• Focused narrowly on reducing sexual risk-taking;
• Were based on a theory of behavior change;
• Were at least 14 hours long or involved intense small-group exercises;
• Used teaching methods that involved the students;
• Provided basic, accurate information about the risks of unprotected intercourse and ways to protect oneself;
• Addressed social pressure to be sexually active;
• Reinforced clear values and presented messages that strengthened individual values and group norms against unprotected sex;
• Modeled and practiced communication and negotiation skills; and
• Trained the individuals who conducted the program.

Based on a theory of behavior change. The four programs with a positive impact on sexual or contraceptive behavior were based on social learning theory, social influence theories, or theories of reasoned action. Social learning theory posits that people learn behavior by observing and imitating others as well as through formal education. Social influence theories suggest that, because behavior is shaped by group and individual norms and attitudes, it is helpful for people to identify social pressures and then to develop individual and group values that support healthy and appropriate behavior. Theories of reasoned action assert that people's intention to adapt new behavior reflects their own beliefs and expectations and perceived social norms.

Rather than teach young people to "just say no," programs based on these theories assume that the decision to have sex may be an individual's choice but is influenced by the social setting. Although young people may seem to be choosing sex, some may in fact have sex because, for example, they are afraid to refuse, crave affection, fear hurting their partners' feelings, or need or want the money or gifts that they receive. Thus the successful US school programs focus on recognizing social influences, changing individual values and group norms, and building social skills (258).

Program content. The four programs all gave students the basic information they needed about sexual health risks and also told them exactly how to protect themselves (258). In a Mexican study as well, students who took FLE courses that presented accurate, specific information about contraceptives and pregnancy prevention were more likely to use contraceptives than those who took courses that avoided these often-controversial subjects. Among students whose courses covered ways of preventing pregnancy, the percentage of sexually active youth who used contraceptives increased from 20% to 70%. Among sexually active students who received information on where to obtain contraceptives, the percentage of students who used contraceptives rose from 42% to 81%. Students whose courses did not cover these topics reported less or no increase in contraceptive use (378). The content of the four US programs that changed behavior also focused on the social pressure on students to be sexually active and on age-appropriate values and skills to help them remain abstinent or to negotiate safer sex.

Program design and methods. The four programs used a variety of methods to involve students and help them practice new responses to situations that might lead to unsafe sex (258). In the "Reducing the Risk" program, students discussed ways that they might be pressured into having intercourse and learned techniques for handling or avoiding such situations. Then, through role-playing exercises they practiced these interpersonal skills (44).

Other programs also have found that involving students actively in learning has greater influence on their behavior than simply lecturing (262, 448). For example, research in Zimbabwe compared a lecture on AIDS with a skills-building session that involved putting a condom on a model and practicing negotiation of condom use. Four months later the young people who took the skills-building course knew more about condoms and their correct use, perceived fewer barriers to action, and had had fewer sexual partners than those who had only heard the lecture (528).

The US programs that led to safer behavior were all at least 14 hours long or involved students in small-group exercises (258). So far, few studies have compared teaching strategies to determine which are most effective at changing behavior.

Emphasis on training. The four US programs with effective curricula provided six hours to three days of training for the teachers and peer educators who taught the courses (258). Here again, there has been little research evaluating training methods and curricula. There are many examples, however, of programs that have failed because teacher training was neglected. In developing-country programs teachers have resisted teaching such courses because they object to the material, feel pressed for time, or feel unprepared to teach the subject (97, 320, 344, 363, 425). Thus, some teacher training courses, such as one in Ethiopia, deal first with improving the attitudes of the teachers who do not want to teach family life material (198).

Unless school FLE programs focus their coverage on specific information and skills, adopt an interactive or skills-building approach to teaching, and train personnel, they are unlikely to change behavior in and of themselves. Increasing knowledge and improving attitudes may be the most reasonable goals for FLE school programs that use only lectures. After all, as Kirby points out, other academic programs that rely on classroom presentations use examination scores, not reports of student behavior outside school, to measure their effectiveness (259). Research has been too limited, however, to assure that all the successful approaches have been identified. The crucial characteristics that distinguish successful programs need to be further identified, refined, adapted to other places and cultures, and tested again. At the same time, program planners and advocates can learn important lessons from others' experience (see sidebar, Lessons Learned: Ten Tips for Serving Young Adults).