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Evidence from intervention evaluations suggests that achieving meaningful and lasting social, behavioural and attitudinal change from relationships, sex and health education (RSHE) in schools requires more than just a curriculum. Whole-school approaches appear particularly promising since they work at multiple levels. For instance, they may: engage with carers, communities and local services; address iniquitous cultures and norms; change school policies and practices; and actively involve young people themselves. They have also been advocated to tackle sexual harassment and abuse in schools. Currently, however, such approaches have not been rigorously evaluated in the UK. This article focuses on the whole-school elements of two recent RSHE pilot studies conducted in English secondary schools. We describe how these elements were variably enacted in different settings. We analyse contextual factors that help account for these differences, including: teacher and departmental professional identity and autonomy; broader education policy including high-stakes testing and school inspection judgements; the significance of support staff; and staff-student relationships and partnerships. We argue that the likely impact of whole-school approaches and RSHE in schools more generally will depend on attending to all of these factors. The paper contributes firstly to debates about the theory and practice of RSHE by highlighting the significance of processes and cultures beyond the classroom in enabling or constraining positive change. Secondly it contributes to scholarship that elucidates the role of contexts, broadly defined, in understanding the enactment of policy and practice.

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. Plain language summary 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 12–14 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. Scientific summary Background The need for relationship and sexuality education (RSE) to especially engage with young men and boys to promote positive sexual health for all, and to be gender transformative to challenge the gender inequalities that underlie young women’s generally poorer sexual health outcomes (especially in relation to sexual violence, adolescent pregnancy and sexually transmitted infections), is widely endorsed by the World Health Organization and the United Nations Educational, Scientific and Cultural Organization, among others. Objectives The JACK trial evaluated the effectiveness and cost-effectiveness of the If I Were Jack intervention, a schools-based RSE intervention, which is designed to especially engage young men as well as young women and promote joint responsibility in preventing adolescent pregnancy by avoiding unprotected sex and in promoting positive sexual health and relationships. We assessed whether there would be higher rates of self-reported avoidance of unprotected sex (either by remaining sexually abstinent or by using a reliable form of contraception) among students in schools allocated to use If I Were Jack than among those in schools that continued with their usual RSE. Design We undertook a multicentre, parallel-group cluster randomised trial of the If I Were Jack intervention with schools as the unit of randomisation. We incorporated a health economic cost–consequences analysis and process evaluation. Setting The trial was conducted in secondary-level schools across the four nations of the UK. Recruitment We sampled schools from Department of Education-listed secondary schools in each nation of the UK (Northern Ireland, Wales, Scotland and England), with consideration of the socioeconomic status of schools [based on the proportion of students eligible for free school meals (FSM) as indicated by the School Meal Census]. In each nation, eligible schools were stratified into two levels according to FSM eligibility rates (schools above and below the median national percentage of FSM for all eligible schools). Independent private, special, and Irish/Welsh-medium and Scottish Gaelic schools and schools with

Student-reported quality and coverage of school-based relationships and sex education (RSE) vary, with gender/sexual-minority and disadvantaged students reporting poorer provision. Experience of RSE among younger adolescents is under-explored. We examined student-reported RSE coverage and priorities and how coverage, and sexual-health knowledge and awareness of services, varies between students and schools. The data came from a pre-intervention survey of students aged 12–13 years within a trial of an RSE intervention involving 50 English schools. There was most coverage of basic information, such as puberty and safeguarding. There was least coverage of topics more appropriate for older students, such as sexual relationships, and topics teachers might find difficult to broach, e.g. pornography and masturbation. Girls, gay/lesbian students, students of bisexual/other sexual orientation, minority-ethnic students and students reporting lower academic commitment reported lower coverage than others. Knowledge of RSE-related topics and sexual-health services was generally low. Boys, students of bisexual/other orientation and students with higher school commitment had higher knowledge. Students of bisexual/other orientation and students of lower commitment reported lower awareness of services. Coverage and knowledge did not vary with school-level attainment or local deprivation. Future forms of RSE provision should ensure content and teaching methods meet the needs of all students. [ABSTRACT FROM AUTHOR]

Background: Existing literature indicates that young people in state care have particular sexual health needs that include addressing their social and emotional well-being, yet little has been published as to how these components of sex education are actually delivered by service-providers. Objective: The aim of this study was to analyse the processes involved in delivering relationship and sexuality education to young people in state care from the perspectives of a sample of service-providers with a role in sexual health-care delivery. Design: Qualitative methodological strategy. Setting: Service-delivery sites at urban and rural locations in Ireland. Method: A total of 22 service-providers were interviewed in depth, and data were analysed using a qualitative analytical strategy resembling modified analytical induction. Findings: Participants proffered their perceptions and examples of their practices of sex education in relation to the following themes: (1) acknowledging the multi-dimensional nature of sexual health in the case of young people in care; (2) personal and emotional development education to address poor self-esteem, emotional disconnectedness and an inability to recognise and express emotions; (3) social skills' education as part of a repertoire of competencies needed to negotiate relationships and safer sex; (4) the application of positive social skills embedded in everyday social situations; and (5) factual sexuality education. Conclusion: Insights into service-providers' perceptions of the multi-dimensional nature of the sexual health needs of young people in state care, and the ways in which these service-providers justified their practice make visible the complex character of sex education and the degree of skill required to deliver it to those in state care.

Aim: This paper is a review protocol that will be used to identify, critically appraise and synthesise the best current evidence relating to the use of online learning and blended learning approaches in teaching clinical skills in undergraduate health professionals. Background: Although previous systematic reviews on online learning vs. face to face learning have been undertaken a systematic review on the impact of online learning and blended learning for teaching clinical skills has yet to be considered in undergraduate health professionals. By reviewing the students' online learning experiences, systems can potentially be designed to ensure all health professional students' are supported appropriately to meet their learning needs. Methods/design: The key objectives of the review are to evaluate how online learning teaching strategies assist students learn; to evaluate the students' satisfaction with this form of teaching; to explore the variety of online learning strategies used; to determine what online learning strategies are more effective and to determine if supplementary face to face instruction enhances learning. A search of the following databases will be made MEDLINE, CINAHL, BREI, ERIC and AUEI. This review will follow the Joanna Briggs Institute guidance for systematic reviews of quantitative and qualitative research. Conclusion: This systematic review protocol intends to support the undertaking of a systematic literature review which will report on a combination of student experience and learning outcomes therefore increasing its utility for educators and curriculum developers involved in health care education.

Arts engagement is gaining recognition as a non-clinical approach to promote mental health and well-being. However, the perceived utility of the arts to promote mental health among men with low socioeconomic status (SES) and how to best engage them is underexplored. This study explores the lived experiences of men with low SES who engage with the arts in Northern Ireland (n = 41). Data collected via focus groups (n = 5) and interviews (n = 11) were analysed using reflexive thematic analysis to inductively derive four themes. Theme 1 highlights how the arts facilitated friendship, a collective identity, peer support and a reason to socialize. Themes 2 and 3 explore how the arts enhanced self-esteem and emotional regulation by developing a routine, purpose, sense of mastery, a sense of catharsis through immersion in a soothing endeavour and an alternative outlet for self-expression. Theme 4 covers strategies that facilitate male engagement in the arts such as using a familiar space, delivering to an existing male group, framing the programme around male interests not health or creativity, building on existing strengths and capacities, enabling ownership, using tangible action-orientated activities, and being non-authoritative and flexible with delivery. This is one of the first studies to highlight the gendered dimensions in which men with low SES engage with and experience mental health benefits through arts engagement. This study points towards relevant theories to further understand the pathways between the arts and improved mental health among men which can inform development of tailored arts programmes for men. [ABSTRACT FROM AUTHOR]

Purpose: Young incarcerated male offenders are at risk of poorer sexual health, adolescent parenthood and lack opportunities for formative relationship and sexuality education (RSE) as well as positive male role models. The purpose of this paper is to report the process of co-production and feasibility testing of a novel, gender-transformative RSE programme with young male offenders to encourage positive healthy relationships, gender equality, and future positive fatherhood. Design/methodology/approach: Using a rights-based participatory approach, the authors co-produced an RSE programme with young offenders and service providers at two UK prison sites using a sequential research design of: needs analysis, co-production and a feasibility pilot. Core components of the programme are grounded in evidence-based RSE, gender-transformative and behaviour change theory. Findings: A needs analysis highlighted the men's interest in RSE along with the appeal of film drama and peer-group-based activities. In the co-production stage, scripts were developed with the young men to generate tailored film dramas and associated activities. This co-production led to "If I Were a Dad", an eight-week programme comprising short films and activities addressing masculinities, relationships, sexual health and future fatherhood. A feasibility pilot of the programme demonstrated acceptability and feasibility of delivery in two prison sites. The programme warrants further implementation and evaluation studies. Originality/value: The contribution of this paper is the generation of an evidence-based, user-informed, gender-transformative programme designed to promote SRHR of young male offenders to foster positive sexual and reproductive health and well-being in their own lives and that of their partners and (future) children. [ABSTRACT FROM AUTHOR]