Phase-III RCT of Positive Choices: a whole-school social-marketing intervention to promote sexual health and reduce health inequalities

Research question What is the effect of the Positive Choices intervention on student-reported non-competent first sex (primary outcome - absence of: contraception, autonomy of decision, equal partner willingness, judgement of being the right time) and secondary outcomes? Background Positive Choices is a whole-school social-marketing intervention to promote sexual health among secondary school students. Intervention comprises: school health promotion council involving staff and students coordinating delivery; student survey to inform local tailoring; teacher-delivered classroom curriculum; student-run campaigns; parent information; and review of sexual/reproductive health services to inform improvements. This RCT proposal builds on an NIHR-funded optimisation/pilot-RCT study which met progression criteria, plus findings from another NIHR-funded pilot RCT of the Project Respect school-based intervention to prevent dating and relationship violence (both too large to upload as part of proposal but available on request) which concluded such work should be integrated within Positive Choices. PPI with policy, practice and youth stakeholders recommended a change to the Positive Choices primary outcome from pregnancy to lack of sexual competence because: while teenage pregnancy rates are declining, other risks such as STIs and DRV are increasing; lack of sexual competence at first sex predicts subsequent risk of STI, unplanned pregnancy, non-volitional sex and sexual dysfunction; and this measure is relevant regardless of young people’s gender and sexual orientation. Young people carry a disproportionate burden of adverse sexual health; most do not report competence at first sex. Relationships and sex education in schools can contribute to promoting sexual health but effects are small, inconsistent and not sustained. Such work needs to be supplemented by ‘whole-school’ (e.g. student campaigns, sexual health services) and ‘social marketing’ (harnessing commercial marketing to social ends) approaches for which there is good review-level evidence but not from the UK. Positive Choices is informed by such interventions with the strongest evidence of effectiveness: the Safer Choices, CAS Carrera and Gatehouse interventions. Aim To conduct an RCT of Positive Choices with public and policy involvement and economic and process evaluation. Methods We will conduct a cluster RCT across 50 schools (minimum 6440, maximum 8500 students) allocated 1:1 to intervention/control assessing outcomes at 33 months. Timelines for delivery To recruit 50 school and undertake baseline surveys by month 6. To implement the intervention over the 2022-24 school years and conduct the economic and process evaluations by month 34. To undertake follow-up surveys by month 39. To complete analyses, all patient and policy involvement and draft the study report by month 42, and engage in knowledge exchange from month 39. Anticipated impact and dissemination The key scientific output will be evidence about the effectiveness, costs and potential scalability and transferability of Positive Choices. If effective, this would be scaled up across secondary schools. Findings will be communicated to multiple audience via diverse outputs.