Journal of Applied Research on Children: Informing Policy for

Children at Risk
Volume 2
Article 7
Issue 2 Teen Pregnancy

2011

Choosing and Maintaining Programs for Sex

Education in Schools: The CHAMPSS Model
Belinda F. Hernandez
University of Texas Health Science Center at Houston, [email protected]

Melissa Peskin
University of Texas Health Science Center at Houston, [email protected]

Ross Shegog
University of Texas Health Science Center at Houston, [email protected]

Christine Markham
University of Texas Health Science Center at Houston, [email protected]

Kimberly Johnson
University of Texas Health Science Center, [email protected]

See next page for additional authors

Follow this and additional works at: http://digitalcommons.library.tmc.edu/childrenatrisk

Recommended Citation
Hernandez, Belinda F.; Peskin, Melissa; Shegog, Ross; Markham, Christine; Johnson, Kimberly; Ratliff, Eric A.; Li, Dennis H.;
Weerasinghe, I. Sonali; Cuccaro, Paula M.; and Tortolero, Susan R. (2011) "Choosing and Maintaining Programs for Sex Education in
Schools: The CHAMPSS Model," Journal of Applied Research on Children: Informing Policy for Children at Risk: Vol. 2: Iss. 2, Article 7.
Available at: http://digitalcommons.library.tmc.edu/childrenatrisk/vol2/iss2/7

The Journal of Applied Research on Children is brought to you for free and
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Choosing and Maintaining Programs for Sex Education in Schools: The
CHAMPSS Model
Acknowledgements
This study was funded by the Centers for Disease Control and Prevention (CDC) (#U48DP001949). The
findings and conclusions in this report are those of the authors and do not necessarily represent the official
position of the CDC. Belinda F. Hernandez is a recipient of an Associations of Schools of Public Health
(ASPH)/CDC/Prevention Research Center (PRC) Minority Public Health Fellowship. The content is solely
the responsibility of the authors and does not necessarily represent the official views of the ASPH, CDC, or
the PRC.

Authors
Belinda F. Hernandez, Melissa Peskin, Ross Shegog, Christine Markham, Kimberly Johnson, Eric A. Ratliff,
Dennis H. Li, I. Sonali Weerasinghe, Paula M. Cuccaro, and Susan R. Tortolero

This article is available in Journal of Applied Research on Children: Informing Policy for Children at Risk:
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 Hernandez et al.: The CHAMPSS Model

Background
Although the teen birth rate in Texas is one of the highest in the nation (63
per 1,000 females ages 15-19), solutions to reduce the rate exist. Other
states, such as California, have been successful in dramatically reducing
the teen birth rate over the past two decades through strategies such as
implementing comprehensive, age-appropriate, and medically accurate
sex education, increasing access to contraceptive services, and involving
private foundations to fund teen pregnancy prevention efforts by state and
community agencies.1 In 1991, the California teen birth rate was among
the highest in the nation (73.8 per 1,000 females age 15-19 years). After
implementing these strategies, California reduced its teen birth rate by
nearly half (38.8 per 1,000) in 2005, making it the nation’s steepest
decline in teen births.2
California’s successful strategies, specifically implementation of
comprehensive sex education, have caught the attention of all who strive
to prevent teen pregnancy, including policymakers and funders. Between
2007 and 2009 policymakers in six states adopted new requirements that
sex education be both medically accurate and age appropriate. In June
2009, roughly half of all U.S. states declined to apply for funds under the
federally funded Title V abstinence-only program because few eligible
programs were evidence-based.3 Further, in 2010, the White House
Administration released a Teen Pregnancy Prevention Initiative that
allocated $75 million exclusively for implementation of evidence-based
programs (EBPs).3
EBPs are important for two reasons. First, they have been
rigorously evaluated, and have demonstrated effectiveness in changing
behavior.4, 5 EBPs have been designed to reduce the teen pregnancy rate
by reducing risky sexual behaviors (e.g. early sexual initiation, lack of
condom/contraceptive use, multiple sexual partners) and increasing
positive behaviors (e.g. delayed sexual initiation, increased use of
condoms/contraceptive, reduced number of sexual partners). When
widely implemented, EBPs can delay sexual initiation and reduce risky
sexual behaviors, ultimately reducing the teen birth rate in a community.6
Second, implementing EBPs is an effective use of limited resources.
Because EBPs are “proven” approaches that have demonstrated
effectiveness over time,4 funders can be assured that their resources are

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being invested wisely. Implementation of EBPs saves time and energy

that would normally go into developing a program, or implementing a
program that has not been proven effective.
More than 50 effective or promising curriculum-based teen
pregnancy prevention programs have been developed,4 yet 94% of Texas
schools are not utilizing any of these programs.7 This is cause for concern
and could partly explain why Texas has the third highest teen birth rate in
the nation.8 Currently, Texas is in the midst of a budget crisis, with an
estimated $4 billion proposed budget cut to education.9 Teen births cost
Texas tax-payers $1 billion annually.10 Therefore, it is important to invest
in EBPs that prevent teen pregnancy. EBPs in public schools would have
a ripple effect on students’ health and the economy. As a result of
widespread school-based implementation of EBPs, students might engage
in fewer risky sexual behaviors. This would result in decreased teen
pregnancies and school dropouts, increased higher educational
attainment, and an increased number of higher paying jobs attained by
students, saving Texas tax-payers billions of dollars.
There are many reasons why Texas public schools do not
implement evidence-based pregnancy prevention programs. School
personnel lack knowledge of where to find EBPs,11 some personnel
perceive lack of support from administrators and parents for sex
education,11,12-14 schools devote very little time to sexual health education
because of competing priorities,14-16 teachers lack sexual health
14,15,17
training, and many school districts do not realize that some sexual
health programs have strong evidence for their success.16 Complicating
the situation is the fact that adolescent sexual health is a controversial
topic and districts differ in their ideologies on how best to approach the
issue.12,13 Subsequently, district and school staff often limit sexual health
education to minimize or avoid controversy.14 These barriers suggest that
school districts lack the guidance needed to successfully implement an
evidence-based sexual health program in their district. School districts
need support from the beginning to end of the adoption and maintenance
or institutionalization process.
Although models/frameworks have been developed to aid
communities through the process of program adoption and
implementation,18-22 to our knowledge, there are no published models that

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have been developed specifically for school districts. Community-based

models may not be applicable to school districts that have their own
unique challenges. For example, community-based organizations might
have the support to implement an EBP but face the challenge of engaging
and retaining youth in their program. School-districts, on the other hand,
face the challenge of obtaining approval from district administrators to
begin implementing a sexual health program. Additionally, current
models heavily emphasize adaptation of EBPs to meet the needs of the
community. The adaptation process involves tailoring curriculum content
to fit the target population’s needs, pretesting program materials, making
revisions based on the pretest, pilot testing the newly adapted program,
making revisions based on pilot tests, and conducting an evaluation to
determine if the adaptation was successful in changing behavior.18, 20 This
process is unrealistic for school districts. In Texas, and across the U.S.,
school personnel are burdened with many school- and policy-related tasks
and they are forced to accomplish these tasks in a short period of time.
Thus, community-based models that stress adaptation are not feasible for
school districts. School districts often lack the expertise, time, and
resources to correctly follow this process. Models that target school-
based settings are greatly needed.
The purpose of this report is to present and describe the CHoosing
And Maintaining Programs for Sex education in Schools (CHAMPSS)
Model. The CHAMPSS Model is a realistic and practical framework for
school districts that facilitates the adoption and implementation process of
EBPs that prevent teen pregnancy in school-based settings. Currently,
there is no set of established best practices for school districts to adopt
and replicate EBPs. This report will be the first to provide a systematic
framework for school districts to increase the probability of adoption,
implementation, and maintenance of EBPs.

Methods Used in the CHAMPSS Model Development

Intervention Mapping (IM) was used to develop the CHAMPSS Model. IM
is a detailed process that provides program planners a systematic
approach for decision-making at each phase of the program development
process.23 IM has been previously used to develop effective interventions
for various health topics including obesity,24 teen pregnancy and sexually

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transmitted diseases,25-27 hearing loss,28 asthma,29 breast and cervical

cancer,30,31 and colorectal cancer.32 Model development occurred in four
phases33 using the core processes of IM:1) knowledge acquisition; 2)
knowledge engineering to develop behavioral and performance objectives;
3) knowledge representation to develop the conceptual framework of the
model; and 4) knowledge validation (Figure 1). Details of each phase are
described below. This study was approved by the University of Texas
Health Science Center Committee for Protection of Human Subjects
(HSC-SPH-09-0414).

Figure 1: Summary of methods used in the CHAMPSS Model

development

33
Adapted from Shegog et al. 2004

Knowledge Acquisition
We conducted a needs assessment to ensure the CHAMPSS Model was
based on a thorough understanding of school districts’ barriers, facilitators,

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and decision-making processes for adoption and implementation of EBPs

in schools using inductive and deductive approaches. A literature review
(deductive) was first conducted to identify the internal and external factors
that influence adoption and implementation, as well as, current adoption or
adaptation models of EBPs targeting teen pregnancy.
Semi-structured in-depth interviews (inductive) with key
stakeholders from school districts in Southeast Texas were conducted in
spring 2010 to identify barriers and facilitators of the adoption and
implementation process. Key stakeholders included: school board
members, superintendents, district wellness/health coordinators, parents,
and School Health Advisory Council (SHAC) i members. Participants were
recruited through a local school health leadership group, which consisted
of representatives from each school district in the county in which the
study was conducted. Representatives from seven school districts
volunteered to participate. Participants were asked to describe the
approval or adoption process of health programs in their district or school,
perceived barriers to implementation, perceived support from school staff
and the community regarding sexual health education, and current
strategies that were being used to prevent teen pregnancy in their
district/school. All interviews were conducted in a private room at the key-
informants’ respective school district by trained research staff and were
audio recorded. Audio recordings were transcribed and transcripts were
coded for themes by a research team member.
To understand the decision-making processes of program adoption,
we observed (inductive) SHAC and school board meetings in local school
districts. Representatives from the school health leadership group who
were interested in selecting a teen pregnancy prevention program for their
districts would ask staff members to give a presentation to their SHAC that
outlined the district’s teen birth rate and other sexual health data along
with possible solutions to this problem. An anthropologist on the research
team attended these meetings to observe the deliberations among

i
SHACs are organizations within the school district that provide advice to the district on
issues of health. SHACs are comprised of parents, teachers, school administrators, and
other community members. According to the Texas Education Code Section 28.004,
each school district is required to have a SHAC.

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attendees. Fieldnotes from these observations were analyzed for

recurring themes.
A total of 10 in-depth interviews were conducted with 12
participants (one interview was conducted as a group interview with three
participants). Participants were classified as follows: 2 school board
members, 1 superintendent, 5 health/wellness coordinators, 1 principal, 1
school nurse, 1 counseling administrator, and 1 parent/SHAC co-chair.
Nine participants were white and one participant was African-American.
Eight participants were female and two were males. Interview data helped
identify barriers and facilitators for adoption and implementation of EBPs.
Additionally, the observations of 29 SHAC and school board meetings
from 12 school districts highlighted salient issues in their decision making
processes. Table 1 summarizes major barriers and facilitators identified
through these needs assessment activities.

Table 1: Summary of barriers and facilitators for adoption and implementation

identified through the needs assessment
Empirical Support
District Level Barriers
In-depth interviews,
Fear of negative parent and community reactions 12, 15
observations ( )

Lack of knowledge about local sexual health curricula

In-depth interviews
and School Health Advisory Council (SHAC) activities

Confusion from curricula vendors that market non-evidence In-depth interviews,

based curricula observations

Confusion on how to integrate sexual health education into

In-depth interviews,
overall curriculum (e.g., what grade to begin and into what
observations
classes)

District Level Facilitators

Use of district level teen birth and sexually transmitted infection In-depth interviews,
data and statistics as advocacy tools observations

“Program champion” to advocate and communicate with In-depth interviews,

administrators observations

Program outcomes as an advocacy tool In-depth interviews

School Level Barriers

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In-depth interviews,
Confusion of district policy regarding sexual health education 15
observations ( )

In-depth interviews,
Fear of negative repercussions (e.g., job loss) 14
observations ( )
In-depth interviews
Perception that sexual health education is not a priority in district 12, 14-16
( )

In-depth interviews,
Perception that parents and community are unsupportive 11-14
observations ( )

In-depth interviews,
Lack of resources (e.g., funding, materials) 12
observations ( )
School Level Facilitators

Identification of most appropriate sexual health educator In-depth interviews

In-depth interviews,
14, 15, 17,
Training to increase comfort to teach sexual health education observations (
34
)
In-depth interviews,
Advocacy to prioritize and plan for sexual health education 15
observations ( )

In-depth interviews,
Perceptions parents and community are supportive 11-14
observations ( )
In-depth interviews,
Resources available (e.g. funding, materials) 12
observations ( )

Knowledge Engineering
Knowledge engineering refers to organizing information for effective
implementation.33 We heavily relied on intervention mapping (IM) to
facilitate this process. IM recommends that interventions have well
defined behavioral objectives, (e.g. teachers will implement EBPs), and
well defined performance objectives, detailed steps needed to achieve the
behavioral objectives (e.g. review the curriculum).23,25 In this case,
behavioral objectives related to adoption, implementation, and
maintenance were defined for all key stakeholders at the district, school
and community levels. Stakeholders were characterized as: users of the
CHAMPSS Model, also known as sexual health advocatesii; school board

ii
We define sexual health advocates as individuals who desire to implement EBPs in their
district/school. Any district level or school level stakeholder can be a sexual health

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members; superintendents; principals and school staff; and community

members, parents, and students (Figure 2). Behavioral objectives were:
1) sexual health advocates will work with the district health coordinators
(or equivalent administrators who oversee school health) to establish an
effective SHAC in their district; 2) SHACs, school board members,
superintendents, principals, and sexual health teachers will adopt an EBP
targeting teen pregnancy and/or HIV/STI prevention; 3) parents,
community members, and students will support an EBP targeting teen
pregnancy and/or HIV/STI prevention in their school district and ensure
continued maintenance; 4) principals and sexual health educators will
implement, with fidelity, an EBP targeting teen pregnancy and/or HIV/STI
prevention in their school; and 5) SHACs, superintendents, principals, and
sexual health teachers will continue to maintain implementation of an EBP
targeting teen pregnancy and/or HIV/STI prevention in their schools with
fidelity. The associated performance objectives for each behavioral
objective are described in Table 2. Performance objectives were based
on key barriers and facilitators identified during the needs assessment.

advocate, including staff that are not directly involved in sexual health education in their
district/school.

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Figure 2: Relationship of stakeholders for the adoption,

implementation, and maintenance process

Note: Any stakeholder can become a Sexual Health Advocate and/or Program Champion

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Table 2: Behavioral outcomes and performance objectives for the CHAMPSS Model
Behavioral Outcome Associated Performance Objective
1. Sexual health advocates (SHA) SHA will join the SHAC. SHA and DHC will review current SHAC member
will work with the district health composition and identify gaps in membership, practices, requirements, and/or
coordinators (DHC) (or equivalent needs. SHA and DHC will identify potential students, parents, community
administrators who oversee school members, health and school board members for the SHAC. SHA and DHC
health) to establish an effective will recruit identified participants to be on SHAC. SHA and DHC will ensure
School Health Advisory Council regular meeting of and attendance to the SHAC.
(SHAC) in their district.
2. SHACs, school board members, District and school level stakeholders will review current data and statistics on
superintendents, principals, and teen pregnancy and HIV/STI in their district/school. Stakeholders will review
sexual health teachers will adopt information on parent/school/community support for evidence-based sexual
an EBP targeting teen pregnancy health education in school. Stakeholders will identify their goals and target
and/or HIV/STI prevention. population regarding sexual health education. Stakeholders will attend a
SHAC meeting when discussions on sexual health education are taking place.
Stakeholders will assess whether or not their district is using an EBP and if the
current curricula, if any, meets their goals and objectives. Stakeholders will
review and evaluate EBPs available to their district that meets their goals,
target population, and desired outcomes. Stakeholders will review and elicit
support of potential EBP with other stakeholders, discussing feasibility,
resources required, and target population. SHACs will adopt an EBP and
create a position statement with recommendation for school board approval.
Stakeholders will review recommendations from SHAC. Stakeholders will
adopt an EBP providing notification of such to stakeholders. Stakeholders will
acquire the EBP.

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3. Parents, community members, Parent and community stakeholders will review current data and statistics
and students will support an EBP on teen pregnancy and HIV/STI in their district. Stakeholders will join
targeting teen pregnancy and/or the SHAC and attend meetings regularly to become a voting member.
HIV/STI prevention in their school Stakeholders will review current state/district/school policy regarding
district and ensure continued sexual health education. Stakeholders will identify their goals and
maintenance. desired outcomes regarding sexual health education. Stakeholders will
review and assess if the current curricula, if any, meets their goals and
objectives and is an EBP. Stakeholders will encourage district and
school staff to find and recommend EBPs that fit their school population,
have desired outcomes, and are feasible in their district. Stakeholders
will attend school board public meetings when discussions on sexual
health education are occurring to elicit support. Stakeholders will
provide positive feedback to district and school staff and encourage
continued implementation of the EBP in the district at SHAC and school
board meetings.

4. Principals and sexual health School staff will identify most appropriate person(s) to implement the
educators will implement, with adopted EBP. School staff will review adopted curriculum in detail,
fidelity, an EBP targeting teen including content, lessons, activities, and assignments, and modify the
pregnancy and/or HIV/STI EBP to fit their needs, without modifying the core elements, if needed.
prevention in their school. School staff will assess school resources and capacity for implementing
the EBP. School staff will attend trainings on the adopted EBP or on
general adolescent sexual health to gain comfort and skills to implement
the program. School staff will ensure teacher training/planning time and
encourage implementation with fidelity. School staff will designate staff
to create an implementation and monitoring/evaluation plan to ensure
implementation with fidelity, while also eliciting support of the EBP from
other school staff involved with implementation (e.g., nurse or
counselor). School staff will obtain parent consent, if needed. School
staff will implement the EBP with fidelity.

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5. SHACs, superintendents, District and school staff will assess the planning and implementation of the
principals, and sexual health EBP and ensure continuous quality improvement. District and school
teachers will continue to maintain staff will evaluate the EBP’s success in achieving desired results.
implementation of an EBP District and school staff will provide encouragement and positive
targeting teen pregnancy and/or feedback to implementers for their achievement. If program was
HIV/STI prevention in their schools successful, district and school staff will create and implement a
with fidelity maintenance plan for continued implementation in district. If program
was successful, staff will advocate for continued implementation of
program by presenting program outcomes to stakeholders. If program
was unsuccessful in meeting goals, objectives, and/or desired
outcomes, district and school staff will create a contingency plan.

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Knowledge Representation
Knowledge representation can occur in various forms, such as conceptual
graphs.33 We used the behavioral and performance objectives to guide the
conceptual development of the CHAMPSS Model. Research team
members organized the performance objectives into a systematic
parsimonious framework. The resulting model guides school districts
through the adoption, implementation, and maintenance process of EBPs.
The foundation of the CHAMPSS Model was built from the needs
assessment activities (inductive approach) and previous community-based
program adaptation models (deductive approach).18-22 The literature
review helped identify five adaptation models related to sexual health in
community settings.18-22 However, none of the identified models targeted
school settings and these models heavily emphasized adaption of EBPs.
Results from in-depth interviews and observations suggested school
districts lack the time and expertise to follow the adaption process
correctly. Additionally, schools face unique challenges (e.g., fear of parent
and community negative reactions) that community-based models did not
address. Thus, the knowledge base for the CHAMPSS Model
emphasizes program replication and the action steps that encompass
program adoption, implementation, and maintenance in school-based
settings.
We identified four phases that schools need to complete/achieve:
1) assessment, 2) preparation, 3) implementation, and 4) maintenance.
Within these four phases, there are seven action steps: 1) Prioritize, 2)
Assess, 3) Select, 4) Approve, 5) Prepare, 6) Implement, and 7) Maintain
(Figure 3).

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Figure 3: Summary of the CHAMPSS Model

School districts vary in their level of readiness to adopt and

implement EBPs; therefore, they can enter the CHAMPSS Model at any
phase. Further, although the model follows a linear path, school districts
may need to revisit action steps when they encounter challenges, and
some steps may occur simultaneously. For example, school districts may
need to revisit “Getting others on Board” often and conduct it concurrently
with other steps. A summary of each of the phases and action steps is
presented in Figure 4.

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Figure 4: Summary of phases and action steps for the CHAMPSS Model

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Knowledge Validation
Knowledge validation consisted of presenting the conceptual model to the
school health leadership group. Members of the group were asked about
the usefulness of the CHAMPSS Model, motivation to use the model,
user-friendliness, and general improvements that could be made. Overall,
members of the group expressed favorable attitudes towards the model.
Participants believed the CHAMPSS Model would be useful in “making the
case” for EBPs and would be beneficial to their district. Major changes to
the model were not suggested. Members did express desire to have
resources readily available, such as district level data on teen births and
graduation rates of teen parents, factsheets and presentations for
advocacy, and templates for making recommendations and writing
position statements to supplement the model.

Description of the CHAMPSS Model

This section provides specific details of the CHAMPSS Model (see Figure
5).

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Figure 5: Detailed action steps of the CHAMPSS Model

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Assessment Phase

Step 1: Prioritize
Needs assessment activities revealed that many school staff did not
perceive sexual health education as a priority in their respective district
compared to other subjects. This made implementing a sexual health
program challenging. Thus, the first step in the adoption process is for the
sexual health advocate to raise awareness of teen pregnancy in the
district and solutions to the problem. This is an important action step as
many stakeholders may be unaware of the magnitude of the problem or
have allowed other school-related tasks to take precedence over teen
pregnancy and sexual health, as observed through the needs
assessment. Therefore, making others aware of the problem, through
distribution of fact sheets or presenting key data on adolescent sexual
health, is the first step needed to begin the dialogue.
Prioritize also involves forming a SHAC (Sexual Health Advisory
Council), or mobilizing an existing SHAC to address teen pregnancy.
According to the Texas Education Code, SHACs are required in each
school district and must have a minimum of five members, the majority of
whom should be parents with children in the district. State law specifies
SHACs are to provide recommendations regarding human sexuality
instruction to the school board.35 Therefore, SHACs are vital to the
adoption process for sexual health education programs. Consequently, it
is important to have a well-functioning SHAC. SHACs may encounter
many challenges such as poor parent participation, disorganization, and
infrequent meetings, making them ineffective. When this occurs,
important decisions and recommendations regarding student health issues
are overlooked. It is important that the sexual health advocate work
collaboratively with the SHAC chair and/or district health/wellness
coordinator to minimize these potential challenges by actively recruiting
members (including health teachers and students), holding meetings at
convenient times and locations, being organized, and leading the
discussion on sexual health education programs.

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Step 2: Assess
During the needs assessment, district administrators expressed a desire
to become knowledgeable on the teen birth rate in their district, the
negative consequences as a result of teen births (e.g., school dropout,
poor academic performance), and current prevention activities in the
district. Additionally, school personnel were unsure at which grade level to
begin sexual health education. Thus assess involves gaining a specific
understanding of the district’s teen pregnancy and birth rates and the
prevalence of students’ risky sexual behaviors, identifying the current
sexual health education program being implemented, and identifying the
available resources for implementation of EBPs. Gaining a thorough
understanding of these factors will facilitate subsequent steps. For
example, some EBPs require more resources than others (e.g.,
computers, DVD players, a school health promotion council).
Understanding the district’s capacity to implement EBPs early in the
process will help decide which EBP to adopt.
This step also involves reviewing the district sexual health
education policies and gauging district and parental support for them.
These activities might also help overcome many perceived barriers and
challenges associated with adopting an EBP, and can ensure that the
most appropriate program for the district is adopted. Most Texas schools
do not have specific policies on sexual health education,16 and thus follow
Texas policy by default. However, the needs assessment revealed some
school staff mistakenly believed that the Texas policy prohibits instruction
on condoms and other contraceptives. According to the Texas Education
Code, instruction related to human sexuality must:
• “present abstinence from sexual activity as the preferred
choice of behavior in relationship to all sexual activity for
unmarried persons of school age;
• devote more attention to abstinence from sexual activity
than to any other behavior;
• emphasize that abstinence from sexual activity, if used
consistently and correctly, is the only method that is 100
percent effective in preventing pregnancy, sexually
transmitted diseases, infection with human
immunodeficiency virus or acquired immune deficiency

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syndrome, and the emotional trauma associated with

adolescent sexual activity;
• direct adolescents to a standard of behavior in which
abstinence from sexual activity before marriage is the most
effective way to prevent pregnancy, sexually transmitted
diseases, and infection with human immunodeficiency virus
or acquired immune deficiency syndrome; and
• teach contraception and condom use in terms of human use
reality rates instead of theoretical laboratory rates, if
instruction on contraception and condoms is included in
curriculum content.” 35

Therefore, it is important for the sexual health advocate to discuss

any misconceptions of Texas laws and any existing district/school policies
with stakeholders.
To gauge stakeholder and parent support for EBP, the sexual
health advocate could conduct surveys or focus groups with stakeholders
and parents. Examples of discussion points include: What is the current
district policy on sexual health education? Does the policy prohibit
instruction on condoms/contraceptives? Does the policy differ by grade
level? Is parent consent needed for implementing any sexual health
education program? Do you support curricula that teach about condoms or
contraceptives? If so, what grade level do you think students should be
taught about condoms/contraceptives?
Few school districts have a policy that requires the use of EBPs
when selecting curricula, so the sexual health advocate may want to
advocate for a change in district policy so that EBPs are explicitly required
To do this, the sexual health advocate may need more time at Step one of
the CHAMPSS Model to emphasize the magnitude of problem and the
need for sexual health education in the district to policymakers, or to other
persons who can influence policy (e.g., parents). The sexual health
advocate may also implement strategies described at the core of the
model, “Getting others on Board” (see below for details) to promote policy
change.

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Step 3: Select
Selecting an EBP is a collaborative effort among stakeholders that
requires ongoing communication. First, the sexual health advocate and
stakeholders must identify the target population based on their thorough
understanding of the teen birth rates and prevalence of students’ risky
behaviors in their district. The needs assessment suggested most school
districts targeted specific classes, such as health/physical education, for
implementing a sexual health education program rather than a specific
group (e.g. females). In some cases this was due to the fact that health
education was a required course for all students in middle school. It is
recommended that the target population closely match the district/school
demographic characteristics such as, age, grade, gender, and
race/ethnicity. Otherwise, stakeholders should discuss targeting specific
groups.
Next, the sexual health advocate and stakeholders must identify the
districts’ goals and objectives for sexual health education. The goals and
objectives will be useful when deciding between EBPs. Key questions
that will help inform district goals and objectives include: Does the district
want to delay sexual initiation among students? Increase condoms and/or
other contraceptive use? Increase parent-child communication? Decrease
repeat pregnancy?
The final task for Select includes choosing an EBP that matches
the school district’s target population, goals, and objectives. The district
must first identify if the current program being implemented in the district,
if any, is an EBP. If not, then the district must identify an appropriate EBP.
There are many organizations such as The National Campaign to Prevent
Teen and Unplanned Pregnancy (http://www.thenationalcampaign.org),
The Program Archive on Sexuality, Health and Adolescence
(http://www.socio.com/pasha.php), and ETR Associates
(http://www.etr.org), that have compiled summaries of evidence-based
sexual health education programs for youth. Additionally these
organizations provide information on each curriculum’s content and
activities, the population in which it was tested, evaluation results,
resources needed, and where to purchase the curriculum. During the
selection process it is important that the sexual health advocate and
stakeholders work together so they become familiar with the curriculum’s

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content, the population in which the program was tested, program

evaluation, and necessary resources for program implementation.
Observations conducted in the needs assessment indicated that the
process of selecting an EBP might be easy for some districts, but more
difficult and time consuming (e.g., requiring more frequent discussions) for
other districts due to various perceived barriers and facilitators.
Regardless of how long the process takes, stakeholders should select a
program that has been tested among a population with similar
demographics to their target population, requires resources that the
district/school can support, and has been shown to change the behaviors
that the stakeholders want to alter.

Preparation Phase

Step 4: Approve
In Texas, a district’s school board must approve the sexual health
education curricula before program implementation can occur. This can
be a long and arduous process for some school districts. Thus, it is
important that school board members are involved in the discussions from
the very beginning of the adoption process so that they are informed of the
magnitude of the problem, are aware of support for the selected EBP, and
are familiar with the content and activities of the EBP. This involvement
helps reduce some of potential challenges associated with the program
approval process (e.g., board members unaware of parent/teacher
support for the EBP, or unfamiliar with the program content).
To begin the approval process, the SHAC must follow the voting
procedures outlined in the SHAC bylaws to approve a recommendation on
sexual health to the school board.36, 37 The SHAC then recommends the
EBP to the school board by presenting a recommendation letter.
Recommendation letters may include information such as the importance
of sexual health education, specific policy recommendations, specific
curricula recommendations, and the benefits of these recommendations.
The SHAC then designates a person to present the recommendation to
the school board along with other supporting documents (e.g., summary
sheet of the recommended program or fact sheets on teen pregnancy). It
is helpful to have parents who are in support of the selected EBP at the

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board meeting when this presentation occurs. The school board then
discusses and votes on the program at this or a later meeting. Once
approved, the sexual health advocate, superintendent, SHAC chair,
principals, and/or health/wellness coordinators should ensure that all
school district personnel are aware of the approved curricula and inform
them of the school board’s support for the program. This can be
accomplished through a memo to district and school personnel or by
posting of approved curricula on the district/school website. This
communication will minimize barriers (e.g., fear to discuss sexual health
topics with students, perceived lack of administrative support) that could
impede program implementation at the school level.
If the program is not approved, it is important for proponents to
understand why it was rejected, and to address concerns with those
expressing resistance. The sexual health advocate and stakeholders
might have to return to the first step of the CHAMPSS Model, putting
greater effort in making sexual health a priority. They may also have to
utilize advocacy strategies presented at the core of the model, “Getting
others on Board” (see below for details). It is important that the sexual
health advocate and stakeholders highlight the magnitude of the problem
in their district by presenting teen birth data, and emphasize parent and
community support for the EBP to those who have concerns or opposing
perspectives.

Step 5: Prepare
Preparation involves creating an implementation plan that will help schools
implement the approved sexual health education program.
Implementation plans provide an opportunity to think through critical
components of the program (e.g., how many students will participate in
each school, how many students in each class, in which classes will the
program be implemented, timeline for implementation), to ensure that
those involved in the implementation of the program understand the
program goals, and to ensure that time and resources are used
effectively.38 This may help reduce implementation barriers. It is
important that planning for EBPs begin before the school year starts or
several months before the EBP is implemented. Planning for the
implementation of an EBP should be a collaborative and coordinated effort

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among all personnel who may be involved in carrying out the program.
These individuals might include the selected sexual health educator(s),
school nurse, counselor, and, in some cases, the librarian, computer
laboratory instructor, or other teachers. Some EBPs require the use of
computers or other audio/visual equipment. Thus, teachers may need to
coordinate with other school staff accordingly. Additionally, some classes
may have large enrollment, requiring that students be divided into two or
more groups. As a result, the sexual health educator(s) may need the
support of other school staff to help with implementation and/or monitoring
of the class. Implementation plans include components such as: the
process for notifying parents about the program or obtaining parent
consent (if required by the district), timing of program implementation,
necessary program materials (e.g., number of lesson handouts),
identification of a sexual health educator, and classroom space needs.
Many school districts automatically assign the health/physical
education teacher with the task of teaching sexual health education.
However, school staff participating in the needs assessment suggested
that this person may or may not be the best person for this task. Some
school staff perceived health/physical education teachers as appropriate,
but others believed some were uncomfortable discussing sexual health
topics and/or lacked training on the subject. Sexual health educators must
be knowledgeable about adolescent sexual health and district standards
regarding sexual health education, comfortable with sexual language and
content, non-moralistic and nonjudgmental, knowledgeable of when to
make referrals, have skills to lead sensitive discussions, build rapport with
students, accept sexual desires and thoughts as natural, be accepting of
self and body image, tolerant of ambiguity, have a sense of humor, and
have a desire to teach sexuality.39 Thus, school districts must select
sexual health educator(s) with care. The sexual health educator must
attend trainings specifically on the adopted EBP, and would also benefit
from training on general topics related to adolescent sexual health. This
training will facilitate the implementation process, increase comfort when
implementing the curriculum, and ensure the EBP is implemented with
fidelity.
Planning for implementation also involves making minor
modifications to the program so that the implementation process occurs

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with little difficulties and the program meets the school’s needs. Minor
modifications could include changing the timeline in which the program will
be implemented, altering classroom management procedures (e.g.,
dividing classes), and/or using additional resources (e.g., computers,
handouts, overhead projectors). These modifications are acceptable and
encouraged so that the implementation process runs smoothly.
Modifications that should not occur include changes that may compromise
the content and integrity of the program, such as deleting whole sections
of a program, adding additional activities, changing the order of activities,
or omitting the program’s core elements.40 It would be useful for the
sexual health educator to consult with the program developers or experts
in behavior change theories when considering modifications to the
program to ensure that the effectiveness of the program is not
compromised.

Implementation Phase

Step 6: Implement
Implementation requires that the adopted EBP program is implemented
with fidelity. Fidelity refers to “the degree to which teachers and other
program providers implement programs as intended by the program
developers.”41 Teachers or administrators cannot make major
modifications to the EBP, especially to the core elements. Core elements
are those activities program developers have identified as being
responsible for the effectiveness of the program. They represent the
theory and internal logic of the program.20 These activities must be kept
intact and implemented as intended to produce outcomes similar to those
demonstrated in the original evaluation of the program. There are many
reasons why a school may not implement a program with fidelity such as:
inadequate training, lack of time for implementation, lack of on-going
support, competition from another program/curriculum, insufficient
resources, poor classroom management, and teachers’ low comfort and
skill in teaching the curriculum.16,42,43 Timely, detailed, and coordinated
planning can overcome these barriers, and increase a school’s ability to
implement the program with fidelity.

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Maintenance Phase

Step 7: Maintain
The final step of the CHAMPSS Model, Maintain, involves creating a
maintenance plan. A maintenance plan may ensure continued
implementation of the program, which allows for long-term positive effects
of the program, and also helps avoid feelings of an investment loss for
those involved with the EBP.44 Similar to implementation plans, the
development of maintenance plans should be a collaborative effort with all
those who are involved in the program. Maintenance or institutionalization
of the program requires on-going discussions beginning early in the
adoption process, such as when composing the implementation plan.
Maintenance plans should be detailed and include specific strategies for
overcoming program implementation challenges. Examples of strategies
include identifying potential quality improvement trainings (e.g., booster
trainings for staff), securing resources for program implementation,
identifying the sexual health educator for the following semester/year,
coordinating with other staff for the following semester/year (e.g., securing
classroom space), and identifying any policy changes needed for
continued program implementation.
It may also be beneficial to consider a process and outcome
evaluation of the program when creating the program maintenance plans.
A process evaluation measures how well the program was planned and
implemented, and if the program was implemented with fidelity.23,45 This
type of evaluation can explain why a program failed, or identify
opportunities for improvements. Questions to consider when conducting a
process evaluation include: Were all lessons implemented and if not, why?
Were activities deleted and if so, why? Did all students in the target
population receive the program? Were any changes to the program
made? Did staff attend appropriate training? This information can be
captured through record keeping such as documentation in teacher logs
and attendance records. An outcome evaluation, on the other hand,
measures if the program was successful in achieving the desired results,45
such as changing attitudes, beliefs, intentions, and, most importantly,
behaviors. Many packaged EBPs supply sample surveys and templates

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for outcome evaluations. Additionally, educators can contact the program

developers for guidance on program evaluation. Evaluations may be
difficult for school districts that have limited resources, time, and expertise;
therefore, the rigor of the evaluation may vary. If possible, the district
health/wellness coordinator and sexual health educator should consult
with expert evaluators, or the program developers, in designing and
implementing their evaluation plans to ensure the greatest rigor possible.
Evaluations are particularly beneficial for school districts that are unsure of
whether they should continue to use the adopted program, or for districts
that may need to justify the continued use of the program to key
stakeholders. For example, the results of the outcome evaluation can be
summarized and presented to the school board so that board members
are aware of the success of the program and can continue supporting
program implementation.

Getting Others on Board

“Getting others on Board” refers to the advocacy activities that are at the
core of the CHAMPSS Model. These advocacy activities ensure that
district personnel have adequate support to carry-out all action steps
during each phase of the program adoption process. They involve
frequent and ongoing discussions with key decision-makers during the
assessment phase, coordination with school staff during the preparation
and implementation phases, and strategizing with all individuals who
contribute to the success of the program during the maintenance phase.
Nearly all school districts will experience resistance at some point during
the adoption, implementation, and maintenance process from school
board members, superintendents, principals, SHAC members, teachers,
and/or parents; however, careful planning and utilization of several key
advocacy strategies may help shift perspectives:
• Know the facts on adolescent sexual health (e.g. teaching
about condoms or contraceptives will not cause young
people to have sex; most parents support sexual health
education that teaches about condoms/contraceptives)
• Distribute fact sheets or other helpful documents to those
who may show resistance
• Present solutions to the problem

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• Bring allies (e.g., parents, students, administrators, nurses,

counselors) when promoting sexual health education37, 46

Future Directions of the CHAMPSS Model

The CHAMPSS Model described above is the first phase of a larger study
to develop an on-line decision support system to help school districts find,
adopt, implement, and maintain EBPs to prevent teen pregnancy. The
tool will be an interactive version of the CHAMPSS Model, named
iCHAMPSS. Tools and resources (e.g., teen birth maps localized by
Texas zip codes, factsheets, templates, and demonstration videos) will be
provided through iCHAMPSS to further support districts in their advocacy
efforts, planning, and implementation of EBPs. This will provide one-stop-
shopping for school districts and sexual health educators. The CHAMPSS
Model will be further tested for its usability and feasibility with school
districts once iCHAMPSS is developed. Revisions to the model will be
made based on the results of these tests. An outcome evaluation is also
planned to determine the impact of iCHAMPSS on program adoption,
implementation, and maintenance by school districts.

Conclusions
Teen pregnancy prevention is a complex and, at times, controversial issue
for school districts. Implementing programs that work is just one solution
to the problem. However, thus far, school districts have received very little
guidance on how to navigate the adoption, implementation, and
maintenance process. The CHAMPSS Model simplifies the process and
provides practical steps for school districts to follow, while minimizing
controversy around the issue. This four-phased model includes seven
action steps and requires that districts elicit support at each step of the
model. This systematic framework will help school districts increase
adoption, implementation, and maintenance of EBPs and to ultimately
improve the status of adolescent sexual health in their district.

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