Reducing the Risk

Featured Grant OpportunitySchool Emergency Response to Violence (Project SERV) (Funding Opportunity) 

Featured Grant OpportunityShare with Youth: NOAA Student Opportunities Database

Developers

Richard P. Barth, M.S.W., Ph.D.

Program Summary

Reducing the Risk: Building Skills to Prevent Pregnancy, STDs & HIV is a 16-session program focused on the development of attitudes and skills that will help teens prevent pregnancy and the transmission of STDs, including HIV. This approach addresses skills such as risk assessment, communication, decision-making, planning, and refusal strategies.

Intended Population

The program was designed for high school students. It was first evaluated with 14 to 17 year old White youth, and more recently has also been tested with Latino and African American youth.

Program Setting

The program was designed to be implemented in a classroom-based school setting. It has been evaluated in community based organizations as well as classroom-based school settings.

Contact and Availability Information

Nancy Gonzalez-Caro, MPH
Evidence-Based Product Specialist
ETR
100 Enterprise Way, Suite G300
Scotts Valley, CA 95066
Ph: 800-321-4407 x237
Website: http://www.etr.org/ebi/programs/reducing-the-risk/

Cody Sigel, MPH, CHES
Health Education Training Coordinator
ETR
1333 Broadway, Suite P110
Oakland, CA 94612
Phone: 510-858-0995
Website: http://www.etr.org/ebi/programs/reducing-the-risk/

Sample of curriculum available for review prior to purchase

Yes

Adaptation guidelines or kit available

Yes

Languages available

English and Spanish

Program Core Components

Category	Component	Core Component	Component present	Notes	Lesson number(s) / activities where present
Content	STIs - Treatment	Yes	Yes (both versions)		Class 12, activity 1
Content	Other	Yes	Yes (both versions)	Personalization of content is key and not really captured in definitions above.	Throughout.
Content	Volunteering/civic engagement		No
Content	Spirituality		No
Content	Morals/values		No
Content	Identity development		No
Content	Social support/capital		No
Content	Social influence/actual vs. perceived social norms	Yes	Yes (both versions)		Class 2, activity 3
Content	Social competence	Yes	Yes (both versions)	Refusal skills lessons counted here. Clearly much broader topic.	Class 3, activity 3,4; Class 4, activities 1-4; Class 5, activities 2-4; Class 6, activities 2,3; Class 15, activity 2
Content	Parenting skills		No
Content	Normative beliefs	Yes	Yes (both versions)		Class 2, activity 3
Content	Leadership		No
Content	Gender roles		No
Content	Gender identity		No
Content	Cultural values		No
Content	Connections with trusted adults	Yes	Yes (both versions)		Class 3, activity 2; Class 6, activity 1
Content	Communication skills	Yes	Yes (both versions)	Refusal skills lessons counted here because they teach verbal and non-verbal approaches.	Class 3, activity 3,4; Class 4, activities 1-4; Class 5, activities 2-4; Class 6, activities 2,3; Class 15, activity 2
Content	Child development		No
Content	Boundary setting/refusal skills	Yes	Yes (both versions)	Lessons identified are where skills introduced/taught. See self-efficacy for all lessons where skills practiced and reinforced.	Class 3, activity 3,4; Class 4, activities 1-4; Class 5, activities 2-4; Class 6, activities 2,3; Class 15, activity 2
Content	Substance use cessation		No
Content	Substance use - Other drugs		No
Content	Substance use - Alcohol		No
Content	Substance use - Abstinence		No
Content	Brain development and substance use		No
Content	Vocational/skills training		No
Content	Supplemental academic services		No
Content	School engagement		No
Content	Graduating from high school		No
Content	College preparation		No
Content	Alternative schooling		No
Content	Self-regulation		No
Content	Self-esteem		No
Content	Self-efficacy/empowerment	Yes	Yes (both versions)	All skill-focused activities are designed to reinforce self efficacy and are listed here.	Class 4, activities 1, 2, 4; Class 5, activities 3,4; Class 9, activities 2,3; Class 10, activities 2, 3; Class 11, activities 1, 2; Class 13, activity 2; Class 15, activity 2; Class 16, activity 3
Content	Conflict resolution/social problem solving		No
Content	Resilience		No
Content	Reproduction		No
Content	STIs - Prevention	Yes	Yes (both versions)		Class 1B, activity 2; Class 6, activity 4; Class 7, activity 1; Class 8, activities 1, 4; Class 9, activity 1; Class 12, activity 1; Class 13, activity 1; Class 14, activity 1;
Content	STIs - Information	Yes	Yes (both versions)		Class 1B, activity 2; Class 12, activity 1; Class 13, activity 1
Content	Sexual risk reduction	Yes	Yes (both versions)		Every class reinforces risk reduction messages
Content	Sexual risk discontinuation		No
Content	Sexual risk avoidance	Yes	Yes (both versions)		Class 1A, activity 3; Class 1B, activity 4; Class 2, activities 2-4; Class 6, activity 3; Class 7, activity 1; Class 12, activity 1; Class 13, activity 2; Class 15, activity 2.
Content	Sexual orientation		No
Content	Sexual health	Yes	Yes (both versions)	Entire program is focused on sexual health so difficult to discern what this row is intending to capture.	Throughout
Content	Risk of STIs and Pregnancy	Yes	Yes (both versions)		Class 1A, activity 1, 2, 3; Class 1B, activity 2; Class 12, activity 1; Class 13, activity 1
Content	Contraception - Other	Yes	Yes (both versions)		Class 7, activity 1; Class 8, activity 4
Content	Personal vulnerability		No
Content	Anatomy/physiology		No	Includes appendix on anatomy/physiology for educators as background material
Content	Contraception - Condoms	Yes	Yes (both versions)		Class 6, activity 4; Class 7, activities 1 and 2; Class 8, activity 1, 4
Content	Contraception - Long-acting reversible contraceptives	Yes	Yes (current version)	LARCs not available at time of original study	Class 7, activity 1; Class 8, activity 2, 4
Content	Maternal health		No

Program Objectives

The program seeks to prevent pregnancy and the transmission of STDs, including HIV. It is designed to reach these goals by teaching youth to:

Evaluate the risks and lasting consequences of becoming an adolescent parent or becoming infected with HIV or another STD.
Recognize that abstaining from sexual activity or using contraception are the only ways to avoid pregnancy, HIV, and other STDs.
Conclude that factual information about conception and protection is essential for avoiding teen pregnancy, HIV, and other STDs.
Demonstrate effective communication skills for remaining abstinent and for avoiding unprotected sexual intercourse.

Program Content

Reducing the Risk is a 16-session program focused on pregnancy and STD/HIV prevention. It is based on several interrelated theoretical models, namely Social Learning Theory, Social Inoculation Theory and Cognitive Behavior Theory.

The core content covered by the program consists of:

Knowledge of pregnancy risk and prevention
Knowledge about STD and HIV risk, prevention, transmission, treatment and consequences
Perception of individual risk for pregnancy, STDs, and HIV and their consequences, if teenagers engage in unprotected sex
Knowledge of how to be abstinent or use birth control methods effectively and how to access health care information and contraception (including condoms)
Effective and ineffective refusal skills
Social and peer norms, as well as personal attitudes, about abstinence, sex, unprotected sex, condoms, and contraception
Refusal and communication skills in pressure situations in order to avoid pregnancy and STDs
Skills to obtain health care information and contraception from a clinic and use it
Skills to communicate with parents or other adults about teen sexual activity and birth control

The program logic model can be found on ETR's website: http://www.etr.org/ebi/programs/reducing-the-risk/

Program Methods

Reducing the Risk is delivered through role plays, skill practice, brainstorming, mini-lecture, and worksheet activities.

Program Structure and Timeline

Reducing the Risk is delivered in sixteen 45- to 60-minute lessons, which are conducted 2 to 3 times per week. The classes must be taught in sequence. The ideal class size is between 10 and 30 youth.

Staffing

This curriculum is designed to be taught by classroom teachers or family life educators.

Program Materials and Resources

Core intervention materials include a teacher's guide (available in English only), student workbooks (available in English and Spanish), activity kit, and pamphlets.

An optional LGBTQ Supplement is also available. It includes a lesson that can be taught before implementing the intervention as well as suggestions for acceptable adaptations to make the program more inclusive of LGBTQ youth.

Additional Needs for Implementation

None specified

Fidelity

ETR provides a fidelity log, adaptation kit, a Reducing the Risk Student Knowledge Survey that can be administered as a pre-test/post-test, and a survey answer key. These materials can be found here: http://www.etr.org/ebi/programs/reducing-the-risk/.

Staff Training

It is highly recommended that educators who plan to teach Reducing the Risk receive professional development to prepare them to effectively implement the curriculum with its intended target group.

Training on Reducing the Risk is available through ETR’s Professional Learning Services. Training options include:

Three-day Training of Educators (TOE)—the learning process includes pre-work, skill-based instruction and post-training follow-up support.
Four-day Training of Trainers (TOT)—available for seasoned trainers who have experience in delivering the intervention. Completion entitles participants to use ETR’s research-based training designs to conduct TOEs for their organization or designated affiliate group. TOT attendees who have completed the four-day TOT are eligible to attend a condensed TOT course on additional EBIs.

Technical Assistance and Ongoing Support

ETR provides in-person and web- or phone-based technical assistance before, during and/or after program implementation. TA is tailored to the needs of the site and is designed to support quality assurance, trouble-shoot adaptation issues, and boost implementation.

ETR also provides evaluation support for EBI implementation. Services address process and outcome evaluation and include assistance with evaluation planning, instrument design and development, implementation fidelity, data management and analysis, performance measurement, continuous quality improvement (CQI) protocols, and effective tools and strategies for reporting results.

Allowable Adaptations

In-depth adaptation guidelines and tools are available through ETR at the following link: http://www.etr.org/ebi/programs/reducing-the-risk/.

Examples of allowable adaptations include adding processing questions; lengthening skills-based classes beyond 45-minutes without cutting the number of classes; and tailoring the content (e.g. for visual learners or particular gender or racial/ethnic groups).

Reviewed Studies

Citation	High-Quality Randomized Trial	Moderate-Quality Randomized Trial	Low Study Rating	Did Not Meet Eligibility Criteria
Abt Associates 2015a Kelsey et al. 2016c Kelsey et al. 2016d	✓
Anderman et al. 2009				✓
Cunningham et al. 2016 (RtR) Barbee et al. 2016		✓
Ebreo et al. 2002			✓
Hubbard et al. 1998			✓
Kirby et al. 1991 Barth 1992
Reyna and Mills 2014		✓
Zimmerman et al. 2008		✓

Study Characteristics

Citation	Setting	Majority Age Group	Majority Racial/Ethnic Group	Gender	Sample Size
Abt Associates 2015a Kelsey et al. 2016c Kelsey et al. 2016d	In school: High school	14 to 17	Hispanic or Latinx of any race	Youth of any gender	2689
Anderman et al. 2009	n.a.	n.a.	n.a.	n.a.	n.a.
Cunningham et al. 2016 (RtR) Barbee et al. 2016	After school	14 to 17	African American or Black	Youth of any gender	939
Ebreo et al. 2002	n.a.	n.a.	n.a.	n.a.	n.a.
Hubbard et al. 1998	n.a.	n.a.	n.a.	n.a.	n.a.
Kirby et al. 1991 Barth 1992	In school: High school	14 to 17	White	Youth of any gender	758
Reyna and Mills 2014	After school	14 to 17	White	Youth of any gender	734
Zimmerman et al. 2008	In school: High school	14 to 17	White	Youth of any gender	1944

Study Findings

Evidence by Outcome Domain and Study

Citation	Sexual Activity	Number of Sexual Partners	Contraceptive Use	STIs or HIV	Pregnancy
Abt Associates 2015a Kelsey et al. 2016c Kelsey et al. 2016d		n.a.
Anderman et al. 2009	n.a.	n.a.	n.a.	n.a.	n.a.
Cunningham et al. 2016 (RtR) Barbee et al. 2016				n.a.
Ebreo et al. 2002	n.a.	n.a.	n.a.	n.a.	n.a.
Hubbard et al. 1998	n.a.	n.a.	n.a.	n.a.	n.a.
Kirby et al. 1991 Barth 1992		n.a.		n.a.
Reyna and Mills 2014				n.a.	n.a.
Zimmerman et al. 2008		n.a.	n.a.	n.a.	n.a.

Detailed Findings

Citation	Details
Abt Associates 2015a Kelsey et al. 2016c Kelsey et al. 2016d	A recent study conducted by a separate group of researchers evaluated the standard version of the program when implemented on a broader scale and among a more broadly-defined target population. The study used a cluster randomized trial involving eighth to tenth grade students in 17 public schools across three states (California, Missouri, and Texas). Students were randomly assigned by classroom to either a treatment group that received the program or to a control group that received either a standardized health class (one site) or the regular school instruction. Surveys were administered before random assignment (baseline) and again 12 and 24 months after baseline. The study findings failed to replicate the favorable impacts on sexual initiation found in prior studies of the program. In particular, 12-months after the baseline, the study found that students in the control group were no more likely than those in the treatment group to report having ever had sex (odds ratio = 0.95). At the 24-month follow-up, the study found no statistically significant program impacts on sexual initiation among the study participants who were not sexually active at baseline. The study also found, for the full study sample and at each of the two follow-ups, no evidence of statistically significant program impacts on other measures of sexual risk behavior such as rates of sexual activity and unprotected sexual activity in the past 90 days. In addition, at the 24-month follow-up, the study found no evidence of statistically significant program impacts on being diagnosed with a STI in the last 12 months or on becoming pregnant (females) or getting someone pregnant (males). The study also examined program impacts on measures of knowledge of pregnancy risk, knowledge of STI risk, attitudes toward protection, attitudes toward risky behavior, motivation to delay childbearing, condom negotiation and refusal skills, and intentions to become sexually active and use protection when sexually active. Findings for these outcomes were not considered for the review because they fell outside the scope of the review.
Anderman et al. 2009
Cunningham et al. 2016 (RtR) Barbee et al. 2016	In a separate recent study, researchers evaluated the standard version of the program when implemented among at-risk youth outside of school as part of a community-based program. The study used a cluster randomized controlled trial involving 23 community-based organizations in Louisville, KY. Youth were recruited into the study on a rolling basis in small groups. Each group was randomly assigned to one of three research conditions: (1) a treatment group receiving the RtR program, (2) a treatment group receiving the Love Notes intervention, or (3) a control group receiving a program on neighborhood assets and community change. Data for the study were collected before the program (baseline), immediately after the program, and at three, six, 12, and 24 months after the end of the program. For the three-month follow-up, the study replicated the favorable impact on sexual initiation found in the earlier studies of the program. In addition, the study found a favorable impact on recent pregnancy at the three-month follow-up. The study also found that at the six-month follow-up, adolescents in the RtR group were more likely than those in the control group to report using birth control during sexual intercourse. The study found no statistically significant impacts at any follow-up on the average number of sexual partners.
Ebreo et al. 2002
Hubbard et al. 1998
Kirby et al. 1991 Barth 1992	The program's evidence of effectiveness was first established in a quasi-experimental study involving high school students from rural and urban areas of northern California. Students from about half the classrooms were assigned to an intervention group that received the program. Students from the other classrooms were assigned to a comparison group that received the usual school instruction. Surveys were administered immediately before the program (baseline), immediately after the program, and again six and 18 months after the program ended. The study found that eighteen months after the program ended, female adolescents participating in the program who were sexually inexperienced at baseline were significantly less likely to report having had sex without using birth control. The study found no statistically significant program impacts on sexual initiation for adolescents who were sexually inexperienced at baseline, having unprotected sex or pregnancy for the full sample of study participants, or having unprotected sex for male adolescents who were sexually inexperienced at baseline. For the six month follow-up survey, the study found no statistically significant program impacts on sexual initiation, recent sexual activity, contraceptive use, or pregnancy. The study also examined program impacts on measures of STD knowledge and self-reported condom failures. Findings for these outcomes were not considered for the review because they fell outside the scope of the review.
Reyna and Mills 2014	A more recent study examined the effectiveness of an adapted version of the program, called RtR+, that places greater emphasis on the bottom-line or "gist" message of the program. The study used a randomized controlled trial involving high-school-aged students across three states (Arizona, New York, and Texas). Study participants were randomly assigned to one of three groups: (1) a treatment group that received the standard version of the program, (2) a treatment group that received RtR+, the adapted version of the program, or (3) a control group that received an unrelated curriculum on communication skills. Surveys were administered immediately before the program (baseline), immediately after the program, and again three, six and 12 months after the program ended. For the standard version of the program, the study replicated the favorable impact on sexual initiation found in the earlier study by Zimmerman et al. (2008). At the time of the 12-month follow-up survey, adolescents in the control group were more likely than those in the standard RtR group to report having initiated sexual intercourse, and the reported odds ratio (odds = 4.76) is larger than the odds ratio reported in the earlier study by Zimmerman et al. (odds = 2.42, confidence interval = 1.54 to 3.80). The study found no statistically significant impacts of the standard version of the program on two other measures of sexual risk behavior: (1)
Zimmerman et al. 2008	A subsequent study conducted by a separate group of researchers examined the effectiveness of an adapted version of the program designed to target high sensation-seeking and impulsive youth. The study used a cluster randomized trial involving ten high schools in the Louisville, KY, area and seven high schools in Cleveland, Ohio. Each school was randomly assigned to one of three groups: (1) a treatment group that received the standard version of the program, (2) a treatment group that received the adapted version of the program for high sensation-seeking and impulsive youth, or (3) a control group in which schools delivered their standard, non-skills-based HIV prevention curricula. Surveys were administered immediately before the program started at the beginning of the ninth grade (baseline), immediately after the program at the end of the ninth grade, and again a year later at the end of the tenth grade. For the tenth grade follow-up, the study found that students in the control group were statistically significantly more likely to report having initiated sexual intercourse than students who received either the standard or adapted version of the program (odds ratio = 2.42, confidence interval = 1.54 to 3.80). The study found no statistically significant impacts when analyzing data for the standard and adapted versions of the program separately. The study also examined program impacts on measures of condom use at last sexual encounter and frequency of condom use. Findings for these outcomes were not considered for the review because they did not meet the review evidence standards. Specifically, findings were reported only for subgroups of youth defined by sexual activity at follow-up.

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