Brave Conversations about Sexual Health and Relationships: Engaging Stakeholders in Intervention Development and Testing

Background: Youth-adult connections, ongoing conversations about sexual health, and positive parenting practices are consistently associated with positive sexual health outcomes for youth. However, in the child welfare system conversations about sexual health are largely taboo. Caregivers and professionals cite lack of training on adolescent sexuality and relationships, conflicting values, confusion about guidelines, and fear of re-traumatizing youth. Given the disproportionate rates of unintended pregnancies and sexually transmitted infections among youth with histories in foster care, training for adults on how to support the sexual health of youth is urgently needed.

Methods: The Texas Foster Youth Health Initiative (TFYHI) centered the community in developing Brave Conversations (BC), a training for caregivers, child welfare professionals, and other supportive adults. Two consultant groups comprised of foster parents (n=14) and young adults with lived experience (n=14) provided input on strategies and messaging and designed training activities. BC is comprised of a 4-hour curriculum, facilitation guide, resource materials for caregivers and youth, and a social media campaign. BC promotes (1) reflection on personal and cultural values about sexuality and relationships, (2) strategies for providing an inclusive, affirming space, (3) positive parenting strategies that model healthy relationships, (4) skills for trauma-informed conversations about sexual health and consent, and (5) knowledge of sexual health resources. Implementation occurs in partnership with child welfare agencies that select an implementation format that best fits their staff, foster caregivers, and other affiliated adults.

A formative evaluation assessed whether BC was feasible to implement, engaging for participants, and supported by the community. The evaluation included implementation data, surveys with training participants, and focus groups with staff at child welfare agencies three months after the training. Measures for pre, post, and 3-month follow-up surveys were selected to reflect the concerns of adults supporting youth in foster care: their sense of confidence and challenges, knowledge, outcome expectancy, and intentions to engage youth in conversations about sexuality and relationships.

Results: Brave Conversations was tested with 352 participants, with 87% receiving at least 75% of the training. Matching pre- and post-surveys were available for 218 participants. Paired sample t-tests found significant positive gains with medium effect sizes from pre- to post-survey for all measures. Positive gains were sustained at 3-month follow-up. Thematic analysis of focus group transcripts showed that participants valued the opportunity to reflect on personal values, learn from others’ perspectives, and practice conversations during the training. Participants noted a shift toward a more open and non-judgmental stance about youths’ sexual behaviors and shared examples of engaging youth in conversations about sexual health post-training.

Conclusions: TFYHI demonstrated the value of community engagement in all stages of designing, implementing, and testing a sexual health intervention. Promising results from the formative evaluation of Brave Conversations showed that participants increased knowledge, confidence, positive expectations, and intentions to talk with youth in their care about sexual health and relationships. Additional research is needed to assess whether the training will increase trust and connections between youth and caregivers and translate into more positive sexual health outcomes for youth.