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Effects of the Seattle Social Development Project on Sexual Behavior, Pregnancy, Birth, and Sexually Transmitted Disease Outcomes by Age 21 Years
Heather S. Lonczak, PhD;
Robert D. Abbott, PhD;
J. David Hawkins, PhD;
Rick Kosterman, PhD;
Richard F. Catalano, PhD
Arch Pediatr Adolesc Med. 2002;156:438-447.
ABSTRACT
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Objective To examine the long-term effects of the full Seattle Social Development
Project intervention on sexual behavior and associated outcomes assessed at
age 21 years.
Design Nonrandomized controlled trial with long-term follow-up.
Setting Public elementary schools serving children from high-crime areas in
Seattle, Wash.
Participants Ninety-three percent of the fifth-grade students enrolled in either
the full-intervention or control group were successfully interviewed at age
21 years (n = 144 [full intervention] and n = 205 [control]).
Interventions In-service teacher training, parenting classes, and social competence
training for children.
Main Outcome Measures Self-report measures of all outcomes.
Results The full-intervention group reported significantly fewer sexual partners
and experienced a marginally reduced risk for initiating intercourse by age
21 years as compared with the control group. Among females, treatment group
status was associated with a significantly reduced likelihood of both becoming
pregnant and experiencing a birth by age 21 years. Among single individuals,
a significantly increased probability of condom use during last intercourse
was predicted by full-intervention group membership; a significant ethnic
group x intervention group interaction indicated that after controlling
for socioeconomic status, single African Americans were especially responsive
to the intervention in terms of this outcome. Finally, a significant treatment
x ethnic group interaction indicated that among African Americans, being
in the full-intervention group predicted a reduced probability of contracting
a sexually transmitted disease by age 21 years.
Conclusion A theory-based social development program that promotes academic success,
social competence, and bonding to school during the elementary grades can
prevent risky sexual practices and adverse health consequences in early adulthood.
INTRODUCTION
THE OFTEN devastating and life-changing implications of early sexual
activity underscore the importance of prevention-focused research. For several
decades, early pregnancy has maintained its standing as one of the United
States' most persistent and troublesome social problems. With more than 900 000
teenagers becoming pregnant each year,1 adolescent
pregnancy rates in the United States have continued to surpass those of almost
all other developed countries.2 Each year,
10% of American females aged 15 to 19 years will become pregnant, and roughly
half of them will give birth.3 Adolescent motherhood
has been associated with academic deficits,4-6
poor socioeconomic outcomes,7-8
repeat pregnancy,9-10 and single-parent
status.11-12
Sexually transmitted disease (STD) is another threat to the health and
well-being of American young people. Adolescents and adults younger than 25
years experience STD in far greater numbers than older adults. For example,
excluding human immunodeficiency virus (HIV), two thirds of the 12 million
cases of STD reported annually occur among individuals younger than 25 years.13 Among the negative consequences of STD are cancer,
ectopic pregnancy, perinatal infection, chronic pain, sterility, and death.14
Pregnancy and STD outcomes occur as a function of early intercourse
onset, multiple sexual partners, and lack of contraceptive use.15-17
Individuals who begin having intercourse at a young age are at an increased
risk for pregnancy and STD because they tend to have more sexual partners
and are less likely to use contraception.18-21
Additionally, given their relatively increased susceptibility to some pathogens,
females are particularly at risk for acquiring certain STDs.22
PREVENTION
While program evaluations have shown improved results in the past several
years (Kirby23 provides a comprehensive review),
there is still much work to be done in the prevention of risky sexual behavior.
Among the program types that have demonstrated effectiveness in reducing youth
sexual behavior–related adverse adverse outcomes are competency-promoting,
positive youth development programs.23 These
programs attempt to foster behavioral, social, emotional, and cognitive competency
to promote healthy adjustment in multiple settings. Examples of effective
positive youth development programs include the High/Scope Perry Preschool
Program24 (an enriched preschool program promoting
early prosocial development among high-risk children), the Quantum Opportunities
Program25 (which used financial incentives,
tutoring, mentoring, and other strategies to promote academic competence among
high school students), and Teen Outreach26
(which promoted prosocial norms, involvement, bonding and self-efficacy by
involving tenth graders in community-based volunteer activities and weekly
classroom discussions). Each of these programs resulted in significantly fewer
adolescent pregnancies among intervention group members as compared with controls,
despite the fact that none of them focused directly on sexual behavior. Additionally,
the Children's Aid Society Carrera Program27
took a broad approach to pregnancy prevention by including a work-related
component (eg, stipends), an educational component (eg, tutoring), family
life and sex education, and individual sports. Relative to a control group,
adolescent females who participated in this program experienced significant
reductions in pregnancies and births, were significantly less likely to have
initiated sex, and were significantly more likely to use contraception.27 This program demonstrates that a comprehensive prevention
approach targeting multiple domains of behavior can result in significant
reductions in adolescent sexual risk taking and its associated outcomes. Evaluations
have also identified the following as important components of effective pregnancy
prevention programs: a theoretical foundation,28-31
a reasonable treatment duration or dose,28
and the inclusion of youths who have not yet initiated sexual activity.32-33
Studies of the antecedents of sexual behavior outcomes can inform prevention
efforts by identifying targets for preventive interventions. For example,
analysis of the National Longitudinal Study of Adolescent Health reported
both parent/family bonding and school bonding to be associated with a delayed
sexual debut, and shared activities with parents to be associated with a reduced
risk of adolescent pregnancy.34 Other familial
factors associated with lower rates of risky sexual behavior include parental
monitoring and supervision, rule-setting about dating, and parent-child relationships
characterized by support and open communication.35-38
Additionally, peer norms have been found to affect the timing and nature of
adolescent sexual behavior.16, 39-41
Finally, academic failure has been found to be a strong predictor of risky
sexual behavior and teen pregnancy.28-29,42
Adolescents who do well in school and have relatively high educational aspirations
engage in less risky sexual behavior36 and
are less likely to become teen parents.31, 38, 43-45
Consequently, empowering families, addressing peer influences, and promoting
academic competence are important goals for prevention programs aimed at reducing
risky sexual behavior and its consequences among young people.
THE SEATTLE SOCIAL DEVELOPMENT PROJECT
The Seattle Social Development Project (SSDP) included an intervention
nested within a longitudinal panel study. The SSDP intervention was guided
by the social development model,46 a theory
of behavior that integrates elements of social control,47
social learning,48 and differential association
theories.49-50 The social development
model hypothesizes that families and schools that provide youths with opportunities
for active, contributing involvement; that ensure that youths develop competency
or skills for participation; and that consistently reinforce effort and skillful
participation in school and family, produce strong bonds between young people
and these social units. Following control theory, the social development model
hypothesizes that strong bonds to school and family protect youths against
socially unacceptable behaviors, including early sexual intercourse and unprotected
sexual behavior.
Based on the social development model,46, 51
the SSDP intervention sought to promote bonding to school and family by enhancing
opportunities and reinforcement for children's active involvement in family
and school, and by strengthening children's social competencies. The intervention
included the following 3 components: teacher training, child social and emotional
skill development, and parent training. These are described further in Table 1.
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Table 1. Seattle Social Development Project Interventions
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Each year during the elementary grades (grades 1 through 6), teachers
in the intervention classrooms received 5 days of in-service training in a
package of instructional methods52 with 3 major
components: proactive classroom management,53
interactive teaching,54 and cooperative learning.55 Teachers of control students did not receive training
in instructional or classroom management skills from the project. Both intervention
and control teachers were observed for 50 minutes on 2 different days during
fall and spring each year using the Interactive Teaching Map.56-57
This structured observation system provides assessment of the degree to which
teachers are using the proactive classroom management, interactive teaching,
and cooperative learning methods outlined in Table 1. These controlled observations indicated greater use of
the targeted instructional and management methods in the intervention classrooms
than in the control classrooms. Effects of implementation of the projects'
instructional methods on students' social development and achievement, and
mediators of the sexual behavior–related outcomes investigated here,
have been reported elsewhere.58
Second, prior to the school year, first-grade teachers in the full-intervention
group received instruction in the use of a cognitive and social skills training
curriculum, Interpersonal Cognitive Problem Solving,59-60
which teaches children the skills to identify a problem, generate alternative
solutions, and choose and implement the chosen solution. This curriculum sought
to develop children's skills for involvement in cooperative learning groups
and other social activities, without resorting to aggressive or other problem
behaviors. Additionally, during grade 6, a study consultant provided students
in the full-intervention group with 4 hours of training in skills to recognize
and resist social influences to engage in problem behaviors and to develop
positive alternatives to stay out of trouble while maintaining friendships.61 Children in the intervention group, therefore, received
child social and emotional skills training during grades 1 and 6, and teacher
interventions during all grades from 1 through 6.
Third, parent training was offered on a voluntary basis to the parents
or adult caretakers of children in intervention classrooms. Child behavior
management skills training was offered when children were in the first and
second grades through a 7-session curriculum, "Catch ‘Em Being Good,"62 grounded in the work of Patterson et al.63 In the spring of second grade and again in the third
grade, parents were offered a 4-session curriculum, "How to Help Your Child
Succeed in School,"64 to strengthen their skills
for supporting their children's academic development. During grades 5 and
6, parents were offered a 5-session curriculum "Preparing for the Drug (Free)
Years,"65 designed to strengthen their skills
to reduce their children's risks for drug use. Parents of 43% of children
in the full-intervention group attended parenting classes. Overall, children
in the full-intervention group received the SSDP intervention for at least
one semester in grade 1, 2, 3, or 4, and for at least one semester in grade
5 or 6; thus participating in the intervention in both early and late elementary
grades.
In summary, the intervention was focused on enhancing the socialization
processes specified by the social development model during grades 1 through
6. No content specific to sexual behavior was provided. The full intervention,
delivered in grades 1 through 6, has demonstrated effects in significantly
reducing sexual behavior at age 18 years.66
This article examines the effects of the full SSDP intervention on sexual
behavior (age of sexual onset, condom use, and sexual partners), pregnancy,
birth, and STD outcomes at age 21 years.
PARTICIPANTS AND METHODS
DESIGN AND DATA COLLECTION
The study of intervention effects is part of a longitudinal panel study
of all consenting fifth-grade students (n = 808) in 18 public schools serving
high-crime areas of Seattle, Wash. All schools contacted by SSDP staff chose
to participate in the study. In 1981, an intervention was initiated among
first-grade students in 8 public schools, and in 1985, when these children
entered fifth grade, the study was expanded to include fifth-grade students
in 10 additional schools. Schools were assigned nonrandomly to conditions
in the fall of 1985, and thereafter, all fifth-grade students in each school
participated in the same interventions. New schools added for the panel study
were matched to the intervention schools with respect to grades served and
inclusion of students drawn from high-crime neighborhoods. Schools added for
the panel study were assigned to conditions to achieve balanced numbers across
conditions. This resulted in a nonrandomized controlled trial with 4 conditions.
The full-intervention group (n = 156) received the intervention described
earlier from grades 1 through 6 if they remained in intervention schools,
with an average dose of 3 years. The late intervention group (n = 267) received
the intervention during grades 5 and 6 only and is not discussed in this article
because no significant effects of the late intervention on sexual behavior
outcomes were found at age 18 years. The "parent training only" group (n =
141) was offered only the "Preparing for the Drug (Free) Years" curriculum
during grades 5 and 6 and is not discussed in this article. The control group
(n = 220) received no intervention. (There was also a small group of individuals
who could not be classified into any of these groups [n = 24]). In sum, parents
of 76% of fifth-grade students (N = 808) in 18 Seattle public schools consented
to participate in the longitudinal follow-up study; this group constitutes
the SSDP sample. Of those 808, 376 were assigned to the full-intervention
and control groups discussed in the present article. At age 21 years, 349
of those 376 were successfully interviewed and constitute the sample analyzed
here.
Research staff interviewed participants in the spring of 1996 when respondents
were age 21 years. Due to item sensitivity, the sex questionnaire was completed
as a separate paper-and-pencil instrument and placed in a sealed envelope
by the respondent. All phases of the study were approved by the Human Subjects
Review Committee at the University of Washington. Participants were informed
about the nature of the interviews and provided consent prior to participation
in the study at age 21 years.
SAMPLE
Because an earlier study66 found significant
effects on sexual behavior outcomes at age 18 years only for the full-intervention
group, this article compares only the full-intervention group with the control
group to test the durability of these findings in early adulthood. Of the
376 youths in these 2 conditions, 27 were not interviewed at age 21 years.
This resulted in a sample size of 349, with 144 participants from the full-intervention
group and 205 from the control group.
INTERNAL VALIDITY
The SSDP has had consistently high sample-retention rates, with 93%
of individuals in the full-intervention group and control group successfully
interviewed at age 21 years. Prior analyses of these groups66
found no significant differences in gender distribution, race distribution
(white vs nonwhite), poverty (free lunch eligibility during grades 5, 6, or
7), proportion from single-parent homes (during grade 5), mean years of parents'
education (during grade 5), mean years living in Seattle (by grade 6), or
mean number of residences lived in (from age 5 to 14 years) between the full-intervention
group and the control group. Hawkins et al66
found no significant attrition effects or differences in treatment group distribution
at age 18 years by gender, race, or poverty. Analyses of possible effects
of attrition on the internal validity of results at age 21 years were conducted
on the following variables: gender, race or ethnicity (white vs nonwhite),
poverty (free lunch eligibility), family size (a continuous measure of the
number of people currently living in the home), mother's educational level
(a continuous measure of mother's highest level of completed schooling), church
attendance (an ordinal measure of yearly church attendance frequency), and
age at the survey. These analyses (Table
2) found no significant differences in the distribution into treatment
groups among those retained in the 21-year-old sample for any of the variables
examined.
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Table 2. Analyses of Attrition and Intervention Group Distribution
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MEASURES
Participants' sexual activity was assessed at the age-21 survey by the
following question: "Have you ever had sex with another person?" As defined
in the sex questionnaire instructions, the terms "sex" and "sexual intercourse"
refer to oral, vaginal, and anal sex. The 2 dichotomous measures of condom
use were assessed by the following questions: "The first time you had sexual
intercourse did you use latex protection such as condoms or gloves?" and "The
last time you had sexual intercourse did you use latex protection such as
condoms or gloves?" Past-year condom use was measured by the following question:
"In the past year, how much of the time was latex protection used when you
had sexual intercourse?" Response choices were as follows: "none of the time
= 1," "less than half of the time = 2," "about half of the time = 3," "most
of the time = 4," and "always = 5." Note that because condom use outcomes
pertain only to individuals who had had sex by age 21 years, sample sizes
are smaller for these variables. Further, aside from the "condom use during
first intercourse" measure, condom-use outcomes include only individuals who
were single (neither married nor living with a partner) at age 21 years. The
relative lack of monogamy among single individuals places this group at greater
risk for engaging in risky sexual behavior and, therefore, experiencing or
causing an unplanned pregnancy or an STD. Further, because single and nonsingle
individuals might have distinct motivations for condom-use or nonuse (eg,
lack of condom use among nonsingle people might be due to the desire to get
pregnant), combining these groups is inappropriate. Thus, samples for these
condom-use measures are smaller because they are limited to single people.
Age of sexual onset was assessed by the following open-ended question: "How
old were you the first time you had sex?" Four individuals reported their
ages at sexual intercourse as before the age of 9 years; they were excluded
from analyses examining age of sexual debut for 2 reasons. First, persons
younger than 9 years would have received only a portion of the intervention
prior to initiating sex; and second, such early ages at sexual intercourse
may represent nonconsensual intercourse. Sexual partners were assessed by
the following question: "How many sexual partners have you had in your lifetime?"
Response choices were as follows: 0, 1, 2, 3, 4, 5, or 6 or more. Finally,
the dichotomous measures of STD, pregnancy, and birth were as follows, respectively:
"Have you ever been told by a nurse or doctor that you had a sexually transmitted
disease (STD or VD [venereal disease], other than HIV/AIDS [human immunodeficiency
virus/acquired immunodeficiency virus]), such as gonorrhea, genital warts,
chlamydia, trich, herpes, or syphilis?"; "Have you ever been pregnant?" (females)
or "Have you ever gotten a woman pregnant?" (males); and "Have you ever had
a baby?" (females) or "Have you ever fathered a baby?" (males).
ANALYSIS
To evaluate the intervention, logistic regression was used to examine
dichotomous outcomes, linear regression was used to examine continuous outcomes,
and survival analysis was used to evaluate effects on age of sexual onset.
Each model was first run to examine whether, with poverty statistically controlled,
there were interaction effects between treatment group, and African American
ethnic group vs all remaining ethnic groups combined. Poverty was measured
by school record data indicating whether or not study children participated
in the federal free or reduced school lunch program in the fifth, sixth, or
seventh grades. African Americans were compared with other ethnic groups because,
without intervention, African American young people have been reported as
having disproportionately high rates of sexual activity,67-69
pregnancies and births,1, 67 and
STD1, 17, 70 relative
to other ethnic groups. For example, African American males have been reported
as 9 times more likely than white males to have initiated sexual intercourse
by age 13 years.71 Interaction terms were also
tested for treatment group x gender. Because they represent distinct
outcomes for males and females, pregnancy and birth outcomes were analyzed
separately by gender. Finally, to provide a more powerful test of the effect
of treatment on age of sexual debut, age of sexual onset was examined using
Cox regression analysis.
RESULTS
DESCRIPTIVE STATISTICS
Demographics
Of the 349 full-intervention and control participants with data at age
21 years, 179 participants (51%) were males and 170 participants (49%) were
females. The mean age of participants at the time of the fifth-grade survey
(fall 1985) was 10.8 years. At the time of the age-21 survey, participants'
ages averaged 21.3 years. The distribution by ethnic groups was as follows:
white, 163 participants (47%); African American, 89 participants (26%); Asian
American, 74 participants (21%); and other ethnic groups, 23 participants
(7%). Fifty-five percent of the sample had experienced poverty, as indicated
by eligibility for the federal free lunch program between the fifth and seventh
grades. Marital status at the time of the age-21 interview was as follows:
single, 260 participants (75%); married, 31 participants (9%); living with
partner, 52 participants (15%); and separated/divorced, 6 participants (2%).
Sexual Activity and Age at Onset
Ninety-three percent of the sample were sexually active by the age-21
assessment. Males reported a significantly earlier mean age at sexual onset
than did females (15.7 years vs 16.3 years, respectively; P<.05). Controlling for poverty, age at sexual initiation also varied
significantly (P<.001) by ethnic group, with African
Americans reporting the earliest mean age at sexual debut (15.1 years) and
Asian Americans reporting the latest (16.8 years). Mean age at sexual initiation
for white participants was 16.0 years, and for those in other ethnic groups,
it was 16.1 years.
Condom Use
Among the 317 individuals who were sexually active by age 21 years,
67% used condoms the first time they had sex. Females were significantly more
likely to report condom use than were males (74% vs 59%, respectively; P<.01). There were no significant differences in condom
use frequencies during first intercourse across ethnic groups. Among the 240
single individuals who were sexually active by age 21 years, 49% used condoms
during their last intercourse experience. There were no significant associations
between condom use during last sexual intercourse and either gender or ethnicity.
Frequency of condom use varied among the 223 currently sexually active,
single individuals in the sample. Thirty-one percent reported using latex
protection "most of the time" during the past year. There were no significant
differences in past-year condom use across gender or ethnicity.
Sexual Partners
Thirty-eight percent of the sample reported having 6 or more lifetime
sexual partners. The average number of sexual partners reported was 3.9. Males
reported significantly more sexual partners than did females (mean number
of partners, 4.14 and 3.68, respectively; P<.05).
Controlling for poverty, differences in the mean number of sexual partners
varied significantly by ethnic group (P<.001).
African Americans reported the highest mean number of sexual partners (4.5
partners), followed by white participants (4.1 partners), those in the other
ethnic groups (3.8 partners), and finally Asian Americans (2.8 partners).
Pregnancy, Birth, and Sexually Transmitted Disease
Experiencing a pregnancy was common in this sample (n = 349), with 41%
reporting having experienced or caused a pregnancy by the age-21 survey. Females
were significantly more likely than males to report having experienced or
caused a pregnancy (48% vs 35%, respectively; P<.05).
Twenty-six percent of the total sample reported experiencing or causing a
birth by age 21 years. Females were significantly more likely to report a
birth than males (33% vs 20%, respectively; P<.01).
Both of these gender differences are likely to be influenced by the relatively
greater certainty of females vs males regarding whether pregnancy or birth
outcomes have occurred. Fifteen percent of the sample reported having been
diagnosed with STD during their lifetimes. Females were significantly more
likely than males to report a STD diagnosis (21% vs 10%, respectively; P<.01).
TESTS OF INTERVENTION EFFECTS
Multiple imputation72-73
was used to estimate parameters. Multiple imputation represents an advancement
over standard missing data strategies such as listwise and pairwise deletion,
which have been shown to systematically underestimate means, variances, and
covariances, and thus to produce biased results.74
In contrast, multiple imputation techniques have been found to produce maximally
unbiased parameter estimates.73 The NORM multiple
imputation program75 was used for imputing
data. This program has been shown to impute unbiased estimates for both continuous
and dichotomous variables.73, 75
There was a minimal amount of missing data overall, with only 7% of
the 5584 data points missing. Three imputed data sets were created for the
present analyses. As shown by Rubin,72 3 imputations
will produce valid inferences in a data set in which data missing for any
variable does not exceed 20%. Condition effect analyses were performed separately
with each of the 3 data sets. Resulting unstandardized ß coefficients
and standard errors were entered back into the NORM program,75
which computed the average of the regression coefficients and the overall
standard errors.
REGRESSION RESULTS
Means by treatment group for each continuous outcome are displayed in Table 3.
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Table 3. Continuous Outcomes by Intervention Group*
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Age at First Sexual Experience
As shown in Table 3, on
average, those in the full-intervention group had their first sexual experience
significantly later (age 16.3 years) than those in the control group (age
15.8 years, P<.05). Using survival analysis to
examine this outcome, each person was coded as a "1" (if they initiated intercourse)
or a "0" (if they did not initiate intercourse) at each age between 9 and
22 years. There were 26 right-censored participants who did not initiate intercourse
by the age-21 survey. Because the Cox proportional hazards model assumes that
the effect of predictors on hazards is proportional over time (Statistical
Product and Service Solutions 7.0; SPSS Inc, Chicago, Ill), the question of
nonproportional hazards was first examined by creating a timextreatment
group interaction variable and testing its significance. The interaction was
not significant (P = .21), indicating that the hazard
function for the treatment groups was proportional over time. The Cox proportional
hazard was marginally significant (P<.10), suggesting
that the full intervention produced a marginally significant effect in reducing
the overall relative risk for engaging in sexual intercourse for the first
time before age 21 years. As shown in Figure
1, the control group had a higher hazard or cumulative risk for
initiating intercourse than the full-intervention group.
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Figure 1. Cumulative hazard rate for age
at first sexual intercourse by intervention group (N = 337). Differences are
statistically significant at P<.10. The nonimputed
data set was used for figure construction, resulting in a sample size of 337.
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Condom Use
There was not a significant main effect of the full intervention on
past-year condom-use frequency among single individuals at age 21 years. However,
after controlling for poverty, the intervention by ethnic group interaction
effect for this outcome was statistically significant (P<.05). The difference in condom use frequency between the full-intervention
group and the control group was significantly greater for single African Americans
than for single non–African Americans. For example, 50% of single African
Americans in the full-intervention group reported always using a condom, compared
with 12% of single African Americans in the control group—a difference
of 38%. Among single non–African Americans, the difference in prevalence
across intervention groups was only 9%.
Sexual Partners
On average, those in the full-intervention group reported significantly
fewer sexual partners in their lifetimes than did those in the control group
(P<.05). As Figure
2 illustrates, the difference between the full-intervention group
and control group was especially pronounced for those reporting the greatest
number of partners, with 43% of the control group reporting 6 or more partners
compared with only 32% of the full-intervention group.
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Figure 2. Percentage of full-intervention
and control groups reporting lifetime sexual partners.
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With regard to dichotomous outcomes, Table 4 shows the prevalences of condom use at first and last intercourse
in addition to lifetime STD for the full-intervention and control groups.
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Table 4. Prevalence of Condom Use and STD Outcomes by Intervention
Group*
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Condom Use
There was not a significant main effect of intervention on condom use
during first intercourse. However, those in the full-intervention group were
significantly more likely to report condom use during last intercourse than
those in the control group. Sixty percent of those in the full-intervention
group used condoms during last intercourse, compared with 44% of those in
the control group. After controlling for poverty, the treatment x ethnic
group interaction was significant for condom use during last intercourse (P<.05; odds ratio, 5.84), indicating that the difference
in last condom use between the full-intervention group and the control group
was significantly greater for single African Americans than for single non–African
Americans. More specifically, 79% of African Americans in the full-treatment
group reported using a condom during last intercourse, compared with 36% of
African Americans in the control group. Among non–African Americans,
56% of those in the full-treatment group reported using a condom during last
intercourse, compared with 47% of those in the control group.
STD Diagnosis
There was not a significant main effect of treatment group on STD diagnosis.
However, after controlling for poverty, the ethnic groupxtreatment group
interaction was significant for this outcome (P<.01;
odds ratio, 0.11). Among African Americans, only 7% of those in the full-intervention
group, compared with 34% of those in the control group, reported being diagnosed
with a STD over their lifetimes. Among non–African Americans, 14% of
those in the full-intervention group reported a STD diagnosis, compared with
11% of those in the control group. Therefore, the difference between the full-intervention
group and the control group was 27% for African Americans, but only 3% for
non–African Americans.
Pregnancy and Birth
Table 5 displays the proportion
of females in each group reporting pregnancies and births and the proportion
of males in each group reporting having caused pregnancies or births by age
21 years. Females in the full-intervention group were significantly less likely
both to become pregnant (P<.05) and to have a
baby (P<.05) by age 21 years than were females
in the control group. Fifty-six percent of the control females compared with
38% of the females in the full-intervention group had been pregnant by age
21 years, and 40% of the control females had given birth compared with only
23% of the females in the full-intervention group. In contrast, as presented
in Table 5, the proportion of
males in each group who reported causing a pregnancy or birth did not differ
significantly.
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Table 5. Prevalence of Lifetime Pregnancy and Birth Outcomes for Females
and Males by Intervention Group*
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COMMENT
These analyses provide evidence that a theory-based intervention that
promoted improved classroom management and instruction, children's social
competence, and parenting practices during the elementary grades, can reduce
potentially dangerous sexual behaviors and their outcomes among young people.
By age 21 years, those in the SSDP full-intervention group reported significantly
fewer lifetime sexual partners. Significantly more single people in the full-intervention
group reported condom use during last intercourse than did those in the control
group. The delay in age of sexual onset by half a year for those in the full-treatment
group is also a notable finding.
After controlling for socioeconomic status, important treatment x
ethnic group interaction effects were also found. Perhaps most striking is
the decreased probability of contracting an STD by age 21 years among African
Americans in the full-intervention group. A greater proportion of single African
Americans in the full-intervention group also reported protecting themselves
from STD through the use of condoms at last intercourse, suggesting that greater
use of condoms may be the mechanism producing this reduction in STD among
African Americans.
It is also noteworthy that significantly fewer females in the full-intervention
group than in the control group had been pregnant and had given birth by age
21 years, though the proportions of males in each group who reported causing
pregnancy or birth did not differ. The absence of effects on these outcomes
for males may reflect a relative lack of knowledge pertaining to these outcomes.
However, these gender differences in intervention effects may also reflect
unique responses to the intervention itself. Females may have more to lose
from becoming pregnant and having children early in life. (There is some evidence,
for example, that teen fatherhood is less detrimental than teen motherhood
in terms of future occupational success).76
Therefore, while the intervention may have enhanced the commitment of both
males and females in the full-intervention group to healthy and prosocial
lifestyles, for females, avoiding pregnancies and births may be a more important
step toward ensuring the realization of such aspirations.
Despite the scope of the problem, a limited number of prevention programs
have shown significant and meaningful effects on sexual behavior and STD outcomes.23, 28 The present SSDP intervention is
quite different from many of the interventions that have previously been studied
for effects on such outcomes. SSDP included no sex education. In fact, it
involved no discussion of sex at all. These results support social developmental
hypotheses regarding the importance of providing children with opportunities
for active involvement in the classroom and family; recognition for participation
in these social units; and the social, emotional, and cognitive skills to
effectively participate in school and family during the elementary grades.
Previously reported findings support the hypotheses that teachers who
use better classroom management and instructional practices when children
are in the elementary grades strengthen children's bonds of attachment and
commitment to school.58 The present results
are consistent with the hypothesis that strengthening children's bonds to
prosocial participation will have wide-ranging effects in reducing health-compromising
behaviors.66 The present results indicate that
enhancing social development in the elementary school period can reduce risky
sexual behavior through age 21 years and can be of particular benefit for
2 groups who may be especially at risk for being harmed by those behaviors:
females and African Americans.
Significant effects were observed for multiple behaviors many years
after the completion of the intervention. These results suggest the importance
of social developmental mechanisms in affecting subsequent sexual behavior
among youth and young adults. They support the promotion of academic success,
social competence, and social bonding as important for the prevention of risky
sexual behavior and its consequences.
| What This Study Adds
Despite public concern regarding adolescent pregnancy and STD, there
is a paucity of well-evaluated prevention programs effective in preventing
risky sexual behavior. Although existing evaluations have generated mixed
findings, they have identified important components of effective programs,
including a theoretical foundation, a reasonable treatment duration or dose,
and the inclusion of youths who have not yet initiated sexual activity. In
line with these criteria, SSDP included a 6-year intervention with youth in
the elementary grades. Guided theoretically by the social development model,
the SSDP intervention sought to promote bonding to school and family by enhancing
opportunities and reinforcement for active involvement of children in family
and school, and by strengthening children's social competencies. This evaluation
shows that the SSDP intervention had long-term effects in preventing risky
sexual practices and adverse health consequences in early adulthood. It is
particularly noteworthy that these effects were achieved despite the fact
that the SSDP intervention included no sex education and involved no discussion
of sex at all.
|
|
AUTHOR INFORMATION
Accepted for publication January 28, 2002.
This research was supported by research grants from the National Institute
on Drug Abuse (1RO1DA09679) and the Robert Wood Johnson Foundation. Points
of view are those of the authors and are not the official positions of the
funding agencies.
We thank David P. Farrington, PhD, for his comments on drafts of the
manuscript.
Corresponding author and reprints: J. David Hawkins, PhD, Social
Development Research Group, 9725 3rd Ave NE, Suite 401, Seattle, WA 98115
(e-mail: jdh{at}u.washington.edu).
From the Schools of Social Work (Dr Lonczak) and Educational Psychology
(Dr Abbott), and the Social Development Research Group (Drs Hawkins, Kosterman,
and Catalano), University of Washington, Seattle.
REFERENCES
| |
1. National Center for Health Statistics. Health, United States, 2000: With Adolescent Health
Chartbook. Hyattsville, Md: Author; 2000.
2. Singh S, Darroch JE. Adolescent pregnancy and childbearing: levels and trends in developed
countries. Fam Plann Perspect. 2000;32:14-23.
FULL TEXT
|
ISI
| PUBMED
3. Henshaw SK. US Teenage Pregnancy Statistics: With Comparative
Statistics for Women Aged 20-24. New York, NY: Alan Guttmacher Institute; 1999.
4. Haggstrom GW, Kanouse DE, Morrison PA. Accounting for the educational shortfalls of mothers. J Marriage Fam. 1986;48:175-186.
FULL TEXT
5. Hotz VJ, McElroy SW, Sanders SG. The impacts of teenage childbearing on the mothers and the consequences
of those impacts for government. In: Maynard RA, ed. Kids Having Kids: Economic
Costs and Social Consequences of Teen Pregnancy. Washington, DC: The
Urban Institute Press; 1996:55-96.
6. Klepinger DH, Lundberg S, Plotnick RD. Adolescent fertility and the educational attainment of young women. Fam Plann Perspect. 1995;27:23-28.
FULL TEXT
|
ISI
| PUBMED
7. Grogger J, Bronars S. The socioeconomic consequences of teenage childbearing: findings from
a national experiment. Fam Plann Perspect. 1993;25:156-161.
FULL TEXT
|
ISI
| PUBMED
8. Teti DM, Lamb ME. Socioeconomic and marital outcomes of adolescent marriage, adolescent
childbirth, and their co-occurrence. J Marriage Fam. 1989;51:203-212.
9. Hofferth SL. Factors influencing initiation of sexual intercourse. In: Hofferth SL, Hayes CD, eds. Risking the Future:
Adolescent Sexuality, Pregnancy, and Childbearing. Washington, DC:
National Academy Press; 1987:7-35.
10. Mott FL. The pace of repeated childbearing among young American mothers. Fam Plann Perspect. 1986;18:5-12.
FULL TEXT
|
ISI
| PUBMED
11. Bennett NG, Bloom DE, Miller CK. The influence of nonmarital childbearing on the formation of first
marriages. Demography. 1995;32:47-62.
ISI
| PUBMED
12. Furstenberg FF Jr, Brooks Gunn J, Morgan SP. Adolescent Mothers in Later Life. New York, NY: Cambridge University Press; 1987.
13. National Center for HIV STD and TB Prevention. Young People at Risk: HIV/AIDS Among America's Youth. Atlanta, Ga: Centers for Disease Control and Prevention; 2000.
14. Santelli JS, Beilenson P. Risk factors for adolescent sexual behavior, fertility, and sexually
transmitted diseases. J Sch Health. 1992;62:271-279.
ISI
| PUBMED
15. Hayes CD. Adolescent pregnancy and childbearing: an emerging research focus. In: Hofferth SL, Hayes CD, eds. Risking the Future:
Adolescent Sexuality, Pregnancy, and Childbearing. Washington, DC:
National Academy Press; 1987:1-6.
16. Millstein SG, Moscicki AB. Sexually-transmitted disease in female adolescents: effects of psychosocial
factors and high risk behaviors. J Adolesc Health. 1995;17:83-90.
FULL TEXT
|
ISI
| PUBMED
17. Tanfer K, Cubbins LA, Brewster KL. Determinants of contraceptive choice among single women in the United
States. Fam Plann Perspect. 1992;24:155-161.
FULL TEXT
|
ISI
| PUBMED
18. Division of STD Prevention. Sexually Transmitted Disease Surveillance, 1999. Atlanta, Ga: Dept of Health and Human Services, Centers for Disease
Control and Prevention; 2000.
19. Koyle PF, Jensen LC, Olsen J, Cundick B. Comparison of sexual behaviors among adolescents having an early, middle,
and late first intercourse experience. Youth Society. 1989;20:461-467.
FULL TEXT
|
ISI
20. Zelnick M, Kanter JF, Ford K. Sex and Pregnancy in Adolescence. Beverly Hills, Calif: Sage Publications; 1981.
21. Zelnik M, Shah FK. First intercourse among young Americans. Fam Plann Perspect. 1983;15:64-70.
FULL TEXT
|
ISI
| PUBMED
22. Tanfer K, Cubbins LA, Billy JOG. Gender, race, class and self-reported sexually transmitted disease
incidence. Fam Plann Perspect. 1995;27:196-202.
FULL TEXT
|
ISI
| PUBMED
23. Kirby D. Emerging answers: research findings on programs to reduce teen pregnancy
(summary). Washington, DC: National Campaign to Prevent Teen Pregnancy; 2001.
Available at:
https://www.teenpregnancy.org/product/pdf/emergingSumm.pdf.
Accessed March 15, 2002.
24. Schweinhart LJ, Berrueta-Clement JR, Barnett WS, Epstein AS, Weikart DP. Effects of the Perry Preschool Program on youths through age 19: a
summary. Top Early Child Special Educ Q. 1985;5:26-35.
25. Hahn A, Leavitt T, Aaron P. Evaluation of the Quantum Opportunities Program (QOP):
Did the Program Work? A Report on the Post Secondary Outcomes and Cost-effectiveness
of the QOP Program (1989-1993). Waltham, Mass: Brandeis University Heller Graduate School Center
for Human Resources; 1994.
26. Allen JP, Philliber S, Herrling S, Kuperminc GP. Preventing teen pregnancy and academic failure: experimental evaluation
of a developmentally based approach. Child Dev. 1997;68:729-742.
FULL TEXT
|
ISI
27. Philliber S, Kaye JW, Herrling S, West E. Preventing Teen Pregnancy: An Evaluation of the Children's
Aid Society Carrerra Program. Atlanta, Ga: Philliber Research Associates; 2000.
28. Kirby D. No Easy Answers: Research Findings on Programs to
Reduce Teen Pregnancy (research review). Washington, DC: The National Campaign to Prevent Teen Pregnancy,
Task Force on Effective Programs and Research; 1997.
29. Moore KA, Sugland BW, Blumenthal C, Glei D, Snyder N. Adolescent Pregnancy Prevention Programs: Interventions
and Evaluations. Washington, DC: Child Trends Inc; 1995.
30. Kirby D, Short L, Collins J, et al. School-based programs to reduce sexual risk behaviors: a review of
effectiveness. Public Health Rep. 1994;109:339-360.
ISI
| PUBMED
31. Moore KA, Miller BC, Glei D, Morison DR. Adolescent Sex, Contraception, and Childbearing:
A Review of Recent Research. Washington, DC: Child Trends Inc; 1995.
32. Frost JJ, Forrest JD. Understanding the impact of effective teenage pregnancy prevention
programs. Fam Plann Perspect. 1995;27:188-195.
FULL TEXT
|
ISI
| PUBMED
33. Philliber S, Namerow P. Trying to Maximize the Odds: Using What We Know to
Prevent Teen Pregnancy. Atlanta, Ga: Philliber Research Associates; 1995.
34. Resnick MD, Bearman PS, Blum RW, et al. Protecting adolescents from harm: findings from the National Longitudinal
Study on Adolescent Health. JAMA. 1997;278:823-832.
FREE FULL TEXT
35. Ensminger ME. Sexual activity and problem behaviors among Black, urban adolescents. Child Dev. 1990;61:2032-2046.
FULL TEXT
|
ISI
| PUBMED
36. Hogan DP, Kitagawa EM. The impact of social status, family structure, and neighborhood on
the fertility of Black adolescents. Am J Sociol. 1985;90:825-855.
FULL TEXT
37. Inazu JK, Fox GL. Maternal influences on the sexual behavior of teenage daughters. J Fam Issues. 1980;1:81-103.
38. Luster T, Small SA. Factors associated with sexual risk-taking behaviors among adolescents. J Marriage Fam. 1994;53:622-632.
39. Billy JO, Udry JR. Patterns of adolescent friendship and effects on sexual behavior. Soc Psychol Q. 1985;48:27-41.
FULL TEXT
|
ISI
40. Billy JO, Udry JR. The influence of male and female best friends on adolescent sexual
behavior. Adolescence. 1985;20:21-32.
ISI
| PUBMED
41. Gillmore MR, Lewis SM, Lohr MJ, Spencer MS, White RD. Repeat pregnancies among adolescent mothers. J Marriage Fam. 1997;59:536-550.
FULL TEXT
|
ISI
42. Hofferth SL, Hayes CD. Risking the Future: Adolescent Sexuality, Pregnancy,
and Childbearing. Washington, DC: National Academy Press; 1987.
43. Hanson SL, Myers DE, Ginsburg AL. The role of responsibility and knowledge in reducing teenage out-of-wedlock
childbearing. J Marr Fam. 1987;49:241-256.
FULL TEXT
|
ISI
44. Jessor R, Costa F, Jessor L, Donovan JE. Time of first intercourse: a prospective study. J Pers Soc Psychol. 1983;44:608-626.
FULL TEXT
|
ISI
45. Marini MM. Women's educational attainment and the timing of entry into parenthood. Am Social Rev. 1984;49:491-511.
FULL TEXT
46. Catalano RF, Hawkins JD. The social development model: a theory of antisocial behavior. In: Hawkins JD, ed. Delinquency and Crime: Current
Theories. New York, NY: Cambridge University Press; 1996:149-197.
47. Hirschi T. Causes of Delinquency. Berkeley, Calif: University of California Press; 1969.
48. Cressey DR. Changing criminals: the application of the theory of differential association. Am J Sociol. 1955;61:116-120.
FULL TEXT
49. Hawkins JD, Catalano RF, Morrison DM, O'Donnell J, Abbott RD, Day LE. The Seattle Social Development Project: effects of the first four years
on protective factors and problem behaviors. In: McCord J, Tremblay RE, eds. Preventing Antisocial
Behavior: Interventions From Birth Through Adolescence. New York, NY:
Guilford Press; 1992:139-161.
50. Matsueda RL. Testing control theory and differential association: a causal modeling
approach. Am Social Rev. 1982;47:489-504.
FULL TEXT
51. Hawkins JD, Weis JG. The Social Development Model: an integrated approach to delinquency
prevention. J Primary Prev. 1985;6:73-97.
52. Cummings C, Barber C, Cuervo AG. School Enhancement Research and Demonstration Project:
Methods of Instruction, Teacher's Manual (Secondary). Washington, DC: Office of Juvenile Justice and Delinquency Prevention,
US Dept of Justice; 1982.
53. Cummings C. Managing to Teach. Edmonds, Wash: Teaching Inc; 1983.
54. Hawkins JD, Doueck HJ, Lishner DM. Changing teaching practices in mainstream classrooms to improve bonding
and behavior of low achievers. Am Educ Res J. 1988;25:31-50.
FREE FULL TEXT
55. Slavin RE. Synthesis of research on cooperative learning. Educ Leadership. 1991;48:71-82.
56. Kerr DM, Cummings C. Interactive teaching map: classroom observation coding
manual. Seattle, Wash: Center for Law and Justice, University of Washington;
1981.
57. Kerr DM, Kent L, Lam TCM. Measuring program implementation with a classroom observation instrument:
the interactive teaching map. Eval Rev. 1985;9:461-482.
FREE FULL TEXT
58. Abbott RD, O'Donnell J, Hawkins JD, Hill KG, Kosterman R, Catalano RF. Changing teaching practices to promote achievement and bonding to school. Am J Orthopsychiatry. 1998;68:542-552.
ISI
| PUBMED
59. Shure MB, Spivack G. Interpersonal problem solving as a mediator of behavioral adjustment
in preschool and kindergarten children. J Appl Dev Psychol. 1980;1:29-44.
FULL TEXT
60. Shure MB, Spivack G. Interpersonal Problem Solving (ICPS): A Training
Program for the Intermediate Elementary Grades. Philadelphia, Pa: Dept of Mental Health Sciences, Hahnemann University;
1982.
61. Comprehensive Health Educational Foundation. Here's Looking at You 2000. Evanston, Ill: Altschul Group Corp; 1996.
62. Hawkins JD, Catalano RF, Jones G, Fine DN. Delinquency prevention through parent training: Results and issues
from work in progress. In: Wilson JQ, Loury GC, eds. From Children to
Citizens: Families, Schools, and Delinquency Prevention. New York,
NY: Springer-Verlag New York Inc; 1987:186-204.
63. Patterson GR. A Social Learning Approach: Coercive Family Process. Eugene, Ore: Castalia; 1982.
64. Developmental Research and Programs. How to Help Your Child Succeed in School. Seattle, Wash: Author; 1991.
65. Hawkins JD, Catalano RF, Brown EO, et al. Preparing for the Drug (Free) Years: A Family Activity Book. Seattle, Wash: Comprehensive Health Education Foundation; 1988.
66. Hawkins JD, Catalano RF, Kosterman R, Abbott R, Hill KG. Preventing adolescent health-risk behaviors by strengthening protection
during childhood. Arch Pediatr Adolesc Med. 1999;153:226-234.
FREE FULL TEXT
67. Centers for Disease Control and Prevention. Youth risk behavior surveillance: United States, 1999. MMWR Morb Mortal Wkly Rep. 2000;49:SS-5.
68. DiClemente RJ, Durbin M, Siegel D, Krasnovsky F, Lazarus N, Comacho T. Determinants of condom use among junior high school students in a minority,
inner-city school. Pediatrics. 1992;89:197-202.
FREE FULL TEXT
69. Newcomer S, Baldwin W. Demographics of adolescent sexual behavior, contraception, pregnancy,
and STDs. J Sch Health. 1992;62:265-270.
70. Buzi RS, Weinman ML, Smith PB. Ethnic differences in STD rates among female adolescents. Adolescence. 1998;33:313-318.
ISI
| PUBMED
71. Loeber R, Farrington DP, Stouthamer Loeber M, Van Kammen WB. Antisocial Behavior and Mental Health Problems: Explanatory
Factors in Childhood and Adolescence. Mahwah, NJ: Lawrence Erlbaum Associates Inc; 1998.
72. Rubin DB. Multiple Imputation for Nonresponse in Surveys. New York, NY: Wiley; 1987.
73. Graham JW, Schafer JL. On the performance of multiple imputation for multivariate data with
small sample size. In: Hoyle RH, ed. Statistical Strategies for Small
Sample Research. Thousand Oaks, Calif: Sage; 1999.
74. Graham JW, Hofer SM, Piccinin AM. Analysis with missing data in drug prevention research. In: Collins LM, Seitz LA, eds. Advances in Data
Analysis for Prevention Intervention Research. Washington, DC: US Government
Printing Office; 1994:13-63. NIDA Research Monograph, Vol
108.
75. Schafer JL, Olsen MK. NORM: Multiple Imputation of Incomplete Multivariate
Data Under a Normal Model. Windows Version 1.0. University Park, Pa: Dept of Statistics, Pennsylvania State University;
1997.
76. Card JJ, Wise LL. Teenage mothers and teenage fathers: the impact of early childbearing
on the parents' personal and professional lives. Fam Plann Perspect. 1978;10:199-205.
FULL TEXT
|
ISI
| PUBMED
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