AIDS Education and Prevention, 18(3), 187–203, 2006

© 2006 The Guilford Press

COYLE ET AL.
ALL4YOU!

ALL4YOU! A RANDOMIZED TRIAL OF

AN HIV, OTHER STDs, AND
PREGNANCY PREVENTION
INTERVENTION FOR ALTERNATIVE
SCHOOL STUDENTS
Karin K. Coyle, Douglas B. Kirby, Leah E. Robin,
Stephen W. Banspach, Elizabeth Baumler, and Jill R. Glassman

This study evaluated All4You!, a theoretically based curriculum designed to re-

duce sexual risk behaviors associated with HIV, other STDs, and unintended
pregnancy among students in alternative schools. The study featured a random-
ized controlled trial involving 24 community day schools in northern California.
A cohort of 988 students was assessed four times during an 18–month period us-
ing a self report questionnaire. At the 6–month follow–up, the intervention re-
duced the frequency of intercourse without a condom during the previous 3
months, the frequency of intercourse without a condom with steady partners,
and the number of times students reported having intercourse in the previous 3
months. It also increased condom use at last intercourse. These behavioral effects
were no longer statistically significant at the 12– and 18–month follow–ups. The
All4You! intervention was effective in reducing selected sexual risk behaviors
among students in alternative school settings; however, the effects were modest
and short term.

Adolescents in alternative education settings are an important target population for

HIV, other sexually transmitted diseases (STDs), and pregnancy prevention interven-
tions. According to the National Center for Education Statistics, there were 612,900
students enrolled in public alternative schools or programs for at–risk students na-
tionwide in October 2000 (Kleiner, Porch, & Farris, 2002). Alternative high schools
serve students who do not progress academically in mainstream high schools, often
owing to issues such as disciplinary problems or chronic absenteeism. Students in al-

Karin K. Coyle, Douglas B. Kirby, and Jill R. Glassman are with ETR Associates, Scotts Valley, CA. Leah E.
Rob and Stephen W. Banspach are with the Division of Adolescent and School Health, U.S. Centers for Dis-
ease Control and Prevention (CDC), Atlanta, GA. Elizabeth Baumler is with Redstone Analytics, Dallas, TX.
The study was supported by Cooperative Agreement U87CCU916390 with the Centers for Disease Control
and Prevention. The authors gratefully acknowledge the contributions to this research project by Nancy
Calvin, Tiffany Chinn, Jill Denner, Jeffery Douglas, Cherri Gardner, Deborah Ivie, Gina Lepore, Lisa
Sterner, Tracy Unti, Chayo Ureno, James Walker, Holly Williams, Vickie Williams, and Dana Zive. Addi-
tionally, they express their sincere appreciation to the district representatives, principals, teachers, school
staff, and students who participated in the study.
Address correspondence to Karin K. Coyle, PhD, ETR Associates, 4 Carbonero Way, Scotts Valley, CA
95066; e–mail: karinc@etr.org

187
188 COYLE ET AL.

ternative school settings are more likely than students in mainstream schools to en-
gage in sexual risk taking behaviors (Grunbaum et al., 1999). For example, 87.8% of
students in alternative high schools reported ever having sexual intercourse, com-
pared with 49.9% of students in mainstream high schools (Grunbaum et al., 1999).
Furthermore, 50.4% of the students in alternative schools reported having four or
more sexual partners during their lifetime, whereas only 16.2% of students in main-
stream schools stated that they had as many partners. Of the students who were cur-
rently sexually active, 45.9% of the alternative school students as compared with
58.0% of the mainstream students used a condom during last sexual intercourse. This
pattern of sexual behavior contributes to a greater risk for HIV infection, other STDs,
and unplanned pregnancy. Indeed, students in alternative high schools are more likely
to have experienced a prior pregnancy and to have had an STD than students in
mainstream settings (Grunbaum & Basen–Engquist, 1993; O’Hara, Messick,
Kennedy, & Zinkin, 1994; Weller et al., 1999).
During the past decade, several skills–based prevention programs and programs
featuring service learning have been shown to reduce sexual risk behaviors and/or
pregnancy (Kirby, 2001). Many of these programs have been conducted in main-
stream high schools or with high school–aged youth (e.g., Allen, Philliber, Herrling, &
Kuperminc, 1997; Coyle et al., 2001; Hubbard, Giese, & Rainey, 1998; Jemmott,
Jemmott, & Fong, 1992; Kirby, Barth, Leland, & Fetro, 1991; Main et al., 1994; St.
Lawrence, Jefferson, Alleyne, & Brasfield, 1995). In contrast, very few published
studies have examined the impact of HIV, other STDs, and pregnancy prevention pro-
grams for students in alternative school settings. One study (O’Hara, Messick,
Fichtner, & Parris, 1996) focused on students in a dropout prevention program in
Florida. Pretest–posttest data suggest the intervention as a whole was successful in en-
hancing students’ awareness and discussion about AIDS; it also increased condom use
at last intercourse among students who reported having sex. Despite the encouraging
findings, the study methodology was severely limited. Several other studies (e.g.,
Gillmore et al., 1997; Magura, Kang, & Shapiro, 1994; St. Lawrence, Crosby, Belch-
er, Yazdani, & Brasfield, 1999) examined programs in juvenile detention or correc-
tional facilities, and showed mixed results. Most recently, a study by St. Lawrence,
Crosby, Brasfield, and O’Bannon (2002) demonstrated that skills training and moti-
vational strategies can reduce sexual risk taking among youth in residential drug
treatment programs.
Given the pattern of risk behavior among students in alternative schools and the
paucity of research with this population, we developed and evaluated All4You!, a
skills–based HIV, other STDs, and pregnancy prevention curriculum combined with
service–learning. We used a combination of a skills–based curriculum and service
learning because both strategies have been shown to reduce sexual risk taking behav-
iors and related determinants (Kirby, 2001) and because the combination addresses a
broader range of potential determinants—both sexual (e.g., attitudes and beliefs re-
garding condom use) and nonsexual (e.g., optimism or hope for the future) than either
approach alone. The primary goal of All4You! was to reduce the number of students
who have unprotected sexual intercourse. It also was designed to affect mediating
variables (e.g., attitudes/beliefs and norms) stemming from our theoretical model.
This article presents the results of a randomized controlled trial undertaken to assess
the short and longer term impact of All4You!
ALL4YOU! 189

METHODS
STUDY DESIGN

The study featured a randomized controlled trial in 24 alternative schools (specifi-

cally, community day schools) located in four large urban counties in northern Cali-
fornia. The four counties were selected because they serve ethnically diverse
populations, they had multiple community day schools that met the study inclusion
criteria, and they were in close proximity to the study investigators. The schools
ranged in size from approximately 12 to 62 students (M = 28). In general, students are
referred to the community day schools for severe discipline issues, substance use, and
chronic absenteeism. The purpose of these schools is to help students make up lost
credits so they can return to their mainstream schools or receive a GED. Students may
spend from less than 1 month to more than 12 months in these schools, depending on
their academic status.
Thirteen schools were randomly assigned to receive the All4You! intervention.
The remaining 11 schools served as control sites. We used a restricted randomization
process involving multiple steps. Schools within each county were initially partitioned
into matched sets. Then two matched groups were formed, each consisting of one
school set from each county. Finally, these two matched groups were randomized to
the intervention or control condition. We used seven school–level variables (the en-
rollment percentages of Asians, Hispanics, Blacks, Whites, others, males, and those on
probation), a county identifier, and enrollment size to guide the creation of the
matched school sets and groups. The equivalence of the final school sets and study
groups was assessed by comparing profiles of the seven school–level variables for each
group.

INTERVENTION
The All4You! intervention featured two primary components that were inte-
grated and delivered as a 14–session program (about 26 hours total): (a) a skills–based
HIV, other STDs, and pregnancy prevention curriculum delivered in alternative
school classrooms and (b) service–learning activities. The curriculum component in-
cluded nine classroom lessons (about 13.5 hours total) that addressed key risk and
protective factors related to sexual behaviors (e.g., essential knowledge, attitudes,
norms, perceived self efficacy). The lessons were drawn from two existing evi-
denced–based curricula—Be Proud, Be Responsible (Jemmott et al., 1992) and Safer
Choices (Coyle et al., 2001). These two programs are based on social cognitive theory
(Bandura, 1986), theory of reasoned action (Fishbein & Ajzen, 1975), and the theory
of planned behavior (Ajzen, 1991), which is an extension of the theory of reasoned ac-
tion. Examples of curriculum activities include (a) building functional knowledge
about HIV, other STDs, and pregnancy (e.g., through creating posters, watching vid-
eos, and playing games); (b) clarifying students’ sense of vulnerability to HIV, other
STDs and pregnancy (e.g., through examining risk of selected sexual behaviors and
participating in activities demonstrating the transmission of HIV), (c) examining atti-
tudes and beliefs about having sex and using condoms (e.g., through the use of a vari-
ety of experiential learning activities, such as role playing, advice columns, videos, and
group discussion); and (d) building negotiation skills and skills to use condoms
correctly (e.g., through role playing, demonstrations, and guided practice).
In the service–learning component, students made five visits as a class (about
12.5 hours total, including transportation) to volunteer sites that included preschools
and elementary schools, senior centers, an organization creating a public mural, and
190 COYLE ET AL.

AIDS service organizations. This component is supported by social development the-

ory (Hawkins & Weiss, 1985), which suggests that a learning process involving op-
portunities for involvement, skills, and reinforcement determines whether a young
person will develop prosocial attitudes and behaviors that produce a bond of attach-
ment to, commitment to, and belief in conventional society (Hawkins & Weiss,
1985). During the service visits, students led activities and provided services, such as
cooking meals, playing games, supervising student activities, and craft projects. The
service visits were scheduled on alternating lesson days to allow time for reflection be-
tween visits. Preparation for service was integrated into curriculum lessons through
small–group planning activities, empathy–building exercises, and an activity identify-
ing the potential benefits of helping in the community. Reflection occurred immedi-
ately following service (through brief verbal exchanges and individual work sheets)
and then again at the beginning of the next curriculum lesson (through a 25–minute
small–group activity). Reflection included identifying the contributions students
made during service–learning visits, identifying and handling challenges using prob-
lem–solving skills, connecting service to health behaviors, and discussing the potential
benefits of volunteering. The program was pilot–tested twice prior to study imple-
mentation with alternative school students who were not part of the study. Student
feedback was collected through brief surveys and informal interviews and group dis-
cussions with the students. The program was refined based on students’ input (e.g., we
modified role-play scenarios and language, we dropped a game–based activity that
wasn’t working as we expected it to, and we used the term reflection folder instead of
journal for the service-learning reflection activities).
During the study, experienced health educators were hired and trained to imple-
ment the program. The educators also practiced implementing the program by teach-
ing it at a school not involved in the study (during the second pilot test). The program
was taught during a specified period, which was scheduled in cooperation with each
school. In most cases, implementation occurred two to three times a week for 5 to 7
weeks.
Based on data collected from the study schools, the study curriculum served as
the primary source of HIV, other STDs, and pregnancy prevention education at the in-
tervention schools, though some schools implemented other activities (e.g., speakers
from local community-based organizations). The control schools continued their
usual activities related to HIV, other STDs, and pregnancy prevention, which typi-
cally consisted of outside presenters from local community–based agencies.

DATA COLLECTION PROCEDURES

Our study design included recruiting and tracking four cohorts over time be-
tween 2000 and 2001. The first cohort was established in spring 2000 and included all
students at the schools who received parental consent to take part in the study. The
second, third, and fourth cohorts were established in fall 2000, spring 2001, and fall
2001, respectively, with all new students at each study school who had permission to
take part.
We collected self–report data from students at each study school using trained
data collectors. Baseline data were collected in class during school hours at the begin-
ning of each semester. Follow–up data were collected at 6, 12, and 18 months after
baseline. For students still enrolled in school, follow–up surveys were collected during
school hours. Most students had left their schools by the first follow–up and were sur-
veyed by mail or had surveys hand–delivered to them at their homes. The study proce-
ALL4YOU! 191

dures were reviewed and approved by the institutional review boards at the federal
funding agency and the funded organization.

PARTICIPANTS AND RESPONSE RATES

Active parental permission and student assent were required for study participa-
tion. Because the settings in which the study took place enroll and lose students on a
regular basis, we adapted criteria used in the Centers for Disease Control and Preven-
tion’s (CDC’s) Alternative School Youth Risk Behavioral Surveillance (Grunbaum et
al., 1999) to establish criteria for study eligibility. All students enrolled at the time of
baseline were eligible unless they met the following criteria: (a) they were on extended
leave (e.g., maternity leave, medical leave); (b) they had been suspended or were incar-
cerated at the time of baseline; or (c) they had functionally dropped out of school (e.g.,
never came to school anymore, had not been seen in weeks, dropped out officially). Of
eligible students, 98% returned parental consent forms and 89% (N = 988) of these
students completed baseline surveys.
Tracking this population was extremely difficult. We lost nearly one quarter of
the students (24.3%) after baseline for various reasons (e.g., extended jail sentences,
death, no home address, families unaware of students’ location), yielding approxi-
mately 76% of the students with at least one follow–up survey (n = 743). Response
rates were affected by student transience, not by student or parent refusals. Family
and friends often reported not knowing students’ whereabouts and in some cases even
asked the study trackers for assistance in finding them. Of the students with at least
one follow–up, response rates for the 6–, 12–, and 18–month follow–up were 73%,
62%, and 56%, respectively.
Baseline demographic characteristics for the cohort are summarized by interven-
tion group in Table 1. The intervention and control groups were equivalent on demo-
graphic variables assessed at baseline, with the exception of age; students in the
intervention condition were slightly older at baseline than were students in the control
condition, and this difference was statistically significant (p < 0.001).

QUESTIONNAIRE INSTRUMENT
The questionnaire consisted of 131 items that assessed demographic characteris-
tics, sexual risk behaviors, theory–based psychosocial antecedents, and program ex-
posure. The questionnaire was available in English or Spanish and was pilot-tested
prior to the study. We classified the sexual risk behaviors as primary or secondary at
the study outset; this distinction was made based on our understanding of the popula-
tion’s pattern of risk behaviors, the program emphasis on the outcomes, and the rela-
tive impact of each behavior on teen STDs and pregnancy. The survey included four
primary sexual behavior outcome variables: (a) frequency of sexual intercourse with-
out a condom in the previous 3 months (fill–in response 0-98+ times); (b) use of con-
doms at last intercourse (yes, no, not sure); (c) number of sexual partners with whom
students had intercourse without a condom in the previous 3 months (fill–in response
0-98+ partners); and (d) use of an effective pregnancy prevention method at last inter-
course (yes or no to a list of various methods such as birth control pills, condoms, “the
shot,” “pulled out,” which were then coded as effective or not). The questionnaire
also measured secondary behavioral outcomes: (a) frequency of sexual intercourse
with a condom in the previous 3 months with steady (defined in the survey as “people
you go with”) and non–steady partners (defined in the survey as “casual partners, or
people you just met or picked up”) (0-98+ times); (b) frequency of sexual intercourse,
previous 3 months (0-98+ times); (c) number of steady and non–steady sexual part-
192 COYLE ET AL.

TABLE 1. Baseline Demographic Characteristics (N = 988)

% of Youth in % of Youth in
Intervention Group Control Group
Variable Category (n = 597) (n = 391)
Race/ethnicity African American 29.0 25.8
Asian American 16.9 12.8
Hispanic/Latino 27.6 31.5
White 12.2 12.3
Other or Multi–
ethnic 14.2 17.6
Gender Male 61.2 65.0
Female 38.8 35.0
Agea 14 years 7.3 11.3
15 years 20.7 27.4
16 years 30.7 33.6
17 years 32.2 21.8
18 years or older 9.1 5.9
Number of parents or guardians at home None 4.4 3.4
One 41.3 42.7
Two or more 54.3 53.9
Probation Status Ever 61.9 57.3
On probation now 53.4 49.0
Ever had sexual intercourse Yes 82.0 84.7
No 18.0 15.3
Had sexual intercourse in previous 3 months Yes 69.5 75.6
No 30.5 24.4
Used a condom at last intercourse Yes 60.7 67.7
(among those who have had No 35.8 28.9
sexual intercourse)

Ever had anal intercourse Yes 21.9 19.0

No 78.1 81.0
Used a condom at last anal intercourse Yes 57.9 51.5
(among those who have had anal No 42.1 48.5
intercourse)
aDifference between intervention and control group p < .001.

ners with whom students had intercourse without a condom in the previous 3 months
(0-98+ partners); (d) number of sexual partners, previous 3 months (0-98+ partners);
(e) alcohol and drug use before past sexual intercourse previous 3 months (4–point
Likert scale ranging from never to always); (f) sexual initiation (yes, no); (g) number of
times tested for HIV and other STDs, lifetime (0 to 4+ times); and (h) pregnancy since
baseline (yes, no). Finally, we assessed a number of psychosocial constructs stemming
from our underlying theoretical model. These scales and their psychometric
properties are summarized in Table 2.

STATISTICAL ANALYSES
Behavioral and Psychosocial Analyses. Multilevel models were used to adjust
for the correlation among students within the same school, and the correlation of re-
peated measurements taken on the same student over time. We used linear and logistic
multilevel models to analyze continuous and dichotomous data, respectively, and
Poisson or negative binomial multilevel models to analyze count data. The negative
binomial regression model is a generalization of the Poisson regression model and is
 TABLE 2. Scale Information for Psychosocial and Other Scaled Variables

Number
Construct of Items Sample Item Response Formata Alpha
Knowledge
HIV and condom knowledge 8 Some sexually transmitted diseases put you at higher risk of getting infected 2–point scale (1 = correct, .59
with HIV. 0 = incorrect)
Condom knowledge 6 A condom should be completely unrolled before it is placed on the penis. .57
Perceived Self–Efficacy
To get and use condoms 8 Imagine that you decided you want to use a condom if you have sex. How 4–point scale (1 = I definitely could .83
sure are you that you could buy or get condoms? not to 5 = I definitely could)
To refrain from having sex 2 Imagine you are with a steady partner—a person you are going with. How .78
sure are you that you could keep from having sex until your steady part-
ner agrees to use a condom?
Attitudes and Beliefs
General attitudes toward condoms 12 Using condoms shows my partner I care about him/her. 5–poing scale (1 = strongly disagree .80
to 5 = strongly agree)
Attitudes about condoms protecting 2 Condoms are very effective at preventing HIV, the virus that causes AIDS. .80
against STDs
Attitudes about condoms protecting 1 Condoms don’t work very well to prevent pregnancy. NA
against pregnancy
Beliefs regarding using condoms when 2 I think teens should always use condoms when having sex with steady part- .50

193
having intercourse ners.
Normative Beliefs
Perceptions of number of peers who have 2 About how many people your age have had sex? 5–point scale (1 = none or almost .77
had sexual intercourse none to 5 = all or almost all)
Perceptions of number of peers who use 2 Think about the people your age who have had sex. How many of them use 5–point scale (1 = none or almost .76
condoms if having sexual intercourse condoms every time or almost every time with steady partners? none to 5 = all or almost all)
Perceptions of peer beliefs supporting 3 My friends think teens should always use condoms when having sex with 5–poing scale (1 = strongly disagree .72
condom use steady partners. to 5 = strongly agree)
Sense of Future
Optimism 9 I believe some good can come out of every situation. 4–point scale (1 = strongly disagree .88
to 4 = strongly agree)
Fatalism 4 My future seems dark to me. 4–point scale (1 = strongly disagree .79
to 4 = strongly agree)
Connectedness
Community orientation 5 I feel like I have something to offer my community. 4–point scale (1 = strongly disagree .82
to 4 = strongly agree)
Connectedness to a caring adult outside 4 I know an adult outside of my family who really cares about me. 4–point scale (1 = strongly disagree .88
of family to 4 = strongly agree)
aMean scores were used in all analyses.
194 COYLE ET AL.

often used for modeling overdispersed count data in which the variable of interest is
the number of occurrences during a given time period.
For the behavioral outcomes, two–level models were used where Level 1 was the
student and Level 2 was the school. Behavioral models represented end point analyses.
An attempt was made to use repeated measures models, but distribution problems,
sparseness of the data, and complexity of the variance structure resulted in poorly fit-
ting models that would not converge with the preferred second-order PQL estimation
technique. Although an end-point analysis does not allow for the estimation of overall
effect across time, it does allow for estimation of effects by time point that are directly
comparable to time point effects taken from interaction terms in a repeated measures
model. We did not experience the same analysis challenges with the psychosocial data.
The psychosocial outcomes were analyzed using three–level models that included sur-
vey measurement occasion as Level 1, students as Level 2, and school as Level 3. We
carried out computations for the multilevel models using MLn WIN Software for
Multilevel Analysis, Version 1.10 (Rasbash et al., 2001).
To adjust for any baseline differences and to control for potential confounders,
we modeled the following variables as predictors for each outcome: participants’
baseline responses on the outcome variable, intervention group, and a set of out-
come–specific covariates. Variables were included as potential covariates for a partic-
ular outcome if they were both significantly related to the outcome and an imbalance
existed between intervention conditions. A particular covariate was retained in the
model if it remained significant in the final stage of multilevel modeling. We used
two–tailed tests and made no adjustments for multiple tests of significance. Statistical
significance was set at p ≤ 0.05. All students were included in the analyses, regardless
of program dose.
Multilevel models such as the ones used in this analysis provide a flexible frame-
work for handling missing data. When analyzing overall intervention effects across
time as in the psychosocial analyses, the multilevel modeling approach allowed for the
inclusion of students with incomplete data (missing one time point, for example) into
the model. By including such cases in the models, they contributed information to-
ward estimation of the time points for which they had valid data. However, students
with missing data on the covariates were excluded from the analyses.
Estimates of the magnitude of effects were calculated for all outcomes. For the be-
havioral outcomes, we used odds ratios to estimate overall effects for dichotomous be-
havioral variables. The effects for the Poisson or negative binomial models represent
the ratio of the adjusted mean for the intervention group to the adjusted mean for the
comparison group. Thus, an effect size of 1.00 indicates no difference, < 1.00 indicates
a mean for the intervention group less than that of the comparison group, and > 1.00
indicates a mean for the intervention group greater than that of the comparison group.
For all other behavioral outcomes and the psychosocial outcomes we calculated Co-
hen’s d (Rosenthal & Rosnow, 1991).
Attrition Analyses. We used multilevel logistic regression models to assess the
significance of the relationship between survey status at each time point (completed a
survey or not) and intervention group; baseline demographic characteristics (gender,
age, race/ethnicity, probation status—ever and current, number of parents at home);
and selected behavioral outcome variables (sexual intercourse in the previous 3
months, condom use at last intercourse, ever had anal intercourse, number of partners
with whom had sexual intercourse previous 3 months, number of times had sexual in-
tercourse without using a condom previous 3 months, and number of partners with
ALL4YOU! 195

whom had sexual intercourse without using a condom previous 3 months) as mea-
sured at baseline. These analyses were repeated examining differences between stu-
dents who completed the baseline survey only versus those who completed two more
follow–up surveys. Finally, for any variable in which individuals lost to follow–up dif-
fered significantly from those retained at each time point (e.g., by gender), we con-
ducted multilevel regression to investigate the relationship between intervention
group and those variables among the subgroup of students lost to follow–up.

RESULTS
ATTRITION
No statistically significant differences were found in the rates of attrition at each
follow–up time point by treatment group. Furthermore, no statistically significant dif-
ferences were found between students lost to follow–up and those retained in terms of
their sexual risk behaviors at baseline, with two exceptions. Students not completing the
first follow–up questionnaire were significantly more likely than those who did com-
plete it to report having had sex in the previous 3 months at baseline (p = .02) and stu-
dents not completing the final follow–up questionnaire were significantly more likely
than those who did complete it to report using a condom at last intercourse at baseline
(p = .01). Four demographic differences were statistically significant: students lost to
follow–up were more likely to report being male (p < .001 at all 3 follow–ups), older (p <
.01 at the first and final follow–up only), on probation at some time in their lives (p = .01
at the second and final follow–ups only), and on probation at the time of the follow–up
(p = .03 for the second follow–up and .01 for the final follow–up). No statistically signif-
icant differences were found in these demographic profiles by treatment group.

BEHAVIORAL OUTCOMES
Primary Outcomes. Two of the four primary outcomes were statistically signifi-
cant in the desired direction at the 6–month follow–up (Table 3), both of which re-
lated to condom use. Specifically, students in the intervention group were less likely to
have intercourse without a condom in the previous 3 months than were students in the
control group (p = .002), and they were more likely to use condoms during last inter-
course (p = .006). These effects diminished by the 12– and 18–month follow–ups.
We found no statistically significant intervention group differences in the number
of partners with whom youth had intercourse without using a condom or their re-
ported use of an effective method of pregnancy prevention at last intercourse.
Secondary Outcomes. We examined nine secondary outcomes (see Table 3) and
found statistically significant differences favoring the intervention group for three of
the nine outcomes, and near–significant differences in the desired direction for two
additional outcomes.
Secondary Outcomes Related to Frequency of Unprotected Intercourse. C o n-
sistent with the primary outcome results, at the 6–month follow–up youth in the inter-
vention condition reported having intercourse without a condom fewer times in the
three months prior to the survey with steady partners than did youth in the control
group (p = .01). These effects attenuated by the 12–month follow–up. Intervention
group youth also reported a trend toward having intercourse without a condom in the
previous 3 months fewer times with non–steady partners than did control group
youth; this difference neared statistical significance (p = .08) at the 6–month fol-
low–up and diminished over time. The intervention also reduced the number of times
youth reported having intercourse in the previous 3 months (p = .04) at the 6–month
196 COYLE ET AL.

TABLE 3. Parameter Estimates for Multilevel Models of Behavioral Variables

6–, 12–, and 18–Month Follow–Up

Group Estimate Estimated

Variable Sample Size (SE or OR and 95% C.I.) p–Value Effect Sizea
Primary Outcomes
Frequency of intercourse without a condom in previous 3 months
6 months 412 –1.09 (0.36) 0.002 0.34
12 months 328 0.18 (0.34) 0.6 1.2
18 months 289 0.38 (0.39) 0.33 1.46
Use of condoms at last intercourse
6 months 469 OR = 2.12 (1.24, 3.56) 0.006 See OR
12 months 386 OR = 0.88 (0.50, 1.55) 0.66 See OR
18 months 359 OR = 1.00 (0.49, 2.02) 0.99 See OR
Number of partners without a condom previous 3 months
6 months 471 –0.20 (0.34) 0.55 0.82
12 months 385 –0.24 (0.22) 0.27 0.79
18 months 355 –0.29 (0.31) 0.34 0.75
Use of effective pregnancy prevention method at last intercourse
6 months 527 OR = 1.15 (0.78, 1.70) 0.27 See OR
12 months 460 OR = 1.12 (0.74, 1.66) 0.6 See OR
18 months 417 OR = 0.77 (0.49, 1.23) 0.28 See OR
Secondary Outcomes
Frequency of intercourse without a condom in previous 3 months—steady partners:
6 months 496 –0.28 (0.11) 0.01 d = 0.19
12 months 415 0.12 (0.18) 0.51 d = 0.09
18 months 373 0.009 (0.19) 0.95 d = 0.01
Frequency of intercourse without a condom in previous 3 months—non–steady partners
6 months 497 –0.07 (0.04) 0.08 d = 0.14
12 months 399 –0.03 (0.06) 0.65 d = 0.10
18 months 367 –0.08 (0.05) 0.15 d = 0.14
Frequency of sexual intercourse previous 3 months
6 months 493 –2.72 (1.33) 0.04 0.19
12 months 418 2.28 (1.95) 0.24 0.12
18 months 383 2.87 (1.75) 0.1 0.18
Number of steady partners without a condom past 3 months
6 months 505 –0.05 (0.06) 0.43 d = 0.08
12 months 429 –0.02 (0.06) 0.74 d = 0.07
18 months 388 0.002 (0.07) 0.98 d = 0.08
Number of non–steady partners without a condom previous 3 months
6 months 493 –0.03 (0.04) 0.43 d = 0.07
12 months 418 0.00 (0.06) 0.99 d = 0.03
18 months 383 –0.12 (0.05) 0.01 d = 0.27
Number of sexual partners previous
3 months 514 –0.24 (0.15) 0.1 d = 0.18
6 months 442 0.08 (0.14) 0.57 d = 0.00
12 months 394 –0.20 (0.17) 0.25 d = 0.18
18 months
Use of alcohol and drugs before intercourse previous 3 months
6 months 374 0.003 (0.13) 0.98 d = 0.00
12 months 322 –0.05 (0.11) 0.62 d = 0.05
18 months 286 –0.12 (0.05) 0.18 d = 0.15
Sexual initiation (among sexually inexperienced at baseline)
6 months NA
12 months NA
18 months 94 OR = 1.23 (0.51, 2.97) 0.65 See OR
Number of times tested for HIV
6 months 422 0.05 (0.17) 0.79 d = 0.02
12 months 372 0.004 (0.14) 0.99 d = 0.00
18 months 338 –0.08 (0.07) 0.67 d = 0.04
Number of times tested for other STD
6 months 422 0.10 (0.15) 0.48 d = 0.06
12 months 373 0.11 (0.16) 0.5 d = 0.06
18 months 338 0.08 (0.09) 0.69 d = 0.04
Pregnancy since baseline (among sub–sample reporting sexual activity previous 3 months)
6 months 308 OR = 0.61 (0.33, 1.12) 0.11 See OR
12 months OR = 1.15 0.66
18 months OR = 0.84 0.61
aEstimated effect sizes for frequency unprotected and partners unprotected interpreted as the ratio of the adjusted means

(intervention vs. control). An ES of 1 = no effect, > 1 indicates a higher mean in the intervention group, and < 1 indicates a
higher mean in the control condition. Estimated effect sizes for remaining outcomes estimated using Cohen’s d effect size
calculations.
ALL4YOU! 197

follow–up. This difference reversed (although not significantly) and attenuated with
time.
Secondary Outcomes Related to Sexual Partners. There were no statistically
significant differences between intervention and control groups regarding the number
of steady partners with whom students had intercourse without using a condom dur-
ing the previous 3 months; however, intervention group youth reported fewer
non–steady partners with whom they had intercourse without a condom in the previ-
ous 3 months. This effect was in the desired direction at the 6–month follow–up but
did not reach statistical significance until the final 18–month follow–up (p = .01). Fi-
nally, at the 6–month follow–up, youth in the intervention group also reported a trend
toward having fewer sexual partners overall in the previous 3 months. This difference
neared significance (p = .10), and diminished over time.
Other Secondary Outcomes. We found no statistically significant effects for the
remaining secondary outcomes (use of alcohol and drugs before intercourse previous
3 months, sexual initiation, number of times tested for HIV and other STDs, preg-
nancy since baseline), though there was a nonsignificant trend toward fewer pregnan-
cies among youth in the intervention group (p = .11) at the 6–month follow–up.

PSYCHOSOCIAL OUTCOMES
Table 4 includes the results of the multilevel analyses for the psychosocial scales.
The table provides estimates of the average overall effects of the intervention over time
achieved by the final follow–up (noted as “overall” in the table), as well as the effects
for each time point. Very few of the psychosocial outcomes were statistically signifi-
cant across time or at specific time points. Overall, intervention students scored higher
on the HIV and condom knowledge scale (p = .01). This difference was significant at
the 6– and 18–month follow–ups but not the 12–month follow–up. No other overall
effects were found, though students in the intervention group demonstrated a trend
toward greater optimism that neared statistical significance (p = .08). Furthermore, of
the time–point specific effects, only three were statistically significant, and they fa-
vored the control group (perceived self–efficacy to get and use condoms, attitudes
about condoms protecting against pregnancy, and beliefs regarding using condoms
when having intercourse).

DISCUSSION
The results of this randomized trial suggest that All4You! had short–term effects on
reducing unprotected sexual intercourse, but these effects diminished with time. This
pattern of attenuation has been found in other HIV and STD prevention studies. For
example, Jemmott, Jemmott, and Fong (1998) found participants in an abstinence in-
tervention were less likely to report sexual intercourse at the 3–month follow–up but
not at the 6– or 12–month follow–ups. Similarly, adolescents participating in a safer
sex curriculum were significantly less likely to report engaging in unprotected sexual
intercourse at the 3–month follow–up; this effect was no longer statistically signifi-
cant at the 6– or 12–month follow–ups (Jemmott et al., 1998). All4You! was a 14–ses-
sion program that was conducted during a 6 to 8 week period. We may have seen more
sustained effects if the intervention included booster activities. Some investigators
have found positive results when using booster sessions (e.g., Botvin, Baker, Filazzola,
& Botvin, 1990; Dijkstra, Mesters, DeVries, van Breulelen, & Parcel, 1999; Elder et
al., 1993), whereas others have not (Shope, Dielman, Butchart, Campanelli, &
Kloska, 1992; St. Pierre, Mark, Kaltreider, & Aikin, 1995). None of these studies
198 COYLE ET AL.

TABLE 4. Parameter Estimates for Multilevel Models of Psychosocial Variables

6–, 12–, and 18–Month Follow–Up

Estimated
Outcome (scale range)a Sample Size Group Estimate (SE) p Value Effect Sizeb
Knowledge
HIV and Condom knowledge (0–1)
Overall 934 0.045 (.019) 0.01 0.13
6 months 530 0.052 (.023) 0.03 0.2
12 months 449 0.030 (.024) 0.27 0.12
18 months 411 0.057 (.025) 0.02 0.23
Condom knowledge (0–1)
Overall 940 0.047 (.024) 0.05 0.11
6 months 532 0.055 (.028) 0.05 0.17
12 months 449 0.026 (.029) 0.4 0.09
18 months 411 0.060 (.030) 0.04 0.2
Perceived Self–Efficacy
To get and use condoms (1–4)
Overall 963 –0.025 (.039) 0.52 0.04
6 months 533 0.020 (.050) 0.69 0.04
12 months 455 –0.108 (.053) 0.04 0.19
18 months 411 0.009 (.055) 0.87 0.02
To refrain from having sex (1–4)
Overall 910 –0.094 (.092) 0.31 0.07
6 months 523 –0.004 (.130) 0.97 0.003
12 months 449 –0.184 (.111) 0.1 0.16
18 months 400 –0.030 (.139) 0.83 0.02
Attitudes and Beliefs
General attitudes toward condoms (1–5)
Overall 939 0.031 (.042) 0.46 0.05
6 months 527 0.086 (.061) 0.16 0.13
12 months 451 0.035 (.052) 0.5 0.06
18 months 413 –0.044 (.066) 0.5 0.07
Attitudes about condoms protecting against STDs (1–5)
Overall 916 0.114 (.078) 0.14 0.1
6 months 522 0.032 (.114) 0.78 0.03
12 months 452 0.175 (.097) 0.07 0.17
18 months 410 0.096 (.123) 0.44 0.08
Attitudes about condoms protecting against pregnancy (1–5)
Overall 935 –0.081 (.075) 0.28 0.06
6 months 523 –0.259 (.102) 0.01 0.23
12 months 450 0.106 (.108) 0.33 0.09
18 months 410 –0.051 (.113) 0.65 0.05
Beliefs regarding using condoms when having intercourse (1–5)
Overall 843 –0.046 (.123) 0.71 0.02
6 months 497 –0.259 (.102) 0.01 0.24
12 months 427 –0.099 (.195) 0.61 0.05
18 months 373 0.015 (.208) 0.94 0.007
Normative Beliefs
Perceptions of number of peers who have had sexual intercourse (1–5)
Overall 921 0.010 (.070) 0.89 0.008
6 months 522 –0.098 (.088) 0.27 0.1
12 months 440 0.035 (.092) 0.7 0.04
18 months 399 0.129 (.096) 0.18 0.14
Perceptions of number of peers who use condoms if having sexual intercourse (1–5)
Overall 840 –0.060 (.079) 0.45 0.05
6 months 490 –0.029 (.113) 0.79 0.02
12 months 417 –0.028 (.097) 0.78 0.03
18 months 378 –0.164 (.123) 0.18 0.14
Perceptions of peer beliefs supporting condom use (1–5)
Overall 857 –0.005 (.051) 0.93 0.006
6 months 510 0.048 (.072) 0.51 0.06
12 months 430 –0.028 (.076) 0.71 0.04
18 months 396 –0.048 (.081) 0.56 0.06
Behavioral Intentions
Condom use intentions (1–5)
Overall 764 –0.077 (.051) 0.4 0.06
6 months 413 –0.048 (.121) 0.7 0.04
12 months 366 –0.048 (.126) 0.7 0.04
18 months 327 –0.147 (.132) 0.27 0.13
ALL4YOU! 199

TABLE 4. continued

Estimated
Outcome (scale range)a Sample Size Group Estimate (SE) p Value Effect Sizeb
Sense of Future
Optimism (1–4)
Overall 938 0.060 (.034) 0.08 0.1
6 months 534 0.063 (.044) 0.15 0.13
12 months 451 0.032 (.046) 0.49 0.07
18 months 410 0.088 (.049) 0.07 0.18
Fatalism (1–4)
Overall 918 –0.043 (.044) 0.33 0.06
6 months 529 –0.054 (.059) 0.36 0.08
12 months 446 –0.028 (.063) 0.66 0.04
18 months 406 –0.044 (.066) 0.5 0.07
Connectedness
Community orientation (1–4)
Overall 915 0.045 (.041) 0.28 0.06
6 months 526 0.031 (.052) 0.56 0.05
12 months 446 0.061 (.056) 0.27 0.11
18 months 405 0.046 (.058) 0.43 0.08
Connectedness to a caring adult outside of family (1–4)
Overall 920 0.004 (.048) 0.93 0.005
6 months 531 –0.081 (.062) 0.19 0.12
12 months 447 0.079 (.065) 0.23 0.12
18 months 408 0.038 (.069) 0.58 0.06

Note. All models were adjusted for baseline values and other relevant covariates (e.g., age, gender, ethnicity) that showed
intervention vs. control differences at p < .01 @ one or more time points and had a Wald test p value of < .10. aHigher val-
ues represent more of the assessed attribute. bRepresents Cohen’s d: .2 = small; .5=medium and .8 = large effects.

were conducted with alternative school youth; thus, the findings may or may not
generalize to alternative high school settings.
Alternative school youth also might benefit from a different type of intervention.
Many of these youth are involved in multiple risk behaviors, and their daily lives often
reflect numerous risk factors (e.g., one parent families, substance using friends and
family members, poor academic performance, and lack of parental monitoring). Con-
sequently, these youth might benefit more from a comprehensive intervention ad-
dressing multiple risk behaviors (e.g., Flay, Graumlich, Segawa, Burns, & Holliday,
2004) or from a more intense individualized approach such as prevention case man-
agement (CDC, 1997). Extending the duration of the service–learning component
may have boosted effects as well. Five studies have consistently indicated that service
learning reduces either sexual activity or teen pregnancy (Allen et al., 1997; Melchior,
1998; O’Donnell, Steuve, O’Donnell, et al., 2002; O’Donnell, Steuve, San Doval, et
al., 1999; Philliber & Allen, 1992). Although none of these studies has examined how
many hours of service are needed to achieve positive effects on indicators of sexual
risk taking, all included significantly more hours of service than we were able to
include in All4You!
Contrary to our hypotheses, the intervention had limited impact on the
psychosocial variables stemming from our theoretical model. Others have reported
similar patterns (e.g., Metzler, Biglan, Noell, Ary, & Ochs, 2000; Stanton et al.,
1996). Of all the psychosocial variables assessed, we saw significant increases in
knowledge and marginally significant gains in optimism. Past research has docu-
mented that knowledge is only weakly related to behavior (e.g., Kirby, 2001). Opti-
mism is a protective factor (Carvajal, Garner, & Evans, 1998), but our impact on that
factor was small. This raises questions regarding what contributed to the behavior
change. It is possible that other factors not measured in this study played an important
200 COYLE ET AL.

role in affecting behavior change (e.g., connectedness and rapport with the educa-
tors). For example, during the intervention, the educators and youth often talked indi-
vidually before and after service–learning visits, which provided a unique opportunity
for the educators to help youth personalize the intervention content. The ser-
vice–learning activities also provided a common learning experience in which all indi-
viduals involved were considered “participants,” including the educators. This
common experience and the opportunity to reflect on it jointly may have helped foster
a stronger bond between the educators and students than could normally be formed in
more traditional classroom–based interventions in which the role of “educator” and
“student” are more clearly defined. This connectedness was evident in students’ pro-
gram evaluation data; students also routinely invited the educators to attend special
events (e.g., graduation ceremonies). It is possible that the connectedness with the ed-
ucator may have influenced students’ risk behaviors in the short term. Other studies
support the importance of connectedness with caring adults (Kirby, 2003; Lammers,
Ireland, Resnick, & Blum, 2000; Laursen & Birmingham, 2003), though the
operationalization of the construct varied somewhat from what we measured in
All4You!
If educator connectedness played a role, it is logical their influence would wane
over time with no further contact between the educators and students. Indeed, we
have anecdotal data suggesting that a few students had expressed disappointment to-
ward the end of the program suggesting the educators were like other adults in their
lives who just come and go. We did not formally measure the connectedness or influ-
ence of the educators in this study; consequently, we cannot confirm our speculations
about the potential influence of this construct. This is an important issue to address in
future studies, particularly for groups of youth who do not have interpersonal and in-
stitutional supports ordinarily available to their peers. We have heard many subjective
accounts from community based health educators involved in other projects suggest-
ing that certain personal characteristics, social mannerisms, and presentation styles
attract at–risk youth and motivate them to learn and change. More research could
provide further insight into whether psychological processes, like identification and
role modeling, might be important moderating influences that facilitate participant
learning and program outcomes.
This is one of the first school–based HIV, other STD, and pregnancy prevention
randomized trials with youth in alternative school settings. The pattern of results
suggests prevention intervention programs can have a positive effect on risk behav-
iors, but more is needed to sustain the effects. All4You! was a multi–component in-
tervention featuring skill development and service–learning. Our research design
studied the impact of the combined program. We cannot tease out which of the com-
ponents contributed to the effects. Further research is needed with this population to
test other types of intervention strategies (e.g., small group plus individualized ap-
proaches) and identify ways to sustain effects over time (e.g., through the use of
booster sessions). The movement of youth in and out of alternative school settings
throughout the school year creates challenges for conducting multiyear or booster
interventions. Despite this challenge, this is an important population to reach, and
effective programs can reduce the morbidity and associated economic and
psychological costs of HIV, STDs, and unintended pregnancy.
ALL4YOU! 201

STUDY LIMITATIONS
Several methodological limitations should be noted. The outcome data were collected
using self–report questionnaires that are subject to potential response biases. Using
self–report questionnaires is standard practice for behavioral trials addressing sexual
risk behavior, and some evidence supports the general reliability and validity of ado-
lescents’ reports of sexual and contraceptive behaviors (Brener et al. 2002).
The youth in this study were attending community day schools—a specific type
of alternative school setting. Youth in other alternative school settings (e.g., schools
for pregnant and parenting teens) are likely to differ from the youth in the study
schools. Furthermore, we also experienced a relatively high level of nonparticipation
following the baseline survey (24% of students who completed the baseline were lost
to follow–up) and varying attrition at follow–up. Investigators working with youth in
a different type of alternative setting have found similar rates of attrition. McCuller,
Sussman, Holiday, Craig, and Dent (2002) documented their tracking procedures and
attrition rates for more than 1,800 youth from continuation schools participating in a
randomized trial that tested the effectiveness of Project Towards No Drug Abuse.
Nearly 18% of the students in their study were lost after baseline, and follow–up rates
at any given time point ranged from 66.9% (first follow–up) to 34.6% (last fol-
low–up). The youth in our community day schools often came from continuation
schools and are at greater risk for drop out, which is evident by our slightly higher loss
following baseline. Based on our attrition analyses, students lost to follow–up were
more likely to be male, older, and on probation; however, almost no statistically sig-
nificant differences were found in sexual risk–taking behaviors between students re-
tained in the cohort and those lost to follow–up. Students in the intervention
condition were slightly older than students in the control condition. However, we saw
no statistically significant differences at baseline in sexual risk behaviors, suggesting
the differences in baseline age did not have a strong influence on sexual risk outcomes.
Finally, we did not correct the statistical procedures for multiple testing. We did
specify all hypotheses a priori; however, it is always possible that some of the signifi-
cant results were due to chance. The overall pattern of results—a pattern that suggests
the intervention had modest short–term effects in the expected direction for numerous
key behavioral outcomes—supports the existence of a true effect. Given the consis-
tency of this general pattern, we are confident the results are not attributable to chance
alone.

CONCLUSION
The All4You! intervention was effective in reducing selected sexual risk behaviors
among youth in alternative school settings, thereby reducing these youth’s risk for
HIV, other STDs, and unintended pregnancy; however, the effects were modest and
short term. This study represents one of the first randomized trials to address sexual
risk behaviors with youth in alternative school settings. It suggests that a theoretically
based intervention that addresses norms, teaches skills, and features service learning
to enhance positive involvement in the community can promote safer sexual behav-
iors. It also suggests, however, that more research is needed to extend and sustain pro-
gram effects, with particular attention to the role that interpersonal and institutional
support play for alternative school students. Finally, given the transient nature of this
population, researchers working in alternative school settings should allow ample
resources for tracking and study follow–up.
202
REFERENCES
Ajzen, I. (1991). The theory of planned behavior.
Organizational Behavior and Human Deci-
sion Processes, 50, 179–211.
Allen, J.P., Philliber, S., Herrling, S., & Kuperminc,
G.P. (1997). Preventing teen pregnancy and
academic failure: Experimental evaluation of
a developmentally based approach. Child
Development, 68, 729–742.
Bandura, A. (1986). Social foundations of thought
and action: A social cognitive theory.
Englewood Cliffs, NJ: Prentice Hall.
Botvin, G.J., Baker, E., Filazzola, A.D., & Botvin, E.
(1990). A cognitive–behavioral approach to
substance abuse prevention: One–year fol-
low–up. Addictive Behaviors, 15, 47–63.
Brener, N.D., Kann L., McManus T., Kinchen S.A.,
Sundberg E.C., & Ross, M.S. (2002). Reli-
ability of the 1999 youth risk behavior survey
questionnaire. Journal of Adolescent Health,
31, 336–342.
Carvajal, S.C., Garner, R.L., & Evans, R. I. (1998).
Dispositional optimism as a protective factor
in resisting HIV exposure in sexually active
inner–city minority adolescents. Journal of
Applied Social Psychology, 28(23),
2196–2211.
Centers for Disease Control and Prevention. (1997).
HIV prevention case management: Guid-
ance. Atlanta, GA: Author.
Coyle, K., Basen–Engquist, K., Kirby, D., Parcel, G.,
Banspach, S., Collins, J. et al. (2001). Safer
Choices: Reducing teen pregnancy, HIV, and
STDs. Public Health Reports, 116(Suppl. 1),
82–93.
Dijkstra, M., Mesters, I., De Vries, H., van
Breulelen, G., & Parcel, G. (1999). Effective-
ness of a social influence approach and
boosters to smoking prevention. Health Edu-
cation Research, 14(6), 791–802.
Elder, J.P., Wildey, M., de Moor, C., Sallis, J.,
Eckhardt, L., Edwards, C., et al. (1993). The
long–term prevention of tobacco use among
junior high school students: Classroom and
telephone interventions. American Journal of
Public Health, 83(9), 1239–1244.
Fishbein, M., & Azjen, I. (1975). Belief, attitude, in-
tention, and behavior: An introduction to
theory and research. Reading, MA: Addi-
son–Wesley.
Flay, B.R., Graumlich, S., Segawa, E., Burns, J.L., &
Holliday, M.Y. (2004). Effects of 2 preven-
tion programs on high–risk behaviors among
African American youth. Archives of Pediat-
ric and Adolescent Medicine, 158, 377–384.
Gillmore, M.R., Morrison, D.M., Richey, C.A.,
Balassone, M.L., Gutierrez, L. & Farris, M.
(1997). Effects of a skill–based intervention
COYLE ET AL.
to encourage condom use among high risk
heterosexually active adolescents. AIDS Ed-
ucation and Prevention, 9(1), 22–43.
Grunbaum, J., Kann, L., Kinchen, S., Ross, J.,
Gowda, V., Collins, J., et al. (1999). Youth
Risk Behavioral Surveillance—national al-
ternative school youth risk behavior survey,
United States, 1998. Morbidity and Mortal-
ity Weekly Report, 48(SS–7), 1–44.
Grunbaum, J.A., & Basen–Engquist, K. (1993).
Comparison of health risk behaviors be-
tween students in a regular high school and
students in an alternative high school. Jour-
nal of School Health, 63(10), 421–425.
Hawkins, J.D. & Weiss, J.G. (1985). The social de-
velopment model: An integrated approach to
delinquency prevention. Journal of Primary
Prevention, 6(2), 72–97.
Hubbard, B.M., Giese, M.L., & Rainey, J. (1998). A
replication of Reducing the Risk, a the-
ory–based sexuality curriculum for adoles-
cents. Journal of School Health, 68(6),
243–247.
Jemmott, J.B., III, Jemmott, L.S., & Fong, G.T.
(1992). Reductions in HIV risk–associated
sexual behaviors among black male adoles-
cents: Effects of an AIDS prevention inter-
vention. American Journal of Public Health,
82(3), 372–377.
Jemmott J.B. III, Jemmott L.S., & Fong G.T. (1998).
Abstinence and safer sex: A randomized trial
of HIV sexual risk–reduction interventions
for young African–American adolescents.
Journal of the American Medical Associa-
tion, 279(19), 1529–1536.
Kirby, D. (2001). Emerging answers: Research find-
ings on programs to reduce sexual risk–tak-
ing and teen pregnancy. Washington, DC:
National Campaign to Prevent Teen
Pregnancy.
Kirby, D. (2003). Risk and protective factors affect-
ing teen pregnancy and the effectiveness of
programs designed to address them. In D.
Roper (Ed.), Reducing adolescent risk: To-
ward an integrated approach (pp. 265–283).
Thousand Oaks: CA, Sage.
Kirby, D., Barth, R.P., Leland, N., & Fetro, J. V.
(1991). Reducing the Risk: Impact of a new
curriculum on sexual risk–taking. Family
Planning Perspectives, 23(6), 253–263.
Kleiner, B., Porch, R., & Farris, E. (2002). Public al-
ternative schools and programs for students
at risk of education failure: 2000–01(NCES
2002–004). U.S. Department of Education.
Washington, DC: National Center for Edu-
cation Statistics.
ALL4YOU!
Lammers, C. Ireland, M., Resnick, M., & Blum, R.
(2000). Influences on adolescents’ decision to
postpone onset of sexual intercourse: A sur-
vival analysis of virginity among youths aged
13 to 18 years. Journal of Adolescent Health,
26(1), 42–48.
Laursen, E.K., & Birmingham, S.M. (2003). Caring
relationships as a protective factor for at–risk
youth: An ethnographic study. Families in
Society, 84(2), 240–246.
Magura, S., Kang, S., & Shapiro, J.L. (1994). Out-
comes of intensive AIDS education for male
adolescent drug users in jail. Journal of Ado-
lescent Health, 15, 457–463.
Main, D.S., Iverson, D.C., McGlin, J., Banspach,
S.W., Collins, K., Rugg, D. et al. (1994). Pre-
venting HIV infection among adolescents:
Evaluation of a school–based education pro-
gram. Preventive Medicine, 23, 409–417.
McCuller, W.J., Sussman, S., Holiday, K., Craig, S.,
& Dent, C.W. (2002). Tracking procedures
for locating high–risk youth. Evaluation and
the Health Professionals, 25(3), 345–362.
Melchior, A. (1998). National evaluation of Learn
and Serve America school and community
based programs: Final report executive sum-
mary, Corporation for National Service,
Washington, DC.
Metzler, C.W., Biglan, A., Noell, J., Ary, D. V. &
Ochs, L. (2000). A randomized controlled
trial of a behavioral intervention to reduce
high–risk sexual behavior among adolescents
in STD clinics. Behavior therapy, 31, 27–54.
O’Donnell, L., Stueve, A., O’Donnell, C., Duran, R.,
San Doval, A. Wilson, R., et al. (2002).
Long–term reductions in sexual initiation
and sexual activity among urban middle
schoolers in the Reach for Health ser-
vice–learning program. Journal of Adoles-
cent Health, 31, 93–100.
O’Donnell, L., Stueve, A., San Doval, A., Duran, R.,
Haber, D., Atnafou, R., et al. (1999). The ef-
fectiveness of the reach for health community
service–learning program in reducing early
and unprotected sex among urban middle
school students. American Journal of Public
Health, 89(2), 176–181.
O’Hara, P., Messick, B.V., Fichtner, R.R., & Parris,
D. (1996). A peer–led AIDS prevention pro-
gram for students in an alternative school.
Journal of School Health, 66 (5), 176–182.
O’Hara, P., Messick, B.J., Kennedy, M.G., &
Zinkin, J.R. (1994). Sexual behaviors and
drug use among youth in dropout–preven-
tion programs — Miami, 1994. Morbidity
and Mortality Weekly Report, 43(47),
873–876.
203
Philliber, S., & Allen, J.P. (1992). Life options and
community service: Teen Outreach Program.
In B.C. Miller, J.J. Card, R.L. Paikoff, & J.L.
Peterson (Eds.), Preventing adolescent preg-
nancy: Model programs and evaluations (pp.
139–155). Newbury Park, CA: Sage.
Rasbash, J., Browne, W., Healy, M., Cameron, B. &
Charlton, C. (2001). MLwiN Software Ver-
sion. 1.10.0007. London: University of Lon-
don, Multilevel Models Project, Institute of
Education.
Rosenthal, R., & Rosnow, R.L. (1991). Essentials of
behavioral research: Methods and data anal-
ysis (2nd ed.). New York: McGraw Hill.
Shope, J.T., Dielman, T.E., Butchart, A.T.,
Campanelli, P.C., & Kloska, D.D. (1992).
An elementary school–based alcohol misuse
prevention program: a follow–up evaluation.
Journal of Studies on Alcohol, 53, 106–121.
Stanton, B. F., Ziaoming, L., Ricardo, I., Galbraith,
J., Feigelman, S., & Kaljee, L. (1996). A ran-
domized, controlled effectiveness trial of an
AIDS prevention program for low–income
African–American youths. Archives Pediat-
rics and Adolesent c Medicine, 150,
363–372.
St. Lawrence, J.S., Jefferson, K.W., Alleyne, E., &
Brasfield, T.L. (1995). Comparison of educa-
tion versus behavioral skills training inter-
ventions in lowering sexual HIV risk
behavior of substance dependent adoles-
cents. Journal of Consulting and Clinical
Psychology, 63(2), 221–237.
St. Lawrence, J.S., Crosby, R.A., Belcher, L,
Yazdani, N., & Brasfield, T.L. (1999). Sex-
ual risk reduction and anger management in-
terventions for incarcerated male
adolescents: A randomized controlled trial of
two interventions. Journal of Sex Education
and Therapy, 24, 9–17.
St. Lawrence, J., Crosby, R., Brasfield, T., &
O’Bannon, R. (2002). Reducing STD and
HIV risk behavior of substance–dependent
adolescents: A randomized controlled trial.
Journal of Consulting and Clinical Psychol-
ogy, 70(4), 1010–1021.
St. Pierre, T.L., Mark, M.M., Kaltreider, D.L, &
Aikin, K.J. (1995). A 27–month evaluation
of a sexual activity prevention program in
boys & girls clubs across the nation. Family
Relations, 44, 69–77.
Weller, N.F., Tortolero, S.R., Kelder, S.H.,
Grunbaum, J.A., Carvajal, S.C. & Gingiss,
P.M. (1999). Health risk behaviors of Texas
alternative school students attending drop-
out prevention/recovery schools in 1997.
Journal of School Health, 69(1), 22–28.