KenIN CoyLE, PHD r KensN BasrN-ENGeursr, PUD r Doucras Ktnnv, PUD

Guv PaRCEL, PHD r STEpHEN BaNspAcH, PHD r JANET CotLtNs, PHD

Ertza.BETH BAUnnLEn, PsD r Scorr CaRVAJAL, PHD r RoNnLo HAnntsr, PsD

Safer Choices: Reducing Teen

Pregnancy,HIV and STDs

Drs. Coyle, Kirby, and Carvalal are with

ETR Associates, Scotts Valley, California. SYNOPSlS
Dr. Coyle is Director of Research, Dr.
K i r b y i s S e n i o r R e s e a r c hS c i e n t i s t ,a n d Objectives.This study evaluatedthe long-term effectivenessof Sofer
Dr. Carvajal is Senior Research Associate.
d ,u l t i - c o m p o n eendt u c a t i o n aplr o g r a md e s i g n etdo
C h o l c e sa,t h e o r y - b a s e m
Dr. Basen-Engquistis an Assistant
Professor, University of Texas MD reducesexualriskbehaviorsand increaseprotectivebehaviorsin preventing
Anderson Cancer Center. At the time of , n d p r e g n a n caym o n gh i g hs c h o o sl t u d e n t s .
H l V ,o t h e rS T D s a
this study, she was an Assistant Professor,
Center for Health Promotion Research . h e s t u d yu s e da r a n d o m i z e cd o n t r o l l e dt r i a l i n v o l v i n g2 0 h i g h
MethodsT
and Development, University of Texas, schoolsin Californiaand Texas.A cohort of 3869 ninth-grade
studentswas
Houston. Dr. Parcel is Director and Dr.
r 9 9 3( b a s e l i n et o) s p r i n gs e m e s -
t r a c k e df o r 3 | m o n t h sf r o m f a l l s e m e s t e 1
Harrist is an Associate Professor, UT
Houston Center for Health Promotion . a t aw e r e c o l l e c t e du s i n gs e l f - r e p o rst u r -
t e r 1 9 9 6( 3 l - m o n t hf o l l o w - u p )D
Research and Development. Dr. Banspach v e y sa d m i n i s t e r ebdy t r a i n e dd a t a c o l l e c t o r sR. e s p o n s rea t e a t 3 l - m o n t h
and Dr. Collins are with the Centers for
follow-upwas79%.
Disease Control and Prevention. Atlanta,
Georgia. Dr. Banspachis Chief, Evaluation involvingcondom
had its greatesteffecton measures
Results.SoferChorces
R e s e a r c hS e c t i o n ,S u r v e i l l a n c ea n d
Evaluation Research Branch, Division of
use.The programreducedthe frequencyof intercoursewithout a condom
Adolescentand School Health. Dr. d u r i n gt h e t h r e e m o n t h sp r i o rt o t h e s u r v e yr,e d u c e dt h e n u m b e ro f s e x u a l
Collins is Deputy Director, National partnerswith whom studentshad intercoursewithout a condom, and
C e n t e r f o r C h r o n i c D i s e a s eP r e v e n t i o n
increaseduse of condomsand other protectionagainstpregnancyat last
and Health Promotion. At the time of this
study, she was Chief, Surveillance and intercourse.Sofer Choicesalso improved7 of l3 psychosocial
variables,
Evaluation Branch, Division of Adolescent effectupon rates
manyrelatedto condomuse,but did not havea significant
and School Health. Dr. Baumleris a
o f s e x u ailn i t i a t i o n .
strategic modeler with Eucid Inc.,
C h i c a g o ,l l l i n o i s .A t t h e t i m e o f t h i s s t u d y ,
Conclusions. programwas effectivein reducingimportant
The SaferCholces
she was an Assistant Professor, UT
Houston Center for Health Promotion
r i s k b e h a v i o rfso r H l V , o t h e r S T D s ,a n d p r e g n a n cayn d i n e n h a n c i nm
g ost
R e s e a r c ha n d D e v e l o o m e n t . p s y c h o s o c idael t e r m i n a n ot sf s u c hb e h a v i o r .

PUBLIC HEALTH REPORTS . 2OOI SUPPLEMENT 1 . VOLUME I I6

 chool-agedadolescentsare an important target
population for health promotion programs,
particularly programs addressingsexual behav-
iors. The number of AIDS casesamongadoles-
cents and young adults ages 13 to 24 remains
relatively small (26,518 reported cases through June,
2000);r however, it has been estimated that approxi-
mately one-half of all new HIV infections occur among
young people between the ages of 13 and 24.2 In addi-
tion, roughly one in four adolescentsages 13-19 who
have had sexualintercourseacquire an STD each year.3
Finally, approximately10% of 15- to l9-year-old females
become pregnant each year;aan estimated B5Voof these
pregnanciesare unintended.5
Numerous HIV, other STD, and pregnancypreven-
tion programs have been implemented in secondary
schoolsacrossthe nation, but relatively few have had a
significant effect on sexualrisk behaviors,6or the effects
have been modest or short term.7-r0Given the significant
consequencesof unprotected sexualintercoursefor ado-
lescentsand the limited results of past HIV, other STD,
and pregnancy prevention studies, we developed Safer
Ch.oices, an innovativemulti-componentprogram.
SaferChoicesis a2-year,school-basedHIV, other STD,
and pregnancy prevention program for high school stu-
dents. It has recently been identified as a "program that
works" by the Centers for DiseaseControl and Prevention
(CDC). The primary aim of SaferChoicesis to reduce the
number of students engagingin unprotected sexualinter-
course by reducing the number of students who begin or
have sexualintercourse during their high school years and
by increasingcondom use among those students who have
sex. In addition, the program seeksto modifr severalfac-
tors related to sexualrisk-taking behavior:knowledgeabout
HIV and other STDs; attitudes about sexualbehavior and
condom use; normative beliefs regardingsexualintercourse
and condom use; students'beliefs in their ability (self-
efficacy) to refuse sexualintercourseor unprotected sexual
intercourse,use a condom, and communicateabout safer
sexualpractices;perceivedbarriers to condom use; per-
ceived risk of becoming infected with HIV or other STDs;
and communication with parents.
This randomizedcontrolled trial tested the effects of
Safer Ckoices. We hypothesizedthat adolescentswho
received Safer Choice.swould initiate sexual intercourse
at a slower rate than adolescentsin the comparison
group. We also hypothesized that adolescentsin the
intervention group who had ever had sexualintercourse
would have unprotectedintercoursefewer times and with
fewer partners in a 3-month period than would adoles-
PUBLIC HEALTH REPORTS.2OOl SUPPLEMENT I. VoLUME
cents in the comparisongroup, after adjustmentfor indi-
vidual-level baseline values. Further, we hypothesized
that studentsin the interventiongroup who reported sex-
ual intercourse would report fewer sexual partners,
greatercondom use at first intercourse(amongthosewho
initiated intercourseduring the study),greatercontracep-
tive use at last intercourse,lessalcohol and drug use prior
to sexualintercourse,and more frequent testing for HIV
and other STDs. Finally, we hlpothesized that interven-
tion students would score more favorably on the psy-
chosocialscalesthan would comparisonstudents.
The evaluation results after the first year of program
implementation showed a positive effect on condom use
and most psychosocialmediating variables among stu-
dents in the cohort.li In this paper, we discuss the 31-
month follow-up results, conducted approximatelyone
year following the intervention.
MsrHoDS
Procedures and assignment. The Safer C'hoicesinter-
vention was implemented during the 1993-1994 and
1994-1995 school years. The evaluation used a random-
ized controlled trial involving 10 public schoolsin an urban
area in northern California and l0 public schools in an
urban area in southeastTexas.The schools ranged in size
from 961 to2733 students(mean= 1767\.Five schoolsin
each state were randomly assigned to the Safer Ckoices
program;the remaining schoolswere assignedto a compar-
ison program (a standard, knowledge-basedHIV preven-
tion curriculum). We used a restricted randomization
process in which schoolswere ranked based on an index
score of possible confounding variables (such as percent
collegebound and number of studentsin school);adjacent
schools in the ranking were then paired and randomly
assignedto either the intervention or control condition.r2
The school districts were chosen because they served
diverse populations in terms of ethnicity and socioeco-
nomic status, were in areasof the country with high HIV
prevalencerates, and were in close proximity to the inves-
tigative team. We chose districts in two different areasof
the country to improve the generalizabilityof study results.
We collected self-reportdata from a cohort of ninth-
gradestudentsat all 20 schoolsusing trained data collec-
tors. The baselinedata were collectedin fall 1993,imme-
diately before the intervention. Follow-up data were
collected in spring 1994 (7 months after baseline and
immediately following the first year of the intervention),
spring 1995 (19 months after baseline and immediately
following the secondyear of the intervention),and spring
II6
 ET AL.
1996 (31 months after baselineand l2 months followinq
the secondyear of the intervention).
Active parental consent was required for surveypar-
ticipation; B}Vo ol students returned parental consent
forms (5184 of 6488): a total of 4733 studentshad con-
sent to take the survey.Baselinesurveyswere completed
by 9\Vo of these students.Becauseschoolswere the unit
of randomization,we used multi-level statisticalanalyses
to accountfor the clusteringof studentswithin schools.A
detailed discussion of the evaluation methods is pub-
lished elsewhere.r2We also collectedcross-sectionaldata
at three time points to assessthe school-wideeffects of
the intervention. The cross-sectionalresults are Dre-
sentedin a separatepaper.13
Participants. The cohort consistedof 3869 ninth-grade
studentswho completedthe baselinesurveyin the fall of
1993 and who were officially enrolled in the secondyear
of the intervention (fall 1994). We excludedstudents (at
both intervention and comparisonschools)who were in
llth or l2th grade;we also excludedstudentswho left
schoolduring the 1993-1994schoolyearand did not re-
enroll in the fall for the 1994*1995 school year. These
criteria were adopted becausethe intervention program
was multi-year. Baselinedemographiccharacteristicsfor
the cohort are summarizedin Table 1.
A total of 3058 (79Vo)of the 3869 studentsin our
final cohort were surveyedat the 3l-month follow-up.
Responseratesfor the 7-month and I9-month follow-ups
w ere 9 5% and B3Vo,respectively.
Intervention.The SaferChoicesinterventionis basedon
social cognitive theoryla social influence theory15-17
and
models of school change.lBThe program consistsof five
primary components: school organization (a School
Health Promotion Council involving teachers,students,
parents,administrators,and community representatives);
curricuium and staff development (a sequential 20-
session classroom curriculum for 9th- and l0th-grade
students that includes 10 sessionsat each grade level
taught by trained teachers);peer resourcesand school
environment(a SaferC'hoicespeer team or club that hosts
school-wide activities); parent education (activities for
parents including parent newsletters, student-parent
homework activities, and other parent events); and
school-community linkages (activities to enhance stu-
dents'familiarity with and accessto support servicesout-
side school, such as homework to gather information
about local services,resource guides, presentationsby
speakerswho are HlV-positive). The Figure includes a
PUBLIC
brief overview of each component. A more detailed
descriptionof the interventionis providedelsewhere.le
During eachyear of the program,interventionschools
implemented activities acrossall five components. Stu-
dents receivedtheir most intensive exposureto the pro-
gram from the 2O-lessoncurriculum and school-wide,
peer-sponsored events.
Measures. The surveyconsistedof items assessing demo-
graphic characteristics,sexuality-relatedpsychosocialfac-
tors, sexual behaviors, and program exposure. The psy-
chosocial scales were: HIV knowledge; other STD
knowledge; attitudes about sexual intercourse; attitudes
about condoms;normativebeliefsabout sexualintercourse;
normative beliefs about condoms; self-efficacyin refusing
sex;self-efficacyin using condoms;self-efficacyin commu-
nicating with partners; barriers to condom use; HIV risk
perceptions;other STD risk perceptions;and communica-
tion with parents.The scalesand their psychometricprop-
ertiesare discussedin more detailelsewhere.IrJ}2o
Prirnary outcolnes. The survey measured three primary
behavioraloutcomes:(a) whether studentsdelayedinitia-
tion of sexualintercourse:(b) the number of times stu-
dents had intercoursewithout a condom in the last three
months (amongthose reporting intercourse);and (c) the
number of sexualpartnerswith whom studentshad inter-
course without a condom in the last three months
(amongthose reportinglntercourse).
Secondaryoutcow.es. The survey also assessednumerous
secondarybehavioraloutcomes:use of a condom at first
intercourse among students who initiated sexual inter-
course following baseline;use of protection at last inter-
course;number of times had sexualintercoursein the last
three months; number of sexualpartnersin the last three
months; use of alcohol or drugs before sexualintercourse
in the last three months; and being testedfor HIV and for
other STDs. The surveyitem assessinguse of protection
at last intercourse was analyzedas two dichotomous vari-
ables: use of a method that effectively protects against
HIV and other STDs (condom) and use of a method that
effectively protects against pregnancy (condom alone,
condom and birth control pills, birth control pills alone).
Statistical analysis. Multilevel models were used to
adjust for the correlation between students within
schools, and correlation within students because of
repeatedmeasurementsover time. The three-levelmod-
els included surveymeasurementoccasionas level 1, stu-
HEALTH REPORTS . 2OO1 SUPPLEMENT' 1 . VOLUME 116
 &lii:r{i::;r::r:i::!:i::r:"'.:

'., ', '

.; uu"a91 ",

.. ..:':;.i--::::- . - 7 O 6 - . - ' - ; - . ; . i " ' : : - : r f i n ' ' a : : . : : : - - : 4 " ' ; ' : ' Z ( l / .{ : : ' : : : : : : ' : ' - ' - ' : ' ) ' f' ' l ' , : " " ; ; ; .
"'-''..'f9'.I
':'.,

dents as Ievel 2, and schoolas level 3. We used linear and negativebinomial regressionmodel is a generalizationof
logistic multilevel models to analyze continuous and the Poissonregressionmodel and is often used for model-
dichotomous data, respectively,and Poissonor negative ing over-dispersedcount data in which the variable of
binomial multilevel models to analyzecount data. The interestis the number of occurrencesduring a given time

PUBLIC HEALTH REPORTS . 2OO1 SUPPLEMENT I . V O L U N , T EI I 6

 Figure. Features ofthe SoferChoicesprogram

Progromcomponent Feotures

School organization A SchoolHeolth PromotionCouncilinvolvingteochers,students,parents,odministrotors,and

The Council plansand conducts Programactivities.
communityrepresentotives.

Curriculum and staff A sequentiol,20-sessionc,ossroomcurrkulum for ninth-ond tenth-grodestudents(10 lessons

develooment ot eochgrodelevel).The curriculum includesin-classpeer leadersto facilitateselected
activities(e.g.,leadingsmall-grouprole playing)and is implementedby classroom
teachers trained by prolect staff.

Peer resourcesand school
environment
A Sofer Choicespeer teom or club ot everyschoo,.The club members meet with an adult
peer coordinator to plan and host six types of school-wideactivitiesdesignedto alter
the normative culture of school. Peer teams also run a resource area on camPus.
Additionally,proiect staff developedrole model stories in which teens tell their per-
sonal stories modelingpositivebehaviors;the stories are presentedin a poster format
(and were presentedin a monthly calendarduring the study).

Parenteducation Activitiesfor porents.Parents receive three project newsletters ayear that provide
information about the program;functionalinformation regardingHIV/AIDS,other
STDs, and pregnancy;and tips on talkingwith teenagersabout these issues.The cur-
riculum includesstudent-parenthomework activitiesto facilitatecommunication
regardingHlV, other STDs and pretnancy.Parentsalso serve on the health Promotion
councilsand help plan other parent-relatedevents.

School-communitylinkages Activitiesdesrgnedto enhoncestudents' fomiliority with ond occessto support servicesoutside

school.The curriculum includeshomework assignmentsrequiringstudentsto gather
informationabout local resourcesand services.lt also includesa lessonin the lOth
grade involvingH|V-positivespeakers.Studentsand teachersreceiveresourceguides
that provided a list of HlV, other STDs,and pregnancy-related servicesfor adolescents.

NOTE: The publishedprogram materialsare availablefor purchasethrough ETR Associates(800) 321-4407(customer service).

period. We carried out computations for the multilevel
models using MLn Softwarefor Multilevel Analysis,Ver-
sion1.0a.21
We examined the effect of the intervention from
baselineto the final follow-up measurement,a period of
approximately 31 months. The analyses included the
baselineand three follow-up measuresof each outcome
to provide a test of the overall intervention effects. The
follow-up measureswere modeledas dependentvariables
in random effectsmodels.We modeledthe following vari-
ables as predictors for each outcome: participants'base-
line responseson the outcome; intervention group; geo-
graphic location (Texas or California); an intervention
group-by-geographic location interaction term; measure-
ment occasion; intervention group-by-measurement
occasioninteraction terms; and a set of outcome specific
covariates.We also created a variable representingthe
number of weeks between baselineand follow-up, and a
variabledenoting whether the surveydata were collected
via mail or in school. Variableswere included as covari-
ates for a particular outcome if they were significantly
related to the outcome and intervention condition, and
remained significantin the final stageof multilevel mod-
eling. The multilevel models provided a flexible frame-
work for handling missing data. Students with incom-
plete data (missing one time point, fbr example) were
included in the analysisand contributed to the estimation
of the overall intervention effects acrosstime. Students
with missing data on the covariateswere excluded from
the analyses.
We used two-tailed tests and made no adjustments
for multiple tests of significance.Our primary and sec-
ondary hypotheseswere stated a priori and were limited
in number. All other analysesbeyond those for the pri-
mary and secondary hypotheseswere considered
exploratory.Statisticalsignificancewas set at P <0.05.

PUBLIC HEALTH REPORTS .2001 SUPPLEMENT 1 . VOLUNIE ll6

 Estimates of the magnitude of effects were calculated
for all outcomes. We used odds ratios to estimate overall
effects for dichotomousbehavioralvariables.The effects for
the Poissonor negativebinomial models representthe ratio
of the adjusted mean for the intervention goup to the
adjusted mean for the comparison group. Thus, an effect
sizeof 1.00indicatesno difference,<1.00 indicatesa lesser
mean for the intervention group relative to the comparison
group, and >1.00 indicatesa greatermean for the interven-
tion group relative to the comparison goup. For the psy-
chosocial variables, we used group coefficients flom the
multilevel models as an er?ression of effect size. This
approach to estimating the magnitude of program effects
was used becausefurther computations of effect size (for
example,conversionto Cohen's d or r family effect sizes)
would not fully use all the elementsof the multilevel ana\tic
model. These group coefficients represent the difference
between the two adjustedmeans (interventionvs. compari-
son group) on the scaleof the outcome variablebeing mea-
sured (such as HIV knowledgeor self-efficacyfor refuslng
sex).Becausethe coefficientsare unstandardized,onlythose
that are measuredon the samescalecan be compared.
RssuLrs
Estimates of the averageoverall effects of the interven-
tion are presented fbr the behavioral and psychosocial
measuresover the 3l-month follow-up period. We also
discusstrends over the three follow-up assessments.
Behavioral factors. Among the primary outcomes, all
three were in the desireddirection and two were statisti-
cally significant (Table 2). Sexuallyexperiencedstudents
in the intervention schools reported having intercourse
without a condom fewer times during the three months
preceding the follow-up survey than did sexuallyexperi-
enced studentsin the comparisonschools(P = 0.05) by a
ratio of 0.63. The group-by-locationinteraction was sig-
nificant for this variable (P = 0.05); it indicated the
effects were greater in Texasthan in California. Similarly,
Safer Choice.sstudents reported having fewer partners
with whom they had sexual intercourse without a con-
dom during the previous three months than did sexually
experienced students in the comparison schools (P =
0.02); the ratio of the adjusted means was 0.73. We
found no statistically significant difference in the inci-
dence of sexualinitiation between students in the Safer
Choieesand comparison schools at the final follow-up;
the effect was in the desireddirecrion (oddsratio = 0.83),
but not closeto significant (P = 0.39).
PUBLIC HEALTH REPORTS . 2OOI SUPPLEMENT I .
A m o n g t h e s e c o n d a r yo u t c o m e s , s t u d e n t s w h o
reported having sexual intercourse during the three
months prior to the survey in the intervention schools
were 1.68 times more likely to have used condoms (P =
0.04), and 1.76 times more likely to use an effectivepreg-
nancypreventionmethod (birth control pills, birth control
pills plus condoms,or condoms alone) (P = 0.05) at last
intercoursethan were studentsin the comparisonschools.
We found no significant differences at final follow-up
between intervention conditions on any other secondary
behavioraloutcomesafter we adjustedfor baselinevalues
(P = 016 to 0.51), althoughthe mean differences
between the two groups are in the desired direction for
five of the six remainingoutcomes.
Psychosocial factors. Thble 3 shows the results of the
multi-level analysesfor the 13 psychosocialscales.Signifi-
cant differences-all favoring the intervention schools-
were found for 7 of the 13 psychosocialscales.Intervention
students scored significantly higher than comparison stu-
dents on the HIV and other STD knowledgescales(by an
adjusted mean difference of I I and 9 percentagepoints);
expressedsignificantly more positive attitudes about con-
doms (P = 0.01); and reportedgreatercondom-useself effi-
cacy(P = 0.00),fewerbarriersto condomuse (P = 0.01),and
higher levelsof perceivedrisk for HIV (P = 0.02) and other
STDs (P = 0.04). Interventionstudentsalsoreportedgreater
normativebeliefs about condom use and more communica-
tion with parentsthan did comparisonstudents;thesediffer-
encesnearedsignificance(P = 0.06 for eachvariable).
There were no significant differences between stu-
dents in the two programgroupsin their attitudesregard-
ing sexual intercourse (P = 0.95), normative beliefs
regardingsexual intercourse (P = 0.79), self-efficacyto
refuse sex (P = 0. l0), or self-efficacyto communicate
with a partner about sexuallimits (P = 0.60).
There were two significantgroup-by-locationinterac-
tions-knowledge about other STDs and condom use
self-efficacy.The data suggestthe effects on other STD
knowledge were greater in Texas than in California, and
the effects on condom-useself-efficacywere greater in
California than in Texas.
Trends over time. As discussedin the analysissection,
we included group-by-time interaction terms in the
multilevel models to examine changesin the magnitude
of effects over time. These interactionterms demonsuare
that both the behavioraland psychosocialeffects endured
over the 3l-month follow-up period. Only one of the
interaction terms (number of partners unprotected) was
VOLUME 1I6
 Covrr ET AL.

Table 2. Parameter estimates for multilevel models of behavioralvariables:cohort sample, 3l-month follow-up
Rotio of group
ktimated estimote'to
efbct Stondord group stondard
Behovior vorioble r'f" siz€ effor et?or' 95"/.Cl P.

Primoryoutcomes
Sexualinitiation 2029 0.83 0.22 0.s4.t.27 o.3e
l
Frequency of intercourse
without
a condomin last3 months 137| 0.63 0.23 -1.97' 0'05
Nymber 9f :sexual'rPartnerS..with9!1t
,::r
a condom in last 3 months. 137| 0.73 o.l4 -2.37 0;0-1

Secondoryoutcomes
Use of condoms at first intercourse '
(amon8Inrtratorsonly) . . 733 t.44 0.27 0.85,?.44 o 1.'
Use of condoms at last
intercourse s49 r.68 0.25
Use of protection againstpregnancy
at last intercourse. .. 549 1.76 0.29
Number of times had sexual
r37t
'i' ,,,
,.,:,intercou!:se
in,last 3 months, . . . . ., 0.81

*rf
Number of sex partners in last
3 months 13,71 ''u,,',
Use of alcohol and other drugs
before sex in last 3 months r37l 0.04 oe7
Testedfor HlV. . . 36t6 t.20
Tested for other STDs 7627 r.52 :.1
"n representsrhe number of individualsincludedin the analyses.The rcsts of significance are basedon the number of observationsrather chan
the number of individuals.Eachindividualhad from two to four observations.
bOdds ratios were used to estimate overall intervention effects for dichotomous outcomes; ratio of adjusted means was used to estimat€ ov€r-
all effecs for Poissonor negativebinomialmodels.
= 2.57
"Group-by-locarion interaction was significantat P = 0.05; ratio of interaction estimate to inrcraction standard error

statistically significant (P = 0.0a); it indicated that the
interwentionhad a smaller effect at the final follow-up
relative to the first follow-up. The other group-by-time
interaction terms also indicated that the interventron
effects diminished somewhatover time [data not shown],
althoughnot to a significantdegree.
We also analyzedthe data following each time period
to examine the averageeffects up to a given time point.
(For example,at the 19-month foilow-up the effects rep-
resentthe averageof the 7-monthand 19-monthresults).
The majority of the findings were relatively consistent
over time. Among the behavioralfactors (Table 4), four
were consistentlysignificantat one of the three follow-up
assessments: frequencv of intercoursewithout a condom
in the previous three months; number of partners with
whom studentshad sex without a condom; use o[ a con-
dom at last intercourse; and use of protection against
pregnancy at last intercourse.Three of these four out-
comeswere statisticallysignificant and favoredthe inter-
vention at the 7-month follow-up; one of the four was sta-
tistically significant at the 19-month follow-up; and all
four were statisticallysignificantby the final follow-up.
Among the 13 psychosocialvariables(Table 5), 9 were
significant and favoredthe intervention condition among
cohort studentsat the 7-month and 19-monthfollow-ups.
They were HIV knowledge,other STD knowledge,atti-
tudes about condoms,normativebeliefs about condoms,
self-efficacyin using condoms, barriers to condom use,

PUBLIC HEALTH REPORTS.200l SUPPLEMENT 1 ' VOLUN'{E 116

 l

Vanable,

t4 3736 oOr 0,26 ,

Condoms . .. .. t4 3584 0.06 l.g8 ,
Yt:"*o
RefusingS*.t......, r-3 3633 l:65
.OO4
C o n d o mu s e . . . . . . . . . . . . . . . . . . . . r-3 .3592 o . tI 4 : 1 5 "r
C o * r u n i . " t i o n. . . . . . . . . . . . . . . . . l-3. 3s76 0.01 o:53
Barriers to condom use . . ., t4 "3682 - 0 . tI .2.51
Risk perceptions

. . . . .
r-5 3584 0J I ',os,
.o0li'
-3'.1";111
Communicationwith parents
r-s
r-3
3685
3632
0.09
0.05 ili 0:06:r
NOTES:.All models were adiustedfor baselinevaluesand other relevant covariates(suchas gender, parens' education,nurnber parents
of
or guardians in household, grade point average,-andethnicky)- hH modek also includld indepindem variables:group (intervention =
|,
control = 0); location (California= l, Texas =.0), and groui-by-l6citibn interaction terms (Calrforniainterven'tjbn= i, re-"ining = 0).

(3-5, depending on the scale) r.ufl".. ror. of the desired anribuce, excep c for variables barriersto
IiSh:: yrllu: ' use and risk perceptlons'
r.rirrr,i.r' nigh"l: r-."Jr"'n-".a s.i"ou.. b1..1"r. and risk perceptions. "condom

3"m;r:,:5Jffiff..;Til:flfiHHf,*J,*:::*:';J5#ff""1''*'.u..*e onthbnumber
arebased ofobservations
rather
than
"Escimateof magniude of effe

[I]"iH,f'tHrff::ii,,::[Tl,J"ffiJ#]rutro;+"*ru;"'*r"i"[""?'i:'ffi.tt
dGroup-by-location
interacdoRsignificantat P <O05; ratio of interacdonestimareto interacdonstandarderror = -2. lB
€roup-by-focation interacdon significant at P <0.05: ratio of interaction estimare to inreracdon standard error = 2.97

HIV risk perceptions,other STD risk perceptions,and
communication with parents. Seven of these variables
remained significant at the 3l-month follow-up (all but
normativebeliefs about condomsand parent communica-
t i o n .n h i c h w e r eb o r hs i s n i f i c a nat t P = O . O O
.f
DrscussroN
Our findings suggestthat the Sat'erChcticesprogram pro-
duced numerouspositiveand programmaticallyimportant
effects among cohort students.In general,SaferChoices
had a consistenteffect on condom use and use of other
protectivemethods.It alsohad a positiveeffect on most of
the psychosocialvariables, particularly HIV and other
STD knowledgeand variablesrelatedto condom use.
Among students who reported having sexual inter-
course, the Safer Choicesstudents had decreasedinter-
coursewithout a condom by slightly more than one-third.
Although muiti-level analysesdo not enable direct calcu-
lation of the adjustedmeans,we can extrapolatefrom the
raw means.Over the study period, students in the com,
parisongroup reported having intercoursewithout a con-
dom an averageof 3.82 times during the previous three
months.An effect size of 0.63 indicatesthat, after proper
adjustments,students in the intervention group had
intercoursewithout a condom an averageof 2.40 times.

PUBLIC HEALTH REPORTS . 2OOI SUPPLEMENT I . VOLUME I I6


r nffi,1[ffi"*,,.,..r,,,ii; -'.,],f,-t.n.,fir"-filtt
.$ffi',,,,.
" ,. ,,.ffiffi
..'ifi'"il*',
ffi-#,;*ffiffi:ffi;';'"Tffi**
;i:r:i:::l
.qga':i
ngsqlve
The results also suggest that Safer Choices students
reduced the number of sexualpartners with whom they
had intercoursewithout a condom by nearly one-quarter:
comparison students reported having unprotected sex
with an averageof .69 partners during the three months
prior to the follow-up survey, and Safer Choices students
reported .50 partners. Tke Safer Ckoices students also
significantlyincreasedthe use of condomsand pregnancy
prevention methods (condoms, birth control pills, con-
dom plus birth control pills) at last intercourse.
Counter to our expectations,the intervention did not
significantly delay the onset of sexual intercourse,
although the effect was in the desired direction for this
variable.Notably, the intervention clearly did not hasten
the onset of intercourse.The programemphasizedchoos-
ing not to have sex as the safest choice for preventing
HIV, other STD, and unplanned pregnancy; nearly all
lessonsin the curriculum reinforced this message.Many
of the school-wideactivities also emphasizedthe impor-
tance and value of choosingnot to have sex.It is possible
PUBLIC
j
" -:'^*,.
that the social norms supportingsexualactivity were too
strong for such an intervention to reverse.Indeed, from
one-fourth to one-third of the students in the study had
reported having sex at baseline, and many others were
probably considering it before the intervention began.
Given the potential influence of such norms, it is possible
that high schoolis too late to have a substantialeffect on
the initiation of sexualintercourse,and that condom use
behaviormay be more salient for this population. Several
studiesof HIV preventionProgramshave found that pro-
grams are often more effective at changing condom use
than at changingthe incidence of sexualintercourse.s'e'22
Finally, it is also possible that the lack of a significant
effect on delaying sexual initiation was statistical in
nature. Becausea limited number of students initiated
sexbetweenbaselineand the 3l-month follow-up(14Vo),
we may have lacked statisticalpower to detect the differ-
ential rate of initiation between the two grouPs.
The intervention produced its most pronounced effects
on HIV knowledge.The program also had a positive effect
HEALTFI REPORTS . 2OO1 SUPPLEMENT I . VOLUME 116
 on other STD knowledgeand most other psychosocialvari-
ables,particularlythoserelatedto condom use.
The program did not significantly affect students'per-
ceived ability to refuse intercourse or unprotected inter-
course or their perceived abillty to communicate with a
partner about not har.ingsexor usingprotection, despitethe
fact that theseskills were amongthe core skills addressedin
the cur"riculum.Howeveqstudents'baseline scoreson both
the refusal self-efficacy and communicarion self-efficacy
scaleswere high initially (2.4 and2.7 out of 3.0), thereby
limiting room for positive changefor thesevariables.
We noted statistically significant group-by-location
interactions for two of the psychosocialeffects in the
cohort sample: oth.erSTD knrnutedgeand comd.om useself-
,ff Studentsin both statesdemonstratedsignificant
"o"y.
gains on both scales.The gains in other STD knowledge
were strongerin Texas,whereasthe gainsin condom use
self-efficacywere strongerin Califomia. Studentsin the
California schools had higher baseline scores on other
STD knowledge than did students in Texas, which may
PUBLIC HEALTH REPOR.I.S.2OOI SUPPLEMENT I .
have restricted potential gains for California students.
Similarly,Texasstudentshad higher baselinecondom use
self-efficacyscores.By the final follow-up, the mean val-
ues for thesevariableswere similar in both states,suggest-
ing the intervention was equally effective in both sites,
and that there may be a ceiling effect for thesemeasures.
The results are strengthenedby their relative consis-
tency over time. The majority of effects remained signifi-
cant over time, although the magnitude of many of the
effects dissipated somewhat. This pattern is typical of
other health promotion intervention trials.23'24 Despite
the general consistencyof effects over time, there were
fewer significant behavioral effects at the l9-month
follow-up than there were at the 7-month and 31-month
follow-ups. This may be due to the difficulty we experi-
enced in tracking the cohort in the Texasschoolsat the
19-month fbllow-up, resulting in lower statisticalpower
at that time point. This hlpothesis is supported by the
fact that the trends for the behavioralvariablesare in the
desired direction at the 19-month assessment,and the
VoLUME 116 9l
magnitudeof the effects are fairly sizeable.The presence
of significant effects at both the 7-month and 3l-month
assessments iend further support to this hypothesis.
Study limitations. The results of this study are encour-
aging;howeveqseveralmethodologicallimitations should
be noted. The outcome data were collectedby using self-
report questionnairesand there are few, if any,acceptable
approachesfor examlning the criterion validity of stu-
dents'responses.However,it is reasonableto assumethat
privacy and confidentiality affect the veracity of self-
report.25'26Thus, severalapproacheswere used to createa
safe and comfortable environment for completing the
questionnaire.These included using trained data collec-
tors, providing students with paper to cover their
answers,and providing a formal assuranceof confiden-
tiality. Although it is impossible to rule out potential
biases due to self-report, some evidence supports the
general reliability and validity of adolescents'reportsof
sexualand contraceptivebehaviors.25'27
Studentsdroppedfrom the cohort or lost to follow-up
differed from studentsretainedin the cohort. Dropped or
lost studentswere older, less likely to live with both par-
ents, more likely to be males,reportedmore risk behavior
at baseline,and had less favorablescoreson many of the
psychosocialscales. In light of these differences, our
study results may not generaiizeto all adolescentswho
are absent frequently from school or who have left
school.Yet, the studentsin our study representan impor-
tant heterogeneouspopulation of young people.
Finally, we did not correct the statisticalprocedures
to adjust for multiple tests of significance.However,we
did limit our analysesto a small number of primary and
secondaryhypotheses,and further testing was regarded
as exploratory.We also consideredthe overall pattern of
the results: if selected results had occurred by chance,
one might expectresultsin both the positiveand negative
direction. The significant results of this study all were
consistentwith the program'stheoreticalfoundation and
consistentover time, suggestingthat the observedresults
are not attributableto chance.
CONCLUSION
SaferChoiceswas successfulin changingfour of five out-
comes addressingcondom use and other protective
behaviors.The program also enhancednumerous behav-
ioral determinants,particularly those related to condom
use.These positiveeffects lastedover a 31-month period.
SaferChoicesdid not significantlydelay the onset of sex-
PUBLIC
ual intercourse,decreasethe frequencyof intercourse,or
reduce the number of sexualpartners;however,it did not
increasethesebehaviors,either.
When the results of this cohort study are combined
with the results of the cross-sectionaistudy that exam-
ined school-wideeffects ol SaferCh'oices,t3the data sup-
port the value of a comprehensive,multi-component
interventionthat includes an intensive2O-lessonsequen-
tial curriculum for 9th- and i0th-grade students sup-
ported by broad-reaching, school-wide activities. The
intensivecomponent providesan opportunity for individ-
ual skill practice and mastery that is not easily gained
through school-wide activities. The school-wide activi-
ties, on the other hand, reinforce the classroomcompo-
nent by serving as environmental cues; they also con-
tribute to a more supportive environment for practicing
healthful behaviors.
These results representstrongerand more consistent
behavioral findings than reported in other randomized
school-basedevaluationsof HIV other STD, and preg-
nancy preventionprograms.28'3o Severalrandomizedstud-
ies conducted in communitl' 5"111tt*thave also found
behavioralchanges,but they were conductedwith adoles-
cents who volunteered to participate in the project.B'lo
Such participants are likely to be more motivated and
interestedin making behavioralchangesthan were the par-
ticipants in our study.The population-basedapproachwe
used is a more conservativetest of the intervention effects.
A high level of rigor was employed in evaluatingthe
program. The study included random assignmentof 20
schools, a large cohort sample, long-term follow-up
assessments,assessmentof multiple sexual and contra-
ceptive behaviors,and the use of multilevel analysesto
adjust for the clusteringof studentswithin schools.Con-
fidence in these results is also strengthenedby the con-
sistencyof results acrosstime and acrossmultiple mea-
suresinvolvingcondom use.
This study indicatesthat theory-driven,school-based,
multi-component programs with a clear messagecan
enhance psychosocialvariables and reduce sexual risk
behaviorsrelatedto HIV, other STDs, and pregnancypre-
vention among high school students.It also suggeststhat
additional research is needed to identify successful
approachesto delaying sexual initiation and enhancing
potentially important determinants(such as self-efficacy
to refuse intercourse and communication with partners
about sexuallimits), and that even larger samplesmay be
neededto measurethe effect on sexualinitiation.
SaferCkoi.ceshas some of the strongestdata suPPort-
ing its effectivenessin reducingimportant sexualrisk-tak-
HEALTH REPORTS . 2OO1 SUPPLEMENT 1 . VOLUME 1I6
 ing behaviors. Several other programs also have been
shown to be effective.6To the extent feasible,school dis-
tricts interested in addressingthese issuesshould adopt
programsthat have been shown to be effective through
research and implement them with fidelity. Our inter-
views with schoolpersonnelinvolvedin the programsug-
gestedthat SaferChoicesis well receivedbv studentsand
staff and can be implementedwith appropriateplanning.
Indeed, the year following the study,most schoolsin the
study continued offering parts of the program, although
we do not have extensivedata regarding the extent of
implementation. For school districts interested in Safer
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Choices,the published program materials include
detailed implementation manuals and other materials
that provide extensiveguidelinesregardinghow to imple-
ment each programcomponent.3l
This study was supported by Contract No. 200-91-0938from the Centers
for DiseaseControl and Prevention-
The authors gratefullyacknowledgethe contributionsto this research
project by Nancy Calvin,BarbaraCollins, Chris Harvey, Deborah lvie,
Chris Markham,JesseNodora, MargoParr,MarshaWeil, and Duane
Wilkerson.
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1 . VOLUME 116