JOURNAL OF ADOLESCENT HEALTH 2000;27:236–247
ORIGINAL ARTICLE
Postponing Sexual Intercourse Among Urban Junior
High School Students—a Randomized Controlled
Evaluation
SIGRID J. AARONS, M.P.H., RENEE R. JENKINS, M.D., TINA R. RAINE, M.D., M.P.H.,
M. NABIL EL-KHORAZATY, Ph.D., KATHY M. WOODWARD, M.D.,
RICK L. WILLIAMS, Ph.D., MARC C. CLARK, M.S., AND BARBARA K. WINGROVE, M.P.H.
Purpose: To describe a randomized, controlled evalua-
tion of a school-based intervention to delay sexual inter-
course among urban junior high school students.
Methods: Six Washington, D.C., junior high schools
were randomly assigned to the intervention or noninter-
vention control condition for an educational program.
During the first school year, seventh graders (n ⴝ 582)
from the six schools obtained written parental consent to
participate. Three health professionals (one per interven-
tion school) implemented the program, which consisted
of reproductive health classes, the Postponing Sexual
Involvement Curriculum, health risk screening, and
From the Department of Obstetrics and Gynecology, Howard Uni-
versity College of Medicine (S.J.A.), Washington, DC (currently at the
Population Council, New York, New York); Department of Pediatrics
and Child Health, Howard University College of Medicine (R.R.J.),
Washington, DC; Department of Obstetrics and Gynecology, George-
town University Medical Center (T.R.R.), Washington, DC (currently
at the Department of Obstetrics and Gynecology, University of Califor-
nia at San Francisco); Research Triangle Institute (M.N.E.-K.), Rock-
ville, Maryland; Division of Adolescent and Young Adult Medicine,
Children’s National Medical Center (K.M.W.), Washington, DC; Re-
search Triangle Institute (R.L.W.), Research Triangle Park, North
Carolina; Office of the Chief Academic Officer, Comprehensive School
Health Program, District of Columbia Public Schools (M.C.C.), Wash-
ington, DC; The National Institute of Child Health and Human
Development (B.K.W.), Bethesda, Maryland.
Dr. Aarons is currently a public health consultant in New York, New
York. Dr. Raine is currently affiliated with the University of California
at San Francisco.
Address correspondence and reprint requests to: Renee R. Jenkins,
M.D., Chairman, Department of Pediatrics and Child Health, Howard
University Hospital, 2041 Georgia Avenue N.W., Washington, DC
20060.
Manuscript accepted December 23, 1999.
The full text of this article is available via JAH Online at http://
www.elsevier.com/locate/jahonline.
1054-139X/00/$–see front matter
PII S1054-139X(00)00102-6 Published by Elsevier Science Inc., 655 Avenue of the Americas, New York, NY 10010
“booster” educational activities during the following
(eighth grade) school year. Cross-sectional surveys were
administered at baseline, the end of the seventh grade,
and the beginning and end of the eighth grade. Interven-
tion and control group differences in virginity, attitudes
toward delayed sex and childbearing, and sexual knowl-
edge and behavior were assessed at all four time points.
Results: At baseline, 44% of the seventh grade males
and 81% of the seventh grade females reported being
virgins. At the end of the seventh grade (first follow-up),
after controlling for baseline study group differences,
intervention-group females were more likely to report
virginity, self-efficacy to refuse sex with a boyfriend, and
the intention to avoid sexual involvement during the
following 6 months. At the end of the eighth grade,
significantly more intervention- than control-group fe-
males reported virginity, birth control use at last inter-
course (for nonvirgins), and knowledge of adolescent
reproductive health and confidentiality rights. No
changes in virginity, self-efficacy to refuse sex, or sexual
intent for the next 6 months were observed among male
participants at any time during the study. However, on
all three follow-up surveys, intervention-group males
scored significantly higher than their control-group
counterparts in knowledge of birth control method effi-
cacy. No change in attitudes toward abstinence was
observed for either gender at any follow-up point.
Conclusions: Gender differences in baseline sexual
activity rates and in various study outcomes suggest a
possible need for separate, gender-specific intervention
activities that can adequately address the social and
cognitive needs of both sexes. © Society for Adolescent
Medicine, 2000
© Society for Adolescent Medicine, 2000
October 2000
KEYWORDS:
Abstinence
Adolescents
Sexuality
Gender differences
Pregnancy prevention
Virginity
Although currently in decline, the teenage preg-
nancy and birth rates in the District of Columbia are
among the highest in the nation (1). In 1991, the birth
rate was 116 per 1000 women aged 15–19 years,
almost twice the national average of 62 per 1000
women (1,2). In 1992, the National Institute of
Health’s Office of Research on Minority Health and
the National Institute of Child Health and Human
Development began a collaborative research effort
known as the NIH-DC Initiative to Reduce Infant
Mortality in Minority Populations in the District of
Columbia. Recognizing the link between early child-
bearing and poor birth outcomes in the District (3),
the investigators devoted one arm of this research
endeavor to studying strategies for reducing adoles-
cent pregnancy. This article describes a randomized
trial of an intervention designed to prevent adoles-
cent pregnancy by delaying sexual activity among
7th graders.
School-based sexuality education programs have
traditionally focused on increasing students’ knowl-
edge of reproductive anatomy and of the risks asso-
ciated with unprotected sexual intercourse (4). While
these efforts have successfully improved knowledge,
behavioral change has been noted only when the
program has included contraceptive information
coupled with strategies for resisting peer or social
pressure to engage in sexual activity (5–7). Programs
that have used this method, in addition to providing
accessible “teen friendly” reproductive health ser-
vices, have demonstrated reductions in early sexual
activity and unintended pregnancy (8).
Although several different teen pregnancy-pre-
vention program strategies have been implemented
(4), few randomized, controlled studies have been
conducted to evaluate their effectiveness (9). This
intervention combined elements of two previously
evaluated school-based adolescent pregnancy-pre-
vention programs: Postponing Sexual Involvement
(PSI) (6), and the Self Center (8). The PSI peer
education curriculum was coupled with individual
and small group education methods adapted from
the Self Center model. The goal was to determine
whether this multifaceted approach would be suc-
SCHOOL-BASED PROGRAM TO DELAY SEX 237
cessful in delaying sexual activity among a sample of
seventh grade students in Washington, DC.
In 1993, 25% of high school males and 12% of high
school females responding to the Youth Risk Behav-
ior Survey (YRBS) in the District of Columbia re-
ported initiating sexual intercourse prior to age 13
years (10). For this reason, the investigators chose to
intervene in the seventh grade and decided on an
“abstinence plus” program strategy that would pro-
mote sexual abstinence while providing contracep-
tive information and referrals to appropriate services
for sexually active participants.
The conceptual model used in designing the study
was derived from Social Cognitive Theory (11),
which posits that an individual’s ability to engage in
or avoid a specific behavior is determined by the
interaction of personal factors such as gender, risk
perception, and self-efficacy, with environmental
factors such as family structure, parental involve-
ment, and peer behavior. The resulting program
model, adapted from Petersen et al. (12), proposed
that the intervention, moderated by gender, aca-
demic performance, living arrangements, and other
risk behaviors such as alcohol and tobacco use,
would enable students to postpone sexual involve-
ment by improving their attitudes towards absti-
nence, self-efficacy to refuse sex, and knowledge of
reproductive health. The project investigators hy-
pothesized that intervention group students would
be more likely than the control group students to
report virginity, self-efficacy to refuse sex, and pos-
itive attitudes toward abstinence and delayed child-
bearing. In addition to these outcomes, the interven-
tion was also expected to have an impact on: 1)
beliefs about sexual activity of peers, 2) sexual intent
for the next 6 months, 3) communication with par-
ents and peers about sexuality, 4) knowledge of
available contraceptive methods and services for
adolescents, and 5) contraceptive use at last inter-
course among sexually active students.
Methods
The study protocol was reviewed and approved by
the Institutional Review Boards (IRB) of each collab-
orating institution, including that of the school sys-
tem, the Office of Educational Accountability, As-
sessment, and Information.
Design
A nonprobability sample of six schools was selected
among the 28 middle and junior high schools in the
238 AARONS ET AL.
District of Columbia. Schools were chosen based on
their proximity to one of the three adolescent health
clinics affiliated with the study, and all agreed to
participate. To enhance the diversity of the student
sample, two of the schools were selected because of
their high Latino student enrollment. The schools
were paired according to 7th grade class size, loca-
tion, and racial/ethnic distribution, and then ran-
domly assigned to the intervention or control group.
The study began in February 1996 with 7th grad-
ers and continued through the following school year
(fall 1996/spring 1997) as students entered and com-
pleted the 8th grade. Students in both study groups
were surveyed at four intervals: baseline (T0: Febru-
ary 1996), the end of 7th grade (T1: May 1996), the
beginning of 8th grade (T2: October/November
1996), and the end of 8th grade (T3: April/May 1997).
The study used a cross-sectional design, and the
instruments were administered anonymously with-
out identifiers.
Written parental consent was obtained prior to the
baseline survey and again at the beginning of the
eighth grade school year. Student assent was ob-
tained by preamble for each survey administration
and by signature for the seventh and eighth grade
intervention activities.
School Recruitment and Parental Consent
Recruitment of the six schools began during the fall
of 1995 with letters to the principals introducing the
project and inviting their participation. As an incen-
tive for participation, each school was guaranteed a
small monetary stipend. Other methods used to obtain
school and community “buy-in” included investigator
attendance at PTA and community meetings and the
appointment of a teacher or staff member to serve as a
liaison to the project in each school.
Parental consent forms were distributed to 7th
grade classrooms by project staff members, who
requested that students bring the forms back with a
parental signature. To increase the rate of consent
form return, new forms were distributed to students
who did not turn in the initial ones, and school staff
made periodic announcements reminding students
to return the forms. Incentives were offered to class-
rooms achieving a 70% or greater consent form
return rate.
Sample
Students from the six schools were considered eligi-
ble for study participation if they were enrolled in
the 7th grade at the beginning of the study, enrolled
JOURNAL OF ADOLESCENT HEALTH Vol. 27, No. 4
in the 8th grade at the beginning of the 1996 –1997
academic year, not truant or suspended during the
consent process or questionnaire administration, and
capable of reading and comprehending the question-
naire in English or Spanish.
Eight-hundred twelve (91%) of the 896 7th graders
enrolled in the six schools at the beginning of the
study met the eligibility criteria for participation. Of
these, 582 students (72%) received parental consent
to participate, 522 (64%) (274 females and 248 males)
completed the baseline survey (T0), and 503 (62%) (271
females and 232 males) completed the first follow-up
survey (T1). These numbers were distributed evenly
between intervention and control groups (262 interven-
tion and 260 control at T0, and 253 intervention and 250
control at T1). Among the 503 students completing
the first follow-up survey (T1), 418 (83%) (202 inter-
vention group students and 216 control group stu-
dents) reported completing the baseline survey.
The following school year, 832 (94%) of the 885 8th
graders enrolled in the six schools met the eligibility
criteria, and 626 (75%) of these students received pa-
rental consent to participate. Among these, 564 stu-
dents (68%) (290 females and 274 males) completed the
second follow-up survey (T2), and 510 students (61%)
(270 females and 240 males) completed the final survey
(T3). Students who reported on the 8th grade follow-up
surveys (T2 and T3) that they did not attend one of the
six study schools or were not in the 7th grade during
the previous school year were excluded from the data
set. In addition, two students, one male and one female,
were excluded from the third follow-up survey be-
cause of a large number of inconsistencies in their
responses to various questions, including their age. As
a result, a total of 459 students (55%) (240 females and
219 males) is included in the data set for the second
follow-up survey and 422 students (51%) (224 females
and 198 males) were included in the data set for the
third follow-up survey. Again, students were evenly
distributed between the two study groups (226 inter-
vention and 233 control at T2, and 209 intervention and
213 control at T3). Among the 422 students completing
the final follow-up survey (T3) at the end of the eighth
grade, 293 (69%) reported completing the second
follow-up survey (T2) at the beginning of the school
year, and 107 (25%) marked “don’t remember.”
Analysis of school-wide demographic data re-
vealed that the study sample was similar to the
overall school population with regard to race and
gender. Participation in the federal reduced-price
and free lunch programs was used as a proxy mea-
sure for socioeconomic status. A review of unpub-
lished data from the D.C. Public Schools’ central
October 2000
database on the school lunch program indicated that
students in the study sample reported only slightly
lower rates of participation in the program, com-
pared with the overall participation rates for D.C.
schools. These differences were statistically signifi-
cant for only one of the six study schools.
The Intervention
A full-time health professional (project “facilitator”)
was assigned to each of the three treatment schools
to implement the intervention. A bilingual facilitator
was assigned to the school with the higher Latino
student enrollment. The intervention began in March
1996, with three classroom sessions on reproductive
health presented by the facilitators using a locally
prepared curriculum (13). These three classes were
followed by the five-session PSI curriculum, which
was taught by peer leaders, 10th and 11th graders
recruited from nearby high schools (14). The repro-
ductive health and PSI sessions were presented dur-
ing regular 45-minute class periods to seventh grade
students with parental consent. The bilingual facili-
tator and peer leaders conducted separate classes for
the Spanish-speaking students.
In May 1996, prior to the first follow-up survey,
intervention students completed a health risk assess-
ment questionnaire adapted from the Improve Your
Medical Care instrument (15). The questions ad-
dressed self-rated health, risk behavior, school per-
formance, physical fitness, social support, and de-
pression. A protocol to assess students’ degree of risk
was developed using the Guidelines for Adolescent
Preventive Services (GAPS) (16). Facilitators con-
ducted individual interviews with high-risk students
(those who reported substance use, physical abuse,
sexual activity, or emotional problems) using a
preprepared series of questions adapted from GAPS.
Intervention activities resumed in November 1996
with facilitators presenting the three reproductive
health classes from the previous year to all consent-
ing 8th grade students. A series of “booster” activi-
ties, educational sessions designed to reinforce the
concepts of abstinence and better self-care, was also
introduced as part of the intervention’s second
phase. The main booster activity consisted of “brown
bag sessions,” small informal voluntary group dis-
cussions (limited to 15 students) offered during
lunch or midday free periods. The decision to in-
clude small group discussions in the intervention
strategy was based on the Self Center project’s suc-
cess in using this method (8). The goal was for all
SCHOOL-BASED PROGRAM TO DELAY SEX 239
consenting students to attend at least one brown bag
discussion. Eight brown bag topics (one per week)
covering a range of adolescent health issues (e.g.,
gang violence, drug abuse, personal hygiene, teen
pregnancy, etc.) were presented. Separate brown bag
sessions were held for the Spanish-speaking stu-
dents. Facilitators were expected to speak privately
at least once with students who attended the brown
bag sessions to find out whether they had questions
about the topics presented or other health-related
matters.
Additional booster activities included an 8th
grade assembly on sexually transmitted diseases and
a student contest. The assembly was a one-time event
presented in each intervention school by health pro-
fessionals from the affiliated clinics. A bilingual
physician gave the same presentation to the Spanish-
speaking students. Eighth grade intervention stu-
dents were also invited to participate in a contest for
which they could create a poem, song, essay, draw-
ing, or T-shirt design on an intervention-related
topic. Three winners were selected from each school
and awarded a small monetary prize. At the end of
the intervention, each student participant received a
T-shirt bearing a drawing inscribed with a message
to reinforce the intervention theme: “Be Smart, Don’t
Start.”
Survey Instrument
The survey instrument was selected and adapted
from previously validated instruments, including the
Centers for Disease Control and Prevention core
questionnaire (17), the YRBS, and evaluation instru-
ments from the PSI and Self Center programs (18 –
20). The final instrument was a 75-item, self-admin-
istered questionnaire that included questions on
demographics, smoking and alcohol use, health ser-
vice utilization, sexual behavior and attitudes, and
contraceptive knowledge and use. It was pretested in
two rounds of in-depth cognitive interviews with
age-appropriate adolescents recruited from a local
summer youth program. Following the cognitive
interviews, a “mock” classroom administration was
conducted in a nonproject school to finalize logistics
and ensure that students could complete the survey
in one classroom period. When item format and
wording were finalized, the instrument was trans-
lated into Spanish and then reviewed independently
by two additional native Spanish speakers.
240 AARONS ET AL.
Outcome Measures
The outcome measures included six single items
(virginity, intention to have sex in the next 6 months,
beliefs about sexual activity of peers, birth control
use at last intercourse, ability to refuse sex within an
established girl/boyfriend relationship, and ability
to refuse sex with someone they just met), and six
scales (attitudes toward postponing sex, attitudes
toward delaying childbirth, birth control knowledge,
parent communication, girl/boyfriend communica-
tion, and knowledge of reproductive health services
for adolescents). The primary outcome variable, vir-
ginity status, was based on the student’s response to
the question “How old were you the first time you
had sex?” (with the word ‘sex’ referring to sexual
intercourse), to which he/she could either respond “I
have never had sex” or mark a specific age. Response
consistency was evaluated by checking students’
answers to other questions on contraceptive use and
pregnancy history. When there were discrepancies in
a student’s responses, the data were considered
missing and excluded from the analysis.
Multi-item scales of variables thought to mediate
the initiation of sexual intercourse among adoles-
cents were also constructed from subsets of single
items. Scaling analysis (i.e., item selection and opti-
mal weighting) was conducted using intervention
school data from the third follow-up survey. Con-
ventional scaling methods were used for preliminary
exploratory purposes. The degree of internal consis-
tency was assessed for each proposed scale using
Cronbach coefficient alpha (21). When a sufficiently
unidimensional set of items was identified, re-
sponses to questions were optimally weighted using
item response theory techniques, as implemented in
the computer program Multilog (22), in order to
produce scales with minimal measurement error. For
a description of the items and complete details of all
scaling analysis and validation of study results, see
Williams et al. (23).
Analytic Procedures
The study was planned as a matched-pair design
using the schools as the unit of randomization. Three
pairs of schools, two pairs with mostly African-
American students, and a third pair with a high
percentage of Latino students, were formed. Stu-
dents were assigned to the control or intervention
group based on the random assignment of the six
schools. Because of unexpected school-level changes
(e.g., closing and relocation of one school, changes in
JOURNAL OF ADOLESCENT HEALTH Vol. 27, No. 4
race/ethnicity distribution, and differentials in socio-
economic status) and the small number of schools,
the decision was made to use students as the units of
analysis (24 –25).
The study was cross-sectional by design, and no
identifiers of any kind were used. Consequently, the
effect of the intervention was estimated by an appro-
priate measure of the difference between the two
groups of students with respect to the outcomes of
interest. For the primary outcome measure, virginity
status, and intermediate outcomes, which are binary
variables, two measures were used: the difference in
rates between the groups and the relative odds (odds
in the intervention group/odds in the control
group). Data were analyzed using exact tests (26)
and FREQ, REG, and LOGISTIC procedures in SAS
software. The difference between the two groups
(intervention ⫺ control) in the means of the mea-
sures was used for continuous measures such as the
derived scales. Data on male and female students
were analyzed separately for two reasons: (1) the
virginity rate prior to the intervention was substan-
tially higher for females, compared with males, and
(2) in some instances, males and females responded
to different sets of questions (e.g., only females
responded to the question on menstruation).
To ensure that intervention effects were not the
result of chance and/or systematic differences be-
tween the two study groups, a battery of statistical
tests and procedures was employed to decide which
set of variables needed to be controlled for in the
multivariate analysis for each gender. Statistical ad-
justments for differences between the two study
groups were made using a logistic regression model
for binary outcomes (e.g., virginity status) and a
linear regression model for the derived scales. A
two-tailed test (95% confidence interval) was used
for assessing the statistical significance of various
differences (e.g., differences between the interven-
tion and control groups on demographic and socio-
economic characteristics and gender differences).
The variables on which the two groups differed were
included as covariates in the models. To examine the
impact of the intervention, a one-tailed test was used
for assessing the statistical significance of differences
found between intervention and control groups,
whereas a two-tailed 95% confidence interval was
used to indicate the precision of the parameters’
estimates. As a result of this dichotomy, the confi-
dence interval might include one (for odds ratios) or
zero (for differences in outcome measures) even
though the differences (based on the one-tailed tests)
are statistically significant.
October 2000 SCHOOL-BASED PROGRAM TO DELAY SEX 241

Table 1. Comparisons of Male and Female Students and Intervention and Control Groups by Gender According to
Baseline (T0) Characteristics
Females Males Total
Intervention Control Intervention Control Females Males
Baseline Characteristics n ⫽ 139 n ⫽ 135 n ⫽ 123 n ⫽ 125 n ⫽ 274 n ⫽ 248
Age, mean (years) 12.70 12.66 12.94 12.99 12.68 12.97
Ethnicity, %:
African-American 84.9 84.4 87.8 76.8 84.7 82.3
Hispanic 11.5 12.6 10.6 17.6 12.0 14.1
Other 2.9 0.7 0 2.4 1.8 1.2
Grade, %:
mostly A/B 25.2 41.5 26.8 20.8 33.2 23.8
mostly B/C 51.8 43.7 39.8 44.8 47.8 42.3
mostly C/D/F 21.6 14.1 30.9 32.8 17.9 31.9
Free lunch program, %: Yes 53.2 68.9 61.8 68.0 60.9 64.9
Household living arrangements, %:
Both parents 53.2 38.5 48.8 40.8 46.0 44.8
Single parent only 21.6 31.9 26.8 30.4 26.6 28.6
One parent and other adult 16.5 19.3 18.7 16.0 17.9 17.3
No parent 8.6 9.6 4.9 11.2 9.1 8.1
Smoking, %: Yes 28.8 27.4 26.0 24.0 28.1 25
Drinking alcohol, %: Yes 46.8 49.6 55.3 44.0 48.2 49.6
Finish high school, %: Yes 99.3 97.8 95.1 96.0 98.5 95.6
Go for further education, %: Yes 60.4 57.8 54.5 54.4 59.1 54.4
Virginity rates, % 83.7 78.0 44.9 43.1 80.9 44
Definitely not have sex in next 6 months, % 57.6 48.9 16.3 20.0 53.3 18.1
Most boys/girls my age are not having sex, % 7.2 3.8 12.7 5.0 5.5 8.8
Used birth control/condoms last time had sex 39.1 27.3 79.7 71.2 32.1 75.4
(for those who had sex), %
Would not have sex with someone just met, % 72.7 78.6 20.5 25.6 75.6 23.1
Would not have sex if friend wants to and 72.7 68.2 23.9 22.1 70.5 23.0
he/she does not feel ready, %
Note: Italics and underline indicate significance at 5% level.

Sample Characteristics may be attributed to changes in individual student

The baseline distribution of background variables
and outcomes of interest is presented in Table 1. The
study population was 52% female, 84% African-
American, and the average age was 12.8 years.
Female students were significantly younger than the
males (12.68 vs. 12.97 years). Participation in the free
or reduced-price school lunch program, a proxy
measure for socioeconomic status, averaged 63%.
Forty-six percent of the students reported living with
both parents, and an equal percentage lived either
with a single parent or with one parent and another
adult. Nearly 9% of students reported living with no
parents at all.
The majority of both male and female students
reported average grades (“mostly B/C’s”), although
males were significantly more likely to report “most-
ly C’s, D’s, and F’s,” and females were significantly
more likely to report “mostly A’s and B’s.” More
than 95% of students expected to finish high school.
Changes in the sample characteristics over time
behavior or to the cross-sectional design of the study,
which resulted in resampling of subjects. Back-
ground demographic variables were similar at each
follow-up measurement, with a few exceptions noted
at the end of the eighth grade (T3): 1) significantly
fewer male students described themselves as Afri-
can-American and more classified themselves as
“other,” and 2) a significant gender difference in
living arrangements was observed, with 48.5% of
males reporting that they lived with both parents,
compared with 38.4% of females.
As for risk behaviors, half of the students reported
having had a drink of alcohol, and less than one third
stated that they had tried smoking a cigarette at
baseline (T0). These proportions increased signifi-
cantly at each follow-up measurement for both male
and female students. At the end of the eighth grade
(T3), 65.6% of females and 60.6% of males reported
having had a drink of alcohol, and 42.9% of females
and 34.8% of males reported having tried smoking.
242 AARONS ET AL.
Forty-four percent of males and 81% of females
reported being virgins at baseline (T0). The gender
differences in this and other selected outcome mea-
sures (Table 1) emphasized the need for separate
analyses.
With regard to study group differences, baseline
data indicated that control-group males were more
likely to be Latino or “other,” to live with a single
parent or no parents, to participate in the free or
reduced-price lunch program, and to report no pre-
vious alcohol consumption. Follow-up data revealed
differences between intervention and control males
in age distribution, grades, lunch program participa-
tion, household living arrangements, and maternal
work time outside the home. These differences were
controlled for in the multivariate analysis.
For females, baseline data indicated that students
in the control group had higher grades and school
lunch participation rates and were less likely to be
living with both parents. Follow-up data depicted
differences between intervention and control females
with respect to age, grades, and school lunch pro-
gram participation, all of which were controlled for
in the multivariate analysis. Further discussion and
analysis of the study population at baseline can be
found in Raine et al. (27).
Results
On the first follow-up survey (T1), 196 of the 202
intervention-group students who reported complet-
ing the baseline survey indicated that they had
attended PSI classes. Among students who reported
PSI participation, 74% of the females and 73% of the
males indicated that they had attended at least three
of the five PSI sessions. A subsample analysis com-
paring students who reported attending three or
more PSI sessions with those who reported atten-
dance at fewer than three sessions revealed a signif-
icantly greater percentage of females with good
grades (“mostly A’s and B’s”) in the higher-atten-
dance group (32% versus 11%, p ⬍ .05). Among
males, a significantly greater proportion of those
who indicated that they would not have sex in the
next 6 months were in the higher-attendance group
(25% versus 4%, p ⬍ .05). It is possible that a
self-selection bias occurred and that students at
lower risk for sexual involvement may have attended
more PSI sessions. No other significant differences
between the two subgroups were noted.
Of the 234 intervention-group students who com-
pleted the health risk assessment instrument at the
JOURNAL OF ADOLESCENT HEALTH Vol. 27, No. 4
end of the 7th grade, 53 (23%) were assessed as high
risk and targeted for individual interviews with the
facilitators. As for the booster activities, attendance
records indicated that 216 students attended one
brown bag session, and 127 of these attended two or
more sessions. Of the 209 intervention students com-
pleting the final follow-up survey (T3), 150 indicated
that they had attended the eighth grade assembly on
sexually transmitted diseases. Participation in the
student contest was minimal, with less than 20
students preparing entries for the three schools com-
bined. In general, the drop in student participation
over time and variable levels of participation created
difficult measurement and evaluation challenges that
are both time and resource intensive to address.
Adjusted outcome measures obtained for both
genders after controlling for the intervention and
control group differences noted above are presented
in Table 2. Results are reported with a 5% signifi-
cance level. For females, after controlling for study
group differences, significant intervention effects
were identified with respect to virginity, sexual
intent for the next 6 months, beliefs about sexual
activity of female peers, use of birth control at last
intercourse (among those who had sex), ability to
refuse sex with a boyfriend, and knowledge of re-
productive health services.
Virginity status. Intervention-group females had
higher virginity rates than control group females at
all four measurement points. The difference was
significant only at the end of the eighth grade (T3),
however (11.1%, 95% confidence interval (CI): ⫺2.0,
24.2). After adjusting for differences between the two
groups (Table 2), the odds ratios were significantly
higher for intervention-group females at the end of
the 7th grade (T1) (2.09; CI: 1.10, 3.95) and at the end
of the 8th grade (T3) (1.9; CI: 1.02, 3.47).
Definitely not have sex in the next 6 months. In all
four surveys, a greater percentage of females in the
intervention group said that they definitely would
not have sex in the next 6 months. The difference
between the two groups, however, was significant
only at the end of the 7th grade (T1) (11.4; CI: ⫺1.2,
24.0) when 57.3% of intervention-group females re-
ported no intention to have sex within the next 6
months, compared with 45.9% of the control-group
females. The odds ratio was also significant at T1 but
only after controlling for differences between the two
groups (Table 2).
 October 2000

Table 2. Adjusted Parameters (Odds Ratios and Regression Coefficients) for the Effect of Intervention by Gender on Virginity Status and Various
Intermediate Outcome Measures
Femalesa Malesb
T1 (End of T2 (Beginning of T3 (End of T1 (End of T2 (Beginning of T3 (End of
Outcome Measures 7th Grade) 8th Grade) 8th Grade) 7th Grade) 8th Grade) 8th Grade)
Single Items Odds Ratios of Intervention vs. Control (95% Confidence Interval)
Virginity 2.09c (1.10, 3.95) 1.77 (0.93, 3.36) 1.88c (1.02, 3.47) 1.46 (0.79, 2.71) 0.95 (0.51, 1.76) 1.18 (0.61, 2.29)
Definitely not have sex in the next six months 1.88c (1.11, 3.19) 1.28 (0.76, 2.18) 1.71 (0.97, 3.03) 1.32 (0.63, 2.77) 0.62 (0.30, 1.28) 0.32 (0.13, 0.80)
Most of those my age are not having sex 16.91c (2.12, 134.62) 3.24 (0.80, 13.07) 2.18 (0.48, 9.84) 3.16c (1.07, 9.33) 3.15 (0.89, 11.13) 1.05 (0.19, 5.78)
Used birth control/condoms last time had sex 3.86c (1.10, 13.47) 7.43c (1.90, 28.99) 3.39c (1.16, 9.95) 1.47 (0.64, 3.42) 1.03 (0.41, 2.61) 1.53 (0.55, 4.26)
Would not have sex with someone just met 1.47 (0.82, 2.63) 1.13 (0.62, 2.08) 1.14 (0.62, 2.13) 1.58 (0.85, 2.92) 0.94 (0.47, 1.88) 0.86 (0.43, 1.71)
Would not have sex if we are friends and 2.02c (1.14, 3.59) 1.09 (0.63, 1.90) 1.30 (0.73, 2.30) 1.71 (0.91, 3.19) 1.07 (0.52, 2.20) 0.75 (0.36, 1.55)
I do not feel ready
Scales Difference of Intervention—Control (95% Confidence Interval)
Attitudes toward delayed initiation of sex 0.08 (⫺0.03, 0.19) 0.03 (⫺0.08, 0.15) 0.06 (⫺0.06, 0.18) 0.06 (⫺0.18, 0.30) 0.03 (⫺0.22, 0.28) ⫺0.002 (⫺0.25, 0.25)
Attitudes toward delayed childbearing ⫺0.05 (⫺0.15, 0.05) ⫺0.02 (⫺0.14, 0.10) ⫺0.03 (⫺0.15, 0.11) 0.24c (0.06, 0.43) 0.21c (0.03, 0.38) 0.07 (⫺0.10, 0.23)
Birth control knowledge 0.09 (⫺0.08, 0.25) 0.12 (⫺0.03, 0.27) 0.02 (⫺0.16, 0.20) 0.34c (0.17, 0.52) 0.21c (0.03, 0.39) 0.23c (0.03, 0.43)
Parent communication ⫺0.03 (⫺0.26, 0.19) 0.04 (⫺0.18, 0.26) 0.04 (⫺0.19, 0.27) 0.002 (⫺0.20, 0.21) ⫺0.03 (⫺0.25, 0.19) ⫺0.19 (⫺0.41, 0.04)
Boy/girlfriend communication ⫺0.20 (⫺0.37, ⫺0.03) ⫺0.08 (⫺0.27, 0.10) ⫺0.09 (⫺0.28, 0.11) ⫺0.05 (⫺0.25, 0.14) ⫺0.02 (⫺0.24, 0.21) 0.03 (⫺0.19, 0.25)
Knowledge of reproductive health services 0.08 (⫺0.10, 0.27) 0.10 (⫺0.09, 0.28) 0.19c (⫺0.02, 0.39) — —
a
Controlling for age, grades, and free lunch program for females.
b
Controlling for age, grades, free lunch program, household living arrangements, and mother’s employment for males.
c
Significant at 5% level of significance (one-sided test).
SCHOOL-BASED PROGRAM TO DELAY SEX
243
244 AARONS ET AL.
Most girls my age are not having sex. A higher
percentage of intervention-group females believed
that most girls their age were not having sex, com-
pared with control group females in all four surveys.
However, this difference was also significant only at
the end of the 7th grade (T1). Similarly, both before
and after adjustment, the odds ratio was significantly
higher in the intervention group at T1 only. The
adjusted odds ratio at T1 was 16.91, indicating that
intervention females were 17 times more likely to
report that girls their age were not having sex.
Used birth control at last intercourse (among nonvir-
gins). At all three follow-up measurements, more
sexually active females in the intervention group
used some form of birth control at last intercourse,
compared with the control group. Similarly, the odds
ratios were 3 to 5.5 times higher for intervention
group females at T1, T2, and T3. After adjusting for
study group differences, the odds ratios varied from
3.5 to 5 times higher for the intervention group.
Would not have sex if boyfriend wants to and she does
not feel ready. At all four measurements, a higher
percentage of intervention-group females reported
that they could refuse sex with their boyfriend if they
did not feel ready. This difference was significant,
however, only at the end of the 7th grade (T1) (12.0%
CI: 0.4, 23.6). Similarly, the odds ratio was signifi-
cantly higher for intervention-group females at T1
only (1.78 CI: 1.1, 3.0). The adjusted analysis gave
similar results.
Knowledge of reproductive health services scales. In-
tervention females had significantly higher knowl-
edge scores than control-group females only at the
end of the 8th grade (T3).
Most boys my age are not having sex. At the end of
the 7th grade (T1), 15.9% of intervention males re-
ported believing that most boys their age were not
having sex, compared with only 4.5% of control
males. There was no significant difference between
the intervention and control groups at any other
follow-up measurement. The odds ratio was three
times significantly higher for intervention males at
baseline (T0) and T1. Similar results were obtained
after adjusting for differences between the two study
groups (Table 2).
Attitudes toward delayed childbearing. Significantly
more intervention- than control-group males indi-
cated positive attitudes toward delayed childbearing
JOURNAL OF ADOLESCENT HEALTH Vol. 27, No. 4
at the end of the 7th and beginning of the 8th grades
(T1 and T2). After controlling for group differences,
results similar to the unadjusted analysis were ob-
tained.
Birth control knowledge scale. The intervention-
group males had significantly higher birth control
knowledge scores, compared with the control group
in all the three follow-up surveys. The adjusted mean
difference for the birth control knowledge scale was
also significant at all three follow-up points.
For males, after controlling for study group dif-
ferences, significant program effects were found with
respect to their belief about whether other boys their
age are having sex, attitudes toward delayed child-
bearing, and birth control knowledge.
Discussion
This study tested the effect of an intervention that
combined reproductive health classes, the PSI curric-
ulum, a health-risk screening, and “booster” educa-
tional activities. The follow-up data suggest positive
intervention effects on virginity for females, contra-
ceptive knowledge for males, and contraceptive use
at last intercourse for sexually active females. The
significant difference in reported virginity between
intervention- and control-group females, noted on
both the first and third follow-up surveys, occurred
despite a lack of change in attitudes toward delayed
sex and childbearing. Self-efficacy to refuse sex with
a boyfriend was significantly different for interven-
tion-group females only on the first follow-up sur-
vey. This disproves the original program hypothesis
that reported virginity would be higher among the
intervention-group students because of the interven-
tion’s impact on attitudes toward abstinence and
self-efficacy to refuse sex. Among intervention-
group males, no change was noted in reported
virginity, attitudes toward abstinence, or self-efficacy
to refuse sex at any follow-up point. A significant
difference in attitudes toward delayed childbearing
was observed, however, on both the first and second
follow-up surveys. This finding is not well under-
stood, although it appears to be consistent with the
high birth control knowledge scores recorded among
intervention-group males on each follow-up survey.
These knowledge gains did not have an impact on
virginity, however, as the investigators hypothesized
it might.
The significant differences in birth control use at
last intercourse among nonvirgin intervention-group
October 2000
females and birth control knowledge among inter-
vention-group males, noted on all three follow-up
surveys, may be partially the result of the facilitators’
reproductive health education and counseling activ-
ities. The change in the knowledge of confidentiality
rights and adolescent health services scale, noted
among female intervention-group students at the
end of the eighth grade (T3), may also be related to
these students’ contact with the facilitators. Unlike
the Self Center program (8), which included a repro-
ductive health service component, this study was not
designed to determine whether knowledge improve-
ments affected utilization of adolescent clinic ser-
vices. Zabin et al. (8) concluded that service utiliza-
tion was affected more by the accessibility of the Self
Center staff and clinic than by gains in knowledge
about reproductive health.
In comparing this study’s results with those ob-
tained from previous evaluations of the PSI curricu-
lum (6,28), there were some similarities and some
differences. Although the original Atlanta-based
evaluation (6) began with a similar gender disparity
in baseline sexual activity, positive results were
noted for both males and females who were virgins
at the beginning of the program. However, that
study was not designed as a randomized trial (28),
and results were derived from a telephone-based
interview used as part of a broader investigation of
adolescent health behavior (6). No effect on sexual
behavior or contraceptive use was noted for either
gender among students who were sexually active at
baseline.
The California Education Now and Babies Later
(ENABL) evaluation of PSI (28) reported no effect on
outcomes by gender but did not present separate
analyses for males and females. No effect on virgin-
ity or contraceptive use was noted at either the
short-term (3-month) or long-term (17-month) fol-
low-up periods. The racial and ethnic makeup of the
ENABL study population may partially explain this
difference in outcome. Unlike the Atlanta and cur-
rent study populations, which were predominantly
African-American, the ENABL study population was
70% white and Latino. It has been suggested that
sexuality education programs originally developed,
tested, and implemented in the African-American
community may be most effective among youths in
that community (9). The ENABL and current study’s
attempts to adapt the PSI curriculum for Latino
students provide support for this concept. Although
the Latino student group in the current study was
too small for a separate analysis, it is believed that
results similar to those obtained by Kirby et al. (28)
SCHOOL-BASED PROGRAM TO DELAY SEX 245
would have been noted, even if more students from
this community had been available. Pregnancy pre-
vention strategies for Latino youth should address
family, cultural, and religious factors (29). Neverthe-
less, PSI was not particularly effective in the current
study population, even though it was predominantly
African-American. Therefore, the effectiveness of the
PSI approach among younger inner-city African-
American adolescents has not been clearly demon-
strated.
This study’s results were similar to those of the
ENABL evaluation with regard to beliefs about sex-
ual activity of peers, expectations for sexual involve-
ment in the next few months, and self-efficacy to
refuse sex. Changes were noted only at the first
follow-up survey or not at all. The current authors
agree that the PSI curriculum may not have had an
impact on these variables because it is too brief and
does not provide sufficient time for practice of asser-
tiveness skills (28). Using the booster activities to
reinforce PSI concepts did not affect the outcome.
This may have been the result of the introduction of
a broad range of topics other than abstinence and the
fact that most booster sessions were voluntary and
held during lunch or free periods, leading to lower
rates of student participation.
No change in students’ reported level of commu-
nication about sex-related topics with parents, boy-
friends, or girlfriends was observed at any follow-up
point. It was anticipated that participants’ ability to
discuss sexual issues with others would be enhanced
by the PSI curriculum’s focus on assertive commu-
nication and by the information provided during the
booster activities. However, the short duration of the
PSI curriculum and variable attendance at the
booster sessions may have diluted the impact of
these activities on communication variables. Because
parent-family connectedness has been identified as a
protective factor in adolescent health risk behavior
(30), future intervention efforts should include strat-
egies to enhance parental involvement and commu-
nication with adolescents. The PSI Curriculum for
Parents was used successfully in the ENABL project
(31), although this did not apparently affect out-
comes for adolescents.
In evaluating this study’s results, several caution-
ary points must be addressed. First, the level of
program participation varied from student to stu-
dent, especially during the 8th grade school year
intervention, which included several voluntary activ-
ities. The purpose of the intent-to-treat analysis was
to determine the overall impact of the intervention
on the treatment group, given the expectation that
246 AARONS ET AL.
participation levels would vary. Nevertheless, an
attempt to measure exposure to the intervention
program was made using attendance records and
recall questions on the follow-up surveys.
A second limitation of the study was the lack of
ability to link specific outcomes to participation in
the intervention because of the cross-sectional, anon-
ymous evaluation design. Although this methodol-
ogy is considered appropriate for school-based inter-
vention studies (8,32), it was impossible to track
individual student outcomes over time or to analyze
these outcomes by level of exposure to the interven-
tion.
The authors acknowledge the problems inherent
in randomizing schools yet using the students as the
units of analysis. Nevertheless, to conduct a
matched-pair analysis using the school as the unit of
analysis, a larger number of matched-pairs (at least
11) would be needed in order to produce statistically
valid results (24,25). Although the schools were as
well matched as possible given the study criteria, a
certain level of variability in school environment and
student population was expected (8), and not all of
these factors could be controlled for. Also, by not
planning a separate intervention for the comparison
schools, this study could not control for the possibil-
ity that positive outcomes in the intervention schools
were more related to the increased level of activity
than to the program itself (33).
The limitations of self-reported data on sexual
behavior among younger adolescents are well docu-
mented (34,35). In addition, the active parental con-
sent procedure, although required by the school
system and all participating IRBs, introduced a cer-
tain level of bias into the sample and definitely
limited overall student participation. Previous re-
search has suggested that students who receive pa-
rental consent may have a different sociodemo-
graphic and risk behavior profile from those who do
not receive parental consent (36). Aside from the
active parental consent requirement, the sample size
was further reduced by student “mobility” (absen-
teeism, school transfers, truancy.)
Finally, although standardized training and qual-
ity control procedures were instituted, it is certain
that the educational program varied according to the
facilitators’ and peer leaders’ teaching abilities and
their rapport with the students.
Conclusions
This study’s results among females, while encourag-
ing, must be viewed within the context of the limi-
JOURNAL OF ADOLESCENT HEALTH Vol. 27, No. 4
tations noted above. The “PSI plus booster” strategy
did not have a significant impact on virginity among
males or on moderators such as attitudes toward
abstinence and self-efficacy to refuse sex among
either gender. The lack of effect on virginity among
males may point to the need for abstinence-focused
curricula and activities that are gender specific. Further
evaluation of gender-specific educational approaches is
needed in order to develop programs that can be
replicated in the school setting.
In general, this study’s outcomes support the
findings of other investigators (28,33,37– 40) who
concluded that abstinence-focused programs and
messages tend to have mixed or short-term effects.
Future research efforts should test the effect of rein-
forcing the abstinence message over several school
terms using role plays and assertiveness-training
techniques. If working in a multicultural environ-
ment, these techniques must be tested and adapted
for each community being targeted. In a dynamic
school system characterized by high administrative
turnover and student mobility, it is necessary to
recruit the largest possible number of schools, and
therefore, students.
The study’s positive findings in reproductive
health knowledge and contraceptive use suggest that
recruiting outside health professionals to provide
education and outreach in the school setting may be
a useful prevention strategy.
This study was supported by a Cooperative Agreement funded by
the NIH Office of Research on Minority Health and The National
Institute of Child Health and Human Development (U18-
HD30447, U18-HD30458, U18-HD30445, U18-HD31919, U18-
HD30454, and U18-HD31206) from the NICHD and the NIH
ORMH.
Consultants to the project: Dr. Laurie Zabin, Johns Hopkins
School of Hygiene and Public Health; Dr. Marion Howard, Emory
University/Grady Health System; Dr. Murray Vincent, University
of South Carolina; Dr. Marianne Felice, University of Maryland at
Baltimore. Allison Rose, Research Triangle Institute, was instru-
mental in the implementation and analysis of the intervention.
Facilitators and Senior Research Assistants: Mark Boss, Fred
Butler, Sonja Green, Beverly Lyles, Christina Villar, and Gilbert
Zelaya.
Other participating institutions were: DC Public Schools, Com-
prehensive School Health Program (Dr. Johnnie Fairfax, Director),
Synergy Adolescent Health Coalition, DC Office of Maternal and
Child Health (Colevia Carter, Director), DC Department of Health,
Bureau of School Health Services (Dr. Mary Ellen Bradshaw,
Chief), National Center for Education in Maternal and Child
Health (Kristin Langlykke), The Mary’s Center for Maternal and
Child Care (Maria Gomez, Director), and the students and prin-
cipals from the participating DC public schools).
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