HealthSmart: Sexual Health Units

HealthSmart is an evidence-informed, K–12 health education program that focuses on the CDC’s six areas of risk for young people and is aligned with the National Health Education Standards and the CDC's Health Education Curriculum Analysis Tool (HECAT). At middle and high school, the program offers two units on sexual health: one focuses on sexual abstinence as a way to protect sexual health and avoid unplanned pregnancy, HIV and other STI; and the other encourages abstinence but also addresses safer sex practices for reducing the risk of HIV, other STI and unintended pregnancy through the use of condoms and other forms of contraception. 

Category Middle School:
Abstinence, Puberty & Personal Health
Middle School:
HIV, STI & Pregnancy Prevention
High School:
Abstinence, Personal & Sexual Health
High School:
HIV, STI & Pregnancy Prevention 

School based

School based

School based

School based

Program Length

16 lessons 14 Lessons 16 lessons 15 lessons
Age Group Ages 12–14 Ages 12–14 Ages 14–18 Ages 14–18
Look Inside

Table of Contents
Sample Lesson

Table of Contents
Sample Lesson

Table of Contents
Sample Lesson

Table of Contents
Sample Lesson

See the SMARTool alignment for Middle School and High School

See alignment with the Tool to Assess Characteristics for Middle School and High School 

See the CDC's HECAT alignment charts for Middle School and High School

Overview | Description | Population | Developers | Who's Using


The HealthSmart sexual health units at middle and high school are intended to achieve the Healthy Behaviors Outcomes for Sexual Health outlined in the CDC's HECAT.

  • Establish and maintain healthy relationships.
  • Be sexually abstinent.
  • Engage in behaviors that prevent or reduce sexually transmitted infection (STI), including HIV.
  • Engage in behaviors that prevent or reduce unintended pregnancy.
  • Avoid pressuring others to engage in sexual behaviors.
  • Support others to avoid or reduce sexual risk behaviors.
  • Treat others with courtesy and respect without regard to their sexuality.
  • Use appropriate health services to promote sexual health.

Each grade span offers two sexual health units, one that covers personal and reproductive health and focuses on concepts and skills that support students in using abstinence to protect their sexual health and avoid unplanned pregnancy, HIV and other STIs, and another that provides instruction about sexual responsibility, HIV, other STIs, testing and the use of condoms and other forms of contraception.



The ultimate goal of the HealthSmart program is to promote the healthy growth and development of youth and give them the knowledge and skills to make healthy choices and establish life-long healthy behaviors.

HealthSmart is grounded in sound educational and behavioral theory. It focuses on the primary areas of risk for children and adolescents identified and monitored by the Centers for Disease Control and Prevention (CDC). HealthSmart meets the National Health Education Standards, and reflects the characteristics of effective health education curricula defined by the CDC. It also incorporates key knowledge and skill expectations detailed in the CDC's Health Education Curriculum Analysis Tool (HECAT) for each grade level.

Lessons are designed to be easy to use, with clear, concise teaching steps focused on the essential concepts and skills that will enable students to develop, practice and support specific healthy behaviors. Activities are developmentally appropriate, challenge students in a variety of ways, and accommodate a range of learning styles.

In addition to the units that address sexual health, the HealthSmart program also offers units on Emotional & Mental Health; Tobacco, Alcohol & Other Drug Prevention; Nutrition & Physical Activity; and Violence & Injury Prevention. Lessons from these other content areas may also be relevant to the prevention of sexual risk behaviors, in particular, those that address knowledge and skills around decision making, healthy relationships, avoiding substance use and preventing dating violence.

The program is available in both print and digital editions. More information about the complete program can be found on ETR’s HealthSmart website.


Populations Served & Setting

HealthSmart is a sequential, school-based K–12 health education program. At the secondary school levels, the program is modular, with content units specifically focused on sexual health available for both middle school and high school students. It is designed to accommodate a wide range of learning styles and to appeal to students from diverse backgrounds.


About the Developers

Susan K. Telljohann, HSD, CHES, is Professor Emerita of Health Education at The University of Toledo. Her experience in health education spans over 35 years, including health instruction from the junior high to the university level. She has conducted research and published over 60 articles on health education in professional journals. Dr. Telljohann was one of the lead authors of the Center for Disease Control and Prevention’s original and revised Health Education Curriculum Analysis Tool (HECAT). She served as the President of the American School Health Association from 2000–2001, on the Board of Directors of the American Association of Health Education and the National Health Education Standards Revision Committee. She is the recipient of several awards, including the Howe Award from the American School Health Association and the Scholar Award from the American Association for Health Education.

William “Bill” M. Kane, PhD, CHES, served as Executive Director of both the American College of Preventive Medicine and the Association for the Advancement of Health Education. He was a Professor of Health Education at the University of New Mexico, and taught at several other colleges and universities over the course of his career. He served as Director of School Health Programs at ETR Associates, and also served on the boards of several nonprofit organizations devoted to public health and health education. Dr. Kane received many honors, and wrote or coauthored over 50 books and curricula focused on health. He remains a consummate model for those who work in health education of how to do this work with passion.

Hilda Quiroz Graham is an educator, international trainer, writer and keynote speaker. She has taught health classes and served as a mentor teacher and leader at both the middle and high school levels. She is the author of books, articles, curricula and training designs addressing K–12 safety, college and university safety, diversity/cultural fluency, school bullying, and health education. Her work serves public schools, community organizations, and law enforcement agencies. Hilda is the former Program Developer for the National School Safety Center. She continues to serve the Center as an associate trainer, and expert voice for national media addressing the topics of school safety, law enforcement/education partnerships, and school bullying.

Susan Giarratano Russell, EdD, MSPH, CHES, has more than 35 years of experience in education, health education and health promotion. For 20 of those years, Susan served as a Professor of Health Science in the undergraduate and graduate programs, and as coordinator of the teacher preparation program in health education for two California State Universities. She went on to consult for the Centers for Disease Control and Prevention’s (CDC) Division of Adolescent and School Health, where she developed curriculum-related tools for use in schools and community-based programs on nutrition, healthy eating and food safety, physical activity, asthma, tobacco use prevention, school connectedness and parenting. She was also a lead author on the recent revision of the CDC’s HECAT. She continues to serve as an expert reviewer, consultant and evaluator in health and education


Who’s Using?

HealthSmart is used in many different schools and districts nationwide. For example, it has been approved as the comprehensive Health Education program for New York City.

Length | Elements | Staffing | Notification

Length of Program

At middle school, lessons are 45–60 minutes long. High school lessons range from 45–75 minutes long.

  • Middle School: Abstinence, Puberty & Personal Health has 16 lessons.
  • Middle School: HIV, STI & Pregnancy Prevention has 14 lessons.
  • High School: Abstinence, Personal & Sexual Health has 16 lessons.
  • High School: HIV, STI & Pregnancy Prevention has 15 lessons.

Lessons can be taught once to several times a week.


Program Elements

Each print edition HealthSmart Sexual Health Unit set at middle and high school includes the Teacher’s Guide that contains the easy-to teach lessons, with clear objectives, teaching steps and assessment; a classroom set of 30 Student Workbooks that include all student reading and activity sheets; and additional teacher resources such as keys and masters, PowerPoint slides, Student Journal pages, scoring rubrics and a health terms glossary in digital format.

The digital edition of the program provides online versions of all unit lessons; a student license that allows for PDF download and/or printing of all student activity sheets from the required student workbook for 30 students; and digital access to teacher keys and masters, PowerPoint slides, Student Journal pages, scoring rubrics and the health terms glossary.

Student workbooks are required for every student. Additional classroom workbook sets of 5 and 30 are available.

HealthSmart teachers also have access to the HealthSmart Teacher Support Website that features a wealth of free digital resources, including a Lesson Planning Tool that allows educators to quickly customize a lesson plan based on content, skills and the time available to teach health.


Staffing Requirements

This curriculum can be used by either classroom teachers or community-based health educators. Individuals implementing HealthSmartshould be knowledgeable about the content, be comfortable discussing the material and answering sensitive questions about sexual risk taking, have experience using interactive teaching strategies such as roleplaying, and have good rapport with youth. Ideally, all educators implementing the program should be trained on its contents and teaching strategies.


Parent/Guardian Notification

It is essential to inform parents and guardians regarding the nature and scheduling of this or any sexual health education program. Prior to implementation of the curriculum, families should receive written notice describing the goals of the HealthSmart Sexual Health unit and the nature of the content to be covered. Parents also should be given an opportunity to view the curriculum and related materials if they wish. The vast majority of parents want their children to receive appropriate instruction and be given the information and skills they need to protect their sexual health, but parents/guardians also must be allowed the chance to opt out or exclude their children from participating in the program, if they wish.

Theory | Logic Models | Characteristics


HealthSmart is grounded in sound educational and behavioral theory. The Theory of Planned Behavior provides the framework for lessons and activities. Concepts from Social Learning Theory are strategically woven throughout the program. The Transtheoretical or Stages of Change Model serves as the foundation for activities designed to support student change of unhealthy behaviors. Activities are designed to appeal to students’ multiple intelligences, utilize brain-based learning methodologies, and promote a constructivist approach to learning.

Theoretical principles woven throughout the lessons and activities increase the likelihood that students will value and practice the healthy actions that prevent excessive morbidity and premature mortality. With the HealthSmart program, teachers utilize educational and health behavior theory to:

  • Build a personal value for health by helping students explore and share their own health beliefs and those of their families, connecting new learning to the experiences students bring to the classroom, providing opportunities to reflect on health behaviors and connecting those behaviors to future health outcomes, and encouraging students to envision a healthy future and explore the choices and actions necessary to achieve that future.
  • Shape healthy peer norms by engaging students in discussions regarding the healthy actions that family and friends want them to pursue, having students participate in activities that increase their motivation to comply with these expectations, and providing opportunities for students to develop support from family and friends for their healthy actions.
  • Build power to use knowledge and skills by teaching the essential, functional knowledge needed to support healthy behaviors and providing structured opportunities for students to develop and practice key skills for health literacy.
  • Enhance students' perception of control over their health behaviors by helping them acquire knowledge, develop skills and establish support systems that increase their power to anticipate situations and act in healthy ways.

In addition, HealthSmart was developed to meet the 15 Characteristics of Effective Health Education Curricula as identified by the CDC Division of Adolescent and School Health. More information about these characteristics can be found below.


Logic Model

Logic models for the HealthSmart Sexual Health units can be found at the links below:

Middle School Abstinence, Puberty & Personal Health Logic Model (pdf)

Middle School HIV, STI & Pregnancy Prevention Logic Model (pdf)

High School Abstinence, Personal & Sexual Health Logic Model (pdf)

High School HIV, STI & Pregnancy Prevention Logic Model (pdf)


Characteristics of Effective Health Education Programs

HealthSmart meets the 15 characteristics of effective health education programs defined by the CDC in the following ways:

  1. Focuses on clear health goals and related behavioral outcomes. HealthSmart has clear health-related goals and behavioral outcomes. The instructional strategies and learning experiences are directly related to the behavioral outcomes. Lesson objectives spell out the knowledge and skills students will gain, and support the healthy behavior outcomes identified by the CDC.
  2. Is research-based and theory-driven. Effective curricula have instructional strategies and learning experiences built on theoretical approaches that have effectively influenced health-related behaviors among youth. HealthSmart is grounded in sound educational and behavioral theory. The Theory of Planned Behavior provides the framework for lessons and activities; concepts from Social Learning Theory are strategically woven throughout the program; and the Transtheoretical or Stages of Change Model serves as the foundation for activities designed to support student change of unhealthy behaviors. The program helps students analyze influences on their behaviors, supports the establishment of healthy peer norms and builds skills.
  3. Addresses individual values, attitudes and beliefs. HealthSmart fosters attitudes, values and beliefs that support positive health behaviors. Lessons help motivate students to examine their personal beliefs, attitudes and values, and understand their own risk behaviors, in support of adopting health-enhancing actions.
  4. Addresses individual and group norms that support health-enhancing behaviors. HealthSmart lessons cover current youth norms around a variety of health behaviors, such as injury, sexual activity and substance use, to reinforce positive norms and help students understand how misperceptions of those norms can affect their health-related behaviors.
  5. Focuses on reinforcing protective factors and increasing perceptions of personal risk and harmfulness of engaging in specific unhealthy practices and behaviors. Students have opportunities to assess their own risks and positive health behaviors throughout the HealthSmart lessons. They also examine influences that can support positive health behaviors, as well as those that can lead them to take risks.
  6. Addresses social pressures and influences. Analyzing influences is a key skill taught throughout the HealthSmart units. Students examine the effects of family, peers, culture, media and technology on their health choices and behaviors.
  7. Builds personal competence, social competence, and self-efficacy by addressing skills. HealthSmart is a skills-based curriculum. It addresses all of the key skills outlined in the National Health Education Standards, including analyzing influences, accessing accurate and credible resources, communicating clearly, resisting pressure using refusal and negotiation tactics, decision making, goal setting and self-management. This skills focus helps students build confidence, deal with pressures, and avoid or reduce risk behaviors. Each skill is thoroughly explained, discussed, modeled and practiced, with opportunities for students to receive feedback and reinforcement.
  1. Provides functional health knowledge that is basic, accurate, and directly contributes to health-promoting decisions and behaviors. HealthSmart’s functional information comes from accurate, reliable and credible sources and is taught in the context of improving knowledge and skills in order to practice healthy behaviors. Students are given ample opportunities to apply the information they are learning to their own lives in the interest of making health-enhancing choices.
  2. Uses strategies designed to personalize information and engage students. HealthSmart includes instructional strategies and learning experiences that are student-centered, interactive and experiential. Learning experiences correspond with students’ cognitive and emotional development, help them personalize information, and maintain their interest and motivation while accommodating diverse capabilities and learning styles. Instructional strategies and learning experiences include methods for:
    • Addressing key health-related concepts
    • Encouraging creative expression
    • Sharing personal thoughts, feelings, and opinions
    • Thoughtfully considering new arguments
    • Developing critical thinking skills
  3. Provides age-appropriate and developmentally appropriate information, learning strategies, teaching methods and materials. HealthSmart addresses students’ needs, interests, concerns, developmental and emotional maturity levels, experiences, and current knowledge and skill levels. The lessons in each HealthSmart unit are designed to build the learning about the topic and help students apply their new knowledge and skills to their lives. Activities are grade-appropriate for each level of the program.
  4. Incorporates learning strategies, teaching methods and materials that are culturally inclusive. HealthSmart is designed to be unbiased and inclusive of diverse cultures and lifestyles. Differences are acknowledged. Case studies and roleplay scenarios in particular are written to be neutral and adaptable so that students can see themselves reflected. Family activities provide opportunities for parents and guardians to share in their children’s and teens’ learning and bring their own family values and perspectives to the discussions. Respect for differences is emphasized throughout the lessons, particularly in regard to sensitive health topics. Learning activities acknowledge the cultural diversity of students; optimize relevance to students from multiple cultures in the school community; and build on the cultural resources of families and communities.
  5. Provides adequate time for instruction and learning. The HealthSmart program is comprehensive and thorough. It is intended to build the learning on a particular health topic sequentially and logically to help ensure student mastery of concepts and skills. Behavior change requires an intensive and sustained effort.
  6. Provides opportunities to reinforce skills and positive health behaviors. HealthSmart builds on previously learned concepts and skills and provides opportunities to reinforce health-promoting skills across health topics and grade levels. Skill practice is often extended beyond a single activity or lesson, and students continue to practice and build their understanding and application of the skills. Each unit at middle and high school includes a performance task unit assessment designed to reinforce the learning through a creative project that allows students to incorporate the skills they have learned.
  7. Provides opportunities to make positive connections with influential others. Take-home family sheets, surveys and interviews help students connect with trusted adults in their lives for information, advice and reinforcement of the concepts, skills and healthy behaviors. Suggestions for Community Connections help teachers find ways to reinforce and extend the learning by inviting community role models to the classroom.
  8. Includes teacher information and plans for professional development and training that enhance effectiveness of instruction and student learning. The pedagogically sound lessons guide teachers—even those with less experience—through each lesson step by step from preparation through assessment, and offer guidance for handling classroom discussions of difficult or controversial topics. The HealthSmart website offers HealthSmart teachers free access to teacher guide resources, content updates, articles and professional development materials. Training is available to school districts and youth-serving agencies that purchase the program.

Training & TA

For over 30 years, ETR has been building the capacity of community-based organizations, schools, school districts, and state, county and local agencies in all 50 states and 7 U.S. territories to implement and replicate evidenced-based programs (EBPs) to prevent teen pregnancy, STD/STI and HIV. Our nationally recognized training and research teams work in partnership with clients to customize training and technical assistance (TA) to address the needs of their agencies and funding requirements.


Professional development on lesson implementation maximizes effectiveness of the HealthSmart curriculum. ETR provides a 2-day training with a 1-day follow-up booster session—the ideal model for educators who are or will be teaching HealthSmart.

ETR provides a research-based approach to our professional learning processes. This includes the provision of pre-work (in order to prime the participants so they have the background and content information needed to fully engage in skill-building) in-person skill-building, and follow-up implementation support.

Day 1: Characteristics of Effective Health Education Curricula

The first day of training focuses on understanding and applying the characteristics in lessons and assessments.

Participants review the characteristics and the research-based process for teaching critical health skills (e.g. goal setting, decision-making, communication, etc.). The major components of the HealthSmart curriculum also are introduced.

Day 2: Teaching HealthSmart

The second day of training focuses on how to effectively use the HealthSmart curriculum. Participants identify the Characteristics of Effective Health Education Curricula within a set of HealthSmart lessons. Then, working in small groups, they take part in practice teaching sessions for specific lessons (based on input from their site) and provide feedback to each other from the learners’ perspective. Participants also receive a reflection journal that will allow them to reflect on how each lesson is received by students and to document concerns and successes for each lesson.

Implementation Booster Session (held 8–12 weeks after Two-Day Training)

The 1-day follow-up booster session is designed to strengthen and support implementation. Educators have an opportunity to share their successes and challenges regarding the specific lessons they’ve taught. They review how each lesson was received by students, discuss questions and challenges, and identify strategies to overcome any problems or concerns.

To request a HealthSmart training, please complete the Training & TA Request Form >>

Technical assistance (TA), coaching and ongoing support

ETR provides in-person and web- or phone-based TA before, during and/or after program implementation. TA is tailored to the needs of the site and is designed to support quality assurance, trouble-shoot adaptation issues, and boost implementation.

Enrichment Training

To support a holistic approach to teen pregnancy and HIV prevention programs, ETR offers a number of additional training and technical assistance opportunities, including content-specific workshops, skill-based trainings, organizational development consultation and much more. To learn more about these opportunities, visit our Training & TA pages >>


Adaptation suppport materials, training and/or TA are available to assist educators in meeting the needs of individual communities by implementing EBPs effectively and consistently with core components. All adaptation support is based on ETR's groundbreaking, widely disseminated adaptation guidelines and kits for effective adaptations.


ETR also provides evaluation support for EBP implementation. ETR uses well-established tools for measuring fidelity and outcomes. ETR's evaluation support blends participatory approaches with cutting-edge evaluation science. Services address process and outcome evaluation and include assistance with evaluation planning, instrument design and development, implementation fidelity, data management and analysis, performance measurement, continuous quality improvement (CQI) protocols, and effective tools and strategies for reporting results.