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Programs that Work

Reducing the Risk


Program Info
Program Overview
Program Participants
Evaluation Methods
Key Evaluation Findings
Probable Implementers
Funding
Implementation Detail
Issues to Consider
Example Sites
Contact Information
Available Resources
Bibliography
Last Reviewed

 

Program Info

Outcome Areas
Healthy and Safe Children

Indicators
Youths abstaining from sexual activity or not engaging in risky sexual behavior

Topic Areas

     Age of Child
       Adolescence (13-18)
     Type of Setting
       Middle School
       High School
       Community-Based Service Provider
       Health Care Provider
     Type of Service
       Health Education
       Youth Development
     Type of Outcome Addressed
       Physical Health
       Teen Sex / Pregnancy

Evidence Level  (What does this mean?)
Promising

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Program Overview

The Reducing the Risk (RTR) curriculum was developed in 1988 (revised in 2004) to help lower the rate of teenage pregnancy and exposure to sexually transmitted diseases (STDs). The RTR curriculum helps teens understand the personal responsibilities and consequences of sexual activity and develop and practice the decisionmaking, negotiating, and refusal skills needed to resist social pressures regarding sexual behavior. In addition, the program aims to strengthen parent-child communication about issues related to sexuality and sexual activity. The RTR curriculum is intended to supplement preexisting sexual education programming, and it is typically presented by specially trained school-system teachers over a three-week period as part of a family life or a general health education program. In addition to school-based settings, RTR has frequently been implemented in other community-based organizations.

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Program Participants

Students in grades 7–12

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Evaluation Methods

Kirby et al. (1991) studied the impact of RTR in a sample of students from 46 classrooms in 13 California high schools. Participating classrooms were required to offer a health education curriculum to students, and those classrooms with teachers who volunteered to attend RTR training were eligible for randomization and treatment group participation. Approximately half of the classes were randomly assigned to RTR or the comparison group with the same teacher teaching both types of classes, while the other half were assigned nonrandomly to treatment and control groups and were taught by separate teachers. Students in both treatment and control groups were assessed at the start of the program and at 6 and 18 months after program completion on their knowledge of contraceptives, sexual beliefs, and sexual behaviors. There were no statistically significant differences between treatment and control groups in terms of background characteristics or pretest scores, indicating that the two groups were fairly well matched. A total of 1,033 students completed the pretest assessment, 722 students completed the 6-month follow-up (a 30 percent attrition rate), and 758 students (429 RTR and 329 control) completed the 18-month follow-up (an attrition rate of 27 percent). The attrition rate was identical for both treatment and control groups.

A second study (Hubbard, Giese, and Rainey, 1998) evaluated RTR’s effectiveness with high school students in Arkansas. Ten school districts from both rural and urban areas were matched for geographic location, ethnicity, and average per-capita income. Five districts were assigned nonrandomly to participate in RTR, and five districts were assigned to the control group (in which students received their district’s regular health/sexual education curriculum). In each school district, RTR was part of a required, one-semester health education class, and teachers implementing the RTR curriculum were those who volunteered to attend a three-day training session. One classroom in each treatment school district and one classroom in each comparison school district were randomly selected for testing. Students were assessed using a 28-item survey measuring sexual behavior, and all participants were tested prior to program administration and 18 months after the completion. The RTR group was fairly well matched to the control group, as indicated by a lack of statistically significant differences in pretest data. However, in terms of demographic differences, the treatment group was more likely to be female and to attend religious services once a week and less likely to attend more than once per week. A total of 532 students were assessed at baseline (with 512 suitable for analysis), and 212 students were matched at the 18-month follow-up (106 RTR students and 106 control students). The overall attrition rate was 58 percent, with graduation accounting for a significant proportion of the loss in respondents because 23 percent of the sample at pretest were high school juniors and seniors. Students who were sexually active prior to the start of the program were excluded from analysis concerning the initiation of sexual activity (41 percent of the original sample), resulting in a final sample of 125 students. The study did not assess program impacts on teens who engaged in ongoing sexual activity.

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Key Evaluation Findings

The research by Kirby et al. (1991) found the following:

  • At both 6 and 18 months after program completion, the increase in knowledge regarding contraceptives and their proper usage was significantly greater among members of the treatment group than among comparison group members.

    • Between pretest and 6-month follow-up, the average percentage of questions answered correctly by the treatment group rose from 57 percent to 75 percent (a gain of 18 percentage points), compared with an increase in the comparison group from 56 to 65 percent (a gain of nine percentage points).
    • From pretest to the 18-month follow-up, the gain in the average score was 18 percentage points among members of the treatment group, and 11 percentage points among members of the comparison group.

  • Among those students who were not sexually active at baseline, significantly fewer RTR students than control students became sexually active after initiation of the program.

    • No significant differences were found between treatment and control groups in the percentage of students who had initiated intercourse after 6 months (12 percent and 14 percent, respectively).

    • After 18 months, significantly fewer treatment than comparison group students had initiated intercourse (29 percent versus 38 percent, respectively).

  • Participation in RTR did not significantly impact proportions of students who became pregnant or created a pregnancy.

  • Among all students (including those both sexually active and nonsexually active at baseline), there were no significant differences between groups in the use of contraceptives at first intercourse, contraceptive use at most recent intercourse, or in the frequency and consistency of contraceptive use.

  • At 18 months, among baseline virgins who initiated intercourse after the start of the program, RTR students were 44 percent less likely than control students to have had unprotected sex at most recent intercourse (9 percent versus 16 percent). RTR students were also 46 percent less likely than control students to report unprotected sex "all or most of the time" (7 percent vs. 13 percent).
At the 18-month follow-up in a separate study, Hubbard, Giese, and Rainey (1998) found:
  • Among baseline virgins (totaling 69 RTR students and 56 comparison students), significantly fewer treatment group students than comparison students initiated intercourse after the start of the program (27.5 percent versus 42.9 percent, respectively).

  • Among baseline virgins who initiated intercourse after the start of the program, RTR youth were significantly more likely to use STD and pregnancy prevention (89 percent versus 46 percent, respectively).

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Probable Implementers

High schools and community-based organizations

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Funding

The evaluations of RTR were funded by the The Stuart Foundation, The William and Flora Hewlett Foundation, and the Arkansas State Department of Education, Comprehensive School Health Program.

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Implementation Detail

Program Design

  • The RTR curriculum emphasizes the development of decisionmaking and interpersonal negotiating skills.

  • Discussion groups and role-playing components give students the opportunity to practice the skills they are being taught.

  • Through out-of-class homework assignments, the curriculum encourages students to discuss program content and related issues with their parents.
Curriculum

The RTR curriculum is now in its 4th edition, and it involves 16 to 17 lessons implemented over a three-week period, normally in the school classroom during the regular school day. It is not a stand-alone program, but is intended to supplement preexisting health and sexual education curricula. Based upon three interrelated theoretical approaches—social learning theory, social inoculation theory, and cognitive behavior theory—the premise of RTR is that the likelihood of using condoms or other methods of birth control is determined by an understanding not only of what must be done to avoid STDs and pregnancy, but also on an individual’s belief in their ability to successfully use a given method of birth control/STD prevention. In addition, the theories suggest that youths need specific cognitive and behavioral skills to successfully recognize various forms of pressures (e.g., peer or internal pressures), resist pressures, and negotiate interpersonal encounters.

Building upon this foundation, the curriculum offers three components: (a) activities to personalize information about sexuality, reproduction, and contraception; (b) training in decisionmaking, communication, and skills to resist peer pressure; and (c) practice in applying those skills. More specifically, the program provides information on abstinence, sexuality, contraceptives, STDs, and HIV/AIDS. Students are taught to avoid unprotected intercourse by not having sex or, for students who choose to have sex, by using condoms or other contraceptives. In addition to teacher-led information sessions, the program emphasizes interactive exercises including group discussions, role-playing, and homework assignments, such as talking with parents or other adults about the material presented in class.

Staffing

RTR is implemented by regular classroom teachers who have attended a one- to four-day training session. The training focuses on giving teachers an overview of the curriculum and an opportunity to practice the activities that will be utilized in implementing the program, including traditional lectures, discussion, role-playing, and out-of-class assignments.

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Issues to Consider

This program received a "promising" rating. RTR was shown to significantly increase the level of knowledge regarding appropriate and correct use of contraceptives, significantly decrease the percentage of teens who initiated intercourse during the 18-month study period, and, for baseline virgins, significantly decreased rates of unprotected sex among those who initiated intercourse.

The two evaluative studies each had significant methodological limitations. Both studies had rather high rates of program dropout or attrition (27 percent and 58 percent, respectively). In the Kirby et al. (1991) study, the students who dropped out of the study differed in several ways from those who remained in the study. Researchers conducted no analysis of how this group of dropouts may have impacted results, but they note that of the 758 students assessed at 18 months, no significant differences were found between RTR and control groups for any of the ten demographic characteristics assessed, including grade, gender, race/ethnicity, mother’s education, and religiosity. Further, the 58 percent attrition rate in the study by Hubbard, Giese, and Rainey (1998) suggests that the study’s findings may not necessarily apply to general populations of high school students.

A further point of consideration relates to the relative homogeneity of the study populations in both studies. The Kirby et al. (1991) study population was more than 60 percent white, around 70 percent lived with both parents, and nearly 50 percent had mothers who had attended college. The Hubbard, Giese, and Rainey (1998) study population was 85 percent white and over half were moderately religious, attending religious services more than once per month. In addition to indicating homogeneity, these characteristics suggest that the populations of both studies were composed of individuals who may not be particularly high risk. This point is further illustrated by contrasting the 1991 study population with the population used in an evaluation of Self Center, a similar pregnancy prevention program that worked with a low-income, minority, inner-city population in Baltimore (Frost and Forrest, 1995). Thirty-seven percent of the Reducing the Risk population, consisting of 9th through 12th graders, was sexually active at pretest, compared with 92 percent of the boys and 79 percent of the girls in grades 10 through 12 who participated in the Self Center study. The issues of homogeneity and risk status may warrant consideration when weighing the appropriateness of the Reducing the Risk curriculum for a given population.

In addition, aspects of the study designs may have biased the outcomes. First, in both studies, only teachers who volunteered to attend the program training were eligible to participate. It is possible that teachers willing to dedicate the time to training are more engaged and/or are better teachers than their counterparts; thus, teacher characteristics may have positively biased the results. Further, the study involved randomization at the classroom level rather than the school level. It is possible that communication and/or relationships (dating) between students of different treatment status influenced control outcomes.

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Example Sites

California, Arkansas

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Contact Information

John Henry Ledwith
ETR Associates
4 Carbonero Way
Scotts Valley, CA 95066-4200
phone: 1-800-321-4407
fax: 1-800-435-8433
email: jhl@etr.org

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Available Resources

The RTR curriculum packet is available from ETR Associates in English and Spanish and includes background information, lecture notes, suggested program activities, and a student workbook. A supplementary activity kit also is available. Materials are available on the ETR Web site, http://www.etr.org/pub.

Another RTR program package is available from the Sociometrics Corporation (http://www.socio.com/srch/summary/pasha/full/paspp04.htm). This package includes a user’s guide, teacher’s manual, student workbook, pamphlets, evaluation instruments, directory of evaluation consultants, and telephone technical support for one year.

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Bibliography

Frost, Jennifer J., and Jacqueline Darroch Forrest, "Understanding the Impact of Effective Teenage Pregnancy Prevention Programs,"  Family Planning Perspectives,  Vol. 27, No. 5, 1995, pp. 188-195. 

Hubbard, Betty M., Mark L. Giese, and Jacquie Rainey, "A Replication Study of Reducing the Risk, a Theory-Based Sexuality Curriculum for Adolescents,"  Journal of School Health,  Vol. 68, No. 6, 1998, pp. 243-247. 

Kirby, Douglas, Richard P. Barth, Nancy Leland, and Joyce V. Fetro, "Reducing the Risk: Impact of a New Curriculum on Sexual Risk-Taking,"  Family Planning Perspectives,  Vol. 23, No. 6, 1991, pp. 253-263. 

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Last Reviewed

February 2007

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