Journal of Adolescent Health 57 (2015) 399e406

www.jahonline.org

Original article

A Rights-Based Sexuality Education Curriculum for Adolescents:

1-Year Outcomes From a Cluster-Randomized Trial
Louise A. Rohrbach, Ph.D., M.P.H. a, Nancy F. Berglas, Dr.P.H. b, Petra Jerman, Ph.D., M.P.H. b,
Francisca Angulo-Olaiz, Ph.D. b, Chih-Ping Chou, Ph.D. a, and Norman A. Constantine, Ph.D. b, c, *
a
Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
b
Center for Research on Adolescent Health and Development, Public Health Institute, Oakland, California
c
Division of Community Health and Human Development, School of Public Health, University of California, Berkeley, California

Article history: Received April 3, 2015; Accepted July 2, 2015

Keywords: Sexuality education; School-based intervention; Sexual behavior; Sexual rights; Relationship rights; Evaluation; Cluster-
randomized trial

A B S T R A C T
IMPLICATIONS AND
CONTRIBUTION
Purpose: The purpose of this study was to evaluate the impact of a rights-based sexuality edu-
cation curriculum on adolescents’ sexual health behaviors and psychosocial outcomes 1 year after
This randomized study
participation. assesses the impact of a
Methods: Within 10 urban high schools, ninth-grade classrooms were randomized to receive a rights-based sexuality ed-
rights-based curriculum or a basic sex education (control) curriculum. The intervention was ucation curriculum for
delivered across two school years (2011e2012, 2012e2013). Surveys were completed by 1,447 adolescents in the United
students at pretest and 1-year follow-up. Multilevel analyses examined curriculum effects on States. The curriculum
behavioral and psychosocial outcomes, including four primary outcomes: pregnancy risk, sexually showed positive effects 1
transmitted infection risk, multiple sexual partners, and use of sexual health services. year after participation on
Results: Students receiving the rights-based curriculum had higher scores than control curriculum sexual health knowledge,
students on six of nine psychosocial outcomes, including sexual health knowledge, attitudes about attitudes, information ac-
relationship rights, partner communication, protection self-efficacy, access to health information, cess, partner communica-
and awareness of sexual health services. These students also were more likely to report use of tion, protection self-
sexual health services (odds ratio, 1.37; 95% confidence interval, 1.05e1.78) and more likely to be efficacy, condom carrying,
carrying a condom (odds ratio, 1.97; 95% confidence interval, 1.39e2.80) relative to those receiving and use of sexual health
the control curriculum. No effects were found for other sexual health behaviors, possibly because services.
of low prevalence of sexual activity in the sample.
Conclusions: The curriculum had significant, positive effects on psychosocial and some behavioral
outcomes 1 year later, but it might not be sufficient to change future sexual behaviors among
younger adolescents, most of whom are not yet sexually active. Booster education sessions might
be required throughout adolescence as youth initiate sexual relationships.
Ó 2015 Society for Adolescent Health and Medicine. All rights reserved.

Conflicts of Interest: The authors declare that they have no potential conflicts to
disclose.
Disclaimer: The funders had no control over the analyses conducted, the results
reported, or any other aspect of this article.
Trial Registration: ClinicalTrials.gov NCT02009046.
* Address correspondence to: Norman A. Constantine, Ph.D., Center for
Research on Adolescent Health and Development, Public Health Institute, 555
12th Street, 10th Floor, Oakland, CA 94607.
E-mail address: nconstantine@berkeley.edu (N.A. Constantine).
Sexuality is a normative and healthy aspect of adolescent
development, yet the negative consequences of risky sexual
behaviors can be great. An estimated 614,000 U.S. adolescent
girls aged 15e19 years become pregnant each year, with 82%
of these pregnancies being unintended [1,2]. Incidence of
sexually transmitted infections (STIs) is particularly high
during the adolescent and young adult years, accounting for

1054-139X/Ó 2015 Society for Adolescent Health and Medicine. All rights reserved.
http://dx.doi.org/10.1016/j.jadohealth.2015.07.004
400 L.A. Rohrbach et al. / Journal of Adolescent Health 57 (2015) 399e406
nearly half of the country’s 19.7 million annual new in-
fections [3]. Moreover, these negative health outcomes
continue to be disproportionately high among African-
American and Hispanic adolescents and within disadvan-
taged communities [2,4].
School-based interventions are a common strategy for pro-
moting healthy behaviors and reducing the sexual risk behaviors
that can lead to unintended pregnancy and STIs. More than 95%
of U.S. adolescents report receiving some formal sexuality edu-
cation in a school or community setting by age 18 years [5],
although the specific form varies widely in its goals, assumptions,
content, and format. Nationwide, most high schoolelevel school-
based interventions are guided by an abstinence-plus approach,
promoting abstinence from sexual activity and condom and
contraceptive use among sexually active youth [6,7]. Across
multiple evaluations of programs employing a wide range of
abstinence-plus approaches, meta-analyses have yielded some
evidence of modest positive effects overall [7e9]. At the indi-
vidual program level, however, the effectiveness of most
abstinence-plus programs is not well supported by the available
evidence [10,11].
Among some sexual health scholars and advocates, there
have been calls for a more comprehensive approach to sexual
health education and researchdone that is based on frame-
works of health promotion and healthy sexual development
[6,12e14]. One emerging framework is the rights-based
approach, which seeks to integrate discussions of sexuality,
human rights, and gender equality and is driven by recognition
of adolescents’ fundamental rights to sexual health information
and services, self-determination, and nondiscrimination [15].
The rights-based approach expands the goals of sexuality edu-
cation to include positive sexuality and empowerment and in-
corporates content related to contextual issues that affect
adolescents’ sexual lives, including gender and cultural norms,
power dynamics in relationships, and sexual orientation.
Effectiveness research on the rights-based approach is still in
early stages, particularly in the United States. Although
conceptually similar interventions (e.g., those incorporating
content on gender norms and equality) have shown
encouraging results through randomized trials [16e21], a
rigorous evaluation of a rights-based sexuality education
intervention with adolescents in the United States has not been
conducted.
We conducted a cluster-randomized trial of a rights-based
sexuality education intervention delivered at 10 high schools
in South and East Los Angeles. The primary aim of the trial was
to evaluate the effectiveness of a rights-based classroom
curriculum, and a secondary aim was to determine the effec-
tiveness of the multicomponent intervention consisting of the
rights-based classroom curriculum plus three school-wide
intervention components (parent education workshops, after-
school peer advocate program, and clinical sexual health ser-
vices). In this article, we present effects of the rights-based
classroom curriculum on behavioral and psychosocial out-
comes at 1-year follow-up. A prior analysis of the short-term
effects of the classroom curriculum immediately after pro-
gram delivery showed a positive, statistically significant impact
on students’ sexual health knowledge, attitudes about sexual
relationship rights, communication with parents, and protec-
tion self-efficacy [22].
Methods
Study design
The study was conducted with ninth-grade students at 10
public charter schools affiliated with a large urban school district.
These schools were selected to reflect the demographic charac-
teristics of students in the local communities while offering the
smaller, contained charter school environment to conduct
intervention research. Across the schools, enrolled students were
predominantly Hispanic (84%) or African-American (14%), and
most were eligible for free or reduced-price lunch (88%) [23]. The
schools were recruited as five pairs that were matched on
school-level demographic characteristics (student ethnicity,
student eligibility for free or reduced-price lunch, and school
size). The intervention was delivered across two school years.
Eight schools participated in Cohort 1 (2011e2012). One
matched pair of schools dropped out of the study because of
school administration changes and was replaced by a new
matched pair of schools, with similar student demographic
characteristics, for Cohort 2 (2012e2013).
The full study employed two levels of randomization, each of
which was designed to address a different aim. The first was at
the school level, to evaluate the effectiveness of the full multi-
component intervention (to be reported elsewhere). Within each
matched pair, schools were randomly assigned to one of the two
following conditions: (1) implementation of all three school-
wide intervention components (parent education, peer advo-
cacy, and sexual health services) or (2) implementation of none
of the school-wide components. Subsequent to randomization
but before baseline data collection, several participating schools
decided to open a shared school-linked clinic. To neutralize this
unexpected study protocol violation, we had no choice but to
implement the sexual health services component in all schools.
Thus, in the final design, the only difference between the two
school-level conditions was the delivery of the parent education
and peer advocate components.
The second level of randomization occurred at the classroom
level, to evaluate the effectiveness of the rights-based curriculum
(the subject of this article). Within each school, regardless of
school-level randomization, ninth-grade classrooms were ran-
domized to receive either the 12-session rights-based intervention
curriculum or a three-session control curriculum. Thus, each
classroom’s probability of assignment to the intervention or control
classroom condition was not affected by its school-level condition.
Curriculum content and delivery
The Sexuality Education Initiative (SEI) intervention was
developed by Planned Parenthood Los Angeles (PPLA) with the
goals of improving the sexual health of low-income high
schooleaged youth, including reducing the risk of pregnancy and
STIs, and improving students’ ability to manage their sexuality
respectfully. PPLA aimed to develop a new intervention that
would address gender norms and power dynamics in relation-
ships, use a rights-based framework, and contextualize sexual
health messages through an ecological model. The intervention
content and format was based on best practices of international
and U.S. organizations, as well as formative research and pilot
testing within the community. A detailed description of the
 L.A. Rohrbach et al. / Journal of Adolescent Health 57 (2015) 399e406
intervention development and conceptual framework has been
published elsewhere [24].
The SEI curriculum comprised 12 sessions designed for de-
livery to ninth-grade students during regular class periods. It
addressed sexual rights and gender roles in relationships and
media messages and provided content on sexual and reproduc-
tive anatomy, pregnancy, STIs/human immunodeficiency virus,
and contraception. In each classroom, the SEI curriculum was
taught over an average span of 53 days by PPLA staff who
received 2 days of training.
The three-session control curriculum covered basic sexual
health topics, including anatomy and prevention of unintended
pregnancy and STIs. The control curriculum had been imple-
mented by PPLA in prior years and reflected the standard of care
for sexuality education in local high schools. The control curric-
ulum was taught over an average span of 9 days by PPLA
volunteer educators who received 1 day of training.
To examine fidelity of curriculum implementation, trained
members of the research team conducted formal observa-
tions of intervention and control curriculum sessions. Across
the 2-year study period, 220 intervention sessions and 43
control sessions were observed (equivalent to 50% of all
sessions in Year 1 and 25% of all sessions in Year 2), with
coverage across all schools and sessions. Observations
showed strong fidelity to the curriculum design in both SEI
and control classrooms [22].
Participants
Participant flow through the study is presented in Figure 1.
Parents provided written or verbal consent, and students pro-
vided informed assent to participate in the study. Of 2,379
eligible students, 2,033 (85.5%) were consented for participa-
tion. At pretest, 6.1% of cases were excluded due to student
absence or invalid data. At 1-year follow-up, 21.8% of cases
were lost due to attrition and 3.0% due to invalid data. The
final sample included 1,447 students in 91 classrooms, of which
769 students (48 classrooms) received the SEI curriculum, and
678 students (43 classrooms) received the control curriculum.
Data collection
Students were administered a written survey at baseline
(pretest) and 1 year after delivery of the curriculum (1-year
follow-up). Research staff administered the surveys in class-
room sessions during regular school hours. School staff distrib-
uted survey packets to absent students, who completed the
survey in a private area of the classroom, placed it a sealed en-
velope, and returned it to the teacher for storage in a locked
cabinet. The study was conducted in compliance with Institu-
tional Review Boards of the University of Southern California and
the Public Health Institute.
Measures
The student survey instrument was developed after a multi-
step process. All items were tested in cognitive interviews and
piloted to ensure respondents’ comprehension [25]. Dependent
variables included primary and secondary behavioral outcomes
and psychosocial outcomes.
Primary behavioral outcomes were selected based on their
common use in the field [9] and alignment with the SEI
401
conceptual framework [24]. These comprised (1) pregnancy risk
(engaging in vaginal or anal sex but not using birth control or
condoms in the previous 3 months, measured with three items
that were combined to create one dichotomous variable repre-
senting those at pregnancy risk versus those who did not engage
in sex or engaged in sex and used protection); (2) STI risk
(engaging in vaginal or anal sex but not using condoms in the
previous 3 months or engaging in oral sex [the survey contained
the following definition of oral sex: “Sometimes this is called
‘going down’ or ‘giving head,’ and it involves putting your mouth
on someone else’s private parts or having someone put their
mouth on your private parts.”] but not using protection in the
previous 3 months, measured with four items that were com-
bined to create one dichotomous variable); (3) multiple sexual
partners (having more than one vaginal, anal, or oral sexual
partner in the previous 3 months, measured with four items that
were combined to create one dichotomous variable); and (4) use
of sexual health services (ever having received such services,
measured with one dichotomous item). (Throughout the
behavioral outcome section of the survey, the following defini-
tion of sex was noted: “In this survey, we use the word sex to
mean vaginal sex [penis in the vagina] or anal sex [penis in the
anus, or butt].”)
Secondary behavioral outcomes, each measured with one
survey item, included (1) ever engaging in vaginal or anal sex; (2)
ever engaging in oral sex; (3) engaging in vaginal or anal sex in
the previous 3 months; (4) engaging in oral sex in the previous
3 months; (5) using a condom at last vaginal or anal sex; (6) using
birth control or condoms at last vaginal or anal sex; and (7)
currently carrying a condom (e.g., in a pocket, purse, or back-
pack). Secondary outcomes 5 and 6 were limited to students who
were sexually experienced at baseline and thus answered sexual
behavior items at both pretest and follow-up.
Psychosocial outcomes hypothesized to be mediators of stu-
dents’ sexual health behaviors included (1) attitudes about rights
in steady sexual relationships (17 items, mean scale, a ¼ .89 at
pretest); (2) attitudes about rights in casual sexual relationships
(17 items, mean scale, a ¼ .91); (3) communication about re-
lationships, rights, and sexuality with partners (nine items,
summative scale); (4) communication about relationships,
rights, and sexuality with parents/guardians (15 items, summa-
tive scale); (5) knowledge about sex, sexual health, and sexual
risk protection (17 items, summative scale); (6) self-efficacy to
assert sexual limits and manage risky situations (six items, mean
scale, a ¼ .78); (7) intentions to protect oneself from sexual risk
through condom use (three items, mean scale, a ¼ .85); (8) access
to accurate information about sexuality and sexual health (single
dichotomous item); and (9) awareness of sexual and reproduc-
tive health services (single dichotomous item). For each
outcome, a higher score indicated a greater level of the construct.
The development and assessment of these measures are
described elsewhere [22].
Sociodemographic characteristics were assessed at baseline.
Socioeconomic status was measured by household crowding,
calculated as the ratio of the number of rooms in the student’s
home to the number of people in the home [26]. Acculturation
was measured using a brief scale developed by Marin et al. [27]
and validated with Hispanic adolescents [28]. Mean scores
were calculated across four items assessing the extent to which
the student used English or another language when reading,
speaking with friends, watching movies or television, and
speaking at home.
402 L.A. Rohrbach et al. / Journal of Adolescent Health 57 (2015) 399e406

Figure 1. Participant flow from randomization to final analysis sample.

Statistical analysis characteristics by curriculum group. Comparisons were made

Analyses were conducted to determine whether attrition
rates were comparable across curriculum groups and examine
whether students lost to follow-up differed on key demographic
and behavioral characteristics from those retained. Descriptive
statistics were calculated at baseline to summarize student
using t tests for continuous variables and c2 tests for categorical
variables.
The curriculum intervention effect on each outcome was
tested with multilevel linear or logistic regression models (using
SAS 9.2 PROC MIXED and GLIMMIX procedures [SAS Institute
Inc., Cary, NC]) to account for interdependence of student
 L.A. Rohrbach et al. / Journal of Adolescent Health 57 (2015) 399e406 403

Table 1 Table 2
Comparison of students retained for analysis with students lost to attrition at Baseline characteristics of students by classroom curriculum intervention group
follow-up
Variable Control SEI Group
Variable Retained Lost to Group (n ¼ 678) (n ¼ 769) difference
students attrition difference p value
p value
Gender (%) .919
Overall (%) n ¼ 1,492 n ¼ 417 .430 Male 48.8 49.0
Control curriculum 79.0 21.0 Female 51.2 50.8
SEI curriculum 77.5 22.5 Missing .0 .1
Gender (%) n ¼ 1,489 n ¼ 398 .962 Age (12e18 years), mean (SD) 14.16 (.55) 14.15 (.60) .901
Male 49.4 49.5 Hispanic (%) .654
Female 50.6 50.5 No 7.7 7.2
Age (12e18 years) n ¼ 1,454 n ¼ 399 .000 Yes 87.0 88.8
Mean (SD) 14.16 (.58) 14.44 (.68) Missing 5.3 4.0
Hispanic (%) n ¼ 1,422 n ¼ 369 .000 Born in the United States (%) .556
No 7.8 16.3 No 13.4 14.6
Yes 92.2 83.7 Yes 81.4 80.8
Born in the United States (%) n ¼ 1,416 n ¼ 384 .024 Missing 5.2 4.7
No 14.9 10.4 Household SES (0e3), mean (SD) .56 (.27) .57 (.28) .920
Yes 85.1 89.6 Student acculturation 3.75 (.68) 3.79 (.69) .300
Household SES (0e3) n ¼ 1,429 n ¼ 385 .005 (1e5), mean (SD)
Mean (SD) .57 (.28) .61 (.28) Ever had sexa (%) .866
Student acculturation (1e5) n ¼ 1,439 n ¼ 392 .000 No 83.9 84.1
Mean (SD) 3.78 (.69) 3.97 (.76) Yes 14.9 14.6
Ever had sexa (%) n ¼ 1,474 n ¼ 408 .000 Missing 1.2 1.3
No 82.6 59.8 Had sex in the last 3 months (%) .345
Yes 17.4 40.2 No 93.2 91.8
Had sex in the last n ¼ 1,471 n ¼ 404 .000 Yes 5.5 6.6
3 months (%) Missing 1.3 1.6
No 93.4 76.2 Ever had oral sex (%) .390
Yes 6.6 23.8 No 85.7 86.5
Ever had oral sex (%) n ¼ 1,477 n ¼ 407 .000 Yes 13.7 12.1
No 86.3 71.0 Missing .6 1.4
Yes 13.7 29.0 Had oral sex in the last .869
Had oral sex in the n ¼ 1,472 n ¼ 407 .000 3 months (%)
last 3 months (%) No 93.8 92.8
No 94.4 85.3 Yes 5.3 5.5
Yes 5.6 14.7 Missing .9 1.7
Ever been for sexual n ¼ 1,469 n ¼ 404 .000 Ever been for sexual .419
health services (%) health services (%)
No 85.4 76.0 No 85.5 83.9
Yes 14.6 24.0 Yes 13.1 14.6
Missing 1.3 1.6
Total N ¼ 1,909.
Difference between groups was tested by chi-square test for categorical Total N ¼ 1,447.
variables and t test for continuous variables, at p < .05. The analyses Percentages might not add up to 100% because of rounding. Differences between
were not adjusted for interdependence because of classroom and school af- control and intervention classrooms were tested by chi-square test for categor-
filiations. ical variables and t test for continuous variables, at p < .05. The analyses were not
SD ¼ standard deviation; SEI ¼ sexuality education initiative. adjusted for interdependence due to classroom and school affiliations.
a
Defined as vaginal or anal sex. SD ¼ standard deviation; SEI ¼ Sexuality Education Initiative.
a
Defined as vaginal or anal sex.

observations due to classroom and school clusters [29e31]. An-
alyses compared students receiving the SEI curriculum with
those receiving the control curriculum. Statistical significance
levels of p < .05 were employed across all analyses.
In each regression model, school was entered as a fixed
effect and classroom as a random effect. Curriculum group (SEI
vs. control) was entered as a fixed effect. Student-level cova-
riates included gender, baseline sexual experience, and the
pretest measure of the tested outcome. In previous studies,
gender and baseline sexual experience have been shown to be
moderators of program impact [32]. To control for the
contextual effects of these variables at the classroom level,
each model included classroom mean gender and classroom
mean sexual experience as covariates. Both classroom-level
variables were centered by subtracting a constant (i.e., the
mean across all classroom means) from each classroom’s
mean.
Results
Attrition
Table 1 presents comparisons of students lost to attrition with
those retained. There were no statistically significant differences in
attrition rates for the SEI and control curriculum groups (22.5% and
21.0%, respectively). Students lost to attrition were more likely to be
older, non-Hispanic, born in the United States, with higher house-
hold socioeconomic status (SES), and with greater acculturation
than were those retained through 1-year follow-up (p < .05). They
were also more likely to have had sex in their lifetime and in the last
3 months, both in terms of vaginal or anal and oral sex (p < .05).
Baseline characteristics and pretest comparability of curriculum
groups
Baseline characteristics of students by curriculum group are
presented in Table 2. Fifty-one percent of students were female.
404 L.A. Rohrbach et al. / Journal of Adolescent Health 57 (2015) 399e406

Mean student age was 14.2 years. Eighty-eight percent of stu-
dents identified as Hispanic, and 81.1% were born in the United
States. Students had a mean household SES score of .57 (scale of
0e3) and a mean acculturation score of 3.77 (scale of 1e5).
Additionally, 14.7% of students reported having had vaginal or
anal sex, and 12.9% reported having had oral sex in their lifetime,
whereas 6.1% reported vaginal or anal sex, and 5.4% reported oral
sex in the previous 3 months. Less than 14% reported having
previously used sexual health services. There were no statisti-
cally significant differences in demographic or behavioral char-
acteristics observed between the SEI and control curriculum
groups at baseline.
Behavioral outcomes
Table 3 presents results for the effects of the SEI curriculum on
student sexual health behaviors. Students in the SEI curriculum
group were significantly more likely to have used sexual health
services than were students in the control curriculum group
(odds ratio [OR], 1.37; 95% confidence interval [CI], 1.05e1.78).
There were no statistically significant effects of the SEI curricu-
lum for the other primary outcomes. In regard to secondary
behavioral outcomes, students in the SEI curriculum group were
significantly more likely to be carrying a condom than were
students in the control group (OR, 1.97; 95% CI, 1.39e2.80). There
were no statistically significant effects of the SEI curriculum for
the other secondary outcomes.
Psychosocial outcomes
Table 4 presents results for the effects of the SEI curriculum on
psychosocial outcomes. The effects were statistically significant
for six of the nine outcomes. The largest effects were for scales
assessing attitudes about relationship rights with a casual part-
ner (adjusted standardized mean difference, .22), sexual health
knowledge (.24), and protection self-efficacy (.20). Additionally,
students in the SEI curriculum group were more likely to report
access to sexual health information and awareness of sexual
health services than students in the control curriculum group
(OR, 1.86; 95% CI, 1.41e2.46 and OR, 1.74; 95% CI, 1.31e2.33,
respectively).
Discussion
The results of this study indicated a number of statistically
significant, positive effects of the SEI on students’ sexual health
behaviors and psychosocial outcomes 1 year after participation
in the curriculum intervention. Previously, we reported that the
SEI curriculum produced positive effects on psychosocial out-
comes immediately after curriculum delivery [22]. In the present
study, we found that most of these short-term effects were
sustained at 1-year follow-up, with higher levels of sexual health
knowledge, self-efficacy, communication, access to sexual health
information, awareness of sexual health services, and more
favorable attitudes among students in the SEI curriculum group
relative to the control (basic sex education) group. The effects of
the curriculum on sexual health behaviors were more limited.
We found positive effects at 1-year follow-up only for use of
sexual health services and condom carrying.
One likely contributor to the pattern of behavioral outcomes
is limited statistical power to detect direct sexual behavior effects
given the relatively low prevalence of sexual behaviors in the
sample. At baseline, 14.7% of the students in the analysis sample
reported having ever had sexual intercourse, which is substan-
tially lower than 2011 prevalence estimates of lifetime sexual
intercourse among ninth-grade students citywide (22.8%) and
across the United States (32.9%) [33]. The relatively lower prev-
alence rate was unanticipated and largely due to the attrition of
higher risk students from baseline to 1-year follow-up.
Although the number of effects on behavioral outcomes was
small, the specific behaviors that were affected by the curriculum
intervention are important. Use of sexual health services and

Table 3
Behavioral outcomes by classroom curriculum group

Outcome, % yes n Control SEI Multilevel regression estimate and effect size ICC

Pretest Follow-up Pretest Follow-up Logit estimate (CI) Odds ratio (CI)

Primary outcomes
Pregnancy riska 1,383 3.6 11.1 3.8 11.8 .09 (.29 to .47) 1.09 (.75e1.60) .000
STI riskb 1,365 5.5 13.4 4.6 12.8 .04 (.40 to .31) .96 (.67e1.37) .000
Multiple sexual partnersc 1,369 2.8 5.6 2.9 4.3 .47 (1.04 to .09) .62 (.35e1.10) .000
Use of sexual health servicesd 1,396 13.1 21.7 15.0 27.7 .31 (.05e.58)* 1.37 (1.05e1.78) .000
Secondary outcomes
Ever had sexe 1,413 15.0 28.6 14.7 31.2 .22 (.10 to .55) 1.25 (.90e1.73) .000
Ever had oral sex 1,400 13.7 22.6 12.3 22.2 .04 (.28 to .36) 1.04 (.75e1.44) .000
Sex in the last 3 months 1,409 5.3 16.7 6.7 18.2 .12 (.20 to .44) 1.13 (.82e1.56) .000
Oral sex in the last 3 months 1,395 5.3 13.0 5.7 10.7 .28 (.65 to .09) .75 (.52e1.09) .000
Condom use at last sexf 202 66.3 58.9 66.4 59.8 .04 (.62 to .70) 1.04 (.54e2.01) .000
Contraceptive use at last sexf 200 71.3 68.1 68.9 64.2 .14 (.81 to .54) .87 (.44e1.71) .000
Currently carrying a condom 1,402 8.9 10.4 12.4 18.4 .68 (.33e1.03)** 1.97 (1.39e2.80) .008

Total N ¼ 1,447.
The final model for all outcomes was adjusted for student gender, classroom mean gender, student sexual experience, classroom mean sexual experience, and pretest
score.
*p < .05. **p < .001.
CI ¼ confidence interval; ICC ¼ intraclass correlation coefficient; SEI ¼ Sexuality Education Initiative; STI ¼ sexually transmitted infection.
a
Sex (vaginal or anal sex) without birth control or condoms in the last 3 months.
b
Sex (vaginal or anal sex) without condoms or oral sex without protection in the last 3 months.
c
More than one sex or oral sex partner in the last 3 months.
d
Ever used sexual health services.
e
Sex was defined as vaginal or anal sex.
f
Limited to students who were sexually experienced at baseline and thus answered sexual behavior items at both pretest and follow-up.
 L.A. Rohrbach et al. / Journal of Adolescent Health 57 (2015) 399e406 405

Table 4
Psychosocial outcomes by classroom curriculum group

Outcome n Control SEI Multilevel regression ICC

estimate and effect size
Pretest Follow-up Pretest Follow-up

Continuous outcomes, mean Estimate (CI) Adjusted standardized

(standard deviation) mean difference (CI)
Rights with steady partnera (1e4) 649 3.25 (.42) 3.37 (.44) 3.23 (.42) 3.41 (.49) .05 (.01 to .12) .13 (.02 to .29) .000
Rights with casual partnera (1e4) 632 3.12 (.47) 3.26 (.46) 3.12 (.47) 3.34 (.52) .09 (.02e.16)* .22 (.05e.38) .012
Communication with partners (0e9) 882 2.78 (2.48) 3.80 (2.98) 2.85 (2.70) 4.20 (2.98) .40 (.04e.76)* .15 (.02e.29) .000
Communication with parents (0e15) 1,356 5.57 (4.47) 7.39 (5.01) 5.89 (4.69) 7.92 (5.19) .32 (.15 to .79) .07 (.03 to .18) .001
Sexual health knowledge (1e17) 1,393 10.89 (2.28) 12.41 (2.11) 10.61 (2.30) 12.81 (2.23) .50 (.24e.75)** .24 (.12e.37) .023
Protection self-efficacy (1e4) 1,290 2.88 (.56) 3.21 (.56) 2.90 (.59) 3.32 (.56) .10 (.05e.16)** .20 (.09e.32) .007
Intentions to protect oneself (1e4) 1,333 3.39 (.66) 3.46 (.60) 3.45 (.60) 3.50 (.63) .02 (.05 to .08) .03 (.08 to .14) .001
Dichotomous outcomes, % yes Logit estimate (CI) Odds ratio (CI)
Access to sexual health information 1,404 42.1% 66.1% 43.5% 77.2% .62 (.34e.90)** 1.86 (1.41e2.46) .022
Awareness of sexual health services 1,411 48.6% 72.6% 47.9% 81.1% .56 (.27e.84)** 1.74 (1.31e2.33) .024

Total N ¼ 1,447.
The final model for all outcomes was adjusted for student gender, classroom mean gender, student sexual experience, classroom mean sexual experience, and pretest
score. The adjusted standardized mean difference represents the regression estimate divided by the within-classroom standard deviation from the final model for each
outcome; CI for the adjusted standardized mean difference represents the regression estimate’s CI divided by the within-classroom standard deviation from the final
model for each outcome.
*p < .05. **p < .001.
CI ¼ confidence interval; ICC ¼ intraclass correlation coefficient; SEI ¼ Sexuality Education Initiative; STI ¼ sexually transmitted infection.
a
Answered by a random half of the sample.

carrying of condoms might be considered indicators of intentions
regarding future sexual behaviors, regardless of whether the
student was sexually experienced at the time. Future research
should examine whether such preparatory behaviors are pre-
dictors of later protective sexual behaviors.
The study exhibits a number of methodological strengths,
including its cluster-randomized design, use of a standard-of-
care control curriculum, strong follow-up rate without indica-
tion of differential attrition between curriculum groups, and use
of multilevel analysis to account for the clustered design [10].
One limitation of the study is the use of self-report outcome
measures, which might be subject to response bias. This concern
should be partly offset by our extensive efforts to enhance the
reliability and validity of the measures, including the use of
cognitive interviews to assess students’ comprehension of the
survey questions [34]; inclusion of items to examine students’
self-reported understanding, honesty, and carefulness [35]; and
protocols to create a confidential environment during survey
administration. A second limitation arises from the different
lengths of the SEI and control curriculum interventions. We
cannot fully disentangle the effect of dosage from the rights-
based content of the SEI curriculum, but the SEI’s conceptual
framework offers a persuasive plausible explanation for the
identified effects. A third limitation is that the SEI and control
curricula were compared within the context of two school con-
ditions representing different versions of the multicomponent
intervention. The study lacked adequate statistical power to
examine the interaction between the effect of the curriculum and
that of the school-wide components. A fourth limitation is the
possibility of control group contamination due to colocation of
intervention and control classrooms in the same schools, which
could reduce the likelihood of detecting actual intervention ef-
fects. Finally, the findings of this study might not be generalizable
to populations beyond this sample of urban, low-income, pre-
dominantly Hispanic high-school students. Additional research
will be needed to understand the potential effects of the cur-
riculum on other population subgroups.
Despite these limitations, this study offers an important step
in understanding the potential impact of rights-based sexuality
education interventions for adolescents. The pattern of sustained
effects of the SEI curriculum on psychosocial outcomes is
consistent with findings from conceptually similar interventions
addressing the intersection of youth sexuality and gender norms,
among school-based populations in Uganda [18] and clinic-based
studies of sexually active African-American adolescent girls
[19,36]. Furthermore, these latter studies of adolescents in the
United States have shown evidence of positive changes in
behavioral outcomes. Our study adds to this literature, high-
lighting the potential influence of discussions of gender equality
and sexual rights in relationships on adolescents’ sexual health
knowledge, attitudes, and behaviors.
The implications of our findings for the larger understanding
of a rights-based approach for young adolescents are not fully
clear. It would not be appropriate to conclude that such in-
terventions can have no effect on adolescent sexual behaviors. It
is a challenge for any study to find an impact of an intervention
on low-prevalence outcomes [37], and this may be particularly so
for sexuality education programs that target younger adoles-
cents. Sustained psychosocial effects are more common to such
intervention studies than are behavioral effects for this reason
[38e40]. Adolescent development theory suggests that in-
terventions should be provided early, and prevention education
before sexual initiation is an important strategy for the promo-
tion of safe sexual behaviors. At the same time, booster sessions
provided throughout adolescence might be required to reinforce
messages, reduce risks, and promote healthy decisions as more
youth begin to engage in sexual relationships.
In conclusion, this study offers evidence that a rights-based
sexuality education curriculum can have positive effects on
young adolescents’ psychosocial outcomes 1 year after partici-
pation and thus may be a good strategy for promoting healthy
sexual development. The rights-based curriculum approach
holds promise for impacting sexual health behaviors, yet it might
not be sufficient to produce measurable changes in these be-
haviors at 1-year follow-up among younger adolescents, most of
whom are not sexually active. Further research with different
populations in diverse settings and over longer periods of follow-
up will increase the field’s understanding of the potential
406 L.A. Rohrbach et al. / Journal of Adolescent Health 57 (2015) 399e406
effectiveness of this and other rights-based approaches to
sexuality education. Similarly, the field would benefit from more
research on multicomponent rights-based interventions,
employing study designs that enable the researcher to determine
which component or combination of components is most effec-
tive in producing the desired outcomes.
Acknowledgments
The authors thank Gaylene Gunning for data collection
management, Jennifer Tsai for analysis support, and the Planned
Parenthood Los Angeles staff and leadership for following the
rigorous study protocol.
Funding Sources
This study was funded by Planned Parenthood Los Angeles
(contract number 04975-01-01), with additional support from
the Ford Foundation (grant number 1120-2773) and the William
and Flora Hewlett Foundation (grant number 2013-9222).
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