“It’s Your Game” Sexual Health Program Assessed by Researchers

Background
Although teen pregnancy rates in the United States have declined steadily since 1990, teenage girls younger than 18 years had an estimated 268,000 pregnancies in 2006.¹ A 2005 CDC survey of seventh graders in seven U.S. cities found that 11%–33% were sexually experienced.² The proportion steadily increased through the higher grades; almost two-thirds of high school seniors have ever had sex and half are sexually active.³ Few school-based sex education programs have been found to have beneficial effects among middle-school students.

In Texas, the decline in teen pregnancy has been one of the smallest in the nation; currently, the state has the country’s third-highest teen birth rate.⁴ Fewer than 10% of Texas school districts implement evidence-based sexual health programs.

Context
The University of Texas Prevention Research Center (UTPRC)external icon has focused on child and adolescent health since its inception in 1986. Primary community partners include parents and youth, schools, and agencies serving youth. The long-established partnerships provided an excellent foundation for addressing the sensitive issues of teen sexual health. Together, the Houston Independent School District and the UTPRC identified representative middle schools serving low-income students from across the district; 10 schools agreed to participate in the UTPRC trial, funded by the National Institute of Mental Health, of a curriculum-based education program called It’s Your Game: Keep it Real (IYG).⁵

Methods and Results
The IYG curriculum was developed using a systematic instructional design process, Intervention Mapping, to ground the content in social cognitive theory, triadic influence theory, and social influence models.⁶ The research team used qualitative and participatory methods to obtain guidance from stakeholders, including a teen advisory board, to develop the curriculum and ensure community support. IYG consists of several components, including 12 seventh-grade and 12 eighth-grade lessons that use role modeling, group discussion, and journaling. Students are taught to set personal limits regarding risk behaviors, to be aware of situations that might challenge these limits, and to use refusal skills to protect these limits. A computer-based component includes quizzes, a virtual world interface, and educational activities that address risk-taking. Homework activities are designed to facilitate dialog between parent and child.

IYG was evaluated using a randomized control trial design to assess whether the program could delay initiation of sexual activity, and for those middle school students who were already sexually active, reduce their risky behaviors.⁷ The intervention and comparison groups each consisted of seventh-grade students in five urban middle schools in Houston having a large proportion of low-income students, predominantly African American or Hispanic. Baseline information collected from the students before the intervention began showed that 9% had ever had sex, and 5% were currently sexually active. These percentages were similar among the intervention and control students. Students in the intervention schools received the IYG curriculum during seventh and eighth grade; students in the comparison (control) schools took part in their regular health education classes. During the ninth grade, all students received a follow-up survey. Almost 30% of the students in the comparison group had initiated sex by ninth grade, compared with 23% of the students who received the IYG curriculum, a difference that was statistically significant. Subgroup analysis revealed the intervention was effective at delaying any sexual behavior among Hispanic and female students, but not among African American females and males. Except for having reduced the number of times students had sex in the last 3 months, no significant differences were noted between intervention and control groups in risky behaviors among students who were sexually active.

Consequences and Potential Impact
A review by the US Department of Health and Human Services to identify evidence-based programs to prevent teen pregnancy included IYG, making it one of 28 programs eligible for $75 million in federal funds to support evidence-based or innovative program models to reduce teen pregnancy.⁸ Given the proven effectiveness of the IYG program, the National Campaign to Prevent Teen and Unplanned Pregnancy included it on its list of effective programs, What Works 2010: Curriculum-based Programs that Prevent Teen Pregnancy.⁷ Efforts are currently under way to disseminate the program across middle schools in Harris County, Texas, the fourth-largest county in the United States, and school districts across the country are implementing the program as well. Nevertheless, getting parents, school officials, and policymakers to implement effective programs for sexual health can be challenging because of the subject’s sensitivity. The UTPRC is currently studying ways to influence decision makers to adopt what works for teens.

References

1. Centers for Disease Control and Prevention. Sexual and reproductive health of persons aged 10–24 years—United States, 2002–2007. MMWR. 2009;58(No. SS-6). https://www.cdc.gov/mmwr/pdf/ss/ss5806.pdf pdf icon[PDF – 1.44MB]. Accessed November 29, 2018.
2. Shanklin SL, Brener N, McManus T, Kinchen S, Kann L. 2005 Middle School Youth Risk Behavior Survey. Atlanta: US Department of Health and Human Services, Centers for Disease Control and Prevention; 2007.
3. Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance—United States, 2009. MMWR. 2010;59(No. SS-5). https://www.cdc.gov/mmwr/pdf/ss/ss5905.pdf pdf icon[PDF – 3.5MB]. Accessed November 29, 2018.
4. Kaiser Family Foundation. State Health Facts: Teen Birth Rate per 1,000 Population Ages 15–19, 2007 website. http://www.statehealthfacts.org/comparemaptable.jsp?typ=3&ind=37&cat=2&sub=11&sortc=1&o=aexternal icon.
5. Tortolero SR, Markham CM, Peskin MF, Shegog R, Addy RC, Escobar-Chavez SL, Baumler E. It’s your game: keep it real: delaying sexual behavior with an effective middle school program. Journal of Adolescent Health. 2010;46(2):169–179.
6. US Department of Health and Human Services. Teen Pregnancy Prevention Research Evidence Review—Programs for Replication. http://www.hhs.gov/ophs/oah/prevention/research/programs/index.htmlexternal icon. Accessed November 29, 2018.
7. Suellentrop, K (2010). What Works 2010: Curriculum-Based Programs That Help Prevent Teen Pregnancy. Washington, DC :The National Campaign to Prevent Teen and Unplanned Pregnancy; 2010.
8. Peskin MF, Markham CM, Shegog R, Baumler ER, Addy RC, Tortolero SR. Effects of the It’s Your Game…Keep It Real program on dating violence in ethnic-minority middle school youth: A group randomized trial. American Journal of Public Health. 2014;104(8):1471–1477. doi:10.2105/AJPH.2014.301902 PMCID: PMC4103231
9. US Department of Health and Human Services, Office of Adolescent Health. Programs for Replication: Intervention Implementation Reports website. 2011; Accessed September 19, 2011
10. Markham CM, Peskin MF, Shegog R, et al. Behavioral and psychosocial effects of two middle school sexual health education programs at tenth-grade follow-up. Journal of Adolescent Health. 2014;54: 151-159. doi:10.1016/j.jadohealth.2013.10.204.
11. National Institute of Justice. Crime Solutions Program Profile: It’s Your Game…Keep It Real website. https://www.crimesolutions.gov/ProgramDetails.aspx?ID=399external icon. Accessed November 29, 2018.
12. Peskin MF, Shegog R, Markham CM, et al. Efficacy of It’s Your Game-Tech: A computer-based sexual health education program for middle school youth. Journal of Adolescent Health. 56(5):515-521. doi: https://www.sciencedirect.com/science/article/pii/S1054139X15000099?via%3Dihubexternal icon
13. Shegog R, Craig Rushing S, Gorman G, et al. NATIVE-It’s Your Game: Adapting a technology-based sexual health curriculum for American Indian and Alaska Native youth. Journal of Primary Prevention. August 2016;37(4). 10.1007/s10935-016-0440-9
14. Hernandez BF, Peskins MF, Shegogo R, et al. iCHAMPSS: Usability and psychosocial impact for increasing implementation of sexual health education. Health Promotion Practice. 2016;18;366–380. doi: https://journals.sagepub.com/doi/10.1177/1524839916682004external icon