A 27-Month Evaluation of a Sexual Activity Prevention Program in Boys & Girls Clubs across the Nation
St Pierre, Tena L., Mark, Melvin M., Kaltreider, D. Lynne, Aikin, Kathryn J., Family Relations
The United States continues to have the highest adolescent pregnancy rate among industrialized nations; more than one million teenage girls become pregnant each year (Moore, 1989). The profound medical, psychological, and social risks associated with teenage childbearing have resulted in a multitude of programs that attempt to prevent adolescent pregnancy. Empirical evaluations of these programs have produced mixed and inconsistent results (Hofferth & Miller, 1989).
In particular, findings for sexual abstinence programs have been disappointing. Most evaluations have included primarily white middle-class junior and senior high school students and assessed only participants' short-term beliefs, attitudes, and knowledge (e.g., Olsen, Weed, Ritz, & Jensen, 1991; Olson, Wallace, & Miller, 1984). Any changes found in sexual attitudes have been modest (Olsen, Weed, Daly, & Jensen, 1992).
Sexual behavior has rarely been measured in evaluations of abstinence. only programs. In studies in which sexual behaviors were assessed, only one published evaluation (Jorgensen, Potts, & Camp, 1993) found desired behavioral effects, specifically on a six-month follow-up measure of sexual behavior for a very small number of youths who were virgins before the program. Other studies reported either no changes in sexual behaviors (Donahue, 1987; Jorgensen, 1991; Miller et al., 1993) or an increase in precoital sexual activity during the treatment period (Christopher & Roosa, 1990).
Results of these evaluations suggest that abstinence-only pregnancy prevention programs may be ineffective in reducing sexual activity and pregnancy risk. This finding has led some researchers (Christopher & Roosa, 1990; Roosa & Christopher, 1990) instead to advocate for multicomponent programs that have demonstrated success in reducing teenage pregnancy by emphasizing abstinence but also offering the alternative of contraceptives for those teens who choose to become sexually active (Howard & McCabe, 1990; Vincent, Clearie, & Schluchter, 1987; Zabin, Hirsch, Smith, Streett, & Hardy, 1986; Zabin et al., 1988)
One example of such a multicomponent program is Postponing Sexual Involvement (PSI; Howard & McCabe, 1990). PSI is based on the social influence model of prevention and is led by older teens. According to the theory underlying this model, young people engage in negative health behaviors, including sexual activity, because of societal and peer influences. Therefore, in addition to learning factual information, teens in the PSI program discuss social and peer pressures to engage in sexual activity and practice skills to help them resist these pressures.
The PSI Educational Series classroom component, which strongly urges teens to postpone having sex, was offered in combination with a human sexuality classroom component that taught factual information about reproductive health, including contraceptives and how to use them. Referral to contraceptive counseling and services also was provided for teens who made the decision to engage in sexual activity. Evaluation results found that the PSI program was effective in helping teens delay initial sexual intercourse (Howard & McCabe, 1990). Eighth-grade program participants who had not had sexual inter. course prior to the program were significantly more likely to postpone having coitus through the end of the ninth grade than those who did not participate in the program.
Although the 5-session PSI program (without the 5-session human sexuality component) is being widely disseminated and touted by the popular press as an effective abstinence program (e.g., Klein, 1934; Newman, 1994; Shinkle, 1992a, 1992b), Howard and McCabe (1992) concede that PSI's effectiveness without the human sexuality component is not known. Moreover, Howard and McCabe advocate that adolescents be offered PSI in combination with information about reproduction, sexually transmitted diseases, and contraceptives so that teens who do become sexually active can protect themselves from disease and pregnancy.
In this article, we report the evaluation of an abstinence-only program designed to postpone sexual activity among youths in Boys & Girls Clubs. (At the time of the study, the parent organization was Boys Clubs of America.) The program is based on the personal and social competence model of prevention, a broader version of the social influence model. Both models are considered psychosocial approaches in that they focus on the psychosocial factors promoting the initiation of problem behaviors. Like social influence-based programs, personal and social competence-based prevention programs focus on peer and other social influences on adolescents to engage in negative health behaviors and on the development of skills to resist those pressures. However, personal and social competence prevention programs also emphasize an array of general personal and social skills for coping with life. A number of psychosocial programs originally aimed at preventing cigarette smoking also sought to prevent other problem behaviors of adolescence such as drinking and marijuana use. Evaluations of these programs found significant reductions in adolescent smoking rates and more moderate success in reducing marijuana and alcohol use (Botvin, Baker, Botvin, Filazzola, & Millman, 1984; Botvin, Baker, Renick, Filazzola, & Botvin, 1984; Hansen, Johnson, Flay, Graham, & Sobel, 1988; Pentz, 1983; Pentz et al., 1989).
Although some psychosocial drug prevention programs have demonstrated initial effectiveness over a one-year period (e.g., Botvin, Renick, & Baker, 1983), these initial effects have tended to disintegrate after one year (Botvin & Wills, 1985). Some recent school-based drug prevention programs added booster sessions one and two years after the initial programs to sustain the behavioral changes as youths experience developmental transitions and influences that make them increasingly at risk for trying different drugs and activities (Battjes & Bell, 1985; Connell, Turner, & Mason, 1985). These programs effectively prevented or reduced young adolescents' use of cigarettes and marijuana over time (Botvin, Baker, Dusenbury, Tortu, & Botvin, 1990; Ellickson & Bell, 1990).
Results from the PSI program indicate that the psychosocial approach, which appears effective in preventing or reducing adolescent drug use, also may be effective in preventing teen sexual activity (Howard & McCabe, 1930). Given that booster sessions reduced cigarette and marijuana use with young teens, it seems plausible that the addition of booster sessions may sustain the effects of an initial sexual activity prevention program.
Despite the emerging pattern whereby psychosocial prevention programs show effects for sexual activity, cigarette smoking, alcohol use, and marijuana use, we are aware of no published evaluations of programs addressing the prevention (or postponement) of teen sexual activity in the context of a multifocus program that also seeks to prevent adolescent drug use. Such a multifocus program appears to be a reasonable strategy because adolescents engaging in one of these problem behaviors are likely to engage in the others (Jessor, 1975). Moreover, because the dynamics and risk factors for these problem behaviors appear to be similar (Jessor & Jessor, 1977), a multifocus program may be more effective and is more efficient than single-focus programs that address sexual activity prevention and drug prevention separately.
To address whether a multifocus psychosocial prevention program would be effective, we conducted a 27-month longitudinal study of Stay SMART, a program that aims to prevent/reduce sexual activity, cigarette smoking, alcohol use, and marijuana use among youths in Boys & Girls Clubs across the country. The study sought to determine whether, unlike the majority of abstinence programs dedicated exclusively to preventing teen sexual activity (Christopher & Roosa, 1990; Jorgensen, 1991; Olsen et al., 1991; Olson et al., 1984), a sexual activity prevention program might be effective as part of a program also designed to prevent cigarette, alcohol, and marijuana use. In this study, we also sought to discover whether the addition of two years of booster programs would enhance program effects.
The Stay SMART program has been shown to have positive effects for drug-related problem behaviors (St. Pierre, Kaltreider, Mark, & Aikin, 1992). The Stay SMART program alone and the Stay SMART program with the booster programs showed effects for marijuana, cigarette, alcohol, and overall drug use, and knowledge concerning drug use. The Stay SMART program with the booster programs produced additional effects for alcohol attitudes and marijuana attitudes after each year of booster programs.
The present article focuses on the effectiveness of the Stay SMART program in preventing/reducing early sexual activity among young teens in Boys & Girls Clubs. In Boys & Girls Clubs, youths voluntarily congregate in a non-school atmosphere to engage in athletic activities, games, and interaction with positive adult role models. The organization, whose motto is "the Club that beats the streets," has traditionally served disadvantaged youths.
The Stay SMART program employs a postponement approach to sexual activity but also conveys the message to teens that if they have been sexually active, they can still decide to postpone further sexual activity. Theoretically, Stay SMART is similar to the 5-session PSI program in that Stay SMART is based on the personal and social competence approach to prevention, a broader version of the social influence model. However, Stay SMART and PSI differ in that Stay SMART is an abstinence-only program containing no contraceptive information or services, whereas PSI, as evaluated, exposed participants to a contraceptive component. In addition, Stay SMART was led by adult Boys & Girls Club staff members, whereas eleventh- and twelfth-grade teens led the PSI program. Furthermore, Stay SMART differs from PSI, as well as previously evaluated abstinence-only programs, in two ways: (a) Stay SMART is a multifocus program simultaneously addressing the prevention of teen sexual activity, smoking, drinking, and marijuana use, whereas other programs focused solely on preventing/postponing sexual activity; and (b) the Stay SMART program was implemented in the Boys & Girls Club setting where youths voluntarily came to the clubs for sessions, whereas most other programs were offered to school students in a classroom setting.
Our study sought to answer the following questions:
1. In the Boys & Girls Club setting, would a personal and social competence program designed to simultaneously prevent/reduce sexual activity, cigarette smoking, alcohol use, and marijuana use, affect sexual activity?
2. Would the addition of a two-year booster program, designed to reinforce skills and knowledge learned in the initial prevention program, enhance program effects?
The Program and Its Implementation
Stay SMART. The multifocus prevention program, Stay SMART, is a component of SMART Moves, the National Prevention Program of Boys & Girls Clubs of America (BGCA). The cigarette, alcohol, and marijuana components of Stay SMART were adapted by BGCA from Botvin's (1983) Life Skills Training (LST) program, originally designed as a school-based drug prevention program.
The 12-session Stay SMART program includes the original topics in the LST program (12 sessions condensed to plus the addition of topics designed by BGCA to prevent early sexual activity (3 sessions). Aspects of sexual activity prevention also were integrated through most of the remaining curriculum. (See St. Pierre et al., 1992, for a description of how Stay SMART was adapted from LST.)
Many of the Stay SMART sessions address sexual activity and gateway drug prevention within the same educational activity. For example, in Session 3, Advertising, youths analyze advertisements to help them see how underlying pressures in the media promote sexual activity and drug use. In Session 10, Assertiveness, teens participate in role-play situations in which they practice resisting pressures to have sex or to smoke, drink, or use other drugs. Youths also discuss "lines" commonly used to pressure teens into having sex and practice responses that assertively convey their desire not to engage in sexual activity.
Session 5, Coping with Change, deals with the physical and emotional changes that occur during puberty. Although emphasizing the postponement of sexual activity, the session focuses on factual information on the physical and developmental changes preparing the body for reproduction, as well as the consequences of teenage sexual activity. Meaningful relationships and ways to show caring while postponing sexual involvement are discussed in Session 11, Relationships. Finally, Session 12, Life Planning Skills, addresses how drugs and pregnancy can keep teens from achieving their goals.
Booster Sessions: SMART Leaders I and SMART Leaders I. Like Stay SMART, SMART Leaders, the two-year booster program developed by St. Pierre and Kaltreider (1989), is based on the personal and social competence approach. This program was presented to Stay SMART completers as a peer leader program that encourages participants to be positive role models and to help their peers resist pressures to engage in sexual activity and to smoke, drink, and use other drugs. At the same time, SMART Leaders was designed to reinforce skills learned in the initial Stay SMART program, to meet the developmental needs of program youths, to keep the teens involved in club and prevention activities after completing sessions each year, and to create an overall Boys & Girls Club environment with positive behavioral norms.
The SMART Leaders I booster program included five small-group sessions designed to build upon the skills and knowledge presented in Stay SMART. These booster sessions focused on identifying pressures to engage in sexual activity and to use alcohol, tobacco, and other drugs; learning skills to resist those pressures; and practicing those skills through roleplaying. In particular, in Session 4, Resisting Media Pressures, discussion focused on the message conveyed by different forms of media that being sexually active and drinking and using other drugs is glamorous, desirable, and normal for teenagers. For example, program participants watched popular music videos, discussed the lyrics, and analyzed messages conveyed. In Session 5, Being Assertive in Pressure Situations, teens reviewed assertiveness skills and again practiced using those skills in roleplays of situations in which they were pressured to have sex or to smoke, drink, or use other drugs. The five-session program was made culturally relevant by prevention program leaders (professional prevention staff at each club) who selected culturally (and regionally) appropriate music videos, TV commercials, roleplays, and records and tapes used in specific sessions.
The SMART Leaders II booster program, developed to follow SMART Leaders I, was designed with a video format upon the advice of program delivery staff (prevention program leaders in the participating Boys & Girls Clubs). The inclusion of videos was designed to maintain the youths' involvement in the second booster program. Several modules were developed on resisting sexual activity, alcohol, and other drugs; an educational video was the core of each session. The common format consisted of session objectives, background information, discussion questions on the video, roleplaying, and other activities. Prevention program leaders were required to conduct one 1.5-hour session on each of the three topics.
As noted, after completing each year's small-group booster sessions, youths participated in club involvement and prevention activities. These activities were designed to keep SMART Leaders active in the prevention program specifically and in the Boys & Girls Club in general. Involvement activities ranged from being positive role models in the Boys & Girls Club and helping with club activities and events, to more specific prevention-related activities such as assisting with the prevention sessions offered to younger club members.
During each year of the project, the prevention program leaders received group training on the implementation of the SMART Leaders booster program. (The leaders had been trained previously by BGCA to implement the Stay SMART program.)
Fourteen Boys & Girls Clubs across the United States participated. A pretest-posttest non-equivalent groups design, with multiple posttests, was employed. Over 27 months, beginning in the winter of 1988: (a) five Boys & Girls Clubs offered only the Stay SMART program (without the two-year booster program), (b) five other Boys & Girls Clubs offered the Stay SMART program plus the two-year sequential SMART Leaders I and II booster programs, and (c) four Boys & Girls Clubs that did not offer a prevention program served as a control group.
Boys & Girls Clubs in the Stay SMART Only condition and the Stay SMART+Boosters condition were purposely selected from the 10 clubs that served as demonstration sites in Boys & Girls Clubs of America's original pilot testing of its SMART Moves prevention program immediately prior to this study. Site selections for this study were made from these 10 clubs because only they had been trained by BGCA and had implemented the Stay SMART program.
Five clubs were invited to participate in the Stay SMART Only condition and five in the Stay SMART+Boosters condition of the study. Efforts were made to ensure as much socioeconomic and demographic comparability as possible between the two groups. Two of the five Stay SMART Only clubs withdrew at the beginning of the project and were replaced by branches of two of the Stay SMART+Boosters clubs. The clubs in each of the two treatment groups were similar in that all 10 clubs were located in economically disadvantaged and high crime areas of their communities and had reported that members' families had higher than national average percentages of welfare recipients, female-headed households, unemployment, and incomes below the poverty level. Control clubs were selected from Boys & Girls Clubs that reported similar demographic characteristics and socioeconomic factors as the treatment clubs.
The pretest was conducted in February 1988, immediately prior to the initiation of the Stay SMART program in the Stay SMART Only and Stay SMART+Boosters groups. The first posttest was administered three months later (May 1988) at the completion of the Stay SMART program in the two treatment groups. Two additional posttests were administered at annual intervals in May of 1989 and 1990, approximately five months after each year's completion of SMART Leaders booster sessions in the Stay SMART+Boosters group. Figure 1 illustrates the testing schedule and study design.[Figure 1 omitted]
Thirteen-year-old members in each Boys & Girls Club in the two treatment groups were invited to participate; a total of approximately 24 youths enrolled in the program at each club. Boys & Girls Clubs in the control group similarly recruited approximately 30 same-aged members to participate only in testing over the 27 months. Table 1 illustrates the number of youths in each condition participating in (and retained through) all phases of the study over the 27 months.[Table 1 omitted] In Table 1, youths are classified in terms of whether they reported being virgins or nonvirgins at the time of the pretest. Youths in the Stay SMART Only group were required to attend 9 of the 12 Stay SMART sessions to be posttested after the program and to be eligible for follow-up posttests at 15 and 27 months. Stay SMART+Boosters youths were required to attend 9 of the 12 Stay SMART sessions, 4 of the 5 SMART Leaders I sessions, and all 3 SMART Leaders II sessions to be posttested each year.
A total of 161 youths participated in all four testing occasions (i.e., the pretest and three posttests) over the full 27 months of the study in the three groups of clubs; 9 of these 161 are excluded from Table 1 and from the analyses below because they failed to report whether they were virgins or nonvirgins at the pretest. The number of participants who met the attendance and/or testing criteria in each condition were: 49 youths in Stay SMART Only, 50 youths in Stay SMART+Boosters, and 53 youths in the control group. Overall, 56% of the participants reported that they were virgins at the pretest. However, the percentage varied by condition, with a lower proportion of virgins in the Stay SMART Only condition (43%) than in the Stay SMART+Boosters (64%) or control (60%) conditions.
Participants were racially diverse, with approximately 45 Caucasian, 14% Hispanic, and 42% Black. Three fourths of the youths were male, and the mean age at baseline was 13.6 years. The 14 Boys & Girls Clubs were located in cities with populations ranging from 17,000 to 630,000, and in states in the East, South, Midwest, and West. The conditions were similar in terms of the proportion of clubs located in urban and rural settings, with the majority in urban areas.
Initial Equivalence on Demographic Characteristics
Given the quasi-experimental nature of the design, it is important to determine whether the groups were initially comparable (i.e., whether they were equivalent at the pretest). In addition, given the longitudinal nature of the design and our criteria for inclusion in the analyses, the issue arises of possible attrition effects. In this section, the initial equivalence and attrition effects on the demographic characteristics of the participants are described.
The analyses of effects presented below are based on those participants who took part in all four of the measurement waves. Thus, for each of the groups of clubs in the study (i.e., Stay SMART Only, Stay SMART+Boosters, and control), the initial participants can be divided into two sets: those who participated in all four measurement waves and contributed to the outcome analyses (the "completion group"), and those who did not (the so-called "attrition" group; note, however, that this title is somewhat misleading, in that someone in the "attrition" group may have completed the program and missed only one wave of measurement). Moreover, for reasons presented below, analyses are presented separately for virgin and nonvirgin respondents. Accordingly, we conducted analyses of pretest equivalence and attrition separately for these two subgroups.
Several analyses were conducted to test for initial equivalence and attrition effects for the nonvirgin respondents. With respect to age, we conducted a 3 x 2 ANOVA, with condition and attrition status as the independent variables (see Jurs and Glass , who explicate the reasoning behind such an analysis). Although no effects were significant in this analysis, we conducted an ANOVA on the age of those who completed all four measurement waves. This analysis revealed a marginally significant effect of condition. Among those nonvirgins who completed the measurement framework of the study, youths in the Stay SMART+Boosters condition (M = 13.44) tended at the pretest to be a few months younger than those in the control group (M = 14.05), with the Stay SMART Only nonvirgins (M = 13.83) intermediate, F(2, 66) = 2.41, p = .10.
For nonvirgins, there also was a significant initial difference between conditions in race. As shown in Table 2, the completion group nonvirgins were primarily Black in the Stay SMART Only and Stay SMART+Boosters conditions, whereas those in the control condition were more varied racially, X sup 2 (4, N = 67) = 15.57, p < .01.[Table 2 omitted] Race also was the only variable (either demographic or outcome) for which the nonvirgins who completed the measurement framework of the study differed from those who dropped out. More Black nonvirgins dropped out of the Stay SMART+Boosters group than the Stay SMART Only or control conditions, X sup 2 (2, N = 104) = 12.23, p < .01, whereas more Caucasian nonvirgins dropped out of the Stay SMART Only condition than the Stay SMART+Boosters or control conditions, X sup 2 (2, N = 44) = 8.43, p < .05.
Analyses of virgin respondents revealed no initial differences between conditions and no differences between those who did and those who did not complete the measurement framework of the study.
Outcomes were assessed with a self-report questionnaire administered by the prevention program staff member in the two intervention conditions and by a staff member at the clubs in the control group. Several steps were taken to enhance accurate reporting. Participants were assured that their answers would be confidential and would never be connected with their names. Participants also were told not to write their names on survey booklets. Instead, they completed several questions (e.g., first letter of first name, gender, race, eye color, month, and day of birth) that produced a self-generated code used to link answers from one testing occasion to the next. Respondents also were told that they had the right to refuse to answer any of the questions. Youths were shown how to place their completed surveys in a large envelope preaddressed to the university where the data were to be analyzed. Upon completing the surveys, youths witnessed the prevention program leader seal the envelope, insuring that neither the prevention program leader, the youths' parents, nor anyone else would see the surveys.
Attitudes. The 9-item Sexual Attitude Scale used a 5-point Likert-type scale ranging from 1 to 5, with 1 indicating strongly disagree and 5 indicating strongly agree. An illustrative item is, "Being sexually active shows you're cool." A low score indicates perception of fewer social benefits from being sexually active. The internal consistency reliability estimates (Cronbach's alphas) of the scale were .87,.87,.91, and .91, respectively, over the four administrations.
Behavior. Sexual behavior was assessed by two single-item measures. Recency was measured with a single item that asked, "How recently (if ever) did you have sexual intercourse?" Response choices for this single-item measure were: 1 = never, 2 = more than 1 year ago, 3 = in the last year, 4 = in the last 30 days, 5 = in the last 7 days, 6 = in the last 24 hours. Frequency of sexual behavior was assessed with a single-item measure that asked, "How often (if ever) do you have sexual intercourse?" Response choices for this single-item measure were: 1 = never, 2 = not in the last year, 3 = less than once a month, 4 = a few times a month, 5 = a few times a week. These two items were standardized and summed into a Sexual Behavior scale. For nonvirgins, the r values between Frequency and Recency were .59, .69,.90, and .84 for the pretest and three posttests, respectively. For virgins, this correlation cannot be computed at the pretest, because there is no variability; for the three posttests, the correlations were .78, .35, and .78.
Analyses of Outcome Measures
For substantive and methodological reasons, outcomes are presented separately for youths who were virgins at the time of the pretest and those who initially were nonvirgins. Substantively, it has been argued that abstinence-only programs may be more effective for youths who have not yet engaged in sexual intercourse (e.g., Olson, 1987), and that adolescents who have engaged in early sexual activity differ in important ways from those who are not sexually active (e.g., Olsen et al., 1992). Methodologically, given the nonnormal distributions on the behavioral items for virgins, our behavioral scales may require dichotomization, at least for virgins. Different dichotomizations are appropriate for virgins and nonvirgins. In particular, it is interesting to examine whether the program affected virgins' transition from virginity to sexual activity. However, the dichotomization that allowed this examination was meaningless for nonvirgins, who had already made this transition. For such reasons, findings are presented separately for the 85 virgins and the 67 nonvirgins (at pretest) in the study. (An analysis on Sexual Behavior treating virginity as a factor results in a significant Condition x Virginity x Time interaction, and similar conclusions to those presented below).
The inclusion of gender as a factor in preliminary analyses resulted in several main effects for gender, but no interactions between gender and condition. Consequently, gender was not treated as a factor in the analyses reported below.
Initial Equivalence and Attrition: Outcome Variables
The initial (pretest) scores on the outcome variables were analyzed, separately for virgins and nonvirgins, to look for initial nonequivalencies between the groups and for attrition effects. Differences were found on only one outcome variable, for the nonvirgin respondents. A 3 x 2 ANOVA conducted on Sexual Attitudes, with condition and attrition status as the independent variables, revealed a marginally significant main effect of condition, F(2, 161) = 2.44, p < .10. An ANOVA on those who completed all four measurement waves (and thus contributed to the primary analyses) revealed that, for Sexual Attitudes, the initial differences were marginally significant, F(2, 63) = 2.61, p < .10, such that the Stay SMART Only nonvirgins (M = 2.85) reported marginally more favorable attitudes toward sexual activity than did the nonvirgins in the Stay SMART+Boosters (M = 2.30) or control (M = 2.38) conditions. Consequently, effects in which the Stay SMART Only condition differs from the other groups might be viewed with caution, to the extent that this initial difference could plausibly account for the posttest differences. No initial differences or attrition effects were observed for the virgins. The analyses conducted to estimate treatment effects controlled statistically for initial differences (via covariates).
Findings for Nonvirgins
Sexual attitudes. The Sexual Attitudes scale was analyzed using Games' (1990) repeated measures analysis of covariance (ANCOVA) strategy, with condition (Stay SMART Only, Stay SMART+Boosters, and control) as the independent variable, scores for the three posttests (at 3, 15, and 27 months) as the levels of the repeated measures factor, and the pretest score, gender, age, and race as the covariates. In these analyses, race was treated as a set of dummy codes representing membership in the categories Caucasian, Hispanic, and Black. We conducted one set of analyses including as covariates the initial pretest level of the variable and all demographic variables. We also conducted a separate set of analyses including only those demographic variables found in preliminary analyses to be related to that particular outcome variable Because the analyses with all covariates and those with only the significant covariates resulted in the same substantive conclusions, we report the analyses with only the significant covariates included.
For those respondents who were nonvirgins prior to the program, the analyses revealed a significant effect of condition, F(2, 61) = 4.34, p < .05. Fisher's Least Significant Difference (LSD) post hoc tests on covariance-adjusted means showed that the nonvirgins in the Stay SMART Only group (M = 2.20) perceived significantly (p < .005) fewer social benefits from engaging in sexual activity than did the Stay SMART+Boosters group (M = 2.69) or the control group (M = 2.71). The absence of a significant interaction with Time indicates that the effect, whereby the Stay SMART Only nonvirgins perceived significantly fewer social benefits from engaging in sexual activity, was consistent across the posttests. Means by condition and time are nevertheless presented in Table 3, which summarizes results across outcome variables.[Table 3 omitted]
Recall that for Sexual Attitudes, the initial (i.e., pretest) differences were themselves marginally significant, such that nonvirgins in the Stay SMART Only condition tended to have more favorable attitudes toward sexual activity than the nonvirgins in the Stay SMART+Boosters or control conditions. This initial difference might seem to suggest caution in interpreting the difference on this outcome. Alternatively, it might be taken as warranting greater confidence in the finding. The Stay SMART Only nonvirgins had marginally more favorable attitudes toward sexual activity before the program but less favorable attitudes after the program. For the initial difference to account for the observed effect, the analysis would have to be overadjusting for the initial difference.
Recency and frequency of sexual behavior. The sexual behavior scale was subjected to a repeated measures ANCOVA (as described in the section on Sexual Attitudes). A significant Condition x Time interaction was observed, F(4, 120) = 5.41, p < .001. As shown in Figure 2, the Stay SMART Only nonvirgins reported marginally less sexual behavior than the control group nonvirgins at the 15-month posttest (P < .10), based on LSD post hoc tests.[Figure 2 omitted] Moreover, the Stay SMART Only nonvirgins reported significantly less sexual behavior than either the control or the Stay SMART+Boosters nonvirgins at the 27-month posttest. Separate analyses of the Recency and the Frequency of sexual behavior items, using either ANCOVA or logistic regression on dichotomized variables, provided similar, generally stronger results.
Findings for Virgins
Sexual attitudes. A 3 (condition) x 3 (time) repeated measures ANCOVA on the attitude scale revealed no significant or marginally significant effects.
Sexual behavior. A repeated measures ANCOVA was conducted on the Sexual Behavior scale. No effects were observed. Similarly, no main effects or interactions involving condition were observed on separate analyses of the Recency and the Frequency items, either through repeated measures ANCOVA or logistic regression analyses on dichotomized variables.
Our first research question sought to determine whether the Stay SMART program, designed to simultaneously prevent/reduce sexual activity, cigarette smoking, alcohol use, and marijuana use, would affect sexual activity. For nonvirgins, results for the Stay SMART Only condition showed the desired effects for attitudes toward sexual activity, and for sexual behavior at the 15- and 27-month posttests (the 15-month effect was only marginally significant in the primary analyses reported, but attained significance in several other analyses). If these were the only findings in the present evaluation, they might be hailed as unique evidence of the effectiveness of abstinence-only prevention programs.
Prior to this evaluation of Stay SMART, the few studies of abstinence-only sexual activity prevention programs that measured sexual behavior found little (Jorgensen et al., 1993) or no change in behavior (Donahue, 1987; Jorgensen, 1991; Miller et al., 1993) or found an increase in precoital sexual behavior (Christopher & Roosa, 1990). It appears that the only other sexual activity prevention program that is frequently referred to as an abstinence program and that has demonstrated significant effects for teens' sexual behavior is the PSI program. However, the 5-session PSI program was accompanied by a human sexuality program containing contraceptive information and, therefore, cannot be considered a solely abstinence program.
Thus, the comparison between the Stay SMART Only and the control group nonvirgins would seem to be noteworthy evidence concerning abstinence-only prevention programs. Some caution in interpreting the findings of the current study might nevertheless be called for by two puzzling issues: (a) why the behavioral effects did not emerge at the 3-month posttest, and (b) why the program was effective for nonvirgins but not virgins, despite evidence and argument to the contrary (e.g., Olsen et al., 1992; Olson, 1987).
However, the present study includes findings for more than the Stay SMART program alone. Our second research question asked whether adding two years of booster programs to Stay SMART would enhance program effects. Findings for the Stay SMART+Boosters nonvirgins were not positive; these participants did not differ from the control group nonvirgins in their attitudes and they perceived more social benefits from engaging in teenage sexual activity than the Stay SMART Only nonvirgins. Furthermore, the behavioral findings for the Stay SMART+Boosters group did not conform to expectations. No differences were found between the Stay SMART+Boosters and the control nonvirgins on sexual behavior. Unexpectedly, relative to the Stay SMART Only nonvirgins, the Stay SMART+Boosters nonvirgins reported more sexual behavior at the 27-month posttest. These findings arose despite the fact that the Stay SMART+Boosters youths received the same initial intervention as the Stay SMART Only youths, plus modest booster activities every year (five multifocus sessions in Year 2 and one video session on sexual activity prevention in Year 3).
How are these results to be accounted for? One might attempt to argue that Stay SMART was indeed effective in reducing sexual behavior, but that the booster sessions were in fact harmful. In principle, it could be argued that Stay SMART+Boosters somehow negated or limited the positive effects generally seen in Stay SMART Only. It is not obvious, however, how the booster sessions would have such a limiting effect. Alternatively, one might argue that the program was not effectively implemented at the Stay SMART+Boosters clubs; however, there are no direct observational ratings of the implementation of the sexual prevention component of the program to confirm or refute this explanation.
Another plausible explanation is that, given the quasi-experimental nature of the study, important initial differences between the groups may not have been measured or adequately controlled for, and these initial differences could account for the observed differences. It can be argued that the stronger behavioral results for the Stay SMART Only condition than for the Stay SMART+Boosters condition might have resulted from uncontrolled selection bias: the two groups may have differed in important ways not adequately controlled for in the analyses. The number and nature of the variables on which the groups might have initially differed are theoretically unlimited, but a few examples include religiosity, educational aspirations, family cohesion, and peer norms about sexual behavior.
The possibility of selection bias arising from the quasi-experimental nature of the design might also account for the apparent emergence of effects among the Stay SMART Only nonvirgins at the 15- and 27-month posttests, but not at the 3-month posttest. Such a pattern might result from inadequate control for the selection x maturation threat to validity (Cook & Campbell, 1979), which is the possibility that the different groups are changing developmentally over time at different rates. For example, the groups might differ in local peer norms about sexual behavior, which might cause the groups to diverge increasingly over time. Alternatively, it may be that the behavioral effects of the program arose, not from the program alone, but from the program in conjunction with subsequent bonding with the program leader or other club staff, which took time to occur. Or behavioral effects may have emerged over time as sexually active youths ended sexually active relationships and did not begin others (cf. Zabin & Clark, 1981, on the episodic nature of sexual activity for female teens). However, selection bias would provide a parsimonious explanation of both the delay in behavioral effects and the anomalous findings for Stay SMART+Boosters.
Methodological shortcomings other than selection bias also exist in the present study. Sites varied in terms of leaders, gender composition, geographical location, recruitment practices, cultural adaptations of sessions, choice of video session in the second-year booster program, and other variables. Consequently, one preferable alternative would be to treat site as the unit of analysis (even though it is common in the literature to treat individuals as the unit of analysis even though sites rather than individuals are assigned to condition). However, given the small number of sites in this study, such an analysis would have had low power (and revealed no effects when conducted). Alternatives such as hierarchical linear modeling (Bryk & Raudenbush, 1992) also do not apply well here, given the small number of nonvirgin respondents per site. In addition, there is reason to ask whether results from youths who have maintained long-term participation in community clubs generalize to other at-risk youths.
Considering the quasi-experimental design of the study and the associated possibilities of selection bias and the methodological artifacts accounting for the results, the question may arise as to the strength of the present design relative to the extant literature on abstinence-only programs. In general, the evidentiary base in the present research seems as strong as in the rest of the literature on the behavioral effects of abstinence-only sexual activity prevention programs. These studies consist of other quasi-experiments (e.g., Christopher & Roosa, 1990; Roosa & Christopher, 199o; Jorgensen et al., 1993) apparently as susceptible to selection bias as the present study, and one study that employed random assignment (Miller et al., 1993), but with a homogeneous sample of low-risk Mormon pre- and young teens, so that floor effects constrained the possibility of behavioral effects. The purpose of this comparison with other studies is not to attempt to strengthen the conclusions from the present study. To the contrary, the possible selection bias, the small sample size, and the overall rate of attrition call for interpreting our results with caution. The point instead is to note the relative state of the literature on the topic of abstinence-only sexual activity prevention programs.
Despite the limitations of this study, there may be some room for encouragement in the findings for the Stay SMART program. Stay SMART offers an alternative for communities whose social norms preclude them from offering pregnancy prevention programs containing contraceptive information and/or services. Moreover, the Stay SMART program can be implemented in a multitude of youth organizations such as YMCA's, YWCA's, Scouts, and 4-H Clubs, thereby complementing sex education programs offered in school settings. Furthermore, Boys & Girls Clubs and many other youth organizations possess unique characteristics conducive to reaching youngsters with sexual activity prevention programming. Boys & Girls Clubs: (a) emphasize the development of personal relationships and positive role modeling by staff who often serve as extended families, friends, and even surrogate parents for youths from dysfunctional and/or single-parent households; (b) provide a relaxed informal atmosphere with social and recreational activities that attract and maintain youth involvement; and (c) have the flexibility to tailor their programming to individual needs of teens.
In conclusion, the recent wave of public attention to and the diffusion of abstinence-only sexual activity prevention programs (e.g., Dennison, 1994; Klein, 1994; Newman, 1994; Shinkle, 1992a, 1992b) and the ongoing debate concerning their effectiveness (e.g., Christopher & Roosa, 1990; Roosa & Christopher, 1990; Thiel & McBride, 1992) strongly suggest the need to move beyond quasi-experimental investigations. Carefully designed randomized experiments are called for to provide more conclusive evidence regarding the efficacy of abstinence-only programs. In the meantime, it seems premature to conclude either that abstinence-only sexual activity prevention programs are effective or that they are not effective.
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Publication information: Article title: A 27-Month Evaluation of a Sexual Activity Prevention Program in Boys & Girls Clubs across the Nation. Contributors: St Pierre, Tena L. - Author, Mark, Melvin M. - Author, Kaltreider, D. Lynne - Author, Aikin, Kathryn J. - Author. Journal title: Family Relations. Volume: 44. Issue: 1 Publication date: January 1995. Page number: 69+. © 2002 Family Relations. Provided by ProQuest LLC. All Rights Reserved.
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