Postponing Sexual Involvement

In Cincinnati, PSI is run as a partnership between Cincinnati Children's Hospital Medical Center (CCHMC) and the Cincinnati Public Schools (CPS). PSI is one of several community health education programs of CCHMC's Division of Adolescent Medicine, and affiliated with the Adolescent Health Center of Greater Cincinnati, Inc. The program is overseen by Christopher Kraus, JD, MTS, Adolescent Advocacy Manager, and Paula Braverman, MD, Director of Community Programs. Five professional staff members deliver the program, along with student interns and Americorps community service fellows.

Cincinnati PSI also operates PSI PAYOFFSM, a community outreach, training and consultation service for school districts and community groups outside of CPS. PSI PAYOFFSM has helped establish PSI teen leadership programs in the tri-state area, and around the country, including Washington DC, Harlem NY, Rochester NY, Corpus Christi TX, Richmond VA, Williston ND, Ft. Smith AK, Columbus OH, Milford OH, Highland County OH, New Miami Schools in Hamilton, OH, St. Bernard-Elmwood Place Schools, OH and Kentucky Department of Health.

Q. How is PSI places in the school curriculum?

This depends on whether the school building has a discrete health class, or an integrative approach where health topics are introduced into the science or language arts curriculum. Both scenarios apply in the 12 school buildings that hosted PSI in 2007-08. The most popular grades for PSI are 6th and 7th.

However, a significant number of 5th and 8th grade teachers host PSI. In each class, the teacher is responsible for teaching basic sexuality information about human anatomy, reproduction, family planning, pregnancy, and sexually transmitted infections. A pair of PSI Teen Leaders and a PSI Adult Leader teach PSI once a week over a six-week period. Teacher training is provided through workshops, orientation sessions, and follow-up support from CCHMC.

Q. Does PSI teach abstinence?

Yes. Don't get caught up in the politics of sex education. Public rhetoric about sex education describes a subtle distinction between "Abstinence Only" and "Abstinence-Based" curricula. Sometimes a distinction is made between "Abstinence Until Marriage" curricula and "Comprehensive Sex Education." The political jargon describes the moral philosophies of program sponsors, as well as the extent to which written curricula and human instructors emphasize abstinence and de-emphasize protection. Certain government grants require adherence to the federal definition of "abstinence only" education. Cincinnati PSI reflects the policies of its sponsors and funders: Cincinnati Children's Hospital, City of Cincinnati, Cincinnati Public School District, the United Way of Greater Cincinnati, and The Rudi Johnson Foundation. PSI takes a medical, social and emotional perspective that emphasizes to young teens that they should postpone sex until they are mature enough to handle the consequences. PSI curricula and instructors discuss marriage as a societal ideal that sometimes does not comport with participants' reality. PSI discusses protection as a way to reduce but not eliminate the risks of sex. PSI adheres to a philosophy of comprehensive sex education.

Q. How is PSI financed in Cincinnati?

PSI has been funded by a variety of private and public foundations. FY 08 revenue supported a program that reached 965 students, and a consultation service that assists other school districts and community groups in implementing a PSI peer-led program. FY 08 funding included the local United Way of Greater Cincinnati (39% of PSI revenue), Adolescent Health Center of Greater Cincinnati, Inc (30%), The City of Cincinnati (10%), 12 Cincinnati Public School buildings primarily through federal Safe & Drug Free Schools grants, The Rudi Johnson Foundation, ReZoom.com and individual donors. There are significant in-kind contributions from Cincinnati Children's Hospital, and Cincinnati Public Schools. Contributors in FY 09 include the The City of Cincinnati, United Way, and Cincinnati Public School buildings that have directed some of their general funds or federal Safe and Drug-Free Schools funds towards PSI.

Historically, over 90 foundations have supported PSI during its eighteen years, including the Adolescent Health Center of Greater Cincinnati, the Cincinnati Public Schools, Health Foundation of Greater Cincinnati, Ohio Wellness Block Grants, Greater Cincinnati Foundation, and many more private foundations committed to short-term start-up objectives.

In Cincinnati, PSI costs about $225 per pupil. Cincinnati PSI charges a $25 per-pupil service fee to CPS buildings hosting PSI in 2007-08. In a small school district that targets 400 students per year, PSI can cost as low as $8 per pupil. PSI PAYOFFsm charges groups outside of CPS a training fee of $800 per 8-hour day ($100/hour), plus travel, meals and lodging. This does not include the cost of PSI books, which must be purchased from Atlanta PSI.

Q. How do we recruit and screen teen leaders?

In 2008, 76 high school students applied for 50 PSI Teen Leader positions. Cincinnati Public School students can pick up applications from their principal, guidance counselor, or the PSI website (www.cincinnatichildrens.org/psi), and return completed PSI applications to the PSI Office by May 15. Grades, personal references, and an essay make up part of the selection criteria. All qualified applicants entering grades 10, 11, or 12 are interviewed in person by a PSI Adult Leader. Final selections are based on the applicant's belief in the philosophy of PSI, ability to speak persuasively in front of peers, and social/academic responsibility. PSI seeks qualified male and female candidates from a variety of schools, neighborhoods, and cultures.

The sexual behavior of Teen Leaders is a private matter, and thus not an explicit selection criterion. PSI Teen Leaders must agree to abstain from sex. Students involved in a teen pregnancy or teen parenthood are not permitted to be a PSI Teen Leader. Qualified teen parents are selected as guest speakers who speak on the realities of teen parenthood.

Q. What do the teen leaders do in PSI?

First, PSI Teen Leaders are role models for responsible sexual behavior, ambitious career aspirations, and community service. Once a week, Teen Leaders travel in pairs to an elementary or middle school class, where they teach six 45-minute lessons from one of the PSI Leaders' guides Postponing Sexual Involvement, or Managing Pressures Before Marriage. Teen Leaders actually run the class, conducting activities, leading discussions and role plays, showing video segments, assigning homework and interactive activities with students' guardians, and developing a positive rapport with the students. Teen Leaders are also involved in some behavior management of their students.

Q. How is adult supervision provided?

The PSI Adult Leaders provide training for the Teen Leaders. There are 20 hours of training in August, and two hours each month throughout the year. The Adult Leaders drive the Teen Leaders from their own senior high schools to the junior high, middle, or elementary school buildings, and assist the Teen Leaders in getting ready for the class, and managing students' performance. The Adult Leaders stay with the class and then take the Teen Leaders back to their own school. Adult Leaders complete written performance evaluations for each Teen Leader.

Q. Is this a high school program? A middle school program? An elementary school program?

In Cincinnati, it is a program that is serving all three levels of the school system.

Q. How is PSI being evaluated in Cincinnati?

In several ways. PSI has been well received by students, parents, teachers and the general community. In 2007-08, 98% of parents of students opted for their son or daughter to participate in PSI. Parent surveys conducted by volunteers indicate a high percentage of satisfaction with the program. It has received numerous favorable feature and editorial comments in the Cincinnati and national press, radio, and television.

Secondly, individually matched pre- and post-tests from 660 student participants in 2007-08 show that PSI had a statistically significant impact on young teens and pre-teens:

• 53% significantly improved their knowledge of assertive techniques. (p <.0001) 
• 81% significantly maintained or strengthened their intentions to abstain from sex. (p <.05) 
• 85% significantly maintained or improved their reported ability to resist peer pressure to have sex. (p <.001) 
• 41% significantly strengthened their intention to talk with their parent/guardian in the next three months about the right time to become sexually active. (p < .0001) 
• 37% significantly increased their comfort level in starting a conversation with their parent/guardian about the right time to become sexually active. (p<.0001) 
• 95% respect the PSI teen leaders who taught their class, and view them as role models. 
• 88% recommend the PSI program for people their age. 
• 82% report that after PSI, they feel more confident about postponing sex when they are pressured.
• 67% report that they have used what they have learned in PSI on average 3.5 times in the past month.

Thirdly, PSI tracks the number of live births by year as well as by age (16 years and younger) for girls in the City of Cincinnati. This information gives some trends, but does not specifically address the effect of the program on an individual student. From 1993 to 2007, the number of births to young female teens in Cincinnati has declined by 51%.

The references below cite research studies in Atlanta, Washington DC, and Exeter, England where PSI had a statistically significant impact on delaying student participants' sexual behavior, compared to similar groups that did participate in PSI.

Q. What advice do you have for smaller and/or suburban school districts who want to start PSI?

First, identify Coordinators, people who have time, are motivated and comfortable with the philosophy and content of PSI. Approval of the material should begin with the Board of Education. Finally, establish a partnership with a regional hospital to pool resources, and finance the program.

Q. Are Cincinnati PSI staff available for consultation?

Yes. Contact

Christopher Kraus, JD, MTS, Adolescent Advocacy Manager
Division of Adolescent Medicine, MLC 4000
Cincinnati Children's Hospital Medical Center
3333 Burnet Avenue
Cincinnati, OH 45229
(513) 803-2033; Fax: (513) 803-0334
christopher.kraus@cchmc.org
www.cincinnatichildrens.org/psi.

Q. Why can't the health teachers teach PSI?

They can. There is some evidence (see references) that PSI is effective for young teens when taught by Teen Leaders, or others who are enthusiastic about the lessons. However, peer education in PSI attracts schools and local funding sources that prioritize youth leadership development and community service.

References

Aarons, S. J., Jenkins, R.R., Raine, T.R., El-Khorazaty, M.N., Woodward, K.M., Williams, R.L., Clark, M.C., and Wingrove, B.K. (2000). Postponing Sexual Intercourse Among Urban Junior High School Students—a Randomized Controlled Evaluation. Journal of Adolescent Health. 27(4):236-247.

Alford, S. (2008) Science and Success, Second Edition: Sex education and Other Programs that Work to prevent teen pregnancy, HIV & sexually transmitted infections, Washington, DC: Advocates for Youth.

Card, JJ, Lessard, L., Benner, T. (2007) PASHA: facilitating the replication and use of effective adolescent pregnancy and STI/HIV prevention programs. Journal of Adolescent Health. 40(3): 275e1-14.

Howard, M. (1985). Postponing Sexual Involvement Among Adolescents. Journal of Adolescent Health Care. 6:271-277.

Howard, M. J. McCabe. (1990) Helping Teenagers Postpone Sexual Involvement. Family Planning Perspective. 22(1): 21-26.

Howard, M. Delaying the Start of Intercourse Among Adolescents. (1992). Adolescent Medicine State of the Art Reviews. Philadelphia: Hanley & Belfus, Inc. 3(2): 181-192

Kirby, D. (1997). No Easy Answers: Research Findings on Programs to Reduce Teen Pregnancy. Washington, DC: The National Campaign to Prevent Teen Pregnancy.

Kirby, D. (2001). Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy. Washington, DC: The National Campaign to Prevent Teen Pregnancy.

Kirby, D. (2007). Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy and Sexually Transmitted Diseases, Washington, DC: National Campaign to Prevent Teen Pregnancy.

Manlove, J., Franzetta, K., McKinney, K., Romano-Papillo, A., and Terry-Humen, E. (2004). No time to waste: Programs to reduce teen pregnancy among middle school-aged youth. Washington, DC: National Campaign to Prevent Teen Pregnancy.

Mellanby, A, and Tripp, J. (1996). Delay in First Sex is Seen Among British Teenagers in Sex Education Program. Family Planning Perspectives. 28:83-84.

14 and Younger: The Sexual Behavior of Young Adolescents. (2003). Bill Albert, et al., Editors, Washington, DC: National Campaign to Prevent Teen Pregnancy.

Sulak, PJ, Herbelin, SJ, Fix, DDA, et al. (2006). Impact of an adolescent sex education program that was implemented by an academic medical center. American Journal of Obstetrics and Gynecology, 195(1): 78-84.

Terry-Human, E, Manlove, J and Moore, K. (2005, January). Playing Catch-Up: How Children Born to Teen Mothers Fare. Washington, DC: National Campaign to Prevent Teen Pregnancy.

Sieving, R.E., Eisenberg, M.E., Pettingell, S. and Skay, C. (2006, March). Friends' influence on adolescents' first sexual intercourse. Perspectives on Sexual and Reproductive Health, 38(1), 13-19.

Fasula, A.M., Miller, K.S. (2006). African-American and Hispanic adolescents' intentions to delay first intercourse: parental communication as a buffer for sexually active peers. Journal of Adolescent Health, 38, 193-200.

Glynn, L.G., MacFarlane, A, Kelly, M, Cantillon, P., and Murphy, A.W. (2006, March). Helping each other to learn – a process evaluation of peer assisted learning. BMC Medical Education, 6:18.

To see a change... Be the change. PSI... Get involved!

How to get more involved in PSI

• See web site www.cincinnatichildrens.org/psi.
• Join Children's Hospital's annual walk-a-thon, October 11, 2008, "Cincinnati Walks for Kids," and sign up with the Teen Health Center/PSI team at www.cincinnatichildrens.org/walk.
• Attend teen leader training on topics like Preparing for college, and How to get along with your Parent.
• Recruit qualified Teen Leader applicants by putting an application in their hand.
• Join the Adolescent Medicine Community Health Education Advisory Committee.
• Call the PSI Office with your ideas, 513-636-7615.