Speakers
Description
Authors: Ruth Ponsford (London School of Hygiene & Tropical Medicine, Department of Public Health, Environments and Society), Veena Muraleetharan (London School of Hygiene & Tropical Medicine, Department of Public Health, Environments and Society), Rebecca Meiksin (London School of Hygiene & Tropical Medicine, Department of Public Health, Environments and Society), Jo Sturgess (London School of Hygiene & Tropical Medicine, Department of Medical Statistics), Nerissa Tilouche (London School of Hygiene & Tropical Medicine, Department of Public Health, Environments and Society), Charles Opondo (London School of Hygiene & Tropical Medicine, Department of Medical Statistics), Josephine McAllister (Department of Social & Policy Sciences, University of Bath), Steve Morris (Department of Public Health, Cambridge University), G.J. Melendez-Torres (Department of Public Health and Sports Sciences, University of Exeter), Alison Hadley (Teenage Pregnancy Knowledge Exchange, University of Bedfordshire), Maria Lohan (School of Nursing and Midwifery, Medical Biology Centre; Hitotsubashi Institute of Advanced Study, University of Hitotsubashi), Catherine Mercer (University College London), Honor Young (DECIPHer Centre, Cardiff School of Social Sciences, Cardiff University), Rona Campbell (Bristol Medical School), Karin Coyle (ETR Associates), Elizabeth Allen (London School of Hygiene & Tropical Medicine, Department of Medical Statistics), Chris Bonell (London School of Hygiene & Tropical Medicine, Department of Public Health, Environments and Society)
Background: Whole-school sexual health interventions that go beyond classroom education have shown potential to improve sexual health outcomes. However, existing literature does not report on implementation and the factors affecting this, important context for interpreting outcomes and understanding conditions for replicability and scale-up. In England, recent legal changes making relationships and sex education (RSE) mandatory also underscore the importance of understanding how schools make sense of their duty to address sexual health.
Methods: We conducted a parallel-arm, cluster RCT in 49 secondary schools across England from 2021 to 2025 with nested process evaluation to assess a whole-school intervention involving 1) a school health promotion council, 2) a student needs report, 3) classroom curriculum addressing RSE, 4) student-led campaigns, 5) parent information, and 6) review of sexual health services. We assessed implementation with 36 semi-structured staff interviews in 22 of 24 intervention schools, alongside researcher observations and implementor logbooks. Interview transcripts were coded inductively, informed by the data, and deductively, informed by research questions. Data were organized into themes and sub-themes according to May’s General Theory of Implementation.
Results: Overall, fidelity was poor with no school delivering all elements with a good level of fidelity and only two schools implementing all components with adequate fidelity. Most schools reported lesson delivery in both years, but only five-to-six delivered all lessons each year with 70%+ fidelity. Lesson delivery was supported by materials and training, but schools varied in their capacity to call on specialist teachers. Whole-school components were challenging to deliver, as staff made sense of sexual health as a curriculum priority, rather than a whole-school issue, particularly in light of recent legislative changes.
Discussion: Resonance with national policy enabled lesson delivery, but detracted from commitments to whole-school elements. Dedicated RSE staff and incorporating sexual health into existing whole-school initiatives could improve implementation.
| Conflict of interest | The authors declare no conflicts of interest. |
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