Reducing Sexual Risk among Racial/ethnic-minority Ninth Grade Students: Using Intervention Mapping to Modify an Evidenced-based Curriculum
" Journal of Applied Research on Children: Informing Policy for
Children at Risk: Vol. 8 : Iss. 1
Reducing Sexual Risk among Racial/ethnic- minority Ninth Grade Students: Using Inter vention Mapping to Modif y an Evidenced- based Curriculum
Opportunities for Teen Pregnancy Prevention 0 1
Christine M. Markham 0 1
Efrat K . Gabay 0 1
0 University of Texas Health Science Center at Houston , USA
1 University of Texas Health Science Center at Houston School of Public Health , USA
See next page for additional authors
Follow this and additional works at: http://digitalcommons.library.tmc.edu/childrenatrisk
Christine M. Markham, Melissa Peskin, Ross Shegog, Paula Cuccaro, Efrat K. Gabay, Kimberly
JohnsonBaker, Honora I. Swain-Ogbonna, Sharon Edwards, and Susan R. Tortolero
This article is available in Journal of Applied Research on Children: Informing Policy for Children at Risk:
Despite declines in teen births in the United States,1 disparities remain in
teen births and sexually transmitted infections (STIs). In 2014, birth rates
among female Blacks and Hispanics 15 to 19 years of age exceeded
those among Whites (34.7, 38.0, and 17.2 per 1000, respectively).2 Rates
of Chlamydia infection among Black and Hispanic youth 15 to 19 years old
exceeded rates among Whites (4151, 1084, and 742 per 100,000,
respectively),3 as did rates of HIV infection among Black and Hispanic
youth compared with Whites (38.2, 7.9, and 1.9 per 1,000, respectively).4
These outcomes adversely affect economic costs5, 6 and adolescents’
Nationally, 25% of ninth graders are sexually experienced, with higher
percentages of racial/ethnic minority ninth graders reporting sexual debut
than White ninth graders.10 Early sexual debut increases the risk for
ineffective condom and contraceptive use.11 Furthermore, 10% of ninth
graders experience dating violence, increasing their risk for pregnancy
Although school-based sexual health education programs may reduce
sexual risk behaviors,13 few specifically target racial/ethnic minority ninth
graders. The U.S. Department of Health and Human Services Office of
Adolescent Health (OAH) review of evidence-based teen pregnancy
prevention programs includes three school-based programs targeting this
population: Reducing the Risk, Safer Choices, and Teen Outreach
Program.14 However, these programs were all developed more than a
decade ago, and they lack important sexual health education innovations,
such as the use of technology to engage learners,15 instruction on highly
effective contraception (including long-acting reversible contraception
[LARC]), and the integration of dating violence prevention, despite strong
associations between dating violence and sexual risk behavior.16
Given the need for a “next generation” of age-appropriate, culturally
sensitive sexual health education curricula, we used a theory- and
evidence-based approach, Intervention Mapping (IM),17 to adapt an
effective sexual health education curriculum, It’s Your Game … Keep It
Real! (IYG), originally developed for racial/ethnic minority middle school
students, to better serve the needs of racial/ethnic minority ninth graders.
IM is a systematic framework that helps program developers utilize theory,
empirical findings, and community input throughout the program-planning
process. Originally published in 2001, IM has been implemented globally
to address multiple health promotion topics, including obesity prevention,
chronic disease management, cancer screening and prevention, violence
prevention, and sexual health.17 IM was used to develop the original IYG
IM also provides a systematic approach for adapting evidence-based
programs for a new context and/or population. Program planners face
multiple challenges when adapting an existing program – for example,
protecting essential elements that made the original program effective and
incorporating formative research so that the adapted program meets the
needs of the new context and population. IM Adapt – a simplified
application of IM designed specifically for program adaptation18 – provides
guidance on how to use theory, empirical findings, and community input to
adapt an evidence-based program for a new context and/or population
while retaining essential elements that made the original program
effective. Using a systematic approach also helps ensure that the adapted
program is age-appropriate, culturally sensitive, and responsive to the
needs of the new population. Here, we describe the use of IM Adapt to
guide the adaptation of IYG for a new context and population: racial/ethnic
minority ninth grade high school students. Elaboration of the specific steps
involved in program adaptation may provide a useful model for other
practitioners to follow and contribute to the limited literature on systematic
theory- and evidence-based approaches for adapting sexual health
IM Adapt comprises six steps: (
) Conduct a needs assessment to
describe the health problems and associated risk behaviors for the new
target population and create a revised logic model of the problem. (
Identify evidence-based interventions that address the needs of the new
population; characteristics of these effective programs may guide the
adaptation process. (
) Assess the fit of the original program for the new
context and/or population in terms of behavioral and environmental
outcomes, determinants, and change methods; it is important to identify
and retain essential elements that made the original program effective. (
Modify materials and activities in the original program to better fit the new
context and/or population. (
) Plan for implementation, making
modifications, if needed, to fit the new context and/or population. (
for program evaluation. Key tasks for each step are described in detail
The planning team included behavioral scientists, epidemiologists, and a
child psychologist, guided by a Youth Advisory Group (30 African
American and Hispanic students in grades 9 through 12 from two high
schools located in urban communities with high teen birth rates). The
Youth Advisory Group provided feedback throughout Steps 1 through 6
and assisted in the adaptation and development of new activities in Step
4. During the Step 1 needs assessment, we conducted a youth risk
behavior survey with students (n = 979) at the two high schools. Survey
participants were female (52%), African American (68%), and Hispanic
(30%); almost one-third (29%) were in the ninth grade. In Step 6, we
conducted a pilot test of the adapted curriculum with ninth grade students
at the two high schools. Pilot study participants (n = 241; mean age, 15.1
years) were female (54%), African American (68%), and Hispanic (32%).
Including youth input during the adaptation process helped to ensure that
the adapted curriculum would be relevant and engaging for the target
RESULTS Step 1. Conduct a needs assessment to describe the health/behavior problems; develop a logic model for the problem.
We conducted a needs assessment with racial/ethnic minority ninth
graders and modified the original logic model of the problem from IYG to
reflect the needs of the new population. We identified teen pregnancy,
STIs, and HIV infection as the primary sexual health problems that
racial/ethnic minority ninth graders face.3,19,20 Associated quality-of-life
issues mirrored those of the original population.5,9,21-23 Risk behavior data
collected from racial/ethnic minority ninth graders in the target setting
revealed high percentages of sexually experienced students; low rate of
condom and contraceptive use, including LARC; frequent substance use
before sex; experience of dating violence; and low rate of use of sexual
health testing services, all risk behaviors similar to those of racial/ethnic
minority middle schoolers.24 Furthermore, 10% of ninth graders reported
engaging in nonconsensual sex in the past year; fewer than 5% reported
receiving the human papillomavirus (HPV) vaccine.25 Thus, dating
violence and HPV vaccination behaviors were added to the logic model.
Regarding environmental factors, about 10% of ninth graders reported
exposure to violence in the past year,10 which is associated with sexual
risk behavior.26 This factor was added to the logic model. Poor
parentchild communication and parental monitoring,27 limited sexual health
counseling,28 and policies restricting minors’ access to sexual and
reproductive health services29 were applicable to ninth graders and were
retained in the model.
Psychosocial determinants of the risk behaviors among ninth graders,
including low levels of knowledge, skills, self-efficacy, outcome
expectations, and perceived susceptibility, were similar to those in the
original population.30,31 Focus groups conducted with youth in the target
population, and discussions with school personnel and community
members, revealed limited knowledge of and negative perceptions about
LARC and HPV vaccination, and limited knowledge of and skills for active
sexual consent. We added these factors to the model.
Step 2. Search for evidence-based interventions.
The planning team previously developed IYG as a sexual health education
curriculum for racial/ethnic minority middle schoolers.32 Based on social
influence models,33,34 IYG comprises 24 lessons for seventh and eighth
graders that address psychosocial determinants of sexual behavior and
healthy dating relationships. It includes six take-home activities for
students and parents to complete together. Evaluated in two randomized
controlled trials, IYG has been demonstrated to delay sexual initiation,
reduce sexual risk behavior, and reduce dating violence among
racial/ethnic minority seventh graders followed into ninth grade.32,35,36 IYG
is recognized by OAH as an evidence-based teen pregnancy prevention
program,14 and by the National Institute of Justice as a promising dating
violence prevention program.37
We reviewed Me & You: Building Healthy Relationships, a dating violence
prevention program for racial/ethnic minority sixth graders adapted from
IYG. Me & You comprises 13 classroom and computer-based lessons that
address psychosocial factors related to dating violence. The program has
been demonstrated to reduce dating violence among racial/ethnic minority
sixth graders followed into seventh grade.38
We also reviewed the three effective school-based sexual health
education programs mentioned above: Reducing the Risk, Safer Choices,
and Teen Outreach Program. Based on social influence models, each
program has been demonstrated to reduce sexual risk behavior among
ninth graders followed into grade 10 and/or grade 11.39-41
Collectively, our review of these programs (content, methods, and
delivery) helped guide the adaptation of IYG to serve the needs of the new
Step 3: Assess the fit and plan adaptations.
The original IYG targeted five behavioral outcomes: (
) choosing not to
have sex; (
) using condoms correctly and consistently; (
) using an
effective method of contraception with condoms; (
) getting tested for HIV
infection, STI, and pregnancy; and (
) having healthy friendships and
dating relationships. Each behavior was subdivided into performance
objectives to specify exactly what a student needs to do to perform the
behavior.17 These behaviors were retained in the adapted program.
However, given the low rate of use of effective contraception identified in
the needs assessment, we expanded the behavioral outcome and
performance objectives for contraception to include selecting, obtaining,
and maintaining effective contraception (Table 1, Behavioral Outcome 3).
We revised the behavioral outcome for getting tested to focus
comprehensively on accessing sexual and reproductive health care
services, and we expanded the healthy relationships outcome to
encompass dating violence prevention and active sexual consent (Table
1, Behavioral Outcomes 4 and 5). Performance objectives for these
behaviors were modified after a review of evidence-based programs, input
from the Youth Advisory Group, and a literature review.
The original IYG included environmental outcomes related to parent-child
communication and parental monitoring. Although parental influence was
salient for ninth graders (Figure 1), school personnel indicated that
parental involvement would be challenging in ninth grade. Thus, we
decided to exclude parent-child activities from the adapted program.
• Lack of knowledge, skills,
• Refusing sex
• Active consent
• Using condoms
• Using birth control
• Getting tested for
• Getting HPV vaccine
• Outcome expectations
about sex, condoms and
LARC, and other birth
• Perceived norms about
sex, condoms, LARC, and
other birth control use
• Perceived barriers to
condom, LARC, and other
birth control use
• Low susceptibility
Note: Text in italics
indicates risk factors
specific to racial/ethnic
minority ninth graders that
were added to the original
logic model for It’s Your
• Early sexual initiation
• Low condom use
• Low birth control use,
• Multiple partners
• Alcohol and drug use
• Dating violence
• Nonconsensual sex
• Low use of testing
services for STI, HIV
• Low uptake of HPV
• Exposure to violence
• Low parent-child
• Low parental
• Lack of sexual health
counseling from health
• Poor access to sexual
• Policies restricting
minors’ access to
• STIs and HIV
Quality of Life Teen
• School dropout
• Reduced job
• Medical and
• Disclosure and
to STI and HIV
Child of Teen Parent
• Increased risk
for neglect or
and becoming a
considering have Speak honestly and openly with provider about sexual
sex or are currently history, risks, drug use, and any other personal history
sexually active. information.
Select and obtain appropriate sexual health and
reproductive health services.
Maintain related behaviors over time.
5. Have healthy peer Decide to have healthy peer and dating relationships.
and dating Identify and evaluate own behavior in past and current
relationships (ie, peer/dating relationships.
free of emotional, Identify and evaluate peers’ and/or dating partners’
physical, and behavior in past and current peer/dating relationships.
sexual violence). Use effective communication strategies to foster
healthy peer/dating relationships
Use active consent (give and obtain) when engaging
in sexual behaviors.
Manage emotional responses (eg, love, anger,
anxiety, stress, depression, jealousy) to foster healthy
peer/ dating relationships.
Avoid peers and potential dating partners who engage
in unhealthy relationship behaviors.
Avoid alcohol and drug use.
Get out of unhealthy peer/dating relationships.
Manage unhealthy peer/dating relationships that are
Disclose abusive dating relationships (emotionally,
physically, or sexually abusive either in person and/or
Access resources to help respond to
currently/potentially violent dating relationships.
a Behavioral outcomes and performance objectives added specifically for the new
target population are in italics.
We reviewed the match of determinants and change methods. A change
method is a general theoretical process used to influence behavioral
determinants.17 Content analysis of the IYG curriculum indicated that the
determinants (eg, knowledge, skills, self-efficacy) and change methods
used to influence those determinants (eg, active learning, modeling, skills
training) were appropriate for racial/ethnic minority ninth graders because
they were similar to those employed in the three identified effective ninth
grade interventions. We modified matrices of change objectives for
Behaviors 3 through 5 to include the new performance objectives. These
matrices specify exactly what needs to change in determinants and
performance objectives to achieve the desired behavioral outcome.17
Table 2 presents a partial matrix for contraceptive use.
We then identified methods and applications (ie, how a method is
operationalized for a specific context and population) to address the new
change objectives. Table 3 presents sample methods and applications for
The team assessed the delivery and implementation of IYG for the new
context and population via discussions with school personnel and review
of the three evidence-based programs. Scheduling 24 lessons across
sequential grades, as in the original IYG, would be challenging because of
graduation requirements. Two of the three evidence-based programs were
fully implemented in ninth grade, supporting implementation of the
adapted program solely in ninth grade. The evidence-based programs
ranged from 16 to 25 sessions; thus, we determined that the adapted
program could be shortened without limiting effectiveness.
Finally, we identified essential elements of IYG that made it effective.
Based on characteristics of effective sexual health programs,42 these
elements included interactivity, personalization, age and cultural
appropriateness, integration of skill-building activities, and reinforcement
of key messages. These characteristics were retained in the adapted
The student will:
decision to use
LARC or other
effective method of
PO.2. Talk to
trusted adult about
LARC or other
PO.3. Make appointment with provider who is
K.1. Describe the
personal and partner
benefits of using
LARC or other
K.2.a. Describe how
gaining support from
trusted adult can
positivity affect ability
to gain access to
K.2.b. List common
K.3. List questions to ask provider/office staff to identify
ability to talk to
parent about getting
LARC or other
confidence in ability
to discuss LARC or
method with parent.
OE.1. State that using
effective LARC or
method will offer the
best way to prevent
pregnancy if having
OE.2. State that
talking with parent will
facilitate adoption of
LARC or other
S.3. Demonstrate the ability to make an appointment with a
SE.3. Express confidence in ability to make an appointment with a
OE.3. State that going
to a provider who can
prescribe LARC will
improve access to
willing to prescribe
LARC to teens.
PO.4. Talk to
LARC or other
PO.5. Select and
LARC or other
whether they are
willing to prescribe
K.4. List questions to
ask about types of
LARC or other
different LARC or
K.5.b. List places to
fill prescription that
are convenient to get
K.5.c. For LARC,
describe procedure to
insert LARC device.
provider who can
provider who can
S.4. Demonstrate the
ability to bring up the
topic of and ask
S.5. Demonstrate the
ability to select and
appropriate LARC or
confidence in ability
to bring up the topic
of and ask
LARC or other
confidence in ability
to select and obtain
LARC or other
OE.5. State that
bringing up the topic
of contraception and
LARC methods will
result in the provider
prescribing the most
appropriate LARC or
OE.5. State that
LARC or other
will result in higher
rates of effectiveness.
PO.6. Monitor how chosen LARC or other contraceptive method is working.
PO.7. Maintain use of chosen LARC or other contraceptive method.
K.6. List side effects
of chosen LARC or
K.6.b. Describe how
to tell that LARC or
is performing as
K.7. List steps to maintaining chosen LARC or other contraceptive method.
ability to tell that
is performing as
S.7. Demonstrate the
ability to follow up
with provider as
chosen LARC or
SE.6.a. Express confidence in ability to identify side effects.
confidence in ability
tell that LARC or
confidence in ability
to maintain chosen
LARC or other
with chosen LARC
K.8. State that using
LARC or a
without a condom
does not protect
S.8. Demonstrate the
ability to negotiate
condom use along
with LARC or other
confidence in ability
to use condoms
along with LARC or
method during sex.
OE.6. State that
evaluating LARC or
will result in better
health outcomes and
greater ease of use.
OE.7. State that
will ensure its
help to reduce or
avert potential side
OE.8. State that using
condoms along with
LARC or other
is the most effective
way to protect against
pregnancy and STIs if
Knowledge about types of
LARC or other contraceptive
Information processing (TIP) Interactive activity about pros/cons and
effectiveness of different birth control methods
Persuasive communication Mock talk show episode with Ms. IUD to address
(ELM) myths about LARC
Knowledge, skills, and selfefficacy to make a clinic appointment Modeling (SCT)
Self-efficacy to select LARC or Individualization (TTM)
other birth control method
Role model video of teen couple accessing health
care services and visiting a clinic together
Classroom discussion about barriers to visiting a
clinic and how to overcome the barriers
Students’ selection of birth control method they
would want to use when they become sexually
Peer video testimonials from youth who chose to
expectations, and perceived
norms about choosing LARC
Skills and self-efficacy to use
condoms along with chosen
LARC or other contraceptive
Guided practice (SCT) Role plays on negotiating with a partner to use
condoms and contraceptive
Information processing (TIP) Interactive activity helping a couple negotiate
contraceptive use, condom use, and dual
ELM, Elaboration Likelihood Model; SCT, Social Cognitive Theory; TIP, Theories of Information Processing; TTM,
Step 4: Make adaptations by modifying materials and activities.
IYG combines group-based classroom lessons with individual
computerbased lessons. This delivery mode is ideal for sexual education because it
combines norms- and skills-based approaches. Classroom instruction
allows teachers to model health-promoting behaviors and elicit group
discussion on norms.42 Integrating computer-based instruction allows
students to personalize and practice these health-promoting behaviors,
often in tailored situations.43 We decided to retain this dual delivery mode
but included “blended” lessons, which embed computer-based activities
into classroom lessons. This blended lesson approach was used in Me &
You. The planning team named the adapted program Your Game, Your
Life (YGYL) to reiterate self-empowerment but distinguish it from the
Lesson Topic and Description
Intro to YGYL, ground rules, myth busting Characteristics of healthy and unhealthy dating relationships
Types of communication strategies, effective communication skills practice Characteristics of active consent, skills practice
Keeping Your Dating violence prevention,
Relationships consequences of unhealthy dating
Healthy relationships, gender stereotypes, power
SELECT, Introduction to SDP theme, identifying
DETECT, personal rules and situations that
PROTECT challenge those rules (related to sex and
Protecting Clear NO and alternative actions,
Personal Rules consequences of not protecting rules,
Know Your Body Anatomy and physiology, reproduction,
Consequences Consequences of pregnancy, birth
of Pregnancy control methods
Pregnancy Risk Birth control methods, LARC, identifying
Reduction effective birth control methods for you
of HIV and STIs
The Clinic Visit
Consequences of HIV and STIs,
importance of HIV/STI testing
Condom knowledge and skills practice,
benefits of dual protection
Sexual and reproduction health services
(importance, skills around visit, etc.)
Protecting personal rules about using
condoms and dual protection
15 Blendeda Putting it All
a Combined classroom and computer lesson.
We modified the IYG teacher training to reflect changes in the adapted
program and met with school personnel to schedule classroom time and
computer access for program implementation.
Step 6: Plan for evaluation.
In 2014-2015, we conducted a pilot test of YGYL with primarily
racial/ethnic minority ninth graders in two large, urban high schools in
areas with high teen birth rates. After receiving YGYL, most students
agreed they would use skills learned in the program (93%), had clear
personal rules regarding healthy relationships and sex (91%), and were
comfortable sharing these rules with their partner (85%). Of 39 students
who were in a situation to use the self-regulatory decision-making
paradigm, 86% reported using it: more than half in a sexual situation,
onethird in a situation with drugs or alcohol, and one-third while online or
texting. Most students would recommend YGYL to others (87%). These
data warrant a more rigorous evaluation of YGYL in a randomized
controlled trial. Effect evaluation measures would assess the effect of
YGYL on the targeted behavioral outcomes (eg, delayed sexual initiation,
condom and contraceptive use, avoidance of dating violence victimization
and perpetration, and utilization of health care services) and related
psychosocial outcomes (eg, knowledge, self-efficacy and outcomes
expectations for condom and contraceptive use, and healthy dating
relationships). Process evaluation measures would assess factors related
to reach, dosage, implementation fidelity, and student/teacher satisfaction
to guide any additional modifications before broader dissemination.
We used the IM Adapt framework to modify an existing evidenced-based
sexual health education curriculum, originally developed for urban,
racial/ethnic minority middle school students, to meet the needs a of new
high-risk population – racial/ethnic minority ninth grade students. IM Adapt
provided guidance on how to incorporate theory, empirical findings, and
community input to modify the original program, while retaining elements
that made it effective. Input from school personnel and students during the
adaptation process ensured that the new program was feasible for
implementation in the new context (urban high schools) as well as relevant
and engaging for the new population. IM Adapt adds to the limited number
of theory- and evidence-based frameworks that have been developed for
adapting effective sexual health education interventions (eg, the
APAPTITT model44 and the Green, Yellow and Red Light Adaptations model)45
and provides another systematic approach for practitioners to use when
adapting existing teen pregnancy, HIV infection, and STI prevention
On the basis of findings from the needs assessment, we identified several
behaviors that were only partially covered in the original IYG program. For
example, the American Academy of Pediatrics and the American
Congress of Obstetricians and Gynecologists both recommend LARC as
front-line birth control for teens.46,47 Previous studies, including the
Contraceptive CHOICE Project conducted in St. Louis, Missouri, indicate
that adolescents ages 14 through 17 years are more likely than
adolescents ages 18 through 20 years to select an LARC method when
they receive detailed contraceptive counseling.48 Although only a small
percentage of US ninth grade students currently report using LARC,10 it is
important to provide ninth graders with information on these highly
effective contraceptive methods so that they are familiar with them in later
Findings from our needs assessment also reiterated national data
indicating that dating violence is prevalent among racial/ethnic minority
ninth graders.10 IYG is one of the few evidence-based sexual health
education curricula that has demonstrated effectiveness to reduce both
dating violence and sexual risk behaviors.36 In YGYL, we included
additional activities on active consent, effective communication skills,
gender stereotypes, and power differentials to help students have
healthier dating relationships and to avoid or get out of unhealthy
relationships. These activities were well received by students in the pilot
Finally, findings from the needs assessment indicated limited utilization of
health care services; thus, we included an entire class session on how to
access sexual and reproductive health care services, with interactive
activities to address students’ knowledge, self-efficacy, perceived norms,
and outcome expectations about accessing services.
The original IYG program included homework activities for students and
parents to complete together. However, high school personnel indicated
that parental involvement would be challenging; thus, we did not include
take-home activities in YGYL. However, given the importance of
parentchild communication and parental monitoring for promoting adolescent
sexual health,27 schools may be encouraged to provide supplemental
materials or resources to parents to help them connect with their teen.
YGYL represents the “next generation” of age-appropriate, culturally
sensitive sexual health education curricula. Given the racial/ethnic
disparities in rates of teen pregnancy, HIV infection, and STIs that still
exist in the United States, it is important that child advocates and policy
makers support school districts in their efforts to implement
evidencebased, comprehensive sexual health education curricula that include
topics such as contraception and dating violence prevention. National data
indicate recent declines in adolescents’ receipt of formal sexual education,
including instruction on birth control.49 Furthermore, federal funding for
comprehensive adolescent sexual health programming may be
threatened.50 These factors point to the importance of health education
efforts at the local, state, and national levels to support comprehensive
sexual health education. Wide-scale implementation of medically
accurate, age-appropriate, and culturally sensitive school-based sexual
health education curricula, such as YGYL, can play an important role in
reducing adolescent sexual health disparities in the United States.
Using a theory- and evidence-based framework, IM Adapt, we adapted an
existing effective sexual health education program for middle school
students for a new population while retaining essential elements that
made the original program effective. Input from school personnel and
students throughout the adaptation process helped ensure that the
adapted program would be suitable for implementation in the new context,
as well as engaging and responsive to the needs of ninth grade
racial/ethnic minority students. Wide-scale dissemination of
ageappropriate, culturally sensitive school-based sexual health education
curricula, such as YGYL, may help reduce racial/ethnic disparities in
adolescent sexual health.
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