Students in Texas middle schools that provided a program designed to help youth avoid STDs and pregnancy were less likely than those in schools that did not offer the program to have initiated sexual activity by ninth grade, according to findings from a randomized trial.1 By ninth grade, 30% of students in comparison schools had had vaginal, oral or anal sex, compared with 23% of students whose schools provided the prevention program (relative risk, 1.3). The difference was particularly apparent among Hispanic (1.6) and female (1.4) participants. Moreover, among students who reported in ninth grade that they had been sexually active in the past three months, those in the comparison group were more likely than those in the intervention group to have had sex multiple times during that period (1.3).
The trial was conducted in 2004–2007 in an urban school district in southeast Texas. Ten middle schools were randomly assigned either to provide the program, called It’s Your Game: Keep It Real, or to serve as the comparison group. In schools assigned to the program, students received 12 lessons of 45 minutes each in the seventh grade and again in the eighth grade; in comparison schools, students had their usual health classes. The inter-vention, which comprised classroom activities, journal-keeping and computer-based instruction, covered such topics as setting personal limits (both in general and in sexual contexts); healthy friendships and dating relationships; puberty, reproduction and STDs; refusal skills concerning sexual behavior; and skills training related to condoms and contraceptives. The program also included homework activities designed to facilitate discussions between students and parents.
A total of 1,307 seventh graders completed a baseline survey in the fall of 2004, and most completed follow-up surveys in each of the following two springs. A final follow-up survey was administered in 2006–2007, when participants were in the ninth grade. The analytic sample consisted of the 907 students who completed the final survey—558 from comparison schools and 349 from intervention schools.
All of the surveys asked students whether they had ever had oral, vaginal or anal sex; ninth graders who had had any type of sex were asked whether they had engaged in specific behaviors that reduce sexual risk (e.g., using condoms) or heighten it (e.g., having multiple partners). The surveys also included questions about demographic characteristics and about beliefs, attitudes and intentions related to sex. All data were collected via audio computer-assisted self-interview. The researchers conducted regression analyses to test for differences between groups in the main outcome (sexual experience by ninth grade) and various secondary outcomes.
Eighty-six percent of students in the analytic sample were black or Hispanic, and 59% were female. About half (47%) lived with two parents, and a similar proportion (51%) reported that their grades in school were mostly A’s and B’s. Attendance sheets indicated that two-thirds of students in the intervention group had attended at least 20 of the 24 It’s Your Game lessons.
At baseline, the proportion of students who had ever had oral, vaginal or anal sex was statistically similar in the comparison (8%) and intervention (11%) cohorts. However, among students who had been sexually inexperienced at baseline, the proportion who had initiated sex by ninth grade was significantly greater in the comparison group (30%) than in the intervention group (23%); after adjustment for age, race and other covariates, the relative risk of having had sex for the first time between baseline and ninth grade was 1.3 times as high in the comparison group as in the intervention group. The increase in risk was evident among Hispanic (relative risk, 1.6) and female (1.4) students, but not among black or male participants.
The apparent benefits of the intervention differed according to the type of sex involved and students’ race. Overall, respondents in the comparison group were more likely than those in the intervention group to have had oral sex (relative risk, 1.8) or anal sex (2.7) for the first time between baseline and ninth grade, but the risk of initiating vaginal sex did not differ by cohort. A similar -pattern was -evident among black students (1.8 and 3.1, -respectively); in contrast, among Hispanic students, the risk of having initiated vaginal sex was elevated in the comparison group (1.7), but the risk of oral or anal sex was not.
The statistical power of analyses of the intervention’s impact on sexually active ninth graders was limited by the relatively small numbers of students who had had oral (85), vaginal (166) or anal (37) sex in the past three months. Nonetheless, those in the comparison group appeared to be more likely than those in the intervention group to have had vaginal sex multiple times (relative risk, 1.3). No differences were apparent between groups in the frequency of oral or anal sex, or of risk behaviors such as having unprotected sex or having sex while using drugs or alcohol.
Finally, at the eighth-grade evaluation, students’ attitudes, beliefs and intentions differed by intervention status. Compared with students not exposed to the program, those in the It’s Your Game cohort had more positive attitudes toward abstinence until marriage, had greater knowledge about condoms and STDs, and were more confident about refusing sex and using condoms. Many of these differences were still evident at the ninth-grade survey.
The researchers note that although the study had several limitations—including its modest sample size and its reliance on self-reported measures—it is the first trial of a comprehensive prevention intervention to show reductions in specific sexual behaviors among middle-school students. Targeting this relatively young population, the investigators note, is imperative, given that a third of ninth graders in the United States have had some form of sex. They suggest that the success of the intervention may be due in part to such features as the program’s use of interactive computer activities. However, they add that because the study sample was not nationally representative, It’s Your Game needs to be evaluated in other contexts and populations.
1. Tortolero SR et al., It’s Your Game: Keeping It Real: delaying sexual behavior with an effective middle school program, Journal of Adolescent Health, 2010, 46(2):169–179.