Evaluating a Future-Oriented Positive Youth Development Intervention to Reduce Sexual Risk Among Highly Mobile Youth: Results and Challenges.

PURPOSE: Youth experiencing or at risk of experiencing homelessness need tailored prevention programming to prevent unplanned pregnancy and sexually transmitted infections. This study evaluated the efficacy of a small-group, future-oriented positive youth development (PYD) intervention to reduce sexual risk behaviors. METHOD: Youth aged 14-19 (n = 483) experiencing or at risk of experiencing homelessness were recruited at youth-serving agencies and in alternative schools. Each cohort enrolled was randomized either to a 10-session, 5-week group future-oriented intervention to support them in adopting health-promoting behaviors such as using contraception, including condom use (n = 244) or to a no-treatment condition where they received usual services/schooling (n = 239). We assessed at baseline and 3-month and 9-month follow-up (1) vaginal intercourse without consistent contraception use, (2) vaginal and anal intercourse without consistent condom use, and (3) sexual risk behaviors, including current (last 3 months) effective contraception use by females who did not report current use at baseline. RESULTS: There was no significant difference between treatment and control conditions for most outcomes. However, among females not currently using contraception at baseline, 34% in the treatment condition compared to 12.9% in the control condition reported using contraception in the 3 months before the 9-month survey, a statistically significant difference. DISCUSSION: This sexual risk reduction intervention, grounded in PYD theory and tailored to address the needs of marginalized groups of youth, demonstrated efficacy at increasing contraceptive uptake among females. The need for PYD interventions that can be delivered in a variety of nontraditional school and service settings are discussed.

Who Benefits from School-Based Teen Pregnancy Prevention Programs? Examining Multidimensional Moderators of Program Effectiveness Across Four Studies.

Recent research has suggested the importance of understanding for whom programs are most effective (Supplee et al., 2013) and that multidimensional profiles of risk and protective factors may moderate the effectiveness of programs (Lanza & Rhoades, 2012). For school-based prevention programs, moderators of program effectiveness may occur at both the individual and school levels. However, due to the relatively small number of schools in most individual trials, integrative data analysis across multiple studies may be necessary to fully understand the multidimensional individual and school factors that may influence program effectiveness. In this study, we applied multilevel latent class analysis to integrated data across four studies of a middle school pregnancy prevention program to examine moderators of program effectiveness on initiation of vaginal sex. Findings suggest that the program may be particularly effective for schools with USA-born students who speak another language at home. In addition, findings suggest potential positive outcomes of the program for individuals who are lower risk and engaging in normative dating or individuals with family risk. Findings suggest potential mechanisms by which teen pregnancy prevention programs may be effective.

Replication of It's Your Game Keep It Real! in Southeast Texas.

Despite the recent efforts of the Office of Adolescent Health to replicate programs with demonstrated efficacy, there are still few evidence-based HIV, sexually transmitted infection (STI), and teen pregnancy prevention programs that have been replicated in "real-world" settings. To test the effectiveness of It's Your Game…Keep It Real! (IYG), an evidence-based STI and pregnancy prevention program for middle schools, the curriculum was implemented by teachers in urban and suburban middle schools in Southeast Texas from 2012 to 2015. IYG was evaluated using a group-randomized wait-list controlled effectiveness trial design in which 20 middle schools in nine urban and suburban school districts in Southeast Texas were randomized equally, using a multi-attribute randomization protocol, to either the intervention condition (received IYG) (n = 10 schools comprising 1936 eligible seventh graders) or the comparison condition (received usual care) (n = 10 schools comprising 1825 eligible seventh graders). All students were blinded to condition prior to administering the baseline survey. The analytic sample comprised 1543 students (n = 804, intervention; n = 739, comparison) who were followed from baseline (seventh grade) to the 24-month follow-up (ninth grade). Multilevel regression analyses were conducted to assess behavioral and psychosocial outcomes at follow-up. There were no significant differences in initiation of vaginal or oral sex between study conditions at follow-up. However, at 12-month follow-up, compared with students in the comparison condition, students in the intervention condition reported increased knowledge, self-efficacy, and perceived favorable norms related to HIV/STIs, condoms, and/or abstinence; decreased intentions to have sex; and increased intentions to use birth control. Knowledge outcomes were statistically significant at 24-month follow-up. This IYG effectiveness trial did not replicate the behavioral effects of the original IYG efficacy trials. However, it adds to the growing literature on the replication of evidence-based programs, and underscores the need to better understand how variations in implementation, setting, and measurement affect the behavioral impact of such programs.Clinical trial registration clinicaltrials.gov (NCT03533192).

It's Your Game Keep It Real in South Carolina: A Group Randomized Trial Evaluating the Replication of an Evidence-Based Adolescent Pregnancy and Sexually Transmitted Infection Prevention Program.

OBJECTIVES: To evaluate the effectiveness of an evidence-based HIV/sexually transmitted infection (STI)/pregnancy prevention program for middle schools implemented by school staff in South Carolina. METHODS: Twenty-four schools, representing 3143 youths, participated in a randomized trial from 2011 to 2014. Students completed surveys before programming (fall of seventh grade), after completing the 2-year It's Your Game…Keep It Real program (spring of eighth grade), and 1-year postprogram (spring of ninth grade). RESULTS: There was no statistically significant effect on initiation of vaginal sex between baseline and eighth grade. Significantly fewer students in the comparison condition reported initiating sex at ninth grade, relative to the intervention condition. No group differences existed on other behavioral outcomes that addressed sexual activity in the past 3 months at ninth grade. Seven of 26 psychosocial outcomes (3 knowledge, 1 attitude, 1 self-efficacy, 2 personal limits) were positively affected at eighth grade; 4 remained significant at ninth grade. CONCLUSIONS: The original studies' behavioral effects were not replicated in this population, possibly as a result of this being an effectiveness trial instead of an efficacy trial, counterfactual exposure design issues, or postprogram exposure to evidence-based programming.

Estimates of Intraclass Correlation Coefficients From Longitudinal Group-Randomized Trials of Adolescent HIV/STI/Pregnancy Prevention Programs.

INTRODUCTION: Group-randomized trials (GRTs) are one of the most rigorous methods for evaluating the effectiveness of group-based health risk prevention programs. Efficiently designing GRTs with a sample size that is sufficient for meeting the trial's power and precision goals while not wasting resources exceeding them requires estimates of the intraclass correlation coefficient (ICC)-the degree to which outcomes of individuals clustered within groups (e.g., schools) are correlated. ICC estimates vary widely depending on outcome, population, and setting, and small changes in ICCs can have large effects on the sample size needed to estimate intervention effects. This study addresses a gap in the literature by providing estimates of ICCs for adolescent sexual risk-taking outcomes under a range of study conditions. METHOD: Multilevel regression analyses were applied to existing data from four federally funded GRTs of school-based HIV/STI/pregnancy prevention programs to obtain a variety of ICC estimates. RESULTS: ICCs ranged from 0 to 0.15, with adjustment for covariates and repeated measurements reducing the ICC in the majority of cases. Minimum detectable effect sizes with 80% power and 0.05 significance levels ranged from small to medium Cohen's d (0.13 to 0.53) assuming 20 schools of 100 students each. CONCLUSIONS: This study provides the first known set of ICC estimates for investigators to use when planning studies of school-based programs to prevent sexual risk behaviors in youth. The results provide further evidence of the importance of using the appropriate adjusted ICC estimate at the design stage to maximize resources in costly GRTs.

Using data to improve fidelity when implementing evidence-based programs.

In fall 2011, the South Carolina Campaign to Prevent Teen Pregnancy (SC Campaign), with funding from Office of Adolescent Health, began replicating an evidence-based curriculum, It's Your Game, Keep It Real in 12 middle schools across South Carolina. Fidelity of the curriculum was monitored by the use of lesson fidelity logs completed by curriculum facilitators and lesson observation logs submitted by independent classroom observers. These data were monitored weekly to identify possible threats to fidelity. The innovative model Fidelity Through Informed Technical Assistance and Training was developed by SC Campaign to react to possible fidelity threats in real time, through a variety of technical assistance modalities. Fidelity Through Informed Technical Assistance and Training guided the 55 hours of technical assistance delivered by the SC Campaign during the first year of It's Your Game, Keep It Real implementation to 18 facilitators across 12 SC middle schools, and achieved 98.4% curriculum adherence and a high quality of implementation scores.

What works? Process evaluation of a school-based fruit and vegetable distribution program in Mississippi.

BACKGROUND: During the 2004-2005 school year, the Mississippi Department of Education, Office of Child Nutrition, initiated a pilot program to distribute free fruit and vegetable snacks to students during the school day. This article describes the first-year implementation of the Mississippi Fruit and Vegetable Pilot Program. METHODS: The process evaluation addressed where, when, and how produce was distributed; what was distributed; challenges and successes; and recommended modifications. Five of the 25 program schools were selected to participate in the evaluation; selection was based on grade levels served and demographic characteristics. Data were collected from program staff (N = 11) and administrators (N = 6) via interviews and logs; student (N = 42) and parent (N = 19) focus groups; student questionnaires (N = 660); and school staff questionnaires (N = 207). RESULTS: Distributing fresh fruit and vegetable snacks at school was well received by staff and students. Most schools distributed the fresh fruit and vegetable snacks at morning break in classrooms or a central courtyard. Twenty-two types of fresh fruit, 4 types of dried fruit, and 7 types of vegetables were served to students during the program year. Commonly distributed fruit included apples, oranges, pears, bananas, and tangerines. Carrots were the staple vegetable, followed by celery. Key challenges included getting students to try new foods and receiving the produce in a timely manner without spoiling. Main successes included seeing students try new fruit and vegetable snacks, having the program run smoothly, and teacher support. CONCLUSIONS: The program fit well within the school structure and could be an effective component of a multifaceted approach to enhancing child nutrition.

Impact of an intervention to improve contraceptive use through follow-up phone calls to female adolescent clinic patients.

CONTEXT: Adolescent females often have questions or concerns about their contraceptive methods, and they may discontinue use if these questions are not answered. Little evidence exists on whether follow-up phone calls to address young women's concerns can help sustain contraceptive use. METHODS: Between 2005 and 2007, a total of 805 females aged 14-18 attending a reproductive health clinic in San Francisco were randomly assigned to receive either regular clinic services or regular clinic services plus nine follow-up phone calls over 12 months. The young women were surveyed at baseline and roughly six, 12 and 18 months later to measure condom and contraceptive use, rates of pregnancy and STDs, and other outcomes and mediators. Multiple linear and logistic regression repeated measures analyses were used to assess the program's effects. RESULTS: Clinic counselors completed only 2.7 calls per patient, and made 7.8 attempts for every completed call. Although contraceptive use increased from baseline to follow-up at six months in both groups, levels of condom and contraceptive use, and rates of pregnancy and STDs, did not differ between the intervention and control groups at any of the follow-up assessments. Moreover, the intervention did not improve clinic utilization or satisfaction or have consistent positive effects on participants' attitudes. CONCLUSIONS: Reaching young women by phone after a clinic visit for contraception is challenging and does not appear to provide significant benefits beyond those provided by basic clinic services. More intensive interventions may be needed to markedly change adolescent sexual and contraceptive behavior.