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