingcondom use.• Internalize valueof using condomscorrectly.Maintain condom usewith every partnerevery time they havesex.• Analyze the importance of usingcondoms with regular partners aswell as with casual partners.• Express favorableattitudes about usingcondoms with allpartners, including aregular partner.Perceptions ofPeer NormsStudents will beable to:• Conclude that sexuallyactive teens negotiatethe use of condoms.• Conclude that partnershould be willing to usecondoms.• Hold the belief thatmost sexually activeteens communicatetheir intentions to usecondoms with theirpartners.• Internalize the factthat teens use condomswith regular and casualpartners.• Conclude that mostteens feel it’s importantto use condoms withregular and casualpartners.Skills andSelf-efficacyStudents will beable to:• Negotiatecondom use witha partner.• Refuse to havesex if condomnegotiation fails.• Communicateintentions to usecondoms.• Use techniquesfor eliciting andhearing partners’intentions to usecondoms.• Use a condomcorrectly.• Use a condomwith regularpartners as wellas with casualpartners.IntentionsStudents will beable to:• Intend tonegotiatecondom use everytime they havesex.• Intend tonegotiate use ofcondoms withpartner.• Intend to use acondom correctly.• Intend to maintaincondom usewith every partnerevery timethey have sex.Parent-ChildCommunicationStudents will beable to:• Identify parents or otherpeople who will supporttheir decision to usecondoms.• Identify parents or otherpeople who will supporttheir decision to use condomsconsistently overtime.26 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

Table2-4Learning Objectives to Increase Hormonal Contraceptive UseSpecific BehaviorsStudents will beable to:Knowledge andPerceptions of RiskStudents will beable to:Attitudes, Valuesand BeliefsStudents will beable to:Make the decisionto use hormonalcontraception.• Explain the function of the maleand female reproductive systemsand how they work.• Evaluate the consequences of notusing contraception, if having sex.• Assess the short-term and longtermimpact of becoming a parentat this time in their lives.• Evaluate the benefits of usingcontraception when having sex.• Evaluate the pressures/influences(peer, media, social) of using andnot using contraception.• View takingresponsibility forsexual behavior bymaking the decisionto use contraceptionfavorably.• Value not gettingpregnant or gettingsomeone pregnant.• Hold the opinionthat deciding touse contraception ishighly important.• Hold favorable attitudestoward a decisionto use hormonalcontraception.Choose anappropriate methodof contraception.• Assess the different types ofcontraception and the relativeadvantages/disadvantages of eachtype.Obtain contraception. • Summarize teens’ legal rightsregarding obtaining contraception.• Analyze places to obtaincontraception.• Demonstrate how to approachand ask for contraception at aclinic.• View obtaining contraceptionfavorably,if having sex.Perceptions ofPeer NormsStudents will beable to:• Internalize the beliefthat most young peopletheir age use contraception,if they have sex.• Summarize peer supportfor hormonal contraceptionuse, if having sex.• Conclude that a majorityof young people believeit’s important to usecontraception, if havingsex.• Internalize the beliefthat significant othersapprove and respecttheir decision to usecontraception, if havingsex.• Identify peers who willsupport their decisionto use contraception, ifhaving sex.• Draw conclusions thatmost sexually activefemale teens obtaincontraception.• Identify people whowould assist them inobtaining contraception.Skills andSelf-efficacyStudents will beable to:• Make adecision to usecontraception.• Assess personalbehaviorsand concernsand select anappropriatemethod ofcontraception.• Buy or obtaincontraception.• Select a clinic/location to obtaincontraception.IntentionsStudents will beable to:• Intend to usehormonalcontraception, ifhaving sex.• Commit to usingcontraception, ifhaving sex.• Intend to obtaincontraception, ifhaving sex.Parent-ChildCommunicationStudents will beable to:• Communicate with parentsand/or other adultsabout the decision to usecontraception.• Identify parents or otherpeople who could providesupport in making adecision to use contraception,if having sex.• Communicate withparents and/or otheradults about choosing anappropriate method ofcontraception.• Identify parents or otherpeople who could providesupport in choosinga hormonal method ofcontraception, if havingsex.• Communicate withparents and/or otheradults about obtainingcontraception.• Identify parents or otherpeople who supporttheir decision to obtaincontraception.(Continued)Chapter 2 Creating a Logic Model and Learning Objectives 27

Table2-4Learning Objectives to Increase Hormonal Contraceptive Use (Continued)Specific BehaviorsStudents will beable to:Knowledge andPerceptions of RiskStudents will beable to:Attitudes, Valuesand BeliefsStudents will beable to:Perceptions ofPeer NormsStudents will beable to:Keep contraceptivemethod readilyavailable (if neededfor chosen method).• Plan how to keep contraceptionavailable, if needed for chosenmethod.• Hold favorableattitudes toward carryingcontraception.• View using contraceptionas a matureand responsible stepto take.• Draw conclusions aboutsexually active teens’use of contraception.• Internalize the beliefthat that most sexuallyactive teens feel it’simportant to usecontraception.Effectively negotiatethe use of contraceptionwith everypartner.• Describe steps to negotiatecontraceptive use.• Plan ways to avoid having sex ifnegotiation of contraceptive usefails.• Value the importanceof takingresponsibility forsexual behavior bynegotiating contraceptionuse, if havingsex.• Summarize peer supportof negotiating contraceptiveuse.• Recognize that femalepartner may want to usehormonal contraceptionto prevent pregnancy(if male).Use contraceptioncorrectly andconsistently.• Describe how to correctly usemost common methods ofcontraception.• Analyze barriers to correct andconsistent use.• Propose solutions to addressbarriers to correct and consistentuse of contraception.• Describe appropriate steps forrefilling/replacing contraceptivemethod (e.g., state time for nextmedical appointment, describehow to refill prescription).• Analyze the benefits of usingcontraception correctly andconsistently.• Conclude that usingcontraception correctlyand consistentlywill reduce therisk of pregnancy.• Conclude that mostyouth support the correctand consistent useof contraceptionSkills andSelf-efficacyStudents will beable to:• Demonstratethe abilityto negotiatecontraceptive usewith a partnerwith confidence.• Demonstrate theability to refuseto have sex ifnegotiation ofcontraceptive usefails.• Prepare a plan forusing contraceptioncorrectly andconsistently.IntentionsStudents will beable to:• Intend to keepcontraceptionreadily available,if needed.• Intend toeffectivelynegotiate the useof contraceptionwith everypartner.• Intend to usecontraceptioncorrectly andconsistently, ifhaving sex.Parent-ChildCommunicationStudents will beable to:• Communicate withparents and/or otheradults about their plansto keep contraceptionavailable, if havingsex, and, if parents areaccepting.• Talk with parents orother adults abouteffective refusalstrategies for avoidingunprotected sex.• Communicate withparents and/or otheradults about plans to usecontraception, if havingsex.• Identify parents or otherpeople who will supportyour decision to usecontraception.28 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

Table2-5Learning Objectives to Increase STD VaccinationsSpecific BehaviorsStudents will beable to:Knowledge andPerceptions of RiskStudents will beable to:Attitudes, Valuesand BeliefsStudents will beable to:Make the decisionto be vaccinated.(Especially foryounger youth, thisdecision may be madepartly or entirely byparents and theirdoctors.)• Summarize key information aboutvaccinations to prevent STDs.• Discuss prevalence and consequencesof these STDs.• Assess the pros and cons ofgetting vaccinated against theseSTDs.• Explain current recommendationsabout STD vaccinations foradolescents.• Recognize the benefitsof vaccinations.• Express benefits oftaking responsibilityfor own health andhealth of partner(s).Make appointmentto be vaccinated byhealthcare provider.(Especially foryounger youth, thismay be arranged byparents and theirdoctors.)• Assemble a list of places wherevaccinations can be obtained.Get vaccinated, ifdesired.• Record time/date ofappointment(s).• Plan how to get to theappointment(s).• For HPV, compose a scheduleshowing the number and timingof vaccinations (e.g., 2nd shot at2 months, 3rd shot at 6 months).• For HPV, analyze how changesin the shot schedule may affectvaccine effectiveness.Perceptions ofPeer NormsStudents will beable to:• Form the belief thatit’s normal for teenswho have sex to bevaccinated againstthese STDs.• Conclude thatit’s expected andresponsible for teenswho have sex to bevaccinated.• Identify individual(s)(e.g., peers/partner/parent/adult) whowill discuss and supporta decision to bevaccinated.Skills andSelf-efficacyStudents will beable to:• Have confidencein decision to bevaccinated.• Initiate aconversation withparents aboutvaccinations toprevent STD.• Make a requestto parents to bevaccinated.• Call a healthcareprovider andschedule anappointment, orask parents to makeappointment.• Create a remindersystem to help keeptheir appointments.IntentionsStudents will beable to:• Intend to bevaccinated.• Intend to bevaccinated.• Intend to bevaccinated.Parent-ChildCommunicationStudents will beable to:• Communicate withparents or guardiansabout currentvaccination statusand/or desire to bevaccinated.• Identify parents orother people whosupport their decisionto be vaccinated, ifhaving sex.• Communicate withparents about desireto be vaccinated.• Identify parents orother people who willhelp them keep theirappointments (e.g.,remind them, accompanythem, providetransportation, andcover payment).Chapter 2 Creating a Logic Model and Learning Objectives 29

Table2-6Learning Objectives to Increase Pregnancy and STD Testing and TreatmentSpecific BehaviorsStudents will beable to:Knowledge andPerceptions of RiskStudents will beable to:Attitudes, Valuesand BeliefsStudents will beable to:Perceptions ofPeer NormsStudents will beable to:Make the decisionto get testedperiodically if havingsex.• Analyze types of STDs and their primarymodes of transmission.• Assess the prevalence of HIV/STD andpregnancy among teens.• Review that any sexually active teencan get HIV/STD or become pregnant/impregnate partner.• Generate reasons teens may want toget tested for HIV/STD and pregnancy ifhaving sex.• State that current absence of symptomsdoes not ensure that a person is notinfected or pregnant.• Explain that tests and results areconfidential.• Evaluate the different types of STD andpregnancy tests available• Appraise the limitations of STD andpregnancy tests (e.g., timing regardingHIV and pregnancy detection, falsenegative/positive lack of counseling withhome tests).• Appraise (or analyze) barriers to gettingtested (cost, access, confidentiality, typeof test, stigma, and embarrassment).• Formulate ways to overcome barriers.• Value the benefits ofknowing their healthstatus.• Make a case for thebenefits of gettingtested (e.g., earlytreatment if a persontests positive, peaceof mind, protectingself/others).• Value benefits oftaking responsibilityfor own health andhealth of partner(s).• Recognize that individualswho are sexuallyactive should betested periodically.• Recognize that peersbelieve it is expectedand responsible forteens who have sexto get tested periodically.• Identify friends whowill discuss and supporttheir decision toget tested.Make and keepappointment to gettested by healthcareprovider if havingsex.• List free or low-cost, teen-friendlytesting sites with contact information.• Identify a place to record the time/dateof appointment.• Plan how to get to the appointment.Obtain test results. • Identify a place to record when testresults will be available.• Identify method to obtain results (e.g.,by phone, in person).• Assess the benefits of obtaining testresults.• Feels responsibleabout getting testresults.• Value the importanceof knowingstatus of test results.Skills andSelf-efficacyStudents will beable to:• Make a decisionto get testedperiodically if havingsex.• Contact clinics toobtain informationabout testingservices.• Make anappointment toget tested by ahealthcare providerif having sex.IntentionsStudents will beable to:• Intend tobe testedperiodically ifhaving sex.• Intend tomake and keepappointmentto be tested ifhaving sex.• Intend to obtaintest results.Parent-ChildCommunicationStudents will beable to:• Identify individuals(e.g., parent/adult)who will discuss andsupport their decisionto get tested.• Identify parents orother individualswho could accompanythem whenreceiving results, ifneeded.• Identify individual(s)who will accompanythem to get results• Identify individual(s)to help them copewith results.(Continued)30 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

Table2-6Learning Objectives to Increase Pregnancy and STD Testing and Treatment (Continued)Specific BehaviorsStudents will beable to:Knowledge andPerceptions of RiskStudents will beable to:Attitudes, Valuesand BeliefsStudents will beable to:Perceptions ofPeer NormsStudents will beable to:Follow throughwith healthcare ifnecessary.• Identify healthcare needs andappropriate providers.• Discuss consequences of not followingthrough with healthcare follow-up.• Recognize that obtaining healthcaremay help to reduce progression ofsymptoms (HIV/STD) or to have ahealthier baby (pregnancy).• Express the value ofobtaining healthcarefor HIV/STD or pregnancy.Notify partner(s) ofpositive test results.• Identify who needs to be informed ofthe results and the best way to informthem.• Generate barriers to notifying past andfuture partners.• Plan ways to overcome barriers.• Analyze the challenges in tellingpartners testing information.• Value the importanceof letting partnersknow test results (ifpositive).• Hold the belief thatit is an individual’sresponsibility tomake past and futurepartners aware ofSTD/HIV status.• View notifyingpartner(s) of testresults as one’sresponsibility if havingsex.Skills andSelf-efficacyStudents will beable to:• Follow throughwith healthcareinstructions asdirected.• Notify partner(s) oftest results.IntentionsStudents will beable to:• Intend to followthrough withhealthcare, ifnecessary.• Commit tonotifyingpartner(s) ofpositive testresults.Parent-ChildCommunicationStudents will beable to:• Identify parents orother individualswho could accompanythem toget treatment, ifneeded.• Identify parents orother individual(s) tohelp cope with treatment,if needed.Chapter 2 Creating a Logic Model and Learning Objectives 31

3 Increasing KnowledgeKeys to Increasing Knowledge inOrder to Change BehaviorFocus primarily on those facts, concepts andskills that are necessary to deliver a compellingmessage about behavior and to provide thefoundation needed to change importantattitudes, perceptions of norms and skills.Actively involve participants in learning andapplying these facts, concepts and skills.BackgroundKnowledge provides a foundation for human action;what people know does affect what they do. Thisis readily seen in daily life. It is also demonstratedby theory and related research. For example, bothknowledge and skills are important components ofthe ability to perform a behavior (“behavioral capability”),a central concept in social cognitive theory(Bandura 1986). Similarly, knowledge is an importantfactor in other psychological theories such as thetheory of planned behavior (Ajzen 1985). Both ofthese theories are commonly used as the theoreticalbasis for effective sex and STD/HIV education programs.Finally, knowledge plays an important rolein the stages of change theory, particularly in theconsciousness-raising process, which is used in someeffective programs (Prochaska, Norcross et al. 1994).Examples of the importance of knowledge in sexualbehavior are numerous. Youth may not avoid situationsthat place them at risk of undesired, unplannedor unprotected sexual activity if they do not knowahead of time that those situations are risky. Youthwill not use contraception consistently and correctlyif they do not know it exists, how to obtainit, or how to use it properly. Knowing all of thisinformation may be necessary for its proper use.On the other hand, even though knowledge mayprovide a foundation, greater knowledge may notnecessarily assure responsible behavior. For example,youth may know that drinking alcohol increasestheir chances of engaging in unintended sexualactivity, but may drink alcohol anyway if they are ata party and all their friends are drinking. Youth mayhave considerable information about contraception,but still not consistently use contraception whenengaging in sexual activity if their values, attitudesand perceptions of peer norms are not favorable tocontraceptive use. Simply put, while knowledgeprovides a foundation for human action, knowledgealone is not sufficient.Knowledge may affect behavior directly. Forexample, if sexually active young women knowthey are supposed to take a contraceptive pill everyday, they are more likely to take that pill every day.Knowledge may also affect behavior indirectly byaffecting values, attitudes, perception of normsand even perceptions of self-efficacy (Ajzen 1985;Bandura 1986). For example, if youth do not knowtheir parents’ values about sexual intercourse amongteens, their own values about sexual intercourse mayChapter 3 Increasing Knowledge 33

e shaped more by their peers and the media andthey may be more likely to engage in sexual activityat an earlier age. If youth do not know that condomsprovide considerable protection against pregnancyand STDs, their attitudes towards condoms maybe more negative and they may be less likely to usecondoms during sexual activity. If youth know howto use condoms or other methods of contraceptionproperly, they are more likely to feel confident usingcondoms or other methods of contraception andactually use them properly.When applying these general concepts to sexualbehavior, four questions should be asked:1. Does teens’ knowledge about different aspects ofsexuality affect their sexual behavior?2. Can we increase knowledge?3. What are the most effective teaching methods forincreasing knowledge?4. What topic areas are most commonly covered incurricula that effectively change sexual behavior?These questions are answered below.Does teens’ knowledge about different aspects ofsexuality affect their sexual behavior?Contrary to what many sexuality educators typicallybelieve, knowledge about sexuality is not allthat highly related to behavior (Tables 3-1 and 3-2).In particular, there is little evidence that knowledgeabout sexuality in general, knowledge about sexuallytransmitted disease (including HIV), or knowledgeabout condoms and contraception is significantlyrelated to the initiation of sex (Table 3-1) (Kirby andLepore 2007). There is very mixed evidence thatknowledge about STD and HIV is related to condomuse (Table 3-2). Finally, there is some evidence,but not always consistent evidence, that knowledgeabout condoms and contraception and their effectivenessis related to condom or contraceptive use.What do these findings mean? How can these findingsbe so inconsistent with the very plausible beliefthat knowledge is needed to provide a foundation forbehavior change?There are at least three partial answers to thesequestions.1. Most young people already know the basics aboutsexual behavior, condoms, contraception, pregnancyand STD, so greater knowledge may notmarkedly affect their behavior.2. The knowledge tests used in these studies may notmeasure the particular facts that are most importantin changing behavior.3. Greater knowledge may improve attitudes, perceptionsof peer norms or skills. These mediatingfactors in turn may affect behavior, but the statisticalanalyses may not always capture this indirectimpact of knowledge on behavior.Nevertheless, the conclusion from these studies isquite clear: if the goal of a program is to changebehavior, it is important to focus on knowledge thatmost directly relates to values, attitudes, perceptionsof peer norms and skills of a specific behavior, ratherthan general knowledge. For example, accurateknowledge about the risk of pregnancy and STDsand the effectiveness of prevention methods mayimprove attitudes about use of condoms and otherforms of contraception, and, in turn, increase theiruse, but general knowledge about sexuality may nothave an impact on sexual behavior.This conclusion is consistent with other kinds ofresearch. In particular, multiple studies have demonstratedthat presenting a clear message about sexualbehavior is an important characteristic of effectiveprograms (Kirby, Laris et al. 2006). A common,clear message is:“Always avoid unprotected sexual activity.Abstinence is the safest choice. If you engagein sexual activity, always use protection againstpregnancy and STDs.”One way that programs can make a compelling casefor a particular behavioral message is by emphasizingall the facts and concepts that support thatmessage.In sum, the overall message from all of these studiesis: Knowledge should be taught, but 1) it should be34 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

Table3-1Number of Studies Reporting Effects ofKnowledge on Sexual BehaviorTable3-3Number of Programs Having Effects onDifferent Knowledge TopicsLaterInitiationof SexNoSignificantEffectsEarlierInitiationof SexKnowledge TopicsHad aPositiveEffectNoSignificantEffectsHad aNegativeEffectKnowledge about sexualityin general (N=1)0 1 0Overall knowledge ofsexual issues (N=9)7 2 0Greater knowledgeabout STD and HIV(N=3)Greater knowledgeabout condoms andcontraception (N=1)0 3 00 0 1Knowledge ofpregnancy (N=5)Knowledge of STD(N=11)Knowledge of HIV(N=31)5 0 08 3 028 3 0Table3-2Number of Studies Reporting Effectsof Knowledge on Condom orContraceptive UseGreater Useof Condomsor OtherContraceptivesNoSignificantEffectsReduced Useof Condomsor OtherContraceptivesKnowledge ofabstinence (N=2)Knowledge of methodsof contraception (N=6)Knowledge of condoms(N=8)2 0 04 2 05 3 0Greater knowledgeabout STD and HIV(N=10)3 4 3Knowledge of methodsto prevent STD/HIV(N=7)6 1 0Greater knowledgeabout condoms andcontraception (N=7)3 4 0Knowledge of communityor reproductivehealth services (N=2)1 1 0Knowledge about effectivenessof condoms inpreventing STD (N=7)2 5 0Knowledge of one’sown sexual limits (N=3)1 2 0focused; 2) it should be very relevant to the particularvalues, attitudes, perceptions of peer norms andskills that are related to sexual behavior; and 3) itshould strongly support the curriculum’s prescriptivemessage.Can we increase knowledge?Studies overwhelmingly demonstrate that it is possibleto increase knowledge. More than 30 studiesmeasured the impact of programs on one or moreknowledge topics. The overwhelming majority demonstratedthat they increased knowledge in one ormore areas (Kirby, Laris et al. 2006). Furthermore,of the 10 knowledge topics that were assessed mostfrequently, at least half the studies increased knowledgein 9 of them (Table 3-3). The tenth topic wasnot really a factual topic; it was an understanding ofoneself—“knowledge of one’s own sexual limits”—and thus quite different from the other topics.What are effective teaching methods for increasingknowledge?Many theories of education and effective instructionprovide important principles for improving knowledge.For examples of types of activities that incorporatethese principles, see Box 3-1.1. Learning is promoted when students are learningabout topics relevant to their lives (Jonassen1999; Nelson 1999; Merrill 2002). Fortunately,sexual relationships (and sexuality more generally)are perceived by many youth as among the mostimportant concerns in their lives and many viewunintended sex, pregnancy and STD as potentialChapter 3 Increasing Knowledge 35

Box3-1Types of Activities to Increase Knowledge in Effective Pregnancy andSTD/HIV Prevention Curricula1. Anonymous Question Box. Anonymous question boxesprovide youth with an opportunity to ask questionswithout having their names associated with the question.Anonymous question boxes may help to elicitmore meaningful questions, especially when teachingabout a sensitive topic. For example, a facilitator canask youth to write questions on index cards (withoutnames), and then place their questions in a basket.The facilitator reads the questions out loud to thegroup and provides answers or can elicit answers fromthe group. When students are given the opportunityto ask any question without having their names associatedwith it, they are likely to ask more questions.They also are more likely to ask questions that mightotherwise be embarrassing for them to ask in theclassroom. Educators also can occasionally add theirown questions to emphasize or clarify particular pointsor to make sure that needed questions are asked.2. Brainstorming. Brainstorming is a teaching methodthat is often used to generate ideas and lists. Inbrainstorming, all ideas are recorded. For example, afacilitator may ask a group of youth, “What are somereasons why young people have sex?” or “What aresome reasons why young people decide not to havesex?” All answers to this question are accepted andrecorded. This technique encourages broad participationand helps students consider all possibilities.3. Competitive Games. Competitive games in curriculaoften mimic common television game shows (e.g.,Jeopardy), sports games (AIDS Basketball) and contests(condom relays) in which teams win by correctlyanswering questions or completing specific tasks.Games often can encourage interaction among youth,be fun, reduce embarrassment discussing sensitive topicsand reinforce learning.4. Flip Charts or Pamphlets. Written materials like flipcharts and pamphlets can provide information abouta particular topic relatively efficiently. Flipcharts canbe thought of as a series of posters bound together.They are commonly used to teach about the reproductivesystem, contraceptive methods, and STDs throughpictures. Pamphlets or fact sheets are available forpurchase on many health topics or can be easily madeby facilitators at a minimal cost. Pamphlets are a goodway to give students information that they can takehome or refer to in the future. Facilitators who usethese materials should make sure that they are culturally,developmentally and linguistically appropriate forthe youth they are serving.5. Guest Speakers. Guest speakers can add a personalperspective and interest to class sessions (e.g., a guestspeaker who has been living with HIV can share his/her experience). Invited speakers should have a specialarea of expertise or experience and should be skilledat talking with youth about their particular topic.6. Homework Assignments. Homework assignments aregenerally given to students to help reinforce learningor explore a topic more deeply. For example, inthe curriculum Reducing the Risk, youth are given ahomework assignment to interview parents abouttheir thoughts on teens and sex. This assignment helpsto reinforce learning from previous classes and alsoprovides an opportunity for parents and youth to communicateabout an important topic.7. Large-Group/Whole-Class Discussions. Large-groupdiscussions generally are led by a facilitator. Informationto be discussed is sometimes presented firstthrough a short lecture, video or skit. After the informationis presented, the facilitator leads a discussionthat allows for recall, analysis, generalization andpersonalization of the information. For example, ateacher might present some statistics about STDs andteenagers to start a discussion (introduction), andthen asks the youth some questions about the statistics(recall). Youth discuss why STD rates are so highfor youth (analysis). Then they list the ways they canprevent STDs (generalization) and how they will usethis new information in their lives (personalization).8. Problem-Solving Activities. Many effective curriculaprovide problems or dilemmas to students and havethem make decisions, either individually or in smallgroups, about what they believe should be done.Sometimes, these problems are presented as lettersto a columnist such as “Dear Abby,” asking for adviceabout some problem related to relationships or sexualbehavior. Other times, they are presented as questionsfrom friends or advice to give to younger siblings.Students typically discuss the problem, weigh the risksof various alternative behavioral solutions and reach adecision about the best approach.9. Quizzes. Quizzes, self-assessments, and myth/factsheets are ways to assess how much informationparticipants have about a subject, what they need tolearn about a subject and/or what they have learnedfrom a session. Reviewing the answers with a groupalso provides additional opportunities to teach orreinforce quiz information.(Continued)36 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

Box3-1Types of Activities to Increase Knowledge in Effective Pregnancy andSTD/HIV Prevention Curricula (Continued)10. Roleplays. Scripted and unscripted roleplays providean opportunity for youth to practice skills. Forexample, after learning the steps for refusal, youthmight act out a roleplay in which they actually applythe steps to a hypothetical scenario. Roleplays areparticularly effective at teaching skills and increasingself-efficacy in those skills.11. Brief Lectures. A lecture is a prepared oral presentationthat may or may not use visual aids (such ascharts, diagrams and slides). A lecture generally isused to present factual material in a direct and logicalmanner, to entertain or to inspire an audience. Lecturesappeal to those people who learn by listening.12. Skill Demonstrations. An important step in skillinstruction includes modeling the skill. In skill demonstrations,the facilitator models the steps of a givenskill (e.g., refusing sex, negotiating condom use, orusing a condom correctly). Afterward the facilitatorelicits feedback on his or her performance of the skillfrom students and sometimes has the students practicethe skill themselves.13. Skits. Skits are dramatic presentations of situationsthat can serve as input for a large- or small-groupdiscussion. Skits are effective at engaging an audiencebecause the performance is live and often involves theparticipants as actors. Skits can sometimes be usedinstead of videos.14. Small-Group Discussions or Other Activities. Smallgroupdiscussions generally allow for more youth tobe involved and express their ideas. Generally, themembers of a small group are given a set of guidelinesor instructions for completing a task together (e.g.,generate a list of reasons why teenagers have sex andwrite those reasons on flip charts). Often, small groupsthen summarize their work for the larger group.15. Simulations. Simulations attempt to demonstrate howsomething works in a hypothetical but realistic situation.For example, the “STD Handshake” is a classicsimulation activity where youth learn how an STD canspread through a group of people by shaking handswith group members and getting signatures on indexcards. The handshaking simulates sexual intercourse.Unbeknownst to one student, she/he has a mark onthe back of her index card that represents an STD.Anyone who has a signature from that student alsohas contracted an STD and anyone else who has thesignatures of those students may have an STD. Simulationsare often followed by large- or small-groupdiscussions of the major points.16. Statistics on Incidence and Prevalence. Incidence isthe number of new cases of a disease or condition in adefined population, within a specified period of time(often a year). Often they are expressed as rates (e.g.,a pregnancy rate or chlamydia rate). Prevalence is thenumber of events, e.g., instances of a given disease orother condition in a given population at a designatedtime (such as the number of people with HIV or thenumber of teen mothers). These also can be expressedas rates. Presenting data about teen pregnancy and/orSTD helps youth understand the scope of the problemand helps them understand their risk. Incidence andprevalence statistics can be found by doing a search onthe Internet. However, local statistics may need to beobtained from local or state health departments.17. Videos and Discussion. Various health educationvideos are available from health education organizations.Videos often are very popular with youth andare effectively used to stimulate group discussionsand reinforce learning. One challenge with videos isthat they can become outdated with respect to theinformation they provide and youth fashion, slang andculture.18. Worksheets. A worksheet requires youth to thinkabout the topic at hand and review important/criticalpoints. Worksheets are better used when the productis authentic. For example, asking youth to write a letterto a friend about preventing HIV is more authenticthan asking youth to answer 10 straightforward questionsabout HIV prevention methods.problems. Thus, sex and STD/HIV educationprograms have the potential to be perceived byyouth as very relevant.However, this potential may not be realized if theinstructional material does not match the students’needs and knowledge. If the instructionaltopics are not developmentally appropriate, theinstruction does not cover questions or broadertopics of interest to the students, and the mostimportant concepts are not covered, then studentsmay become disinterested and learn less.To increase knowledge (as well as improve attitudes,perceptions of peer norms, skills, etc.), theinstructional material needs to meet the particularneeds of the students. It is more importantthat students master the most important conceptsChapter 3 Increasing Knowledge 37

elevant to their lives than learn a greater numberof less important concepts.2. Learning is promoted when material is tailoredto the age, knowledge level, level of sexualexperience and gender of the students (Kirby,Laris et al. 2006). Consistent with the previousprinciple, this means that the information, skillsand behavioral message being taught should beappropriate to the level of experience, knowledgeand skills that the students have. For example, ifstudents are very young and not even consideringsex, then instructing them about methods ofcontraception will not be harmful, but may notseem relevant to the students and they may notremember them. As students begin to go throughpuberty and some begin to have sex or thinkabout it, then material on contraception is likelyto be more relevant to them. Conversely, if moststudents are having sex, focusing solely on abstinencemay seem irrelevant, reducing the potentialfor learning.Teaching methods also should reflect the characteristicsof the students. For example, if studentsdo not have adequate knowledge or relevant experienceabout relationships, then the instructionshould be taught at a more elementary level andshould provide relevant experience from others(e.g., through roleplays, videos, or other means)instead of relying on the students’ experience. Ifthe students are very knowledgeable and have alarge amount of experience and the instructionallevels are too low, then the students may find thematerial too elementary, boring and irrelevant.If these levels vary among the students, as theyoften do, then the instruction needs to addressthe multiple levels of knowledge or experienceto the extent feasible. One way to do this is toreview the material quickly. Another way is toallow more informed students to answer questionsor teach other students (e.g., through small-groupdiscussions, older peer-led activities, games, roleplaying,etc.).Material also should be tailored for each gender,whenever possible. For example, it shouldreflect potentially different learning styles ofeach gender, the particular pressures to engage insexual activity that each gender faces, and differentialcontrol over condom and contraceptive use.3. Learning is promoted when new knowledge isdemonstrated to students rather than simplydescribed (Merrill 2002). For example, simulationscan illustrate how the risks of pregnancyincrease with ongoing unprotected sex over time(see pregnancy risk activity in Chapter 4) andhow sexually transmitted infections can spreadrapidly among sexual networks (see STD handshakeactivity in Chapter 4). Videos can illustratethe effects of unplanned pregnancy or STDs.Roleplaying can demonstrate assertive and refusalskills to avoid undesired sexual activity or to insiston using contraception. Condom demonstrationscan show how to use condoms properly.4. Learning is promoted when complex conceptsor skills are broken into a progressionof smaller concepts or skills, when the smallerconcepts or skills are taught first, and whenthere is then a logical progression to morecomplex skills (Gibbons, Bunderson et al. 1995).For example, skills to avoid undesired or unprotectedsexual activity may be complex. However,they can be broken down into skills to recognizein advance situations that might lead to undesiredor unprotected sexual activity, as well asassertiveness skills to avoid or get out of thosesituations. The assertiveness skills, in turn, canbe broken down into verbal skills and assertivebody language. Then, each of the verbal skillscan be described, modeled and practiced. Theseskills can first be used in simpler situations inwhich a person is not particularly attracted to his/her date for the evening and can then progressto more complex situations in which the personreally likes and is attracted to his/her date, maybe alone, may have had too much to drink andso forth. Similarly, skills to use condoms correctlycan be broken down into skills to purchasecondoms, skills to have condoms available whenneeded, multiple verbal skills to insist on theuse of condoms and the necessary steps to actuallyuse a condom properly. Again, they can firstbe taught in simpler situations (e.g., when the38 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

partner does not mind using a condom) and thenin more challenging situations (e.g., the partnerreally does not want to use a condom).5. Learning is promoted when multiple examplesand perspectives are provided. When possible,multiple examples are beneficial (Merrill 1994).These can both reinforce the principle or conceptbeing illustrated and increase the chancesthat students will relate to one or more of them.Similarly, each example should be approachedfrom multiple perspectives so that students seeand hear different perspectives, concepts arereinforced and students can integrate the material(Spiro, Feltovich et al. 1992).6. Learning is promoted when existing knowledgeis activated as a foundation for new knowledge(Blair and Caine 1995; Merrill 2002). Learningis encouraged when students are directed to recallor apply knowledge from past instruction or pastexperience that can be used as a foundation forthe new knowledge. For example, giving studentsthe opportunity to demonstrate what they alreadyknow also can be an effective way to activelyengage them, refresh their memories and possiblyclarify their thinking.To the extent feasible, students should becomeexplicitly aware of their preconceptions and priorlearning and become willing both to build uponthat knowledge and to unlearn when necessary.For example, lessons should include a discussionof myths about pregnancy commonly held byyoung people, as well as activities to reduce exaggeratedmisperceptions of peer sexual activity.7. Learning is promoted when students areactively engaged in solving problems (Jonassen1999; Nelson 1999; Merrill 2002). Learning isencouraged when students are actively rather thanpassively addressing real problems (Angelo 1998).Students need to participate in instructionalactivities, not listen passively to the provisionof information. This means that the programneeds to include a variety of interactive activities,such as games, simulations and roleplays. Italso should include activities in which studentsare given dilemmas about whether or not theyshould engage in sexual activity or use protectionand must make decisions (individually or in smallgroups) about those choices. Alternatively, programsshould include activities in which studentsare given scenarios and must advise participantsin the scenarios about what to do.8. Learning is promoted when students organizetheir new concepts and skills. If students areprovided with a useful structure to organize theirnew knowledge or skills, they will learn betterthan if the facts or skills are not attached to aframework and are not organized (Andre 1997).One very important structure is the clear prescriptivemessage about responsible sexual behaviorthat should be given to the students. Facts,concepts and skills should be continually linkedto that message. For example, facts about theprobabilities and consequences of pregnancy and/or STDs should be linked to abstinence and useof protection against pregnancy and STDs. If afact, concept or skill is not related to that message,then its inclusion should be questioned.Another way to organize concepts or skills isto use mnemonic devices. For example, in thecurriculum All4You!, “PSST” is used to helpstudents learn three steps for refusing undesiredsexual activity: Pick your limit, Say it strong,Suggest something else to do, and Tell why(Coyle 2006). Similarly, in Making Proud Choices,“SWAT” is used to help students remember fourdifferent steps of a refusal skill model: Say no,explain Why, offer an Alternative, and Talk it out(Jemmott, Jemmott III et al. 2002).9. Learning is promoted when new knowledgeis applied multiple times to solve problems(Merrill 2002). This is consistent with the oldadage “practice makes perfect” (Gardner 1999).As stated above, the problems should be relevantto the students and consistent with the instructionalgoals (Schwartz, Lin et al. 1999). They alsoshould be somewhat varied and provide a rangeof situations. For example, lessons might describedifferent scenarios in which undesired sexualactivity might take place and then ask students todevelop different methods of avoiding or gettingChapter 3 Increasing Knowledge 39

out of these different situations (see situationsactivity in Chapter 4). They also might involveidentifying different situations in which protectionagainst pregnancy or STDs might notbe used and brainstorming methods to avoidor get out of these situations without havingunprotected sex. These activities might includegroup identification of these situations, groupsuggestions for avoiding or getting out of them,roleplaying to practice skills needed to avoid orget out of them, and individual decision makingabout which solutions would work best foreach individual. The key is to provide multipleopportunities to apply the content for maximumknowledge gain.10. Learning is promoted when students are giventhe proper balance of challenge and support(Blair and Caine 1995; Angelo 1998). Studentsshould be taught basic concepts or skills and, asthey strive to apply them, they should be givenfirst reasonably easy and then progressively moredifficult problems to solve or skills to learn. Asneeded, they should be given both appropriatefeedback and coaching. When coaching, giveyoung people ample time to ask questions andexplore options before jumping in with suggestions.Feedback should be timely, specific andconstructive. However, it also should be withdrawnover time. That is, students should begiven the support they need to learn a conceptor skill, but that support should gradually bewithdrawn so that they learn to use conceptsor perform skills well on their own (Collins,Brown et al. 1989).11. Learning is promoted when students areencouraged to apply or integrate their newknowledge or skill into their everyday lives.As noted above, students should be encouragedto think about which decisions are rightfor them, which situations they will avoid, andwhich skills they will need to abstain or useprotection. They also learn more if they have toreflect on, discuss or defend their new knowledgeor skill and if they use their knowledge orskill in new personal ways (Merrill 2002). Forexample, when they encourage their peers eitherto abstain from sex or use condoms or otherforms of contraception, they may use their skillsin new ways. Homework assignments in whichstudents are asked to use a skill or share withothers the information they learned may helpthem integrate that information and understandit more clearly.12. Learning is promoted when instruction isindividualized (Mullen, Mains et al. 1992).There are many ways to individualize instruction.For example, when students roleplay, theycan be given several different scenarios andchoose ones that are most appropriate or realisticfor them individually. When calling STDhotlines or clinics, students can craft questionsahead of time that they wish to have answered.When students are given the opportunity to putquestions in an anonymous question box, theirindividual questions can be answered.If students can move at their own pace, theyalso can learn more. Thus, interactive computerprograms that present or review relevant materialand that allow students to move at their ownpace can be helpful. Similarly, written materialsand resources in the community can allow studentsto access and read them when they wantto do so. Well-designed interactive computerprograms also can tailor the activities for theindividual student’s gender and sexual experienceor intentions.13. Learning is promoted when effective teachersuse an array of teaching methods, becausethere is no single, universal approach thatsuits all situations (Blair and Caine 1995; VanMerriënboer 1997). Different people learn mosteffectively in different ways. For example, somepeople learn most efficiently through hearing,others through seeing and others throughexperiencing. In addition, some methods arebetter suited to teaching certain skills and fieldsof knowledge than are others. At a minimum,teachers should use different instructional methods,and, if possible, should become familiarwith the instructional methods that are mosteffective with their own students and use those40 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

methods more often. For example, they shoulduse short lectures, videos, small-group discussions,simulations, games, roleplaying, individualworksheets and other methods (see Box 3-1).14. Learning is promoted when students workregularly and productively with other students(Gardner 1999; Merrill 2002). Workingtogether may encourage students to reflect onwhat they know, clarify their thoughts anddefend them. It also may provide them withthe opportunity to show others what they havelearned and see their own progress, therebyincreasing their motivation to learn. For example,curricula should regularly include smallgroupactivities among the repertoire of types ofactivities and should allow students to demonstrateknowledge, assertiveness skills and otherskills to one another.15. Learning is promoted when students investtime and make a committed effort (Angelo1998). For example, activities that motivate studentsto learn and that keep them involved canincrease learning. These can include class projectsor activities that involve them and creativeand interesting homework assignments, such asassignments to talk with friends or parents aboutrelevant topics or to obtain information fromclinics or other community organizations.16. Learning is promoted when students areassessed appropriately and understand theassessment criteria (Angelo 1998). Properassessment can motivate some students to learnand can help students review what they havelearned. Under the right conditions, it also candemonstrate to students what they have learned.For example, if the instruction is part of a healthclass, the knowledge aspects can be tested at theend of instruction. If students develop portfolios,completion rates can be assessed. If skillsare taught, those skills can be assessed throughroleplays in small groups.What effective teaching methods are most commonlyused and what topic areas are most commonlycovered in curricula that change sexualbehavior?A review of effective programs identified teachingstrategies that are commonly used and believed tobe effective in increasing knowledge and changingbehavior. These are summarized in Box 3-1.A review of these same programs identified topicsthat are commonly covered in pregnancy and STD/HIV prevention programs (Kirby, Laris et al. 2006).They are included in Box 3-2. If the program isdevoted solely to pregnancy prevention, then someSTD/HIV topics could be excluded. Conversely, ifa program is devoted solely to STD/HIV prevention,then some pregnancy topics could be excluded.However, many youth have stated that they areconcerned about both pregnancy and STD/HIV andthat both possible outcomes of sexual activity motivatethem to remain abstinent or to use condoms.ConclusionsKnowledge is important because it provides thefoundation for many values, attitudes, perceptions ofnorms, skills and, ultimately, for behavior. However,simply increasing knowledge about sexuality ingeneral may not lead to desired changes in sexualbehavior. Rather, what is needed are improvementsin those particular facts, concepts and skills that canchange important mediating factors and can providea compelling case for avoiding sexual risk behavior.Innumerable studies have demonstrated that it ispossible to increase knowledge about numerous topics(and to increase skills as well). Findings from avast body of educational research suggest that thereare important educational principles that increaselearning. To the extent possible, these should beincorporated into sex and STD/HIV curriculaactivities.For additional information on implementing theseinstructional principles, see the “InstructionalMethods/Pedagogy” section of the resources listedat the end of this volume.Chapter 3 Increasing Knowledge 41

Box3-2Important Topic Areas to Cover in Pregnancy and STD/HIV Prevention CurriculaRelationships• Qualities of healthyand unhealthy romanticrelationships• Gender equality andinequality in relationships• How to build healthyrelationships• How to get out ofunhealthy relationships• How to express love andaffection without havingsexPregnancy• How pregnancy occurs• Likelihood of gettingpregnant (or gettingsomeone pregnant)• Myths about chances ofgetting pregnant• Consequences of pregnancyand childbearing,both short term andlong term• Methods of reducing therisk of pregnancySTD/HIV• How STDs aretransmitted• HIV progression andincubation• Symptoms (and lack ofsymptoms)• Myths about STDs• Chances of contractingSTDs, including HIV• Consequences of contractingSTDs, includingHIV, both short term andlong term• Ways to reduce the riskof STDs, including HIV(including high-risk,low-risk and no-riskbehaviors)Influences onSexual Decisions• Internal desires andpressures• Personal values• Parental/family values• Peer pressures• Partner pressure (linespartners use to getpeople to have sex andmethods of resistingthem)• Sexual values portrayedin the media• Alcohol or drug use• Decision-making skillsand problem-solvingstepsValues/Norms• Personal values abouthaving sex and underwhat conditions to havesex• Personal attitudes aboutusing condoms andcontraception• Parents/family and communityvalues aboutteens having sex• Parents/family andcommunity values aboutteens using condoms andcontraception• Peer norms about teenshaving sex• Peer norms about teensusing condoms and contraceptionSituations That MightLead to Unwanted orUnprotected Sex• Their characteristics• How to recognize themin advance• How to avoid them• How to get out of themCommunication andCommunication Skills• Why partners might nottell you they have an STD• The importance of communicatingpersonalbeliefs about sex and useof protection• Aggressive, passive andassertive communicationstyles• How to effectively insiston not having sex—refusal skills• How to effectively insiston using condoms andcontraceptionAbstinence• Advantages of abstinence• Pressures to have sexand ways of overcomingthose pressures• Distorted views of peersexual activity• Ways to show affectionwithout having sexMutuallyMonogamousRelationships• Reasons to have mutuallymonogamous relationshipsinstead of multiplesexual partners• Risks of having multiplesexual partners• Additional risks ofsequential versusconcurrent partners 5Condoms• Reasons to use condoms,if having sex• Effectiveness (includingmyths)• Rights to access• Where to obtain• How to carry and haveavailable• How to use properly—correct steps for using• Barriers to obtaining andusing condoms and waysof overcoming thosebarriers (including waysto prevent condom usefrom ruining spontaneity,mood and pleasure)Contraception• Reasons to use contraception,if having sex• Rights to access• Where to obtain• Different types and theircharacteristics, includingtheir effectiveness rates• Criteria for selecting amethod• How to use properly• Myths aboutcontraceptives• Barriers to obtainingand using contraceptionand ways of overcomingthose barriers• Importance of dualmethodSTD/HIV Testingand Treatment• Importance• Rights to access• Where to obtain• ProceduresCommunity Resources• Counseling• Condoms• Contraception• Pregnancy and STD/HIVtests• Dating violence/sexualabuse• Types of condoms andtheir characteristics5 This topic is not commonly covered, but should be and increasingly is being covered.42 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

4ImprovingPerceptions of Risks—Both Susceptibility and SeverityKeys to ImprovingPerceptions of RiskFocus on important risks (e.g., pregnancy andSTD/HIV) and situations that might lead torisk behavior. Help youth overcome a sense ofinvulnerability by visualizing and personalizingrisks, situations leading to risks and methodsof avoiding them.BackgroundAs we all observe daily, if people believe that somebehavior will greatly increase their likelihood of adeadly outcome, they are less likely to engage inthat behavior. For example, people do not intentionallydrive the wrong way down the freeway, because1) driving the wrong way increases the likelihood ofa head-on collision and 2) the severity of a head-oncollision is great.This basic principle of behavior is embedded in manysocio-psychological theories of human behavior,particularly those that assume that people generallyconsider alternative courses of action, identifythe possible consequences of each course of action,consider the probability of each consequence, assesseach consequence according to its desirability (orundesirability) and make a decision about whichcourse of action to follow.Many theories commonly used to design effectivehealth education programs incorporate thisprinciple. (See the “Health Education and HealthBehavior Theory” section in the resources at the endof this book.) According to the health belief model,individuals’ perceived susceptibility to a disease orhealth problem and their perceived severity of thatdisease or health problem affect their efforts to avoidit (Rosenstock 1974). For example, if people believethat 1) particular behaviors increase their likelihoodof contracting HIV and 2) HIV is a severe disease,then they are more likely to adopt behavior that willreduce their susceptibility to HIV.Similarly, in both the theory of planned behaviorand the theory of reasoned action, one of the threefactors most strongly affecting intentions to engagein any behavior is behavioral beliefs (Fishbein andAjzen 1975; Ajzen 1985; Ajzen and Madden 1986).These are beliefs about the likely outcomes of anybehavior (i.e., the probabilities of possible outcomes)and the evaluations of these outcomes (i.e., theextent to which they are positive or negative). Theseassessments of behavioral outcomes affect attitudestoward the behavior, which in turn affect intentionsand, ultimately, behavior.Finally, according to social cognitive theory, peopleevaluate alternative courses of action and develop“expectancies” (based on both expectations aboutthe consequences of courses of action and the valueattached to those consequences), which in turnaffect their decisions about behavior (Bandura 1986).Chapter 4 Improving Perceptions of Risks—Both Susceptibility and Severity 43

Although a number of possible emotional, social andhealth risks are associated with sexual intercourse,the most commonly researched risks are thoseinvolving pregnancy and STDs. This chapter, andmore generally this book, focuses on those risks.Authors use a variety of related terms involvingrisks differently or even sometimes interchangeably.For example, the following words are allcommonly used: risks, susceptibility, vulnerability,severity and seriousness. In this chapter, the “risks”associated with some course of action will refer tothe negative consequences that may result froma course of action (e.g., unintended pregnancy orSTD). “Susceptibility” will refer to the likelihood ofthose negative consequences occurring and “severity”will refer to the negative assessments of thoseconsequences.It is widely believed that some young people (perhapsa minority) feel invulnerable and that thissense of invulnerability increases their risk behavior(Weinstein 1988; Weinstein 1993; Lapsey 2003).For example, some adolescents may not think thatit is likely that they will become pregnant (or getsomeone pregnant) or that they will contract anSTD; instead, they may believe it will only happento others. According to some psychologists, adolescentsare egocentric and create “personal fables”or modes of understanding that include themes ofinvulnerability, omnipotence and personal uniqueness(Elkind 1967) and these egocentric fables arerelated to sexual risk behavior (Arnett 1990). Otherpsychologists view the creation of personal fablesand adolescents’ sense of invulnerability as adaptivemechanisms to the many challenges they face astheir egos develop (Lapsey 1993).These beliefs about invulnerability are summarizedhere because they are held by many adults workingwith youth and by some psychologists. However, astrong body of research does not yet exist to supportthese beliefs about the role of invulnerability.It is definitely true that many adolescents engagein risk behaviors because they simply do not considerthe possible risks. That is, they may engage inrisk behaviors without even assessing the possibleconsequences (Steinberg 2003). This is especiallytrue when they encounter new situations, are withtheir peers, are more oriented to the present ratherthan the future and are less able to inhibit theirimpulses (Steinberg 2003).Adolescents’ failure to consider risks and plan effectivelymay have a biological basis. In recent years,neuroscientists have learned that adolescents’ brainscontinue to grow and change during the seconddecade of their lives. In particular, the prefrontalcortex, which affects judgment and impulse control,matures with age (Weinberger, Elvevåg et al. 2005).With a less developed prefrontal cortex, adolescentsare less likely to plan and consider risk and morelikely to be impulsive.Regardless of whether sense of invulnerability isadaptive or whether it is biologically based, manyprofessionals commonly accept that correcting adolescents’perceptions of invulnerability to pregnancyor STD has the potential to reduce their sexual riskbehavior.Perceiving risk involves recognizing the conditionsthat might lead to risk and then assessing personalrisk (Millstein 2003). The ability of teens to recognizethese situations, in turn, is affected both bytheir cognitive knowledge of the important characteristicsof the situation and by their experience withsimilar situations (Millstein 2003). Consequently,it is important for teens to review their own experiencesand those of their peers, to identify thosesituations that they or their peers encounteredthat could have led to undesired, unplanned orunprotected sex, and to describe those situationsaccurately.In sum, perceptions of risk play a central role inmany theories of health and risk behavior. Manyhealth education interventions focus on perceptionsof risk in order to improve health behaviors andreduce risk behaviors (Millstein 2003).When applying these concepts about perceptions ofrisk to sexual behavior, there are three questions thatshould be asked:44 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

1. Do teens’ perceptions of risk of different sexualbehaviors affect whether they engage in thosebehaviors?2. Can we increase perceptions of risk, susceptibilityand severity of pregnancy and STDs, includingHIV?3. What are effective teaching methods for improvingperceptions of risk?These questions are answered below.Do teens’ perceptions of risk of different sexualbehaviors affect whether they engage in thosebehaviors?There are at least two kinds of quantitative evidenceassessing the impact of perceptions of risk onsexual behavior. First are the studies measuring therelationship between perceptions of risk and sexualbehavior (Kirby and Lepore 2007). The summaryof studies in Table 4-1 provides little consistentevidence that perceptions of risk are significantlyrelated to initiation of sex. Although three studiesfound that greater perception of risk of pregnancyor STD/HIV was related to later initiation of sex,14 studies found no significant impact and threestudies found that greater perception of risk wasrelated to earlier initiation of sex. These results arenot consistent with the second type of quantitativeevidence—the results of numerous studies of thereasons why young people do not have sex. Thosestudies consistently identify concern about the risksof pregnancy and concern about the risk of STD/HIV as being among the top few reasons that youngteens give for not having sex.Why do these two types of research produce suchdifferent results? Part of the answer is simple.Theory predicts that teens who believe that havingsex will place them at high risk of pregnancyor STD will therefore be less likely to have sex.This would produce a negative correlation betweenperceptions of risk and behavior (higher perceptionof risk is correlated with lower chance of having sex).However, teens who do not have sex are not at riskof pregnancy or STD. This fact produces a positivecorrelation (lower chance of having sex is correlatedwith lower perceived risk). Because it is often difficultto separate out the directions of causality, theresults from studies about the relationship betweenperceived risk and initiation of sex are mixed ornot significant. However, this does not mean thatincreasing perceptions of risk does not lead todelayed initiation of sex.In contrast, the evidence is both much stronger andmore consistent that perceptions of risk have animpact on contraceptive use and condom use specifically(Tables 4-2 and 4-3). Five out of eight studiesfound that concern about the risks of pregnancyhad an impact on contraceptive use, and 9 out of 27Table4-1Perceived severity ofpregnancy or concernabout risk of pregnancyPerceived risk of STD/HIV or concern aboutSTD/HIVTable4-2Number of Studies Reporting Effects ofPerceptions of Risks of Pregnancy orSTD/HIV on Initiation of SexPerceived consequencesof pregnancy andoverall concern aboutpregnancy and importanceof avoiding itTable4-3LaterInitiationof SexNoSignificantEffectsEarlierInitiationof Sex2 7 01 7 3Number of Studies Reporting Effects ofPerceptions of Consequences of Pregnancyand Concern About Pregnancy onContraceptive UseIncreasedContraceptiveUseNoSignificantEffectsDecreasedContraceptiveUse5 3 0Number of Studies Reporting Effects ofOverall Concern About Risks of STD/HIV onCondom UseOverall concern aboutrisks of STD/HIV andmotivation to avoid itIncreasedCondom UseNoSignificantEffectsDecreasedCondom Use9 17 1Chapter 4 Improving Perceptions of Risks—Both Susceptibility and Severity 45

studies found that concern about STD/HIV had animpact on condom use. Not surprisingly, multiplestudies also have found that teens commonly listconcern about pregnancy and concern about STD asimportant reasons why they use contraception andcondoms, respectively.Can we increase perceptions of risk and severityof pregnancy and STDs, including HIV?Multiple studies provide strong evidence that it ispossible to increase perceptions of risk of pregnancyand STDs, both in terms of susceptibility and severity(Table 4-4) (Kirby, Laris et al. 2006). Abouthalf of all the studies that measured programmaticimpact on one or more of these outcomes found asignificant positive effect. All of these outcomesexcept one were positively affected by at least oneprogram. The one exception was perception ofsusceptibility to pregnancy. It may be the case thatyoung people already know that pregnancy canoccur if they have sex, leaving little room for changeon this factor. Alternatively, young women mayhave had unprotected sex, did not become pregnant,and therefore believe they are infertile. Finally, thefailure of these studies to find an impact on perceptionof susceptibility to pregnancy may reflect agreater STD/HIV focus of many of the programs.In any case, the evidence is clear that it is possible toincrease individuals’ perceptions of their own risk ofpregnancy and STDs, including HIV, if they havesex or unprotected sex.What are effective teaching methods for improvingperceptions of risk?In general, many of the principles of effective teachingthat are discussed in the previous chapter applyespecially well to teaching about risk. In addition,a few other principles apply. Examples of activitiesincorporating these principles are presented later inthis chapter. To reduce unprotected sex, curriculaneed to:1. Emphasize the risks of unprotected sex. At aminimum, these risks should include pregnancyand STD. Because teens commonly specify bothconcern about pregnancy and concern aboutTable4-4Number of Programs Having Effectson Perceptions of RiskPerceived susceptibilityof pregnancy (N=3)Perceived susceptibilityof STD (N=2)Perceived susceptibilityof HIV (N=16)Perceived severity ofpregnancy (N=5)Perceived severity ofSTD (N=1)Perceived severity ofHIV (N=4)Had aPositiveEffectNoSignificantEffectsHad aNegativeEffect0 3 01 1 08 8 02 3 01 0 03 1 0STDs as reasons for delaying sex or avoidingunprotected sex, in most curricula, both risksshould be given strong emphasis.However, among some groups of youth, otherrisks also should be identified. These includepossible feelings of guilt, possible disapprovalfrom parents should they find out, possible lossof reputation, possible feelings of being used andother negative personal feelings.Because adolescents’ sense of invulnerability canbe constructive in many social situations, programsshould not try to undermine their generalsense of invulnerability; rather, programs shouldhelp youth realize that they are vulnerable specificallyto unintended pregnancy, STDs and possiblyother specific risks if they have unprotectedsex.2. Use a variety of teaching methods to describe,illustrate, model, and personalize the likelihoodof becoming pregnant or contracting anSTD. They should provide information, provideplausible scenarios with a cause and an outcome,increase fear arousal and produce self-evaluationand re-evaluation. The methods should include allof the following kinds of activities, if possible:46 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

a. Presentations and discussions of accuratestatistical information about the likelihoodof getting pregnant and contracting an STD.These can include national data on teen pregnancyand STD rates or local data on theserates. Local data are especially effective if therates are higher than the national data.b. Activities that demonstrate that teens’ chancesof becoming pregnant continually increaseeach time they have unprotected sex. Mostteens will become pregnant within a year ifthey frequently have unprotected sex. (SeeActivity 4-1: Pregnancy Risk.)c. Interactive activities that model how teensbecome part of rapidly expanding sexualnetworks if they have sex with more than oneperson, on average, and how STDs can rapidlyspread through these sexual networks.If STDs, and especially sexually transmittedHIV, are the focus, programs should includeinteractive activities that demonstrate thatSTDs, and especially HIV, spread more rapidlywhen people have concurrent sexual relationshipsinstead of sequential relationships. (SeeActivity 4-2: STD Handshake.)d. Assessment of the risk of acquiring an STDthrough different activities. For example,students can rate or rank the risk of differentsexual activities, the educator can make surethe rating or ranking are correct and then theclass can discuss the ratings. (See Activity 4-3:STD Risks.)e. Videos, roleplays or other activities involvingyouth like those in the class, which emphasizethat young people can become pregnant(cause a pregnancy) or contract an STD ifthey have unprotected sex. These activitiesshould emphasize the negative consequencesof unplanned pregnancy or STD at their age.Ideally, they should depict both short-termand long-term consequences and consequencesthat matter to the young people. For example,if a group of youth does not believe they willgraduate from high school anyway or that theywill live very long, then focusing on the effectsof childbearing on high school graduationor on long-term effects may not be effective.Clearly, these activities should not glamorizeor trivialize unplanned parenthood, as somemagazines and movies have.f. Activities that rebut myths that adolescentscommonly have about becoming pregnant orcontracting an STD. These include myths suchas: “Pregnancy will not occur if people have sexonly once”; “raising a child alone is not a bigdeal”; and “you can tell if your partner has anSTD by his/her appearance.”3. Use a variety of teaching strategies to describe,illustrate, model and personalize the consequencesof becoming pregnant or contractingan STD. These should include the following:a. Activities to help youth think about howparenting would affect them in the short term,e.g., continuing in school, how they spendtheir weekends and their relationships withtheir friends.b. Activities to help youth think about what theywant to do in the future and how becoming aparent would affect what they want to do. (SeeActivity 4-1: Pregnancy Risk.)c. Activities to help them think about the consequencesof some STDs (e.g., how it wouldfeel to tell their sexual partners that they hadan STD and may have infected them, what itwould be like if they had genital warts, howan STD would affect their sex lives, how itwould feel to tell all future partners that theyhad herpes, how their lives would change ifthey contracted HIV, or how their lives wouldchange if they became sterile).d. One or more activities depicting youth likethemselves (if possible) having an STD, havingHIV, being sterile, etc. These depictions shouldbe balanced and accurate. They should notoverly dramatize the effects of having differentSTDs, but they should not trivialize them,either. They also should not increase stigmaagainst those people who may have an STD,including HIV.Chapter 4 Improving Perceptions of Risks—Both Susceptibility and Severity 47

4. Have youth identify and describe commonsituations in their lives or in the lives of theirpeers that may lead to undesired, unplanned orunprotected sex. To avoid sexual risk behaviors,youth must be able to recognize and assess conditionsthat might lead to sexual risk (Millstein2003). Youth are more likely to personalize therisks if they build upon their own experience orthose of their peers by having the entire class orgroup identify and describe all of the commonsituations that might lead to undesired sex orunprotected sex. When describing these situations,each of the elements that increase the riskshould be identified. For example, one commonsituation that can lead to sexual risk-takingamong youth is: Young people are at a party. Noadults are present. Alcohol is available and peopleare drinking. There are rooms or other placesnearby where people could have uninterruptedsex. Some youth are sexually attracted to otheryouth at the party.After youth have described several different situationslike the above that might lead to unprotectedsex, their common elements (e.g., drinkingor lack of supervision) should be noted.It is extremely important that youth describemethods of avoiding these situations or gettingout of them if they get into them. This can bedone both by verbally describing the strategiesand by conducting roleplays to build skills andchange norms. However, those are covered in thechapter on skills. (See Activity 7-1: Lines ThatPeople Use to Pressure Someone to Have Sexand Activity 7-2: Situations That May Lead toUnwanted or Unintended Sex.)5. Throughout the curriculum, repeatedly emphasizea clear and appropriate message about theneed to avoid sexual risks and how to avoidthem. For many young people, an appropriatemessage might be: “It is very important to avoidunintended pregnancy and STDs. Abstainingfrom sex is the safest method. If you have sex,females should always use hormonal contraceptionto prevent pregnancy and males shouldalways use condoms correctly to prevent STDs.”How has perception of risk been measured?Table 4-5 lists items that have been used to measureadolescents’ perceptions of risk. These are meant tobe illustrative, not comprehensive.Nevertheless, these items may help curriculumdevelopers identify some of the more specific elementsthat programs and their associated researchhave addressed (e.g., perceptions that having a babywould mess up their life or that having a baby wouldmake them feel like an adult). These items also mayhelp researchers conduct formative evaluations ofentire curricula or specific activities and therebyimprove their effectiveness.ConclusionsToo often, youth give too little attention to the risksof sex and unprotected sex, either because of a senseof invulnerability, “just not thinking,” brains thatare still maturing, or for other reasons. Fortunately,multiple studies and different kinds of evidence havedemonstrated that 1) programs can increase perceptionsof sexual risks and 2) increasing perceptions ofrisk can reduce the chances of unprotected sex. Toincrease perceptions of risk, programs should clearlydescribe the risks of unprotected sex, includingunintended pregnancy and STDs—in terms of bothsusceptibility and severity. Programs also shouldhave youth identify the common situations thatmight lead to undesired, unplanned or unprotectedsex and describe methods for both avoiding andgetting out of those situations. Activities should beinteractive and designed to have youth personalizethese risks. Finally, a clear message about the bestmethods of avoiding risks should be emphasizedrepeatedly.48 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

Table4-5Examples of Items That Have Been Used to Measure Perceptions of Risk 7Each item with a + – sign represents a positive perception and a protective factor, while each item with a signrepresents a negative pereception and a risk factor. Thus, within each scale, items with a + sign should be scored inthe opposite direction of those with a – sign .Positive orNegativeFactor+If+If+IfPositive orNegativeFactorPerceived susceptibility topregnancy or STD/HIVI have sex without contraception, I wouldprobably get pregnant (or get someone pregnant).I have sex without using a condom every time, Imight get an STD.I have sex without using a condom every time, Imight get HIV.Perceived consequences of STDs andHIV/AIDS+ If I got an STD, I would be very embarrassed.+If+If+If+If+Getting+Getting+GettingI got an STD, I would hate to have to tell mypartner.I got an incurable STD, it would mess up my life.I got an incurable STD, I might need to deal withit the rest of my life.I got an incurable STD, I would worry aboutinfecting others.HIV/AIDS would really mess up my life.HIV/AIDS might mean that I would have totake lots of pills the rest of my life.HIV/AIDS would prevent me from doingmany things I want to do.7 Most of these items are based on actual questions used to measurefactors in previous research. These items specify more precisely someof the factors that are related to behavior and can therefore be helpfulwhen designing programs to address these factors. They also can beused to create items for questionnaires in survey research.Positive orNegativeFactorPerceived consequences ofpregnancy and childbearing+ I am not emotionally ready to be a parent.+I+Being+Being+Being+If+Getting–Having–If–If–If–If–If–Myam not financially ready to be a parent.a teen parent would make it more difficultto finish school.a teen parent would keep me from doingmany things I like to do.a teen parent would really mess up my life.I got pregnant (or got someone pregnant),I would be very embarrassed.pregnant at this time in my life is one ofthe worst things that could happen to me.a baby to take care of would make me feelloved and needed.I had a baby, for the first time I would havesomething that is really mine.I had a baby, I would never be lonely.I had a baby, my boyfriend would be morecommitted to me.I had a baby, I would feel more like an adult.I had a baby, I would feel I had done somethingmeaningful in life.family would help me raise a baby.Chapter 4 Improving Perceptions of Risks—Both Susceptibility and Severity 49

Activity 4-1Pregnancy Risk Activity and Follow-Up ActivitiesDescription of ActivityObjectives: Students will be able to:1. Describe the chances of becoming pregnant (or getting someone pregnant) when people haveunprotected sex2. Summarize the reduced chances when they either do not have sex or use contraceptioneffectively3. Summarize the personal consequences of unintended pregnancyRisk and Protective Factors Affected:1. Knowledge2. Perception of risk of unprotected sex, including both probability of pregnancy and short-termand long-term consequences of pregnancyActivity:Students choose a number from 1 to 6. The educator tells them that the chances of pregnancy fromunprotected sex are roughly 1 out of 6 each month. Then the educator randomly pulls a numberfrom a bag simulating a pregnancy test, calls the number and tells students who chose that numberto stand up and remain standing, because they just learned they were pregnant. After returning thefirst number to the bag, the instructor randomly chooses another number for the second month,calls it out, etc. This continues until either everyone is standing or 12 months have passed.The educator notes that not everyone got pregnant the first month, but before the year is out, all,or nearly all, of the students are pregnant and standing. She/he also notes that some numbers werecalled twice reflecting the fact that people may become pregnant a second time if they continue tohave unprotected sex.The educator then tells the students that they have all just learned that they are pregnant (or gotsomeone pregnant) and asks them to write a paragraph describing how they feel, whom they willtell, what it will feel like to tell their parents, their girl/boyfriend and other friends and what theywill do during the next few days.The educator then asks youth to create a list of things they would like to do in the following yearsand assess how becoming a parent might impact or prevent some of those activities.Finally, the educator holds up the bag with the six sheets of paper and calls out the numbers.However, this time the educator reads the message on the sheet of paper. Five of the messages statethe students did not become pregnant because 1) they decided not to have sex and stuck to thatdecision or 2) they always used contraception effectively. One of the six sheets of paper states thestudents did become pregnant, because they had unprotected sex.Important Considerations in Using ItPossible Pitfalls That Might Reduce Effectiveness:1. Not all students participate (choose a number).2. Students are not given sufficient time to contemplate how they would feel if they just learnedthey were pregnant or got someone pregnant.(Continued)50 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

Pregnancy Risk Activity and Follow-Up Activities(Continued)References for Lessons That Describe a Similar Activity More Fully1. It’s Your Game, Grade 8, Lesson 2, Activity II: Pregnancy Probability2. It’s Your Game, Grade 8, Lesson 5, Computer-Based Activity: Body Art3. Safer Choices: Level 1, Class 5B, Activity 4: Dealing with a Pregnancy4. Safer Choices: Level 2, Class 4, Activity 2: Pregnancy Risk Activity Round 15. Safer Choices: Level 2, Class 4, Activity 3: Pregnancy Risk Activity Round 26. Safer Choices: Level 2, Class 4, Activity 4: The Impact of a PregnancyChapter 4 Improving Perceptions of Risks—Both Susceptibility and Severity 51

Activity 4-2Description of ActivitySTD HandshakeObjectives: Students will be able to:1. Describe how one or more STDs can pass rapidly throughout a sexual network if people have sexand are not protected by condoms2. Describe how the number of sexual partners each person has dramatically affects the spread ofSTDs3. Describe how concurrent sexual partners instead of sequential sexual partners greatly increasesthe spread of STDsRisk and Protective Factors Affected:1. Knowledge of how STDs spread rapidly through sexual networks2. Perception of risk of sex not protected by condoms and of risk of multiple partnersActivity:The educator gives each student a sheet of paper. On each sheet are three boxes with room for 1, 2and 3 signatures within each box, respectively. On the back of one sheet of paper is a colored dot.The educator asks each student 1) to shake hands with one other person and to record that person’ssignature in box 1, 2) to shake hands with two other people and record both their signatures in box2 and 3) to shake hands with three other people and to record their signatures in box 3.The educator then informs the students that shaking hands hypothetically represents havingunprotected sex and that, hypothetically, the person with a colored dot has an STD. She/he thenasks the person with a colored dot to stand and to read off the name of the person in box 1. Thatperson has become infected and then stands. Because everyone had sex with only one person, noone else has become infected. Thus, one new person becomes infected.In part two, the person with the colored dot stands and reads the name of the person with whomhe/she shook hands and became infected with an STD. That person then stands and reads the nameof the person with whom he/she had sex after the first person. That person then stands. Thus, threenew people become infected.In part three, the same process is repeated and each person who becomes infected reads the namesof the people with whom he/she had sex after becoming infected. Thus, seven new people becomeinfected.This has assumed that all sexual relationships are sequential (people do not have sex with formersexual partners after they have sex with a new partner). If all sexual relationships are concurrent,then each newly infected person infects all partners, both current and past. Thus, students whobecome infected call out all the names on their lists, not just the names of the later sexual partners,and typically everyone in the class becomes infected.There are various modifications of this exercise. For example, a few sheets can have differentcolored dots representing different STDs that young people might have. Some students’ sheetscan have a statement that reads, “refuse to shake hands with anyone.” This, of course, representsrefusing to have sex and these people do not become infected. Similarly, some students can havea different marking on their sheet, indicating they always used condoms consistently and did notbecome infected.(Continued)52 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

STD Handshake(Continued)Important Considerations in Using It1. Make sure that the student(s) hypothetically chosen to have an STD are not made uncomfortableby this. If they might be, use peer leaders or others who would not be uncomfortable.References for Lessons That Describes a Similar Activity More Fully1. Making Proud Choices, Module 5, Activity B: Transmission Game2. Reducing the Risk, Alternative Class 1: HIV Risk Activity3. Safer Choices, Level 1, Class 5A, Activity 1: How Number of Partners Affects STD Risk4. SiHLE, Workshop 2, Activity G: Card Swap GameChapter 4 Improving Perceptions of Risks—Both Susceptibility and Severity 53

Activity 4-3Description of ActivitySTD RisksObjectives: Students will be able to:1. Assess the risk of sexually transmitted disease including HIV through different activitiesRisk and Protective Factors Affected:1. Knowledge of how STD/HIV risk associated with different activities2. Perception of risk of STD/HIVActivity:The instructor gives small groups of students 5 x 7 cards with different activities, including sexualactivities written on them. Each group decides how risky each activity is and then places the cardon the wall along a continuum from “Not at all risky” to “Very risky.” After all the cards are placedon the wall, the educator discusses the placement of each card with the entire class and moves thecards as appropriate.Activities might include no risk activities such as holding hands or sharing eating utensils to low riskactivities such as vaginal sex with correct condom use to moderate risk activities such as oral sex tohigh risk activities such as vaginal or anal sex without condoms.References for Lessons That Describe a Similar Activity More Fully1. Becoming a Responsible Teen, Session2, Activity 4: HIV Feud2. Cuidate!, Module 4, Activity E: La Zona Religiosa3. Making Proud Choices, Module 2, Activity D: HIV Risk Continuum4. Reducing the Risk, Class 13: Risk Continuum5. Safer Choices, Level 1, Class 5A, Activity 2: Rate the STD Risk6. SiHLE, Workshop 2, Activity I: R U at Risk?7. SiHLE, Workshop 3, Activity D: Luv & Kisses54 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

5AddressingAttitudes,Values and BeliefsKeys to Improving Attitudes,Values and BeliefsIdentify exactly which attitudes, valuesand beliefs regarding teen sexual behaviorneed to be addressed. Then, get teens to1) thoughtfully consider relevant informationabout having sex and using condoms/contraception, 2) have more positivethoughts about not having sex or usingcondoms/contraception and 3) integrate thatinformation into their existing knowledgebase.BackgroundThis chapter discusses methods of addressing attitudes,values and beliefs. Many theories and bodiesof research address this topic. In fact, these theoriescan be placed on a continuum. Consequently, thischapter is longer and more challenging than mostof the other chapters. However, all of the theoriesprovide important perspectives on how to changeattitudes, values and beliefs.Attitudes are positive or negative evaluations thatpeople have toward other people, objects, activities,concepts and many other phenomena. For example,young people most likely have attitudes about a varietyof things, including cars, cleaning the bathroom,going to dances, work, English class, the President,chocolate cake and so on.People who have a “positive attitude” toward somebehavior are more likely to engage in that behavior;if they have a “negative attitude” toward something,they are less likely to engage in that behavior.According to many social psychologists, attitudeshave at least two components:1. A cognitive component, which includes one’sbeliefs about something (e.g., “abstinence from sexprevents pregnancy” or “condoms reduce chancesof STD transmission.”2. An affective component, which includes one’sevaluation of the same thing, implying a liking ordisliking or favorable or unfavorable view—e.g.,“I like the idea of abstinence so that I don’t haveto worry about pregnancy” or “I like condomsbecause they reduce the chances of pregnancy andSTD, but I don’t like how they feel” (Breckler1984; Ajzen 1989; Breckler and Wiggins 1989).These two components mean that people have boththoughts and feelings associated with their attitudes.According to psychologists, individuals differin terms of the weight they give to their thoughts(cognitive) versus their feelings (affective) in shapingtheir attitudes. This is partly a function of their generaltemperament. However, when there is a conflictbetween thoughts and feelings, feelings generallyhave a greater role in shaping attitudes (Hall 2008).For example, when it comes to sex, adolescents’ attitudesand decisions are not determined entirely byrational thought. Indeed, their decisions about sexare markedly affected by their feelings such as love,sexual attraction, fear, insecurity and invulnerability,to name a few.Chapter 5 Addressing Attitudes, Values and Beliefs 55

Although attitudes involve likes and dislikes (orfavorable or unfavorable assessments), people alsocan be neutral or ambivalent about some things (i.e.,they can simultaneously like and dislike somethingor favor or disfavor something, or be uncertain ofhow they feel). And they can have no thoughts orattitudes at all about some things.Attitudes and beliefs. The distinctions betweenattitudes and other psychological concepts, such asbeliefs and values, are not always clear because theysometimes overlap. In general, attitudes are differentfrom beliefs in that attitudes must include anaffective component and beliefs do not (Fishbeinand Ajzen 1975; Abelson and Prentice 1989). Thatis, people can have beliefs about many things, butif those beliefs do not have affective componentsassociated with them, then they are simply beliefs,not attitudes. For example, “to be most effective,condoms should be put on the penis before the penisgoes into the vagina” is a belief, but “I do not likecondoms because they have to be put on just beforeintercourse and interrupt the mood” is an attitude.Attitudes and values. Attitudes also are differentfrom values, although again the distinction isnot always clear. Our values are what we considerimportant or of great worth. Generally, we apply theterm “values” to more fundamental things, such ashealth or freedom, rather than more specific, superficialthings, such as history class, cleaning house orchocolate ice cream. Values nevertheless can includea wide variety of items or qualities, such as respect,honesty, caring, meaningful relationships, trust,responsibility, family, education, money, success,freedom, power and citizenship.Values can serve as guidelines to help us makedecisions about larger life choices and individualbehaviors. As a general rule, when we act in accordancewith our own values, we tend to feel goodabout ourselves and our actions. When we act ina way that violates our values, we tend to feel badabout ourselves and our actions. Thus, our valuesaffect how we feel about the rightness or wrongnessof things. Some psychologists believe that manyvalues are determined rather early in life and maybe partly genetically determined (D’Onofrio, Eaveset al. 1999). However, values also evolve as we gainexperience during our lifetimes.Many of the principles for changing attitudes alsoapply to addressing values and changing beliefs.Thus, most of the remainder of this chapter will talkabout attitudes, but also will apply to beliefs andvalues (to the extent that the latter can be changed).Impact on behavior. Attitudes, values and beliefsare important because they influence behavior.They play an important role in numerous theoriesof health behavior, such as the theory of reasonedaction (Fishbein and Ajzen 1975) the theory ofplanned behavior (Ajzen and Madden 1986), socialcognitive theory (Bandura 1986) and the information-motivation-behavioralskills model (Fisher andFisher 1992).According to Petty, Barden and Wheeler (Petty,Barden et al. 2002), experimental research demonstratesthat attitudes are one of the most importanttheoretical constructs affecting behavior. In manypsychological models, attitudes affect intentions,which in turn affect behavior (see Figure 1-1 inChapter 1).The impact of attitudes on behavior is determined byseveral factors:1. Direction: If an attitude toward a behavior ispositive, then people are more likely to engage inthat behavior; if the attitude is negative, peopleare less likely to engage in that behavior.2. Strength: If an attitude is stronger, it will have agreater effect on behavior.3. Specificity: If an attitude is more specific, it willhave a greater effect on behavior (“I do not likecondoms because they reduce sensation” versus “Ido not like to use protection against pregnancy orSTDs”).4. Relevance: If an attitude is more relevant to aperson’s life and behavior, it will have a greatereffect on that behavior.56 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

Theories ofAttitude ChangeAttitudes sometimes change with new informationand experience. They can be influenced by parents,teachers, peers, religion, media, culture andother environmental influences, as well as personalexperience.Theories of attitude change can be used to intentionallychange attitudes about many things. However,in the field of public health, they are most commonlyused to change attitudes about one or morehealth behaviors. The examples used hereafter willinvolve attitudes about health behavior.Theories of attitude change expanded a few decadesago after health promotion interventions designedto increase knowledge and thereby change behaviorfailed to have an impact on behavior. Subsequently,researchers and practitioners became more interestedin how interventions designed to persuade people tochange their behavior actually affected their cognitiveprocesses. Early research studies found thatfactors thought to influence persuasion had differenteffects in different situations.The Elaboration Likelihood Model (ELM) (Petty,Barden et al. 2002) was one of the first modelsto fully recognize that there are many pathwaysthrough which interventions can change attitudesand that these pathways fall along an elaborationcontinuum. At one end of the continuum are processesthat require careful thinking about the argumentsin a communication message as a responseto that message (high elaboration). 7 This is calledthe central route. At the other end of the continuumare those processes that do not require much or anythinking (low elaboration). This is called the peripheralroute (see Figure 5-1).Central route. According to psychologists, thecentral route involves careful consideration of the7 “Messages” and “arguments” are used somewhat interchangeablyin this chapter. However, sometimes “messages” refers to admonitionsto engage in particular behavior conducive to public health and “arguments”refers to the reasons to engage in health-promoting behaviorand to avoid risk behaviors.information in a message about behavior, comparesthat information to knowledge already known aboutthat behavior and integrates it. This considerationprocess generates positive or negative thoughts thataffect attitudes and thereby change behavior. Forexample, new information about the likelihoodof unintended pregnancy, if sexually active, maygenerate positive or negative thoughts about havingunprotected sex. Whether the thoughts are positiveor negative determines whether the attitude changeis positive or negative. The extent to which thethoughts are either more positive or negative determinesthe amount of attitude change.According to Petty et al. (2002), two conditionsare necessary for any conscious cognitive processingrequiring some effort. First, an individual mustbe able to think about and process the information.This ability may be affected by a variety of factorsinvolving the cognitive development of the individual,the individual’s mental state (e.g., in a clearstate of mind or under the influence of drugs), thecharacteristics of the message (e.g., whether theindividual can understand the words being used),the control that the individual has over the process(e.g., whether the individual can review material athis/her discretion), the environment (e.g., the existenceand magnitude of distractions), the number oftimes the information is presented and other factors.For example, using understandable language,self-pacing, and removing distractions can increase aperson’s ability to thoughtfully consider messages.Figure5-1Peripheral RouteLow elaborationRequires little orno thinkingCentral RouteHigh elaborationRequires carefulconsiderationSecond, an individual must be motivated to thinkabout and process the information. This motivationmay be affected by characteristics of the individual(e.g., the general inclination of an individualto think about and process new information); theChapter 5 Addressing Attitudes, Values and Beliefs 57

psychological state of the individual at the time ofthe message (e.g., his/her sense of responsibility forthe behaviors related to the arguments); the characteristicsof the message (e.g., its relevance to theindividual, the newness of the arguments and theability of the individual to process the message); andthe environment (e.g., the extent to which it encourageslearning).Peripheral route. Although thoughtful considerationof the arguments in a message often producesthe greatest amount of attitude change, attitudes canbe changed or reinforced in a variety of ways withoutsuch thoughtful consideration. For example, theadvertising and marketing of innumerable productsoften do not try to get people to think carefullyabout the advertised product. Instead, these adssimply try to get people to associate unconsciouslythe products with various desirable qualities (e.g.,being sexy, attractive, fun or powerful). In addition,persuasion methods employing classical conditioningget people to associate certain products orevents with desirable feelings without ever gettingthe people involved to think about the products orevents. For example, if people commonly engage insome behavior (meeting with colleagues) while theyare doing something else that they like (e.g., eatingfood they like), then they will tend to have positiveattitudes toward the first behavior. This is why manybusiness deals are conducted over lunch or dinner.Other methods of persuasion lie somewherebetween the two ends of the “central-peripheral”continuum. For example, statements from “experts”or “role models” may produce acceptance of someidea, product or behavior and require some awarenessof the message, but not require critical thinkingabout the message. If a sports hero or popularperson in a school encourages a particular behavior,that encouragement may effectively change attitudesand behavior, even if the endorsement is processedthrough a more peripheral route without carefulexamination.Sometimes endorsements from celebrity figures maybe effective, even if the arguments are weak, if thearguments are processed through a more peripheralroute and if they are not well examined. However,celebrity endorsements may not be effective if thearguments are weak and they are examined criticallythrough the central route and are rejected.Although celebrities may get youths’ attention, theirlifestyles are usually so removed from those of mostteens’ realities that their endorsements of ideas mayhave less lasting impact on attitudes than endorsementsfrom people with whom youth can identifymore closely, such as peers, parents or role models intheir own communities.Interventions sometimes give multiple reasons toengage or not engage in a behavior. When multiplereasons are given, people are sometimes persuadedsimply by the number of arguments rather than thestrength of each argument.Strength of arguments. When arguments areprocessed through the central route, the stronger orhigher quality the message, the greater the impact itwill have on the related attitude. According to Pettyand Wegner (1998), five characteristics determinethe quality and impact of arguments:1) Likelihood and desirability of outcome: If anargument for a behavior makes a case that a particularoutcome is likely and desirable, then it willbe stronger than if the outcome is not as likely ordesirable.2) Causality: If an argument for a behavior demonstratesa causal impact on some outcome, then theoutcome is considered more likely.3) Familiarity: If an argument is consistent withthe way people view the world, it will be moreconvincing.4) Importance: If an argument demonstrates thata behavior will have relevant and importantoutcomes, it will be scrutinized more carefullyand may have a greater impact on attitudes andbehavior.5) Newness: If an argument is new and different,it will have a greater impact on changing anattitude than an argument that has already beenheard multiple times and incorporated into anexisting attitude.58 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

Although both quality and quantity of argumentsare important, it is quality, more than quantity, thatmatters. Up to a point, additional strong argumentsmake a stronger case. However, when too manyarguments are presented, people may begin to countthe arguments and use a more peripheral route thanif they carefully analyze each argument and use amore central route (Petty and Wegener 1998). Inthis situation, additional arguments may diminishthe amount of attitudinal change.To increase the strength of messages about behaviorand arguments to support them, both argumentsand messages should be pilot tested with theintended audiences. Sometimes, slightly changingthem (without diminishing their correctness) orchanging how they are presented can improve theextent to which they are thoughtfully considered.Tailoring. Tailoring refers to adjusting messages tomatch the particular characteristics of the audience(e.g., their age, gender, race/ethnicity or culture),their needs or their concerns. Tailoring can increaseboth the ability and the motivation to thoughtfullyconsider a message (Petty, Barden et al. 2002). Itcan increase acceptance of a message. For example,behavioral messages for younger youth who areless likely to be sexually active might focus moreon abstaining or delaying sex than on condom/contraceptive use, while those for older youth whoare more likely to be sexually active might givegreater emphasis to the use of protection. Programsfor older males might focus more on proper use ofcondoms while programs for older females mightfocus more on skills to get their partners to usecondoms. Programs for Hispanic youth might givemore weight to family values and connection to theirfamilies, while those for other racial/ethnic groupsmight emphasize other values. As another example,if communication messages include pictures, thepictures may need to be adjusted to reflect the characteristicsof the targeted groups.Tailoring also can focus more precisely on thoseattitudes that need to be changed. For example,some people may have negative attitudes aboutcondoms because of the discomfort of buying them;others may have negative attitudes because of theawkwardness of asking a partner to use them; andothers may have negative attitudes because of thereduction in sensation. To meet the concerns of eachgroup, messages designed to change attitudes aboutcondoms may need to be adjusted to meet each ofthose concerns.As a final example, stages of change theory stipulatesthat people often pass through five stages ontheir way to adopting and maintaining a healthbehavior (i.e., precontemplation, contemplation,preparation, action and maintenance) (Prochaska,DiClemente et al. 1992). Messages may need tobe tailored for each of these stages. For example, ifpeople are at the precontemplation stage, then messagesshould be designed to get them to think aboutchanging their behavior, whereas if they are in themaintenance stage, then messages should strive toget them to maintain their new positive behavior.Important characteristics of the source. Theamount of attention that people give to a messageoften depends on various characteristics of thesource of the message. For example, people oftengive more attention to message arguments whenthey come from a credible, trusted and respectedsource. They also will give more attention when thesources are familiar and similar to themselves. Itis important to note that the expertise of a sourcehas an impact on attitude change only if the recipientknows before the message is received that thespeaker is an expert. If the recipients learn thisafterward, the expertise of the source has less impacton attitude change.In addition to the characteristics of the source, thecharacteristics of the relationship with the sourcealso are important in achieving attitudinal or valuechange. For example, when people are closely connectedto the source (e.g., to parents, educators orfriends), they may be more willing to consider themessage arguments.Stages of attitude change. Just as Prochaska’stranstheoretical stages of change describes stagesin adopting or changing health behaviors, similartheories exist for attitude change. Depending on theChapter 5 Addressing Attitudes, Values and Beliefs 59

field (e.g., psychology versus marketing), there aredifferent numbers of stages. However, many of theminclude the following steps during attitude change(McGuire 1999):1. Being exposed to a message or intervention2. Paying attention to a message or intervention3. Comprehending the arguments or message4. Accepting the argument or message5. Integrating the argument into existing beliefs6. Eliciting positive or negative thoughts about thenew or revised beliefs7. Retaining the attitudeThese steps in attitude change may take place veryquickly, perhaps within minutes or seconds, but arestill important because they constitute a set of concernsthat each intervention needs to address. Thatis, the intervention should make sure that the targetpopulation is exposed to the message, pays attentionto it, comprehends it, accepts it, integrates it, feelsgood about it and retains it.Use of fear in messages to change attitudes andvalues. Although there has been some debate aboutthe impact of fear in messages, there may be a growingconsensus about its effects. If messages do notincrease fear of possible negative consequences at all,then they may not be effective. If messages increasefear too much without providing a clear method ofavoiding the feared outcome, then fear may causepeople to ignore the message or to become paralyzedwith inaction. What is most effective is a reasonablecombination of fear arousal, presented with clear,achievable directions for how to avoid the negativeoutcome (Witte and Allen 2000).Use of cognitive dissonance. In psychology, cognitivedissonance is an uncomfortable feeling or stresscaused by holding two contradictory attitudes, valuesor beliefs simultaneously. The theory of cognitivedissonance proposes that people have a naturaldesire to reduce this dissonance by modifying oneor more of the existing attitudes, values or beliefs(Festinger 1957). Thus, one effective way of changingattitudes is to demonstrate that specific attitudesare inconsistent with more fundamental and importantvalues or attitudes, e.g., demonstrating thathaving unprotected sex is inconsistent with valuesand goals involving higher education and employmentbefore parenting.Summary of Principles• Attitudes that result from thoughtful criticalexamination of arguments new to an individualtend to be stronger, last longer, be more resistantto change and have a greater impact on behaviorthan do attitudes that result from little or nothought.• When people are more able and motivated toconsider new arguments, they are more likely tothoughtfully consider them.• Creating desired environmental conditions (e.g.,lack of distractions or disruptions) can increasepeople’s ability to thoughtfully consider newarguments.• When issues are considered personally relevant,attitudes have a greater impact on behavior.• When arguments reveal inconsistencies betweendeeply held attitudes and values on the one handand behavior on the other, the arguments aremore likely to lead to behavior change.• When arguments are appropriate for the stage ofchange, they may be more effective.• Tailoring can increase the ability and motivationto thoughtfully process a message and to accept it.It also can focus more precisely on those attitudesthat most need to be changed.• Including strong arguments in messages isimportant.• Both arguments and messages should be pilottested to see which are strongest for particulargroups.• When arguments are presented by someone withaccepted expertise and respect, they are morelikely to be considered and accepted.60 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

• When arguments are presented by someone withwhom there is a strong connection, the argumentsare more likely to be attended to and accepted.• Messages can still have an impact on attitudes,even if people do not critically examine the argumentsbut do unconsciously associate the argumentswith some desired qualities or outcomes.• A particularly impactful combination is a strongargument presented clearly and reinforced overtime by a respected source with whom there isstrong connection.Applying These Theoriesand Principles to TeenAttitudes, Values and Beliefsabout Sexual BehaviorPeople commonly associate values about abstinencewith initiation of sex or number of sexual partners.It is assumed that if youth believe that sex prior tomarriage or at a young age is wrong, they are lesslikely to have sex. Similarly, if youth believe that it iswrong to have sex if they are not in love, this valuemay affect their number of sexual partners. Peoplealso commonly associate attitudes about condomsand contraceptive use with use of condoms andcontraception.When applying these concepts about attitudes,values and beliefs to sexual behavior, four questionsshould be asked:1. Do teens’ attitudes, values and beliefs aboutsexual and contraceptive behaviors actually affecttheir own sexual behaviors?2. Can we change attitudes about sex and condom/contraceptive use?3. What values, attitudes and beliefs should beencouraged?4. How do we improve values, attitudes andbeliefs toward abstinence, minimizing partners,being faithful and using condoms and othercontraceptives?These questions are answered below.Do teens’ attitudes, values and beliefs aboutsexual and contraceptive behaviors actually affecttheir own sexual behaviors?A review of studies examining the relationshipbetween attitudes, values and beliefs and sexualbehavior revealed that at least 14 studies havemeasured the impact of attitudes, values and beliefsabout sex (Table 5-1) (Kirby and Lepore 2007). Tenof the 14 studies found that these attitudes were significantlyrelated to initiation of sex; only four failedto find significant relationships and none foundrelationships in the unexpected direction. Thoseattitudes, values and beliefs having a positive impactincluded less permissive attitudes toward sex, morepersonal benefits of abstaining from sex and moreperceived personal and social benefits than costs ofhaving sex. The failure of four studies (one-third ofthe total) to find a significant impact of attitudes,values and beliefs may reflect measurement problems,small sample sizes and other methodologicalproblems of the studies. It might indicate that attitudes,values and beliefs about sex are not related toinitiation of sex in all groups of teens. Overall, thesestudies represent strong evidence for the impact ofattitudes, values and beliefs about sex on initiationof sex.Forty-six studies measured the impact of attitudesabout condom and contraceptive use on actualTable5-1Less permissive attitudestoward sex (N=5)Personal benefits ofabstaining from sex(N=2)Number of Studies Reporting Effects ofAttitudes About Abstaining on Teens’Own Sexual BehaviorMore perceivedpersonal and socialbenefits than costs ofhaving sex (N=7)LaterInitiationof SexNoSignificantEffectsEarlierInitiationof Sex4 1 02 0 04 3 0Chapter 5 Addressing Attitudes, Values and Beliefs 61

condom and contraceptive use (Table 5-2). Thescales include items about condom effectiveness inreducing pregnancy or STD, perceived impact ofcondom use on sexual pleasure, partner supportof condom use, embarrassment using condoms,accessibility of condoms and other attitudes towardcondoms and other forms of contraception. Of the46 studies, 30 found that the attitudes were significantlyrelated to actual condom or contraceptive use,16 failed to find significant relationships and nonefound significant relationships in the unexpecteddirection. As above, the failure of 16 studies (againabout one-third of the total) to find significant relationshipsmay reflect methodological limitations ormay indicate that attitudes about condoms and contraceptionare not always related to use of condoms/contraception in all groups of teens.Although research demonstrates that attitudes arerelated to sexual behavior, many different attitudesTable5-2Number of Studies Reporting Effects ofAttitudes About Condom/ContraceptiveUse on Teens’ Own Condom/Contraceptive UseStronger belief thatcondoms are effective inreducing pregnancy orSTD (N=7)IncreasedCondom orContraceptiveUseNoSignificantEffectsDecreasedCondom orContraceptiveUse2 5 0might affect each sexual behavior. Some are moregeneral, some are more specific, and some target differentaspects of condom or contraceptive use. Table5-4 on page 67 lists examples of attitudes that mayaffect the decision to have sex and to use condomsor contraception. Note the diversity of the attitudesthat may apply to a single behavior.Given this diversity and given that sex educationprograms cannot address all potentially relevant attitudes,when designing programs, it is very importantto determine which attitudes are most importantin a given population. The importance of differentattitudes can be gleaned from focus groups withyouth, interviews with reproductive health professionalsworking with youth and survey research withthe youth being addressed.Can we change attitudes about sex and condom/contraceptive use?A review of curriculum-based studies of sex andSTD/HIV education programs found that 8 out of13 programs significantly improved attitudes towardabstinence and 5 had no significant impact (Table5-3) (Kirby 2007). These studies demonstrate clearlythat not all programs significantly improved attitudes,but a majority did so. Ten out of 24 studiesimproved attitudes towards condoms and contraceptives,13 had no significant impact and one had anegative impact. These results demonstrate clearlyStronger belief thatcondoms do not reducepleasure (N=8)Greater value orperception of partnersupport of condom use(N=6)More positive attitudestoward condoms andother forms of contraception(N=17)Decreased embarrassmentusing condoms(N=6)Greater perceivedaccessibility of condoms(N=2)7 1 04 2 013 4 03 3 01 1 0Table5-3Number of Programs Having Effectson Attitudes Toward Sex and Condom/Contraceptive UseAttitudes toward havingsex and abstinence(N=13)Attitudes toward usingcondoms (N=12)Belief that condomsare a hassle and reducepleasure (N=7)Perceived barriers tousing condoms (N=5)Had aPositiveEffectNoSignificantEffectsHad aNegativeEffect8 5 06 5 12 5 02 3 062 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

that it is possible to improve these attitudes, but thatnot all curricula do so.What values, attitudes and beliefs should beencouraged?In the United States, teenage sexual behavior is avery divisive topic. That is, different people hold verydifferent values about the conditions under whichyoung people should have sex. Some believe thatpeople should only have sex after they are married;others believe they should only have sex when theyhave a mature love; others believe it is acceptable foryoung people to have sex provided it is informed,consensual, non-exploitative, honest and protectedagainst disease and unintended pregnancy (NationalGuidelines Task Force 2004). These beliefs can bequite strong and are influenced by a variety of factorsincluding family values, participation in communitiesof faith, instruction from school and otherprograms, and so on.Many widely held values could be applied to decisionsabout whether or not to have sex (e.g., honesty,trust, respect, safety, personal responsibility andvirginity until marriage). However, two values—respect for oneself and respect for others—wereidentified as among the most important and themost widely accepted by a large group of individualsrepresenting diverse views (Center for Excellence forSexual Health 2008).Although some people oppose sex outside of marriageand therefore also oppose the encouragementof condom or contraceptive use among teens who arenot married, there is general consensus in our societythat young people should be encouraged to usecondoms and other forms of contraception if they dohave sex. This means that positive attitudes towardscondoms and other forms of protection should beincreased.In addition to general attitudes, values and beliefsabout having sex and using condoms and contraception,interventions may need to address morespecific attitudes, values and beliefs about having sexand using condoms/contraception. Many examplesare included in Table 5-4 (see page 67).How do we improve values, attitudes andbeliefs toward abstinence, minimizing partners,being faithful and using condoms and othercontraceptives?Given the theories above about how to changeattitudes and values, the following general principlesshould be built into activities to improve attitudes,values and beliefs regarding sexual and condom/contraceptivebehavior:1. Identify specific attitudes, values and beliefs thatneed to be improved (e.g., by conducting focusgroups with youth, interviewing practitionerswho work with youth similar to those you aretargeting and reviewing research results fromsimilar youth). Try to understand the source orbasis of these attitudes and values.2. Make sure the environment is conducive to thethoughtful consideration of new information(e.g., minimize distractions).3. Design activities to produce thoughtful criticalexamination of new arguments and messages bythe students (e.g., by using a variety of activitiessuch as short lectures, student summariesof pamphlets or websites, knowledge contests,simulations of important points, worksheets tohave them apply concepts to their own lives, androleplaying to practice and verbalize concepts).4. Design activities so that students are more ableand motivated to thoughtfully consider newarguments (e.g., involve youth in a variety ofinteractive activities that they can understand).5. Include strong arguments in the messages; besure to pilot test to see which arguments havethe strongest appeal and impact.6. Make arguments that are new, strong and personallyrelevant to the students.7. Combine appropriate use of fear with a clearmessage about how to avoid the undesirableoutcomes.8. Associate desirable qualities in people as perceivedby the students with desired attitudes orbehaviors.Chapter 5 Addressing Attitudes, Values and Beliefs 63

9. As appropriate, use cognitive dissonance tochange attitudes by demonstrating that specificattitudes or behaviors to be changed are inconsistentwith more fundamental and importantvalues or attitudes.10. Tailor arguments and activities for the students.11. Include arguments and activities that are effectivewith students at different stages of changetowards adopting a particular behavior.12. Have credible, respected and trusted peoplepresent the arguments; to the extent appropriate,these people should be similar and familiar tothe students.13. Have people with close connections to the students(e.g., parents or peers) present or reinforcearguments favoring particular behaviors.14. Repeat and reinforce the arguments and messagesin different ways over time.15. To the extent feasible, make sure that thestudents are exposed to the message and arguments,pay attention to them, comprehendthem, accept them, integrate them, feel goodabout them and retain them. For example, provideactive learning activities in which studentshave to find, summarize and explain to othersthe main arguments and messages.16. Combine the above in particular powerful combinations,e.g., have educators respected by andvery close to the students present strong argumentsclearly and repeatedly over time and thenhave students inform others.Different kinds of activities can be implementedfor students at different stages of attitude change.Following are examples of activities for differentstages:Stage 1. To provide exposure to importantknowledge or arguments, cover the following topics,among others:a. Background information about reproduction,STD transmission, risks, etc.b. Consequences of having sex—pregnancy,STDs and emotional and social consequencesc. Consequences of unplanned pregnancy andSTDsd. Reasons to not have sex (See Activity 5-1:Reasons to Not Have Sex)e. Personal, family, community and faith communityvalues about sexual behavior amongyoung people (See Activity 5-2: Dreams, Goalsand Values)f. Situations that might lead to undesired orunplanned sex and how to avoid and get out ofthem (See Activity 7-2: Situations That MayLead to Unwanted or Unintended Sex.)g. Skills for avoiding undesired or unplanned sexh. Use of condoms and other forms ofcontraceptioni. Reasons to use protection against pregnancyand STDs, if having sexj. Skills to obtain, use and insist on the use ofcondoms/contraceptionk. Barriers to using condoms/contraception andmethods of overcoming those barriersStage 2. To increase attention to a message orintervention:a. Use activities with vivid visual appeals, e.g.,vivid posters, videos and personal testimoniesof people who have become unintentionallypregnant or contracted HIV or another STDb. Use examples of situations or role models thatstudents know or can relate toc. Provide stories of positive role models on postersor elsewhered. Make arguments or examples concrete andcleare. Use interactive experiential activities, e.g.,small-group discussions, simulations, roleplaying,student completion of stories aboutpregnancy risk and STDs and assignments tolearn and share information with othersStage 3. To increase comprehension of the argumentsor message:a. Make arguments concrete and clearb. Provide familiar examples64 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

c. Use simulations to demonstrate principles (e.g.,simulations of chances of becoming pregnantor simulations of how STDs can spread amongpeople) (See activities in Chapter 4)d. Include activities that allow students to proceedat their own pace (e.g., reading materialsor individualized interactive videos or computergames)e. Include activities in which students mustsummarize information for others (e.g., summarizinginformation about different STDsto other students in the class or to friends asa homework assignment) (See Activity 5-1:Addressing Barriers to Using Condoms)f. Include review activities in different formats(e.g., short lectures, group discussions, andcontests/games on the same topics)Stage 4: To increase acceptance of the argumentor message:a. Same as for stage 3b. Include sources of information (both people,such as parents and role models, and print) thatthe students respect, like and feel connected toc. Combine appropriate amount of fear of negativeconsequences (see Chapter 4) with a clearmessage about how to avoid those negativeconsequencesd. Have students take stands on various issues(See Activity 5-5: Addressing Barriers to UsingCondoms, Activity 5-4: “Dear Abby,” Activity5-1: Reasons Not to Have Sex, Activity 5-3:Sexual Values Line)e. Use cognitive dissonance—show that responsibledecisions are consistent with other valuesand sexual risk behavior is inconsistent withour valuesf. Create peer programs for students (the peersselected will increase their own acceptance andtheir promotion of the arguments will increaseacceptance by other students)g. Include activities in which peers, parents orrole models express support for the argumentor messageStage 5. To increase integration of the argumentinto existing beliefs:a. Same as for stage 4b. Include activities in which students are confrontedwith various scenarios and have tomake decisions about what to do (See Activity5-4: “Dear Abby”)c. Include activities in which students must makepersonal commitments about what they willand will not do sexually and whether they willconsistently use condoms/contraception if theydo have sex (See Chapter 9)Stage 6. To elicit positive or negative thoughtsabout the new or revised beliefs:a. Same as for stage 5b. Include activities in which students must thinkabout the personal consequences of becominga parent or contracting an incurable STD andthe positive feelings of not having to worryabout pregnancy and STDsc. Include activities in which students’ decisionsare affirmed by others (e.g., by other studentsor parents or other adults)Stage 7. To retain the attitude:a. Include booster sessions in later semestersb. Implement schoolwide activities that reinforcethe message as long as the students remain inschoolc. Train some students as peer educators in latersemestersHow have attitudes, values and beliefs beenmeasured?In Table 5-4 are items that have been used tomeasure adolescents’ attitudes, values and beliefsabout various sexual health topics. As in previouschapters, these are meant to be illustrative, notcomprehensive.Chapter 5 Addressing Attitudes, Values and Beliefs 65

ConclusionsAttitudes play an important role in many cognitivebehavioral theories that posit that attitudes affectbehavior and that changing attitudes will lead tobehavior change. These theories are supported bymultiple studies that have demonstrated that attitudes,values and beliefs about having sex or usingcondoms or other contraceptives are related toactually having sex or using condoms or contraception.In addition, multiple studies have found thatprograms can change attitudes about sex and usingcondoms or contraception.To change attitudes and values, program developersshould identify exactly which attitudes, valuesand beliefs are most important to address for theirpopulation. Then, instructional activities shouldincrease the extent to which teens critically assessand integrate new information. They should striveto increase teens’ ability and motivation to thoughtfullyassess the attitudes and behaviors. Instructionalactivities should present strong relevant argumentsand include interactive activities. They also shouldstrive to generate positive thoughts about protectivebehaviors and negative thoughts about risk behaviors.If possible, activities should be delivered bypeople whom the teens like, respect and with whomthey are connected.When instructional activities improve perceptionsof peer norms about sex or contraceptive use andincrease self-efficacy to avoid undesired sex or touse condoms/contraception, they also can improveattitudes. Improving perceptions of peer normsand self-efficacy are discussed in Chapters 6 and 9respectively.66 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

Table5-4Examples of Survey Items from Research Studies of Attitudes, Values and Beliefs in Different Domains 8Each item with a + sign represents a positive perception and a protective factor, while each item with a – sign represents a negativeperception and a risk factor. Thus, within each scale, items with a + sign should be scored in the opposite direction of those with a – sign.Attitudes, Values and Beliefs About Having SexPositive orNegativeFactor+It+Having+Not+Teens+It–It–It–ItPositive orNegativeFactor+I+I+I+I+I+I+If+I+IAttitudes favoring abstinenceis wrong to have sex before marriage or a permanentcommitted relationship.sex before marriage or a permanent committedrelationship is against my religious beliefs.having sex until marriage or a permanentcommitted relationship is important to me.would be better off if they said “no” to sex.is okay for people my age to want to remainabstinent until they get married.is okay for people my age to have sex.is okay for people my age to have sex if they are inlove.is okay for people my age to have sex with someonethey like, but don’t know very well.Perceived costs of having sex and benefitsof abstaining from sexwould not have sex now because I’m not ready tohave sex.would not have sex now because it is against mybeliefs.would not have sex now because it is against myparents’ values and they would be very upset if theybelieved I was having sex.would not have sex now because I do not want to getpregnant.would not have sex now because I don’t want to getHIV or some other STD.would not have sex now because I don’t want to get abad reputation.I had sex with a boyfriend or girlfriend, my friendsmight gossip about me.would not have sex now because I’m waiting for theright person.would not have sex now because my friends think it isbetter to wait to have sex.8 Most of these items are based on actual questions used to measure factorsin previous research. These items specify more precisely some of the factorsthat are related to behavior and can therefore be helpful when designingprograms to address the proximal sexual factors. They also can be used tocreate items for questionnaires in survey research.Positive orNegativeFactor–If–If–I–I–IPositive orNegativeFactor+My+My+My+My–MyPositive orNegativeFactor+Most+Most+Most–Most–Most–Most–MostPerceived costs of having sex and benefitsof abstaining from sex (Continued)I want to be popular, I need to go farther thankissing.I had sex with a boyfriend or girlfriend, it wouldprove that I love him or her.would have sex now if someone I cared aboutpressured me to have sex.would have sex now to satisfy strong sexual desires.would have sex now because I want to have a baby.Perceived parental values abouthaving sexparents think having sex before marriage is wrong.parents think people my age should wait until theyare older to have sex.parents think I should abstain from sex.parents would be very upset if they believed that Iwas having sex.parents wouldn’t care if they found out I washaving protected sex.Perceived peer norms about having sexof my friends have not had sex.of my friends think people my age should waituntil they are older before they have sex.of my best friends think I should wait to have sex.of my friends think having sex while you’re in highschool is normal.of my friends believe it is okay for people my ageto have sex.of my friends think it is okay to have sex with asteady boyfriend or girlfriend.of my friends think it is okay to have sex with acouple of different people each month.(Continued)Chapter 5 Addressing Attitudes, Values and Beliefs 67

Table5-4Examples of Survey Items from Research Studies of Attitudes, Values and Beliefs in Different Domains(Continued)Each item with a + sign represents a positive perception and a protective factor, while each item with a – sign represents a negativeperception and a risk factor. Thus, within each scale, items with a + sign should be scored in the opposite direction of those with a – sign.Attitudes, Values and Beliefs About Having Sex (Continued)Positive orNegativeFactor+If+If+IfPositive orNegativeFactorPerceived susceptibility to pregnancy orSTD/HIVI have sex without contraception, I would probablyget pregnant (or get someone pregnant).I have sex without using a condom every time, I mightget an STD.I have sex without using a condom every time, I mightget HIV.Perceived consequences of pregnancy andchildbearing+ I am not emotionally ready to be a parent.+I+Being+Being+Being+If+Getting–Having–If–If–If–If–If–MyPositive orNegativeFactor+If+Ifam not financially ready to be a parent.a teen parent would make it more difficult tofinish school.a teen parent would keep me from doing manythings I like to do.a teen parent would really mess up my life.I got pregnant (or got someone pregnant), I wouldbe very embarrassed.pregnant at this time in my life is one of theworst things that could happen to me.a baby to take care of would make me feelloved and needed.I had a baby, for the first time I would havesomething that is really mine.I had a baby, I would never be lonely.I had a baby, my boyfriend would be morecommitted to me.I had a baby, I would feel more like an adult.I had a baby, I would feel I had done somethingmeaningful in life.family would help me raise a baby.Perceived consequences of STDs andHIV/AIDSI got an STD, I would be very embarrassed.I got an STD, I would hate to have to tell my partner.Positive orNegativeFactor+If+If+If–Getting+Getting+Getting+GettingPositive orNegativeFactor+I+Not–Getting+MyPositive orNegativeFactor+Getting+My+I+I–If–Sometimes–I’dPerceived consequences of STDs andHIV/AIDS (Continued)I got an incurable STD, it would mess up my life.I got an incurable STD, I might need to deal with itthe rest of my life.I got an incurable STD, I would worry about infectingothers.an STD that is curable is no big deal.HIV would really mess up my life.HIV might mean that I would have to take lotsof pills the rest of my life.HIV would prevent me from doing many thingsI want to do.Motivation to avoid contracting an STDreally want to avoid getting an STD.getting an STD is important to me.an STD is not a big deal.family would be upset if they learned I had an STD.Motivation to avoid pregnancy andchildbearingpregnant (or getting someone pregnant)would really mess up my life.parents would be upset with me if I were to getpregnant (or get someone pregnant).really don’t want to get pregnant (or get someonepregnant).am really not ready to be a parent.I get pregnant (or get someone pregnant), it is not abig deal.I think I’d like to be pregnant (or get someonepregnant).like to be a mother (or father) right now.(Continued)68 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

Table5-4Examples of Survey Items from Research Studies of Attitudes, Values and Beliefs in Different Domains(Continued)Each item with a + sign represents a positive perception and a protective factor, while each item with a – sign represents a negativeperception and a risk factor. Thus, within each scale, items with a + sign should be scored in the opposite direction of those with a – sign.Attitudes, Values and Beliefs About Using Condoms/ContraceptionPositive orNegativeFactor+If+If+If+IfPositive orNegativeFactor+I+I+I+I+I+IPositive orNegativeFactor–It–It–I–I–Having+Having–WhenPerceived effectiveness of condoms andcontraceptionused correctly and consistently, condoms areeffective at preventing pregnancy.used correctly and consistently, contraception such asbirth control pills is effective at preventing pregnancy.used correctly and consistently, condoms are quiteeffective at preventing some STDs.used correctly and consistently, condoms areeffective at preventing HIV.Personal values, attitudes and beliefs aboutcondoms and contraceptionbelieve condoms should always be used if a person myage is sexually active.believe contraception should always be used if aperson my age is sexually active.believe that condoms should always be used if aperson my age has sex, even if the two people knoweach other very well.believe that condoms should always be used if aperson my age has sex, even if they are going together.believe that condoms should always be usedif a person my age has sex, even if the girl usescontraception.believe that another form of contraception shouldalways be used, even if the guy uses a condom.Perceived costs and barriers to usingcondomswould be embarrassing to buy a condom in a store.would be embarrassing to ask my partner to use acondom.would be afraid my partner would be angry if I askedhim/her to use a condom.am afraid that my sex partner would think I aminfected with an STD if I asked him/her to use a condom.condoms in case I have sex makes me appeareasy.condoms in case I have sex makes me feelprepared.I’m all excited, I don’t want to think about usingcondoms.Positive orNegativeFactor–Using–It–Using–Condoms–Condoms–Condoms–Condoms+Condoms+Using+UsingPositive orNegativeFactor+Most+Most+Most–Women–If+Most–VeryPerceived costs and barriers to usingcondoms (Continued)condoms disrupts the mood.would be embarrassing to put on a condom.condoms is a hassle.reduce the pleasure of sex.reduce sensation during sex.are messy.create distrust in a relationship.are comfortable to use.condoms can be sexy.condoms makes me feel more secure that I willnot cause a pregnancy or get an STD.Perceived peer norms about condom orcontraceptive useof my friends believe condoms should always beused if a person my age has sex.of my friends believe condoms should always beused if a person my age has sex, even if the girl usesbirth control pills.of my friends believe condoms should always beused if a person my age has sex, even if the two peopleknow each other very well.who carry condoms are looking for sex.you tell your partner you want to use a condom, yourpartner will think you’re having sex with other people.young people use contraception when they havesex.few young people are doing anything to protectthemselves against STDs.Chapter 5 Addressing Attitudes, Values and Beliefs 69

Activity 5-1Reasons to Not Have SexDescription of ActivityObjectives: Students will be able to:State and evaluate reasons why young people have sex and do not have sexRisk and Protective Factors Addressed:Values and attitudes about having sexActivity:The educator writes on the board “Reasons to have sex” and “Reasons to wait” and asks studentsto suggest reasons young people their age do have sex and reasons they decide not to have sex. Theeducator writes their reasons in the appropriate column on the wall.The educator makes sure that all the important reasons not to have sex are included in the list (e.g.,might get pregnant, might contract an STD or might upset my parents).Then the educator asks the students to rate each reason in each column according to whether it isan important and healthy reason or a relatively unimportant and unhealthy reason. When thereis general class consensus that a reason is an important and healthy reason, the educator puts a“1” beside it; when there is general class consensus that a reason is not an important and healthyreason, the educator puts a “0” beside it.As appropriate, the educator points out that many reasons to have sex are not good reasons (e.g.,to feel like an adult or to give in to peer pressure) or are short term (e.g., feels good). If needed,the educator points out that the reasons not to have sex can negatively affect their lives for a longtime (e.g., becoming parents before they are ready or contracting an STD). At the end, the educatorcounts the number of “1s” on each list to assess the overall pros and cons of having sex at that timein their lives and emphasizes that there are more important and healthy reasons not to have sexthan to have sex at this time.Important Considerations in Using ItBe sure that as many reasons as possible come from students so that they perceive the lists andconclusions as their ideas rather than as the educator lecturing to them.References for Lessons That Describe a Similar Activity More Fully1. Draw the Line, Grade 7, Lesson 2, Activity 2.3: Tina and Marco2. It’s Your Game, Grade 7, Lesson 9, Activity III: Tina and Marco3. It’s Your Game, Grade 7, Lesson 10, Computer-Based Activity: Choosing to Wait4. Making Proud Choices, Module 1, Activity E: Brainstorming About Teens and Sex5. Reducing the Risk, Class 2: Reasons That Many Teens Have Sex6. Safer Choices, Level 1, Class 1, Activity 1: Why Young People Choose to Have or Not Have Sex70 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

Activity 5-2Dreams, Goals and ValuesDescription of ActivityObjectives: Students will be able to:Assess their important values, dreams and goals and whether having sex would be consistent withthose dreams and goalsRisk and Protective Factors Addressed:Values and attitudes about having sexActivity:Students individually complete a worksheet in which they rate the importance of many things intheir lives (e.g., spending time with friends, having their parents’ approval, living according to theirreligious or personal values, finishing high school, getting a job, traveling, being healthy).After assessing what is important to them, students review all the things they rated as importantand consider whether each of those values, dreams and goals is consistent with having sex, withbecoming a parent and with contracting an incurable STD such as herpes or HIV.The whole class then discusses how having sex and possibly becoming a parent or contracting anSTD are inconsistent with their values, dreams and goals.Important Considerations in Using It1. This activity may be more effective with females than males.References for Lessons That Describe a Similar Activity More Fully1. It’s Your Game, Grade 7, Lesson 9, Activity IV: Journal2. It’s Your Game, Grade 7, Lesson 10, Computer-Based Activity: Choosing to Wait3. It’s Your Game, Grade 8, Lesson 3, Computer-Based Activity: On the Air4. Making Proud Choices, Module 1, Activity F: Goals and Dreams Timeline5. Making Proud Choices, Module 1, Activity G: Brainstorming Obstacles to Your Goals and Dreams6. Reducing the Risk, Class 1: Pregnancy Risk Activity7. Reducing the Risk, Alternate Class 1: Personalizing Risks8. Reducing the Risk, Class 12: How HIV Would Change My Life9. Safer Choices, Class 5B, Activity 4: Dealing with a Pregnancy10. Safer Choices, Class 6, Activity 2: Personalizing the Impact11. SiHLE, Workshop 1, Activity J: Thought Works12. SiHLE, Workshop 2, Activity J: Consider This13. It’s Your Game, Keep It Real (Risk Avoidance Curriculum), 8th gradeChapter 5 Addressing Attitudes, Values and Beliefs 71

Activity 5-3Sexual Values LineDescription of ActivityObjectives: Students will be able to:Express reasons young people should or should not have sexRisk and Protective Factors Affected:Values and attitudes about having sexActivity:The educator asks students to imagine that they have a brother or sister who is a year younger thanthemselves and who doesn’t know whether to have sex for the first time. He/she is asking you whathe/she should do.After students spend a few minutes writing down what they would tell their brother/sister, theyare asked to stand in one corner of the room representing their recommendation that theiryounger brother/sister have sex at this time in his/her life, at another corner representing theirrecommendation that their younger brother/sister wait to have sex, or somewhere in betweenrepresenting their uncertainty.When standing in locations representing their beliefs, students are asked to voluntarily state whythey believe their younger brother/sister should or should not have sex. It is important to havestudents in different locations express their views.Important Considerations in Using It1. This activity may only be effective when a majority of the students believe their brother/sistershould not have sex. If the students are older and sexually experienced, the group norm andpressure may be to have sex, rather than not to have sex. Thus, this activity should only beconducted with students who are young enough or sufficiently favorable to abstinence to givestrong reasons for waiting until older.2. Students should not be forced to participate if they are uncomfortable taking a position in theclassroom.3. Sexually active students may use this to give testimony as to why they wish they had waited.References for Lessons That Describe a Similar Activity More Fully1. Reducing the Risk, Class 11: My Kid Sister72 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

Activity 5-4“Dear Abby”Description of ActivityObjectives: Students will be able to:Make responsible decisions about what young people should do in various potential sexualsituationsRisk and Protective Factors Addressed:Values and attitudes about having sex and using condoms or contraceptionActivity:In small groups, students read letters to “Dear Abby” that depict a variety of dilemmas involvingsexual behavior among young people like themselves.In small groups, the students decide what advice they would give the writer of each letter. Typically,they must decide whether the letter writer should have sex and whether the letter writer should usecondoms or contraceptives if she/he does have sex.After all groups have made decisions about what advice to give the letter writers, they share theirletters/scenarios and their advice with the entire class and give their reasons for their advice.References for Lessons That Describe a Similar Activity More Fully1. Making Proud Choices, Module 3, Activity B: Tell It to Tanisha2. It’s Your Game, Grade 8, Lesson 4, Activity II: Talk Show and DiscussionChapter 5 Addressing Attitudes, Values and Beliefs 73

Activity 5-5Description of ActivityAddressing Barriers to Using CondomsObjectives: Students will be able to:Identify barriers to using condoms and suggest methods of overcoming those barriersRisk and Protective Factors Addressed:Attitudes about using condomsActivity:The educator asks students why some people do not use condoms when they have sex and writesthe answers on the board.The students then brainstorm multiple practical ways of overcoming each of the obstacles. Forexample, if cost is perceived as a barrier, then the students or educator identify clinics or otherplaces that provide condoms free of charge. If a partner’s possible negative reaction is a barrier,identify ways to convince the partner that condoms should be used.Important Considerations in Using ItThis activity can be used in combination with the other examples in this chapter to overcome specificbarriers to using condoms (e.g., embarrassment obtaining condoms and possible loss of pleasure).References for Lessons That Describe a Similar Activity More Fully1. Becoming a Responsible Teen, Session 3, Activity 3: Overcoming Embarrassment About BuyingCondoms2. Becoming a Responsible Teen, Session 3, Activity 5: Countering Barriers to Using Condoms3. Cuidate!, Module 5, Activity C: Overcoming Barriers to Condom Use4. Cuidate!, Module 5, Activity D: What Gets in the Way to Caring Behavior5. Cuidate!, Module 6, Activity A: No Hay Razón6. It’s Your Game, Grade 8, Lesson 5: Computer-Based Activity: Teens Talk about Reducing the Risk7. Making Proud Choices, Module 7, Activity B: How to Make Condoms Fun and Pleasurable8. Making Proud Choices, Module 7, Activity C: Barriers to Condom Use/Condom Use Pros and Cons9. Making Proud Choices, Module 7, Activity D: “What to Say if My Partner Says…” Excuses PartnersGive for Not Using Condoms10. Safer Choices, Level 1, Class 9, Activity 3: Barriers to Using Protection11. Safer Choices, Level 2, Class 7, Activity 4: Challenges and Solutions for Condom Use12. SiHLE: Workshop 3, Activity F: Why Don’t People Use Condoms?13. SiHLE: Workshop 3, Activity G: KISS—Keep It Simple Sista!74 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

6CorrectingPerceptionsof Peer NormsKeys to Changing NormsIdentify, model and promote healthy andprotective behaviors that are (or can become)the real norm in a given population and, ifpossible, use evidence (e.g., survey results) tosupport those norms.Basic TheoriesAll of us are affected by our perceptions of whatothers are doing and our perceptions of what othersthink we should be doing. For example, when weare in a new situation (e.g., a new event, a new jobor a new country), we look around to see how othersare behaving and then typically try to behave in amanner consistent with that observed behavior. Wedo this because we often desire to conform to socialnorms (standards of acceptable behavior) or becausewe are explicitly encouraged to do so.Social norms are created by both actual behaviorand beliefs about what that behavior should be.For example, on many highways the speed limitis 65 mph, but a large number of people drive 70mph. Thus, their behavior creates the norm thatit is acceptable to drive 70 mph, even though thespeed limit is 65 mph. Furthermore, if you askpeople whether it is acceptable to drive 70 mph onthe freeway, most will concur that it is acceptable.In contrast, the vast majority of people stop at redlights as required by law and people also state that itis not acceptable to drive through a red light. Theseexamples illustrate that when both behaviors andbeliefs about those behaviors are consistent, they cancreate a social norm.Norms play an important role in several theories,especially the theory of reasoned action and the theoryof planned behavior, which built on the theory ofreasoned action (Fishbein and Ajzen 1975; Ajzen1985).In both theories, it is argued that behavior is determinedprimarily by intention to engage in a specificbehavior and that, in turn, intention to engage inthe behavior is determined by attitudes and normsrelated to the behavior. For example, according tothe theory of reasoned action, the use of condomsduring sex would be determined by intention to usecondoms, and, in turn, intention to use condomswould be determined by attitudes toward condomsand perceptions of norms about condom use. Thetheory of planned behavior built upon this modelby recognizing that intention to engage in behavioralso is determined by perceived ability to engage in aparticular behavior effectively—e.g., perceived abilityto insist on and actually use a condom effectively.Although social cognitive theory does not place asmuch emphasis on the particular term “socialnorms,” it incorporates similar ideas in its constructs.Chapter 6 Correcting Perceptions of Peer Norms 75

In particular, it emphasizes that people learn byobserving the actions of others and the consequencesthat then follow those actions (Bandura 1986).Multiple studies in many fields have revealed thatthese theories do partially predict behavior. Thesetheories also have been the basis for the developmentof educational interventions that, in turn, have effectivelychanged health behavior in a desired manner.More recently, several theorists have built upon thetheories of reasoned action and planned behaviorand developed the social norms approach. Like thetheories of reasoned action and planned behavior,the social norms approach recognizes that peopleoften desire to conform to social norms or feel pressuredto conform to them. However, it also recognizesthat people’s perceptions of social norms may differfrom actual social norms. This theory posits thatpeople often exaggerate the extent to which othersengage in unhealthy or risky behaviors, creating agap between actual behavior and perceptions of thatbehavior. For example, studies demonstrate that collegestudents believe that more of their fellow collegestudents drink excessively than actually do so.By correcting the misperception and demonstratingthat a majority of people do not engage in a particularunhealthy or risk behavior and thereby reducingthat gap, interventions can reduce unhealthyand risk-taking behavior (Berkowitz 2005; Haines,Perkins et al. 2005).According to Haines and colleagues (2005), thereis a growing body of studies demonstrating that thesocial norms approach has been effective at reducinga variety of risk behaviors, including drinking,smoking and substance abuse. Many of these studieshave been conducted in colleges, but some havebeen conducted in middle schools, high schools andcommunities (Perkins and Craig 2003). They areoften, but not always, applicable to adolescent sexualbehavior, as discussed in more detail below.Applying These Theoriesto Peer Norms and TeenSexual BehaviorPeer norms (peer standards of acceptable behavior)are particularly important during adolescence.When applying these theories to peer norms andteen sexual behavior, four questions should be asked.1. Do teens’ perceptions of their peers’ norms aboutsexual behavior and actual sexual behavior affecttheir own sexual behavior?2. Is there a gap between perceptions of peer sexualbehavior and reality? Do teens believe that moreof their friends have sex than actually have sex?3. Can we change perceptions of peer norms?4. How do we change perceptions of peer norms?Do teens’ perceptions of their peers’ norms aboutsexual behavior and actual sexual behavior affecttheir own sexual behavior?According to the theories discussed above, if teensbelieve their friends are engaging in sexual activity,they are much more likely to be sexually activethemselves. Similarly, if teens believe their friendsare using condoms or contraception when theyhave sexual intercourse, they are more likely to usecondoms or contraception themselves. Multiplestudies confirm this, providing support for thesetheories. In a review of 25 studies that measured theimpact of perceptions of peer norms about sexualbehavior or perceptions of actual peer behavior onteens’ own initiation of sexual activity, 24 found thatthese perceptions of peer norms or behavior weresignificantly related to teens’ initiation of sexualactivity (Table 6-1) (Kirby and Lepore 2007). Fewother risk or protective factors were so consistentlyand significantly related to initiation of sexual activity.Similarly, of the 15 studies that examined theimpact of perception of peer norms about condom orcontraceptive use, 12 found that they were significantlyrelated to actual condom or contraceptive use(Table 6-2) (Kirby and Lepore 2007).76 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

Is there a gap between perceptions of peer sexualbehavior and reality? Do teens believe that moreof their friends have sex than actually have sex?According to the social norms approach, such gapsare common. A few quantitative studies also supportthe existence of gaps, specifically in teens’ perceptionsof their peers’ sexual activity (Kinsman, Romeret al. 1998; Robinson, Telljohann et al. 1999; Bacon,Cleland et al. 2002). In addition, many adults workingwith youth on reproductive health issues haveobserved and commented on such gaps, suggestingthey may be quite widespread. Teens also maybelieve that fewer of their friends always use condomsor contraception than actually use condoms orcontraception; however, this is less well studied.Why do teens have distorted views of their peers’sexual behavior? There are several plausible reasonsthat may vary from one group or community toanother:• Teens who have sex talk about and may exaggeratetheir sexual activity. Others may suggestthey’ve had sex, even when they haven’t. Teenswho do not have sex are less likely to talk abouttheir virginity.• Teens (like all people) tend to remember thosebehaviors or events that are unusual or vivid, andstories of sexual exploits are sometimes morevivid and memorable than stories of not havingsex.• The media commonly depicts sex among youngpeople.• Some teens view pornography, either accidentallyor on purpose, which often depicts sexual intercourseand rarely depicts condom or contraceptiveuse.• Some well-intentioned people (such as educators,guidance counselors and parents) may receivebiased information themselves and then becomecarriers of the misperceptions, unintentionallyexaggerating sexual behavior of teens and theconsequences of that behavior.Collectively, the social norms theories as well asempirical evidence suggest that by changing theperceptions of norms and behavior, especially peernorms, programs may change behavior.Can we change perceptions of peer norms?Researchers involved with all these theories haveproduced substantial evidence that it is possible tochange perceptions of peer norms in general. In thearea of teen sexual behavior, a review of 84 studiesof sex and HIV education programs found thata majority of the programs employed one or moreof these theories and about 40 percent (16 out of 38programs) significantly improved perceptions of peernorms (Table 6-3) (Kirby 2007). These studies demonstrateclearly that not all programs significantlychanged perceptions of peer norms, but a substantialnumber of programs did so. Moreover, these studiesillustrate it is possible to change perceptions of peernorms about sexual intercourse as well as condomuse and overall sexual risk-taking.Table6-1Table6-2Number of Studies Reporting Effects ofPeer Norms About Sex on Teens’ OwnSexual BehaviorBelieved peers engagedin sexual activity or hadpermissive attitudestoward sexual activity(N=25)Believed peers usedcondoms or had positivenorms about condom orcontraceptive use (N=15)LaterInitiationof SexNumber of Studies Reporting Effectsof Peer Norms About Condom/Contraceptive Use on Teens’ OwnCondom/Contraceptive UseIncreased Useof Condomsor OtherContraceptivesNoSignificantRelationshipNoSignificantRelationshipEarlierInitiationof Sex0 1 24Reduced Useof Condomsor OtherContraceptives12 3 0Chapter 6 Correcting Perceptions of Peer Norms 77

How do we change perceptions of peer norms?All these theories suggest that people’s perceptionsof norms are affected by their observations of othersand by other kinds of evidence about norms (e.g.,survey-based research of norms or behavior). Thus,perceptions of norms may be improved through thefollowing kinds of activities, among others:• Presenting credible research-based evidencedescribing both actual behavior and expressednorms about that behavior through:o Nationwide, community, or school-wide surveyswith results reported through class discussions,posters, short articles or advertisementsin school newspaperso In-class questionnaires with results presentedand discussed in class (See Activity 6-1:Conducting In-Class Surveys) (These datatend to resonate more effectively with teensthan statewide or national surveys.)o In-class, forced-choice voting activities withdiscussions of reasons why teens chose to avoidsex or insist on using protection• Modeling desired behavior through:o Videos or acted dramas that portray teensavoiding undesired or unintended sexualactivity or using protection against STDs andpregnancy in a way that makes such behaviorseem to be a realistic and popular optiono Oral, written or visual testimonials modelingeither abstinence or use of protection (e.g.,calendars with role model stories and picturesof representative teens or testimonials by peerleaders)o Peer discussions of sexual behavior in whichyouth reach conclusions supporting desirednorms (e.g., how to avoid situations that mightlead to sexual activity, how to respond to pressurelines to engage in sexual activity, how toinsist on using condoms or other forms of contraceptionor where to obtain condoms withoutembarrassment) (See activities in Chapter 7)o Roleplaying activities in which teens themselvespractice in small groups refusingTable6-3Perceptions of PeerValues and BehaviorRegarding sex behavior(N=23)Regarding use ofcondoms (N=10)Number of Programs Having Effects onPerceptions of Peer Norms or BehaviorRegarding avoiding riskof pregnancy or STD(N=5)Had aPositiveEffectNoSignificantEffectsHad aNegativeEffect9 13 14 6 03 2 0Total 16 21 1undesired sexual activity or insisting on usingcondoms or contraception (See activities inChapter 7)• Engaging in part of the desired behavior in a safecontext through:o Visits to drug stores or clinics with peers tolearn about the availability, location, and typesof condoms or contraceptives (if the program isdesigned to increase condom or contraceptiveuse) (See Activity 5-5: Addressing Barriers toUsing Condoms)When educators use these strategies to convinceyouth that their peers have particular norms, themessages they give are called “normative messages.”Different studies have identified different characteristicsof normative messages that they believedwere important. These characteristics sometimesdepended on the methods they were using to changesocial norms. In general, normative messagesshould:1. Be based on credible evidence (e.g., local questionnairescompleted by the teens themselves orother data from credible sources)2. Be communicated by individuals, groups ororganizations that are perceived by youth to becredible78 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

3. Use concepts, language, symbols, pictures orpeople that area. realistic and appropriate to the audience(including the diversity of youth beingtargeted)b. clearc. appealing, persuasive and forcefuld. empowering (e.g., should encourage youth toact on their own behalf and to take control oftheir sexual behavior)4. Include messages about both actual behaviors andbeliefs or norms about behavior—e.g., “7 out of10 teens do not have sex and 8 out of 10 believethat not having sex is the best choice for youngpeople their age”5. Focus on the positive as opposed to the negativein terms of sexual risk—e.g “7 out of 10 teens donot have sexual intercourse” as opposed to “3 outof 10 teens do have sexual intercourse”Important Steps in Usingthe Social Norms ApproachProperly using the social norms approach andestablishing a gap requires collecting data on actualnorms and perceptions and then comparing them.Michael Haines and his colleagues (2005) recommendseveral generic steps that can be applied tocompleting this process for sexual behavior:1. Conduct a representative survey of the school (orother youth population) or use existing surveyresults, analyze results and confirm that a gapexists.Measure:a. Actual sexual and contraceptive behavior (e.g.,“Have you ever had sex?” “Have you had sex inthe last 3 months?” “If you have had sex, howoften do you use condoms or contraception?”)b. Perceptions of friends’ behavior or perceptionsof a larger defined peer group such assame-grade students (e.g., “How many ofyour friends (or students in your 9th grade)have ever had sex?” “If your friends havehad sex, how often do they use condoms orcontraception?”)c. Teens’ own beliefs (e.g., “Do you agree ordisagree with the following statements: It iswrong for teens my age to have sex. Teens myage should wait until they are older to have sex.If teens my age have sex, they should alwaysuse condoms or contraception.”)d. Teens’ perceptions of their friends’ (or largerpeer groups’) beliefs (e.g., “Do you agreeor disagree with the following statements:My friends think it is wrong for teens myage to have sex. My friends think teens myage should wait until they are older to havesex. My friends think that if teens my agehave sex, they should always use condoms orcontraception.”)e. Reasons why they do not have sex, or reasonswhy they use condoms or contraception if theydo have sexf. Protective behaviors or ways to avoid sex orto insist on using condoms or contraception(e.g., “What have you done to avoid undesiredsex? What have you done to make sure thatyou used condoms or contraception if you hadsex?”)Be sure to ask necessary questions for someresults to be positive. For example, if a majority ofstudents in a high school have had sexual intercourse,then a question about ever having hadsexual intercourse should be asked of freshmenwho are less likely to have had sexual intercourse,or a question should be asked about having sexualintercourse in the last 3 months, about use of condomsor contraception, or about beliefs about useof condoms or contraception—all of which mightreveal more positive results to report.Be sure to report results by gender, age or class,if needed. For example, if female students areless likely to have had sexual intercourse, provideresults for males and females separately sothat females do not believe that the norm is forfemales to have sex. When younger students orstudents in lower grades are less likely to have hadChapter 6 Correcting Perceptions of Peer Norms 79

sex, report their results so that they do not believethat students their age are as likely to have hadsex as seniors.In addition, even when a majority or peers hasengaged in some unhealthy behavior, their attitudesabout that behavior might be more protective,and thus a better candidate for publicizingthis norm.Assess gaps between actual behavior and perceivedbehavior and between actual beliefs andperceived beliefs. Report on reasons why youthdo not engage in sexual activity (or always usecondoms or contraception) and strategies they useto avoid engaging in sexual activity (or always usecondoms and contraception).2. Target appropriate people with the survey results.Certainly they include peers, but they may alsoinclude teachers, parents and others who mightpass on incorrect perceptions about teen sexualbehavior.3. Develop and pilot-test messages, materials, andactivities before using them. Include as many ofthe desirable characteristics of messages describedabove as appropriate.4. Use in-class activities, posters, school newspaperarticles and the Internet to transmit crediblenormative messages based on the research. Ifappropriate, also use peer educators, teachers,parents and others who are credible to convey themessages.5. Change messages and activities periodically toavoid habituation.How has perception of peer norms beenmeasured?In Table 6-4 are illustrative items that have beenused to measure adolescents’ perceptions of peernorms. They may help curriculum developersidentify more specific elements that programs andtheir associated research have addressed and helpresearchers conduct formative evaluations.ConclusionsMultiple studies have consistently demonstrated thatteen perceptions of their peers’ norms about sexualactivity and condom or contraceptive use do affecttheir own sexual and contraceptive behavior. A fewstudies have demonstrated that sometimes, but notalways, there is a gap between actual peer norms andbehavior and teens’ perceptions of those norms andbehavior. The social norms approach and studies inother health areas have demonstrated that changingteen perceptions of peer norms and reducing thatgap (if it exists) can reduce risk behavior. In addition,studies have demonstrated that multiple programshave both changed peer norms about havingsexual intercourse and about condom and contraceptiveuse and also changed sexual and condom andcontraceptive behavior. The most common types ofactivities used to address perceptions of peer normsinclude modeling desired norms through a varietyof mechanisms and conducting polls to present datathat help counter incorrect perceptions of norms.80 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

Table6-4Examples of Items That Have Been Used to Measure Perceptions of Peer Norms 9Each item with a + – sign represents a positive per norm and a protective factor, while each item with a signrepresents a negative peer norm and a risk factor. Thus, within each scale, items with a + sign should be scored inthe opposite direction of those with a – sign.Positive orNegativeFactor+ Most of my friends have not had sex.+Most+Most–Most–Most–MostPerceived peer norms about having sexof my friends think people my age shouldwait until they are older before they have sex.of my best friends think I should wait to havesex.of my friends believe it’s okay for people myage to have sex.of my friends think it’s okay to have sex witha steady boyfriend or girlfriend.of my friends think it’s okay to have sex witha couple of different people each month.Positive orNegativeFactor+Most+Most+Most+Most–VeryPerceived peer norms about condomor contraceptive useof my friends believe condoms should alwaysbe used if a person my age has sex.of my friends believe condoms should alwaysbe used if a person my age has sex, even if the girluses birth control pills.of my friends believe condoms should alwaysbe used if a person my age has sex, even if the twopeople know each other very well.young people use contraception when theyhave sex.few young people are doing anything toprotect themselves against STDs.9 Most of these items are based on actual factors that are related to behavior questions used to measure factors in previous research.These items specify more precisely some of the factors that are related to behavior and can therefore be helpful when designingprograms to address the proximal sexual factors. They also can be used to create items for questionnaires in survey research.Chapter 6 Correcting Perceptions of Peer Norms 81

Activity 6-1Conducting In-Class Surveys toChange Perceptions of Peer NormsDescription of ActivityObjectives: Students will be able to:Recognize that their peers believe that not having sex or using protection if having sex is the bestoption for themselvesRisk and Protective Factors Affected:Perception of peer norms about having sex or using condoms or other forms of contraceptionActivity:Students vote anonymously for what choice is the best for themselves: not to have sexualintercourse at that time; to have sexual intercourse and always use protection against pregnancyand STDs; or to have unprotected sexual intercourse. The anonymity of the voting can bemaintained by having students go individually to a corner of the room, selecting one of threecolored chips and placing them in a container. After everyone has voted, the votes are read outloud one at a time and tallied on a bar graph at the front of the room. After all votes are tallied,the educator summarizes the results and makes a statement about what the students in the roombelieve are the best choices for themselves.Important Considerations in Using ItThis activity should be completed near the end of the unit when students are less likely to choosehaving unprotected sexual intercourse as the best option for themselves. In addition, it should onlybe completed in classes where few students will choose having unprotected sexual intercourseas the best option for themselves. If many students do vote for unprotected sexual intercourse,then reasons why they might have done this should be discussed and the importance of avoidingunprotected sex should be emphasized.References for Lessons That Describe a Similar Activity More Fully1. Safer Choices, Level 2, Class 10: Making a Commitment82 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

7 Increasing Self-Efficacy and SkillsKeys to Increasing Self-Efficacyand SkillsDivide skills into small steps and providesufficient modeling and practice to ensuremastery of each step.Basic TheoriesSimply put, if people think they can do somethingwell, they are more likely to try to do it than if theydo not think they can do it well. And, of course,if people actually can do something well, they aremore likely to believe that they can do it well. Theseare the basic ideas underlying interventions designedto increase self-efficacy.Dr. Albert Bandura is the psychologist most commonlyassociated with promoting the importanceof self-efficacy in human behavior (Bandura 1986;Bandura 1994). Self-efficacy is a central componentin the theory he developed, originally called “sociallearning theory” and later revised and called “socialcognitive theory.”Self-efficacy is people’s judgment or confidence intheir ability to perform particular skills or behaviorswell. People with high self-efficacy believe they canperform behaviors well enough to achieve a goal;as a result, they have more confidence and are morelikely to try to perform the behavior or achieve thegoal. Conversely, if they have low self-efficacy, theyhave less confidence in their ability and are lesslikely to try the behavior or succeed in achieving thegoal.Self-efficacy is different from self-esteem. The latterreflects a person’s overall evaluation or appraisal ofhis or her own worth, as opposed to a person’s confidencein performing specific tasks.According to Bandura, there are four primary methodsof increasing self-efficacy.1. Mastery Experiences. If people succeed, theirself-efficacy increases; if they fail, it decreases,especially if they fail before their sense of efficacyis well established.Increases in self-efficacy also may be roughlyproportional to the difficulty of the task accomplished.If people experience only easy successes,their self-efficacy will be strengthened, but not byas much as it will by occasional challenges thatrequire real effort and perseverance and ultimatelylead to success. That is, some adversity and eventemporary failures can strengthen self-efficacy ifthere is ultimate success.The converse is that failure decreases self-efficacy.Failure is especially likely to decrease self-efficacyif 1) people have a low self-efficacy to beginwith and this failure simply reinforces that lowself-efficacy or 2) people really try their best andChapter 7 Increasing Self-Efficacy and Skills 83

persevere, but, nevertheless, ultimately fail. Thus,the task should not be too difficult.Mastery experiences are the most effectiveapproach towards increasing self-efficacy.2. Vicarious Experiences. When people see otherpeople succeed in some sustained effort, thentheir own confidence in succeeding at the samebehavior also is increased. Conversely, if peoplesee others fail, their self-efficacy is diminished.The impact of these vicarious experiences isenhanced when people’s success is acknowledgedfavorably by others. If not acknowledged or ifacknowledged unfavorably, the impact is lesspositive.The impact of these vicarious experiences also isdetermined by the extent to which the observersperceive those people modeling the behavior tobe like themselves. If the observers view thoseengaging in behavior as being very similar tothemselves, the success or failure of those modelingthe behavior will have a greater impact on theobservers’ self-efficacy.Sometimes people’s perceptions of others are notaccurate. They may perceive themselves as similarto someone else who is very skilled at some taskand models behavior well and then they set themselvesup for failure when they cannot perform aswell.When people model successful behavior, they notonly directly increase the self-efficacy of othersby showing that success in some endeavor canbe achieved, they also increase the self-efficacyof others by demonstrating exactly how successcan be achieved—that is, by demonstrating thespecific skills needed to succeed.People also compare their own performances tothose of others. If they perceive they performbetter than others, their efficacy goes up; if theyperceive they perform worse than others, theirefficacy drops.3. Verbal and Social Persuasion. When peopleconvince others verbally that they can achievesomething, then the self-efficacy of the lattergroup is increased.The impact of social persuasion on self-efficacy ishighly related to whether or not mastery occurs.When social persuasion encourages people to tryhard at something and they ultimately succeed,then social persuasion is accompanied by masteryand self-efficacy is especially strengthened. Whensocial persuasion encourages people to try toachieve something, but they fail, then the initialunrealistic boosts in self-efficacy produced by thesocial persuasion are greatly diminished.If social persuasion is negative and discouragespeople from trying very hard and as a resultthey do not try hard and fail, then this negativesocial persuasion may have a particularly negativeimpact on self-efficacy.Given the interaction between social persuasionand either mastery or failure, people trying toincrease self-efficacy should ideally do more thansimply persuade; they also should structure situationsso that the people being persuaded achievemastery and succeed in their efforts. One of manyways to do this is to demonstrate their success bymeasuring and showing their self-improvementrather than exposing them to possible failurethrough competition with others.People trying to persuade others will be moreeffective if they are credible. They may be particularlyeffective if they are a significant other, suchas a friend, family member, partner, or teacher.In addition, if persuaders encourage others to dothings and they succeed, then both the credibilityof the persuaders and the self-efficacy of thosebeing persuaded is enhanced. And, of course, theconverse is true. If persuaders try to convince othersthat they can do something and they fail, thenboth credibility and self-efficacy are diminished.4. Physical and Emotional Reactions. Peoplesometimes have negative physical and emotionalreactions associated with a particular behavior orsituation (e.g., stress or nervousness). These negativereactions may reduce self-efficacy to completethat activity successfully. Improving these physiologicaland emotional responses can improveself-efficacy. For example, people may feel anxietyspeaking in front of others and these negative84 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

feelings may reduce their self-efficacy to speakpublicly. If their anxiety is reduced, then theirself-efficacy and chances of success may increase.Applying These Theoriesto Teen Self-Efficacy andSexual BehaviorIn order to avoid undesired or unprotected sexualactivity, pregnancy and STD, youth need at leastfive distinct skills. These include the ability to:1. Avoid situations that might lead to undesired,unintended, or unprotected sexual activity2. Refrain from and refuse undesired, unintended orunprotected sexual activity3. Obtain condoms or other forms of contraception4. Insist on using condoms or other forms of contraception,if having sexual activity5. Actually use condoms or other forms of contraceptioneffectively, if having sexual activityWhen applying Bandura’s theories on self-efficacyto teen sexual behavior, three questions should beasked.1. Does teens’ self-efficacy to engage in these fivebehaviors affect their own sexual and contraceptivebehaviors?2. Can we increase self-efficacy?3. How do we increase self-efficacy and improveskills?Does teens’ self-efficacy to engage in these fivebehaviors affect their own sexual and contraceptivebehaviors?According to social cognitive theory, if teens havegreater self-efficacy to perform the five specific skillsabove, they will be more likely to use them to avoidundesired or unintended sex or to use condoms orother forms of contraceptives if they do have sex.Multiple studies confirm this basic component ofsocial cognitive theory. A review of many studies ofrisk and protective factors of teen sexual behaviorrevealed that of the nine studies that measured theimpact of self-efficacy to refrain from sex on actualinitiation of sex, five found that self-efficacy torefrain from sex was significantly related to delayedinitiation of sex (Table 7-1) (Kirby and Lepore2007). None of the studies found that it hastenedthe initiation of sex. The fact that four of the ninestudies failed to find a significant relationshipbetween self-efficacy to refrain from sex and actualsexual behavior may reflect measurement problems,small sample sizes, ceiling effects (youth sometimesrate themselves high on self-efficacy when they havenot been in the situations needing the skill) andother methodological problems. Or perhaps it mayindicate that self-efficacy is, in fact, not related toinitiation of sex in all groups of teens. It also shouldbe noted that the review of studies did not distinguishbetween the ability to avoid situations thatmight lead to sex and the ability to refrain from sexor refuse sex.Only three studies measured the impact of selfefficacyto insist on condom use on actual condomuse; all three found positive effects (Table 7-2)(Kirby and Lepore 2007). Although this is a smallnumber of studies, the consistency of the resultsTable7-1Table7-2Number of Studies Reporting Effectsof Self-Efficacy to Refrain from Sex onTeens’ Own Sexual BehaviorSelf-efficacy to refrainfrom sex (N=9)Self-efficacy to insist oncondom or contraceptiveuse (N=3)LaterInitiationof SexNumber of Studies Reporting Effects ofSelf-Efficacy to Insist on Condom/Contraceptive Use on Teens’ Own Condom/Contraceptive UseIncreased Useof Condomsor OtherContraceptivesNoSignificantEffectsNoSignificantEffectsEarlierInitiationof Sex5 4 0Reduced Useof Condomsor OtherContraceptives3 0 0Chapter 7 Increasing Self-Efficacy and Skills 85

suggests this may be an important factor for multiplegroups of teens.Finally, 14 studies measured the impact of self-efficacyto use condoms on actual condom use; 13 of the14 studies found that it increased actual condom use(Table 7-3). This is very strong and consistent evidencethat self-efficacy to use condoms does increaseactual condom use for most groups of teens. Fewother risk or protective factors were so consistentlyand significantly related to condom use. Notably, inthese studies, the assessment of self-efficacy to usecondoms or contraception included self-efficacy toobtain condoms or contraception.Can we increase self-efficacy?A review of studies of sexual behavior and HIVeducation programs found that out of 43 attemptsto increase self-efficacy in different areas, programssignificantly increased self-efficacy or skills in 23 (orabout half) of them (Table 7-4) (Kirby 2007). Thesestudies demonstrate clearly that not all programssignificantly increase self-efficacy, but a majoritydoes so. Moreover, it is possible to increase selfefficacyto refuse sexual activity, to use condoms orcontraception and to avoid STD/HIV risk behaviorsmore generally.The review did not distinguish between self-efficacyto avoid situations that might lead to undesired,unintended or unprotected sex and self-efficacy torefuse sexual activity. However, half the programs(7 out of 14) increased self-efficacy to refuse sexualactivity.Only two studies measured impact on ability toobtain condoms and one of these increased selfefficacyto obtain condoms. Even with a smallsample size, this suggests that it is at least possible toincrease self-efficacy to obtain condoms.Thirteen studies measured program impact on selfefficacyto use condoms and a majority (8 out of 13)increased that self-efficacy, indicating that programscan increase self-efficacy to use condoms given currentcurriculum activities. Only two studies measuredimpact on skills to use condoms properly andone study was effective.Table7-3Self-efficacy to actuallyuse condoms or contraceptives(N=14)Table7-4Number of Studies Reporting Effectsof Self-Efficacy to Actually Use Condomsor Contraceptives on Teens’ OwnCondom or Contraceptive UseIncreased Useof Condomsor OtherContraceptivesNoSignificantEffectsReduced Useof Condomsor OtherContraceptives13 1 0Number of Programs Having Effects onSelf-Efficacy and Skills to Perform ProtectiveBehaviorsSelf-efficacy and skillsSelf-efficacy to refusesex (N=14)Self-efficacy to obtaincondoms (N=2)Self-efficacy to use condoms(N=13)Had aPositiveEffectNoSignificantEffectsHad aNegativeEffect7 7 01 1 08 5 0Condom use skills (N=2) 1 1 0Self-efficacy to avoidSTD/HIV risk and riskbehaviors (e.g., toengage in sexual activitiesor engage in unprotectedsex) (N=12)6 5 1Total 23 19 1How do we increase self-efficacy and improveskills?Given Bandura’s theory on improving self-efficacy,the following general principles should be built intoactivities to increase self-efficacy and skills amongteens.1. If appropriate, activities should use more thanone method to increase teens’ self-efficacy (mastery,vicarious experiences, social persuasionand improvements in physical and emotionalassociations).2. Activities should first increase teens’ self-efficacythrough practice of skills that teens will learnmore easily. Activities should then make the86 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

situations more difficult so that the behavior ismore challenging, but not so difficult that likelyfailure will reduce self-confidence. For example,a refusal skill should be broken into simpler stepswhich are then taught in sequence or a verbal skillactivity should start with scripted roleplays andthen move to unscripted roleplays.3. Skills should be modeled, both to demonstrate toteens that success is possible and to demonstratethe specific skills needed to achieve success.4. People who model the skills or behavior shouldbe credible and as similar as possible to the teens.Teachers are credible; other peers in a classroommay resemble the students. Using a combinationof both can be effective.5. Educators, especially peer educators, shouldbe properly trained so that they model skillscorrectly.6. Educators or other people trying to persuade theteens that they can complete specified behaviorssuccessfully should use praise and encouragementto prompt students with new skills. They shouldalso be credible to teens.7. Activities should be structured so that in the end,teens do not fail. Teens should not be encouragedto learn skills they cannot perform. Thus, theskills taught should be appropriate for the age andmaturity of the students. Educators should assessthe teens’ current skill level and then proceed insmall steps.8. To the extent feasible, activities should createpositive physical and emotional associationswith behavior and diminish negative ones. Forexample, everything reasonable should be doneto make students comfortable when they practicerefusal skills or observe educators putting condomsover their fingers. If condoms are touchedby students, they should not be lubricated so thatthey do not feel “gross.”Self-efficacy to avoid situations that might leadto undesired sex. The ability to avoid situationsthat might lead to unintended sex, such as drinkingalcohol at unsupervised parties in people’s homes,involves:1. Recognizing ahead of time the kinds of situationsthat might lead to unintended or undesired sex.2. Knowing strategies for avoiding those situations(e.g., refusing to go to such parties, refusingto drink at them or forming an alliance with afriend not to leave the main party for an emptybedroom).3. Having the skills to implement one or more ofthese strategies (e.g., to refuse to go to the party,refuse to drink, or refuse to leave the party for anempty bedroom).The ability to recognize situations that might leadto undesired sexual activity and planning strategiesto avoid them can be increased by having teensdescribe the most common situations that they hearabout that might lead to undesired sex and thenhaving them brainstorm strategies for avoidingthem (see Activity 7-2: Situations That May Leadto Unwanted or Unintended Sex). Their suggestionsfor strategies can be both creative and effective.Expression by peers of those strategies may alsoconfirm a peer norm that teens should not participatein situations that might lead to undesired sexualactivity.Self-efficacy to refuse to be in situations thatmight lead to sex, to refuse to have sex or toinsist on using condoms or contraception if havingsexual intercourse. The abilities to refuse tobe in situations that might lead to sex; to refuseundesired, unintended or unprotected sex; and toinsist on using condoms or contraception all inherentlyinvolve communication with a partner. Byfar the most common method for increasing theseskills is roleplaying (see Activity 7-3: Roleplaying toEnhance Refusal Skills). Remarkably, if conductedproperly, roleplaying in small groups can involve allfour methods of increasing self-efficacy. Roleplayingcan create mastery of the needed skills; as teensobserve their peers practicing the skills, they canlearn vicariously; the teacher, peer educators or otherpeers can verbally persuade them that they can usethese skills in the roleplay and use them in actualsituations; and finally, repeatedly practicing particularskills in small groups of peers can reduce possibleChapter 7 Increasing Self-Efficacy and Skills 87

negative physical and emotional reactions associatedwith those behaviors.When using roleplays, several steps should be followedto maximize improvement in self-efficacy:1. Clearly describe the components of the skills.2. Model the skills in a roleplay.3. Provide individual practice through roleplays ingroups of two to four in which everyone practices(e.g., telling a partner a personal limit, avoidingor refusing undesired sex or insisting on usingcondoms).4. Start the roleplays with a plausible scenario forthe youth and then follow the scenario with afully scripted roleplay in which both actors (theperson pressuring to have sex and the personresisting having sex) simply read scripts.5. During the roleplays in small groups, haveobservers in each group use a checklist to see ifthe important components of effective skills areemployed.6. Repeat the roleplay practice with different scenariosuntil teens master the skills.7. Start with easier situations and move to increasinglydifficult situations.8. Move from scripts with lines for both people inthe roleplay to scripts in which the person pressuringto have sex reads his/her lines, whilethe person resisting has to create his/her ownresponses.In the roleplaying activities that involve refusing tobe in situations that might lead to sex or refusing tohave sex, several elements of effective refusals arecommonly taught:• Saying “no”• Repeating the refusal• Explaining why• Using direct words• Using proper body language• Using a clear, confident voice• Being assertive (saying what you think, how youfeel or what you want without hurting the otherperson)• Looking the other person directly in the eyes• Using delaying tactics• Changing the topic• Suggesting an alternative• Showing the partner you care and building therelationship• Walking away, if necessaryWhile roleplaying practice may be designed primarilyto increase self-efficacy and skills, when youthcontinually see other youth like themselves successfullyavoiding situations that might lead to sex,refusing undesired sex or insisting on using condoms,these roleplays also may improve their perceptionsof peer norms about the acceptance of avoidingundesired sex or using condoms.Self-efficacy to obtain condoms and contraception.To increase self-efficacy to obtain condomsor other forms of contraception, teens can identifystores or clinics that provide condoms and contraceptivesand “investigate” each source, assessing theease of getting there, comfort of being there, cost,etc. (see Activity 5-5: Addressing Barriers to UsingCondoms). And finally, teens can actually go to oneor more location in small groups, find and assesscondoms in the store, or interview clinic staff aboutobtaining contraceptives. These activities involvemastery of some of the steps needed to obtaincondoms or contraceptives, as well as modeling andpossible persuasion. They also may reduce anxietyabout obtaining condoms or contraceptives.Self-efficacy to use condoms correctly. At leasttwo activities have been commonly implemented toincrease the ability to use condoms correctly. In thefirst activity, teachers first demonstrate how to use acondom properly and then give condoms to studentsto practice the same behaviors individually (seeActivity 7-5: Using Condoms Correctly).In the second activity, each of the steps for usingcondoms is correctly written on a separate sheet of88 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

paper (e.g., the air should be squeezed out of thereservoir tip before putting the condom on) and students,holding these sheets of paper, arrange themselvesin correct chronological order. The first teamto arrange themselves in the proper order wins thecontest (see Activity 7-4: Condom Line-Up). Thisactivity is used when state regulations or communityvalues might prevent the use of the first activity.How has self-efficacy been measured?In Table 7-5 are items that have been used to measureadolescents’ self-efficacy to abstain from sexualactivity or to use condoms or contraception. Onceagain, they are illustrative, not comprehensive.Table7-5Examples of Items That Have Been Used to Measure Self-Efficacy 10Each item with a + – sign represents a positive perception and a protective factor, while each item with a signrepresents a negative perception and a risk factor. Thus, within each scale, items with a + sign should be scored inthe opposite direction of those with a – sign.Positive orNegativeFactor Self-efficacy to abstain from sex+ I have the ability to abstain from sex until married.+I+My+My+If+If+If+IfPositive orNegativeFactorcan abstain from sex until I’m finished withhigh school.boy/girlfriend cannot pressure me intohaving sex.friends will not pressure me into having sex.someone I liked a lot wanted me to have sex, Iam sure I could say “no.”someone I liked a lot wanted me to have sex, Iam sure I could say “no” without hurting his/herfeelings.someone I liked a lot wanted me to have sex andthreatened to break up with me unless I had sex, Iam sure I could say “no.”someone I liked a lot wanted me to have sex andI had been drinking alcohol, I am sure I could say“no.”Perceived self-efficacy in using condomsor contraception+ It would not be too hard for me to buy condoms.10 Most of these items are based on actual questions used to measurefactors in previous research. These items specify more precisely someof the factors that are related to behavior and can therefore be helpfulwhen designing programs to address the proximal sexual factors. Theyalso can be used to create items for questionnaires in survey research.Positive orNegativeFactor+It+If+If+If+IfPerceived self-efficacy in using condomsor contraception (Continued)would not be too hard for me to carry a condomand have it with me if I needed it.I decided to have sex with someone, I amsure that I could talk to my partner about usingcondoms.I decided to have sex with someone, I amsure that I could get my partner to agree to usecondoms.I decided to have sex with someone but did nothave a condom, I am sure that I could stop myselffrom having sex until I got a condom.my partner refused to use condoms, I couldrefuse to have sex.+If I decided to have sex with someone but did nothave any form of contraception, I am sure that Icould stop myself from having sex until one of uscould get an effective method of contraception.+ I am sure that I could use a condom correctly.+I am sure that I could use a condom correctly evenwhen highly aroused.+I am sure that I could use a condom correctly everytime I have sex.+I am sure that I could use a condom every time,even with my girl/boyfriend.+I am sure that I could use a condom even if I haddrunk alcohol or used drugs.+I am sure that I could use or take contraceptionconsistently and correctly.Chapter 7 Increasing Self-Efficacy and Skills 89

ConclusionsMultiple studies have demonstrated that teens’self-efficacy to refuse sex or to use condoms or othercontraceptives is related to their actually avoidingsexual activity or using condoms or contraception.In addition, multiple studies have found that programscan increase self-efficacy to refuse sex and touse condoms. They also have increased self-efficacyto avoid STD/HIV risk and risk behaviors. Manyof the activities that were used effectively in studiesincorporated important principles gleaned fromBandura’s social cognitive theory.90 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

Activity 7-1Lines That People Use to Pressure Someone to Have SexDescription of ActivityObjectives: Students will be able to:1. State and identify specific, common lines that people may use to get someone to have unwantedor unprotected sex2. Express specific responses to those linesRisk and Protective Factors Affected:1. Knowledge2. Perception of peer norms about avoiding unwanted or unprotected sex3. Skills to refuse unwanted or unprotected sexActivity:The instructor asks students for lines that young people use to get someone to have sex. Afterstudents state a line, the instructor asks for possible responses to those lines. This process iscontinued until students have identified multiple lines and at least one response for each line.Humorous responses and different styles of responses should be encouraged.Notes:1. Because the students describe the lines that their peers are involved in, these situations are realto the students.2. Because the students suggest response to the pressure lines, they establish a clear norm thatyoung people should not give in to these lines.3. They also suggest particular responses that students can use if needed.Important Considerations in Using ItPossible Pitfalls That Might Reduce Effectiveness:1. Students are not given enough time to describe the situations.2. Students are not given enough time or encouragement to describe methods of avoiding orgetting out of such situations.3. Students do not identify many solutions. (If the students struggle to come up with ideas, theeducator should have suggestions ready.)References for Lessons That Describe a Similar Activity More Fully1. Becoming a Responsible Teen, Session 4, Activity 4: Different Communication Styles2. Safer Choices, Level 1, Class 7, Activity 2: Responding to LinesChapter 7 Increasing Self-Efficacy and Skills 91

Activity 7-2Situations That May Lead to Unwanted or Unintended SexDescription of ActivityObjectives: Students will be able to:1. Describe specific common situations that may lead to unwanted or unprotected sex2. Describe ways to avoid or get out of those situationsRisk and Protective Factors Affected:1. Knowledge2. Perception of peer norms about having or avoiding unwanted or unprotected sexActivity:The instructor asks students to describe multiple situations that might lead to unwanted sex. Afterthe students have mentioned a couple, the instructor chooses one of the most common ones andasks for greater detail about it. As appropriate, she/he asks where it would take place, what type ofenvironment, who will be there, who will not be there, will alcohol or drugs be there, etc. A commonsituation might be a party at someone’s home. Other teens will be there. Parents or other adults willnot be there. Music, alcohol and empty bedrooms or other rooms will be part of the environment.The instructor then asks what could be done to avoid such situations and allows time for studentsto give a variety of answers (e.g., check to be sure adults will be there, make sure alcohol and drugswill not be there).The instructor then asks what you could do if you unexpectedly find yourself at such a party andallows time for multiple answers (e.g., ask to go home, make a compact with a girlfriend not to letyou drink or go off with someone).And finally, the instructor asks what you can do if you find yourself in a situation where you arenecking and might become sexually intimate (e.g., go to the bathroom, state clearly you are not readyfor this and want to leave the room, or say you have had too much to drink and do not feel well).After one common situation has been described and discussed, the instructor chooses anotherdissimilar situation and goes through the same process. This is repeated until multiple possiblesolutions have been discussed or until most creative ideas for avoiding and getting out of risksituations have been suggested and described by students.Notes:1. Because the students describe the situations that their peers are involved in, these situations arereal to the students.2. Because the students suggest all the ways to avoid or get out of these situations, they establisha clear norm that students should either avoid or get out of these situations and should not haveunwanted or unprotected sex.Important Considerations in Using ItPossible Pitfalls That Might Reduce Effectiveness:1. Students are not given enough time to describe the situations.2. Students are not given enough time or encouragement to describe methods of avoiding orgetting out of such situations.3. Students do not identify many solutions. (Continued)92 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

Situations That May Lead to Unwanted or Unintended Sex(Continued)References for Lessons That Describe a Similar Activity More Fully1. Becoming a Responsible Teen, Session 7, Activity 2: Getting Out of Risky Situations2. Draw the Line, Grade 7, Lesson 3, Activity 3.3: Warning Signs3. Draw the Line, Grade 7, Lesson 3, Activity 3.4: Risky Situations: Small-Group Activity4. It’s Your Game, Grade 8, Lesson 6, Activity II: The Danger ZoneChapter 7 Increasing Self-Efficacy and Skills 93

Activity 7-3Description of ActivityObjectives: Students will be able to:Refuse having unwanted sexRoleplaying to Enhance Refusal SkillsRisk and Protective Factors Affected:Self-efficacy and skills to refuse unwanted sexActivity:Students are asked to brainstorm situations where they have witnessed others refuse to dosomething they did not want to do and then asked to identify the common characteristics of thoseeffective refusals. If the students do not think of the following characteristics, be sure to includethem:• Stating “no” clearly (e.g., using the word “no,” being direct and saying what you won’t do)• Repeating “no,” if needed• Using a firm tone of voice• Using body language to emphasize the refusalTwo members of the class (preferably peer leaders or two other people who can model the skillswell) complete a scripted roleplay in which one person successfully refuses having sex with the otherperson. The roleplay includes the characteristics above. The educator asks the students whether theroleplay included each of the four characteristics and asks for examples of each of them that weremodeled in the roleplay.The students are divided into groups of three and given two copies of a similar handout with anew scenario and scripted roleplay. Each person in the group practices refusing sex effectivelywhen pressured by a second person in the group. The third person observes the entire roleplay,then verbally answers questions about how well the student refusing sex did so. For example,how did the person refuse sex? What body language was used? How could the refusal have beenmore effective? If need be, the roleplay is repeated in the group until each person completes itsuccessfully.Important Considerations in Using ItThis activity should be followed by additional roleplaying activities that teach refusal skills and thatmay involve more difficult situations. The first activities should be fully scripted in advance so thatthe person refusing unwanted sex simply has to read the lines, state them clearly and forcefully anduse appropriate body language. More advanced and later roleplays should provide a limited scriptfor the person refusing, requiring students to develop their own words to refuse sex.Educators should circulate during the small-group practices to make sure that everyone completesthese roleplays successfully and to actively manage the classroom environment.The educator should compliment the students on their success in effectively refusing unwanted sexand correct any misuses of the roleplays, as needed.(Continued)94 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

Roleplaying to Enhance Refusal Skills(Continued)References for Lessons That Describe a Similar Activity More Fully1. Becoming a Responsible Teen, Session 5, Activity 4: Assertive Communication Demonstration2. Becoming a Responsible Teen, Session 5, Activity 5: Assertive Communication Practice3. Cuidate!, Module 6, Activity B: Using SWAT Technique and Scripted Roleplays4. Cuidate!, Module 6, Activity C: SWAT Techniques and Roleplays5. Draw the Line, Grade 7, Class 4, Activity 4.5: Student Roleplays6. Draw the Line, Grade 8, Class 4, Activity 4.4: Practice, Practice, Practice7. It’s Your Game, Grade 8, Lesson 7, Computer-Based Activity: It’s a Zoo: The Partner Challengeand Protecting Your Rules8. It’s Your Game, Grade 8, Lesson 10, Activity III: Under Pressure9. Making Proud Choices, Module 7, Activity E: Introduction to SWAT and Scripted Roleplays10. Making Proud Choices, Module 8, Activity A: Safer Sex Negotiation Skills and Video Clip11. Making Proud Choices, Module 8, Activity B: Practicing and Enhancing Negotiation Skills:Unscripted Roleplays12. Reducing the Risk, Class 3: Introduce Refusals13. Reducing the Risk, Class 4: Using Refusal Skills (All activities)14. Reducing the Risk, Class 5: Delaying Tactics (All activities)15. Safer Choices, Level 1, Class 2, Activity 2: Effective NO Statements16. Safer Choices, Level 1, Class 2, Activity 3: Student Skill Practice17. Safer Choices, Level 1, Class 3, Activity 2: More Ways to Say NO18. Safer Choices, Level 1, Class 3, Activity 3: Refusal Roleplays19. Safer Choices, Level 1, Class 7, Activity 3: Refusal Skills Roleplays20. Safer Choices, Level 2, Class 6, Activity 3: Student Skill Practice21. Safer Choices, Level 1, Class 6, Activity 4: Real Situations: Unscripted RoleplaysChapter 7 Increasing Self-Efficacy and Skills 95

Activity 7-4Condom Line-UpDescription of ActivityObjectives: Students will be able to:Describe the proper order of steps for using a condom correctlyRisk and Protective Factors Affected:Self-efficacy to use a condom correctlyActivity:In advance, the educator prepares two sets of 5 x 8 cards with the following steps for using acondom properly. Each set has 11 cards; each card has one step. These steps include the followingkinds of steps, which can be modified or supplemented:a. Purchasing a condomb. Checking the date of the package to make sure it has not expiredc. Carefully removing the condom from the wrapper without puncturing it and checking to makesure it is goodd. Putting it on the penis so that it unrolls properlye. Pinching the tip to keep out the air and allow sufficient space at the tip for the semenf. Unrolling it all the wayg. Applying a water-based lubricant (but not an oil-based lubricant), if desiredh. Keeping it on during sexual intercoursei. Holding the condom around the base of the penis and withdrawing from the partnerj. Taking off the condom carefully so that no semen comes outk. Disposing of it properlyTwenty-two students are divided into two teams; each team gets one set of cards, one for eachteam member.The team members have to read and hold up their cards and then get in a line such that the stepsare in the correct order. The first team to line up properly wins the competition.Important Considerations in Using ItThis activity should only be implemented if school policies and community norms support its use.It can generate lots of fun and excitement.References for Lessons That Describe a Similar Activity More Fully1. Making Proud Choices, Module 7, Activity A: Condom Line Up2. Safer Choices, Level 1, Class 9, Activity 2: Practicing Proper Use of Condoms96 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

Activity 7-5Using Condoms CorrectlyDescription of ActivityObjectives: Students will be able to:Demonstrate how to use a condom correctlyRisk and Protective Factors Affected:Self-efficacy and skills to use a condom correctlyActivity:The educator puts on the board the correct steps for using a condom correctly. She/he thendemonstrates using a condom correctly with two fingers or a penis model. The steps should include:• Checking the date of the package to make sure it is not too old• Carefully removing the condom from the wrapper without puncturing it and checking to makesure it is in good condition• Making sure it is latex and not lambskin• Putting it on the penis so that it unrolls properly• Allowing sufficient space at the tip for the semen• Unrolling it all the way• Applying a water-based lubricant (but not an oil-based lubricant), if desired• Keeping it on during sex• After sex, holding the condom around the base of the penis and withdrawing from the partner• Taking off the condom carefully so that no semen comes out• Disposing of it properlyAfter the educator has demonstrated proper use, students individually (or in pairs) are givenwrapped condoms and complete the same steps by putting them over two fingers.Important Considerations in Using ItThis activity should only be implemented if school policies and community norms support its use.Students should be not be forced to touch a condom if they do not wish to do so.References for Lessons That Describe a Similar Activity More Fully1. Becoming a Responsible Teen, Session 3, Activity 4: Using Condoms Correctly2. Cuidate!, Module 5, Activity B: Condom Use Skills3. Draw the Line, Grade 8, Class 6, Activity 6.4: Condom Demonstration4. Making Proud Choices, Module 5, Activity D: Condom Use Skills5. It’s Your Game, Grade 8, Lesson 5, Computer-Based Activity: Marvin’s Story, On the Air: ExpertCorner II and Condom Steps6. Safer Choices, Level 1, Class 9, Activity 1: Condom Demonstration7. Safer Choices, Level 1, Class 9, Activity 2: Practicing Proper Use of Condoms8. Safer Choices, Level 2, Class 7, Activity 2: Condom Demonstration9. SiHLE, Workshop 2, Activity L: Introducing ORRaHChapter 7 Increasing Self-Efficacy and Skills 97

8 Improving IntentionsKeys to Improving IntentionsNot have sexHave sex with a condomHave sex with othercontraceptionHave unprotected sexDon’t knowImprove risk and protective factors affectingintentions (see other factors), have youthidentify their personal sexual intentions, andhave them identify strategies for overcomingpossible barriers to implementing thoseintentions.BackgroundIntentions are courses of actions that people expectto follow. If people intend to do something, theyare more likely to actually do it than if they do notintend to do it. This basic principle is a centerpieceof important theories of health behavior (e.g., thetheory of reasoned action (Fishbein and Ajzen1975), the theory of planned behavior (Ajzen andMadden 1986), and the information-motivationbehavioralskills model (Fisher and Fisher 1992),which are commonly used to develop effectivecurriculum-based sex and STD/HIV educationprograms (Kirby, Laris et al. 2006). Across a varietyof health fields, a great amount of empirical evidencesupporting these theories and the fact that intentionsdirectly affect behavior (Armitage and Conner2001; Backman, Haddad et al. 2002). Many ofthese same theories demonstrate that intentions areaffected by the factors discussed in previous chapters—e.g.,knowledge, perceptions of risk, attitudes,norms and self-efficacy.Although intentions strongly influence behavior, theextent to which they affect behavior may depend onat least three things:1. The strength of the intentions. For example, ifyouth strongly intend to remain abstinent untilthey are older, they are more likely to remainabstinent than if they have only weak intentionsto remain abstinent. Alternatively, if youthstrongly intend to use condoms if they have sexualintercourse, they are more likely to use condomsthan if they have weaker intentions. Thus, it isimportant to increase the strength of healthyintentions.2. The skills or capability of the individuals toimplement their intentions. For example, youthmay intend to remain abstinent, but if they donot have the skills to avoid or get out of situationsthat might lead to unintended sexual contact,then they are less likely to remain abstinent.Similarly, teens may intend to use condoms, but ifthey do not know how to insist on their use or donot know how to use them, their good intentionsmay not be fulfilled.3. Environmental support for the intentions.Whether or not intentions are translated intobehavior may depend on whether or not theenvironment thwarts or encourages the intendedbehavior. For example, young teens may intend tohave sexual intercourse, but if they are properlyChapter 8 Improving Intentions 99

chaperoned, they may not have the opportunity.Or, teens may intend to use condoms when havingsexual intercourse, but if they do not havereasonable access to condoms, then they may notuse them.In sum, intentions may have a large impact onbehavior, but for various reasons, the “best ofintentions” may not translate to behavior. Thus, itis important to increase intentions to avoid sexualrisk behaviors (discussed in this chapter), to providethe skills to implement the intentions (discussed inChapter 7) and to provide environmental support forthe intentions (beyond the scope of this book).When applying these concepts about the impact ofintentions on actual sexual behavior, three questionsshould be asked:1. Do teens’ intentions to engage or not engage inspecific sexual behaviors affect whether or notthey actually engage in those behaviors?2. Can we improve intentions?3. What are effective methods for improvingintentions?These questions are answered below.Do teens’ intentions to engage or not engage inspecific sexual behaviors affect whether or notthey actually engage in those behaviors?At least three studies have found that intendingor pledging to delay initiation of sexual activitywas related to subsequent delay in initiation of sex(Table 8-1) (Blum and Rinehart 1997; Kinsman,Romer et al. 1998; Bearman and Bruckner 2001;Kirby, Lepore et al. 2005). Conversely, one studyfound that intending to have sexual intercourse wasrelated to actually having sexual intercourse. Onlyone study found no relationship between intentionsabout sexual intercourse and actual behavior.Similarly, at least four studies have found thatintentions to use condoms or contraception wererelated to actual use of condoms or contraception(Table 8-2). None of the studies reviewed found alack of relationship or a negative relationship (Kirbyand Lepore 2007). Collectively, research in thefield of teen pregnancy and STD and research inother health areas strongly support the relationshipbetween intentions and behavior.On the other hand, intentions are not perfectlyrelated to behavior. Studies clearly demonstrate thatintentions typically explain considerably less thanhalf the variation in actual behavior; other factorssuch as environmental factors explain more thanhalf (Brown, DiClemente et al. 1992; Kinsman,Romer et al. 1998; Bearman and Brueckner 2001;Armitage and Conner 2001). As noted above, environmentalfactors include such factors as no opportunityto have sexual intercourse, extreme pressureto have sexual intercourse, lack of access to condomsor other forms of contraception and use of condomsor contraception by a partner without one’s knowledgeat the time.It is also true that an intention to engage in onebehavior may conflict with an intention to engagein another behavior. For example, in theory, theintention to abstain from sex may conflict with theintention to use contraception if sex does occur,and conversely, the intention to use contraceptionif sex occurs may conflict with the intention toabstain from sex. However, the review of studiessummarized in Tables 8-1 and 8-2 suggests there islittle evidence that the intention to use condoms orcontraception, if sex does occur, had an impact onabstaining from sex. On the other hand, the intentionto abstain from sex was associated with reduceduse of condoms or other forms of contraception inthree out of three studies (Bearman and Brueckner2001; Manlove, Ryan et al. 2003; Morrison,Gillmore et al. 2003; Kirby and Lepore 2007).Can we improve intentions?Studies provide evidence that it is possible toimprove intentions. Ten out of 18 programs(56 percent) increased intentions to abstain fromsex or to restrict sex or partners (Table 8-3) (Kirby2007). Similarly, 5 out of 11 programs (45 percent)increased intentions to use condoms or contraceptionif they do have sex. Although not every curriculumbasedintervention had a significant impact, abouthalf did so, clearly demonstrating that it is possible100 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

Table8-1Greater intention orpledge to abstain fromsex (N=4)Greater intention tohave sex (N=1)Table8-2Number of Studies Reporting Effects ofIntentions on Initiation of SexGreater intention orpledge to abstain fromsex (N=3)Greater intention tohave sex (N=1)Greater intention to usecondoms or contraception(N=4)Table8-3IntentionsLaterInitiationof SexNoSignificantRelationshipEarlierInitiationof Sex3 1 00 0 1Number of Studies Reporting Effects ofIntentions on Condom or Contraceptive UseIncreased Useof Condomsor OtherContraceptivesNoSignificantRelationshipReduced Useof Condomsor OtherContraceptives0 0 31 0 04 0 0Number of Programs Having Effectson IntentionsIntention to abstainfrom sex or restrict sexor partners (N=18)Intention to use condomsor contraception(N=11)Had aPositiveEffectNoSignificantRelationshipHad aNegativeEffect10 8 05 5 1to influence intentions if the proper strategies areimplemented.What are effective teaching methods for improvingintentions?According to the theory of planned behavior,intentions are influenced by attitudes, perceptionsof social norms and self-efficacy (see Figure 1-1 inChapter 1). For example, if youth have attitudesfavoring abstaining from sexual activity, if theyperceive that their parents and peers believe theyshould remain abstinent and if they believe thatthey can remain abstinent, then they are more likelyto intend to remain abstinent than if any of theseconditions are not met. Similarly, if youth have positiveattitudes about condoms, believe that their peerssupport their use of condoms and believe that theycan obtain and use condoms correctly, they are morelikely to intend to use condoms than if any of theseconditions do not exist. Multiple studies have demonstratedthat these factors (attitudes, perception ofnorms and self-efficacy) do, in fact, affect intentions(Armitage and Conner 2001).In practice, this means that to improve intentions,curriculum activities need to change attitudes,perceptions of social norms and self-efficacy. And,of course, because both knowledge and basic valuesaffect attitudes, perceptions of social norms and selfefficacy,improving knowledge and helping clarifyvalues also may improve intentions. Changingthese factors is addressed in previous chapters (seeChapters 2 through 7).A few additional activities may help youth clarifyand implement their intentions. Although youngpeople may intend to abstain from sexual intercourseor to use condoms or other forms of contraception,sometimes their intentions may not be entirely clearto them or well formulated; sometimes young peoplemay not have moved from merely intending to dosomething to making a definite commitment to dosomething; and sometimes they have not thoughtabout the barriers to implementing their intentionsand possible strategies they could employ to overcomethose barriers. Thus, effective curricula shouldinclude specific activities to help youth:1. Formulate and clarify their intentions. Becauseyouth are exposed to many conflicting messagesand pressures, one or more activities should helpyouth make a clear decision about the best behavioralchoices for them. To do so, activities shouldguide them through a process in which theythink about what they have learned; their valuesabout sexual behavior, pregnancy, and STD; theirChapter 8 Improving Intentions 101

attitudes about condoms and contraception; valuesand pressures from their families and peers;and their skills to avoid situations that might leadto sex and to using contraception. The ultimategoal of activities to address intentions is to helpyouth decide quite clearly what they intend to do(and not do) sexually during the coming monthsor years (Gerrard, Gibbons et al. 2003) (seeActivity 8-1: Creating Personal Sexual Limits).2. Make commitments to themselves (or to others)to implement their intentions. Althoughsome theorists use the words “intentions” and“commitments” almost interchangeably, othersbelieve that people are more likely to implementtheir intentions if they make a pledge or commitmentto themselves or to others to engage inparticular behaviors. For example, research hasshown that public pledges to abstain from sexhave delayed the initiation of sex under someconditions (Bearman and Bruckner 2001).3. Create a clear plan for implementing theirintentions. An effective means to help youthtranslate their intentions into behavior is to helpthem create a clear, specific plan detailing when,where and how the desired behavior will beperformed (Gollwitzer 1999) (see Activity 8-2:Creating a Plan to Stick to Their Limits).4. Identify possible barriers to implementing theirintentions and methods of overcoming thosebarriers so that they are more likely to succeedin implementing their intentions. Youth shouldidentify barriers specific to their own intentionsand find strategies that will help them addressthose barriers. Many of the approaches to identifyingand overcoming barriers are covered in priorchapters, but reviewing them in the context oftheir own intentions may be helpful (see Activity8-2: Creating a Plan to Stick to Their Limits).How have intentions been measured?Table 8-4 lists illustrative items that have been usedto measure adolescents’ intentions.Table8-4Positive orNegativeFactorIntention to have sex+ I intend to abstain from sex until I am older.+I intend to abstain from sex until I am married.Positive orNegativeFactor+If+IfExamples of Items That Have Been Usedto Measure Intentions to Have Sex orUse Condoms or Contraception 11Each item with a + sign represents a positiveintention and a protective factor, while each itemwith a – sign represents a negative intention and arisk factor. Thus, within each scale, items with a +sign should be scored in the opposite direction ofthose with a – sign.Intention to use condoms orcontraceptionI have sexual intercourse in the next year, I amsure that I will always use a condom.I have sexual intercourse in the next year, I amsure that I will always use an effective method ofcontraception.11 Most of these items are based on actual questions used to measurefactors in previous research. These items specify more precisely someof the factors that are related to behavior and therefore can be helpfulwhen designing programs to address the proximal sexual factors. Theyalso can be used to create items for questionnaires in survey research.ConclusionsMultiple studies have demonstrated that, in general,people’s intentions to engage in particular behaviorsare directly related to their subsequently engaging inthose behaviors. Multiple studies also have demonstratedthat young people’s intentions to engage insexual activity or remain abstinent or to use condomsor other forms of contraception are related tothose behaviors. However, good intentions do notalways lead to desired behavior. Sometimes intentionsare weak, people do not have the needed skillsto implement them, or their environment thwartstheir efforts.Nevertheless, if curricula improve young people’sknowledge and values about sexual issues, improvetheir attitudes, increase perceived support from102 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

others for desirable behavior and increase theirperceived skills, then those curricula are likely toimprove and strengthen intentions, thereby increasingthe likelihood of desired sexual behavior (e.g.,not having sex, limiting partners and using protection).Other strategies—such as helping youth makeclear decisions about what behaviors are right forthem, make a commitment to themselves or othersto engage in particular behaviors, create a clearand specific plan to implement their intentions andreview potential obstacles and methods of overcomingthose obstacles—will provide further support fortranslating intentions to protective behaviors.Chapter 8 Improving Intentions 103

Activity 8-1Description of ActivityObjectives: Students will be able to:Clarify or create their own sexual limitsRisk and Protective Factors Affected:Intentions to avoid unprotected sexCreating Personal Sexual LimitsActivity:Students view stories or videos of young people who were unsure about what they wanted to door not do sexually and then had sexual intercourse that they regretted, perhaps because they weresorry they had sexual intercourse or perhaps because they got pregnant or contracted an STD. Thus,they understand the importance of being clear about what they want to do and not do sexually.As a group, students brainstorm possible limits involving relationships and sexual behavior thatstudents might have—e.g., holding hands and kissing, but nothing further. Students are remindedthat the safest choice is to not engage in sexual intercourse and that, if they do, they should alwaysuse effective protection against pregnancy and STD.Students then individually review the risks of unprotected sexual intercourse, their values andattitudes about sexual activity, their parents’ values, their peers’ norms, and their goals, and makea clear decision about what they will and will not do sexually. Students make this decision concreteby either drawing a line in a list of progressively more risky sexual behaviors that is given them (withtheir own line separating what they would and would not do sexually) or by writing a pledge tothemselves to stick to their chosen limit.Students are encouraged to tell their friends what their limits are, so that their friends can supportthem in keeping these limits. Telling their friends their limits also strengthens their intentions.Important Considerations in Using ItThis activity is often completed near the end of the course when students can review all that theyhave learned during the course, select their personal limits, and make a commitment to them.References for Lessons That Describe a Similar Activity More Fully1. Becoming a Responsible Teen, Session 1, Activity 5: Deciding Your Level of Risk2. Safer Choices, Level 1, Class 10, Activity 3: Closure—What You Can Do3. Safer Choices, Level 2, Class 5, Activity 2: Avoiding UNSAFE Choice4. Safer Choices, Level 2, Class 5, Activity 3: Analyzing the Situation104 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

Activity 8-2Description of ActivityCreating a Plan to Stick to Their LimitsObjectives: Students will be able to:Identify possible threats to their chosen sexual limits, and describe methods of overcoming thosethreatsRisk and Protective Factors Affected:Intentions to avoid unprotected sexSelf-efficacy to avoid unprotected sexActivity:The educator emphasizes that in the coming years, there may be challenges to their personal sexuallimits and that they can best resist those challenges if they remember their limits clearly and have aplan in place ahead of time to resist challenges. Students in the class brainstorm possible challengesor threats to avoiding sexual activity or using protection if they do engage in sexual activity. Theybrainstorm ways of resisting or overcoming those threats and either avoiding sexual activity oralways using effective protection.Students then individually write down on their own sheets of paper their own plan for sticking totheir limits. Students do not put their names on the sheets and these plans are kept confidential.Important Considerations in Using ItThis activity is often completed near the end of the course when students can review all that theyhave learned, select their personal limits and make a commitment to them.References for Lessons That Describe a Similar Activity More Fully1. Reducing the Risk, Class 15, Worksheet 15.1: Sticking with Abstinence and Protection2. Safer Choices, Level 2, Class 5, Activity 3: Analyzing the Situation3. Safer Choices, Level 2, Class 5, Activity 4: My Personal LimitsChapter 8 Improving Intentions 105

9IncreasingParent-ChildCommunication About SexI ha v equ e s t io ns.Let’s talk.Keys to Increasing Parent-ChildCommunication About SexProvide homework assignments in whichstudents are asked to talk with their parentsor other trusted adults about various topicsrelated to sexual behavior. To reduce teensexual risks, parents should discourage sexualinitiation before their teens initiate sex andsupport contraceptive use before and aftertheir teens initiate sex.BackgroundParents’ communication with their children hasdiverse and life-long effects on their children’sbehavior. After all, parents communicate theirknowledge, beliefs, values, expectations and manyother messages, all of which affect their children’sbehavior. Parent-child communication is anessential part of parents’ supervision and monitoringof their children, including their adolescentchildren. Parent-child communication is part ofand contributes to parent-child connectedness, a“super-protector” that affects more than 30 differentadolescent health outcomes such as tobacco use,depression, eating disorders, academic achievement,pregnancy, sexually transmitted disease, and others(Lezin, Rolleri et al. 2004). Most generally, parentchildcommunication is a critical part of the entiresocialization process, which greatly affects children’sbehavior. Thus, it has a huge impact on adolescentbehavior (Miller 1998).However, the impact of parent-child communicationdepends greatly on many factors, including:• The characteristics of the parents (e.g., their parenting,time availability and cultural norms)• The characteristics of the children (e.g., their age,gender, genetic predispositions, beliefs, cultureand acculturation)• The characteristics of the relationship betweenthe parents and their children (e.g., whether theyare close and connected)• The content of the ideas being communicated(e.g., the facts, beliefs, and values beingcommunicated)• The characteristics of the communication process(e.g., whether the parent is conveying beliefs in amonologue or there is an open dialogue betweenthe parents and their children)Reviewing the extensive literature on all of thesetopics is beyond the scope of this chapter. Rather, itfocuses more specifically on parent-child communicationabout sexual activity.Clarifying Termsand PhrasesConsistent with the literature on parent-childcommunication about sex, the term “parents” inthis chapter is broadly defined to include biologicalparents, adopted parents, grandparents and othersChapter 9 Increasing Parent-Child Communication About Sex 107

who have primary responsibility for young people.Although this chapter will focus mostly on communicationbetween parents and their adolescent (orteen) children, verbal or non-verbal communicationabout sexuality can and typically does begin muchearlier. And finally, considerable research on parentchildcommunication focuses on verbal communicationabout particular sexual topics, but it should befully recognized that parents commonly communicatetheir values about sexual activity, contraception,teen pregnancy and the like both non-verbally andthrough their own modeling of relationships andsexual behavior.Focusing on Parent-ChildCommunication About SexFor decades, professionals concerned about youngpeople have worked to increase parent-child communicationabout sexuality as part of their effortsto reduce the rates of teen pregnancy and STDs,including HIV infection. These efforts frequentlywere based upon several beliefs:• Parents should be the primary sexuality educatorsof their children, but youth are exposed to a greatdeal of sex-related content in the media, on theInternet, from their friends and sometimes fromschool.• Parents talk infrequently and inadequately withtheir children about sexuality because they haveconsiderable difficulty and discomfort discussingthe subject.• Effective parent-child communication aboutsexuality will lead to less sexual risk-taking on thepart of young people.• Properly designed programs can increase effectiveparent-child communication about sexuality andcomfort with that communication, thereby reducingadolescent sexual risk-taking.• Encouraging parents to be the primary sexualityeducators of their children is less controversialthan teaching sex or STD/HIV education inschools.For all these reasons, people concerned about adolescentsexuality have developed activities or entireprograms (sometimes for children and their parentsand sometimes for parents alone) to help parents andtheir children communicate more effectively andmore comfortably about sexuality.When reviewing the research on parent-child communication,several questions should be asked:1. Does parent-child communication about sexaffect adolescent sexual behavior?2. Can activities and programs for teens increaseparent-child communication about sex and contraception?How?3. Can programs for parents and their teens togetherincrease parent-child communication about sexand contraception and actually reduce sexual risk?How?4. Can programs for only parents increase parentchildcommunication about sex? How?5. What are tips for parents about how to talk aboutsexual topics?Does parent-child communication about sex affectadolescent sexual behavior?According to theorists, parent-child communicationabout sexuality affects teens’ sexuality-relatedknowledge, values, attitudes, self-efficacy and intentionsto engage in sexual behaviors, which, in turn,affect actual behavior.In dozens of studies, investigators have examinedthe assumption that parent-child communicationabout sex actually reduces adolescent sexual risktakingeither by delaying sex or using condomsor other forms of contraception (Miller 1998).Typically, they have used survey data to analyzethese relationships. Unfortunately, it is difficult tomeasure the impact of this communication on teensexual behavior, both because there are numerousmethodological challenges (e.g., difficultiesin measuring the extent of communication and inestablishing causality) and because the relationshipbetween such communication and teen sexual108 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

ehavior may be quite complex (Jaccard, Dittus etal. 1993).Greater parent-child communication about sex andbirth control is not consistently related to sexualbehavior (Table 9-1). One of the reasons is that theremay be a positive spurious (non-causal) relationshipbetween parent-child communication and initiationof sexual intercourse. That is, when teens becomeinvolved in romantic relationships and situationsthat might lead to initiating sexual activity, theybecome more likely to have sexual activity and theirparents become more likely to discuss delayingsexual activity (and using contraception) with them.Thus, it is not surprising that some studies showthat teens who have had sex are more likely to havediscussed delaying sex with their parents than teenswho have not had sex. However, this does not meanthat if parents talk to their teens about delaying sexbefore their teens actually have sex, their teens willhave sex sooner. In fact, two studies show that whenparents did talk with their teens about delaying theirinitiation of sex before teens had initiated sex, thenthe teens were likely to wait longer to initiate sex(Table 9-2) (East 1996; Whitaker and Miller 2000).Studies also suggest that the impact of parent-childcommunication about sexual activity may depend onvarious characteristics of parents, their children andtheir message. For example, if mothers disapproveof teens having sexual relations, communicationtakes place early, and there is a close mother-childrelationship, then mother-daughter communicationmay delay the daughter’s initiation of sexual intercourse.However, there may be less impact on delayof sexual contact if parents do not disapprove ofteens having sexual relations, the parents are talkingto sons rather than to daughters, the communicationtakes place too late, or the parents are not closeto their children (Jaccard, Dittus et al. 1993; Miller1998; Kirby and Lepore 2007).There is stronger and more consistent evidence thatwhen parents accept and support contraceptive useand encourage their teens to use contraception,then the teens are more likely to use contraception.Three studies found positive effects of parentalacceptance and support of contraception on teenuse of contraception; none found non-significantor negative effects (Kalagian, Loewen et al. 1998;Jaccard and Dittus 2000; Longmore, Manning et al.2003). Similarly, five studies found a positive effectof parent-child communication about contraception,only two found insignificant effects, and nonefound a negative effect (Table 9-3) (Casper 1990;Loewenstein and Furstenberg 1991; Reschovsky andGerner 1991; Moore, Morrison et al. 1995; Jaccard,Dittus et al. 1996; DiClemente, Wingood et al.2001; Kirby and Lepore 2007). Practical implicationsof this research are that in order to reducesexual risks, parents should discourage sexual initiationbefore their teens initiate sexual activity andsupport contraceptive use before or as soon as theirteens have sexual intercourse.Table9-1Parent-child communicationabout sex and birthcontrol (N=14)Table9-2Number of Studies Reporting anAssociation Between Parent-ChildCommunication About Sex and Teens’Initiation of SexParent-child communicationabout sex beforethe teens had initiatedsex (N=3)Table9-3LaterInitiationof SexNoSignificantRelationshipsEarlierInitiationof Sex2 6 6Number of Studies Reporting Effects ofParent-Child Communication About Sex onTeens’ Subsequent Initiation of SexDelayedInitiationof SexNoSignificantRelationshipsHastenedInitiationof Sex2 1 0Number of Studies Reporting Effectsof Parent-Child Communication AboutSex on Teens’ Condom or OtherContraceptive UseParent-child communicationabout sex and birthcontrol (N=7)Increased Useof Condomsor OtherContraceptivesNoSignificantRelationshipReduced Useof Condomsor OtherContraceptives5 2 0Chapter 9 Increasing Parent-Child Communication About Sex 109

Can activities and programs for teens increaseparent-child communication about sex and contraception?How?At least seven studies of sex education programsfor teens have measured impact on the frequency ofparent-child communication about sex (Table 9-4)(Kirby 2007). Four increased communication andone study found that it also increased comfort withthat communication. When greater communicationdid occur, it was not clear how long that increasedcommunication lasted.All four programs for teens that included homeworkassignments to talk with a parent or anothertrusted adult about specific sexual topics significantlyincreased communication about those topics(Kirby, Barth et al. 1991; Weed, Olsen et al. 1992;Middlestadt, Kaiser et al. 1998; Coyle, Basen-Enquist et al. 2001), while none of the three programsthat lacked such an assignment increasedparent-child communication. These results indicatethat homework assignments are both important andeffective (see Activity 9-1: Homework Assignmentto Talk with Parents).It should be noted that activities to increase parentchildcommunication not only actually increasethat communication, but also increase supportfor sex education programs and diminish opposition.Sometimes parents believe that sex educationprograms may not incorporate their values and mayinstill values in opposition to their own. Whenparents see that programs are striving to help themexpress their own values to their own teens, they arecomforted and support these programs.Table9-4Number of Programs for Teens HavingEffects on Parent-Child CommunicationAbout SexImpact on frequency ofparent-child communicationabout sex (N=7)Impact on comfort talkingwith parents aboutsex, condoms or contraception(N=1)Had aPositiveEffectNoSignificantEffectHad aNegativeEffect4 3 01 0 0Homework assignments also provide a legitimatereason for talking about sexuality. If teens suddenlystart asking parents about condoms and contraception,their parents may fear they are having sexualintercourse or are about to start having sexualintercourse and the resulting conversations may beuncomfortable and unproductive. However, whenthese questions are asked as part of a school homeworkassignment, then the assignment provideslegitimacy for the questions and discussions. Parentsare then less likely to have this concern and are morelikely to be comfortable discussing the topic.Although not all students will talk with their parentsand some may not talk with any adult, typicallylarge majorities of students do talk with their parentswhen they are given these assignments (Kirby,Barth et al. 1991; Blake, Simkin et al. 2001). Whenthese homework assignments are implemented inschool settings, they represent a unique method ofsignificantly increasing parent-child communicationabout sex in a large percentage of families.A variety of strategies can improve the effectivenessof these homework assignments:1. Notify parents in advance that their teens willbe asking them questions about particular sexualtopics so that they can prepare possible answersand think about what they want to say and how tosay it. Consider handing out a copy of the assignmentat a parent orientation meeting.2. Provide parents in advance with tips on how tohave effective conversations about sex with theirteens.3. Provide parents with information about teensexual activity (in their teens’ schools or communities,if possible), local teen pregnancy and STDrates, the effectiveness of condoms in preventingSTDs and different methods of contraception inpreventing pregnancy.4. Provide parents with brief summaries of a rangeof different values about sexual activities andcondoms or contraception that they might wish toexpress to their own teens.110 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

5. Give students multiple homework assignments totalk with their parents, first starting with mucheasier, less sensitive topics (such as what it waslike dating when the parents were young, whatpressures they experienced as a teen, reasons teensback then chose for not having sex) and movingin subsequent homework assignments to morecontroversial topics (such as whether it is okayfor teens their age to have sex today, under whatconditions young people could have sex, and howteens should protect themselves from pregnancyand STDs).6. Prior to giving students homework assignments,have them discuss what it might feel like to havethese conversations with their parents or othertrusted adults and what they can do to reduce anydiscomfort.7. After the first homework assignment, have thestudents debrief in class their experiences (notwhat parents said) and discuss ways to make subsequentassignments more comfortable and moreeffective.8. Always emphasize to everyone (both students andtheir parents) that their conversations are confidentialand make sure that they remain so.9. Encourage students to talk with their own parents.If they cannot do so, encourage them to talkwith other trusted adults.In sum, studies of the effects of homework assignmentsindicate that:• It is possible to reach large numbers of parentsthrough student homework assignments.• Large proportions of students and their parentswill complete these assignments.• Homework components can include as many asfive different assignments as well as various andmore complex activities, such as roleplaying.• These assignments do increase parent-child communication,at least in the short run.• Homework assignments may or may not changethe students’ sexual attitudes or sexual behaviorin the long run.Can programs for parents and their teenstogether increase parent-child communicationabout sex and contraception and actually reducesexual risk? How?When both parents and teens participate together inprograms designed to increase parent-child communicationabout sex, those programs typicallyinclude activities in which parents and their teenstalk about various sexual topics. Logically, suchprograms should increase parent-child communication.Consistent with this expectation, 10 out of12 studies measuring impact of these programs onparent-child communication found positive effectson the frequency of this communication (Table 9-5)(Kirby and Miller 2002). This greater communicationoccurred both when the programs were implementedin the home (one study) and in communitysettings (nine studies).Furthermore, seven studies meeting more stringentresearch criteria have measured the impactof programs for parents and their teens on actualsexual behavior (Kirby 2007). One of them delayedthe initiation of sex, one reduced the frequency ofsex and four increased condom use. None of theseseven programs had negative effects—that is, noneincreased sexual behavior or reduced condom orcontraceptive use.Table9-5Number of Programs for Parents andTeens Having Effects on Parent-ChildCommunication About Sex and Teen SexualBehaviorImpact on frequency ofparent-child communicationabout sex (N=12)Impact on teen initiationof sex (N=5)Impact on frequency ofsex (N=1)Impact on condom use(N=4)Impact on contraceptiveuse (N=1)Had aPositiveEffectNoSignificantEffectHad aNegativeEffect10 2 01 4 01 0 04 0 00 1 0Chapter 9 Increasing Parent-Child Communication About Sex 111

Programs for parents and their teens have a fewobvious advantages over programs for teens only.They can:1. Increase the knowledge of both parents and teens.2. Model discussion of sexual topics and increasecomfort with the discussion of sexual topics.3. Provide opportunities in the group and immediatelyafterward (e.g., on the way home) for youngpeople and their parents to talk about sexual topicswith each other.4. Provide a comfortable climate where everyoneexpects they are going to talk about sexuality andwhere they see everyone else doing so.5. Provide an environment where prompt guidanceor assistance is available, if needed.Programs for parents and their teens have one significantdisadvantage: they have to recruit parentsand teens to participate and many organizationshave found this extremely difficult. After all, parentsmay have busy work schedules or may be involvedin other after-school activities; they may not havechild care or transportation available; or they maynot have the energy or interest to participate. Somegroups trying to implement such programs havefound it effective to work with other existing youthservingand parent-serving organizations that recruitand involve parents and teens for other reasons (e.g.,faith communities or Boys and Girls Clubs). Somealso have provided transportation, child care andincentives such as meals for participation.Essential elements of parent-child programs aredescribed more fully elsewhere (Kirby, Lezin etal. 2003). Programs often meet for several nights(about four or five, but sometimes for more) and thesessions typically last about 1½ to 2 hours. Someprograms divide participants by gender (fathersongroups and mother-daughter groups) and age(groups for young people 9 to 12 years old andgroups for young people 13 to 17 years old), andlimit each group to 10 parent-child pairs. Whileparents and their teens may be separated in one ormore sessions, most sessions involve both parentsand their children.Programs often present didactic material about topicscommon to sexuality education classes, such asanatomy, changes during adolescence, sexual behavior,reproduction, contraception, teen pregnancy andSTDs. It is very important, however, to balance thecontent by also including multiple interactive activities,such as small-group discussions, games, contests,simulations, films and experiential activitiesthat facilitate parent-child communication duringthe class.For example, as an ice breaker, parents can competeagainst their kids in a relay race in which they haveto blow up a balloon, retrieve the coiled questioninside, read the question about sexuality, and answerit (either correctly or incorrectly) (see Activity 9-2:Relay Race for Parent-Child Programs). The excitementof the race can diminish their embarrassmentas they talk rapidly and generally about a range ofsexuality-related topics.Similarly, two parents and their two teens can play aboard game in which they roll dice and move aroundthe board toward home base while landing on bluesquares (requiring them to draw a card and answer aknowledge question) or red squares (requiring themto draw a green card and answer a question abouthow they felt about some aspect of sexuality) (seeActivity 9-3: Human Sexuality Board Game forParent-Child Programs).Another popular activity involves “Dear Abby”letters that describe various situations and ask foradvice. Again, in small groups, parents and theirown children can read, answer, and discuss the letters(see Activity 9-4: “Dear Abby” for Parent-ChildPrograms).Another approach that involves parents in theirteens’ sexuality education is to reach them in theirown homes through video or written materials.Home-based video programs have several possibleadvantages. First, they do not require parentsor their teens to go to any particular location at aparticular time. Instead, schools, libraries, or healthclinics can loan the materials to parents. In addition,parents can review the program and make certainthey are comfortable with both the values discussed112 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

and the activities suggested prior to using them withtheir own children. Finally, the home-based programscan teach skills that parents can practice anduse in the home to teach their children.On the other hand, home-based video programshave several disadvantages. For example, familiesmay not complete the activities or may simplyview them (which is relatively easy to do), withoutcompleting the roleplaying or skill practice (whichrequires much more initiative, involvement andthinking and may feel threatening). In addition, thevideos may not prove realistic to both young peopleand parents. Youth often think the teens in videosdress or act differently than they themselves do andthat the situations are not realistic. Both the youthand their parents also may have difficulty relatingto the youth and the situations in the video becausethey feel they are contrived.Home-based video programs can be quite comprehensive.For example, a video program thatincluded six videos and written materials providedinformation, modeled parent/child communicationin dramatic scenarios and emphasized sexual valuesconsistent with abstinence (Miller, Norton et al.1993). Each of the six videos was brief (about 15 to20 minutes) so that families could discuss the topicsafter viewing each video. The written materials suggestedquestions and topics for discussion. Togetherthey covered changes in puberty, facts about reproduction,parent/teen communication, values andsexual behavior, sexuality in the media, decisionmakingskills and communication skills. Becauseof the targeted age group (10- to 14-year-olds), theprogram focused on abstinence.Can programs for only parents increase parentchildcommunication about sex?Although most multi-session programs focus onboth parents and their children, a few target onlyparents, especially parents of older youth. Typically,these programs adopt a different approach fromthat used with parents and their children together.Instead of trying to provide opportunities forcommunication during the sessions, they strive toimprove parents’ knowledge, attitudes and skills sothat they can more effectively communicate withtheir children about sexuality-related issues.These programs sometimes cover topics such as datingand sexuality and general communication skills(such as listening, taking turns talking and listeningand giving supportive responses to adolescents’comments).Two studies have measured the impact of these programson parent-child communication; both foundthat they increased communication (Table 9-6).Table9-6Number of Programs for Only ParentsHaving Effects on Parent-ChildCommunication About SexImpact on frequency ofparent-child communicationabout sex (N=2)Had aPositiveEffectNoSignificantEffectHad aNegativeEffect2 0 0What are tips for parents about how to talk aboutsexual topics?When helping parents talk about sexual topics withtheir teens, it is not sufficient to simply providethem with accurate information about sexual topics.Rather, programs need to help parents know howto discuss these topics with their teens in ways thatwill make the discussions more comfortable andmore effective. With that in mind, here are tips forparents that could be featured in a program:• Start early, when children are young, with conversationsappropriate for their age. Do not waituntil children are adolescents or until they askyou questions about sexuality. If you wait, theywill learn this is not a topic to be discussed andare less likely to ask.• Avoid the single “big talk” and instead havenumerous shorter conversations, so that sexualityis discussed like other topics.• Take advantage of “teachable moments,” such asstories on TV or events in the community.Chapter 9 Increasing Parent-Child Communication About Sex 113

• Help make the conversation a dialogue and not amonologue; encourage children to express theirviews and ask questions.• If need be, become informed about the levels ofsexual activity among your children’s friends andpeers.• Think about your beliefs and values and sharethem clearly and honestly.• Recognize that conversations about sex maysometimes be uncomfortable, but that it is importantto have them anyway.• Always remember that talking about sex does notencourage young people to have sex, but may helpthem make more responsible sexual decisions.How has parent-child communication beenmeasured?Table9-7Communication questionsHave you ever talked with your parents about the followinglist of topics? (No; Yes, a little; Yes, a lot)If yes, how many times?If yes, how comfortable were you? (Very comfortable; Kind ofcomfortable; Not at all comfortable)List of topicsBody changesMenstruation and wet dreamsReproductionExamples of Items That Have Been Usedto Measure Parent-Child CommunicationAbout SexualityTable 9-7 lists illustrative questions that have beenused to measure parent-child communication aboutsexuality.ConclusionsIn sum, these studies indicate that reaching parentsthrough homework assignments may prove the mostpromising method of reaching large numbers ofparents and actually having an impact on parentchildcommunication. These homework assignmentsand programs for parents and their teens togetherhave the strongest evidence that they increaseparent-child communication about sex. Theseresults undoubtedly reflect the fact that homeworkassignments and activities in parent-child programsdirectly involve parents and teens talking togetherabout sex. That is, if activities are completed, theywill necessarily increase parent-child communication.However, the longer-term impact on this communicationis less clear. A few of these programs,either with homework assignments to talk with parentsor with the direct involvement of parents andtheir teens, actually delayed the initiation of sexualactivity or increased condom use.Numerous studies indicate that other family characteristics(e.g., parental support/connectednessand parental monitoring) are related to adolescentsexual behavior. To the extent that programs toincrease parent-child communication about sex alsocan increase parental support, connectedness andpossibly even appropriate monitoring, they also mayreduce teen sexual risk behavior.Going out; going together at different agesReproductionPregnancySexually transmitted diseaseValues about sexual behaviorAlternatives to sexYoung people having sex (under what conditions, if at all)Using condoms or other types of contraceptionHealthy and unhealthy relationshipsDating violence114 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

Activity 9-1Description of ActivityHomework Assignment to Talk with ParentsObjectives: Students will be able to:Increase the frequency and quality of parent-child conversations about sexRisk and Protective Factors Affected:Parent-child communication about sexActivity:Students are given a homework assignment to go home and talk with their parents (or other trustedadults) about sexuality. They ask their parents the questions on a worksheet, but do not recordanswers. The worksheet should include questions about when it is okay for a person to have sex,what people should consider before deciding to have sexual intercourse, and what the parents’beliefs are about using condoms or other types of contraception. Students are encouraged to takethis opportunity to talk with their parents about other issues involving sex.After the students and parents discuss these questions, the parents (or other trusted adults) sign theworksheet, indicating they had a conversation about the questions.As an option, students can brainstorm questions beforehand in class that they would like to asktheir parents. They then choose questions from the brainstormed list that they would like to asktheir parents, in addition to those on the worksheet.In subsequent class periods, students debrief their experience talking with their parents aboutsex. To maintain confidentiality, they do not reveal what their parents said. Students then identifystrategies for making it easier to talk with their parents about sex.Important Considerations in Using ItParents should be notified ahead of time that their teens will be bringing home an assignment totalk with them about sexuality, so that the parents can think about and prepare their answers, ifnecessary.Parents can be given information about sexual behavior among teens in their communities, teenpregnancy and STD rates and the effectiveness of condoms and other forms of contraception.Multiple consecutive homework assignments can lead to more in-depth conversations.References for Lessons That Describe a Similar Activity More Fully1. It’s Your Game, Grade 7, Lesson 10, Activity IV: Parent-Student Homework2. It’s Your Game, Grade 8, Lesson 11, Activity IV: Parent-Student Homework3. Reducing the Risk, Class 3: Talk to Your Parents4. Safer Choices, Level 1, Class 1, Activity 4: Homework—Then and Now5. Safer Choices, Level 1, Class 5B, Activity 2: Homework Review—Then and Now6. Safer Choices, Level 1, Class 7, Activity 5: Homework—What Do You Think?7. Safer Choices, Level 2, Class 1, Activity 3: Homework—Talk About It8. Safer Choices, Level 2, Class 5, Activity 1: Homework Review—Talk About It9. Safer Choices, Level 2, Class 8, Activity 4: What Do You Think?10. Safer Choices, Level 2, Class 10, Activity 1: Homework Review—What Do You Think?Chapter 9 Increasing Parent-Child Communication About Sex 115

Activity 9-2Description of ActivityRelay Race for Parent-Child ProgramsObjectives: Teens will be able to:Talk more comfortably with their parents or other trusted adults about various topics about sexRisk and Protective Factors Affected:Parent-child communication about sexActivity:This is a fast-paced relay race between parent and teen teams.Prior to the race, factual questions about a variety of sexual topics are printed on a sheet of paper,cut into individual questions and inserted in balloons—one question per balloon. At one end ofthe room are placed two piles of balloons (not blown up) with equal numbers of balloons and theirrespective questions.The parents form one line and the teens form a second line at the other end of the room from thepiles of balloons. When the educator says “Go,” the parent at the head of the parent line and theteen at the head of the teen line run across the room and grab one balloon each with questionsinside from their respective piles. They then blow up the balloons, pop the balloons, retrieve thequestions that fall out, read the questions out loud and answer them out loud. They do not have toanswer the questions correctly. When each is done, they run back to their side of the room and thenext adult or teen repeats the same process. This continues until either the adult team or the teenteam has blown up and broken all the balloons and answered all the questions. The team that doesthis first wins.At the end of the race, if any questions were answered incorrectly, the correct answers should begiven. In addition, if either students or parents had any questions about any of the questions, thoseshould be addressed. If either students or parents might not be comfortable asking questions, thenthey can be encouraged to put questions into an anonymous question box.Important Considerations in Using ItThis is a relay race and is designed to be fun, so clapping and cheering should be encouraged.Typically, in the heat of the race, teens will read and answer questions that might normally makethem uncomfortable.If anybody answers a question incorrectly, that question should be noted and the correct answershould be given in a subsequent activity; the correct answer should not be given during the race, forthat might destroy the competition in the race.There should be enough balloons for everyone to participate. If there are more teens than parentsor vice versa, then one or more members of the smaller team will have to blow up two balloons andanswer the questions so that each team has to blow up and answer the same number of balloons/questions.References for Lessons That Describe a Similar Activity More Fully1. Parent Child Sex Education Training Module, Balloon Race116 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

Activity 9-3Human Sexuality Board Game for Parent-Child ProgramsDescription of ActivityObjectives: Teens will be able to:Discuss various topics about sex more comfortably with their parents or other trusted adults.Risk and Protective Factors Affected:Parent-child communication about sexKnowledge about selected issues involving sexual behaviorActivity:Two teens and their parents play a board game.On the boards are many adjacent squares that form pathways around the board. Each pathway has a“start” square and an “end” square. The number of squares between the “start” and “end” squaresis the same for each pathway. All squares are colored red, blue and green (in that order) along eachpath.Players can start at the same square or different squares by placing markers on those squares. Eachplayer rolls a die and moves the marker the number of squares on the die in a clockwise direction.If the player lands on a blue square, he/she must draw a blue card from the blue pile of cards. Bluecards have a factual question on each card, which the player must read and answer. If a player landson a green card, he/she must draw a green card. Each green card has a question about values,attitudes or feelings regarding sexuality, which the player must answer. If a player lands on a redsquare, he/she must abide by the directions on the red square. These include directions such as“lose one turn,” “go back two spaces,” or engage in some other action that reduces the chances ofreaching the “end” square first and winning.In this activity, if a knowledge question is answered incorrectly, the correct answer should be givenby any of the other players. However, not answering a question does not affect the movement ofthe players.The first player to get to the end of the pathway (around the board) wins. If a player wins beforemost of the cards are drawn, then the game can be played repeatedly until all the cards are read.Important Considerations in Using ItThis activity is designed to be fun, but it is also designed to increase thoughtful discussions abouteach of the topics asked on the blue and green cards. It should not be rushed.The game may only be as good as the topics on the cards, so questions and topics that are importantand relevant for the age group should be included on the cards.If a player does not wish to answer a question, he/she may “pass” and that right must be respected.References for Lessons That Describe a Similar Activity More Fully1. Parent Child Sex Education Training Module, Human Sexuality Game (Note: This game can bepurchased by itself)Chapter 9 Increasing Parent-Child Communication About Sex 117

Activity 9-4Description of Activity“Dear Abby” for Parent-Child ProgramsObjectives: Students and their parents will be able to:Discuss sexual situations encountered by teens more comfortably and effectivelyRisk and Protective Factors Addressed:Parent-child communication about sexActivity:Parents form one or more teams (with up to six parents per team) and their teens form separateteams (with up to six teens per team). Each team is given the same set of “Dear Abby” letters thatdepict a variety of sexual dilemmas or situations sometimes encountered by young people like theteens. Each group independently reads and discusses the letters.All the parents and teens reconvene in a single large group and representatives from each groupshare and compare the team’s solutions to the problems.After all the parents and teens have had a chance to read a dilemma/situation and suggest advice,a larger group involving all the parents and teens (up to about 16 people) is formed, the dilemma/situations are then read again, and representatives from each small group share their advice andgive their reasons for their advice. Each time the advice is given for a particular dilemma/situation,all the teens are asked the question: “Is this realistic?”Important Considerations in Using ItAfter solutions are given for each dilemma/situation, all the teens should be asked whether thesolution is realistic.References for Lessons That Describe a Similar Activity More Fully1. Parent Child Sex Education Training Module, Dear Abby2. Brown, J., Downs, M., Peterson, L., and Simpson, C. (1978). Human Sexuality Game: Parent-ChildSex Education: A Training Module. St. Joseph, MO: YWCA.3. Brown, J., Downs, M., Peterson, L., and Simpson, C. (1989). Parent-Child Sex Education: A TrainingModule. St. Joseph, MO: YWCA.118 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

10 ConclusionsKeys to Reducing Sexual RiskBehaviorFocus on the sexual psychosocial factors andimplement a sufficient number of activitiesthat incorporate the principles to address,improve and impact sexual behavior.OverviewTo reduce their high rates of unintended pregnancyand STDs, including HIV, young peoplemust reduce their sexual risk behavior by initiatingsex later, having sex with fewer sexual partners, orusing condoms or other forms of contraception moreconsistently and correctly. Because programs thatare designed to address unintended pregnancy andSTDs cannot directly control the sexual risk behaviorof young adults, they must affect various risk andprotective factors that, in turn, affect young people’sdecision-making and behavior.Logically, if programs correctly focus on the factorsthat have a strong impact on behavior and ifprogram activities markedly change those factors,then the program will have an impact on behavior.However, if programs focus on factors that onlyweakly affect behavior or if program activities failto change the factors sufficiently, then the programsmay not affect behavior. Thus, it is critical thatprograms focus on the important factors affectingbehavior and implement activities that change thosefactors.This book was written to help people design curriculum-basedprograms that effectively address thosefactors. The previous chapters have discussed sevenimportant factors that affect sexual behavior:1. Knowledge about numerous sexual topics2. Perception of risk of undesired sex, pregnancyand STDs3. Attitudes, values and beliefs about sexual behavior,use of condoms and other forms of contraception,pregnancy, childbearing and STDs4. Perception of peer norms about sexual behaviorand use of condoms and contraception5. Self-efficacy and skills to avoid undesired sex orto use condoms or other forms of contraception6. Intentions to avoid undesired sex or to use condomsor other forms of contraception7. Parent-child communication about adolescentsexual behavior, condoms or other forms of contraception,pregnancy, childbearing and STDsThese factors are important because appropriatecurriculum-based activities have the capability ofaddressing and improving them, and each of thesefactors, in turn, has an impact on actual sexualbehavior.Chapter 10 Conclusions 119

The previous chapters also have provided instructionalprinciples. These are important because activitiesthat incorporate the principles for addressingeach factor are more likely to have an impact on thatfactor than activities that do not incorporate theseinstructional principles.The previous chapters included many theories,results from hundreds of studies and a large numberof principles for effectively changing the sevenfactors. All of this can be overwhelming whenpeople are faced with applying this material todevelop or adapt a curriculum. Fortunately, some ofthe instructional principles that are important foraddressing one factor are also important for addressingothers. This overlap makes the process of usingthe information simpler.Table 10-1 (p. 125) presents many of the mostimportant instructional principles and the factors towhich they should be applied. The table can be usedas a checklist for curricula being considered, adaptedor created.Applying These Principles toExisting Curricula or to theDevelopment of New OnesIf you are revising or adapting existing curricula,you should:1. Create a matrix specifying 1) all the factors youwish to address (across the top as column headings)and 2) all the activities you intend to includein the curriculum (down the side as row headings).See Figure 10-1 (p. 121).2. Review each activity in the curriculum and assesswhich, if any, of the seven factors (or other potentiallyimportant factors) the activity addresses andput a “✓” in the appropriate cell in the matrix,indicating the factor is addressed by the activity.See Figure 10-1.3. After reviewing all the activities and putting “✓”sin the appropriate cells, make sure that a sufficientnumber of factors are addressed by activities.(Typically, several factors affecting a particularbehavior need to be addressed in order to markedlychange that behavior.)4. Make sure the activities addressing each factorare sufficiently strong to affect the factor.(Typically, multiple activities are needed to markedlychange any factor.)5. For all the activities that address each factor,incorporate as many of the instructional principlesfrom the appropriate chapter as possible. Forexample, incorporate the principles for improvingself-efficacy to the activities that are designed toincrease self-efficacy.6. By reviewing all the revised activities that addresseach factor, assess realistically whether thoseactivities collectively will markedly improve thefactor addressed. If not, then either improve theexisting activities or add more activities. Forexample, assess whether the activities designedto improve self-efficacy to avoid situations thatmight lead to undesired sex are sufficient toimprove self-efficacy to avoid those situations. Ifnot, improve the activities or add new, effectiveones. If an activity is fun, but doesn’t really contributetoward moving youth to behavior change,then it may need to be dropped or modified toimprove the curriculum’s fit with the goals of theprogram.If you are creating new curricula, then you shouldfirst identify which set of factors you are going toaddress based on your population needs, review thechapters in this book and others that address theorybasedapproaches for changing the factors, and thenselect or revise activities from existing curricula(with appropriate permission) or develop entirelynew ones. Then you should complete the stepsabove. Other excellent resources exist for designingeffective curricula (Bartholomew, Parcel et al. 2006).There is much more to adapting existing curriculathan the six steps above suggest. However, theprinciples of adaptation are beyond the scope of thisbook. Fortunately, other excellent resources existfor adapting widely implemented curricula (Rolleri,Fuller et al., unpublished).120 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

Figure10-1Assessing Factors in CurriculaKnowledgePerception of risk ofpregnancy and STDAttitudes and valuesregarding sex and # ofpartnersAttitudes and valuesregarding condoms/contraceptionPerceptions of peernorms regarding sex,# partners and condoms/contraceptionSelf-efficacy to avoidunwanted sexSelf-efficacy to insiston condoms/contraceptionSelf-efficacy touse condoms/contraceptioncorrectlyIntentions to abstainor use condoms/contraceptionParent-child communicationregardingsex, # partners, andcondoms/ contraceptionSpecifyActivity 1✓ ✓ ✓SpecifyActivity 2SpecifyActivity 3Continue forall activities✓ ✓ ✓ In each cell, specify whether the activity identified on the left can significantly improve the factor above.Notes:1. Typically, multiple activities are needed to significantly improve each factor.2. Often, factors need to be specified more precisely than in the example above.Final Activities—Conducting FocusedReviews and Pilot TestingThe final phase of developing or adapting your curriculumshould include two types of activities: 1)using focused reviews to assess the entire curriculumfor specific instructional principles, inadvertentbiases and/or imbalances that may not be as obviousin any single lesson and 2) pilot testing individualactivities as well as the entire curriculum.To conduct focused reviews, read a draft versionof the entire curriculum for specific characteristics(e.g., key instructional principles or biases) that, ifnot addressed, could reduce its relevance or impact.The approach requires that one or more internal staffreview the lessons with a single focus one at a time(e.g., inclusiveness for sexual minority youth—i.e.,gay, lesbian, bisexual and questioning youth, or thecognitive level of the objectives). Reviewing a curriculumfor a single issue is more productive in identifyinginconsistencies or imbalances than trying toconsider all issues during a single reading. A few ofthe key areas for review are highlighted below.Reviewing for InstructionalDesign Issues• Types of activities. One review pass should focuson the types of activities (learning strategies) usedacross the lessons. Most critically, these strategiesshould reflect the theory-based approaches forchanging the targeted risk and protective factorsas outlined in this and other books. They alsoshould be aligned with the program goals andChapter 10 Conclusions 121

learning objectives. (See Box 3-1 for examples ofcommonly used types of activities.) Curriculumdevelopers then should fine-tune activities toensure the curriculum uses an array of strategiesthat appeal to a range of learning styles (e.g.,print, oral, visual, kinesthetic).Another review pass for the learning strategiesshould focus on the level of student interactionand/or collaboration included in the plannedactivities. As noted in Chapter 3, this literaturesuggests that interactive and collaborative strategiesare more effective at promoting learningthan less interactive strategies. Activities thatare less interactive (e.g., watching a video), canbe enhanced with the addition of a brief collaborativeactivity following the video (askingstudents to watch and listen for two new insightsor “learnings” on HIV or other STDs and thenturning to a partner after the video to share thoseinsights). While completing the focused review ofthe instructional strategies, it might be helpful tocreate a tally or table showing the types of strategiesused across the curriculum (e.g., mini lecture,large-group discussion, small-group discussion,roleplay, quiz, game) to ensure the curriculumuses a range of theory-based, interactive strategiesthat address different learning styles.• Time allocation per activity. Another focusedreview should center on the time allocated foreach activity. During development, it is easy tounderestimate the time needed for a particularactivity, which contributes to creating overcrowdedlessons that lack time for discussion,reflection and personalization. This focusedreview should be completed by staff members orothers who have experience or expertise with thetiming of activities. Reviewers also should lookfor timing-related issues such as the number oftransitions required in a single lesson and howmuch disruption is likely to occur as a result ofthe transitions. Lessons with numerous transitionsmay result in significant time loss simplydue to the transition process.• Sequencing of lessons. Reviewers also shouldassess the lesson sequencing, looking for possibleadjustments within or across lessons. Oneapproach to sequencing, the deductive approach,moves from providing concepts and informationto analysis and specific inferences and application(Hedgepeth and Helmich 1996), which is similarto the levels of Bloom’s taxonomy. Anotherstrategy is to include activities that first establishmotivation for avoiding sexual risk taking andthen addressing attitudes and skills to reducesexual risk taking. Further, skill lessons should besequenced to build on each other, from the lesscomplex tasks and situations to more complex.Reviewing forContent Issues• Inclusion of key messages. Research shows thatprograms with clear messages have been moresuccessful in reducing risk behaviors than in thosethat lack such messages (Kirby 2007). These messagesshould be balanced and consistent with theoverall goals of the program; should be developmentally,linguistically and culturally appropriate;and should be used repeatedly throughoutthe lessons. This review pass would be used toensure the curriculum’s key messages are woventhroughout the lessons and that they incorporatethe characteristics just noted (e.g., balanced, consistentwith program goals).• Inclusiveness and biases (e.g., gender, racial,sexual orientation). This review pass shouldfocus expressly on identifying biases in contentand/or activities that exclude sub-groups of youth(e.g., sexual minority youth) or portray them ina stereotypical fashion. Reviewers should centeron factors such as the language used in the curriculum,key messages, roleplay scenarios, stories,examples and names used in roleplays and otheractivities, noting any instances in which thecontent is biased or excludes individuals based oncharacteristics such as gender, race/ethnicity, orsexual orientation. For example, a curriculum inwhich all roleplay scenarios depict males pressuringfemales could be considered biased; it alsoexcludes pressure situations that might arise for122 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

sexual minority youth and pressure situationsthat involve friends pressuring each other to gobeyond their personal limits.Simple changes in language or situations can helpbalance the scenarios to which youth respond.Other strategies, such as allowing youth tochange the scenarios to make them more realistic,also can achieve more balance. Similarly, usingroleplay scenarios that only depict situations inwhich individuals are having sex and not situationsin which individuals are choosing abstinenceis unbalanced and may feel irrelevant toyouth who are making that choice. One option tobroaden relevance is to present multiple scenariosfor each roleplay and allow a variety of youth toselect which ones they believe are most realistic.Finally, this review pass can also be used to makethe lessons more gender neutral (e.g., using theterms sexual partner, or one’s partner in place ofboyfriend or girlfriend) to ensure the program isinclusive of sexual minority youth.Pilot TestingBefore implementing a curriculum widely, pilottest and observe the implementation of individualactivities, lessons and the entire curriculum withparticipants similar to the intended population. Thisprocess is an essential element of program developmentand provides an opportunity to see howstudents respond to the content and strategies, toassess whether the lessons generate the expected discussionsand reflections, and to collect feedback andsuggested changes from participants (see Box 10-1for examples of pilot test probes). Pilot testing alsoallows developers to test out activity and/or lessonsequences and test the time allocations for specificactivities and lessons.Numerous resources are available to provide moredetailed steps for conducting formative research.Some key considerations are highlighted below.• Small-scale pilot testing of individual activities.This type of pilot testing typically involvesassembling small groups of youth and implementingselected activities. Youth are asked to providefeedback on the activities and share thoughts onhow to improve them. For the best results, besure to actually implement the activities as partof these small-scale pilot testing events, ratherthan having youth just read and review them,since youth will be better able to provide feedbackif they experience the instruction. It also givesdevelopers a chance to see the activities in action.Small-scale pilot testing also can be accomplishedby establishing a youth advisory committee whosemembers serve as an ongoing feedback and pilottest group. Youth involved in these activities generallyreceive a stipend or gift certificate for theirtime and participation as well as recognition fortheir contributions.• Small-scale pilot testing of individual lessons.Once individual activities have been tested withyouth, it is helpful to test entire lessons to examinesequence and timing issues and to get a senseof the likely impact of a lesson. This type of pilottesting is ideally done in the setting in which thecurriculum will be used (e.g., a classroom or anafter-school program). This type of pilot testingalso could be done with a youth advisory group.Schools and community agencies generally arewilling to partner for these types of activities,particularly if they receive small incentives (e.g.,classroom supplies).Box10-1Potential Pilot Test Probes• If you were to describe the main points of this activity(lesson/program) to a friend, how would you describethem?• Using your thumbs, how would you rate this activity:thumbs up, thumbs down, or thumbs sideways?• How can we make this activity (lesson/program)better?• What part of the activity (lesson/program) do youthink will be of most interest to other teens your age?What about least interesting?• What did you think of (insert specific area of interest)?• We’ve posted several pieces of chart paper on thewall for today’s lesson. Please write three words thatdescribe what you think other teens would say aboutthis lesson.Chapter 10 Conclusions 123

• Full curriculum pilot test. Testing the entirecurriculum is extremely useful as a final step inthe development process. This type of pilot testnot only provides invaluable data on sequencing,timing and potential impact, but also provideseducators with an opportunity to practice usingthe content before the program is delivered andevaluated. This type of pilot testing typicallyinvolves partnering with a school or communitybasedagency to deliver the entire curriculum toat least one (and ideally two or three) groups ofyouth similar to the intended population.To maximize the pilot test opportunities, observersshould:• Have a copy of the activity or lesson in front ofthem• Time each activity• Watch and listen to students and how they movethrough an activity (noting key comments andquestions)• Note key phrases used by the educators duringthe activity• Note immediate reactions to the activity or lessonThese notes should be used as part of an immediatedebrief process, along with input from students (e.g.,simple thumbs up, down, or sideways polls; brieffeedback forms; general comments and reactions;and suggestions for improvements).124 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

Table10-1Instructional Principles Important for Each FactorChapter 3KnowledgeChapter 4Perceptionof RiskChapter 5Attitudes, Values,BeliefsChapter 6Perception ofPeer NormsChapter 7Self-Efficacyand SkillsChapter 8IntentionsChapter 9Parent-ChildCommunicationEnvironment• The educator should make sure the environment is conducive to thethoughtful consideration of new information (e.g., minimize distractions)✓ ✓ ✓ ✓ ✓ ✓• The educator should make sure the classroom is a safe social environmentfor young people to participate✓ ✓ ✓ ✓ ✓ ✓Specific Content and Instructional StrategiesTopics should be relevant to young people’s lives ✓ ✓ ✓ ✓ ✓ ✓ ✓Activities should:• Cover topics about sexuality that are important to young people• Emphasize the risks of unprotected sex ✓ ✓ ✓ ✓ ✓ ✓ ✓• Present credible research-based evidence describing both actual behaviorand expressed norms about that behavior✓ ✓• Identify and describe common situations that may lead to undesired,unplanned or unprotected sex✓ ✓ ✓• Repeatedly emphasize a clear and appropriate message about how toavoid and reduce sexual risks✓ ✓ ✓ ✓ ✓• Include strong arguments in their messages about behavior that have thegreatest appeal and impact✓ ✓• Provide arguments about behavior that are new, strong, and personallyrelevant to the students✓ ✓• Combine appropriate use of fear with a clear message about how to avoidthe undesirable outcomes✓ ✓ ✓ ✓✓• Use cognitive dissonance to change attitudes by demonstrating that specificattitudes to be changed are inconsistent with more fundamental andimportant values or attitudes, as appropriate• Increase skills and self-efficacy to:o Avoid situations that might lead to undesired or unprotected sexo Refrain from and refuse undesired, unintended or unprotected sexo Obtain condoms or other forms of contraceptiono Insist on using condoms or other forms of contraception, if having sexo Actually use condoms or other forms of contraception effectively, if havingsex✓✓ ✓ ✓ ✓ ✓• Demonstrate concepts and skills to students rather than simply describethem✓ ✓ ✓ ✓• Model desired behaviors (e.g., refusal skills and condom use skills) andhave youth practice and model the desired behavior to others✓ ✓ ✓• Break down complex concepts or skills into a progression of smaller conceptsor skills, with the smaller concepts or skills taught first, followed by alogical progression to more complex skills• Break refusal and communication skills into simpler steps that are modeledand then practiced; begin with scripted roleplays and easier situations andthen move to unscripted roleplays and more difficult situations• Use praise and encouragement to prompt students with new skills✓✓✓✓✓(Continued)Chapter 10 Conclusions 125

Table10-1Instructional Principles Important for Each Factor (Continued)Chapter 3KnowledgeChapter 4Perceptionof RiskChapter 5Attitudes, Values,BeliefsChapter 6Perception ofPeer NormsChapter 7Self-Efficacyand SkillsChapter 8IntentionsChapter 9Parent-ChildCommunicationSpecific Content and Instructional Strategies (Continued)Activities should:• Provide the proper balance of challenge and support ✓ ✓• Structure skill-building activities so that students are challenged, but donot fail✓• Create positive physical and emotional associations with healthy sexualbehaviors and diminish negative associations with these behaviors✓ ✓• Help students assess all that they have learned and then formulate andclarify their intentions✓• Pose typical situations or dilemmas confronted by youth and students tomake decisions about the healthiest choices✓ ✓ ✓ ✓ ✓• Help students make commitments to themselves or to others to implementtheir intentions• Help students create a clear plan for implementing intentions• Help students identify possible barriers to implementing their intentionsand methods of overcoming them so that they are more likely to implementtheir intentions✓✓✓• Include homework assignments or other activities to have students talkwith their parents about their beliefs about young people having sex anduse of condoms or other forms of contraceptionGeneral Instructional Methods✓✓• Instructional material should build on existing knowledge as a foundationfor new knowledge✓• Students should be actively engaged in activities and solving problems ✓ ✓ ✓ ✓ ✓• Activities should help students organize their new concepts and skills, e.g.,by providing a clear message about ways to avoid or reduce sexual risk✓ ✓ ✓ ✓ ✓• Activities should encourage students to apply new knowledge multipletimes to different problems✓ ✓ ✓ ✓ ✓• Activities should help students apply or integrate their new knowledge orskill into their everyday lives✓ ✓ ✓ ✓ ✓• Instructional material and methods should be tailored to the characteristicsof the students, their needs, and their communities✓ ✓ ✓ ✓ ✓ ✓ ✓o Both the content and instructional methods should be tailored to thestudents’ gender, age, knowledge level and level of sexual experience✓ ✓ ✓ ✓ ✓ ✓ ✓o Curricula should include arguments and activities that are effective withstudents at different stages of change towards adopting a particularbehavior✓✓o Activities should address specific attitudes, values and skills that need tobe improved✓ ✓ ✓ ✓ ✓ ✓(Continued)126 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

Table10-1Instructional Principles Important for Each Factor (Continued)Chapter 3KnowledgeChapter 4Perceptionof RiskChapter 5Attitudes, Values,BeliefsChapter 6Perception ofPeer NormsChapter 7Self-Efficacyand SkillsChapter 8IntentionsChapter 9Parent-ChildCommunicationGeneral Instructional Methods (Continued)• Activities should include an array of different types of teaching methods,including:✓ ✓ ✓ ✓ ✓ ✓ ✓o A variety of teaching methods to describe, illustrate, model and personalizethe likelihood and consequences of becoming pregnant or contractingan STD✓ ✓ ✓ ✓o A variety of methods to produce thoughtful critical examination of newarguments and messages by the students✓ ✓o More than one method to increase teens’ self-efficacy (e.g., mastery,vicarious experiences, social persuasion and improvements in physicaland emotional associations)✓✓• Multiple examples should be provided ✓ ✓ ✓ ✓ ✓• Repeat and reinforce the arguments and messages in different ways overtime✓ ✓ ✓ ✓ ✓ ✓ ✓• Instruction should be individualized, when feasible ✓ ✓ ✓ ✓ ✓ ✓ ✓• Students should work regularly with other students in small groups ✓ ✓ ✓ ✓ ✓ ✓• Students’ knowledge and skills should be assessed appropriately• To the extent feasible, educators should make sure that the students areexposed to risk avoidance or reduction messages and arguments, payattention to them, comprehend them, accept them, integrate them, feelgood about them and retain them✓✓ ✓ ✓• Credible, respected and trusted people should present new material andarguments and model desired behavior; to the extent appropriate, thesepeople should be similar and familiar to the students• People with close connections to the students (e.g., parents or peers)should present or reinforce information and arguments favoring healthybehaviors✓ ✓ ✓ ✓ ✓ ✓✓ ✓ ✓ ✓Chapter 10 Conclusions 127

GlossaryAdaptation The process of modifying an intervention,curriculum or program without removing orcontradicting the core elements or internal logic.Affective The feelings or emotional state of anindividual.Attitudes Positive or negative evaluations thatpeople have of other people, objects, activities,concepts and many other phenomena.Behavior change theory A structured set ofunderstandings that describe, predict and explainwhy people act as they do and how to changewhat they do. These understandings underlieinterventions to change health behaviors.Behavioral capability The ability to do something,which typically requires both the knowledge ofwhat is to be done and the skills needed to do it.Belief A statement or proposition, declared orimplied, that is accepted as true by a person orgroup.Causal relationships Two factors are causallyrelated if one of them is the direct result of theother.Cognitive Knowledge gained through perception,reasoning, or intuition.Cognitive dissonance Conflict between a person’sbeliefs and behaviors.Contraception A general term for methods toprevent pregnancy.Concurrent sexual partners Two or more sexualrelationships overlapping in time.Correlation A statistical measure of the degree ofrelationship between variables.Curriculum-based programs Instructional methodsthat use an educational plan incorporating astructured, developmentally appropriate series ofintended learning outcomes and associated learn-ing experiences for students, typically in classroominstruction or after school.Determinants Factors hypothesized to affectoutcomes, such as individual factors (e.g., beliefs,perceptions, attitudes, values and skills); demographicfactors; environmental factors; or aspectsof a particular social, economic, educational,healthcare or cultural system.Developed countries Countries in which citizensusually have access to a wide range of publiclyprovided and private services in health, education,social welfare, housing, transport, commercialand industrial sectors, as well as state-supporteddefense and security services.Empirical evidence Based directly on experience,e.g., observation or experiment, rather than onreasoning alone.Forced-choice voting activities An activity oftenused in youth pregnancy/HIV/STD preventionprograms to address peer pressure. The activityprovides a scenario or question and participantsare required to make a decision based on twochoices and move to a designated area in a roomthat represents the choice. Discussion followsto address whether decisions were influenced byanother person, how it feels to be alone on oneside of the room, what role peer pressure couldplay in decision making and what reasons theperson has for holding that position.Formative evaluation Gathering information duringthe early stages of a project or program, with afocus on finding out whether efforts are unfoldingas planned, uncovering any obstacles or unexpectedopportunities that may have emerged, andidentifying needed adjustments and corrections tothe program.Human Papillomavirus (HPV) A sexually transmitteddisease.Glossary 129

Incidence The number of new cases of a disease ina defined population, within a specified period oftime.Information-Motivation-Behavioral Skills Model(IMB) The model that states HIV preventioninformation and motivation work through preventivebehavioral skills to influence risk reductionbehaviors.Instructional principles Standards or guidelinesthat can help improve the quality of instruction.Intentions Courses of action that people expect tofollow.Intervention mapping A framework for healtheducation intervention development consistingof five steps: (1) creating a matrix of proximalprogram objectives, (2) selecting theory-basedintervention methods and practical strategies, (3)designing and organizing a program, (4) specifyingadoption and implementation plans, and (5)generating program evaluation plans.Invulnerability The belief that one will not beinjured, damaged or wounded. Some peoplebelieve this characterizes adolescent beliefs aboutrisk behaviors.Learning objective A brief, clear, specific statementof what participants will be able to performat the conclusion of instructional activities.Logic model A pictorial diagram that shows therelationship among program components, activitiesand desired health outcomes.Normative messages Communications directedtoward a targeted group (such as youth) designedto convey expectations or standards of expected oracceptable behavior.Norms Standards of expected or acceptable behaviorfor a specific group.Parent-child connectedness The strength of theemotional bond between parent and child andthe degree to which this bond is both mutual andsustained over time.Pedagogical principles Instructional principlesthat increase learning.Pedagogy Teaching methods; the principles andmethods of instruction.Perceptions of peer norms What individualsbelieve that others like themselves believe isexpected or acceptable for them to do.Perceptions of risk The extent to which individualsfeel they are subject to a health threat.Pilot testing Trying out research interventions andmethods or health education programs and projectsto uncover problems or identifying improvementsbefore the actual program or researchproject is launched.Poll A questioning or canvassing of personsselected at random or by quota to obtain informationor opinions to be analyzed.Prevalence The number of events, e.g., instancesof a given disease or other condition in a givenpopulation at a designated time.Principle A rule or standard.Protective factor A factor that reduces the likelihoodthat a particular disease or adverse healthoutcome will occur.Reciprocal causality Two events directly influenceeach other simultaneously.Representative survey A survey with a samplethat well represents the population from whichthe sample is drawn, e.g., a survey based on alarge randomly selected sample.Risk factor A factor that increases the chances ofa negative behavior or outcome, or reduces thechances of a positive behavior or outcome.Roleplay An educational and training method thatallows learners to practice new communicationskills in life-like vignettes or dramas.Self-efficacy Confidence in one’s ability to engagein a behavior successfully.130 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

Sequential sexual partners Two or more nonoverlappingsexual relationships.Sexual networks Group of persons who are connectedto one another through sexual activity.Sexual psychosocial factors Factors such asknowledge, perceptions of risk, attitudes, perceptionsof norms, self-efficacy, and intentionsrelated to sexual activity.Severity The seriousness of a condition and itsconsequences.Simulation An interactive educational activity thatdemonstrates a particular phenomenon or principle,such as the number of young people that getpregnant in a year if not using protection.Skills Capability of accomplishing something withprecision and certainty.STD or HIV education program An interventionbased on a written curriculum implementedamong groups of youth in schools, clinics, orother community settings to reduce adolescentsexual risk behaviors and, ultimately, STDs,including HIV.Social cognitive theory A structured set of ideasthat stress the dynamic interrelationships amongpeople, their behavior, and their environment.Susceptibility Vulnerability, often specific to particularthreats.Taxonomies of learning The classification of formsand levels of learning into different domains.Teachable moment A moment that presents anopportunity to talk about or reinforce importantinformation, attitudes, beliefs, values orbehaviors.Theory of Planned Behavior An extension of thetheory of reasoned action that incorporates aperson’s attitudes toward a behavior.Theory of Reasoned Action A social-psychologicalmodel of voluntary behavior based on theassumption that intentions are the most immediateinfluence on behavior.Undesired sexual activity Sexual activity that isnot wanted by the people involved.Unplanned sex Sex that is not planned ahead oftime.Unprotected sex Sex that is not protected by condomsor other methods of contraception to reducethe risk of pregnancy or STD.Values General and highly esteemed attitudes orbeliefs that affect decision making.Social persuasion A change in an individual’sthoughts, feelings or behaviors caused by otherpeople.Stages of Change Theory Also called the transtheoreticalmodel; the sequence of stages a persongoes through when attempting to change abehavior: precontemplation, contemplation, decision,action and maintenance.Glossary 131

ResourcesThree kinds of resources are provided in this appendix. The first set of resources provides information to identifyscience-based programs and curricula to prevent unintended pregnancy, HIV, and other STDs. These resourcesidentify specific curricula or provide tools to assess them.The second set of resources provides data on adolescent reproductive health. The third set of resources lists healtheducation tools to provide effective health education programs and curricula.This is not an exhaustive list; rather, these are resources that are readily available from the Internet, free, andrelatively easy-to-use.Science-Based Programs and Curricula toPrevent Unintended Pregnancy, HIV and Other STDsFederal and non-federal resources to identify science-based programs and curriculaFederal ResourcesCompendium of HIV Prevention Interventions with Evidence of Effectiveness(this list focuses on non-school based programs)http://www.cdc.gov/hiv/resources/reports/hiv_compendium/Replicating Effective Programs Plushttp://www.cdc.gov/hiv/topics/prev_prog/rep/index.htmPrograms for Replication—Intervention Implementation Reportshttp://www.hhs.gov/ash/oah/prevention/research/programs/index.htmlPromoting Science-Based Approaches to Prevent Teen Pregnancyhttp://www.cdc.gov/reproductivehealth/AdolescentReproHealth/ScienceApproach.htmNational Registry of Evidence-Based Programs and Practices (NREPP)http://nrepp.samhsa.gov/Non-Federal ResourcesChild Trends Guide to Effective Programs for Children and Youth: Teen Pregnancy and Reproductive Healthhttp://www.childtrends.org/Lifecourse/programs_ages_teenpregreprohealth.htmChild Trends “What Works” program table for reproductive healthhttp://www.childtrends.org/what_works/youth_development/table_adrehealth.aspDiffusion of Effective Behavioral Interventions (DEBI): Science-Based Interventions That Workhttp://www.effectiveinterventions.org/en/home.aspxResources 133

Innovative Approaches to Increase Parent-Child Communication About Sexuality: Their Impact and Examples from theField. (2002). New York, NY: Sexuality Information and Education Council of the United States (SIECUS).http://apha.confex.com/apha/132am/techprogram/paper_78986.htmKirby, D. (2007). Emerging Answers 2007: Research Findings on Programs to Reduce Teen Pregnancy and SexuallyTransmitted Diseases. Washington DC: National Campaign to Prevent Teen Pregnancy.http://www.thenationalcampaign.org/EA2007/EA2007_full.pdfKlerman, K. (2004). Another Chance: Preventing Additional Births to Teen Mothers. Washington DC: NationalCampaign to Prevent Teen Pregnancy.http://www.thenationalcampaign.org/resources/pdf/pubs/AnotherChance_FINAL.pdfManlove, J., Franzetta, K., McKinney, K., Romano Papillo, A., and Terry-Humen, E. (2004). A GoodTime: After-School Programs to Reduce Teen Pregnancy. Washington DC: National Campaign to Prevent TeenPregnancy.http://www.thenationalcampaign.org/resources/pdf/pubs/AGoodTime.pdfManlove, J., Franzetta, K., McKinney, K., Romano Papillo, A., and Terry-Humen, E. (2004). No Time toWaste: Programs to Reduce Teen Pregnancy Among Middle School-Aged Youth. Washington DC: National Campaignto Prevent Teen Pregnancy.http://www.thenationalcampaign.org/resources/pdf/pubs/No_Time.pdfManlove, J., Romano Papillio, and Ikramullah, E. (2004). Not Yet: Programs to Delay First Sex Among Teens.Washington DC: National Campaign to Prevent Teen Pregnancy.http://www.teenpregnancy.org/works/pdf/NotYet.pdfManlove, J., Terry-Humen, E., Papillo, A. R., Franzetta, K., Williams, S., and Ryan, S. (2002). PreventingTeenage Pregnancy, Childbearing, and Sexually Transmitted Diseases: What the Research Shows. Washington, DC:Child Trends and the Knight Foundation.http://www.childtrends.org/files/K1Brief.pdfPapillo, A. R., and Manlove, J. (2004). Science Says: Early Childhood Programs. Washington, DC: The NationalCampaign to Prevent Teen Pregnancy.http://www.preschoolcalifornia.org/assets/teen-pregnancy-research-0604.pdfThe Program Archive on Sexuality, Health, and Adolescence (PASHA). (2011). Los Altos, CA: Sociometrics.http://www.socio.com/pasha.phpResource Center for Adolescent Pregnancy Preventionhttp://www.etr.org/recappScience and Success, Second Edition: Sex Education and Other Programs That Work to Prevent Teen Pregnancy, HIV andSexually Transmitted Infections. (2008). Washington DC: Advocates for Youth.www.advocatesforyouth.org/programsthatwork134 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

Science-Based Practices: A Guide for State Teen Pregnancy Prevention Organizations, (2004). Washington, DC:Advocates for Youth.http://www.advocatesforyouth.org/publications/frtp/guide.htmSolomon, J. and Card, J. J. (2004). Making the List: Understanding, Selecting, and Replicating Effective TeenPregnancy Prevention Programs. Washington DC: The National Campaign to Prevent Teen Pregnancy.http://www.thenationalcampaign.org/resources/pdf/pubs/MakingTheList.pdfTroccoli, K. (ed.). (2006). It’s a Guy Thing: Boys, Young Men, and Teen Pregnancy Prevention. Washington DC:National Campaign to Prevent Teen Pregnancy.www.teenpregnancy.orgTools to assess, select, or adapt programs and curriculaThe School Health Index (SHI): Self-Assessment and Planning Guide was developed by CDC in partnershipwith school administrators and staff, school health experts, parents, and national nongovernmental healthand education agencies for the purpose of enabling schools to identify strengths and weaknesses of health andsafety policies and programs, enabling schools to develop an action plan for improving student health, whichcan be incorporated into the School Improvement Plan, and engaging teachers, parents, students, and thecommunity in promoting health-enhancing behaviors and better health.http://www.cdc.gov/HealthyYouth/SHI/introduction.htmHealth Education Curriculum Analysis Tool (HECAT). The Health Education Curriculum Analysis Tool(HECAT) can help school districts, schools, and others conduct a clear, complete, and consistent analysis ofhealth education curricula based on the National Health Education Standards and CDC’s Characteristics ofEffective Health Education Curricula. The HECAT results can help schools select or develop appropriate andeffective health education curricula and improve the delivery of health education to address sexual health andother health education topics. The HECAT can be customized to meet local community needs and conformto the curriculum requirements of the state or school district. The Sexual Health Module contains the toolsto analyze and score curricula that are intended to promote sexual health and prevent risk-related healthproblems, including teen pregnancy, Human Immunodeficiency Virus (HIV) infection, and other sexuallytransmitted diseases (STD). This module can be used to analyze curricula emphasizing sexual risk avoidance(abstinence) and sexual risk reduction.http://www.cdc.gov/HealthyYouth/HECAT/index.htmCharacteristics of Effective Sex and STD/HIV Education ProgramsCDC’s School Health Education Resources (SHER): Characteristics of an Effective Health EducationCurriculumhttp://www.cdc.gov/HealthyYouth/SHER/characteristics/index.htmKirby, D. (2007). Emerging Answers 2007: Research Findings on Programs to Reduce Teen Pregnancy and SexuallyTransmitted Diseases. Washington DC: National Campaign to Prevent Teen Pregnancy.http://www.thenationalcampaign.org/EA2007/EA2007_full.pdfResources 135

Kirby, D. Laris, BA, and Rolleri, L. (2006). The Impact of Sex and HIV Education Programs in Schools andCommunities on Sexual Behaviors Among Young Adults. Washington DC: Healthy Teen Network.www.healthyteennetwork.orgKirby, D., Rolleri, L., and Wilson, M. M. (2007). Tool to Assess the Characteristics of Effective Sex and STD/HIVEducation Programs. Washington, DC: Healthy Teen Network.http://www.etr.org/recapp/documents/programs/tac.pdfData Sources on Adolescent Reproductive HealthFederal and Non-Federal National Data ResourcesFederal ResourcesAIDS.govhttp://www.aids.gov/Centers for Disease Control and Prevention Division of Adolescent and School Healthhttp://www.cdc.gov/healthyyouth/Centers for Disease Control and Prevention Division of HIV and AIDS Preventionhttp://www.cdc.gov/hiv/topics/research/index.htmCenters for Disease Control and Prevention Division of Reproductive Healthhttp://www.cdc.gov/reproductivehealth/index.htmCenters for Disease Control and Prevention: HIV/AIDS Surveillancewww.cdc.gov/hiv/Centers for Disease Control and Prevention: Reproductive Health Atlashttp://www.cdc.gov/Features/AtlasReproductiveHealth/Centers for Disease Control and Prevention: Sexually Transmitted Disease Surveillancewww.cdc.gov/std/Healthy People 2010http://www.healthypeople.gov/Office of Population Affairs, Office of Adolescent Pregnancy Programshttp://www.hhs.gov/opa/National Center for Health Statisticswww.cdc.gov/nchs/136 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

National Longitudinal Study of Adolescent Health (Add Health)http://www.cpc.unc.edu/projects/addhealthNational Institutes of Healthhttp://www.nih.gov/National Mental Health Information Centerhttp://www.mentalhealth.samhsa.gov/National Prevention Information Networkhttp://www.cdcnpin.org/scripts/index.aspNational Survey of Family Growth (NSFG)http://www.cdc.gov/nchs/nsfg.htmYouth Behavior Risk Surveillance Datahttp://www.cdc.gov/HealthyYouth/yrbs/index.htmObtaining Published Local Adolescent Reproductive Health Data• State Pregnancy Prevention Coalition• State or County Department of Health• State or County Office of Minority Health• State or County Department of Education• Local HIV Planning Board• Local Foundations (e.g., United Way)• Local Community-Based Organizations (e.g., Planned Parenthood, Boys and Girls Club, etc.)• Local UniversitiesNon-Federal ResourcesChild Trendswww.childtrends.orgChild Trends Data Bankwww.childtrendsdatabank.orgData Resource Center for Child and Adolescent Healthhttp://www.childhealthdata.org/content/Default.aspxGuttmacher Institutewww.guttmacher.orgKaiser Family Foundationwww.kff.orgResources 137

Kids Countwww.aecf.org/kidscount/National Campaign to Prevent Teen and Unplanned Pregnancyhttp://www.thenationalcampaign.org/State Health Facts On-Linewww.statehealthfacts.kff.orgHealth Education ResourcesHealth Education and Health Behavior TheoryFederal ResourcesMotivational Interviewinghttp://www.health.nsw.gov.au/public-health/dpb/supplements/supp6.pdfTheory at a Glance: A Guide for Health Promotion Practicehttp://www.nci.nih.gov/theory/pdfNon-Federal ResourcesEcological Systems Theoryhttp://pt3.nl.edu/paquetteryanwebquest.pdfHealth Belief Modelhttp://www.etr.org/recapp/index.cfm?fuseaction=pages.TopicsInBriefDetailandPageID=51Social Learning (Cognitive) Theoryhttp://www.etr.org/recapp/index.cfm?fuseaction=pages.TheoriesDetailandPageID=380Stages of Change Theoryhttp://www.etr.org/recapp/index.cfm?fuseaction=pages.theoriesdetailandPageID=360Theory of Reasoned Action/Planned Behaviorhttp://www.etr.org/recapp/index.cfm?fuseaction=pages.TheoriesDetailandPageID=517Health Education and Health Belief TheoryInstructional Methods/PedagogyNon-Federal ResourcesBest Practices: Social Normshttp://wch.uhs.wisc.edu/13-Eval/Tools/Resources/Social%20Norms.pdf138 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

Changing Social Normshttp://www.etr.org/recapp/index.cfm?fuseaction=pages.ProfessionalCreditsDetailandPageID=229Classroom Management to Promote Learninghttp://www.etr.org/recapp/index.cfm?fuseaction=pages.EducatorSkillsDetailandPageID=78Cooperative Learninghttp://edtech.kennesaw.edu/intech/cooperativelearning.htmConstructivist Theoryhttp://www.exploratorium.edu/ifi/resources/constructivistlearning.htmlElaboration Likelihood Model (ELM)http://www.cios.org/encyclopedia/persuasion/Helaboration_1likelihood.htmGuiding Large-Group Discussionshttp://www.etr.org/recapp/index.cfm?fuseaction=pages.EducatorSkillsDetailandPageID=82Instructional Design Models – University of Colorado at Denverhttp://carbon.ucdenver.edu/~mryder/reflect/idmodels.htmlM. David Merrill, First Principles of Instructionhttp://mdavidmerrill.com/Papers/firstprinciplesbymerrill.pdfManaging Small Groupshttp://www.etr.org/recapp/index.cfm?fuseaction=pages.EducatorSkillsDetailandPageID=87Principles of Adult Learninghttp://honolulu.hawaii.edu/intranet/committees/FacDevCom/guidebk/teachtip/adults-2.htmPrinciples of Teaching and Learninghttp://www.cmu.edu/teaching/principles/Roleplay for Behavioral Practicehttp://www.etr.org/recapp/index.cfm?fuseaction=pages.EducatorSkillsDetailandPageID=94Self-efficacyhttp://en.wikipedia.org/wiki/Self-efficacyTheory of Reasoned Actionhttp://www.cios.org/encyclopedia/persuasion/Gtheory_1reasoned.htmTheory of Reasoned Actionhttp://en.wikipedia.org/wiki/Theory_of_reasoned_actionResources 139

Program Fidelity and AdaptationFederal ResourcesNon-Federal ResourcesBacker, T.E. (2002). Finding the Balance: Program Fidelity and Adaptation in Substance Abuse Prevention.Rockville, MD: Substance Abuse and Mental Health Services Administration.http://sshs.promoteprevent.org/resources/finding-balance-program-fidelity-and-adaptation-substanceabuse-preventionAdaptationhttp://www.healthyteennetwork.org/index.asp?Type=B_BASIC&SEC=%7BE8F6E426-AID8-4DBC-8CCF-1C68EB3BFEDB%7D&DE=%7B1EE1BD19-468D-918B-F36FA6134243%7DPractice Profiles for Get Real About AIDS and Reducing the Risk. (1999). Santa Cruz, CA: ETR Associates.http://www.etr.org/recapp/index.cfm?fuseaction=pages.TheoriesDetailandPageID=547Cultural Competency ResourcesFederal ResourcesBancroft, M. (2002). Cultural Competence and Reproductive Health: A Guide to Services for Immigrants andRefugees. Philadelphia, PA: DHHS Region III Family Planning Training Center.www.region3ipp.org/datadir/200772145314.pdfCenters for Disease Control and Prevention, National Prevention Information Network (NPIN)www.cdcnpin.org/scripts/population/culture.aspHealth Resources and Services Administration (HRSA): Cultural Competence Resources for Health CareProviderswww.hrsa.gov/culturalcompetenceManagement Sciences for Health. Provider’s Guide to Quality and Culturehttp://erc.msh.org/mainpage.cfm?file=1.0.htmandmodule=providerandlanguage=EnglishOffice of Minority Health (OMH)www.cdc.gov/omhdNon-Federal ResourcesAdvocates for Youth, Cultural Competency and Adolescent Reproductive and Sexual Healthwww.advocatesforyouth.org/culturalcompetency.htmAdvocates for Youth, MySistahshttp://www.advocatesforyouth.org/index.php?option=com_contentandtask=viewandid=796andItemid=115140 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

Advocates for Youth, Young Women of Color Initiativewww.advocatesforyouth.org/about/ywoc.htmaha! Processwww.ahaprocess.comCommunity Tool Boxhttp://ctb.ku.edu/tools/enhancecompetence/index.jspDiversity Rx. Resources for Cross Cultural Health Care (RCCHC) and Drexel University School of PublicHealth’s Center for Health Equalitywww.diversityrx.orgEsack, F., Alam, S. and Kabir, B. (2007). HIV, AIDS, and Islam: A Workshop Manual Based onCompassion, Responsibility and Justice. Washington, DC: Communities Responding to the HIV/AIDSEpidemic.www.coreinitiative.org/Resources/Publications/CORE_PM.pdfExpanding the Movement for Empowerment and Reproductive Justice (EMERJ)http://reproductivejustice.org/emerjFamily Health International, YouthNet Programwww.infoforhealth.org/youthwg/pubs/youthnet.shtmlGeorgetown University, National Center for Cultural Competence (NCCC)http://www11.georgetown.edu/research/gucchd/ncccInter-University Consortium for Political and Social Research, Minority Data Resource Centerwww.icpsr.umich.edu/MDRCJames Bowman Associates, Reaching New Heights. Assessing Organizational Capacity to Provide CulturallyCompetent Services (brochure)www.jamesbowmanassociates.com/projects.htmlKennedy, E., Jacinta Bronte-Tinkew, J., and Matthews, G. (2007). Enhancing Cultural Competence in Outof-SchoolTime Programs: What Is It, and Why Is It Important? Washington, DC: Child Trends.http://www.childtrends.org/files//child_trends-2007_01_31_rb_culturecompt.pdfLeón, J., Sugland, B. W., and Peak, G. L. (2003). Engaging Parents and Families as Partners in AdolescentReproductive Health and Sexuality. Baltimore, MD: Center for Applied Research and Technical Assistance(CARTA).http://www.training3info.org/resources_manuals.aspxResources 141

Resource Center for Adolescent Pregnancy Prevention. Racial/Ethnic Disparities and Cultural Competency inTeen Pregnancy, STD and HIV Prevention (presentation)http://www.etr.org/recapp/index.cfm?fuseaction=pages.currentresearchdetailandPageID=440andPageTypeID=18SIECUS. Annotated Bibliography: Culturally Competent Sexuality Education Resourceshttp://www.thefreelibrary.com/A+SIECUS+annotated+bibliography%3A+Culturally+Competent+Sexuality...-a090888997The SisterSong Women of Color Reproductive Health Collectivewww.sistersong.net/index.htmlTools for Building Culturally Competent HIV Prevention Programswww.socio.com/srch/summary/misc/happubl3.htmUCLA. School Mental Health Projecthttp://smhp.psych.ucla.eduUniversity of Michigan. Program for Multicultural Healthhttp://med.umich.edu/multicultural/ccp/tools.htmWeber, J. (2004). Youth Cultural Competence: A Pathway for Achieving Outcomes with Youth. Focus on Basics7(A).http://ncsall.net/?id=126Williams, B. (2001). Accomplishing Cross Cultural Competence in Youth Development Programs. Journal ofExtension 39(6).http://www.joe.org/joe/2001december/iw1.php142 Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs

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Reduce rates of unplanned pregnancy,STD and HIV—this invaluable guideshows you how.Written by Dr. Douglas Kirby and his colleagues, long known for their groundbreaking workin adolescent sexuality, Reducing Adolescent Sexual Risk helps you design, adapt and selectcurriculum-based programs to effectively address critical factors that affect adolescents’sexual decision making.Reducing Adolescent Sexual Risk:n Offers a research-based, step-by-step guide to understanding 7 “sexual psychosocial”factors that affect sexual behavior:– Knowledge about sexual issues, pregnancy, HIV and STD– Perceptions of risk– Personal values,attitudes and beliefs about abstaining from sex and using condomsand contraception– Perception of peer norms and behavior around sex, condoms and contraception– Self-efficacy and skills to refuse undesired sex or to use condoms and contraception– Intention to abstain, restrict sexual activity or use condoms and contraception– Communication with parents about sex, condoms and contraceptionn Begins with a detailed logic model and learning objectives forkey sexual behaviors—these guide curriculum development.n Summarizes the important psychological andpedagogical theories relevant to each of the 7 factors,and research results to support those theories.n Provides examples of effective classroom activitiesfrom evidence-based programs.n Gives examples of survey items to measure these factors.n Draws conclusions about the most effective waysto address each psychosocial factor.n Gives important tools to design or adaptspecific activities that change these factorsand thereby reduce sexual risk behavior.n Serves as a resource when selectingexisting programs.