Many AOE programs were preachy, moralistic, criticized condom use, and advocated for abstinence until marriage. Unfortunately for children everywhere, these were the programs that were funded. Anyway, word got around more than Paris Hilton and the idea of AOE fell upon hard times.
Imagine my surprise when I saw headlines like that on NPR's Health Blog, noting that an abstinence-only intervention actually did work. (See the article from Scientific Blogging's excellent News Staff on the journal article here.) But does it really?
Policy and scientific research
The ramifications of a finding like this are huge, especially for public policy. That's why I was relieved to read the accompanying editorial by Frederick Rivara and Alain Joffe, which stressed caution in using research to formulate policy:
No public policy should be based on the results of one study, nor should policy makers selectively use scientific literature to formulate a policy that meets preconceived ideologies.Rivara and Joffe write that while science is driven by facts and findings and strives to be objective, "Formulation of public policy is very different. Good public policy will rest on a solid knowledge base, but the knowledge base must be broad enough to encompass the many factors and facets that bear on a policy issue. It also includes political will and social strategy, the means by which we apply our knowledge and political will to improve or initiate programs."
The study, conducted by John Jemmott III, Loretta Jemmott, and Geoffrey Fong, "was designed to test some specific hypotheses within the larger public policy question of how to prevent human immunodeficiency virus/AIDS and other sexually transmitted infections, as well as unwanted pregnancies, among adolescents in this country," the editorial says. "This is an immensely important issue, and one that clearly will not be solved through any single intervention. If prevention of risky sexual behaviors was easy to accomplish, we would already have accomplished this goal."
Jemmott et al. tested whether "an educational program aimed at preventing risky sexual behaviors among young adolescents would be most effective if it was based on teaching abstinence and delaying sexual activity, teaching young adolescents how to practice safer sex, or a combination of both approaches. The results may be surprising to some in that the theory-based abstinence-only curriculum appeared to be as effective as a combined curriculum and more effective than the safer sex–only curriculum in delaying sexual activity." And importantly, none of the curricula "had any effect on the prevalence of unprotected sexual intercourse or consistent condom use."
Abstinence-only programs are controversial (and could be risky), yet there haven't been many randomized clinical trials to actually test their efficacy, and more research is needed. "They're not based on an understanding of the motivation of children to have sex or to practice abstinence," Jemmott said in a Reuters article. Jemmott et al. said the "ideal abstinence intervention would incorporate principles of efficacious HIV/STI risk reduction behavioral interventions. It would draw on formative research on the population and behavior change theory to address motivation and build skills to practice abstinence; it would not be moralistic, and it would not stress the 'inadequacies' of condoms."
And good timing - the NY Times reported that the Obama administration is eliminating federal financing for abstinence-only programs, and starting a pregnancy-prevention initiative that will finance programs that have been shown in scientific studies to be effective.
A total of 662 African American students in grades 6 and 7 in 4 urban public schools in the northeastern U.S. were randomly assigned to an 8-hour abstinence-only intervention, an 8-hour safer sex–only intervention, an 8- or 12-hour combined abstinence and safer-sex intervention, or an 8-hour health-promotion control group. They were also randomly assigned to intervention maintenance or no intervention maintenance. The primary outcome was self-report of ever having sexual intercourse by the 24- month follow-up. The authors hypothesized that fewer participants in the abstinence-only intervention than in the control group would report ever having sexual intercourse by the 24-month follow-up. Kids were paid $20 to participate.
(1) The 8-hour abstinence-only intervention "encouraged abstinence to eliminate the risk of pregnancy and STIs including HIV. It was designed to (1) increase HIV/STI knowledge, (2) strengthen behavioral beliefs supporting abstinence including the belief that abstinence can prevent pregnancy, STIs, and HIV, and that abstinence can foster attainment of future goals, and (3) increase skills to negotiate abstinence and resist pressure to have sex. It was not designed to meet federal criteria for abstinence-only programs."
(2) The 8-hour safer sex–only intervention "encouraged condom use to reduce the risk of pregnancy and STIs, including HIV, if adolescents had sex. It was designed to (1) increase HIV/STI knowledge, (2) enhance behavioral beliefs that support condom use, and (3) increase skills to use condoms and negotiate condom use. It was not designed to influence abstinence."
(3) Two comprehensive interventions "combined the abstinence and safer-sex, HIV risk–reduction interventions. One was 12 hours, and the other was 8 hours and contained similar content. Both targeted beliefs and skills to encourage abstinence and condom use. Both were designed to (1) increase HIV/STI knowledge, (2) strengthen behavioral beliefs supporting abstinence, (3) strengthen behavioral beliefs supporting condom use, (4) increase skills to negotiate abstinence, and (5) increase skills to use condoms and negotiate condom use."
(4) Finally, the 8-hour health-promotion intervention, which served as the control, focused on behaviors associated with risk of heart disease, hypertension, stroke, diabetes, and certain cancers. It was designed to increase knowledge and motivation regarding healthful dietary practices, aerobic exercise, and breast and testicular self-examination, and to discourage cigarette smoking.
The intervention maintenance program consisted of two 3-hour booster intervention sessions (6 weeks and 3 months after initial intervention sessions), 6 issues of a newsletter, and six 20-minute 1-on-1 counseling sessions during a 21-month period with their original facilitator.
Participants completed preintervention, immediate postintervention, and 3-, 6-, 12-, 18-, and 24-month follow-up questionnaires.
Not surprisingly, Sarah Brown of the National Campaign to Prevent Teen and Unplanned Pregnancy told the New York Times that the study is "game-changing."
The study did not say that abstinence-only education worked wholesale - instead, in a small group of a select population, a particular theory-based program delayed sexual activity.
One paragraph summed up the changing of said game: "The abstinence-only intervention reduced sexual initiation (p=0.03). The model-estimated probability of ever having sexual intercourse by the 24-month follow-up was 33.5% in the abstinence-only intervention and 48.5% in the health-promotion control group. The safer sex and comprehensive interventions did not differ from the control group in sexual initiation."
Sounds dry and boring, but it packs a punch - two-thirds of the students in the abstinence-only intervention delayed sexual initiation at least 24 months, whereas just over half of the kids in any other intervention program (including the control) delayed sexual initiation at least 24 months.
The abstinence intervention also significantly reduced recent sexual intercourse compared with the control group (p=0.02). The authors also note that a "common concern about abstinence-only interventions is that they have the unintended effect of reducing condom use, ie, that children exposed to such interventions are subsequently less likely to use condoms if they have sexual intercourse," but in this study none of the interventions had significant effects on consistent condom use or unprotected intercourse.
This was "the first randomized controlled trial to demonstrate that an abstinence-only intervention reduced the percentage of adolescents who reported any sexual intercourse for a long period following the intervention, in this case, 24 months after intervention," the authors said.
The promising results "suggest that theory based abstinence-only interventions can have positive effects on adolescents’ sexual involvement. This is important because abstinence is the only approach that is acceptable in some communities and settings in both the United States and other countries. This trial showed that having had a theory-based abstinence-only intervention would not necessarily reduce adolescents’ condom use. Nevertheless, the results do not mean that abstinence-only intervention is the best approach or that other approaches should be abandoned."
Why did this work when others haven't?
The programs didn't insist on abstinence until marriage, portray sex in a negative light, or suggest condoms are ineffective. Nobody likes to be lectured to, and that method of "intervention" doesn't usually work anyway. Instead, groups of 6-8 participants listed pros and cons of abstinence and sexual activity, and discussed what their goals and dreams for the future are, where they see themselves five years from now, and where they see themselves 10 years from now.
Instead of an adult saying, "Don't do this, it's bad," the kids figured out on their own that sexual activity could put a crimp in their style. If having a sexually transmitted infection or having a baby would prevent you from achieving your goals (or make it a lot harder), you might think first before having sex. This cognitive process will have a greater impact on behavior change than passively absorbing information or simply being told to not do something.
Whether an intervention like this would work in other settings needs to be tested. Plus, in older student populations, where teens may already be having sex, the messages may have to be adapted - instead of "don't start," perhaps focus on reducing the number of partners, or reducing frequency.
Editorial: Arch Pediatr Adolesc Med. 2010;164(2):200
Article: Arch Pediatr Adolesc Med. 2010;164(2):152-159