Program

Nov 16, 2016

OVERVIEW

It’s Your Game: Keep it Real (IYG) is a school-based HIV-, STI-, and pregnancy-risk reduction and prevention program that targets 7th and 8th graders.  Through grade-specific curricula that utilize both group and individual components, the program encourages students to set limits on their personal risk behaviors, and to use refusal skills, while also providing information on puberty, safe sex, dating, STIs, HIV, and pregnancy. A parent-child homework component is also used at both grade levels to help encourage dialogue on relevant topics. An experimental evaluation found that the program was successful in reducing the proportion of participants who had initiated sex from 7th to 9th grade. The program also had significant impacts on initiation of oral and anal sex, as well as on selected psychosocial outcome measures (e.g., general beliefs about waiting to have sex, self-efficacy to use condoms).

A more recent version of the program is It’s Your Game-Tech (IYG-Tech), which is completely computerized. An evaluation of IYG-Tech did not find a significant difference between the intervention and standard state-approved sexual health education in delaying sexual behavior, but significant impacts on several psychosocial outcomes were found. The third and fourth studies report on two adaptations of the IYG curriculum: Risk Avoidance (RA), an abstinence-until-marriage program, and Risk Reduction (RR), focusing on abstinence-until-older. Many statistically significant positive impacts were found, including delaying sexual initiation, reducing the incidence unprotected sex at last intercourse, and delaying initiation of anal sex, as well as some psychosocial outcomes.

DESCRIPTION OF PROGRAM

Target Population: Middle school students

IYG consists of 24, 45-minute school-based sessions, 12 conducted in the 7th grade and 12 in the 8th grade.  At both grade levels, lessons utilize both group-based and individual activities, the latter including keeping a personal journal (to express opinions and feelings), and working through program material on laptop computers (educational activities on determinants of sexual risk-taking, specifically adapted to gender and sexual experience).  Classroom sessions teach students decision-making life skills that revolve around selecting personal limits for engaging in risky behaviors, detecting warning signs of situations that could challenge those limits, and protecting limits by utilizing refusal skills and other strategies (Select, Detect, Protect paradigm).  For the 7th-grade curriculum, topics covered include setting personal limits and practicing refusal skills for sexual behavior and in a general context (e.g., skipping school, cheating, drug and alcohol use); characteristics of healthy relationships; and information on puberty, sex, and STIs.  The 8th-grade curriculum includes the same topics, as well as the importance of STI, HIV, and pregnancy testing for sexually active individuals, training for contraceptive/condom use, and healthy dating relationships.  All lessons are conducted by trained facilitators. A separate parent-child homework component is also built into both the 7th- and 8th- grade versions of the program.  Activities are designed to initiate and encourage dialogue between parents and their children on topics that include sexual behavior, dating, and friendship qualities.

IYG-Tech consists of 13 lessons, approximately 35 to 45 minutes each, to be completed in eighth grade. It incorporates the same life skills paradigm that is used in the original IYG program, as well as components that cover characteristics of healthy and unhealthy friendships and dating relationships; anatomy and reproduction; social, emotional, and physical consequences of sex; communication skills; Internet communication and safety; consequences of teen pregnancy and STIs; knowledge and skills for condom and contraception use; and condom use negotiation.

The third and fourth studies evaluate a parallel Risk Avoidance (RA) program that emphasized abstinence, but was otherwise comparable to a Risk Reduction (RR) program in duration, delivery, and theoretical framework. The two programs are comparable in duration, delivery, and theoretical framework, but the RA program is framed to reinforce abstinence-until-marriage beliefs, whereas the the RR program emphasizes abstinence-until-older .  Both programs include medically accurate statements about condoms. Sexually experienced-seventh graders received tailored activities regarding condoms/contraception, and all eighth-graders received skill-based activities involving practicing steps for correct condom use, and an activity rating the advantages and limitations of different contraceptive methods.  The RA program also incorporated elements of character development and future orientation, while RR program elements promoted self-respect and responsibility, and included activities addressing knowledge and self-efficacy regarding condom and contraceptive use.

EVALUATION(S) OF PROGRAM

Study 1:

Tortolero, S.R., Markham, C.M., Peskin, M.F., Shegog, R., Addy, R.C., Escobar-Chaves, S.L., & Baumler, E.R. (2010).  It’s Your Game. Keep it Real: Delaying sexual behavior with an effective middle school program. Journal of Adolescent Health, 46(2), 1-19

Evaluated population: Participants consisted of 907 7th-grade students (average age = 13 years) from ten urban, low-income, middle schools in Texas.  Fifty-nine percent of the total sample was female; 42 percent of the sample was African American, and 44 percent was Hispanic.  The authors made an a priori decision to define the analysis sample as comprised of all students who took the 8th-grade survey.  These students were followed into more than 50 high schools to collect follow-up data.

Approach: The ten schools selected for the study were randomized into either the intervention (n=349 students) or control (n=558 students) conditions, at which point students were recruited.  Significant differences existed between groups at baseline: the control group included a significantly lower proportion of African American participants and a significantly higher proportion of participants whose race/ethnicity was neither African American or Hispanic; the mean age of participants in the intervention group was significantly older (by 0.1 years); and there were significant differences on psychosocial measures that assessed perceptions of friends’ beliefs about waiting to have sex, intentions to have oral sex within the next year, and reasons for not having sex.  Students assigned to the control condition continued to receive their regular health classes, which were school-specific. Seventh-grade surveys were completed by 1,193 students (91 percent of the baseline sample), and eighth-grade surveys were completed by 981 students (75 percent of the baseline sample).  This attrition reflects the high mobility and withdrawal rates in the school district.

To evaluate the program’s effectiveness, self-report data were collected from students, using audio-computer assisted interviews about their participation and initiation of sexual activity (oral, vaginal, anal), as well as on the following psychosocial outcomes: general beliefs about waiting to have sex; beliefs about abstinence until marriage; perceived friends’ beliefs about waiting to have sex; perceived friends’ sexual behavior; self-efficacy to refuse sex; condom knowledge; perceived friends’ beliefs about condoms; self-efficacy to use condoms; exposure to risky situations; knowledge  of STI signs/sex; HIV/STI knowledge; reasons to have sex; reasons not to have sex; intention to have oral sex in next year; intention to have vaginal sex in next year; intention to be abstinent through high school; and intention to remain abstinent until marriage.  Data were collected at baseline, and at the 9th-grade follow-up (approximately 24 months later).  Multi-level models were estimated, and controls were included for baseline measures of outcomes, as well as for confounding variables specific to each dependent variable.

Results: At the 9th-grade follow up, sexual initiation was assessed among participants who had reported having no sexual experience at the 7th-grade baseline; a significantly lower proportion of the intervention group reported initiating sex than in the control group (20 percent vs. 30 percent).  In looking at specific types of sex, the intervention group had significantly lower proportions initiating oral and anal sex.  There were no significant differences between conditions in initiation of vaginal sex.

Significant program differences were also found in the subgroup analyses.  On overall reports of initiating sex, significant positive impacts were found for Hispanics and females, but not for males and African Americans.  For initiation of oral sex, significant positive impacts were found for African Americans and females, and for initiation of anal sex, these impacts were found for African Americans, males, and females.  Hispanics were the only subgroup found to have a significant positive difference for initiation of vaginal sex.

Psychosocial outcomes for the intervention and control conditions were compared at both 8th– and 9th-grade levels.  At 8th grade, significant positive program impacts were found for beliefs about abstinence until marriage, perceived friends’ beliefs about waiting to have sex, self-efficacy to refuse sex, condom knowledge, self-efficacy to refuse condoms, exposure to risky situations, STI signs/sex knowledge, HIV/STI knowledge, reasons not to have sex, and intention to have oral sex within the next year.  At 9th grade, significant positive differences were found for beliefs about abstinence until marriage, perceived friends’ sexual behavior, condom knowledge, perceived friends’ beliefs about condoms, exposure to risky situations, knowledge of STI signs/sex, and HIV/STI knowledge.  No significant differences were found at either grade level for general beliefs about waiting to have sex, reasons to have sex, intention to have vaginal sex in the next year, or intention to remain abstinent until marriage.

Study 2:

Peskin, M. F., Shegog, R., Markham, C. M., Thiel, M., Baumler, E. R., Addy, R. C. Gabay, E.K., Emery, S. T. (2014). Efficacy of It’s Your Game-Tech: A Computer-Based Sexual Health Education Program for Middle School Youth. Journal of Adolescent Health56, 515–521.

Evaluated Population: Participants were English-speaking eighth-grade students from 19 large schools in an urban, southeast Texas district who were followed into ninth grade. The final analytic sample included 1,374 students, 59 percent of whom were female. At baseline the mean age of participants was 14.3 years. The sample was 74 percent Hispanic, 17 percent African American, and nine percent other race/ethnicity.

Approach: This study randomly assigned 10 schools to receive IYG-Tech and 10 schools to receive state-approved health education (usually from a textbook). After randomization, one intervention school was dropped due to changes in administration, resulting in 19 participating schools. At baseline in eighth grade, students completed self-interviews on the computer, and again one year later. The primary outcome measure was delayed initiation of any sexual activity (oral, vaginal, or anal sex) in ninth grade among students who were sexually inexperienced at baseline. Other outcomes assessed were psychosocial measures, such as knowledge of STIs and condom use, beliefs toward abstinence and condoms, beliefs about friends’ attitudes toward abstinence, perceived norms regarding peer sexual behavior, self-efficacy for refusing sex and using condoms, sexual intentions, and parental communication about sex, among others. Multilevel models were used to adjust for clustering within classes.

Results: There was no significant difference between the control and intervention groups in the delay of sexual behavior, but there were significant differences for psychosocial variables. At post-test in ninth grade, students in the intervention group reported greater knowledge about STIs and condoms, more positive beliefs about abstinence until marriage, and greater self-efficacy to use condoms, compared with students in the control group. They were also more likely to perceive their friends as having positive beliefs about abstinence, that most teens their age were not having sex, and that other teens who had had sex wished they had waited. However, no impacts were found for the other psychosocial variables examined, which were beliefs about abstinence, perceptions of friends behavior, reasons against having sex, refusal and condom negotiation self-efficacy, condom beliefs, global character, exposure to risky situations, parent communication, intentions to engage in sexual behaviors, and personal limits.

Study 3:

Markham, C. M., Tortolero, S. R., Peskin, M. F., Shegog, R., Thiel, M., Baumler, E. R., Addy, R. C., Escobar-Chaves, S. L., Reininger, B., Robin, L. (2012). Sexual risk avoidance and sexual risk reduction interventions for middle school youth:A randomized control study. Journal of Adolescent Health, 50(3), 279-288.

Evaluated population: Participants were students from fifteen middle schools, and were 78 percent economically disadvantaged, 60 percent female, 50 percent Hispanic, and 39 percent black.  The seventh-grade mean age was 12.6 years.

Approach: The fifteen participating schools were randomly assigned to Risk Avoidance (RA), Risk Reduction (RR), or control groups (five schools to each group) before the baseline assessment.  The two intervention programs are comparable in duration, delivery, and theoretical framework, but the RA program is framed to reinforce abstinence-until-marriage beliefs, while the RR program emphasizes abstinence-until-older beliefs.  Both programs include medically accurate statements about condoms.  RA activities targeted beliefs about the benefits of abstinence-until-marriage, and the benefits of marriage and parenting-within-marriage. The RA program also incorporated elements of character development and future orientation.  The RR program targeted beliefs about the benefits of abstinence-until-older, promoted self-respects and responsibility, and included activities addressing knowledge and self-efficacy regarding condom and contraceptive use.  Sexually experienced seventh-graders received tailored activities regarding condoms/contraception; all eighth-graders received activities practicing steps for correct condom use, and an activity rating the advantages and limitations of different contraceptive methods. Students in the control group received their regular health classes, which varied by school Students who agreed to participate turned in parental consent forms, completed the baseline survey (N = 1,742), and completed the ninth-grade surveys (N = 1,333) were eligible for the analysis (N = 1,258). Attrition was 23.5 percent. Students who were lost to follow-up were more likely to be male and sexually experienced at baseline, with no significant differences across study conditions. Data were collected using laptop computers at three time points: baseline, immediately after the eighth-grade intervention (16 months after baseline), and in ninth grade (26 months after baseline).                                

Results: All analyses compared one of the experimental groups to the control group.  The RR program had a statistically significant positive impact on delaying any kind of sexual initiation in the overall sample (Adjusted Odds Ratio [AOR] = 0.65), among females (AOR = 0.43), and among African-Americans (AOR = 0.38), compared with the control group. There were also statistically significant positive impacts on unprotected sex at last intercourse (AOR = 0.67), frequency of anal sex in last three months (AOR = 0.53), and unprotected vaginal sex (AOR = 0.59). The RA program had statistically significant positive impacts on any sexual initiation among Hispanics (AOR = 0.40), and unprotected sex at last intercourse (AOR = 0.70), but had a statistically significant negative impact on the number of recent vaginal sex partners.

Both programs had statistically significant positive impacts on some psychosocial outcomes. RA students had significantly greater HIV/STI knowledge; more positive beliefs about waiting to have sex and abstinence-until-marriage; perceived their friends as having more positive beliefs about waiting and engaging in less risky behavior; and reported more reasons for not having sex, fewer intentions to have vaginal sex in the next year, and greater intentions to remain abstinent through high school and until marriage, and to get tested for HIV/STI, relative to controls. Conversely, RA students had significantly lower condom knowledge. In ninth grade, RA students maintained significantly better scores on 5 of 23 outcomes (greater HIV/STI knowledge, more positive beliefs about abstinence-until-marriage and friends’ beliefs about waiting, more reasons for not having sex, and perceived parental beliefs about waiting to have sex). Additionally, RA students reported significantly greater condom -use self-efficacy and intentions, relative to controls. No outcomes were statistically significant in a negative direction.

Among RR students, immediately after the eighth-grade intervention, 10 of 23 psychosocial outcomes were statistically significant in a positive direction, 1 was significant in a negative

direction,  and 16 were non-significant, compared with outcomes in the control group. RR students had greater condom-use knowledge and refusal self-efficacy; reported more positive beliefs about abstinence-until-marriage, and more reasons for not having sex; perceived their friends to have more positive beliefs about waiting; reported greater intentions to remain abstinent through high school and until marriage

and to get tested for HIV/STI; and had greater parental communication about sexual topics and more positive character qualities, relative to controls. Conversely, RR students perceived their parents to have more permissive beliefs about sex. In ninth grade, RR students maintained significantly higher scores on 5 of 23 outcomes (greater condom use knowledge, more positive beliefs about abstinence-until-marriage, more reasons for not having sex, greater intentions to remain abstinent through high school and to get tested for HIV/STI). Additionally, RR students reported greater condom-use self-efficacy and intentions, relative to controls. No outcomes were statistically significant in a negative direction

Study 4:

Markham, C. M., Peskin, M. F., Shegog, R., Baumler, E. R., Addy, R. C., Thiel, M., Escobar-Chaves, S. L., Robin, L., Tortolero, S. R. (2014). Behavioral and psychosocial effects of two middle school sexual health education programs at tenth-grade follow-up. Journal of Adolescent Health, 54, 151-159.

Evaluated Population: Same as Study 2.

Approach: Tenth-grade surveys were completed by 1,233 students, with 29.2 percent attrition. Surveys from 46 students were excluded because of missing or inconsistent responses, leaving 1,187 surveys for analysis. Students who were lost to follow-up were more likely to be older, male, and sexually experienced at baseline.

Results: At the 10th-grade follow-up, both the RA and RR programs had a statistically significant positive impact for the entire sample on anal sex initiation (AOR = 0.64 and 0.65, respectively), and among Hispanics (AOR = 0.53 and 0.82, respectively). Students in the RA group were less likely to report unprotected vaginal sex, either by using a condom or by abstinence (AOR = 0.61). Students in the RR group were less likely to report recent unprotected anal sex (AOR = 0.34).

Both the RA and RR programs had sustained statistically significant positive impacts on some psychosocial outcomes. Among RA students, 8 of 22 psychosocial outcomes were statistically significant in a positive direction (greater HIV/STI knowledge; greater self-efficacy for sex refusal, condom-use, and condom-use negotiation; more positive beliefs about abstinence until marriage; more reasons for not having sex; more positive beliefs about condoms; and more frequent parent-child communication about sexual topics). Among RR students, 7 of 22 psychosocial outcomes were statistically significant in a positive direction (greater HIV/STI and general condom knowledge; greater self-efficacy for sex refusal; more positive beliefs about abstinence until marriage; more positive perceived parental beliefs about waiting to have sex; more frequent parent-child communication about sexual topics; and greater character qualities). One outcome was statistically significant in a negative direction: RR students reported greater intentions to engage in vaginal sex in the next year, compared with control students.

SOURCES FOR MORE INFORMATION

Web site:  https://sph.uth.edu/research/centers/chppr/iyg/

References

Markham, C. M., Peskin, M. F., Shegog, R., Baumler, E. R., Addy, R. C., Thiel, M., Escobar-Chaves, S. L., Robin, L., Tortolero, S. R. (2014). Behavioral and psychosocial effects of two middle school sexual health education programs at tenth-grade follow-up. Journal of Adolescent Helath, 54, 151-159.

Markham, C. M., Tortolero, S. R., Peskin, M.F., Shegog, R., Thiel, M., Baumler, E. R., Addy, R.C., Esocbar-Chaves, S.L., Reininger, B., Robin, L. (2012). Sexual risk avoidance and sexual risk reduction interventions for middle school youth: A randomized control study. Journal of Adolescent Health, 50(3), 279-288.

Peskin, M. F., Shegog, R., Markham, C. M., Thiel, M., Baumler, E. R., Addy, R. C. Gabay, E.K., Emery, S. T. (2014). Efficacy of It’s Your Game-Tech: A computer-based sexual health education program for middle school youth. Journal of Adolescent Health56, 515–521.

Tortolero, S. R., Markham, C.M., Peskin, M. F., Shegog, R., Addy, R. C., Escobar-Chaves, S. L., & Baumler, E. R. (2010). It’s Your Game. Keep it Real: Delaying sexual behavior with an effective middle school program. Journal of Adolescent Health, 46(2), 1-19

KEYWORDS: Adolescents, Middle School, Males and Females (Co-ed), Black/African American, Hispanic/Latino, Urban, School-Based, Parent or Family Component, Computer-Based, Skills Training, Abstinence Education, Social Skills/Life Skills, Teen Pregnancy, STD/HIV/AIDS, Sexual Activity, Condom Use and Contraception

Program information last updated  11/16/2016.

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