JOIRMI.OI'
ADOLESCENT
HEALTH
ELSEVIER
Journal of Adolescent Health 40 (20071 275.cl-275.cl4
Original article
PASHA: Facilitating the Replication and Use of Effective Adolescent
Pregnancy and STI/HIV Prevention Programs
Josefina J. Card, Ph.D.*, Laura Lessard, M.P.H., and Tabitha Benner, M.P.A.
Sociometrics Corporation, hn Altos. California
Manuscript received June 15. 2006: manuscript accepted Ociobcr 3. 2006
Abstract
Purpose: It is important that interventions that have been shown effective in changing risky
behavior be disseminated, so that they can be replicated (implemented in a new site) and so that their
effectiveness in a new setting can be investigated. This article provides an update on an innovative
resource for promoting the replication of effective teen pregnancy and STI/HIV prevention programs. The resource is called the Program Archive on Sexuality. Health & Adolescence (PASHA).
Methods: A Scientist Expert Panel rales candidate adolescent pregnancy and STI/HIV prevention
programs based on the strength of the evidence of their effectiveness in changing risky sexual
behavior among youth ages 10-19 (10-21 for STI/HIV prevention programs). Developers of selected
programs arc invited to make their program and evaluation materials publicly available through PASHA.
PASHA publishes and disseminatesreplicationkits for programs it successfully acquires.
Results: Fifty-six programs have been selected by PASHA's Scientist Expert Panel as "effective"
in changing one or more risky behaviors associated with adolescent pregnancy or STI/HIV.
Complete program and evaluation materials from 35 of these programs are now currently available
through PASHA, five arc pending. 12 arc publicly available from other sources, and only Tour arc
not publicly available. PASHA programs arc aimed at a diverse largei population and cover diverse
content on many abstinence and contraception/condom-related topics. Many pedagogical techniques
are used to effect behavior change, noticeably role play and group discussion.
Conclusions: PASHA illustrates well the productive research-to-practice feedback loop that is the
backbone of "translation research." The resource can be used by adolescent pregnancy and STI/HIV
prevention practitioners to put what works to work to continue the lowering of the nation's
adolescent pregnancy and STI/HIV rates. © 2007 Society for Adolescent Medicine. All rights
reserved.
Keywords:
Contraception; Health education; HIV; Pregnancy in adolescence; Primary prevention; Program evaluation; Risk
reduction behavior; Sex education: Sexual abstinence: Sexually transmitted diseases
Teen pregnancy and birth rates in ihe United States have
declined steadily since 1991. Both abstinence (decreased
sexual experience among American teens) and contraception (improved contraceptive use among the sexually active)
have contributed, in roughly equal proportions, to the decline [1].
The same time period saw the mushrooming of many
teen pregnancy prevention programs delivered in schools.
•Address correspondence to: Dr. Josefina J. Card, Sociomeirics Corporation. 170 Stale Street. Suite 260. Los Altos. CA 94022.
E-mail address: [email protected]
communities, and clinics around the country. These prevention programs typically had one or both of the following
goals: (1) to promote abstinence (i.e., to delay or decrease
sexual experience among teens); and/or (2) to promote contraception (i.e., to increase and improve contraceptive practice among sexually active teens).
How much did these pregnancy prevention programs
contribute to the now 15-year decline in the U.S. teen
pregnancy and birth rates? The answer to this question is
unknown. There is now a growing body of evidence that
shows that some {at least a few dozen) of the teen pregnancy
prevention programs achieved their goals 12-5]. Yet, it
I054-I39X/07/S - see front matter <D 2007 Socieiy for Adolescent Medicine. All rights reserved,
doi: 10.1016/j.jadohealth.2006.10.004
I75.c2
J.J Card vi til. / Jounuil of Adolescent Health 40 (2007} 275.vl -275c 14
remains difficult, if not impossible, to estimate precisely the
magnitude of the contribution of effective pregnancy prevention programs, taken as a set. lo the decline in U.S.
pregnancy and birth rales. For surely: "Making true and
lasting progress in preventing teen pregnancy requires a
combination of . . . (prevention) programs and broader efforts to influence values and popular culture, to engage
parents and schools, to change the economic incentives that
face teens" [6|. Both types of efforts are necessary for
sustained progress.
This paper describes an important resource of the first
type (prevention programs) for both researchers and practitioners working in ihe field of adolescent sexual and reproductive health. The Program Archive on Sexuality.
Health, and Adolescence (PASHA) is aimed at assembling
in one place all the materials that a school, community, or
clinic would need to replicate an effective teen pregnancy or
ST1/HIV prevention program. Prior to the establishment of
PASHA in the early 1990s, it was difficult for practitioners
to make sense of the body of evidence surrounding what
worked to prevent teen pregnancy or sexually transmitted
infection (STls). Even if one succeeded in finding, from the
literature, a program that worked, the journal article seldom
contained sufficient information to implement the program
as it was implemented in the siie(s) where it was proven
effective. The result was failure lo fully leverage lessons
from research. Much money and lime were lost in the
process.
PASHA is a resource aimed at assisting adolescent reproductive health practitioners around the country meet the
field's demands for meeting best practice standards by. first,
facilitating access to effective adolescent pregnancy and
ST1/HIV prevention programs, and, second, encouraging
implementation and re-evaluation |7.8| of these programs at
sites different from the ones in which they were developed.
The PASHA collection includes complete program and
evaluation materials from intervention programs judged by
a scientist expert panel to have demonstrated salutary impact on one or more fertility- or STI/HIV-related behaviors,
in at least one subgroup of adolescents and/or young adults
aged 10-19 years (10-21 years for STl/HIV prevention
programs), in at least one site in the United Stales.
Bridging research and practice, ihe PASHA resource
makes a contribution to ihe field in several ways. First, it
pulls together scientific research findings on the effectiveness of existing adolescent pregnancy prevention and ST1/
HIV prevention programs, highlighting the most promising
of the lot for national attention and scrutiny. Second, it goes
beyond identification of these promising programs to the
innovative assembly in. and dissemination from, a single
place of materials needed to re-implement and reevaluate
the promising programs. Third, il supports faithful replication of effective programs in the world of practice | 9 | by
providing users with a comprehensive set of program ma-
terials along with a user's guide describing in detailed
fashion how the supplied materials were used in the original
implementation along wilh implementation tips supplied by
the original developer or learned from the PASHA field test
(lo be described later) in independent sites 110.111.
Methods
The foundation for PASHA's credibility and utility lies
in the process used to identify and select effective programs,
assemble ihe intervention materials into program packages,
and review the accuracy, comprehensiveness, and usability
of these packages for practitioners working with adolescents. Below we describe each of these sieps in turn.
Enlistment of a scientist expert panel to guide the
development of selection criteria and the selection of
programs
At the inception of the project in the early 1990s, four
nationally-recognized experts in adolescent pregnancy prevention research were invited, to serve on the PASHA Scientist Expert Panel, charged with selecting promising programs for PASHA. They were: Drs. Claire Brindis
(University of California, San Francisco); Brent Miller
(Utah Stale University): Kristin Moore (Child Trends. Inc.):
and Freya Sonenstein (Urban Institute). In the mid-1990s,
we added adolescent STI/HIV prevention as a second, related PASHA focus. Dr. Jeffrey Fisher (University or Connecticut), an expert in the area of increasing HIV preventive
behavior, joined the Panel at that point. Since then. Drs.
Fisher and Moore have asked to be replaced lo move on to
other responsibilities. They have been replaced by Drs.
Brian Wilcox and Jennifer Manlove. Thus, current PASHA
Panel members are: Drs. Claire Brindis (University of California, San Francisco); Brent Miller (Utah State University); Jennifer Manlove (Child Trends): Freya Sonenstein
(now at Johns Hopkins University); and Brian Wilcox (University of Nebraska).
Delineation of criteria for program effectiveness
At the inception of ihe project, we worked in iterative
fashion with our original Panel lo delineate key criteria for
assessing the effectiveness of adolescent pregnancy prevention programs. We wanled the criteria to reflect both the
scientific rigor of the evaluation as well as salutary impact
on outcome variables that were, per the literature, key behavioral antecedents lo adolescent pregnancy (reflective of
abstinence or of contraceptive use among the sexually active).
In the mid-1990s, the scope of PASHA was enlarged to
include effective adolescent STI/HIV prevention programs,
because these infections were looming as important to public health, and shared many of the risky sexual behaviors
associated with adolescent pregnancy. Once again, Panel
members (now including Dr. Fisher) and project staff
J.J. Card et id. /Journal of Adolescent Health 40 (200?) 275.el-27S.el4
275.C3
Table I
PASHA selection criteria
I. Substantive relevance: We require that a primary or secondary pregnancy prevention program he targeted toward adolescents between the ages of 10
and 19 vears. For STI/IIIVprevention programs, we include programs aimed tit youth between the ages of 10 and 21 years, because lite early college
years are a high-risk period for STIsfor many young adults because of sexual experimentation and multiple partners.
2 Methodologically rigorous scientific evaluation: We define a scientifically rigorous evaluation as one with appropriate design and methods (e.g..
pretest, post-test, and follow-up assessments: random assignment to a control group where feasible) and for which a follow-up assessment occurs at
least 6 months beyond the end of the intervention period for pregnancy prevention programs. (From approximately 19% to 2000, we only required a
.i-month follow-up for STi/tllV prevention programs, as they were more recent and tended toward briefer intervals between immediate post-test and
follow-up assessment, liy the turn of the century, evaluations of STI/lttV prevention programs had developed to the point where Panel members and
project staff felt that the bar for the follow-up period could he raised to be the same as the requirement for the adolescent pregnancy prevention
program: a minimum 6-month follow-up after the end of the intervention delivery I.
} . Positive behavioral impact: We require that evaluation data demonstrate the program's salutary impact on one or more of Ihe following sex-related
behaviors or outcomes for one or more subgroups of 10-19-year-olds (10-21- year-olds for 577///IV prevention progrums). Because PASHA includes
both pregnancy prevention and STI/HIV prevention programs, both fertility- and STI-reluled behaviors and outcomes are included in the criterion list:
• Postponing sexual intercourse
• Decreasing the frequency of sexual intercourse
• Decreasing the number of sexual partners
• Increasing contraceptive use at first intercourse
• Increasing contraceptive use at most recent intercourse
• Increasing consistent contraceptive use among the sexually active
• Increasing use of effective STI-prophyfaclic method at firsi intercourse
• Increasing use of effective STI-prophylactic method at most recent intercourse
• Increasing consistent use of effective STI-pmphylactic method among the sexually active
• Substitution of lower-risk sexual behaviors for high-risk behaviors
• Increasing STI/HIV prevention-related behaviors (i.e.. increased condom purchasing, increased condom carrying)
• Preventing (first or subsequent) pregnancy or parenthood or STI
4 For the youngest adolescents, positive impact on skills, values, and attitudes: For programs aimed primarily at children 15 years or younger,
demonstrated salutary impact on fertility- or STl/IUV-related refusal/negotiation skills, intentions, values and/or altitudes (perception that the above
behaviors are worthwhile and of value) is accepted as preliminary, age-appropriate evidence of effectiveness. These factors, unlike knowledge alone,
have been demonstrated to relate to abstinence and contraception-related behaviors.
worked in iterative fashion lo add lo PASHA's selection
criteria those behaviors found in the literature to be effective
in preventing adolescent STI/HIV.
The criteria used to select programs for the PASHA
collection are given in Table 1 (in the table, italics note the
criteria relevant to the selection of effective STI/HIV prevention programs).
Identification of candidate programs
In assembling candidate programs, we apply one criterion to screen potential candidates for our archive: the
existence of at least one evaluation-related paper or publication documenting, in scientifically acceptable fashion, the
program's success in changing at least one fertility- or
STI-related behavior in adolescents and/or young adults. To
identify candidate program, we annually conduct a systematic and extensive literature review. The process continues
to yield a range of programs developed in a variety of sites,
utilizing a variety of approaches, and including a variety of
components. Because the universe from which PASHA
programs have been culled is restricted to evaluations published in reports, journal articles, or books, it is possible that
other effective programs exist that have not (yet) been
evaluated or that have been evaluated but not written for
publication in reports, journal articles, or books.
Preparation of briefing materials for the candidate
programs
To assist the Panel in making final selection decisions,
we prepare briefing materials for each of the candidate
programs. These materials include a 3-5-page summary
describing both the program content and procedures (rationale, history, schedule, materials) and evaluation methods/
findings, together with a copy of the scientific paper(s) on
which the summary is based.
Selection of promising programs
Members of the Scientist Expert Panel individually assign each candidate program a score ranging from 1 (lowest
priority for PASHA) to 10 (highest priority). In assigning
priority scores, the Panel considers the methodological rigor
and positive impact criteria described above. Is the evaluation study scientifically valid in terms of its design, sampling procedures, follow-up rates, and analytic methods?
What is the magnitude (substantive significance, statistical
significance) and consistency of positive effects? How
many behavioral outcome variables (or skill, values, and
altiludinal outcome variables for programs aimed at children aged 15 years or younger) are affected in a positive
manner? Are there any negative effects?
275.c4
J.J. Card el al. /Journal of Adolescent Health 40 (2007) 275.ci-275.el4
Panel members are instructed that average priority scores
of 7-10 are interpreted as "include in PASHA." Programs
that gamer a median score of 7 or higher (i.e.. a majority
vote to include in the collection) as well as a mean score of
6.6 or higher are included in the target collection.
Acquisition of selected programs
We work with developers or current holders of the selected programs to acquire their program and evaluation
materials for archiving and dissemination by PASHA.
Preparation of PASHA program packages
Each acquired program is packaged in an attractive and
engaging hox (the PASHA "program package" or "replicalion kit") containing everything needed to replicate the
promising program: a complete set of program materials
such as training manuals, curriculum guidebook, facilitator's manual, student workbooks, videos, board games, etc..
along with a User's Guide, prepared by archive staff, describing the program/evaluation packet and providing tips
and guidelines for program implementation. In addition, a
starting point for re-evaluating the promising program is
provided in the form of two accompanying evaluation packets—the original evaluation questionnaire!s) used to assess
the program's effectiveness and a modular Prevention Minimum Evaluation Data Set (PMEDS) that can be used with
most adolescent pregnancy prevention and STI/HIV prevention programs |7.8|. Several PASHA program packages
include training materials for staff, when provided by their
original developers. Free telephone technical assistance on
program implementation is provided by PASHA staff for all
PASHA program packages. For users desiring more intense,
up-front training or on-site technical assistance on program
implementation, a section of the User's Guide points to
where and how these opportunities may be obtained.
Ensuring the quality of the PASHA program packages
Review of PASHA program packages by the original developer.
A review of the PASHA box by the original program
developer is the final task in our development process. After
archive staff finish preparing each PASHA replication kit
and prior to dissemination, we obtain the original program
developer's approval, certifying the accuracy and completeness of the PASHA materials in capturing implementation
details of their effective program.
Field test of the first set of PASHA program packages.
Early in PASHA's lifecycle. when we had completed
development of the first 7 PASHA program packages, a
field test of the 7 packages was conducted at 13 sites around
the country. Sites included a teen health clinic, a Planned
Parenthood affiliate, a County hospital, an AIDS service
organization, a juvenile rehabilitation facility, a County
Health Department, and several high schools in the South,
Midwest, West, and Northeast. Field lest sites volunteered
to implement one PASHA program that they believed
would be a good lit with their school, organization, or clinic,
using the PASHA program package to implement the program. A requirement was that the field test site's first encounter with the program be from the PASHA program
package. The field test sought to answer two questions: (I)
Can programs be "packaged" in a format readily usable by
new sites wishing to implement the program? (2) Would
these programs, found effective at one lime and place,
remain effective when replicated in new settings, and under
different conditions? Detailed information on field test
methods and findings is provided in a monograph published
in 1998 [91.
Results
PASHA's effective program list
Over the last 15 years, we have presented 92 adolescent
pregnancy and STI/HIV prevention programs to our Scientist Expert Panel as candidates for inclusion in PASHA. Of
these. 56 programs have been selected for the PASHA
collection by its Scientist Expert Panel, based on the
strength of the evidence for their effectiveness. The 56
selected programs are described succinctly in Table 2.
The diversity of effective programs is also highlighted in
Table 2. There are 21 primary pregnancy prevention. 6
secondary pregnancy prevention programs, and 26 STI/HIV
prevention programs. In addition, there are three programs
with the explicit dual focus of preventing both adolescent
pregnancy and STI/HIV. Twenty-six programs have been
developed for use in schools; 23 of the programs are community-based, and 13 have been developed for delivery in
clinics. Eight dual-site programs are also included. In addition, many programs developed and proved effective in only
one type of setting (e.g.. schools) are also suitable for use in
other settings (e.g., community-based organizations), according to their developers.
The geographic and social diversity of effective prograins is also shown as we examine demographic profiles of
programs and participants. Such programs have been developed in all parts of the country, often in multiple locations,
with samples as small as 57 participants and as large as
4000. Similarly, the age range of participants is wide, encompassing early, middle, and late adolescence and early
adulthood. Only a few programs target a specific age group.
For example. Draw the Line/Respect the Line encourages
students as young as the 5th grade to postpone sexual
intercourse: at the other end of the age range, the Safer Sex
Efficacy Workshop teaches the basics of HIV transmission
and prevention to college students in their dorms. Most
programs in the collection are suitable for use with youth
from a range of ages.
Tabic 2
Programs selected by ;t scientist expert panel fur the Program Archive on Sexuality, Health and Adolescence (PASHA)
Program tide
Program
ivpc
Original
site
Aban Aya Youth Project:
High Risk Behaviors
Prevention Program for
African American Youth in
Middle School
Abstinence ami Safer-Sex
IIIV Risk Reduction
Interventions Tor African
American Adolescents
Adolescent Compliance in the
Use of Oral Contraceptives
Adolescents Living Safely:
PPP
School
PPP
No.
Participants
Age (years)
Sex
Racc/Filuiiciry
Geographic
protilc
668
avg.
50,5'* F
100'* AA
Urban
School
ft5"
11-16
M - F
KXF.t AA
Urban
PPP
Clinic
57
I-I-1'J
ION'S F
4 * \V. % q A A
li'i ban
SUA
Community
78
11-18. avg.
8 * W. 6.1* AA.
2 2 * L. 7 * O
Urban
SUA
Community
I.18
100'* M
12'* W. 3 1 *
A A. 519 L.
6* O
PPP
School
211
58* M
SUA
Clinic
SUA
School
10.8
AIDS Awareness. Altitudes
and Actions
Adolescents Living Safely:
I ft 3 6 * M.
64* F
4-19. avg. = 17
AIDS Awareness. Altitudes
and Actions for Gay.
I .esbiitn & Bisexual Teens
Adult Identity Mentoring
(Project A i M )
AIDS Prevention and Health
Promotion among Women
AIDS Prevention lor
Adolescents in School
AIDS Risk Reduction
Fducalion and Skills
Training Program
(ARRFST)
AIDS Risk Reduction for
College Students
SUA
Coiinnuniiv
SUA
School
20ft young
women
1.201
87
744
12-U
16-29. avg.
21
100'* F
12-20, avg.
Id
4 2 * M.
12-16. avc. = 14
av». = 20
58* V
4 5 * M.
55* F
4 9 * M.
SI* F
Other
characteristic;*
Low income
Panel scores'1
" '
Mean
Median
.Status
7.75
Avail
PASHA
8.5
9.2
10.0
8.4
9.0
Not Avail
High risK
K.2
s.o
Avail
PASHA
Urban
High risk
7.0
7.0
Avail
PASHA
100* AA
Subuiban
7.0
6,(1
Pending
4 0 * W. 5 7 *
AA. 3 * O
.17* AA. 3 5 * I.
28* W t A
4 1 * A A. 5 9 * 1.
Urban
School on
academic
probation
Low-income
sample
K.2
80
8.8
9.0
7.2
7.0
Avail
PASHA
Avail
PASHA
Avail
PASHA
8.5
X.5
8 8 * W. 3 * AA.
4 * L. 4 * A
Urban
Urban
N/A
High risk
Avail
Other
Avail
PASHA
ss
0
Tabic 2
Continued
Projjram title
Program
type
Original
site
ASSESS: For Adolescent
SUA
Clinic
Community
Age I vcars)
Sex
Rncc/Fthnicity
(icojrrupluc
profile
215
12-15
M * F
157
avg. = 15
KKl'-i M
fiS'J A A . I'Kf
\V. 7'r L. 13%
O
I00« A A
14-18
M * F
100% A A
MIO
13-15
M * F
75
13-21
100% F
60% A A . 411% L
or 0
48<tf W. 52%
AA
Mid-si/cd
city
Urban
No.
Participants
Risk Reduction
He ProudlBe Responsible!
SUA
Becoming A Responsible
SUA
Commumiy
Teen (B.A.K.T.)
Children's Aid
Sociely/Carreru Program
A Clinic-Based AIDS
Community
mil sj>ccilicd
PPF
Clinic
SUA
Oilier
characteristics
Panel scores'
"
~
Mean
Median
Status
Uthan
7.4
8.0
Avail
PASHA
Urban
88
9.0
9.3
9.0
"2
9.0
No
information
ft.S
7.0
Avail
Other
Avail
Other
Avail
Other
Avail
PASHA
Urban
8.5
9.5
Avail
PASHA
7.X
R.O
Avail
Other
7.4
7.0
Avail
PASHA
7.6
8.0
Avail
Low income
Rdttcnlion P r o g r a m for
Female Adolescents
D r a w the Line/Respect the
School
2K2<>
av g .
11
47'-? < 19
100% F
59.3% L. 15.9*
A, 163*3. W.
5.2% AA.
3.1% O
88% W
< 19
100% F
97% A A . 3% W
Small city in
rural
region
Urban
9-15
M + F
11)0% A A
Urban
PPJ1
Nearly equal
M-F
Line
Flmiia Nurse Home Visiting
Proliant
SPP
Family Growth Center A
Community-Based Social
Support Program for Teen
Mothers and Their Families
SPP
Focus on Kids: An
Adolescent HIV Risk
Prevention Program
FOCUS: Preventing STls &
Unintended Pregnancies
among Young Women
Get Real about AIDS
SNA
Health Care Program for
First-Time Adolescent
Mothers and their Infants
Clinic.
401) Women
community
and their
infants
Common:ly ft 3 First-lime
leen
mothers
and their
infants
Community
383
Many low
income
PASHA
SUA
SHA
SPP
Community
School
Clinic
2157
2X4"
243 Teens
and their
infants
90% < 22
avg. = 15
< 17
IOO'« F
5 1 % M.
49% F
I00S F
5fi% W . 19.7%
L. In.1% A A.
8% O
65% W . 6% AA.
21% L. 3% A.
5-2 O
100% A A
Military base
7.25
7.5
Avail
PASHA
Rural. U I I I J I I .
6.8
7.0
Avail
PASHA
7.2
7.0
Avail
PASHA
stiburbau
Uiban
Table 2
Continued
Program liik*
Program
lypc
Original
silo
Human Sexuality-Values A
Chokes: A Valucs-Hasccl
Curriculiuii for 7 ,h and 8"'
Grades
Information-Molivaiimilichavioral Skills HIV
Prevail ion Program
PPP
School
657
SUA
School
1577
Kccpin" li R.F..A.L. A
Molhcr-Adnlcsccnl IIIV
Prevention Program
McMnslcr Teen Program
SUA
Coinmnniiv
PPP
School
.1374
Memphis Nurse Home
Visitation
SPP
Community.
clinic
Multieomponciit School
Community Mwlel I'm
Preveittini! Adolescent
Pregnancy
Foder Latino: A Community
AIDS Prevention I'jojjram
PPP
Communit v
11.19 Mothers
and their
infants
1714
SUA.
PPP
Community
PPP
School
582
PPP
School
SUA
for Inner-City Latino Voiilli
Postponing Sexual Intercourse
Among Urban Junior High
Students
Postponing Sexual
Involvement
Project Aware: Tailored
Minimal Sell-Help
hitrrvcniinn l<> Promote
Condom Use in Voting
Women
Project T A K I N G CHARGH
Qaanltnn Opportunities
Program
No.
Participants
582
58ft
Age <years)
Sex
Ruce/Etlmicity
Geographic
prolilc
Oilier
chaiaclcrislics
Panel scores''
Siaius
Mean
Median
Rural, urban,
and
suburban
7.5
7.5
Avail
PASHA
Urban
7.4
8.0
Avail
PASHA
12-14
48'* M,
52% V
avg. = 14.8
UVA F. .17'*
M
11-14
60% M
97.9% AA
Urban
7.0
7.0
iYndhij!
M + 1-
Predominantly \V
Urban
7.(1
7.0
avg. = 18
100W F
92% AA. 8tf 0
Urban
8.5
9.0
Avail
Othe
Avail
Othe
14-17
M * F
No information
Rural,
suburban,
urban
7.8
8.0
Not Avail
14-20
M * F
I00« I.
Urban
8.0
8.0
Avail
Id
62% W. 19*
AA. lOW U
VA 0
fil<sf
AA. 28% L.
11%WorO
High risk
PASHA
avg. = 12.8
523 F
84</f AA. \W
1(305
13-15
M i F
Clinic
1210
18-24
PPP
School
136
PPP
School,
125
community
Urban
Low income
7.0
7.0
Noi Avail
99% AA
Urban
Low-income
sample
8.8
9.0
100% F
6"% W . 19%
A A. 12% O
Urban
7.25
7.0
Avail
Oilier
Pending
12-1.1
50% M .
50Cf F
No
information
ft.ft
7.0
Avail
PASHA
1.1-17
M
6.1% W. 29%
A A. 4 t f l _ 4 « 3
O
7 6 ^ A A. I.W
W. WX H. A
orO
8.0
Avail
PAS MA
t F
L
Urban
Low-income
sample
8
Tabic 2
Continued
Program title
Program
type
Original
site
No.
Participants
Ace (yours)
Sex
Rucc/Ethnicity
Geographic
profile
Other
characteristics
Panel stores''
Status
Mean
Median
7.fi
8.0
Avail
PASHA
< 20
lOOCf F
No Information
Urban
13-15
52.8Cf F
79«? A A, I f t * L
Urban
7.4
8.0
Avail
PASHA
avg. = 15
M
-t- r-"
6 K f W. 2'* A A .
2 1 * L. WX A.
8.8
8.5
Avail
PASHA
1195
15-18
1003 M
8.4
S.t)
MO
16-18
KXKf M
7.2
7.0
School
-l(K)l
12—IK
M * F
Hi hail
74
7.(1
Avail
PASHA
Avail
PASHA
Avail
Other
SUA.
PPP
School
3SM)
14-15
5.TO F
Urban.
suburban
6.6
7.0
Avail
PASHA
Surer Sex Efficacy Workshop
SUA
School
20V
avg. = 22
N/A
8.0
8.0
School/Community Program
for Sexual Risk Reduction
among Teens
PPP
School,
NA
community
NA
Wr M.
Wl</c V
M +• V
<iVA W, 5tf AA.
4 ' * A. 1 * 0
33r.f W, 64Cf
A A . VI O
Wi A A . \m L.
2 0 * W, 14</;
0
3 i t f W. TM L.
18% A. 17%
A A. 8 * 0
82* W
Rural, mhan,
and
suburban
Urban
8.0
8.0
School-Based Intervention
Program for Adolescent
Mothers
School-Linked Reproductive
Health Services (The Self
Center)
SPP
School
avg. = 17
Low-income,
high teen
pregnancy
rate
Low-income
community
Avail
PASHA
Avail
PASHA
7.0
8.(1
Not Avail
I'PP
School.
clinic
Low-income
sample.
high teen
pregnancy
88
8.5
Avail
PASHA
Seattle Social Development
Program
PPP
School
StilLls: Health Workshops lor
Young Black Women
Slay Hcallhy/Acl Safe: An
Intervention for Youths
Living with AIDS
SUA
Community
SUA
Clinic
Queens Hospital Center's
Teenage Program
SPP
Clinic
4<)8 Teens
iiml their
infants
1157
Reach fur Health: A School
Sponsored Youth Service
lmcr\ enlion for Middle
Seliool Students
Reducing the Risk
PPP
School.
community
PPP.
SUA
School
758
Reproductive Health
Counseling for Young Men
Riker's Health Advoeaev
Program <RHAPI
PPP
Clinic
SUA
Community
Rochester AIDS Prevention
Program (RAPP)
SUA
Safer Choices
m 0
Urban
Low-income
sample
High risk
42% W. 58';*
AA
Rural
BMW F
mow A A
Urban
12—IS
M r F
MO* A A
Urban
10-12
M * E:
Uibati
8.6
9.0
Avail
Other
522
14-18
l<UK» F
44% \V. 26%
AA. 2 2 * A
8 * 0.
HXK3 A A
Urban
7.75
8.5
310
13-24
7 2 * M.
28%. F
2 7 * A A . 37% 1.
Uihan
7()
8.(1
Avail
PASHA
Avail
Other
102
httrollmcni in
schools
varied over
program
643
8 8 * (lay or
hisc.Miid
Tabic 2
Continued
Program
type
Original
site
No.
Participants
Ase tvcais)
Tailoring Family Planning
Services to Meet the
Special Needs of
Adolescents: New
Adolescent Approach
Protocols
Teen Health Project: HIV
Prevention fur Adolescents
PI*P
Clinic
I2M
15-17
SUA
Community
1172
12-17
Teen Ouireaeh
PPP
School
Teen Talk
PPP
Whai Could You Do'!
Interactive Video
Intervention lo Reduce
Adolescent Females' STD
Risk
Women's Heullli Project:
HIV/STD Risk Reduction
for African American and
Latino Adolescent Girls
Youth AIDS Prevention
Project (YAPP)
Program lillc
Sex
I HO* F
M-F
Race/Uihniciiv
Geographic
profile
Other
characteristics
Low-income,
high risk
Panel scores'*
Stains
Mean
Median
7.8
X.(l
Avail
PA.SU A
I * W. 9 X * AA.
lf* O
No
information
51'? A A. 2 0 *
A. 3 * L. 5 9
\V. 21'.? O
41* W . «
AA. 1 3 * L,
Urban.
suburb tin
8.4
9.0
Pending
Nn
information
7.7
8.5
Avail
Other
Rural and
urban
8.0
8.0
Avail
PASHA
7.0
7.0
Avail
PASHA
9.0
Peiidiii"
ll-2l.avg. = 15
25*. M.
75* F
School.
14-14
community
13-19
M - F
\yi VV. 2 4 *
AA. 5 3 * L.
SHA
Community.
Clinic
.KM)
I4-1K
100* F
75f? A A. 1 5 *
W. 1(1* o
Urban
SHA
Clinic
682
avg. = 15.5
100* F
08* AA. 32* L
Urban
SUA
School
1.154
12-M
4 8 * M.
52* F
Urban
High risk
7.0
7.0
Avail
PASHA
SHA
Community
139
13-21
1(H)* M
2.VJ W. 5 6 *
AA. \TA L.
5* 0
7 5 * W. 1 4 *
AA. 3 * L. 4 *
A. 3 * O
No
itUoi matioti
High risk
7.11
7.0
Avail
PASHA
985
m O
m 0
Youth and AIDS Project's
HIV Prevention Program
PPP = Primary pregnancy prevention: SPP = Secondary pregnancy prevention: SUA = ST1/H1V/A1DS prevention: School = School-based program: Community = Community-based program: Clinic
Clinic-hascd program: W - White: AA African American; I. Latino; A - Asian; O • Other: Avail PASHA - Currently available through PASHA: Avail Other - Available elsewhere: Pending
= Pending acquisition or processing by PASHA; Not Avail -- Not publicully available.
•' Panel members were asked to rate candidate programs from I (lowest priority for PASHA) to 10 {highest priority). They were informed that a scute of 7 or higher would be interpreted as "Include
in PASHA."
275 e 10
J.J. Cant et ul. /Journal of Adok•strut Health 40 (2007l
275.el-275.el4
Tabic 3
Usage Figures for ihi; PASHA Collection
Internet usage
Visits lo Sociometrics websiie
Hits lo all PASHA pases
Downloads of PASHA-related products
Number of PASHA units .shipped
Total. 1996 2000
2001
2002
2003
2004
2005
Total. 2001-2005
Not Avail
Not Avail
Not Avail
1.478
136.598
21.026
2.533
355
145.237
22.144
4.433
112
175.984
32.364
7.305
199
182.528
44.996
7.086
111
253.636
64.574
8.195
135
893,983
185.104
29.552
912
Table 2 also indicates that effective programs have paid
particular attention lo teens demonstrated to he at greatest
risk for teen pregnancy. Fourteen of the 56 programs—
including 7 of the 21 primary pregnancy prevention programs. 3 of the 6 secondary pregnancy prevention programs, and 4 of the 26 STI/HIV prevention programs—
target adolescents in low-income communities, where rales
of adolescent pregnancy and STIs are often elevated.
Among the effective STI/HIV prevention programs, there
are programs that have been designed to meet the particular
needs of gay. bisexual, incarcerated, and runaway youth, all
of whom have elevated risk. Additionally, there ate programs that use culturally sensitive materials to appeal to one
or more minority or ethnic groups, particularly in urban
settings, including Latinos and African Americans.
The PASHA effective-program list given in Table 2
overlaps significantly with lists developed by researchers
independent of PASHA [2-5|. Differences in the lists are
accounted for by program selection criteria (including program goals, prevention approach, and age of target population) and evaluation criteria (including evaluation design,
length of follow-up. and sample size) |5J.
As the last column of Table 2 shows, replication kits for
35 of the 56 programs selected as "effective" by PASHA's
Scientist Expert Panel are currently available ihrough
PASHA (www.socio.com/pasha.htm). We are working with
five developers lo acquire and process their programs for
PASHA. Twelve programs selected by ihe PASHA Scientist Expert Panel as effective are publicly available from
either the original program developer and/or another publisher. This means that of the 56 programs selected as
effective by the PASHA Scientist Expert Panel, only 4 are
not publicly available. The public access to effective programs facilitated by PASHA—not only via general descriptions in a report, journal article, or book (as was the staleof-the-art prior to PASHA's inception) but also via program
packages containing all the materials needed lo replicate the
original program—has been helpful to dissemination of
programs that work, especially to practitioners working on
the front line to lower adolescent pregnancy, birth, and
STI/HIV rates in this country.
PASHA usage
Table 3 gives usage figures for PASHA-relaled products, including publications, program evaluation instru-
ments, user's guides, and replication kits. We include
information for available time periods: 2001-2005 for
Internet usage and 1996-2005 for orders of PASHArelated products shipped by traditional means (mail, UPS,
FedEx) to the customer. From 2001 to 2005. there were
893.983 visits to the Sociometrics web site. These visits
resulted in 185.104 hits to PASHA web pages and 29,552
downloads of PASHA products. Examination of visits,
hits, and downloads over the 5-year period for which data
are available shows that, not surprisingly. Internet usage
trend is up. as more and more practitioners and researchers become comfortable with internet browsing and ordering. In ihe 5-year period from 1996 lo 2000. 1478
PASHA-relaled products were shipped lo customers: this
number was down lo 912 in the next 5-year period (20012005), as downloading replaced traditional methods of
obtaining PASHA-relaled products (user's guides, evaluation instruments). All PASHA program materials have
now been digitized and we are in the process of adding
such materials to the PASHA websiie. The availability of
complete effective-program replication kits in digitized
format should spur even more dissemination of PASHA
products, consistent with the increasing trend in download figures.
PASHA content
Tables 4 and 5 provide a content analysis of the 35
program packages currently in the PASHA collection.
PASHA programs' abstinence and contraception dosage.
We looked at the abstinence and contraception content of
the 30 PASHA programs covering a specific curriculum or
protocol (5 of the 35 PASHA programs are more generic
community- or clinic- based programs that are meant lo be
flexible in adapting to the needs and values of an entire
community; specific hours spent on abslinence/contraception are not prescribed in program materials). Table 4 shows
that 19 of the 30 programs have abstinence-related content
ranging from .2 to 5.75 delivery hours: 28 of the 30 programs have contraception (especially condom-related) content ranging from .1 to 13 delivery hours. For 7 of the 30
PASHA programs, the abstinence education dosage is more
than the contraception/condom education dosage; the reverse is true for 21 of the 30 programs. Two of the 30
PASHA programs are abstinence-only (no contraception
J.J. Card el at. /Journal of Adolescent Jh'tdlh 40 (2007)
275.cl-275.vN
275.cH
Tabic 4
PASHA programs" abstinence and contraception dosage
Toliil program dosage
Abstinence dosjgc
Contraception dosage
Sessions
Hours
Activities
Aciivitie.s
I lours
1. Abitn Ayu Youth Project: High Risk Behaviors
Prevention Program for Atrium American Youth in
Middle School
2. Adolescents Living Safely: AIDS Awareness. Attitudes
and Actions
3. Adolescents Living Safely: AIDS Awareness. Attitudes
and Actions for Cay. Lesbian & Bisexual Teens
4. AIDS Prevention and Health Promotion among
Women
5. AIDS Prevention lor Adolescents in School
6. AIDS Risk Reduction Education ami Skills Training
Program (ARREST)
7. AIDS Risk Reduction tor College Students
8. ASSESS: For Adolescent Risk Reduction
9. A Clmic-liused AIDS Education Program for Female
Adolescents
10. Draw the Line/Respect the Line
11. Family Growth Center: A Community-Based Social
Support Program for Teen Mothers and Their Families
12. Focus on Kids: An Adolescent HIV Risk Prevention
Program
13. FOCI'S: Preventing STis & Unintended Pregnancies
among Youth Women
71
37
23
21
31.5-42
3
35
14
II)
25
37-50
0
1)
2(J-
13-
6-8
1
-i
y
1.1
6
4.5
3
2
1.6
.5
8
7
3.5
2.5
3
0
1
1
<l
1
0
1
0
PASHA program reference number anil name
4
fi
3
19
N/A
14-16
N/A
E lours
0
<l
0
12
1
i
44
<\
1
16
4.4
3
0.9
8
12
4
1
8
2.5
4
8
0
0
13
4.1
14. C.ct Real about AIDS®
14
15. Health Care Program lor First-Time Adolescent
Mothers and their Infants
16. Human Sexuality - Values & Choices: A Values-Based
Curriculum for 7tli and 8th (trades
17. Inform.ilioii-Motivatiim-Beliavioral Skills HIV
Prevention Program
li-
14
1 »
II
0
5.5
0
8
I
3.5
1-r
IS
13
8
1.8
1
0.1
2
.5
7
2.3
18. Pinter Latino: A Community AIDS Prevention
Program for Inner-City Latino Youth
21-2*5
84
19.
20.
21.
22.
27
N/A
N/A
32
20.25
>75t)
N/A
32
16
1
4
12
1.5
4
20
I
N/A
15
3
N/A
N/A
N/A
4
3
8
1+
0
0
6
1
12-14
<1
T
15
10-11
4
23.
24.
25.
26.
27.
28.
2".
30.
31.
32.
33.
34.
35.
Project TAKING CHARGE
Quantum Opportunities Program
Queens Hospital Center's Teenage Program
Reach for Health: A School Sponsored Community
Youth Service Intervention for Middle School Students
Reducing the Risk
Reproductive Health Counseling for Young Men
Rikers Health Advocacy Program (RHAP)
Safer Choices
Safer Sex Efficacy Workshop
School/Community Program lor Sexual Risk Reduction
among Teens
School-Linked Reproductive Health Services (The Self
Center!
SiHLE: Health Workshops for Young Black Women
Tailoring Family Planning Services to Meet the
Special Needs of Adolescents: New Adolescent
Approach Protocols
Teen Talk
What Could You Do? Interactive Video Intervention to
Reduce Adolescent Females' STD Risk
Youth AIDS Prevention Project (YAPP)
Youth and AIDS Project's HIV Prevention Program
4
i
2.5
0
0
4*
4~
15
4.75-5
0
0
21
5.75
U
0
14
1
0
13
0
3:8-5.3
.5
0
17
3.3
0
3
15
6
5-6.3
1
1
3.25
2.5
0
0
21
3
4.5
0.75
1
1
<l
5
1
1
0
0
.25
i
7
2
6
<l
1.5
2.5
N/A menus that these programs do not outline specific curricular lessons, in.slcad they are general community- or clinic based programs that are tailored
by the user to the needs and values of a particular community Specilic hours spent on abstinence/contraception are not prescribed in program materials.
275.cl2
J.J. Cunt vl ul. /Jotinutl t>( Adolfsunt Ilvnlilt 40 (2007) 275 vl 275x14
Table 5
PASHA programs' abstinence and contraception content, by pedagogical technique employed
Cieneral topical locus
Abstinence
Contraception
Specilic topical locus
Refusal skills
Resisting peer pressure
Negotiating abstinence
Risks of becoming sexually active
Alternatives to intercourse
Struggling with abstinence
Parent-child communication
Non-verbal communication
Communicating with friends and
family about abstinence
Relationships and dating
Identifying values
Media influences
Comfort discussing condoms
Negotiating condom use with partner
Pedagogical technique
PASHA programs using role play
PASHA programs using group discussion
1.2. 3. 5. 10. 12. 14.
16. 19. ! l . 26
10. 19. 22
1.4. f>. 7. 12. 14. 22.
23. 26, 34
10. 14. 17. 23
12. 15
1. 10. 14. 23.26, 34
I. 2. 3. 5. 10. 12. 14. 16. 19. 22. 26. 32. 34
I. 10. 19. 22
1.23
1. 2. 5. 10. 16. 23
1.23
1.6. 10. 14
1.6. 7. 12. 14. 22. 23. 26
1. 10. 12. 14. 16. 17. 22.23. 26
I. 10. 12. 16.34
1.5, 10. 14. 17. 23. 26. 34
I. 10. 14. 19. 28
1.5. 10. 16.22. 23
Non-verbal communication
Risk reduction strategies
Risks assessment
Risk continuum
Barriers to condom use
1. 30
2 3. 34
t 3. 13. 30
2. 3. 5. 13. 14. 23. 26. 27. 34
I.6. U). 14. 19. 22
.
1..S. 14. 16. 19. 26. 18
:. 2S
1. ->2
"1 3, 5. 7. 14. 17. 23,25
1. > 3. 4. 5. 6. 7. 12. 13. 14. n'. 18. 2?!,
25. 26. 27. 30. 32
4. 5.6. 7. 14. 17. 23. 26. 32
10. 12.
1 13.14, 17. 23
1.i 3. 4. 5. 6. 7. 8.
24.26.27. 31.34. 35
7
2 3, 30. 34
2, 3. 5. 13. 17. 26. 2'7. 3(1i. 34
?. 3,6. 10. 27. 30
2_ 3. 5.6. 7. 13. 14.16.:!3. 25.26. 27. 30.
Effect of drug/alcohol use on
condom use
Relationships and dating
STD fads
Values
General contraception information
2. 3. 6. Hi. 34
2 3.6. 7. 18. 30. 34
Comfort obtaining condoms
Proper use of condoms
1. 2. 3. 4.5.6.7. 12. 13. 14. 18.23.
26. 27. 32. 34. 35
4. 5. 6. 7. 32
i 3.4. 6.7. |(). 12.
13. 17.26. 27. 30
31 . 34
content), and 11 programs arc contraception-only (no abstinence content): the majority (17 programs I have both abstinence as well as contraception content.
P:\SHA programs' pedagogical techniques.
Many different pedagogical techniques are represented
in the PASHA collection, including case management,
group discussion, lectures, peer counseling/instruction, public service announcements, role plays, and videos. The most
commonly used pedagogical techniques have been role play
and group discussion. Table 5 shows PASHA programs'
abstinence and contraception/condom content, by these two
most commonly used pedagogical techniques.
In Table 5. the programs covering various abstinence and
contraception topics are represented by program numbers.
The program titles corresponding to each of these program
numbers can be found in Table 4. Popular abstinencerelated topics—covered in 7 or more PASHA programs—
are: Refusal Skills (covered by 14 programs). Negotiating
Abstinence (10 programs). Risks of Becoming Sexually
Active (9 programs). Struggling with Abstinence (8 programs). Communicating with Friends and Family about
Abstinence (7 programs), and Identifying Values (7 pro-
2. 3. 6. 7. 14. 30. 34
I. 2.3. 5. 7 . 9 . 19. 30
30
I. 12. 13. 16.23. 24.26. 28. 31.32
grams). Popular contraception-related topics are: Proper
Use of Condoms (21 programs). Negotiating Condom Use
with Partner (20 programs). Barriers to Condom Use (15 programs). General Contraception Information (10 programs).
Comfort Obtaining Condoms (9 programs). Risks Assessment
(9 programs). Comfort Discussing Condoms (8 programs). ST1
Facts (8 programs). Effect of Drug/Alcohol Use on Condom
Use (7 programs), and Relationships and Dating (7 programs).
Discussion
Our experience with development and use of the PASHA
resource over the past 15 years provides helpful lessons for
resource developers (researchers) and consumers (practitioners) alike.
Developing a PASHA-like resource
The resource-development methods described in this paper arc applicable to other fields. For example. PASHA has
beeii used as the model for establishing a collection of
effective adult H1V/A1DS prevention programs [I2.13| as
well as a collection of effective youth substance abuse
J.J. Card vi ul. /Journal of Adolescent lleuhh -40 t2W)7i 275.el-275.eN
prevention programs (I3|. Another collection modeled after
PASHA, on effective treatments for children's emotional
disorders, is being assembled, showing that the methodology for establishing PASHA can be used for both prevention and treatment interventions.
The following are required: (1) a field in which the
scientific base is sufficiently developed such that a critical
mass of intervention programs has been documented as
effective in preventing a particular disorder, disease, or
social problem; in treating the problem; or in ameliorating
the problem's negative consequences; (2) a group of scientists who are leaders in the field, preferably reflecting multiple disciplines and diverse perspectives on the problem,
who are willing to serve as members of the resource's
Scientist Expert Panel (developing selection criteria for effective programs and actually selecting the programs to
include in the resource!; and (3) cooperative program developers who are willing to share their program that worked
with the outside world, provide implementation tips gleaned
from their own experiences with program implementation, and who welcome widespread dissemination of their
work.
Using PASHA
How can adolescent pregnancy and STI/H1V prevention
professionals working in schools, clinics, and communitybased organizations use the PASHA resource in their work?
What remaining challenges await users of the PASHA program packages?
The National Campaign to Prevent Teen Pregnancy has
just published a pamphlet entitled What Works: CurriculumBased Programs That Prevent Teen Pregnancy |6). Here is
what the brochure says about how to choose a teen pregnancy prevention program:
• "Best choice: choose a program already shown
through careful evaluation to be effective with similar
groups of adolescents, and then put it into action as it
was designed—no changes, no additions or deletions.
• Next best choice: If using an existing successful program is not possible, communities should select or
design programs that incorporate as many characteristics of effective programs as possible .. ."
The PASHA program packages can be used in these two
ways to attempt to change teen sexual behavior. Schools,
clinics, and communities can choose from among 35 replication kits those best suited to their local goals, norms, and
target population. The field test of the early PASHA program packages | 9 | found them to be usable "as is." with no
extraneous training needed, for purposes of replicating an
effective program "as it was designed—no changes, no
additions or deletions." It was the case, however, that several PASHA field lest sites did decide to diverge from the
curriculum in the PASHA replication kit for reasons such as
275.L-I3
stakeholders' objections to program content, instructors'
perceptions of needs of their particular group of teens (the
teens* knowledge base, whai it look to keep them interested
and engaged, shortage of deliver) lime when the teens did
become extremely engaged). Sites also faced challenges
recruiting and retaining participants for the accompanying
evaluation and, in the end. sample si/cs were loo small to
yield any definitive findings about whether the PASHA
programs continued to be effective in the new siies. However, there was suggestive evidence that the programs were
more successful in impacting the pregnancy prevention outcomes than the ST1/HIV prevention outcomes |9).
The field test experience supports the assertion that
PASHA replication kits continue to be useful for what the
National Campaign to Prevent Teen Pregnancy calls "next
best choice" {to total fidelity to an effective program). Tables -4 and 5 present the PASHA programs from several
different content perspectives: dosage (Table 4). abstinence
and contraception-related topical content, as well as pedagogical technique used to teach such content (Table 5).
Adolescent pregnancy and ST1/HIV prevention practitioners can select PASHA programs with content or pedagogical components serving their program's goals and desired
approach and use/adapt the component(s) of interest. While
this is not the best choice of using an effective program "as
is." it is the next best choice of incorporating as many
characteristics and components of effective programs as
possible ((>].
Conclusions
The Program Archive on Sexuality. Health, and Adolescence (PASHA) is a growing, an antrmnt national resource
that exemplifies the successful translation of research findings for use in the real world of education and practice.
PASHA identifies intervention programs that research has
shown to be effective in preventing adolescent pregnancy,
STI/HIV. or their risky sexual behavior antecedents.
PASHA provides schools, communities, and clinics around
the country with easy access lo replication kits for these
programs. PASHA users then "put what works to work" in
the prevention of adolescent pregnancy and STI/HIV. While
there is no guarantee that what works in one site will be
effective in another, and while the magnitude of effeci or
impact of a single program is undoubtedly limited. PASHA
provides many starting points for science-based activity in
the world of practice.
Acknowledgments
This work was funded by National Institute of Child
Health and Human Development Contract N01-HD-4-3387
(Dr. Card). The authors thank Project Officer Susan Newcomer. Ph.D.. for her unfailing support or PASHA throughout the years.
r75.cN
JJ. Curd el id. /Jvurihd of Adt>h\tcui llitttth 40 (2W7\
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