Reducing the Risk (RTR)

High school students

Reducing the Risk (RTR): Building Skills to Prevent Pregnancy, STD & HIV is a 16-session pregnancy and human immunodeficiency virus (HIV)/sexually transmitted disease (STD) prevention curriculum designed to help high school age youth delay the initiation of sex or increase the use of protection against pregnancy and STD/HIV if they choose to have sex. RTR addresses skills such as risk assessment, communication, decision making, planning, refusal strategies and delay tactics. The program is based upon several interrelated theoretical models: Social Learning Theory, Social Inoculation Theory, and Cognitive-Behavior Theory. The program content strives to be medically accurate, inclusive to lesbian, gay, bisexual, and transgender (LGBT) youth, and trauma-informed.

ETR Customer Service

• Agency/Affiliation: ETR
• Website: https://www.etr.org/ebi/programs/reducing-the-risk/
• Email: customerservice@etr.org
• Phone: (800) 321-4407

The goals of Reducing the Risk (RTR) are:

• Prevent becoming pregnant or causing someone to become pregnant
• Prevent acquiring or transmitting HIV and other STDs
• Able to evaluate and personalize the risks and lasting consequences of becoming an adolescent parent or becoming infected with HIV or another STD
• Recognize that abstaining from sexual activity or using contraception are the only ways to avoid pregnancy
• Recognize that abstaining from sexual activity or using condoms and other safer sex practices are the only ways to avoid HIV and other STD
• Demonstrate effective communication skills, including refusal skills, for remaining abstinent and for avoiding unprotected sexual intercourse
• Access health care information and contraception (including condoms)
• Able to communicate with parents or other adults about teen sexual activity, protection, and birth control

The essential components of Reducing the Risk (RTR) include:

• Implemented in a classroom or other group setting
• Sixteen 45- to 60-minute classes, ideally conducted 2 to 3 times per week
• Lessons must be taught in sequence
• Ideal group size between 10 and 30 youth
• Sessions consist of:
  • Group discussions of key concepts
  • Games to illustrate pregnancy and/or STD/HIV risk
  • Small-group work
  • A risk continuum exercise
  • Condom demonstration and practice
  • Multiple roleplays that allow youth to practice refusal and safer-sex negotiation skills and receive coaching and feedback
• The following program materials are provided:
  • Teacher’s Guide
  • Student Workbooks (comes with a classroom set of 30)
  • Activity Kit, with posters, risk cards and roleplay cards
  • STD Facts for Teens pamphlets
  • HIV Facts for Teens pamphlets
  • Birth Control Facts for Teens pamphlets
• The Teacher’s Guide for the curriculum provides:
  • Detailed steps for leading each activity
  • Demonstration role-play scripts
  • Teacher background information
  • Preparation steps for each session
  • An outline of activities that gives approximate time and needed materials for each part of the lesson
• The Student Workbooks contain all of the student activity sheets for the program.

Child/Adolescent Services

Reducing the Risk (RTR) directly provides services to children and addresses the following:

• Lack of knowledge of risk of getting pregnant or contracting HIV/STD, lack of knowledge about types of contraception, poor communication skills around the topic of sexual intercourse

Recommended Intensity

At least sixteen 45- to 60-minute classes, ideally conducted 2 to 3 times per week. Most lessons can be expanded up to two full class periods to allow more time for skills practice and discussion, if desired.

Recommended Duration

8 weeks if sessions are conducted twice a week

Delivery Settings

This program is typically conducted in a(n):

• Community-based Agency / Organization / Provider
• School Setting (Including: Day Care, Day Treatment Programs, etc.)

Homework

This program does include a homework component.

There are three homework assignments in the curriculum: talking with parents/guardians, visiting or calling a clinic, and a shopping information homework assignment in which students research availability and costs of condoms and spermicides at local stores.

Languages

Reducing the Risk (RTR) has materials available in the following languages other than English:

• Spanish

For information on which materials are available in this language, please check on the program's website or contact the program representative (contact information is listed in this page).

Resources Needed to Run Program

The typical resources for implementing the program are:

• Classroom or other meeting space
• Trained facilitator(s) comfortable with presenting sexual health topics, answering questions and leading discussions with teens
• RTR curriculum materials

Prerequisite/Minimum Provider Qualifications

Facilitators for RTR should be comfortable with presenting sexual health topics, answering questions and leading discussions with teens. A 3-day Training of Educators is available through ETR: http://www.etr.org/ebi/training-ta/types-of-services/training-of-educators. In addition, educators interested in implementing RTR should be skilled in using interactive teaching methods and guiding group discussions. It is highly recommended that educators who plan to teach RTR receive research-based professional development to prepare them to effectively implement and replicate the curriculum with fidelity for the intended target group.

Manual Information

There is not a manual that describes how to deliver this program.

Training Information

There is training available for this program.

Training Contact

Training Type/Location:

ETR offers on-site training for schools and agencies with a minimum of 10 participants. Sites with fewer than 10 participants should contact ETR for inclusion in an onsite training in their region as these occur.

Number of days/hours:

The RTR Training of Educators is a 3-day training. Daily sessions are 8 hours, with a 1-hour lunch and appropriate breaks. All ETR trainings include follow-up support.

Additional Resources:

There currently are additional qualified resources for training:

ETR also offers RTRWorks! a self-paced, interactive, evidence-based online training designed to prepare and support educators to effectively lead RTR.

Child Welfare Outcome: Child/Family Well-Being

“What is included in the Relevant Published, Peer-Reviewed Research section?”

• 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.  https://doi.org/10.2307/2135776

  Type of Study: Pretest–posttest study with a nonequivalent control group (Quasi-experimental)

  Participants: 758

  Sample / Population:

  • Age — 9th–12th grade (approximately 13–18 years)
  • Race/Ethnicity — 62% White, 20% Latino, 9% Asian, 2% Black, 2% Native American, and 5% Other
  • Gender — 53% Female and 47% Male
  • Status —

    Participants were high school students in Grades 9 to 12 enrolled in a mandatory health class.

  Location/Institution: Thirteen California high schools

  Summary:

  The purpose of the study was to examine the impact of the Reducing the Risk program. Participants were assigned at the classroom level to Reducing the Risk (treatment group) or a control group. Measures utilized include a 20-item knowledge test on contraception, perceptions and intentions, initiating intercourse, contraceptive practices, unprotected sexual intercourse, pregnancy, and communication with parents. Results indicate that among all participants, Reducing the Risk significantly increased participants’ knowledge and participants’ parent-child communication about abstinence and contraception. Among students who had not initiated intercourse prior to the pretest, Reducing the Risk significantly reduced the likelihood that they would have intercourse by 18 months later. Reducing the Risk did not significantly affect frequency of sexual intercourse or use of birth control among sexually experienced youth. Among all lower-risk youth and among all students who had not initiated intercourse prior to their exposure to Reducing the Risk, the curriculum appears to have significantly reduced unprotected intercourse, either by delaying the onset of intercourse or by increasing the use of contraceptives. Among the students not sexually active before participation in Reducing the Risk, effects seem to have extended across a variety of subgroups, including both Whites and Latinos and lower-risk and higher-risk youth, but were particularly strong among lower-risk youth and females. Limitations include reliance on self-reported measures and generalizability due to the ethnicity of participants.

  Length of controlled postintervention follow-up: 6 and 18 months.

• Barth, R. P., Fetro, J. V., Leland, N., & Volkan, K. (1992). Preventing adolescent pregnancy with social and cognitive skills. Journal of Adolescent Research, 7(2), 208–232. https://doi.org/10.1177/074355489272006

  Type of Study: Pretest–posttest study with a nonequivalent control group (Quasi-experimental)

  Participants: 1,033

  Sample / Population:

  • Age — 9th–12th grade (approximately 13–18 years)
  • Race/Ethnicity — 61% White, 21% Latino, 9% Asian, 2% Black, 2% Native American, and 5% Other
  • Gender — 527 Male and 506 Female
  • Status —

    Participants were high school students in Grades 9 to 12 enrolled in a mandatory health class.

  Location/Institution: Eighteen California high schools

  Summary:

  The study used the same sample as Kirby et al. (1991). The purpose of the study was to examine the impact of the Reducing the Risk program. Participants were randomly assigned at the classroom level to Reducing the Risk or a control group. Measures utilized include a 20-item knowledge test on contraception, intention to avoid unprotected intercourse, sexual and contraceptive practices, and a parent satisfaction survey. Results indicate that by posttest, Reducing the Risk students were more likely to report that fewer of their friends were having sexual intercourse and were less likely to report that most of their friends were having sexual intercourse. Knowledge about birth control and intentions to avoid actions that increase the likelihood of having unprotected sexual intercourse were significantly increased for the Reducing the Risk participants. Limitations include reliance on self-reported measures, generalizability due to the ethnicity of participants, and the length of follow-up.

  Length of controlled postintervention follow-up: 6 months.

• Hubbard, B. M., Giese, M. L., & Rainey, J. (1998). A replication study of Reducing the Risk, a theory-based sexuality curriculum for adolescents. Journal of School Health, 68(6), 243–247.  https://doi.org/10.1111/j.1746-1561.1998.tb06347.x

  Type of Study: Pretest–posttest study with a nonequivalent control group (Quasi-experimental)

  Participants: 532

  Sample / Population:

  • Age — 15–16 years
  • Race/Ethnicity — 85% White, 14% Black, and 1% Other
  • Gender — 52% Female and 48% Male
  • Status —

    Participants were high school students in 9th and 10h grade.

  Location/Institution: Arkansas

  Summary:

  The purpose of the study was to examine whether the effects of the Reducing the Risk program could be duplicated in a southern rural state. Participants were classrooms from ten school districts using Reducing the Risk or a one-semester health education program that included whatever sexuality instruction was provided in that school district. One classroom in each treatment and comparison school district was randomly selected. Measures utilized include 22 items from the 1993 Youth Risk Behavior Survey (YRBS). Results indicate that Reducing the Risk students showed a significant increase in condom use and use of effective contraceptives for treatment group students who became sexually active during the study. A similar but nonsignificant trend was found with Reducing the Risk students who were sexually active at pretest but did not use STD and pregnancy prevention at that time. Limitations include lack of randomization of students and classrooms and the small sample size.

  Length of controlled postintervention follow-up: 18 months.

• Zimmerman, R. S., Cupp, P. K. , Donohew, L., Sionean, C., Feist-Price, S., & Helme, D. (2008). Effects of a school-based, theory-driven HIV and pregnancy prevention curriculum. Perspectives on Sexual and Reproductive Health, 40(1), 42–51. https://doi.org/10.1363/4004208

  Type of Study: Randomized controlled trial

  Participants: 1,944

  Sample / Population:

  • Age — 13–16 years
  • Race/Ethnicity — 51% White, 36% Black, 6% Hispanic, and 8% Other
  • Gender — 53% Female and 47% Male
  • Status —

    Participants were high school students in 9th through 11h grade enrolled in a health class.

  Location/Institution: Louisville, Kentucky and Cleveland, Ohio

  Summary:

  The purpose of the study was to compare several outcomes experienced by peer educators involved in a modified version of the standard Reducing the Risk program with those of their classmates to determine areas in which involvement in the curriculum had an effect on peer educators. Participants were randomized into three groups: the school’s standard pregnancy and HIV prevention curriculum; the Reducing the Risk curriculum; or a modified Reducing the Risk curriculum, adapted for high-sensation seekers and impulsive decision makers. Measures utilized include the Zuckerman Sensation-Seeking Scale and the Decision-Making Style Scale, along with self-report measures of sexual behaviors and knowledge. Results indicate that the combined Reducing the Risk interventions led to a reduction in initiation of sexual activity when compared with the standard school curriculum. These effects were even stronger for Black youth than for White youth, an important finding since this is the first time that Reducing the Risk has been found to be effective in this population. The modified Reducing the Risk program did not result in either a greater reduction of sexual initiation than the original Reducing the Risk intervention or an increase in condom use. Additionally, no significant differences were found among the three curriculum groups in frequency of condom use or use of alcohol with sex. Limitations include attrition, variations in the level of implementation that may have reduced impact differences between groups; because race and ethnicity, school engagement, and sexual activity are strongly related, complex interactions among interactions between the intervention and the community may not have been fully accounted for in the analyses, and the lack of follow-up.

  Length of controlled postintervention follow-up: None.

• Reyna, V. F., & Mills, B. A. (2014). Theoretically motivated interventions for reducing sexual risk taking in adolescence: A randomized controlled experiment applying fuzzy-trace theory. Journal of Experimental Psychology: General, 143(4), 1627–1648. https://doi.org/10.1037/a0036717

  Type of Study: Randomized controlled trial

  Participants: 734

  Sample / Population:

  • Age — 15–16 years
  • Race/Ethnicity — 328 White, 202 African American, 121 Hispanic, and 83 Other
  • Gender — 422 Female
  • Status —

    Participants were adolescents in high school and youth programs.

  Location/Institution: Southern Arizona, Northern Texas, and Central New York

  Summary:

  The purpose of the study was to examine attempts to increase the efficacy and durability of a multicomponent intervention to promote risk reduction and avoidance of premature pregnancy and sexually transmitted infections (STIs). Participants were randomly assigned to one of three curriculum groups: RTR (Reducing the Risk), RTR+ (a modified version of RTR using fuzzy-trace theory), and a control group. Measures utilized include self-reported sexual behavior (defined as oral, anal, or vaginal sex) and prophylactic behavior, and the Marlowe-Crowne Social Desirability Index. Results indicate that the modified RTR+ curriculum was effective at reducing sexual risk-taking in adolescence, such as delaying initiation of sex and reducing the number of sexual partners. Assignment to RTR+ produced superior results relative to the control group, for 17 outcomes, whereas assignment to RTR produced superior results for 12 outcomes. RTR+ was significantly more effective than RTR for nine of these outcomes. Effects were sustained over the follow-up period for most outcomes, and remained detectable for 12 outcomes more than a year after the intervention, despite decreased sample sizes as delay increased. The interventions did not produce significant effects on measures of self-reported prophylactic behavior (number of unprotected sexual acts and the prophylactic risk index [PRI]), although they influenced attitudes toward prophylaxis, perceived norms for prophylaxis, and behavioral intentions to use prophylaxis (each of which ordinarily predicts prophylactic behavior). Limitations include reliance on self-reported measures and generalizability due to gender and ethnicity.

  Length of controlled postintervention follow-up: 1 year.

• Barbee, A. P., Cunningham, M. R., van Zyl, M. A., Antle, B. F., & Langley, C. N. (2016). Impact of two adolescent pregnancy prevention interventions on risky sexual behavior: A three-arm cluster randomized control trial. American Journal of Public Health, 106(Suppl 1), S85–S90. https://doi.org/10.2105/AJPH.2016.303429

  Type of Study: Randomized controlled trial

  Participants: 1448

  Sample / Population:

  • Age — 14–19 years
  • Race/Ethnicity — 89% Non Hispanic Black, 7% Non Hispanic White, and 4% Hispanic
  • Gender — 60% Female
  • Status —

    Participants were youth at faith-based agencies, community centers, child welfare-serving social service agencies, and resource centers located in low-performing schools in the parts of Louisville with the highest poverty rates and minority youths.

  Location/Institution: Twenty-three community-based organizations in Louisville, Kentucky

  Summary:

  The purpose of the study was to test the efficacy of Reducing the Risk (RTR) and Love Notes (LN) on reducing risky sexual behavior among youths yet to experience or cause a pregnancy. Participants were randomly assigned to either RTR, LN, or the Power of We (POW) control group. Measures utilized include a demographic questionnaire and a questionnaire about sexual activity. Results indicate that at 3 and 6 months, compared with the control condition, youths in RTR reported fewer sexual partners and greater use of birth control. At 6 months, LN participants reported greater use of birth control and condoms, fewer sexual partners, and were less likely to have ever had sex compared with the control condition. Limitations include reliance on self-reported measures, low generalizability due to the ethnic population of participants, and the length of follow-up.

  Length of controlled postintervention follow-up: 3 and 6 months.

• Barbee, A. P., Cunningham, M. R., Antle, B. F., & Langley, C. N. (2022). Impact of a relationship‐based intervention, Love Notes, on teen pregnancy prevention. Family Relations, 72(5), 2569–2588. https://doi.org/10.1111/fare.12798

  Type of Study: Randomized controlled trial

  Participants: 1,448

  Sample / Population:

  • Age — 14–19 years (Mean=15.42 years)
  • Race/Ethnicity — 88% Non Hispanic Black, 7% Non Hispanic White, 4% Latin, and 1% Asian
  • Gender — 60% Female
  • Status —

    Participants were youth at faith-based agencies, community centers, child welfare-serving social service agencies, and resource centers located in low-performing schools in the parts of Louisville with the highest poverty rates and minority youths.

  Location/Institution: Twenty-three community-based organizations in Louisville Kentucky

  Summary:

  The study used the same sample as Barbee et al. (2016). The purpose of the study was to test the efficacy of two teen pregnancy prevention (TPP) curricula, Reducing the Risk and Love Notes, compared with a group of adolescents in a control condition, on primary pregnancy prevention among youth at high-risk for teen pregnancy. A secondary purpose was to examine two potential mediators, negative beliefs about teen pregnancy and intentions to follow the sequence of completing education, marrying, or establishing a committed relationship, and then having children. Participants were randomly assigned to either Reducing the Risk, LN, or the Power of We (POW) control group. Measures utilized include a demographic questionnaire and a questionnaire regarding pregnancy and negative attitudes about pregnancy. Results indicate that at the 1-year follow-up, youth in LN report significantly fewer pregnancies compared with the control condition. There was no significant difference between Reducing the Risk and the control condition in number of pregnancies. Less favorable attitudes about having a child as a teenager and other attitudes were associated with predicted outcomes. Limitations include reliance on self-reported measures and low generalizability due to the ethnic population of participants.

  Length of controlled postintervention follow-up: 3 months, 6 months, and 1 year.

• Advocates for Youth. (2012). Science and success: Sex education and other programs that work to prevent teen pregnancy, HIV and sexually transmitted infections. (3rd ed.). Washington, DC. Executive summary available at https://advocatesforyouth.org/wp-content/uploads/storage/advfy/documents/thirdeditionexecutivesummary.pdf

• Kirby, D. (2007). Emerging answers 2007: Research findings on programs to reduce teen pregnancy and sexually transmitted diseases. Washington, DC: National Campaign to Prevent Teen and Unplanned Pregnancy.