Elizabeth Baumler

Safer choices: reducing teen pregnancy, HIV, and STDs.

Objectives. This study evaluated the long-term effectiveness of Safer Choices, a theory-based, multi-component educational program designed to reduce sexual risk behaviors and increase protective behaviors in preventing HIV, other STDs, and pregnancy among high school students. Methods. The study used a randomized controlled trial involving 20 high schools in California and Texas. A cohort of 3869 ninth-grade students was tracked for 31 months from fall semester 1993 (baseline) to spring semester 1996 (31-month follow-up). Data were collected using self-report surveys administered by trained data collectors. Response rate at 31-month follow-up was 79%. Results. Safer Choices had its greatest effect on measures involving condom use. The program reduced the frequency of intercourse without a condom during the three months prior to the survey, reduced the number of sexual partners with whom students had intercourse without a condom, and increased use of condoms and other protection against pregnancy at last intercourse. Safer Choices also improved 7 of 13 psychosocial variables, many related to condom use, but did not have a significant effect upon rates of sexual initiation. Conclusions. The Safer Choices program was effective in reducing important risk behaviors for HIV, other STDs, and pregnancy and in enhancing most psychosocial determinants of such behavior.

It's Your Game: Keep It Real: Delaying Sexual Behavior with an Effective Middle School Program

PURPOSE This study tested the effects of a theory-based, middle-school human immunodeficiency virus, STI, and pregnancy prevention program, Its Your Game: Keep it Real (IYG), in delaying sexual behavior. We hypothesized that the IYG intervention would decrease the number of adolescents who initiated sexual activity by the ninth grade compared with those in the comparison schools. METHODS The target population consisted of English-speaking middle school students from a large, urban, predominantly African-American and Hispanic school district in Southeast Texas. Ten middle schools were randomly assigned either to receive the intervention or to the comparison condition. Seventh-grade students were recruited and followed through ninth grade. The IYG intervention comprises 12 seventh-grade and 12 eighth-grade lessons that integrate group-based classroom activities with computer-based instruction and personal journaling. Ninth-grade follow-up surveys were completed by 907 students (92% of the defined cohort). The primary hypothesis tested was that the intervention would decrease the number of adolescents who initiated sexual activity by the ninth grade compared with those in the comparison schools. RESULTS Almost one-third (29.9%, n=509) of the students in the comparison condition initiated sex by ninth grade compared with almost one-quarter (23.4%, n=308) of those in the intervention condition. After adjusting for covariates, students in the comparison condition were 1.29 times more likely to initiate sex by the ninth grade than those in the intervention condition. CONCLUSIONS A theory-driven, multi-component, curriculum-based intervention can delay sexual initiation up to 24 months; can have impact on specific types of sexual behavior such as initiation of oral and anal sex; and may be especially effective with females. Future research must explore the generalizabilty of these results.

Schoolwide Effects of a Multicomponent HIV, STD, and Pregnancy Prevention Program for High School Students

Few studies have tested schoolwide interventions to reduce sexual risk behavior, and none have demonstrated significant schoolwide effects. This study evaluates the schoolwide effects of Safer Choices, a multicomponent, behavioral theory–based HIV, STD, and pregnancy prevention program, on risk behavior, school climate, and psychosocial variables. Twenty urban high schools were randomized, and cross-sectional samples of classes were surveyed at baseline, the end of intervention (19 months after baseline), and 31 months after baseline. At 19 months, the program had a positive effect on the frequency of sex without a condom. At 31 months, students in Safer Choices schools reported having sexual intercourse without a condom with fewer partners. The program positively affected psychosocial variables and school climate for HIV/STD and pregnancy prevention. The program did not influence the prevalence of recent sexual intercourse. Schoolwide changes in condom use demonstrated that a school-based program can reduce the sexual risk behavior of adolescents.

Can education policy be health policy? Implications of research on the social determinants of health

Research on the social determinants of health has demonstrated robust correlations between several social factors, health status, and life expectancy. Some of these factors could be modified through policy intervention. National-level public policies explicitly based on population health research are in various stages of development in many Western countries, but in spite of evident need, seemingly not at all in the United States. Because research shows such a strong association between education and good health, we offer evidence to show that at least two pressing problems in American society, namely the uneven distribution of educational attainment and health disparities linked to socioeconomic position, may be ameliorated through policy initiatives that link quality early childhood care, child development programs, and parental training in a seamless continuum with strengthened K-12 education.

Sexual Risk Avoidance and Sexual Risk Reduction Interventions for Middle School Youth: A Randomized Controlled Trial

PURPOSE To evaluate the efficacy of two, theory-based, multimedia, middle school sexual education programs in delaying sexual initiation. METHODS Three-armed, randomized controlled trial comprising 15 urban middle schools; 1,258 predominantly African American and Hispanic seventh grade students followed into ninth grade. Both programs included group and individualized, computer-based activities addressing psychosocial variables. The risk avoidance (RA) program met federal abstinence education guidelines; the risk reduction (RR) program emphasized abstinence and included computer-based condom skills-training. The primary outcome assessed program impact on delayed sexual initiation; secondary outcomes assessed other sexual behaviors and psychosocial outcomes. RESULTS Participants were 59.8% females (mean age: 12.6 years). Relative to controls, the RR program delayed any type of sexual initiation (oral, vaginal, or anal sex) in the overall sample (adjusted odds ratio [AOR]: .65, 95% CI: .54-.77), among females (AOR: .43, 95% CI: .31-.60), and among African Americans (AOR: .38, 95% CI: .18-.79). RR students also reduced unprotected sex at last intercourse (AOR: .67, 95% CI: .47-.96), frequency of anal sex in the past 3 months (AOR: .53, 95% CI: .33-.84), and unprotected vaginal sex (AOR: .59, 95% CI: .36-.95). The RA program delayed any sexual initiation among Hispanics (AOR: .40, 95% CI: .19-.86), reduced unprotected sex at last intercourse (AOR: .70, 95% CI: .52-.93), but increased the number of recent vaginal sex partners (AOR: 1.69, 95% CI: 1.01-2.82). Both programs positively affected psychosocial outcomes. CONCLUSIONS The RR program positively affected sexually inexperienced and experienced youth, whereas the RA program delayed initiation among Hispanics and had mixed effects among sexually experienced youth.

Effectiveness of an Intervention to Increase Pap Test Screening Among Chinese Women in Taiwan

This study assessed the effectiveness of a theory-based direct mail campaign in encouraging non-compliant women, aged 30 and older or younger if married, to obtain a Pap test. Participants were female family members of inpatients admitted to one of the major teaching hospitals in Taiwan during August–September 1999. A total of 424 women were recruited in the randomized intervention trial. Three months following implementation of the intervention, women in the intervention group reported a higher rate of Pap test screening than women in the comparison group (50% versus 32%) (p = 0.002). Women in the intervention group also showed higher perceived pros of a Pap test at follow-up (p = 0.031). Although women in both groups showed an increased knowledge and intention to obtain a Pap, only the intervention group had significantly higher follow-up scores on perceived pros and susceptibility. The results shows that the intervention was effective in increasing Pap test screening among Chinese women within three months. The results also support the use of Intervention Mapping, a systematic program development framework for planning effective interventions.

Dating Violence Among Urban, Minority, Middle School Youth and Associated Sexual Risk Behaviors and Substance Use

BACKGROUND Whereas dating violence among high school students has been linked with sexual risk-taking and substance use, this association has been understudied among early adolescents. We estimated the prevalence of physical and nonphysical dating violence in a sample of middle school students and examined associations between dating violence, sexual, and substance use behaviors. METHODS Logistic regression models for clustered data from 7th grade students attending 10 Texas urban middle schools were used to examine cross-sectional associations between dating violence victimization and risk behaviors. RESULTS The sample (N = 950) was 48.5% African American, 36.0% Hispanic, 55.7% female, mean age 13.1 years (SD 0.64). About 1 in 5 reported physical dating violence victimization, 48.1% reported nonphysical victimization, and 52.6% reported any victimization. Adjusted logistic regression analyses indicated that physical, nonphysical, and any victimization was associated with ever having sex, ever using alcohol, and ever using drugs. CONCLUSIONS Over 50% of sampled middle school students had experienced dating violence, which may be associated with early sexual initiation and substance use. Middle school interventions that prevent dating violence are needed.

Multilevel models and unbiased tests for group based interventions: Examples from the safer choices study

For many large-scale behavioral interventions, random assignment to intervention condition occurs at the group level. Data analytic models that ignore potential non-independence of observations provide inefficient parameter estimates and often produce biased test statistics. For studies in which individuals are randomized by groups to treatment condition, multilevel models (MLMs) provide a flexible approach to statistically evaluating program effects. This article presents an explanation of the need for MLMs for such nested designs and uses data from the Safer Choices study to illustrate the application of MLMs for both continuous and dichotomous outcomes. When designing studies, researchers who are considering group-randomized interventions should also consider the features of the multilevel analytic models they might employ.

CORRELATES OF CERVICAL CANCER SCREENING AMONG WOMEN IN TAIWAN

In this study we examine several theory-based psychosocial factors on cervical cancer screening among Chinese women in Taiwan (N = 125). The reliabilities of the scales showed good internal consistence (Chronbach alpha ranged from 0.68 to 0.88). We found that 30% of the women had never received a Papanicolaou (Pap) test, and only 58% reported a screening in the past 3 years (adherent). Intention to have a Pap test in the coming year was higher among screening adherence women (90%) than nonadherents (58%). Multiple logistic regression analysis revealed significant associations between screening adherence and womens knowledge (p = 0.034), perceived pros (p = 0.041), cons (p = 0.000), and norms (p = 0.019) of a Pap test. In addition to identifying screening associated factors, we also provided a basis for measuring important theory-based constructs. Although we developed some scale items for Chinese culture, data showed that psychosocial factors were universally relevant. Future intervention efforts tailoring these factors could potentially impact cancer screening for women internationally.

A Cross-National Comparison of Youth Risk Behaviors in Latino Secondary School Students Living in El Salvador and the USA

Objectives. As Latin Americans’ exposure to the USA increases through migration patterns and US political and economic ties to their countries of origin, they become susceptible to adopting not only the cultural expressions of the USA such as fashion, but also the health-related behaviors of the US population. In assessing potential health risks for Salvadoran youth that may result from the connection between Latin Americans and the USA, this study compared the prevalence of health risk behaviors from four behavior domains (aggression and victimization, depression and suicidal ideation, substance use, and sexual behavior) between Salvadoran and US Latino secondary school students aged 14–17 years. Design. A secondary analysis was performed on two 1999 cross-sectional survey data. In the USA, results were based on 1,063 Latino high school students who answered the nationally representative Youth Risk Behavior Survey (YRBS) conducted by the Centers for Disease Control and Prevention. In El Salvador, results were based on 793 public secondary school students who answered a local YRBS survey conducted in coordination with the Ministry of Education of El Salvador. Results. The prevalence rates for aggression/victimization and for depression and suicidal ideation behaviors were similar between Salvadoran and US Latino adolescents. Substance use prevalence, however, was 10–40% higher for US Latino adolescents. While the prevalence of sexual intercourse was higher among US Latino youth (between 13 and 27% higher, depending on age), the prevalence of condom use was lower among sexually active Salvadoran youth (between 11 and 42% lower, depending on age). Conclusions. In the context of the transnationalization of the Salvadoran population, with potential for increased influence of the USA in Salvadoran culture, these differences in risk behavior are important for targeting effective interventions for Latino adolescents in El Salvador and in the USA.