Attachment A

ATTACHMENT A

PPA INSTRUMENT

QUESTION-BY-QUESTION JUSTIFICATION

Question #		How question data will be used				Purpose
		Covariate	Subgroup	Intermediate outcome	Behavioral Outcome
SECTION 1. YOU AND YOUR BACKGROUND
1.1	Date of birth					There are marked differences in sexual activity among teens by age, gender, and race/ethnicity. These differences in sexual behavior are reflected in the large differences in reproductive outcomes such as the pregnancy, birth and abortion rate by teens' age and race. (Browning et. al. 2004; Abma et. al. 2004; Guttmacher 2006; Santelli et. al. 2000; Blinn-Pike 1999; Watt and Nagy 2000)
1.3	Gender		
1.4-1.5	Race and ethnicity		
1.2	Grade level					This question is important to determine in what grade the respondent entered the pregnancy prevention program.
1.6	Primary language					Acculturation has been linked to initiation of sexual activity and to teen fertility among Hispanic youth. One of the measures often used in the literature as a proxy for acculturation among first or later generation Hispanic immigrants is language spoken at home or with friends. (Adam et. al. 2005; Afable-Munsuz and Brindis 2006; Aneshensel et. al. 1990)
1.7-1.8	Importance of religion					Religiosity has been linked to later initiation of sexual activity among teens. While some of the link between religiosity and sexual behavior can be explained by the relationship between religiosity and a more conservative attitude towards sex, there seems to be a somewhat reduced but significant direct relationship between religiosity and initiation of first intercourse. (Rostosky et. al. 2004; Meier 2003; Rostosky et. al. 2003)
1.9	Exposure to health education					These questions will be used to control for teens’ previous exposure to the messages presented in the program under evaluation.
1.10	Extracurricular activities					Participation in extracurricular activities is has been linked to teen sexual activity. Some extracurricular activities are associated with less risky sexual behavior and a later onset of intercourse, while others, such as sports are associated with a higher reported rate of sexual experience among male adolescents. (Feldman and Matjasko 2005)
1.11	Expectation for future education					There is an extensive literature that shows that positive expectations for future education lead to delayed sex, decreased frequency of sex, a decreased number of partners, an increase in condom use, and decreased pregnancy and childbearing. (Beuhring et al., 2000, Halpern, et al., 2000, Lanctot, et al., 2001, Moore, et al., 1998)
SECTION 2. FAMILY
2.1-2.2	Household structure/living situation/ marital status of parents					There is a well established link between family structure and the probability that youth will engage in sexual activity. While some researches argue that this relationship can be explained by mediating factors such as mother-child relationship and mother's attitude toward sex, others argue that there is a direct link, independent of such mediating factors. (Sturgeon 2008; Davis and Friel 2001; Pearson et al 2006)
2.3-2.4	Family routines					Among young women and non-Latino white adolescents shared dinnertime with parents is significantly and independently related to sexual initiation (Pearson, Muller, & Frisco, 2006). Family routines have also been found to be protective against early sexual debut for low-income adolescent boys (Lohman & Billings, 2008).
2.5-2.8 2.13-2.16	Parents’ education and employment status					These questions will be used to construct indicators of socioeconomic status, which will serve as control variables. Socioeconomic status is correlated with the probability that youth will engage in sexual and other high-risk behaviors. (Forste and Haas 2002; Santelli et al 2000; Miller et al 2001)
2.9-2.10 2.17-2.18	Parent-child relationship quality					There is an extensive literature evaluating the relationship between parent-child connectedness and teen sexual activity. All but a few studies indicate that parent-child closeness is negatively associated with pregnancy risk, early sexual initiation, number of sexual partners and consistent use of contraception. (Miller et al 2001)
2.11-2.12, 2.19-2.20	Perceptions of parents’ values about teen sex					Perceived maternal and paternal disapproval of teen sexual activity is associated with a delay in sexual intercourse, and lower frequency of sex among teens. (Miller et al 2001; Dittus and Jaccard 2000; Watts and Nagy 2000)
2.21-2.24	Parental supervision/ monitoring					These questions will be used to measure the perceived level of parental supervision. Parental monitoring and supervision have been found to be inversely related to a number of problem behaviors among adolescents, including early sexual debut, number of sexual partners, & pregnancy risk. (Miller et al 2001; Rodgers 1999; Li et al 2000; Sieverding et al 2005)
2.25	Communication with parents about sex					The literature on the relationship between parent-child communication about sex and teen sexual behavior is mixed. Some studies indicate that it is a protective factor, while others find that it is a risk factor. Results also vary depending on whether the communication is reported by the parent or the teen. However, we expect that certain programs will focus on this measure and view it as an important mediating outcome. (Miller et al 2001; Pearson et al 2006)
SECTION 3. VIEWS AND PERCEPTIONS
3.1	Attitudes towards abstinence and teen sex					Teens’ attitudes about sex and abstinence are associated with the intension to have sex and with early initiation of sexual activity, where a more positive/less permissive attitude towards sex serves as a protective factor. (Buhi and Goodson 2007; Gillmore et al 2002; Carvajal et al 1999; Cleveland 2003; DiIorio et al 2004; Meier 2003; )
3.2	Attitudes towards teen pregnancy					Teens with a more positive attitude towards pregnancy are more likely to become pregnant. Attitudes towards teen pregnancy are also related to contraceptive use among females, where those with a higher motivation to avoid pregnancy are more likely to use contraception. (Ryan et al 2007; Bruckner et al 2004; Jaccard et al 2003;)
3.3	Refusal skills					Adolescent males who received instruction on “how to say no to sex” as part of an AIDS education were more likely to use a condom, had fewer sexual partners and a lower frequency of sexual intercourse. (Ku et al 1992)
3.4	Attitudes towards contraception					Positive attitude towards contraception has been linked to an increased likelihood of contraceptive use among sexually active adolescents (inconsistent and consistent use as opposed to no use). Therefore, programs that can successfully shape teens’ attitude towards contraception are likely to reduce the risk of pregnancy and STDs among sexually active youth. (Bruckner et al 2004; Sheeran et al 1999; Ryan et al 2007)
3.5-3.11	Knowledge of STDs and the effectiveness of contraceptives in reducing risk and teens’ confidence in their knowledge					Findings on the relationship between knowledge of STDs and prevention and teen sexual activity are inconsistent. However, according to Rock et al 2005, this might be due to the fact that prior studies focused on objective knowledge, and ignored teen’s confidence in their knowledge. (Rock et al 2005; Boyer et al 1999; DiClemente et al 1996; DiClemente et al 1992)
3.12-3.14	Intention to engage in / abstain from sexual activity					Intention to engage in sexual activity is the single most stable predictor of initiation of sexual intercourse and of participation in sexual behavior. (Buhi and Goodson 2007)
3.15-3.16	Dating status					Dating during early adolescence is associated with an increased likelihood of sexual initiation in adolescence. At the same time more than half of sexually active teens had at least one sexual experience outside of a romantic relationship (Thornton 1990; Cooksey et. al. 2002; Manning et. al. 2005).
3.17	Ever had sex					This question will be used to identify teens with and without prior sexual experience. Sexually inexperienced teens will receive an alternate version of Section 4 of the questionnaire and will not be asked about sexual activity.

SECTION 4. EXPERIENCES AND BEHAVIORS – SEXUALLY ACTIVE (only questions that appear in the version for sexually active teens are listed below)
4.1-4.6, 4.14-4.15	Initiation of sexual activity					These are the primary outcome measures for the study. They will be used to control for baseline sexual experiences. Furthermore, baseline sexual activity will be used to stratify the sample and to allow differential program impact among the sexually experienced and inexperienced teens at baseline.
4.9-4.11, 4.17, 4.19, 4.21,4.23	Frequency of sexual activity				
4.10, 4.11,4.16, 4.20	Number of sexual partners				
4.7-4.8, 4.12-4.13, 4.18, 4.22	Contraceptive use				
4.24c,4.25b	Pregnancy				
4.26-4.29	STDs				
4.24-4.25	Physical Maturity					Early physical maturity has been linked to higher reported levels of sexual activity. (Moore et al. 1995)
4.30	Sexual victimization					Sexual victimization is associated with age at first intercourse, number of sexual partners, as well as STD history among adolescent girls. (Davis and Friel 2001; Upchurch and Kusunoki 2004)
4.31	Dating violence					The literature on the link between physical abuse by a partner and risky sexual activity is mixed. However, reducing dating violence is a common feature of sex education programs. This question will be used to construct a measure of dating violence that will serve as a behavioral outcome for certain programs. (Manlove, et al., 2004, Silverman, et al. 2004, Yarber and Milhausen, 2002; Manlove, et al., 2003, Manlove, et al., 2004, Yarber and Milhausen, 2002).
SECTION 4. EXPERIENCES AND BEHAVIORS – NON-SEXUALLY ACTIVE (only questions that do not appear in the version for sexually active teens are listed below)
4.4-4.10	Household structure/Living Situation					For a description of the importance of the questions on household structure/living situation see question 2.1. These additional questions are designed to inform how well question 2.1 works for the population of youth we are targeting.
4.11	Peer support					See question 6.1.
4.12	Diligence					This question will be used to construct a measure of diligence. Diligent adolescents are hard working and dependable and are more likely to be good students who avoid risky behaviors. (Small and Luster, 1994).
4.13	Perceived costs and benefits of teen sex					These questions will be used to construct measures of perceived benefits and costs of having sex at an early age. Baseline measures will be used as control variables in the impact models and as subgroup identifiers to help us determine the mechanisms through which and for whom the programs are beneficial. (Moore et al 1995a; Moore et al 1995b; Olsen and Farkas 1990; Olsen et al 1991).
4.16	Pre-sexual romantic behaviors					Pre-sexual behaviors such as kissing and petting are mediating factors that increase the chances that youth will engage in sexual activity. (Thornton 1990)
4.20	Intention to use a condom					Intention to use a condom in the future has been linked to an increased likelihood of condom use. (Sheeran et al 1999)
SECTION 5. TOBACCO, ALCOHOL AND DRUG USE
5.1-5.3	Smoking					The consumption of cigarettes, alcohol and drug use among adolescents is associated with early initiation of sexual activity as well as sexual risk taking. While much of the association can be explained by common risk factors that predispose teens to both alcohol misuse and risky sexual behavior, there exists a direct link between alcohol consumption and post-drinking risky sexual behavior. This direct link is strongest among teens who expect alcohol consumption to lead to risky sex. (Tapert et al 2001, Li et al 2001, Boyer et al 1999; Fergusson and Lynskey 1996; Sen 2002; Dermen 1998 et al; Santelli et al 2001).
5.4-5.7	Alcohol consumption	
5.8-5.12	Drug use	
SECTION 6. FRIENDS AND RELATIONSHIPS
6.1	Peer support					There is a rich body of research pointing to a strong association between teens' behavior and the behavior or the perceived norms of their peers. While some of this observed relationship is the result of teens selecting peers who have similar values, a weaker, but stable relationship remains after taking into account the selection process. These questions will allow us to identify teens under a possible positive or negative influence of their peers as well as the level of involvement with friends. (Jaccard et al 2005; Buhi and Goodson 2007; Kinsman et al. 1998; Sieving et al 2006)
6.2-6.3	Perceived norms/behavior of peers	
6.4	Peer pressure	
6.5	Sexual orientation					Some studies have shown that same-sex attraction or behavior is a risk factor for increased initiation of sex, an increased number of sexual partners, and an increased risk of pregnancy. Others have shown that same-sex attraction or behavior leads to a decrease in the initiation of sex and an increase in condom use. One study has found that it is not a significant predictor of these behaviors. The differences in findings may be due to differences in methodology and differences in the youth sampled. This question will be important to control for baseline differences in sexual orientation, and to evaluate differential program impacts for gay, lesbian and bisexual youth. (Blake, et al. 2001, Goodenow et al., 2002; Resnick, et al., 1998, Magura, et al. 1994; Raj, et al. 2000).

SUPPORTING REFERENCES FOR INCLUSION OF SPECIFIC QUESTIONS

OR GROUPS OF QUESTIONS

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