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Fourth R: Skills for Youth Relationships

The Fourth R: Skills for Youth Relationships is a curriculum for 8th- and 9th-grade students that is designed to promote healthy and safe behaviors related to dating, bullying, sexuality, and substance use. Based on social learning theory and grounded in stages of social development, the Fourth R focuses on improving students' relationships with peers and dating partners and avoiding symptomatic problem behaviors (e.g., violence, aggression).

The Fourth R is composed of three units: (1) personal safety and injury prevention, (2) healthy growth and sexuality, and (3) substance use and abuse. Each unit contains seven 75-minute classes, which are delivered by trained teachers and integrated into the school's standard health and physical education curriculum. The Fourth R engages students with exercises to define and practice the rights and responsibilities associated with healthy relationships. The curriculum includes many examples of the types of conflicts faced by teens on a daily basis, and examples of both peer and dating conflicts are used concurrently (where possible) so that youth who are not dating will find the material relevant. The Fourth R makes extensive use of role-playing, with feedback from peers and teachers, to increase students' interpersonal skills and problem-solving abilities. Boys and girls participate in slightly different exercises and activities, which are intended to raise their level of awareness of social norms and minimize gender-based defensive or hostile reactions.

Descriptive Information

Areas of Interest Mental health promotion
Substance abuse prevention
Outcomes Review Date: February 2011
1: Physical dating violence
2: Condom use
3: Violent delinquency
Outcome Categories Violence
Ages 13-17 (Adolescent)
Genders Male
Female
Races/Ethnicities Non-U.S. population
Settings School
Geographic Locations Suburban
Rural and/or frontier
Implementation History Implementation of the Fourth R began in 2004, and the program is used in more than 1,200 schools (1,000 in Canada and 200 in the United States), reaching more than 100,000 students each year.

In Canada, the Fourth R has been implemented in Alberta, British Columbia, Manitoba, Newfoundland, Northwest Territories, Nova Scotia, Nunavut, Ontario, Saskatchewan, and Yukon. In the United States, the program has been implemented in Alabama, Alaska, California, Colorado, Florida, Idaho, Illinois, Kansas, Massachusetts, Michigan, Missouri, New York, North Dakota, Ohio, Oklahoma, Rhode Island, Texas, and Washington. Four U.S. sites are using the program as part of the Robert Wood Johnson Foundation's Start Strong teen dating violence prevention initiative: Boise, Idaho; Bronx, New York; Providence, Rhode Island; and Wichita, Kansas. The Fourth R also has been implemented in Australia, Portugal, and Spain.

Two evaluations of the Fourth R have been conducted in Canada, and a third evaluation is being conducted in the United States.
NIH Funding/CER Studies Partially/fully funded by National Institutes of Health: Yes
Evaluated in comparative effectiveness research studies: No
Adaptations The Fourth R has been adapted for use with Canadian Aboriginal populations (e.g., First Nations, Métis, Inuit), Catholic school students, and students in alternative education settings. Program materials have been translated into French, Portuguese, and Spanish.
Adverse Effects No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories Universal

Quality of Research
Review Date: February 2011

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

Crooks, C. V., Scott, K., Ellis, W., & Wolfe, D. A. (2011). Impact of a universal school-based violence prevention program on violent delinquency: Distinctive benefits for youth with maltreatment histories. Child Abuse and Neglect, 35(6), 393-400.  Pub Med icon (NOTE: At the time of the NREPP review, the manuscript of this article had been submitted for publication but not yet accepted.)

Crooks, C. V., Scott, K. L., Wolfe, D. A., Chiodo, D., & Killip, S. (2007). Understanding the link between childhood maltreatment and violent delinquency: What do schools have to add? Child Maltreatment, 12(3), 269-280.  Pub Med icon

Wolfe, D. A., Crooks, C., Jaffe, P., Chiodo, D., Hughes, R., Ellis, W., et al. (2009). A school-based program to prevent adolescent dating violence: A cluster randomized trial. Archives of Pediatrics and Adolescent Medicine, 163(8), 692-699.  Pub Med icon

Supplementary Materials

Wolfe, D. A., Scott, K., Reitzel-Jaffe, D., Wekerle, C., Grasley, C., & Straatman, A.-L. (2001). Development and validation of the Conflict in Adolescent Dating Relationships Inventory. Psychological Assessment, 13(2), 277-293.  Pub Med icon

Outcomes

Outcome 1: Physical dating violence
Description of Measures Physical dating violence (PDV) was assessed using 8 items from the Conflict in Adolescent Dating Relationships Inventory (CADRI), a self-report measure. Students responded to each item with "yes" or "no" to indicate behaviors they had used in the past year toward a boyfriend/girlfriend while they were having an argument, angry at one another, or having a fight. PDV was indicated if the student responded with "yes" to one or more of the items that involved physical abuse or threats to harm (e.g., "I pushed, shoved, or shook him/her," "I threatened to hurt him/her").
Key Findings Participating public schools in Ontario, Canada, were randomly assigned to an intervention group, which received the Fourth R, or to a control group, which received the school's standard grade 9 health and physical education curriculum. Findings at the 2.5-year follow-up included the following:

  • A smaller percentage of students in the intervention group reported engaging in PDV in the past year compared with students in the control group (7.4% vs. 9.8%; p = .05).
  • A smaller percentage of male students in the intervention group reported engaging in PDV in the past year compared with male students in the control group (2.7% vs. 7.1%; p = .002).
  • Similar percentages of female students in both groups reported engaging in PDV in the past year (11.9% for the intervention group and 12.0% for the control group).
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 3.0 (0.0-4.0 scale)
Outcome 2: Condom use
Description of Measures Condom use was assessed using a question from the University of Victoria's Healthy Youth Survey. Only sexually active students responded to this question, and condom use was defined as the male always wearing a condom.
Key Findings Participating public schools in Ontario, Canada, were randomly assigned to an intervention group, which received Fourth R, or to a control group, which received the school's standard grade 9 health and physical education curriculum. Findings at the 2.5-year follow-up included the following:

  • A larger percentage of sexually active male students in the intervention group reported condom use compared with sexually active male students in the control group (68% vs. 59%; p < .01).
  • However, a smaller percentage of sexually active female students in the intervention group reported partner condom use compared with sexually active female students in the control group (44% vs. 51%; p < .01).
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 2.6 (0.0-4.0 scale)
Outcome 3: Violent delinquency
Description of Measures Violent delinquency was assessed using 8 items from the Canadian National Longitudinal Survey of Children and Youth. Students indicated whether they engaged in any of the following behaviors over the past 3 months: (1) "fought with someone to the point where they needed care for their injuries," (2) "been in a fight where you hit someone with something other than your hands," (3) "carried a knife for the purpose of defending yourself or using it in a fight," (4) "carried a gun other than for hunting or target shooting," (5) "carried any other weapon such as a stick or club," (6) "threatened someone in order to get their money or things," (7) "tried to force someone to have sex with you," and (8) "set fire on purpose to a building, car, or something else not belonging to you." Students who indicated that they engaged in at least two of these behaviors were classified as exhibiting violent delinquency. Data were then statistically analyzed to determine the risk of violent delinquency.
Key Findings Participating public schools in Ontario, Canada, were randomly assigned to an intervention group, which received Fourth R, or to a control group, which received the school's standard grade 9 health and physical education curriculum. Findings at the 2.5-year follow-up indicated that among students with a history of childhood maltreatment, those in the intervention group had a 3% risk of violent delinquency and those in the control group had a 46% risk of violent delinquency (odds ratio = 0.66; p < .05).
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 2.8 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study Age Gender Race/Ethnicity
Study 1 13-17 (Adolescent) 53% Female
47% Male
100% Non-U.S. population

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

  1. Reliability of measures
  2. Validity of measures
  3. Intervention fidelity
  4. Missing data and attrition
  5. Potential confounding variables
  6. Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome Reliability
of Measures
Validity
of Measures
Fidelity Missing
Data/Attrition
Confounding
Variables
Data
Analysis
Overall
Rating
1: Physical dating violence 3.0 3.0 2.5 2.8 3.0 4.0 3.0
2: Condom use 2.0 2.0 2.5 2.0 3.0 4.0 2.6
3: Violent delinquency 2.0 3.0 2.5 2.5 3.0 4.0 2.8

Study Strengths

Research established the psychometric properties of the CADRI items, which had good test-retest reliability and convergent/divergent validity. Teachers participated in a training workshop and received detailed lesson plans, training videos, role-play demonstrations, and individual feedback from an experienced educator. Self-report fidelity checklists completed by teachers indicated that 89% of the intervention lessons were completed. Participating schools were stratified by size and location before randomization. Intent-to-treat analyses were conducted with all participant data. Separate analyses were conducted with a subsample of students who had been dating in the year before the follow-up.

Study Weaknesses

Classroom sessions were not observed by an independent rater for fidelity. Student data were collected by self-report only. Analysis indicated that students lost to attrition (12% of the sample) were more likely to be male and more likely to report problem alcohol use, introducing potential confounds.

Readiness for Dissemination
Review Date: February 2011

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Gibbings, P., Crooks, C., & Hughes, R. (2009). Youth Safe Schools Committee manual: A guide for the creation and operation of a committee of students who support and encourage healthy-living choices among teens. London, Canada: Centre for Addiction and Mental Health, Centre for Prevention Science.

Program Web site, http://www.youthrelationships.org

The Teen Files Series [4 DVDs]:

  • Binge drinking blowout. (1999).
  • Smoking: Truth or dare? (2000).
  • The truth about drugs. (1999).
  • The truth about sex. (2000).

Wolfe, D., Crooks, C., Hughes, R., & Jaffe, P. (2009). Youth Relationships Program: Featuring the Fourth R for Healthy Relationships: A relationship-based program for 8th grade physical and health education. London, Canada: Centre for Addiction and Mental Health, Centre for Prevention Science.

Wolfe, D., Crooks, C., Hughes, R., Jaffe, P., & Chiodo, D. (2010). Master trainer manual. 4R: Strategies for healthy youth relationships. London, Canada: Centre for Addiction and Mental Health, Centre for Prevention Science. Includes:

  • Master Trainer Manual [CD-ROM]
  • Media Violence: Understanding Media Literacy, a Guide for Parents [Pamphlet]
  • Strategies for Healthy Youth Relationships [Pamphlet]
  • Wolfe, D. A. (2007). What parents need to know about teens: Facts, myths and strategies. Toronto, Canada: Centre for Addiction and Mental Health.

Other implementation materials:

  • Name the Violence (Headings/Scenarios) [Laminated cards]
  • Quiz (Fact or Myth?) [Trade cards]
  • Role-Play Examples [DVD]
  • Skills for Effective Relationships [2 DVDs]
  • Youth Relationships Program Handouts, Overheads, Parent Newsletters, and Unit Test [CD-ROM]

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

  1. Availability of implementation materials
  2. Availability of training and support resources
  3. Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation
Materials
Training and Support
Resources
Quality Assurance
Procedures
Overall
Rating
4.0 4.0 4.0 4.0

Dissemination Strengths

Comprehensive grade-specific implementation materials include DVDs, CD-ROMs, and a detailed manual. Each lesson is sequenced and includes objectives, learning strategies, and overheads. Role-playing is used for practicing skills. The Master Trainer Manual includes a training agenda, copies of training slides with detailed notes, model role-play scripts, and background information. On-site trainings for teachers and master trainers are offered; trainings include an opportunity for participants to provide feedback to each other during role-play scenarios and to the trainer via a feedback form. A fidelity checklist for each component, a student satisfaction survey, and a teacher implementation questionnaire are available to support quality assurance.

Dissemination Weaknesses

No weaknesses were identified by reviewers.

Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description Cost Required by Developer
Fourth R Curriculum Binder, for teachers (includes cards; a DVD with role-play examples; two DVDs with skills for effective relationships; and a CD-ROM with handouts, overheads, a unit test, and other resources for printing) $135 per binder Yes
4-DVD Teen File Series:

  • Binge Drinking Blowout
  • Smoking: Truth or Dare?
  • The Truth About Drugs
  • The Truth About Sex
$325 per set No
Youth Safe Schools Committee Manual $25 each No
1-day, off-site teacher training workshop $150 per person No
1-day, on-site teacher training workshop $1,500 for 25 participants plus trainer travel expenses No
1.5-day, on-site master trainer training $12,500 for 25 participants plus trainer travel expenses No
Master Trainer Manual (includes fidelity checklists) $150 each No
2-day, on-site consultation $2,000 plus travel expenses No
Phone and email support Free No
Student Satisfaction Questionnaire Free No
Teacher Implementation Questionnaire Free No

Additional Information

In the study reviewed by NREPP, approximately 1,700 students participated in the program, at an average cost of $16 per student. This amount included expenses for teacher release time for training and the cost of curriculum materials.

Replications

No replications were identified by the developer.

Contact Information

To learn more about implementation, contact:
Shanna Burns, M.Ed.
+ 5198585154
shanna_burns@camh.net

To learn more about research, contact:
David A. Wolfe, Ph.D., CPsych
+ 5198585161
dawolfe@uwo.ca

Consider these Questions to Ask (PDF, 54KB) as you explore the possible use of this intervention.

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