Rigorous Evaluation of High School FLASH
Condition: Pregnancy Related; Sexual Behavior; STD
Study type: Interventional

Summary: 
      High School FLASH is a 15-session comprehensive sexual health curriculum designed for
      classroom settings in grades 9 to 12. The basis of High School FLASH is a public health
      approach to behavior change. The primary strategy used in the FLASH curriculum for preventing
      teen pregnancy, sexually transmitted diseases (STDs), and sexual violence is to address
      student behaviors and attitudes. To this end, FLASH uses a harm reduction and behavior change
      framework, implements best practices as outlined in the research on effective programs,
      addresses risk and protective factors for program goals, and rests on the theory of planned
      behavior. The instructional approach of High School FLASH employs key concepts in every
      lesson, which enables teachers to hone in on the risk and protective factors outlined in the
      curriculum logic model. The curriculum covers the following topics: reproductive system,
      pregnancy, sexual orientation and gender identity, healthy relationships, coercion and
      consent, online safety, abstinence, birth control, preventing human immunodeficiency virus
      (HIV) and other STDs, condoms, STD testing, communicating and decision making, and improving
      school health. The curriculum aligns with national health education standards.
    

Detailed description: 
      High School FLASH is a 15-session comprehensive sexual health curriculum designed for
      classroom settings in grades 9 to 12. The basis of High School FLASH is a public health
      approach to behavior change. The primary strategy used in the FLASH curriculum for preventing
      teen pregnancy, sexually transmitted diseases (STDs), and sexual violence is to address
      student behaviors and attitudes. To this end, FLASH uses a harm reduction and behavior change
      framework, implements best practices as outlined in the research on effective programs,
      addresses risk and protective factors for program goals, and rests on the theory of planned
      behavior. The instructional approach of High School FLASH employs key concepts in every
      lesson, which enables teachers to hone in on the risk and protective factors outlined in the
      curriculum logic model. The curriculum covers the following topics: reproductive system,
      pregnancy, sexual orientation and gender identity, healthy relationships, coercion and
      consent, online safety, abstinence, birth control, preventing human immunodeficiency virus
      (HIV) and other STDs, condoms, STD testing, communicating and decision making, and improving
      school health. The curriculum aligns with national health education standards. FLASH is
      ideally taught 2-5 times per week for 15 sessions lasting 50 minutes, or 10 sessions lasting
      70-80 minutes, covering the same content. The curriculum is designed to be flexible to ensure
      sustainability in a variety of school environments.

      The counterfactual condition is called Sexual Health Education for Adolescents, which is a
      five-session knowledge-based sexual health curriculum designed for classroom settings. The
      lessons cover the reproductive system, pregnancy, birth control, abstinence, HIV and other
      STDs, and healthy relationships. The goal of the curriculum is to increase student knowledge
      in all content areas. The primary strategy employed by Sexual Health Education for
      Adolescents is to address the cognitive learning domain. The curriculum aligns to national
      health education standards and is intended to be implemented by classroom teachers. The
      lessons can be delivered according to the schedule that works best for schools (e.g., twice a
      week, once a week, every days) within a school semester.

      Students were recruited from 9th (South) or 10th (Midwest) grade health classes. The research
      team met with district and school administrators and health teachers to explain the study,
      data collection processes, and to answer questions. The FLASH study enrolled students from
      required health classes from 20 schools in the South and the Midwest. In the Midwest, we
      worked with two districts; one of the districts contributed 9 of the 10 high schools and the
      other district contributed one high school to the evaluation study. In the South, we have
      partnered with 10 schools in 5 counties, representing 5 different districts. One of these
      districts contributed 6 schools to the evaluation study and the remaining 4 districts each
      contributed 1 high school to the study.

      Randomization was staggered and rolled-out by region to ensure that implementation started at
      the same time for all schools but only started in one region at a time. School enrollment was
      used as a stratification variable, so that schools assignments to the intervention and
      control arm were balanced within stratum. Randomization was performed within each region at
      the school level and was stratified into two categories by school size. For the Midwest
      region, small was defined as <500 enrollment and large was =>1000. For the Southern region,
      small was defined as <700 enrollment and large was =>700.

      Active parental consent and student assent were obtained prior to any data collection. The
      steps in the consent process are discussed below:

        1. Two weeks or more prior to the surveys (as determined by the participating schools),
           evaluation staff went to each participating health class and provided an overview of the
           study and distributed parent consent forms to all students in the class, requesting that
           they take them home to their parents for review and return the signed forms to their
           classroom teacher with parents' decisions regarding participation marked on the form. In
           the Southern schools, students received a gift card worth $10 for returning parent
           consent forms. The Midwestern schools' administration would not allow for the
           distribution of any type of incentives; thus, these schools received a class reward for
           taking part in the parent consent process and reaching a threshold (e.g., 75% or more of
           students return parent consent regardless of whether parents say "yes" or "no"). All
           consent forms were translated into languages requested by each district.

        2. Evaluation staff returned multiple times (e.g., 2-3) during the collection period as
           agreed upon with the classroom teacher to check on the parent consent return rates and
           did brief reminders to students.

        3. Between evaluation staff visits to the classrooms, teachers were asked to remind
           students to return parent consent forms daily over the collection period and provided
           additional forms to students who needed them.

        4. After two weeks, evaluation staff worked with the schools to make calls to parents using
           a scripted protocol to read the consent form over the phone and secure parents'
           decisions or send them the form for them to return it by mail with their decision. In
           nine schools within one district in the Midwest region, we trained their nursing office
           staff (which included Health Educational Assistants and Licensed Practical Nurses) to
           make verbal consent calls home to parents at the request of district administration.
           These staff members are already responsible for communicating with parents about
           health-related matters and given that this was a health-related research study, the
           administration felt that these calls would be better received by their staff, rather
           than unfamiliar data collectors.

      The primary source of data for the outcome analyses is the student self-report survey. The
      survey was administered three times over the course of the study. In the Midwest region this
      occurred: Fall 2016 (baseline), Spring 2017 (3-month follow-up), and Fall-Winter 2017-2018
      (12-month follow-up). In the Southern region, data collection took place: Fall 2017
      (baseline), Spring 2018 (3-month follow-up) and Fall-Winter 2018-2019 (12-month follow-up).
      Data were collected by trained data collectors in schools using handheld tablets. For
      students who left school after baseline but before follow-up surveys could be administered,
      we worked to survey these students at their new schools, online, or by mail.
    

Intervention name(s): FLASH curriculum; Sexual Health Education for Adolescents
Intervention type(s): Behavioral; Behavioral
Intervention description(s): High School FLASH is a 15-session comprehensive sexual health curriculum designed for classroom settings in grades 9 to 12. The basis of High School FLASH is a public health approach to behavior change. The primary strategy used in the FLASH curriculum for preventing teen pregnancy, sexually transmitted diseases (STDs), and sexual violence is to address student behaviors and attitudes. To this end, FLASH uses a harm reduction and behavior change framework, implements best practices as outlined in the research on effective programs, addresses risk and protective factors for program goals, and rests on the theory of planned behavior. The instructional approach of High School FLASH employs key concepts in every lesson, which enables teachers to hone in on the risk and protective factors outlined in the curriculum logic model.; Sexual Health Education for Adolescents is a five-session knowledge-based sexual health curriculum designed for classroom settings. The lessons cover the reproductive system, pregnancy, birth control, abstinence, human immunodeficiency virus (HIV) and other sexually transmitted diseases (STDs), and healthy relationships. The goal of the curriculum is to increase student knowledge in all content areas. The primary strategy employed by Sexual Health Education for Adolescents is to address the cognitive learning domain. The curriculum aligns to national health education standards and is intended to be implemented by classroom teachers. The lessons can be delivered according to the schedule that works best for schools (e.g., twice a week, once a week, every days) within a school semester.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Prevention
Keywords: Pregnancy; Adolescents; STD; Decision making; Harm reduction; Prevention education