In a largely Hispanic middle school population in California, male youth receiving a three-year, 20-lesson, theory-based curriculum on pregnancy and sexually transmitted disease (STD) prevention had delayed sexual initiation compared with their peers receiving regular sex education;1 however, the program did not delay sexual initiation for females. Even a full year after the program ended, males who had received the intervention were significantly less likely than their peers to report having any sexual activity in the previous 12 months; this is explained, in part, by program participants' successful avoidance of situations that could lead to sex.
The intervention, called Draw the Line/Respect the Line, aims primarily to decrease the proportion of students having sex and to increase condom use among sexually active youth. Program participants and controls in this randomized trial came from three ethnically and socioeconomically diverse urban school districts in northern California. Students at 10 middle schools were randomly assigned to receive the intervention as their main source of school-based pregnancy and STD prevention education throughout grades 6-8; students at nine other schools, the control group, received their school's usual education on these topics. The intervention group received 20 lessons presented in English or Spanish by experienced health educators during classroom periods; instruction techniques were interactive and included small group discussions and skills practicing.
Sixth-grade intervention recipients and controls—2,829 students in all—completed a baseline survey in the spring of 1997; they also completed annual follow-up surveys at the end of grades 7-9. Surveys asked about demographic characteristics, sexual behaviors and psychosocial measures that used scaled scores to assess students' knowledge of HIV and condoms, attitudes toward potential reasons for having or not having sex, normative beliefs, self-efficacy to refuse sex, sexual limits and situations that could lead to sex.
Nearly equal numbers of males and females completed the baseline survey; the mean age at baseline was 11.5. More than half the students were Hispanic (59%); 17% were white, 16% were Asian, 5% were black and 3% were of other races or ethnicities. Four percent of students reported having had intercourse at baseline.
Males in the intervention group differed statistically from those in the control group at each follow-up in the proportions reporting two key sexual behavior variables: The adjusted proportions reporting any sexual experience were 10% among intervention recipients and 14% among controls in seventh grade, 15% vs. 22% in eighth grade, and 19% vs. 27% in ninth grade. Sex in the past year was reported by 7% of intervention recipients and 11% of controls in seventh grade, 11% and 19% in eighth, and 17% and 25% in ninth. The groups also differed significantly (and increasingly) over time in the proportions reporting any sexual experience.
On these same two variables, no statistically significant differences were found between females receiving the intervention and female controls. The adjusted proportions reporting ever having had sex were 6% for both groups in seventh grade, 11-12% in eighth grade and 20-22% in ninth. Sex in the past year was reported by 4-5% in seventh grade, 9% of both groups in eighth and 18-20% in ninth.
No group differences were found for either males or females in the proportions reporting recent condom use. However, statistical power for this analysis was limited.
In regression analyses, improvements over time were significantly greater among males in the intervention group than among male controls in the adjusted mean scores reflecting HIV and condom knowledge, attitudes favoring reasons for not having sex, sexual limits and situations that could lead to sexual behavior. For each gender, the intervention group demonstrated greater improvements over time in peer normative beliefs favoring sex; in addition, the intervention and control groups differed at each follow-up for HIV and condom knowledge.
The investigators also used regression models to examine whether psychosocial variables measured in the eighth grade mediated the effects of the intervention on males' report in the ninth grade of having had sex in the previous 12 months. According to the investigators, being in situations that can lead to sex was "the most important behavioral mediator": Males receiving the intervention had 30% lower odds of being in such situations than males in the control group; meanwhile, those who reported being in such situations had increased odds of reporting sex in the past year (odds ratio, 1.6). Other mediators were ability to set sexual limits, peer norms supporting sexual activity and belief that it is all right for females to pressure males to have intercourse.
Commenting on the program's success among males, the authors note that "this intervention may have created a new norm within the school environment—one that made boys more comfortable with the idea of refraining from sex." In addition, they assert that the intervention "provided boys with a crucial skill—recognizing and avoiding situations that might lead to sexual intercourse."
1. Coyle KK et al., Draw the Line/Respect the Line: a randomized trial of a middle school intervention to reduce sexual risk behaviors, American Journal of Public Health, 2004, 94(5):843-851.