ARDEN HANDLER: Good afternoon, everybody. I want to encourage you to eat and have fun. I welcome you to the last session of 17th annual making change happen conference. Again we encourage you to fill out your evaluation forms, to complete the form that fox about the format of the conference and hope that you all had an excellent time like I did. Also the planning committee meeting I talked about, I do have a room for it. It will be after this session. Theoretically it is supposed to be 2:30. I know it will take us time to regroup. My guess is somewhere between 2:30 and 2:45 we will be in the Ohio room for the planning committee meeting. Even if I don't want to make a definite commitment to join the planning committee, if you join with us today and give us your thoughts and ideas, we would like to have those as we plan for our next conference. Last but not least, this is going to be a very exciting session. I would like to introduce, an introducer, Melissa Gilliam at the University of Illinois. She is at the school of public medicine and she is a professor of obstetrics and gynecology. She works in adolescent health and decision making and she will introduce our final speaker today. Any comments or questions, feel free to write them down on the salmon colored sheet. Thank you very much.
DR. GILLIAM: Good afternoon. It gives me great pleasure to introduce our next speaker, Dr. Douglas Kirby. Dr. Kirby is a senior research scientist at ETR associates in Scotts Valley, California. For more than 25 years he directed statewide and nationwide studies of adolescent sexual behavior in the program sexuality and HIV education programs. His work is important because he pained a more comprehensive and detailed picture of the risk and protective factors associated with adolescent sexual behavior. Contraceptive use, pregnancy and he identified important common characteristics of effective sexually education programs and effective HIV programs. He authored, coauthored many articles on programs designed to change adolescent sexual behavior. ... centers for disease prevention, national institutes of health. More recently he actually was worked on international programs. In particular he is focusing on AIDS reduction and HIV in Uganda today he will summarize important results from, an assessment of sex and HIV aide education for teenagers. Some programs reduced teen AIDS and some did not. He will discuss the ten characteristics of successful programs. He told me this will be a spirited and interactive program. All the questions will occur during, no questions after are wards. I will be able to take those questions. So if anybody wants to send a question in, we'll take those during the presentation. Dr. Kirby? (Applause.)
DR. KIRBY: Thank you very much for that warm welcome. It is especially nice given that this is the last session that you are all still here. That is terrific. (Laughter.) Somehow I'm reminded of a true story that a friend of mine experienced. He was speaking in Hawaii. He was the fourth speaker in the last session. When the first speaker spoke, a number of the people in the audience left. At the second there were very few. He looked out there was only one person in the audience. He said to that person why don't we just go to the beach? He said I can't, I'm the last speaker. (Laughter.) And this is the anti-thesis of this. All of you are here and I very much appreciate that. It is exciting and I feel very privileged to have the opportunity to talk with you and to participate in the conference that is giving a lot of emphasis to research and the impact of research and the importance of research. Of course, I'm a researcher. So I naturally feverently believe in all of that. I also do so because of my own historical experiences. I have been doing work in this field for 25 years. That is a long time.
For the first 11 years in which I did research in this field, what I consistently did was to go out and try to find promising programs that everybody thought would have an impact upon changing sexual behavior. I would evaluate them to prove that they were effective and really did change behavior. What did I find? Consistently I found that they did not change behavior. Then I would report that back to the news. I was not a popular guy at various times. I would have been giving speeches on behalf of programs and come back in a year and a half and a half and say well, they didn't happen after all. What happened during that period of time? Good news is that number one, we did the research. Also, number two, people listen to that research. People like yourselves. We then try to figure out, well, why didn't they work? How can we make them better? We launched a new generation of programs. I and other people went out and evaluated those. Those didn't have an impact on behavior either. But we kept on doing this.
Now after 25 years, today I can talk about a lot of success. But this is success that didn't just suddenly materialize. This is success that is based upon years of not having success and changing behavior. So there is without question research and all the people in the field who listened to that research and what we found had an impact in terms of helping us know what really does make a difference. That's my topic for today. I'll talk about what do we know about the programs that work versus those that don't work. And as has been said, I do want this to be interactive. At any time if you disagree, speak up, raise your hand and feel free to disagree with me. Or if you have a question or whatever, certainly feel free to do that. I'm happy to answer questions at the end. If we run out of time, you may not have a chance. I mean, I'm stay here and answer them. Typically, some people may need to leave. Feel free to ask me questions or challenge me as I'm talking. I want to start by just thinking and having -- and talking a little bit about risk factors and protective factors. My first question for you is: Why do we care about risk factors and protective factors if our goal is to change behavior? Sexual behaviors in this place, we want to change teen pregnancy, S.T.D.s, et cetera. Why do we care about risk factors, protective factors? Anybody?
AUDIENCE: (inaudible).
DR. KIRBY: To assess the status of the community, that's one factor. Why else do we care about risk factors and protective factors?
AUDIENCE: For educational purposes.
DR. KIRBY: For educational purposes. In what way?
AUDIENCE: For interventions.
DR. KIRBY: Okay. Can you add any more to that?
AUDIENCE: When we identify and make people aware of those risk factors that will change behavior.
DR. KIRBY: So if you identify the risk factors and protective factors related to behavior and identify the factors that you can change -- two criteria. The risk factors and protective factors that change behavior and then those risk factors and what I have factors that change -- by focusing on those you end up changing behavior. I have a teenage daughter. She is 15. Wow, have I learned a lot! As many of you who are parents (Chuckles.) All these things I have been writing about, they are suddenly coming home. Someone called the other night and said Kathryn, can I do something? She said no on her own fortunately. But at times when I hear stories like that, I wish I could just hold my daughter's hand, 24 hours a day, seven days a being and make sure she not engage in zek, certainly not unprotected sex. What my wife an everybody around us can do is try to change the risk factors and protective factors which will improve the chances she will not have sex and improve the chances when she does have sex she will be using contraception.
That is true for all teens, not just my daughter. In the hand outs you have -- you are eating, it may not be easy, there's a whole page of risk factors and protective factors. If you have them there, great. I'll mention a couple. Not the most important ones, but to give you a flavor. At the community level, things such as poverty and level of community education, those end of having an impact on whether or not teens engage in sex and unprotected sex and become pregnant. If you look at the family, again the parents' income, their education, marital status, whether or not there's two parents in the home or just one, those have an impact upon the teen. If you look at the parents' values about sexuality, attitudes about contraception, those have an impact on the teen. If you look at the peers of the teen, whether or not they are having sex very much influences whether or not a teen has sex. If you look at a romantic partner of the teen. If that partner is much older, especially if it's a girl, but also true for boys, especially if it's a girl, that girl is much more likely to have sex and less likely to use contraception.
If the romantic partner supports the use of contraception, the teen is more likely to use it. Look at the teens themselves, hormones plays an impact, age plays an impact. The values about s sexuality, the performance in school. Their belief in the future, all of those things have an impact. Attitudes, about having sex, premarital sex, about contraception, all of those have an impact. If you look at all of these, there are several broad conclusions I think we can reach about risk factors and protective factors. The first is that there's not just a single would be. If there was one single factor that was so critically important, our job would be simple. We would change the factor and we would change behavior presumably. But there are lots of them and that makes our job more challenging. Some of these are risk factors. They increase the chances of sex and unprotected sex. Some are highly related and changeable. And some of these that are highly related to actual behavior and are changeable are those that are related to sexual beliefs, attitudes and values and skills about sexuality.
Those are highly related in a causal impact to actual behavior and we've learned that we can change them. But there are other factors that have nothing to do with sexuality at all, such as performance in school. Community poverty, family education. Yet those also have an impact upon sexual behavior of young people. Some of these are more amenable to change. I am now going to talk for the most part today, I am going to talk primarily about sex and HIV education programs. These, of course, tend to target the sexuality related risk and protective factors. Sex and HIV education programs do have multiple goals. They include things such as reducing unintended pregnancy and decreasing S.T.D., including HIV and aide. To be absolutely honest, that's why many of us care. Those are the reasons we care. I got into this field 25 years ago because I was very concerned about teenage pregnancy. On the other hand many people are concerned that sex and HIV education programs place far too much emphasis on the reduction of teen pregnancy and re-dukes of sexual transmitted disease.
They tell us and I agree with them there are many goals that involve sexual health. It's much more than avoiding S.T.D. and pregnancy. It's broader. Some sex and HIV education programs are designed to improve sexual health in these other ways. I will focus today on the first two and not on the third. I will do that in part because that's what many people are more concerned about, and also that is where most ever of the research is. I am going to summarize in just a minute. I will show you a table. It will be a table of all the studies which meet these criteria. The programs targeted youth of middle school or high school age. They were implemented in groups, in schools, or in community settings. It includes both school and non-school. These studies and these programs were implemented in the United States or Canada. Incidentally, I'm also doing a review currently of programs in the developing world and many of the things that I'm going to say today does also apply to those as well. I have incorporated those into the slide presentation -- I have not -- but that will happen in the coming week. The studies to be included, the studies had to involve experimental or quasi experimental design. What do I mean by that? That means we had to have an intervention group, comparison group.
They had to collect data before the intervention and afterwards. They had to have a sample size of at least 100 or larger and measure impact on actual behavior. Almost all of the programs end up doing positive things such as increasing knowledge, improving attitudes, et cetera. For many of us what we really care about is behavior. Are they actually changing behavior? In order to be included, the study had to measure that as well. Any questions before I go on? Okay. This is what we find. Now, these numbers do not represent youth. These numbers represent studies of programs. So if we look in the far left-hand column, it says abstinence only programs, what these numbers tell us is that there were three studies that were meeting the criteria I just talked about, three studies that measured the impact of abstinence only programs on the initiation of sex. Of those, they had no significant impact and none hastened the initiation of sex. We see there were two studies that measure the impact on frequency of sex. Neither of those two studies either decreased or increased the frequency of sex. One study measured the impact on the number of partners. That one study also did not find an impact upon the number of sexual partners of that program. So given those data, what would you be tempted to conclude about the impact of abstinence only programs?
AUDIENCE: That they don't --
DR. KIRBY: That they don't work, okay. You know, if you look just at these numbers, it is tempting to reach that conclusion and notice I emphasize as I ask that question, tempting. It is tempting to reach that conclusion. I would reach a slightly different conclusion. I would say these are not encouraging numbers and frankly they are not. On the other hand, abstinence only programs represent a very, very diverse group of programs. Some of them are very short. Some are very long. Some are strictly didactic. Some are interactive. Many are entirely secular. Some are very religious based. Some involve only instruction about sexuality. Others involve basically whole girls clubs or youth component. They are very, very different. It's not appropriate to try to generalize from these three studies to the great diversity of abstinence only programs. Therefore, the conclusion that I would reach is at this point we simply don't know. The jury is still out about the impact of abstinence only programs. Yes?
AUDIENCE: What were these three types?
DR. KIRBY: What were the three types? One was a five-session program. It was quite short. Twa somewhat interactive, but it was short. Generally we know that short programs do not have much of an impact upon behavior. What were the other two? A couple of the other two were slightly longer. They were not religion based. They were implemented in schools. They did not have all the characteristics that I will talk about shortly, about effective programs. So the jury is still out. Personally, my best guess is that we will find in the next number of years that some abstinence only programs are effective and others are not. And that, of course, is what we are also going to find and we already know about section in education programs. I will shift now to the far right-hand side. The number there is simply the sum of sexuality education programs and HIV education programs. By sexuality education programs I mean basically programs that are designed to reduce both pregnancy and S.T.D. and HIV, all three.
Typically they tend to emphasize the abstinence is the best approach, but if you have sex you should always use condoms and contraception. These programs do not talk about pregnancy, they are focused on hitch and other S.T.D.s, but primarily HIV. The numbers in bold, six plus three equals nine, that's all we are doing here. We see there there are 28 programs which, sex and HIV information programs which measure the impact on initiation of sex. Nine of them delayed the initiation of sex. Eighteen had no impact tom and one of them hastened the initiation of sex. Coming down we see frequency of sex, we see there are 19 studies, five decreased the frequency of sex. Thirteen had no impact and one of them increased the frequency, the same one that was associated with having a hastening effect. Looking at number of partners, we see there are ten studies, three decreased the number of sexual partners, the others had no impact. Given those numbers, what would you conclude? (There is no audible response.)
DR. KIRBY: Anybody?
AUDIENCE: The one that had hastened initiation ... (inaudible).
DR. KIRBY: You think some of them, oh, the one --
AUDIENCE: That one was --
DR. KIRBY: You wonder if it was a blinds study. I'll address that in a second. It's certainly different from some of the others. What would you, what conclusions would you draw from this, given these numbers?
AUDIENCE: The majority --
DR. KIRBY: The majority had no significant effects, okay. What else would you conclude?
AUDIENCE: And not all of them can ... (inaudible).
DR. KIRBY: Okay. Not all of them have positive impact upon those three. What else would you conclude?
AUDIENCE: That they delayed initiation --
DR. KIRBY: Okay. Maybe something key about initiation. Okay. There are more studies finding a delay in initiation than in reducing frequency or number of partners. There are also a smaller number of studies that measured those. Any other conclusions? Okay. I look at these numbers and I see, I reach two conclusions. The first conclusion I reach is that this is very strong evidence that programs which emphasize that abstinence is the safest approach but also talk openly about condoms and contraception and encourage young people to use condoms and contraception if they do have sex, the programs that do those two things do not increase sexual behavior. Out of all of those studies, out of 28 studies examining the impact upon initiation of sex, only one found a negative response, that it hastened. Only one. All the rest found either no impact or a positive impact. So in my mind you look at all of this and it tells us in, quite strongly, I believe, that programs which emphasize abstinence and talk about condoms an contraception do not increase sexual behavior. And in our country right now that is a huge concern.
There are lots of people who believe that if you talk about condoms and contraception and how to use it, that therefore you will make it easier for people to have sex an they will become more likely to have sex. That is plausible. It just simply is not true. Okay? A second conclusion I would reach from these numbers is that some of them did not work. In fact, the majority did not have a positive impact upon behavior. On the other hand, roughly about a third of them did have a positive impact upon behavior. Realize, this is all the studies. This includes all the ones that I was evaluating 25 years ago and 20 years ago and so forth. The first couple generations did not have a positive impact. So some of them do have a positive impact. Many of them do not. So obviously, we don't want to go out and implement the programs that didn't work. We want to implement the programs that did work. It's also true but you can't tell from these numbers, a couple of the programs had a positive impact on all three of these outcomes. Let's talk to condoms and contraception.
Some people expressed the concern that if a program emphasizes only abstinence, it will decrease the chances of using condoms or contraception. Here we find there is only one study, the short one, five sessions long, that focused on abstinence and it did not have an impact on condom or contraception use either way. We cannot generalize from that study either way. Far right-hand, the sex and HIV education programs, we see that there were 18 programs that measure the impact on condom use and now a little over half of them, that is ten of them did increase condom use. We see that those were mostly the HIV education programs. Eleven programs measured impact upon contraceptive use. About a third of them, or four increased contraception use. Given those numbers, more than hatch -- actually eight out of 11 HIV education programs increased condom use, but only four out of seven sexual .. You would think that HIV education programs are inherently more effective. That is not necessarily the case. It might be the case but this is not strong evidence. It turns out the HIV education programs are newer, better, based on better theory and have other characteristics which make them more effective. Before I go on, any questions about the numbers?
AUDIENCE: I can't understand why you would consider abstinence only to the rest of those ... (inaudible) -- programs. Why would you look at abstinence only-
DR. KIRBY: They are different. I'm including studies for all of them. I'm making them separate in part because we are spending hubs of millions of dollars on abstinence only programs. That's the category. I'm saying let's look at abstinence only and the jury is still out on that. Yes?
AUDIENCE: (inaudible) if you had enough studies, you might --
DR. KIRBY: We might. So far we don't know. We can't generalize from that one. It is a fear that people have. It may or may not be correct.
AUDIENCE: Because that last ...
DR. KIRBY: Sure.
AUDIENCE: (inaudible).
DR. KIRBY: Sure, I'll be sure to do that. If I fail to do that, mention it again. I want to turn to two programs that have particularly interesting data, particularly strong data. People sometimes ask me the question: Doug, what is the best program in the country? I have no clue. Somewhere out in the community is a really terrific program but it is not being evaluated, or hasn't been. We don't know that that's the best program in the country. I can answer a different question. That question is: Which programs have the strongest evidence that they actually had a positive impact upon behavior? So there's a difference there. Which is the best versus which has the strongest evidence? It's the latter that I can answer. There are five of them that I'm going to mention. Safer choices is a program that is designed to prevent HIV, other sexually transmitted diseases and teen pregnancy. It was a comprehensive program. Randomized trial. Twenty schools were involved. ETR were involved. Ten got the program, ten did not. We tracked this study. We tracked the cohort of youth for 31 months. What we found is that among Hispanics that delayed initiation of sex, among all youth regardless of ethnicity, it increased -- sorry. It decreased the frequency of sex, increased condom use.
It increased contraceptive use and it decreased the frequency of unprotected sex. It had positive outcomes in terms of delaying sex and also increasing condom use, contraceptive use and did all of this for 31 months. Now, it's that 31 months which in my mind is the important key. Twenty-five years ago, our goal was to change behavior for three months. We finally achieved that goal. Then it was six months. Then it was a year. Now we are developing interventions which have an impact on behavior for 31 months. In my mind, that's very encouraging. Reducing the risk is noteworthy because it addresses or answers a different question that some of us have. We did develop it at ETR associates where I work. We evaluated the impact at four different sites in California. We found it delayed the initiation of sex and increased condom and contraceptive use among some youth, but not all. If that was the end of the story, I wouldn't be mentioning it. Completely independent of us in our consulting, was then implemented and evaluated.
And there also they found that the, reducing the risk delayed the initiation of sex and increased the use of condoms among some groups of youth but not all groups of use. It was then implemented in Kentucky. It there initial -- delayed the initiation of sex but at that time it did not increase the use of condoms. It is not known why. In the first site, a four state it did not have an impact on behavior. In three out of four states, it did have a positive impact on behavior. It partially answers the question: What happens if you take an intervention that has been designed by researchers and people doing work in the field and there's a fair amount of money from NIH or CDC to do the research and monitor it carefully and when it's implemented by different people elsewhere in the country, what happens? This tells us when you do implement it elsewhere, you can have a positive impact on behavior in most but not all cases. That's encouraging. The last three programs all were designed primarily for African American youth. All focused on hitch/AIDS. All were randomized trials. All measured impact for a year. All found that the programs either delayed the initiation of sex and or increased condom use over that one-year period of time. That also is very encouraging. These are the studies that we have that are the strongest which measure an impact upon behavior. Any questions before I do-p go on? (There was no audible response.)
DR. KIRBY: Okay. Oh, yes?
AUDIENCE: Before that one, if you know that all of the programs were implemented as designed?
DR. KIRBY: We know that they were implemented fairly well in these particular cases for reducing the risk. There is actually one study done -- reducing the risk is 16 sessions long. It was implemented in one case and evaluated poorly and the results were not positive. I didn't report that because they only implemented three to four sessions out of the 16. In my mind, that is really not implementing the program. Here out of 16 they implemented somewhere between 13 and 16 of the sessions, something like that. Fidelity to implementation is important. Yes?
AUDIENCE: With regard to the curriculum -- (inaudible) evaluated.
DR. KIRBY: The question is, with the American red cross evaluation has been implemented? I don't remember the evaluation of it. I don't know that there was an evaluation that met the criteria that I described. There are close to 100 different studies. I may have lost some back there. I don't remember that one.
AUDIENCE: I hear you saying that for the curricula that were given to the American red cross -- (inaudible) -- African American train the trainer --
DR. KIRBY: I don't think there has been a study meeting the criteria mentioned. If there was, I don't remember and I am not sure of the results. So some study we saw worked. We actually changed behavior. Others did not change behavior. What we then did was to take the curricula of those that did change behavior and put them in a pile and then the curricula of those that did not change behavior and put them in a pile and read through them and said what distinguishes between these two groups of curricula. We talked to the people who implemented them, the designers, et cetera and tried to gain in sight from them. We came up with ten different characteristics. These are standing the test of time. These are not terribly new. Much of this today is in emerging answers. Which you can download free of charge the executive summary. And if you are from a developing country, I can send you a pdf file with the entire volume, but only if you are from a developing country. These ten characteristics are standing the test of time. I keep wanting to change this because I'm ready for something new, and I'm doing this review as I just mentioned and they still seem to be pretty accurate. They are what -- effective substance abuse programs, not identical, but close. The first characteristic of effective programs are that those that did change behavior really focused on behavior.
The people identified particularly the behaviors that they wanted to change. Delaying sex, increasing condom use, increasing contraception use, limiting the number of partners. It was designed to change those behaviors. They didn't talk amorphously. They focused on changing behaviors. They did not talk about gender roles and loch and romance and all of those things. Those are nice things to talk about, but these focused on behavior. I'll give you examples shortly of how. They are based on psychosocial theories that have been effective in other areas such as substance abuse. Two, these theories identified psychosocial risk and protective factors. We talked at the beginning briefly about risk and protective theories. What these theories did was identify the particular risk and protective factors that the programs then tried to change. If you are looking at logic models, they created a logic model. They specified here are the behaviors you are trying to change and here are the psychosocial risk and protective factors associated and they are implementing within the curricula -- They were -- come on, computer. Things such as knowledge about S.T.D. HIV transmission.
They did provide basic information, but not only that. Values about adolescents having sex. Their personal values had a large impact on whether or not they initiate sex at an early age. Attitudes about sex and contraception. If they think they cause cancer, they are less likely to use them. If they are a great hassle, destroy the mood or whatever, they are less likely to use them. Other attitudes have an attitude, perception of peer norms and about contraception and condoms, those had an impact. They tried to change these. Self efficacy, to refuse unwanted sex or than insist on condoms or contraception use. You are confident that you can say no to sex if you want to or confidence that you can insist upon using condoms or contraception, these are the things that they tried to change. Third characteristic. They gave a clear message about sexual activity and condom or contraceptive use. That message was typically something like: Abstinence really is the safest approach. That is your best option. If you have sex, you should always use condoms and contraception every single time that you have sex. That was a clear message to them.
These programs, the programs that did not work essentially did something like: Here is a decision making model. Here is the steps to making a decision. Here are the pros of having sex or using condoms or contra semtion. Here are the cons to having sex or using condoms or contraception. Some implicitly said: You decide what is right for you. The programs that did that were not effective at changing behavior. The ones that were effective at changing behavior essentially gave this very clear message all the way through. All the activities, everything was designed to reinforce na clear message. They didn't do this in a moralistic lecturing judgmental way. The kids are not going to respond to that. They are much more subtle. Nevertheless the activities were designed to get young people to realize this was the right decision. Either not having sex or always using condoms or contraception is what they should be doing. The programs did provide accurate information about the risks of unprotected intercourse, using condoms and contraception. They didn't draw on information. There is basic information but not lots of details about lots of things. They addressed social pressures on sexual behavior. One way they did this was to talk about lines that young people have used to get someone to use sex. What are the lines you have heard in your life or -- doesn't have to be your life (Chuckles.)
DR. KIRBY: That you've heard other people use or whatever. What are the lines in your communities that young people use to get someone to have sex?
AUDIENCE: I'm sterile. (Laughter.)
DR. KIRBY: I'm sterile, okay. What is the response? What is -- I haven't heard that one before. That's new. What is the response to that line?
AUDIENCE: How do you know?
DR. KIRBY: How do you know you're sterile, okay. What is another line that someone might use?
AUDIENCE: Nobody gets pregnant the first time.
DR. KIRBY: No one gets pregnant the first time. And the response to that?
AUDIENCE: (inaudible).
DR. KIRBY: Okay, that's another line. If you love me, have sex with me. What is another response to the line if you love me, you would have sex with me.
AUDIENCE: (inaudible).
DR. KIRBY: Going where?
DR. KIRBY: You're going off to war tomorrow. Another line. I need more responses. What is the response to if you love me, you'll have sex with me?
AUDIENCE: If you love me you'll wait.
DR. KIRBY: If you love me, you wouldn't put pressure on me to do something I'm not ready to do. What's the response to the line I'm going off to war tomorrow.
AUDIENCE: I'm wait for you.
DR. KIRBY: Good, I'll wait for you. (Laughter.) Okay. So the effect, what the effective curricula did was essentially ask young people what were the lines they thought they heard in their lives. These are not the kids' lines, not the instructors. These came from the kids, things that they heard. And they would get, of course, president responses to this. Doing this, I think does about three things. First it makes people aware of what some of the lines are. So that if they hear it, you know, if a girl hears a boy saying I love you, will you have sex with me? She may say he may love me and that may be the case but if he's saying he loves me and there by should have sex with him, that's putting pressure on me and it's a line. It gives them an idea what the lines are. Secondly, they might remember the p responses to the lines. They might or might not but it helps. The third thing that is happening, in the classroom we don't do this for 30 seconds as we did just now. Rather you do it for a period of time. So the kids are identifying the lines and then everybody is coming up with multiple responses to those lines. Sometimes funny, sometimes serious, but always coming up with responses. What is that doing? That is emphasizing --
AUDIENCE: (inaudible).
DR. KIRBY: It is making them aware, that's right. That's reinforcing the norm that you don't give into these lines. Reinforcing the norm that you don't give into the lines. You know, now it's not the teacher lecturing on this. It's the kids reinforcing the norm that you don't have sex when you are not ready to, reinforcing the norm that you don't give in to these lines. Next characteristic is that they provided modeling and practice in communication and refusal skills. Now, typically that means role playing. Role playing can work great for these kinds of things. Some of the effective curricula have many role plays in them. They start off with role plays which are easier, easier situations such as you are not particularly attracted to the other person but that person wants you to have sex to maybe a situation where you really like the other person and you're afraid you might lose your boyfriend or girlfriend if you don't have sex. How can you say no, et cetera?
They provide practice in those different kinds of situations. They start off with both sides reading. I'm the male trying to get someone have sex and I'm reading the script. The girl is also reading the script. Modeling and showing skills, ways to say no. How to say no grace fully and how to suggest other activities, how to make it a clear no, et cetera. After some practice, and anybody practices, you break into groups of two or three and practice. After everybody practices, the person resisting no longer has a script. They have to use their own words. That's more challenging and internalizing as well. If they do the role playing, where they are resisting sex that they don't want or insisting on condoms and contraception, what are they doing? They're looking around the room and reinforcing the norm that you don't have sex when you don't want to and use condoms an contraception if you do want to. It's changing peer norms as well. It's coming from them. As well, it is teaching the skill. Using teaching methods to involve participants and help them personalize information.
Let me model two different ways of teaching a particular session. And I'm going to do this very quickly. The ineffective way is this: Class, do you realize that if you have sex you might get pregnant? Chances are one out of six. You might not get pregnant the first time, but sooner or later you are going to get pregnant if you do have sex. That will go in one ear an out the other ear. This is more effective way: Class, we realize that many of you are not having sex and that's the best way to avoid pregnancy. But for this activity, we are going to make the assumption that you are having sex for this one activity. I want all of you to choose a number between one and six. I want all of you to choose a number much everybody write down a number or make a clear mental note. People on web TV or whatever, you write down a number. Choose a number between one and six. Okay? Anybody know what this is?
AUDIENCE: Bag.
DR. KIRBY: It looks like a bag. It's actually a new Chicago pregnancy test. (Laughter.)
DR. KIRBY: One out of six people get pregnant each month if they have unprotected sex. One month has gone by. Everybody with the number three, I want you to stand up. You just became pregnant. Stand up and please remain standing. (Laughter.) (Applause.)
DR. KIRBY: First month. Now, month number two. Everybody with the number one, will you stand up and radio main standing? You just became pregnant the second month. If any of you didn't have a number between the number one and six. Everybody with the number five, third month, stand up -- next month, everybody with the number four, will you stand up and remain standing? You just became pregnant. Next month, everybody with the number two, will you stand up? Are you already standing? Okay, number two. Next month, everybody with number three, you already standing. You are incredible risk takers. You don't learn. You became pregnant twice in the same year. (Laughter.)
DR. KIRBY: I could keep going. The only number I haven't called is six. I could keep going. I might’ve called six or six might be lucky. Before you sit down, look around and realize, after a few months, just about everybody is standing. You might not get pregnant the first month, but then you will get pregnant, you probably will sooner or later. What did that activity just do? First of all, think about a typical classroom. Imagine it's after lunch -- this wouldn't apply to any of you here. Maybe it's after lunch and you are getting sleepily. I at least got your attention. You stood up and are further engaged. You are very much engaged. You're losing the class, you have the interaction. You have their attention. Visually you see, everybody is getting pregnant. Not the first month, but if they have sex and don't use contraception. We use the activity the second time. I'll do a couple of three months -- I'll choose another number. Four, okay? Number four.
I just pulled four, but you do not have to stand up because you decided that you would use contraception every single time you had sex, and you did. And you did not become pregnant. This time, number one. You did not become pregnant because you decided you are going to abstain from sex, and you did. You did not become pregnant. This time, number six, you decided you were going to abstain from sex, but you didn't and you became pregnant! All the sixes, stand up. Have to give you -- no sixes? Okay, thank you. So you then see the contrast. We have only sixes standing up versus, before it was just about everybody is standing up. We then immediately follow that activity with something like the following two kinds. You've just learned that you became pregnant. You just learned moments ago that you became pregnant. I want you to write just for yourself a couple paragraphs, what you think about how do you female and what are you going to have to do in the next few days? What will it feel like to go home and tell your parents? What is the going to feel like to tell your boyfriend, girlfriend, some of your other friends. You're pregnant or your girlfriend is pregnant. How would it feel? What do you do?
They write a couple paragraphs. What does it do? It personalizes, internalizes the information. Another activity. Write down the list of all the things that you would like to do in the next three to five years. Think about work, travel, school, all the fun things you want to do. What are the things you want to go do in the next three to five years. Now go through the list and put an X through all those which you can't do because you are a mother or father. Put a single line through those that you can do, but not as well because you are a parent now. Doing that is much more effective than telling them if you have a baby, you may not go to the prom, you might have to drop out of school, et cetera. It's getting them to personalize it. It's their list. It's the things they want to do, et cetera. The eighth characteristic is that the behavioral goals, teaching methods and all the materials are appropriate to their age, sexual experience and the culture of the students. What does this mean? This means if it's a really young group where very few of them are having sex, much more emphasis is being placed on abstinence. Maybe some discussion of condoms and contraception, but much more on abstinence.
If many of them are sexually experienced and having sex, more emphasis is placed on condoms and contraception while still emphasizing that abstinence is the safest approach. The three curricula designed for African American youth have a whole bunch of activities built into them to get them to realize that HIV was a big problem in their communities and it's their responsibility, not just to themselves but also to their community to eat, to other African American young people to not engage in unprotected sex because of HIV or other S.T.D.s. Different activities designed for their particular group. They last a sufficient length of time. You can't provide information and do multiple role plays and the kinds of activities I just mentioned in an hour or two or even five. You need more than that. Most of the effective programs that are implemented in school have lasted 15 or 16 sessions. It's also true there have been some that were implemented on weekends that were shorter and were also effective. Why? Well, would be reason is, on the weekend ones, the kids who came volunteered. If they came voluntarily instead of being part of school, they are more at tuned. The other thing, they hadn't just sat through algebra, chemistry and English. They were more focused.
The bottom line, these do take time. You can't do all the activities in just a couple of hours. Finally they selected peers or teachers who believed in the program and who implemented it and then provided training for them. It's not easy to do all of these things. It's not easy to do role playing in a RAM bunk should say classroom. It is not easy to talk about sexuality. You may get sued if you say the wrong things. One needs training in order to implement these programs effectively. Conclusions then regarding these programs are that not all of the curricula were effective, as we well saw. The ones that were ineffective focused the first generation mostly on increasing knowledge. We knee to do that, but that alone is not enough. I didn't talk much about the ineffective, but they tend to focus on generic values, clarifications. That is not enough. The effective ones have all ten of the characteristics I described. The programs only had five or six of those characteristics, they are highly unlikely to have effective. If they had all ten, almost all programs that do have ten characteristics are effective in changing behavior.
AUDIENCE: Do all of the effective programs have ... (inaudible) or are there effective programs that just deal with contraception?
DR. KIRBY: These are mostly but not solely implemented in schools. They are younger people so almost all of them, I probably can take out the word "almost". All of them did emphasize that abstinence was the safest approach. Some did give more weight to condom and contraception use if most of the kids were sexually active and tended to continue being sexually active. This of these programmed reduced the number of sexual partners and some increased the use of contraception and condoms. We are fining and this is important, emphasis on abstinence and condoms and contraception are compatible, not conflicting. We can do both. A couple of the programs delayed sex and increased condom and contraception use. That was the goal and they did all of it. We can do both. We don't have to choose one or the other. We can have a positive impact on both. These programs are quite robust in terms of effectiveness with multiple groups. They have been found to be effective with males and females, with all ethnic groups, with sexually experienced and inexperienced youth. With advantaged and youth in disadvantaged communities.
There is some evidence indicating that they are especially effective with higher risk youth in disadvantaged, meaning that they have fewer of the protective factors and more of the risk factors that I spoke about. These did not reduce all unprotected sex. They reduced unprotected sex by about a third. What do I mean by that? If in the control group 30 percent initiated section, in the group, 20 percent. In the control group, 30 percent, the intervention group, that was reduced from 30 down to 20 roughly. So roughly about, you know, reducing it by about a third. That raises the question: How big a difference is that? Is the glass one-third full or two thirds empty? In my mind, it is one-third full. If we, with these relatively brief programs, 15 to 20 sessions long, if we can reduce unprotected sex by a third, and there by reduce pregnancy rates and S.T.D. rates by a their, that is an enormous achievement, enormous achievement. One-third in my mind is a huge amount of success.
We shouldn't expect much more from what is basically a pretty modest program. On the other hand, it is not three thirds. It is only one thirt. That tells us if we really want to reduce pregnancy and S.T.D. even more, we need to do other things. These programs in my mind can become an effective component in a more pre-hence I have initiative. What are the implications of this for policy? First, we should encourage the implementation of programs, specific programs that have been demonstrated to be effective, and similar to the ones we are working with. We should implement with fidelity those that have been found to be effective, with populations similar to our own. Second, if we can't do that first, which is the more promising approach, then we should encourage the implementation of programs that have those ten characteristics. We need to provide adequate time in the classroom or in youth serving programs for these programs.
One of the things we learned, obstacles that teachers taught us, we can't devote 15 sessions to this, to sexuality. We can only devote two or three or five, but not 15. That's a problem. If you have a high pregnancy rate or high S.T.D. rate in the community, in my mind these are serious programs and out of all the years of instruction, it is worthwhile to spend 15 class periods on this particular topic with programs that are in fact effective. We need to provide adequate training for teachers. Far too often teachers, they love to pick and choose. They may implement the conference one with fidelity appear then they go to another conference and they choose other programs and the program then looses effectiveness and looses its effectiveness. We see that all the time. We need to encourage fidelity in other ways. I want to switch now from sex and HIV education programs which is what I'm talking about mostly today to a couple other types of programs.
This will be relatively brief. I have been talking about programs that are curriculum based, multi-session, implemented in schools or in the community as well. I now want to shift to one-on-one -- sex education/counseling programs in a clinic setting. This is one-on-one. This is a practitioner, a nurse, health educator, somebody in a clinic working one-on-one with an adolescent. There are several studies that have been conducted. And they all found that they were able to have an impact upon teen sexual behavior when they changed the protocols that they use for working with young people. And the different studies changed them in slightly different ways, but when you look across those different studies, we found that there were several things that were in fact common tho those programs that were effective. We are comparing there their new protocols with the preexisting protocols. In the new protocols, they provided much more than routine information.
They asked questions about the adolescent' sexual behavior and barriers to abstaining from sex and protection. They asked the person: Are you having sex? Is this the right decision for you? Do you want to continue having sex? If not, what are the barriers to stopping having sex? They continue that one-on-one. If you continue using sex, are you always using condoms, contraception? What are the barriers to doing that? How can we change that? Some used role playing, where the other person tried to get the sex to have -- adolescent to have sex without protection and the adolescent did role playing to resist having sex or insist on using condoms or contraception if they did have sex. They also gave a very clear message, similar to the one I just mentioned: Either abstain or always use condoms or contraception. These are four of the characteristics of these clip I can based on one-on-one. Do they all look familiar? What do they seem to resemble?
AUDIENCE: (inaudible).
DR. KIRBY: That's right. They resemble the school and community based ones. These are some or similar to the characteristics I just talked about. The ten characteristics do work in the school setting and community setting. If you adjust them appropriately and select from them, you can also use them on a one-on-one basis effectively in a clinic setting. Yes?
AUDIENCE: We just want -- (inaudible).
DR. KIRBY: No, not school based clinic. Family based clinic, S.T.D. clinic, the clinic that people came to. Maybe they had a rash or the measles or something else and after dealing with that, they turned to sexuality. Not a school based clinic, although one can do the same thing in school based clinics. Would be a great thing to do in school based clinics.
AUDIENCE: Are they -- (inaudible).
DR. KIRBY: Sometimes, yes. They didn't have a lot of time. Ten or 15 minutes. They extended the amount of time that they had with the patient. Not 45 minutes or an hour, but more than five minutes, to be sure. Completely different kind of program. I'm just going to talk about a couple more quickly. Completely different program is a teen outreach program. How many of you are familiar with the service learning, the teen outreach program? Raise your hand. A couple people are. Service planning basically involves two components. The first is doing voluntary service in your community and the second involves small group discussions to prepare young people for that voluntary service, hopefully to get them to decide what that voluntary service will be, what kinds of activities they are going to engage in. And then talk about debrief, after each time they have done the service, think about the implications for their lives.
What is remarkable is that teens who participated in service learning all intensive programs, incidentally, not short, hour or two. If you go down to the beach and spend two hours cleaning up the beach, it won't have an impact on your sexual behavior. This included between 45 and roughly 100 hours of involvement in either the voluntary service or in the small group discussions. What we found -- not we but others have found in several different studies is that these actually reduced teen pregnancy during the academic year in which they were involved. These programs did not involve sexuality. They may not have talked about sex at all. They may not have talked about condoms and contraception at all. They may not have given as clear a message or role play or anything of that nature. What they did do probably was to address some of the nonsexual risk and protective factors that I talked about at the beginning. They may have made young people feel that they are part of a solution as opposed to part of a problem. Made them feel that, you know, they can do something with their lives. They can be effective. They can have a positive impact. May have done other things as well.
We don't fully understand why they were effective, but we do know that they reduced teen pregnancy during the academic year in which they were involved. I want to put this in for a balance. They indicate, I talked mostly about those programs that focused on sexual risk and protective factors. But you can have an impact on adolescent sexual behavior by addressing the nonsexual risk and protective factors as well. If you look at youth developed prasms, some did not reduce sexual activity or con dray -- how many of are -- how many of you are familiar with bania -- some of you may be very much involved with this. They know this much better than I do. It was implemented in grades five to eight. Focused on management skills to manage potential high risk situations, randomized trials. Among girls it did not have an impact, but among boys, it reduced recent sexual behavior, reduced recent sexual behavior and condom use and demonstrated that the broad och approach can have an impact. Not will, but can. There's, how many of you are familiar with the children's aid society program? A few of you. This has been evaluated very, very intensive.
Youth are involved for many years. They start in junior high school an remain throughout high school. It involves job club, sex education, health and mental health services, arts, sports and included in the health services are family planning, reproductive health services. So it includes good sex Ed and all these other things as well. And what did it do? For over a three-year period of time it delayed the initiation of sex among females, increased contraceptive use among females, particularly long-term contraceptive use and reduced pregnancy rate by half for three years. So that's a huge achievement, to actually reduce pregnancy by half for three years. That's in my mind probably the strongest, most important result that we have.
AUDIENCE: Did it focus on --
DR. KIRBY: Yes, randomized trial. Multilevel analysis. Not multi-. It was different sites throughout the country. They randomly assigned individual youth in each of those sites either to participate or not, track them for three years, cohort study. And had this very large impact. Did not have an impact on boys.
AUDIENCE: Did they involve the parents in --
DR. KIRBY: In the career program, parents were involved in a variety of different ways. These were all very high risk youth and they reached out to parents in multiple ways, tried to help them get employment, communicate more with their own kid, different kinds of things. Any other questions about this one? Some of the sex and HIV education programs also tried to increase parent child communication about sexuality and succeeded in doing that by giving homework assignments. If you want to increase parent child communication about sex, the simplest easiest way to do that, since you are working in schools, that's a big assumption, is simply to incorporate homework assignments in which you ask young people -- for this homework assignment, you go home and talk to your parents. You need to have an out. Some of them can't talk with their own parents. You can say you can have another adult if you are not comfortable talking with your clients.
Send the materials home ahead of time so they know this is going to happen. Give them suggestions, values they may want to talk about, et cetera, a broad list of values. Parents often appreciate that. And then have the kid talk with them not once or twice, but several times. Starting with easier topics and moving to more sensitive topics about when should young people or should young people have sex? Condoms, contraception, et cetera. And most, not all, most young people will do this and end up then having greater communication with their parents and greater comfort with that communication. Looking across all these programs, I reached the following four conclusions: The first is that sex and S.T.D. HIV education programs and some clinic programs address sexual risk and protective factors, can delay sex, can increase condom and contraception use. Some programs such as youth learning address some risk and protective factors and can also address teen pregnancy.
Some comprehensive programs such as children's aid society career program address both groups of factors, both the sexual and the nonsexual. They may have the greatest impact on teen pregnancy, S.T.D. and HIV. Finally, most of the effective programs and the service learning is about the only exception I know of, most effective programs give a clear message about avoiding unprotected sex and involve youth interactively so they end up personalizing that message. You have been a great group. I want to thank you. I am happy to take as many questions, but I realize that it is a few minutes after 2:30 and anybody that wishes to leave should certainly feel free to do so. Thank you very much.