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Reducing the Risk

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

Program Contact Information
Email: sales@etr.org
Phone: (800) 321-4407
Website: http://www.etr.org/ebi/programs/reducing-the-risk/

Training Contact Information
Kelly Gainor, M.Ed.
ebptraining@etr.org
Website: http://www.etr.org/ebi/programs/reducing-the-risk/

Sample of Curriculum Available for Review Prior to Purchase

Yes

Languages Available

English, Spanish

Monitoring and Evaluation Tools

Monitoring and evaluation tools available

Yes

Monitoring and evaluation tool usage required

Information about available monitoring and evaluation tools (if applicable)

ETR provides a fidelity log that enables staff to evaluate if they are fully implementing the core components of the program. Pre- and post-tests are also available to assess short-term learning goals and to measure changes in knowledge from pre-instruction to post-instruction. There is an English and Spanish version of each test.

Program Components and Core Components

Last updated in 2024

The data presented on this page reflect responses from the program’s developer or distributor to a program component checklist that asked them to report on the individual components within their TPP program. The same program component checklist was sent to the developer or distributor of every active TPP program with evidence of effectiveness. The program component table provides information on seven types of program components including content, delivery mechanism, dosage, staffing, format, context, and intended population characteristics; whether the component was present or optional in the program; whether the component is considered to be core to the program; and the lesson number or activity where the component can be found in the program.

In the drop-down menu below, under “Has component,” there are four options that indicate a component as present in the program: (1) “Yes” indicates that the component is present in at least one version of the program (whether that be the program version that was evaluated, the current version, or both versions); (2) “Yes (both versions)” indicates that the component is present in both the evaluated version of the program and the current version of the program; (3) “Yes (current version)” indicates that the component is present in the current, but not the evaluated, version of the program; and (4) “Yes (evaluated version)” indicates that the component is present in the evaluated version of the program, only. Note that for dosage components, the only possible response option was “Yes”, and the dosage is described in the Notes when available. For more details, refer to the FAQ.

Category	Component	Core Component	Component present	Notes	Lesson number(s) / activities where present
Content	Substance use cessation		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	Child development		No
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	Connections with trusted adults	Yes	Yes (both versions)		Class 3, activity 2; Class 6, activity 1
Content	Cultural values		No
Content	Gender identity		No
Content	Gender roles		No
Content	Leadership		No
Content	Normative beliefs	Yes	Yes (both versions)		Class 2, activity 3
Content	Parenting skills		No
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	Social influence/actual vs. perceived social norms	Yes	Yes (both versions)		Class 2, activity 3
Content	Social support/capital		No
Content	Identity development		No
Content	Morals/values		No
Content	Spirituality		No
Content	Volunteering/civic engagement		No
Content	Other	Yes	Yes (both versions)	Personalization of content is key and not really captured in definitions above.	Throughout.
Delivery mechanism	Method: Anonymous question box	No	Optional
Delivery mechanism	Method: Artistic expression		No
Delivery mechanism	Method: Assessment/survey	Yes	Yes (both versions)	Quizzes
Delivery mechanism	Method: Booster session		No
Delivery mechanism	Method: Case management		No
Delivery mechanism	Method: Cognitive behavioral therapy (CBT)		No
Delivery mechanism	Method: Demonstration	Yes	Yes (both versions)
Delivery mechanism	Method: Discussion/debrief	Yes	Yes (both versions)
Delivery mechanism	Method: Family session		No
Delivery mechanism	Method: Game	Yes	Yes (both versions)
Delivery mechanism	Method: Home visiting		No
Delivery mechanism	Method: Homework assignment	Yes	Yes (both versions)
Delivery mechanism	Method: In-session assignment	Yes	Yes (both versions)
Delivery mechanism	Method: Introduction	Yes	Yes (both versions)
Delivery mechanism	Method: Lecture	Yes	Yes (both versions)
Delivery mechanism	Method: Motivational interviewing		No
Delivery mechanism	Method: Music		No
Delivery mechanism	Method: Parent-focused activity	Yes	Yes (both versions)
Delivery mechanism	Method: Peer-to-peer		No
Delivery mechanism	Method: Public service announcement		No
Delivery mechanism	Method: Reading	Yes	Yes (both versions)
Delivery mechanism	Method: Role play/Practice	Yes	Yes (both versions)	Key for role playing is use of increasing challenge in terms of scripting--moving from fully scripted to fully unscripted allows for deeper skill practice.
Delivery mechanism	Method: Self-guided activity	Yes	Yes (both versions)
Delivery mechanism	Method: Service learning		No
Delivery mechanism	Method: Slide show	No	Optional	Optional PPT available to support instruction
Delivery mechanism	Method: Social media		No
Delivery mechanism	Method: Spiral learning	Yes	Yes (both versions)
Delivery mechanism	Method: Storytelling	Yes	Yes (both versions)
Delivery mechanism	Method: Text message		No
Delivery mechanism	Method: Video		No
Delivery mechanism	Method: Other	Yes	Yes (both versions)	Skill observation checklist--reinforces vicarious learning through observing peers and sharing feedback

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.

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.

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/.

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).

Adaptation Guidelines or Kit

Yes

Reviewed Studies

Citation	High-Quality Randomized Trial	Moderate-Quality Randomized Trial	Moderate-Quality Quasi-Experiment	Low Study Rating	Did Not Meet Eligibility Criteria
Kirby et al. 1991 Barth 1992			✓
Hubbard et al. 1998				✓
Ebreo et al. 2002				✓
Zimmerman et al. 2008		✓
Anderman et al. 2009					✓
Reyna and Mills 2014		✓
Abt Associates 2015a Kelsey et al. 2016c Kelsey et al. 2016d	✓
Cunningham et al. 2016 Barbee et al. 2016 Barbee et al. 2022		✓

Study Characteristics

Citation	Setting	Majority Age Group	Majority Racial/Ethnic Group	Gender	Sample Size
Kirby et al. 1991 Barth 1992	In school: High school	14 to 17	White	Youth of any gender	758
Hubbard et al. 1998	n.a.	n.a.	n.a.	n.a.	n.a.
Ebreo et al. 2002	n.a.	n.a.	n.a.	n.a.	n.a.
Zimmerman et al. 2008	In school: High school	14 to 17	White	Youth of any gender	1944
Anderman et al. 2009	n.a.	n.a.	n.a.	n.a.	n.a.
Reyna and Mills 2014	After school	14 to 17	White	Youth of any gender	734
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
Cunningham et al. 2016 Barbee et al. 2016 Barbee et al. 2022	After school	14 to 17	African American or Black	Youth of any gender	939

Study Findings

Evidence by Outcome Domain and Study

Citation	Sexual Activity	Number of Sexual Partners	Contraceptive Use	STIs or HIV	Pregnancy
Kirby et al. 1991 Barth 1992		n.a.		n.a.
Hubbard et al. 1998	n.a.	n.a.	n.a.	n.a.	n.a.
Ebreo et al. 2002	n.a.	n.a.	n.a.	n.a.	n.a.
Zimmerman et al. 2008		n.a.	n.a.	n.a.	n.a.
Anderman et al. 2009	n.a.	n.a.	n.a.	n.a.	n.a.
Reyna and Mills 2014				n.a.	n.a.
Abt Associates 2015a Kelsey et al. 2016c Kelsey et al. 2016d		n.a.
Cunningham et al. 2016 Barbee et al. 2016 Barbee et al. 2022				n.a.

KEY

Evidence Indication

Favorable findings

Potentially favorable findings

Indeterminate findings

Conflicting findings

Potentially unfavorable findings

Unfavorable findings

Note: n.a. indicates the study did not examine any outcome measures within that particular outcome domain, or the study examined outcome measures within that domain but the findings did not meet the review evidence standards.

Detailed Findings

Citation	Details
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."
Hubbard et al. 1998	This is a quasi-experimental study that received a low rating because it did not establish baseline equivalence for the final analysis sample
Ebreo et al. 2002	This is a quasi-experimental study that received a low rating because it did not establish baseline equivalence for the final analysis sample
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.
Anderman et al. 2009	This study did not meet the review's screening criteria
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)
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.
Cunningham et al. 2016 Barbee et al. 2016 Barbee et al. 2022	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 control trial involving 23 community-based organizations in Louisville, Kentucky. 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 Reducing the Risk 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. The manuscripts included in this review focused on data collected at the three-, six-, and 12-month follow-ups. For the three-month follow-up, the study replicated the favorable impact on sexual initiation found in the earlier studies of the program (effect size = -0.17). In addition, the study found a favorable impact on recent pregnancy at the three-month follow-up (effect size = -0.15). The study also found that at the six-month follow-up, adolescents in the Reducing the Risk group were more likely than those in the control group to report using birth control during sexual intercourse (effect size = -0.24). The study found no statistically significant impacts at any follow-up on the average number of sexual partners. The study also examined impacts of Reducing the Risk on negative attitudes about teen pregnancy and the success sequence (the likelihood that youth thought they would order their lives in a conventional way). Findings for these outcomes were not considered for the review because they fell outside the scope of the review. Finally, the study examined impacts of Reducing the Risk on a measure of pregnancy (or causing a pregnancy) within the first year after the end of the intervention. Findings for that outcome measure were not considered for the review because they did not meet the review evidence standards. Specifically, the review had concerns about sample composition change, and the analyses of that outcome did not meet the TPPER baseline equivalence requirement.

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Reducing the Risk

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