Health Education Research, Vol. 19, No. 2, 185-197,
April 1, 2004
© 2004 Oxford University Press
Evaluation of a theoretically based AIDS/STD peer education program on postponing sexual intercourse and on condom use among adolescents attending high school
1 Public Health Direction, Planning and Evaluation, Regional Health Board Monteregie, Longueuil, Quebec J4K 2M3, 2 Research Group on Behaviors in the Field of Health, Faculty of Nursing, Laval University, Quebec G1K 7P4 and 3 Department of Sexology, University of Quebec at Montreal, Quebec H3C 3P8, Canada 4 Correspondence to: F. Caron; e-mail: f.caron{at}rrsss16.gouv.qc.ca
 |
Abstract |
|---|
 Top Abstract IntroductionMethodResultsDiscussionConclusionReferences |
|---|
The effectiveness of an intervention based upon the theories of Ajzen and Triandis was evaluated among 698 junior and 306 senior high school students. The intervention to juniors was offered by senior students who were trained during a course integrated into the school curriculum. Respondents in the control and experimental groups completed a questionnaire at baseline and 9 months after the program. Compared to junior respondents in the control group, those in the experimental group positively modified their attitude, perceived behavioral control, personal normative beliefs, perceived role beliefs, anticipated regret and intention with respect to postponing sexual intercourse and with respect to condom use, as well as perceived self-efficacy to negotiate both behaviors. Compared to senior respondents in the control group, those in the experimental group showed a significant positive modification of all the above variables except perceived behavioral control (indirect measure), anticipated regret and intention with respect to postponing sexual intercourse. At post-test, seniors in the experimental group were more likely to use condoms on a regular basis than those in the control group. Program effects occurred among both sexes, but a few differences in response were observed among males and females. Results suggest this type of theory-based program is effective in modifying psychosocial variables related to postponing sexual intercourse and related to condom use among adolescents. Personal involvement in designing intervention appears to be effective in modifying the behavior of peer educators.
|
Introduction |
|---|
|
TopAbstractIntroductionMethodResultsDiscussionConclusionReferences |
|---|
Adolescents are at risk for STD and HIV infection. In Canada, genital chlamydial infections are most prevalent among teenage girls aged 15–19 years (Laboratory Center for Disease Control, 1999
). When untreated, chlamydia can cause serious health problems. It is estimated that up to 40% of women with untreated chlamydia will develop pelvic inflammatory disease, and, of these, 20% will become infertile, 18% will experience debilitating pelvic pain and 9% will have a life-threatening tubal pregnancy (Centers for Disease Control and Prevention, 2001a). Furthermore, recent research suggests that women with chlamydia have a 3- to 5-fold increased risk of acquiring HIV, if exposed (Centers for Disease Control and Prevention, 2001a).
In the US, the AIDS incidence from 1996 through 2000 has declined in most populations, but increases were observed notably among women and persons infected through heterosexual contact. Among females aged 13–19 years who were infected with HIV, but did not have AIDS, heterosexual contact was the most frequently reported risk factor (Centers for Disease Control and Prevention, 2001b).
From 1991 to 1997, condom use at last intercourse significantly increased (from 46 to 57%), birth control pill use decreased (from 21 to 17%) and use of withdrawal decreased significantly (from 18 to 13%) among high school students in the US (Everrett et al., 2000). Despite recent decreases in sexual risk taking (Centers for Disease Control and Prevention, 1998), adolescents still face a potentially high risk of STD and HIV infection because of their behavior. Half (49.9%) of the high school students in the Youth Risk Behavior Survey reported sexual intercourse and 58% reported the use of a condom at last intercourse. Furthermore, 50% of high school students had drunk alcohol during the 30 days preceding this survey and 26.7% had used marijuana (Kann et al., 2000). Studies have shown that marijuana use is associated with unprotected sexual intercourse among adolescents (Kingree et al., 2000), and substance abuse is related to earlier onset of sexual activity, more sexual partners, less consistent use of condoms and more STDs among adolescent detainees (Tapert et al., 2001).
Over the past decade, schools have implemented numerous STD/HIV prevention programs, but results have been mixed (Song and Pruitt, 2000; Kirby, 2001). Peer education programs have also grown in popularity internationally and have targeted a wide range of youth in a variety of settings. One reason why peer education has become so popular may be an underlying belief that youths are effective educators because they are credible and influential role models. In fact, there is theoretical evidence for this belief since, according to Social Cognitive Theory, adolescents are more likely to enact modeled behavior if they perceive the models as warm, supporting, and similar to themselves with respect to such characteristics as gender, ethnicity and age (Bandura, 1986). Research findings also suggest that peer norms influence the process of sexual initiation (Carvajal et al., 1999) and condom use (Kirby, 2001). For example, adolescents who believe their friends are not in favor of sexual intercourse for teenagers are more likely not to have engaged in intercourse (DiIorio et al., 2001) and those who perceive their peers as having a favorable attitude toward condom use are more likely to use a condom themselves (Turner, 2001). However, even though peer-led programs have received positive anecdotal reviews from program coordinators, peer educators and young audiences, only a few programs have been evaluated for their impact.
Recent studies do suggest that peer education can bring about short-term positive changes in attitude (Caron et al., 1998), self-efficacy (Smith et al., 2000) and behavioral intention regarding condom use (Caron et al., 1998), attitude towards abstinence (Caron et al., 1998), self-efficacy to refuse sex (Aarons et al., 2000), more conservative sexual norms (Mellanby et al., 2000), delay in the initiation of sexual behaviors (Aarons et al., 2000), the frequency of intercourse (Jemmott et al., 1998) and the use of condoms among sexually active teens (Smith et al., 2000). Such effective programs tend to be theory-based, highly structured and led by well-trained peers (Smith et al., 2000).
A few studies have compared the effectiveness of peer-led sex education programs with adult-led interventions. One such study found that peer leaders were more effective in establishing conservative norms and attitudes related to sexual behavior than were adults, but they were less effective than adults in imparting factual knowledge (Mellanby et al., 2000). In contrast, students who attended another peer-led program had significantly higher knowledge scores on HIV prevention than did those who participated in the same intervention led by community health nurses (Dunn et al., 1998). In a review of 13 studies that compared peer-led and adult-led health education programs, peer leaders were found to be at least as, or more, effective than adults in most studies reporting positive outcomes (Mellanby et al., 2000).
There does appear to be a shortage of well-designed studies that have evaluated the medium- and long-term effects of AIDS/STD peer education among both the peer educators themselves and their target audience. This paper presents the evaluation results of a school-based peer education program. The goal was to determine the extent to which this peer education program was effective in changing medium-term behavior and its underlying social cognitive determinants among both senior and junior high school students with respect to postponing sexual intercourse and with respect to condom use.
Overview of the program
The Protection Express Program is based on the theories of Planned Behavior (Ajzen, 1991) and Interpersonal Behavior (Triandis, 1980), and a teaching model based on Social Cognitive Theory. According to the theories used, individual’s behavior is determined by intention and a number of key social cognition constructs. In the Protection Express Program, the content is developed in order to affect attitude, perceived social norm, perceived behavioral control, personal normative belief, role beliefs and the beliefs underlying these main constructs. The information used to define the content of the Protection Express Program is based on a previous study that identified the salient modal beliefs as well as the main determinants of the targeted behaviors among the population under study (Caron et al., 1998). These beliefs are listed in Table I.
|
The training of peer educators
Peer educators were senior high school students who participated in a 25-hour training program integrated into regular Moral and Religious Education classes. The training program was offered by the teacher with support from the school nurse or a supervised undergraduate student in Sexology.
The peer-training program was interactive and highly structured. Students worked in teams of five individuals to develop an educational presentation on one of five topics: postponing sexual intercourse, communication and assertiveness in relationships, equality in relationships, conditions to a healthy relationship, and condom use. Each team developed their own sketches, which were often based on their personal experience. However, all of the sketches on a particular topic dealt with the same content (e.g. advantages of postponing sexual intercourse). The content was therefore consistent from one school to another, but it was presented in various ways by different teams. Content fidelity was monitored by using formative evaluation tools. Thus, all peer presentations were evaluated twice by both teachers and peers, and only those judged to be educational according to the pre-established criteria utilized in the formative evaluations were subsequently presented to junior students.
|
Method |
|---|
|
TopAbstractIntroductionMethodResultsDiscussionConclusionReferences |
|---|
Design and site of study
The impact evaluation design was quasi-experimental and included an experimental group composed of respondents who attended six high schools located in two regions in Quebec, Canada. One of these schools was located in a rural setting while the remaining five were all situated close to a major city. Two schools were large in size with over 2000 students enrolled, two others were of medium size with approximately 1300 students and the final two were small high schools with less than 600 students. The comparison groups were also composed of respondents attending high schools that were matched in size and location. The experimental group received the Protection Express Program, and the comparison group received their usual sex education program and were not involved in the development or delivery of the program being evaluated. The design of the study allowed for the evaluation of the program at two levels: among the senior respondents (i.e. those trained to offer the intervention to junior students) and among the junior respondents (i.e. those receiving the peer education component of the program). The impact of the intervention was evaluated with a self-administered questionnaire completed by respondents during three observation periods: (1) before the Protection Express Program, (2) 2 weeks following the end of the program and (3) 9 months later. Also, two behaviors were targeted by this evaluation: (1) postponing sexual intercourse and (2) condom use.
Population and sample
A total of 1166 students at the junior level and 549 at the senior level composed the potential pool of participants. A total of 945 (junior level) and 477 (senior level) students agreed to participate. This represented approximately 87 and 81%, respectively, of the junior and senior targeted populations. Nine months after the intervention, the final sample of senior respondents consisted of 147 and 159 respondents, respectively, in the experimental and control groups. The final sample of junior respondents consisted of 369 juniors in the experimental group and 329 juniors in the control group. For both groups, 29.4% were lost at follow-up or excluded from the analysis since all three questionnaires (pre-test and both post-tests) had to be included in the analysis. There was also a fairly high student absentee rate at either the first or the second post-tests. Students retained in the study were more likely to be female (P < 0.001), younger (P < 0.001), sexually inactive (P < 0.001) and to have higher scores on many of the dependent variables evaluated.
Procedure for data collection
Data was collected by the research team between November 1999 and February 2000 (T0), 2 weeks following the end of the program (T1), and 9 months later (T2: February 2001–May 2001). All questionnaires were completed in the classroom within approximately 60 min. Respondents were given a code to ensure confidentiality and allow for the matching up of questionnaires. Written parental consent was obtained prior to the study for students under the age of 14 years. All respondents signed a consent form on a voluntary basis. Approval was obtained from the Ethics Review Board of Laval University.
Instrumentation for impact evaluation
The questionnaire used to evaluate the impact of the Protection Express Program was an adaptation of validated instruments based on the theories of Planned Behavior and Interpersonal Behavior (Godin et al., 1997). Questions were formulated to take into account the sex of the respondents, and all questions were pilot tested to ensure they were clear and that phrasing of items was appropriate for the population under study. Sexual intercourse was defined as including the penetration of the penis into the vagina or the anus.
The primary outcomes were self-reported sexual behaviors in the previous 3 months, including postponing sexual intercourse (no, yes, no partner in last 3 months), sexual intercourse (no, yes, no partner in last 3 months), frequency of condom use with a regular boyfriend or girlfriend or with a partner who is not a boyfriend or a girlfriend (a ‘one night stand’). Frequency of condom use was rated on a five-point scale: never, 25% of the time, 50% of the time, 75% of the time and always.
The direct measures of attitude toward postponing sexual intercourse and toward condom use were each assessed by means of five items on a five-point differential semantic scale. Respondents were asked to answer to the following questions. ‘If in the next 3 months, I was with a boy and I postponed having sexual intercourse with him (or we used a condom during intercourse) it would be...unpleasant/pleasant, frustrating/satisfying, disagreeable/agreeable, useless/useful, unsafe/safe’. Cronbach’s coefficient 
was 0.76 for the subscale on postponing sexual intercourse and 0.79 for the condom use subscale.
The remaining items were assessed on five-point Likert scales (agree–disagree). The indirect measure of attitude was based on respondents’ beliefs regarding the advantages and disadvantages of postponing sexual intercourse (10 items: = 0.81) and of using condoms (eight items: = 0.74).
Three items were used to assess the direct measure of behavioral control. Respondents indicated to what degree they could easily (or not easily) postpone sexual intercourse ( = 0.59) or use a condom ( = 0.78). The direct measure of behavioral control was based on respondents’ beliefs regarding their ability to overcome (or not) the obstacles associated with postponing sexual intercourse (five items: = 0.89) and with condom use (eight items: = 0.88). For example, ‘If in the next 3 months I was with a boy I would be able to postpone sexual intercourse with him even if...the boy insisted we have intercourse, my friends insisted I should have intercourse, etc.’. Similarly, ‘If in the next 3 months, I was with a boy, I would be able to use a condom even if...I was already taking the birth control pill, I was worried the condom would break, etc.’.
Five self-efficacy items measured respondents’ perceived ability to negotiate postponing sexual intercourse ( = 0.78) and to negotiate condom use ( = 0.84). For example, ‘If a boy insists I have sex and I have already decided to postpone sexual intercourse (if a boy insisted we have intercourse without a condom), I would be able to...say no and maintain my decision, tell him how I feel, refuse to discuss it further, etc.’.
Role beliefs refer to one’s perception of how a person of one’s own age, gender or status should behave (Triandis, 1980). Three items measured to what degree respondents felt it was normal (or not) for a person of their age and gender to postpone sexual intercourse ( = 0.76) and use a condom ( = 0.81).
Personal normative beliefs are feelings of personal responsibility regarding the performance or not of a given behavior (Triandis, 1980). Three items measured to what extent respondents felt that postponing sexual intercourse ( = 0.90) and use of a condom ( = 0.84) were in keeping with their own values.
Anticipated regret refers to the various worries and regrets that one takes into account before making a decision (Richard et al., 1998). Three items were used to measure this variable. ‘If in the next 3 months I had sex even though I had already decided to postpone sexual intercourse (I had sexual intercourse without a condom)...I would worry afterwards, I would regret it the next day, I would feel preoccupied in the days that followed.’ Cronbach’s values were 0.84 (postponing intercourse) and 0.92 (condom use). Finally, three items were used to assess intention to postpone sexual intercourse ( = 0.88) and condom use ( = 0.88).
Analysis
In order to take into account the clustering effects, a hierarchical model procedure (with the SAS PROC MIXED procedure or GLIMMIX macro provided by SAS for dichotomous variables) was applied. For the junior respondents, no clustering effects were detected and the analyses based on groups or individuals yielded similar significant results. As for the senior respondents, only three variables were affected by clustering effect, but they were not significant. For the remaining variables, the analyses based on students yielded similar significant results. Consequently, the results based on individuals are reported.
For the impact evaluation, frequencies were computed to determine the demographic characteristics of the respondents. The 
2-test was used to compare the demographic characteristics of the experimental groups with those of the comparison groups. Because the variable concerning the postponement of sexual intercourse in the last 3 months was dichotomous, the GENMOD procedure (SAS version 8.02) was used to measure the impact of the program on this variable. The remaining hypotheses were tested using covariance analysis (ANCOVA) whenever the F-test showed parallelism of regression slopes (Cook and Campbell, 1979). When parallelism of regression slopes could not be demonstrated, hypothesis testing was accomplished using the Johnson–Neyman method of analysis (Huitema, 1980). In this case, the P value refers to results obtained when the effects of the program became significant. These methods of regression analysis were used because the focus was to determine the effect of the program on the response variables adjusted for the presence of the control variables in the model (score on pre-test and sex of respondents). To determine the short-term impact of the program, pre-test data was compared to data from the first post-test (T0–T1). Finally, pre-test data was compared to data collected 9 months after the end of the program (T0–T2). Data analysis was completed with SAS 6.32. Because the short-term impacts (T0–T1) were similar in pattern to those observed 9 months later, only the results contrasting T0–T2 are presented.
|
Results |
|---|
|
TopAbstractIntroductionMethodResultsDiscussionConclusionReferences |
|---|
Demographic characteristics of the respondents
Descriptive data of senior and junior respondents in the experimental and control groups are presented in Tables II and III, respectively. At both high school levels, the experimental and control groups were similar. The only exception was a significant difference in the proportion of respondent ethnicity; at both high school levels, compared to control groups, there were in the experimental groups a higher proportion of respondents born outside Quebec/Canada.
|
|
Impact on behavioral and psychosocial variables
Senior respondents: impact on postponing sexual intercourse
Nine months after the end of the program, experimental and control groups did not differ in behavior with respect to postponing sexual intercourse, nor did they differ regarding intention, perceived behavioral control (indirect measure) and anticipated regret. The experimental group, however, scored higher than the control group on the remaining psychosocial variables (Table IV, top portion), i.e. attitude (P < 0.001, direct and indirect measure), the direct measure of perceived behavioral control (P < 0.001), perceived normative beliefs (P < 0.01), role beliefs (P < 0.001) and perceived self-efficacy (P < 0.001). The impact of the program on all variables was similar for both sexes.
|
Junior respondents: impact on postponing sexual intercourse
Nine months after the program, experimental and control groups did not differ in behavior with respect to postponing sexual intercourse in the last 3 months. The experimental group, however, scored higher than the control group on all of the psychosocial variables (Table VI, top portion): intention (P < 0.001), attitude (P < 0.001, direct measure), perceived self-efficacy (P < 0.001), role beliefs (P < 0.001) and anticipated regret (P < 0.001) with respect to postponing sexual intercourse. As shown in Table VII (top portion), the impact of the program on the following variables was greater among respondents with the lowest pre-test scores: indirect measure of attitude (P < 0.03), indirect measure of perceived behavioral control (P < 0.02) and personal normative beliefs (P < 0.02). The program also had a greater impact among boys than among girls on the direct measure of perceived behavioral control (boys P < 0.02; girls P < 0.02).
|
|
Senior respondents: impact on condom use
Nine months after the intervention, respondents in the experimental group were more likely to use a condom consistently with their regular or occasional sexual partner (P < 0.01) than respondents in the control group. The experimental group scored higher on all psychosocial variables related to condom use. As shown in Table IV (lower portion), the results indicated a positive change in perceived behavioral control (P < 0.001; indirect measure) and perceived self-efficacy (P < 0.001) among the experimental group. The impact on the remaining variables was greater among respondents with the lowest pre-test scores (Table V): attitude (P < 0.05, direct and indirect measure), perceived normative beliefs (P < 0.01) and anticipated regret (P < 0.03). A greater impact on females was also observed with respect to three variables: perceived behavioral control (direct measure: girls P < 0.001; boys P < 0.01), role beliefs (girls P < 0.001; boys P < 0.05) and intention (Figure 1: girls P < 0.001; boys P < 0.02).
|
|
Junior respondents: impact on condom use
Nine months after the intervention, experimental and control groups did not differ in behavior with respect to condom use. However, compared to the control group, the experimental group scored higher on all psychosocial variables related to condom use. As shown in Table VI (lower portion), the results indicated a positive change in respondents in the experimental group regarding intention (P < 0.001) and role beliefs (P < 0.001). The remaining results indicated a greater impact among respondents with the lowest pre-test scores (Table VII, lower portion): the direct measure of attitude (P < 0.01), the indirect measure of attitude (P < 0.02), the direct measure of perceived behavioral control (P < 0.01), the indirect measure of perceived behavioral control (P < 0.02), perceived normative beliefs (P < 0.02), perceived self-efficacy (P < 0.02) and anticipated regret (P < 0.05). The impact of the program on males and females was similar.
|
Discussion |
|---|
|
TopAbstractIntroductionMethodResultsDiscussionConclusionReferences |
|---|
The evaluation results indicate the Protection Express Program had a positive effect on most evaluated psychosocial variables related to postponing sexual intercourse, and related to condom use among both senior peer educators and junior respondents. The former were also more likely to use condoms on a regular basis than senior respondents in the control group. All of these effects were still observable 9 months following the intervention, and both males and females showed a significant positive change.
As these results suggest, involvement by peer educators in the development of creative and educational activities for others brought about a positive change in their own behavior with respect to condom use. Although past research has found peer education to be effective, few evaluations have measured the impact of this type of program on the behavior of the peer educators themselves. In one such study, exposure to a 36-hour theory-based training program resulted in a positive long-term impact on perceived self-efficacy and consistency of condom use (Smith et al., 2000). Our results are in keeping with this study, and lend support to the mounting evidence regarding the effectiveness of programs that are theory-based and employ teaching methods designed to involve participants and have them personalize the information (Kirby, 2001).
However, senior peer educators and junior respondents in the experimental groups did not modify their behavior with respect to postponing sexual intercourse following exposure to the Protection Express Program. These results are similar to those of other program evaluations where sexual intercourse was not delayed but a positive impact was found on condom use (Coyle et al., 1999). In fact, evidence for the effectiveness of abstinence programs is meager (Kirby, 2001). In another literature review, only six of the 19 non-peer-led programs examined were found to have an impact on postponing sexual intercourse (Santelli et al., 1999).
The impact of the Protection Express Program among junior respondents was encouraging, given the entire peer intervention lasted only 150–180 min. Previous research suggests that brief peer interventions can modify psychosocial variables related to condom use (Dunn et al., 1998). The lack of impact on behavior regarding condom use was not surprising, given the short duration of the intervention and the fact that being younger, they were, as a group, less sexually active than their older peers.
These positive effects of the Protection Express Program among both male and female junior respondents may be related to the approach utilized and the relevance of the content based on the theories of Planned Behavior and Interpersonal Behavior. Presentations prepared by peers were transmitted in a language that was age and culture appropriate, and teaching methods employed such as sketches and role-plays were interesting and pertinent to both sexes because they were created by a mixed team of peer educators. The presentations were also highly structured since all activities prepared by the peer educators were laid out in a detailed lesson plan. Previous research suggests that strong classroom organization can enhance the efficacy of peer education, particularly if it is enacted in the presence of high positive regard for peer educators (Ozer et al., 1997).
In most evaluated programs, peer educators were opinion leaders who were selected after an interview or referral process (Smith et al., 2000). In contrast, the peer educators in the Protection Express Program were not screened. Our findings suggest that slightly older, regular students can be effective peer educators if they are well trained. In this regard, peer educators in the Protection Express Program received substantial training (i.e. 25 hours), and much support and supervision from the adults involved.
Even though a positive response to the Protection Express Program occurred among both male and female respondents, a greater impact on perceived behavioral control with respect to postponing sexual intercourse was observed among junior boys, and a greater impact on perceived behavioral control, role beliefs and intention related to condom use was observed among senior girls. Moreover, the greatest response on many psychosocial factors occurred among respondents with the lowest pre-test scores. This suggests that subjects who responded the most to the Protection Express Program were those who were perhaps most vulnerable to sexually transmissible infections as evidenced by weak scores on most psychosocial factors related to safer sexual conduct. Overall, these findings do not support the need for separate, gender-specific interventions as suggested by Aarons et al. (Aarons et al., 2000), who found gender differences in various study outcomes among adolescents exposed to the peer-led ‘Postponing Sexual Involvement Program’.
To ensure the effectiveness of the Protection Express Program, teachers and nurses must be well trained to stimulate cooperative learning among peer educators and supervise the quality of their presentations to junior students. Thus, adequate training and access to a competent program consultant are absolutely required. It is also important to create a balanced team of peer educators, when working with regular students who are not necessarily opinion leaders. Homogenous groups should be avoided, i.e. putting all the students with strong social skills together on the same team. Reinforcement by teachers of the messages left by peers is needed to increase the impact on behavior among junior students.
Finally, the quasi-experimental design utilized does not allow generalization of these results to other groups of adolescents; too many factors may not have been fully controlled. Also, the number of groups involved in the study was small and may not be representative of the whole student population. Careful interpretation of these results is also required because of differences found between students lost to the program and students who remained in the final sample. In addition, the required parental consent procedure may have introduced bias into the sample of junior respondents as students who obtained parental consent may have a different sociodemographic profile and differ with respect to their risk behavior than those who did not receive parental consent (Anderson et al., 1995).
|
Conclusion |
|---|
|
TopAbstractIntroductionMethodResultsDiscussionConclusionReferences |
|---|
To conclude, the Protection Express Program produced positive results over a period of 9 months among both male and female peer educators, and their target audience of junior high school students. Also, compared to the control groups, the peer educators were more likely to use condoms on a regular basis. The results of this study suggest that this well-designed theory-based, highly structured and supervised AIDS/STD peer education program was effective among adolescents in a high school setting.
|
Acknowledgements |
|---|
F. C., G. G. and J. O. are members of a provincial research team funded by the Quebec Council for Social Research (CQRS). This project was funded by a grant from the Quebec Council for Social Research RS-3251.
|
References |
|---|
|
TopAbstractIntroductionMethodResultsDiscussionConclusionReferences |
|---|
Aarons, S.J., Jenkins, R., Raine, T.R., El-Khorazaty, M.N., Clark, M.C. and Wingrove, B.K. (2000) Postponing sexual intercourse among urban junior high school students—a randomized controlled evaluation. Journal of Adolescent Health, 27, 236–247.[CrossRef][Web of Science][Medline]
Ajzen, I. (1991) The theory of planned behavior. Organization Behavior and Human Decision Processes, 50, 179–211.[CrossRef]
Anderson, C., Cheadle, A., Curry, S., Diehr, P., Shultz, L. and Wagner, E. (1995) Selection bias related to parental consent in school-based survey research. Evaluation Review, 19, 663–674.
Bandura, A. (1986) Social Foundations of Thought and Action: A Social Cognitive Theory. Prentice-Hall, Englewood Cliffs, NJ.
Caron, F., Otis, J. and Pilote, F. (1998) Evaluation of an AIDS peer education program on multiethnic adolescents attending an urban high school in Quebec Canada. Journal of HIV/AIDS Education and Prevention for Adolescents and Children, 2, 31–53.
Carvajal, S.C., Parcel, G.S., Basen-Engquist, K., Banspach, S.W., Coyle, K.K., Kirby, D. and Chan, W. (1999) Psychosocial predictors of delay of first sexual intercourse by adolescents. Health Psychology, 18, 443–452.[CrossRef][Web of Science][Medline]
Centers for Disease Control and Prevention (1998) Trends in sexual risk behaviors among high school students—United States, 1991–1997. Morbidity and Mortality Weekly Report, 47, 749–752.
Centers for Disease Control and Prevention (2001a) Chlamydia in the United States. National Center for HIV and TB Prevention, Division of Sexually Transmitted Diseases, CDC, Atlanta, GA.
Centers for Disease Control and Prevention (2001b) US HIV and AIDS cases reported through June 2001. HIV/AIDS Surveillance Report, 13, 1–41.
Cook, T.D. and Campbell, D.D. (1979) Quasi-experimentation: Design and Analysis Issues for Filed Settings. Rand McNally, Chicago, IL.
Coyle, K., Basen-Engquist, K., Kirby, D., Parcel, G., Banspach, S., Harrist, R., Baumler, E. and Weil, M. (1999) Short-term impact of safer choices: a multicomponent, school-based HIV, other STD and pregnancy prevention program. Journal of School Health, 69, 181–188.
DiIorio, C., Dudley, W.N., Kelly, M., Soet, J.E., Mbwara, J. and Sharpe Potter, J. (2001) Social cognitive correlates of sexual experience and condom use among 13 through 15-year-old adolescents. Journal of Adolescent Health, 29, 208–216.[CrossRef][Web of Science][Medline]
Dunn, L., Ross, B., Caines, T. and Howorth, P. (1998) A school-based HIV/AIDS education program: outcomes of peer-led versus community health nurse-led interventions. Canadian Journal of Human Sexuality, 7, 339–345.
Everrett, S.A., Warren, C.W., Santelli, J.S., Kann, L., Collins, J.L. and Kolbe, L.J. (2000) Use of birth control pills, condoms and withdrawal among US high school students. Journal of Adolescent Health, 27, 112–118.[CrossRef][Web of Science][Medline]
Godin, G., Fortin, C., Michaud, F., Bradet, R. and Kok, G. (1997) Use of condoms: intention and behaviour of adolescents living in juvenile rehabilitation centres. Health Education Research, 12, 289–300.
Huitema, B.E. (1980) The Analysis of Covariance and Alternatives. Wiley, New York.
Jemmott, J.B., III, Sweet Jemmott, L. and Fong, G.T. (1998) Abstinence and safer sex HIV risk-reduction interventions for African American adolescents. Journal of the American Medical Association, 279, 1529–1536.
Kann, L., Kinchen, S.A., Williams, B.I., Ross, J.G., Lowry, R., Grunbaum, J.A. and Kolbe, L.J. (2000) Youth risk behavior surveillance—United States, 1999. Morbidity and Mortality Weekly Report, 49, 1–32.
Kingree, J.B., Braithwaite, R. and Woodring, T. (2000) Unprotected sex as a function of alcohol and marijuana use among adolescent detainees. Journal of Adolescent Health, 27, 179–185.[CrossRef][Web of Science][Medline]
Kirby, D. (2001) Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy. National Campaign to Prevent Teen Pregnancy, Washington, DC.
Laboratory Center for Disease Control (1999) Genital chlamydia in Canada. STD Epi Update, May, 1–5.
Mellanby, A.R., Rees, J.B. and Tripp, J.H. (2000) Peer-led and adult-led school health education: a critical review of available comparative research. Health Education Research, 15, 533–545.
Ozer, E.J., Weinstein, R.S., Maslach, C. and Siegel D. (1997) Adolescent AIDS prevention in context: the impact of peer educator qualities and classroom environments on intervention efficacy. American Journal of Community Psychology, 25, 289–323.[CrossRef][Web of Science][Medline]
Santelli, J.S., DiClemente, R.J., Miller, K.S. and Kirby, D. (1999) Sexually transmitted diseases, unintended pregnancy and adolescent health promotion. Adolescent Medicine: State of the Art Reviews, 10, 87–108.
Smith, M.U., Dane, F.C. Archer, M.E., Devereaux, R.S. and Katner, H.P. (2000) Students Together Against Negative Decisions (STAND): evaluation of a school-based sexual risk reduction intervention in the rural south. AIDS Education Prevention, 12, 49–70.
Song, E.Y. and Pruitt, B.E. (2000) A review of sexuality education programs for adolescents, 1960–1997. Journal of Health Education, 31, 225–230.
Richard, R., De Vries, N.K. and Van Der Pligt, J. (1998) Anticipated regret and precautionary sexual behavior. Journal of Applied Social Psychology, 28, 1411–1428.[CrossRef][Web of Science]
Tapert, S.F., Aarons, G.A., Sedlar, G.R. and Brown, S.A. (2001) Adolescent substance use and sexual risk-taking behavior. Journal of Adolescent Health, 28, 181–189.[CrossRef][Web of Science][Medline]
Triandis, H.C. (1980) Values, attitudes and interpersonal behavior. In Page, M.M. (ed.), Nebraska Symposium on Motivation. Beliefs, Attitudes and Values. University of Nebraska, Lincoln, NE, vol. 1, pp. 195–259.
Turner, T.J. (2001) Using psychosocial factors and the theory of reasoned action to predict sexual behavior in adolescent females. Dissertation Abstracts International A, 61, 95011–95163.
Received on June 27, 2002; accepted on January 21, 2003
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  D. Koniak-Griffin, J. Lesser, T. Henneman, Rong Huang, Xin Huang, J. Tello, B. Kappos, E. Gonzalez-Figueroa, and W. G. Cumberland HIV Prevention for Latino Adolescent Mothers and Their Partners West J Nurs Res, October 1, 2008; 30(6): 724 - 742. [Abstract] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||