this reason, the committee believes that sequential, age-appropriate health education before high school is essential.

In many communities, there is considerable controversy regarding the role of "abstinence-based" (i.e., delaying intercourse until marriage) versus harm-reduction approaches (i.e., promoting use of condoms) to school-based education curriculum design. Some communities and school boards, in spite of predominant scientific evidence to the contrary, believe that harm-reduction approaches such as condom promotion encourage sexual intercourse among adolescents. Because of the controversial nature of school-based STD education programs, it has been strongly suggested that health departments and private organizations that desire to implement such programs work closely with school administrators, health educators, teachers, parents, and students throughout the planning and implementation process (Molbert et al., 1993).

It should be noted that although school-based programs will reach the overwhelming number of adolescents in the United States, as discussed in Chapter 3, a sizable number of adolescents are homeless, in detention facilities, or otherwise not attending school. These youths, who are at high risk for STDs because they are likely to be sexually active, have a history of being sexually abused, and use drugs and alcohol, present many challenges to prevention efforts. Information regarding the effectiveness of interventions to prevent STDs among youths who are not in school settings are limited (Rotheram-Borus et al., 1991).

Effectiveness of School-Based Programs. The quality of studies that have evaluated the effectiveness of school-based programs to reduce risky sexual behaviors varies greatly. Many studies that have evaluated the effectiveness of school-based programs in reducing risky sexual behaviors have used some type of experimental design, commonly randomization of students or schools to intervention and control groups to measure program effectiveness. Other evaluation methodologies include the use of data from national surveys of adolescent sexual behavior to relate past participation in health education programs to subsequent sexual health behaviors. Limitations of many of these studies include lack of appropriate control or comparison groups, insufficient sample size of students and resulting inadequate statistical power, variability of the time frame chosen for postintervention follow-up, and difficulty in accurately measuring health outcomes. For example, studies based on national surveys of adolescent sexual behavior are problematic because they rely on the recall of the respondent's past participation in health education activities. In addition, many specifics regarding the scope and quality of health education programs are not captured, thereby essentially grouping together programs of varying quality and scope. Because of ethical concerns and other problems associated with assessment of rates of STDs among students, it is not feasible to evaluate the direct impact of such programs on rates of STDs in most situations. Therefore, most studies evaluate effectiveness



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