Healthy Communities Baltimore (HCB), Providing Abstinence-Until Marriage Education to Baltimore City Youth

Barbara W. Sugland, MPH, ScD and Shameeka M. Jelenewicz, MA
Center for Applied Research and Technical Assistance, Inc.
Al Essien MS, Marilyn Patton, RN, ND and Rashaad Emory
HOPE worldwide Baltimore

Introduction
Rates of sexual activity and teen birth in the city of Baltimore indicate ongoing prevention efforts are needed. In 2006, Baltimore City’s teen birth rate was 78.2 per 1,000, roughly two times higher than the rate for white teens. According to the 2005 local Baltimore Youth Risk Behavior Surveillance (YRBS), 64 percent of Black 9th graders surveyed had already had sexual intercourse; 26% had sex before age 13. National survey estimates show the percentage of 9th graders that have had sex is 34 percent; the national percentage of Black 9th graders that have had sex is 55.4 percent; and the proportion of black youth who had sex before age 13 is 17 percent.

Healthy Communities Baltimore (HCB) is a comprehensive abstinence-until marriage education program for targeted Baltimore City youth in grades four through eight and their primary caregivers (parents/guardians). HCB is implemented by the staff of HOPE worldwide Baltimore (HWW-Balt), in close partnership with the Y of Central Maryland (formerly YMCA). HCB is being delivered as one of the enrichment activities provided through the Y’s Baltimore Out-of-School Time (BOOST) program.

HCBs goal is to provide youth and their caregivers with knowledge and skills that create an environment that supports adolescents’ decisions to postpone sexual activity until marriage.

The HCB has six program outcomes. Youth will: (1) Understand that abstinence from sexual activity is the only certain way to avoid out-of-wedlock pregnancy and sexually transmitted diseases, (2) Understand the social/psychological and health gains realized from abstinence, (3) Report self-efficacy to refuse sexual urges and advances, (4) Intend to remain abstinent, (5) Intend to avoid situations and risk behaviors, such as drug use and alcohol consumption, and (6) Primary caregivers will demonstrate increased involvement in student’s lives as measured by reported parent-student communication regarding health issues, risk behaviors, and personal goal choices.

The youth curriculum consists of 48, 45 to 60 minute sessions, held over 24 weeks during the school year. The primary caregiver curriculum workshops consist of a 120-minute session, offered once per month for eight months during the school year.

The purpose of the HCB evaluation is to understand the extent to which youth attending HCB sessions demonstrate improved attitudes and behaviors that support sexual abstinence, and demonstrate improved parent-child communication and relationships relative to a group of young people not involved in the HCB sessions.

Methods
A randomized cluster design is used to evaluate the HCB program. Five participating BOOST sites for 2008-09 are randomly assigned to either the intervention – HCB + BOOST (three sites) –or comparison condition – BOOST only (two sites). Two Baltimore public schools not receiving BOOST or HCB will serve as a second comparison group, to ensure the evaluation can fully isolate the influence of HCB from the influence of the BOOST after school enrichment activities on attitudes and behaviors of students and caregivers.

The evaluation consists of surveys (primary caregiver and student), along with data collection tools documenting frequency and intensity of participation in HCB, BOOST and other after-school efforts (e.g., attendance logs, session module tracking forms, time spent on topics). Surveys are administered to youth and primary caregivers (intervention and comparison groups) at baseline (before the first HCB session), post HCB (after the last HCB session), and at follow-up (12 and 18 months from the start of the HCB curriculum).

The youth survey includes questions about participant’s opinions and experiences related to sexual development, risk taking behavior (i.e., drug and alcohol use), relationships with caregivers and other adults; pregnancy and parent-child communication. Primary caregiver surveys focus on different aspects of the caregiver’s own life, attitudes, and beliefs regarding abstinence and their child’s, as well as communication with their child about various issues, including abstinence and life goals, as well as demographics (i.e., age, sex, and race). Descriptive and background information will be gathered from youth and primary caregivers as well. Descriptive, bivariate, and multivariate analysis will be conducted using SPSS.

Results
The first year of the program has focused on program and evaluation redesign activities and preparation for implementation. The team developed a theory of change framework outlining the assumptions guiding the HCB intervention; refined the program logic model; identified an appropriate set of questions and designed instruments to document participant characteristics and attitudes and receipt of the intervention and student/caregiver outcomes. The team also significantly revamped the evaluation design, submitted and received IRB approval, and conducted a pilot test of the youth and primary caregiver baseline surveys and survey administration procedures. Modifications were made to surveys and procedures as a result of information learned from the pilot. Additionally, participating site staff was trained on the data collection protocols and forms. Implementation will begin in the second year of the program.

Discussion
There are several lessons learned as a result of preparing for implementation and evaluation of HCB. First, logistical challenges associated with BOOST, particularly how students enroll in BOOST, prevented random assignment in the most rigorous manner. Students self-select into BOOST and sites are granted permission and funding to implement BOOST through a RFP process. As such, randomly assigning students to receive/not receive BOOST activities was not possible. A randomized cluster design was selected to allow us to determine the incremental influence of the HCB intervention relative to BOOST and to no intensive after-school enrichment on student outcomes.

Secondly, since BOOST is delivered on school property, the team needed to set aside time to collaborate with the Y to introduce the HCB intervention and the evaluation to school principals and BOOST site directors. These additional meetings were designed to get sign off and support from school principals, make sure all parties were familiar with the HCB intervention, and to ensure all parties understood the process of random assignment, recruitment, and securing consent/assent of parents and students.

Finally, ensuring a sufficient sample size for detecting results requires implementation of HCB in two waves – 2008-2009 and 2009-2010 due to the level of funding and average number of students involved in BOOST at each site in a given school-year. These two cohorts should provide a sample size sufficient for detecting significant differences. The maximum length of follow-up will be 18-months in order to complete follow-up and analyses within the five year contract period. Collaboration with a community-based organization (CBO) around the implementation of HCB and the evaluation offers an important lesson into the process of conducting community-based efforts. These include having clear expectations, roles and responsibilities for HCB and the CBO being recruited, as well as a clear understanding of the CBO’s infrastructure and commitment to the HCB initiative.

Implications
Results from the HCB evaluation can provide a better understanding of:

• Educational activities that influence attitudes and behaviors that support sexual abstinence among black inner city youth;
• How parent engagement in abstinence programming impacts youth’s decision to delay sexual activity; and
• The benefits of partnering with community based organizations to deliver abstinence until marriage education programming.

The findings will inform current and future prevention efforts in the city of Baltimore focusing on reducing teen pregnancy and delaying early onset of sexual activity among black inner city youth.

Contact information:
Shameeka M. Jelenewicz, MA
Research Associate & HCB Evaluation Manager
Center for Applied Research and Technical Assistance, Inc. (CARTA)
(410) 625-6250 ext. 221
sjelenewicz@cartainc.org

Al Essien, MS
Executive Director
HOPE worldwide Baltimore
(484) 744-9306
sjelenewicz@cartainc.org