Showing Girls They Have Control When Having Sex Is A Possibility
The following article was published in the November 2012 issue of the Office's newsletter Developments. To download a PDF of the issue, click here.

Julie Downs and her colleagues had a few ideas of what they would likely hear when they began interviewing teenaged girls more than a decade ago about how they make decisions that lead to sexual behaviors. Pressure from boys to have sex, for example, was one they thought they’d hear a lot about. What they learned surprised them.

The girls spoke not of being pressured into having sex or wanting to have sex because it was pleasurable or any of the other reasons the researchers anticipated hearing. What the teenaged girls confided was a profound lack of awareness that having sex is something they can control.

"They talked a lot about not even realizing that there were decisions being made – about how situations just kind of led to sex and that they didn’t realize that, if they wanted to make a different decision, they had some agency, some ability to change the outcomes," said Downs, Ph.D., an associate professor and the director of the Center for Risk Perception and Communication, Department of Social and Decision Sciences at Carnegie Mellon University.

Such findings were used to create an interactive video, which dramatized situations that can lead to sexual behavior in an effort to arm teenaged girls with knowledge and options that would help them better negotiate similar circumstances in their own lives. In a small-scale evaluation, the video showed promise in promoting safer decisions among girls and lowering their rates of sexually transmitted infections.

CMU researchers have improved the quality of the video and refined, updated and expanded its contents with a $7.4 million grant from the U.S. Department of Health and Services. And to assess its effectiveness, they are recruiting some 3,000 teenaged girls from health clinics in three states to be part of a larger-scale evaluation conducted by the University of Pittsburgh Office of Child Development (OCD) Division of Applied Research and Evaluation.

Having A Choice
The project dates to the late 1990s, when Downs and colleagues received a National Institutes of Health grant to look at the prevention of sexually transmitted infections. The work focused on the decisions that result in risky behaviors and lead to sexually transmitted infections and other negative outcomes. For teenaged girls, those decisions are around having sex, the partners they choose, and the protections they take.

It became clear during interviews with girls aged 14-18 years those decisions were strongly influenced by a lack of understanding that they have a choice in the matter and options to help them negotiate the outcomes of situations that lead to having sex.

“We used those findings to create a video where we just hit them over the head with the idea of having a choice,” Downs said. “We wanted to make it super concrete for them and help them practice: Here is a place where a girl can make a decision. Here are some options she has, several of which lead to less risky outcomes. Now, you can practice making these kinds of decisions in your own life.”

The video, “What Could You Do?” used actors in a series of vignettes to recreate situations that arise in relationships that can lead to sexual behaviors. The situations depicted range from that of a girl confronting the prospect of having sex when she is attracted to a boy at a party to a girl and her boyfriend confronting the issue of condom use.

In each case, the viewer chooses how the situation will unfold from several options. In the vignette depicting the girl’s encounter at a party, for example, there were three options to choose from, each portraying different responses and consequences that range from one that has the girl saying, “don’t stop” to one in which she gently pushes the boy away and says, “don’t.”

Other segments of the video offered information on common sexually transmitted diseases, and topics such as what happens during a gynecological examination and proper use of condoms.

Researchers from CMU, Children’s Hospital of Pittsburgh of UPMC and Slippery Rock University developed the “What Could You Do?” content.

A small-scale evaluation was done to determine the impact the video on 300 girls aged 14-18 years recruited from urban Pittsburgh-area clinics, including two control groups. It suggested that overall the video resulted in positive changes in the girls’ behavior, at least in the short term.

“One outcome was whether they stopped having sex,” Downs said. “We found the girls who saw our video were more likely to become abstinent by a fairly large odds ratio, about two-and-a-half, compared to controls. We attribute that to giving them skills to say no to sex if they want to say no to sex, so they were less likely to find themselves having sex if they really didn’t want to.”

The girls were also tested for Chlamydia, which is the most frequently reported bacterial sexually transmitted disease in the United States. Although the sample was small, the clinical tests showed a pattern consistent with lower chlamydia rates among girls exposed to the video compared to the controls. Self-reported rates of other sexually transmitted diseases were also lower among girls who watched the video.

Version 2.0
With the recent grant, researchers retooled the original video, drawing, in part, from lessons learned from the first group of girls.

The medical content, for instance, has been updated to include information about the vaccine for human papillomavirus, which didn’t exist when the first video was released in 1998. And the new version is shot in widescreen, can be streamed on the Web and the vignettes have the more watchable look of a mock-reality television show.

In the earlier study, researchers found that girls tended to choose which vignette to watch based on the race of the actors in the scene. The original video contained a limited number of scenarios, each devoted to a particular situation common in relationships. Some situations were portrayed with African American actors. In others, the actors were white. Because girls tended to view only the situations that were portrayed by actors of their race, they were not being exposed to the lessons found in others.

As a remedy, the number of scenarios in the new video was expanded to include multiple takes of every situation so each situation is available with actors who match a girl’s race.

The new video will also be evaluated with a larger group of teenaged girls, which will be 10 times the of the original cohort and recruited from clinics in western Pennsylvania, West Virginia and Ohio.

OCD, which was hired to be an independent evaluator, will use a number of data collection tools to measure the effectiveness of the new video intervention. Baseline data will be gathered at the beginning of the intervention. Data will be collected three months later and again at six months, which marks the end of the intervention. Another round of data will be collected one year from the end of the intervention to assess longer-term outcomes.

At each data collection point, girls complete a calendar in which they are asked to report on their sexual behavior, partners, use of birth control, and outcomes, such as a sexually transmitted disease diagnosis or a pregnancy test, that occurred over the previous three months. They also complete a survey, which includes questions related to self-efficacy, an influential factor in girls’ decisions when confronted with situations that can lead to sexual behaviors. In addition, they are given a pregnancy test and are tested for chlamydia and Gonorrhea.

The evaluation should also provide insight into the video’s effectiveness across a broader demographic representative of the audience it would likely find if widely used by girls across the nation. The larger cohort, for example, includes girls recruited from rural clinics in addition to urban clinics, from which most of the girls in the earlier study were recruited.

“I think that will be interesting to see,” said Milena Nigam, director of the OCD’s Division of Applied Research and Evaluation. “The current study is looking at how this video can be used in normal clinic operations. We have clinics in rural areas, in urban areas and those in between. Some communities are quite rural and isolated in terms of geography. And, in some counties, there is not much education available to girls around sexual health.”

If the new video is found to be effective, plans call for making it available as a DVD and online to help teenaged girls across the nation understand their choices in sexual situations and give them the means to avoid poor decisions that lead to unwanted consequences.