The Effectiveness of Sexuality Education Curriculum

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Background

Youth & Shelter Services, Inc. (YSS) is a non-profit organization that has been working to improve the lives of Iowa’s families since 1971 (YSS, 2016). YSS (2014) provides ” prevention, education, treatment, and residential services to children, youth, and families,” and its vision consists of a “world where society values its youth and together they thrive” (p. 3). The program that is going to be evaluated is a component of the YSS Adolescent Pregnancy Prevention Program (YAPP) that emerged in Boone County in 2002 but expanded its services to Story County in 2009. The resulting coalition was titled “Teaming Together 4 Teens,” TT4T (YAPP, n.d., par. 1). The program includes educational programs and a free teen clinic located at the Boone County Hospital. Given the scope of the program’s activities, this evaluation is going to be devoted to one of them: an abstinence-plus (APL) curriculum, “Making Proud Choices” (ReCAPP, 2016). It contains eight modules and strongly promotes abstinence; the safe sex alternative is supposed to be achieved with the help of condoms.

The Need for the Program

The adolescent pregnancy (AP) rates in the US have dramatically decreased since the 1990s, but they are still an issue (CDC, 2015). AP harms young parents (high college dropout rates), children (they are less likely to receive high grades and more likely to be involved in the crime), and taxpayers (the medical and foster care). Iowa performs relatively well: in 2011, 40 of the US states had greater rates of AP. Since 1988, the rate of Iowa APs dropped by 40%, and the teens of Iowa demonstrate better sexual literacy than the youth of the US on average. On the other hand, in 2011, 7% of Iowa teens did not use any protection for their sexual intercourse (HHS Office of Adolescent Health, 2014). Therefore, the need for YAPP does exist.

Staffing

The TT4T coalition facilitates the implementation of the program; one of its members, Deborah Arringdale, is the YAPP (n.d.) director. Participatory members include teachers, principals, counselors, and advisors. The curriculum requires the participation of one or two facilitators, and both variants are expected to be equally efficient (ReCAPP, 2016).

Clients

The clients of the program are children aged 11-12; the target audience includes “African-American, Hispanic and White adolescents” (ReCAPP, 2016, para. 4).

Stakeholders of the Evaluation

The TT4T coalition will be contacted, and their approval of the evaluation is necessary. They might assist in reaching schools and centers willing to participate and finding facilitators and other staff. Naturally, the evaluation is going to involve the children from Boone and Story Counties (Iowa) and their parents. YSS is likely to benefit from the evaluation as well and can be addressed for funding through TT4T or directly.

Outcomes of the Program

Given the type (abstinence-plus, APL) and size of the program (8 lessons), its outcomes are not comprehensive. They are supposed to include improved knowledge about condom contraception, STDs, and pregnancy; increased intention to use condoms and positive attitude towards them; the adoption of relevant communication skills (negotiation and refusal); condom use skills, and eventually reduced risky sexual behavior (ReCAPP, 2016, para. 7).

Mechanisms of the program

The mechanisms of the program include the provision of scientifically accurate information to dispel stereotypes and increase knowledge level, skill practice, and attitude-forming discussions. Also, the program encourages the feeling of pride (for one’s community and themselves) to help students develop responsibility “for the sake of themselves, their families, and their communities” (ReCAPP, 2016, para. 10-12).

Activities of the Program

The program’s activities should encourage participation, interaction, and learning, improve children’s decision-making and critical thinking skills, and be fun. They include games, role-playing, group discussions, brainstorming, skills practicing, the use of media (primarily video clips), and presentations for eight 1-hour lessons.

Making It Useful

The proposed evaluation is a summative one (Bamberger, Rugh, & Mabry, 2012). Its basic goal of the evaluation consists in defining the effectiveness of MPC, its worth, and merits. The key questions include:

1. What groups of the population do the program affect, and how much?
2. Are all the expected outcomes of MPC achieved? For which groups?
3. What are the children’s opinions concerning the program?
4. Should TT4T use MPC in the modern environment of the Counties?

Rationale

MPC is one of the nine educational interventions employed by TT4T. The curriculum was already evaluated by Jemmott, Jemmott III, and Fong (1998), but the study has a number of limitations. First, it studied black teenagers from low-income families. The teens of Boone and Store Counties are predominantly white (with 4% and 12% of the population belonging to other races and nationalities, respectively), with the median household income amounting to $52,714 and $51,270, which is close to the average in the US (US Census Bureau, 2015a; US Census Bureau, 2015b). Second, the evaluation did not take into account all the outcomes (only condom use and abstinence intentions). Third, the evaluation was carried out more than 15 years ago. As shown by Nixon, Rubincam, Casale, and Flicker (2011), the socio-cultural parameters of a community have the potential of affecting the effectiveness of APPs. Society has changed since 1998, and it could alter MPC effectiveness. Finally, MPC is an APL. The criticism directed at this kind of programs contributes to the conclusion that MPC can and should be reevaluated in the context of the modern Boone and Stone Counties and their diversity patterns with attention paid to all the program outcomes to define if it is still effective, to which extent, for which groups, and if it is reasonable to continue to use it.

Literature Review

As of 2015, sexuality education was considered mandatory by 22 of the states of the USA; 33 states required HIV education (Peter, Tasker, & Horn, 2015). MPC is one of the governmentally-approved evidence-based APL curricula that are eligible for the dissemination of sex-related information among youngsters, which is why this literature review is devoted to the types of APP and their effectiveness.

In the 1990s, the Abstinence-Only-Until-Marriage Programs (AOPs) were the only APPs funded by the government (Dworkin, & Santelli, 2007). AOPs were criticized for the lack of information concerning safe sex; in the end, evidence was found for the possibility of AOP leading to increased rates of AP (Stanger-Hall, & Hall, 2011). APLs appeared in response to this criticism to contain safe sex (contraception) component with a specific emphasis on abstinence. AOPs were compared to APLs, and it was discovered that the latter is much more effective in the long term, even though the former can outperform them in a short-term perspective (Jemmott et al., 1998).

However, APLs were also criticized: they were labeled as controversial and inconsistent, and it was predicted that one of their components could be discredited by the other (Beshers, 2007). Nixon, Rubincam, Casale, and Flicker (2011) provide evidence of such an adverse effect that is made more powerful by the lack of education and adverse attitudes towards contraception. The attempts at refuting this thesis were made, for example, by Underhill, Operario, & Montgomery (2007). Their study demonstrates that none of the APLs resulted in a statistically relevant negative impact. Still, nine of the evaluated programs failed to have any effect on one of the conflicting elements while promoting the other. Sixteen programs had no effect at all, but 24 were useful, and it can be concluded that APL can be at least partially effective.

Some researchers, for example, Dworkin and Santelli (2007), regard APLs as a type of comprehensive APPs (Capps), but others, including Beshers (2007), insist that this is an overestimation. An example of CAPP is provided by Rosenthal et al. (2009): it is a very complex and costly case management program that has reduced the rates of pregnancy in a neighborhood of New Britain by almost 50% (p. 280). According to Peter et al. (2015), comprehensive programs tend to include information on more complex aspects: for example, abortion or gender orientation. There is evidence for the effectiveness of all the programs, but CAPPs are expected to be free of the limitations and controversies of AOP and APLs, which makes modern researchers trust them more (Beshers, 2007). As for the public acclaim, Barr, Moore, Johnson, Forrest, and Jordan (2014) report that parents tend to prefer CAPPS as well, although at least 20% of the study participants favored AOPs, and 36% wanted APLs for their children. However, the study of Peter et al. (2015) demonstrates that the majority of parents (50%) are ignorant of the programs that their children are attending and can agree to any option (p. 30).

To sum up, the literature review proves that MPC is an APL, and the possible issues of MPC (including potential inconsistency and lack of comprehensiveness) should be taken into account during the evaluation. The review also indicated that APLs could be effective, and parents can favor them, but to stay competitive, MPC needs to demonstrate its effectiveness.

Program Theory

Program theory evaluation presupposes defining the theory that underlines a program and analyzing its intended and unintended results chain while taking into account the context of its implementation (Bamberger et al., 2012, pp. 187-188). The primary theory of change of MPC consists in the idea that the improved knowledge of the consequences of risky sexual behavior leads to reduced risky sexual behavior (Lee, Cintron, & Kocher, 2014). Also, as an APL, MPC is based on the idea that AOPs are ineffective due to their lack of information on contraception (Dworkin, & Santelli, 2007). As a result, MPC contains the relevant information and skills practicing, which is supposed to help the participants develop these skills.

Besides, MPC includes the elements of empowerment (proud choices making) that are meant o result in increased responsibility. The complexity of all the mentioned components (knowledge, skills, empowerment) is expected to lead to abstinence and condom use promotion, which should reduce the number of AP and HIV occurrence. The possible negative outcomes are the lack of effect and the chance of discrediting one of the conflicting methods of protection: abstinence and condom use (Beshers, 2007). The process analysis that was carried out by Jemmott et al. (1998) indicated the positive effect of MPC on condom use and frequency of sexual acts, but not on abstinence; skills development and empowerment were not measured. The program was not tested in an environment similar to that of Boone and Story Counties. In other words, given the environment and the type of program, MPC needs to prove its effectiveness.

Logic Model

See Table 1 for the logic model of MPC.

Mixed Methods

The methods of the assessment will be mixed; both qualitative and quantitative data will be collected with the help of closed and open-ended questions.

The data collection methods include a number of surveys; the specific instruments are the parent’s questionnaire (PQ) and the children’s questionnaires: basic (CQs) and anonymous (CQA). PQ will gather background information on children; CQs will include the measurable outcomes of MPC participation (knowledge, risky sexual behavior, condom usage, abstinence, intent to negotiate condom use, and empowerment and responsibility component perception). Most of these questions will be closed, but many will have open options. CQA will be used to receive feedback after the program; the questions are going to be open.

PQ and CQA will be administered once. CQ will be administered four times: before the MPC and 3, 6, and 12 months after.

Below is an overview of the questions of interest. The final questionnaires will contain instructions, gratitude, possibly extra or modified questions, and answer options and will be arranged differently.

Parent/Guardian Questionnaire

Name _____

The information about the child

1. Name
2. Gender
3. Age
4. Race/ethnicity
5. The level of income of the child’s family
6. The sexuality education received by the child.

Children’s Questionnaire

Name and Age.

• Have you ever received sexuality education?
• Do you think Sex Ed is necessary? Why or why not?

Question Block 1. General knowledge.

• Do you know what sex is? If not, do you want to find out?
• Do you know what risky sex is? Can you define it?
• Do you know what pregnancy is? Do you know how a person becomes pregnant? Could you explain it briefly?
• Do you know what sexually transmitted diseases and infections (STD and STI) are?
• Do you know what condoms are for? Can you explain it briefly?

Answers for the block:

• Yes, it is___
  • Yes, I know, but I can’t (don’t want to) define it.
  • No.
  • I’m not sure.

Question Block 2.

• If you have sex, will you use a condom? Why?
• If not, would you insist on having sex without a condom when your partner is not sure?
• If your partner does not want to use a condom, what will you do? Why?
• When do you think it is normal to start having sex?
• Do your family members think the same? Do you think they would agree with you?
• Who is responsible for the consequences of risky sex?
  • The elder partner.
  • The younger partner.
  • The one who had insisted on having sex without protection.
  • The one who has to deal with the consequences.
  • Both partners.
  • Parents/guardians/teachers/society/God.
  • Other variant _____
  • Have you ever had sex?
  • Did you use a condom?

Feedback Questionnaire (Anonymous)

1. You have just completed the “Making Proud Choices” program. What are your impressions?
2. Did you learn something new? What is it?
3. What is your opinion about activities?
4. Was there something you loved?
5. Was there something you did not like?
6. Do you think something could be changed?

Rationale

PQ will provide the information, according to which the data gathered by CQs will be organized; the CQs will be designed to assess all the intended outcomes of MPC. At least one of the results (perceived outcomes) can only be evaluated through qualitative data, and others can benefit from it, which is why the methods are mixed. MPC will not be compared to other APPs, and no control group is needed.

Measurement Tools and Analysis Strategy

To measure the effectiveness of the program (the achievement of its outcomes), the results of the questionnaires will be analyzed for every child. The data of the whole sample will be coded, and quantitative information will be statistically analyzed; qualitative one will be used for more in-depth understanding. Apart from that, the data of the groups will be statistically analyzed and compared to each other. The PQ is needed to ensure correct grouping. The initial CQ data will be regarded as the baseline.

Evaluation Instrument

The evaluation instrument, therefore, consists of several qualitative and quantitative questionnaires, the results of which will be coded to facilitate their analysis and compared to baseline data for every child with respect to their assigned group.

Sampling

Convenience sampling will be complemented by quota sampling for this evaluation for the following reasons.

The sample size needs to be large enough to reflect the groups of interest. All the groups will be equally sized with a quota of 20-25 students to ensure insight into the influence of MPC on them. The groups will be stratified geographically (Boone and Story) and from the point of view of gender and income (which means 12 groups). Apart from that, groups of non-white children from both Counties will be formed. Given the lack of racial diversity in the Counties, a sufficient number of non-white children for further stratification is unlikely to be found. The resulting sample will amount to 280-350 students. Other eligibility criteria include age (11-12) and the absence of former MPC sexuality education.

The initial sampling will involve the schools and communities that can and want to participate (convenience); they will be used to define possible participants (quotas ensured) and contact parents. The latter will be provided with emails or flyers that will contain accurate data about children’s eligibility and assent, the nature of the study, and collaborating centers and schools. The eligible children of the parents who are in contact with the said schools and communities and express the wish to participate will be the intermediate sample. The final sample will be formed after the participant’s consent and provide the CQs.

Procedures and Logistics and Budget

The number of two-day sessions for 350 children will amount to at least 28 8-hour 2-day ones (for 12-people groups). It is suggested that the number of investigator groups is four to shorten the time limits. The price of four MPC kits is $2592.

The four locations (most certainly schools/community centers) will be found with the help of TT4T. The rooms can be expected to be provided by the locations. If all the members are based in the locations, traveling costs will be nonexistent. The work of facilitators will require $3360 (hourly wage around $15). The team will also need the principal investigator and the analysts. The payments for these people can be assumed to amount to $15 per hour, but it is impossible to define their working hours yet. Also, YSS (2016) and YAPP (n.d.) actively involve volunteers.

About a month and a half will be needed for every location’s sampling to provide for all the kinds of unexpected situations. The additional costs of this period include flyer printing, but it can be avoided if emails are used.

If four teams work simultaneously, half a month will be required for the MPC to be carried out. To ensure the possibility of organization of the lessons, a month is stated as a limit for the second stage. The costs may include printed materials (questionnaires unless they are digital), consent forms, and $3500 of incentive for the participants ($10 for two completed questionnaires). The results will be analyzed within one or two weeks.

Three more meetings should be arranged for children and the team: in 3, 6, and 12 months. It is suggested that the four teams will be able to finish this task during a week. The costs include printing questionnaires and $5250 of incentive.

If printing one page costs $0.05, the materials will require $210 for all the questionnaires (if they are two-paged) and $70 for the consent and assent forms (four pages for both).

Expected costs:

• Materials and incentives: $11622.
• Facilitators’ work: $3360 (224 hours).
• Other staff: $15-20/hour. Working for about 13 weeks.

Timeframe:

• Sampling: up to 6 weeks.
• MPC: 4 weeks.
• Analysis: up to 2 weeks.
• Subsequent questionnaires and analysis: 1 week each (3 weeks).
• Final analysis and report making: up to 2 weeks.

Ethical Considerations

Given the specifics of the study (sexuality education), it is necessary that parents and children sign consent forms. We must be sure that the parents and the children understand the nature of the study and the MPC program. According to the studies by Peter et al. (2015) and Lee et al. (2014), most of the parents approve of sexuality education at the ages of 11-12, and APLs receive their acclaim. The information gained from the questionnaires will be confidential and used for research purposes. The only exception is concerned with the evidence of a child being abused or otherwise endangered: such a case needs to be reported (Graham, Powell, Taylor, Anderson, & Fitzgerald, 2013). The parents or guardians will be informed of such a possibility.

Another possible ethical concern is the stratification methods we use, but it will not become an issue. While we will use quotas to define the number of participants, we will not necessarily group children for the lessons according to the criteria. Similarly, if we cannot accept children because of the quotas, we will not inform them or their parents that they cannot be accepted due to belonging to a particular group. We will respect the children’s diversity and work to create diversity-sensitive and bias-free questionnaires. There is a very small chance that a child who does not speak English will be involved. In this case, we will need to solve the problem through translation and interpreting.

Participants will be informed about all the specifics of the study and its procedures through the following form as required by research ethics (Bamberger et al., 2012). The assent form will be an age-adjusted version of the parental consent presented below. The introduction, voluntary nature of participation, question part, notification about data usage, and agreement are left out since they can be taken from templates without many changes. The unique parts are presented below.

Purpose of the Study

The study is designed to evaluate one of the adolescence prevention programs that are used by the schools of the US: “Making Proud Choices” (MPC). It is meant for the children aged 11-13. The curriculum emphasizes abstinence as the best protection strategy, but it also includes the information about condoms. It is a well-established program, but it may be outdated. We want to assess its effectiveness nowadays, and for this, we have involved 350 children aged 11-12 who had not participated in MPC program before.

Description of the Study

After you sign the consent form, you will be asked to fill out a questionnaire about your child so that we could check their eligibility and learn more about them. If you are eligible, your child will be asked to do the following.

• Fill out a questionnaire meant to assess the level of understanding of sexuality subjects.
• Participate in two four-hour sessions of MPC lessons (two days) in the local school classroom #123.
• Fill out a feedback questionnaire after the final session.
• Fill out a questionnaire similar to the first one in 3, 6, and 12 months.

We will ask your children to meet with us for questionnaires to ensure that the results are not affected by Internet surfing and other hints.

What is Experimental in this Study

The study uses experimental questionnaires, and all of the information is being collected for analysis.

Risks or Discomforts

The risks associated with the study are minimal. The questions may make children uncomfortable, and they will be warned about this fact. To reduce their discomfort, we will explain that the information is confidential, and they can leave the study anytime.

Benefits of the Study

It cannot be guaranteed that you and you child will benefit from the study immediately. Still, the study will evaluate the ongoing program, which will help us to improve it along with the sexuality education of Iowa and similar adolescent pregnancy prevention activities.

Confidentiality

The data collection tools of the study include questionnaires that require the names of the children, which is necessary for the repeated procedures. No personal information will ever be published. The questionnaires will be used for academic purposes only. The access to the questionnaires will only be granted to the staff of the study. We have to warn you though that if children’s answers indicate that they are in danger or suffer from abuse, we will have to report the case.

Incentives to Participate

Your children will receive the governmentally approved sexuality education. Besides, for the agreement to participate in the initial questionnaire, your children will receive a token payment of $1; for the completion of the questionnaire, $4 will be added to make it $5. Every next questionnaire will also bring your child $5.

Costs and/or Compensation for Participation

The only costs that you can encounter are transportation costs, and we are ready to reimburse them.

Annotated Bibliography

Bamberger, M., Rugh, J., & Mabry, L. (2012). Real World Evaluation (2nd ed.). Thousand Oaks, Calif.: Sage Publications.

The book contains vital information on program evaluation and covers every of the elements that are described in the presented paper.

Barr, E. M., Moore, M. J., Johnson, T., Forrest, J., & Jordan, M. (2014). New Evidence: Data Documenting Parental Support for Earlier Sexuality Education. Journal Of School Health, 84(1), 10-17 8p. Web.

The article reviews an opinion survey of 1715 parents of young children concerning adolescent pregnancy prevention (APP) education. The results indicated that comprehensive programs (CAPPs) were favored by 40% of the parents, abstinence-plus ones (APLs) by 36%, and 23% of the parents insisted on abstinence-only (AOP) programs. The study demonstrates the public opinion concerning APP methods and contributes to their understanding.

Beshers, S. (2007). Abstinence-what? A critical look at the language of educational approaches to adolescent sexual risk reduction. The Journal of School Health, 77(9), 637-9. Web.

The article analyzes the theory and philosophy of APPs. The author describes AOP, APL, and CAPP and criticizes APL for inconsistency (the conflict between abstinence and condom use components). The author also criticizes the tendency of describing APLs as comprehensive programs and draws the line between the two APP types. All of these aspects are significant for the presented evaluation.

CDC. (2015). Teen Pregnancy. Web.

The CDC webpage provides accurate and most recent information about pregnancy in the US.

Dworkin, S. L., & Santelli, J. (2007). Do Abstinence-Plus Interventions Reduce Sexual Risk Behavior among Youth? PLOS Medicine,4(9), e276-1439. Web.

The article dwells on the results of an APPs review by Underhill, Operario, and Montgomery (2007) and discusses its implications within the context of APP diversity. The article describes the history of AOP refusal and emphasizes that long-term effectiveness of APLs that has been demonstrated by the studies is limited (about six months). The article provides APP-related evidence and emphasizes possible drawbacks.

Graham, A., Powell, M., Taylor, N., Anderson, D. & Fitzgerald, R. (2013). Ethical Research Involving Children. Florence: UNICEF Office of Research – Innocenti.

An ethics and legal guide for research that involves children; it is approved by UNICEF.

HHS Office of Adolescent Health. (2014). Iowa Adolescent Reproductive Health Facts. Web.

The government webpage provides accurate and recent information on adolescent pregnancy situation in Iowa.

Jemmott, J.B., Jemmott III, L.S., & Fong, G. (1998). Abstinence and Safer Sex HIV risk-reduction interventions for African-American adolescents: A randomized control trial. Journal of American Medical Association (JAMA), 279, 1529-1536.

The source is outdated, but it is included in the bibliography since it contains the previous evaluation of the evaluated curriculum. The study demonstrated the effectiveness of both AOP and APL, but the former showed better short-term results, and the latter had a more lasting impact. The article provides a better understanding of what the curriculum was designed for and how it was assessed; the blank spots in the assessment invite a new one.

Lee, Y. M., Cintron, A., & Kocher, S. (2014). Factors Related to Risky Sexual Behaviors and Effective STI/ HIV and Pregnancy Intervention Programs for African American Adolescents. Public Health Nursing, 31(5), 414-427 14p. Web.

The authors provide an overview of the factors that contribute to risky sexual behavior. Particular attention is paid to African American youngsters. The results indicate that the key factors include peer and parent influence, gender roles, sex- and STD-relevant knowledge, and substance use. These factors help to understand the development of APPs.

Nixon, S., Rubincam, C., Casale, M., & Flicker, S. (2011). Is 80% a passing grade? Meanings attached to condom use in an abstinence-plus HIV prevention programme in South Africa. AIDS Care, 23(2), 213-220. Web.

The article is devoted to a qualitative study of the culture-affected perception of contraception and its interaction with APLs. The article focuses on HIV prevention, but since it explores the perception of contraception use by youths, it was deemed appropriate for this paper. The research indicates that the attitudes towards safe sex were diverse, but they included negative ones: gender bias, mockery, distrust, and conspiracy ideas, all of which negatively affected responsible sexual behavior. The authors insist that APL idea of contraception methods serves to discredit them further in a similar environment. For the evaluation, the article provides a greater understanding of the aspects that affect the effectiveness of programs (socio-cultural impact) and more information on APLs.

Peter, C., Tasker, T., & Horn, S. (2015). Parents’ attitudes toward comprehensive and inclusive sexuality education. Health Education, 115(1), 71-92. Web.

The article provides evidence on parental opinion concerning sexuality education (sample: 301 Illinois parents). The results indicate that a half of the parents were unaware of the kind of APP that their children were offered. Also, most parents were ready to accept any kind of curriculum (90% agreed to CAPP and 80% to AOP). This evidence is of interest for the evaluation; the article contributes to APP types classification.

ReCAPP. (2016). Making Proud Choices! Web.

The website and page are created by California’s non-profit APP organization; this page provides extensive and referenced information about the chosen curriculum and defines is as an effective abstinence-plus program.

Rosenthal, M., Ross, J., Bilodeau, R., Richter, R., Palley, J., & Bradley, E. (2009). Economic Evaluation of a Comprehensive Teenage Pregnancy Prevention Program. American Journal Of Preventive Medicine, 37(6), S280-S287. Web.

The article evaluates a costly and complex comprehensive case-management APP with the help of intervention and extrapolation analysis. The estimation took into account the operating costs and social costs (reduction of teen pregnancy rates by 54%) and demonstrated that the latter outweigh the former when the participants reach the age of 20 years (about 9 years since the enrollment). For the proposed evaluation, the study provides the information on the economic feasibility of APPs.

Stanger-Hall, K., & Hall, D. W. (2011). Abstinence-only education and teen pregnancy rates: Why we need comprehensive sex education in the U.S. PLoS One, 6(10). Web.

The article provides evidence to the idea that AOPs are not effective in reducing teen pregnancy and can be correlated with the increase in the latter, which is demonstrated through the analysis of the data gathered from various governmental sources (Education Commission, Council for Community and Economic Research).

Underhill, K., Operario, D., & Montgomery, P. (2007). Systematic review of abstinence-plus HIV prevention programs in high-income countries. PLoS Medicine, 4(9), e275. Web.

The article reviews 39 APL with the total sample of 37,724 youths. The results indicate that the programs were harmless, and 23 of them had a positive effect on at least one of the key behaviors. The authors conclude by denying the idea that APLs are inconsistent, but the results show that 9 of the programs had a positive effect on only one of the conflicting components, even though both were targeted (see the table on p. 1477). For the proposed evaluation, the article contributes to the understanding of APLs and their effectiveness.

US Census Bureau. (2015a). Boone County, Iowa. Web.

The official Census Bureau webpage provides accurate and recent statistics on the population of Boone County.

US Census Bureau. (2015b). Story County, Iowa. Web.

The official Census Bureau webpage provides accurate and recent statistics on the population of Story County.

YAPP. (n.d.). Teaming Together 4 Teens. Web.

The official website of the evaluated program that provides the necessary information about it.

YSS. (2016). About Us. Web.

The official website of the organization that supports the evaluated program provides the information about its history.

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