This document summarizes research on disseminating an evidence-based pregnancy, STD, and HIV prevention program called "It's Your Game...Keep It Real" in middle schools in Houston, TX. It finds that while most school staff agree sexual health education should be taught, they lack knowledge of effective programs, policies, and self-efficacy and perceive little support. To overcome these barriers, the researchers recommend dissemination strategies that provide training and support to staff, inform them of policies and programs, and engage administrators, parents and community leaders. The goal is to increase adoption of effective sexual health programs in middle schools.

1. Dissemination of an Evidence-based Pregnancy, STD, and HIV Prevention Program in Middle Schools in Houston, TX Belinda Flores, MPH, CHES, Melissa Peskin, PhD, Christine Markham, PhD, Ross Shegog, PhD, Shellie Tyrrell, MA, MSW, Kimberly Johnson, MPH, Robert Addy, MA, Susan Tortolero, PhD Center for Health Promotion and Prevention Research University of Texas School of Public Health Funded by the City of Houston Department of Health and Human Services and the Centers for Disease Control and Prevention May 26, 2010

2. Overview of the prevalence of sexual behaviors and HIV/AIDS/STIs among adolescents What is prevention Current Study and overview of “It’s Your Game… Keep It Real” Findings: Perspectives from school personnel Conclusions Overview

3. Students in Texas are more likely to be sexually experienced compared to the national average Percent of High School Students Reporting to Have Ever Had Sex (2007) Texas U.S. Source: Centers for Disease Control and Prevention. (2007). YRBSS: Youth Online Comprehensive Results. Retrieved June 4,2008 from http://apps.nccd.cdc.gov/yrbss/

4. Students begin having sex at early ages About 1 in 10 sixth grade students have had sex Source: Shanklin, S.L., Brener, N., McManus, T., Kinchen, S., Kann, L. (2007). 2005 Middle School Youth Risk Behavior Survey. Atlanta, G.A.: Centers for Disease Control and Prevention.

5. 8.0% Oral 6.5% Anal 14.4% Any 12.2% Vaginal Students engage in different types of sex Sexual behaviors among 7th grade students in 2004 Source: Markham, C.M., Peskin, M.F., Addy, R.C., Baumler, E.R., Tortolero, S. Patterns of vaginal, oral, and anal sexual intercourse in an urban seventh grade population. Journal of School Health. 79:193-200, 2009.

6. 2006 8.0% Oral 6.5% Anal 2004 14.4% Any 12.2% Vaginal 15.9% Any 13.0% Vaginal 8.7% Oral 6.8% Anal 7th grade sexual behavior has increased over a two year period

7. Therefore… in Texas with over 2 million students in 6-12 grade, the estimated total number of students having sex in any given year 826,644 Source: Shanklin, S.L., Brener, N., McManus, T., Kinchen, S., Kann, L. (2007). 2005 Middle School Youth Risk Behavior Survey. Atlanta, G.A.: Centers for Disease Control and Prevention. YRBS Results YRBSS: Youth Online Comprehensive Results. Retrieved June 4,2008 from http://apps.nccd.cdc.gov/yrbss/ Source for TX student numbers: Enrollment in TX Public Schools, 2007-2008. Available at: http://ritter.tea.state.tx.us/research/pdfs/enrollment_2007-08.pdf

10. Chlamydia and Gonorrhea Rate among 15-19 year olds (2008) U.S. Texas U.S. Source: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for HIV, STD and TB Prevention (NCHSTP), Division of STD/HIV Prevention, Sexually Transmitted Disease Morbidity for selected STDs by age, race/ethnicity and gender 1996-2008, CDC WONDER On-line Database, November 2009. Accessed at http://wonder.cdc.gov/std-std-v2008-race-age.html on Apr 26, 2010

11. Estimated New HIV Infections in the U.S. by Age Source: CDC. Estimates of new HIV infections in the United States. CDC HIV/AIDS Facts. 2008.

12. In TX, over half of all HIV cases among youth occur among African Americans. Source: Texas Department of State Health Services. (2008). Texas HIV/AIDS Quarterly Report. Accessed March 4, from http://www.dshs.state.tx.us/HIVSTD/stats/pdf/HARSQ22008.pdf.

13. In TX, over one fourth of all HIV cases among youth occur among Hispanics. Source: Texas Department of State Health Services. (2008). Texas HIV/AIDS Quarterly Report. Accessed March 4, from http://www.dshs.state.tx.us/HIVSTD/stats/pdf/HARSQ22008.pdf.

14. Percent of parents who are very concerned about their child becoming infected with HIV Sources: Kaiser Family Foundation

15. Total direct medical cost for new STI infections among 15-24 year olds. $6,500,000,000 Source: Chesson, H., Blandford, J.M., Gift, T.L., Tao, G., Irwin, K.L. (2004). The estimated direct medical cost of sexually transmitted diseases among american youth. Perspectives on Sexual and Reproductive Health, 36(1): 11-19.

16. Prevention Consistent and clear prevention messages Societal support for young people Access to contraceptive Comprehensive sexual health education and reproductive health services

18. Includes medically accurate information

19. Mentions contraception

20. Teaches abstinence as the only healthy and morally correct optionSource: Wiley, D., & Wilson, K. (2009). Just Say Don’t Know: Sexuality education in Texas public schools. Texas Freedom Network Education Fund.

21. One in three teens do not get formal education about birth control 46% of males and 38% of females received no instruction about birth control methods prior to first sex Barriers to implementation: concerns about negative community reaction, unclear policies, lack of teacher skills Focus: Comprehensive sexual health education in schools Sources:Texas Freedom Education Network, 2009; Abma, J.C., Martinez, G.M., Mosher, W.D., Dawson, B.S. (2004). Teenagers in the United States: Sexual activity, contraceptive use, and childbearing 2002. Vital and Health Statistics, Series 23, No. 24.. Landry, 1999; Schaalma, 2004, Levesque, 2000

25. Scope & Sequence 7th Grade 8th Grade

26. It’s Your Game…Keep It Real Curriculum:www.itsyourgame.org

27. It’s Your Game…Keep It Real

28. Information transfer Information transfer Skills / practice Activities Peer modeling Real-life serial - modeling Skills / practice

29. Methods: Recruitment and data collection All middle schools from large school district in SE Texas invited to participate; 33 agreed to participate Letters of information about the study were distributed via email, as well as in individuals’ school mailboxes school administrators, physical education/health teachers, nurses, counselors, and to random sample of non health/PE teachers at each school Within each email, a unique hyperlink of the self-administered survey was embedded Emails reminding school staff of the survey were distributed approximately every three weeks beginning two weeks after the initial email

30. Methods (cont.) Paper surveys in manila envelopes were distributed to non-responders after three email reminders Upon completion of the web-based survey or receipt of paper surveys, participants were emailed a $5 gift certificate 315 school staff completed surveys 84.3% of the surveys were web-based and 15.7% were paper

31. Results: Demographics

32. 92.7% agree/strongly agree that sexual health education (SHE) should be taught in middle schools 91.7% agree/strongly agree that PE/health teachers can play an important role in informing students about the risks associated with sex 87.3% are in favor of including SHE in the middle school PE/health curriculum at their middle schools Attitudes

33. 18.3% agree/strongly agree that their school has too many other priorities 23.9% agree/strongly agree that a SHE curriculum that teaches about contraceptives would be difficult to implement in their schools Barriers: School-level

34. 44.4% are not aware/slightly aware of curricula which address SHE 50.2% do not know/slightly know where to find a SHE curricula 50.2% are not aware/slightly aware of district policy towards SHE Barriers: Knowledge

35. 63.9% agree/strongly agree that they can talk comfortably about sexuality in the classroom 61.2% agree/strongly agree that they can discuss contraceptive practices in the classroom 51.8% agree/strongly agree that they can get students to do an assignment that involves them talking with parents about sexual topics Barriers: Self-Efficacy

36. 36.9% agree/strongly agree that administrators support teachers who teach about SHE in the classroom 20.3% agree/strongly agree that administrators support teachers who teach about condoms and other contraceptives Barriers: Support

37. 84% think that PE or health teachers support comprehensive SHE 73.1% think that other teachers support comprehensive SHE 52.4% think that community leaders support comprehensive SHE 43% think that parents support comprehensive SHE Other Support for Comprehensive SHE

38. Teachers and other school officials want to teach SHE But, they lack knowledge of programs & policies, self-efficacy, and perceived support They need support to overcome these barriers Survey Conclusions

39. Implications for dissemination of effective SHE in middle school Dissemination strategies should: Provide administrators and policy makers with pertinent data and advocacy materials and stress the importance of effective programs Inform other staff about policies and effective programs Provide trainings to school staff on how to adapt and use effective programs Determine staff for teaching SHE Make schools aware of strong parental and community support for SHE in schools

40. Questions? Belinda Flores Belinda.Flores@uth.tmc.edu