Overview
Safer Choices is a two-year long school-based sex education program for ninth and tenth graders (the program is designed for high school students in general, but was evaluated with students in these two grades). In 20 sessions, the Safer Choices program promotes delaying sexual initiation and increasing condom use among teens who choose to have sex.
The program includes five broad components: 1) school organization; 2) curriculum and staff development; 3) peer resources and school environment; 4) parent education; and 5) school-community linkages.
An experimental evaluation found that Latinos in the program were 43 percent less likely to initiate sexual intercourse than Latinos in the control group. Furthermore, sexually active teens in Safer Choices were more likely than control group teens to use a condom or other contraceptive method at last sexual intercourse at the 31-month follow-up.
Teachers receive four days of training and additional support throughout the duration of the program. Curriculum and implementation materials for Safer Choices can be purchased for $189.
Insights After the Fact
Key Challenges
Managing and organizing of the multiple components of the program is quite challenging.
- Some schools experienced recruiting and scheduling difficulties. A few School Health Promotion Councils and peer resources committees had difficulties finding convenient meeting times and maintaining participation by group members.
Lessons learned
- The School Health Promotion Council site coordinator should be someone from the school so that they can get others/school leaders involved in the program.
- Booster trainings between years 1 and 2 for teachers are an important supportive element.
- Providing formal recognition and appreciation for the Health Promotion Council and Peer Resources group goes a long way towards solidifying their participation.
Source: Karin Coyle, Ph.D., Director, Research, ETR Associates, Program evaluator
Program Description
Safer Choices is a school-based sexuality education intervention program designed to reduce the number of high school teens having sex and those having unprotected sex. This two-year program was evaluated in five high schools in Northern California and five high schools in Southeastern Texas, serving ninth and tenth graders. The evaluated program began in the fall of 1993, and data collection for the evaluation took place in the spring of 1996.
Population Served
The Safer Choices program serves primarily 9th and 10th grade students, but can be used with high school students in general. It is a co-education program, and is suitable for all racial/ethnic groups. The program is also suitable for all teens regardless of sexual experience
Setting
Safer Choices is a school-based program that was evaluated in an urban setting.
Goals
The Safer Choices program is designed to delay first sex and to increase condom use among teens who are sexually active. It also strives to enhance knowledge, attitudes, and beliefs about prevention of HIV/STDs and sexual decision-making.
Type of Intervention
Safer Choices has five components:
- school organization;
- curriculum for students and staff development;
- peer resources and school environment;
- parent education;
- and school-community linkages.
Together, these components aim to create a supportive, positive atmosphere for the teens.
Safer Choices draws on social cognitive theory, social influence theory, and models of school change. Social cognitive theory posits that individual behavior is influenced by personal, environmental, and behavioral factors. Social influence theory examines how individuals have influence over others. It focuses on identifying existing behavioral expectations and social norms and ways to resist negative pressures. School change is based on the idea that school climate and culture have a strong influence on students’ behavior. Thus, broad changes within a school (such as policies and organizational structures and missions) can affect how students act.
Main Messages
Safer Choices teaches that abstinence is the best way to prevent STDs and unplanned pregnancy. It also emphasizes that contraception is important for reducing these risks for students who decide to have sex.
Operation/Logistics
Length of intervention: Safer Choices serves students during the 9th and 10th grades in 20 sessions (10 in each year of the program). Each session lasts for 45 minutes.
Size of program: A total of 1,983 students participated in the evaluation of the Safer Choices program.
Components of intervention: The five components of the Safer Choices program are:
- The school organization component creates a School Health Promotion Council that organizes various program activities such as inviting speakers to the school, sponsoring a health fair, visiting a local AIDS hospital ward, or presentations at PTA meetings. The council members included teachers, students, parents, administrators, and community members.
- The curriculum and staff development component consists of a two-year, 20-session skills-based curricula led by classroom teachers (see below). The teachers receive four days of training and additional support throughout the program period.
- The peer resources and school environment component establishes a Safer Choices peer club for peer education activities related to HIV/STD and pregnancy prevention. The clubs hold six school-wide programs, manage an information/resource outlet at their school, and create posters with messages that promote positive behaviors.
- The parent education component informs parents about the Safer Choices program and effective parent/teen communication strategies. It includes some student-parent homework assignments.
- The school-community linkages component increases students’ awareness of relevant resources and services in their communities.
Staffing requirements: Classroom teachers received four days of training in leading the program. Student peer leaders were elected by their classmates and received three hours of training.
Curriculum
The ninth-grade classroom sessions address the following topics:
- Not Everybody’s Having Sex. Students discuss why adolescents choose to abstain from or have sex. They identify various influences and discuss ways to be affectionate without sex.
- The Safest Choice: Deciding Not to Have Sex. Students learn about “social norms.” They discuss perceptions of how many of their peers have had sex and how these perceptions compare to actual statistics. Using role-playing, students also learn refusal skills.
- Saying No to Having Sex. Meeting in small groups, students practice refusal skills, alternative actions and delay tactics.
- Understanding STD and HIV. Students learn basic facts about HIV and other STDs, including how they are transmitted, and ways to reduce the risk of infection. They also discuss why some teens choose not to get tested for STDs.
- Examining the Risk of Unsafe Choices. This lesson tries to personalize the risk of contracting HIV. Students receive colored index cards that they then exchange with classmates. The four colors represent four specific behaviors: 1.having sex without a condom, 2. sharing needles, 3. having sex using a condom, and 4. remaining abstinent and not sharing any needles. Teachers then discuss the potential consequences of each behavior.
- Teens with HIV: A Reality. Students watch and discuss a video featuring teens and adults living with HIV.
- Practicing the Safest Choices. Students review refusal skills, work in groups to write refusals for several pressure statements, and use role-plays to practice their refusal skills.
- Safer Choices: Using Protection, Part I. Students learn about various methods of contraception are and which are effective against HIV/STDs and/or pregnancy. As homework, students go to local stores to see which types of contraception are easily available.
- Safer Choices: Using Protection, Part II. Students learn how to use condoms correctly and how to respond to pressure for unprotected sex.
- Know What You Can Do. Students fill out a worksheet on how to delay having sex and refuse unprotected sex.
Tenth grade classroom sessions address the following topics:
- Making Safer Choices. The students review unsafe sex (unprotected), safer sex (with a latex condom), and safest sexual choices (abstinence). Students work in groups to identify positive and negative outcomes related to each choice.
- The Safest Choice Challenge. The teacher reviews lessons from ninth grade. Students are assigned to call or visit a local clinic to get information about available reproductive health services.
- Talking with a Person Infected with HIV. A guest speaker shares his/her experience living with HIV/AIDS, and students ask questions. A homework assignment asks participants to reflect on how their feelings and opinions changed after the presentation.
- Personalizing the Risk for Pregnancy. Teachers tell students that one out of six teens having unprotected sex over a year become pregnant each month. In a related activity, each student is assigned a number between one and six, the teacher rolls a die, and students with that number stand up, as a representation of teens who became pregnant (or caused a pregnancy) in one month.
- Avoiding Unsafe Choices. Students discuss barriers to speaking with parents or other adults. They learn three steps for avoiding unsafe choices: Know your personal limits, be aware of circumstances that may challenge your limits, and be prepared in advance with a plan to stay within your set limits.
- Sticking with Your Decision. Students use role-playing to practice refusal skills.
- Using Condoms Consistently and Correctly. Students practice correct condom use.
- Resources. Students learn about pregnancy and HIV/STD testing and available health services resources.
- Media Influences. Students discuss media’s influence regarding sex. They work in groups to create positive media messages about avoiding pregnancy, STDs/ HIV.
- Making a Commitment. Students participate in an activity in which they practice committing to protecting themselves from pregnancy, STDs/ HIV.
Evaluation
Type
The experimental evaluation of Safer Choices included 3,869 ninth-grade students (1,983 in the experimental group and 1,886 in the control group) in 10 Northern California and 10 Southeastern Texas public schools. Five schools in each area were assigned to the experimental group and five to the control group. About 80 percent of students completed the 31-month follow-up.
Population
The Safer Choices program was evaluated with 9th graders—20 percent were African American, 14 percent were Asian, 29 percent were Latino, 29 percent were White, and 8 percent were of other racial or ethnic backgrounds. Half were male and half were female. Nearly half were A and B students. Prior to the program, 31 percent of teen participants were sexually experienced.
Components
Instruments and frequency: Self-report data were collected at baseline (fall 1993), and at three other time points (7-month follow-up in spring 1994, 19-month follow-up in spring 1995, and 31-month follow-up in spring 1996).
Outcomes measured: The evaluation instrument included measures of sexual behavior and sexuality-related psychosocial scales. The evaluation assessed three main outcomes: “(a) whether students delayed initiation of sexual intercourse; (b) the number of times students had intercourse without a condom in the last three months (among those reporting intercourse); and (c) the number of sexual partners with whom students had intercourse without a condom in the last three months (among those reporting intercourse)” (Coyle, et al, 2001: 84).
Additional outcomes measured include: condom use at first sex among students reporting first having sex after the program began; use of contraception at the last sexual experience (condom and/or birth control pills); frequency of intercourse in the last three months; number of partners in the last three months; and alcohol/drug use before last intercourse in the past three months.
Findings
Before the start of the program, 31 percent of program participants reported having had sexual intercourse, compared to 26 percent of students in the control group.
Sexual experience: Overall, no differences were found regarding sexual initiation between program teens and control group members at any of the follow-ups. However, analyses of racial/ethnic subgroups found that Latino program participants were 43 percent less likely to initiate sexual intercourse than Latino students in the control group at the 31-month follow-up.
Other outcomes: At the 31-month follow-up, students who participated in Safer Choices were 37 percent less likely to report having intercourse without a condom and reported fewer sexual partners who did not use condoms in the past three months compared with students in the control group. In addition, sexually active program participants were more than 1.5 times more likely to report using a condom and more than 1.5 times more likely than control group students to report using another method of birth control the last time they had intercourse.
Analyses by gender showed that the program increased condom use more among males than females. Analyses by race/ethnicity showed increases among all racial/ethnic groups for rates of condom use. Latino program participants were 65 percent more likely than the Latino control group members to use a condom at last sex. Likewise, White participants were 57 percent more likely than the control group to use condoms at last sex.
Evaluator Viewpoints
The authors believe that the program’s failure to delay first sex more broadly might have been because it did not start until high school. In addition, more than one-fourth of students were sexually experienced at the start of the program, which could indicate strong norms that support sexual activity (Coyle, et al., 2001).
Evaluators suggested that the multi-component nature of the program contributed to its success in improving condom and other contraceptive use. They note that the school-wide activities contributed to the intervention’s effectiveness by creating an environment that was supportive of safe and healthy behaviors (Coyle, et al, 2001). The evaluators concluded, based on findings from the full sample and from subgroup analyses, that Safer Choices could be an effective program for diverse communities and groups of adolescents (Kirby, et al, forthcoming).
Contact Information
Program Contact
Karin Coyle, Ph.D.Director, Research
ETR Associates
PO Box 1830
Santa Cruz, CA 95061-1830
Phone: 831-438-3577
E-mail: karinc@etr.org
Evaluation Contact
Doug Kirby, Ph.D.
Senior Research Scientist
ETR Associates
4 Carbonero Way
Scotts Valley, CA 95066-4200
Phone: 831-438-4060
E-mail: dougk@etr.org
Resources
Kirby, D.B., Baulmer, E., Coyle, K.C., Basen-Engquist, K., Parcel, G.S., Harrist, R., and Banspach, S.W. (forthcoming). The Safer Choices Intervention: Its impact on the sexual behaviors of different subgroups of high school students. Journal of Adolescent Health.
Coyle, K., Basen-Enquist, K., Kirby, D., Parcel, G., Banspach, S., Collins, J., Baumler, E., Carvajal, S., and Harrist, R. (2001). Safer Choices: Reducing teen pregnancy, HIV, and STDs. Public Health Reports, supplement 1, volume 116, 82-93.
Coyle, K. & Fetro, J. (1998). Safer Choices: Level 2. ETR Associates, Santa Cruz, CA.
Coyle, K., Kirby, D., Parcel, G., Basen-Engquist, K., Banspcach, S., Rugg, D., and Weil, M. (1996). Safer Choices: A multicomponent school-based HIV/STD and pregnancy prevention program for adolescents. Journal of School Health, 66, 3, 89-94.
Fetro, J., Barth, R., and Coyle, K. (1998). Safer Choices: Level 1. ETR Associates, Santa Cruz,
CA.
Safer Choices: Implementation Manual. (1998). ETR Associates, Santa Cruz, CA., and Center for Health Promotion Research and Development, University of Texas-Houston, Health Science Center.