Executive Summary of “An Abstinence Program’s Impact on  Cognitive Mediators and Sexual Initiation,”
by Weed, et al., 2008, Am J Health  Behav, 32(1):60-73

 December 12,  2007

PROBLEM:  Sexual activity continues to threaten the health of American adolescents, and condom-based solutions have not proven to be an adequate remedy. Two-thirds of American adolescents have experienced sexual intercourse by the end of high school1 and 1 in 7 have sex for the first time at age 14 or younger.2  One in 13 teenage girls in  the United States becomes pregnant each year3, and 4 million new STD  infections occur in U.S. adolescents each year,4 including one-fourth  of all new HIV infections.5  U.S. teens have the highest STD  rates of all age groups;6 it has been estimated that 1 in 4 sexually  active teens is infected with an STD.7  In addition, teen sexual  activity has been associated with poorer emotional health for adolescents,  including lower self-esteem, regret for sexual initiation, depression, and  suicide, as well as higher likelihood of sexual exploitation (such as statutory  rape), dating violence, and unwanted or forced  intercourse/rape.8–15  

One strategy for responding to these threats to adolescent health has been the risk reduction approach, that is, to teach adolescent to use condoms.  When used consistently and correctly, condoms can reduce the risk of HIV infection by 80%16 and the risk of other STDs by rates that vary from 25% to 60%. 17–19 These  partial protection levels are only achieved by consistent, correct condom use;  several studies have found an increase in STDs with inconsistent  use.17,20  Unfortunately, U.S. teens have fairly low rates of consistent  condom use.  Among the sexually active, only 47.8% of males and 27.5% of females report they are consistent condom users over a one-year time period.21  While several interventions appear to have increased  teen condom use at first or last intercourse, or frequency of use, efforts to  increase adolescent rates of consistent condom use have produced little evidence of success.  A recent  review of over 100 studies of comprehensive sex education programs reported that  only two had increased consistent condom use by teens for a period of at least  12 months.22  And rates of condom user error are high, even with  adult populations: error rates ranged from 21.7% to 50% across four  studies.23–26  In addition, condoms do not prevent any of the  emotional harm, sexual exploitation, or violence that is related to teen sexual  activity.

INTERVENTION:  The Reasons of the Heart (ROH) abstinence program was an intervention designed to help teens avoid all of the negative consequences of  sexual activity, by reducing their rate of sexual  initiation.

The many shortcomings of the risk reduction strategy have contributed to an increased interest in the risk avoidance, or abstinence approach to adolescent sexual  health.  The study reported here is an evaluation of an abstinence-only intervention that was implemented with 7th-grade students in suburban Virginia in 1999–2001.  The evaluation measured the program’s impact on youth one year after their participation, with regard to: a) the  number of virgins who initiated sexual intercourse, and b) teen attitudes and  values that influence the decision to abstain (called cognitive mediators).

The study sample consisted of all 7th-grade virgin students in three  program schools and two comparison (i.e., non-program) schools.  Students filled out anonymous questionnaires before the program, immediately afterwards,  and one year later.  Individual surveys were linked across the three time  periods using anonymous ID codes, with a good linkage rate (80%).  The  survey data provided reliable measures of teen sexual behavior and of six  cognitive mediators of teen abstinence.  There were 357 linked program group students and 193 linked comparison group students, for a total of 550 students in the overall sample.  In order to ensure that the program and  comparison groups were well-matched, the two groups were compared for similarity  on key demographic characteristics and attitudes that put a teen at-risk for  sexual initiation.  The groups were essentially the same, with the exception of their racial composition; there were somewhat fewer African  American students in the program group (9% vs. 22%, p<.0001).  This difference was  controlled for statistically in the outcome analysis, and the outcomes for  African Americans were also examined as a separate subgroup.

OUTCOME: The program achieved a significant and sizable reduction in teen sexual initiation, and the importance of emphasizing  cognitive mediators was underscored. 

One year after participating in the ROH curriculum, the program youth were about one-half as likely as the comparison youth to have initiated sexual  intercourse (relative risk=.457,  p=.008). This program effect held  up when the racial difference between the groups was controlled for  statistically and when the African American students were examined as a  subgroup.  The fact that ROH  participants improved significantly on 4 of the 6 cognitive mediators of  abstinence, which were a focus of the ROH curriculum, provides further evidence  that the Reasons of the Heart  program had the desired effect, and suggests how that effect may have  occurred.

Full study (pdf)

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PDF POLICY Regarding thePDF, you will be able to print copies of [the] manuscript, email it to colleagues and Listservs, and/or have it available for personal and professional use. However, due to copyright laws, you cannot use the PDF for profit or potential profit.  This includes, but is not limited to:
1) re-sale 2) publish in another publication media (book, manual, or journal), or 3) have businesses, corporations or companies distribute at conferences or online. These uses all require publisher approval. Essentially, it can only be used by the individual for personal and professional use, not for mass distribution. If you are unsure, please contact the Editor. Moreover, should you violate use of the copyright laws PNG Publications reserves the right to withdraw this specific limited use of the PDF manuscript and to pursue copyright infringement to the full extent of the law.   We hope this journal article will help you respond to the concerns of policy makers about the efficacy of the abstinence approach to teen sexual health, and will also help you focus your abstinence intervention on the things that matter most. Please let us know if we can provide further information of this type for you.  

REFERENCES

1.  Eaton DK, Kann L, Kinchen S, et al. Youth Risk Behavior Surveillance–United States, 2005. Surveillance Summaries. Vol.55, No.SS-5.  Centers for Disease Control and Prevention (online).  June 9, 2006. Atlanta, GA: U.S. Department of Health and Human Services. Retrieved September 14,  2006 from  _http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5302a1.htm_ (http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5302a1.htm) ..

2.  National Campaign to Prevent Teen Pregnancy.  Highlights: 2002 National Survey of Family Growth.  December 10, 2004 (online). Washington DC: Author.  Retrieved December 16, 2004 from _http://www.teenpregnancy.org_ (http://www.teenpregnancy.org/) . Accessed. 

3.  Guttmacher Institute. U.S. Teenage Pregnancy Statistics, National and State Trends, and Trends by Race and Ethnicity. New York: Guttmacher Institute; September, 2006.  Retrieved September 25,  2006 from _http://www.guttmacher.org/pubs/teen_stats.html_ (http://www.guttmacher.org/pubs/teen_stats.html).

4.  Sulack PJ. Sexually transmitted diseases.  Semin Reprod Med. 2003;21(4):399–413.

5.  Centers for Disease Control and  Prevention, Division of HIV/AIDS Prevention. Fact Sheet—Young People at  Risk:HIV/AIDS Among America’s Youth (online). Atlanta, GA: U.S. Department of Health and  Human Services, 2003.  Retrieved June 24,  2003 from _http://www.cdc.gov/hiv/pubs/facts/youth.htm_ (http://www.cdc.gov/hiv/pubs/facts/youth.htm)

6.  Centers for Disease Control and  Prevention. Sexually Transmitted Disease Surveillance, 2002 (online). Atlanta, GA: U.S. Department of Health and  Human Services September, 2003.  Retrieved February 9,  2004 from _http://www.cdc.gov/stats/tables/table12B.htm_ (http://www.cdc.gov/stats/tables/table12B.htm) ..

7.  The Alan Guttmacher Institute.  (1994).  Sex and America’s Teenagers.  New York: Alan Guttmacher  Institute.

8.  Bearman PJ, Bruckner H. Promising the future:  virginity pledges and the transition to first intercourse. Am J Sociol.  2001; 106:859–912.

9.  National Campaign to Prevent Teen Pregnancy.  (2003).  America’s Adults and Teens  Sound Off About Teen Pregnancy: An Annual National Survey.   December 2003. Washington DC: Author.  Retrieved January 5, 2004, from http://www.teenpregnancy.org.

10.  Hallfors DD, Waller MW, Ford CA, et al. Adolescent depression and suicide risk:  association with sex and drug behaviors. Am  J Prev Med. 2004;27:224–230.

11.  Rector R, Johnson K, Noyes L. Sexually Active Teenagers are More Likely to be Depressed and to Attempt Suicide. Heritage Foundation Center for Data Analysis 2003: Report  #03-04.  Retrieved June 5, 2003 from _http://www.heritage.org/Research/Family/cda0304.cfm_ (http://www.heritage.org/Research/Family/cda0304.cfm) ..

12.  Abma JC, Martinez GM, Mosher WD, et al.  Teenagers in the United  States: Sexual  activity, contraceptive use, and childbearing, 2002. Vital Health Stat. 2004;23(24).  Hyattsville, MD: National Center for Health Statistics, U.S. Department of Health and Human  Services.

13.  Moore K, Manlove J. A demographic portrait of statutory rape.  Presentation to Conference on Sexual Exploitation of Teens. March 2005. Washington, DC: Child Trends.  Retrieved October 30, 2006 from _Statutory_rape-final_version_sent_to_OPA.ppt.

_ (http://www.childtrends.org/Files/Statutory_rape-final_version_sent_to_OPA.ppt) 14.   Silverman JG, Raj A, Clements K. (2004).  Dating violence and associated  risk and pregnancy among adolescent girls in the United States.  Pediatrics,114(2),  e220–225.

15.  Danice K. Eaton, PhD, Laura Kann, Ph.D, Steve Kinchen,  James Ross, MS, Joseph Hawkins, MA, William A. Harris, MM. (2006). Youth Risk  Behavior Surveillance—United States, 2005. MMWR  Surveillance Summaries, June 9, 2006/55(SS05);1–108.  Retrieved Jan. 12, 2007 from   _http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5505a1.htm_ (http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5505a1.htm) .

16.  Weller S & Davis K.  (2002).  Condom effectiveness in reducing heterosexual HIV  transmission.  Cochrane Database Syst  Rev, 1. [Abstract].  

17.  Holmes KK, Levine R, Weaver M.  Effectiveness of condoms in preventing sexually transmitted infections. Bull World Health Organ.  2004;82(6):454–461.

18.  Niccolai LM, Rowhani-Rahbar A,  Jenkins H, Green S, & Dunne DW. (2005).  Condom effectiveness for  prevention of Chlamydia trachomatis infection.  Sex Transm Infect, 81(4),  323–5.

19.  Sanchez J, Campos P, Courtois B,  Gutierrez L, Carrillo C, Alarcon J, et al. (2003).  Prevention of  sexually transmitted diseases (STDs) in female sex workers: Prospective  evaluation of condom promotion and strengthened STD services.  Sex Transm Dis,  30:273–9.

20.  Ahmed S, Lutalo T, Wawer M, Serwadda D, Sewankambo  NK, Nalugoda F, et al. (2001).  HIV incidence and sexually transmitted  disease prevalence associated with condom use: a population study in Rakai, Uganda.  AIDS, 15(16), 2171–9.

21.  Abma JC, Martinez GM, Mosher WD, et al.  Teenagers in the United  States: Sexual  activity, contraceptive use, and childbearing, 2002. Vital Health Stat. 2004;23(24), Table  23.  Hyattsville, MD: National Center for Health Statistics, U.S. Department of Health and Human Services.  Retrieved December 16, 2004 from _http://www.cdc.gov/nchs/data/series/sr_23/sr23_024.pdf_ (http://www.cdc.gov/nchs/data/series/sr_23/sr23_024.pdf) .

22. Laris, BA, & Kirby,  D. (2007).  One Page Summaries of the  Evaluations Referenced in Emerging Answers 2007.   November, 2007. Washington DC: National Campaign to Prevent Teen and Unwanted  Pregnancy.  Retrieved November 20, 2007 from http://www.teenpregnancy.org.

23.  Mertz KJ, Finelli L, Levine WC, et al.  Gonorrhea in male adolescents and young adults in Newark, NJ: implications of  risk factors & patient preferences for prevention strategies. Sex Transm Dis 2000;27:201–6.

24.  Crosby RA, Sanders SA, Yarber WL, et al.  Condom use errors and problems among college men. Sex Transm Dis. 2002;29:552–557.

25.  Grimley DM, Annang L, Houser S, Chen H.  (2005). Prevalence of Condom Use Errors Among STD Clinic Patients. Am J Health Behav,  29(4):324–330.

26.  Shlay JC, McClung MW, PatnaikJL, Douglas JM.  (2004).  Comparison of sexually transmitted disease prevalence by reported  condom use: errors among  consistent condom users seen at an urban  sexually transmitted disease clinic.  Sex Transm Dis,  31(9):526–3