Narrative of Grant Application for CARE to Wait Research

Narrative of Adolescent Family Life Grant
Title: Comparison of Care to Wait family class and CARE to Wait with middle school youth only in diverse implementation sites.

I. Summary. This multi-site model will provide a powerful research design: the enriched model will be the family-based CARE to Wait program (20 hours) which both parents and 12-14 year-old youth attend together as compared to the primary abstinence education program for youth, which will be the 20 hour track for 12–14 year old youth in the CARE to Wait (CTW) program. Five years of research show youth 12-14 years old who attend CTW with their parents and complete baseline, 6- 12- and -18 month surveys, enhance self-efficacy, refusal skills, relationships and communication with parents, have fewer high risk peers and lower risky sexual behaviors, an index which includes abstinence. This is significantly improved over randomized controls.
The model will be tested in 18 sites which will be randomized into youth only or enriched family based sites. The target population will be accessed through six sponsoring organizations: Pueblo County (2 sites) and Washington/Morgan Counties (2 sites) through County extension programs in Colorado (rural and urban mixed populations); La Clinica del Pueblo, community health care agency in northern New Mexico, primarily Hispanic and rural/small town (2 sites); Accomack County, Eastern Shore Community Services in Virginia with African American and mixed populations (2 sites); Garrett County Health Department in Maryland (4 sites) with mixed populations; and the Elijah Network and Family Alliance in Dade County, Florida (6 faith-based sites – 3 matched pairs of African American, Hispanic, and mixed populations). All pairs of sites will be randomized into youth and enriched programs. The six sponsors for 18 sites access matching, non-contaminating pairs of sites, have experience in successfully implementing youth and family based programs, proven through research and provide a broad range of populations to determine whether enriched programs have an added benefit over youth programs.


II. Applicant Organization. Colorado State University Extension (CSUE) DARE to be You program is the coordinating agency for this demonstration project. Colorado State University Office of Sponsored Research routinely manages large contracts and grants and is in compliance with all federal regulations. The DARE to be You (DTBY) program is a component of the Youth Development/4H program and the program director, Jan Miller-Heyl, PI (.6 FTE) answers directly to the youth program director, Jeff Goodwin (.05). Decisions are approved by the youth program director and the Extension Director, Deb Young. CSUE is the educational outreach branch of CSU. It includes state specialists in human and youth development, psychology, health education and community development. It has branches reaching all Colorado counties as well as links to the resources of the federal Cooperative Extension program. The DTBY program began within CSUE in 1979 and has conducted 15 major federal research projects in prevention, youth and family development: abstinence based family-programs (6 years), middle school aged youth (10 years), schools (3 years), families with young children (18 years) and with teen parents (3 years). DTBY consistently reaches its objectives with significant impact results, which are reported in peer reviewed journals and at dissemination conferences. This program has a track record of providing the rapid and effective use of resources needed to conduct the project, collect data and evaluate it. The DTBY family program was one of the first national replication models for Centers for Substance Abuse Prevention and the Office of Juvenile Justice. In 2006 and 2007, it was selected as a National 4-H Council Program of Distinction and Annie E. Casey National Strengthening Family Awards. It is on the National Registry for Effective Programs and Practices (NREPP).
CSUE program administration and Sue Sidinger .7 FTE) , key administrative assistant and on campus liaison for the DTBY program are located on the CSU campus. The DTBY program coordinator/PI of this project, Jan Miller-Heyl (.6 FTE), and the training and monitoring staff, Dana Cox (.2 FTE) and Renee Podunovich (.2 FTE) are housed in Cortez, Colorado.
The head of the evaluation team, Dr. David MacPhee (.38 FTE) is supervised directly by the head of the Department of Human Development and Family Studies, Lise Youngblade. He has done independent evaluation of DTBY projects for over 16 years. He was involved in the development of this proposal and evaluation design. He is a professor, he has developed well-known assessment tools for parents and youth, and published research in peer reviewed journals. The evaluation team includes a graduate research assistant (full time) and volunteer coders who work under the direction of Dr. MacPhee.. Facilities for on-campus staff and the evaluation team are provided by CSU.
The PI and evaluator have established a mutual working relationship through numerous federal research/demonstration grants where both are involved in the initial proposal. The PI directly oversees the program, data collection and relationships with site sponsors. Data is submitted to the evaluator who is responsible for coding and analysis, and evaluation reports which are submitted to the PI.
The sites have been selected because, through previous projects with the DTBY program, they have proven to have capacity to access adult and youth populations who have a high level of need, manage quality programs and conduct research,. The PI and site monitors will oversee the multi-site project by 1) development of MOU or subcontracts with each sponsoring agency which specify budgets, contributions and time lines, 2) conducting on-site training for personnel at each site in program and evaluation (research design and survey administration), 3) site visits during the initial startup interventions for each sponsoring organization, 4) monthly monitoring calls or web-based conferences (Breeze or similar) with the coordinator of each sponsoring agency; 5). review, by the PI and monitoring staff, of monthly workshop log sheets, filled out by the facilitators of the youth and family programs (to insure fidelity}. An end of the year mini-conference will be used for process evaluation and program strengthening activities with three representatives from each sponsoring agency All staff, currently on board or to be hired will be selected because their education, training and cultural background reflects the needs of the target population. The DTBY model has proven itself to be effective across many cultures because of the structure of the staff training and curriculum.
The sponsors of the sites are: 1). County extension office in Pueblo county. Pam Neelan, agent, with two faith-based sites in this urban area of Colorado; 2) The county extension offices in Washington and Morgan Counties. Giselle Jefferson, agent, and Janice Dixon, director, will oversee two community sites, one per county, in rural northeast Colorado; 3) La Clinica del Pueblo, a community health services agency in northern New Mexico. Paula Gurule, agency health coordinator, will oversee rural/small town, Hispanic community based sites; 4). Eastern Shores Community Services Board, Nassawadox, Virginia. Kelly Bulin, director, will oversee two rural, ethnically mixed sites in separate communities. 5). Garrett County Health Department, Maryland. Nancy Brady, program coordinator, will overse sites located in four communities in Garrett County. (6)..The Elijah Network and Family Alliance of Dade County Florida. Kate Witte, director, will oversee six matching faith-based sites in non-overlapping church based communities. These have pairs of African American, Hispanic, and general population sites. The project coordinator in each sponsoring agency will be directly responsible for hiring and supervising all staff on the project and will report site results directly to the PI. Project coordinators in each site have extensive program management experience within their agencies (10-28 years) including experience in providing workshops to families, parents and youth.
III. Need Statement.
A. Description of Sites, Prevention Services and Gaps in Target Areas. Please see Table 1.
Pueblo County lies in south central Colorado along an urban corridor. The county has a population of 149,742 persons with 33,596 under 18 years of age. Pueblo County, a diverse urban site, ranks 4th highest in the state in rates of Chlamydia, 19th for gonorrhea. The majority of cases fall in the 15-24 year old range. Teen pregnancy rate for Pueblo is 42 and 89% of Pueblo’s births to teens were to unmarried girls. The per capita income is $16,026 compared to the state rate of $39,491 and 17% of the population lives under the poverty level. The County Health Department offers family planning clinics that include individual education and counseling, disease testing and contraceptive service. Some school districts offer sex education in the middle schools however, this is not uniform. One school district has participated in the Wait training. For the youth who will be accessed through the two separate churches (Family Worship Center in Pueblo and Ecumenical Church of Pueblo West). Many churches have some “low dosage” programs about abstinence but no proven interventions with substantial doses and there are no enriched intensive family programs with this goal at all.
Morgan County and Washington County are rural, primarily agribusiness, communities in the northeast corner of Colorado. Both counties show per capita incomes much lower than the state and national average and clearly rank high in state rates for Chlamydia and gonorrhea, specifically in the 15-24 year old range. Their combined populations are 32,097 with 8,783 claiming Hispanic ethnicity. Northeast Colorado Health Department, serving numerous counties including Morgan and Washington, has family planning testing and counseling services but no pregnancy prevention classes. One middle school in Morgan County (out of six) offers sex education classes. Washington County schools have no abstinence or sex education programs. A primary issue in this area is that the rural families do not believe there is a problem with early, risky sexual behaviors so there is a dearth of prevention/abstinence programs. However, county health department staff reports increased incidences in STD’s. There are no family based (enriched) programs abstinence programs for youth in this entire region.
Rio Arriba County, New Mexico is composed primarily of rural and small town communities in northern New Mexico. The county population is 41,190 with 30,025 claiming Hispanic ethnicity. 11,674 of the residents are under 18 years of age. Rio Arriba County ranks 2nd in the state for teen births in New Mexico. As of 2003, Rio Arriba County reported a teen birth rate of 86.5. The per capita income is $22,821 and 20.3% live under the poverty level, higher than the state rate of 18.4%. Rio Arriba County has programs through local health departments for comprehensive sex education for teens, but no current programs that would be replicating services for youth-only abstinence based intervention for 12-14 year old youth or the enriched family based intervention. La Clinica del Pueblo, the area’s community health agency, provides family planning services. They also provide some parent education and youth education for life skills, however, none of these classes are abstinence based. The communities they have identified do not have the parent or youth abstinence based education programs.
The Eastern Shore of Virginia is a 90 mile long peninsula bordered by the Atlantic Ocean and the Chesapeake Bay. It is a rural isolated community made up of several barrier islands and two counties, Accomack County and Northampton County. The total population is about 50,000 with 38,305 in the Accomack County. Of this population 31.6% are African American and 5% report Hispanic ethnicity. The per capita income is $26,480, lower than the $39,540 state average and has higher than average rates of Chlamydia and gonorrhea.
Preventive care and family planning services are offered (STD testing and birth control) by branches of the Eastern Shore Health District. The district also offers a family support program for high risk families which will serve as a referral source for the proposed program. To the north, the Eastern Shore of Virginia is bordered by the state of Maryland. To the south, the Eastern Shore’s only geographic connection to Virginia is a 20 mile bridge and tunnel system. The Chesapeake Bay Bridge and Tunnel (CBBT) stands as a buffer and barrier to residents of the Eastern Shore of Virginia. While allowing residents to access medical and commercial services in the Hampton Roads-Tidewater area, the CBBT has a $24.00 toll. The sponsor for these sites is the Eastern Shore Community Services Board which is a coalition of the service agencies in the area and has identified that abstinence education is a specific need for the targeted communities. Families enrolled in the project will be 55% African American and 45% Caucasian and all youth will be enrolled in the public schools. All participating individuals will be experiencing some degree of community isolation, social deprivation, economic disadvantage and chronic family management problems, including a family history of substance abusing behaviors, criminality and single parenthood and/or spit families. CTW will target those families living in isolated rural pockets with high levels of dependence on some level of public aid.
Garrett County Maryland lies in the upper leg of Maryland between Pennsylvania and West Virginia (Appalacia) and is isolated from the rest of Maryland and the services available in more urban areas. The total population is 29,846, primarily white. The teen pregnancy rate is 36.6, higher than the state rate of 33.6. The bulk of Chlamydia and gonorrhea cases fall in the 15-24 year age group. The median household income is $32,238 compared to the state average of $52,868. Garrett County Health Department provides teen pregnancy prevention which focuses primarily on STD testing and counseling and birth control methodology. The Teen Pregnancy Prevention Coalition sponsors “Baby Think it Over” programs in the schools and communities. The health department is the sponsor of four sites in this county, which will be divided between communities in the north and the south section so there are not overlapping services. The services will be provided where there are no other abstinence based curricula or family classes.
Dade County, Florida, is the large urban area containing Miami. County population is 2,253,362 of which 20.3% are African American and 57.3% list themselves as Hispanic. For Miami-Dade, the teen pregnancy rate is 36. Reported cases of Chlamydia and gonorrhea are highest in the 15-24 year age group. The median household income is $34,682 while the state average is $40,900. 17.1% of the population lives under poverty level compared to the 11.9% state rate. The focus population is located in small communities south of Miami with even higher rates of poverty and teen pregnancy. Standard family planning resources are available to those who have transportation to the health clinics. In Miami, two faith based agencies have HHS abstinence contracts: Family and Children Faith Coalition and Trinity/Peacemakers (curriculum driven for youth). However, our sponsor is on the Family and Children Board and partners with them on many projects including teen pregnancy reduction, and works with numerous communities, through churches, that are not accessed by these services. This area sponsor is the Elijah Network and Family Alliance and has identified the following six sites: 1) Hosanna Foundation and 2) CMB Visions who serve African (Caribbean and American) populations. They are both in areas with high concentrations of teen pregnancy, poverty, community violence and child abuse. 3) Entre Nosotros and 4) Faith Church of Redland which serve Hispanic populations from low income and some migrant populations with tendencies toward domestic violence. 5) Agape Family Ministries and 6) Christian Family Worship Center which serve the general population with an emphasis on family systems.
Table 1. Pregnancy, STD rates and Income Levels by Sponsor Region.
Region Adolescent
Pregnancy Rate STD rates Median Income levels
Pueblo County 42.2 Ranked 4th highest in state for
rates of Chlamydia & gonorrhea. The majority of th in the 15-24 year olds. $16,026
($39,491 state average)
17.8% under poverty level
Washington and
Morgan Counties,
Colorado Morgan: 50.7
Washington: data
Not available Ranked 24th highest in
state for rates of
Chlamydia, 19th for
Gonorrhea. The majority
Of these were in the
15-24 Year age group. Morgan: $26,193
PCPI ranked 44th in the state
($39,491 state average)
12.9% under poverty level
Washington: $17,788
11.9% under poverty level
Northern New
Mexico,
Rio Arriba
County 2nd in the state for teen births in New Mexico. As of 2003, Rio Arriba County reported a teen birth rate of 86.5 70% of reported cases of
Chlamydia are in 10-24
Year age group.
73% of reported cases of
gonorrhea in 10-24 year
age group. $22,821
20.3% under poverty level
(18.4% state rate)

Eastern Shore
Virginia
Accomack County “One of highest
Rates in the state”
Reported by local HD Chlamydia- 805
Gonorrhea- 175
(Rate per 100,000) $26,481
($39,540 state average)
Garret County
Maryland 36.6 County
33.6 State rate The majority of Chlamydia and gonorrhea cases fall in
the 15-24 year age group.
$32,238
($52,868 state average)
Dade County,
Florida 36 County rate 72% of reported cases of
Chlamydia and 57%gonorreah
are in 15-24 year olds. $34,682($40,900 state rate) 17.1% under poverty level (11.9% state rate)

B. Proposed Program Benefits. Youth in both the primary abstinence education and the enriched family program will reduce risky sexual behavior (increased abstinence), reduce involvement with high risk peers, increase competence in decision-making, communication and refusal skills. Youth will learn the benefits of abstinence until marriage, skills leading to healthy relationships and dangers of STD and risky sexual behaviors. Youth in the enriched intensive family involvement program will additionally benefit by improved communication with parents and parental monitoring. Parents in enriched model will benefit from increased parental management skills, monitoring skills, communication skills and knowledge of ways to communicate with their youth about abstinence and their own family values and expectations.
IV. Rationale.
A. Model Choice, Literature, Need for Evaluation. The primary abstinence education component will be the youth component of the CARE to Wait (CTW) curriculum for 12-14 year old youth. The enriched program will use the CTW curriculum with both parents and 12–14 year old youth together. Both provide 20-22 hours of intervention, over 11 weeks, 2 hours/week The evaluation component, for a minimum of 24 month followup will compare the youth only with the enriched model, This is essential to determine if the additional resources required for a family based program actually increases the short and long-term outcomes of the intervention. From our previous research, we know we can affect outcomes up to 24 months with youth in the family based programs, however the youth component has not yet been tested alone.
Research of prevention of adolescent problem behaviors, specifically risky sexual behavior and substance use in adolescents, clearly associates the two as interrelated risk factors (American Academy of Pediatrics, 2001; Valois, 1999). Therefore it is reasonable to target both behaviors in prevention programs (French & Dishion, 2003). The DTBY program from which CTW is adapted is a national substance abuse prevention model on the National Registry for Effective Prevention Programs and Practices. CTW funded by AFL, tested the addition of abstinence education to this 20 hour curriculum for parents and 12-14 year old youth.
Enriched model – family based intervention. Parents are a key protective factor for youth (Blake, et al, 2001; Harris, 2000). Family-based prevention programs are promising approaches to preventing anti-social behavior in middle school youth (Lederman & Mian, 2003). Key components of successful prevention programs include sound theory, interactive instruction, targeting known risk factors for problem behaviors, consideration of age and developmental level, dosage, and multicultural awareness (Jenson et al, 2006). CTW integrates all of these components.
Theories of deviance that emphasize socialization processes share a core set of family and peer factors that consistently predict a variety of problematic adolescent behaviors including substance use, sexual risk taking, and aggression. Both social control theory (Herschii, 1969) and problem behavior theory (Jessor & Jessor, 1977) assert that weak family and school bonds and affiliation with deviant peers predict problem behaviors. Primary socialization theory (Oetting & Donnermeyer, 1998) explains the family and peer processes that contribute to adolescent behavior: families and schools typically are the source of pro-social norms and behaviors that protect adolescents from health-compromising behaviors and close associations with peers who behave in deviant ways. One implication of this (Dishion et al, 1988; Snyder & Dishion, 1986) is that interventions to prevent adolescent deviant behavior need to include parental skill building (effective child-rearing practices), effective monitoring of child behavior, consistent rule enforcement, warmth and responsiveness, open communication about values and expectations. Alternately, disruption of family management practices, high rates of conflict, low rates of communication and involvement, and lack of parental investment in and attachment to their children are risk factors for youth (Liddle & Hogue, 2000). Family involvement, family structure, parental values, parental monitoring, and parent-child communication are important influences on teen decision making and a critical part of delayed onset of sexual activity and related risk behaviors (French et al, 2003; Lederman et al, 2003; Jensen et al, 1994; Metzler et al, 1994). Care to Wait was effective in strengthening these important factors in its initial research.
Parents with permissive sexual attitudes tend to have teens with similar attitudes (Thornton & Camburn, 1987), correlated with earlier sexual experimentation (Small & Luster, 1994). Adolescents who perceive that their parents disapprove of teens’ sexual activity are less likely to be sexually active (Jaccard et al, 1996; Jensen et al, 1994). CTW parents and youth receive medically accurate information on reproductive health and STD’s. The program focuses on information on abstinence (as defined by A-H standards). Family communication patterns are important for adolescent socialization, and parent communication about sex correlates to daughters delaying sexual activity (Miller & Whitaker, 2001). Improved parent-child relationships/communication improve knowledge and a positive attitude in youth toward abstinence (Thomas, 2000; White & White, 1991). Successful programs focus on how parents communicate and identify barriers to communication (Kirby & Miller, 2002).
Parent monitoring is related to delayed sex. Metzler (1994) found that poor parental monitoring was related to risky sexual behavior and association with deviant peers. Results are best when monitoring is not intrusive and reflects a caring, intimate relationship (Kerr & Stattin, 2000). Results from CTW show increases in parent monitoring, parent-youth communication, family cohesion (Miller-Heyl et al, 2005).
Primary abstinence education component (youth only). Research (Miller & Fox, 1987; Petersen, 1985) shows that adolescent interest in sex is determined by biological forces associated with puberty. Puberty is related to age of first coitus (Buchanan et al, 1992; Miller et al, 1987 ). CTW activities normalize sexual interest in adolescents and teach youth how to channel feelings in ways that are not risky (decision-making, refusal skills, future orientation, intimate vs. sexual activities).
The peer group plays two key roles. Peers establish social norms related to sexual experimentation (Peterson, 1985). Rodgers, 2000, showed that when youth associate with peers who engage in antisocial behavior, are disengaged from school, and participate in health-compromising behaviors, they are more likely to learn deviant attitudes and behaviors. Members of these peer clusters share attitudes that justify their antisocial behavior (Oetting & Beauvais, 1986). One prevention strategy is to teach young adolescent’s peer refusal skills, bolster their confidence, and find ways to meet their social needs through pro-social activities to reduce the likelihood of gravitating to deviant peer clusters. CTW youth showed increases in refusal skills and were less likely to affiliate with deviant peers (Miller-Heyl et al, 2005).
Theories of control and conformity (Gottfredson & Herschi, 1994) implicate several processes. Refusal skills self-efficacy is associated with delayed initiation of sex (Basen-Engquist et al, 1999). Teens should be taught concrete behavioral skills to assess risks and make good decisions to regulate behavior (Metzler et al, 2000). In CTW, based on social learning approaches adapted from Mischel (1996), youth learn to focus on long-term rewards and a stronger sense of competence (Miller-Heyl & MacPhee, 2001). CTW youth learn and practice refusal skills with peers. Behavioral and emotional self-control are related to adolescent decision-making (Wills et al, 2006). Feelings identification, coping skills, empathy development, social skills and self-responsibility are core content areas in Care to Wait. In adolescence, cognitive changes and behavioral skills can be out of synchrony (Schulenberg, 2001). Iinformation is not enough, teens need practice with skills, a defining feature of CTW. Through interactive activities participants learn how to convey attitudes and values to peers and partners, recognize when a high-risk situation is developing, and communicate to extricate themselves from it. Bandura’s (1986, 1995) social-learning theory and underlying factors that allow implementation of knowledge, such as self-efficacy, responsibility, age, gender, and culture all influence the effectiveness of any prevention approach (Aarons et al, 2000; Aquilino & Bragadottir, 2000; De Gaston et al, 1996). Youth 12-14 years old, have been selected because many risk factors predictive of adolescent problem behavior manifest in middle childhood, such as affiliation with deviant peers (Coie et al 1993). Research on developmental trajectories of conduct disorders, sexual risk-taking, or substance use (Zapert & Snow, 2002) finds that some problem behaviors begin to emerge and stabilize in early adolescence, indicating that programs directly targeting such behaviors – through self-regulation, addressing risk-taking beliefs and behaviors, and – may be most effective if targeted at 12-14 year olds.
B. Experience and Lessons Learned. The PI and staff have had extensive experience with evaluation of multi-site programs over the past 25 years through the research and development of the DARE to be You family model as it applies to different age groups, ethnic groups and community settings. This has included grants with multiple sites within Colorado as well as research with multiple sites in Utah, Arizona , New Mexico and California. Two federal research grants were conducted not only in multiple states but also with the Navajo tribe. Most of the processes proposed in this grant have evolved from this experience. Our experience has also confirmed the belief that randomization of control and intervention populations, as well as a multi-point follow-up are essential to determine the impact of the model. However, we also know that the processes involved in this type of research must be very closely supervised to insure true randomization, uniform administration of surveys and a method for training staff in program processes that maintains fidelity to the curriculum yet allowing some flexibility for cultural/site differences. In addition, we have been involved in the training of staff replicating DTBY and conducting evaluation and research of DTBY programs in 35 states since 1983 and have developed monitoring processes which allow us to be effective in a multi-site format. These are characteristics of the DARE to be You processes, as now applied to CARE to Wait, that make our curriculum applicable to and used by over 35 states and almost every ethnic subgroup in the United States.
V. Program Outcome Objectives. The goals of the Care to Wait program are to (a) increase adolescents understanding of the positive health and emotional benefits of abstaining from premarital sexual activity and give them the skills to make the choices and carry out the abstinence goal and (b) increase the involvement of parents in the lives of their middle school youth by increasing relationships, monitoring and communication.
A third goal (c ) is to determine whether or not the enriched model, intensive family involvement, makes a significant difference in the youth outcomes over the primary abstinence education model.
Outcome Objective 1. Primary abstinence education program. By August 30, 2009, 180 youth ages 12 to 14, from 9 diverse sites, will have participated in 20 hours of CARE to Wait youth classes provided by trained staff at the sites, and will increase (a) their skills and efficacy in refusal, communication and decision making skills, (b) their association with low risk peers, (c) their knowledge of the health, emotional and social benefits of abstaining from sex until marriage and will have a commitment to abstinence and a rate of risky sexual activity comparable to the lower rate experienced in previous research on DTBY , and (d) learn key factors in establishing healthy marriages as measured by baseline, six, 12, and 24 month surveys using CTW project specific and AFL core instruments. By August 31, 2013, 720 youth will be enrolled in the project and have completed follow-up surveys.
Process Objectives.
The PI and monitoring staff will adapt the youth component of the Care to Wait curriculum, replacing parent/youth activities in that curriculum with youth specific activities which target the same prevention processes. The curriculum adaptation will be reviewed by AFL and by outside reviewers.
PI, training and evaluation staff will conduct onsite training with staff for each of the nine sites in the six regions. This on-site training will cover both curriculum and evaluation design and be scheduled prior to beginning the youth workshop series in each site. Additionally, six area stakeholders will be invited to attend the on-site training as part of developing on-going community support and understanding of the intervention.
Staff in all 9 sites will complete one cohort of 20 youth, a series of 11 week (2 hours/week) sessions, by June 30, 2009. PI and/or monitoring staff will conduct a minimum of one site visit / site during the sessions.
See participant grid for cohorts/year in subsequent years.
Outcome Objective 2. Intensive Parental/Family Involvement. By August 31, 2009, 180 parents or other adult family members in 9 diverse sites (20/site) will participate with their middle school youth in a minimum of 20 hours of CARE to Wait parent/youth classes as conducted by trained site staff.
2a. Parents will increase (a) their efficacy in parental monitoring, positive relationships and communication with youth and (b) their knowledge of abstinence and healthy relationships in marriage and be able to communication with their youth about their sexual decision making as measured by baseline, six, 12, and 24 month surveys using CTW specific and AFL core instruments. By August 31, 2013, 720 parents will be enrolled in the project and have completed the classes and follow-up surveys.
2b. Youth, participating with parents, will increase (a) their skills and efficacy in refusal, communication and decision making skills, (b) their association with low risk peers, (c) their knowledge of the health, emotional and social benefits of abstaining from sex until marriage and will have a commitment to abstinence and a rate of risky sexual activity comparable to the lower rate experienced in previous research on DTBY. By August 31, 2013, 720 youth will have participated with their parents.
Process Objectives.
PI, training and evaluation staff will conduct onsite training with staff for each of the nine sites in the six regions. This on-site training will cover both curriculum and evaluation design and be scheduled prior to beginning the enriched family workshop series in each site. Additionally, six area stakeholders will be invited to attend the on-site training as part of developing on-going community support and understanding of the intervention.
Staff in all 9 sites will complete one cohort of 20 youth and 20 parents, a series of 11 week sessions, by June 30, 2009. PI and/or monitoring staff will conduct a minimum of one site visit / site during the sessions and conduct monthly support calls.
See participant grid for cohorts/year in subsequent years.

Outcome Objective 3. Comparison of Primary abstinence education of youth with Youth participating in Enriched, Intensive Parental/Family Based Intervention.
By August 2009, 180 12-14 year old youth from 9 sites participating in the Primary Abstinence Education program will have completed the interventions (Objective 1) and 180 youth in 9 matching, randomly selected sites participating in the Enriched Family based model (Objective 2) will have completed their 20 hour interventions (Objective 2). Baseline data from both groups will be tested and shown to be comparable. Both groups in each matched pair of sites will complete workshops within six months of each other (time frame schedules this for within 4 months of each other.
By August 2013, the youth participating with families will show significantly high positive results (see objectives 1 and 2) than youth in the primary abstinence education program.

VI. Prevention Services, Multi-site Model.
A. Primary Abstinence Education Services. The youth component of the Care to Wait curriculum will be used during the 11 weeks of each workshop series. Each week contains two hours of program outlined specifically by the curriculum as well as a social/snack time. A minimum dose of 20 hours has been determined by previous research (see XI Evaluation plan) as being the optimum dosage for program impact. One additional session is scheduled as a makeup class.
Staff Training. All on-site training staff will receive 24 hours of training on the project implementation including logic model and how each activity is processed and fits within the logic model, the research design, confidentiality procedures, model fidelity and administration of surveys Site staff will also receive training how to handle sexual exploitation of teens, state reporting laws regarding child sexual abuse, sexual assault, incest and family violence. These components will be supported during technical assistance visits and monthly phone calls.
Asset building, youth development activities and services. Asset building and youth development activities are the primary focus of the youth curriculum. Each class will have an average of 20 youth participants (ages 12 to 14) and will follow the timetable described in the work plan
A typical schedule: youth arrive 5:30 PM for light meal/social time. Youth sign-in with times of arrival (for dosage requirements) and serve themselves dinner. At 5:45 youth participate in a series of interactive educational activities until 7:45. During the abstinence portion of the curriculum, youth may be divided into males and females for part of that discussion although previous experience has not shown that to be necessary.
The DARE to be You Curriculum as a foundation. has shown to be effective in building the resiliency factors for other problem behaviors such as substance abuse (Miller-Heyl, MacPhee & Fritz, 2001). It is built on a social learning model that build youths skills and knowledge. Care to Wait was developed using the life-skill base of the original model. It has gained approval from AFL regarding compliance with A-H standards, medical accuracy, and religion and abortion issues and will make any necessary changes as determined by an OAPP review. It showed positive results in building youth assets such as efficacy in using refusal skills, commitment to abstinence and a lowering of risky sexual behavior in with includes abstinence. The youth component of the family program will be adapted to be a youth-only curriculum by replacing parent youth activities with youth only activities designed to meet key objectives in each session. This adaptation will be submitted for AFL review.
In the first three weeks, the activities are designed to enhance efficacy through identifying personal strengths, gaining skills and confidence to use those skills. Building efficacy is a foundation of Care to Wait upon which all further activities are built. Youth are asked weekly to identify areas in their lives where they feel successful through an activity, “Success Sharing.” This focuses youth on strengths so they can feel capable and effective with their new skills. It also increases positive peer communication and empathy. Activities in this part also have participants identify positive characteristics in themselves and their family members, understanding and valuing differences in terms of personality and learning styles, understanding the aspects of a positive self-concept. Youth focus on what makes them unique and what qualities they value in themselves. Participants learn the importance of positive self-talk.
The second three weeks develop self responsibility through internalizing locus of control, stress and anger management, and personal management skills. To successfully use skills, participants must understand that they have control, through choices, in many aspects of their lives and believe their choices make a difference. Participants learn about external versus internal control and experience activities that demonstrate they have choices. Marionette puppets are used to demonstrate how everyone has “strings” that either support them or pull them down. Youth are given skills for understanding stress and anger and how to manage these normal life factors. Youth who are able to identify and manage stress and anger, are better able to integrate the skills in the curriculum.
The final four weeks focus on the development of communication, decision-making skills, abstinence and healthy relationships. This begins with feelings identification and empathy building. In an activity called “Feelings Cube,” participants use a large cube that has different facial expressions on each side. Participants sit in a circle, take turns rolling the “dice,” and describe a time they experienced the feeling that is on the top of the cube. Especially valuable for youth is the realization that all people experience these emotions, which serves to normalize as well as educate about feelings. Skills to manage feelings are identified, including identifying “wounding words” and managing hurt emotions. Identifying feelings is a building block for communication skills. Participants need to be able to identify how they feel in a situation in order to communicate effectively about it and to make healthy decisions regarding it. Specific skills for communication follow the feelings component. Participants learn three styles of communication and the effectiveness and consequences of each: Aggressive, Passive, and Assertive. Youth identify barriers to communication with their family and friends and practice skills to enhance this important factor. Participants learn to use “I-Messages” and reflective listening through interactive games, skits, and role playing. Decision-making skills are addressed next. Participants learn decision points that lead up to risky situations, and consequences of those decisions. An activity called “Taking Care of Me” has participants list the decision points that led up to a risky scenario, the choices that are available and the consequences of those choices. Giving participants the skill to identifying choices in their lives helps build internal locus of control as well as empowering them to make change in their lives based on reasoned choices.
The abstinence component is integrated throughout the curriculum, but specifically in these four weeks. In the eighth session a qualified health educator presented the curriculum, giving medically accurate and approved information about anatomy, STD’s, abstinence and is available to answer medical questions. Participants learn why abstinence (as defined by the A-H guidelines) is the safest and soundest choice for youth. Further discussion focuses on intimacy and sexuality, and how they are different and interrelated. An activity called “Risk-o-meter” has participants decide where to stand holding a card describing certain behaviors (kissing passionately, holding hands, etc) on a large floor scale where 0 = no risk of having sex and 10 = sure to lead to sex. They learn how sexuality fits into needs and how to get needs met without having sex. This section will be expanded to include information on healthy peer, family, romantic and marriage relationships.
Participants learn and practice refusal-skills. Youth practice, in small groups, words or actions that are necessary to extricate themselves from difficult situations. Along with understanding that certain decisions lead up to risky situations, participants gain skills in navigating their way through such situations. Youth develop “escape plans” by which they can safely leave risky situations.
Future orientation is integrated throughout the curriculum, but receives special focus in terms of how risky behaviors, especially risks from becoming sexually active, impact future goals and aspirations. Earlier in the curriculum, participants envision a positive future and now are asked to examine the consequences of risky behavior on that vision. Finally, youth are asked to set a standard around abstinence for themselves and sign a contract that states their intentions toward remaining abstinent (as defined by A-H standards). A graduation ceremony concludes the program.
B. Enriched Model – Intensive Family Involvement. The Care to Wait curriculum will be used during the 11 weeks of each workshop series. Each week contains two hours of program outlined specifically by the curriculum. A minimum dose of 20 hours has been determined by previous research (see XI. Evaluation Plan) as being the optimum dosage for program impact.
Staff Training. Parent and youth facilitators at each site will receive 24 hours of training in the Care to Wait curriculum on site All staff will receive training on the project logic model, research design, confidentiality procedures, model fidelity and oral administration of surveys. Site visits and monthly support web-conferences or conference calls will support training.
Asset building, youth development activities and services. Asset building and youth development activities are the primary focus of the youth portion of the family workshops. Youth and parents participate together to meet objectives outlined in Section V. Each class will have an average of 20 adult and 20 middle school participants (ages 12 to 14) and will follow the timetable described in the workplan. A typical schedule: families arrive 5:30 PM for group meal, families sign-in with times of arrival (for dosage requirements) and serve themselves dinner. Families engage with each other and with adult and teen staff members. At 6:00 PM younger siblings go to their classroom with the sibling facilitator, while adults and middle-school youth participate in a combined activity. At 6:30-7:30 PM, families divide into appropriate age groups (parents and middle-school youth). In the separate classes, parents and youth learn a series of skills each night. All groups focus on the theme for the night so that the whole family is given congruent messages and skills. At 7:30 PM, parents and youth regroup for a final parent-youth activity. This ensures that parents and youth have quality time in a nurturing environment to practice skills and gain knowledge together. During the abstinence portion of the curriculum, youth may be divided into males and females for part of that discussion.
The DARE to be You Curriculum as a foundation. The model DTBY curriculum has shown to be effective in building the resiliency factors for other problem behaviors such as substance abuse (Miller-Heyl, MacPhee & Fritz, 2001). It is built on a social learning, ecological model that emphasizes family strengths. Care to Wait was developed using the life-skill base of the original model. It has gained approval from AFL regarding compliance with A-H standards, medical accuracy, and religion and abortion issues and will make any necessary changes as determined by an OAPP review if funded. It showed positive results with the parents in mentoring, communication and relationships and youth assets such as efficacy in using refusal skills, commitment to abstinence and a lower rate of onset of sexual activity (or return to abstinence) than control peers.
In the first three weeks, parents and youth participate in activities designed to enhance efficacy through identifying personal strengths, gaining skills and confidence to use those skills. Building efficacy is a foundation of Care to Wait upon which all further activities are built. Families are asked weekly to identify areas in their lives where they feel successful through an activity, “Success Sharing.” This focuses families on strengths so they can feel capable and effective with their new skills. It also increases family communication and empathy. Activities in this part also have participants identify positive characteristics in themselves and their family members, understanding and valuing differences in terms of personality and learning styles, understanding the aspects of a positive self-concept. Parents learn skills to enhance this in youth through focusing on accurate attributions, giving positive and authentic encouragement (positive messages) to youth. Parents are given many opportunities each week to notice and express positive, unique aspects in their youth. Youth focus on what makes them unique and what qualities they value in themselves. Participants learn the importance of positive self-talk.
The second three weeks develop self responsibility through internalizing locus of control, stress and anger management, family and personal management skills. To successfully use skills, participants must understand that they have control, through choices, in many aspects of their lives and believe their choices make a difference. Participants learn about external versus internal control and experience activities that demonstrate they have choices. Marionette puppets are used to demonstrate how everyone has “strings” that either support them or pull them down. Parents learn skills to enhance their youth’s ability to manage their own “strings” (increase self-responsibility in their youth) and understand that if youth are not given the skills to manage their own strings; those strings will often be picked up by negative peer groups. Parents learn the value and necessity of parental monitoring, clear rules and consequences for youth. Parents learn about discipline strategies that encourage youth participation in family rules and the consequences for breaking those rules. This increases internal control and decision making processes in their youth. Families are given skills for understanding stress and anger and how to manage these normal life factors. Families, who are able to identify and manage stress and anger, are better able to integrate the skills in the curriculum (such as structuring their home life).
The final four weeks focus on the development of communication, decision-making skills, abstinence and healthy relationships. This begins with feelings identification and empathy building. In the parent/youth activity called “Feelings Cube,” participants use a large cube that has different facial expressions on each side. Participants sit in a circle, take turns rolling the “dice,” and describe a time they experienced the feeling that is on the top of the cube. Especially valuable for youth is the realization that all people experience these emotions, which serves to normalize as well as educate about feelings. Skills to manage feelings are identified, including identifying “wounding words” and managing hurt emotions. Families list wounding words in their own home, and contract with themselves to stop these messages. Identifying feelings is a building block for communication skills. Participants need to be able to identify how they feel in a situation in order to communicate effectively about it and to make healthy decisions regarding it. Specific skills for communication follow the feelings component. Participants learn three styles of communication and the effectiveness and consequences of each: Aggressive, Passive, and Assertive. Parents identify barriers to communication with their youth and practice skills to enhance this important factor. Participants learn to use “I-Messages” and reflective listening through interactive games, skits, and role playing. Decision-making skills are addressed next. Participants learn decision points that lead up to risky situations, and consequences of those decisions. An activity called “Taking Care of Me” has participants list the decision points that led up to a risky scenario, the choices that are available and the consequences of those choices. Giving participants the skill to identifying choices in their lives helps build internal locus of control as well as empowering them to make change in their lives based on reasoned choices.
The abstinence component is integrated throughout the curriculum, but specifically in these four weeks. In the eighth session a qualified health educator presented the curriculum to parents and youth together, giving them medically accurate and approved information about anatomy, STD’s, abstinence and is available to answer medical questions. The theory behind this is to help parents and youth break down barriers around communicating about sexual decision-making by identifying the barriers and benefits of such discussion, and providing an opportunity to receive accurate information around anatomy and STDs. For this reason, parents and youth work together on activities where they label female and male anatomy, getting used the vocabulary that may be embarrassing at first. In order to talk effectively with their youth about abstinence, parents need accurate information as much as the youth. This was a successful component of the previous study, and both parents and youth reported that it has helped their relationships and given them a sense of relief about approaching the topic. Participants learn why abstinence (as defined by the A-H guidelines) is the safest and soundest choice for youth. Further discussion focuses on intimacy and sexuality, and how they are different and interrelated. An activity called “Risk-o-meter” has participants decide where to stand holding a card describing certain behaviors (kissing passionately, holding hands, etc) on a large floor scale where 0 = no risk of having sex and 10 = sure to lead to sex. They learn how sexuality fits into needs and how to get needs met without having sex. This section will be expanded to include information on healthy peer, family, romantic and marriage relationships.
Participants learn and practice refusal-skills. Youth practice in small groups then with parents in order to practice the words or actions that are necessary to extricate themselves from difficult situations. Along with understanding that certain decisions lead up to risky situations, participants gain skills in navigating their way through such situations. Parents are encouraged to help youth develop “escape plans” by which they can safely leave risky situations.
Future orientation is integrated throughout the curriculum, but receives special focus in terms of how risky behaviors, especially risks from becoming sexually active, impact future goals and aspirations. Earlier in the curriculum, participants envision a positive future and now are asked to examine the consequences of risky behavior on that vision. Finally, youth are asked to set a standard around abstinence for themselves and sign a contract that states their intentions toward remaining abstinent (as defined by A-H standards). A graduation ceremony concludes the program.
Through the mechanism of an annual mini-conference, staff from all sites as well as the evaluation team meet and discuss successes and any needed adaptations to the curriculum. This has been key in the past development of both DTBY and Care to Wait curriculum. At these meetings, staff from both sites bring observations and participant feedback. Members of the evaluation team give updates on data analyses and how the program is meeting its stated objectives. From this information, program staff develop procedures to better meet these needs.

C. Recruitment and Retention Plan.
As learned in the first study of Care to Wait, recruitment takes longer and more staff time than originally anticipated. For both the Primary Abstinence Education (youth only) program and the Enriched Family Involvement components, the procedure must be highly focused and planned in advance to gain approval to attend scheduled community or church based events. For both components, youth will be recruited primarily through their families. In the community-based sites, staff will attend parent-teacher nights at schools, sporting events and visit local agencies to personally recruit youth and families for programs. Local middle schools, newspapers and radio, churches and other agencies serving families of middle-school youth will be targeted through existing and new collaborations. In the church based sites, staff will attend family and youth related activities for recruitment activities and church staff involved in the program will be active in recruiting.
Retention is a key to reach the desired dosage in any program. Although the activities are highly engaging and offered in a positive, non-judgmental environment, upon completing a minimum of 20 hours of CTW youth program activities, each youth will receive a $50 gift card to an appropriate local merchant. A meal incentive is also provided for the youth each week. Youth will also receive $20 gift cards for completing each follow up survey.
For the Intensive Family Involvement component, Care to Wait uses an incentive program that includes family meals, high quality activities for all family members, (including younger siblings), non-judgmental and accepting environment, and a completion honorarium of $150 for up to two adult family members who attend a minimum of 20 hours of workshops. (Make-up sessions will be scheduled for those who have health, work or other major reasons for not attending.) Adults in the family receive $30 for each follow-up survey completed with their youth at 6, 12, and 24 months. (Shared incentive).
D. Addressing sexual exploitation and coercion. In addition to the multiple components of the existing curriculum that address this both implicitly and explicitly (described above), staff will be trained regarding state laws regarding sexual exploitation and coercion and will develop plans to address such issues based on local policy and procedure. These plans will be submitted to the PI to insure they are implemented.
E. Coordination/Integration/Linking Existing Services. Three of the sponsoring agencies in the six regions are integral parts of the existing services (i.e., La Clinica del Pueblo in New Mexico, the Garrett County Health Department in Maryland, and the Eastern Shore Community Services Board in Virginia) and by the nature of their organizational connections provide an integration to existing services. The other three sponsors have historically developed close relationships with county health departments and serve on boards, community partnerships or other integrating agencies and already work closely with the existing services. The project coordinators in the County Extension Offices in both Pueblo and in Northeast Colorado (Morgan/Washington) have close working relationships with both school, social services and health departments. The project coordinator in Florida serves on three major boards and committees in the Miami/Dade county area dedicated to improving teen health and reducing teen pregnancy.
Additionally, as part of the on-site start of training in each region, a minimum of six stakeholders from agencies with existing services will be invited to attend all or part of the start up training as a step to more closely integrate and coordinate.
Site sponsors and program staff at each region will be encouraged to make program presentations to local agencies for recruitment and to enhance program knowledge and support in the broader community.

VII. A-H Criteria.
The youth curriculum for both the primary abstinence education component and the enriched, intensive family involvement component are designed to specifically meet the A-H components and are identical except for the parent involvement components.. All sessions within the 11 week series address one or more of the eight A-H required components and all of the components are addressed more than once. In addition, the parent curriculum for the family component also includes activities that meet A-H standards. The following table outlines the A-H Compliance Strategies for Care to Wait Youth Curriculum.
Table 2. Activities meeting A-H Critieria. (Also A-H Table in Appendix I)
Abstinence Education Criteria DTBY Care to Wait,
Session & Lesson themes Supporting Activities/Services
a. teaches the social, psychological, and health gains to be realized by abstaining from sexual activity Session VIII: Abstinence Education Body Puzzles, You’re It- STD Awareness Game, Health Educator Presentation, Abstinence, Part I
Session IX: Abstinence Education & Decision Making Abstinence, Part II, Needs Activity
Session X: Refusal Skills Taking Care of Me, Intimacy vs. Sex
Session XI: Future Orientation High Standard Contract
b. abstinence from sexual activity outside of marriage as the expected standard for all school age children Session VIII: Abstinence Education Abstinence, Part I
Session IX: Abstinence Ed & Decision Making Abstinence, Part II


c. abstinence from sexual activity is the only certain way to avoid out-of-wedlock pregnancy, sexually transmitted diseases, and other health problems Session VIII: Abstinence Education Body Puzzles, You’re It- STD Awareness Game, Health Educator Presentation, Abstinence, Part I
d. mutually faithful monogamous relationship in the context of marriage is the expected standard of human sexual activity Session IX: Abstinence Education & Decision Making Abstinence, Part II
Healthy Relationships/Marriage
e. teaches that sexual activity outside the context of marriage is likely to have harmful psychological and physical effects Session IX: Abstinence Ed & Decision Making Abstinence, Part II
Session X: Refusal Skills
Healthy relationships Taking Care of Me, Intimacy vs. Sex. Healthy Relationships
f. bearing children out-of-wedlock is likely to have harmful consequences for the child, the child’s parents and society Session II: Future Orientation Wish Upon a Star
Session VIII: Abstinence Education Health Educator Presentation, Abstinence, Part II
g. teaches young people how to reject sexual advances and how alcohol and drug use increases vulnerability to sexual advances Session V: Self-Responsibility I Have To, I Choose To, Puppets- Internal/External Control, Who Is Pushing My Buttons
Session VII: Communication Play it Again
Session X: Refusal Skills Jelly Bean Game, Taking Care of Me, Refusal Skills
h. teaches the importance of attaining self-sufficiency before engaging in sexual activity. Session II: Future Orientation Wish Upon a Star
Session VI: Future Orientation Time Line. Will be expanded upon as part of sequencing activities
f. teaches that bearing children out-of-wedlock is likely to have harmful consequences for the child, the child’s parents and society Session II: Future Orientation
Wish Upon a Star
Session VIII: Abstinence Education Health Educator Presentation, Abstinence, Part I


g. teaches young people how to reject sexual advances and how alcohol and drug use increases vulnerability to sexual advances Session V: Self-Responsibility I Have To, I Choose To; Puppets- Internal/External Control; Who Is Pushing My Buttons
Session VII: Communication Play it Again
Session X: Refusal Skills Jelly Bean Game, Taking Care of Me, Refusal Skills
h. teaches the importance of attaining self-sufficiency before engaging in sexual activity. Session II: Future Orientation, Session XI, Debit Card Game Wish Upon a Star
Session VI: Future Orientation Time Line, Debit Card Game
(Sequencing)


VIII. Work Plan and Time Tables.
Activity Time Frame Persons Resp
Curriculum revisions completed and approved by sites, OAPP. Revisions will be to modify youth-only component to replace parent youth activities 9/1/-12/15/08 Miller-Heyl
Podunovich
Cox, Sponsors.
Unfilled staff positions will be advertised, interviewed, filled. New staff orientation held for agency specific info 9/1-12/30/08 Miller-Heyl
Sponsors
Evaluation instruments will be finalized and approved through OAPP. Coding books and data bases developed. 9/1-12/30/07 Miller-Heyl
MacPhee
On site staff training for implementation of the curriculum and administration of the evaluation component will be held for all eight Sponsors. Stakeholders invited to training. 11/15-1/20/09 Miller-Heyl
Podunovich, Cox
Site pairs will be randomized for each region/sponsor
Sept, 08-Jan 15th, 09 .Miller-Heyl
Research Coordin
Recruitment activities will be held for youth-only abstinence education component and enriched family based components in all sites. October 08 – Feb 15th, 09 Sponsoring agency staff, Podunovich
Teen assts recruited, screened & trained. Schools & youth organizations contacted with teen assistant recruitment information. Teens meet regularly with family & youth facilitators before & after each class for planning review. Dec. 1 – Jan 15
Ongoing Site Managers and teen facilitators in both sites
Presurveys
Participants in both the youth only and the family based workshops will complete pre-surveys. Data bases on contact information established locally. Data management systems established by evaluation team. Baselines coded. Baseline analysis run and feedback provided to sponsors. Jan- March, 09

March 1-30
By June 30 09 Site Research Coordinators.

MacPhee
GRA, coders.
MacPhee,
Workshop series scheduled and completed in all 18 sites for both youth only and family based programs Jan15- June 30, 09 Site Staff
PI and DTBY trainers conducts site visits on all sites during first cohorts as well as monthly support contacts. Jan15-- Aug 30 Miller-Heyl, Cox
Podunovich
6-Month Surveys, Administrated to both youth and family based participants as they are due. July 15- Aug 30 Site Research Coordinators
All evaluation, program, administrative staff attend year end follow-up mini-conference to review curriculum/processes with an average of three representatives from each research pair of sites. This is to discuss evaluation plan, results and set program for year 02. Data from participants, staff and evaluators inform changes. August – September 09 Sidinger
Miller-Heyl, key site staff, Cox
Podunovich
MacPhee
PI and evaluator will attend required OAPP conference OAPP M-Heyl, MacPhee
Recruiting for Year 02, will start in all sites Aug. 08 Site staff
Collect site data for year end reports/ complete final report Sept –July Miller-Heyl


IX. Target Population.
A. Estimates of Overall Participants: Total youth in study (5 years) = 1,440.
Intervention Group: Youth, 12-14, 180 each year for four years = 720
Parents/adults family, 180 each year for four years = 720.
Control Group: Youth, 12-14, 180 each year for four years = 720
B. Estimates of Participants by Year, Site, Race and Ethnicity.
Participants in the Treatment (Enriched Intensive Family Involvement)
Nine sites are in the treatment group. Each site will reach 20 adult family members and 20 12-14 year old youth in year 01 (and year 02. 03, 04). The adults and youth will participate together in 11 weekly sessions, 2 hours of activities each week as described in the program description. Both youth and adults, who started in Year 01 will be maintained in the study through 6-, 12, and 24 month surveys. These surveys will fall into years 2 and 3 for the year 1 cohort.
Youth in Treatment Group in Year 1 (and identical new numbers in Year 02)
Site # Race Ethnicity
Pueblo County, Colorado 20 20 White 15 Non-Hisp. 5 Hispanic
Washington/Morgan County, CO 20 20 White 15 Non-Hisp, 5 Hispanic
Rio Arriba County, New Mexico 20 20 White 5 Non-Hisp, 15 Hispanic
Accomack County, Virginia 20 9 White, 11 Afri Am 20 Non- Hisp.
Garrett County Virginia
(2 sites) 40 35 White, 5Afri Am 35 Non-Hisp. 5 Hispanic
Dade County, Florida
African American church 20 20 African Am 20 Non-Hisp
Dade County, Florida
Hispanic Church 20 20 White 20 Hispanic
Dade County, Florida
Mixed population church 20 15 White, 5 Afri Am 15 Non-Hisp 5 Hispanic
Totals 180 139 White, 41 Afri Am 125 Non-hisp 55 Hispanic

Parents in Treatment Group in Year 1 (and identical new numbers in Year 02)
Site # Race Ethnicity
Pueblo County, Colorado 20 20 White 15 Non-Hisp. 5 Hispanic
Washington/Morgan County, CO 20 20 White 15 Non-Hisp, 5 Hispanic
Rio Arriba County, New Mexico 20 20 White 5 Non-Hisp, 15 Hispanic
Accomack County, Virginia 20 9 White, 11 Afri Am 20 Non- Hisp.
Garrett County Virginia
(2 sites) 40 35 White, 5Afri Am 35 Non-Hisp. 5 Hispanic
Dade County, Florida
African American church 20 20 African Am 20 Non-Hisp
Dade County, Florida
Hispanic Church 20 20 White 20 Hispanic
Dade County, Florida
Mixed population church 20 15 White, 5 Afri Am 15 Non-Hisp 5 Hispanic
Totals 180 139 White, 41 Afri Am 125 Non-hisp 55 Hispanic

Participants in the Control Group (Primary Abstinence Education for Youth).
Nine sites are in the control group. As described above, these sites will be randomly selected from matched pairs by the PI and monitoring staff during a telephone conference with the coordinator of the sponsor sites to insure accurate randomization. Each of the nine sites will reach 20 12-14 year old youth in year 01 through 11 weekly sessions, 2 hours of activities each week. Youth who started in Year 01 will be maintained in the study through 6-, 12, and 24 month surveys. These surveys will fall into years 2 and 3 for the year 1 cohort.
Youth in Control Group in Year 1 (Primary Abstinence Education) (identical in Year 02)
Site # Race Ethnicity
Pueblo County, Colorado 20 20 White 15 Non-Hisp. 5 Hispanic
Washington/Morgan County, CO 20 20 White 15 Non-Hisp, 5 Hispanic
Rio Arriba County, New Mexico 20 20 White 5 Non-Hisp, 15 Hispanic
Accomack County, Virginia 20 9 White, 11 Afri Am 20 Non- Hisp.
Garrett County Virginia
(2 sites) 40 35 White, 5Afri Am 35 Non-Hisp. 5 Hispanic
Dade County, Florida
African American church 20 20 African Am 20 Non-Hisp
Dade County, Florida
Hispanic Church 20 20 White 20 Hispanic
Dade County, Florida
Mixed population church 20 15 White, 5 Afri Am 15 Non-Hisp 5 Hispanic
Totals 180 139 White, 41 Afri Am 125 Non-hisp 55 Hispanic


X. Documentation of Community Support and Commitment.
In each of the sponsoring areas, the program has been with a wide support. Documentation of this is to be found in the Appendices and includes:
Pueblo County, Colorado: Pueblo County Extension: Memorandum of Understanding to over see two sites in the region, training and research staff and cost share of staff, supplies and equipment and facilities; Ecumenical Church of Pueblo West: Memorandum of Understanding for contributions and a letter of support; Family Worship Center, Letter of Support
Morgan and Washington Counties (Northeastern Colorado): Washington County Extension: Memorandum of Understanding to oversee two sites in the region, training and research staff and cost share of staff, supplies and equipment and facilities;
Morgan County Extension, Letter of Support and MOU to collaborate to provide the programs.
Rio Arriba County, New Mexico: La Clinica del Pueblo, Subcontract to oversee two sites, contributions of staff time, space and other resources: North Central Community Based Services, Letter of support.
Accomack County, Virginia: Eastern Shore Services Board, Subcontract to oversee two sites, contributions of staff time, space and other resources: Eastern Shore Coalition Against Domestic Violence, letter of support.
Garrett County, Maryland: Garrett County Health Department, Subcontract to oversee four sites, contributions of staff time, space and other resources: Kitzmiller Empowerment Group, letter of support
Dade County, Florida: Elijah Network and Family Alliance. Subcontract to oversee six sites, contributions of staff time, space and other resources. MOU and letters of support from six faith based organizations ;1) Hosanna Foundation 2) CMB Visions, 3) Entre Nostros, 4) Faith Church of Redland, 5) Agape Family Ministries and 6) Christian Family Worship Center.

XI. Continuation Funding. One of the true benefits of using a strong research design with randomly selected control and experimental groups and follow-up for at least two years is that it is possible to show hard statistics on changes that programs make in the community. DARE to be You has been successful in continuing programs through funding or subcontracts in the community. These have included subcontracts with local health departments, social services, the school district and the Ute Mountain Ute tribe. This mechanism will be used to gain community funding for Care to Wait, if the data is positive, from community agencies that have funding for family-based programs. In addition, data from the project strengthens further funding from research or implementation grants. We plan for the Care to Wait program to be integrated into regular site programming by the end of Year 05 as staff will be trained, there will be positive community support, and research will support its positive impact
XII. Evaluation Design
A. Process Evaluation of the intervention and control workshop series.
Given that an existing, empirically supported curriculum will be used at diverse sites for both the control (youth only primary abstinence education) and intervention (enriched, intensive family involvement workshops), process objectives are to determine that (a) appropriate staff is hired in each site, (b) facilitators receive adequate training in how to implement the curriculum, and (c) the curriculum is delivered with fidelity while documenting adaptations that are made for local populations. Two additional process objectives are to assess (d) program coverage (i.e., is the intended target population being reached), and (e) whether variations in group processes (across sites and cohorts) and dosage are related to differences in program impact.
Staffing and training will occur during the lst six months of the grant. The PI and site monitors will insure that each site has hired staff that meet the criteria of the roles (job descriptions) that they will fill and that they are culturally appropriate for the sites. This will be done by phone conferences, review of resumes and finally, by personal contact during the onsite facilitator training that will occur in the first six months of the grant.
Facilitator training will be documented through records kept by the PI of how many hours of training each facilitator received. Training will completely cover the processing of the activities in the curriculum as well as specific guidelines on fidelity and how and when to culturally adapt certain activities The PI and site monitors also monitors how well facilitators are implementing the curriculum through on-site observations of sessions, regular conference calls, and annual conferences (that include evaluation staff) that focus on problem solving and feedback related to delivery of the intervention. Facilitators rate their preparation for each intervention session, and describe any difficulties in delivering the intervention, on logbooks that are completed after each session. Deviations from curricular guidelines are discussed with program facilitators in terms of the potential to compromise program impact versus the need to adapt to local contexts. The latter information is useful in identifying facilitators’ needs for additional training as well as curriculum modules that need to be modified. Training will include information on reporting of child abuse and other state mandated criteria.
Several steps will be taken to insure that the curriculum is delivered with fidelity. Because all materials must be approved by AFL, cultural adaptations have to be suggested by program staff well in advance and be reviewed by both program and AFL review.
Workshop facilitators complete weekly logbooks that track (a) attendance (from which dosage information is extracted), (b) which curriculum activities were used, (c) the degree to which the activities adhered to protocol (as described in the curriculum manual), and (d) engagement of participants, meaning how much they participated, completed homework, focused on the topics (instead of discussing pet personal issues), and so forth. We pay particular attention to adherence to protocol (fidelity): In analyses of previous CARE to Wait trials, there were relatively few deviations from the curriculum guidelines, and the vast majority of these (79%) were due to time constraints.
Related to program coverage, descriptive analyses of participant demographics can be compared to both agency records and local community demographics to determine whether the intervention sample is representative of the intended audience. The number of participants relative to those in need (from local community surveys) indicates the degree of coverage. Concerning dosage, CARE to Wait participants typically receive the same amount of intervention (20+ hours), which is achieved by offering make-up classes to those who do miss a session.
Group processes are assessed in several ways. Facilitator ratings in logbooks completed after each session provide quantitative data related to engagement; open-ended questions elicit qualitative information related to resistance, rehearsal of skills, and factors that contributed to any disruptions of the group. Also, at the first follow up, participants rate the workshop dynamics in terms of supportiveness and task orientation. Participant ratings indicate whether there are site variations in how the program is perceived, and provide global insights as to the learning climate that might be related to program impact.
B. Outcome Evaluation
Outcome evaluation will be identical for the youth in the control and intervention components of the program. Both sets of youth will complete identical surveys as described below at baseline, six, 12 and 24 months. This will allow us to determine short, intermediate and longer-term outcomes as described in the Logic Model in Appendix B.
C. Research (Outcome) Objectives and Hypotheses
The goals of the Care to Wait program are to (a) increase adolescents understanding of the positive health and emotional benefits of abstaining from premarital sexual activity and give them the skills to make the choices and carry out the abstinence goal and (b) increase the involvement of parents in the lives of their middle school youth by increasing relationships, monitoring and communication.
A third goal (c ) is to determine whether or not the enriched model, intensive family involvement, makes a significant difference in the youth outcomes over the primary abstinence
Outcome Objective 1. Primary abstinence education program. By August 30, 2009, 180 youth ages 12 to 14, from nine diverse sites, will have participated in (11 weekly sessions) 20 hours of CARE to Wait youth classes provided by trained staff at the sites, and will increase (a) their skills and efficacy in refusal, communication and decision making skills, (b) their association with low risk peers, (c) their knowledge of the health, emotional and social benefits of abstaining from sex until marriage and will have a commitment to abstinence and a rate of risky sexual activity comparable to the lower rate experienced in previous research on DTBY , and (d) learn key factors in establishing healthy marriages as measured by baseline, six, 12, and 24 month surveys using CTW project specific and AFL core instruments. By August 31, 2013, 720 youth will be enrolled in the project and have completed follow-up surveys.
Outcome Objective 2. Intensive Parental/Family Involvement. By August 31, 2009, 180 parents or other adult family members in 9 diverse sites (20/site) will participate with their middle school youth in a minimum of 20 hours of CARE to Wait parent/youth classes(11 weekly sessions) as conducted by trained site staff.
2a. Parents will increase (a) their efficacy in parental monitoring, positive relationships and communication with youth and (b) their knowledge of abstinence and healthy relationships in marriage and be able to communication with their youth about their sexual decision making as measured by baseline, six, 12, and 24 month surveys using CTW specific and AFL core instruments. By August 31, 2013, 720 parents will be enrolled in the project and have completed the classes and follow-up surveys.
2b. Youth, participating with parents, will increase (a) their skills and efficacy in refusal, communication and decision making skills, (b) their association with low risk peers, (c) their knowledge of the health, emotional and social benefits of abstaining from sex until marriage and will have a commitment to abstinence and a rate of risky sexual activity comparable to the lower rate experienced in previous research on DTBY. By August 31, 2013, 720 youth will have participated with their parents.
Outcome Objective 3. Comparison of Primary Abstinence Education Of Youth with Youth in Enriched, Intensive Parental/Family Based Intervention.
By August 2009, 180 12-14 year old youth from 9 sites participating in the Primary Abstinence Education program will have completed the interventions (Objective 1) and 180 youth in 9 matching, randomly selected sites participating in the Enriched Family based model (Objective 2) will have completed their 20 hour interventions (Objective 2). Baseline data from both groups will be tested and shown to be comparable. Both groups in each matched pair of sites will complete workshops within six months of each other (time frame schedules this for within 4 months of each other. By August 2013, the youth participating with families will show significantly high positive results (see objectives 1 and 2) than youth in the primary abstinence education program.
Summary of Goals and Objectives.
Of the above, the principal long term intervention goal is that participating youth will delay sexual intercourse, ideally until marriage. The following outcome objectives are most strongly aligned with this aim; the first two reflect the performance measures for AFL prevention demonstration programs. Previous evaluations of CARE to Wait (CTW) have found an enriched model to have the intended impact, in comparison to a control group. In the current project, we hypothesize that the enriched (family) program will have more impact than the youth-only intervention because previous findings showed that changes in youth participants’ sexual attitudes and risk taking were mediated by changes in parent-reported communication about intimacy and sex as well as parent monitoring. That is, support for effective parent involvement can reduce adolescent sexual risk taking.
 Within a year of entering the intervention, youth in the enriched program will exhibit significantly more favorable attitudes toward abstinence, and will be less likely to initiate sexual intercourse, than those in the youth-only program. (Short Term)
 Within a year of enrolling in CtW, parents and youth in the enrichment program will report significantly healthier family relationships as measured by relationship quality, communication about intimacy and sex, and parent monitoring of their youth. (Short Term)
 Youth who complete the CtW enriched program will demonstrate significantly more effective skills to resist negative peer pressure. Such changes may appear after 12 to 24 months because they take time to practice and consolidate. (Intermediate and Long-Term)
 As a result of improvements in peer refusal skills and parent monitoring, youth in the enriched program will be less likely to affiliate with peers who engage in deviant behavior.
(Intermediate and Long Term)
Several of the variables in our impact model (see Figure 1, Appendix B) are not modifiable through our intervention, such as puberty and dating. Others, such as parent and youth self-efficacy, future orientation, and impulsivity, are either indirectly related to abstinence or are difficult to change given the emphasis of the DTBY curriculum. Yet these processes are still measured in order to test our impact model.
Mediating Factors to the Intervention Theory. As described in our intervention theory above, we believe that the intervention effects will be mediated by several processes. Specifically, we hypothesize that:
 At baseline, sexual risk taking among adolescents is most strongly associated with permissive sexual attitudes, deviant peer affiliation, parent monitoring, and impulsive risk taking;
 Reductions in youths’ sexual risk taking behavior are mediated by increases in conservative sexual attitudes, peer refusal skills, and parent monitoring;
 Changes in conservative sexual attitudes are mediated by improved family communication about intimacy and sex, changes in deviant peer affiliation, and normative adolescent changes in puberty and dating. (Note that the latter influence is not directly amenable to our intervention, other than to normalize it.)
D. Randomized Design
Nine pairs of sites have been identified at the six sponsoring organizations in five states. Sites within a pair have similar population profiles but are separate (geographically and socially) enough that there will not be contamination due to participants from different groups sharing information. Within each pair, one site will be assigned by random draw to the youth-only group and the other will receive the enriched program. Eight of the sites will be faith-based entities which have been matches into four matching pairs and serve populations/regions: Pueblo and Pueblo West Colorado (1 matching pair) and Dade County Florida (3 matching pairs). The pairs are described above under Target Population. All of these entities have agreed to the randomization. Ten of the sites are matched geographic regions within given counties or regions: Northeast Colorado – providing two sites in matching communities in two counties (Morgan and Washington); Garrett County Maryland will divide the state geographically into two pairs each in North and South county sites (four sites); sites in Rio Arriba County will be divided geographically between several small communities (2 sites); Eastern Shore of Maryland will also divide the matching sites geographically by working with separate communities. (2 sites). See maps in Appendix H. which indicate geographic separation of the sites.
Upon receiving the grant, sponsors and PI/site monitors will have a phone conference and the PI will perform a coin flip for the sites in each pair to assure randomization.

E. Threats to Validity
One threat to the internal validity of the study is nonequivalence of groups. Differences between the two groups at baseline will be tested with 2 (group) x 6 (locale) ANOVAs. As well, logistic regression will be used to predict group membership, given the recommendation that covariates should be considered as a set rather than in isolation. Luellen et al. recommend that when computing propensity scores to correct for initial group differences in quasi-experimental designs, covariates should be considered for inclusion if p < .50 and if the potential covariate is related to the outcomes of interest. With a large sample such as ours, small differences are more likely to have a p < .50 so we will use p < .25 to identify potential covariates, which will be incorporated into analyses as lambda scores.
Control group contamination also is a possibility, wherein participants at one site may have greater access to community services than families at another site. If families in the youth-only group have more exposure to school- or community-based sex education programs, then they may show greater program impact, contrary to the intervention hypotheses. In order to control for this possibility, participants will complete a set of questions at each follow-up related to their use of other intervention services including sex education.
The impact of selective attrition will be assessed by comparing families who dropped out of the study to those who were retained. First, missing data imputation will be used for missing data points. Then, differential attrition will be assessed by comparing participants who completed the 24-month follow-up to those who did not. We will first conduct univariate analyses on the key demographic variables and outcome variables measured at baseline, selecting those for which a difference of p < .25 emerges. These variables are then entered into a logistic regression to determine whether any were significant predictors of attrition when considered as a set. The set of predictors of missingness are used as covariates in the analyses of intervention effects.
F. Sampling Strategy and Power Analysis
Sampling. When the sites are faith based pairs, the workshops will be advertised to all 12-14 year old youth (control sites) or families with 12-14 year old youth (intervention sites) reached by these entities (which may include youth in the general population in their communities) and will be open to participants on a first come/first served basis. There will be no stratification within individual sites. In our experience, this has yielded a fairly representative sample. Although self-selection or specific referrals by, i.e., a youth minister might seem to have some groups more highly represented than others, it seems to have a balancing effect on the sample.
When the sites are more broadly based community sites, recruitment, which is the primary sampling strategy, is as described below (Section G). Again our experience shows that this yields a fairly representative sample. There is no stratification within sites as youth and families are accepted on a first come/first served basis and again self-selection and referrals have historically provided a balanced sample.
Additionally, youth for the control/youth only intervention will be recruited through the parents as well as directly. This enhances the equality of the youth groups as parents have to have an initial involvement of enrolling their youth and consenting for their participation.
Statistical power. Statistical power was calculated with PASS software. At baseline, there will be 720 youth in one group and 720 caregivers and 720 youth in the enriched group in Cohorts 1-4; year 5 is devoted to follow-up assessments and dissemination. We will be able to collect 24-month follow-ups for Cohorts 1-3 but only 12-month follow-ups for Cohort 4. If we assume 15% attrition between baseline and the 24-month follow-up, then we will have 459 per group at the 24-month testing. For an effect size of .15, this results in a power of .98 for the Between Groups effect, .99 for the Within Groups effect (change over time), and .99 for the Treatment by Time interaction effect, the latter being the key one. If we assume 20% attrition, then we will have 432 in each group at the 24-month testing, which still results in power = .99 for the Treatment by Time interaction effect. Obviously the power will be higher for larger effect sizes of .25, even though a .25 effect size is considered small. Power will be reduced by considering treatment effects in conjunction with various moderating variables such as ethnicity, gender, and pubertal status, but will still be in excess of .80. And since we are primarily testing for the difference between the control and intervention strategies, these measurements are not key to the evaluation design. If the interaction of intervention with a moderating variable is of practical importance – that is, different interventions might need to be developed for boys versus girls, or pre-pubertal vs. post-pubertal participants – then that practical importance should be reflected in a relatively large effect size, which would mean that we will have sufficient power to detect it Stated differently, small effect sizes (which compromise power) involving moderating variables are not likely to lead interventionists to design different programs for the various subgroups. In previous projects, we have used a number of strategies to minimize sample attrition. These include gathering location information on friends and relatives who are likely to maintain contact with the families; securing release information at intake in order to contact network members; establishing relationships with agencies who might have periodic contact with the families; making use of trackers such as the research coordinators; and maintaining regular contact through birthday cards and project newsletters. (Such newsletters are something that parents have suggested as a way to help families talk about sexuality. ) Incentives also help to reduce attrition as well as to recruit participants. Our past experience indicates that we can anticipate 15-20% sample attrition over 24 months with a retention strategy that is adequately implemented.
Please see Section IX for tables with estimates of numbers, race and ethnicity projected, by site, for both the control youth and intervention youth and parents.
G. Recruitment Plan
For both control and intervention groups, youth or families will be recruited into the program by information disseminated through local middle schools, youth groups and agencies. This includes staff being willing to attend youth based events and set up a booth or hand out fliers and explain individually to parents the program and it’s benefits. Site staff will contact appropriate persons at a minimum of 6 organizations or agencies and 3 schools in each site with recruitment information and fliers. (Or more as needed until the appropriate number of youth or families have been recruited). Youth or families who are interested in participating will give permission to be contacted by site staff or will contact program staff directly. We have previously been successful recruiting participants for family programs for middle school families so we feel these strategies are effective in our target sites. Recruiting families and youth in this age group, especially in a community based program, requires a well-thought out strategy.
Additional strategies for recruitment include completion incentives for both the programs and the follow up surveys. These strategies also affect retention. Retention is a key to reach the desired dosage in any program. Although the activities are highly engaging and offered in a positive, non-judgmental environment, upon completing a minimum of 20 hours of CTW youth program activities, each youth will receive a $50 gift card to an appropriate local merchant. A meal is also provided for the youth each week. Youth will receive $20 gift cards for completing each follow up survey.
For the Intensive Family Involvement component, Care to Wait uses an incentive program that includes weekly incentives, a meal, high quality activities for all family members, (including younger siblings), non-judgmental and accepting environment, and a completion honorarium of $150 for up to two adult family members who attend a minimum of 20 hours of workshops. One extra session is scheduled and additional make-up sessions will be scheduled for those who have health, work or other major reasons for not attending. Adults in the family $30 for each follow-up survey completed with their youth at 6, 12, and 24 months.
H. Performance Measures and Instruments.
The outcome measures selected (a) tap into the key processes in our impact model, (b) are reliable and valid, and (c) are appropriate for diverse cultural groups. A brief description of each measure is provided below along with evidence that they are psychometrically sound. The AFL Core Instrument assesses processes that are central to our logic model, and so the current program and evaluation staff are committed to using the Core Instrument in the proposed project. As was the case in one of our earlier demonstration project with AFL, we will include the AFL Core Instrument in one evaluation packet and our supplemental measures as a second booklet.
There is some but not sufficient overlap between the Core Instrument and certain of the scales we would prefer to use. For instance, the Core Instrument includes general three items on future orientation (3a-c) whereas the instrument we have used to measure the same construct has additional items on specific goals. In such cases, we plan to adopt the Core Instrument but supplement it with additional items from our preferred measure. In other instances, the Core Instrument includes a measure that is similar to what we have used in the past (e.g., sexual attitudes). In these cases, we describe the instrument we have used in the past, in order to document scale psychometrics, but note that we will adopt the one recommended by AFL.
As in past projects, all measures will be reviewed for readability and cultural relevance by human services professionals who are members of or familiar with local ethnic groups. To assess cross-cultural equivalence, alpha reliabilities for each outcome measure will be compared. In past projects, the coefficients were similar to those from standardization samples and did not vary with ethnicity by more than ±.06.
(1) Youth Surveys. For youth in both the control and intervention groups, the following surveys will be used.
Descriptive information. Dating may moderate program impact, so teens will report their level of involvement from have not dated to steady, serious boy/girlfriend. One item on religiosity will be included as in our past AFL projects and a previous cross-site evaluation with teen mothers. Items on school, community, and church sex education classes as well as how often the family talks about dating, intimacy, and sex provide information on dosage for both groups. Data will be collected on ethnicity (Core Instrument) and size of the school the youth attends.
Pubertal development. Pubertal development is related to dating and interest in sex as well as social perceptions of the teen. It may be an important moderator of program effects in that attitudes but not behavior may be affected for pre-pubertal participants whereas the reverse may be true for pubertal teens. The Pubertal Development Scale is a gender-specific, 5-item self-report measure of pubertal stage based on breast development, secondary sex characteristics, and menses. Teens rate themselves on a 1 (no development) to 4 (development complete) scale. Cronbach’s alpha is adequate (.70 to .76). Both Petersen et al. (1988) and Brooks-Gunn et al. found that self-reported pubertal development corresponds well with physicians’ Tanner ratings or parents’ reports of pubertal development.
Sexual attitudes and behavior. Items 34-44 from the Core Instrument will be used to assess whether teen participants have ever had intercourse or have in the last 6 months, and if they engage in pre-coital or risky sexual behaviors. The items related to risky sexual behavior are similar to those from the Scale of Sexual Risk-Taking (SSRT), which are weighted by risk level. SSRT items are interrelated consistently across samples (α = .75-.90), and scale scores are correlated with measures of peer deviance as well as other problem behaviors, as predicted by theory. One item on dating is coded as whether or not the teen is dating someone exclusively.
We will adopt items 24-33 from the Core Instrument to measure teen attitudes toward non-marital sex, supplemented by additional items from the Sexual Risk Behavior Beliefs and Self-efficacy Scales (SRBBS) that were used in a previous OAPP-funded project. Construct validity of the SRBBS has been demonstrated through confirmatory factor analysis; comparisons showing that virgins had more conservative social norms and attitudes toward sexual intercourse than non-virgin teens; and correlations with sexual self-efficacy. The items on behavioral intentions related to abstinence typically are a component of a latent construct of sexual risk-taking attitudes; this was confirmed in an earlier study so the abstinence intentions items will be combined with the attitude items into a single scale (α = .86). Recent evaluations of abstinence education programs indicate that intentions and attitudes toward premarital sex are distinct from sexual behaviors: The former may be altered in the short run but the latter typically are not.
Perceptions of risk. Effective pregnancy prevention programs typically have a decision-making component that teaches teen to assess risks. Therefore, we included one scale from the Adolescent Risk-Taking Questionnaire that measures thrill-seeking and reckless behavior. On each item, teens report their perceptions of and engagement in various risky behaviors such as smoking cigarettes regularly, speeding in a car, using marijuana several times a month, and having unprotected sex. The ARQ was developed and validated with large samples of 11-18 year olds. Both test-retest (.44-.80) and alpha reliabilities (α > .80) are adequate. The ARQ was validated with confirmatory factor analysis, group analyses showing that older teens and males reported lower risk perceptions and greater risky behaviors, and correlations between perceived risk and risk-taking behaviors.
Self-efficacy. Teen girls who avoid early pregnancy, despite facing many contextual risk factors, have in common a belief in self-responsibility as well the goal of being self-sufficient. Other research shows that girls who believe they are able to refuse high-risk behavior do so. The first finding highlights the importance of general self-efficacy whereas the latter focuses on situational self-efficacy. We will use the Pearlin Mastery Scale and a short form of the Rosenberg Self-Esteem Inventory General to assess self-efficacy, which is a key construct in our impact model. This is also measured through the competency measures for refusal skills which is a specific belief, within general self-efficacy, that they can and will use the skills.
Future orientation. When adolescents are optimistic about their future or have a positive life script, they are less likely to become teen parents. In a previous project, we used a measure based on Nurmi’s interview but it was weakly related to other variables in our logic model, including sexual attitudes and behavior. Therefore, we will adopt item 3 from the Core Instrument, supplemented by several items on sequencing; e.g., plans to complete school before marriage.
Peer orientation. One of the most potent predictors of high-risk behavior is affiliation with deviant peers. Peer disapproval of health risk and their modeling of health-risk behaviors outweigh parental influences in predicting early sexual activity. Teen and parent participants will complete two measures related to peer orientation and peer deviance. The measure of extreme peer orientation has four items that tap into adolescents’ willingness to sacrifice their talents, school performance, and parents’ rules in order to spend time with their friends. Although its internal consistency is marginal (.62), it has good validity in that scores predict later school adjustment, parental monitoring and strictness, and problem behavior. Peer deviance will be assessed 12 (adolescent) items (α > .86) by having respondents rate the extent to which the teen’s peer group engages in activities such as drinking, using drugs, skipping class, delinquency, and sex. Finally, teens will complete Beal et al.’s 4-item measure, which provides more specific information on how peers would respond if the teen engaged in behaviors that might compromise the teen’s health (α = .90), and indeed this measure is strongly related to risky sex.
Refusal skills. Even confident teens who know about sex and endorse abstinence have premarital intercourse, perhaps because they do not yet have well-developed interpersonal problem-solving skills for such situations. To assess participants’ repertoire of refusal skills, we adapted the Preschool Interpersonal Problem-Solving Test for dating and peer pressure situations. As with the PIPS, teens are posed four different scenarios, and are asked to generate as many possible responses as they can that defuse pressure from a dating partner or peer. They are then asked to select the two they would be most likely to use. Similar measures were used by other researchers to evaluate their behavioral interventions to reduce risky sexual behavior. In the Santor et al. study, for instance, their measure of conformity to peer pressure had an alpha of .88, was correlated with other measures of peer relations (e.g., conformity, popularity), and predicted risk behaviors such as sexual activity and substance use. Responses are coded (interrater reliability = .92, using Cohen’s kappa) for the number of unique solutions (fluency) and confidence, or how certain the respondent is that peer pressure could be resisted. With the assistance of experts on adolescence and dating violence, we devised weights for response categories according to their likely effectiveness; e.g., acquiesce = 0 to exit situation = 4 (similar to Metzler et al.'s Safety of Suggested Alternatives codes). Our previous research has shown the CARE to Wait program to have a large, significant effect on these skills. This measure supplements self-report items 16-18 in the Core Instrument.
Family relationships. Teen risk taking is less likely when they are able to talk openly with their parents, and when there is low conflict and high support. Teens will complete two measures of the quality of their relationship, in addition to those in the Core Instrument. First, the Parent-Adolescent Communication Scale includes 20 items that assess open communication as well as problems in family communication. We selected the 10 items with the highest factor loadings and supplemented these with five items from the Dyadic Adjustment Scale short form. The DAS assesses relationship quality and satisfaction (e.g., argues, confides). The PACS can be used with youth as young as 12; alphas range from .77 to .87. The DAS is the most widely used measure of relationship satisfaction; reliabilities for the short form exceed .90 and it consistently discriminates between couples who are divorced versus married. In two previous studies with adolescent mothers and with 12-14 year old youth, we found this 15-item scale to have an alpha coefficient > .90 and to be strongly related to measures of child problem behaviors, attachment security, and disciplinary practices.
Parent monitoring. The eight items that measure the monitoring construct (α = .79 for youth in this sample) are primarily from Kerr and Stattin (2000), supplemented with several items from Capaldi and Patterson’s work. These items reflect the degree to which parents monitor their children’s activities, whereabouts, and plans. Alpha reliabilities were .82 and above in four other studies. Various research groups have found parent monitoring to correlate well with adolescent risk-taking and antisocial behavior. These items supplement items 5 and 6 of the Core Instrument.
(2) For Parents in the Intervention Group
Data will be collected on ethnicity, family size (supplemented by information on sibling ages, given research showing that older sibs who are close in age may “spawn” earlier dating and intercourse ) and marital status.
We will adopt items 24-33 from the Core Instrument to measure parent attitudes toward non-marital sex, supplemented by additional items from the Sexual Risk Behavior Beliefs and Self-efficacy Scales (SRBBS) that were used in a previous OAPP-funded project. Construct validity of the SRBBS has been demonstrated through confirmatory factor analysis; comparisons showing that virgins had more conservative social norms and attitudes toward sexual intercourse than non-virgin teens; and correlations with sexual self-efficacy. The items on behavioral intentions related to abstinence typically are a component of a latent construct of sexual risk-taking attitudes; this was confirmed in an earlier study so the abstinence intentions items will be combined with the attitude items into a single scale (α = .86).
Parent self-appraisals are an important mediator of child-rearing practices and changes in parent self-efficacy are related to improved disciplinary practices. We will measure parent self-appraisals with the Competence and Investment scales from the Self-Perceptions of the Parental Role (SPPR). This 6-item scale has high internal (.80-.87) and test-retest (.80-.88) reliabilities, convergent and factorial validity, and construct validity in terms of relations to difficult child behavior, punitive child-rearing practices, and social support.
Peer orientation. One of the most potent predictors of high-risk behavior is affiliation with deviant peers. Peer disapproval of health risk and their modeling of health-risk behaviors outweigh parental influences in predicting early sexual activity. Parent participants will complete two measures related to peer orientation and peer deviance. The measure of extreme peer orientation has four items that tap into adolescents’ willingness to sacrifice their talents, school performance, and parents’ rules in order to spend time with their friends. Although its internal consistency is marginal (.62), it has good validity in that scores predict later school adjustment, parental monitoring and strictness, and problem behavior. Peer deviance will be assessed with 8 (parent) items (α > .86) by having respondents rate the extent to which the teen’s peer group engages in activities such as drinking, using drugs, skipping class, delinquency, and sex.
Parents will complete two measures of the quality of their relationship, in addition to those in the Core Instrument. First, the Parent-Adolescent Communication Scale includes 20 items that assess open communication as well as problems in family communication. We selected the 10 items with the highest factor loadings and supplemented these with five items from the Dyadic Adjustment Scale short form. The DAS assesses relationship quality and satisfaction (e.g., argues, confides).
Family communication about sexual issues will be assessed with items 13-14 from the Core Instrument. Given that the CARE to Wait intervention provides homework assignments related to these topics, we anticipate that conversations will increase significantly. Positive family relations foster teen self-disclosure, trust, and adoption of the parents’ value system - all elements of social control. Family closeness and cohesion are measured with items from Metzler et al. as well as the Family Environment Scale that assess the degree of trust, warmth, fun, and togetherness between parents and children. The alpha reliabilities are high (.89 to .91), and the measure is correlated with other scales that tap into family functioning. These scales supplement items 7-10 from the Core Instrument.
Parent monitoring. The eight items that measure the monitoring construct (α = .72 for parents; α = .79 for youth in this sample) are primarily from Kerr and Stattin (2000), supplemented with several items from Capaldi and Patterson’s work. These items reflect the degree to which parents monitor their children’s activities, whereabouts, and plans. Alpha reliabilities were .82 and above in four other studies. Various research groups have found parent monitoring to correlate well with adolescent risk-taking and antisocial behavior.
(3) For Youth in both groups and for parents:
Validity of responses. Given the sensitive nature of many of the above questions, it is important to gauge the validity of the responses. First, the 13-item short form of the Marlowe-Crowne Social Desirability Scale (MCSDS), developed by Reynolds, will be intermingled with other survey questions. This short form has adequate reliability (α > .76) and construct validity. However, the MCSDS is correlated with various personality traits indicative of high psychological adjustment, such as emotional intelligence and stability, openness to experience, conscientiousness, and self-esteem, which suggests that the MCSDS will be inversely related to measures of risk taking. Second, three validity questions conclude the survey; these ask whether the respondent understood the questions and answered them carefully and honestly. Third, responses are cross-checked against other answers to look for inconsistencies, and scale scores are correlated with each other to see if there are outliers when there should be evidence of convergent validity.
I. Data Collection Plan
Informed consent will be sought from all potential participants following requirements of the Colorado State University Institutional Review Board. Following IRB requirements, all participants are permitted to withdraw at any time.
For the intervention (family based program), parents and youth come to the initial meeting together, because they will be attending the workshops together. Before the surveys are read, parents are read the consent form which includes consent for their youth, parents are allowed to ask questions and the voluntary nature of the program is emphasized. Youth also have a short, descriptive consent form which they sign. Parents are given a copy of the signed consent form.
For the control (youth based program), parents will also have to sign a consent form. Two strategies will be used to obtain this signature. Parents will be required to attend the first (survey session) with their youth unless there are extenuating circumstances (work, illness) and at that time will sign the consent form. A special session will be held for those parents while the youth complete the surveys which will include an overview of the program for the youth, an opportunity to ask questions about the curriculum and to look at the curriculum materials and an opportunity to participate in a sample activity from the youth curriculum.
Surveys will be administered to the intervention and control groups on a 6-month schedule, beginning with the baseline pretest through a 24-month follow-up. These surveys will be administered in groups at baseline by trained data collectors, who are provided with an administration manual to help guide them in how to present items, and respond to questions..
Data collectors are trained by the evaluator and PI at the initial on-site training and supplemented training can occur by ongoing monitoring and support site visits, email, and annual staff conferences Because of the nature of some of the agency staffing patterns, some facilitators play duel roles in both program and research and when that happens the following steps will be taken. Those data collectors will not administer surveys to any of the youth or adults for whom they facilitate the workshops. Upon completing the surveys, behind security screens, participants seal their surveys into coded envelopes which are only opened by either the DTBY PI or monitors (in Cortez) for quality assurance or the Evaluation team at CSU. These are not opened by on-site personnel. And the evaluation team will never see the names as they receive only coded surveys. The on-site staff will never have an opportunity to see the completed surveys. Follow-ups are given to participants individually or, if it can be scheduled, in groups. All surveys are administered orally to ensure that participants understand the items. This approach, combined with use of privacy screens, has been successful at minimizing nonresponse to questions. To reduce bias, data collectors who can administer surveys in Spanish will be available if needed.
Data collectors at each site distribute surveys, which are identified with a code number (not names), will administer them, collect them in envelopes (to ensure confidentiality), and send them to the administrative office in Cortez. Once they are logged in there, they will then be sent to the evaluator in Fort Collins, who again logs them in
Confidentiality will be ensured in four ways. First, only ID numbers appear on the test booklets. Any information with a name, such as consent forms or master lists with IDs and names, are kept in locked filing cabinets at the local sites whereas the survey instruments are sent to the evaluation coordinator at a location remote from all of the sites (Fort Collins, CO) . The evaluation team does not have access to participant names, and the local sites do not have access to completed surveys. Second, privacy screens are made available to participants as they complete the surveys, and we ask that teens complete the forms independent of their parent(s) – usually in a separate room. Third, as noted above, respondents put the forms directly into mailing envelopes and seal them so that the local site staff do not see them before they are sent to the evaluation team. As part of staff training, staff are trained not to release information about participants to anyone other than authorized staff or when abuse reports are required.
Regarding data management, open-ended questions are content coded twice by research assistants who have been trained to 90% reliability, and who are naïve to group membership. Surveys are scanned, using Remark OMR software, into an SPSS data base by research assistants and the evaluator; this software flags suspect responses. Also, 25% of the surveys are randomly selected for accuracy checks by the GRA, and data check programs are run to identify out-of-bounds values, inconsistent responses, and exaggeration (including responses to the validity and MCSDS scales). Electronic data are stored on a password-protected hard drive, and paper surveys are stored in locked filing cabinets.
J. Quantitative and Qualitative Data Analyses
Group equivalence. The first set of analyses will be to determine if the youth-only and enriched groups are equivalent. Differences between the two groups at baseline, on various demographic and outcome measures as well as exposure to school- or church-based sex education programs, will be tested with 2 (group) x 6 (locale) ANOVAs. As well, logistic regression will be used to predict group membership, as described in the earlier section on threats to internal validity. Assuming the two groups are equivalent, repeated-measures ANOVAs will be used to determine if there are program differences in impact, indicated by a significant Group by Time interaction effect. If treatment group differences are found at baseline, then lambda scores will be used as a covariate in the analyses.
Differential attrition will be assessed by participants who complete the long-term follow-up to those who do not on various demographic and outcome measures. In previous projects involving random assignment to groups, there were very few baseline differences. If such differences emerge, and if those differences are associated with outcomes, then the variables on which the groups differ will be used as covariates in analyses of program impact. (See earlier section related to threats to internal validity.) Missing data will be imputed using AMOS.
Intervention effects. Repeated-measures ANOVAs will be used to test for group differences in intervention effects on attitudes about sex and risky sexual behavior. The primary outcome variable is binary: Were teens in the intervention group more likely to remain abstinent, regardless of whether or not they were virgins at baseline? This question will be tested with survival analysis in which predictors (e.g., pubertal status, dating experience, treatment group) of the likelihood of remaining a virgin at each follow-up will be entered. This approach allows us to estimate the odds ratio for exposure to the intervention, controlling for other variables that might account for changes in abstinence.
Correlational analyses will be used to assess implementation and dosage variables in relation to changes on the mediating and outcome variables. These implementation variables include information from the workshop logbooks on group dynamics, adherence to protocol, and which curriculum modules received more emphasis; and participant ratings of the workshop climate. As well, self-report data on exposure to sex education in schools and at home will be entered, along with DTBY dosage information, in logistic regressions in order to estimate the relative impact of different forms of intervention.
Moderation. In an earlier OAPP-funded project, we examined the role that sexual experience might play in moderating program impact. Although nonvirgins as well as high-risk youth (i.e., full pubertal development, in a monogamous dating relationship) differed from the other youth on a number of variables at baseline, there were no differences between these groups in terms of intervention effects. Such results provide some assurance that our intervention is suitable for youth with diverse experiences. Similar analyses will be conducted for the proposed project, which will include analyses of gender and ethnic differences in program impact.
Mediation. Our impact model identifies five types of processes that might account for adolescent sexual behavior: (1) pubertal development, which is associated with dating; (2) aspects of personality such as impulsivity and self-efficacy; (3) behavioral skills related to peer pressure and high-risk behavior, such as refusal skills; (4) the peer culture in terms of peer orientation and affiliation with deviant peers; and (5) the family climate including conflict, communication, cohesion, and monitoring. Latent growth modeling with MPlus will be used to determine whether intervention effects on sexual attitudes and behavior are due to 2-5 above. (Attitudes and behavior will be modeled separately, and then attitudes will be treated as a mediator of sexual behavior.) Pubertal status and dating will be treated as moderators, such that models of intervention effects may differ for prepubertal vs. pubertal youth. Using LGM, we can test whether the impact of family variables is mediated by peer variables, as much of the recent literature indicates, and whether impulsive risk takers are more prone to affiliate with deviant peers. Previous research indicates that although these different processes are additive, the peer variables are most important. Finally, LGM will be used to identify which processes contribute to level (intercept) and change over time (slope) in sexual attitudes. This intervention study will permit tests of the potency of various pathways to adolescent sexual experience, which might be more amenable to change, and whether family-based interventions are more potent albeit more costly.
K. Evaluation Training Activities, Statistical Experts
Data collectors are trained by the evaluator and PI at the initial on-site training and supplemented training can occur by ongoing monitoring and support site visits, email, and annual staff conferences. They are also provided with an evaluation administration manual which has the most commonly asked questions and protocols for administering the surveys.
In year 5, support for a statistical consultant will be included in our budget: Randy Swain is a quantitative psychologist with in-depth training in multivariate statistics (including SEM and LGM), which she has applied to various prevention projects. His principal role will be to provide assistance with the tests of our impact model.
L. Followup Assessments.
The followup assessments will be 6, 12, and 24 months and will be the same format as the baseline and other followup surveys.
M. Dissemination and Publication
Program results will be disseminated initially to program participants and community collaborators through newsletters and community presentations. Findings related to intervention practices and program impact will be presented at grantee conferences as well as professional conferences such Society for Prevention Research, Society for Research on Adolescence, and Society for Research on Child Development. Finally, journal articles related to tests of the intervention theory and program impact will be submitted to prevention and research journals such as Prevention Science, Journal of Adolescent Research, Journal of Primary Prevention, and Developmental Psychology. DARE to be You staff and the evaluation team are currently actively disseminating other successful components of the DARE to be You program so this is a regular activity for us. We are also currently developing a paper with the results of our first five years model. We have long been interested in this particular comparison and will be anxious to disseminate and publish the results.
N. Institutional Review
It is a standard requirement at CSU for any research or demonstration project to be submitted to the Human Research at the time that the grant is submitted to the funder. DTBY has consistently been approved for the past 25 years by the CSU institutional review board for all research involving human subjects and will submit the review as required by OAPP and CSU.
O. Evaluator Abilities.
Dr. David MacPhee as served for evaluator on federal research projects for the past 18 years, has developed instruments which are broadly used, published results and served on federal cross-site evaluation boards. This evaluator roles have involved the training of staff to conduct field studies, evaluation multi-site research projects and disseminating the information through presentations and poster sessions at national conferences. He is a professor of Human Development and Family Studies and therefore understands the theory as well as the practical limitations and possibilities of evaluating multi-site field research. He has established a long term working relationship with the DARE to be You program staff.
P. Theoretical Basis of Proposed Research.
Pregnancy prevention programs with a “just say no” approach, especially if they are brief, are generally ineffective at altering adolescents’ behavior—either age of first intercourse, unprotected sex, or multiple sexual partners, although there are some short-term effects on sexual attitudes and knowledge. However, certain risk and resiliency factors are consistently related to various dimensions of adolescent risk taking, including early sex and substance use. Our belief is that by altering these risk factors and promoting resiliency, teens will be better able to delay sexual experimentation. Both theory and research are quite clear that adolescents’ interest in sex is determined by multiple influences. Consistent with this literature, we adopt a systems approach that focuses on individual, family, and peer factors, and an empowerment/skill building emphasis that is grounded in social learning and social control theories.
Biological forces associated with puberty, especially testosterone levels, relate to interest in sex, and earlier puberty is related to age of first coitus. These findings have implications for both our intervention and evaluation: The program needs to normalize sexual interest in adolescents but also teach teens how to channel these feelings in ways that are not risky, and the evaluation needs to assess pubertal development because it is likely to affect outcome variables. Prepubertal youth are less interested in sex, and so abstinence is less a matter of behavior than attitudes and intentions.
The peer group plays two key roles. First, the peer culture in a particular ethnic group or high school establishes social norms related to sexual experimentation, substance use, and so forth. This social contagion model is the basis for recent substance abuse prevention programs that impart accurate information about age at initiation and prevalence rates of risky behavior. Modifying social norms will receive minimal emphasis in the current project, however, because findings from one of our recent multi-site intervention efforts with 12-14 year olds indicate that social norms are less strongly related to sexual attitudes and behaviors than are peer deviance, parent monitoring, and perceptions of risk. Our previous project also confirmed the importance of targeting peer orientation; deviant peers affiliation is implicated in various risky or antisocial behavior. For instance, virgins often care more about their parents' feelings while nonvirgins care more about what their boyfriends or girlfriends think, and peer orientation predicts deviance independent of parent support and monitoring.
Second, teens who begin dating earlier initiate sex earlier because of opportunity for sexual experimentation, although pubertal development likely contributes to interest in both dating and sex. These studies have several implications for intervention related to how to establish dating communication and self-regulation, which in turn are consistently related to avoidance of high-risk behavior.
Theories of control and conformity implicate several processes that will be incorporated into our approach. First, certain personality traits are related to earlier sexual behavior, especially impulsivity or risk taking. Some research indicates that novelty seeking is more important than harm avoidance in predicting behaviors such as substance use, especially when combined with indicators of poor control such as deviant peer affiliations. Self-efficacy also relates to initiation of sex. Teens will be taught concrete behavioral skills to assess risks and make good decisions, adopted from the health belief model; regulate their behavior, based on social learning approaches adapted from Mischel, in which youth are taught to focus on long-term rewards and self-distraction methods; and ways to develop a stronger sense of competence, based on previous success in the DTBY model.
Second, parent monitoring is consistently related to delayed sex. For example, Metzler et al. found that poor parental monitoring was directly related to risky sexual behavior as well as to association with deviant peers. Also, less availability of parental figures in the family was related to risky sexual behavior as well as poor parental monitoring. When such monitoring is not intrusive and rather reflects a caring, intimate relationship, daughters delay sex in part because of shared conventional beliefs in the family. That is, various family processes appear to be interrelated and predispose teens toward abstinence: parent involvement and warmth, teen self-disclosure that is related to parent monitoring, and open communication.
Further, in families marked by open communication, parents more often convey their values and attitudes toward sex, which along with religiosity is another form of social control. Parents with permissive sexual attitudes tend to have teens with similar attitudes, and these permissive attitudes are correlated with earlier sexual experimentation. Furthermore, adolescents who perceive that their parents disapproved of teens’ sexual activity are less likely to be sexually active.
Recent reviews of pregnancy prevention efforts point to insufficient reliance on sound theory as one factor that hampers program effectiveness. Our intervention is designed to alter several processes that theory and empirical evidence indicate are key to delaying sex:

 Social Learning theory indicates that self-efficacy beliefs are a key mechanism underlying achievement, good decision making and self regulation, and these in turn may delay the age of first intercourse.
 Social control theory implicates impulsivity, peer norms and behaviors, and parent modeling and monitoring as explanations for adolescents’ high-risk behavior. Health belief models also emphasize the role of risk assessment, evaluation of potential outcomes, and decision making. The CARE to Wait program is expected to increase adolescents’ decision-making skills such that they will (a) more accurately assess the risks of early sex (as well as substance use), (b) be less likely to endorse risk-taking cognitions and behaviors, and (c) dissociate themselves from deviant peers. As well, information about effective parent monitoring – as opposed to permissiveness or intrusiveness – and practice with it will (d) increase open communication and parent awareness of the teens’ friends and whereabouts. These changes, in turn, will increase the abstinence rate of the intervention group.
 Contextual and systems theories highlight the importance of family, peers, school, and cultural norms in high-risk behavior. DARE to be You has had an enduring emphasis on family communication, nurturant discipline, and behaviors that encourage self-efficacy. A recent intervention in which regular classroom instruction was enhanced by homework assignments completed by students and their parents showed that the enhanced program increased self-efficacy for refusing high-risk behaviors, and increased parent-child discussions about prevention and sexual consequences (Blake et al., 2001). Thus, we postulate that DTBY will decrease parent-teen conflict, increase open communication, and increase shared attitudes about sex, all of which have been shown to delay adolescents’ sexual experimentation.
Finally, we have a developmental perspective, which has two implications. First, sexual development is an inherent part of adolescence, so it is important that programs normalize biological changes, increased interest in sex, dating, and intimacy. This also means that program impact may vary with pubertal stage. Second, adolescence is a period when cognitive changes and behavioral skills can be out of synchrony. The implication for us is that transmitting information is not enough; teens need practice with skills. A defining feature of DARE to be You is that facilitators keep lectures to a minimum. Instead, there are opportunities to practice behaviors, experience managing difficult situations and problem solve. Thus, participants should learn how to convey their attitudes and values to peers and partners, recognize when a high-risk situation is developing, and have the communication skills to extricate themselves from such situations.
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