School-based interventions TO Prevent Dating and Relationship Violence and Gender-Based Violence: STOP-DRV-GBV systematic review.

Background: Schools have a duty of care to prevent violence between students but a significant amount of dating and relationship violence and gender-based violence occurs in schools. These are important public health issues with important longitudinal consequences for young people. Objectives: To understand functioning and effectiveness of school-based interventions for the prevention of dating and relationship violence and gender-based violence. Review methods: We undertook a mixed-methods systematic review to synthesise different types of evidence relating to school-based interventions for the prevention of dating and relationship violence and gender-based violence to understand if, how and in what ways these interventions are effective. We searched 21 databases and 2 trial registers and undertook forwards and backwards citation chasing, author contact and other supplementary search methods. Searches identified all literature published to June 2021. All screening was undertaken in duplicate and independently, and we quality appraised all included studies. Results: We included 247 reports (68 outcome evaluations, 137 process evaluations). Synthesis of intervention components produced an intervention typology: single-component, curricular, multicomponent, and multilevel programmes. Synthesis of intervention theories suggested that interventions aiming to increase students' sense of school belonging and sense of safety in the school building could encourage increased learning of prosocial skills and increased prosocial peer norms, and so potentially reducing dating and relationship violence and gender-based violence. Synthesis of factors affecting delivery highlighted school organisation and leaders who believed in the importance of addressing dating and relationship violence/gender-based violence, along with time and resources to deliver the interventions. The ease with which the intervention could be delivered and modified was also important. Meta-analysis found stronger evidence for intervention effectiveness in reducing dating and relationship violence than for gender-based violence, with significant long-term impacts on dating and relationship violence victimisation and perpetration, and some evidence that interventions in high-income countries could be effective for reducing victimisation and perpetration of gender-based violence in the long-term. Impacts on knowledge and attitudes were primarily short-term. Network meta-analysis did not suggest superiority of any intervention type. Moderation evidence suggested interventions reduced dating and relationship violence perpetration in boys more than girls, but reduced gender-based violence perpetration more in girls. Metaregression by intervention component did not explain heterogeneity in effectiveness, but qualitative comparative analysis suggested that reducing perpetration was important to reducing victimisation, and that perpetration could be reduced via focus on interpersonal skills, guided practice and (for gender-based violence) implementation of social structural components. Limitations: Despite an exhaustive search, trials may have been missed and risk of publication bias was high for several analyses. Conclusions: This is the most comprehensive systematic review of school-based interventions for dating and relationship violence and gender-based violence to date. It is clear that the prevention of dating and relationship violence and gender-based violence in schools will require longer-term investment to show benefit. Future work: Future research is needed to understand why intervention effectiveness appears stronger for dating and relationship violence than gender-based violence. Study registration: The study is registered as PROSPERO CRD42020190463. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (NIHR award ref: NIHR130144) and is published in full in Public Health Research; Vol. 12, No. 3. See the NIHR Funding and Awards website for further award information.

Schools are places where dating and relationship violence and gender-based violence occur. Therefore, interventions conducted within schools are ideally placed to prevent and reduce dating and relationship violence and gender-based violence. We reviewed existing research on these interventions, exploring how they were expected to work, what factors affected their implementation in practice, how they had an impact on dating and relationship violence and gender-based violence, and what specific parts of the interventions were most effective and in what contexts. We defined what sort of evidence to include in the review, carried out a comprehensive search and found 247 reports on school-based interventions to prevent dating and relationship violence or gender-based violence, most of which were conducted in North America. Most interventions aimed to provide students with the knowledge, attitudes and skills needed to prevent perpetration and victimisation. They varied in complexity; some had one activity, others had multiple activities, some were integrated into the existing school curricula and others were complex in that they sought to change how schools as a whole respond to dating and relationship violence or gender-based violence. We theorised that complex interventions would bring about greater and more sustainable change, but this was not supported by our findings. The implementation of interventions was affected by factors such as school organisation and leaders who believed in the importance of addressing dating and relationship violence/gender-based violence, along with time and resources to deliver the interventions. The ease with which the intervention could be delivered and modified was also important. There was stronger evidence for intervention effectiveness in reducing dating and relationship violence than for gender-based violence, with significant long-term impacts on dating and relationship violence victimisation and perpetration. There was some evidence that interventions in high-income countries could be effective for reducing victimisation and perpetration of gender-based violence in the long-term. More complicated interventions were not more effective, and interventions tended to reduce dating and relationship violence perpetration in boys more than in girls. We have also been able to identify where there are gaps in available evidence, which may provide avenues for future research.

School-based relationship and sexuality education intervention engaging adolescent boys for the reductions of teenage pregnancy: the JACK cluster RCT.

Background: The need to engage boys in gender-transformative relationships and sexuality education (RSE) to reduce adolescent pregnancy is endorsed by the World Health Organization and the United Nations Educational, Scientific and Cultural Organization. Objectives: To evaluate the effects of If I Were Jack on the avoidance of unprotected sex and other sexual health outcomes. Design: A cluster randomised trial, incorporating health economics and process evaluations. Setting: Sixty-six schools across the four nations of the UK. Participants: Students aged 13-14 years. Intervention: A school-based, teacher-delivered, gender-transformative RSE intervention (If I Were Jack) versus standard RSE. Main outcome measures: Self-reported avoidance of unprotected sex (sexual abstinence or reliable contraceptive use at last sex) after 12-14 months. Secondary outcomes included knowledge, attitudes, skills, intentions and sexual behaviours. Results: The analysis population comprised 6556 students: 86.6% of students in the intervention group avoided unprotected sex, compared with 86.4% in the control group {adjusted odds ratio 0.85 [95% confidence interval (CI) 0.58 to 1.26], p = 0.42}. An exploratory post hoc analysis showed no difference for sexual abstinence [78.30% intervention group vs. 78.25% control group; adjusted odds ratio 0.85 (95% CI 0.58 to 1.24), p = 0.39], but more intervention group students than control group students used reliable contraception at last sex [39.62% vs. 26.36%; adjusted odds ratio 0.52 (95% CI 0.29 to 0.920), p = 0.025]. Students in schools allocated to receive the intervention had significantly higher scores on knowledge [adjusted mean difference 0.18 (95% CI 0.024 to 0.34), p = 0.02], gender-equitable attitudes and intentions to avoid unintended pregnancy [adjusted mean difference 0.61 (95% CI 0.16 to 1.07), p = 0.01] than students in schools allocated to receive the control. There were positive but non-significant differences in sexual self-efficacy and communication skills. The total mean incremental cost of the intervention compared with standard RSE was £2.83 (95% CI -£2.64 to £8.29) per student. Over a 20-year time horizon, the intervention is likely to be cost-effective owing to its impact on unprotected sex because it would result in 379 (95% CI 231 to 477) fewer unintended pregnancies, 680 (95% CI 189 to 1467) fewer sexually transmitted infections and a gain of 10 (95% CI 5 to 16) quality-adjusted life-years per 100,000 students for a cost saving of £9.89 (95% CI -£15.60 to -£3.83). Limitations: The trial is underpowered to detect some effects because four schools withdrew and the intraclass correlation coefficient (0.12) was larger than that in sample size calculation (0.01). Conclusions: We present, to our knowledge, the first evidence from a randomised trial that a school-based, male engagement gender-transformative RSE intervention, although not effective in increasing avoidance of unprotected sex (defined as sexual abstinence or use of reliable contraception at last sex) among all students, did increase the use of reliable contraception at last sex among students who were, or became, sexually active by 12-14 months after the intervention. The trial demonstrated that engaging all adolescents early through RSE is important so that, as they become sexually active, rates of unprotected sex are reduced, and that doing so is likely to be cost-effective. Future work: Future studies should consider the longer-term effects of gender-transformative RSE as students become sexually active. Gender-transformative RSE could be adapted to address broader sexual health and other settings. Trial registration: This trial is registered as ISRCTN10751359. Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (PHR 15/181/01) and will be published in full in Public Health Research; Vol. 11, No. 8. See the NIHR Journals Library website for further project information.

Adolescent pregnancy is often thought to be an issue for young women alone, but it is important to engage young men to tackle the problem and find solutions. The If I Were Jack intervention was especially designed to engage with boys as well as girls aged 14 years and to promote positive masculinity and gender equality to prevent adolescent pregnancy and promote positive sexual health. It uses tailored interactive films and resources, made with the help of students and teachers, to make it relevant to each of the four UK nations. This relationship and sexuality education intervention encourages adolescents to avoid unprotected sex by delaying sexual activity until they feel ready and to use reliable contraception once sexually active. It also promotes knowledge, attitudes (such as beliefs about gender and masculinities), skills and intentions for safe and pleasurable relationships. In this trial, we compared students in 33 schools randomly allocated to deliver the intervention with students in 33 schools that continued with their usual relationship and sexuality education practices. Four schools withdrew, two because of COVID-19 school closures. This left a total of 6556 students who completed questionnaires at the start of the study and 12­14 months later. Responses from all these students showed that If I Were Jack had a positive impact on knowledge, attitudes and intentions required for safe and pleasurable relationships, but did not have a significant effect on overall avoidance of unprotected sex. This was because the intervention had no effect on delaying sexual activity. However, we found that the intervention was effective in increasing the use of reliable contraception as students became sexually active, as well as for those who already were sexually active prior to receiving the intervention. We also found that If I Were Jack was likely to provide value for money by reducing unintended pregnancies and improving sexual health.

Re-orientating systematic reviews to rigorously examine what works, for whom and how: Example of a realist systematic review of school-based prevention of dating and gender violence.

Conventional systematic reviews offer few insights into for whom and how interventions work. 'Realist reviews' examine such questions via examining 'context-mechanism-outcome configurations' (CMOCs) but are insufficiently rigorous in how evidence is identified, assessed and synthesised. We developed 'realist systematic reviews', addressing similar questions to realist reviews but using rigorous methods. We applied this to synthesising evidence on school-based prevention of dating and relationship violence (DRV) and gender-based violence (GBV). This paper reflects on overall methods and findings, drawing on papers reporting each analysis. Drawing on intervention descriptions, theories of change and process evaluations, we developed initial CMOC hypotheses: interventions triggering 'school-transformation' mechanisms (preventing violence by changing school environments) will achieve larger effects than those triggering 'basic-safety' (stopping violence by emphasising its unacceptability) or 'positive-development' (developing students' broader skills and relationships) mechanisms; however, school transformation would only work in schools with high organisational capacity. We used various innovative analyses, some of which aimed to test these hypotheses and some of which were inductive, drawing on available findings to augment and refine the CMOCs. Overall, interventions were effective in reducing long-term DRV but not GBV or short-term DRV. DRV prevention occurred most effectively via the 'basic-safety' mechanism. 'School-transformation' mechanisms were more effective in preventing GBV but only in high-income countries. Impacts on long-term DRV victimisation were greater when working with a critical mass of participating girls. Impacts on long-term DRV perpetration were greater for boys. Interventions were more effective when focusing on skills, attitudes and relationships, or lacking parental involvement or victim stories. Our method provided novel insights and should be useful to policy-makers seeking the best interventions for their contexts and the most information to inform implementation.

Are school-based interventions to prevent dating and relationship violence and gender-based violence equally effective for all students? Systematic review and equity analysis of moderation analyses in randomised trials.

School-based interventions for the prevention of dating and relationship violence (DRV) and gender-based violence (GBV) take advantage of universal opportunities for intervention. Information on differential effectiveness of interventions is important to assess if they ameliorate or worsen social gradients in specific outcomes. This is especially important in DRV and GBV prevention given the gendered context of these behaviours and their common aetiologies in patriarchal gender norms, and social acceptance in school contexts of sexual harassment, such as catcalling or unwanted groping. We undertook a systematic review of moderation analyses in randomised trials of school-based interventions for DRV and GBV prevention. We searched 21 databases and used supplementary search methods without regard to publication type, language or year of publication, and synthesised moderation tests relating to equity-relevant characteristics (principally sex and prior history of the outcome) for DRV and GBV perpetration and victimisation. Across 23 included outcome evaluations, programme effects on DRV victimisation were not moderated by gender or prior experience of DRV victimisation, but DRV perpetration outcomes were greater for boys, particularly for emotional and physical DRV perpetration. Findings for GBV outcomes were counterintuitive. Our findings suggest that practitioners should carefully monitor local intervention effectiveness and equity to ensure that interventions are working as intended. However, one of the most surprising findings from our analysis-with clear relevance for uncertainties in practice-was that differential impacts by sexuality or sexual minority status were not frequently evaluated.

School-Based Interventions to Prevent Dating and Relationship Violence and Gender-Based Violence: Systematic Review and Network Meta-Analysis.

Background. Schools are sites of dating and relationship violence (DRV) and of gender-based violence (GBV) victimization and perpetration. School-based interventions can reach a broad range of students, targeting both individual and group processes that may underpin DRV and GBV. Considering DRV and GBV jointly is important because of their shared etiologies. Comparing the effectiveness of interventions using network meta-analysis (NMA) can support decision-making on optimal resource use. Objectives. To evaluate the comparative effectiveness of school-based interventions for children aged 5 to 18 years on DRV and GBV victimization, perpetration, and related mediators. Search Methods. We searched 21 databases in July 2020 and June 2021, alongside extensive supplementary search methods, including gray literature searches, forward and backward citation chasing, and searches on first and last author names. Selection Criteria. We included randomized-controlled trials of interventions for children of compulsory school age implemented within the school setting, and either partially or wholly aimed at changing DRV or GBV outcomes. Data Collection and Analysis. Pairwise meta-analyses using random-effects robust variance estimation considered intervention effectiveness on DRV and GBV victimization and perpetration using odds ratios, and on mediators (e.g., knowledge and attitudes) using standardized mean differences. Effects were divided into short-term (< 12 months postbaseline) and long-term (≥ 12 months postbaseline). NMAs on victimization and perpetration outcomes compared interventions categorized by breadth of mechanism and complexity of delivery and implementation. Meta-regression tested sensitivity to percentage of girls in the trial sample and country context. Main Results. Our analysis included 68 trials. Evidence was stronger overall for effects on DRV than for GBV, with significant long-term impacts on DRV victimization (odds ratio [OR] = 0.82; 95% confidence interval [CI] = 0.68, 0.99) and DRV perpetration (OR = 0.78; 95% CI = 0.64, 0.94). Knowledge and attitudinal effects were predominantly short-term (e.g., for DRV-related violence acceptance, d = 0.16; 95% CI = 0.08, 0.24). NMAs did not suggest the superiority of any intervention type; however, most analyses for GBV outcomes were inconsistent. A higher proportion of girls in the sample was associated with increased effectiveness on long-term victimization outcomes. Author's Conclusions. Evidence is stronger for DRV than for GBV, despite considerable heterogeneity. Certainty of findings was low or very low overall. Public Health Implications. Violence reductions may require more than 1 school year to become apparent. More extensive interventions may not be more effective. A possible reason for stronger effectiveness for DRV is that whereas GBV is ingrained in school cultures and practices, DRV is potentially more open to change via addressing individual knowledge and attitudes. (Am J Public Health. 2023;113(3):320-330. https://doi.org/10.2105/10.2105/AJPH.2022.307153).

Systematic Review of the Economics of School-Based Interventions for Dating Violence and Gender-Based Violence.

Dating and relationship violence (DRV) and gender-based violence (GBV) among children and young people incur a high cost to individuals and society. School-based interventions present an opportunity to prevent DRV and GBV early in individuals' lives. However, with school resources under pressure, policymakers require guidance on the economics of implementing interventions. As part of a large systematic review funded by the National Institute for Health and Care Research (NIHR), we searched for economic evaluations and costing studies of school-based interventions for DRV and GBV. No formal economic evaluations were identified. Seven studies reporting costs, cost savings, or resource use for eight interventions were identified. The largest costs of implementing interventions were related to staff training and salaries but savings could be made by implementing interventions on a large scale. The potential cost savings of avoided DRV and GBV far outweighed the costs of implementation.

Exploring the Activities and Target Audiences of School-Based Violence Prevention Programs: Systematic Review and Intervention Component Analysis.

Adolescents are at an increased risk for experiencing dating and relationship violence (DRV) and gender-based violence (GBV). School-based interventions remain an important and frequently used method for DRV/GBV prevention. A clear understanding and description of the different components of school-based interventions specific to DRV/GBV is needed to organize and advance the array of prevention efforts being utilized in school settings. We conducted an intervention component analysis to create a taxonomy for school-based interventions addressing DRV and GBV. We searched 21 databases in July 2020 and updated searches in June 2021, alongside extensive supplementary search methods. We included randomized controlled trials (RCTs) in adolescents of compulsory school-age that were implemented within the school setting which partially or wholly focused on DRV and GBV topics. Our analysis included 68 studies describing 76 different school-based interventions. Through an iterative coding process we identified 40 intervention components organized within 13 activity categories, including both student-directed components and non-student-directed components such as activities for school personnel and family members of students. We also identified components addressing higher levels of the social-ecological model including structural-social and structural-environmental aspects of DRV/GBV which prior reviews have not considered. This taxonomy of components and synthesis of intervention efficacy for DRV/GBV school-based interventions provides a framework for comparing past intervention evaluations and constructing new interventions to address these issues at multiple levels within a community.

Young people's online communication and its association with mental well-being: results from the 2019 student health and well-being survey.

BACKGROUND: Online communication has become an integral aspect of daily life for young people internationally. Very little research has examined whether the association between social media use and well-being depends on who young people engage with (i.e. real, or virtual friendships). METHODS: Data were drawn from a subsample of students (N = 38,736) who took part in the School Health Research Network (SHRN) 2019 Student Health and Well-being (SHW) survey. A series of multivariable regression models were used to assess the association between who adolescents were communicating with online and well-being, controlling for confounders: passive social media use; friendship quality; and cyberbullying. We also tested whether these associations were modified based on gender. RESULTS: Students are highly engaged on social networking sites, and these sites are used to communicate with existing friendship groups and develop virtual friendships. Frequent online communication with best friends (b = .340, p < .001) and bigger friendship groups (b = .397; p < .001) was associated with higher levels of well-being. However, the frequency of online contact with virtual friends made online was negatively and significantly associated with well-being (b = -.760; p < .001), with a larger negative association for girls than boys. CONCLUSIONS: Online communication with virtual friendship networks were associated with lower mental well-being, with stronger associations for girls than boys; however, frequent online communication with 'real' friends was associated with better well-being. Our results indicate the importance of considering the nature of adolescent online communication, rather than just its quantity, in developing interventions to improve adolescent well-being.

Effects of gender-transformative relationships and sexuality education to reduce adolescent pregnancy (the JACK trial): a cluster-randomised trial.

BACKGROUND: The need to engage boys in gender-transformative relationships and sexuality education (RSE) to reduce adolescent pregnancy is endorsed by WHO. We aimed to test an intervention which used a gender-transformative approach to engage adolescents in RSE to prevent unprotected sex. METHODS: This cluster-randomised trial with process and economic evaluations tested a school-based intervention entitled If I Were Jack versus standard RSE (control) for students (aged 14-15 years) in UK schools. Schools were randomly allocated (1:1) and masked to allocation at baseline. The primary outcome was self-reported avoidance of unprotected sex (sexual abstinence or use of reliable contraception at last sex) after 12-14-months. We analysed the data using intention-to-treat mixed effects regression models. FINDINGS: Of 803 schools assessed for eligibility, 263 schools were invited by letter, of which 66 schools agreed to be randomly assigned, of which 62 schools completed follow-up. The trial was done between Feb 1, 2018, and March 6, 2020. 8216 students participated at baseline in 2018; 6561 (79·85%) provided 12-14 months follow-up. There was no significant difference in the primary outcome of avoidance of unprotected sex: 2648 (86·62) of 3057 in the intervention group avoided unprotected sex versus 2768 (86·41%) of 3203 in the control group (adjusted odds ratio [aOR] 0·85 [95% CI 0·58-1·26], p=0·42). Exploratory post-hoc analysis of the two components of the primary outcome showed that significantly more intervention students used reliable contraception at last sex compared with control students and there was no significant difference between the groups for sexual abstinence. No adverse events were reported. INTERPRETATION: The intervention had a null effect on the primary outcome of preventing unprotected sex (increasing sexual abstinence or use of reliable contraception) in the whole student population. However, the results showed significant increases in use of reliable contraceptives for sexually active students. Engaging all young people early through RSE is important so that as they become sexually active, rates of unprotected sex are reduced. FUNDING: National Institute for Health Research.

The Positive Choices trial: update to study protocol for a phase-III RCT trial of a whole-school social-marketing intervention to promote sexual health and reduce health inequalities.

BACKGROUND: Positive Choices is a whole-school social-marketing intervention to promote sexual health among secondary school students. Intervention comprises the following: 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 trial builds on an optimisation/pilot-RCT study which met progression criteria, plus findings from another pilot RCT of the Project Respect school-based intervention to prevent dating and relationship violence which concluded such work should be integrated within Positive Choices. 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. 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. Our primary outcome is non-competent first sex. Secondary outcomes are non-competent last sex, age at sexual debut, non-use of contraception at first and last sex among those reporting heterosexual intercourse, number of sexual partners, dating and relationship violence, sexually transmitted infections and pregnancy and unintended pregnancy for girls and initiation of pregnancy for boys. We will recruit 50 school and undertake baseline surveys by March 2022, implement the intervention over the 2022-2024 school years and conduct the economic and process evaluations by July 2024; undertake follow-up surveys by December 2024; complete analyses, all patient and policy involvement and draft the study report by March 2025 and engage in knowledge exchange from December 2024. DISCUSSION: This trial is one of a growing number focused on whole-school approaches to public health in schools. The key scientific output will be evidence about the effectiveness, costs and potential scalability and transferability of Positive Choices. TRIAL REGISTRATION: ISRCTN No: ISRCTN16723909 . Registered on 3 September 2021.

School-based interventions for preventing dating and relationship violence and gender-based violence: A systematic review and synthesis of theories of change.

School-based interventions for preventing dating and relationship violence (DRV) and gender-based violence (GBV) are an important way of attempting to prevent and reduce the significant amount of DRV and GBV that occurs in schools. A theoretical understanding of how these interventions are likely to cause change is essential for developing and evaluating effectiveness, so developing an overarching theory of change for school-based interventions to prevent DRV and GBV was the first step in our systematic review. Theoretical data were synthesised from 68 outcome evaluations using methods common to qualitative synthesis. Specifically, we used a meta-ethnographic approach to develop a line-of-argument for an overarching theory of change and Markham and Aveyard's (2003, Social Science & Medicine, 56, 1209) theory of human functioning and school organisation as a framework for structuring the concepts. The overall theory of change generated was that by strengthening relationships between and among staff and students, between the classroom and the wider school, and between schools and communities, and by increasing students' sense of belonging with student-centred learning opportunities, schools would encourage student commitment to the school and its values, prosocial behaviour and avoidance of violence and aggression. The theory of human functioning informed our understanding of the mechanisms of action but from our analysis we found that it required refinement to address the importance of context and student agency.

The Positive Choices trial: study protocol for a Phase-III RCT trial of a whole-school social marketing intervention to promote sexual health and reduce health inequalities.

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 trial builds on an optimisation/pilot RCT study which met progression criteria, plus findings from another pilot RCT of the Project Respect school-based intervention to prevent dating and relationship violence which concluded such work should be integrated within Positive Choices. 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. 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. Our primary outcome is non-competent first sex. Secondary outcomes are non-competent last sex, age at sexual debut, non-use of contraception at first and last sex among those reporting heterosexual intercourse, number of sexual partners, dating and relationship violence, sexually transmitted infections, and pregnancy and unintended pregnancy for girls and initiation of pregnancy for boys. We will recruit 50 school and undertake baseline surveys by March 2022; implement the intervention over the 2022-2024 school years and conduct the economic and process evaluations by July 2024; undertake follow-up surveys by December 2024; complete analyses, all patient and policy involvement and draft the study report by March 2025; and engage in knowledge exchange from December 2024. DISCUSSION: This trial is one of a growing number focused on whole-school approaches to public health in schools. The key scientific output will be evidence about the effectiveness, costs and potential scalability and transferability of Positive Choices. TRIAL REGISTRATION: ISRCTN No: ISRCTN16723909 . Trial registration summary: Date:. Funded by: National Institute for Health Research Public Health Research Programme (NIHR131487). SPONSOR: LSHTM. Public/scientific contact: Chris Bonell. Public title: Positive Choices trial. Scientific title: Phase-III RCT of Positive Choices: a whole-school social marketing intervention to promote sexual health and reduce health inequalities. Countries of recruitment: UK. INTERVENTION: Positive Choices. INCLUSION CRITERIA: Students in year 8 (age 12-13 years) at baseline deemed competent by schools to participate in secondary schools excluding pupil referral units, schools for those with special educational needs and disabilities, and schools with 'inadequate' Ofsted inspections. STUDY TYPE: interventional study with superiority phase III cluster RCT design. Enrollment: 1/9/21-31/3/22. SAMPLE SIZE: 50 schools and 6440-8500 students. Recruitment status: pending. PRIMARY OUTCOME: binary measure of non-competent first sex. SECONDARY OUTCOMES: non-competent last sex; age at sexual debut; non-use of contraception at first and last sex; number of sexual partners; dating and relationship violence (DRV) victimisation; sexually transmitted infections; pregnancy and unintended pregnancy for girls and initiation of pregnancy for boys using adapted versions of the RIPPLE measures. Ethics review: LSHTM research ethics committee (reference 26411). Completion data: 1/3/25. Sharing statement: Data will be made available after the main trial analyses have been completed on reasonable request from researchers with ethics approval and a clear protocol. Amendments to the protocol will be communicated to the investigators, sponsor, funder, research ethics committee, trial registration and the journal publishing the protocol. Amendments affecting participants' experience of the intervention or important amendments affecting the overall design and conduct of the trial will be communicated to participants.

Risk Behaviours Associated with Dating and Relationship Violence among 11-16 Year Olds in Wales: Results from the 2019 Student Health and Wellbeing Survey.

(1) Background: This study examines the associations between risk behaviours and adolescent emotional and physical dating and relationship violence (DRV) victimisation and perpetration, and how these vary by gender. The risk behaviours explored include bullying, cyberbullying, sexting, alcohol, and cannabis use; (2) Methods: Cross-sectional self-report data from the School Health Research Network (SHRN) 2019 Student Health Wellbeing (SHW) survey of 48,397 students aged 11-16 from 149 schools across Wales were analysed using single and multiple-behaviour logistic regression models to explore the associations between each risk behaviour and emotional and physical DRV victimisation and perpetration; (3) Results: Bivariate analyses revealed a statistically significant association between DRV and all risk behaviours. In multivariate analyses, students who reported bullying, cyberbullying, sexting, and substance use, compared to those that had not, had significantly higher odds of experiencing and perpetrating emotional and physical DRV; and (4) Conclusions: Future studies on DRV should consider a mixed-methods approach to explore the context in which DRV and risk behaviours interrelate. Results from this study indicate the possibility that prevention and intervention programmes in school settings that seek to develop healthy school environments and peer-to-peer relationships, could inadvertently reduce the occurrence of future DRV and associated risk behaviours.

Co-production of two whole-school sexual health interventions for English secondary schools: positive choices and project respect.

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.

Dating and relationship violence victimization and perpetration among 11-16 year olds in Wales: a cross-sectional analysis of the School Health Research Network (SHRN) survey.

BACKGROUND: This study examines the prevalence of dating and relationship violence (DRV) victimization, perpetration and joint victimization and perpetration, and associations between DRV and socio-demographic characteristics. METHODS: Cross-sectional self-report data from 74 908 students aged 11-16 from 193 schools across Wales were collected and analysed using generalized estimating equations to examine prevalence and predictors of emotional and physical DRV victimization, perpetration and joint victimization and perpetration. RESULTS: More girls reported emotional victimization (28%) and perpetration (18%) than boys (20% and 16%, respectively). More girls (8%) than boys (7%) reported physical perpetration. However, boys (17%) reported more physical victimization than girls (12%). Age-related trajectories of DRV victimization and perpetration were stronger in girls than in boys. Students from single or step parent homes, those in care, and certain ethnic minority groups had increased odds of DRV. No association was found between socioeconomic status and DRV. CONCLUSIONS: Age-related trajectories and the lack of social patterning by socioeconomic status point to the value of early, universal interventions, while some evidence of ethnic patterning and family structure-related risk factors suggest areas for further research and targeted interventions. DRV continues to be a major public health problem for which little UK-specific intervention evidence exists.

Engaging parents in digital sexual and reproductive health education: evidence from the JACK trial.

BACKGROUND: Research evidence and international policy highlight the central role that parents play in promoting positive sexual behaviour and outcomes in their children, however they can be difficult to engage in sexual and reproductive health (SRH) education programmes. Digital health promotion that uses online and mobile technologies (OMTs) to promote parent-child communication may offer an innovative solution to reach parents, however, few programmes have used OMTs to involve parents in SRH, and none have reported lessons learned in relation to optimising engagement. This study addresses this gap in the literature by reporting acceptability and feasibility of using OMTs to engage parents in SRH education. Findings will be relevant for those wishing to develop and implement digital SRH programmes with parents internationally. METHODS: The Jack Trial is a UK-wide cluster randomised controlled trial recruiting over 8000 adolescents from 66 socially and religiously diverse post-primary schools. An embedded mixed-methods process evaluation explored user engagement with parent components of the If I Were Jack SRH education programme, which include online animated films and a parent-teen homework exercise. RESULTS: A total of 109 adolescents, teachers, parents and SRH policy experts took part in semi-structured interviews and focus groups, 134 parents responded to an online survey, and 3179 adolescents completed a programme engagement and satisfaction questionnaire. Parents who accessed the materials were positive about them; 87% rated them as 'good or excellent' and 67% said they helped them have conversations with their child about SRH. Web analytics revealed that 27% of contacted parents accessed the digital materials, with 9% viewing the animated films. Only 38% of teachers implemented the homework exercise, mainly because they assumed that students would not complete it or it might result in backlash from parents. CONCLUSIONS: While digital parental materials show promise for engaging parents in SRH education, this study suggests that in order to optimise engagement, parental components that give parents the necessary skills to have conversations with their children about sex should be coupled with efforts to increase school and teacher confidence to communicate with parents on sensitive topics. TRIAL REGISTRATION: ISRCTN99459996 .

Self-Reported Health and Patterns of Romantic Love in Adolescents from Eight European Countries and Regions.

Purpose: Sexual minority youth (SMY) are at increased risk of poor health, but it remains unclear whether this phenomenon is universal. In this study, nationally representative samples of 15-year olds from eight European countries and regions were investigated to test if adolescents who have been in love with same- or both-gender partners report poorer health than those exclusively in love with opposite-gender partners or who have never been in love. Methods: A subsample of 13,674 adolescents participating in the 2014 Health Behaviour in School-aged Children (HBSC) study was used. We conducted binary logistic regression, adjusted for gender, region, and relative family affluence, to analyze associations between self-reported romantic love, multiple psychosomatic symptoms, and poor self-rated health. Results: Adolescents reporting same-gender love (adjusted odds ratio [aOR] = 1.50, 95% confidence interval [CI]: 1.11-2.02) and both-gender love (aOR = 3.57, 95% CI: 2.65-4.83) had significantly higher odds for multiple psychosomatic symptoms than those who reported opposite-gender love. Similarly, both SMY groups had higher odds of poor self-rated health (aOR = 2.95, 95% CI: 1.64-5.31 and aOR = 3.08, 95% CI: 1.79-5.31, respectively). Those who reported that they have never been in love had significantly lower odds for multiple symptoms. Adjustment for sociodemographic variables and stratifying by gender did not substantially change the odds ratios. Conclusion: Adolescents in love with same- and both-gender partners reported poorer subjective health outcomes than those in love with opposite-gender partners or who reported never being in love, suggesting that SMY health inequalities are found across various European countries and regions.

Romantic Attraction and Substance Use in 15-Year-Old Adolescents from Eight European Countries.

Sexual minority youth are at higher risk of substance use than heterosexual youth. However, most evidence in this area is from North America, and it is unclear whether the findings can be generalized to other cultures and countries. In this investigation, we used data from the 2014 Health Behaviour in School-aged Children (HBSC) study to compare substance use in same- and both-gender attracted 15-year-old adolescents from eight European countries (n = 14,545) to that of their peers who reported opposite-gender attraction or have not been romantically attracted to anyone. Both-gender attracted, and to a lesser extent, same-gender attracted adolescents were significantly more likely to smoke cigarettes, consume alcohol, get drunk and use cannabis, or be involved in multiple substance use in the last 30 days compared to their opposite-gender attracted peers. Those adolescents who have not been in love had significantly lower odds for substance use than all other youth. The pattern of results remained the same after adjusting for country, gender and family affluence. These findings are compatible with the minority stress and romantic stress theories. They suggest that sexual minority stigma (and love on its own) may contribute to higher substance use among adolescents in European countries.

Formative mixed-method multicase study research to inform the development of a safer sex and healthy relationships intervention in further education (FE) settings: the SaFE Project.

OBJECTIVES: Sexual health includes pleasurable, safe, sexual experiences free from coercion, discrimination and violence. In the UK, many young people's experiences fall short of this definition. This study aimed to inform the development of a safer sex and healthy relationships intervention for those aged 16-19 years studying in further education (FE) settings. DESIGN: A formative mixed-method multicase study explored if and how to implement four components within a single intervention. SETTING: Six FE settings in England and Wales and one sexual health charity participated between October and July 2015. PARTICIPANTS: Focus groups with 134 FE students and 44 FE staff, and interviews with 11 FE managers and 12 sexual health charity staff, first explored whether four candidate intervention components were acceptable and could have sustained implementation. An e-survey with 2105 students and 163 staff then examined potential uptake and acceptability of components shortlisted in the first stage. Stakeholder consultation was then used to refine the intervention. INTERVENTION: Informed by a review of evidence of effective interventions delivered in other settings, four candidate intervention components were identified which could promote safer sex and healthy relationships among those aged 16-19 years: 1) student-led sexual health action groups; 2) on-site sexual health and relationships services; 3) staff safeguarding training about sexual health and relationships and 4) sex and relationships education. RESULTS: On-site sexual health and relationships services and staff safeguarding training about sexual health and relationships were key gaps in current FE provision and welcomed by staff, students and health professionals. Sex and relationships education and student-led sexual health action groups were not considered acceptable. CONCLUSIONS: The SaFE intervention, comprising on-site sexual health and relationships services and staff safeguarding training in FE settings, may have potential promoting sexual health among FE students. Further optimisation and refinement with key stakeholders is required before piloting via cluster randomised controlled trial.