BACKGROUND:Relationships and sex education (RSE) impacts some sexual behaviours but could be strengthened by incorporating whole-school approaches (eg, building engagement, providing contraception). These can prevent pregnancies and sexually-transmitted infections but are unevaluated in UK schools. METHODS:A cluster-randomised trial of 'Positive Choices' compared it with usual practice in English secondary schools. Intervention comprised: RSE, school-health-promotion councils involving students, student-needs data to tailor provision; student-led campaigns; review of sexual-health services; and parent information. The primary outcome was prevention of non-competent sexual debut (lacking decision autonomy, judging timing as right, partners' equal willingness or contraception). RESULTS:Of 2845 schools invited, 50 (1.76%) consented, 1 leaving post-allocation. Of 25 control and 24 intervention schools, 4 withdrew pre-endline. 6970 (77.3%) students participated at baseline and 6268 (77.9%) at 33-month endline. Fidelity of whole-school components was suboptimal. No schools achieved 'good' fidelity; two achieved 'adequate' fidelity across components. 11 achieved 'adequate fidelity on selected components' (student-needs report, school-health-promotion council meetings, lessons, parent information). Control schools delivered similar activities to intervention schools. Among 780 (12.44%) students sexually debuting between baseline and endline, non-competent debut was reported by 268 (64.42%) in the control and 240 (65.93%) in the intervention group (risk difference=0.020 (95% CI -0.05 to 0.09)). There were no effects on secondary outcomes. Incremental costs were £1337 per school (£10 per student). CONCLUSION:Positive Choices did not prevent non-competent sexual debut (primary outcome) or impact secondary outcomes compared with usual RSE, possibly explained by weak fidelity of whole-school elements and/or comprehensive RSE in control schools. TRIAL REGISTRATION NUMBER:ISRCTN16723909.

Whole-school relationships and sexual health interventions represent promising approaches to promoting healthy sexual development. However, data from a randomised controlled trial of the Positive Choices whole-school intervention demonstrate these may be challenging to implement in English secondary schools. We draw on qualitative data to examine staff perspectives on the implementation of the intervention and the factors affecting delivery. Interviews were conducted with 52 staff in 22 schools. Analysis was guided by May's General Theory of Implementation, focussing on how processes of sense making, cognitive participation, collective action and reflexive monitoring were shaped by intervention capability, school capacity, and staff potential. Quality training, materials and support, alongside a strong commitment to delivery of statutory relationships and sex education promoted curriculum implementation. However, whole-school components were viewed as more challenging to implement and often beyond the 'core business' of schools. Successful implementation of whole-school components was facilitated by a supportive school culture, school leads having the authority to enable collective action and close alignment with school priorities and institutional processes. For whole-school interventions to succeed, sufficient time and resources must be allocated. A pragmatic approach might be to develop whole-school approaches that address health more holistically and build effectively on existing provision.

Previous trials of whole-school relationships and sexual-health programmes have not reported on fidelity, reach or acceptability, despite the importance of these factors for interpreting outcomes. Our trial of the Positive Choices whole-school relationships and sexual-health programme found limited effectiveness in secondary schools in England. We aimed to understand whether sub-optimal fidelity, reach or acceptability might explain the results. A process evaluation was nested within a parallel-arm, cluster randomised-controlled trial in 49 schools from 2021 to 2025. Using staff log-books, researcher observations, student surveys and staff interviews, we assessed the delivery of the programme in 24 schools and awareness and acceptability among students, including subgroup differences. While most schools delivered lessons, fewer completed 'whole-school components', such as school-health promotion councils, sexual-health services reviews and student-led campaigns. No school reached a pre-defined level of 'good fidelity' across all components, and only 11 schools achieved 'adequate fidelity for selected components'. Evidence of programme acceptability and awareness among students was weak, with higher awareness among sexuality- and gender-minority students, and higher acceptability among white students. Findings highlight difficulties implementing whole-school programmes focused on relationships and sexual health. More holistic whole-school programmes addressing multiple health issues, including sexual health, may be more feasible.

Purpose There is evidence that academic pressure has been rising among adolescents in the UK. While this may be a modifiable risk factor for mental health problems, there are few validated measures of academic pressure and all have limitations. Methods With secondary-school students, we co-produced a student-reported measure of academic pressure, the 7-item Academic Pressure Questionnaire (APQ). This was included in the baseline survey of students aged 12-13 within the Positive Choices trial, a whole-school intervention to promote sexual health in English secondary schools. We ran factor analyses and assessed internal consistency, associations with sex and depressive symptoms, and variation in academic pressure between schools. Results We extracted one factor (Cronbach's alpha 0.76). Female students had higher APQ scores than males (mean difference = 2.18, 95% CI: 1.88 to 2.49). Higher APQ scores were associated with more depressive symptoms (coefficient = 0.51, 95% CI: 0.48 to 0.55) and associations were larger in female than male students (p value for interaction <0.001). School-level factors explained 2.6% of variation in APQ scores after adjusting for individual-level factors (ICC = 0.026, 95% CI: 0.01 to 0.06). Conclusion The APQ is a valid and reliable tool to investigate academic pressure in secondary-school adolescents.

Whole-school interventions go beyond classroom education, promoting health by modifying school environments. These can be effective in delaying sexual debut and increasing contraception use but mechanisms are poorly understood. Qualitative research within realist evaluation can explore mechanisms via building 'context-mechanism-outcome configurations', describing how interventions trigger mechanisms that interact with context to generate outcomes. We explored these for the Positive Choices whole-school sexual health intervention within the intervention arm of a randomised trial conducted 2021-2025. Using 'dimensional analysis', we analysed 52 interviews with teachers and 40 focus-groups involving 266 students from 22 English secondary schools. Our results suggest seven mechanisms through which whole-school interventions might 'work': improving knowledge using diverse pedagogies; improving confidence and ability to talk by normalising talk about sexual health; changing gender attitudes through challenging stereotypes and providing insights and empathy with others' perspectives; promoting access to sexual health and other services via helping students understand their needs and entitlements; building school engagement by providing new student roles on decision-making groups; increasing inclusion of sexual-minority students by normalising consideration of non-heterosexual identities and practices; and reducing sexual harassment and abuse by helping students understand consent and when to intervene in harassment. Contextual contingencies included: high initial student needs; teacher skills and commitment; and school commitment and capacity. Our research suggests novel mechanisms via which whole-school interventions might promote sexual health. Quantitative analyses will now be conducted to examine these mechanisms and contingencies.

There is little research on sexual harassment among younger adolescents or on how rates vary by gender and other student/school characteristics. Drawing on data from 50 English schools, we explored the prevalence and patterning of victimization in the past year among students aged 12-13. Of 7,060 participants, almost a tenth had experienced sexual harassment. Girls, non-binary students, and sexual-minority students reported the highest rates. Student commitment to school was associated with reduced victimization, particularly among straight students and in higher-attaining schools. Sexual harassment is a priority area for intervention, particularly for students facing the highest risk.

BACKGROUND:There has been much critical reflection among global health researchers about how power imbalances between high-income countries and low- and middle-income country collaborators are perpetuated through research programmes. Research capacity strengthening (RCS) is considered both a mechanism through which to redress structural power imbalances in global health research and a vehicle for their perpetuation. This paper examines the RCS programme of a multi-county study on violence against women, focussing on how it addressed power imbalances between countries and the challenges involved in doing so. It provides specific examples and lessons learnt. METHODS:18 semi-structured interviews were conducted online with group members from all five countries involved in the collaboration between April and June 2020. Reflexive thematic analysis, with inductive and deductive approaches was adopted. FINDINGS:Participants articulated their understandings of RCS as an opportunity for (1) mutual learning, understanding and collaboration and (2) personal and team career development. Participants perceived the RCS programme activities to simultaneously reinforce and challenge power asymmetries within global health research. Power dynamics within the RCS programme operated across three levels; the global health research environment, the research group level and within individual country teams. Participants described structural barriers at all three levels, but felt there were more opportunities to challenge power imbalances at the research group level. CONCLUSION:Despite a strong commitment to addressing power imbalances through the RCS programme, progress was often hampered by the fact that these inequalities reflected broader structural issues in global health, as seen within Healthcare Responding to Violence and Abuse. The programme faced tensions between enhancing researchers' careers while building capacity under the current model, which sometimes conflicted with creating social value or challenging epistemic and normative structures. Participants clearly expressed concerns about power imbalances within the partnership and were keen to address them through the RCS programme. This led to a steep learning curve and significant adaptations within the RCS programme to navigate these issues within existing structural limitations.

Student-reported quality and coverage of school-based relationships and sex education (RSE) vary, with gender/sexual-minority and disadvantaged students reporting poorer provision. Experience of RSE among younger adolescents is under-explored. We examined student-reported RSE coverage and priorities and how coverage, and sexual-health knowledge and awareness of services, varies between students and schools. The data came from a pre-intervention survey of students aged 12-13 years within a trial of an RSE intervention involving 50 English schools. There was most coverage of basic information, such as puberty and safeguarding. There was least coverage of topics more appropriate for older students, such as sexual relationships, and topics teachers might find difficult to broach, e.g. pornography and masturbation. Girls, gay/lesbian students, students of bisexual/other sexual orientation, minority-ethnic students and students reporting lower academic commitment reported lower coverage than others. Knowledge of RSE-related topics and sexual-health services was generally low. Boys, students of bisexual/other orientation and students with higher school commitment had higher knowledge. Students of bisexual/other orientation and students of lower commitment reported lower awareness of services. Coverage and knowledge did not vary with school-level attainment or local deprivation. Future forms of RSE provision should ensure content and teaching methods meet the needs of all students.

Implementation studies rarely examine how health interventions are delivered in emergencies. Informed by May's general theory of implementation (GTI), we undertook qualitative longitudinal research to investigate how schools in England implemented Covid-19-prevention measures and how this evolved over the 2020-2021 school year in a rapidly changing epidemiological and policy context. We conducted 74 semi-structured interviews over two time-points with headteachers, teachers, parents and students across eight primary and secondary schools. School leaders rapidly made sense of government guidance despite many challenges. They developed and disseminated prevention plans to staff, parents and students. As defined by GTI, 'cognitive participation' and 'collective action' to enact handwashing, one-way systems within schools and enhanced cleaning were sustained over time. However, measures such as physical distancing and placing students in separated groups were perceived to conflict with schools' mission to promote student education and wellbeing. Commitment to implement these was initially high during the emergency phase but later fluctuated dependant on perceived risk and local disease epidemiology. They were not considered sustainable in the long term. Adherence to some measures, such as wearing face-coverings, initially considered unworkable, improved as they were routinised. Implementing home-based asymptomatic testing was considered feasible. Formal and informal processes of 'reflexive monitoring' by staff informed improvements in intervention workability and implementation. Leaders also developed skills and confidence, deciding on locally appropriate actions, some of which deviated from official guidance. However, over time, accumulating staff burnout and absence eroded school capacity to collectively enact implementation. Qualitative longitudinal research allowed us to understand how implementation in an emergency involved the above emergent processes. GTI was useful in understanding school implementation processes in a pandemic context but may need adaptation to take into account the changing and sometimes contradictory objectives, time-varying factors and feedback loops that can characterise implementation of health interventions in emergencies.

Background The UK still has the highest rate of teenage births in western Europe. Teenagers are also the age group most likely to experience unplanned pregnancy, with around half of conceptions in those aged < 18 years ending in abortion. After controlling for prior disadvantage, teenage parenthood is associated with adverse medical and social outcomes for mothers and children, and increases health inequalities. This study evaluates Positive Choices (a new intervention for secondary schools in England) and study methods to assess the value of a Phase III trial. Objectives To optimise and feasibility-test Positive Choices and then conduct a pilot trial in the south of England assessing whether or not progression to Phase III would be justified in terms of prespecified criteria. Design Intervention optimisation and feasibility testing; pilot randomised controlled trial. Setting The south of England: optimisation and feasibility-testing in one secondary school; pilot cluster trial in six other secondary schools (four intervention, two control) varying by local deprivation and educational attainment. Participants School students in year 8 at baseline, and school staff. Interventions Schools were randomised (1 : 2) to control or intervention. The intervention comprised staff training, needs survey, school health promotion council, year 9 curriculum, student-led social marketing, parent information and review of school/local sexual health services. Main outcome measures The prespecified criteria for progression to Phase III concerned intervention fidelity of delivery and acceptability; successful randomisation and school retention; survey response rates; and feasible linkage to routine administrative data on pregnancies. The primary health outcome of births was assessed using routine data on births and abortions, and various self-reported secondary sexual health outcomes. Data sources The data sources were routine data on births and abortions, baseline and follow-up student surveys, interviews, audio-recordings, observations and logbooks. Results The intervention was optimised and feasible in the first secondary school, meeting the fidelity targets other than those for curriculum delivery and criteria for progress to the pilot trial. In the pilot trial, randomisation and school retention were successful. Student response rates in the intervention group and control group were 868 (89.4%) and 298 (84.2%), respectively, at baseline, and 863 (89.0%) and 296 (82.0%), respectively, at follow-up. The target of achieving ≥ 70% fidelity of implementation of essential elements in three schools was achieved. Coverage of relationships and sex education topics was much higher in intervention schools than in control schools. The intervention was acceptable to 80% of students. Interviews with staff indicated strong acceptability. Data linkage was feasible, but there were no exact matches for births or abortions in our cohort. Measures performed well. Poor test–retest reliability on some sexual behaviour measures reflected that this was a cohort of developing adolescents. Qualitative research confirmed the appropriateness of the intervention and theory of change, but suggested some refinements. Limitations The optimisation school underwent repeated changes in leadership, which undermined its participation. Moderator analyses were not conducted as these would be very underpowered. Conclusion Our findings suggest that this intervention has met prespecified criteria for progression to a Phase III trial. Future work Declining prevalence of teenage pregnancy suggests that the primary outcome in a full trial could be replaced by a more comprehensive measure of sexual health. Any future Phase III trial should have a longer lead-in from randomisation to intervention commencement. Trial registration Current Controlled Trials ISRCTN12524938. Funding This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 9, No. 1. See the NIHR Journals Library website for further project information.

Abstract Background Whole-school interventions represent promising approaches to promoting adolescent sexual health, but they have not been rigorously trialled in the UK and it is unclear if such interventions are feasible for delivery in English secondary schools. The importance of involving intended beneficiaries, implementers and other key stakeholders in the co-production of such complex interventions prior to costly implementation and evaluation studies is widely recognised. However, practical accounts of such processes remain scarce. We report on co-production with specialist providers, students, school staff, and other practice and policy professionals of two new whole-school sexual heath interventions for implementation in English secondary schools. Methods Formative qualitative inquiry involving 75 students aged 13–15 and 23 school staff. A group of young people trained to advise on public health research were consulted on three occasions. Twenty-three practitioners and policy-makers shared their views at a stakeholder event. Detailed written summaries of workshops and events were prepared and key themes identified to inform the design of each intervention. Results Data confirmed acceptability of addressing unintended teenage pregnancy, sexual health and dating and relationships violence via multi-component whole-school interventions and of curriculum delivery by teachers (providing appropriate teacher selection). The need to enable flexibility for the timetabling of lessons and mode of parent communication; ensure content reflected the reality of young people’s lives; and develop prescriptive teaching materials and robust school engagement strategies to reflect shrinking capacity for schools to implement public-health interventions were also highlighted and informed intervention refinements. Our research further points to some of the challenges and tensions involved in co-production where stakeholder capacity may be limited or their input may conflict with the logic of interventions or what is practicable within the constraints of a trial. Conclusions Multi-component, whole-school approaches to addressing sexual health that involve teacher delivered curriculum may be feasible for implementation in English secondary schools. They must be adaptable to individual school settings; involve careful teacher selection; limit additional burden on staff; and accurately reflect the realities of young people’s lives. Co-production can reduce research waste and may be particularly useful for developing complex interventions, like whole-school sexual health interventions, that must be adaptable to varying institutional contexts and address needs that change rapidly. When co-producing, potential limitations in relation to the representativeness of participants, the ‘depth’ of engagement necessary as well as the burden on participants and how they will be recompensed must be carefully considered. Having well-defined, transparent procedures for incorporating stakeholder input from the outset are also essential. Formal feasibility testing of both co-produced interventions in English secondary schools via cluster RCT is warranted. Trial registration Project Respect: ISRCTN12524938 . Positive Choices: ISRCTN65324176

Background: ‘Dating and relationship violence’ is intimate partner violence during adolescence. Among dating adolescents in England, 66–75% of girls and 32–50% of boys report victimisation. Multicomponent school-based interventions might reduce dating and relationship violence. We optimised and piloted Project Respect, a new intervention in secondary schools in England, and study methods, to assess the value of a Phase III randomised controlled trial. Objectives: To optimise Project Respect and to then conduct a pilot randomised controlled trial in southern England, addressing whether or not progression to a Phase III trial is justified in terms of prespecified criteria. To assess which of two dating and relationship violence scales is optimal, to assess response rates and to consider any necessary refinements. Design: Optimisation activities aimed at intervention development and a pilot randomised controlled trial. Setting: Optimisation in four secondary schools across southern England, varying by region and local deprivation. A pilot cluster randomised controlled trial in six other such schools (four intervention schools and two control schools), varying by region, attainment and local deprivation. Participants: School students in years 8–10 at baseline and staff. Interventions: Schools were randomised to the intervention or control arm in a 2 : 1 ratio; intervention comprised staff training, mapping ‘hotspots’ in school for dating and relationship violence, modifying staff patrols, school policy review, informing parents and carers, an application supporting student help-seeking, and a classroom curriculum for students in years 9 and 10 (including student-led campaigns). Main outcome measures: Prespecified criteria for progression to Phase III of the trial, concerning acceptability, feasibility, fidelity and response rates. Primary health outcomes were assessed using the Safe Dates and short Conflicts in Adolescent Dating Relationships Inventory measures collected and analysed by individuals who were masked to allocation. Feasibility of economic analysis was assessed. Data sources: Baseline and follow-up student and staff surveys, interviews, observations and logbooks. Results: The intervention was optimised and approved by the Study Steering Committee. The student response rates in intervention and control groups were 1057 (84.8%) and 369 (76.6%) at baseline, and 1177 (76.8%) and 352 (83.4%) at follow-up, respectively. Safe Dates and the short Conflicts in Adolescent Dating Relationships Inventory had high levels of completion and reliability. At follow-up, prevalence of past-year dating and relationship violence victimisation was around 35% (Safe Dates scale and short Conflicts in Adolescent Dating Relationships Inventory). Staff response rates were very low. Training occurred in all four schools, with suboptimal fidelity. The curriculum was delivered with optimal fidelity in three schools. Other components were delivered inconsistently. Dating and relationship violence was addressed in control schools via violence prevention and responses, but not systematically. Intervention acceptability among students and staff was mixed. An economic evaluation would be feasible. Limitations: One school did not undertake baseline surveys. Staff survey response rates were low and completion of the logbook was patchy. Conclusions: Our findings suggest that progression to a Phase III trial of this intervention is not indicated because of limited fidelity and acceptability. Future work: High prevalence of dating and relationship violence highlights the ongoing need for effective intervention. Potential intervention refinements would include more external support for schools and enhanced curriculum materials. Any future randomised controlled trials could consider having a longer lead-in from randomisation to intervention commencement, using the short Conflicts in Adolescent Dating Relationships Inventory as the primary outcome and not relying on staff surveys. Trial registration: Current Controlled Trials ISRCTN65324176. Funding: This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 8, No. 5. See the NIHR Journals Library website for further project information.

Aim To explore how women and their partners navigate (pre)conception healthcare and the role of Natural Cycles fertility awareness technology in this process. Methods In-depth interviews with 24 cisgender women aged 24–43 years who had used Natural Cycles’ ‘Plan a Pregnancy’ mode, and six partners of Natural Cycles users, all cisgender men aged 30–39 years. Participants were recruited via direct messaging in the Natural Cycles app, social media and, for partners, snowball sampling. Purposive sampling was conducted to ensure diversity among participants. Interviews were audio-recorded and transcribed verbatim. An iterative, inductive approach was adopted for thematic data analysis. Results Natural Cycles helped most users better understand their menstrual cycles and fertility. Fertility awareness and preconception counselling with healthcare providers were uncommon. Women felt discussions about planning pregnancy in healthcare settings were often fraught with difficulties. They described not wanting to be an extra burden to overworked staff, being concerned that their worries about trying for pregnancy would be dismissed, or feeling staff did not have expertise in fertility awareness. Some women had shared their Natural Cycles data with healthcare professionals to demonstrate their menstrual cycle data or time of conception. However, it was not always clear to those not accessing services when they should seek further advice, for example, those using the app for longer time periods who had not yet conceived. Conclusions Digital technologies can provide information and support for those wanting to conceive. They should, however, complement care in statutory services, and be accompanied by greater investment in fertility awareness and preconception support.

Background We update a previous systematic review to inform new World Health Organization HIV self-testing (HIVST) recommendations. We compared the effects of HIVST to standard HIV testing services to understand which service delivery models are effective for key populations. Methods We did a systematic review of randomised controlled trials (RCTs) which compared HIVST to standard HIV testing in key populations, published from 1 January 2006 to 4 June 2019 in PubMed, Embase, Global Index Medicus, Social Policy and Practice, PsycINFO, Health Management Information Consortium, EBSCO CINAHL Plus, Cochrane Library and Web of Science. We extracted study characteristic and outcome data and conducted risk of bias assessments using the Cochrane ROB tool version 1. Random effects meta-analyses were conducted, and pooled effect estimates were assessed along with other evidence characteristics to determine the overall strength of the evidence using GRADE methodology. Results After screening 5909 titles and abstracts, we identified 10 RCTs which reported on testing outcomes. These included 9679 participants, of whom 5486 were men who have sex with men (MSM), 72 were trans people and 4121 were female sex workers. Service delivery models included facility-based, online/mail and peer distribution. Support components were highly diverse and ranged from helplines to training and supervision. HIVST increased testing uptake by 1.45 times (RR=1.45 95% CI 1.20, 1.75). For MSM and small numbers of trans people, HIVST increased the mean number of HIV tests by 2.56 over follow-up (mean difference = 2.56; 95% CI 1.24, 3.88). There was no difference between HIVST and SoC in regard to positivity among tested overall (RR = 0.91; 95% CI 0.73, 1.15); in sensitivity analysis of positivity among randomised HIVST identified significantly more HIV infections among MSM and trans people (RR = 2.21; 95% CI 1.20, 4.08) and in online/mail distribution systems (RR = 2.21; 95% CI 1.14, 4.32). Yield of positive results in FSW was not significantly different between HIVST and SoC. HIVST reduced linkage to care by 17% compared to SoC overall (RR = 0.83; 95% CI 0.74, 0.92). Impacts on STI testing were mixed; two RCTs showed no decreases in STI testing while one showed significantly lower STI testing in the intervention arm. There were no negative impacts on condom use (RR = 0.95; 95% CI 0.83, 1.08), and social harm was very rare. Conclusions HIVST is safe and increases testing uptake and frequency as well as yield of positive results for MSM and trans people without negative effects on linkage to HIV care, STI testing, condom use or social harm. Testing uptake was increased for FSW, yield of positive results were not and linkage to HIV care was worse. Strategies to improve linkage to care outcomes for both groups are crucial for effective roll-out.

Adolescent dating and relationship violence is associated with health harms and is an important topic for sex education. School-based interventions addressing this have been effective in the USA, but schools in England confront pressures that might hinder implementation. We assessed the feasibility of, and contextual enablers/barriers to implementing Project Respect, a whole-school intervention. We conducted a pilot trial with process evaluation in six English secondary schools. Intervention comprised: training; policy-review; mapping and patrolling 'hotspots'; parent information; help-seeking app; and a curriculum (including student-led campaigns) targeting dating violence. Process evaluation included assessments of fidelity and interviews with the trainer and school staff. Schools delivered training and lessons partially or completely and made parent and app information available. Two schools conducted policy reviews; none patrolled hotspots or implemented campaigns. Implementation was strengthened where staff saw dating violence as a priority. Delivery was undermined where staff were insufficiently involved, lacked time for planning or struggled to timetable lessons, and where new school challenges undermined engagement. School-based health interventions must work to build staff buy-in and ensure they do not overburden schools. Dating and relationship violence might best be addressed in this context as a broader aspect of sex education.