Patterns of digital health access and use among US adults: A latent class analysis.

Background Digital technologies allow users to engage in health-related behaviors associated with positive outcomes. We aimed to identify classes of US adults with distinct digital technologies access and health use patterns and characterize class composition. Data came from Health Information National Trends Survey Wave 5 Cycles 1-4, a nationally representative cross-sectional survey of US adults ( N = 13,993). We used latent class analysis to identify digital technologies access and health use patterns based on 32 behaviors and access to requisite technologies and platforms that include the internet, internet-enabled devices, health monitors, and electronic health records (EHRs). We ran a multinomial logistic regression to identify sociodemographic and health correlates of class membership ( n = 10,734). Results Ten classes captured patterns of digital technology access and health use among US adults. This included a digitally isolated, a mobile-dependent, and a super user class, which made up 8.9%, 7.8%, and 13.6% of US adults, respectively, and captured access patterns from only basic cellphones and health monitors to near complete access to web-, mobile-, and EHR-based platforms. Half of US adults belonged to classes that lacked access to EHRs and relied on alternative web-based tools typical of patient portals. The proportion of class members who used digital technologies for health purposes varied from small to large. Older and less educated adults had lower odds of belonging to classes characterized by access or engagement in health behaviors. Hispanic and Asian adults had higher odds of belonging to the mobile-dependent class. Individuals without a regular healthcare provider and those who had not visited a provider in the past year were more likely to belong to classes with limited digital technologies access or health use. Discussion Only one third of US adults belonged to classes that had near complete access to digital technologies and whose members engaged in almost all health behaviors examined. Sex, age, and education were associated with membership in classes that lacked access to 1 + digital technologies or exhibited none to limited health uses of such technologies. Results can guide efforts to improve access and health use of digital technologies to maximize associated health benefits and minimize disparities.

Noncigarette Tobacco Product Use Among Smoking-Susceptible and Nonsusceptible Adolescent Never Smokers, 2009-2021.

PURPOSE: Examine trends in noncigarette tobacco use among smoking susceptible and nonsusceptible adolescents from 2009-2021. METHODS: Data came from cross-sectional samples of the National Youth Tobacco Survey (N = 183,198). Using Pierce's smoking susceptibility scale, participants were classified as either susceptible or nonsusceptible to cigarette smoking. Their use of noncigarette tobacco products was classified into four mutually exclusive categories: nonuse, noncigarette combustibles use, noncombustibles use, and noncigarette combustibles and noncombustibles dual use. We produced covariate-adjusted predicted marginal proportions of noncigarette tobacco use for 12 National Youth Tobacco Survey years, which were entered into Joinpoint trend analysis software to determine (a) trends in noncigarette tobacco use from 2009-2021 using the average annual percent changes (AAPCs) and (b) changes in each time segment using the average percent change. Models were fitted by smoking susceptibility, sex, and race/ethnicity. RESULTS: Nonuse was lower among susceptible (vs. nonsusceptible) adolescents whereas noncigarette tobacco use was higher. Trends show significant declines in nonuse (nonsusceptible: AAPC = -0.3%) and noncigarette combustibles use (susceptible: AAPC = -12%) between 2009-2021, increases in noncombustibles use (susceptible: AAPC = 18%, nonsusceptible: AAPC = 19%) between 2009 and 2019, and steadiness in dual use. Parallel trends were observed when stratified by sex and race/ethnicity with notable increases in noncombustibles use among females and Latinos. DISCUSSION: Noncigarette tobacco use differed by smoking susceptibility. Observed trends, especially when stratified by sex and race/ethnicity, raise concerns about tobacco use disparities among females and Latinos. Smoking susceptibility can help identify at-risk adolescents for current or future tobacco use.

Intervention targeting and retention, engagement and abstinence outcomes among Latino and White users of Smokefree.gov text messaging programmes: a cross-sectional study.

Background: We examined retention, engagement, and abstinence among Latino users of SmokefreeTXT en Español (SFTXTesp), a Latino-targeted text messaging smoking cessation intervention, and Latino and White users of SmokefreeTXT (SFTXT), a non-targeted intervention. Methods: Data came from 12281 users (1562 Latino SFTXTesp users and 2301 Latino and 8418 White SFTXT users). We conducted time-to-dropout analyses by race/ethnicity. Using logistic regression, we examined associations between intervention targeting, race/ethnicity, and responses to smoking status prompts, an engagement metric, and self-reported abstinence on quit day, intervention end, and one-month follow-up. Age, gender, census region, smoking frequency, cigarettes smoked per day, prequit time, and number of quit attempts were covariates. Results: Latinos in SFTXTesp (aOR 0.63) and SFTXT (0.88) were less likely to drop out of the intervention than Whites. SFTXTesp Latino users had higher response rates to smoking prompts than SFTXT Latinos users (aORs 1.35, quit day; 1.84, intervention end; 1.82, one-month follow-up). However, SFTXTesp and SFTXT Latino users had lower response rates than Whites (aORs 0.68, 0.45, quit day; 0.60, 0.30, intervention end; 0.64, 0.33, one-month follow-up). Abstinence was equivalent among Latinos in SFTXTesp and SFTXT interventions, but Latinos using SFTXTesp and SFTXT were less likely to be abstinent than Whites (aORs 0.42, 0.41, quit day; 0.45, 0.37, intervention end; and 0.53, 0.35, one-month follow-up). Conclusion: Linguistic intervention targeting improved retention and engagement among Latinos, but not abstinence. Latinos had higher retention but lower engagement and abstinence rates than Whites. Cultural targeting may engage Latinos in smoking cessation interventions and improve abstinence.

Barriers to Seeking Medical Care Among Youth Victims of Sexual Violence.

PURPOSE: Youth victims of sexual violence often experience physical health problems but are unlikely to receive medical care. However, victims' reasons for not accessing medical care have been understudied. We examined barriers to seeking medical care among youth victims who contacted the National Sexual Assault Online Hotline. METHODS: We used archival data about one-on-one chat sessions with youth victims between June 2018 and February 2020. Hotline staff described victims' reasons for not accessing medical care via an online assessment. We coded and qualitatively examined these reasons using data about 520 victims with physical health concerns who had not received medical care. RESULTS: Victims' barriers were rooted in individual beliefs and contextual realities reflected in three categories: (1) perception that medical care was not needed, (2) anticipated consequences of seeking medical care, and (3) inability to physically access medical care. Victims who perceived care as unnecessary did not understand the health implications of abuse or minimized their need for care. Anticipated consequences included privacy and control over disclosure, stigmatization, retaliation from the perpetrator, family disruptions, and retraumatizing medical treatment. Victims unable to physically access care were uncertain how to access care independently, lacked social support, or were prevented from care by the perpetrator. DISCUSSION: Medical treatment can ameliorate acute health concerns and increase safety, but youth victims perceived numerous barriers to care. Several barriers implied unintended consequences of child maltreatment policies, including mandatory reporting. Trauma-informed policy and practice are critical for improving victims' access to medical care and other support services.

Online Help-Seeking Among Youth Victims of Sexual Violence Before and During COVID-19 (2016-2021): Analysis of Hotline Use Trends.

BACKGROUND: Three years since the onset of COVID-19, pandemic-related trends in child sexual abuse (CSA) remain poorly understood. Common administrative surveillance metrics may have underestimated abuse during the pandemic, given youths' limited access to mandatory reporters. Research using anonymous service-use data showed increased violence-related online help-seeking but overlooked youth-specific help-seeking for CSA during COVID-19. Understanding pandemic-related trends in CSA can inform abuse detection practices and mental health service provision for youth victims. OBJECTIVE: The purpose of this study was to harness anonymous help-seeking data from the National Sexual Assault Online Hotline (NSAOH) to glean insights about CSA occurrence in the United States during the COVID-19 pandemic. METHODS: We used an archival sample of victims who contacted NSAOH from 2016 to 2021 (n=41,561). We examined differences in the proportion of youth and adult victims contacting NSAOH during the first COVID-19 year (March 2020 to February 2021) compared to the prior year (March 2019 to February 2020; n=11,719). Further, we compared key characteristics of hotline interactions among youth victims during the first COVID-19 year to the prior year (n=5913). Using joinpoint regression analysis, we examined linear trends in the number of monthly sampled youth and adult victims (excluding victims of unknown age) from 2016 to 2021 who discussed any victimization event (n=26,904) and who discussed recent events (ie, events occurring during the pandemic; n=9932). RESULTS: Most youth victims were abused by family members prior to (1013/1677, 60.4%) and after (2658/3661, 72.6%) the onset of COVID-19. The number of youth victims contacting NSAOH spiked in March 2020 and peaked in November 2020 for all youth (slope=28.2, 95% CI 18.7-37.7) and those discussing recent events (slope=17.4, 95% CI 11.1-23.6). We observed a decline in youth victims into spring 2021 for all youth (slope=-56.9, 95% CI -91.4 to -22.3) and those discussing recent events (slope=-33.7, 95% 47.3 to -20.0). The number of adult victims discussing any victimization event increased steadily from January 2018 through May 2021 (slope=3.6; 95% CI 2.9-4.2) and then declined (slope=-13.8, 95% CI -22.8 to -4.7). Trends were stable for adults discussing recent events. CONCLUSIONS: This study extends the use of hotline data to understand the implications of the pandemic on CSA. We observed increased youth help-seeking through the NSAOH coinciding with the onset of COVID-19. Trends persisted when limiting analyses to recent victimization events, suggesting increased help-seeking reflected increased CSA during COVID-19. These findings underscore the utility of anonymous online services for youth currently experiencing abuse. Further, the findings support calls for increased youth mental health services and efforts to incorporate online chat into youth-targeted services.

Survivors' Concerns During the COVID-19 Pandemic: Qualitative Insights From the National Sexual Assault Online Hotline.

With the onset of the COVID-19 pandemic and the implementation of stay-at-home orders in March 2020, experts warned of the possible threat of increased interpersonal violence among individuals isolated with abusers. Researchers have sought to understand how the pandemic impacted victims primarily through the analysis of administrative data sources, such as hospital and police records. However, the preponderance of this data shows a decrease in formal help-seeking among victims during the pandemic, speaking to an impaired access to services but limiting our understanding of other ways in which the pandemic has affected survivors. To overcome these limitations, we examined data collected about users of the National Sexual Assault Online Hotline (NSAOH). Information was collected through staff based on retrospective recall following one-on-one chat sessions with 470 victims of sexual violence who contacted the NSAOH in the first six months of the pandemic and discussed COVID-19-related concerns. We qualitatively examined open-ended descriptions of COVID-19-related concerns and identified the four most common: (1) mental health concerns, (2) creation or exacerbation of an unsafe living situation, (3) not being able to access services, and (4) not having access to a mandatory reporter or trusted adult. These findings demonstrate the myriad ways in which the pandemic affected the lives of victims of sexual violence and can inform practices for services and practitioners to best meet the needs of survivors moving forward. Specifically, these findings highlight the need for more accessible mental health services and funding for sexual assault service providers, as well as the importance of safety planning, particularly in times of crisis.

Multilevel Barriers to Sexual Health Behavior Among Vulnerable Adolescent Girls in the USA.

Introduction: Most sexual health interventions focus on individual-level predictors of sexual behavior. Given the considerable influence of environmental factors on adolescent girls' sexual health, current interventions may be insufficient to promote safer sex. In this study, we aimed to understand adolescent girls' anticipated barriers to engaging in safer sex behavior after completing a brief, web-based sexual health intervention called HEART. Methods: This study used qualitative interviews with 50 adolescent girls who were recruited from community-based organizations that serve vulnerable youth. All participants were 12 to 19 years old (mean age=15.62, SD=1.83), and identified with a marginalized racial/ethnic group (58% Black; 18% Latinx; 24% Asian, biracial, or multiracial). Further, 24% identified as LGBTQ+, and 58% were sexually active. Results: Guided by the social ecological model, we delineate six unique barriers to safer sex discussed by adolescents: partner manipulation, slut shaming, unclear sexual values, present time orientation, embarrassment, and access to sexual and reproductive health services. Discussion: We conclude with recommendations for addressing these barriers to optimize adolescent girls' sexual health.

Dropout, response, and abstinence outcomes of a national text-messaging smoking cessation intervention for teens, SmokeFreeTeen.

Although text-messaging interventions are effective for smoking cessation, few target teens in the USA and little is known about their effectiveness. The purpose of this manuscript is to examine correlates of dropout, response to smoking status prompts, and abstinence rates among subscribers of SmokeFreeTeen, a free, publicly available text-messaging smoking cessation intervention sponsored by the National Cancer Institute's SmokeFree.Gov initiative, on quit day through 1 month follow-up. In a sample of teens (N = 2,685), aged 13-19, we examined demographics, smoking frequency, cigarettes smoked per day, prequit intervention time (i.e., maximum of 14 days of prequit day preparation), and number of quit attempts as correlates of response and abstinence rates among program initiators (i.e., participants who reached quit day but dropped out on or before intervention end) and completers (i.e., participants who reached quit day and completed the intervention). We also conducted Cox regression analysis of time from quit day to dropout by daily and nondaily smoking status. Two-thirds (n = 1,733, 64.54%) dropped out before the intervention ended, with dropout rates peaking on quit day (n = 289, 13.10%). Response rate to smoking status prompts remained below 30% throughout the intervention. At intervention end and 1 month follow-up, abstinence was 2.63% and 2.55% among program initiators, whereas abstinence was 6.09% and 6.01% among program completers. Dropout, response, and abstinence rates did not consistently differ by subscriber characteristics. Prequit time was associated with decreased likelihood of dropping out (adjusted hazards ratio: 0.94, confidence interval [CI]: 0.93-0.95), responding to smoking status prompts (adjusted odds ratio [aOR]: 0.94, CI: 0.92-0.96), and being abstinent (aOR: 0.96, CI: 0.93-0.99) on quit day. Two or more quit attempts were associated with increased response (aOR: 1.61, CI: 1.16-2.23) and abstinence (aOR: 1.91, CI: 1.25-2.92) rates on Day 7. In a first assessment of SmokeFreeTeen outcomes, we document high dropouts and low response and abstinence rates. SmokeFreeTeen produced abstinence rates lower than comparable text-messaging interventions targeting teens and young adults. Improving SmokeFreeTeen's reach, engagement, and effectiveness is needed.

Adolescent Smoking Susceptibility: Gender-Stratified Racial and Ethnic Differences, 1999-2018.

INTRODUCTION: Susceptibility, or openness to smoking, is a predictor of future smoking. This study examines within-gender racial/ethnic differences in smoking susceptibility over historical time (1999-2018) and developmental age (11-18 years). METHODS: Data were obtained from 205,056 adolescent never smokers in 14 waves of the National Youth Tobacco Survey. Weighted time-varying effect models were used to estimate nonlinear trends in smoking susceptibility among minority (versus white) adolescents. Analyses were conducted in 2019. RESULTS: Compared with whites, Latino/a adolescents were consistently more susceptible to smoking, whereas black and Asian adolescents fluctuated between being less and equally susceptible over time. American Indian, Alaska Native, Native Hawaiian, and Pacific Islander adolescents were more susceptible from 2014 to 2017, with differences being larger for girls. Susceptibility peaked at age 14 years. Compared with whites, Latino/a adolescents were more susceptible throughout adolescence. Black adolescents were more susceptible in early adolescence, whereas Asian adolescents were less or equally susceptible to smoking in early to mid-adolescence. American Indian, Alaska Native, Native Hawaiian, and Pacific Islander girls were more susceptible in early and mid-adolescence, but boys were more susceptible in early adolescence only. American Indian, Alaska Native, Native Hawaiian, and Pacific Islander girls were less susceptible than white girls aged 18 years. CONCLUSIONS: Twenty-year racial/ethnic differences in smoking susceptibility were evident, particularly among girls, but were mostly equivalent between genders over developmental age. Targeting susceptible adolescents with gender-, race/ethnic-, and age-tailored prevention efforts may prevent or delay adolescents' transition to tobacco use and reduce tobacco-related disparities.

Understanding Adolescents' Attitudes Toward Affirmative Consent.

A clear understanding of sexual consent is important for sexual violence prevention. To date, most research has focused on how college students understand and negotiate consent. Although adolescence is a critical period for the development of sexual attitudes, identity, and intimate relationships, the perspectives of high school-aged youth have been largely absent from the consent literature. The current study investigated adolescents' attitudes toward affirmative consent in a sample of 226 high school students (58% female; 46% White, 24% Black, 25% Hispanic) from the southeastern U.S., as well as associations between affirmative consent attitudes and gender, gender role beliefs, and sexual activity status. Additionally, we tested whether gender role beliefs were a mediator between gender and affirmative consent attitudes. Overall, adolescents reported supportive attitudes toward affirmative consent. On average, girls and adolescents with more egalitarian gender role beliefs had more positive attitudes toward affirmative consent than boys and those with less egalitarian gender role beliefs, though no differences by sexual activity status were found. Gender role beliefs mediated the relationship between gender and attitudes toward affirmative consent. The results suggest that adolescents are generally supportive of affirmative consent practices, although some important group differences emerged.

Feasibility, Acceptability, and Preliminary Efficacy of a Brief Online Sexual Health Program for Adolescents.

This study evaluated the feasibility, acceptability, and preliminary efficacy of a 45-minute interactive, online sexual health program for adolescents, called Health Education and Relationship Training (HEART). The program was originally developed and evaluated among adolescent girls (HEART for Girls); the current project describes and evaluates a new version of the program that was adapted for boys and girls. Participants were 226 high school students (mean age = 16.3; 58% girls; 46% White; 79% heterosexual). Students were randomized to HEART or an attention-matched control and assessed at pre-test and immediate post-test. Overall, the program was feasible to administer in a school setting and youth found the program highly acceptable (83% liked the program, 87% learned new things, and 93% would use program content in the future). At post-test, students who completed HEART demonstrated improvements on every outcome we examined: sexual communication intentions, condom use intentions, HIV/STD knowledge, condom attitudes, condom norms, self-efficacy to practice safer sex, and sexual assertiveness compared to control participants (effect size ds = .23 to 1.27). Interactions by gender and sexual orientation revealed the program was equally acceptable and worked equally well for boys and girls and for heterosexual and sexual minority youth. We propose several avenues to further adapt and tailor HEART given its promise in promoting adolescent sexual health.

Safer Sex Communication and Sexual Health Behaviors Among a Representative Statewide Sample of Homeless Adolescents.

Homeless adolescents are at substantial risk of human immunodeficiency virus (HIV), other sexually transmitted infections (STIs), and unplanned pregnancy; however, little research has assessed factors, such as safer sex communication, that may protect homeless adolescents against these negative outcomes. Using the 2015 North Carolina Youth Risk Behavior Survey (YRBS; unweighted N = 5,486; ages 12 to 18; 5% homeless), we compared homeless adolescents' primary safer sex communication sources (i.e., health care providers, parents, teachers, peers, religious leaders) to housed adolescents' communication sources and assessed how these sources relate to sexual health behaviors, including condom use, HIV testing, and number of sexual partners. Most homeless adolescents (61%), and 46% of housed adolescents reported having questions about sex. Further, twice as many homeless adolescents communicated primarily with health care providers compared to housed adolescents. Importantly, among homeless adolescents, communicating primarily with health care providers or teachers was related to greater likelihood of condom use and communicating primarily with religious leaders was related to greater likelihood of HIV testing. Parent communication was unrelated to homeless adolescents' sexual health behaviors. Last, communicating primarily with peers was associated with reduced likelihood of HIV testing. Having nonparental adult communication sources, including health care providers, teachers, and religious leaders, may be critical for encouraging safer sex behaviors among homeless adolescents.

Gender Differences in Parents' Communication With Their Adolescent Children about Sexual Risk and Sex-Positive Topics.

A healthy sexual self-concept that captures an understanding of the risky and the positive aspects of sexuality is imperative to life-long well-being. Parents have a unique opportunity to instill knowledge of sexual risk as well as confidence and comfort around sexuality in their adolescents. Although parent-child communication about sexual risk is fairly common, less is known regarding the frequency of parent-child communication about sex-positive topics, such as sexual desire and satisfaction. This study examined the frequency of parents' communication with their children about sexual risk and sex-positive topics among a sample of 901 parents of 13-17-year-old adolescents (parent Mage= 40.61; 71% mothers) from across the U.S. Parents reported on sexual communication with their adolescent children (child Mage = 14.68; 50% daughters). We examined gender differences in communication patterns. Few parents communicated with their adolescents about sex-positive topics. Only 38% discussed sexual satisfaction, 38% discussed different types of sexual practices (e.g., oral sex), and 55% discussed sexual desire. Parents communicate more about sexual risk than sex-positive topics with their adolescents and this discrepancy was largest for mothers of daughters. Fathers of daughters communicate the least about sex-positive topics. Implications for intervention development and future research on sexual communication are discussed.

Dropout and Abstinence Outcomes in a National Text Messaging Smoking Cessation Intervention for Pregnant Women, SmokefreeMOM: Observational Study.

BACKGROUND: Population-level text messaging smoking cessation interventions may reduce racial and ethnic differences in smoking among pregnant women. OBJECTIVE: Our objective was to examine racial and ethnic differences in dropout, response, and abstinence rates among users of a US national, publicly available text messaging cessation intervention targeting pregnant women, SmokefreeMOM. METHODS: Participants were online subscribers to SmokefreeMOM who set a prospective quit date within the 9 months before their due date. We examined demographics, smoking frequency, number of cigarettes smoked per day, and prequit time (up to 14 days of preparation time before quit date) as correlates of response rate and abstinence at 8 time points: quit date, day 7, day 14, day 21, day 28, day 35, day 42 (intervention end), and day 72 (1-month follow-up). We conducted survival analysis of time from quit date to dropout by race and ethnicity. RESULTS: The mean age of the analytic sample of 1288 users was 29.46 (SD 7.11) years. Of these, 65.81% (848/1288) were white, 16.04% (207/1288) were black, 8.86% (114/1288) were Latina, and 9.29% (120/1288) were multiracial, American Indian/Alaska Native, Native Hawaiian Pacific Islander, or other; 82.68% (1065/1288) had some college education or less. Point-prevalence abstinence was 14.51% (157/1082) on quit day, 3.51% (38/1082) at intervention end, and 1.99% (21/1053) at 1-month follow-up. Black users (hazard ratio 0.68, 95% CI 0.51-0.91) and those with a high school degree or less (hazard ratio 0.66, 95% CI 0.49-0.89) or some college education (hazard ratio 0.75, 95% CI 0.57-0.99) were less likely to drop out than whites or users with a bachelor's degree or higher. Response and abstinence rates were similar across race, ethnicity, and education. CONCLUSIONS: Enrollment was low among racial and ethnic minority women but high among less-educated women. Abstinence at intervention end and 1-month follow-up was lower than that in controlled trials of text messaging cessation interventions for pregnant women (range 7%-20%). Increasing the reach, engagement, and effectiveness of SmokefreeMOM, especially among women with high rates of smoking during pregnancy, must be prioritized.

Applying a Multifactorial Communication Framework to Better Understand Differences between Father-daughter and Mother-daughter Sexual Health Discussions.

While the literature on parent-child sexual communication among adolescent girls is robust overall, research that is specifically focused on communication between fathers and daughters is more limited. Further, there have been calls for work on parent-child sexual communication to be situated within a multi-factorial conceptual framework that distinguishes between different communication components, such as the communication source, content, frequency, quality, and timing. Using such a framework, this study examined aspects of father-daughter sexual communication as they compare to mother-daughter communication in a diverse sample of 193 girls (Mage = 15.62). Results highlighted several gaps between father-daughter and mother-daughter communication. Girls reported covering less content and communicating less frequently about sexual topics with their fathers compared to their mothers. Girls also reported being less comfortable communicating and found their discussions to be less helpful with fathers than mothers. Girls were also less likely to report communicating with fathers about sexual topics before their sexual debut than with mothers. No significant differences were found in communication style (i.e., conversational or like a lecture) between fathers or mothers. Results highlight the importance of understanding the multifaceted process of parent-child communication and signal the need for targeted intervention efforts to improve upon father-daughter communication.

Technology-Based Interventions to Reduce Sexually Transmitted Infections and Unintended Pregnancy Among Youth.

PURPOSE: Technology-based interventions to promote sexual health have proliferated in recent years, yet their efficacy among youth has not been meta-analyzed. This study synthesizes the literature on technology-based sexual health interventions among youth. METHODS: Studies were included if they (1) sampled youth ages 13-24; (2) utilized technology-based platforms; (3) measured condom use or abstinence as outcomes; (4) evaluated program effects with experimental or quasi-experimental designs; and (5) were published in English. RESULTS: Sixteen studies with 11,525 youth were synthesized. There was a significant weighted mean effect of technology-based interventions on condom use (d = .23, 95% confidence interval [CI] [.12, .34], p < .001) and abstinence (d = .21, 95% CI [.02, .40], p = .027). Effects did not differ by age, gender, country, intervention dose, interactivity, or program tailoring. However, effects were stronger when assessed with short-term (1-5 months) than with longer term (greater than 6 months) follow-ups. Compared with control programs, technology-based interventions were also more effective in increasing sexual health knowledge (d = .40, p < .001) and safer sex norms (d = .15, p = .022) and attitudes (d = .12, p= .016). CONCLUSIONS: After 15 years of research on youth-focused technology-based interventions, this meta-analysis demonstrates their promise to improve safer sex behavior and cognitions. Future work should adapt interventions to extend their protective effects over time.

Sexual Assertiveness Skills and Sexual Decision-Making in Adolescent Girls: Randomized Controlled Trial of an Online Program.

OBJECTIVES: To evaluate the efficacy of an interactive, Web-based sexual health program (Health Education and Relationship Training [HEART]) for developing sexual assertiveness skills and enhancing sexual decision-making in adolescent girls. METHODS: Participants were 222 tenth-grade girls (mean age = 15.2; 38% White, 29% Hispanic, 25% Black) in the Southeastern United States who were randomized in fall 2015 to the HEART intervention or an attention-matched control. We assessed participants at pretest, immediate posttest, and 4-month follow-up. RESULTS: Both groups had similar demographic and sexual behavior characteristics at pretest. At immediate posttest, girls who completed the HEART program demonstrated better sexual assertiveness skills measured with a behavioral task, higher self-reported assertiveness, intentions to communicate about sexual health, knowledge regarding HIV and other sexually transmitted diseases (STDs), safer sex norms and attitudes, and condom self-efficacy compared with the control condition. At 4-month follow-up, group differences remained in knowledge regarding HIV and other STDs, condom attitudes, and condom self-efficacy. CONCLUSIONS: This brief online sexual health program can improve short-term outcomes among adolescent girls and offers an exciting new option in the growing array of digital health interventions available to youths. TRIAL REGISTRATION NUMBER: NCT02579135.