A Scoping Review of Digital Health Interventions to Promote Healthy Romantic Relationships in Adolescents

Abstract

Despite a robust field of study in healthy romantic relationship education and risk prevention interventions that employ traditional forms of delivery, the field of digital health interventions (DHIs) in healthy relationship programming for adolescents remains undefined. The purpose of this scoping review was to summarize the scope of published research in DHIs that promote healthy romantic relationships in adolescents. We conducted database searches, 2000–2022; hand searches; reference list and literature review searches, and emailed study authors to identify articles. Included were experimental, development, and feasibility studies. We summarized features of selected studies and their healthy relationship aims/components and identified patterns of emphasis and areas of future need. Sixteen publications describing 15 unique DHIs were reviewed with interventions developed and or trialed in 11 countries. We identified 10 web-based or downloadable applications, four serious game applications, one video-voice program, and one social media-based program. DHIs focused on improving knowledge/attitudes/skills of healthy adolescent romantic relationships directly or through prevention-focused programs. Interventions that measured outcomes found small effects, primarily in healthy romantic relationship communication skills. DHIs offer unique opportunities to provide user-responsive and culturally-specified programming to adolescents and involve them in processes of program design, development, and evaluation. Further research is warranted to define healthy relationship outcomes and validated measures to evaluate them. Future research might seek to address the social ecology of adolescent romantic relationships beyond the individual and interpersonal and explore combinations of virtual and explore adult-moderated in-person delivery to ensure youth are adequately supported.

Peer relationships assume critical importance during adolescence, when the management of identity through interaction with peers is a primary developmental task with implications for sexual and reproductive health and overall quality of life. The American Academy of Pediatrics (Breuner et al., 2016) and the American College of Obstetricians and Gynecologists (2018) have issued guidelines recommending that health care providers guide teens to cultivate healthy relationships and avoid potentially harmful ones. Healthy relationships in youth have been an emphasis for the Centers for Disease Control and Prevention (CDC, 2006), and they occupy a central place in policy. In the United States, support for healthy relationships as a cornerstone of healthy marriages was formalized in the Deficit Reduction Act of 2005, which made $150 million per year available to fund research to promote healthy marriage and fatherhood, including support for youth healthy relationships programming (Fincham & Beach, 2010). In the United Kingdom (UK) similar trends have led to mandatory healthy relationship education for adolescents in secondary schools. Increasing acknowledgment of the role adolescence plays in forming expectations, values, and behaviors that shape relationships throughout life has meant increased interest in finding ways to intervene with adolescents.

Experts argue that healthy romantic relationships in adolescence provide important opportunities for youth to develop emotional autonomy from family and an independent self-concept, including sexual identity (Kansky & Allen, 2018). Romantic relationships provide a forum in which to develop skills in self-regulation, self-expression, and healthy reciprocity that contribute to mental health in adolescence and later wellbeing in adult romantic relationships (Davila et al., 2017; Kansky & Allen, 2018;). Timing can be important. Research grounded in stage-based models of adolescent romantic development describes links between early-adolescent romantic relationships and aggression, alcohol use, early sexual debut, and risky sexual behaviors as well as increased depressive symptoms and reduced emotional wellbeing (Connolly et al., 2013, 2014; Davila et al., 2017). Most experts agree that adolescents need to learn how to identify and build healthy relationships. That process can involve practicing self-management and communication skills and debunking unhealthy romantic relationship myths, norms, and ideals that may be reinforced by peers, family, and the larger culture. Some adolescents are exposed to models of healthy intimacy at home, but many are not. Even when adolescents have good examples, they exist in a complex social ecology where competing, unhealthy versions of intimacy may be just as influential.

Despite the importance of romantic relationships in the lives of adolescents and the impact on future health, most research to address this important element of adolescent development has been conducted in the classroom or community using traditional face-to-face or didactic delivery methods. In this scoping review, we sought to describe the work has been done in the development and trialing of digital health interventions (DHIs) to address health romantic relationships in adolescents.

Defining Healthy Romantic Relationships in Adolescents

Complicating any project to identify and assess healthy relationship programming for adolescents is the lack of standard definition of healthy romantic relationships, though most recent work includes a cluster of common elements. Benham-Clarke et al. (2022), for example, cite the U.K. Department for Education (2019) definition of healthy “one-to-one intimate” relationships in adolescents as involving “mutual respect, consent, loyalty, trust, shared interests and outlook, sex and friendship” (p. 29). Hielscher et al.’s (2021) systematic review of interventions to foster healthy romantic relationships in youth draws on behavioral systems approach (BSA) theory (Furman & Wehner, 1997), the Duluth Healthy Relationship Wheel (Pence & Paymar, 1993), and factors of adolescent relationship abuse (ARA) (Dick et al., 2014) to propose that healthy adolescent romantic relationships are defined by communication and negotiation skills, caregiving behaviors, self-expression, respect, trust, and honesty—all in the absence of verbal, emotional, psychological, and sexual abuse. Reviews by Janssens et al. (2020) and McElwain (2017) and guidance from the CDC (2006) offer largely congruent definitions, with communication, nonviolence, autonomy, reciprocal care, and trust as central elements.

Promotion and Prevention in Research on Healthy Romantic Relationships

Programs to guide adolescents in recognizing and forming healthy romantic relationships can be found in several areas of interventional research. In prevention science, such work has been defined by two broad approaches: the promotion-oriented, such as positive youth development and youth relationship education programs, and the prevention-oriented, which often centers on mitigating risk of harmful outcomes, like dating violence or unplanned teen pregnancy. The promotion-prevention dichotomy is a helpful way to distinguish between two emphases (Catalano et al, 2002), but in practice there is much that is overlapping or complementary in the categories (Bonell et al., 2015; Guerra & Bradshaw 2008). Interventions that address healthy romantic relationships in adolescents are broadly-focused healthy relationship education and comprehensive sex education programs—where one might expect to see a promotion focus—as well as more narrowly defined prevention programs seeking to reduce risk of dating violence, sexually transmitted infections (STIs), unplanned pregnancy, substance use, or some combination of these.

Theory Use in Research on Healthy Romantic Relationships in Adolescence

Both promotion programs centered on healthy relationships in adolescence and prevention-oriented programs that integrate healthy-relationship-promoting features embody a broader trend in sexual health toward holistic and strengths-based perspectives (Ivankovich et al., 2013). These embrace the salutary and risky sexuality and acknowledge the multilayered, socioecological influences on sexual health (Mitchell et al., 2021). In tandem with these socioecological assumptions, social cognitive, social learning, self-regulation, and social control theories help explain the relational character of adolescent self-awareness, learning, risk-taking, and decision-making processes in romantic relationships (Meier & Allen, 2009). Also common are behavior change-focused theories such as the theory of planned behavior and theory of reasoned action (TPB/TRA), transtheoretical stages of change model, integrated change (I-Change) model, and information motivation behavioral (IMB) skills model (Meier & Allen, 2009). Romantic relationships and sexual behaviors in adolescence are also commonly addressed through forms of developmental theory, including dual process theory (Anderson et al., 2021) and attachment theory (Cassidy et al., 2013), behavioral systems (i.e., four-systems theory), and stages of relationship theory (Meier & Allen, 2009). All provide ways to explain how, why, when, and at what risk adolescents form romantic attachments.

Effectiveness of Interventions to Address Healthy Romantic Relationships for Adolescents

Healthy relationship education promotion interventions and risk prevention interventions that include healthy relationship components have shown various evidence of effect. McElwain et al. (2017) conducted meta-analysis with 15 of the 33 healthy relationship education programs for youth (ages 15–18) they reviewed. The authors calculated small but significant effect sizes for conflict management skills and faulty relationships beliefs, while effects for improved healthy relationship attitudes did not meet significance. In 2021, Hielscher et al.’s systematic review and meta-analysis of 27 randomized controlled and quasi-experimental studies “with a healthy relationship skills/knowledge component” (p. 196) (25 of them with youth in high school, middle school, or combined) found that improvement of perceived knowledge about romantic relationships was the most consistent significant result across studies. Results were mixed for changing attitudes and beliefs, and Hielscher found limited effect on behaviors. Simpson et al.’s (2018) meta-analysis of relationship-focused interventions for adolescents and young adults calculated medium-sized effects for relationship knowledge, attitudes, and healthy relationship skills in 30 studies, with stronger effects in low-income youth populations. Across reviews, authors found heterogeneity in healthy relationship outcomes; a lack of validated measures for outcomes; and a need for higher quality studies, including longitudinal designs.

Digital Technology to Address Healthy Romantic Relationships in Adolescents

Our purpose in this review was to scope the published work on development and testing of digital health interventions (DHIs) to address healthy romantic relationships in adolescents. The focus on DHIs is unique. Programs to improve healthy romantic relationships in adolescents have predominately featured traditional modes of format and delivery. Digital health is defined by the World Health Organization (2019) as “the use of information and communications technology in support of health and health-related fields.” The category includes eHealth and its subset mHealth or mobile health. Digital health interventions (DHIs) use mobile apps, short message service (SMS) messages, wearable and ambient sensors, social media, and interactive websites to promote behaviors associated with the prevention or self-management of disease and delivery of health care (Michie et al., 2017).

Adolescents’ Use of Digital Technology

Leveraging digital tools to engage adolescents in the cultivation of healthy romantic relationships makes good sense, given that many youth already use digital technology to conduct those relationships (Hoehe & Thibaut, 2020). Adolescents worldwide own mobile devices and use social media frequently in their relationships (Paul et al., 2020). The prevalence of devices and their use by adolescents differs only minimally by gender, race, location, and socioeconomic status, and the younger the youth the less these digital gaps seem to apply (Atske & Perrin, 2021). Since the late 1990s, digital technology has increasingly been mobilized to engage adolescents in health management, education, and promotion, including sexual health, mental health, chronic illness management, substance use, and nutrition, and physical activity (Celik & Toruner, 2020; Lehtimaki et al., 2021).

DHIs in Healthy Romantic Relationship Promotion Research

Most interventions that promote healthy romantic relationships in adolescence are still delivered in-person, in traditional school- or community-based formats. In fact, Janssens et al. (2020) claimed their systematic review of adolescent “relationship and sex education” intervention studies (1997–2018) was the first on the topic to include delivery format as a focus at all. Janssens et al. found that 16 of 17 healthy-relationship education programs for adolescents aged 11–18 were delivered in schools using traditional delivery methods (e.g., classroom-based instruction, discussion, role-play, PowerPoint slides, films, student diaries). Recent systematic reviews of healthy relationship education interventions for adolescents by Hielscher et al. (2021) and Benham-Clarke et al. (2022) included few examples of programs delivered in any other than traditional classroom formats. In McElwain et al. (2017), all but one (Mustanski et al., 2015) of 27 youth relationship education interventions was delivered in a traditional in-person format.

DHIs in Risk-Prevention Research with Healthy Romantic Relationship Components

Technology appears to be only slightly more prevalent in violence and sexual risk prevention interventions that include healthy romantic relationship elements. In prior systematic reviews by Piolanti and Foran (2022) and Russell et al. (2021) of dating violence prevention studies for adolescents, we found 12 of 18 studies in Piolanti and Foran and seven of nine studies in Russell et al. reported traditional, in-person—classroom or community—delivery. Systematic reviews of technology-based interventions to mitigate adolescent sexual health risk (i.e., unplanned pregnancy, STIs) have been conducted by Guse et al. (2012), Widman et al. (2019), and Wadham et al. (2019) in the past decade. But most focused pointedly on prevention and risk reduction. Only three of the DHIs—all in Widman et al. (2019)—featured an aim or specific intervention component to promote healthy romantic relationship knowledge, attitudes, skills, or behaviors.

To the best of our knowledge, this scoping review is the first to focus on DHIs designed for adolescents to address healthy romantic relationships. We scoped the field to review DHI development, feasibility, evaluation, and research studies, published 2000 to 2022, that included an aim or primary interventional component that focused on healthy romantic relationships in adolescents. We identified these programs, summarized their key features, and noted gaps and future opportunities.

Method

Design and Scope

Scoping reviews are conducted to summarize a field that is comparatively new or not well articulated (Arksey & O’Malley, 2005). In scoping a field or problem area, reviewers address a range of literature, including formative, descriptive (qualitative and quantitative), and experimental studies. The flexibility and relative inclusivity of a scoping review allows authors to assess the general extent or parameters of a field, its points of conceptual emphasis, and the gaps that remain to be addressed before the evidence base is ready for systematic review.

Search and Selection

We followed Arksey and O’Malley’s (2005) steps, first developing a review protocol (unpublished) and defining our focus to be digital health interventions that address healthy relationships in adolescents. Eligible articles were available in English; published between January 2000-March 2022; featured the development or testing of a DHI that included at least one intervention component (e.g., lesson, session, module, game component, storyline) or outcome specific to knowledge, attitudes, or skills linked to positive or healthy romantic relationships; and included a sample primarily within ages 13 and 18. Our date range reflects the just-over two decades in which publication of any kind of work (not necessarily health or interventional) that included a focus on digital technology and adolescents increased dramatically, with only a smattering of publications prior to 2002. We searched for eligible literature in CINAHL, PubMed, and Scopus, using the search string displayed in Supplemental File 1. We excluded articles describing risk prevention and sexual education programs that lacked a healthy relationship focus or component; mentoring programs; passive interventions, such as community-based media campaigns and text messaging blasts; website or bulletin board analytic studies; and studies that described digital applications for providing mental health services.

We also conducted backward and forward searches, hand searches of individual journals, and reviewed previously published systematic reviews. After duplicates and clearly ineligible titles were excluded from the initial database search results, two authors read each abstract and indicated exclusions with reasons in a shared spreadsheet. We met as a team to resolve disagreements through discussion and split up the remaining sources for full-text review and data extraction. We followed this basic process twice because our original review time frame was 2015–2020 and we later extended that range to 2000–2022. Finally, because so many articles in our full-text selection reported intervention development or feasibility studies, we emailed corresponding authors after the first round to ask if subsequent trials had been conducted that we missed. In two instances, authors directed us to more recently conducted studies, and in one case, an earlier trial of an intervention was substituted for a process evaluation. Figure 1 displays our combined search and selection process.

Figure 1.

Flow Diagram

Analysis

Data were extracted from the articles into a matrix with columns for geographic location and study setting; study population and size; study design; intervention description; relationship features, objectives, and/or outcomes; and use of theory. We divided the sources and charted the data individually and then discussed and resolved differences as a team. Last, we re-read the articles to identify overarching themes and trends, including points of special emphasis or divergence, and implications and needs for future research. We each drafted one or more sections of the results and discussion, which we discussed in weekly meetings over 18 months, with the first author revising and standardizing language and flow.

Results

Sample and Setting

Sixteen articles met criteria for inclusion (Supplemental File 2. Study Characteristics). Eight reported study activities (development, evaluation, trialing) conducted in the United States (US). Other studies were set in Brazil, Hong Kong, New Zealand, Portugal, Uganda, and the United Kingdom (UK). One source described a protocol for a multi-national study to take place in Spain, Italy, UK, Romania, Poland, and Portugal (Vives-Cases et al., 2019). Sample sizes ranged from 13 to 2,605 and participants ranged in age from 9 to 29 years; with most either falling within our 13–18 year range or citing a mean age in that range. One study included dyads of adolescent children with a parent (Rizzo et al., 2021). A few studies addressed specific populations such as youth who identify as sexual minority (Mustanski et al., 2015) and youth who identify culturally as American Indian (Shegog et al., 2017) or African American (Patchen, 2020). Rizzo et al.’s (2021) program was designed for boys.

Study Designs

Most studies that conducted feasibility and acceptability assessment also included an efficacy evaluation. Six of those reporting efficacy had randomized samples, with participants allocated to a true control or used a wait list or cluster scheme. Two studies evaluated preliminary efficacy using before-and-after comparison as part of a feasibility study. Three sources included a protocol for future trials. About half the studies directed significant attention to intervention development, including detail about how DHIs were conceived and designed, often involving participatory processes. The majority of studies included feasibility and acceptability evaluations, with measures for doses/exposures/completions and retention; user satisfaction and perceived relevance of content; usability of the technology, including function, efficiency, effectiveness, and satisfaction, as well as motivational appeal and appropriateness for specific audiences.

Use of Theory

All but one of the studies we reviewed applied at least one theory and most were guided by several (Table 1). Theories used to explain behavior change and thus guide intervention design included the IMB skills model, the health beliefs model, the integrated change model, the theory of reasoned action, and transtheoretical change. Theory was also used to describe or explain the action of particular intervention components to address aspects of relationships, such as family interactional theory (Bourdeau et al., 2021) and development assets theory (Rizzo et al., 2021), and in one case communication theory to explain effects of messaging on adolescent users (Brady et al., 2015). Life skills theory, social learning theory, and most commonly, social cognitive theory were used to explain how behavior adoption or change occurs as youth interact with others and reflect on and respond to what they experience. Learning theories like experiential and problem-based learning, problem-solving theory, and game-based learning were invoked to explain broadly the prospective effects of interventions. Some authors referred to theories or models to conceptualize a problem area or guide interventional strategy. For example, Murta et al. (2020) invoked attachment theory, specifically the insecure attachment style, to explain why some adolescents are at greater risk for relationship violence.

Table 1.

Intervention Types, Theories, and Relationship Emphases

Author	Intervention Type	Theory(ies)	Relationship Emphasis
Bourdeau et al. (2021) Smart Choices 4 Teens	Interactive online program with self-paced activities and offline guided discussion and skills practice	Family interactional theory; control theory, social learning theory	One of three main components: fostering communication around healthy relationships and reflecting on healthy relationships, readiness for relationships and sexual relationships.
Bowen et al. (2014) Green Acres High	Serious game computer program with five scenario-based lessons	Information-motivation-behavioral skills model, social cognitive theory, control theory, operant conditioning	Lessons 1 and 3 of five lessons: determining relationship values; identifying characteristics of healthy relationships; practicing skills in conflict resolution.
Brady et al. (2015) TeensTalkHealth	Interactive online program with (1) video vignettes; board; (2) moderated website message boards (3) video, text, resources and archives	Information-motivation-behavioral skills model; communication theory; design theory	Multiple of 20 video vignettes with “tasks”: building healthy relationships, healthy decision making, and motivation to engage in health protective behaviors in romantic and sexual relationships.
Chu et al. (2015) Making Smart Choices	Serious game application with five 1-hour, scenario-based mini-games	Game-based learning	Mini-game 1 and 2 of five: healthy love relationships; setting/maintaining intimate boundaries; respecting others’ feelings.
Koziol-McLain et al. (2021) Harmonised	Interactive, moderated social networking mobile application with value-based relationship profiles, information re relationship issues, and moderated social posting	Māori-centered approach premised on bicultural relationship between Māori as tangatawhenua (indigenous people of the land) and tauiwi (nonindigenous people)	Reducing relationship abuse and promoting healthy relationships; identifying relationship values; learning healthy relationship skills.
Levesque et al. (2017) Teen Choices	Interactive online program: three 25–30-minute, multimedia, skills- building sessions, tailored to 5 risk-based user tracks	Transtheoretical model of behavior change (decisional balance, processes of change, self-efficacy)	Five healthy relationship skills: 1) understanding and respecting others’ feelings and needs; 2) managing disagreement; 3) respecting others’ boundaries; 4) communicating feelings and needs clearly and respectfully; and 5) healthy relationship decisions.
Murta et al. (2020) Dating SOS	Interactive online program with 4 weekly, 15-minute sessions and text messaging tailored to participants’ attachment styles, experiences, knowledge, attitudes	Integrated change model (I-Change) (i.e., composite of theory of planned behavior, social cognitive theory, transtheoretical model, health beliefs model, goal setting theory); attachment theory	Sessions 2 and 3 of four sessions: identification of positive relationship characteristics and models; action planning and strategies for acknowledging and sharing needs, respecting partner’s individuality; action planning for conflict management, emotion regulation, assertiveness, self-critique, empathy.
Mustanski et al. (2015) Queer Sex Ed	Interactive online program with avatar and quizzes in five 15-minute modules	Information motivation behavior skills model	Module 3 of five modules: forming and sustaining healthy LGBT relationships with emphases on communication, expectations, and reciprocal needs-meeting.
Patchen et al. (2020) Sexually Active Adolescent-Focus-ed Education (SAAFE)	Serious game mobile application with 7 “missions”	Social cognitive theory; problem-solving theory	Storyline 6 of seven storylines or “missions”: “All Romance”: relationship-building and healthy communications about sex.
Peskin et al. (2014) It’s Your Game ... Keep it Real	Interactive online program with 24 class-based lessons and homework activities (e.g., virtual world environment w/quizzes, individualized intervention messaging, videos, animations)	Social cognitive theory; social influence models; theory of triadic influence	“Major thematic focus” was development of healthy relationships as foundation for healthy adolescent sexual health, including characteristics of healthy relationships; identifying social support; setting/respecting limits; recognizing peer norms.
Rizzo et al. (2021) STRONG	Serious game application with built-in parent-child discussion in one training and five play-modules.	Developmental assets theory. Social cognitive theory, CBPR framework	Intervention designed to support parent-child communication about romantic relationships, managing feelings, meeting relationship challenges, identifying relationship values.
Shegog et al. (2017) Native, It’s Your Game	Interactive online program with thirteen 35-minute lessons—activities, videos	Life-skills training; and cultural sensitivity adaptation frameworks	Building and recognizing healthy relationships, protecting personal limits, awareness of consequences of sexual relationships (HIV, STI, and pregnancy), negotiation and assertion skills.
Velosa et al. (2021) GoodVibes	Interactive online program with embedded games and downloadable materials for additional classroom or home activities	None	Aim of project was preventing dating violence and helping teens learn concepts and develop healthy behaviors in a love relationship.
Vives-Cases et al. (2019) Lights4Violence	Class-room cinema-voice intervention in five 50-minute modules. Students plan, produce, discuss, and exhibit “video capsules” or short films they create to explore assets for reducing dating violence.	Assets-based change; experiential and problem-based learning	Program goals included acknowledging IPV-related protective factors; increasing awareness about positive interpersonal relationship qualities (esteem, trust); promoting communication and negotiation skills; empowering youth to self-determine in sexual relationships and protect selves from abuse.
Widman et al. (2020) HEART for Teens	Interactive online program: a 45-minute, skills-based program with games and quizzes, skills-building exercises	Reasoned action model; fuzzy-trace theory; sexual health paradigm	Program description in Widman et al. [2016]: Module “Motivation” purpose is empowering healthy decisions that fit values, importance of communicating in healthy relationships. Module “Communication” purpose is improving sexual communication and refusal skills, negotiating abstinence and condom use, assertiveness in communicating about sex.
Ybarra et al. (2013) CyberSenga	Interactive online program: 5-week, 1-hour modules and 1-hour review module delivered as booster after 3 months	Information-motivation-behavior skills model	Three of six modules: 2) Decision making and communication skills, including strategies for assertiveness in problem-solving; 3) Motivations to be healthy in behaviors related to sex; 5) Healthy relationships—components, strategies.

Intervention Types

Serious Game Applications

Four of the articles described serious game interventions, that is, video games with pedagogical aims. Examples included Chu et al.’s (2015) Making Smart Choices which comprises a series of mini-games in which youth follow comic-strip animations that depict scenarios in which the user is asked to make choices or provide information. STRONG, Rizzo et al.’s (2021) 6-module, web-based game for sons and parents, places players on Planet Z where the dyads work together to meet challenges and then discuss what they experienced. Patchen et al.’s (2020) game allows players to customize an avatar who must complete seven missions that involve romantic and sexual relationship decision-making.

Interactive Applications for Computers or Mobile Devices.

Ten of the studies reported interventions in which educational and skills-building content was delivered through web-based or computer or mobile device programs. All of these applications were described as interactive. Examples included Brady et al.’s (2015) TeensTalkHealth which combines video vignettes and readings with message board discussions moderated by health educators. Teen Choices (Levesque et al., 2017) is a web-based dating violence prevention program with multimedia (text, images, video) interactive, educational activities. Program users are tracked to different intervention experiences based on their assessed risk level for dating violence. Dating SOS (Murta et al., 2020), another intervention to prevent adolescent dating violence, includes tailored education based on attachment style, past violence, and other protective and risk-related factors. Mustanski et al.’s (2015) Queer Sex Ed is a sexual health program for youth who identify as lesbian, gay, bisexual, and transgender that includes avatar-led, educational, and motivational activities. The project by Widman and colleagues (2020), HEART for Teens, is a web-based, interactive intervention (with components described in Widman et al. [2016]) that includes education and skills-training modules. The program is delivered online through audio/video content, games, quizzes, self-assessment, peer feedback, and role-play.

Alternative Format Digital Health Interventions

We included two interventions that did not fit the profiles of interactive application or serious game, Vives-Cases et al.’s (2019) cinema-voice school-based program and Koziol-McClain’s et al.’s (2021) social networking mobile application, Harmonised. Based on photovoice method, Vives-Cases et al.’s Lights4Violence uses short, student-produced digital video narratives (“video capsules”) to guide student reflection and experiential learning about healthy relationship challenges and strategies. Harmonised (Koziol-McLain et al., 2021) is a moderated site in which adolescent users create a relationship-values profile and then participate in interactive activities including posting peer-to-peer comments and questions to the site about readings, quizzes, videos and posting.

Intervention Objectives and Themes

All 16 interventions included aims, components, and/or outcomes that addressed themes related to the promotion of healthy romantic relationships (Table 1). Of these, eight programs had as the primary objective the prevention of dating violence; six focused on sexual risk reduction (e.g., sex initiation, STIs, unplanned pregnancy); and two were healthy romantic relationship education and promotion programs. A declared focus in one area did not mean the others remained unaddressed in an intervention. Across the sample, repeated healthy relationship themes clustered in two areas: (a) recognizing attributes, values, and norms of healthy romantic relationships and (b) developing skills, resources, and behaviors to facilitate healthy romantic relationships.

Recognizing Attributes, Values, and Norms of Healthy Romantic Relationships

The intervention components to which this theme was applied included knowledge, self-reflection, and self-expression related to identifying characteristics of healthy relationships (eight studies), identifying one’s relationship values (five studies), establishing trust and mutual empathy and respecting the needs and feelings of others (five studies), and identifying healthy boundaries and personal limits in sexual relationships (four studies). Other topics addressed in this category involved identifying, critiquing and/or managing romantic relationship expectations, myths, and peer norms (three studies).

Developing Skills, Resources, and Behaviors to Facilitate Healthy Romantic Relationships

This theme included the development of communication skills for managing conflict or other challenges in romantic relationships (four studies) and negotiating condom use or asserting refusal/abstinence (four studies). Identifying social support and resources and being receptive to help-seeking were other points of frequent focus in this theme (four studies).

Intervention Features

Participatory Design and Development

Participatory intervention design and project development was a prominent feature in nearly all the studies that described the methods that were followed in creating a program. Vives-Cases et al. (2019) stressed the assets-based, youth-empowerment roots of the participatory orientation of their study, Koziol-McClain et al. (2021) identified participatory research principles along with Maori cultural appreciation of youth involvement as undergirding the Harmonised project, and Patchen et al. (2020) cited community-engaged research with African American youth as “critical to the successful development” (p. 11) of their program. Nearly all the sources included description of youth involvement in formal advisory boards or focus groups, often during initial design phases and as co-creators of content. Participatory project development also involved other stakeholders, including parents; community members; cultural leaders; and health, education, and gaming and technology experts.

Cultural Specification and Tailoring

Many of the programs used cultural specification and/or individual tailoring features to enhance fit of an intervention to its audience. Culturally-specified interventions in the sample included Shegog et al.’s (2017) program, which adapts the It’s Your Game-Tech (Peskin et al., 2014) program to an American Indian/Alaskan Native adolescent audience by incorporating values, symbols, and language of pan-tribal significance; Chu et al.’s (2015) application, which is culturally specified for adolescents in what the authors described as a socially conservative East Asian culture; Patchen et al.’s (2020) SAAFE application for African American adolescents, which incorporates culturally-relevant references, vocabulary, and beliefs; Koziol-McLain et al.’s (2021) intervention for taitamariki (i.e., youth) grounded in Maori cultural beliefs and values; and Ybarra et al.’s (2013) CyberSenga, which embeds Ugandan cultural values and draws its inspiration from the figure of the senga or paternal aunt who gives guidance to girls about sexual health and household roles as they reach womanhood. Mustanski et al.’s Queer Sex Ed (2015) was designed for sexual minority youth.

About a third of the programs used tailoring, or individually responsive features and content. For example, Levesque et al.’s (2017) Teen Choices tracks users to different intervention experiences or content based on levels of dating-violence risk. Murta et al.’s (2020) Dating SOS provides guidance based individual attachment styles of users, and Widman’s HEART for Teens (2020) applies user input to guide messaging and other content. In other programs, users design their game avatars (Patchen et al., 2020) or social profiles (Koziol-McLain et al., 2021), which then influence the subsequent experience of the game or program.

Facilitation and Moderation

All but one (Vives-Cases et al., 2019) of the interventions we reviewed were delivered via a computer or mobile device. Five were school-based but not designed to be moderated by an adult. A few others include some form of adult facilitation, moderation, or support. For instance, adult health-educator moderators pose questions and respond to user comments in Brady et al.’s (2015) sexual health risk prevention program. In Koziol-McClain et al.’s (2021) Harmonised, adult moderators interact with adolescents’ comments on the site and review site activity for safeguarding (i.e., for suicide or violence). In a couple cases, authors describing programs that did not include adult facilitation nonetheless noted its potential desirability (Rizzo et al., 2021; Bowen et al., 2014). One group observed that a strength of their program was its not-incorporating adult moderation but added that the flexibility of the digital format would easily accommodate that feature (Levesque et al., 2017).

Intervention Outcomes and Program Evaluation

Half the studies included measurement of intervention or program outcomes, including changes in sexual health knowledge, attitudes, self-efficacy and behaviors like abstinence and use of condoms; dating violence perpetration, victimization, attitudes, and communication; self-identity, self-acceptance, and self-esteem; and parent-child communication about romantic and sexual relationships. Data collected in the studies were self-reported, a feature observed by Widman et al. (2020) to be characteristic of DHI research in sex education and promotion with youth in general.

Despite the range of healthy romantic relationship emphases in the programs, among those that measured outcomes specific to healthy romantic relationships centered around improved communication skills. Most showed effectiveness. Smart Choice 4 Teens (Bourdeau et al., 2021) demonstrated improved parent-child communication, including increased frequency of communications about sexual relationships and personal dating rules following the intervention. Participants who played Making Smart Choices by Chu et al. (2015) reported improved ability to communicate with partners and improved ability to make smart choices about love and sex. In Queer Sex Ed, Mustanski et al. (2015) found small but significant changes in participants’ relationship communication skills. In that study, the sexual health improvement goal selected most frequently by female-born participants and second most frequently by male-born participants was to improve communications with their partner. Participants who completed Widman et al.’s (2020) HEART reported significantly higher sexual communication intentions (to discuss pregnancy and sexually transmitted infections with partner), higher self-efficacy/confidence in communicating about sexual topics with their partner, and higher sexual assertiveness compared to controls. Consistent use of healthy relationship skills was measured by Levesque et al. (2017) as part of Teen Choices, where changes in five healthy relationship components were measured on a four-point Likert scale. Participants had higher odds of reporting consistent use of all five skills compared to controls at both 6- and 12-month follow up.

Other sources offered feasibility and acceptability assessment using questionnaires, interviews, and focus groups or community boards. Authors reported perceived value/effectiveness of the DHIs; usability; satisfaction; ease of use; time in intervention, completion, and retention as well as participants’ perceptions of and experiences with intervention content. The feasibility studies reported mostly positive outcomes and evaluations from users and stakeholders with a few notable challenges. In Peskin et al. (2014), the authors described dose-fidelity challenges in the school-based It’s Your Game-Tech, which is important because better consistency of delivery than traditional programming is an oft-cited advantage of DHIs. Bowen et al. (2014) reported feedback on Green Acres High indicating difficult-to-meet user expectations, such as impatience with low-fidelity graphics and slow processing speeds. And Ybarra et al.’s CyberSenga (2013) identified limitations of infrastructure (i.e., access to electricity) as a potential barrier to feasibility of their DHI study in Ugandan schools.

Discussion

The field of research in DHIs for adolescents is an active and growing one. Our focus on DHIs that promote healthy romantic relationships in adolescence narrowed the field considerably, even with an international scope and no limits on study design. About half the work we identified involved measurement measurement of effects; the other half was developmental, describing and evaluating processes of intervention design, feasibility, and user feedback. Our findings highlighted some areas of strength in this work and some needs for future research.

A Spectrum of Adolescents and Interventions to Reach Them

Most healthy relationship programming for youth remains classroom-based and face-to-face. There is much potential for DHIs to deliver healthy relationship programming to a broader audience than in-person approaches, including groups who might be difficult to reach or uncomfortable with traditional delivery methods. Widman et al. (2019) have pointed out that digital interventions allow youth in some minority groups, who may feel stigmatized or devalued in traditionally-delivered classroom programs, to engage more fully and comfortably with online programs. Mustanski et al. (2015) noted that sexual minority youth often find their experiences unacknowledged, silenced, or stigmatized in classroom-based, in-person programming. In other research, interventions have been developed to promote healthy romantic relationships in adolescents who have autism (Rothman et al., 2021), visible facial differences (Williamson et al., 2019), and youth who live with chronic disease or chronic pain (Jordan et al., 2021). DHIs can overcome barriers of in-person interventions through their greater convenience, privacy, flexibility, and tailorability.

The same reasoning about expanded reach to audience might be applied to topics that are difficult to address using in-person programming, such as adolescents’ sexual rights or issues related to self-determination in reproduction and contraception. Only a couple studies, both outside the U.S., referred specifically to intervention content that aimed to empower adolescents in respect to sexual and reproductive rights (Vives-Cases et al., 2019) or included learning about reproductive choice options (Chu et al., 2015). Though currently few in number, healthy romantic relationship DHIs that offer such content have the potential to become more common in the current political and legal climate, at least in the U.S., given the flexibility and relative privacy of the medium.

Participatory Development of Interventions

We found, encouragingly, that nearly all the studies in our sample described some use of participatory methods. Adolescents played a role in developmental needs assessment, evaluation of usability and acceptability of programs, and in a few cases took part in designing intervention components. Youth-led participatory action research (Ozer, 2017) has been applied elsewhere in HIV prevention research (Melles & Ricker, 2018) and in intervening to increase minority and low-income youth involvement in community-based programs (McCuistian et al., 2021). Participatory methods may be developmentally important for adolescents, who benefit from feeling heard and exercising ownership over the projects that aim to change them (Melles & Ricker, 2018). Participatory practices in research are allied with user-centered and human-centered design approaches in technology development (Cook et al., 2017), some of which have been applied in programs in adolescent sexual and reproductive health (Fakoya et al., 2022), sexual self-determination in gender and sexual minority youth (Coulter et al., 2021), and adolescent self-management of diabetes (Pike et al., 2021).

Cultural Specification and Tailoring

Like participatory design approaches, the cultural specification and tailoring we found in the interventions helps ensure programs address user needs (Cortese et al., 2012). Several programs included content and features specified for particular ethnic, racial, or sexual minority groups. More intentional cultural specification of programs has been associated with improved outcomes in health research. In a meta-analysis of substance use intervention studies with adolescent samples, interventions with culturally specific elements exhibited larger pooled random effects (g = 0.37; 95% CI [0.12, 0.62]) than comparison interventions that lacked cultural specificity (Steinka-Fry et al., 2017). Tailoring, too, has been associated with better outcomes in interventions than non-tailored approaches (Tong et al., 2021), though no review or meta-analysis of tailoring in health interventions designed specifically for adolescents could be located. Digital interventions are particularly amenable to tailoring, since applications can be programmed to direct content based on user inputs.

Implications

The studies we reviewed have implications for research and program development. First, in the eight studies that measured outcomes, nearly all of those outcomes were some form of communication skills. Measurement of other healthy relationship outcomes of knowledge, skill, and behavior were difficult to locate—even when likely objectives were detailed in interventions and curricula. In their review of primarily non-DHI healthy relationship programs for adolescents, Benham-Clarke et al. (2022) identified a lack of coherency in outcome domains and measurement across studies. Defining a fuller spectrum of salient positive outcome domains for healthy romantic relationships in adolescence and developing validated tools to measure them would advance this field. Second, as others have noted, the research processes of design, development, testing, and dissemination tend to lag behind development of new digital technologies (Liverpool et al., 2020). Researchers may need to explore approaches to rapid, adaptive testing and alternative outcomes reporting to keep up with the technologies used by adolescents (Kalke et al., 2018). Third, most of the studies in our review involved youth participation in the design and/or evaluation of programs. This is a feature worthy of replicating. Participatory research can be empowering for adolescents during a developmental period when such opportunities might be especially important (Ozer, 2017).

Fourth, most of the DHIs addressed straight relationships and cis-gender youth, and the field might benefit from a more diverse view of youth and their romantic relationships. Future interventions might attune to the complex shape and dynamics of youth relationships to address a broader spectrum of healthy relationship types (Manning et al., 2014). Fifth, we were encouraged that several of the interventions integrated culturally specific language, practices, history, and art into program design. The cultural specificity in interventions calls attention to how readily digital health technology can be adapted to forms youth find familiar and appealing. Tailoring in interventions further suggested how programming might leverage computer learning capabilities to adjust to individual responses in real-time and provide person-centered experiences. Finally, future DHIs might do more to emphasize community- and society-level change to support youth in forming and maintaining healthy romantic relationships. Developing DHIs as scaffolding for youth to find and use their voices in community and other levels of the social ecology would be a welcome supplement to the cognitive and behavioral changes such tools typically address.

Limitations

This review is the first to identify and summarize work on DHIs for adolescents that feature healthy relationship promotion. The work was scattered across a range of healthy relationship education, sex education, violence prevention, and other interventional literature, which means we likely missed pockets of relevant work. We tried to safeguard against this by meeting with a research librarian on two occasions to shape our search strategy, emailing authors to check for new publications on existing interventions, carefully examining articles in recent and not-so recent systematic reviews for eligibility. Even so, we likely overlooked sources, especially non-indexed and non-published work, some of which has been reviewed in Kalke et al. (2018). Our focus on DHIs also means that interventions in our review are likely to be revised or rendered moot in upcoming months or years, replaced by newer technologies. The scoping review nevertheless gathers and summarizes a previously unorganized body of research and development, providing a snapshot of the scope of DHIs that promote healthy romantic relationships in adolescents, while highlighting trends and areas for future investigation.

Conclusion

Giovanelli et al. (2020) have observed of adolescents that they “are often early adopters, savvy users, and innovators of technology use” (p. S7). Given the ubiquity of that use, it is not surprising that health interventionists would turn to technology for means to influence youth health behaviors, beliefs, and norms. Even so, our findings suggest a surprising paucity of study to apply DHIs to the crucial project of promoting healthy relationships in adolescence. Our scoping of this work pointed to numerous points of emphasis and need toward which future work might be usefully directed.