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.
Key Findings
Results
The Positive Choices whole-school RSE intervention did not prevent non-competent sexual debut compared with usual practice.
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), indicating no statistically significant effect.
Non-competent sexual debut was defined as lacking decision autonomy, judging timing as right, partners' equal willingness, or contraception use.
The trial was a cluster-randomised design with 33-month follow-up in English secondary schools.
Results
There were no effects of the Positive Choices intervention on any secondary outcomes.
No secondary outcomes showed a significant effect of the intervention compared with usual RSE.
The trial compared the intervention with usual practice across 25 control and 24 intervention schools.
Secondary outcomes were not specified in the abstract but were part of the pre-registered trial (ISRCTN16723909).
Results
Fidelity of whole-school intervention components was suboptimal across participating schools.
No schools achieved 'good' fidelity across components.
Only two schools achieved 'adequate' fidelity across all components.
Eleven schools achieved 'adequate fidelity on selected components' (student-needs report, school-health-promotion council meetings, lessons, parent information).
Weak fidelity is cited as a possible explanation for the null primary outcome.
Results
Control schools delivered similar RSE activities to intervention schools, representing potential contamination or a strong usual-practice comparator.
Control schools delivered similar activities to intervention schools during the trial period.
This is identified as a possible explanation for the null finding alongside weak fidelity.
The authors describe this as 'comprehensive RSE in control schools.'
Results
School recruitment for the trial was very low, with only 1.76% of invited schools consenting to participate.
Of 2845 schools invited, 50 (1.76%) consented to participate.
One school left post-allocation.
Four schools withdrew pre-endline, leaving 25 control and 24 intervention schools at endline.
This low recruitment rate may affect the generalisability of the findings.
Results
Student participation rates at baseline and endline were high.
6970 (77.3%) students participated at baseline.
6268 (77.9%) students participated at the 33-month endline.
The trial followed students over a 33-month period.
Results
The incremental cost of the Positive Choices intervention was £1337 per school, or £10 per student.
Incremental costs were £1337 per school and £10 per student.
These costs are reported in the context of a null primary outcome.
The intervention comprised RSE lessons, school-health-promotion councils, student-needs data, student-led campaigns, review of sexual-health services, and parent information.
Background
The Positive Choices intervention was a whole-school RSE programme incorporating multiple components beyond standard lessons.
Components included: RSE lessons, school-health-promotion councils involving students, student-needs data to tailor provision, student-led campaigns, review of sexual-health services, and parent information.
The intervention was designed to build student engagement and provide contraception access.
The intervention was compared with usual RSE practice in English secondary schools.
The theoretical basis included whole-school approaches intended to prevent pregnancies and sexually transmitted infections.
What This Means
This research examined whether a comprehensive school-based programme called 'Positive Choices' could reduce the number of young people having sex before they felt truly ready or in situations where they lacked contraception, equal willingness between partners, or a sense that the timing was right (called 'non-competent sexual debut'). The programme went beyond standard sex education lessons to include student councils, peer-led campaigns, review of school health services, and information for parents. The study randomly assigned 49 English secondary schools to either receive the programme or continue with their usual sex education, and followed over 6,000 students for nearly three years.
The study found that the programme made no measurable difference: about 64-66% of students who had sex for the first time during the study period reported that their debut was 'non-competent' in both the programme and control groups, a difference too small to be meaningful. No other outcomes were affected either. Two main reasons are suggested for why the programme did not work: first, most schools did not implement the programme as intended (no school achieved 'good' fidelity, and only two achieved adequate fidelity across all components); and second, control schools ended up delivering similarly comprehensive sex education on their own, making it hard to detect any added benefit.
This research suggests that even well-designed, multi-component school health programmes can fail to show effects when implementation is weak and when the comparison schools are already doing similar things. The findings highlight the challenges of recruiting schools into trials (only 1.76% of invited schools agreed to participate) and of achieving high-quality implementation of complex interventions in real school settings. Future programmes aiming to improve young people's sexual health may need stronger support for schools to implement all components as planned.
Ponsford R, Meiksin R, Sturgess J, Muraleetharan V, Tilouche N, Opondo C, et al.. (2026). Effects of a whole-school relationships and sexual health intervention on non-competent sexual debut: cluster-randomised trial.. Journal of epidemiology and community health. https://doi.org/10.1136/jech-2025-225004