This paper is one of a few to present data on the sexual activity and expectations of sexual activity among American children as young as 10 or 11 years old. In Washington, DC, where teenage pregnancy rates are considerably higher than across the United States, the proportions of youths who reported they have had sexual intercourse or are anticipating such activity in the next 12 months are both alarmingly high. By the end of the sixth grade, 47–51% of boys had experienced sex and 70–78% anticipated engaging in sexual intercourse in the next 12 months. Similar to other research efforts, the levels of both past and anticipated sexual intercourse are two to three times higher among boys than girls (Raine et al. 1999
Within this context, it is perhaps not surprising that the only significant behavioral effect found was for boys: the slowing of the rise of proportions anticipating having sex among intervention versus control boys. The significant decrease in the anticipation of sex among intervention boys over the four time points was not accompanied, however, by a significant reduction in the rate of sexual experience among the intervention boys compared with the controls. Thus, it appears that the intervention was successful in getting male students to realize they should not have sex in the next year, to the point that they said that they would not do so in the survey. However, this intention was not supported by corresponding changes in attitudes toward abstinence and the use of refusal skills to resist sex or in the ability to identify benefits of postponing sex, consequences of having a baby while in school, peer pressure, and influences on youths to have sex. Thus, the intention to abstain from sex was not sufficiently grounded in attitudes and perceptions that would have facilitated actual delay in sexual initiation. Nevertheless, it should be noted that the biggest difference in anticipation of sex occurred at the end of the sixth grade, so that it is possible that after the end of the study, the lowered rates of anticipation of sex among intervention boys at the end of the sixth grade may yet result in reduced sexual experience among the intervention males.
The intervention also significantly increased boys’ and girls’ knowledge of pubertal changes, both in males and females, compared with control students. This result is not surprising given that two children’s intervention sessions during each school year focused specifically on puberty and reproduction. Anecdotally, interventionists confirmed students’ lack of prior knowledge and consequent interest in these sessions. In addition to pubertal knowledge, there was a slight positive effect among intervention versus control girls in their ability to identify the benefits of postponing sex and influences on children to have sex.
The study’s findings are reinforced by the analyses investigating the effects of children’s attendance on the behavioral outcomes. The only effect discerned was again upon the anticipation of sex among boys. Boys with complete attendance in the first seven sessions had a lower rate of increase in their anticipation of sex, and this was true compared with both the control boys and the intervention boys with lower attendance. This result may mean that greater exposure to the intervention increased its effect on not anticipating sex. However, it could also reflect the self-selection of boys who were less inclined to anticipate sex to attend all beginning sessions; it may be, for example, that boys who were more likely to think they would have sex were also more likely to have been absent from curricular sessions.
Because this sample represents a compelling test case for decreasing rates of early adolescent sexual activity among a very high-risk population, it is all the more disappointing that, even for youths as young as 10–13 years old, a carefully conceptualized and pretested classroom program failed to delay sexual initiation. Part of the lack of impact may potentially be due to inadequacies in the curriculum itself or in its implementation.
A review of 83 domestic and international HIV/STD and pregnancy prevention curricula suggested that written curricula implemented in school, clinic, and community settings ‘are a promising type of intervention to reduce adolescent sexual risk behaviors’, and they highlighted 17 key characteristics of effective programs (Kirby, Laris, and Rolleri 2006
, 9). Our BFY intervention includes nearly all of these key elements in the: development of the curriculum
(namely, multidisciplinary team of developers, assessment of population needs through focus groups, development and use of a program logic model, culturally relevant and appropriate for level of resources available, and pilot-tested); curriculum content
(clear health goals, focus on specific behaviors leading to health goals, addresses multiple sexual psychosocial risk and protective factors, safe social environment for learning, instructionally sound teaching methods, age-appropriate and youth-oriented, and logical sequence of topics); and curriculum implementation
(secured school and community support, utilized appropriate and well-trained educators, implemented strategies to enhance participation, and implemented activities as designed). Only one of the 83 studies in the review, however, included youths in the elementary school years; therefore, one may suggest that additional or different criteria are necessary when implementing a curriculum among very early adolescents. Kirby, Laris, and Rolleri (2006)
also noted significant gaps in the effectiveness of such programs among very high-risk youths, such as our study’s population.
One may also suggest that our intervention lacked the intensity necessary for achieving significant behavioral change and that increasing children’s exposure to the curriculum content or strengthening the messages of the curriculum content would improve its impact. However, in a study of four abstinence-only education programs (including three among poor, African-American youths in the elementary and/or early middle school years), even 50 hours of curriculum contact were not sufficient to produce significant behavioral effects (Trenholm et al. 2007
In a meta-analysis including only rigorous randomized controlled trials of programs designed to reduce sexual risk-taking among teens, Scher, Maynard, and Stagner (2006)
used pooled effects to compare four types of programs: one-time consultations (mostly in clinical settings with high school-aged youths); sex education programs with an abstinence focus; sex education programs with a contraception component; and multicomponent youth development programs. Results highlight the lack of rigorously evaluated abstinence-only programs (only three studies were ‘rigorous randomized controlled trials’), the limited effects on sexual abstinence rates for all types of programs, and the potentially positive effect of youth development programs on pregnancy risk (unprotected intercourse vs. intercourse with contraceptives or abstinence). Similar to another review (Kirby 1997
), none of the studies in this review included elementary school students.
Other research highlights the potential of community-based efforts and some service learning and youth development programs as particularly promising strategies for delaying and reducing sexual activity and pregnancy (Gallagher et al. 2005
; Kirby 2002
; O’Donnell et al. 1999
; Philliber, Kaye, and Herrling 2001
). Kirby’s (2002)
review of 73 research studies examining the effectiveness of efforts to reduce unprotected sex, pregnancy, and childbearing among youths suggests that adding either an individualized clinician–patient approach or a more experiential, non-classroom component could enhance intervention effectiveness. By engaging children in activities that broaden their perspectives of life and community, such approaches may be more effective in convincing very high-risk pre-teens and young teenagers that delaying sexual initiation and avoiding pregnancy have tangible and attainable rewards.
There are several limitations to the present work. The sample is limited to schools located in areas with very high adolescent pregnancy rates in Washington, DC, and nearly all students were African American. Thus, the sample has limited generalizability. On the other hand, this is precisely the sample in greatest need of intervention and is thus a compelling test case. Another limitation is the relatively small sample size, a particular problem in estimating rare events, such as sexual intercourse among young girls. This is compounded by the fact that sexual intercourse, and all other outcomes, was measured by self-reports in questionnaires. Furthermore, the data on attendance were not complete. This weakness in the data, however, is not important in view of the limited intervention effects overall. Finally, we based our analysis on all students, regardless of participation in only one or two years, under the assumption that the data missing from students who participated in only one grade were missing at random. However, results from a second analysis based only on students who participated in both grades did not differ substantively from the results based on all students.
Regardless of these limitations and the small number of significant effects, our study marks a significant advance in adolescent pregnancy prevention by targeting very high-risk youths in the elementary school years and conducting a randomized controlled trial. Despite concern about obtaining school, community, and parental support, we gained their cooperation and were able to successfully implement an abstinence-based curriculum that also included comprehensive information on contraceptive methods during the sixth-grade year (as well as implement a randomized design). It is possible that increasing the level of the curriculum exposure and even greater engagement of the broader community could have further strengthened the intervention program by improving its content and applicability to the target youths and their parents, engaging more parents in workshops, and addressing early sexual debut beyond the classroom setting (e.g. via youth development or service learning programs that would be conducted after school hours or during weekends) (Gallagher et al. 2005
; Green and Documét 2005
It is important to remember that the intervention failed to have greater effects on children’s behaviors and attitudes in the face of overwhelming odds. Many of these children live in extremely adverse circumstances and are subjected to barrages of influences opposite those of the intervention, from public media to personal examples pushing them toward early sexual intercourse (Walker et al. 2008
). In this sense, the lack of intervention impact is not surprising and calls for a redoubling of efforts and dedication to the cause of improving children’s futures at the community level by helping them to avoid too-early sexual activity.