Identifying Barriers and Facilitators of Implementing a Sexual and Relationship Health Intervention within the Child Welfare System: A Mixed Methods Study

Abstract

Access to sexual health education is critical for the wellbeing of youth in out-of-home care. HEART (Health Education and Relationship Training) is an online, evidence-based sexual health program that may benefit this group of youth, but reaching youth in the child welfare system remains challenging. This study aimed to identify barriers and facilitators to implementing HEART within the child welfare system. We used a convergent parallel mixed methods design and applied the Consolidated Framework for Implementation Research (CFIR) to guide data collection and analysis. We collected 1) qualitative data through semi-structured interviews with foster caregivers and child welfare professionals (n = 14) in one state in the United States; and 2) data through an online survey among youth in care (n = 72) across several states. Participants identified barriers and facilitators at four CFIR domains. Barriers included the religious and conservative beliefs of foster families and staff; the sensitive nature of discussing sex among youth who have experienced trauma; youth pushback to authority; and a lack of structure for offering youth sexual health education. Results provide a foundation for developing implementation strategies to implement HEART within the child welfare system.

Youth in out-of-home care (OOHC; youth living in foster care, kinship care, and group homes) in the United States (US) between the ages of 14–21 are at risk for experiencing worse sexual health outcomes compared to their same-aged peers (Dworsky & Courtney, 2010). Youth in OOHC, for example, experience higher rates of sexually transmitted infections (STIs), early and repeat pregnancy, and dating violence (Ahrens et al., 2010; Dworsky & Courtney, 2010; Herrman et al., 2017).As many as 46% of girls in foster care in the US become pregnant before the age of 19 – more than double that of their same-age peers (Dworsky & Courtney, 2010). Youth in OOHC also have at least three times the risk of a diagnosed STI compared to youth not in foster care (Ahrens et al., 2010). Sexual health education provides youth with the knowledge and skills they need to develop healthy relationships, and make informed, safe, and positive choices about their sexual health (WHO, 2018). Yet among a nationally representative sample of youth in OOHC from across the US, only 49% of youth had received sex education about abstinence, condoms, or contraception (Brasileiro et al., 2023), compared to 80–90% of youth in a general population national sample who received sex education about abstinence and STI/HIV prevention (Lindberg & Kantor, 2022). Understanding the challenges that are preventing youth in OOHC from accessing sexual health education is critical for promoting the sexual health and wellbeing of youth in OOHC.

Youth in OOHC face barriers on multiple levels that prevent them from accessing sexual health education. First, most youth in the US, both those in and out of care, face barriers to accessing sexual health education. At the societal level, taboos and stigma surrounding adolescent sexuality arise from restrictive social norms that deem expressions of sexuality inappropriate for young people. This, in turn, restricts their access to essential sexual health education and care (Buller & Schulte, 2018). At a community level, comprehensive sexuality education in schools across much of the US is either lacking entirely or insufficient (Hall et al., 2016). Only 19 states, for example, require sex education programs to cover contraception or condoms and only five states require comprehensive sexuality education (SIECUS, 2022).

On top of these more general barriers to sex education, youth in OOHC face additional barriers. At the systems level, there are no clear federal policies in the US dictating that sexual health education should be provided to youth in OOHC and who should be responsible for providing it (Fitzgerald, 2023). This barrier is unique to youth in OOHC who’s access to sexual health education can depend on services provided by child welfare staff and foster families (Harmon-Darrow et al., 2020). At the community level, youth in OOHC often miss sexual health education offered in schools due to their transient care placements (Ramseyer Winter et al., 2016). At the relationship level, youth in out-of-home care are more likely to lack models of healthy romantic relationships (Scott, 2012). Modeling of healthy romantic relationships is critical and protective during this developmental period, as adolescents’ relationship styles tend to mirror those of their caregivers (Scott, 2012). Further, communication with parents/guardians about sexual health is an important way that youth learn about safe sex behaviors; however a systematic review revealed that there is a lack of conversations between parents/guardians and youth about these topics (Robertson, 2013). A critical part of upholding youths’ human rights is providing youth in OOHC with access to sexual health education (Sexology, 2014).

Health Education and Relationship Training (HEART) is a brief online evidence-based intervention (EBI) for youth that could address this gap in access to sexual health education for youth in OOHC (Javidi et al., 2021; Widman et al., 2016). HEART is grounded in the Reasoned Action Model (RAM; (Fishbein & Ajzen, 2011), Fuzzy Trace Theory (Reyna & Brainerd, 2011), and interpersonal communication theories (Hargie, 2010). The program is set up as a town where users navigate through five interactive buildings to receive program content targeting sexual health behavior change including: 1) safer sex motivation, 2) HIV/STI knowledge, 3) norms/attitudes, 4) self-efficacy, and 5) sexual communication. Content is taught within a sexual health paradigm that emphasizes personal values, positive aspects of sexuality, and the importance of competent interpersonal skills, as well as risk reduction (Fortenberry, 2013). Material is presented with brief bulleted text and matching audio, as well as video/audio clips, information sheets, quizzes, games, and skill-building exercises. HEART was developed with extensive input from a Youth Advisory Board as well as qualitative interviews and usability testing with youth (Widman et al., 2016). HEART is hosted on a web platform accessible on smartphones, tablets, or computers, allowing participants to complete it anywhere with internet access. HEART is designed to be completed online in approximately 45 minutes. See Figure 1 for screenshots of HEART content.

Figure 1.

Sample Images of HEART

HEART has now been evaluated in three randomized control trials (RCT1 n = 222; RCT 2 n = 226; RCT 3 n = 457) with high school students and a fourth quasi-experimental study with at-risk youth (n = 162) in a community center in the US (McCrimmon et al., 2023; Widman et al., 2017; Laura Widman et al., 2020). Overall, youth found HEART to be highly acceptable, with around 90% of youth who completed the program saying they liked the program, learned new things, would recommend HEART to a friend, and plan to use the information from HEART in the future (Laura Widman et al., 2020). Immediately following the intervention, participants who completed HEART demonstrated better sexual assertiveness skills measured with a simulated role-play behavioral task (Gordon et al., 1997), compared to youth who completed the control (d = .28; (Widman et al., 2017). HEART participants also reported significantly higher self-reported sexual assertiveness (ds = .29–1.13), sexual communication intentions (ds = .18-.57), HIV/STI knowledge (ds = 1.17–4.78), perceived peer norms for condom use (ds = .15-.53), condom attitudes (ds = .21-.83), and condom self-efficacy (ds = .12-.87; (McCrimmon et al., 2023; Widman et al., 2017; Widman et al., 2016; L. Widman et al., 2020). At 4-month follow up, youth who completed HEART retained significantly higher HIV/STI knowledge (d = .56), more positive condom use attitudes (d = .45), and greater condom self-efficacy compared to the control group (d = .30; (Widman et al., 2017) Importantly, HEART effects did not differ based on race/ethnicity or sexual activity status, suggesting the HEART was equally effective for a diverse sample of youth (McCrimmon et al., 2023).

We recently adapted HEART for youth in OOHC by conducting a series of focus group discussions with youth to seek input on how to adapt HEART (Brasileiro, 2023). Overall, youth expressed enthusiasm at having access to the HEART program and appreciated the short, online format. Youth noted three areas to bolster to make the program more relevant to their lived experiences: 1) healthy relationships and setting boundaries 2) birth control options for unique bodies and needs; and 3) sexual rights. These content areas have been adapted in HEART.

Study Purpose

The purpose of this study was to identify barriers and facilitators to the implementation of HEART within the child welfare system. This study is needed as youth in OOHC have insufficient access to sexual health education and experience worse sexual health outcomes compared to their same aged peers (Dworsky, 2018). HEART is a promising EBI for youth in OOHC, yet no studies have been conducted to determine how to implement this program within this new community setting. To address these gaps, we used a convergent parallel mixed methods design, drawing on the strengths of both qualitative and quantitative data (Creswell, 2018). Quantitative and qualitative data were collected concurrently, but separately. The use of qualitative and quantitative methods provided distinct information from both the implementers (i.e., caregivers and professionals) and the beneficiaries of the program (i.e., youth), and information from these sources was compared to identify any differences or confirmation in perceived barriers and facilitators to implementing HEART. The Consolidated Framework for Implementation Research (CFIR; (Damschroder et al., 2022) guided the collection and analysis of 1) qualitative data collected through semi-structured interviews with foster caregivers and child welfare professionals and 2) an online survey among youth in OOHC.

The overarching research question for this mixed methods study was: what are the barriers that prevent and facilitators that promote the implementation of HEART within the child welfare system? A secondary aim for the qualitative analysis among adults was to explore any differences in barriers and facilitators by participant role (i.e., child welfare professionals vs. foster caregivers). Specific research questions from survey data among youth included: 1) What percent of youth in care want more information about sexual and relationship health? 2) What percent of youth in care know where to access sexual health services? 3) How helpful do youth in care believe that HEART would be? 4) Where do youth believe that the best places to offer the HEART program would be? Barriers and facilitators were identified by merging the results from the qualitative and quantitative data.

Method

Theoretical Framework

We applied the CFIR, a meta-theoretical framework comprised of constructs across five key domains, to guide the systematic identification of barriers and facilitators to implementation effectiveness (Damschroder et al., 2009, 2022). These domains include innovation (the HEART/program being implemented), outer setting (community, system, or state setting), inner setting (setting in which the innovation is implemented), individuals (roles and characteristics of individuals involved with the EBI implementation), and implementation process (activities and strategies used to implement the innovation). Only four of the CFIR domains – the innovation, inner setting, individuals, and implementation process -- were captured in this study as they were the domains most relevant to the study purpose and methods. CFIR was selected for this study as it is a widely used framework in the field of implementation science, that can be adapted to many health fields and interventions (Damschroder et al., 2022; Kirk et al., 2016). For example, the CFIR is among the most highly cited papers in implementation science and has been used worldwide in a variety of community settings on projects with diverse health foci (Kirk et al., 2016; Means et al., 2020). This is a benefit of the CFIR as it facilitates comparison of findings across different contexts and studies (Mbengo et al., 2022). This consistency can enhance the generalizability of results and contribute to a cumulative knowledge base in implementation science (Damschroder et al., 2022). We used the CFIR to guide the thorough identification of potential barriers and facilitators to the implementation of HEART within the child welfare system.

Data Collection

Interviews with Adults

The North Carolina State University Institutional Review Board approved all study procedures. Participants provided electronic consent and demographic information in a screening survey prior to the interview. Between April-July 2023, we conducted semi-structured interviews over Zoom with six foster caregivers, five child welfare professionals, and three participants holding a dual role (i.e., caregiver and child welfare professional) in one state in the Southeastern US. We recruited participants until data saturation was reached (Fusch & Ness, 2015). Broadly, drawing from Strauss and Corbin, we defined data saturation as reaching the point where additional data collection was “counter-productive,” and where “new” data did not necessarily add to the overall story (Corbin, 2008). We identified data saturation during the data collection stage among the whole sample by assessing whether new responses to semi-structured interview questions were arising or whether the same pattern of answers was emerging (Saunders et al., 2018). Participants were recruited via community partners and a listserv of foster caregivers. Participants answered questions from the interview guide covering questions from four CFIR Domains: Innovation, Inner Setting, Individuals, and Implementation Process Domains (See Figure 2 & Supplemental File - Appendix A). Participants were compensated $25 for completing an approximately 30-minute interview.

Figure 2.

CFIR Constructs Captured in Interview and Survey

Survey with Youth

Youth provided electronic assent or consent beforehand and were compensated $10 for completing the 10-minute survey. We recruited youth by contacting youth advocacy boards from all 50 states as well as through community partners. We conducted six data quality checks, including three attention checks, a minimum survey duration of five minutes, relevance of qualitative responses, and age verification. Fifteen participants missed one quality check, and two participants missed two checks. All participants were included in the analysis, and a sensitivity analysis revealed no differences in results or demographics between those who missed quality checks and those who did not. The final sample consisted of 72 youth ages 14–24 from 14 states. Youth completed an online survey and answered questions covering three of the CFIR Domains (i.e., Inner Setting, Individuals, and Implementation Process) across five specific constructs (Figure 2). We did not gather data on the innovation domain in this survey, as feedback on HEART was elicited during focus group discussions in a prior study (Brasileiro, 2023).

Participants did not complete the full 45-minute program before taking part in the survey or interview. Instead, they received an overview of HEART and viewed videos or images from the program prior to answering survey or interview questions. This approach is commonly used in implementation science studies assessing barriers and facilitators of digital health interventions, primarily due to practical considerations such as challenges in recruiting participants who are fully familiar with the intervention or time constraints related to completing both the intervention and the interview/survey (Kip et al., 2022; Seljelid et al., 2021; Ventuneac et al., 2020). Additionally, the focus of the interview and survey was on identifying barriers and facilitators to the implementation of HEART, rather than assessing the program’s content.

Measures

Inner Setting Domain

We assessed the construct of relative priority with one question: ‘Think about how important it is for youth in out-of-home care to receive sex education compared to other forms of education and services (like mental health, substance use, and financial services). Please rank where you think a relationship and sexual health program like HEART would fall compared to other services and education. Rank these topics with (1) being the most important and (7) being the least important. Response options included: ‘Sexual and relationship health program(s) like HEART,’ ‘Mental health program(s),’ ‘Alcohol use program(s),’ ‘Other substance use (e.g., tobacco, opioids) program(s),’ ‘School and academic program(s),’ ‘Financial & other practical life skills program(s),’ ‘Aging out of foster care system into adulthood program(s).’

We assessed the construct of incentive systems with one question: ‘Should we offer an incentive or payment to youth to take this program?’ with answer choices ‘Yes’ or ‘No.’

We assessed the construct of available resources to take HEART with two questions: 1) ‘What device did you use to complete the survey today?’ with answer choices of: ‘personal cell phone,’ ‘caregiver/family cell phone,’ ‘personal computer, ipad or tablet,’ ‘caregiver/family computer, ipad, or tablet,’ ‘other’ and 2)’Where did you complete this survey?’ with answer choices of: ‘at home,’ ‘at school,’ and ‘somewhere else.’

Implementation Process Domain

We measured the construct, assessing needs, with one survey question and one open-ended question. Participants responded to a question to assess the helpfulness of HEART: ‘How much do you think a program like HEART could be helpful to you?’ on a scale from 0 (Not at all) to 3 (Extremely). Participants who selected 0 (Not at all) were directed to an open-ended question asking, ‘Why wouldn’t this program be helpful to you?’ Those who selected 1–3 (A little, Very much, or Extremely) were asked, ‘Why would this program be helpful to you?’

We assessed the process for implementing HEART with two questions. The first question assessed the format of HEART that youth would prefer: ‘There are many ways we could offer HEART. We could offer the whole program at one time, or we could break it into smaller chunks. Please look at these options and choose all of the options that you would use to look at the program:’ with answer choices of: ‘Look at all of it at one time (45 minutes total),’ ‘Look at in parts of 20 minutes each time,’ ‘Look at in parts of 10 minutes each time,’ ‘Look at in parts of 5 minutes each time,’ and ‘Offer a menu and only look at the parts you want.’ Participants answered a second question about how to offer HEART to youth: ‘Where would be the best place(s) to offer the program so more youth can take it?’ with response options of: ‘Through social workers,’ ‘At doctor’s offices,’ ‘At health departments or STD clinics,’ ‘At schools,’ ‘Social media (e.g., TikTok, Instagram),’ ‘Through caregivers/parents’ or ‘Somewhere else.’

Individuals Domain

We assessed the innovation recipient by collecting data on participant characteristics relevant to engaging with a sexual health program. We asked two questions about participants romantic relationships: ‘Have you ever had a dating partner, romantic partner, or a sexual relationship of any kind? This could be a boyfriend, girlfriend, someone you dated, or someone you had any sexual experiences with’ and ‘Are you currently in a romantic or sexual relationship?’ Responses options for both questions were ‘yes’ or ‘no.’

We asked one question about participants access to sexual health services: ‘Do you know where to access sexual health services (e.g., birth control, STI testing) if you need them?’ with answer choices: 0 (No), 1 (Yes) and 3 (I don’t need sexual health services). Participants also responded to a question assessing desire for more information: ‘Would you like more information about sexual and relationship health?’ with answer responses ‘yes’ or ‘no.’ We asked four questions to assess where youth had learned about sexual and relationship health: 1) ‘Have you had any formal instruction at school about these topics?’ 2) ‘Have you talked to your biological parents about these topics?’ 3) ‘Have you talked to another caregiver (e.g., foster parent, adoptive parent) about these topics?’ and 4) ‘Have you talked to a social worker about these topics?’ The topics listed for each of the four questions were: ‘abstinence/waiting until marriage to have sex;’ ‘how to say no to sex;’ ‘STDs, pregnancy, condoms, birth control;’ ‘healthy relationships and boundaries;’ and ‘enjoyable or pleasurable aspects of sex.’

Finally, participants also answered questions about their former (i.e., Have you ever lived in one of these placements? ) and current foster placements (i.e., What is your current placement?). We also assessed the importance of religion with one question: ‘How important is religion to you?’ with response options from 1 (not important) to 5 (extremely important).

Sociodemographic Characteristics

Participants self-reported their age, gender, sexual orientation, state of residence, and whether they live in a rural, urban, or suburban area.

Data Analysis

Interviews with Adults

We used the thematic analysis approach to guide the analysis of the qualitative data (Braun & Clarke, 2006). First, two authors (JB and KS) became familiar with the data by listening to all interviews and correcting transcripts. Second, these authors created a codebook deductively based on the CFIR domains and constructs in the interview guide and inductively based on initial impressions of the data. This was an iterative process involving multiple discussions and three rounds of coding to determine the final codebook. For example, initially some data fit into multiple codes; we discussed whether we needed both codes or how to better define these codes. In some cases, these discussions led to more clearly defined codes, while in others, we eliminated codes that were deemed insufficiently distinct. We used NVivo V14 to code all data. Once the coding process was complete, we conducting a Coding Comparison query in NVIVO for each transcript to calculate a Kappa Coefficient and percentage agreement for each combination of code and file. The two coders convened twice to discuss any transcripts and codes that had a Kappa Coefficient below .8 (Gisev et al., 2013). During these discussions, the coders reached a consensus on the recoding of these transcripts. This iterative process not only strengthened our coding reliability but also deepened our understanding of the data. In the third phase, we used matrices and memos as analytic tools to sort the different codes into themes, and to explore main themes (Braun & Clarke, 2006). More specifically, the first author wrote a memo for each CFIR construct to explore how the various codes within each construct interrelated and to understand the overarching theme. We also created a matrix that categorized participant roles (e.g., foster caregivers vs. professionals vs. those with dual roles) alongside each code. To facilitate a clearer understanding of potential differences in findings across participant roles, we included 2–3 relevant quotes for each code within the matrix. Subsequently, we utilized memos as an analytical tool to reflect on our insights from the matrix and to assess any variations in perspectives based on participant role. The end result of this analysis was a final set of themes organized by the CFIR framework.

Survey with Youth

Online surveys with youth produced quantitative and qualitative data. Quantitative survey data were analyzed in SPSS v28 across two steps. We conducted descriptive analyses to characterize the sample on demographic features and answer research questions about general receipt of sexual health education, need for sexual health resources, and the implementation of HEART.

We analyzed the qualitative data derived from open-ended survey questions about possible barriers and facilitators using content analysis (Hsieh & Shannon, 2005). We followed a similar analytic process used for adult interviews. We read open-ended responses from the survey and created a codebook deductively based on CFIR domains and inductively as other codes emerged. Data were coded. We then used memos as an analytic technique to deduce main themes regarding barriers and facilitators to offering HEART to youth in OOHC. Any coding uncertainties as well as broader analysis of the main themes were discussed among two authors (JB and LW) in one meeting until consensus was reached.

Mixed Methods Data Integration

We analyzed the qualitative findings from the adult interviews and youth surveys separately, and then integrated the data together to create a results and discussion section (Creswell & Plano Clark, 2018). We assigned equal weight and priority to both types of data (Palinkas et al., 2011), though this study generated more qualitative than quantitative data. We integrated the data using the weaving approach, where qualitative and quantitative data are presented in a theme-by-theme basis (Fetters et al., 2013). We also used a joint display to present youth and adult qualitative data organized by CFIR theme to provide a richer understanding of the barriers and facilitators to implementation of HEART within the child welfare system (Fetters et al., 2013).

Results

Descriptives

All adult participants were female, the majority were white (64%), and held a range of roles within the child welfare system (Table 1). The average age of youth participants was 19.4 (range of 15–24) and the average age of adult participants was 40 (range of 29–53; Table1). The youth sample was racially and ethnically diverse (2.8% Asian; 33.3% Black; 15.3% Hispanic; 2.8% Native Hawaiian; 12.5% Multiracial; 33.3% White) and most youth identified as a girl/woman (76.4%; Table 1). Qualitative data from youth and adults illustrating each theme are organized by CFIR domain and constructs in Table 2. Our qualitative analysis, employing detailed matrices to systematically compare the data from caregivers and child welfare professionals, revealed no significant differences in the barriers and facilitators identified by both groups. Notably, similar themes emerged across all CFIR constructs, indicating that both caregivers and professionals anticipated comparable supports and challenges with implementing HEART. In contrast, some differences emerged between youth and adults and are discussed below theme-by-theme within each CFIR domain.

Table 1.

Participant Demographics

Demographic Characteristic	Adult (n = 14)	Youth (n = 72)
	n (%)	n (%)
Age - M (SD)	40 (9.3)	19.4 (2.2)
Race
Asian	1 (7.1%)	2 (2.8%)
Black	2 (14.3%)	24 (33.3%
Hispanic/Latine	2 (14.3%)	11 (15.3%)
Native Hawaiian or Other Pacific Islander	--	2 (2.8%)
Multiracial	--	9 (12.5%)
White	9 (64.3%)	24 (33.3%)
Gender Identity*
Girl/Woman	14 (100%)	55 (76.4%)
Boy/Man	--	11 (15.3%)
Transgender	--	2 (2.8%)
Gender Non-conforming	--	4 (5.6%)
Gender Queer	--	1 (1.4%)
Non-Binary	--	1 (1.4%)
Other: (Gender-fluid)	--	1 (1.4%)
Role
Foster Caregiver	6 (42.9%)	--
Child Welfare Professional	5 (35.7%)	--
Dual Rolea	3 (21.4%)	--
Average Time in Role - M (range)	8 years (2–21)	--
Sexual Orientation
Heterosexual	--	50 (69.4%)
Gay	--	3 (4.2%)
Lesbian	--	2 (2.8%)
Bisexual	--	12 (16.7%)
Queer	--	1 (1.4%)
Unsure/Questioning	--	2 (2.8%)
Pansexual	--	2 (2.8%)
Importance of religion - M (SD) b	--	2.9 (1.4)
Ever had a partner	--	56 (77.8%)
Currently in a relationship	--	35 (48.6%)
Current Placement
Foster Home	--	18 (25.0%)
Group Home	--	8 (11.1%)
Kinship Home	--	5 (6.9%)
Adoptive Home	--	1 (1.4%)
Independent Living Program	--	6 (8.3%)
On My Own	--	31 (43.1%)
Otherc	--	3 (4.2%)
Ever Lived in Placement*
Foster Home	--	60 (83.3%)
Group Home	--	33 (45.8%)
Kinship Home	--	5 (6.9%)
Adoptive Home	--	9 (12.5%)
Independent Living Program	--	19 (26.4%)
On My Own	--	26 (36.1%)
Otherd	--	6 (8.3%)

Note.

^*Denotes that participants could select multiple response options.

^aDual role means that a participant is both a foster caregiver and works for a nonprofit serving youth in OOHC

^bMeasured with 1 question, ‘How important is religion to you?’ with response options from 1 (not important) to 5 (extremely important).

^cOther locations listed include: hotel, boyfriend’s mom’s house, and back home with biological parent.

^dOther locations listed include: homeless, long-term therapeutic setting, shelter, and a residential treatment facility

Table 2.

Adult and Youth Representative Quotations by each CFIR Domain

CFIR Construct	Theme	Representative Quotations
Innovation Domain
Innovation Relative Advantage	Primarily Facilitator: HEART is better than other sexual health education youth are receiving	“I feel like I’ve gotten in some really… in conversations with her about other girls that are in the home with her and their perspectives, and what information that they’re getting. So a lot of it. I think it’s coming from each other like, especially in these group home situations. So I don’t know that it’s, it’s always the best, or close to up-to-date.” – Foster Caregiver “I believe it’d be very beneficial. It’s...first of all, it sounds like it’d be quick. It’s not anything that’s kind of bogged down and um, it um is approachable to their, you know, to where they are, and I believe it would be...it would be very beneficial.” – Child Welfare Professional
Inner Setting Domain
Culture	Barrier: Conservative or Religious Culture	“I don’t think I’m the typical foster family. But I, from what I’ve seen, is there is a lot of a lot of like church communities that, I don’t want to say push their members towards fostering, but like kind of encourage it, like that sense of community. And in my experience churches don’t necessarily want to talk about all things related to sexual education, or having sex before marriage” -- Foster Caregiver “You’re gonna get push back from people regardless. Again, this is the Bible Belt. People think you know, ’John shouldn’t know anything about sex.’ And so, you know, being so, making sure that some of the information that you have is data driven.” -- Dual Role “In my own experience, it’s been similar to my first reason/example of conservative/traditionalists shaming you around those ‘taboo’ topics. So many churches and especially Christians I think shame so much around anything sex related and make someone’s value based upon their ‘sexual purity’ rather than just who that person is. Honestly, even just having a basic correct and scientific understanding and names of bodily parts and using those terms in a mature way in conversation in an attempt to create more safety and understanding in a conversation has gotten me and others I know weird.” --Youth “Feeling judged, feeling as if they shouldn’t be having sex because of the way parents portray it as wrong before marriage.” -- Youth
Compatibility	Barrier: There are not clear processes & systems that HEART could be integrated into	“Oh, yeah, but I don’t know what process…like it would like lump in with [laughter in voice]…because, I mean like, we talk about it [sexual health], but you know and we do some things around it. But like I don’t think it would interfere?” – Child Welfare Professional “Yeah, I think that’s just…it seems like a lot of things fall through the cracks. Yeah, in the in the system that even if it gets out there, you know it just takes one person to drop the ball…” -- Dual Role “I can’t think of any practices right now in the child welfare system like at all, and we’re even, I mean, like we’re therapeutic foster parents…so like we received extra training on like how to deal with trauma responses, and there is literally nothing… And so it is scary to think about having a conversation about sex or relationships with a child, that they may go repeat to a biological family member who then gets mad at you for how you handled it differently than they would and it. It makes you really hesitant to have those conversations with a child in care.” – Dual Role
Relative Priority	Mixed: Some believed HEART would be a high priority, low priority or dependent on the youth.	High Priority: “It is definitely important, because if it wasn’t, it wouldn’t be mentioned….it it ranks really high up there. Again, when you think of some of these relationships they get involved in with others… can make any difference on how they view themselves, and how they do their relationship and to maybe be able to make those relationships healthier…it’s a benefit.” – Child Welfare Professional “I think of more like this relationship-type stuff as like it’s stuff that weaves through all those other things. And so if that can be addressed fundamentally then perhaps there could be success in these other areas.” – Foster Caregiver Low Priority: “I think that it would fall down, if I am being honest. Just because it…we do look at a lot of like, you know, we want to get their mental health and their physical health and make sure they’re getting those. If they’re not talking to a therapist about what they’ve been through and what they’ve gone through, and how to like have those coping skills. A class like this is going to go in one ear and out the other because they’re going to be like, nobody really cares. So it’s one of those things where I think it would fall down on the list a little, just because you do have things that you want to prioritize, and you know make sure that they’re getting first and foremost, and then this would be considered like a I mean lack of better words, like an extracurricular.” – Child Welfare Professional
Incentive Systems	Facilitator: Offering financial incentives would make youth more likely to take HEART.	“Well, youth seem to be money motivated a lot of times like they they’ve, they’ve already been taught by the system that you get paid for completing things. So if there is a financial incentive, I think that it might be a motivator.” -- Foster Caregiver “Yeah, you know *laughs* like everybody loves money. I’m pretty sure any teen anywhere would always be open to food.” – Child Welfare Professional “Kids love rewards. So if you rewarded them somehow, that would never be wrong, but I also think that for parents, if you can provide training hours for, provide a certificate at the end of it we have to get I think it’s 24 training hours a year for at least for therapeutic foster care... So if you can sell it to an agency as here’s a 2 hour training for your parents. They get training hours for it. They’ll likely buy in and so that they can provide that for their families.” – Dual Role “Incentives such as money, candy, privileges.” -- Youth.
Available Resources	Facilitator: Youth have the resources needed to complete HEART	“I mean, kids these days have like phones and wi-fi, like even foster kids most of the time, like they work pretty hard either the foster parents or DSS work to get them Wi-fi and phones or tablets or computers.” -- Foster Caregiver “Yeah, because most of the foster parents will allow them to do like virtual therapy and stuff like that. So our foster parents are aware that, you know, since Covid, everything’s pretty much gone virtual. And so, whether they allow electronics in their home or not, they are still able to set them up with, like, maybe a home computer or something like that for them to participate in things like that?” – Child Welfare Professional “One hundred percent has access to internet and phone. The foster parents have to have access for them, and, like everyone in my home, has their own computer, their own tablet and their own phone so they can get on it in the room by themselves, because they also have their own bedrooms.” – Foster Caregiver
Individuals Domain
Innovation Recipients	Barrier: Youth pushback to authority	“I mean, the only thing I can think of is like some teens may not think that they need it. You know, I think it’s typical teen they’re like: ‘I know everything you don’t…you don’t need to tell me something I already know.’ But I mean, that’s a typical teen behavior, right?”-- Foster Caregiver “Ultimately, then the kid, you know, sort of trying to win over the kids, haha, which it is hard, because anytime that they are told to do something, then, you know, there’s automatic push back kind of no matter what it is. You know, sort of framing it for the youth, you know that, and helping them understand like what they can get out of it.”—Foster Caregiver “They may not want to because so many people have already told us and we feel like you would just tell us the same thing again.”—Youth “Its adults telling teenagers what to do doesn’t go well.” – Youth
	Barrier: Talking about sex is embarrassing	“As someone who comes from a very small town purely full of old white cis straight traditional conservative men, there is a lot of weird shame and stuff around anything related to sex, sexual health, sexual exploration, and even just healthy relationships. So a lot of people, especially youth, might have a lot of fear/insecurity/embarrassment around these topics even if they disagree with that type of opinion or voice in their life.” -- Youth “It can be embarrassing - many are taught sex is embarrassing to talk about” – Youth “Embarrassment. They could be afraid to speak to their parents or others about this because of how society has viewed/treated sex historically.”—Youth
	Barrier: Experiences of trauma among youth	“You know, a good portion, it could be triggering and just based on this, each child’s specific trauma history. And so that would be one reason, sort of like, I think, having an opportunity to like debrief and discuss and like would be important. But I think for sure, it fits the need.” – Foster Caregiver “A main reason may be because of past trauma.” – Youth “Some youth in foster care are traumatized from the sexual concepts that may be talked about therefore they shy away from learning these things.” --Youth
Implementation Process
Assessing Needs	Facilitator: Creating an adult companion program	“The, the other thing that I think you should have, is a piece where foster parents get, have a separate video that they watch because you have…especially again, this is the Bible Belt..’I don’t want them to know about sex!’ and you’re like, ‘Awww, you’re stupid, really? They already do know.’ So this is actually giving them the real information instead of the information from their friends, you know. And so kind of along those lines like, ‘hey, foster parent, this is actually helping kids to make better decisions about relationships. This is helping them to make better decisions about abstinence,’ you know, stuff like that.” – Dual Role “Maybe the same exact content that you’re covering, they [foster caregivers] watch? But then, also here’s how to talk to your youth about what they did in their activity, and just guiding them on, not necessarily the same activity, but how to process that activity with your kid.” – Dual Role
	Facilitator: Youth would find HEART helpful	“I think it [HEART] would be helpful just because they because they um... they’re in out of home care. Their picture of healthy relationships may be distorted just from either what they’ve been through and or what they’ve seen, and things like that, so just reiterating what a healthy and positive relationship looks like. Because some of these kids just don’t have that.” – Child Welfare Professional
Planning/Process	Facilitator: Multipronged approach to offering HEART through multiple avenues.	Department of Social Services: “So, I would think, putting it on a website like fostering [state name], or even the [state name] DHHS website, because I often utilize those resources to send out to my foster parents, so that would be something we could send and say, hey, have your kiddo do this” – Child Welfare Professional “I think the beauty of a LINKS coordinator* is that you kind of make it whatever you want. I do see that if it is following the very generic definition of what a LINKS coordinator is, and I do think that this program would be best to be given, and you know, filtered through the LINKS coordinator, just because their main role and purpose is to really facilitate, you know, building independent living skills, and allow them to allow our youth to, you know, transition smoothly into adulthood.”– Child Welfare Professional Private Agencies: “DSS is hard to break into sometimes so private agencies at least give you a starting place, and then word of mouth spreads from there.” – Dual Role “I know the Foster Care Agency that I was at before the DSS. And the private agency I’m with now we do a foster parent newsletter. So if you could get that out to the different agencies, and I think the DSS website has, like a list of all the agencies in the State. If you could like, get it to them, you know they could, they could put it in their newsletter. It’s something I would definitely advocate for my agency. So get it to them. They could put it in their newsletter.” – Child Welfare Professional “And make it a requirement for our foster parents, which is something that I would like to see done in the private agency that I work with our teens, you know, connecting with their legal guardians. It’s like this is something we would like have our kids do if they’re in our care.” – Child Welfare Professional Schools: “So I mean I could see it being, I think schools will be the best place, because it’s where you get the most kids at once. And also it’s more like uniform and blanketed, like they just sent home the form that says: “Hey, we have the program. Please sign it.” Whereas if you went through…you could give it to foster agencies. But then you are still having to like still…get every single like DSS worker to essentially be like, “yeah, this is, this is okay to show.” And like having to vet it that way, whereas if it goes through a school pretty much if it comes from the school, there’s not a question.”– Dual Role “Through school because mostly everyone goes to school.” – Youth Peer-led: “Peer-led, make it interactive and engaging.” – Youth “It would be easier if other teens encouraged each other to do the program.” -- Youth Social Media: “Advertising and offering it as much as possible is always helpful. I think social media (at least for me) would probably be the biggest way just because most youth use social media at least to some extent, and not all youth have accessible/realistic access to things like social workers (or at least very often), clinics, etc. and not a large percentage of youth usually are willing to talk that openly with any staff at school (again esp. if its high school).” -- Youth “Definitely advertise the program on social medias. That’s the fastest easiest way to reach an adolescent audience.” -- Youth

Note.

^*The LINKS program is specific to the state this study was conducted. It is a program that provides additional services and support to current and former youth in foster care aged 13–21.

Innovation CFIR Domain

Innovation Relative Advantage (Facilitator).

All adult participants stated that HEART would be better than other current, sexual health education sources as they are not evidence-based and included sources such as: TikTok, social media, school, peers, internet, TV, porn, or “nowhere.” An adult holding a dual role explained: “What they’re, what they’re getting is from Tik Tok. So when you’re, the key word in your sentence was healthy, and so, so it, that’s not healthy.” Further, a few participants highlighted some strengths of HEART; it is relatively brief and delivered online so youth can watch it on their own time. One caregiver, however, felt that the online format of HEART was a disadvantage as youth are “tired” of engaging in videos.

Innovation Design (Facilitator).

Youth selected survey responses on their preferred structure of HEART. The two most popular formats for offering HEART identified by youth were the full, 45-minute program in one session or as an interactive menu where youth could pick and choose what topics they would like to engage with (Table 3).

Table 3.

Youth Feedback on Inner Setting and Implementation Process Barriers and Facilitators

Variable	n (%)
Perceived helpfulness of HEART
Very or extremely helpful	45 (62.5%)
A little helpful or not at all	27 (37.5%)
What format to offer HEART*
Full, 45-minute program	31 (43.1%)
20-minute chunks	21 (29.2%
10-minute chunks	15 (20.8%)
5-minute chunks	5 (6.9%)
Interactive menu	30 (41.7%)
How to offer HEART*
Social Workers	60 (83.3%)
Schools	43 (59.7%)
Social Media	41 (56.9%)
Doctor’s Offices	38 (52.8%)
Health Departments	35 (48.6%)
Caregivers/Parents	29 (40.3%)
Pay youth to take HEART	71 (98.6%)
Device used for survey
Personal iPhone	54 (75.0%)
Personal Computer/Tablet	14 (19.4%)
Caregiver Computer/Tablet	3 (4.2%)
Caregiver iPhone	1 (1.4%)
Location survey competed
Home	53 (73.6%)
School	15 (20.8%)
Elsewhere	4 (5.6%)

Note.

^*Denotes that participants could select multiple choices

Inner Setting CFIR Domain

Culture (Barrier).

Conservative/Religion: Most caregivers stated that they were not the “typical” foster family, and they suspected that a program focused on sex and relationships would clash with foster families holding more traditional religious or conservative beliefs, especially in rural counties. Both adults and youth qualitatively commented that discussing sex and relationships is a “sensitive topic” or “taboo topic” that many adults and youth do not want to discuss. A child welfare professional explained this: “I feel like with certain counties, especially those that are even more rural than my county, and even more conservative. I’m curious as to if that this topic, it being such a I don’t want to say taboo, but a very sensitive topic that could make certain, you know, people feel some types of ways about this topic being explored with our youth.”

Compatibility (Barrier).

When asked about how HEART could be integrated into current processes and systems, most adults expressed that there were not systems related to offering youth sexual health education. A professional commented that many topics such as sexual health often “fall through the cracks.” A caregiver also described how talking to youth in her care about sex is “scary” because foster caregivers do not receive any training on how to have conversations about sex and relationships.

Relative Priority (Mixed).

Most adults felt that offering HEART to youth would be a top priority for providers and caregivers. However, there was some nuance to these views. A few adults felt that HEART would be a lower priority topic behind mental and physical health or believed it would depend on the needs of the teen as to whether it was a priority. A professional explained the nuance in need for HEART: “I think you know it, it would depend on that specific child; whereas like for this young lady, it would be extremely high, but for a for another consumer that’s never been sexually active, and goes to a school in a high violence crime area like it, it might fall, fall down.” Most caregivers and providers saw HEART as a high priority as these skills are interconnected and fundamental to other pressing priorities (e.g., mental health). As one participant explained:

I think that any tool that helps prevent the cycle of foster care should be considered high priority, and we know that youth in care are at a higher rate of being pregnant before they’re 18, or being involved in sexual abuse type relationships, and unhealthy and unstable because they come from a cycle of it. And so the information, if it’s comprehensive, helps break those cycles. Foster parents are tired. We’re breaking trauma cycles in our kids, and we’re really trying to heal them… I think if sold as a cycle breaker or something that can at least help is what will, will really make it a priority for all families.

Incentive Systems (Facilitator).

Most adult and youth participants thought that offering incentives to youth to complete the HEART program would be needed to motivate youth to complete HEART. Participants suggested incentives such as: gift cards, food, allowing youth to stay up a few extra hours, candy, and including a pre and post program survey. Almost all youth (98.6%) indicated in the survey that youth should be paid to take the HEART program (Table 3). A few adults also suggested incentives for caregivers, such as giving foster caregivers training hours if they learned about sexual health and/or offered HEART to youth in their care.

Available Resources (Facilitator).

Most adults stated that youth have access to the necessary resources to use HEART, including Wi-Fi and an electronic device. In line with these findings, most youth took this survey on a personal device such as an iPhone (75.0%) or a computer/tablet/iPad (19.4%). Approximately three-quarters of youth took this survey at home (73.6%; Table 3).

Individuals CFIR Domain

Innovation Recipients (Barrier).

Both adults and youth discussed the potential for a lack of youth interest to participate in HEART. One frequently suggested reason for this was an “automatic push back” from youth. A professional captured this sentiment when she said: “So they might have that mentality of like. ‘Why do I need to watch this 45 min program? When I’m grown, and I know about my sex life like, who are you to tell me about my body?’ And especially again coming from DSS. It’s like this is another area that y’all are telling me like I just trying to educate me on, and even more so it’s about my body.” Many youth and adults also qualitatively described traumatic experiences as a potential reason for lack of youth interest in HEART. A professional described this theme: “I think due to their trauma this might be a topic that is very, depending on the abuse that they received, could be a topic that is very scary to talk about…of course, there’s nothing due to the program, but I do see it kind of be like. ‘Oh, I don’t want to. I don’t want to watch this. I don’t want to talk about this kind of thing’ and so I feel like the individual just trauma behind might be a huge barrier.” Qualitatively, about half of youth also mentioned the “embarrassing” nature of discussing sexual health as a key barrier, a concern not expressed by adults.

Implementation Process CFIR Domain

Assessing Needs (Facilitator).

Innovation Deliverers. A few adults spontaneously suggested developing a companion education program for child welfare professionals and caregivers to teach adults the necessary skills to engage in supportive conversations with youth about sexual health after they have taken HEART. Innovation Recipients. All adults expressed a critical need for a program such as HEART as youth in OOHC are experiencing unhealthy relationships and adverse sexual health outcomes. A professional described the unhealthy relationships of a youth in her care:

She was a victim of sexual assault, so anyone who told her she was pretty or offered, you know, gave her any kind of compliment, she kinda offered herself to them. She would sneak out of the house to go meet multiple different people…I’m like, you know, if she could just set those boundaries and know what a healthy relationship ought to look like that could have been extremely different for her.

In contrast, most youth reported in the survey that they are already receiving sexual health education. Youth are most commonly receiving sexual health education from schools compared to other sources (Table 4). Approximately half of youth (47.2%) are receiving sexual health education about abstinence, consent, safe sex, healthy relationships, and pleasure from at least one of the sources. More than three-quarters of youth (76.4%) indicated that they knew where to access sexual health services if needed. Additionally, less than half (41.7%) of youth stated that they currently wanted more information about sexual health. Overall, 62.5% of youth felt that the HEART program would be very or extremely helpful to them (Table 3).

Table 4.

Youth Who Report Receipt of Sexual Health Education from School, Biological Parents, Caregivers, and Social Workers

Sexual health Topic	School	Biological Parent	Caregiver	Social Worker
	n (%)	n (%)	n (%)	n (%)
Abstinence	36 (50.0%)	32 (44.4%)	29 (40.3%)	23 (31.9%)
Consent	52 (72.2%)	32 (44.4%)	41 (56.9%)	31 (43.1%)
Safe sex	64 (88.9%)	40 (55.6%)	49 (68.1%)	36 (50.0%)
Healthy relationships	46 (63.9%)	30 (41.7%)	45 (62.5%)	42 (58.3%)
Pleasure	31 (43.1%)	19 (26.4%)	24 (33.3%)	21 (29.2%)

Planning/Process (Facilitator).

Adults had numerous ideas on how to implement HEART and recommended that a multi-pronged approach may be the most effective process. HEART could be offered through the Department of Health and Human Services and private agencies. A few adults also suggested incorporating HEART into an existing foster care independence program consisting of monthly meetings led by a social worker for youth in foster care aged 13–21. In addition, one adult participant suggested offering HEART in alternative schools -- schools across the U.S. that serve at risk youth, including high percentages of youth OOHC. The primary way youth selected in the survey to offer HEART was through their social workers (83.3%). In line with adult feedback on employing a multi-pronged approach, youth also frequently selected the other possible avenues for offering HEART including schools (59.7%), social media (56.9%), and doctor’s offices (52.8%). Qualitatively, most youth mentioned that this program should be peer-led or offered through social media avenues.

Discussion

This mixed methods study identified barriers and facilitators to the implementation of HEART within the child welfare system in the US across four domains and multiple constructs of the CFIR (Figure 3). The barriers identified in this study, such as religious/conservative culture, lack of systems for sexual health education, and the sensitive nature of the topic, are also common barriers to sexual health education among general populations of youth (Pediatrics, 2024). Participants identified several facilitators and outlined a multi-pronged approach to implementation to reach youth in OOHC with HEART.

Figure 3.

Key Barriers and Facilitators to Implementing HEART Within the Child Welfare System

HEART could fill a gap in sexual health education for youth in OOHC. This research echoes literature documenting the insufficient access to, yet desperately needed, sexual health education for youth in OOHC (Brasileiro et al., 2023; Dworsky, 2018). Youth in OOHC are not only navigating the developmental changes of adolescence related to sex and relationships but dealing with removal from their families and childhood traumas putting them at heightened risk for poor sexual health outcomes (Brandon-Friedman et al., 2020; Finigan-Carr et al., 2018). HEART may be a promising EBI for this vulnerable group of youth – as both this study and past research demonstrates that it is feasible to deliver, highly accessible, and effective at improving sexual health knowledge and behaviors among youth (McCrimmon et al., 2023; Widman et al., 2017; Widman et al., 2016; Laura Widman et al., 2020). The brief, online format of HEART was overall touted by most adults as a strength of the program as the resources (i.e., technology and WIFI) needed to use the program are readily accessible to youth. For example, smartphone use among teens in the US is ubiquitous - 95% of teens have access to a smartphone and 92% report that they are online daily (Anderson, 2023). Further, there is strong evidence that digital platforms are an effective and savvy platform for reaching youth with sexual health education (Guse et al., 2012; Maloney et al., 2020).

A prominent barrier identified by both youth and adults at the inner setting domain is that adults may not want youth to engage with HEART, as learning about sexual health conflicts with their religious beliefs. Faith-based organizations, particularly those affiliated with Catholic and Protestant traditions, play an important role within the child welfare system but can also hinder the provision of sexual health services for youth (Hodge et al., 2022; Katz, 2024). For instance, some of these faith-based organizations prohibit staff from discussing certain issues, like contraception, with youth in OOHC believing that doing so conveys the “wrong message”(Dworsky, 2018). One study found that foster caregivers perceive that talking about sexual health is against policy of their supervising child welfare agency, fearing potential accusations of abuse if they engage in such conversations (Albertson et al., 2020). Relatedly, foster families holding conservative religious beliefs are often more hesitant to discuss sexual health topics with youth in OOHC or allow access to sex education (Constantine & Constantine, 2009; Harmon-Darrow et al., 2020). More broadly, these findings align with research among parents in the general population that consistently demonstrates that families with more conservative and religious beliefs are generally less supportive of their teens receiving sexual health education (Bleakley et al., 2010). Therefore, developing implementation strategies that respectfully attend to the conservative or religious beliefs of adults will be critical for the successful integration of HEART within the child welfare system. Several programs exist for foster caregivers and professionals within the system, equipping them with the knowledge and skills necessary to support the sexual health of youth (Ahrens et al., 2021; Ball et al., 2023). These programs aim to enhance adults’ understanding of sexual health by providing facts about high pregnancy rates, STI’s, and intimate partner violence among youth in OOHC, along with evidence that sexual health education can help prevent these adverse outcomes (Ball, 2023; Goldfarb & Lieberman, 2021). Additionally, they encourage caregivers to reflect on their own values regarding sexuality and relationships, ultimately fostering their ability to communicate effectively with youth on these important topics (Ahrens et al., 2021; Combs & Taussig, 2021). By fostering an environment that respects adult beliefs while equipping them with essential knowledge and communication skills, these strategies could enhance the overall effectiveness of sexual health education for youth in OOHC.

At the individuals domain, low interest among youth to participate in a 45-minute sexual health education program - whether recommended or required by adults - emerged as a barrier. This may be indicative of a typical teen, where teens test their boundaries and desire independence (Pickhardt, 2013), or due to service burnout at the number of services youth are required to complete. Additionally, one adult participant also stated that the online format may be a downside of HEART as youth are “tired” of engaging in videos – another potential explanation for the low enthusiasm among youth. Furthermore, nearly all youth indicated that they would want to be compensated for their participation in this program. This raises critical questions about the sustainability of an online sexual health program, like HEART. Namely, how can we sustainably deliver online health interventions to youth, and who will pay for these incentives? These questions are part of a larger conversation surrounding the delivery of digital interventions in the US that may require innovative approaches to funding and program delivery (Li et al., 2024).

Youth and adults cautioned that just by nature of HEART focusing on the topic of sexual health, it may be challenging for youth to engage with since many youth in OOHC have experienced sexual trauma (Serrano et al., 2018). Ensuring that youth do not experience harm from engaging in this program and have access to supportive resources will be critical to address during the implementation of HEART. In line with best practices for trauma-informed sexual health education, creating a companion program for caregivers and professionals to equip adults with skills to effectively engage with youth after they complete the HEART program is an important future direction (Fava & Bay-Cheng, 2013).

A multi-pronged approach to delivering HEART was described by adult and youth participants. This suggested approach makes sense given that there is no federal policy and limited state policy mandating that youth in OOHC receive sexual health education. Most states lack clear policies that 1) require caregivers and foster care staff to be trained on how to talk to youth about sexual health and 2) require that youth within the child welfare system are provided with medically accurate information about sexual health (Dworsky, 2018; Shaw et al., 2010). This lack of formal policy means that often no one takes responsibility for educating youth in OOHC about sexual health (Dworsky, 2018). Thus, offering HEART through many avenues including social workers, foster caregivers, alternative school settings, and social media may be needed to comprehensively reach youth in OOHC.

Youth also highlighted that peer-led approaches along with using social media would be effective implementation methods. Studies have echoed these findings, revealing that youth prefer learning about sexual health from peers with relatable, lived experiences rather than authority figures (Ball et al., 2023; Opara et al., 2022). Indeed, peer-led approaches to offering technology-based sexuality education can be empowering and effective (Hightow-Weidman et al., 2021; Maticka-Tyndale & Barnett, 2010). For instance, a recent novel study in Scotland used peer-led use initiatives through social media and in-person discussions to promote shifts in sexual and reproductive health norms across six school systems (Mitchell et al., 2020). This peer-led approach was not only feasible and effective, but also enabled young people to actively engage in and influence their learning about quality sexual and reproductive health. Such peer-led strategies could be beneficial to youth in OOHC, as some youth in this study expressed resistance to the various resources imposed on them by adults and the system. In contrast, these peer-led and social media approaches were infrequently acknowledged by adults, possibly due to concerns highlighted in other research regarding the necessity for adult oversight in the sexual health education content provided to youth (Hirvonen et al., 2021; Martin et al., 2020). Peer-led approaches may be one of many effective approaches for reaching youth in OOHC with HEART. These findings to reach youth via many avenues echo recommendations from a recently published framework for designing sexual health interventions for youth in OOHC that emphasized that youth need multiple access points to this education (Ball et al., 2023). HEART is a free and highly accessible sexual health intervention that could be integrated into current practices and offered multiple ways.

Limitations

This study has several limitations. First, many adult participants stated that they were not the “traditional foster caregiver,” and therefore more open to discussing topics related to sexual health compared to most foster caregivers. This self-disclosure arose in response to interview questions about the challenges of implementing HEART and the values and beliefs of their organizations. This indicates that the sample may be biased toward caregivers who are supportive of offering sexual health education to youth. Selection bias can pose significant challenges when certain demographic groups are overrepresented in samples, particularly on studies focused on sensitive topics such as sexual health, thereby affecting the validity of the results (Cheung et al., 2015; Crooks, 2024). Second, we collected data from adult participants in only one state. The homogenous nature of the sample in terms of demographics and perspectives could explain why data saturation was achieved with a relatively small sample. This is a limitation of this study in terms of generalizability of findings (Korstjens & Moser, 2018). Future studies should determine strategies for engaging a more diverse group of caregivers and child welfare professionals. Third, adult and youth participants did not complete the full, 45-minute HEART program before answering interview and survey questions. Rather, they were given a brief overview of the program and then watched a few videos or viewed pictures from the program to get a sense of the style and content. It is possible participants did not understand all elements of the program prior to commenting on barriers and facilitators to implementation.

Conclusion

This study explored adult and youth perceptions of barriers and facilitators towards the implementation of HEART within the child welfare system. This study underscores the challenges in providing sexual health education to youth in OOHC. Yet, an online program, like HEART, may be a promising solution for youth in critical need of sexual health education. Study findings lay the groundwork for a hybrid type 2 trial to test the effectiveness of HEART among youth in OOHC as well as implementation strategies to overcome identified challenges (Landes et al., 2019).

Data Availability Statement:

Data will be made available upon request of the first author, Julia Brasileiro.