The Healthy Relationships Program: A pilot study of a healthy relationships, HIV/STI prevention, and pornography education program for high schoolers.

The Healthy Relationships Program: A pilot study of a healthy relationships, HIV/STI prevention, and pornography education program for high schoolers - PMC Skip to main content An official website of the United States government Here's how you know Here's how you know Official websites use .gov A .gov website belongs to an official government organization in the United States. Secure .gov websites use HTTPS A lock ( Lock Locked padlock icon ) or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites. Search Log in Dashboard Publications Account settings Log out Search… Search NCBI Primary site navigation Search Logged in as: Dashboard Publications Account settings Log in Search PMC Full-Text Archive Search in PMC Journal List User Guide PERMALINK Copy As a library, NLM provides access to scientific literature. Inclusion in an NLM database does not imply endorsement of, or agreement with, the contents by NLM or the National Institutes of Health. Learn more: PMC Disclaimer | PMC Copyright Notice Am J Sex Educ . Author manuscript; available in PMC: 2026 Apr 20. Published before final editing as: Am J Sex Educ. 2025 Apr 20:10.1080/15546128.2025.2493652. doi: 10.1080/15546128.2025.2493652 Search in PMC Search in PubMed View in NLM Catalog Add to search The Healthy Relationships Program: A pilot study of a healthy relationships, HIV/STI prevention, and pornography education program for high schoolers Kimberly M Nelson Kimberly M Nelson , PhD, MPH 1. School of Public Health, Department of Community Health Sciences, Boston University, Boston, MA 2. Chobanian & Avedisian School of Medicine, Department of Psychiatry, Boston University, Boston, MA Find articles by Kimberly M Nelson 1, 2 , Julia K Campbell Julia K Campbell , MPH 1. School of Public Health, Department of Community Health Sciences, Boston University, Boston, MA 3. Gillings School of Global Public Health, Department of Health Behavior, University of North Carolina- Chapel Hill, Chapel Hill, NC Find articles by Julia K Campbell 1, 3 , Shira Dunsinger Shira Dunsinger , PhD 4. Center for Health Promotion and Health Equity, Department of Behavioral and Social Sciences, Brown University, Providence, RI Find articles by Shira Dunsinger 4 , Tomeka M Frieson Tomeka M Frieson , MPH 1. School of Public Health, Department of Community Health Sciences, Boston University, Boston, MA Find articles by Tomeka M Frieson 1 , Rana Saber Rana Saber , MPH 5. Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, Chicago, IL 6. Feinberg School of Medicine, Department of Medical Social Sciences, Northwestern University, Chicago, IL Find articles by Rana Saber 5, 6 , Kathryn Macapagal Kathryn Macapagal , PhD 5. Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, Chicago, IL 6. Feinberg School of Medicine, Department of Medical Social Sciences, Northwestern University, Chicago, IL 7. Feinberg School of Medicine, Department of Psychiatry and Behavioral Sciences, Northwestern University, Chicago, IL Find articles by Kathryn Macapagal 5, 6, 7 , Emily F Rothman Emily F Rothman , ScD 1. School of Public Health, Department of Community Health Sciences, Boston University, Boston, MA 8. Sargent College of Health and Rehabilitation Sciences, Boston University, Boston, MA Find articles by Emily F Rothman 1, 8 Author information Copyright and License information 1. School of Public Health, Department of Community Health Sciences, Boston University, Boston, MA 2. Chobanian & Avedisian School of Medicine, Department of Psychiatry, Boston University, Boston, MA 3. Gillings School of Global Public Health, Department of Health Behavior, University of North Carolina- Chapel Hill, Chapel Hill, NC 4. Center for Health Promotion and Health Equity, Department of Behavioral and Social Sciences, Brown University, Providence, RI 5. Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, Chicago, IL 6. Feinberg School of Medicine, Department of Medical Social Sciences, Northwestern University, Chicago, IL 7. Feinberg School of Medicine, Department of Psychiatry and Behavioral Sciences, Northwestern University, Chicago, IL 8. Sargent College of Health and Rehabilitation Sciences, Boston University, Boston, MA ✉ Corresponding Author : Kimberly M. Nelson, PhD, MPH, 801 Massachusetts Ave, 4th Floor, Room 451, Boston, MA 02118, [email protected] PMC Copyright notice PMCID: PMC12440125  NIHMSID: NIHMS2075279  PMID: 40963951 The publisher's version of this article is available at Am J Sex Educ Abstract Sexual health experts are advocating for schools to address healthy relationships and pornography in sex education. We developed and pilot tested the Healthy Relationships Program, an online intervention to be assigned as sex education homework covering healthy relationships, sexually transmitted infections, pregnancy prevention, and pornography use for high schoolers in Massachusetts ( N =54; ages 14–19 years). Participants found the content useful, the format enjoyable, and would recommend the program. Preliminary results suggest the intervention may increase condom use, sexual knowledge, and pornography literacy, and decrease dating violence. The Healthy Relationships Program appears feasible, acceptable, and may positively impact student sexual health. Keywords: sex education, pornography, dating violence, adolescent, relationships, online intervention INTRODUCTION Multiple studies have established that adolescents and young adults around the world are now turning to online pornography for information about sex, particularly in the absence of comprehensive sex education ( Cerbara et al., 2023 ; Cheney et al., 2017 ; Litsou et al., 2021 ; Nelson, Pantalone, et al., 2019 ; Rothman et al., 2021 ; Srivastava et al., 2023 ). In fact, emerging research suggests that many adolescents use pornography as a primary source of information about how to have sex ( Litsou et al., 2020 ; Nelson, Perry, et al., 2019 ; Rothman et al., 2015 , 2021 ). Yet, evidence is accruing that pornography can misinform consumers about sex ( Miller & Stubbings-Laverty, 2022 ; Wright et al., 2022 ). Indeed, pornography use is positively associated with adverse sexual health outcomes, including experiences of dating violence and sexual behaviors that increase the likelihood of sexually transmitted infections (STIs), including HIV, and pregnancy ( Brown & L’Engle, 2009 ; Crabbe & Flood, 2021 ; Dawson et al., 2019 ; Nelson, Perry, et al., 2019 ; Ybarra et al., 2011 ; Ybarra & Thompson, 2018 ). It is therefore no surprise that researchers, sex educators, and other sexual health experts are now advocating for sex education programs to address the topics of healthy relationships and pornography ( Baker, 2016 ; Cerbara et al., 2023 ; Dawson et al., 2020 ; ETR, 2021 ; Fitzpatrick et al., 2022 ; Rodríguez-Castro et al., 2021 ; Srivastava et al., 2023 ). Educational standards in the United Kingdom, some U.S. states, and the national U.S. Future of Sex Education Initiative now specify that youth should be educated about topics such as consent, dating abuse, healthy communication in sexual relationships, underage sexting, child pornography, or the ways in which pornography does not reflect reality ( Fox, 2022 ; Future of Sex Education Initiative, 2020 ; Illinois State Board of Education, 2022 ; Massachusetts Department of Elementary and Secondary Education, 2023 ; State of New Jersey Department of Education, 2020 ). And, there have been some efforts in England, Sweden, the Netherlands, Australia, and the U.S. to teach youth to become critical consumers of pornography and strive for healthy communication in their sexual partnerships in both school- and afterschool settings ( Bengry-Howell, 2012 ; Crabbe & Flood, 2021 ; Maas et al., 2022 ; Planting-Bergloo & Arvola Orlander, 2024 ; Rothman et al., 2020 ; Vandenbosch & van Oosten, 2017 ). However, advocating for and implementing changes in U.S. secondary school-based sex education content is challenging. In the U.S. many school boards are now rolling back the content of sex education, rather than expanding it or taking on new, and possibly more controversial, topics ( Associated Press, 2023 ). Further, some politically conservative parent groups seek to dismantle comprehensive sexual education on the basis that it sexualizes children, promotes rights for gender and sexual minority youth, and advances racial equity ( LaMarche, 2023 ; Moms for Liberty, 2023 ). As such, a present challenge for sex educators in the U.S. is to create new materials that deliver accurate and up-to-date information on appropriate topics for the current era and that are acceptable to the decision-makers who control what can be shared with youth ( e.g ., school board members, superintendents) ( Nelson et al., 2024 ). Fortunately, advances in technology have enabled educators to create online sex education content that students can self-deliver at their own pace to supplement in-person didactic learning ( Green et al., 2015 ; Muller et al., 2017 ). Because it is a public health priority to increase the percentage of U.S. youth who receive formal sex education before age 18, and to address calls for sex education to include information about healthy relationships and pornography use, our team developed a new, online, sex education program that addresses four main topics: (1) healthy vs. controlling relationships; (2) STI, including human immunodeficiency virus (HIV), prevention; (3) pregnancy prevention; and (4) pornography ( Fox, 2022 ; Future of Sex Education Initiative, 2020 ; Illinois State Board of Education, 2022 ; Massachusetts Department of Elementary and Secondary Education, 2023 ; Office of Disease Prevention and Health Promotion, 2022 ; State of New Jersey Department of Education, 2020 ). We created six online activities/games that each pertain to one of the four main topics. We developed the content of the intervention using an iterative, multistep process involving extensive formative research with Massachusetts high school students, Massachusetts school administrators, sexual education experts, and others ( Nelson et al., 2024 ; Rothman et al., 2023 ). We chose to focus on Massachusetts for two reasons: (1) it provides a sex education environment that is common across many states (e.g., Massachusetts does not mandate sex ed, instead allowing local school boards to decide sex ed content) and (2) Massachusetts recently passed a new framework for sex education that specifies healthy relationships education, information about STIs, and information about pornography is expected, enabling us to align our intervention content to this new framework as recommended in our preliminary work ( Massachusetts Department of Elementary and Secondary Education, 2023 ; Nelson et al., 2024 ; Rothman et al., 2023 ; SIECUS, 2024 ). The present study was designed to investigate the feasibility and acceptability of the self-delivered, online healthy relationships and sexual education intervention, which is called the Healthy Relationships Program, as well as conduct a preliminary evaluation of potential intervention impacts on sexual health outcomes. Although the program focuses more on sexual and reproductive health topics than on relationship skill-building, we elected to name the program “Healthy Relationships” because we thought this more innocuous title would be more palatable to schools than a title that mentions sex or reproductive health directly. MATERIALS AND METHODS Study design We used a one-group pre-/post-test, mixed methods approach to evaluate the Healthy Relationships Program. Baseline and 3-month follow-up surveys were used to quantitatively assess the feasibility, acceptability, and potential impacts of the intervention. Qualitative interviews with a subsample of participants at the conclusion of the pilot period were used to further understand feasibility and acceptability. All materials, protocols, and procedures were approved by the Boston University Medical Campus Institutional Review Board (H-41969). Recruitment and eligibility Participants ( N =54) were recruited between April and September 2022. To be eligible participants needed to be: (1) 14–18 years old, (2) currently enrolled in a high school (public or private) in Massachusetts, (3) have a valid email address, (4) have access to the Internet in order to engage in the intervention and to complete research surveys, and (5) be able to read and speak English. We also used a targeted recruitment scheme to ensure that we enrolled youth who were diverse in terms of race, ethnicity, gender, and sexual orientation. Recruiting was done through schools, K-12 educators, youth organizations, and social media. Specifically, Massachusetts-based schools and K-12 educators were contacted by study staff via email and asked to share a recruitment flyer and/or link to the eligibility survey with their students or other youth in their networks. We additionally conducted phased outreach to youth-based centers, organizations, and programs, first emailing these organizations to ask that they share the eligibility survey with youth, and then following up with calls and/or in-person visits to distribute flyers if no email response was received. We also contacted various schools and youth programs over social media to ask that they post a social media graphic advertising the study to their followers, who were primarily youth. Finally, the research team posted two social media advertisements on their personal accounts. Depending on how they were recruited, youth interested in taking part in the study scanned a QR code on the recruitment flyer and were directed to a website where the eligibility survey was hosted, or the youth received a link to the eligibility survey via email. After completing the eligibility survey online, eligible youth were automatically routed to an online assent/consent form. Potential participants younger than 18 years old were asked to enter a guardian’s email address, and guardians were subsequently contacted by a member of the study team with a link to the online guardian consent form. Participants who assented/consented and whose guardians consented (when applicable) received an email containing a unique link to the baseline survey. Fraud protocol Two research assistants checked every response for suspicious answers that could indicate potential fraud (e.g., odd email address, reported going to a high school that does not exist in Massachusetts, responses there were not internally consistent). If the research assistants suspected that someone provided a peer’s email address instead of a parent email address, reported going to a high school that does not exist in Massachusetts, or provided information that was not internally consistent, they reached out to the potential participant to confirm eligibility and parental email. If the potential participant did not respond, were unable to verify their eligibility, or were unable to provide a valid parental email address, they were deemed ineligible and did not move forward. The Healthy Relationships Program Intervention The intervention was informed by two formative research studies and refined through consultation with six experts in sexual health and sex education ( Nelson et al., 2024 ; Rothman et al., 2023 ). The first study investigated the opinions of high-school attending youth ( N =28) in Massachusetts related to the content of their sexuality education, what they wished they could learn from a sex education class, and whether and how pornography was addressed ( Rothman et al., 2023 ). The second investigated the opinions of high-school administrators ( N =8) and sexual education teachers ( N =9) in Massachusetts related to students sex education needs and barriers and facilitators to the provision of education about pornography as a part of school-based sex education ( Nelson et al., 2024 ). Youth, teachers, and administrators all agreed that an online, sex education program that addresses healthy relationships, pornography literacy, and STI/HIV information would be useful for sex educators to be able to assign as homework. As such, the intervention was designed to be a stand-alone, online program that could be completed in one sitting in under 30 minutes. Initial content was informed by our previous intervention work in this area ( Nelson et al., 2022 ; Nelson, Pantalone, et al., 2019 ; Rothman et al., 2018 , 2020 ). As outlined in Table 1 , four main topics were identified by the study team, high school attending youth, and high school sexual education teachers and administrators as important foci for the intervention: (1) HIV and STIs, including how they are transmitted, testing, and prevention; (2) pornography, including what it is, why it is problematic to learn about sex through pornography, and how common or uncommon sexual acts that are portrayed in pornography are when people have sex in real life; (3) pregnancy prevention, including how to use a condom, and the effectiveness of different types of contraception; and (4) healthy and unhealthy dating relationships. These topics were covered in 6 distinct activities (see Table 1 for activity descriptions and screenshots). Intervention activities were interactive ( e.g . games, videos, open response questions, animation), and the website had an interface whereby each activity had a clickable icon that displayed instructions when participants clicked on it. Intervention content was intentionally inclusive regarding sexuality and gender (e.g., content included queer couples and couples whose genders you could not infer from their names). Once content was developed, we used a two round Delphi process with six experts in sexual health and sex education to further refine the material ( Hsu & Sandford, 2007 ; Powell, 2003 ). Website programming followed an iterative process from initial development/design to alpha/beta testing in collaboration with the website developer. The website was designed to work on a mobile device, tablet, or computer and was compatible with different types of software ( e.g . Mac, PC, iPhone, Android). Upon login, users had access to all six activities and could engage with the activities in any order and as often as they chose. Table 1. Detailed descriptions and screenshots of the Healthy Relationships Program activies Activity Description Screen shot Test Your Knowledge! In this game, participants earn points for correctly answering questions about HIV and STIs. Questions covered content related to what HIV and STIs are, how to get tested for them, how they are transmitted, and how to prevent them. Fact or Fantasy? This 2-minute and 53-second long animated video explains how sex in porn is different from sex “in real life” and how to discuss sexual preferences, including trying new things, with partners in a healthy way. Condom Check This 2-minute and 23-second long animated video walks through the steps of using a condom, including how to check the expiration date; open the package; and put on, take off, and properly dispose of a condom. Contraception Selection This game presents participants with 9 different types of contraception and asks them to put them in order from most to least effective. When participants hover over a listed type of contraception, they are provided with more information about it. Got Advice? In this activity, participants read short vignettes about people who are dating and have an issue they need to work out. Participants are then asked to think through and type up possible advice that they might give to the person with the issue. Is This For Real? In this game, participants are presented with things that can happen during sex. Some of the things are often shown in porn ( e.g . choking); others are not often shown in porn ( e.g . discussing consent). Some of the things also happen in real life. Participants are asked to rate how common or uncommon they think the things are when people are having sex in real life. Get Help (Non-Activity Resource Section of the Website) This section lists 6 local and national resources that provide helping services to individuals struggling with mental health, substance use, sexual assault, and more. Open in a new tab Quantitative survey Participants ( N =54) completed a baseline and three-month follow-up survey between September 2022 and February 2023. All participants received the follow-up survey regardless of whether they completed the intervention. After participants completed the baseline survey, they received a $15 electronic gift card and instructions about how to complete the intervention website. Study staff then registered participants on the intervention website using the email address on file. Once registered, participants received an email inviting them to create a username and password and complete the activities on the intervention website. Participants received up to five automated reminders to complete the intervention content, and study staff sent up to four additional personalized text messages and/or email reminders if the content was not fully completed after the automated reminders. Participants that completed the follow-up survey received a $25 electronic gift card. Qualitative interviews We conducted 23 semi-structured qualitative interviews between December 2022 and February 2023 to obtain additional information about study and intervention feasibility and acceptability. Participants were chosen randomly from the full sample of N =54. Nineteen of the qualitative interview participants completed the intervention, two did not complete the intervention, and two partially completed the intervention. We included interview participants that did not complete the intervention to determine barriers to engagement and ways to improve engagement and enrollment. Interviews were conducted via Zoom, audio-recorded, and lasted approximately 20 minutes. Youth that completed the intervention were asked 13 open-ended questions about their overall impressions of the program, what they liked and did not like about each activity, what they thought other teens might think about the program, whether they would recommend the program to their peers, and what suggestions they had to improve the program. Youth were probed about both the content of the program and the website’s interface, aesthetics, and user experience. An example question is, “Here is a game called Test Your Knowledge. If you remember, it involves getting points for answering questions about HIV and other sexually transmitted infections. What do you think of this game?” Youth who did not complete the program were asked three questions about why they did not log on to the program website to complete the intervention and what might boost engagement and enrollment in the future. Measures Demographics of high school participants Demographic characteristics included age, race, ethnicity, gender identity, whether the participant identified as transgender, sex assigned at birth, sexual orientation, urbanicity, type of school attended, grade, qualification for free/reduced lunch, and whether the participant had a disability (as evidenced by the presence of an Individualized Education Plan (IEP) or 504 plan at school). Study and program feasibility Adapted from previous pilot studies of online sexual health interventions, study feasibility measures included the percentage of individuals who completed the eligibility survey, were eligible, consented, completed the baseline survey, and were retained at the 3-month follow-up survey. Intervention feasibility measures included the percentage of participants who logged on to the website and started at least one activity, the average time it took to complete each activity, the number of sessions it required to complete all of the activities, the number of participants that completed each activity, and the number of participants that completed all six activities ( Mustanski et al., 2015 ; Nelson et al., 2022 ). Program acceptability Adapted from previous pilot studies of online sexual health interventions, following completion of each activity, the website prompted each participant to rate how useful they found the activity (1 to 5 “stars,” with more stars indicating that the activity was more useful). Participants were also asked to complete a satisfaction questionnaire at the 3-month follow-up survey, and we calculated average ratings for recruitment, assent/consent, and assessment procedure questions. Participants were asked whether they visited the program website (yes, no). For those who reported visiting the website, they were asked about the extent to which the program met their sexual health and relationship information needs (1=none of my needs were met, 2=only a few of my needs were met, 3=most of my needs were met, 4=almost all of my needs were met), whether the program made them feel more prepared to have a sexual relationship (1=no, it made me feel less prepared, 2=no, it didn’t really help, 3=yes, it helped somewhat, 4=yes, it helped a great deal), whether they would recommend the program to a peer (1=no, definitely not, 2=no, I don’t think so, 3=Yes, I think so, 4=yes, definitely), and aspects of the program that they found most and least useful (open-ended). Participants were also asked to indicated how much they agreed or disagreed with statements about how easy the program and surveys were to complete on a four point Likert scale (strongly agree to strongly disagree) and what they believe could have been improved about their overall experience in the study (open-ended) ( Nelson et al., 2022 ). Assessment of Potential Impact on Sexual Health Outcomes Outcome variables included condom use, experiences of dating violence, intentions to use condoms, HIV knowledge, STI knowledge, and pornography literacy. Condom use Participants were asked if they had a dating or intimate partner within the past year. “Dating or intimate partner” was defined as a “boyfriend, girlfriend, someone you dated, or with whom you were romantically or sexually involved.” Participants that answered “yes” were asked about the number of times in the past 3 months (90 days) they had sex that involved a penis going into a vagina or a penis going into an anus and, of those times, how many times they used a condom. We calculated the number of times a condom was used and the proportion of times a condom was used out of the amount of times a condom could have been used in the past 90 days. Experiences of dating violence Experiences of dating violence were measured using the Measure of Adolescent Relationship and Abuse (MARSHA) Victimization and Perpetration version ( Rothman, Cuevas, et al., 2022 ; Rothman, Paruk, et al., 2022 ). The MARSHA is a 68-item scale that assesses adolescent dating violence victimization and perpetration. It includes items on physical, sexual, and psychological adolescent dating violence, as well as cyber dating abuse, social control, and invasion of privacy. Participants were instructed to think about all of the people they were “dating, hooking up with or in a romantic relationship within the past year” and to answer the questions thinking about these people. They were asked to estimate how many times certain behaviors happened, excluding times when those behaviors were conducted for fun or as a joke. Participants were asked to rate their response on a scale of 0–3 where 0 represents “0 times,” 1 represents “1–3 times,” 2 represents “4–10 times,” and 3 represents “more than 10 times.” An example item is, “they used social media or other apps to keep track of me or monitor where I was going or where I had been.” Higher scores indicate greater frequency of unhealthy relationship behavior experiences. Internal consistency was acceptable in this sample (Cronbach’s alpha = 0.85). Intentions to use condoms Intentions to use condoms were measured using two items that asked participants how likely they will be to use a condom in the next three months if they have vaginal or anal sex ( Nelson et al., 2022 ). For example, participants were asked “if you have vaginal sex in the next three months, how likely is it that you will use a condom?” Participants were asked to rate their response using a 4-item Likert scale from “very unlikely” to “very likely.” As the data had very high agreement between these questions (i.e., most participants reported the same likelihood for both questions), participants were categorized as very unlikely, unlikely, likely, or very likely based on their max response to both questions. HIV and STI knowledge An abbreviated version of the HIV Knowledge Questionnaire ( Carey & Schroder, 2002 ) was used to assess HIV knowledge among participants. The questionnaire was shortened to eleven key statements that aligned with intervention content and current information about HIV transmission (e.g., “A woman can get HIV if she has anal sex with a man”). Participants were asked to indicate whether these HIV-related statements were true, false, or whether they did not know. Correct answers were summed, with a higher score indicating more HIV knowledge. Internal consistency was acceptable in this sample (Cronbach’s alpha = 0.89). We similarly shortened the STI-Knowledge Questionnaire to nineteen key statements that aligned with intervention content and current information about STI transmission (e.g., “Human Papillomavirus [HPV] can lead to cancer in women”) ( Jaworski & Carey, 2007 ). Participants were asked to indicate whether these STI-related statements were true, false, or whether they did not know. Correct answers were summed, with a higher score indicating more STI knowledge. Internal consistency was acceptable in this sample (Cronbach’s alpha = 0.89). Pornography Literacy Pornography literacy was assessed using the 23-item Pornography Knowledge, Expectancies, and Norms Scale. The scale consisted of original items developed by the research team and items adapted from previous research assessing pornography use among adolescents ( Nelson, Perry, et al., 2019 ; Wright et al., 2021 ). The instructions say: “One of the ways that we think young people might be learning about sex is through pornography or porn. By ‘porn,’ we mean any material, such as websites, magazines, videos or photos that are meant to be sexually exciting. Porn often contains explicit pictures of body parts, such as the genitals, and sexual acts, such as oral sex, masturbation, anal sex, etc.” Participants were asked to rate how much they agree or disagree with the given statement using a 5-item Likert scale where 1 represents “totally agree” and 5 represents “totally disagree.” A sample item is, “Sexual situations depicted in porn often appear in real life.” Higher scores indicate greater pornography literacy. Internal consistency was acceptable in this sample (Cronbach’s alpha = 0.87). Data analysis Feasibility and acceptability analysis Descriptive statistics were calculated for quantitative variables and summarized as means (standard deviations) for continuous variables and frequencies (percentages) for categorical variables. For the qualitative data, a thematic content analysis was conducted to identify key themes relative to feasibility and acceptability using NVivo ( Krippendorff, 2012 ; QSR International Pty Ltd, 2021 ). An initial coding framework was developed using a deductive approach. Inductive codes were developed after reading all transcripts, and a codebook was finalized by synthesizing codes across pairs of coders. Each transcript was double coded to assure internal validity. Coding pairs met frequently (i.e., after every two transcripts) to discuss discrepancies in code application. Interrater reliability was calculated to assess the validity of the data analysis process for each group. The kappa score was 0.84, indicating good interrater reliability ( McHugh, 2012 ). Key themes (e.g., good intervention length) and illustrative quotations (e.g., “short, concise and straight to the point”) were extracted after coding was completed. Assessment of potential impact on sexual health outcomes To determine preliminary intervention efficacy, we examined within-group changes in study outcomes using a series of generalized linear models (GLMs) ( McCullagh & Nelder, 1989 ). GLMs are flexible in that they allow for a range of outcomes distributions ( e.g., Normal, Poisson) and link functions ( e.g., identity, logit). Analyses were run on the intent to treat sample (all enrolled participants were included in the analysis regardless of the amount of data they contributed, N =54) and on the per-protocol sample (those who logged on and started at least one activity on the program website were considered engagers with the program, N =42). In the case of the intent to treat analyses, model effects were estimated using a likelihood-based approach, thus making use of all available data without directly imputing missing values. Finally, we explored potential moderating effects, including age, gender (categorized: boy/man, girl/woman, non-binary), and sexual orientation (categorized: straight/heterosexual, bisexual, gay/lesbian, other) using a similar analytic approach to that described above. Models included main effects of the potential moderator, as well as interactions with time. All analyses were run in R with significance level set at 0.05 a priori ( R Core Team, 2021 ). Reflexivity Statement The team involved in conducting this study were cisgender women who identify as straight, sexually minoritized, White, Black, Asian, Middle Eastern. The recruiters, qualitative interviewers, and qualitative coders were close in age to the participants (i.e., a young adults). Disciplinary backgrounds included public health, clinical psychology, and software design. This project was grounded in the team’s collective commitment to improving the sexual health of adolescents in the U.S. RESULTS Study feasibility A total of 209 potential participants completed the eligibility survey and 80% ( n =168) were eligible ( Figure 1 ). The majority (83%, n =140) of participants that passed the initial eligibility survey agreed to move on to the consent form, and of these, 99% ( n =139) agreed to participate. Most (78%, n =109) participants that provided assent to participate were under 18 years old and therefore required guardian permission. Approximately one-half ( n =55) received guardian consent to participate. Nine participants were excluded because they completed the eligibility survey after the study period had ended (this resulted from a programming error). Thus, the baseline survey was sent to 75 eligible, consenting participants, and 72% completed the baseline survey resulting in an analytic sample of 54. Overall retention was 78% ( n =42) at 3-month follow-up. Figure 1. Study flow diagram. Open in a new tab *n=109 participants required parental consent. Of those, 55 (50%) received parental consent. n=30 participants did not require parental consent because they were 18 years old. As shown in Table 2 , the final sample included 54 participants who were 17 years of age on average ( SD =1.1). Participants were predominantly White (46%) or Black/African American (30%). Approximately one quarter (26%) identified as Hispanic/Latine. About half the sample (56%) identified as a girl/woman. When asked about their sexual orientation (check all that apply), 48% reported being heterosexual, 30% reported being bisexual, 9% gay or lesbian, 7% pansexual, 8% queer, and 2% asexual. Of the 54 participants who completed baseline, 42 completed follow-up with no significant differences at baseline between those who returned for follow-up and those who did not (p’s>.10). Table 2. Participant demographics at baseline ( N =54) n (%) Age Average ± std 17.09 ± 1.06 Range 14–19 * Hispanic/Latine Yes 14 (25.9%) No 40 (74.1%) Race Native American or Alaska Native 1 (1.9%) Asian 10 (18.5%) African American or Black 16 (29.6%) African National or Caribbean Islander 2 (3.7%) Middle Eastern 2 (3.7%) Native Hawaiian/ Pacific Islander 0 (0.0%) White 25 (46.3%) Multiracial 3 (5.6%) Other 1 (1.9%) Prefer not to answer 1 (1.9%) Gender identity Girl/woman 30 (55.6%) Boy/man 20 (37.0%) Nonbinary ( e.g . genderqueer, gender non-conforming, another nonbinary identity) 4 (7.4%) Sex assigned at birth Female 32 (59.3%) Male 22 (40.7%) Transgender No 52 (96.3%) Yes 2 (3.7%) Sexual orientation Straight/heterosexual 26 (48.1%) Bisexual 16 (29.6%) Gay or lesbian 5 (9.3%) Pansexual 4 (7.4%) Queer 2 (3.7%) Asexual 1 (1.9%) Type of residential area City/urban area 26 (48.1%) Suburban area 24 (44.4%) Small town/rural area 4 (7.4%) Type of school Public 40 (74.1%) Private 8 (14.8%) Charter 3 (5.6%) Other 3 (5.6%) Grade 9 th 1 (1.9%) 10 th 4 (7.4%) 11 th 10 (18.5%) 12 th 30 (55.6%) Other ** 9 (16.7%) Has ever received free or reduced lunch Yes 30 (55.6%) No 22 (40.7%) Unsure 2 (3.7%) Currently has IEP or 504 plan Yes 6 (11.1%) No 35 (64.8%) Unsure 11 (20.4%) Prefer not to answer 2 (3.7%) Open in a new tab Note. Mean ± standard deviation reported for continuous variables; Frequency (%) reported for categorical variables; * One participant was 18 years old when they completed the screener and 19 years old when they completed the baseline; ** Nine participants were seniors in high school when they completed the screener and were freshmen in college when they completed the baseline. The 23 participants who completed qualitative interviews were 17 years of age on average ( SD =1.0). Approximately half (48%) were Black/African American, 22% were White, 13% were Asian, 13% were multiracial, and 4% were African National or Caribbean Islander. Almost a quarter (22%) were Hispanic/Latine. Almost half identified as boys/men (48%), half as girls/women (48%), and one participant (4%) identified as gender non-binary or gender queer. About half (48%) reported being heterosexual, 22% gay or lesbian, 17% bisexual, 9% pansexual, and 4% asexual. Program feasibility Of the 54 participants, 77% ( n =42) began the activities, and 59% ( n =32) completed all six.. Of those who logged on to the website, most (93%, n =38) completed the “Test your knowledge!” game; 85% ( n =35) completed the “Is This For Real” game; 80% ( n =33) watched the “Condom Check” and “Fact or Fantasy” videos; and 78% ( n =32) completed the “Got Advice?” vignette response activity. Participants spent 1.5 to 7.5 minutes per activity, with most completing all the games and activities in one session. ( Table 3 ). Table 3. Health Relationships Program feasibility Contraception Selection Test Your Knowledge! Is This For Real? Video Events a Got Advice? Number of participants 31 38 35 33 32 Average time 0:01:21 0:03:32 0:05:38 0:07:05 0:07:39 Minimum time 00:00:17 0:00:16 0:00:00 ** 0:00:24 0:01:11 Maximum time 0:05:57 00:23:53 0:30:58 0:23:09 0:26:30 Number of sessions * Average 1.06 1.16 1.03 1.18 1.06 Min 1 1 1 1 1 Max 2 2 2 3 2 Open in a new tab Note: Time is listed in the hh:mm:ss format. For example 2:13:00 represents 2 hours, 13 minutes and 0 seconds. a. Video events include both the Condom Check and Fact or Fantasy videos * A session is defined as any amount of time that a participant was consistently engaged with the website. Any time that a participant started and stopped engagement, indicated by major time gaps (hours or days between engagements), we consider a new session to begin. The total time is calculated as the sum of time spent during each session. For example, image that participant ID 1 logged on to the Contraception Selection game on Tuesday, January 25, and was engaged from 11:24:36 am to 11:26:46 am (session one: 2 minutes and 10 seconds), but didn’t finish the activity in one sitting. The participant returned to the game later on that day and reengaged at 2:13:25pm and was engaged until 2:18:30pm (session two: 5 minutes and 5 seconds). The total time is the sum of the two sessions (7 minutes and 15 seconds) and NOT the entire time frame between 11:26:46am and 2:18:30pm. ** Participant appears to have opened the activity and closed it again within the same second. No additional engagements were made. Qualitative feedback on program length Many participants appreciated the games and activities on the website that were “short, concise and straight to the point” (16-year-old girl); participants especially liked the video about putting on a condom. For example, one 16-year-old girl said, “I really liked the video, and it didn’t feel like a documentary I was watching. It was a short, brief video that got all the points across.” Other participants described getting bored or skipping through activities that had too much text. As a different 16-year-old girl explained about her experience with the “Test your knowledge!” game: “I will say, for the answers that are correct and incorrect, I think that the explanations for it are just too long. My attention span is really short, as is my entire generation. So, the first question is what does HIV stand for. I read the first sentence, and I clicked next because I wanted to know the next sentence.” Qualitative feedback on website layout and usability Overall, participants liked the simplicity of the website and found it easy to use, but there were some technical issues with respect to usability on different devices. The activity that participants found the most difficult to play was the “Contraception Selection” game given that they found it hard to drag and drop the choices when they were playing on their cell phones. Despite the technical issues with that specific activity, most participants found the website easy to navigate and described the simple layout as visually appealing. In the words of one 17-year-old girl: It was visually appealing, which makes the person want to actually participate and do the activities. So, I think that was helpful. So, at first glance, it looked really nice and organized, and it was labeled nicely. So, I knew what each [activity] was gonna be about. So, I think that was really well done. Qualitative feedback on ways to improve engagement The most common suggestion participants gave for improving engagement and enrollment was to add an element that allowed participants to interact – either online or in-person – with other humans. Youth wanted the opportunity to get feedback from knowledgeable adults and to share ideas with their peers. An 18-year-old girl exemplified this sentiment when she said: And maybe there could be a group chat, more like a group class, on the website, where people come in weekly and they get new things, or if you have questions, you can always ask either on the group page or the website, or having a particular section to call into the counselor on the website, people going through relationship stress, or relationship struggle, or anything related to that. When talking about the “Got Advice?” game, many participants wanted an option to discuss the scenarios with peers. A 15-year-old boy explained that it would be helpful to “have many people coming together and sharing ideas [so] we could come up with a solution on how to deal with such events, such circumstances.” Relatedly, some participants that did not complete the intervention explained that it was because it was challenging to stay engaged in a purely online format. A 17-year-old boy explained it this way: And I feel like just learning, for me, it didn’t work that well. Just being very into visual and clicking through the screen there wasn’t any motivation to understand the topics that were shown, and also, connecting those facts to a broader issue, I guess. Other suggestions to increase engagement included adding a points system to the “Test Your Knowledge” game because, as a 18-year-old girl shared, “people […] would probably be interested to try and get the highest score.” A 17-year-old girl stated: I think this game would go over really well with other teens, especially those who are competitive. They’ll want to get every point right. And so, they’ll really think about each question and they’ll really learn from each question and their answers. Finally, many participants enjoyed the animation, especially in the videos, because it was fun and visually appealing. However, some participants suggested making the website more eye-catching and appealing overall to increase engagement. An 18-year-old boy said: I think it’s very informative, and the information passed across is very good and relevant to teenagers out here. But the only problems I had were some of the games are a little boring because they are just plain text, or the graphics are not enticing. Program acceptability Across all activities, participants rated the content 4.6 stars out of 5 ( SD =0.21). Average ratings ranged from 4.38 to 4.90 stars with the Get Help section ( M =4.90 stars) and the “Fact or Fantasy?” game ( M =4.86 stars) having the highest average star scores and the “Contraception Selection” game ( M =4.38 stars) and the “Got Advice” game ( M =4.48 stars) having the lowest scores ( Table 4 ). When asked about overall satisfaction with the program, 62% reported it was “good” and an additional 18% reported it was “excellent.” Almost all (98%) reported that the information about sexual health and relationships was useful, and 80% reported their informational needs were met by the program. Table 4. Health Relationships Program acceptability Game Average rating Min rating Max rating A: Contraception Selection 4.38 2 5 A: Condom Check 4.70 4 5 B: Test Your Knowledge! 4.50 3 5 C: Is This For Real? 4.48 2 5 C: Fact or Fantasy? 4.86 4 5 D: Got Advice? 4.45 3 5 Get Help 4.90 4 5 Overall 4.60 2 5 Open in a new tab A=Pregnancy prevention activities; B=HIV/STI prevention activities; C=Pornography literacy activities; D=Healthy relationships activities Qualitative feedback on content Many participants perceived the information on the website as educational and felt that they learned new things that are applicable to their lives. As a 15-year-old boy said, “I thought it was great, really. It had a lot of fun activities that were also very educational, especially for me, who is a teenager doing all this stuff. And it was very helpful because it’s a lot like sex ed that [teens] don’t really get in school. But it’s needed.” A 16-year-old girl further explained: I think overall, I like the concept or the fact that it’s just trying to get teens to learn more about sexual education because it’s obviously, like not really spoken about, especially in high school, and it should be talked about. And [it has] a lot of things that schools shy away from, especially talking about pornography […] it almost feels illegal to talk about, to be honest, because it’s not spoken about in health class and things like that. It’s just briefly mentioned. An 18-year old boy echoed this sentiment: I do appreciate the fullness of the content on the website because [it] actually [has] a lot of information that a lot of people in sexual education actually shy away about. And so, you have everything that’s combined into this one website that has all of the actual things that people will use [when] looking for what it means to like get consent. Or what is birth control or something like that […] And so, the content on this actually would be very beneficial compared to like standard high school, middle school sexual education courses. Participants also found the program website to be a trustworthy source of information and appreciated that it covered different scenarios and information about a wide variety of relationship types. As one 17-year-old girl explained: It was really interactive, and it made learning about these things easier to do, I guess. Because you can hear about it from teachers, or your parents, or something like that. But it can mean more when it’s coming from a polished piece of, I don’t know, something online that you know is backed up with evidence and stuff. So, hearing it from that kind of standpoint, that was really helpful. Another 17-year-old girl put it this way: In all, it was a good experience, and I think the inclusivity and nonjudgmental aspect of it is really unique to this website and it’s really good, because I never felt like there was something missing from my experience or my friends’ experience. It felt like it covered everything. Finally, all participants in the qualitative interviews reported that they would recommend the program to other teens for informational purposes. Participants supported using the program in schools, having parents share it with their teens, and sharing it with their friends and peers. As a 16-year-old girl said: I definitely think all schools should use this website in addition to their own curriculum for sexual education. I think it’s a really interactive activity and engaging way to teach sex ed versus just the normal classroom setting. It’s another thing that the students can go and see themselves. Participants also explained that when they fail to get information from their parents or at school, they confide in friends and peers, but that friends and peers are often unequipped to answer each other’s questions. As such, many participants expressed that they would direct friends to this program for information. As a 16-year old girl stated: If my friends were having questions that I couldn’t answer myself, I think this website is – I think it’s almost like an encyclopedia for sex ed. It’s really easy and really accessible, and I think the information given out is very helpful. So, I would feel confident in referring a friend to the website for informational purposes. Overall, teens stated that they would “definitely” recommend the program to others because, as one 18-year-old boy stated, “it’s educative and has information that would not be shared in the classroom,” and they “would want [others] to have same knowledge as [them].” Assessment of potential impact on sexual health outcomes: Intent-to-treat sample Unadjusted values of the primary efficacy outcomes pre- and post-test are presented in Table 5 . Analyses of the intent to treat sample indicate statistically significant improvements in the number of condom-protected sexual encounters, proportion of condom protected sexual encounters, experiences of dating violence, intentions to use condoms, HIV knowledge, STI knowledge, and pornography literacy. Specifically, there was a 54% increase in the number of condom-protected sexual encounters at follow-up compared to baseline ( RR =1.54 95% CI :1.07–2.76). Average scores on the dating violence questionnaire decreased at follow-up compared to baseline ( b =−.36, SE =.12, p =.01), suggesting that participants were less likely to be involved in dating abuse as a victim and/or perpetrator. HIV and STI knowledge scores improved from baseline to follow-up ( b =.66, SE =.12, p <.001 for HIV knowledge and b =.53, SE =.15, p =.001 for STI knowledge). Moreover, intentions to use condoms increased at follow-up such that at post intervention, 93% of participants who felt they were likely to have sex in the next 3 months reported being likely or highly likely to use a condom. At baseline, this figure was 84%. Finally, the total average score on the pornography literacy scale improved between baseline and follow-up ( b =.56, SE =.14, p <.001). Table 5. Assessment of the potential impact of the Health Relationships Program on sexual health outcomes: Intent to treat analysis * Efficacy outcome Pre-test ( n =54) Post-test ( n =42) P-value Condom use Times used in the past 90 days ( M , SD ) 3.38 (2.91) 5.22 (5.43) <.001 Proportion of Protected Events 77.99% 86.57% <.001 Dating violence score a ( M , SD ) 6.04 (8.75) 5.00 (6.66) .01 Intention to use condoms ( n , % ) <.001 Very unlikely 7 (13.0%) 1 (2.3%) Unlikely 0 (0.0%) 2 (4.7%) Likely 8 (14.8%) 12 (27.9%) Very likely 37 (71.2%) 28 (65.1%) HIV Knowledge score b ( M , SD ) 5.96 (2.70) 7.43 (2.60) <.001 STI Knowledge score b ( M , SD ) 6.33 (3.56) 9.02 (3.84) <.001 Pornography literacy score c ( M , SD ) 45.72 (11.67) 55.91 (11.66) <.001 Open in a new tab * Sample includes all enrolled participants regardless of the amount of data contributed. P-value refers to within-group change pre to post. a Lower scores indicate less unhealthy relationship behavior experiences. b Higher scores indicate greater knowledge. c Higher scores indicate greater pornography literacy. Assessment of potential impact on sexual health outcomes: Per-Protocol Sample When analyses were restricted to the per-protocol sample ( N =42), the same pattern of findings emerged with more pronounced effects, with the exception of dating violence, which was no longer significant, likely because of the reduction to a smaller sample, resulting in less power. A full description is provided in Table 6 . Specifically, the number of condom-protected sexual encounters and the proportion of condom-protected sexual encounters was higher post-intervention, and improvements were seen in intention to use condoms, HIV knowledge, STI knowledge, and pornography literacy, all with p’s<.05. Table 6. Assessment of the potential impact of the Health Relationships Program on sexual health outcomes: Per-protocol analysis Efficacy outcome Pre-test ( n =42) Post-test ( n =42) P-value Condom use Times used in the past 90 days ( M , SD ) 3.69 (3.09) 4.87 (4.41) .04 Proportion of Protected Events 80.35% 90.89% .01 Dating violence score a ( M , SD ) 5.33 (8.83) 5.27 (7.08) .96 Intention to use condoms ( n , % ) .001 Very unlikely 7 (17.1%) 1 (2.6%) Unlikely 0 (0.0%) 2 (5.3%) Likely 6 (14.6%) 10 (26.3%) Very likely 28 (68.3%) 38 (65.8%) <.001 HIV Knowledge score b ( M , SD ) 6.02 (2.56) 7.43 (2.60) <.001 STI Knowledge score b ( M , SD ) 6.33 (3.56) 9.02 (3.84) <.001 Pornography literacy score c ( M , SD ) 47.28 (11.08) 57.28 (10.90) <.001 Open in a new tab P-value refers to within-group change pre to post. a Lower scores indicate less unhealthy relationship behavior experiences. b Higher scores indicate greater knowledge. c Higher scores indicate greater pornography literacy. Assessment of potential impact on sexual health outcomes: Potential Moderators Across outcomes, models did not show significant moderating effects of age or sexual orientation ( p ’s>.10). However, there was some indication of differences in changes in preliminary efficacy outcomes by gender. Unadjusted estimates show that among boys, mean STI knowledge was 7.24 ( SD =3.87) at baseline and 9.24 ( SD =3.42) at follow-up. For girls, mean STI knowledge scores were 6.07 ( SD =4.29) at baseline and 8.86 ( SD =4.23) at follow-up. For nonbinary participants, these scores went from 5.67 ( SD =3.79) at baseline to 9.00 ( SD =4.00) at follow-up. Models indicate significant improvements in STI knowledge over time for boys ( b =.47, SE =.22, p =.04) and girls ( b =.52, SE =.23, p =.03), with relatively equal magnitude, but not for non-binary participants ( b =.98, SE =.40, p =.25). A similar pattern of findings was observed for HIV knowledge, with no effects among non-binary participants ( p ’s>.43). Unadjusted estimates showed increases from 7.05 ( SD =2.06) to 8.12 ( SD =1.69) for boys, 5.10 ( SD =2.91) to 7.05 ( SD =2.95) for girls and 7.00 ( SD =1.73) to 6.33 ( SD =4.04) for nonbinary participants. For pornography literacy, unadjusted changes were 45.95 ( SD =13.79) to 57.53 ( SD =12.44) for boys, 45.50 ( SD =10.50) to 55.22 ( SD =11.60) for girls and 45.67 ( SD =2.52) to 52.00 ( SD =9.17) for nonbinary participants. Models showed significant changes over time for boys ( b =.71, SE =.16, p =.001) and non-binary participants ( b =3.62, SE =.27, p =.04), but not for girls ( b =.19, SE =.26, p =.48). There were no differences in effects by gender for number of condom-protected sexual encounters, proportion of condom-protected sexual encounters, or intention to use condoms. DISCUSSION Increasing the percentage of youth who receive formal, comprehensive sex education before age 18 is a public health priority in the U.S. ( Office of Disease Prevention and Health Promotion, 2022 ). Despite a stated desire by adolescents, health teachers, school administrators, and sex education experts to include more comprehensive and up-to-date sex education in high school health education curricula, including discussions of pornography, there are mounting barriers to providing education that addresses contemporary sexual health concerns ( e.g ., healthy relationships, HIV/STIs, pregnancy prevention, pornography use) in secondary school settings ( Nelson et al., 2024 ; Rothman et al., 2023 ). Barriers include both political pushback and the limited time allotted to health educators to focus on sex education ( Associated Press, 2023 ; LaMarche, 2023 ; Moms for Liberty, 2023 ; Nelson et al., 2024 ). The online, self-paced, self-delivered Healthy Relationships Program was developed to address these barriers in two ways. First, it aligns with the new Massachusetts framework for health education and recommendations from Massachusetts high school students, health teachers, and administrators ( Massachusetts Department of Elementary and Secondary Education, 2023 ; Nelson et al., 2024 ; Rothman et al., 2023 ). It is also responsive to calls that sexual education contain information about healthy relationships and pornography ( Baker, 2016 ; Cerbara et al., 2023 ; Dawson et al., 2020 ; ETR, 2021 ; Fitzpatrick et al., 2022 ; Rodríguez-Castro et al., 2021 ; Srivastava et al., 2023 ). Second, the Healthy Relationships Program is a stand-alone, online program that can be completed outside of the classroom as a homework assignment. This ensures that it will not require health educators to incorporate this information into their already limited classroom time. The results of this pilot study indicate that the Healthy Relationships Program is feasible, acceptable, and may positively impact sexual health behaviors and knowledge. Feasibility and acceptability Consistent with research supporting the use of online methods for the provision of sex education content to adolescents and previous pilot tests of pornography education interventions with adolescents ( Nelson et al., 2022 ; Rothman et al., 2018 , 2020 ), the Healthy Relationships Program was feasible and acceptable ( E. Chen & Barrington, 2017 ; M. Chen et al., 2023 ; Green et al., 2015 ; Muller et al., 2017 ; Mustanski et al., 2015 ; Nelson et al., 2022 ; Rothman et al., 2018 , 2020 ; Van Lieshout et al., 2017 ; Widman et al., 2018 ). A diverse sample of 54 Massachusetts high school students were recruited efficiently, and retention was high at three-month follow-up. Further, most participants logged into the program website, completed all of the content in one sitting, and took less than 30 minutes to do so. Participants also reported finding the program helpful, engaging, and inclusive. Multiple participants in the qualitative interviews noted that the program provided critical information that is not currently covered in their high school curricula. Although most participants enjoyed and engaged with the program content, participants also had suggestions for ways to make the Healthy Relationships Program more compelling, including adding peer interaction during the program, additional gamification by creating a scoring system, and revising content to include less text. Potential impact on sexual health outcomes In addition to being feasible and acceptable, a preliminary assessment of potential sexual health impacts of the Healthy Relationships Program suggests that the program may have positively impacted the sexual health outcomes of participants. As compared to prior to the intervention, after participating in the program, there were significant improvements in the number of condom-protected sexual encounters, proportion of condom-protected sexual encounters, experiences of dating violence, intentions to use condoms, HIV knowledge, STI knowledge, and pornography literacy. Notably, these improvements were consistent across participant age and sexual orientation, indicating that the program has the potential to work effectively for high school students in all grades and with any sexual orientation. Improvements in the three sexual behavior outcomes ( i.e ., number of condom-protected sexual encounters, proportion of condom-protected sexual encounters, and intention to use condoms) were also observed among participants of all genders, indicating that the program may beneficially impact these behavioral outcomes of high school students of any gender. We did see some indication of potential differences in the influence of the program on knowledge outcomes ( i.e., STI/HIV knowledge, pornography literacy) by gender. Statistically significant improvements in HIV/STI knowledge were seen for girls and boys, but not for non-binary participants. This may be attributable to the smaller number of non-binary participants, because the magnitude of improvement in HIV/STI knowledge for non-binary participants was larger than the improvement observed for boys and girls. Lastly, for knowledge about pornography, improvements over time were observed for boys and non-binary participants, but not for girls. It is possible that more improvement was seen among boys and non-binary participants because the information was more salient to them as boys and non-binary adolescents are more likely to view pornography compared to girls, and male adolescents are more likely to report pornography as a useful source of sexual health information ( Bőthe et al., 2020 ; Rothman et al., 2021 ). Our results are consistent with prior studies that have similarly investigated the impact of self-delivered, self-paced, online sex education programs for youth. For example, a 16-session pregnancy and HIV prevention intervention, originally designed for classroom presentation by a teacher, was successfully adapted to be delivered online in rural high schools in North Carolina ( E. Chen & Barrington, 2017 ). Similarly, an 8-session online, educational intervention on reproductive health, pregnancy, sexual health and relationship health delivered to 10 th grade students in China was found to have a positive effect on sexual and reproductive health knowledge ( M. Chen et al., 2023 ). Online interventions for undergraduates, women ages 15–30 years old in the United Kingdom, and 16–19-year-old women in the U.S. have also been found to be engaging, feasible, and helpful ( Saucier et al., 2022 ; Stephenson et al., 2020 ; Yoost et al., 2021 ). A review of technology-based sexual health interventions conducted in 2018, inclusive of 16 studies, found that there were protective effects on condom use behavior, abstinence, sexual health knowledge, safer sex attitudes, and social norms related to safer sex ( Widman et al., 2018 ). In sum, evidence has been accruing for more than a decade that substantiates the idea that online, self-delivered sex education can be efficacious. Our findings extend existing evidence, as it appears that the Healthy Relationships Program is feasible, acceptable, and may have a positive impact on the sexual health outcomes U.S. high school students. Limitations There are limitations to this study that should be considered. First, the sample is limited to high school students in Massachusetts. Massachusetts is a relatively progressive state with a robust public education system, which may make Massachusetts schools and students more amenable to the inclusion of the developed intervention as a homework assignment. As such, it is possible that the results would be different in a different state or context. This study also did not include a control group. Thus, the observed pre-post changes may be due to factors other than the intervention. A larger evaluation of the intervention via a randomized controlled trial is warranted. Further, although it is a strength of the study that 77% of youth engaged with the intervention, there were 23% who did not engage. There are many potential reasons a youth may not have engaged with intervention content, including technical difficulties signing on to the website, the emails with login information going to their spam folder, or that intervention engagement was not incentivized. Additional information about why they did not engage, and how future iterations could encourage even more participation, would be useful. As this program is designed to be given as a homework assignment it is possible that simply having it as a required part of a class will be enough to increase engagement. Additionally, our dating violence measure instructed participants to think about events in the past year, instead of only in the past three months. Because the measure referred to the past year at both baseline and follow-up, the window for events overlapped. This may explain why significant differences in experiences of dating violence were no longer observed in the per-protocol analysis. In the future, this measure should be limited to a recall period of three months to match the follow-up period. Lastly, although we took multiple steps to ensure that potential participants were eligible and not fraudulent, it is still possible that fraudulent participants may have been included in the sample. Conclusion Overall, our conclusion is that the Healthy Relationships Program was feasible, acceptable, and may have positively impacted sexual health outcomes among Massachusetts high school students. As such, a fully powered, randomized controlled, efficacy trial with a longer follow-up period is warranted. Ideally, that trial would be conducted in high schools across multiple states to ensure efficacy across different educational and political contexts. That said, conducting such a study is likely to prove challenging given the current political climate and the pervasive cultural norms that limit discussions about sex in the U.S. ( di Mauro & Joffe, 2007 ; Zimmerman, 2022 ). Our formative work with high school administrators and teachers indicates that to move this program forward within high schools, it will be imperative to engage parents, teachers, and administrators early in the implementation process and to gather their feedback in advance of any adaptations that are made to incorporate the suggestions of the pilot participants ( Nelson et al., 2024 ). Further, given that differences by gender were observed among the pilot participants, it will be important for any future trials of this program to assess for and potentially address these differences to ensure that the program works for adolescents of all genders. As adolescents in the U.S. continue to face a significant sexual health burden, including high rates of STIs and pregnancy, there is a clear need for sex education programs that address the current needs of students and include content specific to healthy relationships, HIV/STI and pregnancy prevention, and pornography use ( Centers for Disease Control and Prevention, 2021 ; The Lancet Child & Adolescent Health, 2022 ). The Healthy Relationships Program has the potential to be a beneficial addition to the sex education content already being provided in high schools and provides a tangible intervention to address students’ contemporary sexual health needs. Acknowledgements: We would first like to thank our participants. 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