Understanding the limited effectiveness of a whole-school relationships and sexual-health programme: fidelity of implementation, reach and acceptability of Positive Choices

Muraleetharan, Veena, Ponsford, Ruth, Meiksin, Rebecca, Sturgess, Joanna, Tilouche, Nerissa, Opondo, Charles, McAllister, Josephine, Morris, Stephen, Melendez-Torres, G.J., Hadley, Alison, Lohan, Maria, Mercer, Catherine H., Young, Honor ORCID: https://orcid.org/0000-0003-0664-4002, Campbell, Rona, Coyle, Karin, Allen, Elizabeth and Bonell, Chris 2026. Understanding the limited effectiveness of a whole-school relationships and sexual-health programme: fidelity of implementation, reach and acceptability of Positive Choices. Sex Education: Sexuality, Society and Learning Item availability restricted.

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Abstract

Previous trials of whole-school relationships and sexual-health programmes have not reported on fidelity, reach or acceptability despite their importance 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 these 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 how well the programme was delivered in 24 schools and awareness and acceptability among students, including subgroup differences. We found that 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 eleven 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.

Item Type:	Article
Status:	In Press
Schools:	Schools > Social Sciences (Includes Criminology and Education) Research Institutes & Centres > Centre For Development and Evaluation of Complex Interventions for Public Health Improvement (DECIPHer)
Publisher:	Taylor and Francis Group
ISSN:	1468-1811
Date of First Compliant Deposit:	19 March 2026
Date of Acceptance:	19 March 2026
Last Modified:	19 Mar 2026 12:15
URI:	https://orca.cardiff.ac.uk/id/eprint/185873

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