It's good to talk: Adolescent perspectives of an informal, peer-led intervention to reduce smoking

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Abstract

Although peer education has enjoyed considerable popularity as a health promotion approach with young people, there is mixed evidence about its effectiveness. Furthermore, accounts of what young people actually do as peer educators are scarce, especially in informal settings. In this paper, we examine the activities of the young people recruited as ‘peer supporters’ for A Stop Smoking in Schools Trial (ASSIST) which involved 10,730 students at baseline in 59 secondary schools in south-east Wales and the west of England. Influential Year 8 students, nominated by their peers, were trained to intervene informally to reduce smoking levels in their year group.

The ASSIST peer nomination procedure was successful in recruiting and retaining peer supporters of both genders with a wide range of abilities. Outcome data at 1-year follow-up indicate that the risk of students who were occasional or experimental smokers at baseline going on to report weekly smoking at 1-year follow-up was 18.2% lower in intervention schools. This promising result was supported by analysis of salivary cotinine. Qualitative data from the process evaluation indicate that the majority of peer supporters adopted a pragmatic approach, concentrating their attentions on friends and peers whom they felt could be persuaded not to take up smoking, rather than those they considered to be already ‘addicted’ or who were members of smoking cliques.

ASSIST demonstrated that a variety of school-based peer educators, who are asked to work informally rather than under the supervision of teaching staff, will engage with the task they have been asked to undertake and can be effective in diffusing health-promotion messages. Given the serious concerns about young people's smoking behaviour, we argue that this approach is worth pursuing and could be adapted for other health promotion messages.

Introduction

Peer education has enjoyed considerable popularity as a health promotion approach with young people, covering a range of topics including tobacco, drug and alcohol use, sexual health and pregnancy prevention, fitness and nutrition (Harden, Weston, & Oakley, 1999). However, there have been very few rigorously evaluated studies, and evidence about the effectiveness of this approach is both limited and inconsistent (Harden, Oakley, & Oliver, 2001; Mellanby, Newcombe, Rees, & Tripp, 2001; Milburn, 1995; Turner & Shepherd, 1999). Furthermore, accounts of what young people actually do as peer educators, especially in informal settings, are scarce.

Most published work has focussed on classroom-based interventions and has described significant benefits to the young people who are selected and trained. These include: the acquisition of new knowledge and skills; improved personal organisation and decision-making; and increased confidence and self-esteem (Cowie, 1998; Hartley-Brewer, 2002; Orme & Starkey, 1999; Strange, Forrest, Oakley, & The RIPPLE Study Team, 2002). However, the role of peer educator can also raise problems including: constraints on the message they are allowed to deliver; feeling undermined by teachers; dealing with personal questions about their own experiences; lack of trust, derision or hostility from members of their peer group; reduced confidence when unable to deal with difficult situations; frustration when hopes and expectations are not met; and feeling unable to address their own problems or ask for help (Cowie, 1998; Frankham, 1998; Hartley-Brewer, 2002; Orme & Starkey, 1999). Giving up time and taking on additional work may also be regarded negatively by some young people, so it cannot be assumed that the benefits of being a peer educator outweigh the costs, or that all peer educators fulfil the role with the same degree of enthusiasm, ability and commitment.

It has been argued that similarities between influencer and recipient increase the persuasiveness of any message (Milburn, 1995). If so, it is probable that many school-based peer education projects fail to reach their target audience because peer educators tend to be predominantly female ‘high achievers’ who volunteer, or are invited by teaching staff, to take on responsible roles in the school (Cowie, 1998; Frankham, 1998; Harden, et al., 1999; Strange, Forrest, & Oakley, 2002). This raises questions about their ability to influence males, ‘low achievers’, and disaffected young people.

However, recruiting young ‘risk-takers’ can be problematic if, rather than promoting the desired health message, they reinforce negative attitudes and behaviour (Dishion, McCord, & Poulin, l999). In one classroom-based sexual health programme where risk takers were actively recruited as peer educators, the only significant result appeared to be in a negative direction (Ebreo, Feist-Price, Siewe, & Zimmerman, 2002). The authors concluded that, despite the appeal of including at-risk students, they may lack credibility in relation to risk reduction; they may not work well with teachers; and their relatively low level of involvement in school may result in their level of activity as peer educators being ineffective.

Despite the proliferation of peer education projects in recent years, relatively little is written about the strategies peer educators use to communicate their message. In classroom settings peer educators have demonstrated team-working skills and shown readiness to adapt sessions if required (Backett-Milburn & Wilson, 2000). Familiar strategies for classroom management have been noted, including splitting students into smaller groups, separating disruptive students and focussing on the message. Less positive tactics have included confronting or embarrassing individuals and threatening to send them to a teacher (Strange et al., 2002).

Where sessions are classroom based, teaching staff are in a position to monitor and support peer educators but a number of problems have been identified. Classroom-based peer education tends towards a didactic ‘teacher’ model and may appear as formal as other more traditional modes of education (Frankham, 1998; Neesham, 1997). Opportunities to deliver the health promotion message may also be constrained by available classroom space and the need to fit in with school timetables (Strange et al., 2002). In contrast, an informal approach allows young people increased autonomy over the timing, style and content of the message (Green, 2001).

One informal peer education approach is based on ‘diffusion of innovation’ theory, which attempts to explain how new ideas and practices spread within and between communities through interpersonal communication (Rogers, 1995). According to this model, behaviour change is initially propelled by ‘early adopters’ who are often popular or well-regarded individuals. This approach was used in the United States with the aim of reducing unsafe sexual practices among men attending gay bars in small mid-Western towns (Kelly et al., 1997). ‘Popular’ men, identified by people working in the bars, were recruited and trained as peer educators to promote changes in sexual behaviour. The evaluation showed a reduction in reported high-risk behaviour in communities where the peer educators were active, with no change reported by the control communities.

In this paper, we consider the role of the young people recruited as ‘peer supporters’ to a school-based health promotion intervention derived from Kelly's approach. Influential Year 8 students, nominated by their peers, were trained to intervene informally to reduce smoking levels in their year group. The intervention is described in detail elsewhere (Audrey, Cordall, Moore, Cohen, & Campbell, 2004) and was rigorously evaluated as part of A Stop Smoking in Schools Trial (ASSIST) which involved 10,370 students at baseline in 59 schools in south-east Wales and the west of England (Starkey, Moore, Campbell, Sidaway, & Bloor, 2005). Here we focus on the strategies used by ASSIST peer supporters to diffuse the smoke-free message amongst their year group.

Section snippets

ASSIST

The trial's primary outcome measure was smoking prevalence among the ‘high-risk’ group who, at baseline, had experimented with cigarettes, were ex-smokers, or were occasional (less than weekly) smokers. These students were chosen as the primary target group because they were at risk of becoming regular smokers and the feasibility study had shown a promising effect in this group (Bloor et al., 1999).

The trial began with the administration of baseline smoking behaviour questionnaires and the

Peer supporter recruitment and retention

ASSIST used peer nomination in an attempt to recruit from a wide range of friendship groups. Separate male and female lists were used during the tallying process to ensure that those invited to the recruitment meeting would reflect the gender balance of the year group as a whole. Teaching staff were encouraged to allow all nominated students to participate in the training programme and, while it was agreed that students could be removed from the list if schools had serious concerns about their

Discussion

Although school-based peer education is a favoured model within health promotion, very little has been written about what young peer educators actually do. This gap in our understanding is exacerbated when young people are asked to work informally as was the case with ASSIST. In this paper, we have focussed on data from the process evaluation to examine the activities of ASSIST peer supporters who were asked to informally encourage their peers not to smoke.

Statistical analysis of outcome data

Acknowledgements

We would like to thank all the students and school staff who participated in this research so willingly. In relation to this paper we are particularly grateful to the peer supporters for their hard work and enthusiasm, and all the students who completed questionnaires and agreed to be interviewed for the process evaluation. Thanks to Professor Laurence Moore, Dr. Fenella Starkey and Dr. Lucy Biddle for valuable contributions to earlier drafts. Valerie Karatzas provided much valued clerical

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