Family Health International (FHI) recently published a working paper, Impact of Sex and HIV Education Programs on Sexual Behaviors of Youth in Developing Countries, analyzing 83 evaluations that measured the impact of programs focused on pregnancy and HIV/STD prevention. The programs included in this review took place at schools, clinics, or community settings in both industrialized and developing countries across the world; 18 of the programs were conducted in developing countries (Belize, Brazil, Chile, Jamaica, Kenya, Mexico, Namibia, Nigeria, South Africa, Tanzania, Thailand, and Zambia) 56 were conducted in the United States and nine in Canada or Europe.
The review analyzed the impact programs had on sexual risk-taking behaviors among young people. It addressed two primary research questions:
- What are the effects, if any, of curriculum-based sex and HIV education programs on sexual risk behaviors, STD and pregnancy rates, and mediating factors such as knowledge and attitudes that affect those behaviors?
- What are the common characteristics of the curricula-based programs that were effective in changing sexual risk behaviors?
For the purposes of this report "sex" education is used to refer to programs focusing on pregnancy or HIV/STD prevention; this differs from "sexuality" education, which ideally encompasses a wide range of topics. This working paper is a review of research studies measuring the impact of programs, not an evaluation of the programs themselves.
The review analyzed the impact programs had on one or more aspects of sexual behavior including initiation of sex, frequency of sex, number of sexual partners, condom use, contraceptive use in general, and composite measures of sexual risk taking (e.g., frequency of sex without condoms). Some studies also reported on pregnancy and STD rates. Overall, the results indicate that these programs were far more likely to have positive impact on behavior than a negative impact.
- 65% of the studies found a significant impact on one or more of these sexual behaviors or outcomes while only 7% found a significant negative impact
- 3% of the programs had a positive impact on two or more behaviors and outcomes.
- Some of these programs had positive impacts for two or three years or more.
- In general, the patterns of findings for all the studies were similar in both developing and developed studies.
- These programs were effective with both low- and middle-income youth, in both rural and urban areas, with boys and girls, with different age groups, and in school, clinic, and community settings.
A review of replication studies of four different curricula in the United States revealed that curricula did have similar positive behavioral effects when they were replicated, provided that all activities were implemented and designed in the same type of setting and with similar populations of youth. When many activities were omitted or the setting changed, the curricula were less likely to have positive effects.
The review of these studies found strong evidence that many programs can improve knowledge about HIV, other STDs, pregnancy, and methods of preventing these risks; awareness of HIV; values and attitudes about sex, condoms, risky sexual behavior, and people living with HIV; self-efficacy to refuse sex and to use condoms; intention to abstain from sex or restrict sex and number of partners; and communication with past partners, current partners, and parents. The authors believe it is highly likely that changes in knowledge, awareness of risk, values and attitudes, self-efficacy, and intentions contributed to the changes in sexual risk-taking behaviors.
Characteristics of the Curricula-Based Programs that Had Positive Effects on Behavior
This review also included a qualitative analysis of the written curricula on which these programs were based to determine the common characteristics that were effective in changing sexual risk-taking behaviors. The analysis identified 17 common characteristics, many of which the effective programs incorporated. Programs that had these characteristics were much more likely to change behavior positively than programs that did not integrate many of the characteristics.
Process of Developing the Curriculum
- Involved multiple people with different backgrounds in theory, research, and sex/HIV education in developing the curriculum.
- Used a logic model approach to develop the curriculum that specified the health goals, the behaviors affecting those health goals, the risk and protective factors affecting those behaviors, and the activities addressing those risk and protective factors.
- Assessed relevant needs and assets of target groups.
- Designed activities consistent with community values and available resources (e.g., staff time, staff skills, facility space, and supplies).
- Pilot-tested the program.
Content of the Curriculum
- Created a safe social environment for youth to participate.
- Focused on clear health goals-the prevention of HIV/STDs and/or pregnancy.
- Focused narrowly on specific behaviors leading to these health goals (e.g., abstaining from sex or using condoms or other contraceptives), gave clear messages about these behaviors, and addressed situations that might lead to them and how to avoid them.
- Addressed multiple sexual psychosocial risk and protective factors affecting sexual behaviors (e.g., knowledge, perceived risk, values, attitudes, perceived norms, and self-efficacy).
- Included multiple activities to change each of the targeted risk and protective factors.
- Employed instructionally sound teaching methods that actively involved the participants, helped participants personalize the information, and were designed to change each group of risk and protective factors.
- Employed activities, instructional methods, and behavioral methods that were appropriate to the youths' culture, developmental age, and sexual experience.
- Covered topics in a logical sequence.
Implementation of the Curriculum
- Whenever possible, selected educators with desired characteristics and then trained them.
- Secured at least minimal support from appropriate authorities such as ministries of health, school districts, or community organizations.
- If needed, implemented activities to recruit youth and overcome barriers to their involvement (e.g., publicized the program, offered food, or obtained consent).
- Implemented virtually all activities with reasonable fidelity.
This working paper demonstrates yet again, that pregnancy - and HIV/STD - prevention programs directed at young people do not increase sexual activity but can in fact, delay teens' initiation of intercourse, reduce the number of sexual partners teens have, and/or increase teens' use of condoms/contraception.
In the United States , the federal government supports abstinence-only-until-marriage programs by allocating over two hundred million dollars each year to states and community-based organizations providing these restrictive programs. Yet, to date, no research has found that these programs work to help young people avoid risk behavior or pregnancy and STDs.
In contrast, there are many programs that take a more comprehensive approach and include messages about abstinence as well as medically accurate and complete information about STD/HIV and pregnancy prevention. Such programs have proven to be an effective strategy in helping young people adopt healthy behaviors and attitudes that will enable them to avoid unwanted consequences and ultimately help them become sexually healthy adults.
It is SIECUS' hope that the recommendations and 17 characteristics set forth by this working paper be used as a standard in the future direction of legislation, education, and research both in the United States and abroad.
View the 45-page working paper Impact of Sex and HIV Education Programs on Sexual Behaviors of Youth in Developing and Developed Countries by Douglas Kirby, B.A. Laris, and Lori Rolleri, Youth Research Working Paper No. 2, published December 2005 released January 2006.
This information update was written by Amy Levine, M.A., SIECUS' Information Services Manager