Attendance at an evidence-based, near-peer-led comprehensive sexual education program for female adolescents in South African secondary schools was suboptimal, even after extensive community engagement and modifying the delivery of the program based on the school's preference.

Participants reported high interest and acceptability, but this did not translate to consistent attendance because of barriers, including participants' security concerns and competing priorities on their time.

Providing adolescent-friendly health care screenings early as part of the study may have influenced learners' desire to later attend the program intervention sessions.

National stakeholders in South Africa should consider new ways to address barriers to after-school programming, without which adolescent learners may be deprived of access to extracurricular activities. In-school programming, although effective, is not a sustainable strategy to overcome these barriers because if it is overused, it risks congesting the school day and interfering with core educational activities.

Program managers should promote clear roles and responsibilities among near-peer educators and limit research facilitation responsibilities.

Comprehensive sexual education (CSE) is an important approach for health promotion dissemination in schools, particularly when delivered in participatory ways that are sport based, peer or near-peer led, and include concepts of gender and power dynamics. Sufficient attendance at CSE sessions is critical to ensure content exposure and build potential for impact. This article details implementation lessons from the delivery of an after-school, near-peer-led CSE program called SKILLZ during a cluster randomized controlled trial among 40 secondary schools in Cape Town, South Africa. SKILLZ is an evidence-based program previously implemented in similar contexts. Attendance in this study was suboptimal (less than 50%) despite qualitative indications of high acceptability and extensive efforts to adapt implementation and boost attendance. Qualitative and quantitative data gathered during anonymous surveys, in-depth interviews, and focus group discussions with participants with high and low attendance records, near-peer coaches, and school staff from both cohorts indicated that poor attendance could be attributed to several factors. Program adaptations, such as delivering difficult-to-access health services before participants attended the SKILLZ program rather than after, may have reduced the incentive for young people to attend the program. Practical barriers to attendance were identified, including security concerns, competing priorities, and unfamiliarity with after-school programming culture in this setting. Community engagement and acceptability of sexual education programs for adolescents alone may be insufficient to ensure program uptake and engagement.

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