Advancing Sexual and Reproductive Health and Rights
 
Family Planning Perspectives
Volume 32, Number 5, September/October 2000
COMMENT

Conducting Adolescent Sexuality Research in Schools: Lessons Learned

By Lynn Blinn-Pike, Thomas Berger and Melinda Rea-Holloway

In the adolescent sexuality arena, some facts are clear and well-accepted and some are not. For example, it is clear that adolescents now put themselves at risk for HIV, sexually transmitted diseases (STDs) and pregnancy at younger ages than they did in previous decades.1 However, it is not clear—to parents, teachers, school administrators, religious leaders, school boards or politicians—who should be addressing adolescent sexuality issues and how they should be addressed.

Deciding on what messages to give students has proved to be a cause of conflict and polarization in many communities.2 These confusing messages range widely: Remain abstinent until emotionally and developmentally ready for sex; remain abstinent until marriage; remain abstinent, but be informed about contraception and disease prevention; and use that information to effectively protect against disease and unwanted pregnancy.

In 1989, every state had a policy supporting HIV education, and two-thirds of states had policies supporting sexuality education.3 However, in 1990, a conservative backlash began that resulted in legal battles over sexuality education in more than 500 communities. The battle lines were thus redrawn in the early 1990s—from whether there should be sexuality education in schools to what should be taught in such classes.4

In 1992, the Division of School Health of the Centers for Disease Control and Prevention (CDC) initiated an ongoing evaluation effort entitled "Programs That Work," in which a panel of experts reviews existing evaluation data and evidence published in peer-reviewed scientific journals. So far, the initiative has identified five curricula as having the strongest evidence of effectiveness in delaying sexual activity or increasing safe sex.5 Three of these are community-based programs (known as Be Proud, Be Responsible,6 Being a Responsible Teen,7 and Focus on Kids8) and were evaluated in community settings in several states using samples of primarily black adolescents. Two are school-based curricula (titled Get Real About AIDS9 and Reducing the Risk10) and were first evaluated in Colorado11 and California,12 respectively, using samples of primarily white adolescents.

Data on adolescent sexual activity collected in nationally representative surveys point to the urgent need for the "Programs That Work" initiative. For example, data from the 1999 Youth Risk Behavior Survey indicate that 50% of high school students have ever had sexual intercourse, 8% had had sexual intercourse before age 13, and 36% had had sexual intercourse during the three months preceding the survey.13 While school-based interventions provide the greatest opportunity to reach large numbers of adolescents, using schools as the arena for sex education has been described as a "battle," given the diverse opinions on how these efforts should be handled.14

Recently, an evaluation of the two school-based curricula on the CDC list was conducted in Maine schools.15 That evaluation explored the supports and barriers to adopting curricula, the extent to which teachers implemented them and the types of modifications they made. The evaluators concluded that modifying a curriculum during implementation can reduce its effectiveness.

RECRUITMENT ISSUES

Research that analyzes school-based health education efforts often includes the intervention's strategies, the instrument used to gauge its effectiveness, the sample sizes employed in those studies and results (such as changes in students' knowledge, attitudes and behaviors or behavioral intentions). Few research initiatives, however, include detailed descriptions of issues related to recruiting and retaining participants in a sexuality education research project; the impact of institutional review board requirements for informed consent from parents; recruitment methods used at the district, school, teacher and student levels; and differences between students who are eligible to participate and those for whom consent is eventually obtained.16

This lack of published analyses on recruitment issues, especially on the recruitment of teachers and of students, hinders research by limiting our under- standing of how to plan for participation rates in future studies. The team conducting the Maine evaluation concluded that school-based researchers would benefit from learning of others' recruitment experiences, whether positive or negative, to supply a base on which to build.

Other researchers have suggested using school-based personnel as allies.17 This strategy was successfully used in a large nutrition research project (in 28 schools) in which school district nutritionists were brought onboard when the project started; their enthusiasm and efforts to lay the groundwork were instrumental in securing a 100% approval rate for the superintendents, school boards, principals and teachers who were approached to participate.18 However, no studies have reported this strategy's outcome when the research involves the controversial topic of sexuality education.

We describe here our experience using such a strategy in a longitudinal evaluation of the Reducing the Risk curriculum, using 1,141 adolescents to explore its impact on adolescent attitudes and behaviors. We planned to gather longitudinal data to follow up a large sample over three years (allowing for a 25% attrition rate over the period).

BACKGROUND

The Curriculum

The 16-lesson, school-based Reducing the Rick curriculum is implemented by trained adult instructors and is designed around a social influence model of behavior change.19 The curriculum, which consists of skills-based lessons that emphasize student role-playing, includes the following topics: abstinence; sex and protection; refusal skills; tactics to delay sex; avoidance of high-risk situations; acquisition and use of protection; and knowledge and discussions about protection.

The two published evaluations of this curriculum came to similar conclusions.20 Researchers found that it improved parent-child communication about abstinence and contraception; significantly reduced the likelihood that students who had not yet had intercourse would have done so within 18 months of the course; and significantly reduced the likelihood of unprotected intercourse among low-risk and previously inexperienced students.

Teachers who have implemented the curriculum have consistently found two of the 16 lessons to be problematic and thus have frequently deleted or modified these two items.21 One asks students to shop for condoms in their community; the other asks them to investigate the services provided at a local family planning clinic.

Planning the Research Project

In January 1997, we developed a research plan that called for accomplishing the following tasks within one year: soliciting teachers to implement the Reducing the Risk curriculum; gaining approval from their school administrators for a research project that would assess the effectiveness of that curriculum; bringing the teachers together for training in administering the curriculum; testing students in grades 8-10 on measures of sexual knowledge, attitudes, behaviors and perceived sexual confidence in negotiating sexual issues, both before and after the semester-long course; and finally, implementing the 16 lessons, adhering as closely as possible to the integrity of the curriculum. In addition, we planned to survey the same students at 12, 24 and 36 months postintervention. (The students in 10th grade at baseline, who would have graduated by the time of the 36-month follow-up, were to be interviewed in their homes or by mail.) As of this writing, all steps have been completed, except the 36-month follow-up.

The project was to be conducted and analyzed by researchers from the University of Missouri-Columbia, in accordance with research guidelines issued by the university's institutional review board. Moreover, funding was provided, in part, by a large pharmaceutical company and also by the federal Office of Population Affairs.

In the original plan, we anticipated including a sample of 2,000 students, 1,000 of whom would participate in the curriculum intervention and 1,000 who would serve as controls. Each teacher agreed to secure equal numbers of students who would participate in the Reducing the Risk curriculum and who would take their school's regular sexuality education program. In addition, we recruited a second "comparison" group from eight other schools that had a minimal sexuality education program to test whether the comparison students in the intervention schools were "corrupted" by the students enrolled in Reducing the Risk. Because our emphasis is on the events surrounding the implementation of that curriculum, we do not discuss here the students in the nonintervention schools. Nonetheless, we encountered little opposition to administering the survey that assessed the sexual knowledge, attitudes and behaviors of students in those schools, despite the active parental consent requirement for the survey.

Our teacher and student recruitment efforts yielded final samples of 1,141 students overall within the 12 intervention schools (11 high schools and one middle school)—525 students who were exposed to the Reducing the Risk curriculum and 616 students from those same schools who took the regular sexuality education program.

RECRUITMENT AND PARTICIPATION

The Teachers

In 1996, the year before the study began, experienced Reducing the Risk trainers from the Missouri Department of Elementary and Secondary Education held eight training sessions for a total of 132 teachers who taught health or family and consumer sciences. We also attended the two-day training session in anticipation of our research on the effectiveness of the curriculum. The training sessions covered the following topics: the research and theoretical foundation for the curriculum; each of the 16 lessons; practice teaching of selected lessons; strategies for recruiting both students and parents; and the importance of maintaining the integrity of the curriculum. In 1997, we invited the 132 teachers to participate in the research project. Given that they were recently trained, we expected that enough would volunteer to produce a sample of 1,000 students who would be exposed to the Reducing the Risk curriculum.

In response to an introductory letter sent to the 132 teachers inviting them to participate and describing the specific details of the study (including a $750 honorarium for the participating schools), only 34% returned a written response stating that they would like to be involved; 11% responded that they were not interested, and the remaining 55% failed to respond.

Telephone or face-to-face interviews with each of the 45 assenting teachers determined whether their school contributed to the research goals of the project (i.e., achieving a geographically and racially diverse sample for the evaluation, involving schools with a high likelihood of administrative and parental acceptance of the curriculum and its evaluation, and reaching a sample size of least 50 students who would be exposed to the curriculum in grades 8-10 per school during the fall of 1997). In addition, we asked the teachers to discuss the sexuality education curriculum they currently used, their experience teaching Reducing the Risk and where it fit within their school's existing curriculum.

Ultimately, 26 of the 45 responding teachers from school districts across Missouri were selected to participate based on their fit with the above criteria. They were asked to have a school administrator sign a contract that spelled out the responsibilities and amounts of compensation for all parties involved. In addition, we offered to meet with each school administrator and provided teachers with resources to share with administrators (i.e., background information on the effectiveness of Reducing the Risk, copies of the teachers' guide and a description of the research project).

Three teachers requested that we visit their schools and discuss the project with their principals before the contract was signed, and we recruited five other principals through telephone conversations. When talking to school administrators, we answered questions, described the positive outcomes that have been reported with Reducing the Risk and described the procedures that would be followed by both the university and the participating schools. The principals typically asked about restrictions on the use of the $750 honorarium, whether modifications to the curriculum were allowed and what other schools were involved in the project.

Ten of the selected 26 teachers dropped out of the project at this time; of these 10, eight were from rural school districts with total high school enrollments of fewer than 500 students, and two were from suburban school districts with total high school enrollments of 2,000-4,000 students. We contacted these 10 teachers and their administrators after they notified us and learned that their main reasons for dropping out were the administrator's opposition to the project (all 10 teachers), time constraints (three teachers) and staff changes (one teacher lost her job for the coming year).

In May 1997, we held a one-day meeting with the remaining 16 teachers who had returned signed contracts. The covered topics included a refresher review of the curriculum, our expectations regarding data collection, issues of student and parental consent, the selection of incentives for student participation and maintaining the integrity of the curriculum. The teachers were told that they needed prior approval to make significant changes in more than two lessons. These 16 teachers estimated that they could involve 1,000 students in the Reducing the Risk curriculum in the coming school year. We maintained contact with all 16 teachers over the summer through letters and phone calls to their homes, with the goal of beginning pretesting soon after the beginning of the 1997-1998 school year.

Although their administrators had signed the contracts in May, four of the 16 teachers (two from urban schools and two from rural schools) called in late August to say they were dropping out of the study because their superintendents had concerns over anticipated community reactions to the curriculum (i.e., parental objections to the content on condoms and other birth control methods). According to the teachers, this opposition had not surfaced earlier either because the superintendents were unaware that their school principals had signed the contracts or because the superintendents were newly hired and were unfamiliar with the proj-ect and curriculum. In all four cases, the superintendents were not the administrators who had signed the contracts the previous spring, and none felt obligated to honor the contracts signed by either a previous superintendent or by a school principal.

Two of these four teachers were reluctant to answer further questions on why they had dropped out (feeling that further inquiry would negatively affect their jobs) and were disappointed that their superintendents had decided not to participate. We respected their concerns and had no further contact with them. The third teacher was still interested in being involved, and although we had several conversations with the superintendent, permission was never granted. The fourth teacher had moved to a new school system over the summer and was not interested in pursuing the project in her new school.

Eleven of the 12 teachers who ultimately participated in the research proj-ect taught at public schools and one taught at a private Catholic school. All 12 were female and represented schools in districts with high school enrollments of fewer than 500 students (five teachers), of 500-1,000 students (one teacher), of 1,000-2,000 students (four teachers) and of more than 7,000 (two teachers). The two schools in districts with total high school enrollments of more than 7,000 students were in the urban areas of Kansas City and St. Louis City. One of the 12 participating teachers (in St. Louis) was black and the rest were white. Their teaching experience varied from five to 22 years.

The Students

We expected that with our support, each of the 12 teachers would distribute and gather signed parental permission forms, pretest the agreed-upon number of students and begin implementing the 16 lessons within one month after the start of school in the fall of 1997.

As of mid-October, six of the 12 teachers had not yet secured the signed parental permission forms needed to begin the project. The teachers had not been able to begin for the following reasons, in order of frequency: administrators had lingering reservations and fears of community reprisals (e.g., one perceived the corporate funder to be too pro-contraception); incentives were needed to motivate student participation in the project; parents had concerns about a sentence on the parental permission form;* the promised payment for a substitute to free up the teacher's time had not yet come through; and last-minute changes in one school's administration complicated the start of school and delayed students' class schedules.

We handled the above situations in a variety of ways to enable all 12 teachers to pretest their students and being implementing the curriculum by October 30, 1997. First, we gave the teachers a $20 Wal-Mart gift certificate for each class that participated; these were used primarily to induce students to return forms that had already been signed, but had just not been returned to school. In addition, one teacher appealed to parents that the students truly needed the information contained in the curricula, and another described it as an "honor" to be selected to participate in a university research study.

Second, we met with the administrators at each of these six late-starting schools. We encouraged one principal to "make good" on her promise to hire a substitute teacher. We also stressed the urgency of beginning the curriculum to fit all 16 lessons into the semester. Finally, we notified one school that additional support was available from a source other than the project's corporate sponsor.

POSTINTERVENTION FEEDBACK

Ratings of Integrity and Interviews

After each lesson, the teachers were asked to complete a form assessing how closely they preserved the integrity of the curriculum, using a scale from four (complete integrity) to one (very little integrity). Comment sections were provided for explanations of particular ratings.

Based on assessments of the 10 teachers who returned completed feedback forms, the mean scores across the 16 lessons showed high levels of curricular integrity, ranging from 3.4 to 4.0, with a grand mean of 3.9. The means were at or above 3.5 for each of the 16 lessons, except for the one lesson asking students to shop for condoms. All 10 responding teachers said they maintained the complete integrity of eight lessons; three teachers maintained the complete integrity of all 16 lessons.

As we had encountered a high refusal rate among many school systems, we were particularly interested in learning how these specific "insiders" (i.e., teachers) successfully gained administrative and parental approval. We conducted semistructured qualitative telephone interviews with 10 of the 12 teachers. (Two were no longer teaching at that time and were thus unavailable for interview.) Each audiotaped interview lasted approximately two hours. To address possible researcher bias, a doctoral student who was not a part of the research team transcribed the tapes and analyzed their content.

The qualitative interviews focused on the interrelated issues of permission and curricular integrity. The teachers were asked to describe their initial feelings about being a part of the project, their initial expectations regarding school-district approval, how the lines of authority in the schools affected the granting of permission, whether the use of incentives encouraged students to return parental permission slips, why they thought they had succeeded in gaining permission and how they had handled parental and student responses to the project.

Obtaining Permission

Administrative consent. When they were initially recruited, all 12 teachers reported feeling confident of winning administrative approval for four reasons. First, the curriculum was very similar to some of the content they were already covering. Second, administrators were particularly concerned about adolescent pregnancy in their schools and thus would welcome the project.

Third, some administrators provided almost unconditional or blanket support by giving well-respected teachers a great deal of autonomy and academic freedom. The teachers felt that they were regarded as responsible professionals, who would not do anything extreme. Many of the teachers had been teaching at their school for more than 10 years, and they felt that both administrators and parents trusted them to teach the subject matter. As one teacher affirmed, "You see, I've had [school] board members' kids before . . . I've had preachers' kids and teachers' kids and they have all sat in my class and watched childbirth films and STD films and every other thing for years. So, I really don't think anybody thought that much about this one. They just kind of figured it was just the same old stuff."

"Teachers invented creative ways of providing extra encouragement, including raffling off the gift certificates or a small prize to students who returned [permission] forms."

The fourth reason why some teachers were initially optimistic was that administrators viewed participation in any additional activities as politically advantageous. As one teacher noted, "This year the state team is going to come out and look at all of our records and evaluate our school and so anything that makes your school look good. Anything that makes him or the school look better, anything extra like that."

Two teachers were unaware of the overall administrative approval process, however, and reported that their principals gave them signed contracts without telling them what procedures had been followed. Although all teachers were required to obtain administrative permission to participate in the Reducing the Risk study, the level or position of the person making the final decision varied across the schools. In most cases, permission was granted directly by the principal or superintendent; in only one case was permission sought from the school board and then subsequently denied.

Parental permission. While most teachers anticipated that parental permission would be a potential obstacle, in reality parents presented relatively little difficulty. According to one teacher from an inner-city St. Louis school, some of the lack of parental resistance, unfortunately, stems from the lack of parental involvement in the lives of students who have nontraditional living arrangements. As this teacher observed, "We have children that are living in different settings. We have some teens that live with their grandparents...and then the children are living with maybe an aunt or relative, so I guess they do not have the same kind of resistance as maybe a parent. We also have some kids that live with roommates. They have been emancipated."

The first hurdle was getting students to return the signed parental consent forms, because students either lost them on the way home or forgot to return them once they had been signed. All of the teachers used the gift certificates to encourage students to return the forms.

Teachers invented creative ways of providing extra encouragement, including raffling off the gift certificates or a small prize to students who returned the forms and using the gift certificates to purchase small gifts for all those who returned the forms. The incentives generally revolved around food. One teacher was honest when she said, "I think I probably wouldn't have gotten any if I hadn't bribed them with junk food."

Some teachers attempted to promote participation by stressing the prestige or educational value of being involved in the study. One teacher who took this approach said, "I talked to the kids about having an impact on the future and tried to give them a big picture about what you were trying to do and about what the impact of them participating could be. And some of them I guess got into that." Another teacher stated, "Just telling them they were going to be a part of something special and that there would be a little something for them, I think that helped."

Another hurdle in gaining parental consent was the reluctance of a few parents to sign the permission slips. We gave each teacher a sample letter about the project to send home along with the permission forms. Some teachers used our letter and some chose to use letters that they had been using for many years to introduce parents to their sex education curricula.

A few parents were suspicious of the research and seemed uncomfortable with the subject matter. Several parents granted approval for their children to participate in the curriculum, but not to complete the survey. One parent said she did not want her child to be a part of "any government study." Another said, "I don't think any of this is anybody else's business."

Finally, one teacher discovered that some of the reluctance was coming from the students, rather than from their parents. She quoted her student as saying, "I never gave it to them, because I know if I give it to them, I'm going to have to talk about this stuff to them and I don't want to, so I just threw it away."

Changes to the Curriculum

We used data from both the comment portion of lesson feedback forms and the telephone interviews to analyze how the teachers modified the Reducing the Risk curriculum. The 12 teachers who agreed to teach the curriculum did so in a variety of classroom settings, reflecting their own varied titles as teachers of health and of family sciences and consumer sciences; some sought out other teachers, usually science teachers, who would allow them to guest-teach the Reducing the Risk curriculum.

Most teachers explained that they made modifications in response to school policy on teaching about birth control and condoms, in response to logistical difficulties in carrying out some of the assignments in rural areas or because they believed that their students needed more information on a particular subject.

The most frequently mentioned modifications involved deleting the lessons on shopping for condoms and visiting family planning clinics. The teachers working in rural areas also consistently mentioned logistical problems, such as a lack of student transportation. As one such teacher said, "If I had sent that home (condom shopping assignment), I guarantee somebody would have griped. And besides there's no place in town, I guess you can go to the gas station, to get condoms. We have to drive nine miles....I mean, a lot of my kids don't drive. So for them, they would have to say, 'Mom, I have to go pretend to buy condoms at Wal-Mart,' and this would have created problems."

"We had assumed that the teachers had accurately predicted the number of students in their Reducing the Risk classes in the coming year. In every case, however, they overestimated the number of students who would be exposed to the curriculum."

Some teachers altered the condom-shopping and clinic-visiting assignments by using class discussions, videos and guest speakers instead. They thus covered the information without requiring their students to do the assignments outside of school.

Several teachers added games, panel discussions or videos to the Reducing the Risk curriculum. In most cases, the teachers added these items because they felt the students had a particular need for information that was not addressed in the curriculum. One St. Louis teacher tried to make a connection to the local situation by bringing in a newspaper article about high rates of STDs among young adults in that city. Others added information about abusive relationships, date rape, educating parents on sexuality issues, and childbirth.

DISCUSSION

General Observations

This project involved data collection efforts in 12 schools spread across a large state. While the far-flung nature of this effort added to project costs for travel and staff, it allowed us to compare data from a geographically diverse sample of schools. The results suggest that urban and rural schools differed little in how they obtained permission from school administrators, parents and students, and both rural and urban schools were equally likely to drop out of the project because of administrators' concerns. Although urban schools did not have the same transportation problems with the condom-shopping lesson as did rural schools, teachers in both areas were equally likely to delete or modify this controversial lesson.

Future research of this type needs to be conducted with larger numbers of schools, and with the influence of school-level variables built into the analysis. These variables might include school location (level of urbanization), individual school characteristics (size, location and history), and administrator and teacher characteristics (key personality traits, gender, race and ethnicity, number of years of administrative or teaching experience, number of years in the school district, and personal views about school-based sexuality education).

One limitation of our research is the inherent difficulty in comparing teachers who chose to participate with those who did not participate. In most cases, the negotiation stage had clearly reached closure when the teachers or administrators told us that the school did not want to participate. Although it would have been interesting and informative to ascertain their reasons, especially those of officials who dropped out after signing contracts, it would have been politically unwise for us to push for additional detail.

Essential Channels of Communication

What can other researchers learn from our experience? The first step in answering this question requires analyzing the four communication channels with the greatest direct impact on the project (in terms of both recruitment issues and the implementation of the curriculum).

Teacher and researcher communication. Effective communication between the research team and the sexuality education teachers evolved slowly, but resulted in warm and collegial relationships as the project progressed. During the summer after the curriculum was implemented, we invited all 12 teachers and their administrators to an all-expenses-paid gathering in their honor at the university; nine teachers, but no administrators, ultimately attended. Doug Kirby, from ETR Associates, the publishers of Reducing the Risk, was also present to hear the teachers' comments and suggestions about the curriculum.

Early on in the project, we realized that four teachers were not returning our telephone calls. We later learned that they were not allowed to make long-distance calls from school, and none had telephones in their classrooms. Their limited window of time outside the classroom to return calls and our full schedules made daytime communication very difficult.

We handled this problem by calling the teachers at home in the evening and encouraging them to call us collect at home, evenings or weekends, if they had questions. We also established a standing weekly teleconference after school hours to foster intraproject communication and to make sure we were available at a set time to answer questions. However, no more than three teachers ever participated in a conference call at any given time (although two teachers called faithfully throughout the project, and we developed very close relationships with them). Teachers' comments led us to attribute their poor participation in the conference calls to scheduling conflicts and to a low comfort level and inexperience with such calls. Teachers seemed to respond more rapidly to faxed messages than to telephone messages.

Communication between teacher, principal and superintendent. It was often unclear to us, and to some teachers, who had the authority to approve the project in the school. At least four principals signed contracts without adequately examining the curriculum or deferring to their superiors. Two teachers remarked that perhaps they should have gone above their principals for permission. Another, however, mused that she should have left well enough alone, since although her principal gave permission for her to participate, going to her superintendent for additional approval ultimately resulted in permission being denied.

Communication between superintendent and school board. In general, superintendents did not bring up the project to their school boards, although one superintendent allowed a teacher to present the proposed project at a school board meeting. We offered to drive six hours to attend the meeting to support the teacher, but the principal told us that such a trip was unnecessary, because the superintendent supported the study and attendance at the school board meeting was only a formality. Surprisingly, however, the school board voted to deny approval to participate in the research project.

The superintendents of those teachers who dropped out of the study felt there was no need to approach the school boards because, as one stated, "it is a conservative community and [the project] would never receive school board approval, and this would create a problem for many of our parents and school board members."

Teacher-parent communication. Communicating about the research project with parents proved to be complicated, particularly regarding the consent requirements put in place by the university's institutional review board. Although many teachers had different longstanding procedures for informing parents about sex education activities, they understood the need to follow the procedures required by the university, and used the permission forms provided.

One teacher, however, reported after the fact that she had felt morally and ethically bound to bring to her students' attention—and through them, to parents' attention—the sentence on the permission form regarding the requirement that we report suspected child abuse. This teacher's reaction reduced the number of students who returned signed permission forms in her classes.

LESSONS LEARNED

We had assumed that teachers had accurately gauged the amount of opposition they expected in implementing this research project. The teachers may have been overly optimistic in their presumption of approval because they wanted to be selected; they perhaps found participation highly desirable and also wanted their schools to receive the monetary incentive.

We also had assumed that the teachers had accurately predicted the number of students in their Reducing the Risk classes in the coming year. In every case, however, the teachers overestimated the number of students who would be exposed to the curriculum. Sometimes this smaller sample size resulted from the lack of expected cooperation from other teachers who ultimately did not allow one of the 12 project teachers to "guest-teach" Reducing the Risk in their classes. Moreover, three of the 12 participating teachers had planned to implement the curriculum in more than one of their classes, but scheduling issues or curricular conflicts prevented them from doing so. These faulty assumptions about approval and sufficient sample size taught us lesson number one: Be conservative in planning around teachers' projections and their assessments of how large a sample size they can provide.

We expected that when an administrator signed a contract, it represented the school system's view on the project and that incoming administrators would honor it. We assumed that signed contracts with the university carried more legal weight than many administrators perceived them to carry. Since we feared that insufficient sampling might jeopardize the continuation of funding, we asked the university for legal advice on how to proceed with breach of contract; we soon learned, however, that any legal efforts would be ineffective.

These faulty assumptions taught us lesson number two: Oversample the number of schools, teachers and students involved to achieve the desired sample size, because there are few consequences for school systems that drop out, even when money has already been invested in teacher training, travel and resources.

We believed that an "insider" approach would be effective, because it would rely on teachers who were well-respected by the school and the community, who had established positive relationships with parents and who had dealt with controversy over sex education in their schools in the past. We had great respect for the teachers and recognized that many of them had been teaching sex education in the same school system for years and had set ways of operating.

One disadvantage of using this approach, however, was that these teachers would bring their own values and strongly held beliefs to the research process. As previously mentioned, one teacher felt strongly that the students specifically show their parents the sentence about child abuse on the parental consent form, an action that lowered the number of forms that were eventually returned.

In addition, some teachers just feel more comfortable than others in "pushing the issue" of sex education in their schools and communities. This experience taught us lesson number three: There are pros and cons that need to be weighed very carefully when deciding to ask teachers to play the pivotal role of "insider" in gaining permission to implement sex education research in schools; it cannot be assumed that because they are insiders, they can change the policies or decisions of their administrators.

An attitude of "let well enough alone" (i.e., only go as high in the hierarchy as you have to) seemed to pervade each level of this project. The teacher and principal alike were hesitant to request permission from the superintendent, who likewise was hesitant to request permission from the school board. Some principals believed that asking for higher-level permission would result in denial, and the loss of the opportunity to implement the curriculum, as well as the loss of the $750 honorarium. All parties involved, including us, were hesitant to "push the envelope," which might potentially block the project.

For example, even though one principal of a rural school supported his teacher who wanted to be involved, he preferred not to meet us. It was made very clear that when we were in the school, we were to go directly to her classroom, direct any administrative questions to the school counselor, and refer to the research as the "child development project." We assumed that he took this position so he could claim ignorance if confronted by a school board member or parent; he would not have been willing to go to his superintendent or school board for permission to participate. This attitude taught us lesson number four: Be willing to meet with and answer any and all questions from school administrators at all levels, but recognize that requiring approval signatures from the principal, superintendent and school board at each participating school may reduce the number of schools that are willing to cooperate. We would not recommend that researchers specify which administrator is required to sign the contract.

In conclusion, while we are heartened that the CDC has begun to identify effective sexuality education curricula, our research shows how difficult it can be to gain permission to conduct research on the implementation of those curricula. Moreover, it is often difficult to maintain the integrity of research-based curriculum in the midst of local conditions, values and preferences. While our findings are similar to those that we have heard about in informal conversations with other researchers, few authors have systematically recorded and analyzed the processes we describe here. We hope that this article will draw attention to, and open dialogue about, the complex relationships between sexuality researchers and school personnel.

References

1. Kann L et al., Youth Risk Behavior Surveillance—United States, 1999, Morbidity and Mortality Weekly Report, 2000, 49(SS-5):1­96.

2. Kirby D, No Easy Answers: Research Findings on Programs to Reduce Teen Pregnancy, 1997, Washington, DC: National Campaign to Prevent Teen Pregnancy.

3. Haffner D, 1987­1997: some progress; some problems, Family Life Matters, New Brunswick, NJ: Network for Family Life Education, State University of New Jersey­Rutgers, 1997.

4. Ibid.

5. Centers for Disease Control and Prevention (CDC), Programs That Work, Atlanta: CDC, 2000; and http:// www.cdc.gov/nccdphp/dash/rtc/curriculum.htm.

6. Jemmott JB, Jemmott LS and Fong GT, Reductions in HIV risk-associated sexual behaviors among black male adolescents: effects of an AIDS prevention treatment, American Journal of Public Health, 1992, 82(3):372­377.

7. St Lawrence JS et al., African-American adolescents' knowledge, health related attitudes, sexual behavior and contraceptive decisions: implications for the prevention of adolescent HIV infection, Journal of Consulting and Clinical Psychology, 1993, 6(11):104­112.

8. Stanton BF et al., A randomized, controlled effectiveness trial of an AIDS prevention program for low-income African-American youths, Archives of Pediatrics and Adolescent Medicine, 1996, 150(4):363­372.

9. Main DS et al., Preventing HIV infection among adolescents: evaluation of a school-based education program, Preventive Medicine, 1994, 23(4): 409­417.

10. Barth RP, Reducing the Risk: Building Skills to Prevent Pregnancy, 3rd ed, Santa Cruz, CA: ETR Associates, 1989.

11. Main DS et al., 1994, op. cit. (see reference 9).

12. Kirby D, et al., Reducing the Risk: a new curriculum to prevent sexual risk-taking, Family Planning Perspectives, 1991, 23(6):253­263.

13. Kann L et al., 2000, op. cit. (see reference 1).

14. Wilson SN, The next ten years, Family Life Matters, New Brunswick, NJ: Network for Family Life Education, State University of New Jersey­Rutgers, 1997, p. 2.

15. Lohrmann DK et al., Characteristics of local high school HIV curricula: adoption and implementation in Maine, 1999, paper presented at the annual meeting of the American School Health Association, Kansas City, MO, Oct. 27­31, 1999.

16. Harrington KF et al., Recruitment issues in school-based research: lessons learned from the High 5 Alabama Project, Journal of School Health, 1997, 67(10): 415­421.

17. Olds SR and Symons CW, Recommendations for obtaining cooperation to conduct school-based research, Journal of School Health, 1990, 60(3):96­98.

18. Harrington KF et al., 1997, op. cit. (see reference 16).

19. Barth RP, 1989, op. cit. (see reference 10).

20. Hubbard BM, Giese ML and Rainey J, A replication study of Reducing the Risk: a theory-based sexuality curriculum for adolescents, Journal of School Health, 1998, 68(6):243­247; and Kirby D, 1991, op. cit. (see reference 12).

21. Kirby D, ETR Associates, Santa Cruz, CA, personal communication, June 2, 1999.

*This specific sentence, required by the university's institutional review board, stated that any information provided by the student that might lead the teacher or researcher to suspect child abuse would be reported to the authorities.

One teacher did not complete the requested rating form, and another who taught at the Catholic school deleted five lessons on birth control and condoms, without our approval. On her feedback form she wrote, "I wish I could have talked about protection. It was hard to teach in a Catholic school."

For example, when the superintendent of a large suburban school that had agreed to involve 200 students dropped out, he was sent a letter by the university legal counsel reminding him of his contractual obligations to the project. His reply was "So sue me."

 

AUTHOR AFFILIATIONS

Lynn Blinn-Pike is director, and Thomas Berger is project coordinator, both at the Center on Adolescent Sexuality, Pregnancy, and Parenting, University of Missouri-Columbia. Melinda Rea-Holloway is a doctoral student at the University of Missouri-Kansas City. Funding for the study on which this article was based was provided by grants from the Pharmacia-Upjohn Corporation, Missouri Department of Health, and grant APR 000971-01-0 with the Office of Population Affairs, U.S. Department of Health and Human Services.