Science and Success in Developing Countries: Holistic Programs That Work to Prevent Teen Pregnancy, HIV & Sexually Transmitted Infections

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Executive Summary [HTML] [PDF]

Program Components

• Comprehensive school-based sex education curriculum, including information about abstinence and contraception
• Ongoing involvement of physicians in developing the curriculum, orchestrating educational sessions, and evaluating the program
• Two teachers' manuals: one for working with students and one for working with parents
• Teacher training
• Medical staff working at intervention schools to conduct presentations and to serve as a resource to students, teachers and parents
• Availability of medical staff to students via e-mail or phone regarding questions and medical assistance
• School-based counselors
• Referral of youth to youth-friendly health services

For Use With

• In-school youth, ages 12 to 17
• Urban youth

Evaluation Methodology

• Quasi-experimental case control cohort study among students at two intervention schools and three control schools in the metropolitan area of Santiago, Chile
• Baseline anonymous survey among students in intervention and control schools (n=4,448); follow-up surveys among students in intervention and control schools at 21 and 33 months after the launch of the intervention (n=4,169 and 4,129, respectively)

Evaluation Findings

• Reduced incidence of pregnancy
• Reduced incidence of imposed abortions*
• Delayed initiation of sexual intercourse
• Increased use of contraception—females

Program Description

Adolescence: Time of Choices is a program developed by the Centro de Medicina Reproductiva y Desarrollo Integral del Adolescente (CEMERA) at the Facultad de Medicina de la Universidad de Chile. Adapted from a US-based initiative (the Self Center), the project seeks to provide comprehensive sex education, including information about both abstinence and contraception, for adolescents in school.[21]

The program includes training for teachers, lasting four and a half days as well as two manuals for the teachers: one for working with students and one for working with parents. The curriculum for students consists of 18 sessions, including topics integral to adolescent development, short-term and long-term decision-making, and reproductive and sexual health.** Teachers may repeat sessions they find important to revisit but must cover all of the material. CEMERA also convenes regular meetings to build teachers' capacity on sex education and the curriculum as well as to obtain feedback on the program from teachers and students.[21]

Physicians and other health care professionals from CEMERA lead presentations in the schools and encourage students to contact them, via e-mail or phone, with questions and with medical concerns.22 CEMERA also provides staff on-site within the schools to serve as a resource for students, teachers, and parents. As part of the program, school counselors are also available to assist students with questions and/or to refer students to youth-friendly reproductive and sexual health services.[21]

Evaluation Methodology

The quasi-experimental case control cohort study was carried out in two intervention schools and three control schools. CEMERA obtained approval from the Ministry of Education, other government entities, the schools, and parents to provide the program in the two intervention sites in Santiago, Chile; comparison schools were also in Santiago. The Adolescence: Time of Choices project was carried out over a two-year period, between 1994 and 1996. The baseline anonymous survey was conducted with 4,448 students, including 2,512 in intervention schools and 1,936 in comparison schools. The 21-month follow-up was conducted with 4,169 students, 2,249 at the intervention schools, and 1,920 at the comparison schools. The 33-month follow-up was conducted with 4,129 students, including 2,192 at the intervention schools and 1,937 at the comparison schools.[21]

At baseline, knowledge of sexuality and reproduction, contraception, and HIV/STIs was similar among females in intervention and comparison schools; knowledge levels were also similar among males in intervention and comparison schools. For example, 66.2 percent of female students in intervention schools correctly answered questions relating to contraception, as did 64.2 percent of females from comparison schools. Among males, the proportions that correctly answered questions about contraception were 65.9 and 63.9, respectively. The proportions of females and males with sexual experience were somewhat higher among youth in comparison schools, especially among males. Among females, 17.3 percent in intervention schools reported ever having had sexual intercourse versus 21.4 percent in comparison schools. Among males, 30.7 percent in intervention schools reported ever having had sexual intercourse, versus 41.7 percent in comparison schools.[21]

Outcomes

• Knowledge—
  • Between baseline and 21-month follow-up, knowledge of sexuality, reproduction, contraception and STIs, including HIV, increased significantly more among youth in intervention schools versus those in comparison schools.
    • In the intervention schools knowledge scores on sexuality and reproduction increased from 57 to 72 percent among females and from 51 to 68 percent among males; in comparison schools, knowledge increased from 55 to 62 percent among females and from 47 to 55 percent among males.[21]
    • Knowledge of contraception increased from 66 to 82 percent among females and from 66 to 80 percent among males in the intervention schools; among students in comparison schools, contraceptive knowledge increased from 64 to 73 percent among females and from 64 to 72 percent among males.[21]
    • Knowledge of HIV/STIs increased from 67 to 86 percent among females and from 72 to 88 percent among males in intervention schools; among students in comparison schools, HIV/STI knowledge increased from 62 to 72 percent among females and from 69 to 79 percent among males.[21]
    • For overall sexual health knowledge, knowledge of contraception, and knowledge of HIV/STIs, the differences were statistically significant for both male and female intervention youth (p<0.05 for each area, respectively).[21]
• Behaviors—
  • Delayed initiation of sexual intercourse—
    • Among females, the proportion in the intervention schools reporting sexual initiation rose from 17 percent at baseline to 28 percent at 21-month follow-up and 30 percent at 33-month follow-up. By contrast, reports of sexual initiation among females in comparison schools rose from 21 percent at baseline to 34 percent at 21-month follow-up and 37 percent at 33-month follow-up. At both follow-up points, evaluation found that the program had a statistically significant effect in reducing the rate of sexual initiation among females at intervention schools versus females at comparison schools.[21,22]
    • Among males, the proportion in the intervention schools reporting sexual experience at baseline was 31 percent rising to 36 percent at 21-month follow-up and to 42 percent at 33-month follow-up. By contrast, the reports of sexual experience among males at comparison schools rose from 42 percent at baseline to 45 percent at 21-month follow-up and to 49 percent at 33-month follow-up. At both follow-up points, evaluation found statistically significant lower rates of sexual initiation among male students in the intervention schools than in the comparison schools.[21,22]
  • Increased use of contraception—Evaluation found a statistically significant increase in contraceptive use among sexually experienced female students in the intervention schools versus sexually experienced female students from comparison schools. The difference for each class was statistically significant (p< 0.001).[21]
  • Middle school, class one: a rise in contraceptive use from 14 to 51 percent of sexually experienced intervention females between baseline and 33-month follow-up, versus a rise from 17 to 30 percent of sexually experienced comparison females;[21]
  • Middle school, class two: a rise in contraceptive use from 29 to 56 percent of sexually experienced intervention females between baseline and 33-month follow-up, versus a rise from 24 to 43 percent among sexually experienced comparison females;[21]
  • Middle school, class three: a rise in contraceptive use from 33 to 67 percent of sexually experienced intervention females between baseline and 33-month follow-up, versus a rise from 31 to 45 percent among sexually experienced comparison females;[21] and
  • Middle school, class four: a rise in contraceptive use from 43 to 73 percent of sexually experienced intervention females between baseline and 33-month follow-up, versus a rise from 38 to 56 percent among sexually experienced comparison females.
• Health Outcomes—
  • Reduced incidence of pregnancies—At follow-up, evaluation found a statistically significant decline by about one-third in the proportion of young women from the intervention schools who became pregnant (down from 15 to 10 percent). In the comparison schools, the decline was not significant. The difference between intervention and comparison schools was also statistically significant (p<0.05).[21]
  • Reduced incidence of imposed abortion—Among students who became pregnant, evaluation found a decline in imposed abortions in the intervention sites from three to zero percent. By contrast, evaluation found an increase in imposed abortions among pregnant students in the comparison schools (four rising to 14 percent). Thus, there was a significant net decline in the proportion of imposed abortions among young women in the intervention schools and a statistically significant difference in outcomes related to imposed abortion (p< 0.01).[21]

For More Information, Contact

• Virginia Toledo: This e-mail address is being protected from spambots. You need JavaScript enabled to view it ; El Trovador 4280 – Of.612, Las Condes, Santiago, Chile
• Ximena Luengo: This e-mail address is being protected from spambots. You need JavaScript enabled to view it ; El Trovador 4280 – Of.612, Las Condes, Santiago, Chile
• Nancy Murray: This e-mail address is being protected from spambots. You need JavaScript enabled to view it ; The Future's Group, One Thomas Circle NW, Suite 200, Washington, DC 20005 USA

* Imposed abortions are defined in this study as abortions insisted upon by parents or partners.
** The curriculum for parents consists of five sessions that focus on understanding adolescence and on improving parent-child communication.