Academic journal article Journal of School Health

The Safer Choices Project: Methodological Issues in School-Based Health Promotion Intervention Research

Academic journal article Journal of School Health

The Safer Choices Project: Methodological Issues in School-Based Health Promotion Intervention Research

Article excerpt

Schools provide a point of access to most adolescents: Nearly 95% of all children and adolescents attend elementary or secondary schools.[1] Because its primary mission is to impart knowledge and teach skills, school is the ideal place for promoting health among adolescents. Some school-based programs -- such as those for children with asthma or for young people who use drugs -- target specific student groups based on special health needs or risks. Other programs -- such as those on smoking prevention, AIDS prevention, or nutrition education curricula -- are designed to change risky behavior by targeting all students in the classroom. By establishing school-wide norms for drug use or unprotected sex, for example, these programs can also address students in the larger school environment. For those involved in school-based health promotion research, differences between individual-level and school-wide programs raise several important methodological issues, such as identifying the proper unit of randomization and analysis, randomizing a small number of units, and identifying the most appropriate research design and data collection strategy.

This article addresses several key methodological issues concerning research on school health promotion programs with a school-wide focus. Using the Safer Choices project as an example, it discusses how to randomize a small number of units, like schools, rather than individuals; reasons for using a cohort or cross-sectional design; and how to analyze data when randomization and intervention delivery are at the school level, but observations are at the student level.


Safer Choices, a five-year project funded by the Centers for Disease Control and Prevention, tested the effectiveness of a state-of-the-art program to prevent human immunodeficiency virus (HIV) infection, the spread of other sexually transmitted diseases (STDs), and the incidence of unintended pregnancy among high school populations. HIV infection and other STDs are serious problems for adolescents. Approximately 20% of the people diagnosed with Acquired Immunodeficiency Syndrome (AIDS) are 20 to 29 years old.[2] Because of the long latency period between infection with HIV and diagnosis of AIDS, many adults in this age group are likely to have been infected with HIV during adolescence. Sexually transmitted diseases also are a significant problem for this group. Approximately 25% of sexually experienced adolescents contract an STD each year.[3]

The Safer Choices project aimed to develop, implement, and evaluate a theory-driven, school-based, multiple-component HIV, STD, and pregnancy prevention intervention for high school students. To evaluate the program, the project team used a trial that randomly assigned schools to either a multiple-component intervention or a control condition that provided an information-based classroom curriculum on HIV and other STDs.

Social cognitive theory,[4] social influences,[5,6] and models of school change[7] formed the intervention basis for the Safer Choices project. Its unique multiple-component intervention focused on school-wide change and the influence of the total school environment on student behavior. Change strategies embodied five components, summarized in Table 1. A complete description of the intervention and its theoretical basis has been published elsewhere.[8]

Table 1
Safer Choices Project Components

Component                 Description

1. Curriculum and         A skills-based education curriculum is
  Staff Development       provided to all ninth- and 10th-grade
                          students; the curriculum includes 10
                          lessons at each grade level. The
                          10th-grade curriculum reinforces and
                          builds upon the concepts introduced
                          in the ninth grade unit. Teachers
                          who use the curriculum participate
                          in four-day teacher training and
                          receive coaching while the program
                          is under way. … 
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