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Sieccan Newsletter
Vol. 4 3 , N o . 1-2, 2 0 0 8 (ISSN: O834-O455)
Editor: Michael Barrett, Ph.D. Associate Editor: Mary Bissell, Ph.D.

Girl Time: Development and implementation of a healthy sexuality program for girls in Grades 7 and 8
Tammie Brunk^ Sue Morris^ B.J. Rye^, Glenn J. Meaney^, Jennifer Yessis", Lisa Wenger^ and Alexander McKays
'Region of Waterloo Public Health, Sexual Health Program ^Departments of Psychology and Sexuality, Marriage, and Family Studies, St. Jerome's University at the University of Waterloo, Waterloo, ON 'Department of Psychology, Wilfrid Laurier University, Waterloo, ON "NRC Picker Canada, Markham, ON Information and Education Council of Canada, Toronto, ON
Abstract: This article describes the development and implementation of a sexual health education program designed to support Grade 7 and Grade 8 girls in the development of healthy relationships and healthy sexuality. Region of Waterloo Public Health, acting on "grassroots" demands, assessed the need for such a program and, consequently, developed Girl Time: Grade 7/8 Healthy Sexuality Program in consultation with sexual health experts (e.g., public health nurses & behavioural consultants) and stakeholders (e.g., teachers, students). This curriculum was based on a theoretical and empirical literature review, as well as the information-motivation-behavioural skills model of the determinants of sexual health behaviour (Fisher & Fisher, 2002), and was informed by The Canadian Guidelines for Sexual Health Education (Health Canada, 2003). A small pilot delivery and process evaluation led to refinements of the curriculum and larger-scale implementation. Results of an outcome evaluation (reported extensively elsewhere; Rye et al., 2008) suggest that Girl Time was effective at achieving its measurable goalspositively affecting psychological constructs theorized to determine the sexual health of the girls who participated. Adoption of Girl Time by other agencies is encouraged. Acknowledgements: This manuscript is dedicated to Tammie Brunk, whose tireless efforts and enthusiasm for Girl Time made the program a success. Tammie (1958-2005) passed away on 24 November 2005 after a courageous battle with ovarian cancer. Gih Time was funded in part by the Ontario Ministry of Health and Long-Term Care and sponsored by the Ontario Women's Health Council. The discussion and conclusions contained within this manuscript are those of the authors and do not necessarily reflect the positions of the Ontario Women's Health Council, the Ontario Ministry of Health and Long-Term Care, or NRC Picker Canada.

Correspondence concerning this article should be addressed to Sue Morris, ROWPH, 99 Regina St. S, 3rd Floor, Waterloo, ON, N2J 4V3. E-mail: msue@region.waterloo.on.ca

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Why the need for Girl Time? The initial impetus for the development of this Adolescent sexuality is an issue that consistently program was concerns from high school students, captures the attention of our communities. The school personnel, and public health nurses situated complexity of this issue is heightened by the range in the schools that young girls were not receiving of ideologies that interface with experience and adequate training to promote healthy sexual attitudes, research as we seek to more fully understand, inform, to make healthy sexual choices, and to promote and helpfully guide the sexual health decision- healthy sexual behaviours. Anecdotally, risk-taking making of teenagers. Amidst the intricacies of the behaviours and adverse consequences were being ongoing discussion, the Canadian Guidelines for Sexual noted with female students in Grades 7,8, and 9 (i.e., Health Education (Health Canada, 2003) outline two reports of sexual assaults at parties, concerns with central goals in the delivery of sexuality education for possible pregnancies, and concerns about STIs). This word-of-mouth concemcoupled with regional all Canadians and particularly for youth: sexual health statistics (in particular, the reported rates of Chlamydia, which are highest among 15- to i. To help people achieve positive outcomes 24-year-old females [ROWPH, 2007])led ROWPH (e.g., self-esteem, respect for self and others, Sexual Health Program to conduct a qualitative Youth non-exploitive sexual relations, rewarding Sexual Health Needs Assessment (Brunk, 2004). This sexual relationships, the joy of desired assessment indicated that primary prevention needed parenthood); and to take place at the senior elementary school level ii. To avoid negative outcomes (e.g., prior to the sexual debut of the adolescent girlsa unintended pregnancy, HIV/STIs, sexual finding echoed in the extant literature (e.g., Mueller, coercion, sexual dysfunction) (p. 1). Gavin, & Kulkarni, 2008; O'Leary, Jemmott, With these goals in mind, the Girl Time: Grade 7/8 Goodhart, & Gehelt, 1996). Therefore, the various Healthy Sexuality Program (Girl Time) was established stakeholders felt that the provincially mandated to support young women in making healthy choices sexuality education curriculum (Ministry of related to their sexuality and to help them avoid Education and Training, 2005) needed to be sexuality-related health risks. Based on a needs supplemented with an enriched sexual health assessment (Brunk, 2004), a small-scale, initial Girl curriculum to address more of the needs of students. Time program was implemented by the Region of Waterloo Public Health (ROWPH). Then, this program Local concerns about the need for sexuality education was extensively implemented in 2001 by ROWPH, are supported by more representative samples of Sexual Health Program with funding, in part,fromthe adolescent Canadian sexual behaviour and their Ontario Ministry of Health and Long-Term Care indicators (i.e., pregnancy, birth, abortion, STI rates, through the Ontario Women's Health Council (OWHC). and contraceptive use, see Canadian Federation for The Girl Time program was launched in collaboration Sexual Health, 2007; Public Health Agency of with the public school board. Planned Parenthood Canada [PHAC], 2007); these statistics also support Waterloo Region, and several other community the idea that youth would benefit from additional sex organizations. An evaluation of the program was education as a primary prevention initiative. developed and conducted by a research group including members from ROWPH, St. Jerome's Canadian youth are less likely to have had sexual University, the Sex Information and Education intercourse than their U.S. counterparts (Canadian Council of Canada, and NRC Picker Canada. Girl Federation for Sexual Health, 2007; Centers for Time continues to be offered by ROWPH, Sexual Disease Control and Prevention, 2005), but a sizeable Health Program. The goal of the current paper is to percentage are sexually active at a young age. describe the Girl Time program with a focus on Research suggests that the median age of first development and implementation. Program intercourse may be mid way between 16 and 17 years evaluation is described elsewhere (Brunk, Yessis, (Maticka-Tyndale, McKay, & Barrett, 2001; Rotermann, 2005; Statistics Canada, 2005). While Rye, McKay, & Morris, 2004; Rye et al., 2008).

Introduction

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the rate of unexpected adolescent pregnancies in Canada is declining (McKay, 2004; Statistics Canada, 2004, 2006), cases of unplanned pregnancy among young women may be further reduced by effective sexual health education. Additionally, there remain concerns regarding unacceptable STI rates among adolescents (McKay, 2004). This concern is amplified for girls^many STIs are transferred more efficiently from males to females (Moscicki, 2005; Wong, Singh, Mann, Hansen, & McMahon, 2004). As not all teen sexuality results in unexpected pregnancy or STIs, these may be considered conservative markers of unprotected adolescent sexual activity. These are the negative consequences of sexual activity that health care professionals seek to prevent or ameliorate. Primary prevention efforts geared toward avoiding these negative consequences of premature and unprotected sexual activity are consistent with the second key goal identified in the Canadian Guidelines for Sexual Health Education (Health Canada, 2003). Therefore, Girl Time was developed as a primary prevention intervention for girls who were unlikely to have made their sexual debuts (a need identified by youth in the Needs Assessment; Bnink, 2004). The first goal of the Canadian Guidelines for Sexual Health Education (Health Canada, 2003), "achieving positive outcomes of sexual activity" (p. 1), is often overshadowed by concern about the potential severity of the negative consequences of sexual activity (addressed by the second goal). However, healthy sexual relationships can be an essential component of a happy, productive, and fulfilling life (Abramson, & Pinkerton, 1995; Meaney & Rye, 2007; Rye & Meaney, 2007). The need for the inclusion of positive aspects of sexuality is highlighted by the Needs Assessment that prompted the development of Girl Time (Brunk, 2004): Young people in the Region of Waterloo said they wanted to know about more than just the negative consequences of sexual activity; in particular, they were very concerned with learning about healthy relationships and decision-making, communication, identity issues, and personal value systems. With this in mind. Girl Time was designed to help participants develop healthy relationships sexual and otherwisethroughout their lives. Therefore, Girl Time was designed to address both

goals of sexual health education as identified by the Canadian Guidelines for Sexual Health Education (Health Canada, 2003). Theoretical and empirical framework The Guidelines suggest that these goals are perhaps best met by employing the information-motivationbehavioural skills model (Fisher & Fisher, 1992, 2002). To this end. Girl Time was designed to equip participants with the knowledge and behavioural skills necessary to protect themselves, to increase the motivation to use this knowledge actively, and to support their intention to enact these skills when faced with sexual health situations. These skills include, but are not limited to, the ability to refuse sexual activity, to set sexual limits, and to insist on safer sexual practices (if and when they eventually choose to engage in sexual activity). Guidance for intervention development also comes from previous research. Research-based recommendations Programs showing a positive impact on sexual risk behaviours and/or unintended pregnancies have been found to include the following characteristics (DiCenso, Guyatt, & Willan, 1999; Frost & Forrest, 1995; Health Canada, 1994, 2003; Kirby, 2000a, 2000b, 2001; Kirby, Laris, & Rolled, 2006; Kirby, Korpi, Barth, &. Cagampang, 1997; Kirby et al., 1994; McKay, 2000; Parker, 2001; Schaalma, Abraham, Gillmore, & Kok, 2004; Yamada et al., 1999). Such programs: 1. are based on social learning theories, 2. actively involve participants to facilitate personalizing the provided information, 3. address multiple psychosocial risk and protective factors, 4. analyze social influences, pressures, and normative factors, 5. deliver and reinforce clear prevention messages, 6. sharerelevant,scientifically-based information, 7. focus on specific behaviours, rather than more abstract concepts such as "safer sex", 8. focus on delay of first intercourse and consistent use of contraception, 9. model and rehearse communication and negotiation skills using active participant learning.

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10. 11. 12. 13. 14. 15. 16. 17.

cover topics in a logical sequence, are of substantial duration (e.g., 8-15 hours), use trained adult or peer leaders who endorse the program, include opportunities for discussion and feedback within a safe environment, reinforce group norms against high-risk activity (i.e., create a "culture of safety"), are appropriate to age, experience, and culture of participants, are supported, at least minimally, by local authorities, and, are pilot-tested and informed by evaluation.

Effective programs should provide guidance in knowledge and skill development prior to experienced challenges. In this way, it is crucial that sexual health programming and educational strategies reach sexually inexperienced or recently sexually active adolescents with developmentally appropriate interventions (Lieberman, 2006; Pedlow &. Carey, 2004). TTie designers of Girl Time attempted to include each ofthe above components by designing aprogram under the auspices of local authorities (ROWPH and the local school boards) with a strong base in empirical research backed by an over-arching social-learning theory (the information-motivation-behavioural skills model; Fisher & Fisher, 1992, 2002). This approach resulted in a carefully designed curriculum that presents relevant knowledge in a logical order and actively involves program participants.

Separate sexual health programming for girls can provide crucial communication abilities, empowerment strategies, and skills-development that are of particular relevance to the development of healthyrelationships.Creating an environment which is supportive of healthy sexual decision-making is vital not only for the prevention of infections, unintended pregnancies, and other potential negative consequences of sexual activity, but also for the realizations of benefits which can accompany healthy sexuality (e.g., intimacy, sexual satisfaction, healthy reproduction; see Aarons et al., 2000; Coyle, Kirby, Marin, Gmez, & Gregorich, 2004; Garriguet, 2005; Metzler, Biglan, Noell, Ary, & Ochs, 2000; O'Leary et al., 1996; Siegel, Aten, & Enaharo, 2001 for the importance of gender-specific sexuality education). It should be noted that students who participated in Girl Time did so in addition to, not instead of, regular "co-ed" sexuality education. In addition to their strong support for comprehensive, school-based sexual health education (Byers et al., 2003a, 2003b; McKay, 2004; McKay & Holowaty, 1997), youth also value their parents as sources of sexual education (Byers et al., 2003a, 2003b; Hampton, McWatters, Jeffery, & Smith, 2005; Measor, 2004). Research suggests that parental communication about sex has an impact on the sexual behaviours of adolescents (Dilorio et al., 2006; Fisher, 1993; Lieberman, 2006; Miller, Levin, Whitaker, & Xu, 1998; Simanski, 1998). However, the extant literature suggests that communication with parents is more frequent, more comfortable, and more accurate (Blake, Simkin, Ledsky, Perkins, & Calabrese, 2001; Brock & Beazley, 1995; Klein et al., 2005; Oliver, Leeming, & Dwyer, 1998; Swain, Ackerman, & Ackerman, 2006)and possibly more effective (Dilorio et al., 2006; Lieberman, 2006) when combined with a strong evidence-based sexual health curriculum. Therefore, Girl Time was constructed to encourage communication with parents while providing a strong, evidence-based sexual health curriculum.

Focus on girls
Perhaps partially due to the content of much of sexual education in the schools (Strange, Oakley, & Forrest, 2003) and their higher level of risk in sexual activities (i.e., the possibility of pregnancy and greater vulnerability to some STIs), young women often identify sexual health education and decision-making as a more relevant and pressing concem than do their male peers (Brunk, 2004; Measor, 2004). Girls also tend to show some preference for gender-segregated sexuality education (Byers et al., 2003a, 2003b; McKay & Holowaty, 1997; Strange et al., 2003) and more strongly than boys support a parent's role in sexual education (Byers et al., 2003a, 2003b; Somers & Surmann, 2004).

Creating Girl Time; Addressing the sexuai heaith of Grade 7 and Grade 8 giris
Girl Time was developed by I^iblic Health staff and behavioural consultants from a local school board in response to feedback from students, school staff, and

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Public Health Nurses (PHNs), who saw the need for an enriched sexuahty education curriculum for Grade 7 and Grade 8 girls. These stakeholders felt that the current brief information sessions presented in a Health Fair format were not intensive enough to meet the needs of young students. As a result, the original Girl Time curriculum was developed with a strong basis in relevant intervention literature. This curriculum was pilot-tested and subjected to a process evaluation (Brunk et al., 2(X)4), which, in tum, led to refinements in the curriculum. When funding was obtained from the OWHC, further refinements to the curriculum were undertaken to align Girl Time more closely with the information-motivation-behavioural skills model (Fisher & Fisher, 1992,2002) of sexual health behaviour and the Canadian Guidelines for Sexual Health Education (Health Canada, 2003). A subsequent implementation of the program was evaluated in terms of proximal outcomes (Rye et al., 2008) and the program continues to be offered at several regional schools. This section will describe the Girl Time curriculum and its evaluation process.

The overall goal of Girl Time is to promote healthy sexual attitudes, choices/decisions, and behaviours in program participants. To this end, we identified two objectives: (a) program participants will delay sexual initiation until they feel cognitively, emotionally, and physically mature enough to engage in healthy sexual activity, and (b) program participants will use safer sex practices (i.e., avoid higher risk behaviours, and practice consistent contraception and condom use), if they become sexually active. Intended short-term outcomes include an increase in sexual health knowledge, comfort level with sexuality, and communication with parents/guardians, and an increase in the array of attitudes/beliefs, norm perceptions, skills, and intentions associated with postponement of sexual involvement and/or the practice of safer sex. Intermediate outcomes include maintenance of short-term changes and an increase in the numbers of girls who postpone sex or practice safer sex (if sexually active).

General program format

The program runs with groups of 10 to 15 Grade 7 girls who meet weekly with a PHN and Guidance Counsellor (or other school staff) for 90-minute Development of the Girl Time program was based sessions over a 10-week period (with an optional on the information-motivation-behavioural skills eleventh session). Each session, briefly summarized (1MB) model of sexual health behaviour (Fisher & in Table 1, focuses on a separate topic area, but Fisher, 1992, 2002). While the 1MB model was includes the following standard activities: check-in, originally designed with respect to HTV/AIDS risk- discussion/questions carried over from previous reduction behaviour (see Fisher & Fisher, 1992,2002 sessions, current session introduction, experiential for a review of empirical evidence), it is a general activity (i.e., leaming by doing), and discussion, model of the determinants of behaviour that has been debriefing, and closure. Specific session topics successfully applied to other domains of sexual health include (a) Introduction and Self Awareness, (b) (Fisher, Fisher, Harmon, 2003). This framework Personal Values, (c) Body Awareness, (d) Attraction & suggests an active, participant-based approach to and Desire, (e) Healthy Relationships, (f) Risks of sexual health education that aims to (a) equip students Early Sexual Activity, (g) Safer Sex Choices, (h) with information relevant to sexual health, (b) Decision-Making and Assertive Communication, (i) provide social support for sexual health behaviours Peer and Social Pressure, (j) Sexual Health Clinic (i.e., a motivational construct), and (c) teach specific visit; and (k) Open Sessions. Two refresher sessions behavioural skills that can be used in the pursuit of are held in Grade 8 to reinforce prevention sexual health. The acquisition of relevant information and limit-setting. information, motivation, and behavioural skills is theorized to lead to the adoption of safer-sex behaviours While the Girl Time curriculum was developed (which may include postponing sexual involvement or around the information-motivation-behavioral skills appropriate use of contraceptives and condoms). The model, different sessions sometimes stressed separate 1MB framework has been recommended by Health aspects of the model, as appropriate. For example, Canada (2003) as a model for designing effective sexual the third session. Body Awareness, focuses on giving health education programs. girls accurate information about girls' (and boys')

Development of Girl Time; Concept, content, and outcome expectations

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Table 1

Session Topics and Descriptions for Girl Time

1. Introduction and Self-Awareness Introduced program content, goals, and objectives. Engaged in activities including trust-building exercises, created a time capsule, wrote a self-referential letter, and started a communication folder. 2. Personal Values 3. Body Awareness 4. Attraction and Desire 5. Healthy Relationships 6. Risks of Early Sexual Activity 7. Safer Sex Choices Identified personal values and learned how values affect decisions about sexuality, created a sexual health plan to facilitate limit-setting. Learned factual information about physical and emotional changes during puberty, discussed importance of hygiene and self-care. Explored feelings of attraction and desire and practised setting sexual limits based on personal values. Identified healthy, unhealthy, and neutral characteristics in a romantic partner, development of respectful, caring relationships in all areas of life. Explored why young people become sexually active and why they should wait. Potential risks of early sexual activities were discussed and skills for setting sexual limits were practised. Presented factual information about contraceptive methods/precautions which reduce the risk of unintended pregnancies and STIs, informed about community agencies which support sexual health. Learned about decision-making and assertive communication; role-plays and activities used to allow participants to practice new skills. Identified and practised skills to help resist peer and social pressures related to sexual activity. Toured the Sexual Health Clinic at ROWPH; intended to increase participants' knowledge of and comfort with a clinic setting. Completed unfinished material, held evaluation interviews, and/or celebrated the end of the main program. Held two refresher sessions in Grade 8 to reinforce the prevention infonnation and limit-setting skills.

8. Decision-Making and Assertive Communication 9. Peer and Social Pressure 10. Sexual Health Clinic Visit 11. Open Sessions Refresher Sessions

Note. Sessions were conducted in the listed order when possible. Materials to im|dement Girl Time are presented in a binder and on CD and these are availablefromROWPH, Sexual Health Program.

bodies, and how their bodies might be changing (or have changed) during early adolescence. This session also contains practical advice about how girls can take care of their bodies and deal with the demands of their growth and development (e.g., how to choose a bra, how to deal with menstruation); this advice, combined with accurate information, is readily translatable to behavioural skills. Motivation does not constitute a large component of this session, but instructors do attempt to establish a social norm (an aspect of motivation) of self-acceptance and positivity (e.g., "it is okay to look at and touch your body"; "your breasts are the best breasts for you"). Other sessions focus more extensively on developing behavioural skills. In Healthy Relationships (session S), for example, girls are asked to participate in role-

playing scenarios. In one scenario, the girl has a boyfriend who is "kind, loyal, and lots of fun"; so far, the couple has only kissed, but the boy wants to go further. In this situation, girls are asked to imagine how they would deal with setting sexual limits such as refusing to have intercourse or using condoms if they were to choose to have sex. This activity allows girls to develop relevant behavioural skills (i.e., how to negotiate within the context of a relationship) in a safe environment. Also included in this session is information about the characteristics of healthy and unhealthy relationships (e.g., having a partner who respects your choices; having a partner who threatens to hit or hurt you if you will not comply). Further, activities in this session are aimed at establishing supportive social norms and personal attitudes (motivation); for example, "Perfect Partner

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Poker"which is fun and engagingallows for a leader-facilitated discussion about characteristics of boyfriends (positive and negative), which would foster the development of social norms and individual beliefs for appropriate relationship behaviour. Motivation is strongly emphasized in session 9: Peer and Social Pressure. This session encourages girls to analyze and critically evaluate different sources of normative influence on people's behaviours (e.g., television, group status); this allows girls to become aware of, and better able to resist, those influences. For example, one activity was designed to expose all the girls to how it would feel to be treated as a high status, middle status, or low status person. This perspective-taking exercise makes the girls aware of the impact of how class and status differences may impact behaviour. To a lesser extent, the development of behavioural skills is fostered in that they may glean some techniques for resisting pressure from peers or the media to behave in a particular way. Facilitators also communicate accurate information about what constitutes peer pressure and social pressure. To encourage parental involvement and communication, activities associated with the inschool sessions include take-home questions and a parent handbook (including program content, background information, communication tips, and resources). Parents/guardians are also invited to an evening session to learn about the program and how they could support their daughters.

Region of Waterloo. Comparison schools were comprised of a slighter higher percentage of K to Grade 8 elementary schools with smaller Grade 7 classes and included representation from one rural school. Following a presentation by the project's evaluation coordinator or a PHN to all Grade 7 girls in the program schools, consent forms were sent home. Only girls who both retumed a parental consent letter and consented themselves were eligible to participate. Over the course of the two year evaluation period, including fall and winter offerings, 359 girls participated in the Girl Time main program sessions in Grade 7. Eighty-five of these participants dropped out before completing the main program (drop-out was defined as being asked to leave or attending fewer than 7 sessions). In the first year, programs were co-led by PHNs and school staff (i.e., guidance counsellors and behavioural consultants). While PHNs continued in this role for the second year, school-based time constraints led to variation in co-facilitation to include other school staff (i.e., teachers, youth care workers, special education teachers) or a second PHN. All participating schools received an honorarium to offset staff and administration costs. To foster transparency, parents of students participating in Girl Time were invited to attend one of two information sessions. Unfortunately, attendance was low; regardless, we feel this is an important component to offer.

Evaluation of the Girl Time program Program implementation and delivery

Following the pilot implementation and process evaluation, the revised Girl Time program was promoted on a larger scale to staff and administration at 22 schools in the Regional public system. Promotion was limited to schools with 40 or more Grade 7 girls enrolled. Five schools declined paiticipation due to a lack of staff resources or lack of comfort with the evaluation procedures. Ten of the remaining schools received the program while seven served as a source of comparison. Among the schools receiving the program, nine were senior elementary schools with approximately 110 Grade 7 girls and one was an elementary school offering K to Grade 8 classes with approximately 80 Grade 7 girls. The program schools came nom three cities within the The Girl Time program was evaluated twice. A formative evaluation was conducted after the initial program pilot to assess the implementation process and success of activities, and to inform further modification of the curriculum and/or implementation procedures. Some changes were made to the curriculum based on the process evaluation and, separately, to more closely align the curriculum with the 1MB framework. Subsequently, a more elaborate implementation was launched. This second launch was subjected to an outcome evaluation, which aimed to assess whether Girl Time program participants scored more favourably than a group of girls who served as a comparison group (who did not participate) on factors which have been found to predict sexual health behaviours.

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Process evaluation. Within the school setting and in the community, information on the success of curriculum activities, group dynamics, and reactions to the program by participants and leaders were collected through audio-taped participant group interviews (309 participants), session evaluation forms completed weekly (324 participants), and four meetings between the project manager and PHN group leaders. Program participants were generally positive about program participation and the content of the program. In particular, girls supported the program; they enjoyed the activities (e.g., role-playing), the information, and the learning process. Some negative feedback from participants resulted in changes to program delivery (e.g., some topics felt rushed and were consequently modified). However, negative comments tended to involve external complications surrounding program participation (e.g., being teased by other children, being questioned hy teachers, feeling discomfort with parental exercises). Session evaluations suggested that the majority of activities were implemented as intended and those activities that could not be completed as planned were modified via a split session, incorporated into discussion (rather than activity), or made up at a following session. Most activities received a high success rating (5 or more on a 7-point scale). Those receiving lower ratings tended to cover difcult concepts (e.g., personal values), were less active (e.g., individual writing), or involved factual content (e.g., anatomy). Ratings of group dynamics were high throughout the sessions or increased to high levels over time. Group leaders primary concems were programmatic, such as the cognitive maturity of participants, the difficulty of involving parents, behavioural difficulties, and pragmatic concems. There were initial concems that program participants were too young, but by the end of the program, group leaders were satisfied with participants' maturity. Leaders found it a challenge to convince girls to take questions home to discuss with their parents. To address this concem, parents were sent an information letter that explained the importance of participating with their daughters, along with a printed list of very specific

questions to he discussed with their daughters over the course of the program. While the majority of leaders felt that participants formed supportive groups with high levels of trust, some girls were removed from the program because of disrespectful, bullying, or aggressive behaviour. Challenges related to meeting space and staffing were encountered and resolved primarily through compromise and informal discussion within the school setting. Overall, the process evaluation suggests that the Girl Time pilot was largely successful. The results of the process evaluation suggested that Girl Time was a welldesigned, well-implemented program that still left some room for improvement. The program was modified to meet identified challenges and implemented on a wider scale; the next stage of the evaluation process involved an outcome study. Outcome evaluation. In the outcome evaluation. Girl Time participants were compared with girls who were not exposed to Girl Time (comparison girls were drawn both from schools that offered Girl Time and schools that did not) on a number of sexual health indicators (see Rye et al., 2008). Girl Time participation had a positive impact on some key outcome measures: Participants were more likely than non-participants to gain sexual health knowledge, discuss sexual matters with parents, feel confident in their ability to enact a variety of safer sexual hehaviours (e.g., obtaining condoms), he more comfortable with sexual matters, and intend to engage in safer sexual practices (e.g., abstaining from intercourse). Less consistent effects were evident in a few other areas (e.g., attitudes toward safer sexual practices). Collectively, this suggests that the Girl Time program positively infiuences at least some factors thought to determine safer sexual behaviour. While there were some limitations to the evaluation process (in particular, a quasi-experimental design and subject self-selection; Rye et al., 2008), we can he cautiously optimistic that Girl Time is a successful program that benefits its participants; that is. Girl Time seemed to successfully achieve its measurable goals.

Conclusion
Girl Tune has some exceptional strengths that contribute to the ongoing success of the program: (a) a "grassroots" initiative evolved into a community-research

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partnership involving a variety of stakeholders and Brock, G C , & Beazley, R.P (1995). Using the health beUef model to explain parents' participation in adolescents' professionals with a broad range of perspectives and at-home sexuality education activities. Journal of skills, (b) program development was driven by a strong School Health, 65, 124-128. theoretical and empirical framework, and (c) the program was subjected to rigorous evaluation using Bmnk, T. (2004). Sexual Health in Waterloo Region: A diverse methods. While the future success of Girl Time community needs assessment and planning initiative, depends on continuing evaluation and refinement, it youth component. Waterloo, ON: Region of Waterloo is robust enough to be offered in a variety of settings. Public Health, Sexual Health Program. The potential for spread of program offerings beyond the Region of Waterloo has been demonstrated by Brunk, T., Sims, A.M., & Rye, B.J. (2004, June). "Girl the interest of other individuals and agencies (who Time ": More than just the facts for grade 7 &8 girls. have been exposed to Girl Time at conference Presented at the 26* Annual Guelph Conference and Training Institute on Sexuality, Guelph, Ontario. presentations; Brunk, Sims, & Rye, 2004; Millar, Morris, Rye, & Sims, 2004). Consequently, ROWPH has offered training in Girl Time procedures, which Brunk, T., Yessis, J., Rye, B.J., McKay, A., & Moms, S. (2004). "Girl Time": Grade 7/8 sexual health has been undertaken by interested individuals and program and outcome evaluation (rev.). Technical agency personnel from inside and outside of the Report to the Ontario Women's Health Council: Region of Waterloo. Region of Waterloo Public Health, Waterloo & Cambridge, Ontario. The demand and need for Girl Time is evident within the Region of Waterlooit is offered yearly in 8 to Byers, E.S., Sears, H.A., Voyer, S.D., Thurlow, J.L., Cohen, 10 local schools and there is a consistent waiting list J.N., & Weaver, A.D. (2003a). An adolescent perspective on sexual health education at school and for more offerings. Most public health catchment at home: I. High school students. Canadian Journal areas would likely demonstrate a similar need and of Human Sexuality, 12, 1-17. would be well-served by offerings of intensive sexual health programs. Given the multiple service demands and many emergent community needs to which public health programs must respond. Girl Time fits the mandate of, and can be readily adopted by, many public health units and other community organizations. Byers, E.S., Sears, H.A., Voyer, S.D., Thurlow, J.L., Cohen, J.N., & Weaver, A D . (2003b). An adolescent perspective on sexual health education at school and at home: II. Middle school students. The Canadian Journal of Human SexuaUty, 12, 19-33. Canadian Federation for Sexual Health (2007). Sexual Health in Canada: Baseline 2007. Ottawa, ON: Author. Centers for Disease Control and Prevention. (2005, June 9). Youth risk behavior surveillance - United States, 2005. Morbidity and Mortality Weekly Report, 55(SS-5).

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