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Background Although schools often implement evidence-based sexual health education programs to address sexual and reproductive health disparities, multiple factors may influence program effectiveness. Methods Using student-reported perceived impact measures as a proxy for program effectiveness, we employed a socio-ecological approach to examine student, teacher, school, and district factors associated with greater perceived impact of It's Your Game (IYG), an evidence-based middle school sexual health education program. The student sample was 58.7% female, 51.8% Hispanic, mean age 13.2 years, from 73 middle schools. We assessed students' (N = 4531) perceived impact of IYG on healthy decision-making (α = 0.75) and sexual communication (α = 0.71); satisfaction with IYG activities and teacher; and demographics. We assessed teachers' (N = 56) self-efficacy to teach IYG, perceived administrative support, implementation barriers, and demographics. School and district data were abstracted from state records. We used multilevel logistic regression to estimate associations between independent variables and student-reported perceived impact. Results In final multivariate models, students' demographics (sex, β = 0.06, SE = 0.015), satisfaction with IYG (β = 0.21, SE = 0.012), and their IYG teacher (β = 0.18, SE = 0.013) (all p = .000) were significantly associated with perceived impact on healthy decision-making. Similar findings resulted for sexual communication. No other variables were significantly associated with perceived impact. Conclusions Helping schools select age-appropriate, culturally relevant programs, and facilitate supportive learning environments may enhance the perceived impact of sexual health education programs.

Although adolescent pregnancy rates have declined steadily in the United States over the past decade, adolescent births and sexually transmitted infections (STIs) remain serious public health issues. In 2006, births to mothers aged 15-19 years increased for the first time since the early 1990s.1 In 2000, youth between the ages of 15 and 24 accounted for 9.1 million (48%) of all new STI cases.2 Minority youth are disproportionately affected. Birth rates among Hispanic and black teens remain higher than other racial/ethnic groups, including rates among those aged 10-14 years.1 Although black teens represent only 17% of US teenagers, they account for 70% of HIV/AIDS cases reported among teens.3 Early sexual initiation has been associated with an increased risk of pregnancy and STI.4-6 Youth who initiate vaginal intercourse at age 14 or younger are more likely to have multiple lifetime sexual partners, engage in greater frequency of sex, use alcohol or drugs before sex, and have sex without a condom compared to youth who initiate sex at an older age.5-8 Some adolescents engage in oral or anal intercourse as perceived less risky alternatives to vaginal sex;9-13 however, both have been implicated in the transmission of nonviral and viral STIs.13-15 In order to develop effective pregnancy and STI prevention efforts for early adolescents (aged 11-14 years), it is important to understand the prevalence of vaginal, oral, and anal intercourse in this age-group and the characteristics of early initiators. It is also helpful to understand the sequence of initiation of these different types of sexual behavior to ensure that interventions are relevant to youth’s needs. However, public sensitivity regarding sexual behavior surveys among early adolescents, particularly in public school settings, has impeded this research. Active parental consent is typically required, and parents and school administrators may be reluctant to expose students to explicit questions regarding sexual behavior, particularly those regarding oral and anal sex. In the 2003 Middle School Youth Risk Behavior Surveillance Survey (MSYRBS) (grades 6-8 and roughly ages 11-13), 6 of 8 states administered items on sexual behavior. Across states, the percentage of seventh graders who reported ever having “sexual intercourse” (implicitly vaginal sex) ranged from 6.6% to 31.2%, with a median of 15.6%. Of those students, between 3.2% and 13.2% (median 8.5%) reported having 3 or more sexual partners.16 Other studies have examined sexual behavior among middle school students;5,6,17-21 however, few have included examination of oral and anal intercourse, and none have examined the sequence of initiation of types of sexual behavior among early adolescents. Previous studies among older adolescents report contrasting findings regarding the sequence of sexual initiation. Several studies among 9th- and 10th-grade students indicate earlier initiation of oral sex compared to vaginal sex.11,22 In contrast, data from the 2002 National Survey of Family Growth (NSFG) among 15- to 19-year-olds indicate greater likelihood of initiating vaginal sex prior to other types of sex. The NSFG data also indicate significant differences in sexual behavior by racial/ethnic group and by socioeconomic status with white and higher socioeconomic status teen more likely to engage in oral and anal sex than their peers.23 However, it is unclear whether patterns of sexual activity and initiation among older adolescents accurately reflect patterns among younger teens, who become sexually active. Given this lack of detailed information, further epidemiological studies examining sexual behavior among middle school youth are needed to help prioritize effective sexual health education efforts. The goals of the present study were to (1) examine the prevalence of vaginal, oral, and anal intercourse among a population of urban, public middle school seventh-grade students; (2) to examine the demographic characteristics of those youth who engaged in each type of sexual intercourse, and (3) to examine the sequence of initiation of the 3 types of sexual intercourse. This information may help to prioritize needs for middle school sexual health education to prevent or mitigate the consequences of early sexual initiation among potentially high-risk youth populations.