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Article Excerpt
Because minority adolescents and those living in impoverished areas have an increased risk of contracting HIV and other STDs, (1) prevention programs directed at urban, at-risk youth have received considerable attention. (2) As a result, many such interventions have been developed, the most successful ones being well controlled, theoretically derived, community-based and culturally sensitive. (2-5) However, the generalizability of these successful interventions to other settings (e.g., school classrooms) and populations (e.g., white adolescents and black suburban adolescents) has not been established. (6)
One successful intervention with the above prescribed characteristics is Be Proud! Be Responsible! (BPBR), developed by Jemmott et al. (7) Originally designed for inner-city, black males, (8) the six-session ethnocentric curriculum has been found to significantly reduce levels of risky sexual behaviors (for up to at least 12 months) in this intended audience, as well as influence the cognitive mechanisms (e.g., knowledge, efficacy) that are theoretically linked to behavioral changes. (8-12) The program has been replicated among other minority youth and females, and in international settings, with continued success. (7) However, published evaluations of BPBR have been largely limited to its use with young adolescents (average age, 11-13) and with urban, minority youth receiving the intervention in nonschool environments (e.g., Saturday programming) and in small groups (6-8). (8-12) The intervention has not been tested within school settings, taught by teachers or other school personnel, and little information exists on its effectiveness when extended beyond the urban environment. Its effectiveness in diverse settings, where program fidelity may be variable and the delivery less controllable, and where participants include young people who may be unlikely to volunteer for a weekend program, is important to assess.
This article presents the results of a school-based, group-randomized replication of BPBR with enrolled students from five pairs of large urban and suburban high schools in the Midwest. Schools were paired by socioeconomic status and racial composition; one school of each pair implemented the BPBR curriculum, while its matching school implemented a health promotion curriculum focused on good nutrition, physical activity and stress reduction, developed by the Cleveland Health Museum. The primary aim of this study was to determine if BPBR would be effective when taught within a high school health curriculum by school personnel (e.g., health teachers and school nurses). The secondary aim was to determine whether the curriculum would be effective among white youth, as well as among black suburban youth. On the basis of the original intent and focus of the curriculum, we hypothesized that the program would be more effective among urban, black, male adolescents than among suburban, female or white adolescents.
THE CURRICULUM
The BPBR curriculum consists of six 50-minute modules that include a variety of developmentally appropriate teaching methods, such as group discussions, role model stories depicted in videos, interactive exercises and role-playing. (7) Drawing on social cognitive theory (13,14) and the theories of reasoned action (15) and planned behavior, (9,16,17) the curriculum is intended to influence a set of principles (i.e., perceived risk, knowledge, beliefs, efficacy, control) that are related to health behavior change. Its three core themes are the role of sexual responsibility and accountability, the importance of having a sense of community and the role of pride in making safer sexual choices. (7) While the focus is clearly on safer-sex decision making and practices, the curriculum is taught with an abstinence-first philosophy; that is, the main message promotes abstinence as the most effective way for adolescents to protect themselves from pregnancy and STDs. Activities promote the understanding of vulnerability to HIV infection and building negotiation and refusal skills. However, should adolescents decide to be sexually active, the curriculum also provides them with information and appropriate skill building about safer-sex practices (e.g., condom use).
METHODS
Participants
The study population comprised 1,576 ninth- and 10th-grade students enrolled between 2000 and 2002 in mandatory health education classes in 10 high schools in a midsize, metropolitan area in the Midwest. The urban school district expressed concern that nonparticipating students needed a separate place to go while the program was being conducted, but that they could provide this only for students whose parents refused consent, and not for students whose parents did not return the consent form or could not be reached. Thus, we obtained a waiver of consent from the National Institutes of Health. However, to ensure that parents were well informed about the study, parental or guardian consent was still actively sought. Introduction letters from school principals and the research team were mailed to students' homes informing parents of the survey and instructing them to indicate their consent by any of five methods (delivering, mailing or faxing a consent form to school, or e-mailing or phoning their consent). Those who used the last two methods received a confirmation letter. Two reminder letters were mailed to nonresponding parents, and up to five phone calls were made before a passive consent process was enacted. In addition, parent information meetings took place in the evenings at each participating school, parents were encouraged to contact the principal investigator with any questions or concerns, and a 24-hour telephone number was available. The written assent of students was also obtained. Ninety-three parents and 26 students refused to participate (6% and 2%, respectively), and 100 students (6%) were unable to complete the pretest that was administered 7-14 days prior to the start of the curriculum (because they had transferred or been expelled, were no longer attending school or had inconsistent attendance). Hence, the baseline sample consisted of 1,357 students.
Procedures
Five pairs of high schools were recruited; pairs were selected on the basis of the schools' location (inner city, inner-ring suburb or outer-ring suburb) * and similarity regarding community socioeconomic status (proportion of neighborhood households at or below the federal poverty line) and racial composition of the student body. Two pairs were from an urban school district in an area of low socioeconomic status; one pair had predominantly black student bodies, and the other had mixed student bodies (no racial group accounted for more than 40% of the study population). Two pairs of schools were from inner-ring suburbs; one pair was in an area of low socioeconomic status and had predominantly white student bodies, and the other was in an area of moderate socioeconomic status and had racially mixed populations. The last pair of schools were from outer-ring suburbs; both schools were in areas of high socioeconomic status and had predominantly white populations.
For schools to be included, officials had to agree to be randomly assigned to the intervention or control curriculum and to recruit all teachers responsible for teaching health to be trained in their respective curriculum. We used a two-stage, double-blinded randomization procedure (18) to randomize each pair. In this procedure, we flipped a coin, and the side that landed face-up represented the intervention condition. School representatives then chose between two sealed envelopes---one containing the word "heads" and the other "tails." Assignments were based on which card matched our coin flip. The curricula were taught in health classes facilitated predominantly by health education teachers. However, in three pairs of schools, approximately a quarter of the classes were taught by school nurses, who were randomly assigned to the health classes at that school.
Data were collected from students via confidential, self-administered questionnaires at four time points: prior to the intervention (baseline), immediately following the intervention, and four and 12 months later. All participants received a study-branded T-shirt and a small gift (e.g., pencil, CD case, hat, movie pass) each time they completed a survey. The study was approved by the institutional review board of Case Western Reserve University.
Curriculum Adaptations and Facilitator Training
Because this was a replication study, fidelity to the original BPBR curriculum was crucial. However, a few small but important adaptations to the curriculum were deemed necessary. First, because of objections from several urban as well as suburban schools, one 10-minute activity (How to Make Condoms Fun and Pleasurable) in the condomuse skills session was dropped; all other condom-related activities were retained in all schools. Second, the ethnocentric and urban focus of the curriculum was retained across all schools, except that the term "inner-city" was replaced with "community," Third, both intervention and control groups received a message-specific booster session between four and 12 months after the initial programs. Students in the intervention arm attended an assembly featuring a young HIV-positive woman, while students in the control arm attended an assembly in which a speaker discussed healthy eating and exercise. Otherwise, the control curriculum was designed to match the BPBR curriculum in structure and nature of the activities (i.e., interactive exercises, role-playing, lecture).
The teacher and nurse facilitators for both curricula attended separate two-day training sessions (12 hours in total). The two individuals responsible for training the BPBR facilitators had previously attended a training session offered by the curriculum authors and had three years of experience teaching the curriculum in middle schools. Training was conducted on consecutive Saturdays, and facilitators were reimbursed for their time, as well as travel and parking expenses. They were instructed on how to complete a detailed checklist for each session, including rating their command of the materials, their rapport...
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