Choosing and Maintaining Programs for Sex Education in Schools: The CHAMPSS Model

Background: Despite effective solutions to reduce teen birth rates, Texas teen birth rates are among the highest in the nation. School districts can impact youth sexual behavior through implementation of evidence-based programs (EBPs); however, teen pregnancy prevention is a complex and controversial issue for school districts. Subsequently, very few districts in Texas implement EBPs for pregnancy prevention. Additionally, school districts receive little guidance on the process for finding, adopting, and implementing EBPs. Purpose: The purpose of this report is to present the CHoosing And Maintaining Programs for Sex education in Schools (CHAMPSS) Model, a practical and realistic framework to help districts find, adopt, and implement EBPs. Methods: Model development occurred in four phases using the core processes of Intervention Mapping: 1) knowledge acquisition, 2) knowledge engineering, 3) model representation, and 4) knowledge development. Results: The CHAMPSS Model provides seven steps, tailored for school-based settings, which encompass phases of assessment, preparation, implementation, and maintenance: Prioritize, Asses, Select, Approve, Prepare, Implement, and Maintain. Advocacy and eliciting support for adolescent sexual health are also core elements of the model. Conclusion: This systematic framework may help schools increase adoption, implementation, and maintenance for EBPs.

Adolescents’ Sexual Health Matters: Texas Should Get on Board

Texas has an appalling record on adolescent sexual health. The Markham, et al. analysis of three data sets comparing Texas with the United States suggests what can be done to remedy the state's negative trends: (1) acknowledge that teens are having sex; (2) provide earlier, medically-accurate sex education; and, (3) provide reproductive health services in school-based health centers.

A Coordinated and Systematic Model for Adopting, Implementing and Maintaining Effective Sexual Health Education Programs in Schools

Getting evidence-based sexual health education activities into schools can be a complicated process. Working models that assist our educational system in the selection, implementation, and maintenance of effective school-based adolescent health programs are needed. Replicating sexual health programs in school-based settings: A model for schools provides a comprehensive and applied approach that engages all of the important stakeholders within a school district. The results from this study hold much potential to inform Texas and the nation about how a coordinated and practical model can assist school districts to increase the use of evidence-based programs addressing teen pregnancy prevention and sexual health issues.

Implications for Adoption and Implementation of Effective Sexual Health Education Programs

Research on school-based sexual health education programs is at a critical juncture. With the growing number of evidenced-based programs, more focus is needed on how to help schools adopt and implement these programs. The article in this issue titled “Sexual Health Education from the Perspectives of School Staff: Implications for Adoption and Implementation of Effective Programs in Middle School” provides data on individual cognitive factors that may influence adoption and implementation. This commentary explores another framework, Concerns Based Adoption Model, as a tool for examining and supporting change associated with adoption and implementation of sexual health education programs.

Diffusion and implementation of a tobacco prevention program: A replication study

Tobacco use is a major health hazard, and the onset of tobacco use occurs almost entirely in the teenage years. For this reason, schools are an ideal site for tobacco prevention programs. Although studies have shown that effective school-based tobacco prevention programs exist, all too frequently these programs are not used. In order for effective programs to achieve their potential impact, strategies for speeding the diffusion of these programs to school districts and seeing that, once adopted, programs are implemented as they are intended, must be developed and tested.^ This study (SC2) set out to replicate the findings of an earlier quasi-experimental study (The Smart Choices Diffusion Study, or SC1) in which strategies based on diffusion theory and social learning theory were found to be effective in encouraging adoption and implementation of an effective tobacco prevention program in schools. To increase awareness and encourage adoption, intervention strategies in both studies utilized opinion leaders, messages highlighting positive aspects of the program, and modeling of benefits and effective use through videotape and newsletters. To encourage accurate implementation of the curriculum, teacher training for the two studies utilized videotaped modeling and practice of activities by teachers. SC2 subjects were 38 school districts that make up one of Texas' 20 education service regions. These districts had served as the comparison group in SC1, and findings for the SC1 comparison and intervention groups were utilized as historic controls.^ SC2 achieved a 76.3% adoption rate and found that an average of 84% of the curriculum was taught with an 82% fidelity to methods utilized by the curriculum. These rates and rates for implementation of dissemination strategies were equal to or greater than corresponding rates for SC1. The proportion of teachers implementing the curriculum in SC2 was found to be equal to SC1's video-trained districts but lower than the SC1 workshop-trained group.^ SC2's findings corroborate and support the findings from the earlier study, and increase our confidence in its findings. Taken together, the findings from SC2 and SC1 point to the effectiveness of their theory-based intervention strategies in encouraging adoption and accurate implementation of the tobacco prevention curriculum. ^

Effect of nonnormal random components on level and power in group-randomized trials

The use of group-randomized trials is particularly widespread in the evaluation of health care, educational, and screening strategies. Group-randomized trials represent a subset of a larger class of designs often labeled nested, hierarchical, or multilevel and are characterized by the randomization of intact social units or groups, rather than individuals. The application of random effects models to group-randomized trials requires the specification of fixed and random components of the model. The underlying assumption is usually that these random components are normally distributed. This research is intended to determine if the Type I error rate and power are affected when the assumption of normality for the random component representing the group effect is violated. ^ In this study, simulated data are used to examine the Type I error rate, power, bias and mean squared error of the estimates of the fixed effect and the observed intraclass correlation coefficient (ICC) when the random component representing the group effect possess distributions with non-normal characteristics, such as heavy tails or severe skewness. The simulated data are generated with various characteristics (e.g. number of schools per condition, number of students per school, and several within school ICCs) observed in most small, school-based, group-randomized trials. The analysis is carried out using SAS PROC MIXED, Version 6.12, with random effects specified in a random statement and restricted maximum likelihood (REML) estimation specified. The results from the non-normally distributed data are compared to the results obtained from the analysis of data with similar design characteristics but normally distributed random effects. ^ The results suggest that the violation of the normality assumption for the group component by a skewed or heavy-tailed distribution does not appear to influence the estimation of the fixed effect, Type I error, and power. Negative biases were detected when estimating the sample ICC and dramatically increased in magnitude as the true ICC increased. These biases were not as pronounced when the true ICC was within the range observed in most group-randomized trials (i.e. 0.00 to 0.05). The normally distributed group effect also resulted in bias ICC estimates when the true ICC was greater than 0.05. However, this may be a result of higher correlation within the data. ^

Assessing childhood difficulties: Comparing the SDQ and the BASC-2

This study of the Behavior Assessment System for Children, Second Edition (BASC-2), had two objectives. First, was to compare the Strengths and Difficulties Questionnaire (SDQ) and the BASC-2. Participants were students from SBISD, identified as having difficulties, assessed with the BASC-2 and completed the SDQ. Based on the small sample (N=8), scores from the SDQ and the BASC-2 were found to correlate highly with one another on most conceptually similar scales. With both Parent and Teacher raters, diagnostic concordance was high for nearly all behavior and emotional problem scales. While the diagnostic concordance of the SDQ and BASC-2 looks promising, results need to be replicated with a larger sample. ^ The second objective was to assess the BASC-2 inter-informant concordance (parent, teacher and child). Participants were 145 students, 3-17 years, 78.6% male, 28% Hispanic, 37% White, 34% Black, and 64% were economically disadvantaged. Of the four dyads, teacher-teacher pairs had the highest correlations and agreement levels, especially on externalizing scale items, regardless of the subjects' age group, gender or ethnicity. ^ Overall, parent-teacher pairs had low to moderate concordance for most scale items, with slightly higher agreement for externalizing problems, with better concordance for preschool children, very low correlations with girls' ratings, but moderate correlations with boy ratings. Correlational results were generally moderate for teachers and parents of White children and low for teachers and parents of Hispanic and Black children. ^ Parent-child self-reports had low concordance for nearly all scale items evaluated, particularly with girl self-raters, but moderate with the boys. Conversely, Teacher-Girl pairs had larger correlations than with Boy. Parents reported substantially higher frequency of disorder endorsement than reported by the children, regardless of the child's ethnicity or gender. While generally low, Teachers and Black students had higher concordance on internalizing measures than Hispanic or White students. Parents of Black students had higher frequency of disorder endorsements than other ethnicities. ^ The difference in format and lack of externalizing measures on the self-report version (SRP) hinders inter-rater comparisons. Future studies using the revised, BASC-2 with children in a school-based setting are needed to assess further its rater reliability. ^

The association of food sources of calcium with weight class in adolescent girls

To determine the association of food sources of calcium with weight class in adolescent girls, the major food sources of calcium were determined for 718 sixth grade girls at three different time periods during an 18 month school-based health intervention program using a FFQ. To determine weight class, the BMI of each girl was stratified using CDC age and gender specific criteria at each time period. The percent contribution of the major food sources of calcium to total calcium intake was compared among the different weight classes at each time period, among those girls who had changed weight class at the different time periods and for those girls who did not change weight class at the different time periods. The mean total calcium intake increased by 20% between the first two time periods and by 12% between the first and last time periods with the intervention despite baseline total calcium intake already being greater than the recommended 1300 mg/day. The percent contribution of the major food sources of calcium were highly correlated among the weight classes that were compared throughout the study. Those girls who remained in the normal weight class throughout the study had the most consistent intake of food sources of calcium. Their top four food sources of calcium were different types of milk which provided greater than 50% of their total calcium intake. Despite there being no significant differences in the major food sources of calcium among the different weight classes, these data show a successful intervention for increasing calcium intake among adolescent girls. ^

Tobacco use and related psychosocial risk factors among youth in urban India: Assessment of Project MYTRI follow-up surveys

Project MYTRI (Mobilizing Youth for Tobacco-Related Initiatives in India) was a large 2-year randomized school-based trial with a goal to reduce and prevent tobacco use among students in 6th and 8th grades in Delhi and Chennai in India (n=32 schools). Baseline analyses in 2004 showed that 6th grade students reported more tobacco use than 8 th grade students, opposite of what is typically observed in developed countries like the US. The present study aims to study differences in tobacco use and psychosocial risk factors between the 6th grade cohort and 8th grade cohort, in a compliant sub-sample of control students that were present at all 3 surveys from 2004-06. Both in 2004 and 2005, 6th grade cohort reported significantly greater prevalence of ever use of all tobacco products (cigarettes, bidis, chewing tobacco, any tobacco). These significant differences in ever use of any tobacco between cohorts were maintained by gender, city and socioeconomic status. The 6th grade cohort also reported significantly greater prevalence of current use of tobacco products (cigarettes, chewing tobacco, any tobacco) in 2004. Similar findings were observed for psychosocial risk factors for tobacco use, where the 6th grade cohort scored higher risk than 8th grade cohort on scales for intentions to smoke or chew tobacco and susceptibility to smoke or chew tobacco in 2004 and 2005, and for knowledge of health effects of tobacco in all three years.^ The evidence of early initiation of tobacco use in our 6th grade cohort in India indicates the need to target prevention programs and other tobacco control measures from a younger age in this setting. With increasing proportions of total deaths and lost DALYs in India being attributable to chronic diseases, addressing tobacco use among younger cohorts is even more critical. Increase in tobacco use among youth is a cause for concern with respect to future burden of chronic disease and tobacco-related mortality in many developing countries. Similarly, epidemiological studies that aim to predict future death and disease burden due to tobacco should address the early age at initiation and increasing prevalence rates among younger populations. ^

The association between classroom characteristics and student physical activity in physical education classrooms

Background. With the rapid rise in childhood obesity, physical activity participation among young children has become the subject of much recent attention. Physical education classes have been specifically targeted as a method of providing opportunities for all children to be active. Unfortunately, student participation in moderate-to-vigorous physical activity during these classes still falls far below the current recommendations. While some research to date has reported the levels of activity among elementary-aged children, research is limited on the relationship between these activity levels and the environmental characteristics that exist within the PE classroom. ^ Purpose. The purpose of this study is to examine the association between specific classroom characteristics and contextual characteristics (lesson context, class size, class location, teacher gender, and teacher encouragement for PA) with elementary aged children's moderate-to-vigorous activity during PE class. ^ Methods. A secondary analysis of 211 3rd, 4th and 5th grade physical education classes amongst 39 elementary schools in Harris County, TX and 35 elementary schools in Travis County, TX was conducted using cross-sectional data from the evaluation of a school-based health program. Lesson context and student activity levels were measured using a direct observation measurement tool. Additionally, these variables were further analyzed against a number of classroom characteristics to determine any significant associations. ^ Results. Overall, elementary PE classes are still participating in low levels of moderate-to-vigorous physical activity averaging only 38% of class time. Additionally, close to 25% of class time is spent in classroom management. Male directed classes spent significantly more time in game activities and female directed classes spent more time in fitness, knowledge, and skill activities. Classes that took place outdoors were more active and spent more time in games than those that took place indoors. Significant correlations were demonstrated between class size and time spent in management context. Time spent in management context was also correlated with time spent sitting and standing. Additionally, positive correlations were demonstrated between time very active and teachers that praised students and encouraged physical activity among their classes.^

Mandating the HPV vaccine

Background. HPV is the underlying cause of cervical cancer, a malignant tumor of the female genital tract. Each year, cervical cancer is newly diagnosed in approximately 10,000 women, and over 3,000 women die from the malignancy. In addition, HPV is implicated as a cause of other cancers involving the genital tract, male and female, and the head and neck. ^ Gardasil, a vaccine against HPV, was licensed by the FDA in June 2006. Early study results have shown Gardasil to be safe and effective at preventing HPV infections that are commonly associated with the development of cervical cancer, as well as other HPV-related cancers and genital warts. The vaccine is most effective when administered in childhood, before initial exposure to HPV, which typically occurs shortly after the onset of sexual activity. Accordingly, the CDC's Advisory Committee on Immunization Practices (ACIP) has recommended routine vaccination of females aged 11-12 years. ^ Taking the ACIP recommendation one step further, many states have considered school-based mandates of the HPV vaccine in an attempt to reduce the burden of HPV-related illness, in particular to reduce the disparately high incidence of cervical cancer in medically underserved populations. These mandate attempts have sparked heated debate—highlighting public concerns regarding adolescent sexuality, corporate greed, and vaccines in general. ^ Methods. My research focuses on publicly available sources of information such as medical journals, government reports (federal and state), NGO reports, newspapers, and books. I begin with a background discussion of HPV, cervical cancer, and the HPV vaccine. I then discuss public health policy issues related to vaccines, vaccine mandates, and HPV-related illness. Specifically, I discuss the public health benefit of previous vaccine mandates, the legality of vaccine mandates, and the undue corporate influence on the politics of instituting HPV vaccine mandates. In addition, I examine some of the causes behind the anti-vaccine movement and the controversy surrounding adolescent sexuality as it pertains to the HPV vaccine. In the final section, I focus on the recent failed attempt by Governor Rick Perry to mandate the HPV vaccine in Texas. A retrospective analysis of Governor Perry's policy decisions is undertaken and recommendations are made regarding future attempts to mandate the HPV vaccine, or other vaccines under development for similar sexually transmitted viral diseases such as HIV and herpes simplex. ^ Results. In Texas, as in other states across the country, HPV vaccine mandates faced opposition from those who, while they may support mandates of other vaccines, oppose mandates for the HPV vaccine based largely on the idea that HPV is a sexually transmitted disease—they see responsible sexual behavior as the appropriate method for preventing HPV-related illness. A second major group of opposition comes from those who are generally opposed to all vaccine mandates, due to concerns that mandates are intended primarily for the financial benefit of the pharmaceutical industry or due to concerns—largely unfounded—that vaccines pose a greater health threat than the illnesses they are designed to prevent. ^ Conclusion. In order to reduce opposition to vaccine mandates, care must be taken to educate the public regarding the benefits of vaccination by mobilizing the public health sector, avoid the impression that the decision to institute mandates is rash or pressured by allowing time for open debate, and minimize lobbying efforts by vaccine manufacturers. ^

Formative Evaluation of the "Time Twisters": A Comic Book Based Obesity Prevention Curriculum for Elementary School Students

Introduction: Obesity is a public health problem, particularly in Hispanic children. Alternative media channels may offer the potential to motivate children to engage in health promoting behaviors. A comic book, “Time Twisters”, was developed to impact screen time use, physical activity, and dietary behavior for elementary school children and evaluated for acceptability and feasibility prior to implementation in a multi-component physical activity intervention. [See PDF for complete abstract]

Sexual Health Education from the Perspective of School Staff: Implications for Adoption and Implementation of Effective Programs in Middle School

Introduction: US teens are having sex early; however, the vast majority of schools do not implement evidence-based sexual health education (SHE) programs that could delay sexual behavior and/or reduce risky behavior. This study examines middle school staff’s knowledge, attitudes, barriers, self-efficacy, and perceived support (psychosocial factors known to influence SHE program adoption and implementation). Methods: Professional school staff from 33 southeast Texas middle schools completed an internet or paper-based survey. Prevalence estimates for psychosocial variables were computed for the total sample. Chi-square and t-test analyses examined variation by demographic factors. Results: Almost 70% of participants were female, 37% white, 42% black, 16% Hispanic; 20% administrators, 15% nurses/counselors, 31% non-physical education/non-health teachers, 28% physical education/health teachers; mean age = 42.78 years (SD = 10.9). Over 90% favored middle school SHE, and over 75% reported awareness of available SHE curricula or policies. More than 60% expressed confidence for discussing SHE. Staff perceived varying levels of administrator (28%-56%) support for SHE and varying levels of support for comprehensive sex education from outside stakeholders (e.g., parents, community leaders) (42%-85%). Overall, results were more favorable for physical education/health teachers, nurses/counselors, and administrators (when compared to non-physical education/non-health teachers) and individuals with experience teaching SHE. Few significant differences were observed by other demographic factors. Conclusions: Overall, study results were extremely positive, which may reflect a high level of readiness among school staff for adopting and implementing effective middle school SHE programs. Study results highlight the importance of several key action items for schools.

Current United States stem cell policy considerations and a recommendation for an alternative policy based on guidelines from existing international policies

Embryonic stem cell research is a widely debated topic in modern politics and religion. Differing views on the fetal rights conflict with the rights of an embryo. Those who believe an embryo has the same human qualities as a fetus accordingly believe embryonic stem cell research is unethical because it destroys a potential human life. However, scientists advocate the embryo does not have human qualities and should be used for valuable research in the stem cell field. Stem cell research may lead to vast developments in medical treatments, including cancer and brain conditions and injuries that are currently incurable. ^ The current stem cell policy introduced by President Bush in 2001 in an attempt to balance the moral issues with the need for scientific research has broad negative implications on the furthering of stem cell research. There is a limited diversity of available stem cell lines, there may be constitutional issues, there is an increasing disparity between the public and private research spheres, and the U.S. is struggling to maintain its scientific community. The U.S. must develop a new stem cell research policy that will balance the interest of science and public health with the moral issues that concern the public. ^ The United Kingdom allows researchers great liberty in conducting research, permitting the creation of embryos for the sole purpose of research, while Germany is equally conservative in their laws, as their policies support the philosophy that all embryos deserve the protection of full life. The United States should adopt a policy that takes the "middle ground" approach and permit research on excess embryos created for IVF purposes, rather than simply discarding those potentially valuable research tools. ^

School screening for tuberculosis in high risk areas of Texas

Screening for latent tuberculosis infection (LTBI) is an integral component of an effective tuberculosis control strategy, but one that is often relegated to the lowest priority. In a state with higher than national average rates of tuberculosis, due consideration should be given to LTBI screening. Recent large scale contact investigations in the middle school of Del Rio, Texas, raised questions about the status of school screening for LTBI. An evidence based approach was used to evaluate school screening in high risk areas of Texas. A review of the literature revealed that the current recommendations for LTBI screening in children is based on administration of a risk factor questionnaire that should be based on the four main risk factors for LTBI in children that have been identified. Six representative areas in Texas were identified for evaluation of the occurrence of contact investigations in schools for the period of 2006 to 2009 and any use of school screening programs. Of the five reporting areas that responded, only one utilized a school screening program; this reporting area had the lowest percentage of contact investigations occurring in schools. Contact investigations were most common in middle schools and least common in elementary schools. In metropolitan areas, colleges represented up to 42.9% of contact investigations. The number of contact investigations has increased from 2006 to 2008. This report represents a small sample, and further research into the frequency, distribution and risk for contact investigations in schools and the efficacy of screening programs should be done. ^