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Objective: Guided by the Operating Conditions Framework, the goal of this study was to identify how and for whom an online sexual health program called Health Education and Relationship Training (HEART) worked. Design: Data come from a randomized controlled trial among 198 U.S. high school girls who completed HEART or an attention-matched control. We conducted mediation and moderated mediation models to determine if sexual self-efficacy was a mediator and if program acceptability and sexual activity status were moderators of HEART efficacy. Main Outcome Measure: Sexual communication skills were assessed with a behavioral role-play task. Results: HEART significantly improved sexual communication skills. These effects were fully mediated through sexual self-efficacy. Specifically, HEART improved sexual self-efficacy which in turn increased sexual communication skills. Also, when participants liked the program more, the effect of HEART on sexual self-efficacy was stronger. Further, among girls who had engaged in sexual activity, sexual self-efficacy was significantly associated with sexual communication skills. Conclusion: This study provides insights into the mechanisms of behavior change underlying HEART. Results highlight the need to further ‘unpack’ the effects of other sexual health programs, as we showed that programs may work better under certain conditions.

Sexual self-efficacy and sexual communication among adolescent girls: moderated mediation results from a randomized controlled trial