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. Author manuscript; available in PMC: 2024 Jul 2.
Published in final edited form as: Health Promot Pract. 2023 Apr 3;25(4):689–697. doi: 10.1177/15248399231162379

Evaluation of a Brief Online Sexual Health Program for Adolescents: A Randomized Controlled Trial

Jordyn McCrimmon 1, Laura Widman 1, Hannah Javidi 2, Julia Brasileiro 1, Jeffrey Hurst 1
PMCID: PMC10966929  NIHMSID: NIHMS1979374  PMID: 37013260

Abstract

Adolescents are at increased risk of acquiring sexually transmitted infections (STIs) and experiencing unintended pregnancy. In particular, adolescents from marginalized communities experience significant sexual health disparities compared to their more advantaged peers. Digital sexual health programs, such as HEART (Health Education and Relationship Training), may be effective in reducing these risks and addressing these disparities. HEART is a web-based intervention focused on the promotion of positive sexual health outcomes, such as sexual decision-making skills, sexual communication skills, sexual health knowledge, and sexual norms and attitudes. The current study evaluates the efficacy of HEART, and examines whether effects were moderated by gender, socioeconomic status (SES), race, English as a second language, and sexual orientation to ensure the program is effective for diverse groups of adolescents. Participants were 457 high school students (Meanage=15.06, 59% girls, 35% White, 78% heterosexual, 54% receive free or reduced-price lunch). Students were randomized to HEART or an attention matched control and assessed at pretest and immediate posttest. HEART was effective in increasing sexual assertiveness, sexual communication intentions, HIV/STI knowledge, condom attitudes, and safer sex self-efficacy compared to the control condition. There were no significant interactions by gender, SES, race, English as a second language, or sexual orientation, suggesting the program worked equally well for all groups of youth. The findings of this study suggest that HEART may be a promising avenue for the promotion of positive sexual health outcomes for diverse groups of youth.

Keywords: sexual health, health disparities, adolescent health

Introduction

Adolescence is a critical time for exploring romantic and sexual relationships (Olmstead, 2020). For example, among high school students who participated in the Youth Risk Behavior Survey in 2019, approximately 38% had ever engaged in sexual intercourse (Centers for Disease Control and Prevention [CDC], 2021). Although these are developmentally normative behaviors, they often come with risk. Research suggests many adolescents experience negative sexual outcomes, with adolescents ages 15–24 accounting for almost half of all sexually transmitted infection (STI) diagnoses each year (CDC, 2019). These negative outcomes are even more prevalent in adolescents from marginalized populations, such as racially minoritized adolescents, lesbian, gay, and bisexual adolescents, and adolescents of economically disadvantaged backgrounds (CDC, 2019; Everett, 2013; Harling et al., 2013). Thus, there is a need for sexual health interventions that reach these vulnerable populations.

Digital health interventions may play an important role in addressing these sexual health disparities. These programs can reach many communities as they have the potential to be highly accessible, affordable, and customizable (Guse et al., 2012). In addition, individuals from marginalized populations are more likely to use online platforms to obtain health-related information than other avenues due to mistrust with traditional health care settings, and lack of representation in other sources of health information (e.g., doctors’ offices; Ray et al., 2017; Steinke et al., 2017). Consequently, digital interventions may be particularly useful for these adolescents.

Digital sexual health interventions, specifically, have several potential advantages. These programs can be highly interactive and personalized (Hightow-Weidman et al., 2015). A recent review of digital sexual health interventions found them to be feasible to administer and likable among adolescents (Wadham et al., 2019). In addition, these programs improve safe sex behaviors, such as condom use, increase knowledge of STIs and HIV, and increase safer sex attitudes and norms in several adolescent populations (Guse et al., 2012; Wadham et al., 2019; Widman et al., 2018).

With the rapid growth of technology over the past decade, there has been an increase in tailored digital sexual health interventions (Guse et al., 2012). Tailored programs often target specific subgroups of adolescents, such as adolescents from marginalized racial and ethnic backgrounds (Wadham et al., 2019). Although tailored interventions hold purpose for use with their intended populations, their specificity may make them unsuitable for use with heterogeneous groups of adolescents. Thus, there is still a need for interventions that are effective for use with groups of adolescents with various social identities. Digital sexual health interventions with a broad reach may be more suitable for use in community settings, such as schools or churches, whose populations often include individuals from various backgrounds and sociodemographic identities.

HEART (Health Education and Relationship Training) is a digital sexual health intervention that our team recently created to promote safer sex knowledge, attitudes, self-efficacy, and sexual communication skills in adolescents (Widman et al., 2020). HEART is grounded in psychological, and health-behavior change theories, including an extended version of the reasoned action model (RAM; Fishbein & Ajzen, 2010). The RAM posits that attitudes, norms, and self-efficacy surrounding sexual behaviors, including condom use, predict one’s intentions to use condoms (Fishbein & Ajzen, 2010). These behavioral intentions are then influential to one’s actual condom use (Fishbein & Ajzen, 2010). Extensions of this model have proposed that sexual communication (i.e., communication with one’s partner regarding sexual health topics), may also play a role in condom use intentions and behaviors (Widman et al., 2013). Thus, HEART targets factors found influential to condom use outlined by extensions of the RAM. Overall, the 45-min program has been found effective in two randomized controlled trials in the United States, with no differences found by gender or sexual orientation (Widman et al., 2018; Widman et al., 2020).

HEART was recently adapted using open-source technologies, allowing for broader dissemination (Javidi et al., 2021). During this adaptation, language and content inclusive of the lesbian, gay, bisexual, transgender, and queer (LGBTQ+) community was added. This latest iteration of HEART also included an additional goal-setting module, aimed at improving long-term efficacy of the program and included more interactive content (Javidi et al., 2021). Although HEART has only under-gone slight modifications in recent years, the recent iteration of HEART has yet to be evaluated, and the conditions under which the program is efficacious are unknown. As previous iterations of HEART have shown promising results for use with adolescents, it is important to demonstrate the program’s efficacy can be replicated in larger samples of adolescents with diverse identities.

Thus, the purpose of this study was to assess the efficacy of the latest version of HEART, specifically whether the program increases sexual decision-making skills, sexual communication skills, sexual health knowledge, and sexual norms and attitudes, in a large population of adolescents in a rural, Southeastern school district. In addition, we examined the efficacy of the program by gender, SES, race, English as a second language, and sexual orientation to ensure the program was equally efficacious for multiple groups of adolescents. Given the focus on ensuring HEART was inclusive of adolescents from various backgrounds, we hypothesized that the efficacy of the program would not differ by race/ethnicity, gender, sexual orientation, SES, and English as a second language.

METHOD

Participants

Participants were recruited from a rural high school in the southeastern U.S. to take part in a randomized controlled trial (NCT04156516). As 10th graders from this district were previously recruited for another study, only 9th and 11th graders were invited to participate through class announcements. During this time, consent forms were passed out, and students were asked to return these forms either to their teacher or a drop box located in the front office of the school. Approximately 1,600 students were eligible to participate in the study, with 616 returning consent forms signed by parents. Of these, 488 parents granted consent for their child to participate. Only participants who received parental consent and indicated their own assent to participate were included in the study, providing a final sample of 457 students.

Procedure

After receiving both parental consent and adolescent assent, pretest data were collected using online surveys in a small classroom setting. Participants were randomly assigned to HEART, or an attention matched control program focused on promoting growth mindsets of mental health (Lipsey et al., 2022). During a 90-min class period, participants completed a computerized pretest assessment, followed by the intervention or control program, and then a computerized posttest assessment. Pretest and post-test surveys were similar, with the removal of demographic data and addition of a survey to assess acceptability at post-test.

Intervention Description

Participants worked through six modules targeting five areas of sexual decision-making, including safer sex motivation, HIV/STI knowledge, sexual norms and attitudes, safer sexual self-efficacy, and sexual communication skills. A full description of program redevelopment and acceptability is detailed elsewhere (Javidi et al., 2021).

Measures

Demographics.

Data were gathered on demographic variables including participant age, gender, race/ethnicity, sexual orientation, receipt of free or reduced-priced lunch, and English as a first language. For the purposes of this study, receipt of free or reduced-priced lunch was used as a proxy for SES (Nicholson et al., 2014).

Sexual Assertiveness.

Self-reported sexual assertiveness was assessed using three items (e.g., “I’m very assertive about the sexual aspects of my life”) of the Multidimensional Sexual Self-Concept scale (α = .82; Snell, 1998). Items were rated from 1 (strongly disagree) to 5 (strongly agree).

Communication and Condom Intentions.

Intentions to communicate about sexual health and condom use were assessed using two items based on the AIDS Risk and Behavior Survey (Donenberg et al., 2001). The first item assessed how likely participants were to discuss sexual health issues such as pregnancy and STIs with their partner prior to sexual activity. The second item assessed participants’ intentions to use condoms the next time they had sex. Items were rated from 0 (not at all likely) to 4 (very likely). Items were analyzed separately in analyses.

Sexual Knowledge.

HIV/STI knowledge was assessed using nine items (e.g., “STIs usually have noticeable symptoms, like itching or burning”) adapted from previous sexual health knowledge questionnaires (Brown et al., 1992; Morton et al., 1996). Responses were recoded as 0 (incorrect or don’t know) and 1 (correct). Scores were summed to reflect the total number of HIV/STI knowledge questions ranging from 0 to 9.

Condom Attitudes.

Attitudes about condoms were assessed using three items (e.g., “Condoms take away the pleasure of sex”) from the Effect on Sexual Experiences subscale of the Condom Attitudes Scale—Adolescent Version (α = .79; St Lawrence et al., 1994). Items were rated from 1 (strongly disagree) to 5 (strongly agree).

Condom Norms.

Participants’ perceptions of their peers’ views of condom use were measured using three items (e.g., “Most teenagers believe condoms should always be used if a person my age has sex”) from the Sexual Risk Behavior Beliefs and Self-Efficacy scale for Adolescents (α = .92; Basen-Engquist et al., 1999). Items were rated from 1 (strongly disagree) to 5 (strongly agree).

Sexual Self Efficacy.

Self-efficacy for communication and condom use was assessed with the 8-item Self-Efficacy for HIV Prevention Scale (α = .81; Brown et al., 2014). Six items assessed confidence communicating about sexual topics (e.g., “How sure are you that you could talk to your partner about safer sex?”). Two items assessed confidence obtaining and using condoms (e.g., “How sure are you that you could have condoms available when you need them?”). Items were rated from 1 (couldn’t do it) to 4 (very sure).

Analysis Plan

Descriptive statistics were used to summarize sociodemographic variables and pretest levels of each outcome variable. To analyze pretest equivalence, differences between groups were assessed using t-tests for continuous variables and χ2 tests for categorical variables. To assess the efficacy of the intervention from pretest to immediate post-test, linear regression analyses were used. For each outcome, the corresponding pretest measure was controlled for. Moderation analyses were conducted to examine if intervention effects were moderated by race, gender, sexual orientation, SES, or first language. To facilitate analyses, racial categories were dichotomized to compare both Black and Latinx participants to White participants. Those who indicated being multiracial or any other racial identity were not included in the analyses. Sexual orientation was dichotomized, with only exclusively heterosexual participants classified as heterosexual, and all other sexual orientation groups (including “mostly heterosexual”) classified as sexual minority. Analyses by gender were conducted only among adolescents who selected the option “boy” or “girl” for their gender. Two participants who selected “transgender” were removed.

RESULTS

Descriptive Characteristics

Overall, sample characteristics were similar in the intervention and the control group at pretest (Table 1). There were no significant differences between demographic characteristics or study-related variables between participants in intervention and control groups with one exception: More girls received HEART than the control intervention (t = 6.25, p = .013). Fifty-nine percent of participants identified as girls, 40% as boys, and 1% as transgender. The average age of participants was 15.06. Thirty-five percent of the sample identified as White, 25% as Black, 33% as Latinx, and 7.4% as multiracial or as another race that was not listed. Fifty-four percent of participants reported receiving free or reduced-price lunch (i.e., low SES). Seventy-eight percent of participants identified as exclusively heterosexual. Twenty percent of participants reported English being their second language.

TABLE 1.

Sample Characteristics at Pre-Test Assessment

Characteristics Full sample (n = 457) Intervention (n = 233) Control (n = 224) Difference testa
χ2 or t p
Sociodemographics—n (%)
 Gender—girls 268 (58.6) 150 (64.4) 118 (52.7) 6.23 .013
 Race/ethnicity—White 158 (34.6) 74 (31.8) 84 (34.4) 1.66 .198
 Race/ethnicity—Black 114 (24.9) 59 (25.3) 55 (22.5) 0.04 .850
 Race/ethnicity—Hispanic 151 (33.0) 80 (34.3) 71 (31.7) 0.36 .550
 Race/ethnicity—Other/Mixed 34 (7.4) 20 (8.6) 14 (5.7) 0.90 .343
 Free/reduced price lunch 247 (54.0) 118 (50.6) 129 (52.9) 2.22 .137
 Heterosexual sexual orientation 355 (77.7) 177 (76.0) 178 (73.0) 0.81 .370
Sexual behaviors—n (%)
 Ever engaged in sexual activity 161 (35.2) 75 (32.2) 86 (35.2) 1.93 .165
 Ever had sexual intercourse 93 (20.4) 42 (18.0) 51 (20.9) 1.65 .200
 Condom use at last sexb 54 (11.8) 24 (10.3) 30 (12.3) 0.08 .784
Outcomes—M (SD)
 Communication intentionsc 3.52 (1.35) 3.52 (1.35) 3.52 (1.37) −0.06 .954
 Condom intentionsc 4.35 (1.22) 4.35 (1.23) 4.34 (1.20) 0.07 .943
HIV/STI knowledged 4.74 (1.96) 4.75 (2.08) 4.73 (1.83) 0.55 .960
 Condom attitudesc 3.59 (0.94) 3.61 (0.90) 3.58 (0.98) 0.30 .765
 Condom normsc 3.57 (1.19) 3.59 (1.13) 3.56 (1.25) 0.30 .770
 Self-efficacye 3.07 (0.60) 3.06 (0.61) 3.08 (0.61) −0.39 .698
 Sexual assertivenesse 3.11 (1.01) 3.13 (1.02) 3.10 (1.02) 0.35 .725
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Note. HIV = human immunodeficiency virus. STI = sexually transmitted infection.

a

Difference test was χ2 for categorical variables and t-test for continuous variables.

b

Percentage based on sexually active teens.

c

Range: 1–5.

d

Range: 0–9.

e

Range: 1–4.

Efficacy of Program

Immediately following the intervention, participants who completed HEART reported significantly higher levels of sexual assertiveness (B = .38, p < .001), sexual communication intentions (B = .21, p = .019), HIV/STI knowledge (B = 2.42, p < .001), condom attitudes B = .20, p = .004) and safer sex self-efficacy (B = .10, p < .001) compared to control participants (Table 2). Effect sizes for each of the significant regressions ranged from d = .12 to d = 1.17, with the smallest effect size found for safer sex self-efficacy, and the largest effect found for HIV/STI knowledge. Participants did not show significant improvements in condom use intentions or condom norms from pretest to post-test.

TABLE 2.

Efficacy of HEART at Post-Test (n = 452)

Outcomes Intervention Control Effects at post-testa
M (SD) M (SD) B (SE) p Effect sizeb
Sexual assertiveness 3.44 (1.02) 3.05 (1.07) 0.38 (0.06) <.001 0.37
Communication intentions 4.22 (1.04) 4.01 (1.26) 0.21 (0.09) .019 0.18
Condom intentions 4.36 (1.05) 4.29 (1.19) 0.06 (0.08) .421 0.06
HIV/STI knowledge 7.03 (2.18) 4.61 (1.96) 2.42 (0.16) <.001 1.17
Condom attitudes 3.70 (1.00) 3.49 (1.00) 0.20 (0.07) .004 0.21
Condom norms 3.74 (1.15) 3.56 (1.24) 0.17 (0.09) .078 0.15
Self-efficacy 3.24 (0.67) 3.16 (0.70) 0.10 (0.04) .019 0.12
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Note. HIV = human immunodeficiency virus. STI = sexually transmitted infection.

a

Linear regression results, controlling for pre-test level of each variable.

b

Cohen’s d standardized difference in covariance adjusted means between treatment group and control group (Cohen, 1992). Additional analyses were run controlling for gender with no significant differences in outcomes.

Efficacy of Program Across Subgroups

Additional moderation analyses were conducted to examine if intervention effects differed by gender, SES, race, English as a second language, or sexual orientation (all test statistics are shown in Table 3). As condom use intentions and condom norms were not significantly improved by the intervention, they were not included in these analyses. In line with hypotheses, intervention effects were similar across groups for all outcomes (ps =.098–.994), with no significant interactions with gender, SES, race, English as a second language, or sexual orientation.

TABLE 3.

Interactions With Efficacy of HEART at Post-Test

Outcomes Gender SES Race Blacka Race Latinxa English first language Sexual orientation
B (SE) p B (SE) p B (SE) p B (SE) p B (SE) p B (SE) p
Sexual assertiveness .02 (.13) .884 −.16 (.14) .258 .26 (.17) .122 .19 (.18) .297 −.11 (.20) .568 −.04 (.16) .813
Communication intentions .03 (.19) .944 −.26 (.20) .192 .28 (.24) .245 .09 (.26) .723 −.36 (.28) .196 .01 (.19) .488
HIV/STI knowledge .30 (.34) .376 −.02 (.36) .953 −.34 (.44) .433 .57 (.47) .225 .10 (.51) .841 .13 (.40) .746
Condom attitudes −.24 (.14) .098 .07 (.15) .647 −.35 (.19) .060 −.23 (.20) .251 .00 (.22) .994 −.06 (.17) .737
Self-efficacy .10 (.09) .264 .01 (.09) .914 −.04 (.11) .706 .09 (.12) .448 .16 (.14) .219 −.07 (.10) .503
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Note. SES = socioeconomic status. HIV = human immunodeficiency virus. STI = sexually transmitted infection.

a

Reference group = White.

DISCUSSION

Adolescents from historically marginalized populations experience significant sexual health disparities (CDC, 2019). One way to address these disparities is through digital sexual health intervention. Given their accessibility, affordability, and potential for personalization, digital interventions may be particularly beneficial for adolescents from marginalized backgrounds (Guse et al., 2012; Hightow-Weidman et al., 2015). Therefore, it is important to ensure these interventions are effective in increasing positive sexual health outcomes with adolescents of various backgrounds and identities. The current study replicated a digital sexual health program, HEART, in a large, diverse sample of adolescents, and examined the efficacy of the program by various identities.

This study found that HEART increased sexual assertiveness, sexual communication intentions, HIV/STI knowledge, condom attitudes, and safer sexual self-efficacy at immediate post-test among the whole sample. Our current results are similar to those of previous evaluations of HEART, which also showed increases in sexual communication intentions, HIV/STI knowledge, condom attitudes, sexual self-efficacy, and sexual assertiveness in adolescents. In addition, in line with previous study findings, our results suggest that digital sexual health interventions are effective in increasing STI knowledge, promoting safer sex behaviors, and improving condom attitudes (for recent reviews, see Wadham et al., 2019; Widman et al., 2018).

Interestingly, there were no significant differences in condom use intentions and condom norms at immediate post-test for those who participated in the program. It is possible that factors beyond the scope of this intervention may be more influential to these variables. For example, previous research suggests condom use intentions may be a product of both individual and relationship dynamics (VanderDrift et al., 2013). As HEART is an individual-focused intervention, we were unable to address the influence of sexual partners on these outcomes, specifically for those who were sexually active. Future examinations of HEART should attempt to understand the role of relationship dynamics in these outcomes, such as with the use of dyads.

A primary focus of this study was to ensure HEART was effective for diverse groups of adolescents. Specifically, this study examined differences in intervention efficacy by gender, SES, race, English as a second language, and sexual orientation. Research suggests that people from marginalized groups endure inequitable social conditions, such as poverty, which contribute to disparate access to sexual health services, resulting in significant sexual health disparities compared to their more advantaged peers (CDC, 2019). For example, sexual minority boys, Black and Latinx adolescents, and economically disadvantaged adolescents are at increased risk for experiencing negative sexual health outcomes (e.g., STIs), compared to their more advantaged peers (CDC, 2019; Everett, 2013; Harling et al., 2013). Ensuring sexual health interventions are sensitive to multiple groups of adolescents with various social identities is vital to reducing these disparities.

Importantly, we found no differences in HEART’s efficacy by gender, SES, race, English as a second language, or sexual orientation. Currently, there are several effective digital sexual health interventions tailored for use with specific groups of adolescents. For example, SiHLE (Sisters Informing, Healing, Living, Empowering), an evidence-based digital sexual health intervention tailored for use with Black girls (Klein & Card, 2011), was found efficacious in improving condom-protected intercourse for Black girls ages 14 to 18. Thus, tailored programs may be particularly valuable for use with certain community organizations primarily consisting of their target population. However, these programs may not be applicable to broader populations. Interventions that are efficacious in increasing positive sexual health outcomes in groups of youth that hold various social identities are still needed. For example, general sexual health interventions with a broad reach can be useful in settings consisting of adolescents with diverse gender, racial, and sexual identities, such as schools, clinics, or churches. The results of this study suggest that HEART may be effective for use in diverse settings, such as schools, where population-specific interventions may not be appropriate.

Limitations

A few important limitations of this study should be considered when interpreting the findings and considering directions for future research. First, this study was conducted among high school students in the Southeastern United States. These results may not be generalizable to adolescents from other regions of the country, or adolescents who are not currently in school. Second, although the open-source platform used to disseminate HEART allows for use on personal devices, this study was conducted in person, in a controlled school setting. Therefore, the effectiveness of this program when completed remotely is unknown. Future studies should allow for completion of the intervention in a self-directed format on personal devices to assess the effectiveness of the program in various formats. Third, only three racial identities were examined in moderation analyses. Thus, these results are not generalizable to other racial groups or multiracial individuals. In addition, although results showed program effects did not differ by race, gender, sexual orientation, SES, or English as a second language, the sample was primarily heterosexual and lacked gender-diverse adolescents. Sexual and gender minority adolescents experience unique sexual health disparities (Everett, 2013); thus, these groups could benefit from programs specifically adapted for their needs. Future replications of HEART should include more diverse samples of adolescents to assess needs specific to these groups. Fourth, both testing effects and response shift bias are a concern. Due to the short period from pretest to post-test, responses on the posttest survey may have been influenced by the memorization of responses on the pretest survey. Response shift bias is a possible limitation as participants may have gained insight to the study variables while taking the intervention, and then re-evaluated their responses on pretest measures. Thus, responses on the posttest survey may have been a result of participants’ reconceptualization of measures, and not of the intervention itself (Sibthorp et al., 2007). Recommendations to mitigating the effects of these biases include changes in study designs, specifically implementing a posttest only design to address testing effects (Pasnak, 2018), or a retrospective pretest design to address response shift bias (Sibthorp et al., 2007). Future evaluations of HEART should consider utilizing alternative study designs, including the use of behavioral measures, longitudinal designs, and retrospective pretest designs, to better ensure that posttest responses are a result of the intervention.

A final limitation worth mentioning is that this data was collected immediately prior to the onset of the COVID-19 pandemic and only assessed at a single pre-post timepoint. We had initially intended to follow participants over 18 months to determine longer-term efficacy of HEART; however, school-based data collection was stopped due to the pandemic, leaving these results unknown. In addition, the onset of the COVID-19 pandemic had profound effects on adolescent well-being and sexual behavior. For example, adolescents reported decreased sexual desire and sexual intercourse, but increased pornography use and masturbation through-out the pandemic (Stavridou et al., 2021). Future studies should not only examine the efficacy of HEART longitudinally to determine whether changes in outcomes persist over time, but in the context of a post-lockdown world.

Implications for Practice and Research

These findings support the role of digital sexual health programs in the promotion of positive sexual health outcomes, including sexual decision-making skills, sexual communication skills, and sexual health knowledge, for adolescents from various marginalized social backgrounds. Due to the lack of adequate sexual health resources and education, especially for youth from underserved communities, incorporating digital sexual health interventions such as HEART into established health education curricula may be a promising avenue for reducing sexual health disparities. As HEART is completely online, it can be easily adapted to fit the needs of specific schools and community-based organizations. In addition, as the program is self-led, no prior training from facilitators is necessary, making it suitable for use in schools with limited resources.

An important next step for future research is to expand implementation of HEART to other community settings. Implementation studies specifically would allow us to address both barriers and facilitators to wider dissemination of the program, which were not captured by the current study. For example, due to the online nature of the program, internet access is necessary. Although studies suggest roughly 95% of adolescents have access to a smartphone, some adolescents still do not (Anderson & Jiang, 2018). Beyond this efficacy trial, understanding the best settings to implement HEART is necessary to getting HEART into the hands of the individuals who most need it.

CONCLUSION

Adolescents continue to experience STIs and unintended pregnancy at disproportionately high rates. These disparities are further evidenced by the increased negative sexual health outcomes experienced by adolescents from marginalized communities. Thus, efforts to reduce these disparities are crucial. This study found that there were no differences in program efficacy by gender, SES, race, English as a second language, or sexual orientation. Thus, HEART may be a promising avenue for the promotion of safer sexual decision-making skills in diverse groups of youth, including those of marginalized backgrounds.

Acknowledgments

This work was supported by the Laura and John Arnold Foundation. Research reported in this publication was supported by the National Institute of Mental Health of the National Institutes of Health under Award Number F31MH126763 awarded to Julia Brasileiro. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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