Creative Education
2011. Vol.2, No.3, 193-198
Copyright © 2011 SciRes. DOI:10.4236/ce.2011.23027
ESTEEM and FACTS: Creative Ways to Teach Healthy
Lifestyles to Youth from Diverse Backgrounds
Tary J. Tobin
College of Education, University of Oregon Eugene, Eugene, USA.
Received June 8th, 2011; revised June 27th, 2011; accepted July 7th, 2011.
Two health education programs illustrating different ways to engage youth from racially and ethnically diverse
backgrounds in positive youth development lessons and activities are described for practitioners in schools and
community agencies. Both programs were developed in collaborative efforts between public school health
teachers and community organizations and resulted in abstinence education curricula suitable for use in either
schools or community agencies. Both programs were effective with youth from different racial and ethnic back-
grounds in promoting setting wholesome personal goals, developing prosocial and healthy relationships, and
avoiding risky behaviors such as premature sexual activity or abuse of alcohol and illegal drugs. Federal pro-
grams designed to prevent teen pregnancy facilitated the development and evaluation of both programs. ES-
TEEM was developed in Texas at the Longview Wellness Center and FACTS was developed in Oregon by
Northwest Family Services.
Keywords: Health Education, Teaching Methods, Racial and Ethnic Diversity, Teen Pregnancy Prevention
Unintended teen pregnancies are serious problems for the
following reasons: 1) early prenatal care often is not received; 2)
the fetus often is exposed to alcohol, tobacco, and drugs; 3)
about half of all unintended pregnancies lead to abortions; 4) it
is a risk factor for low birth weight, death in the first year of life,
and neglect or abuse; 5) maternal depression is may occur; 6)
physical abuse of the mother is a serious risk; 7) the couple’s
relationship may be negatively affected; and 8) both mother and
father may experience financial difficulties and difficulty in
achieving educational and career goals (Brown & Eisenberg,
1995). Health educators need creative ways to help youth form
intentions that will guide their behaviors, form habits associated
with healthy lifestyles, and enable attainment of goals of com-
pleting school and preparing for a successful personal and fu-
ture family life. ESTEEM and FACTS are two such creative
ways. These two health education programs are described to
show two different ways to engage youth in positive youth
development lessons. Both programs were effective with youth
from different racial and ethnic backgrounds in promoting set-
ting wholesome personal goals, developing prosocial and
healthy relationships, and avoiding risky behaviors.
The East Texas Abstinence Program (ETAP) started in the
2001-2002 academic school year with support from the Long-
view Wellness Center, a medical clinic (now called Wellness
Pointe) and the Texas Department of Health. During the
2002-2003 and 2003-2004 school years, ETAP was a Special
Project of Regional and National Significance grant recipient.
During the 2004-2005, 2005-2006, 2006-2007, and 2007-2008
school years, ETAP was a Community-Based Abstinence Edu-
cation program under the Administration for Children and
Families (ACF) of the federal Department of Health and Hu-
man Services.
ETAP was designed to prevent teen pregnancy and sexually
transmitted disease while helping youth from diverse racial and
ethnic backgrounds make physically, mentally, and emotionally
healthy decisions. The demographic characteristics of the stu-
dents who participated in this program varied slightly over the
years but typical percentages were White 54%, African Ameri-
can 23%, Hispanic1 18%, Other 4%, Asian 0.84%, and Native
American 0.56%. The total number of participants was more
than 2000 most years.
Methods used included 1) health education classes in public
schools; 2) programs, activities, and special events in commu-
nities and alternative schools; 3) meetings of a supportive coali-
tion of youth and adults; and 4) a multimedia campaign using a
range of methods of outreach, including entertaining and in-
formative Public Service Announcements (PSAs) for radio and
television, billboards, car bumper stickers, an d a Web site,, where copies of PSAs, bill-
boards, and other information for youth, parents, schools,
community members, and the public in general are posted.
With headquarters in Longview, Texas, abstinence education
classes were provided to schools in multiple counties in the
eastern part of Texas (e.g., Camp County, Gregg, Harrison,
Marian, Panola, Rusk, Smith, and Upshur).
ETAP offered programs suitable for upper elementary, mid-
dle school, and high school students. Initially, before ESTEEM
was developed in Texas, ETAP used a curriculum developed in
1At the time of the development of ESTEEM, the funders allowed this
type of demographic breakout. The common current requirements to
first ask about Hispanic or Latino ethnicity and then ask about race
was not yet in place.
Oregon, Family Accountability Communicating Teen Sexuality
(FACTS; Fuller & Asato, 1998; Fuller, Denman, & McLaugh-
lin, 1997; Fuller & McLaughlin, 1998). Annual reports from an
independent evaluator that included results from surveys were
used to guide program development over the years (e.g., Tobin,
2002, 2003). The younger students participated in a charac-
ter-based health education program that did not specifically
address sexuality but was designed to serve as a foundation for
such lessons at higher grade levels (Fuller et al., 2000a, 2000b).
ETAP worked with local schools and communities to develop
ESTEEM: An Abstinence Based Curriculum for Grades 6 - 9
(East Texas Abstinence Program, 2006b) and other materials
for the EQUIP (East Texas Abstinence Program, 2006a) series
for different grade levels.
The ESTEEM curriculum uses workbooks with facts and
figures, questions and answers, demonstrations, games, and
activities to engage students. Materials to help the teachers also
are provided as well as educational incentives, such as book
marks, contract cards, and stickers. The contract cards are about
the size of a credit card and they are type of pledge to be sexu-
ally abstinent before marriage. One ETAP youth leader reports
that on a return visit to a school about a year after he had made
a presentation and handed out these cards, he decided to ask if
anyone still had the card he had given last year. Thinking that
no one would have one, he offered to give 5 dollars to the first
person who could show him that they still had the card. He was
glad that he said the first person because students were keeping
the cards in their wallets and it could have been quite an expen-
sive day for him if he had to pay everyone who kept their cards!
However, this incident suggests that the cards were a worth-
while part of the program.
The ten lessons in the ESTEEM curriculum cover the fol-
lowing topics:
1) Finding My Way: a) my values and beliefs, b) short and
long term goals, c) commitment and dreams.
2) The Media and Me: a) facts about the media, b) sex sells:
Its influence on you, c) internet safety guidelines.
3) STDs Are Not for Me: a) What are STDs? b) Can they be
prevented? c) Braniac Quiz.
4) What about Teen Pregnancy? a) What if? Options and
choices, b) the truth for girls and guys, c) life of a teen mom.
5) What does the law say about sex? a) learn to protect your-
self, b) legal consequences of underage sex, c) you be the
6) Feeling the Squeeze: a) everybody is doing it—peer pres-
sure, b) conflict resolution, c) come back lines.
7) Drugs and Alcohol: a) real friends and drug use, b) effects
of alcohol and drug use, c) case study: Nicole and Trisha.
8) Having Freedom with Friends: a) healthy relationships, b)
establishing personal boundaries, c) positive peer power.
9) Relationships: a) dating through the years, b) boundaries
in the dating relationship, c) my individual contract.
10) Setting Your Goals: a) reviewing your goals? b) your big
day, c) crossword puzzle.
The annual evaluations typically found that pre- to post-in-
tervention changes were statistically significant (p < .01), with
positive changes in areas such as the proportion of adolescents
who 1) understand that abstinence from sexual activity is the
only certain way to avoid out-of-wedlock pregnancy and sexu-
ally transmitted disease; 2) report they have the refusal or as-
sertiveness skills necessary to resist unwanted sexual advances;
3) commit to abstain from sexual activity until marriage; 4)
intend to avoid situations and risk behaviors, such as drug use
and alcohol consumption, which make them more vulnerable to
sexual advances. The ETAP program made good use of forma-
tive evaluation over the years and continually improved their
program, as illustrated Figure 1, showing post-intervention
responses over the years.
Concurrent Validity
The ESTEEM curriculum for 7th and 8th graders was com-
pared with an established, traditional abstinence education cur-
riculum (FACTS) that was already being used by many schools,
especially in Texas and in Oregon (Tobin, 2007). The partici-
pating students in this descriptive study reported diverse racial
and ethnic backgrounds, with the three largest groups being
White (54%), Black (23%), and Hispanic (18%). A multiple
regression analysis indicated that race/ethnicity, as well as type
of curriculum used, accounted for some of the variance in pre-
to post-intervention changes.
Both groups of 7th and 8th grade students, the ones using the
EQUIP materials and the ones using the FACTS materials, on
average, improved after the abstinence education lessons in
attitudes, intentions, and perceptions. These were measured in
surveys containing several scales, such as the Future Orienta-
tion sca le, which i s explained below:
Future Orientation (FO) Scale
Indicates awareness of the value of abstinence for attain-
ment of future goals
3 questions (goals for education, future marriage and family,
and career/job)
Low scores indicate attitudes favorable to abstinence
Cronbachs Alpha = .82
The questions used the following format:
Do you think that abstinence (not having sex) as a teen
would make it easier for you to get a good education in the
1) It would make it a lot easier.
2) It would make it a little easie r.
3) It wouldn’t make any difference.
The EQUIP group consisted of 750 students in 7th and 8th
grade from 5 schools in 4 counties in East Texas: Camp County,
Gregg, Harrison, and Rusk County. The FACTS group con-
sisted of 1160 students in 7th and 8th grade from 15 schools in 7
counties in East Texas: Gregg, Harrison, Marian, Panola, Rusk,
Smith, and Upshur Counties. The average age, in years, for the
FACTS group was 13.08 (SD = 1.27); for EQUIP it was 13.01
(SD = 1.53), not a statistically significant difference (p < .05).
Females made up 52% of the FACTS group and 47% of EQUIP,
also not a statistically significant difference (p < .05).
Using multiple linear regression, post-intervention scale
scores were predicted on the basis of 1) race/ethnicity, 2)
pre-intervention scores, and 3) type of curriculum used (i.e.,
“group” being EQUIP or FACTS). Controlling for race/ethni-
city first, and then for pre-intervention score, group made a
statistically significant (p < .05) difference for Future Orienta-
tion (FO), as shown in Table 1.
In an Analysis of Variance test (using the PROC NPAR1
WAY procedure in SAS 9.1 for Windows), for both groups, the
average on the FO Scale changed in the intended direction
T. J. TOBIN 195
Figure 1.
Percent who agree or strongly agree that The best way for teenagers to avoid unintended pregnancy, HIV/AIDS and
other sexually transmitted infections is to wait until they are married before having sex.
Table 1.
Summary of simultaneous regression analysis for variables predicting
post-intervention future orientation (FO) score.
(down) after the intervention. The group averages were not
statistically significantly (p < .05) different at Time 1 (pre-
intervention) but were post-intervention. Both groups improved.
The EQUIP group average changed more than the FACT aver-
age did. On the FO Scale, the difference between Time 1 and
Time 2, group differences, and the interaction between time and
group, were all statistically significant, as shown in Table 2.
Variable B SE B β
Race/Ethnicity 0.12 0.21 0.06*
Pre-Intervention Score 0.61 0.02 0.64*
Group 0.25 0.08 0.06*
Although both curricula were beneficial, the ESTEEM cur-
riculum may be particularly useful for schools in Texas serv-
ingstudents from diverse backgrounds. Positive changes were
most noticeable for the African American and Hispanic stu-
dents using ESTEEM.
*p < .001. Note. R2 = .41 (F [3, 1806] = 418.60), p < .001 for predictor variables.
Table 2.
Future orientation: repeated measures an alysis of variance.
Figure 2 illustrates the average changes for African Ameri-
can students who responded to the Future Orientation (FO)
marriage question on both the pre- and post-intervention ques-
tionnaire. Results were similar for the other FO questions and
for Hispanic students.
Source df F
Between Subje cts
Group 1 3.86*
Error 1849 (6.95)a
Within Subjects
Time 1 58.21**
Time x Group 1 4.26*
Error (Time ) 1849 (1.56)a
The study was limited in that random assignment was not
used and although the groups were similar in many ways, dif-
ferences that may have affected the results did exist, such as
previous abstinence education classes (more common for the
FACTS group). Another factor to consider was that in the Tex-
as implementation, the full FACTS program (to be described
below) as it is implemented in Oregon was not used. That is,
the FACTS printed materials (text books) were used but peer
leaders, socio-dramas, and other non-printed elements of the
Oregon style FACTS program were not used in Texas.
aValues enclosed in parenthesis represents mean square errors. *p < .05. **p
< .001. Note: Dunnett’s t indicates that the group averages were not statistically
significantly different at Time 1 but we re at Time 2 (p < .05).
Figure 2.
African American students average responses to the FO marriage
FACTS: Oregon Style Implementation
The FACTS curriculum (Fuller & McLaughlin, 1998), part
of the Youth Solutions program, was developed by Northwest
Family Services (NWFS), a non-profit, non-sectarian organiza-
tion based in Portland, Oregon, with partial funding from a
series of grants from the federal Office of Adolescent Preg-
nancy Programs (OAPP), over more than 15 years. Every year,
an independent evaluation was conducted and results were used
to refine the program (e.g., Tobin, 2000, 2001; Tobin & Sugai,
1998; 1999; Weed, 1993, 1995). Most recently, the evaluation
used the Adolescent and Family Life (AFL) Baseline and Fol-
low Up Questionnaires for prevention programs and a psycho-
metric evaluation of this questionnaire was conducted, one of
the few efforts to establish the reliability and validity of an
abstinence education measure (Vincent, Xue, Tobin & Fuller,
FACTS was designed to teach sexual abstinence to middle
school students in a clear, direct, and unequivocal way by using
multiple strategies including 1) up to 15 lessons in health
classes in public schools with topics related to goal setting,
healthy choices, and positive relationships; 2) trained staff from
a community agency who work with peer leaders, parents, and
teachers; 3) festivals and cultural events; and 4) high school
peer leaders who help interactive lessons in middle schools,
such as the development of multi-media materials, and who act
in socio-dramas. A social marketing strategy included bill-
boards in the project area as well as airing English and Span-
ish-language PSAs, which referred parents to a bilingual web-
site, A website to engage the youth par-
ticipants also was developed,
Positive youth development (Catalano, Berglund, Ryan,
Lonczak, & Hawkins, 1998; Benson, Scales, Hamilton, &
Sesma, 2006; Greenberg et al., 2003) principles provided a
foundation for the emphasis in the FACTS program on activi-
ties and lessons to enhance self-efficacy, positive identity, and
pro-social behaviors, which are all critical elements associated
with abstinent behavior. The benefits of delaying sexual in-
volvement include avoiding sexually transmitted infections,
unintended pregnancy, and the negative experiences related to
having multiple sexual partners over time (Cokler, 1994; Ge-
nuis & Genuis, 2004; Guilamo-Ramos, Jaccard, Dittus, Gon-
zalez, & Bouris, 2008; James, Montgomery, Leslie, & Zhang,
2009; Jemmott, et al., 2010; Mohn, Tingle, & Finger, 2003;
O'Donnell, O'Donnell, & Stueve, 2001; Romeo & Kelly, 2009).
A study with a one year follow up of an abstinence program’s
impact on sexual behavior found a reduction in sexual initiation.
Virgin students in the experimental group were less likely—
about half as likely—to initiate sexual intercourse as the virgins
in the comparison groups during the year following the inter-
vention (Weed, Ericksen, Lewis, Grant, & Wibberly, 2008).
A particular target population for some of the FACTS pro-
jects was the rapidly growing Latino population in Oregon. The
Spanish version is called “DATOS.” For Latinas, more than for
other ethnic groups, school dropout is associated with teen
pregnancy (Manlove, 1998). The demographic characteristics
of the students who participated in the surveys used in the
evaluations of the FACTS program in Oregon varied over the
years but typical percentages were White 78%, Hispanic or
Latino 9%, Other 5%, Asian 4%, African American 2%, and
Native American 2%. Annually, the number of participants in
the surveys for the evaluation of FACTS varied from about
1,000 to more than 2,000. More youth, particularly more Latino
youth, were actually served than were available for both the
pre- and the post-intervention surveys. The FACTS/DATOS
curriculum also was used successfully in a program in New
York State with at-risk urban youth from diverse racial and
ethnic backgrounds (Carter-Jessop, Franklin, Heath, Jimenez-
Irizarry, & Peace, 2000).
The FACTS/DATOS curricula, when used as a part of the
full Youth Solutions intervention, was particularly successful
with the Latino population (Tobin & Sánchez, 2007). By the
end of the program, 69% of participants reported that they in-
tend to be sexually abstinent until marriage. In addition, Latino
parents reported being more comfortable in talking with their
child about sex and that their child’s values were more in
agreement with their own values after the intervention.
The Youth Solutions project offered different levels of inter-
vention: socio-dramas in both English and Spanish, (Promises,
Truth or Consequences, and Encuentros—see, the FACTS/DATOS curricula series,
and peer leaders. Under the direction of NWFS staff and school
faculty, the high school peer leaders gave personal testimonies
about abstinence, conducted role plays, reinforced refusal skills,
gave examples on how to navigate high school, and answered
the questions of middle school students. Training for peer lead-
ers followed procedures documented in a manual (Fuller &
Bankston, 2002). These leaders also assisted with positive
youth development activities such as organizing soccer tour-
naments and Latino festivals. NWFS worked with middle
school students to develop PSAs, posters, songs and rap lyrics,
and newsletter articles that supported abstinence. These were
submitted in a contest with the winners selected at the end of
the school year. NWFS staff members provided in-service
training for teachers and counselors to implement abstinence
education. They also recruited, selected, trained, and supervised
teenage actors and peer leaders. Language-specific services
were offered in Spanish during school and in after-school La-
tino clubs. Motivational speakers were used to reinforce the
T. J. TOBIN 197
In the early years of the development of this program, a se-
ries of studies (e.g., Tobin, 2002, 2003) compared the effect of
different “doses,” from 1) minimal, just the socio-drama; to 2)
medium, the socio-drama plus the FACTS lessons in school but
without the peer leaders or the interactive multi-media projects;
and 3) maximum, the full or “intensive” Youth Solutions pro-
gram with all materials and activities (i.e., socio-dramas,
FACTS lessons, peer leaders, interactive multi-media projects,
cultural festivals, and parent support). For the intensive inter-
vention, a statistically significant (p < .01) increase occurred in
the percentage of students expressing the intention to remain
abstinent until marriage, with rise from 50 percent before the
intervention to 70 percent afterwards. The brief intervention
also showed improvement, but it was not as impressive an im-
provement (Fuller & Tobin, 2005).
In our society, it is common to hear jokes being made at the
expense of proponents of abstinence education by cynical indi-
viduals who suggest that “everyone is doing it” and who do not
believe there is any point in encouraging teens to practice sex-
ual abstinence. However, the students, teachers, parents, and
developers and implementers of ESTEEM and FACTS know
that for many youth, these programs are life changing. The
following description of a youth’s experiences provides a clear
view of how this type of intervention can have a powerful im-
I had never really thought about abstinence education or
even heard of it, really. ... I auditioned [to act in a socio-
drama] ... and almost overnight I started learning about absti-
nence. We perform a play, also called Promises,” which ad-
dresses STIs and other sex-ed ideas, and abstinence is defi-
nitely the biggest message. ... We talk about waiting, and we
give our own testimonials about staying abstinent, and the fi-
nancial consequences of having a kid ... I think a lot of their
excitement comes from our serious, but relaxed, approach.
We ... let them get their giggles out, but the second time we
explain how serious these real-life situations can be. We ...
make them assert themselves and exercise good refusal skills.
They see that you can face these pressures from your best
friend, or boyfriend or girlfriend, and suddenly you see them
getting more confident and really responding to abstinence, a
concept they can take pride in.
(Northwest Family Services’ Drama Troupe Member and
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