V. Evidence-Based Intervention Models

Substantial work has been done in the areas of sexual health and responsible sexual behavior, through public-private partnerships at the national as well as community level, by many researchers and organizations throughout the country. Many of these approaches and programs to improve sexual health have been evaluated and shown to be effective. They include: community-based programs, school-based programs, clinic-based programs, and religion-based programs.

Community-Based Programs

Youth development programs, although they typically do not specifically address sexuality, have been shown to have a significant impact on sexual health and behavior. Programs that improve education and life options for adolescents have been demonstrated to reduce their pregnancy and birth rates (Olsen and Farkas, 1990; Allen et al., 1997; Melchior, 1998; Hawkins et al., 1999). These programs may increase attachment to school, improve opportunities for careers, increase belief in the future, increase interaction with adults, and structure young people's time.

The CDC has identified a number of effective STD and HIV prevention programs that are curriculum-based and presented by peer and health educators in various community settings (CDC, 1999c). Other community interventions have involved changing community norms and the distribution of condoms to reduce unwanted pregnancies and STDs, including HIV. Such interventions have the advantages of reaching large numbers of people at a relatively low cost and engaging the active involvement of community members, including local opinion leaders. They have had considerable success in changing community norms about sexual behavior as evidenced by substantial increases in condom use (Arnold and Cogswell, 1971; Kelly et al., 1991; Grosskurth et al., 1995; Kegeles et al., 1996; Kelly et al., 1997). It is important to point out that although the correct and consistent use of condoms has been shown to be effective in reducing the risk of pregnancy, HIV infection, and some STDs, more research is needed on the level of effectiveness.

School-Based Programs

A majority of Americans favor some form of sexuality education in the public schools and also believe that some sort of birth control information should be available to adolescents (Smith, 2000). School-based sexuality education programs are generally of two types: abstinence-only programs that emphasize sexual abstinence as the most appropriate choice for young people; and sexuality and STD/HIV education programs that also cover abstinence but, in addition, include condoms and other methods of contraception to provide protection against STDs or pregnancy.

To date, there are only a few published evaluations of abstinence-only programs (Christopher and Roosa, 1990; St Pierre et al., 1995; Kirby et al., 1997; Kirby, 2001). Due to this limited number of studies it is too early to draw definite conclusions about this approach. Similarly, the value of these programs for adolescents who have initiated sexual activity is not yet understood. More research is clearly needed.

Programs that typically emphasize abstinence, but also cover condoms and other methods of contraception, have a larger body of evaluation evidence that indicates either no effect on initiation of sexual activity or, in some cases, a delay in the initiation of sexual activity (Kirby, 1999; Kirby, 2001). This evidence gives strong support to the conclusion that providing information about contraception does not increase adolescent sexual activity, either by hastening the onset of sexual intercourse, increasing the frequency of sexual intercourse, or increasing the number of sexual partners. In addition, some of these evaluated programs increased condom use or contraceptive use more generally for adolescents who were sexually active (Kirby et al., 1991; Rotheram-Borus et al., 1991; Jemmott et al., 1992; Walter and Vaughn, 1993; Magura et al., 1994; Main et al., 1994; St Lawrence et al., 1995; Hubbard et al., 1998; Jemmott et al., 1998; Coyle et al., 1999).

Despite the available evidence regarding the effectiveness of school-based sexuality education, it remains a controversial issue for many -- in terms of whether schools are the most appropriate venue for such education, as well as curriculum content. Few would disagree that parents should be the primary sexuality educators of their children or that sexual abstinence until engaged in a committed and mutually monogamous relationship is an important component in any sexuality education program. It does seem clear, however, that providing sexuality education in the schools is a useful mechanism to ensure that this Nation's youth have a basic understanding of sexuality. Traditionally, schools have had a role in ensuring equity of access to information that is perhaps greater than most other institutions. In addition, given that one-half of adolescents in the United States are already sexually active -- and at risk of unintended pregnancy and STD/HIV infection -- it also seems clear that adolescents need accurate information about contraceptive methods so that they can reduce those risks.

Clinic-Based Programs

Prevention programs based in health clinics that have an impact on sexual health and behavior are of three types: counseling and education; condom or contraceptive distribution; and STD/HIV screening. Successful counseling and education programs have several elements in common: they have a clear scientific basis for their design; they require a commitment of staff time and effort, as well as additional time from clients; they are tailored to the individual; and they include building clients' skills through, for example, exercises in negotiation. Even brief risk-reduction messages have been shown, in some studies, to lead to substantial increases in condom use (Cohen et al., 1991; Cohen et al., 1992; Mansfield et al., 1993; Kamb et al., 1998;) although other studies have shown little effect (Wenger et al., 1992; Clark et al., 1998). More extensive counseling, either individual or small group, can produce additional increases in consistent condom use (Boyer et al., 1997; Shain et al., 1999).

Most school clinic-based condom and contraceptive availability programs include some form of abstinence or risk-reduction counseling to address the concern that increased condom availability could lead to increased sexual behavior (Kirby and Brown, 1996). The evidence indicates these programs, while still controversial in some communities, do not increase sexual behavior and that they are generally accepted by adolescents, parents, and school staff (Guttmacher et al., 1995; Wolk and Rosenbaum, 1995).

Because many STDs have no clear symptoms, STD/HIV screening promotes sexual health and responsible sexual behavior by detecting these diseases and preventing their unintentional spread. Routine screening in clinics has also been shown to reduce the incidence of some STDs, particularly chlamydia infection (Hillis et al., 1995; Scholes et al., 1996).

Religion-Based Programs

Religion-based sexuality education programs have been developed and cover a wide spectrum of different belief systems. Taken as a whole, they cover all age ranges, from early elementary school to adults, as well as youth with different sexual orientations and identities. Although it is reasonable to expect that religion-based programs would have an impact on sexual behavior, the absence of scientific evaluations precludes arriving at a definitive conclusion on the effectiveness of these programs. More research is needed.