Abstract
Supplementing substance use prevention with sexual health education would allow educators to address the risk and protective factors that influence both health issues. This streamlined approach may minimize the inefficiencies of multisession, single-purpose interventions. Our team developed a supplemental sexual and reproductive health (SRH) unit to align with an existing evidence-based intervention, LifeSkills Training (LST). This goal of this article is to describe our process, final product, lessons learned, and future directions. Our partner-informed approach took place across three key phases: (1) formative insights, (2) unit development, and (3) pilot implementation. The final supplemental SRH unit is ten, 45-minute sessions offered to seventh- and eighth-grade students and includes a set of learning objectives that are aligned with individual sessions. The supplemental SRH unit also mirrors existing LST modules in length, flow, layout, facilitator instructions, focus on prevention, and utilization of a student workbook. Lessons learned include strategies to effectively incorporate a wide range of ongoing feedback from multiple sources and quickly respond to staff turnover. This partnership approach serves as a model for researchers and practitioners aiming to extend the reach of existing evidence-based programs.
Introduction
Adolescence is a sensitive period in the life course, during which young people are tasked with navigating myriad physical, neurocognitive, emotional, and social changes. In many settings, it is normative for young people to be exposed to opportunities, engage in sexual or romantic activity, or use substances such as alcohol, tobacco, and marijuana during their teenage years. An increased emphasis on the opinions of others, heightened reward sensitivity, and increased sensation seeking during adolescence leave young people more likely to engage in these behaviors in ways that may compromise their health in the near and long term (Blakemore, 2008; Blakemore & Mills, 2014; Crone & Dahl, 2012; Steinberg, 2008). Young people aged 15 to 24 years account for half of new sexually transmitted infections (STIs) in the United States, with prevalence being up to 9 times higher among Black teens compared to White teens aged 15 to19 years (Centers for Disease Control and Prevention, 2019). Approximately one in six adolescents aged 12 to 17 years use illicit substances such as marijuana and nearly one in 10 drink alcohol, with over half of young people who drink alcohol reporting binge drinking in the previous month (Substance Abuse and Mental Health Services Administration, 2019). Because substance use behaviors developed during adolescence influence adult behaviors and health, interventions that support adolescents in navigating sexual activity and substance use are important preventive measures in protecting long-term health (Ohannessian et al., 2015; Sawyer et al., 2012).
Adolescent sexual activity, substance use, and engagement in violence are commonly framed as risk behaviors and have been shown to both co-occur and influence one another (de Winter et al., 2016). For example, adolescent substance use has been associated with earlier age of first sex, increased risk of unprotected sex, and a higher number of sexual partners (Ritchwood et al., 2015; Tucker et al., 2012). In turn, substance use is associated with increased perpetration of violence, including violence against dating partners in adolescence (Ellickson & McGuigan, 2000; Temple et al., 2013). The interrelationship between different adolescent risk behaviors, such as substance use and sexual risk taking, is further supported by their shared risk and protective factors. Early exposure to adverse childhood experiences or maltreatment, including physical or sexual abuse, growing up in a low-income neighborhood, and engaging with peers who practice deviant or violent behavior have been linked with increased propensity for violence, substance use or misuse, and sexual risk taking in adolescence (Cubbin et al., 2005; Haynie et al., 2006; Hussey et al., 2006; Thibodeau et al., 2017). At the same time, school connection, parental attachment, and neighborhood collective efficacy are linked with decreased propensity for substance use and sexual risk taking, demonstrating the potential for shared protective factors to support multiple healthy behaviors (Browning et al., 2004; Fagan et al., 2014; Resnick et al., 1997).
Researchers have developed a number of evidence-based interventions that have proven to be effective in preventing or reducing health risk behaviors, including tobacco and substance use, violence and aggression and unsafe sexual behaviors (Kirby & Laris, 2009; Mytton et al., 2002; Soole et al., 2008). School-based programs in particular have been shown to positively affect multiple health risk factors and academic outcomes (Flay, 2002). However, schools may lack the capacity to implement different multisession, single-purpose interventions to address individual health risk behaviors, presenting a key gap between intervention developers and implementers. This is especially inefficient given the co-occurrence of adolescent health risk behaviors and their shared underlying causes and protective factors.
LifeSkills Training
LifeSkills Training (LST) for middle school is a skills-based cognitive behavioral prevention program delivered over 3 years during Grades 6 to 8 that focuses on building competence in three domains—personal self-management, social competence, and risk behavior resistance. LST combines subject-specific knowledge related to particular risk behaviors with foundational skills-building in line with positive youth development approaches that target youth asset-building as a risk prevention approach (Botvin & Griffin, 2014). LST has been widely implemented in diverse contexts and has been shown to reduce the risks of alcohol, tobacco, drug abuse, and violence among middle school students (Botvin et al., 2006; Botvin & Kantor, 2000). However, to date, LST has not included a focus on sexual and reproductive health (SRH), which may be a missed opportunity to expand the reach and impact of this curriculum.
A Partnership Approach to Intervention Development
In 2014, the Johns Hopkins Center for Adolescent Health, Baltimore City Public Schools, and the Baltimore City Health Department partnered to address the high rates of substance use and sexual risk-taking experienced among middle school-aged students across the city. Many of Baltimore’s young residents experience considerable risks and have limited access to factors that promote positive youth development (Leaf et al., 2013; Marshall et al., 2014). Compared with the nation, the city has a higher percentage of children living below the poverty line (32% vs. 18%) (Annie E. Casey Foundation, 2020). Over one half of the city’s high school students have had at least one drink of alcohol and nearly one half have used marijuana at least once (Maryland Department of Health, 2018a). The teen birth rate in the city is over two times the state average and 1.5 times the national average (Annie E. Casey Foundation, 2020; Hogan et al., 2018). Middle school students in the city are at a uniquely high risk of negative sexual health outcomes. An estimated 13% of middle school students in the city have engaged in sexual intercourse, compared to 6.8% in the state of Maryland (Maryland Department of Health, 2018b).
The city has a history of implementing LST in middle schools, primarily among sixth graders. The goal of this partnership was to expand risk prevention efforts through the addition of a supplemental sexual health unit to the LST curriculum, and the implementation of LST in middle school classrooms across Grades 6 to 8. This article describes our process, product, lessons learned, and future directions of developing a supplemental sexual health unit for the LST curriculum.
Process
The development of a supplemental SRH unit was led by the Johns Hopkins Center for Adolescent Health (CAH). Together with its community partners, the CAH conducts research that identifies the needs and strengths of young people and tests programs designed to promote their health and well-being. Accordingly, the CAH took on a partner-informed approach to developing a supplemental sexual health unit for LST. This partner-informed approach ensured that all content was informed by both researchers and practitioners. This process took place across three key phases: (1) formative insights, (2) unit development, and (3) pilot implementation. Each phase is described in detail below.
Phase 1: Formative Insights
The CAH began by conducting key informant interviews with principals at five partner middle schools to better understand the factors important for successful implementation of a classroom-based risk prevention curriculum. Topics covered included needs of the student population, barriers and opportunities to program implementation, decision-making processes in selecting programs, and past experiences implementing programs. Principals expressed desire for comprehensive and ongoing teacher training, including a “complete package” of a curriculum and supplemental training materials. In addition, while all principals acknowledged significant need for a risk behavior prevention curriculum, they also highlighted the time constraints of teachers, and the need for flexibility in unit length and design. Principals noted that sexual health topics were addressed differently across schools. Some schools invited outside programs to address the issues (e.g., planned parenthood or medical students from local hospital). Others introduced a limited number of topics through their science courses when appropriate. This information was later used to inform successful unit development and implementation.
The CAH also conducted a review of the existing health standards used by the school district. The lesson content of three other evidence-based teen pregnancy prevention curricula were also reviewed to better understand the common components of those programs, their overlap with existing LST curriculum and Maryland standards, and common strategies that may be adapted for the supplemental SRH unit. The following curricula were reviewed: It’s Your Game: Keep It Real, Draw the Line/Respect the Line, and Making Proud Choices! Out of Home Care (Coyle et al., 2004; Jemmott et al., 1998; Tortolero et al., 2010). Information from these curricula, combined with city data conveying earlier sexual initiation and higher pregnancy and STI rates among adolescents compared to state and national averages, led the team to focus on two key behavioral outcomes for the supplemental SRH unit: (1) delaying sexual initiation and (2) increasing protective behaviors among students when they become sexually active.
Phase 2: Unit Development
The original development of the LST curriculum was informed by social learning theory and problem behavior theory (Bandura, 1978; Botvin et al., 1984; Jessor, 1982). Social learning theory posits that behaviors are learned in the context of a social environment through the process of observation, imitation, and modeling. Behaviors are motivated by social influencers and individual factors (Bandura, 1978; Botvin et al., 1984). Problem behavior theory involves the application of social learning theory to adolescent “problem” or risk behaviors (Jessor, 1982). We extended these theoretical groundings to the development of the supplementary SRH unit. In addition, we applied a positive youth development approach, which harnesses young peoples’ existing competencies and resources by further equipping them with relevant skills and information, rather than attempting to overcome deficits through behavioral corrections (Damon, 2004).
To develop learning objectives tied to our intended behavioral outcomes of delayed sexual initiation and increased protective behaviors, the CAH held a 2-day working meeting facilitated by a youth sexual and reproductive behavior change expert. The workshop was attended by faculty, staff, and graduate research assistants from the university. Based on achieving a balance of classroom time and SRH content, the team determined that the supplemental SRH unit would be a minimum of eight, 45-minute sessions offered to seventh- and eighth-grade students. Based on this guidance, the team developed a set of learning objectives for the supplemental SRH unit and aligned them with individual sessions, ensuring that all learning objectives were met over the course of LST implementation.
Sessions were collaboratively written by the CAH and a middle school teacher. The following common core components of adolescent pregnancy prevention programs were incorporated (1) clear health goals; (2) a focus on specific reproductive health behaviors; and (3) an emphasis on multiple psychosocial protective factors affecting sexual behaviors (Kirby et al., 2005). The team developed a set of corresponding activities for each objective in partnership with stakeholders and consultants. In line with social learning theory, behavioral modeling and rehearsal were commonly incorporated into activities. Finally, the team sought to ensure that the curriculum was inclusive of diverse genders and sexual orientations. Schools that teach LGBTQ (lesbian, gay, bisexual, transgender, and questioning or queer)-inclusive sex education have been shown to have lower odds of LGBTQ students reporting being bullied in school and experiencing adverse mental health outcomes (Proulx et al., 2019).
The supplemental SRH unit was developed to align with the LST program. Specifically, the supplemental SRH unit aligns with LST in length and flow of lessons, layout of content, written instructions for facilitators, focus on prevention, and utilization of a student workbook alongside sessions. In addition, teaching strategies used in LST, including facilitation, coaching, behavioral rehearsal, and assessment were extended to the supplemental SRH unit. Similarly, the supplemental SRH unit was designed to build on objectives and skills introduced and practiced in LST class sessions—such as decision making, communication, and assertiveness—by reinforcing them and applying them to another domain of health. In total, eight sessions comprising the initial supplemental SRH unit were developed.
Phase 3: Pilot Test
The CAH partnered with two public middle schools to pilot the implementation of the supplemental SRH unit among seventh- and eighth-grade students. All sessions were delivered during science class. Based on insights collected from principals during Phase 1, we prioritized three areas to ensure successful pilot implementation: comprehensive training, school-specific scheduling, and ongoing support. To ensure facilitators received comprehensive training, the CAH team provided trainings at accessible times and locations and allowed facilitators to practice with their peers before implementing with students. Each school required school-specific scheduling, which meant that the time of year and weekly frequency of implementation varied across schools. Finally, the CAH agreed to quickly respond to requests for classroom support, additional materials (e.g., Post-its, flip charts, markers, and funding for student activities) to show their ongoing support of the school and program.
Prior to conducting the pilot test, all school personnel who would be implementing the supplemental SRH unit—all of whom were teachers—attended a half-day training developed by a team member from the university. During the training, the trainer explained key elements of a sex positive teaching approach and how the supplemental SRH unit aligned with the existing LST program. Teachers shared their previous experiences and their concerns about leading discussions around SRH with students. They practiced strategies for teaching content related to adolescent SRH and discussed the content of each session. Time was allotted for practice leading the sessions, answering questions, and providing a set of local and national resources. It was crucial for implementers to feel both comfortable and competent that they could deliver it as designed and evaluations from the training showed this to be the case.
Because the supplemental SRH unit was designed to both build onto one another and the LST program, the pilot test was conducted over a period of 2 years with one cohort of students receiving LST and the supplemental unit in two public middle schools. The seventh-grade sessions were delivered in the first year, and the eighth-grade sessions were delivered in the second year. Each session was observed by a member of the research team using a standardized observation form. Facilitators also provided feedback for each session using an electronic fidelity log that asked a set of standard questions about the delivery of each session (e.g., student engagement and modifications made). The pilot test period allowed the research team to iteratively improve the unit and resources based on feedback from facilitators, who had a range of prior experience teaching sexual health education. For example, prior to Year 2 of the pilot test, modifications were made to the eighth-grade sessions based on seventh-grade facilitator feedback.
At the end of the 2-year pilot test with both seventh- and eighth-grade students, the research team revised the supplemental SRH unit based on feedback obtained from teacher fidelity logs and in-person observations. In addition to the observation notes, and fidelity logs, the research team solicited feedback on implementation through one on one meetings with individual facilitators. Facilitators provided feedback on the following topics: flow of the SRH unit, student responses, challenges, and future considerations. Additionally, the university partnered with the national Gay, Lesbian Sexuality Education Network to ensure inclusivity and that proper terminology was being used throughout the supplemental SRH unit. Table 1 lists examples of the types of feedback received and addressed in the final version of the supplemental SRH unit.
Examples of Partner Feedback
Note. GLSEN = Gay, Lesbian Sexuality Education Network; LGBTQ = lesbian, gay, bisexual, transgender, and questioning or queer.
Product
The final supplemental SRH unit had 10 sessions; five sessions that could be delivered in seventh grade and five sessions in eighth grade. Sessions were confined to 45 minutes to be consistent with both the original LST curriculum and responsive to teacher schedules. Two sessions were allotted for topics that required more than 45 minutes. Throughout the unit, students are able to demonstrate their understanding through a range of activities facilitated during class and described in a corresponding student guide. Table 2 lists the final titles and objectives for each session.
Session Titles and Goals of Final Supplemental Sexual and Reproductive Health Unit
The seventh grade sessions introduce students to the topics of SRH, accurate terminology, boundary setting, and protective and risky behaviors. Not all students receive health education in elementary school. Therefore, there seemed to be little consensus on the basic set of knowledge among middle school students. Implementing the supplemental SRH unit with seventh-grade students proved to be challenging. As a result, there is an optional session at the start of the unit, which reviews puberty, available for facilitators whose students need it. Session 1 includes a transition to bridge the LST program to the new modules and invites students to examine statistics and think about reasons young people their age may or may not be engaging in sex. In the first session, an anonymous question box is introduced. The anonymous question box allows students to ask questions that they might not feel comfortable asking in front of their peers due to fear of embarrassment or fear of exposing their behaviors or identities. For example, an LGBTQ student might have a question about behaviors or resources specific to their sexual orientation or gender identity which they may not feel comfortable asking if they are not out to their classmates. Sessions 2 and 3 are combined and provide a scaffolded approach for students to apply the boundary setting skills and decision-making model developed in prior LST sessions to sexual health with a new focus on consent. During Session 4, students learn about the potential consequences of unsafe sexual behavior, specifically information related to STIs.
The five eighth-grade sessions follow a similar pattern, first providing an overview of SRH, then examining boundaries. These sessions serve as reinforcement of the sessions in seventh grade and focus more heavily on the application of skills than the seventh-grade sessions. They have a specific focus on relationships, then skill building around identifying and reducing risks. Session 1 provides a review of SRH and puberty, challenges students to analyze media portrayals of sex, discusses teen pregnancy, and again serves as a bridge between the LST program and the SRH unit. In Session 2, students are given the chance to reevaluate and update their personal boundaries around sex, in addition to identifying risk situations, and practicing techniques when they are pressured to engage in an activity that goes against their personal boundary. Characteristics and responsibilities within relationships, including dating relationships, are the main topic in Session 3. Finally, Sessions 4 and 5 concentrate on the risks associated with sexual activity. Behaviors, including masturbation and vaginal sex, are discussed. Actions to protect against pregnancy and STIs are also discussed; students are also challenged to identify the benefits of seeking clinic care to address their sexual health and learn about the use of condoms as a barrier method.
Lessons Learned and Future Directions
Existing evidence-based interventions may be too costly or narrowly focused for some schools to implement. Moreover, adaptations not informed by knowledgeable stakeholders or supported by evidence may not meet the needs of the school. Through our process, we learned that there is both interest and need for more integrated interventions that address the common risky behaviors experienced by adolescents. School personnel were committed to helping youth grow; this flexible and easy-to-teach integrated intervention allowed facilitators to address a range of risk-taking behaviors in a systematic way across time. The strengths of this process were rooted in its ability to apply a multidisciplinary, collaborative approach to developing an SRH module for urban middle school students.
Learning to effectively incorporate ongoing feedback from multiple sources throughout the process was also essential. Not all feedback came at the same time nor was the feedback always aligned. Partnering with content experts and school personnel allowed the research team to develop a supplemental SRH unit that aligned with both National Health Education Standards and the current needs of the school settings. Involvement from teachers in the initial development phases helped the team easily translate complex topics into middle school reading levels and social context. Feedback from teachers also allowed the team to consider and include additional resources to prepare facilitators with responses to commonly asked questions about SRH topics. To ensure that all feedback was appropriately captured in the resulting supplemental health unit, we created a matrix to track the feedback and ways to incorporate all voices. Drafts were shared with partners along the way for their approval.
We learned how to thoughtfully use inclusive language throughout the supplemental SRH unit. It became evident that surface level inclusion efforts (e.g., gender-neutral names) were insufficient in properly representing the diverse experiences of young people. We challenged heteronormative norms and attempted to integrate language, characters, and tips to support both facilitators and students. The involvement of Gay, Lesbian Sexuality Education Network, an expert in this area, helped ensure that the supplemental SRH unit was contemporary, appropriate, and respectful.
We also had to quickly learn to seamlessly address administration and teacher turnover. Having a clear onboarding packet was key to ensuring that the partnerships with schools would continue regardless of personnel changes. Our onboarding packet included a description of the overall project, the role of each stakeholder, a list of project and school contacts, and a FAQ sheet.
Our partnership approach to developing this supplemental SRH unit resulted in sessions that easily align with an existing evidence-based intervention and is responsive to stakeholder feedback. Field testing of the final supplemental SRH unit is currently being implemented in two schools. This includes pre- and posttest assessments from students, fidelity assessments from facilitators, as well as an analysis of school and community level trends. We must await the findings from the evaluation research to know if the supplemental SRH unit has the intended preventative effect on adolescent sexual risk taking.
There is great potential in taking a partnership approach to developing supplemental materials for existing interventions. The development of this supplemental SRH unit was informed by existing theories, content experts and most important, school personnel. By relying on a rigorous research plan, knowledgeable partners, and an intense piloting process, this collaborative approach has resulted in a set of inclusive sessions that incorporate medically accurate and developmentally appropriate middle school content that aligns with National Health Education Standards. This partnership approach may serve as a model for future researchers and practitioners aiming to extend the reach of existing evidence-based programs.
Footnotes
Authors’ Note:
We would like to thank Baltimore City Public School System and the schools who participated in this research. This work was financially supported by the Cooperative Agreement (1-U48-DP-000040) funded by the Centers for Disease Control and Prevention, Prevention Research Center Program. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention and prevention or the Department of Health and Human Services. This work was also funded by the National Institute on Drug Abuse (1K01DA042134-01A1). The funders did not play a role in the design, conduct or analysis of the study nor in the drafting of this manuscript.
