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Introduction
Sexually active teenagers are a matter of serious
concern. In the past decades many school-based
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M. Silva
grams currently implemented in the US, a delay
in the initiation of sexual activity constitutes a
positive and desirable outcome, since the likelihood
of responsible sexual behavior increases with age
(Howard and Mitchell, 1993).
Even though abstinence is a valued outcome of
school-based sex education programs, the effectiveness of such interventions in promoting
abstinent behavior is still far from settled. Most of
the articles published on the effectiveness of sex
education programs follow the literary format of
traditional narrative reviews (Quinn, 1986; Kirby,
1989, 1992; Visser and van Bilsen, 1994; Jacobs
and Wolf, 1995; Kirby and Coyle, 1997). Two
exceptions are the quantitative overviews by Frost
and Forrest (Frost and Forrest, 1995) and Franklin
et al. (Franklin et al., 1997).
In the first review (Frost and Forrest, 1995), the
authors selected only five rigorously evaluated sex
education programs and estimated their impact
on delaying sexual initiation. They used nonstandardized measures of effect sizes, calculated
descriptive statistics to represent the overall effect
of these programs and concluded that those
selected programs delayed the initiation of sexual
activity. In the second review, Franklin et al.
conducted a meta-analysis of the published
research of community-based and school-based
adolescent pregnancy prevention programs and
contrary to the conclusions forwarded by Frost and
Forrest, these authors reported a non-significant
effect of the programs on sexual activity (Franklin
et al., 1997).
The discrepancy between these two quantitative
reviews may result from the decision by Franklin
et al. to include weak designs, which do not allow
for reasonable causal inferences. However, given
that recent evidence indicates that weaker designs
yield higher estimates of intervention effects
(Guyatt et al., 2000), the inclusion of weak designs
should have translated into higher effects for the
Franklin et al. review and not smaller. Given the
discrepant results forwarded in these two recent
quantitative reviews, there is a need to clarify the
extent of the impact of school-based sex education
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M. Silva
(whether the intervention was comprehensive/safersex or abstinence-oriented), the type of monitor who
delivered the intervention (teacher/adult monitor or
peer), the length of the program in hours, the scope of
the implementation (large-scale versus small-scale
trial), the time elapsed between the intervention and
the post-intervention outcome measure (expressed
as number of days), and whether parental participation (beyond consent) was a component of the intervention.
The type of sex education intervention was
defined as abstinence-oriented if the explicit aim
was to encourage abstinence as the primary method
of protection against sexually transmitted diseases
and pregnancy, either totally excluding units on contraceptive methods or, if including contraception,
portraying it as a less effective method than abstinence. An intervention was defined as comprehensive
or safer-sex if it included a strong component on
the benefits of use of contraceptives as a legitimate
alternative method to abstinence for avoiding
pregnancy and sexually transmitted diseases.
A study was considered to be a large-scale trial
if the intervention group consisted of more than
500 students.
Finally, year of publication was also analyzed
to assess whether changes in the effectiveness of
programs across time had occurred.
The decision to record information on all the
above-mentioned variables for their potential role
as moderators of effect sizes was based in part
on theoretical considerations and in part on the
empirical evidence of the relevance of such variables
in explaining the effectiveness of educational interventions. A limitation to the coding of these and of
other potentially relevant and interesting moderator
variables was the scantiness of information provided
by the authors of primary research. Not all studies
described the features of interest for this metaanalysis. For parental participation, no missing
values were present because a decision was made to
code all interventions which did not specifically
report that parents had participatedeither through
parentyouth sessions or homework assignments
as non-participation. However, for the rest of the
variables, no similar assumptions seemed appro-
474
Continuous predictors
Valid n
Socioeconomic status
low
middle
Type of program
comprehensive
abstinence-oriented
Type of monitor
teacher/adult
peer
Virginity status
virgins-only
all (virgins non-virgins)
Parental participation
yes
no
Scope of the implementation
large scale
small scale
8
5
3
12
8
4
11
9
2
12
6
6
12
2
10
12
7
5
Valid n
Mean
SD
Min
Max
percent of females
11
54
40
66
percent of whites
12
39
33
93
14
1.5
12
16
10
7.4
age
timing of post-test
10
221
218
4.5
30
540
475
M. Silva
Table II. Effect sizes of studies
Study
Effect
size (di)
95% CI for di
Lower
Upper
0.11
0.13
0.36
0.07
0.00
0.03
0.10
0.13
0.02
0.23
0.21
0.09
0.01
0.11
0.13
0.82
0.91
0.38
0.14
0.10
0.18
0.40
0.23
0.11
0.09
0.09
Results
The search for school-based sex education interventions resulted in 12 research studies that complied
with the criteria to be included in the review and for
which effect sizes could be estimated.
The overall effect size (d) estimated from these
studies was 0.05 and the 95% confidence interval
about the mean included a lower bound of 0.01
to a high bound of 0.09, indicating a very minimal
overall effect size. Table II presents the effect size
of each study (di) along with its 95% confidence
interval and the overall estimate of the effect size.
Homogeneity testing indicated the presence of variability among effect sizes (Q(11) 35.56; P
0.000).
Among the set of categorical predictors studied,
parental participation in the program, virginity status
of the sample and scope of the implementation were
statistically significant.4
Parental participation appeared to moderate the
effects of sex education on abstinence as indicated
by the significant Q test between groups (QB(1)
5.06; P 0.025), as shown in Table III. Although
476
Between-classes
effect (QB)
Mean weighted
effect size
95% CI for di
Lower
Parent participation
yes
no
Virginity status
virgins-only
all
Scope of implementation
Small scale
Large scale
*P
Upper
Homogeneity
within each class
(QW)a
5.06**
2
10
0.24
0.04
0.07
0.00
0.42
0.08
1.6
28.9***
6
6
0.09
0.01
0.03
0.04
0.14
0.07
27.09***
5.03
5
7
0.26
0.01
0.16
0.03
0.36
0.05
14.71**
1.73
3.47*
19.16***
aSignificance
SE
Parent participationa
Percent females
Constant
R2
QEb
0.22**
0.02**
0.89
0.28
18.8**
0.09
0.01
0.47
aParent
Discussion
This review synthesized the findings from controlled sex education interventions reporting on
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M. Silva
Interventions appeared to be more effective
when geared to groups composed of younger
students, predominantly females and those who
had not yet initiated sexual activity. The association
between gender and effect sizeswhich appeared
significant both in the univariate and multivariable
analysesshould be explored to understand why
females seem to be more receptive to the abstinence
messages of sex education interventions.
Smaller-scale interventions appeared to be more
effective than large-scale programs. The larger
effects associated to small-scale trials seems worth
exploring. It may be the case that in large-scale
studies it becomes harder to control for confounding variables that may have an adverse impact
on the outcomes. For example, large-scale studies
often require external agencies or contractors to
deliver the program and the quality of the delivery
of the contents may turn out to be less than optimal
(Cagampang et al., 1997).
Interestingly there was a significant change in
effect sizes across time, with effect sizes appearing
to wane across the years. It is not likely that this
represents a decline in the quality of sex education
interventions. A possible explanation for this trend
may be the expansion of mandatory sex education in the US which makes it increasingly difficult
to find comparison groups that are relatively
unexposed to sex education. Another possible line
of explanation refers to changes in cultural mores
regarding sexuality that may have occurred in
the past decadescharacterized by an increasing
acceptance of premarital sexual intercourse, a proliferation of sexualized messages from the media
and increasing opportunities for sexual contact in
adolescencewhich may be eroding the attainment
of the goal of abstinence sought by educational
interventions.
In terms of the design and implementation of
sex education interventions, it is worth noting
that the length of the programs was unrelated to
the magnitude in effect sizes for the range of 4.5
30 h represented in these studies. Program length
which has been singled out as a potential explanation for the absence of significant behavioral effects
in a large-scale evaluation of a sex education
478
Notes
1. Five pairs of publications were detected which may have
used the same database (or two databases which were likely
to contain non-independent cases) (Levy et al., 1995/Weeks
et al., 1995; Barth et al., 1992/Kirby et al., 1991/Christoper
and Roosa, 1990/Roosa and Christopher, 1990 and
Jorgensen, 1991/Jorgensen et al., 1993). Only one effect
size from each pair of articles was included to avoid the
possibility of data dependence.
2. Alternative methods to deal with non-independent effect
sizes were not employed since these are more complex and
require estimates of the covariance structure among the
correlated effect sizes. According to Matt and Cook such
estimates may be difficultif not impossibleto obtain
due to missing information in primary studies (Matt and
Cook, 1994).
3. QE provides the test for model specification, when the
number of studies is larger than the number of predictors.
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Received on April 24, 2001; accepted on July 3, 2001
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