Publications by authors named "Karin Coyle"

28 Publications

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A Group Randomized Trial Evaluating High School FLASH, a Comprehensive Sexual Health Curriculum.

J Adolesc Health 2021 Apr 11;68(4):686-695. Epub 2021 Feb 11.

Behavioral Health and Research Department of Obstetrics & Gynecology, University of Texas Medical Branch, Galveston, Texas.

Purpose: To evaluate the effectiveness of a school-based comprehensive sexual health curriculum (FLASH) on high-school students' sexual behavior and related outcomes.

Methods: A cohort of 1,597 9th and 10th grade students representing 20 schools from two regions in the U.S. (Midwest and South) were enrolled and completed the baseline survey. Following baseline, the 20 schools were randomly assigned to receive FLASH (n = 10 schools, five per region) or a knowledge-based sexual health curriculum (n = 10 schools, five per region). Follow-up surveys were administered at 3 months and 12 months after the instruction period.

Results: There were no statistically significant differences between conditions for the overall sample on rates of vaginal sex in the past 3 months or the rates of vaginal sex without a condom or other birth control. In supplementary subgroup analyses of students who were not sexually experienced at baseline, FLASH showed a statistically significant protective impact at the 3-month follow-up on vaginal sex without a condom or birth control (p = .04). FLASH also showed statistically significant gains in psychosocial outcomes, such as refusal and condom use self-efficacy, attitudes toward birth control and condoms, and perceived norms.

Conclusions: FLASH demonstrated consistent short-term and long-term impacts on key behavioral determinants. It also showed a significant impact on vaginal sex without a condom or other birth control for the subgroup of students who were not sexually experienced at baseline. Behavioral impacts were not evident for the entire study population.
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http://dx.doi.org/10.1016/j.jadohealth.2020.12.005DOI Listing
April 2021

The Health Equity Framework: A Science- and Justice-Based Model for Public Health Researchers and Practitioners.

Health Promot Pract 2020 Aug 19:1524839920950730. Epub 2020 Aug 19.

ETR, Scotts Valley, CA, USA.

In this article, we describe a science- and justice-based framework for promoting health equity designed for researchers and practitioners working across public health and social science fields. We developed the health equity framework (HEF; etr.org/healthequityframework) in two phases of iterative development. Building on existing models, the HEF illustrates how health outcomes are influenced by complex interactions between people and their environments. The framework centers on three foundational concepts: equity at the core of health outcomes; multiple, interacting spheres of influence; and a historical and life-course perspective. Health equity is defined as having the personal agency and fair access to resources and opportunities needed to achieve the best possible physical, emotional, and social well-being. By centering population outcomes, the HEF encourages researchers and practitioners to think beyond traditional approaches that focus on individual behaviors and choices to assess and identify their gaps in acknowledging and addressing factors from multiple spheres of influence. We identified four, interacting spheres of influence that represent both categories of risk and protective factors for health outcomes as well as opportunities for strategies and interventions that address those factors. The HEF highlights the explicit and implicit interactions of multilevel influences on health outcomes and emphasizes that health inequities are the result of cumulative experiences across the life span and generations. The HEF is a practical tool for leaders and professionals in public health research and practice to reflect on and support a shift toward addressing health inequities resulting from the interplay of structural, relational, individual, and physiological factors.
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http://dx.doi.org/10.1177/1524839920950730DOI Listing
August 2020

Condom Use and Error Experience Among Young Adolescents: Implications for Classroom Instruction.

Health Promot Pract 2020 Jun 15:1524839920935431. Epub 2020 Jun 15.

ETR, Scotts Valley, CA, USA.

We examine condom failure and use error experienced by high school youth in two regions of the United States. Data are from a baseline survey of a randomized controlled trial to evaluate FLASH, a sexual health education curriculum for high school students. Participants were 1,597 ninth- or 10th-grade students in health class who had parental consent and who assented to participate in the study. This study examines condom use behavior among students who reported vaginal or anal sex at baseline. Of the 222 participants who reported having vaginal or anal sex in the 3 months prior to baseline survey, 180 of them reported using a condom at least once. Of these youth, 70.6% reported that they did not squeeze the tip of the condom before sex, 25.0% of youth reported that they did not roll the condom all the way down to the base of the penis, and 49.4% reported that they did not hold the base of the penis when pulling out; 36.9% reported experiencing condom breakage or slippage. The frequency of condom error and/or failure reported by young adolescents in this study indicates a need for further education on potential condom use errors with an emphasis on the correct steps for using a condom to prevent condom failure. High rates of error and failure suggest an opportunity for educators to tailor preexisting condom use interventions to further reinforce the skills necessary for effective condom use and to educate on what to do in the event of condom failure.
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http://dx.doi.org/10.1177/1524839920935431DOI Listing
June 2020

Socio-Ecological Factors Associated With Students' Perceived Impact of an Evidence-Based Sexual Health Education Curriculum.

J Sch Health 2020 08 8;90(8):604-617. Epub 2020 Jun 8.

The University of Texas Health Science Center at Houston School of Public Health, 7000 Fannin Street, Houston, TX, 77030.

Background: Although schools often implement evidence-based sexual health education programs to address sexual and reproductive health disparities, multiple factors may influence program effectiveness.

Methods: Using student-reported perceived impact measures as a proxy for program effectiveness, we employed a socio-ecological approach to examine student, teacher, school, and district factors associated with greater perceived impact of It's Your Game (IYG), an evidence-based middle school sexual health education program. The student sample was 58.7% female, 51.8% Hispanic, mean age 13.2 years, from 73 middle schools. We assessed students' (N = 4531) perceived impact of IYG on healthy decision-making (α = 0.75) and sexual communication (α = 0.71); satisfaction with IYG activities and teacher; and demographics. We assessed teachers' (N = 56) self-efficacy to teach IYG, perceived administrative support, implementation barriers, and demographics. School and district data were abstracted from state records. We used multilevel logistic regression to estimate associations between independent variables and student-reported perceived impact.

Results: In final multivariate models, students' demographics (sex, β = 0.06, SE = 0.015), satisfaction with IYG (β = 0.21, SE = 0.012), and their IYG teacher (β = 0.18, SE = 0.013) (all p = .000) were significantly associated with perceived impact on healthy decision-making. Similar findings resulted for sexual communication. No other variables were significantly associated with perceived impact.

Conclusions: Helping schools select age-appropriate, culturally relevant programs, and facilitate supportive learning environments may enhance the perceived impact of sexual health education programs.
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http://dx.doi.org/10.1111/josh.12908DOI Listing
August 2020

You-Me-Us: Results of a Cluster Randomized Trial of a Healthy Relationships Approach to Sexual Risk Reduction.

J Prim Prev 2019 12;40(6):607-629

ETR, 100 Enterprise Way, Suite G300, Scotts Valley, CA, 95066, USA.

By middle adolescence, most young people have been involved in at least one romantic relationship, a context in which many sexual interactions occur. Indeed, researchers have suggested the importance of attending to relationships in programs focused on sexual risk, yet few evidence-based programs have a strong relationships focus. Our study examined the impact of a healthy relationship program called You-Me-Us that included a classroom curriculum and a school-wide peer norms approach. We evaluated the intervention using a small group randomized trial that included nine participating urban middle schools (defined as schools that include grades 6-8) in three urban school districts. We invited all 7th grade students within the study schools to enroll. Students completed three surveys during 7th and 8th grades (baseline plus two follow up surveys at 6 and 18 months following baseline). A total of 911 youth with positive consent and assent were enrolled in the study. Follow up survey response rates among those taking the baseline were 92% at 6 months and 80% at 18 months. Multilevel regression models were used to adjust for the correlation among students within the same school, and the correlation of repeated measurements taken on the same student over time. The intervention reduced vaginal sexual initiation by about half at the 6-month follow-up, and this approached significance. Further, youth in the intervention condition were less likely to believe it is okay for people their age to have vaginal sex without using condoms if the girl is on birth control. None of the remaining variables differed significantly by intervention condition. This study provides insights on using a healthy relationship approach for younger urban adolescents. This approach produced a programmatically significant reduction in sexual initiation that did not reach standard levels of statistical significance, and warrants further exploration.
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http://dx.doi.org/10.1007/s10935-019-00569-wDOI Listing
December 2019

Blended Learning for Sexual Health Education: Evidence Base, Promising Practices, and Potential Challenges.

J Sch Health 2019 10 9;89(10):847-859. Epub 2019 Aug 9.

Prevention Research Centerm The Pennsylvania State University, 119 Health & Human Development, University Park, PA 16802.

Background: Blended learning is a combination of online learning and face-to-face instruction, and is increasingly being used in K-12 settings. A meta-analysis conducted for the Department of Education suggests blended learning is more effective than either group-based or online learning alone, particularly in K-12 settings.

Methods: This paper provides a narrative review of the literature from 2000 to 2017 on blended learning as it applies to sexual health education programs, and discusses outcomes, best practices and potential challenges of blended learning that may be important for practitioners and researchers considering this approach.

Results: Blended learning approaches are being used successfully in sexual health education programs, including school-based programs, and have yielded positive behavioral and psychosocial changes. Similar to traditional group-based programs, not all outcomes tested in these programs showed positive impact. Designing blended learning programs can be challenging, but there is a large best-practice literature that can inform practitioners interested in using it.

Conclusions: Blended learning approaches are viable for sexual health education and offer numerous advantages to group-based only programs, such as confidential personalization and an instructional approach that is familiar and engaging for participants.
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http://dx.doi.org/10.1111/josh.12821DOI Listing
October 2019

Implementation Science Research Examining the Integration of Evidence-Based Practices Into HIV Prevention and Clinical Care: Protocol for a Mixed-Methods Study Using the Exploration, Preparation, Implementation, and Sustainment (EPIS) Model.

JMIR Res Protoc 2019 May 23;8(5):e11202. Epub 2019 May 23.

College of Medicine, Florida State University, Tallahassee, FL, United States.

Background: The Exploration, Preparation, Implementation, and Sustainment (EPIS) model is an implementation framework for studying the integration of evidence-based practices (EBPs) into real-world settings. The EPIS model conceptualizes implementation as a process starting with the earliest stages of problem recognition (Exploration) through the continued use of an EBP in a given clinical context (Sustainment). This is the first implementation science (IS) study of the integration of EBPs into adolescent HIV prevention and care settings.

Objective: This protocol (ATN 153 EPIS) is part of the Scale It Up program, a research program administered by the Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN), described in this issue by Naar et al. The EPIS study is a descriptive study of the uptake of 4 EBPs within the Scale It Up program. The goal of EPIS is to understand the barriers and facilitators associated with the Preparation, Implementation, and Sustainment of EBPs into HIV prevention and clinical care settings.

Methods: The EPIS study is a convergent parallel mixed-methods IS study. Key implementation stakeholders, that is, clinical care providers and leaders, located within 13 ATN sites across the United States will complete a qualitative interview conducted by telephone and Web-based surveys at 3 key implementation stages. The Preparation assessment occurs before EBP implementation, Implementation occurs immediately after sites finish implementation activities and prepare for sustainment, and Sustainment occurs 1 year postimplementation. Assessments will examine stakeholders' perceptions of the barriers and facilitators to EBP implementation within their clinical site as outlined by the EPIS framework.

Results: The EPIS baseline period began in June 2017 and concluded in May 2018; analysis of the baseline data is underway. To date, 153 stakeholders have completed qualitative interviews, and 91.5% (140/153) completed the quantitative survey.

Conclusions: The knowledge gained from the EPIS study will strengthen the implementation and sustainment of EBPs in adolescent prevention and clinical care contexts by offering insights into the barriers and facilitators of successful EBP implementation and sustainment in real-world clinical contexts.

International Registered Report Identifier (irrid): DERR1-10.2196/11202.
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http://dx.doi.org/10.2196/11202DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6552408PMC
May 2019

Replication of It's Your Game…Keep It Real! in Southeast Texas.

J Prim Prev 2019 06;40(3):297-323

Center for Health Promotion and Prevention Research, The University of Texas Health Science Center at Houston (UTHealth) School of Public Health, Houston, TX, 77030, USA.

Despite the recent efforts of the Office of Adolescent Health to replicate programs with demonstrated efficacy, there are still few evidence-based HIV, sexually transmitted infection (STI), and teen pregnancy prevention programs that have been replicated in "real-world" settings. To test the effectiveness of It's Your Game…Keep It Real! (IYG), an evidence-based STI and pregnancy prevention program for middle schools, the curriculum was implemented by teachers in urban and suburban middle schools in Southeast Texas from 2012 to 2015. IYG was evaluated using a group-randomized wait-list controlled effectiveness trial design in which 20 middle schools in nine urban and suburban school districts in Southeast Texas were randomized equally, using a multi-attribute randomization protocol, to either the intervention condition (received IYG) (n = 10 schools comprising 1936 eligible seventh graders) or the comparison condition (received usual care) (n = 10 schools comprising 1825 eligible seventh graders). All students were blinded to condition prior to administering the baseline survey. The analytic sample comprised 1543 students (n = 804, intervention; n = 739, comparison) who were followed from baseline (seventh grade) to the 24-month follow-up (ninth grade). Multilevel regression analyses were conducted to assess behavioral and psychosocial outcomes at follow-up. There were no significant differences in initiation of vaginal or oral sex between study conditions at follow-up. However, at 12-month follow-up, compared with students in the comparison condition, students in the intervention condition reported increased knowledge, self-efficacy, and perceived favorable norms related to HIV/STIs, condoms, and/or abstinence; decreased intentions to have sex; and increased intentions to use birth control. Knowledge outcomes were statistically significant at 24-month follow-up. This IYG effectiveness trial did not replicate the behavioral effects of the original IYG efficacy trials. However, it adds to the growing literature on the replication of evidence-based programs, and underscores the need to better understand how variations in implementation, setting, and measurement affect the behavioral impact of such programs.Clinical trial registration clinicaltrials.gov (NCT03533192).
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http://dx.doi.org/10.1007/s10935-019-00549-0DOI Listing
June 2019

Examining the Effects of an Adolescent Pregnancy Prevention Program by Risk Profiles: A More Nuanced Approach to Program Evaluation.

J Adolesc Health 2019 06 6;64(6):732-736. Epub 2019 Mar 6.

ETR Associates, Scotts Valley, California.

Purpose: The objective of the study was to examine whether latent class analysis (LCA) could (1) identify distinct subgroups of youth characterized by multiple risk and protective factors for early sexual initiation and (2) allow for a more nuanced assessment of the effects of a middle school program to prevent teen pregnancy/HIV/sexually transmitted infection.

Methods: LCA was applied to data from the baseline (seventh grade) sample of 1,693 sexually inexperienced students participating in a randomized controlled trial of It's Your Game…Keep It Real in Harris County, Texas. Multilevel analysis was applied within subgroups defined by the latent classes to assess for potential differential program effects.

Results: LCA identified 3 distinct profiles of youth: family disruption, other language household, and frequent religious attendance. Multilevel analyses found differential effects of the program across these profiles with a significant and substantial reduction (30%) in initiation of vaginal sex by ninth grade for students in the family disruption profile only.

Conclusions: Application of LCA may hold promise for conducting more nuanced evaluations and refinements of behavior change interventions for youth.
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http://dx.doi.org/10.1016/j.jadohealth.2018.12.003DOI Listing
June 2019

Developing a Video Intervention to Prevent Unplanned Pregnancies and Sexually Transmitted Infections Among Older Adolescents.

Health Promot Pract 2019 07 15;20(4):593-599. Epub 2018 Jun 15.

3 Rietmeijer Consulting, Denver, CO, USA.

Older adolescent African American and Latina females have disproportionately high rates of unintended pregnancies and sexually transmitted infections (STIs). This article describes the development of a new video intervention for this population, modeled on Safe in the City (SITC), an evidence-based STI prevention video. Plan A was created from 2015 to 2016, using a systematic process similar to SITC. This included forming a project team with reproductive health experts, hiring a video production company and screenwriter, conducting a clinic staff survey (n = 8), and soliciting priority population input using three focus groups (n = 41) followed by a review panel (n = 9). The expert input, clinic staff survey, focus groups, and review panel informed the content and format of Plan A. The 23-minute video includes three interconnected stories with relatable characters and two animated sequences. Topics covered include condoms, long-acting reversible contraception, emergency contraception, STI prevention and testing, and patient-provider communication. SITC provided a model to create a new entertainment-education intervention for a different audience and to address pregnancy prevention as well as STIs. Sustained priority population involvement, input from stakeholders, and a highly iterative process were vital to developing Plan A, which is currently being evaluated in a randomized controlled trial.
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http://dx.doi.org/10.1177/1524839918778832DOI Listing
July 2019

Dual Contraceptive Method Use Among Youth in Alternative Schools.

J Prim Prev 2016 Dec;37(6):561-567

ETR, 100 Enterprise Way, Suite G300, Scotts Valley, CA, 95066, USA.

Dual contraceptive method use, or using a highly effective contraceptive method plus a barrier method like condoms, is gaining attention as a strategy for preventing unplanned pregnancy and sexually transmitted diseases. We investigated rates of dual method use among a sample of youth in urban alternative schools, and explored the relationship between dual method use and sexual partner type. The study analyzed data from 765 students enrolled in 11 district-run continuation high schools in northern California. We explored the association between dual method use and sexual partner type (steady only, a mix of steady and non-steady, and non-steady only) using logistic regression. Differences in dual rates by partner type were statistically significant, with higher rates of dual methods use reported among young people reporting non-steady sexual partners only, as compared to those with steady partners only. The data illustrate that young people in alternative school settings could gain from further intervention on the benefits, skills, and challenges of using two methods of contraception as opposed to one with both steady and non-steady sexual partners.
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http://dx.doi.org/10.1007/s10935-016-0453-4DOI Listing
December 2016

It's Your Game…Keep It Real in South Carolina: A Group Randomized Trial Evaluating the Replication of an Evidence-Based Adolescent Pregnancy and Sexually Transmitted Infection Prevention Program.

Am J Public Health 2016 Sep;106(S1):S60-S69

Susan C. Potter, Karin K. Coyle, and Jill R. Glassman are with ETR, Scotts Valley, CA. Sarah Kershner and Mary S. Prince are with the South Carolina Campaign to Prevent Teen Pregnancy, Columbia.

Objectives: To evaluate the effectiveness of an evidence-based HIV/sexually transmitted infection (STI)/pregnancy prevention program for middle schools implemented by school staff in South Carolina.

Methods: Twenty-four schools, representing 3143 youths, participated in a randomized trial from 2011 to 2014. Students completed surveys before programming (fall of seventh grade), after completing the 2-year It's Your Game…Keep It Real program (spring of eighth grade), and 1-year postprogram (spring of ninth grade).

Results: There was no statistically significant effect on initiation of vaginal sex between baseline and eighth grade. Significantly fewer students in the comparison condition reported initiating sex at ninth grade, relative to the intervention condition. No group differences existed on other behavioral outcomes that addressed sexual activity in the past 3 months at ninth grade. Seven of 26 psychosocial outcomes (3 knowledge, 1 attitude, 1 self-efficacy, 2 personal limits) were positively affected at eighth grade; 4 remained significant at ninth grade.

Conclusions: The original studies' behavioral effects were not replicated in this population, possibly as a result of this being an effectiveness trial instead of an efficacy trial, counterfactual exposure design issues, or postprogram exposure to evidence-based programming.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5049477PMC
http://dx.doi.org/10.2105/AJPH.2016.303419DOI Listing
September 2016

Exploring Alternative Outcome Measures to Improve Pregnancy Prevention Programming in Younger Adolescents.

Am J Public Health 2016 Sep;106(S1):S20-S22

Karin K. Coyle is a Senior Research Scientist at ETR, Scotts Valley, CA. Jill Glassman is a Senior Research Associate at ETR.

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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5049475PMC
http://dx.doi.org/10.2105/AJPH.2016.303383DOI Listing
September 2016

Estimates of Intraclass Correlation Coefficients From Longitudinal Group-Randomized Trials of Adolescent HIV/STI/Pregnancy Prevention Programs.

Health Educ Behav 2015 Aug 27;42(4):545-53. Epub 2015 Jan 27.

ETR Associates, Scotts Valley, CA, USA.

Introduction: Group-randomized trials (GRTs) are one of the most rigorous methods for evaluating the effectiveness of group-based health risk prevention programs. Efficiently designing GRTs with a sample size that is sufficient for meeting the trial's power and precision goals while not wasting resources exceeding them requires estimates of the intraclass correlation coefficient (ICC)-the degree to which outcomes of individuals clustered within groups (e.g., schools) are correlated. ICC estimates vary widely depending on outcome, population, and setting, and small changes in ICCs can have large effects on the sample size needed to estimate intervention effects. This study addresses a gap in the literature by providing estimates of ICCs for adolescent sexual risk-taking outcomes under a range of study conditions.

Method: Multilevel regression analyses were applied to existing data from four federally funded GRTs of school-based HIV/STI/pregnancy prevention programs to obtain a variety of ICC estimates.

Results: ICCs ranged from 0 to 0.15, with adjustment for covariates and repeated measurements reducing the ICC in the majority of cases. Minimum detectable effect sizes with 80% power and 0.05 significance levels ranged from small to medium Cohen's d (0.13 to 0.53) assuming 20 schools of 100 students each.

Conclusions: This study provides the first known set of ICC estimates for investigators to use when planning studies of school-based programs to prevent sexual risk behaviors in youth. The results provide further evidence of the importance of using the appropriate adjusted ICC estimate at the design stage to maximize resources in costly GRTs.
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http://dx.doi.org/10.1177/1090198114568308DOI Listing
August 2015

Time-varying risk behaviors among adolescents: implications for enhancing the effectiveness of sexual risk reduction interventions.

J Adolesc Health 2014 Oct;55(4):465-6

Rollins School of Public Health, Emory University, Atlanta, Georgia.

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http://dx.doi.org/10.1016/j.jadohealth.2014.07.017DOI Listing
October 2014

An exploratory study of adolescent pimping relationships.

J Prim Prev 2014 Apr;35(2):113-7

ETR Associates, 4 Carbonero Way, Scotts Valley, CA, 95066, USA,

In the last decade, public attention to the problem of commercially sexually exploited children (CSEC) has grown. This exploratory qualitative study examines adolescent pimping relationships, including how urban youth perceive these types of relationships. Study data stem from interviews with three young adult informants with first-hand knowledge of adolescent pimping, as well as three gender-specific focus group discussions with a convenience sample of 26 urban high school students who have first- or second-hand knowledge of adolescent pimping. Findings indicate that respondents believe teen pimping exists in their schools and communities, and that those exploited typically do not self-identify as victims. Respondents also believed that younger pimps are more likely to use violence to induce compliance among the girls they exploit, whereas older pimps are more likely to emotionally manipulate young women into exploitation. Further, respondents indicated that some young people agreed to exchange or sell sex for money as a favor to their boyfriends or girlfriends, and some young people believed that selling sex is acceptable under certain circumstances. The growing attention to CSEC provides an important opportunity to expand prevention efforts to reach those most affected and at risk for exploitation. The findings highlight critical areas for augmenting traditional content in school-based HIV/STI and sexuality education classes.
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http://dx.doi.org/10.1007/s10935-014-0338-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4079071PMC
April 2014

"They were only joking": efforts to decrease LGBTQ bullying and harassment in seattle public schools.

J Sch Health 2014 Jan;84(1):1-9

Supervisor, Health Education, Health Education Office, Seattle Public Schools, 2445 3rd Avenue, Seattle, WA 98124.

Background: Seattle Public Schools has implemented policies and programs to increase safety, family involvement, and student achievement for lesbian, gay, bisexual, transgender, and questioning (LGBTQ) youth. This case study examines students' perceptions of bullying and harassment in the school environment, and teacher intervention when these problems arise in the presence of strong district policies and programs aimed at reducing LGBTQ bullying and harassment in schools.

Methods: We surveyed students in Gay-Straight Alliance (GSA) groups at 13 secondary schools (N = 107). We also conducted focus groups with GSA students and students not involved in the GSAs in 7 of 13 schools (N = 16 groups, including 154 students).

Results: GSA students who were lesbian, gay, bisexual, or questioning (LGBQ) were significantly more likely than straight students to experience several types of harassment. On the basis of student report, the 2 most common intervention strategies by teachers for verbal harassment included stopping the harassment and explaining why it is wrong; teachers intervened in physical harassment by trying to stop the harassment. Students provided input on how to strengthen teacher interventions, including the need for more consistency in responding and following up. Students also noted a need for more focus on educating those who harass, rather than just asking them to stop.

Conclusions: Seattle Public Schools has made great strides in creating safe and welcoming schools for LGBTQ students, but still have to work further toward reaching this goal. Data from students on how they experience their school environment can help identify areas for improvement.
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http://dx.doi.org/10.1111/josh.12120DOI Listing
January 2014

Interventions to reduce sexual risk behaviors among youth in alternative schools: a randomized controlled trial.

J Adolesc Health 2013 Jul 3;53(1):68-78. Epub 2013 Apr 3.

Research Department, ETR Associates, Scotts Valley, CA 95066, USA.

Purpose: This paper presents results from a randomized controlled trial that assessed the short- and longer-term impact of a skills-based HIV/STI/pregnancy prevention curriculum, service learning, and the combination.

Methods: The study featured a four-arm experimental design involving 47 classrooms (765 youth) from continuation high schools. Classrooms were randomly assigned to one of four conditions: (1) HIV/STI/pregnancy prevention curriculum only; (2) service learning only; (3) HIV/STI/pregnancy prevention curriculum plus service learning; or (4) an attention control curriculum. Students completed 3 surveys over 18 months. Multi-level analysis was used to adjust for the correlation among students within the same classroom and school, and the correlation of repeated measurements.

Results: Participants were 53% male (mean age: 16.2 years). The majority of youth reported being Hispanic/Latino or African-American (37.9% and 22.3%, respectively). Students in the HIV/STI/pregnancy prevention curriculum condition were less likely to have vaginal intercourse without a condom in the 3 months prior to the survey [odds ratio (OR) = .58, p = .04]; these effects diminished by final follow-up. The program also significantly reduced students' exposure to risky situations. These changes were not significant in the service learning only or combined intervention conditions relative to control.

Conclusion: This study is one of a few controlled studies of HIV/STI and pregnancy prevention programs in continuation settings, and suggests the curriculum was effective in changing selected risk behaviors in the short term.
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http://dx.doi.org/10.1016/j.jadohealth.2012.12.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3691297PMC
July 2013

Condom use: slippage, breakage, and steps for proper use among adolescents in alternative school settings.

J Sch Health 2012 Aug;82(8):345-52

Research Department, ETR Associates, 4 Carbonero Way, Scotts Valley, CA 95066, USA.

Background: School-based human immunodeficiency virus (HIV)/sexually transmitted infection (STI), and pregnancy prevention programs often focus on consistent and correct condom use. Research on adolescents' experience using condoms, including condom slippage/breakage, is limited. This exploratory study examines proper condom use and the occurrence of condom slippage/breakage among alternative school youth.

Methods: Data are from an HIV/STI prevention trial for youth in continuation school settings (N = 776). Analyses included separate hierarchical logistic regression analyses to explore the relationship between potential correlates and each outcome variable.

Results: Students' use of steps for proper condom use varied-73.8% put on the condom before sexual contact, 71.1% squeezed air from the tip, and 92.0% unrolled the condom fully. Notably, 28.5% reported condom slippage/breakage. Results from the regression analyses showed that 4 sets of variables (demographic, substance use, sexual risk behaviors, and condom psychosocial factors) were associated with putting on a condom before sexual contact; none of the variable sets were associated with the other 2 condom steps measured. For slippage/breakage, the demographic and sexual risk behaviors were significant correlates; steps for proper condom use approached statistical significance (p = .058).

Conclusions: This study extends the limited research on how adolescents use condoms, and highlights important targets for prevention interventions.
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http://dx.doi.org/10.1111/j.1746-1561.2012.00708.xDOI Listing
August 2012

What works? Process evaluation of a school-based fruit and vegetable distribution program in Mississippi.

J Sch Health 2011 Apr;81(4):202-11

Department of Research, ETR Associates, 4 Carbonero Way, Scotts Valley, CA 95066, USA.

Background: During the 2004-2005 school year, the Mississippi Department of Education, Office of Child Nutrition, initiated a pilot program to distribute free fruit and vegetable snacks to students during the school day. This article describes the first-year implementation of the Mississippi Fruit and Vegetable Pilot Program.

Methods: The process evaluation addressed where, when, and how produce was distributed; what was distributed; challenges and successes; and recommended modifications. Five of the 25 program schools were selected to participate in the evaluation; selection was based on grade levels served and demographic characteristics. Data were collected from program staff (N = 11) and administrators (N = 6) via interviews and logs; student (N = 42) and parent (N = 19) focus groups; student questionnaires (N = 660); and school staff questionnaires (N = 207).

Results: Distributing fresh fruit and vegetable snacks at school was well received by staff and students. Most schools distributed the fresh fruit and vegetable snacks at morning break in classrooms or a central courtyard. Twenty-two types of fresh fruit, 4 types of dried fruit, and 7 types of vegetables were served to students during the program year. Commonly distributed fruit included apples, oranges, pears, bananas, and tangerines. Carrots were the staple vegetable, followed by celery. Key challenges included getting students to try new foods and receiving the produce in a timely manner without spoiling. Main successes included seeing students try new fruit and vegetable snacks, having the program run smoothly, and teacher support.

Conclusions: The program fit well within the school structure and could be an effective component of a multifaceted approach to enhancing child nutrition.
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http://dx.doi.org/10.1111/j.1746-1561.2010.00580.xDOI Listing
April 2011

The association between school-based physical activity, including physical education, and academic performance: a systematic review of the literature.

Prev Med 2011 Jun 1;52 Suppl 1:S10-20. Epub 2011 Feb 1.

Centers for Disease Control and Prevention, 4770 Buford Highway, NE MS: K-33, Atlanta, GA 30341, USA.

Objective: The purpose of this review is to synthesize the scientific literature that has examined the association between school-based physical activity (including physical education) and academic performance (including indicators of cognitive skills and attitudes, academic behaviors, and academic achievement).

Method: Relevant research was identified through a search of nine electronic databases using both physical activity and academic-related search terms. Forty-three articles (reporting a total of 50 unique studies) met the inclusion criteria and were read, abstracted, and coded for this synthesis. Findings of the 50 studies were then summarized.

Results: Across all the studies, there were a total of 251 associations between physical activity and academic performance, representing measures of academic achievement, academic behavior, and cognitive skills and attitudes. Slightly more than half (50.5%) of all associations examined were positive, 48% were not significant, and 1.5% were negative. Examination of the findings by each physical activity context provides insights regarding specific relationships.

Conclusion: Results suggest physical activity is either positively related to academic performance or that there is not a demonstrated relationship between physical activity and academic performance. Results have important implications for both policy and schools.
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http://dx.doi.org/10.1016/j.ypmed.2011.01.027DOI Listing
June 2011

Distributing free fresh fruit and vegetables at school: results of a pilot outcome evaluation.

Public Health Rep 2009 Sep-Oct;124(5):660-9

ETR Associates, 4 Carbonero Way, Scotts Valley, CA 95066, USA.

Objectives: Consumption of fruit and vegetables among children is generally below recommended levels. This evaluation addressed two questions: (1) To what extent did children's attitudes toward, familiarity with, and preferences for fruit and vegetables change during the school year? and (2) To what extent did children's consumption of fruit and vegetables change during the school year?

Methods: During the 2004-2005 school year, the Mississippi Department of Education, Child Nutrition Programs initiated a pilot program to distribute free fruit and vegetables to students (kindergarten through 12th grade) during the school day. Data were collected in 2004-2005 within a one-group pretest/posttest design using a self-report questionnaire (n=725) and 24-hour dietary recalls (n=207) with a sample of students from five schools in Mississippi. Data were analyzed in 2006-2007.

Results: Results showed greater familiarity with fruit and vegetables at all grade levels (p<0.05) and increased preferences for fruit among eighth- and 10th-grade students (p<0.01). Eighth-grade students also reported more positive attitudes toward eating fruit and vegetables (p<0.01), increased perceived self-efficacy to eat more fruit (p<0.01), and increased willingness to try new fruit. Finally, results showed increased consumption of fruit, but not vegetables, among eighth- and 10th-grade students (p<0.001).

Conclusions: Distributing free fruit and vegetables at school may be a viable component of a more comprehensive approach for improving students' nutrition attitudes and behaviors. More program emphasis is needed on ways to promote vegetable consumption.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2728658PMC
http://dx.doi.org/10.1177/003335490912400508DOI Listing
October 2009

All4You! A randomized trial of an HIV, other STDs, and pregnancy prevention intervention for alternative school students.

AIDS Educ Prev 2006 Jun;18(3):187-203

ETR Associates, Scotts Valley, CA 95066, USA.

This study evaluated All4You!, a theoretically based curriculum designed to reduce sexual risk behaviors associated with HIV, other STDs, and unintended pregnancy among students in alternative schools. The study featured a randomized controlled trial involving 24 community day schools in northern California. A cohort of 988 students was assessed four times during an 18-month period using a self report questionnaire. At the 6-month follow-up, the intervention reduced the frequency of intercourse without a condom during the previous 3 months, the frequency of intercourse without a condom with steady partners, and the number of times students reported having intercourse in the previous 3 months. It also increased condom use at last intercourse. These behavioral effects were no longer statistically significant at the 12- and 18-month follow-ups. The All4You! intervention was effective in reducing selected sexual risk behaviors among students in alternative school settings; however, the effects were modest and short term.
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http://dx.doi.org/10.1521/aeap.2006.18.3.187DOI Listing
June 2006

Boyfriends, girlfriends and teenagers' risk of sexual involvement.

Perspect Sex Reprod Health 2006 Jun;38(2):76-83

Division of Violence Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, USA.

Context: Having a boyfriend or girlfriend, especially an older one, is associated with increased sexual risk in early adolescence. The mechanisms underlying this association are unclear.

Methods: Middle school students in Northern California were surveyed annually from 1997 to 2000. For a sample of 1,214 males and 1,308 females who were sexually inexperienced in seventh grade, logistic and linear regression were used to explore associations between relationship status in seventh grade and sexual activity in ninth grade, controlling for sixth-grade and eighth-grade characteristics.

Results: Males who had had a girlfriend their age by seventh grade were more likely than those who had had no relationship to report sexual activity in ninth grade (odds ratio, 2.1). Similarly, for females, the odds of being sexually active in ninth grade were elevated among those who had had a boyfriend their age (2.9); however, they also were higher among those who had had an older boyfriend than among those who had had one their age (2.1). With sixth-grade risk factors controlled, relationship status in seventh grade remained significant only for females; the association was explained by early menarche and by participation in situations that could lead to sex and riskier peer norms in eighth grade. For males, eighth-grade situations that could lead to sex, Hispanic ethnicity and sixth-grade peer norms explained ninth-grade sexual behavior.

Conclusions: To reduce the risk of adolescent sexual activity, parents and communities should encourage youth in middle school, especially females who experience early menarche, to delay serious romantic relationships.
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http://dx.doi.org/10.1363/psrh.38.076.06DOI Listing
June 2006

Integrating service learning into a curriculum to reduce health risks at alternative high schools.

J Sch Health 2005 May;75(5):151-6

ETR Associates, 4 Carbonero Way, Scotts Valley, CA 95066, USA.

Service learning has been identified as a promising approach to reduce sexual risk behavior, among other outcomes. This study used qualitative data analysis to offer suggestions for optimally integrating service learning into a program to reduce sexual risks among alternative school students. Data were collected from student participants in the All4You! Project using classroom materials, focus groups, and individual interviews. Project educators and project staff also provided data through summary forms and field notes. Qualitative data analysis revealed 5 strategies for creating positive service experiences for alternative school students: (1) find appropriate service-learning sites, (2) create staff support, (3) maintain appropriate student participation and behavior; (4) enhance student reflection on service-learning experiences, and (5) address students' self-images.
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May 2005

The "Safer Choices" intervention: its impact on the sexual behaviors of different subgroups of high school students.

J Adolesc Health 2004 Dec;35(6):442-52

Department of Research, ETR Associates, Scotts Valley, CA 95066-4200, USA.

Purpose: To measure the relative impact of a school-based human immunodeficiency virus (HIV)-, sexually transmitted disease (STD)-, and pregnancy-prevention intervention on sexual risk-taking behaviors of different subgroups of students.

Methods: Twenty schools were randomly assigned to receive Safer Choices or a standard knowledge-based HIV-education program. Safer Choices was designed to reduce unprotected sex by delaying initiation of sex, reducing its frequency, or increasing condom use. Its five components included: school organization, an intensive curriculum with staff development, peer resources and school environment, parent education, and school-community linkages. A total of 3869 9th-grade students were tracked for 31 months. Results are presented for initiation of sex, frequency of unprotected sex, number of unprotected sexual partners, condom use, and contraceptive use. These results are presented separately by gender, race/ethnicity, prior sexual experience, and prior sexual risk-taking. Statistical analyses included multilevel, repeated measures logistic and Poisson regression models.

Results: Safer Choices had one or more positive behavioral effects on all subgroups. On four outcomes that could be affected by condom use, it had a greater impact on males than on females. It had greater effects on Hispanics, including a delay in sexual activity, than on other racial/ethnic groups. Its greatest overall effect was an increase in condom use among students who had engaged in unprotected sex before the intervention.

Conclusions: Safer Choices reduced one or more measures of sexual risk taking over 31 months among all groups of youth, and was especially effective with males, Hispanics, and youth who engaged in unprotected sex and thus were at higher risk for HIV, other STD infections and pregnancy.
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http://dx.doi.org/10.1016/j.jadohealth.2004.02.006DOI Listing
December 2004

Draw the line/respect the line: a randomized trial of a middle school intervention to reduce sexual risk behaviors.

Am J Public Health 2004 May;94(5):843-51

ETR Associates, 4 Carbonero Way, Scotts Valley, CA 95066-2400, USA.

Objectives: This study evaluated the long-term effectiveness of Draw the Line/Respect the Line, a theoretically based curriculum designed to reduce sexual risk behaviors among middle school adolescents.

Methods: The randomized controlled trial involved 19 schools in northern California. A cohort of 2829 sixth graders was tracked for 36 months.

Results: The intervention delayed sexual initiation among boys, but not girls. Boys in the intervention condition also exhibited significantly greater knowledge than control students, perceived fewer peer norms supporting sexual intercourse, had more positive attitudes toward not having sex, had stronger sexual limits, and were less likely to be in situations that could lead to sexual behaviors. Psychosocial effects for girls were limited.

Conclusions: The program was effective for boys, but not for girls.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1448347PMC
http://dx.doi.org/10.2105/ajph.94.5.843DOI Listing
May 2004

Behavioural risk factors and protective factors in adolescents: a comparison of Latinos and non-Latino whites.

Ethn Health 2002 Aug;7(3):181-93

Research Department, Education, Training, Research (ETR) Associates, Santa Cruz, CA, USA.

Objectives: This study investigated differences in behavioural health protective and risk factors in US Latino and non-Latino White adolescents as well as differences among Latinos with different levels of acculturation using a bicultural acculturation model. The bicultural model is consistent with current understanding of cultural change processes; however it has infrequently been applied to understand adolescent health outcomes. The outcomes included risk and health behaviours as well as mental health factors consistent with Jessor's framework for describing adolescents' health status.

Design: Participants included 1119 students randomly selected from all middle schools of a Northern California district. Respondents completed project staff administered self-reports surveys in their schools that included assessments of health behaviours, mental health, and socio-cultural variables-including acculturation level.

Results: Latinos were at higher risk than non-Latino Whites in the following areas: academic orientation, physical activity, and sunscreen use. Boys and those of lower social class were more likely to report use of various substances and violence. Among Latinos, those in the marginalised acculturation group-those with less attachments and adaptations to Latino and other cultures, showed less desirable mental health outcomes than the bicultural group.

Conclusion: These results extend prior research by assessing the health needs of early adolescent youth. The study found important differences within Latinos using a bicultural acculturation model. The use of a bicultural acculturation model, or cultural orientation approach more generally, may have special utility for addressing health issues wherever minority populations interact with a dominant society.
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http://dx.doi.org/10.1080/1355785022000042015DOI Listing
August 2002