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Journal of Child and Adolescent Psychiatric Nursing ISSN 1073-6077

A Pilot Program to Address Healthy Sexual Behaviors Among

Girls in Juvenile Detention
Judith W. Herrman, PhD, RN, ANEF, and Julie K. Waterhouse, PhD, RN
Judith W. Herrman, PhD, RN, ANEF, is an Associate Professor, School of Nursing, University of Delaware, Newark, Delaware; Julie K. Waterhouse, PhD,
RN, is an Associate Professor, School of Nursing, University of Delaware, Newark, Delaware, USA.

Search terms: PURPOSE: This pilot study was designed to determine the effectiveness of an inter-
Girls, juvenile detention, pilot study, vention on sexual behavior among girls in juvenile detention.
responsible sexual behavior, sexuality
METHODS: The pre/posttest model assessed for changes in knowledge, attitudes,
education
and reported behaviors. This program merged three curricula to create the unique
Author contact: Young Women Get Real Program with nursing student program facilitators.
jherrman@udel.edu, with a copy to the Editor: FINDINGS: Despite high levels of satisfaction with the program, the data related to
poster@uta.edu the final sample (n = 35) failed to reveal significant changes in measured variables.
CONCLUSIONS: The results may inform nurses as they pursue interventions to
This research was funded by Sigma Theta Tau promote responsible sexual behavior in selected populations.
International, the honors society for nursing, as
a Small Grant Project. The authors report no
actual or potential conflicts of interest. Special
thanks are extended to the following UD
nursing students who served as mentors:
Audrey Arcuri, Nicole Bylsma, Elizabeth Cahill,
Michelle Erli, Brittney Jones, Janelle Pickering,
and Kelly Westgate.

doi: 10.1111/jcap.12007

Peralez-Dieckmann, & Martinez, 2007; Ruffulo et al., 2004).

Introduction
Learning about reproductive health and the consequences of
unsafe sexual practices are important for every teen; they are
paramount for young people involved in the juvenile justice
system. Teens in the juvenile justice system report high rates
of risky sexual behaviors and associated negative conse-
quences (Broaddus & Bryan, 2008; Chang, Bendel, Koopman,
McGarvey, & Canterbury, 2003; Godin et al., 2003; Guthrie,
Hoey, Ravoira, & Kinter, 2002; Kelly, Bair, Baillargeon, &
German, 2000; Kelly, Cheng, Dieckmann, & Martinez, 2009;
Kelly, Morgan-Kidd, Champion, & Wood, 2003; Perper &
Manlove, 2009). Youth in juvenile detention have a greater
risk for mental health issues and, in turn, those with mental
health issues have a higher risk for legal interface and incar-
ceration (Bonham, 2006; Ruffulo, Sam, & Gookind, 2004).
These mental health issues and sexual health behaviors
may serve as a foundation for significant health risks
warranting nursing intervention (Chang et al., 2003; Kelly,
Hall, Martinez, & Peralez-Dieckmann, 2004; Kelly, Owen,
Nursing may serve a key role in empowering young women
in sexual decision making, enhancing the development of a
positive self-esteem, and promoting the sexual health of this
population (Kelly, Lesser, & Paper, 2008; Kelly et al., 2007).
This article describes a unique pilot intervention designed to
provide a short-term sexual decision-making curriculum
using a nursing student teaching model with girls in a Level
IV juvenile detention faculty.
Although the literature is replete with sexuality curricula
and evidence-based interventions designed to enhance posi-
tive sexual behaviors, few have been developed for or imple-
mented with girls who are incarcerated. However, statistics
reflect that girls in detention gravely need this information
(St. Lawrence, Snodgrass, Robertson, & Baird-Thomas,
2008). This project uses a blend of three curricula with
nursing students as program facilitators to increase girls’
knowledge about sexuality to promote self-improvement,
realization of the impact of personal decision making, and
self-empowerment (Becker & Barth, 2000).

224 Journal of Child and Adolescent Psychiatric Nursing 25 (2012) 224–231

© 2012 Wiley Periodicals, Inc.
 A Pilot Program to Address Healthy Sexual Behaviors Among Girls in Juvenile Detention
Review of the Literature
Adolescent Sexuality and Youth in Juvenile Justice
Adolescents in an out-of-home detention experience com-
pounded health threats related to participation in risk-taking
behaviors, poor health care prior to adjudication, lack of
healthcare facilities while detained, and a dearth of positive
health role models in the juvenile justice system (Gallagher,
Dobrin, & Douds, 2007; Greene, Lucarelli, & Shocksnider,
1999). Adolescents in detention centers are more likely to
drop out of high school, live in poverty, and participate in
substance abuse than nondetained adolescents (Guthrie
et al., 2002; National Council on Crime and Delinquency,
2009).
Incarcerated adolescents are at increased risk related to
sexual health when compared to their undetained counter-
parts. Researchers recount that detained adolescents report
earlier initial sexual activity, a greater number of reported
sexual partners, higher rates of anal intercourse, more fre-
quent participation in sexual activity, higher reports of preg-
nancy, less use of contraception during last sexual activity
(both condoms and other birth control), higher rates of elec-
tive abortions, more experience in sex work, increased rates of
diagnosed sexually transmitted infections, and higher rates of
teen dating violence (Broaddus & Bryan, 2008; Godin et al.,
2003; Guthrie et al., 2002; Kelly et al., 2000, 2003, 2009; Perper
& Manlove, 2009). Adolescent women in juvenile justice are
more likely to have been pregnant than other school-aged
adolescents (Golzari, Hunt, & Anoshiravani, 2006; Schaffner,
2006). More than 20% of adolescents in juvenile justice are
infected with chlamydia (Kelly et al., 2000, 2003) and preg-
nant teens are at increased risk of incarceration (Golzari et al.,
2006). Young mothers at risk in juvenile detention centers
have an increased incidence of subsequent pregnancies with
poor birth outcomes and the cumulative challenges associ-
ated with multiple children (Herrman, 2006; Perper &
Manlove, 2009).
Studies suggest that risky behaviors are perpetuated by
poor knowledge of sexuality information, decreased belief in
self-efficacy to impact sexual health, and negative attitudes
toward condom use (Golzari et al., 2006; Guthrie et al., 2002;
Kelly et al., 2003). It is estimated that more than 80% of girls
in the juvenile justice system experience mental health
issues, including depression, attempted suicide, and trauma
(Bonham, 2006; Ruffulo, Sam, & Gookind, 2004). Ruffulo
et al. (2004) indicated that only about one-third of the girls in
juvenile detention who report mental health issues receive
treatment. This level of unaddressed emotional pathology
may be associated with high-risk sexual behaviors; chronic
exposure to stress and exhausted coping measures; and envi-
ronmental, social, and cultural factors that disempower
young women (Bonham, 2006; Golzari et al., 2006; Ruffulo
Journal of Child and Adolescent Psychiatric Nursing 25 (2012) 224–231
© 2012 Wiley Periodicals, Inc.
et al., 2004). These may lead to decreased perceptions of self-
worth and motivation to use contraception (Golzari et al.,
2006; Guthrie et al., 2002; Kelly et al., 2003).
Girls are especially vulnerable to sexual health risks in
detention services. In 1980, 11% of those in juvenile deten-
tion were girls; in 2002, this rose to 18% (Zahn et al., 2008).
In 2005, 30% of all juvenile arrests were of girls and 25% of
those adolescents in juvenile detention centers were girls
(Zahn et al., 2008). Despite these percentages, most juvenile
justice systems lack gender sensitive services and healthcare
provision designed for females (Kelly et al., 2001, 2004).
High percentages of girls in juvenile justice report histories
of sexual victimization, teen dating violence, and forced
sexual activity placing them at even higher risk of other
unsafe sexual practices (Kelly & Morgan-Kidd, 2001; Perper
& Manlove, 2009). Mason, Zimmerman, and Evans (1998)
noted a high correlation between history of sexual abuse
and early sexual activity, nonuse of contraceptives, and preg-
nancy in populations of adolescents who were incarcerated.
Schaffner (2006) proposed that girls in juvenile justice often
develop sexual strategies to deal with nonsexual issues in
their lives such as poverty, homelessness, or family discord.
Girls in out-of-home care may have an intense desire for
affection, may seek out romance in return for sex, may be
exposed to violence, may demonstrate high levels of impul-
sivity, and may lack the reliable social supports and skills to
garner resources, adding to their personal vulnerability
(Becker & Barth, 2000; Devieux et al., 2002; Gallagher et al.,
2007; Kelly et al., 2001).
Researchers describe deficiencies in resources available to
adjudicated girls, including lack of access to routine gyneco-
logical care, contraception and education about birth control,
clinic facilities, and information about sexual health (Clark
et al., 2000; Gallagher et al., 2007; Godin et al., 2003). Kelly
et al. (2004) concluded that detention facilities focus on
screening and treatment for sexually related health issues
rather than providing programs in promoting sexual health,
responsible sexual behavior, and primary prevention efforts.
Becker and Barth (2000) also contended that girls in out-of-
home care may lack sexual education because of absences
from school and chaotic life events, which prevent regular
participation in school-based classes. Curricula for those in
juvenile justice should emphasize sexual decision making,
relationship skills, negotiation, contraception, self-esteem,
healthy sexuality, and personal safety (Chang et al., 2003;
Office of Juvenile Justice and Delinquency Prevention, 2010).
This project explores the ability of a curriculum specifically
designed for girls in the juvenile justice system, based on three
curricular streams and a nursing student education model, to
effect positive change in girls. Characteristics of effective peer
mentoring programs (Kim & Free, 2008) and those curricular
factors cited above are woven together as key components of
this intervention.
225
A Pilot Program to Address Healthy Sexual Behaviors Among Girls in Juvenile Detention
Programs and Interventions
Surprisingly, few teen pregnancy prevention programs exist
for girls in juvenile justice. Kelly et al. (2004) created an
intervention entitled Girl Talk-2 for use with females in
detention settings. The Girl Talk-2 program was adapted
from the Girl Talk Program, a gender-specific, theory-based,
peer-led program focusing on health, sexuality education,
and self-protective behaviors (Guthrie et al., 1996). It also
incorporated components of Safe Dates, an interpersonal
violence prevention initiative (Foshee et al., 1998). The Girl
Talk-2 program included six 1-hr sessions focusing on per-
sonal safety related to sexual behavior, domestic violence,
and relationships. Kelly et al. (2004) reported that this
pilot program demonstrated a small increase in knowledge,
limited increase in condom use, and modest reduction in
reports of domestic violence after participation in the
program. Replications of the program failed to yield signifi-
cant differences, however (Kelly & Dimmitt, 2005; Kelly
et al., 2007). The authors conjectured that increased class
time was needed in order to achieve more promising
results (Kelly et al., 2004, 2007). Other educational programs
designed for adolescents in detention focused on prevention
of human immunodeficiency virus and sexually transmitted
diseases rather than healthy sexual behavior and parenting
readiness. These demonstrated success in enhancing levels
of knowledge and changes in attitudes about sexual activity
(Clark et al., 2000; Godin et al., 2003). The current study
uses Power Through Choices as a component of this three-
pronged curriculum. Power Through Choices has not been,
as yet, tested in girls in juvenile detention facilities, the
subjects of this pilot program.
Methods
Design
The purpose of this study was to determine the effectiveness
of the Young Women Get Real Program to enhance positive
sexual behaviors, knowledge about sexuality, and realistic
attitudes toward teen parenting in girls detained within
the juvenile justice system. The study was designed as a pre/
posttest, single group comparison pilot study. Following
Institutional Review Board approval by the associated aca-
demic institution, and review by a prison advocate, permis-
sion was obtained from the state agency overseeing juvenile
detention services. The principal investigator then met with
agency personnel and distributed an informational brochure
to acquaint them with program specifics, gain information to
enhance group success, and discuss philosophies about sexual
education, the unique needs of girls in the juvenile justice
system, potential areas of sensitivity, and ensure agency com-
mitment to the efforts.
226
The Young Women Get Real Program was taught by
educated nursing students. Interventions that include college
students, specifically nursing students, have been found to be
effective in portraying positive health messages to adolescents
in juvenile justice populations, wherein relationships, respect,
sensitivity, and positive role modeling are integral in the
support of positive behavior change (Kelly et al., 2007). The
nursing students were senior level prelicensure students from a
baccalaureate program. All were required to have completed
their community nursing class prior to this program, submit
an essay about their desire to be in the program,and participate
in a one-on-one interview with the principal investigator. All
seven of the selected nursing students were female, ages 20–22.
Five of the students were Caucasian, one was Asian, and one
wasAfricanAmerican.The nursing students were highly moti-
vated, creative, and brought a high level of energy to imple-
menting the program. The students’ ages fostered rapport
building and the potential for positive role modeling because
of “chronological closeness”(Kim & Free, 2008, p. 90).
The nursing students received copies of the curriculum
and informative articles. The students participated in two full
days of orientation, including a complete review of the Power
Through Choices curriculum, coverage of the two extra units,
a discussion of teaching strategies, and sessions on the devel-
opmental and social aspects of working with teens and girls in
juvenile detention. Frequent team meetings, communication
via email, and ongoing contact between the principal investi-
gator and each student ensured preparation for the class
sessions. The faculty member or consultant attended each
program session.
Prior to implementing the pilot, a focus group was con-
ducted with six girls from the detention center. These young
women completed and commented on the study’s proposed
measurement tool, their learning needs with regard to sexual-
ity, and a unit from the curriculum to determine the potential
unique needs of girls in the juvenile justice system. The unit
was related to decision making and the responsibilities associ-
ated with teen parenting, including an activity in which par-
ticipants drafted a want-ad seeking individuals who hold
those qualities they believed were inherent of the ideal parent.
The agency psychologist obtained parent/guardian per-
mission for all the participants and, as girls were admitted to
the agency, they were offered the program. None of the girls in
detention chose not to participate.
Intervention
This intervention was based on three curricula. The major
component of the curriculum was Power Through Choices,
which is the only identified and studied curriculum designed
to meet the needs of marginalized youth (Becker & Barth,
2000). Originally designed for adolescents in foster care, the
program was also implemented in out-of-home care and
Journal of Child and Adolescent Psychiatric Nursing 25 (2012) 224–231
© 2012 Wiley Periodicals, Inc.
 A Pilot Program to Address Healthy Sexual Behaviors Among Girls in Juvenile Detention
alternative school settings. This is the first known use of
Power Through Choices with girls in the juvenile justice
system. The major tenets of this intervention include self-
improvement, realization of the impact of decisions on
the future, and navigation of the world by fostering self-
empowerment skills (Becker & Barth, 2000). This curriculum
was developed based on a variety of theoretical under-
pinnings, including the health belief model, self-regulation
theory, the theory of reasoned action, and social/cognitive
learning theory. Power Through Choices focuses on making
positive choices related to sexual behavior, building con-
traceptive knowledge and skills, finding and using local
resources, and developing effective communication skills
(Becker & Barth, 2000). In preliminary evaluation, Becker
and Barth (2000) reported that teens accrue higher levels of
knowledge, increased personal confidence, and satisfaction
with the program. The authors charged other researchers to
continue to study this program’s effectiveness.
The Power Through Choices program uses group exercises
and games to reinforce each lesson. Activities include estab-
lishing ground rules, an anonymous box for questions,
condom races, sexuality bingo, a variety of role plays reflect-
ing teens in different situations related to sexuality, contra-
ception and interpersonal relationships, interviews with each
other as potential babysitters, and other activities. Supplies,
such as assertive/aggressive/passive voting cards, communi-
cation flash cards, and sexual risk-taking identification
prompts were prepared, to be used at each session. The
anonymous box allowed participants to write on an index
card at each session and place it in the box. The cards could
have a question, a statement, or may say “I don’t have a ques-
tion,” ensuring confidentiality of the questioner’s identity.
One area noted to be missing in the Power Through
Choices curriculum is a review of the anatomy and physiol-
ogy of reproduction. A single unit from the Big Decisions cur-
riculum was added as the second component of this program
highlighting female and male internal and external genital
anatomy, a game about the journey of the sperm and the
egg, and a “What’s it called” exercise highlighting the correct
names of anatomical structures. Big Decisions, a comprehen-
sive sexuality education curriculum, has demonstrated posi-
tive impacts on youth in the areas of knowledge acquisition
and reported behavior changes (Realini, 2008). Although not
previously used with girls in the juvenile justice system, the
unit met a critical need in addressing anatomy of the repro-
ductive system with teens.
Authors described that teen women in juvenile justice per-
ceived few negative consequences and associated positive
rewards with early parenting (Kelly et al., 2008). Girls saw
sexual activity and pregnancy as a means to gain affection,
freedom, and family attention and to escape from current life
stressors, while not considering the realities of teen parenting
(Becker & Barth, 2000; Herrman, 2008; Kelly et al., 2008).
Journal of Child and Adolescent Psychiatric Nursing 25 (2012) 224–231
© 2012 Wiley Periodicals, Inc.
Kelly et al. (2008) noted that teens in foster and out-of-home
care, as in detention residences, were less cognizant of the
challenges and hardships associated with adolescent child-
bearing. Therefore, the Young Women Get Real Program
included a unit based on the Thoughts on Teen Parenting
Survey (TTPS) as a framework for the third component of the
curriculum designed to illustrate impact of a birth on teen
lives and the importance of goal setting for future successes.
Based on Adler, Kegeles, Irwin, and Wibblesman’s (1990)
theory of reasoned action, which delineates that individuals
deliberate costs and rewards to decide to engage in a behavior,
the TTPS addresses teen perceptions of the cost and rewards
of the teen parenting experience (Adler et al., 1990; Herrman
& Nandakumar, 2012). The survey generated content for one
of the class sessions highlighting the impact and responsibili-
ties of adolescent parenting. These three curricular compo-
nents created a unique program as the Young Women Get
Real Program and reinforced the concepts of respect, goal
setting, holistic sexual health, and responsibility to increase
safe sexual behavior.
Implementation
The course was conducted in eight 90-min sessions over 4
weeks. The entire curriculum was implemented four times
during the funding period. The seven nursing students self-
scheduled such that four were present at each class session.
The class handouts and curriculum were distributed each day
of the class and recollected at the end of each session. No
homework was included but students were allowed to keep all
materials at the end of the program. A small graduation cer-
emony was held during the last class of each session wherein
girls received their gift cards and an inscribed certificate of
completion. Table 1 includes information on the class topics.
Measurement
The pre/posttest was designed to determine program effects
and was administered during the first and final sessions of the
Table 1. Young Women Get Real Curriculum
Session 1 Introduction/choices: Creating the future you want
Pretests
Session 2 Big decisions—Anatomy and reproduction/communication:
How to make your choices stick
Session 3 Empowerment: Understanding STIs and HIV and how to
reduce your risk
Session 4 Empowerment: Increasing your knowledge about protection
Session 5 Empowerment: Practice makes perfect and how to use
resources to support your choices
Session 6 Making choices that fit your lifestyle
Session 7 Parenting: Making an informed choice
Session 8 Empowerment: Demonstrating your skills and knowledge
Posttests
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A Pilot Program to Address Healthy Sexual Behaviors Among Girls in Juvenile Detention

program. The survey included three parts. Part A of the tool American descent, low income status, and had a parent who
obtained demographic data. Part B (the TTPS) measured the had sustained a teen pregnancy. Large proportions of the
attitudes toward the impact of a teen birth on the life of the sample reported living with one parent and in urban settings.
participant. This survey, developed by the principal investiga- Several of the girls shared that they were pregnant or parent-
tor, demonstrated high levels of reliability in previous studies, ing during the course of program implementation.
with alpha levels ranging from 0.89 to 0.93 (Herrman & Nan-
dakumar, 2012; Herrman & Waterhouse, 2011; Herrman,
Waterhouse, & Chiquoine, 2011). Part B yields a total score, Setting
wherein higher scores indicate more positive perceptions and
The classes were held during girls’ incarcerations at a Level IV
lower scores are more negative attitudes toward a teen birth.
detention facility in a Mid-Atlantic state. This setting is a
Part B contains eight subscales to describe the construct,
locked facility and each section is also locked to ensure the
including relationships (with friends, parents/families, and
safety and containment of the girls. The girls participate in an
boyfriends/girlfriends), vocation (education, work, and
on-campus school program, family and individual counsel-
money), and personal life (personal characteristics and life in
ing, in-depth mental health services, case management with a
general). Part B measured the concepts associated with the
youth rehabilitation counselor, outside programming, and
realities of teen parenting. Part C was a self-report measure,
transitional care for postdischarge success. New efforts to
which assessed positive sexual health behaviors and changes
provide gender-specific programming have been initiated to
in knowledge levels with questions from Power Through
respond to the large increase in girls involved in juvenile
Choices and Big Decisions. Part C yields a total score on
justice in the state of study.
the knowledge and behavior scales.

Sample Results
The final sample of 35 female participants, who completed at For the TTPS part B scores, which represent the teens’ atti-
least 75% of the course and the pre/posttests, were given $15 tudes and thoughts on teen parenting, the mean pretest score
gift cards to a craft store as recognition for their time. The girls was 133.1 and the mean posttest score was 133.9. The differ-
ranged from 12 to 18 years of age, with a mean age of 15.8 ence was not statistically significant (t = - 0.19, p = 0.854). On
years. Sample characteristics are found in Table 2. The sample the part C scores, which assessed the girls’ knowledge and
included a majority of young women who reported African reported behaviors, the pretest score was 47.5 and the average
posttest score was 48.4. This was also not found to be statisti-
cally significant (t = - 0.41, p = 0.683). These statistics demon-
Table 2. Demographic Characteristics of Sample (n = 35)
strate the girls’ attitudes toward teen parenting actually
Number % became slightly more positive and their knowledge and
Ethnic origin behavior scores improved slightly. t-tests revealed no signifi-
Latino/Latina 1 3% cant differences on the total survey scores, subscale scores,
African American 18 51% or in comparisons of selected demographic variables with
Caucasian 7 20% total or subscale scores. Table 3 includes the total and subscale
Mixed 9 26%
scores of the TTPS.
Eligible for reduced or free lunch
Yes 22 63%
No 13 37%
Sibling who had a teen pregnancy Table 3. Results of t-tests Between Pre- and Posttest Means on
Yes 14 40% the TTPS
No 21 60%
Pretest M Posttest M t p
Parent who was a teen parent
Yes 21 60% Total TTPS scale 133.1 133.9 -0.19 0.854
No 14 40% Subscales
Describe where you live Friends 9.63 9.07 1.40 0.171
Urban 16 46% Boyfriend/girlfriend 15.86 15.72 0.33 0.741
Suburban 15 43% Family 12.37 12.48 0.40 0.693
Rural 4 11% Money 11.94 13.07 -1.76 0.089
Describe with whom you live Education 12.66 12.00 0.57 0.576
Two parents 8 23% Career 14.11 14.07 0.07 0.942
One parent 13 37% Personal characteristics 33.03 32.45 -0.73 0.474
Other 14 40% Life in general 25.77 26.79 -0.98 0.333

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 A Pilot Program to Address Healthy Sexual Behaviors Among Girls in Juvenile Detention
Discussion
The results of this study indicate that a short-term curricular
intervention did not change knowledge, attitudes, or behav-
iors of girls in juvenile detention. The nursing students and
group participants expressed high levels of satisfaction with
this initiative despite the lack of significant findings, reinforc-
ing the role of human interaction elements and the qualitative
nature of study impacts. This validates the findings of Girl
Talk-2, in which only small gains in knowledge, attitudes, or
behaviors were found with short-term interventions but that
participants enjoyed the interactions (Kelly et al., 2007). Fol-
lowing each session, the nursing student group met with the
principal investigator for a debriefing period. The nursing
students shared anecdotal stories of interactions with the
young women, frank discussions with the young women
about their personal life histories, and their observations
about the program. These experiences and insights reinforced
the value of interpersonal connections and the potential for
intangible or difficult to measure gains from strategies focus-
ing on relationships and self-exploration.
A few of the exercises did not prove successful when
adapted for girls in the juvenile justice system. For example,
the activity in which the students were asked to interview an
important person in their life was omitted because of its lack
of feasibility for girls in detention settings. The condom races,
in which participants competed in putting the condom on a
model using the correct steps, created a tense and nonproduc-
tive environment among the participants. When participants
were asked to interview each other for jobs as a babysitter,
the exercise was much more effective when introduced as
“You are interviewing someone to babysit YOUR child.” It
appeared that this personalization helped participants feel
more invested in the task.
As noted by Aalsma, Tong, Wiehe, and Tu (2010), youth in
juvenile justice are plagued by a myriad of social, environmen-
tal, and contextual stressors, which add to the complexity of
their behaviors, including those related to sexuality. Authors
call for comprehensive and early interventions to have more
significant impact on teen behaviors (Aalsma et al., 2010;
Devieux et al., 2002; Guthrie et al., 1996; Kelly et al., 2004;
Kelly & Dimmitt, 2005). Girls’ levels of knowledge, attitudes,
and behaviors reflect family values, lifelong experiences, social
norms, personal beliefs, and environmental influences, which
are difficult to change in an eight-session program. The study
findings may suggest that the behaviors of the young women,
already imbedded in their daily practices, will be difficult to
change at this point in time, and may indicate a need for earlier
intervention, identification of high risk youth prior to incar-
ceration, and a focus on norms and values.
Adolescent intervention research indicates that, in order
to be effective, programs must not only include a curricular
intervention that is based on comprehensive sexuality
Journal of Child and Adolescent Psychiatric Nursing 25 (2012) 224–231
© 2012 Wiley Periodicals, Inc.
education but also opportunities for role modeling, peer
mentoring, credible future options, and means to develop
relationship skills (Devieux et al., 2002; Guthrie et al., 2002;
St. Lawrence et al., 2008). Classes designed to provide infor-
mation alone may not be effective in creating subsequent
behavior change, especially in sexually active teens who may
already have been pregnant, are parenting, have a history of
negative sexual experiences or sexual abuse, or are diagnosed
with mental health issues (Clark et al., 2000; Godin et al.,
2003; Mason et al., 1998; Mylant & Mann, 2008). St. Lawrence
et al. (2008) suggested that individual, risk focused interven-
tions must also include group norms, family values, and com-
munity reinforcement in order to change behavior when free
of the context of incarceration. Future study of interventions
framing responsible sexual behavior related to future goal
setting, the impediments pregnancy and parenting may pose
to those goals, and realistic next steps in the course of the lives
of the young women may foster personal self-worth, reflect
the importance of healthy sexuality, and capitalize on the
mentoring and role modeling inherent of curricular models.
Limitations
This study, though providing valuable information about a
potential intervention to encourage positive sexuality in
young women who are incarcerated, is limited by a variety of
factors. The small sample size and lack of a control group
are the most apparent. Both Power Through Choices, which
focused on youth in out-of-home care, and the Big Decisions
curricula were based on mixed-gender samples. Neither were
specific for women in the juvenile justice system, limiting
their use with this sample. In addition, though Power
Through Choices is designed for marginalized youth from a
variety of cultures and for the adolescent group in general,
specific cultural and developmental variables may impact
curricular effectiveness. Findings were also limited by their
self-report nature. Teens often do not report authentic results
or respond well to survey administration (Kelly et al., 2005).
The pre/posttest generated a high level of discussion but the
tool itself appeared to frustrate participants. Though the
reading level of this tool was 4.3 and young women with
poorer reading skills were offered coaching, participants
complained about the tool length, calling its reliability into
question for this sample. The nursing students provided indi-
vidual assistance to participants during survey completion
but the impacts of these measures are not known. The young
women’s stressed lives, changes in moods, and daily events
may have impacted their answers and attentiveness during
survey completion. Kelly et al. (2004) noted that survey
research often denies participants the ability to spontaneously
discuss topics and interact with others about survey content.
Future studies may include focus groups or semistructured
individual interviews to gather evaluative data.
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A Pilot Program to Address Healthy Sexual Behaviors Among Girls in Juvenile Detention
Varying lengths of stay and subsequent attrition of class
participants reduced the sample size and threatened the valid-
ity of the findings. Girls entered and exited the program based
on their individual sentences. These varied in length of time
and in their alignment with class sessions. Although the pre/
posttests were only administered to youth attending at least
75% of the sessions, only a small number of the girls attended
all eight classes. Sentences, court dates, and other variables,
along with the scheduling of the classes, reduced the sample
size from that which was originally anticipated.
The young women received their medications prior to the
classes and these often included antidepressants, central
nervous system stimulants for attention disorders, and mood
stabilizers. As the medications took effect, some of the girls
became fatigued and less attentive, decreasing the potential
program impacts.
As noted by Becker and Barth (2000), the abilities and
teaching styles of the facilitators are critical to program
success. The nursing students needed encouragement and
support to command the attention of the students and to
maintain order in the classroom. The nursing students
excelled during the spontaneous activities and discussions,
including the anonymous question box. This may suggest the
need for adult program coordinators to deliver the curri-
culum with fidelity while allowing the nursing students to
mentor and participate in more impromptu discussions.
Finally, the principles introduced in the eight 1 1/2-hr ses-
sions required reinforcement during the daily lives of each
participant and in all encounters. It is not known if the girls
were encouraged to use assertive communication skills, self-
advocate, and implement class components during their day,
nor how these skills would be received in their home settings.
More longitudinal data collection is needed to learn mean-
ingful ways to sustain changes in knowledge, attitude, and
behavior (Clark et al., 2000).
As noted, considering the impact of mental health, socio-
cultural contextual factors, and historical life events is essen-
tial in addressing sexual decision making and empowerment
with youth populations. A holistic perspective that embodies
all components of the human mind and body is needed to
create meaningful change in any one life area, including
sexual decision making (Kelly et al., 2001).
The results of this study may prove valuable for nurses
exploring options in teaching selected populations about
responsible sexual behavior. Nurses are often called upon to
provide individual and group instruction on positive health
behaviors. Suggestions in this manuscript may inform future
programs.
Conclusions
The spontaneous discussion between the college students and
young participants was perhaps the most gratifying compo-
230
nent of this project, and validated the effort involved. One of
the Power Through Choices strategies, the anonymous ques-
tion box, and role modeling appeared to garner positive, if not
measurable results. Partnerships between schools of nursing
and agencies may foster further collaborative efforts designed
to promote health in marginalized youth. The participants
actively engaged in the discourse on mothering,parenting,and
pregnancy. Because it appeared that the girls were already
sexually active, as reflected in the literature, frank discussions
about personal safety, assertiveness, and contraception were
more valuable than those about abstinence or the negative
aspects of teen sexual activity (Godin et al., 2003).
The nursing profession, grounded in strong skills of assess-
ment and holistic care, is well positioned to meet the learning
needs of young women in juvenile justice. The merging of the
three curricula may offer a valuable intervention warranting
additional research. Although the short-term curricular
intervention failed to significantly influence the knowledge,
attitudes, and behaviors of this sample of girls in juvenile
justice, this study provides an important step in the adapta-
tion and blending of the curricula tailored for the needs of
girls in juvenile justice. Additional revision of psychometric
evaluation of the survey measure may increase sensitivity and
the ability to detect pre- and postintervention differences.
The observations made in this study provide a foundation for
ongoing assessment of this program that may prove its value
in the future. A clear perspective of the unique cultural, situ-
ational, and developmental needs of girls in juvenile deten-
tion may inform further exploration of strategies or may be
used to shape the current intervention for more effective
results.
References
Aalsma, M. C., Tong, Y., Wiehe, S. E., & Tu, W. (2010). The impact
of delinquency on youth adult sexual risk behaviors and
sexually transmitted infections. Journal of Adolescent Health,
46, 17–24.
Adler, N. E., Kegeles, S. M., Irwin, C. E., & Wibblesman, C. (1990).
Adolescent contraceptive behavior: An assessment of decision
processes. Journal of Pediatrics, 116, 463–471.
Becker, M. G., & Barth, R. P. (2000). Power through choices:
The development of a sexuality curriculum for youths in out
of home care. Child Welfare, 79, 269–281.
Bonham, E. (2006). Adolescent mental health and the juvenile
justice system. Pediatric Nursing, 32, 591–595.
Broaddus, M. R., & Bryan, A. (2008). Consistent condom use
among juvenile detainees: The role of individual differences,
social bonding, & health beliefs. AIDS Behavior, 12, 59–67.
Chang, V., Bendel, T. K., Koopman, C., McGarvey, E. L., &
Canterbury, R. J. (2003). Delinquents’ safe sex attitudes:
Relationships with demographics, resilience factors,
and substance use. Criminal Justice and Behavior, 30,
210–229.
Journal of Child and Adolescent Psychiatric Nursing 25 (2012) 224–231
© 2012 Wiley Periodicals, Inc.
 A Pilot Program to Address Healthy Sexual Behaviors Among Girls in Juvenile Detention
Clark, J. N., Van Eck, R. N., King, A., Glusman, B.,
McCain-Williams, A., Van Eck, S., & Beech, R. (2000).
HIV/AIDS education among incarcerated youth. Journal of
Criminal Justice, 28, 415–433.
Devieux, J., Malow, R., Stein, J. A., Jennings, T. E., Lucenko,
B. A., Averhart, C., & Kalichman, S. (2002). Impulsivity &
HIV risk among adjudicated alcohol and other drug abusing
adolescent offenders. AIDS Education and Prevention, 14,
24–35.
Foshee, V., Bauman, K., Arriaga, V., Helms, R., Koch, G., & Linder,
G. (1998). An evaluation of Safe Dates, an adolescent dating
violence prevention program. American Journal of Public
Health, 88, 45–50.
Gallagher, C. A., Dobrin, A., & Douds, A. (2007). A national
overview of reproductive health care services for girls in
juvenile justice residential facilities. Women’s Health Issues, 17,
217–226.
Godin, G., Michaud, F., Alary, M., Otis, J., Masse, B., Fortin, C., . . .
Gagnon, H. (2003). Evaluation of an HIV and STD prevention
program for adolescents in juvenile rehabilitation centers.
Health and Education Research, 30, 601–614.
Golzari, M., Hunt, S. J., & Anoshiravani, A. (2006). The health
status of youth in juvenile detention facilities. Journal of
Adolescent Health, 38, 776–782.
Greene, E., Lucarelli, P., & Shocksnider, J. (1999). Health
promotion and education in youth correctional facilities.
Pediatric Nursing, 25, 312–314.
Guthrie, B. J., Hoey, E., Ravoira, L., & Kinter, E. (2002). Girls in
the juvenile justice system: Leave no girl’s health un-addressed.
Journal of Pediatric Nursing, 17, 414–423.
Guthrie, B. J., Wallace, J., Doerr, K., Janz, N., Schottenfeld, D., &
Selig, S. (1996). Girl talk: Development of an intervention for
prevention of HIV/AIDS and other sexually transmitted
diseases in adolescent females. Public Health Nursing, 13,
318–330.
Herrman, J. W. (2006). The voices of teen mothers: The
experience of repeat pregnancy. MCN. The American Journal
of Maternal Child Nursing, 31(4), 243–249.
Herrman, J. W. (2008). Adolescent perceptions of teen births.
Journal of Obstetrical, Gynecological, and Neonatal Nursing,
37, 1–9.
Herrman, J. W., & Nandakumar, R. (2012). Development of a
survey to assess adolescent perceptions of teen parenting.
Journal of Nursing Measurement, 20(1), 3–20.
Herrman, J. W., & Waterhouse, J. K. (2011). What do adolescents
think of teen parenting? Western Journal of Nursing Research,
33(4), 577–592.
Herrman, J. W., Waterhouse, J. K., & Chiquoine, J. (2011). An
evaluation of an infant simulator intervention for teen
pregnancy prevention. Journal of Obstetrical Gynecological and
Neonatal Nursing, 40(3), 322–328.
Kelly, P., & Morgan-Kidd, J. (2001). Social influences on the
sexual behaviors of adolescent girls in at-risk circumstances.
Journal of Obstetric, Gynecologic, and Neonatal Nursing, 30,
481–489.
Journal of Child and Adolescent Psychiatric Nursing 25 (2012) 224–231
© 2012 Wiley Periodicals, Inc.
Kelly, P., Bair, R. M., Baillargeon, J., & German, V. (2000). Risk
behaviors and the prevention of Chlamydia in a juvenile
detention facility. Clinical Pediatrics, 39, 521–527.
Kelly, P., Lesser, J., & Paper, B. (2008). Detained adolescent’
attitudes about pregnancy and parenthood. Journal of Pediatric
Health Care, 22, 240–245.
Kelly, P. J., Cheng, A., Dieckmann, E. P., & Martinez, E. (2009).
Dating violence and girls in the juvenile justice system. Journal
of Interpersonal Violence, 24, 1536–1551.
Kelly, P. J., Hall, S., Martinez, E., & Peralez-Dieckmann, E. (2004).
Health promotion in the juvenile justice system. Journal of
Multicultural Nursing and Health, 10(2), 48–56.
Kelly, P. J., Morgan-Kidd, J., Champion, J. D., & Wood, R. (2003).
Sexuality knowledge, attitudes, and practices of young women
in the juvenile justice system. Pediatric Nursing, 29, 271–275.
Kelly, P. J., Owen, S. V., Peralez-Dieckmann, E., & Martinez, E.
(2007). Health interventions with girls in the juvenile justice
system. Women’s Health Issues, 17, 227–236.
Kelly, P. K., & Dimmitt, J. (2005). Results of a gender-specific
intervention in the juvenile justice system. Communicating
Nursing Research, 38, 347.
Kim, C. R., & Free, C. (2008). Recent evaluations of the peer-led
approach in adolescent sexual health education: A systematic
review. International Family Planning Perspectives, 34, 89–96.
Mason, W. A., Zimmerman, L., & Evans, W. (1998). Sexual and
physical abuse among incarcerated youth: Implications for
sexual behavior, contraceptive use, and teenage pregnancy.
Child Abuse and Neglect, 22, 987–995.
Mylant, M., & Mann, C. (2008). Current sexual trauma among
high risk teen mothers. Journal of Child and Adolescent
Psychiatric Nursing, 21(3), 164–176.
National Council on Crime and Delinquency. (2009). Fact sheet.
Retrieved from http://www.nccd-crc.org
Office of Juvenile Justice and Delinquency Prevention. (2010).
What does gender specific programming look like in practice?
Retrieved from http://www.ojjdp.ncjrs.gov
Perper, K., & Manlove, J. (2009). Vulnerable youth: A closer look at
reproductive health outcomes. Washington, DC: ChildTrends.
Realini, J. (2008). Big decisions. Retrieved from http://www.
bigdecisions.org
Ruffulo, M. C., Sam, R., & Gookind, S. (2004). Study of delinquent,
diverted, and high risk adolescent girls: Implications for mental
health intervention. Social Work Research, 28, 237–245.
Schaffner, L. (2006). Girls in trouble with the law. New Brunswick,
NJ: Rutgers University Press.
St. Lawrence, J. S., Snodgrass, C. E., Robertson, A., &
Baird-Thomas, C. (2008). Minimizing the risk of pregnancy,
sexually transmitted diseases, and HIV among incarcerated
adolescent girls: Identifying potential points of intervention.
Criminal Justice and Behavior, 35(12), 1500–1514.
Zahn, M. A., Brumbaugh, S., Steffensmeier, D., Feld, B. C.,
Mosash, M., Chesney-Lind, M., . . . Kruttachnitt, C. (2008).
Girls study group: Understanding and responding to girls’
delinquency. Retrieved from https://www.ncjrs.
gov/pdffiles1/ojjdp/218905.pdf
231