An informal school-based peer-led intervention for smoking prevention in adolescence (ASSIST): a cluster randomised trial

How does removing menthol tobacco product displays at point-of-sale affect adolescents' cigarette smoking intentions? The mediating effects of social norms

This study investigates the psychological mechanisms through which a removal of mentholated tobacco products from retail stores affects future smoking intentions among youth. Descriptive norms and injunctive norms were examined as candidate mediators. The study was conducted in the RAND StoreLab (RSL), a life-sized replica of a convenience store developed to evaluate how changing point-of-sale (POS) tobacco advertising influences tobacco use outcomes during simulated shopping experiences. Participants were assigned to shop randomly in the RSL under one of three experimental conditions that were (1) status quo condition in which all tobacco-, sweet-, and menthol-flavors were displayed; (2) tobacco/menthol condition in which only tobacco- and menthol-flavored tobacco products were displayed (sweet characterizing flavors other than tobacco or menthol/mint were removed from the display, effectively "banned"); and (3) tobacco-only condition in which only tobacco-flavored products were displayed (all sweet- and menthol-flavored products were removed). Results revealed that injunctive norms mediated the relationship between the removal of menthol cigarettes from the POS setting and increased intentions to smoke menthol-flavored cigarettes, whereas descriptive norms were not a significant mediator. These findings suggest that targeting injunctive smoking norms in public health communications may be a promising strategy to mitigate potential unintended consequences of a menthol ban on future smoking intentions for youth.

How Do Adolescent Smoking Prevention Interventions Work in Different Contextual Settings? A Qualitative Comparative Study Between the UK and Colombia

BACKGROUND

Adolescent smoking is associated with significant health and social risks. Previous research has demonstrated the effectiveness of interventions based on behavior change theories in preventing adolescent smoking uptake. However, evidence from the theory-based perspective of evaluation is limited, especially for how such complex interventions work, and how they work when implemented in different contextual settings.

METHOD

A comparative qualitative analysis was conducted to explore various influences on behavior change among participants taking part in two smoking prevention interventions in Northern Ireland and Bogotá. Twenty-seven focus groups were conducted in 12 schools (6 in Northern Ireland and 6 in Bogota, n = 195 pupils participated; aged 11-15 years). The Theoretical Domains Framework guided a content analysis of the data.

RESULTS

We found similarities across settings in terms of knowledge, skills, and beliefs related to smoking or vaping behavior change, as well as differences in contextual resources and social influence. Different environmental resources included availability to purchase tobacco products in the neighborhoods and previous information about tobacco risk. Participants in both interventions perceived behavioral change outcomes related to personal skills and intention to not smoke or vape.

CONCLUSION

These findings have highlighted how both individual factors and contextual resources influence behavior change for smoking prevention in practice. Local contextual factors and social influences affecting pupils should be taken into account in the implementation and evaluation of health behavior change interventions. In particular, this study supports using social and contextual influence strategies in interventions to reduce the onset of adolescent smoking and vaping.

Smoking cessation program preferences of individuals with chronic obstructive pulmonary disease: a qualitative study

AIM

To explore the views of tobacco-smoking chronic obstructive pulmonary disease (COPD) and asthma-COPD overlap (ACO) patients on telehealth-based cessation programs and the role of e-cigarettes as an aid to quit smoking.

BACKGROUND

Tobacco smoking accelerates the progression of COPD. Traditional smoking cessation programs often do not entirely address the unique needs of COPD patients, leading to suboptimal effectiveness for this population. This research is aimed at describing the attitudes and preferences of COPD and ACO patients toward innovative, telehealth-based smoking cessation strategies and the potential application of e-cigarettes as a quitting aid.

METHODS

A qualitative exploratory approach was adopted in this study, employing both focus groups and individual interviews with English-speaking adults with diagnosed COPD or ACO. Participants included both current smokers (≥ 5 cigarettes/day) and recent ex-smokers (who quit < 12 months ago). Data were systematically coded with iterative reliability checks and subjected to thematic analysis to extract key themes.

FINDINGS

A total of 24 individuals participated in this study. The emergent themes were the perceived structure and elements of a successful smoking cessation program, the possible integration of telehealth with digital technologies, and the strategic use of e-cigarettes for smoking reduction or cessation. The participants stressed the importance of both social and professional support in facilitating smoking cessation, expressing a high value for insights provided by ex-smokers serving as mentors. A preference was observed for group settings; however, the need for individualized plans was also highlighted, considering the diverse motivations individuals had to quit smoking. The participants perceived online program delivery as potentially beneficial as it could provide immediate access to support during cravings or withdrawals and was accessible to remote users. Opinions on e-cigarettes were mixed; some participants saw them as a less harmful alternative to conventional smoking, while others were skeptical of their efficacy and safety and called for further research.

Effect of a peer-led prevention program (P2P) on smoking in vocational high school students: Results from a two-school-year cluster-randomized trial

AIMS

The aim of this work was to measure the impact of P2P (i.e. peer-to-peer), a peer-led smoking prevention intervention, on daily smoking prevalence of adolescents over 2 school years.

DESIGN

A cluster-randomized controlled trial was performed over a 16-month follow-up (trial status: closed to follow-up). P2P was implemented 1-3 and 13-15 months after baseline. Assessments took place at baseline and 4, 10 and 16 months after baseline. The research team, assessors and adolescents were blinded to the study-arm assignment only at baseline.

SETTING

Fifteen vocational high schools in France were randomized into two clusters, using a 1:1 allocation ratio per French department (n intervention = 7, n control = 8).

PARTICIPANTS

Participants comprised a sample of 2010 students in year 11 (i.e. 15-16 years) in vocational high schools. A total of 437 students could not be assessed at baseline (absent or left school), yielding a total sample of 1573 students (n intervention = 749, n control = 824).

INTERVENTION AND COMPARATOR

The P2P programme trained voluntary students to become peer educators and design smoking prevention actions for their schoolmates in the intervention group (n = 945 students), compared with a passive control group (n = 1065 students).

MEASUREMENTS

The primary outcome was change from baseline in the prevalence of self-reported daily smoking (i.e. at least one cigarette per day) at 16 months.

FINDINGS

The 'time × group' interaction indicated that, compared with the control group, the intervention group had statistically significantly fewer daily smokers after 16 months [odds ratio (OR) = 0.33, 95% confidence interval (CI) = 0.20, 0.53]. Similarly, compared with the control group, the intervention group had statistically significantly fewer daily smokers after 4 months (OR = 0.50, 95% CI = 0.30, 0.82) and 10 months (OR = 0.60, 95% CI = 0.37, 0.98). No adverse events of P2P2 were reported.

CONCLUSIONS

A cluster-randomized trial found evidence that the peer-led P2P (peer-to-peer) smoking prevention intervention reduced the uptake of daily smoking among high school students in France over 16 months.

Exposure to user-generated e-cigarette content on social media associated with greater vulnerability to e-cigarette use among youth non-users

INTRODUCTION

Social media are important venues for youth's exposure to e-cigarette content. This study examined how exposure to user-generated e-cigarette content (i.e., content created and shared by individual social media users) is associated with vulnerabilities to e-cigarette use among youth non-users.

METHODS

We pooled data from the 2021 and 2022 National Youth Tobacco Survey. Youth who have never used e-cigarettes were included. Weighted linear and logistic regressions were conducted to examine how exposure to user-generated e-cigarette content (from real-life friends, online-only friends, and celebrities/influencers) on social media was associated with e-cigarette use vulnerabilities measured by perceived norms, perceived risk, and susceptibility of use, controlling for demographics, advertising exposure, and mental health conditions. Multiple imputations were performed to account for missing data.

RESULTS

Exposure to e-cigarette content on social media posted by real-life friends, online-only friends, and celebrities/influencers were associated with more positive descriptive norm (βs = 1.56, 0.37, and 0.35, respectively, all ps < .001), more positive injunctive norm (βs = 0.46, 0.19, and 0.10, respectively, all ps < .001), and higher odds of e-cigarette use susceptibility (ORs = 1.48, 1.50. 1.29, respectively, all ps < .001). Exposure to content posted by real-life and online-only friends were associated with reduced risk perception of e-cigarette use (β = -0.04, p < 0.05 and β = -0.07, p < 0.001).

CONCLUSIONS

Our study highlighted that friends and celebrities/influencers are important sources on social media that can influence youth non-users' vulnerabilities to e-cigarette use. Interventional messages communicated through friends and influencers on social media may in turn help reduce e-cigarette vulnerability among youth non-users.

Understanding Knowledge Mobilisation between Community Champions and Parents: Evidence from a Community-Based Programme to Support Parents with Young Children

BACKGROUND

Community champions have been employed across various settings to disseminate evidence-based public health information. The Building Babies' Brains programme trains champions to work with parents in communities, equipping them with child development knowledge and parental engagement strategies. We explored what makes community champions effective in distributing information to parents, including how the champion-parent relationship and champions' personal characteristics affect information dissemination.

METHODS

Champions included both peers and professionals working with parents in target communities. We administered an online survey (n = 53) and follow-up interviews (n = 14) with champions, with representation from across all training cohorts. We conducted a realist-informed reflexive thematic analysis to generate themes in the data and highlight the contexts, mechanisms, and outcome patterns identified.

RESULTS

We observed 15 Context-Mechanism-Outcome configurations across five themes: information sharing opportunities, information relevance, the nature of the champion-parent relationship, interaction expectations, and champion confidence. Our programme theory for how the community champion approach works identified that peer champions focused more on building rapport, modelling behaviours, and being a trusted community resource than direct information transfer. Professional champions, in contrast, showed greater expertise and confidence in discussing parenting practices directly. For both groups, traits such as friendliness and the ability to establish a trusting relationship enhanced effectiveness.

CONCLUSIONS

This research identifies the impacts of champion role, characteristics, and the champion-parent relationship on the effectiveness of knowledge mobilisation in this context, with implications for training and recruitment of champions. Those using a champion model in comparable settings should ensure that champions have the necessary knowledge, skills, and confidence to engage parents and share information effectively.

A new framework for developing and evaluating complex interventions: update of Medical Research Council guidance

The UK Medical Research Council's widely used guidance for developing and evaluating complex interventions has been replaced by a new framework, commissioned jointly by the Medical Research Council and the National Institute for Health Research, which takes account of recent developments in theory and methods and the need to maximise the efficiency, use, and impact of research.

Mechanisms of school-based peer education interventions to improve young people's health literacy or health behaviours: A realist-informed systematic review

INTRODUCTION

Peer education interventions are widely used in secondary schools with an aim to improve students' health literacy and/or health behaviours. Although peer education is a popular intervention technique with some evidence of effectiveness, we know relatively little about the key components that lead to health improvements among young people, or components that may be less helpful. This review aims to identify the main mechanisms involved in school-based peer education health interventions for 11-18-year-olds.

METHODS

Five electronic databases were searched for eligible studies during October 2020, an updated search was then conducted in January 2023 to incorporate any new studies published between November 2020 and January 2023. To be included in the review, studies must have evaluated a school-based peer education intervention designed to address aspects of the health of students aged 11-18 years old and contain data relevant to mechanisms of effect of these interventions. No restrictions were placed on publication date, or country but only manuscripts available in English language were included.

RESULTS

Forty papers were identified for inclusion with a total of 116 references to intervention mechanisms which were subsequently grouped thematically into 10 key mechanisms. The four most common mechanisms discussed were: 1) Peerness; similar, relatable and credible 2) A balance between autonomy and support, 3) School values and broader change in school culture; and 4) Informal, innovative and personalised delivery methods. Mechanisms were identified in quantitative, qualitative and mixed methods intervention evaluations.

DISCUSSION

This study highlights a number of key mechanisms that can be used to inform development of future school-based peer education health interventions to maximise effectiveness. Future studies should aim to create theories of change or logic models, and then test the key mechanisms, rather than relying on untested theoretical assumptions. Future work should also examine whether particular mechanisms may lead to harm, and also whether certain mechanisms are more or less important to address different health issues, or whether a set of generic mechanisms always need to be activated for success.

Implementation processes of social network interventions for physical activity and sedentary behavior among children and adolescents: a scoping review

BACKGROUND

The characteristics of the implementation process of interventions are essential for bridging the gap between research and practice. This scoping review aims to identify the implementation process of social network interventions (SNI) to address physical activity and sedentary behaviors in children and adolescents.

METHODS

The scoping review was conducted adhering to the established guidelines. The search was carried out in the ERIC, EBSCO, EMBASE, SCOPUS, and Lilacs databases in April 2023. Social network intervention studies in children and adolescents were included, addressing physical activity or sedentary behaviors. Replicability (TIDieR), applicability (PRECIS-2), and generalizability (RE-AIM) were the explored components of the implementation process. Each component was quantitatively and separately analyzed. Then, a qualitative integration was carried out using a narrative method.

RESULTS

Most SNI were theoretically framed on the self-determination theory, used social influence as a social mechanism, and used the individual typology of network intervention. Overall, SNI had strong replicability, tended to be pragmatic, and three RE-AIM domains (reach, adoption (staff), and implementation) showed an acceptable level of the generalizability of findings.

CONCLUSIONS

The analyzed SNI for physical activity and sedentary behaviors in adolescents tended to be reported with high replicability and were conducted pragmatically, i.e., with very similar conditions to real settings. The RE-AIM domains of reach, adoption (staff), and implementation support the generalizability of SNI. Some domains of the principles of implementation strategies of SNI had acceptable external validity (actor, action targets, temporality, dose, and theoretical justification).

A Pilot Randomized Trial Evaluating the Cool 2 Be Safe Junior Playground Safety Program for Preschool Children

OBJECTIVE

Unintentional injury is the leading cause of death to children worldwide, and playgrounds pose a significant risk of injury. Those aged 5 and 6 years are particularly vulnerable to playground injuries. Previous interventions have typically targeted environmental modifications or increased supervision to reduce playground injuries; however, minimal research has focused on implementing behavioral interventions that seek to change children's safety knowledge and risk-taking behaviors on the playground. The current randomized trial addressed these gaps in the literature and sought to increase preschool children's hazard awareness skills and knowledge of unsafe playground behaviors and decrease their intentions to engage in risk-taking behaviors on the playground.

METHOD

A total of 77 children aged 5 and 6 years were tested at a laboratory on a university campus, using a parallel group design, with 38 randomized to the playground intervention group and 39 randomly assigned to a control group. The intervention was manualized and delivered to small groups of children (3-5) over several sessions.

RESULTS

Statistical analyses revealed significant group differences. Intervention experience led to significant increases in hazard awareness skills and knowledge of unsafe playground behaviors, and significant decreases in children's risk-taking behavioral intentions, whereas those in the control group showed no significant changes in these scores. Attention scores for those in the intervention group highlighted that the program content was successful in maintaining children's attention and engagement, and memory scores indicated excellent retention of lesson content.

CONCLUSION

The program shows promise in addressing the issue of unintentional playground injuries in young children.

Social network enhanced behavioral interventions for diabetes and obesity: A 3 arm randomized trial with 2 years follow-up in Jordan

While obesity and diabetes are rising pandemics, few low-cost and effective prevention and management strategies exist, especially in the Middle East. Nearly 20% of adults in Jordan suffer from diabetes, and over 75% are overweight or obese. Social network-based programs have shown promise as a viable public health intervention strategy to address these growing crises. We evaluated the effectiveness of the Microclinic Program (MCP) via a 6-month multi-community randomized trial in Jordan, with follow-up at 2 years. The MCP leverages existing social relationships to propagate positive health behaviors and information. We recruited participants from 3 community health centers in Amman, Jordan. Participants were eligible for the study if they had diabetes, pre-diabetes, or possessed ≥1 metabolic risk factor along with a family history of diabetes. We randomized participants into three trial arms: (A Group) received the Full MCP with curriculum-activated social network interactions; (B Group) received Basic MCP educational sessions with organic social network interactions; or (C Group-Control) received standard care coupled with active monitoring and parallel screenings. Groups of individuals were randomized as units in a 3:1:1 ratio, with resulting group sizes of n = 540, 186, and 188 in arms A, B, and C, respectively. We assessed the overall changes in body weight, fasting glucose, hemoglobin A1c (HbA1c) and mean arterial blood pressure between study arms in multiple evaluations across 2 years (including at 6-months and 2-years follow-up). We investigated the effectiveness of Full and Basic MCP social network interventions using multilevel models for longitudinal data with hierarchical nesting of individuals within MCP classrooms, within community centers, and within temporal cohorts. We observed significant overall 2-year differences between all 3 groups for changes in body weight (P = 0.0003), fasting blood glucose (P = 0.0015), and HbA1c (P = 0.0004), but not in mean arterial blood pressure (P = 0.45). However, significant changes in mean arterial pressure were observed for Full MCP versus controls (P = 0.002). Weight loss in the Full MCP exceeded (-0.97 kg (P<0.001)) the Basic MCP during the intervention. Furthermore, both Full and Basic MCP yielded greater weight loss compared to the control group at 2 years. The Full MCP also sustained a superior fasting glucose change over 2 years (overall P<0.0001) versus the control group. For HbA1c, the Full MCP similarly led to greater 6-month reduction in HbA1c versus the control group (P<0.001), with attenuation at 2 years. For mean arterial blood pressure, the Full MCP yielded a greater drop in blood pressure versus control at 6 months; with attenuation at 2 years. These results suggest that activated social networks of classroom interactions can be harnessed to improve health behaviors related to obesity and diabetes. Future studies should investigate how public health policies and initiatives can further leverage social network programs for greater community propagation. Trial registration. ClinicalTrials.gov Identifier: NCT01818674.

Practical and methodological challenges when conducting a cluster randomized trial: Examples and recommendations

The use of cluster randomized trial design to answer research questions is increasing. This design and associated variants such as the cluster randomized crossover and stepped wedge are useful to assess complex interventions in a pragmatic way but when adopting such designs, one may face specific implementation challenges. This article summarizes common challenges faced when conducting cluster randomized trials, cluster randomized crossover trials, and stepped wedge trials, and provides recommendations.

A Systematic Review of Qualitative Studies on Factors Associated With Smoking Cessation Among Adolescents and Young Adults

OBJECTIVE

To summarize findings from qualitative studies on factors associated with smoking cessation among adolescents and young adults.

DATA SOURCES

We searched Pubmed, Psychinfo, CINAHL, Embase, Web of Science, and SCOPUS databases, as well as reference lists, for peer-reviewed articles published in English or French between January 1, 2000, and November 18, 2020. We used keywords such as adolescents, determinants, cessation, smoking, and qualitative methods.

STUDY SELECTION

Of 1724 records identified, we included 39 articles that used qualitative or mixed methods, targeted adolescents and young adults aged 10-24, and aimed to identify factors associated with smoking cessation or smoking reduction.

DATA EXTRACTION

Two authors independently extracted the data using a standardized form. We assessed study quality using the National Institute for Health and Care Excellence checklist for qualitative studies.

DATA SYNTHESIS

We used an aggregative meta-synthesis approach and identified 39 conceptually distinct factors associated with smoking cessation. We grouped them into two categories: (1) environmental factors [tobacco control policies, pro-smoking norms, smoking cessation services and interventions, influence of friends and family], and (2) individual attributes (psychological characteristics, attitudes, pre-quitting smoking behavior, nicotine dependence symptoms, and other substances use). We developed a synthetic framework that captured the factors identified, the links that connect them, and their associations with smoking cessation.

CONCLUSIONS

This qualitative synthesis offers new insights on factors related to smoking cessation services, interventions, and attitudes about cessation (embarrassment when using cessation services) not reported in quantitative reviews, supplementing limited evidence for developing cessation programs for young persons who smoke.

IMPLICATIONS

Using an aggregative meta-synthesis approach, this study identified 39 conceptually distinct factors grouped into two categories: Environmental factors and individual attributes. These findings highlight the importance of considering both environmental and individual factors when developing smoking cessation programs for young persons who smoke. The study also sheds light on self-conscious emotions towards cessation, such as embarrassment when using cessation services, which are often overlooked in quantitative reviews. Overall, this study has important implications for developing effective smoking cessation interventions and policies that address the complex factors influencing smoking behavior among young persons.

The Usefulness of Web-Based Communication Data for Social Network Health Interventions: Agent-Based Modeling Study

BACKGROUND

Social network interventions are an effective approach to promote physical activity. These interventions are traditionally designed using self-reported peer nomination network data to represent social connections. However, there is unexplored potential in communication data exchanged through web-based messaging apps or social platforms, given the availability of these data, the developments in artificial intelligence to analyze these data, and the shift of personal communication to the web sphere. The implications of using web-based versus offline social networks on the effectiveness of social network interventions remain largely unexplored.

OBJECTIVE

This study aims to investigate the differences in the impact of social network interventions on physical activity levels (PALs) between networks derived from web-based communication and peer nomination data.

METHODS

We used the data on sociometric questionnaires, messages from a web-based communication app, and PAL (number of steps per day) of 408 participants in 21 school classes. We applied social network analysis to identify influential peers and agent-based modeling to simulate the diffusion of PAL and explore the impact of social network interventions on PAL among adolescents in school classes. Influential peers (n=63) were selected based on centrality measures (ie, in-degree, closeness, and betweenness) to spread the intervention. They received health education, which increased their PAL by 17%. In sensitivity analyses, we tested the impact of a 5%, 10%, and 20% increase in PAL among influential peers.

RESULTS

There was a 24%-27% overlap in selected influential peers between the 2 network representations. In general, the simulations showed that interventions could increase PAL by 5.0%-5.8% within 2 months. However, the predicted median impact on PAL was slightly higher in networks based on web-based communication data than peer nomination data for in-degree (5.7%, IQR 5.5%-6.1% vs 5.5%, IQR 5.2%-5.8%; P=.002), betweenness (5.6%, IQR 5.4%-5.9% vs 5.0%, IQR 4.7%-5.3%; P<.001), and closeness centrality (5.8%, IQR 5.6%-6.1% vs 5.3%, IQR 5.0%-5.6%; P<.001). A large variation in impact was observed between school classes (range 1.5%-17.5%). Lowering the effectiveness of health education from 17% to 5% would reduce the overall impact of the social network intervention by 3-fold in both networks.

CONCLUSIONS

Our findings showed that network interventions based on web-based communication data could increase PAL. Web-based communication data may therefore be a valuable addition to peer nomination data for future social network intervention design. Artificial intelligence methods, including agent-based modeling, can help to design these network interventions and provide insights into the role of network characteristics in their effectiveness.

Factors influencing tobacco use behaviour initiation - From the perspective of the Capability, Opportunity, Motivation- Behaviour (COM-B) Model

Introduction

Non-communicable diseases such as ischemic heart disease, cancer, diabetes, and chronic respiratory diseases are the leading causes of death worldwide, and are associated with tobacco use. The ultimate goal of health professionals and researchers working to combat smoking's extremely harmful health effects is to prevent smoking initiation. Nearly 5500 new smokers are added each day, for a total of almost 2 million new smokers each year. The COM-B model's primary goal is to determine what needs to be done for a behaviour change to occur. Behaviour modification requires an understanding of the factors that drive behaviour.

Aim

The current qualitative study intends to explore the factors affecting tobacco use initiation (TUI) using the COM-B model, given the relevance of investigating the factors affecting TUI and the model.

Methods

The present qualitative study has used a directed content analysis approach. Seventeen participants who reported having started any kind of tobacco in the last six months were recruited in the study using a purposive sampling method to understand the factors affecting TUI. The data was collected through interviews, and all of the participants were from the Hyderabad-Karnataka region of Karnataka, India (a state which has been reported as having the highest prevalence of cigarette smoking in India).

Results

Directed content analysis revealed six categories: psychological capabilities affecting TUI (lack of knowledge about adverse health effects of tobacco, behavioural control, and poor academic performance), physical capabilities affecting TUI (lack of better physical resilience), physical opportunities favouring TUI (tobacco advertisements, easy access of tobacco products, and favourite star smoke on screen), social opportunities favouring TUI (peer influence, tobacco use by parents, tradition of hospitality, tobacco use as a normal behaviour, and toxic masculinity), automatic motivation causal factors of TUI (affect regulation, risk taking behaviours and tobacco use for pleasure) and reflective motivation causal factors of TUI (perceived benefits of tobacco, risk perception, perceived stress, and compensatory health beliefs).

Conclusion

Identifying the factors that influence TUI may help to limit or prevent people from smoking their first cigarette. Given the importance of preventing TUI, the findings of this study indicated the factors that influence TUI, which can be valuable in improving behaviour change processes.

Diffusion effects of a sexual violence prevention program leveraging youth-adult partnerships

The purpose of the current study was to examine the diffusion effects of a youth-led sexual violence prevention program (i.e., Youth Voices in Prevention [Youth VIP]). Specifically, social network analysis was used to measure the extent to which Youth VIP changed behaviors for 1172 middle and high school youth who did not attend program events but were friends with Youth VIP participants and completed the first and final survey (approximately 2 years apart). Findings suggest that there was considerable interpersonal communication about Youth VIP among the students generated by program participation. Specifically, youth with friends who participated in Youth VIP were more likely to report hearing their friends talk about Youth VIP and reported talking to their friends about Youth VIP compared with those not connected to Youth VIP participants. However, there were no diffusion effects found for behavioral outcomes (i.e., bystander intervention behavior, violence victimization, and perpetration). Given the mixed findings, further research is needed to determine the extent to which youth-led sexual violence prevention initiatives lead to changes in broader community-wide changes in youths' behaviors.

A peer-led, school-based social network intervention for young people in the UK, promoting sexual health via social media and conversations with friends: intervention development and optimisation of STASH

BACKGROUND

The quality of school-based sex and relationships education (SRE) is variable in the UK. Digitally-based interventions can usefully supplement teacher-delivered lessons and positively impact sexual health knowledge. Designed to address gaps in core SRE knowledge, STASH (Sexually Transmitted infections And Sexual Health) is a peer-led social network intervention adapted from the successful ASSIST (A Stop Smoking in Schools Trial) model, and based on Diffusion of Innovation theory. This paper describes how the STASH intervention was developed and refined.

METHODS

Drawing on the Six Steps in Quality Intervention Development (6SQuID) framework, we tested a provisional programme theory through three iterative stages -: 1) evidence synthesis; 2) intervention co-production; and 3) adaptation - which incorporated evidence review, stakeholder consultation, and website co-development and piloting with young people, sexual health specialists, and educators. Multi-method results were analysed in a matrix of commonalities and differences.

RESULTS

Over 21 months, intervention development comprised 20 activities within the three stages. 1) We identified gaps in SRE provision and online resources (e.g. around sexual consent, pleasure, digital literacy), and confirmed critical components including the core ASSIST peer nomination process, the support of schools, and alignment to the national curriculum. We reviewed candidate social media platforms, ruling out all except Facebook on basis of functionality restrictions which precluded their use for our purposes. 2) Drawing on these findings, as well as relevant behaviour change theories and core elements of the ASSIST model, we co-developed new content with young people and other stakeholders, tailored to sexual health and to delivery via closed Facebook groups, as well as face-to-face conversations. 3) A pilot in one school highlighted practical considerations, including around peer nomination, recruitment, awareness raising, and boundaries to message sharing. From this, a revised STASH intervention and programme theory were co-developed with stakeholders.

CONCLUSIONS

STASH intervention development required extensive adaptation from the ASSIST model. Although labour intensive, our robust co-development approach ensured that an optimised intervention was taken forward for feasibility testing. Evidencing a rigorous approach to operationalising existing intervention development guidance, this paper also highlights the significance of balancing competing stakeholder concerns, resource availability, and an ever-changing landscape for implementation.

TRIAL REGISTRATION

ISRCTN97369178.

Perceptions of and Satisfaction with Sexual and Reproductive Health Interventions in Pre-Adolescent and Adolescent Students in UE/EEA Countries: A Systematic Review

The objective of this review is to investigate perceptions of and satisfaction with sexual and reproductive health (SRH) interventions among pre-adolescents and adolescents of all genders and ethnicities in EU/EEA countries. This systematic review was conducted in accordance with PRISMA recommendations. A systematic literature search was conducted on MEDLINE (PubMed), Cochrane Central Register of Controlled Trials (Central), CINAHL (EBSCO), and PsycINFO (EBSCO) up to March 2022 to identify all published articles that included information on perceptions and levels of satisfaction with SRH interventions. The selected studies were independently and blindly evaluated for risk of bias. Finally, only five papers were included in our review, divided according to the implemented intervention design: conducted by research groups (health or non-health professionals) or structured entirely in a peer-to-peer approach. Both types of program designs analyzed in the included studies were well accepted by students, even though satisfaction assessment methods were not standardized. Peer-to-peer conducted SRH programs or interventions with practical components (e.g., exercises, discussion) were more appreciated. We also found higher levels of satisfaction among younger participants. Future SRH educational programs should consider an assessment of participants' perceptions and satisfaction, possibly adopting standardized tools. Following a peer-to-peer structure and delivering programs early could lead to greater participant satisfaction.

Perceptions of friendship, peers and influence on adolescent smoking according to tobacco control context: a systematic review and meta-ethnography of qualitative research

BACKGROUND

A relationship between smoking and interpersonal influences has been well established within the literature. There have been cultural shifts in denormalisation and a reduction in tobacco smoking in many countries. Hence there is a need to understand social influences on adolescents' smoking across smoking normalisation contexts.

METHODS

The search was conducted in July 2019 and updated in March 2022 within 11 databases and secondary sources. Search terms included schools, adolescents, smoking, peers, social norms and qualitative research. Screening was conducted by two researchers independently and in duplicate. Study quality was assessed using the eight-item Evidence for Policy and Practice Information and Co-ordinating Centre (EPPI-centre) tool for the appraisal of qualitative studies. Results were synthesised using a meta-narrative lens for meta-ethnography and compared across smoking normalisation contexts.

RESULTS

Forty one studies were included and five themes were developed, mapping onto the socio ecological model. The social processes by which adolescents take up smoking differed according to a mixture of school type, peer group structure and the smoking culture within the school, as well as the wider cultural context. Data available from smoking denormalised contexts, described changes in social interactions around smoking to cope with its stigmatisation. This was manifested through i) direct peer influence, whereby subtle techniques were employed, ii) group belonging whereby smoking was less likely to be seen as a key determinant of group membership and smoking was less commonly reported to be used as a social tool, and iii) popularity and identity construction, whereby smoking was perceived more negatively in a denormalised context, compared with a normalised context.

CONCLUSIONS

This meta-ethnography is the first study to demonstrate, drawing on international data, that peer processes in adolescent smoking may undergo changes as smoking norms within society change. Future research should focus on understanding differences across socioeconomic contexts, to inform the adaptation of interventions.

The impact of peer-led support groups on health-related quality of life, coping skills and depressive symptomatology for women with PCOS

Support groups can be a powerful medium in providing psychological support to women with Polycystic Ovary Syndrome (PCOS). The study evaluated the impact of peer support group on Health-Related Quality of Life (HRQoL), depressive symptomatology and coping strategies among women with PCOS. The pre- and post-test experimental design was used. Women with PCOS not receiving psychiatric medication and attending clinics of a teaching hospital in Colombo were recruited. They were randomly allocated based on clinic days to the experimental (n = 20) and control (n = 22) groups. The Intervention group participated in the specific peer support program for 10 weeks, while the control group received general health reading material for 10 weeks through the post. The Modified Polycystic Ovary Syndrome Questionnaire (M-PCOSQ), Centre for Epidemiologic Studies Depression Scale (CES-D) and Brief COPE inventory were administered to both groups before and 1 month after completing the intervention. Before the intervention, there was no significant difference between the two groups regarding the scores of HRQoL, depressive symptomatology and coping skills. One month after the intervention, the support group exhibited improvement in HRQoL, depressive symptomatology and coping skills (p < 0.01) compared to the control group. The peer support group is an effective intervention to uplift the psycho-social wellbeing of women with PCOS through receiving emotional support from those similarly afflicted.

Exploring the mechanistic pathways of how social network influences social norms in adolescent smoking prevention interventions

We know little about how smoking prevention interventions might leverage social network structures to enhance protective social norms. In this study we combined statistical and network science methods to explore how social networks influence social norms related to adolescent smoking in school-specific settings in Northern Ireland and Colombia. Pupils (12-15 years old) participated in two smoking prevention interventions in both countries (n = 1344). A Latent Transition Analysis identified three groups characterized by descriptive and injunctive norms towards smoking. We employed a Separable Temporal Random Graph Model to analyze homophily in social norms and conducted a descriptive analysis of the changes in the students' and their friends' social norms over time to account for social influence. The results showed that students were more likely to be friends with others who had social norms against smoking. However, students with social norms favorable towards smoking had more friends with similar views than the students with perceived norms against smoking, underlining the importance of network thresholds. Our results support the notation that the ASSIST intervention takes advantage of friendship networks to leverage greater change in the students' smoking social norms than the Dead Cool intervention, reiterating that social norms are subject to social influence.

Attention Deficit Hyperactivity Disorder Symptoms, Smoking Initiation, and Social Integration among Adolescents

This observational, longitudinal study's purpose was to investigate whether social network integration has a moderating effect on smoking initiation among those with attention deficit hyperactivity disorder (ADHD). Data were drawn from the National Longitudinal Study of Adolescent to Adult Health, a nationally representative longitudinal dataset. Social network and smoking data were collected in schools, with a 6-year follow-up that included ADHD symptoms and reported smoking. Social integration was measured as peer friendship nominations (degree) and the influence of an individual on the entire social network (centrality). Multilevel logistic regression found a main effect for ADHD symptoms and low numbers of friendship nominations on smoking initiation, but social network measures were not significant moderators of the relationship between ADHD symptoms and smoking initiation among adolescents. Further investigation of the drivers of smoking initiation among those with ADHD is warranted.

Multilevel network interventions: Goals, actions, and outcomes

COVID-19 has resulted in dramatic and widespread social network interventions across the globe, with public health measures such as distancing and isolation key epidemiological responses to minimize transmission. Because these measures affect social interactions between people, the networked structure of daily lives is changed. Such largescale changes to social structures, present simultaneously across many different societies and touching many different people, give renewed significance to the conceptualization of social network interventions. As social network researchers, we need a framework for understanding and describing network interventions consistent with the COVID-19 experience, one that builds on past work but able to cast interventions across a broad societal framework. In this theoretical paper, we extend the conceptualization of social network interventions in these directions. We follow Valente (2012) with a tripartite categorization of interventions but add a multilevel dimension to capture hierarchical aspects that are a key feature of any society and implicit in any network. This multilevel dimension distinguishes goals, actions, and outcomes at different levels, from individuals to the whole of the society. We illustrate this extended taxonomy with a range of COVID-19 public health measures of different types and at multiple levels, and then show how past network intervention research in other domains can also be framed in this way. We discuss what counts as an effective network, an effective intervention, plausible causality, and careful selection and evaluation, as central to a full theory of network interventions.

A systematic review and meta-analysis of the benefits of school-based, peer-led interventions for leaders

The aim of our systematic review and meta-analysis was to quantitatively synthesise the effects of school-based peer-led interventions on leaders' academic, psychosocial, behavioural, and physical outcomes. Eligible studies were those that: (i) evaluated a school-based peer-led intervention using an experimental or quasi-experimental study design, (ii) included an age-matched control or comparison group, and (iii) evaluated the impact of the intervention on one or more leader outcomes. Medline, Sportdiscus, Psychinfo, Embase, and Scopus online databases were searched on the 24th of October, 2022 which yielded 13,572 results, with 31 included in the narrative synthesis and 12 in the meta-analysis. We found large positive effects for leaders' attitudes toward bullying (d = 1.02), small-to-medium positive effects for leaders' literacy (d = 0.39), and small positive effects for leaders' self-esteem (d = 0.18). There were mixed findings for behavioural outcomes and null effects for physical outcomes. Notable limitations of this research are the inclusion of a relatively small number of studies, and high heterogeneity in those included. Our findings have the potential to inform educational practice, but also highlight the need for further research examining the mechanisms that might account for the observed effects. Our systematic review was prospectively registered with PROSPERO (CRD42021273129).

School-based peer education interventions to improve health: a global systematic review of effectiveness

INTRODUCTION

Peer education, whereby peers ('peer educators') teach their other peers ('peer learners') about aspects of health is an approach growing in popularity across school contexts, possibly due to adolescents preferring to seek help for health-related concerns from their peers rather than adults or professionals. Peer education interventions cover a wide range of health areas but their overall effectiveness remains unclear. This review aims to summarise the effectiveness of existing peer-led health interventions implemented in schools worldwide.

METHODS

Five electronic databases were searched for eligible studies in October 2020. To be included, studies must have evaluated a school-based peer education intervention designed to address the health of students aged 11-18-years-old and include quantitative outcome data to examine effectiveness. The number of interventions were summarised and the impact on improved health knowledge and reductions in health problems or risk-taking behaviours were investigated for each health area separately, the Mixed Methods Appraisal Tool was used to assess quality.

RESULTS

A total of 2125 studies were identified after the initial search and 73 articles were included in the review. The majority of papers evaluated interventions focused on sex education/HIV prevention (n = 23), promoting healthy lifestyles (n = 17) and alcohol, smoking and substance use (n = 16). Papers mainly reported peer learner outcomes (67/73, 91.8%), with only six papers (8.2%) focussing solely on peer educator outcomes and five papers (6.8%) examining both peer learner and peer educator outcomes. Of the 67 papers reporting peer learner outcomes, 35/67 (52.2%) showed evidence of effectiveness, 8/67 (11.9%) showed mixed findings and 24/67 (35.8%) found limited or no evidence of effectiveness. Of the 11 papers reporting peer educator outcomes, 4/11 (36.4%) showed evidence of effectiveness, 2/11 (18.2%) showed mixed findings and 5/11 (45.5%) showed limited or no evidence of effectiveness. Study quality varied greatly with many studies rated as poor quality, mainly due to unrepresentative samples and incomplete data.

DISCUSSION

School-based peer education interventions are implemented worldwide and span a wide range of health areas. A number of interventions appear to demonstrate evidence for effectiveness, suggesting peer education may be a promising strategy for health improvement in schools. Improvement in health-related knowledge was most common with less evidence for positive health behaviour change. In order to quantitatively synthesise the evidence and make more confident conclusions, there is a need for more robust, high-quality evaluations of peer-led interventions using standardised health knowledge and behaviour measures.

Opportunities in Health Education in the Post-COVID-19 Era: Transforming Viral to Vital

Although the current pandemic is associated with many difficulties and social challenges, in parallel, it has been linked with new opportunities. The field of education and, in particular, health education, represent a highlighted example. According to the United Nations Educational, Scientific and Cultural Organization (UNESCO) statistics, the education of more than 1.5 billion students in 188 countries around the globe was affected due to the closure of educational institutions following the coronavirus outbreak. In the present study, we examine the development of possibilities, prospects, and opportunities in the post-COVID-19 era in the field of health education. Using reflective observations on what we have gained as knowledge during this pandemic, we summarize five VITAL aspects of health education: the emerging value in health; the power of preventive interventions in health education; the transmission of health messages by students in the context of communication between school, family, and community; the exploitation of contemporary e-learning applications as a mixed hybrid learning mode; and the life examples as projected from the theoretical principles of health education to real scenarios. In conclusion, the global pandemic crisis, serving as a "violent teacher," presents us with hidden potential, promising new prospects in the field of health education that we need to exploit.

Use of Focus Groups to Inform a New Community-Based Youth Diabetes Prevention Program

There have been few youth-led diabetes prevention programs. Our objective was to conduct focus groups to explore peer influences on adolescent lifestyle behaviors and strategies for implementing a youth peer education model for diabetes prevention. We conducted six focus groups with 52 youth (ages 13-22; 62% male, 38% female; 64% Hispanic, 36% non-Hispanic Black) from East Harlem, NYC. We used a Thematic Analysis approach to identify major themes, compared findings, and resolved differences through discussion and consensus. Three dominant themes arose: (1) Adolescents generally encounter more unhealthy peer influences on diet and more healthy peer influences on physical activity; (2) Adolescents endorse youth-led diabetes prevention strategies and describe ideal qualities for peer leaders and methods to support and evaluate leaders; (3) Adolescents prefer text messaging to monitor behaviors, track goals, and receive personalized guidance. Using study findings, our Community Action Board developed a peer-led diabetes prevention program for prediabetic adolescents.

The person-based development and realist evaluation of a pre-consultation form for GP consultations

Background

Use of telephone, video and e-consultations is increasing. These can make consultations more transactional, potentially missing patients' concerns. This study aimed to develop a complex intervention to address patients' concerns more comprehensively in general practice and test the feasibility of this in a cluster-randomised framework.The complex intervention used two technologies: a patient-completed pre-consultation form used at consultation opening and a doctor-provided summary report provided at consultation closure. This paper reports on the development and realist evaluation of the pre-consultation questionnaire.

Methods

A person-based approach was used to develop the pre-consultation form. An online questionnaire system was designed to allow patient self-completion of a form which could be shared with GPs. This was tested with 45 patients in three rounds, with iterative adjustments made based on feedback after each round.Subsequently, an intervention incorporating the pre-consultation form with the summary report was then tested in a cluster-randomised framework with 30 patients per practice in six practices: four randomised to intervention, and two to control. An embedded realist evaluation was carried out. The main feasibility study results are reported elsewhere.

Results

Intervention Development: 15 patients were recruited per practice. Twelve patients, six GPs and three administrators were interviewed and 32 changes were made iteratively in three rounds. Recruitment rates (proportion of patients responding to the text) increased from 15% in round one to 50% in round three.Realist evaluation: The pre-consultation form was most useful for people comfortable with technology and with hidden concerns or anxiety about the consultation. It resulted in more issues being discussed and support provided, more effective use of time and greater patient satisfaction.

Conclusions

The person-based approach was successful. The pre-consultation form uncovers more depth and improves satisfaction in certain consultations and patients. Technological improvements are required before this could be rolled out more widely.

Motivating Social Influencers to Engage in Health Behavior Interventions

Social influencers are widely known as the promotors of purchase behavior as well as for their potential to change health behaviors among individuals in their social networks. For social influencers to be successful in changing behaviors, it is essential that they convey their message in an authentic, original, credible, and persistent manner. In the context of health behavior interventions, this requires a focus on the motivation of social influencers to engage in the intervention. This perspective article describes the importance of motivating social influencers to engage in the desired health behaviors themselves and to promote it within their social network. We briefly describe the current state of knowledge and our empirical experience in implementing health interventions with social influencers. Using insights from self-determination theory, we demonstrate how social influencers can be motivated optimally in health behavior interventions and, thereby, improving the success of the intervention. To illustrate these insights and guide intervention practice, we provide concrete examples of techniques that can be applied in health interventions involving social influencers. We conclude with directions for further research and intervention practice to improve the delivery of health behavior interventions.

Perspectives on Cigarette Use, Vaping, and Antitobacco Campaigns Among Adolescent Sexual Minority Males and Gender Diverse Youth

Purpose: This qualitative study examined perceived benefits and drawbacks of smoking/vaping and attitudes toward antitobacco campaigns among adolescent sexual minority males and gender-diverse (ASMM/GD) youth. Methods: In July 2019, 215 U.S. ASMM/GD youth (mean_age 16.78, 95.3% cisgender male, 61.9% racial/ethnic minority) answered questions about smoking/vaping behaviors, motivations for smoking/vaping, and attitudes toward antitobacco campaigns via an online survey. Data were analyzed with thematic analysis. Results: Overall, 17.2% of participants had smoked cigarettes, and 34.9% had vaped. Teens described psychological (e.g., stress relief), chemical (e.g., nicotine buzz), and social incentives (e.g., fitting in with peers) for smoking/vaping. Teens also reported concerns about physical health, costs, and self-image as drawbacks of smoking/vaping. Most considered antitobacco campaigns unrelatable and uninteresting, while others reported that campaigns reinforced their decisions to not smoke/vape. Most participants wanted antitobacco campaigns to be tailored to the sexual and gender minority (SGM) community. Conclusions: These findings shed light on ASMM/GD youth's perspectives of smoking/vaping and antitobacco campaigns. Results suggest that equipping teens with skills to cope with minority stress and resisting peer pressure could indirectly reduce smoking/vaping, and that SGM-inclusive campaigns may better reach SGM adolescents.

Protocol: Mapping social networks, social influence and sexual health among youth in rural KwaZulu-Natal, the Sixhumene cohort study

Background: Sexual behaviour and sexually transmitted infections are strongly affected by social connections, and interventions are often adapted more readily when diffused through social networks. However, evidence on how young people acquire ideas and change behaviour through the influence of important social contacts is not well understood in high-HIV-prevalence settings, with the result that past peer-led HIV-prevention interventions have had limited success. Methods: We therefore designed a cohort study (named Sixhumene or 'we are connected') to follow young people in three rural and small-town communities in uMkhanyakude district, KwaZulu-Natal, South Africa, and the people that these youth identify as important in their lives. We will interview them five times over three years, at each visit collecting information on their socioeconomic, social and sexual health lives, and testing them for HIV and herpes simplex virus 2 (HSV-2). We will use this information to understand how these young people's sexual health decisions are formed. This will include evaluating how poor sexual health outcomes are correlated across social networks, how youth mimic the attitudes and behaviours of those around them, who is at greatest risk of acquiring HIV and HSV-2, and who might be most influential within communities and thus best able to promote protective interventions. Discussion: The information gathered through this study will allow us to describe social connection and influence spread through these real-world social networks, and how this leads to sexual health outcomes. Sixhumene will provide vital inputs for mathematical models of communities and spreading processes, as well as inform the development of effective interventions to protect the sexual health of community members through appropriate targeting with optimised messaging requiring fewer resources.

A comparison of peer change agent selection methods: Evidence from a high-school based suicide preventive intervention

BACKGROUND

Peer-led interventions for adolescents are effective at accelerating behavioral change. The Sources of Strength suicide preventive program trains student peer change agents (peer leaders) in secondary schools to deliver prevention messaging and conduct activities that increase mental health coping mechanisms. The program currently has school staff select peer leaders. This study examined potential for more efficient program diffusion if peer leaders had been chosen under network-informed selection methods.

METHODS

Baseline assessments were collected from 5,746 students at 20 schools. Of these, 429 were selected by adults as peer leaders who delivered intervention content through the school year. We created theoretical alternate peer leader sets based on social network characteristics: opinion leadership, centrality metrics, and key players. Because these sets were theoretical, we examined the concordance of these sets with the actual adult-selected peer leaders sets and correlated this metric with diffusion of intervention modalities (i.e., presentation, media, communication, activity) after the first year.

RESULTS

The sets of adult-selected peer leaders were 13.3%-22.7% similar to theoretical sets chosen by other sociometric methods. The use of friendship network metrics produced peer leader sets that were more white and younger than the general student population; the Key Players method produced more representative peer leader sets. Peer opinion leaders were older and more white than the general population. Schools whose selected peer leaders had higher overlap with theoretical ones had greater diffusion of intervention media and peer communication.

CONCLUSIONS

The use of network information in school-based peer-led interventions can help create more systematized peer leader selection processes. To reach at-risk students, delivery of an indirect message, such as through a poster or video, may be required. A hybrid approach where a combination of visible, respected opinion leaders, along with strategically-placed key players within the network, may provide the greatest potential for intervention diffusion.

A two-stage social network intervention for reducing alcohol and other drug use in residential colleges: Protocol for a feasibility trial

BACKGROUND

In many countries, the rate of binge drinking and alcohol-related harms among students living in residential colleges exceeds that observed among young people in the general population. Peer influence plays a key role in driving alcohol and other drug (AOD) use in colleges. This highlights the potential role of peer influence AOD-interventions in college student-networks. This protocol paper outlines the design of a two-stage social network intervention (SNI) for reducing AOD-use in four Australian first-year residential college networks.

METHODS

In Stage 1, a peer-led workshop will provide education about AOD-use and harm-minimisation strategies to four first-year cohorts in the first week of semester one (N ~ 500). In Stage 2, a targeted SNI will be delivered to the largest co-educational, first-year cohort (N ~ 160), wherein heavy drinking 'Strategic Players' (influential students) will be identified and offered a brief, telephone-delivered motivational interviewing intervention for AOD-use (QuikFix). Participants will complete online surveys at baseline and 12-, 26-, and 52-weeks follow-up.

RESULTS

Recruitment occurred in February 2021 and is now closed. Results are expected to be submitted for publication in late 2022.

CONCLUSIONS

This protocol paper outlines the design of a feasibility trial exploring the impact of applied SNIs for reducing AOD-use and related consequences in residential college student networks. If effective, the two-stage SNI proposed could (i) reduce AOD-use and risk of harm across first-year student networks and (ii) provide an effective brief intervention (QuikFix) to high-risk drinkers who have greatest potential to spread the intervention effects to other risky drinkers in their network.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ACTRN12621000494831).

The Influence of a School Social Network Intervention on Adolescent's Health Behaviors: A Gender-Specific Agent-Based Model

Introduction

Adolescence is a crucial stage for health behavior development, which is associated with health in adulthood. School closures caused by the coronavirus disease 2019 (COVID-19) pandemic have exposed adolescents to an increased risk of obesity due to a lack of physical activity. Although social network interventions provide an effective approach for promoting health-related behavior, current practices neglect gender differences in adolescent behavioral patterns and emotional preferences. The aim of this study was to examine the effectiveness of centrality-based methods integrated with of gender contexts in a social network intervention to improve adolescent's health behavior.

Methods

We developed an agent-based model (ABM) that supports the small-world characteristics of adolescent social networks. Health-related data for junior middle school students (n = 234, 48% girls) were collected in November 2018, 2019 and 2020 in Tianjin, China. We simulated multiple network-based interventions with different criteria for influential agents (i.e., betweenness centrality, closeness centrality, eigenvector centrality, and PageRank) and a random condition. The rules for generating peer influence and accelerating behavioral changes were based on the diffusion of innovations theory, with gender specifications.

Results

After the school closures, there was a significant increase in the prevalence of overweight and obesity among adolescents, with a greater increase in girls than in boys (+8.85% vs. +1.65%, p < 0.001). Simulations showed that centrality-based network interventions were more effective than the random condition (average 6.17% per tick vs. 5.22% per tick, p < 0.05), with a higher efficiency in girls than boys (average 3.68% vs. 2.99% per tick, p < 0.05). PageRank outperformed other centrality conditions at the population level (6.37% per tick, p < 0.05). In girls, betweenness centrality was the best method (3.85% per tick, p < 0.05), while in boys, PageRank still had the greatest efficiency (3.21% per tick, p < 0.05).

Conclusions

We found evidence for gender differences in the negative impact of COVID-19-related school closures and the potential for centrality-based social network interventions to affect adolescent health behavior. Therefore, we emphasize the importance of gender-specific targeting strategies to further promote health-related school programs in the post-pandemic era.

Spread of gambling abstinence through peers and comments in online self-help chat forums to quit gambling

Habit formation occurs in relation to peer habits and comments. This general principle was applied to gambling abstinence in the context of online self-help forums to quit gambling. Participants in this study, conducted between September 2008 and March 2020, were 161 abstinent and 928 non-abstinent gamblers who participated in online self-help chat forums to quit gambling. They received 269,317 comments during their first 3 years of forum participation. Gamblers had an increased likelihood of 3-year continuous gambling abstinence if they had many peers in the forums. However, they had a decreased likelihood of gambling abstinence if they received rejective comments from the forums. Based on these results, online social network-based interventions may be a new treatment option for gamblers.

Peer-led physical activity intervention for girls aged 13 to 14 years: PLAN-A cluster RCT

Background

Increasing physical activity among girls is a public health priority. Peers play a central role in influencing adolescent behaviour. Peer-led interventions may increase physical activity in adolescent girls, and a feasibility trial had shown that PLAN-A (Peer-led physical Activity iNtervention for Adolescent girls) had evidence of promise to increase physical activity in adolescent girls.

Objective

The objective was to test whether or not PLAN-A can increase adolescent girls’ physical activity, relative to usual practice, and be cost-effective.

Design

This was a two-arm, cluster-randomised controlled trial, including an economic evaluation and a process evaluation.

Participants

State-funded secondary schools in the UK with girls in Year 9 (aged 13–14 years) participated in the trial. All Year 9 girls in participating schools were eligible.

Randomisation

Schools were the unit of allocation. They were randomised by an independent statistician, who was blinded to school identities, to the control or intervention arm, stratified by region and the England Index of Multiple Deprivation score.

Intervention

The intervention comprised peer nomination (i.e. identification of influential girls), train the trainers (i.e. training the instructors who delivered the intervention), peer supporter training (i.e. training the peer-nominated girls in techniques and strategies underpinned by motivational theory to support peer physical activity increases) and a 10-week diffusion period.

Outcomes

The primary outcome was accelerometer-assessed mean weekday minutes of moderate to vigorous physical activity among Year 9 girls. The follow-up measures were conducted 5–6 months after the 10-week intervention, when the girls were in Year 10 (which was also 12 months after the baseline measures). Analysis used a multivariable, mixed-effects, linear regression model on an intention-to-treat basis. Secondary outcomes included weekend moderate to vigorous physical activity, and weekday and weekend sedentary time. Intervention delivery costs were calculated for the economic evaluation.

Results

A total of 33 schools were approached; 20 schools and 1558 pupils consented. Pupils in the intervention arm had higher Index of Multiple Deprivation scores than pupils in the control arm. The numbers randomised were as follows: 10 schools (n = 758 pupils) were randomised to the intervention arm and 10 schools (n = 800 pupils) were randomised to the control arm. For analysis, a total of 1219 pupils provided valid weekday accelerometer data at both time points (intervention, n = 602; control, n = 617). The mean weekday moderate to vigorous physical activity was similar between groups at follow-up. The central estimate of time spent engaging in moderate to vigorous physical activity was 2.84 minutes lower in the intervention arm than in the control arm, after adjustment for baseline mean weekday moderate to vigorous physical activity, the number of valid days of data and the stratification variables; however, this difference was not statistically significant (95% confidence interval –5.94 to 0.25; p = 0.071). There were no between-arm differences in the secondary outcomes. The intervention costs ranged from £20.85 to £48.86 per pupil, with an average cost of £31.16.

Harms

None.

Limitations

The trial was limited to south-west England.

Conclusions

There was no evidence that PLAN-A increased physical activity in Year 9 girls compared with usual practice and, consequently, it was not cost-effective.

Future work

Future work should evaluate the utility of whole-school approaches to promote physical activity in schools.

Trial registration

This trial is registered as ISRCTN14539759.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 10, No. 6. See the NIHR Journals Library website for further project information. This trial was designed and delivered in collaboration with the Bristol Randomised Trials Collaboration (BRTC), a United Kingdom Clinical Research Commission (UKCRC)-registered Clinical Trials Unit that, as part of the Bristol Trials Centre, is in receipt of NIHR Clinical Trials Unit support funding. The sponsor of this trial was University of Bristol, Research and Enterprise Development www.bristol.ac.uk/red/. The costs of delivering the intervention were funded by Sport England.

Employing the theory of planned behaviour to design an e-cigarette education resource for use in secondary schools

Background

An extended version of the theory of planned behaviour (TPB) was used to inform the design of a framework for an educational resource around e-cigarette use in young people.

Methods

A sequential exploratory design was employed. In Phase 1, elicited behavioural, normative and control beliefs, via 7 focus groups with 51 participants, aged 11–16 years, identified salient beliefs around e-cigarette use. These were used to construct a questionnaire administered to 1511 young people aged 11–16 years, which determined predictors of e-cigarette use and ever use. In Phase 2, sociodemographic variables, e-cigarette knowledge, access, use, marketing and purchasing of e-cigarettes and smoking behaviour were also gathered. The composite findings from Phase 1 and 2 informed the design of a post primary educational resource in Phase 3 around e-cigarette use.

Results

Current e-cigarette use was 4%, with almost 23% reporting ever use, suggesting current use is stable but experimentation may be increasing in this cohort. Sociodemographic variables, knowledge of e-cigarettes, smoking behaviour and TPB variables (direct and indirect measures of attitudes, subjective norm, and perceived behavioural control) accounted for 17% of the variance in current e-cigarette use, with higher intentions to use e-cigarettes within the next month, having the strongest impact on use (p < 0.001), followed by self-efficacy (p = 0.016). Sociodemographic and TPB variables accounted for 65% of the variance in intentions to use e-cigarettes in the next month; current e-cigarette use (p < 0.001), more positive attitudes (p < 0.001), stronger social influence (p < 0.001), higher self-efficacy (p < 0.001), higher control beliefs (p < 0.001) and greater motivation to use e-cigarettes (p < 0.001) were the main predictors of intentions. Phases 1 and 2 informed the mapping of key predictors of intentions and use of e-cigarettes onto the Theoretical Domains Framework, which identified appropriate intervention functions and behaviour change techniques.

Conclusions

This paper is the first to bridge the theoretical-practice gap in an area of significant public health importance through the development of a framework for a novel theory driven school-based educational resource aimed at reducing experimentation and uptake of e-cigarette use in young people.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12674-3.

A Systematic Literature Review of Peer-led Strategies for Promoting Physical Activity Levels of Adolescents

Background. Low levels of physical activity (PA) in adolescents highlight the necessity for effective intervention. During adolescence, peer relationships can be a fundamental aspect of adopting and maintaining positive health behaviors. Aim. This review aims to determine peer-led strategies that showed promise to improve PA levels of adolescents. It will also identify patterns across these interventions, including training provided and the behavior change techniques (BCTs) employed. Method. Adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, PubMed, PsychINFO, and Scopus were searched using key concepts of peer, PA and adolescent for articles that examined interventions that had a peer-led component and reported on at least one PA outcome in 12- to 19-year-olds. Following title and abstract screening of 1,509 studies, and full text review stage, 18 progressed to data synthesis. Methodological quality was assessed using an adapted scale. Results. Quality assessment identified 11 studies as high quality. Half of the included studies (n = 9) reported improved PA outcomes in the school setting. The most prominent behavioral change techniques were social support, information about health consequences, and demonstration of the behavior. Older adolescents leading younger peers and younger adolescents leading those of the same age showed potential. Seldom have older adolescents been targeted. Gender-specific interventions showed the most promise. Conclusion. Peer leadership requires careful planning and in the school setting can be a resourceful way of promoting adolescent PA.

Exploring the association between school-based peer networks and smoking according to socioeconomic status and tobacco control context: a systematic review

BACKGROUND

Whilst prevalence of youth smoking in middle and high income countries has decreased, inequality has prevailed. The introduction of legislation regulating tobacco use in public spaces varies across countries, impacting the tobacco control context. Thus reviewing our knowledge of how social networks may influence smoking differently within different contexts is required to facilitate the development of context-specific interventions.

METHODS

The search, conducted on 31st May 2019, included the following smoking-related terms; schools, adolescents, peers and social networks. Inclusion and exclusion criteria were applied throughout the title and abstract screening and full text screening. Quality assessment and synthesis followed. Studies were narratively synthesised to identify changes according to legislative context. This synthesis was conducted separately for findings relating to three categories: socioeconomic status; social selection and influence; and network position.

RESULTS

Thirty studies were included. Differences in the relationship between network characteristics and smoking according to socioeconomic status were measured in five out of fifteen studies in Europe. Results varied across studies, with differences in network characteristics and their association with smoking varying both between schools of a differing and those of a similar socioeconomic composition. For studies conducted both before and after the introduction of comprehensive smoking legislation, the evidence for selection processes was more consistent than influence, which varied according to reciprocity. Findings showed that isolates were more likely to smoke and in-degree and out-degree centrality were related to smoking both before and after the introduction of legislation. The relationship between popularity and smoking was contingent on school level smoking prevalence in studies conducted before the introduction of legislation, but not after.

CONCLUSIONS

Overall, effects according to socioeconomic status were underreported in the included studies and no consistent evidence of change after the introduction of a comprehensive smoking ban was observed. Further network analyses are required using more recent data to obtain a comprehensive understanding of how network processes may influence smoking differently according to socioeconomic status, and how adaptation could be used to enhance intervention effectiveness.

SYSTEMATIC REVIEW REGISTRATION

International Prospective Register of Systematic Reviews (PROSPERO) registration number: CRD42019137358 .

Educational level and alcohol use in adolescence and early adulthood-The role of social causation and health-related selection-The TRAILS Study

Both social causation and health-related selection may influence educational gradients in alcohol use in adolescence and young adulthood. The social causation theory implies that the social environment (e.g. at school) influences adolescents' drinking behaviour. Conversely, the health-related selection hypothesis posits that alcohol use (along other health-related characteristics) predicts lower educational attainment. From past studies it is unclear which of these mechanisms predominates, as drinking may be both a cause and consequence of low educational attainment. Furthermore, educational gradients in alcohol use may reflect the impact of 'third variables' already present in childhood, such as parental socioeconomic status (SES), effortful control, and IQ. We investigated social causation and health-related selection in the development of educational gradients in alcohol use from adolescence to young adulthood in a selective educational system. We used data from a Dutch population-based cohort (TRAILS Study; n = 2,229), including measurements of educational level and drinking at ages around 14, 16, 19, 22, and 26 years (waves 2 to 6). First, we evaluated the directionality in longitudinal associations between education and drinking with cross-lagged panel models, with and without adjusting for pre-existing individual differences using fixed effects. Second, we assessed the role of childhood characteristics around age 11 (wave 1), i.e. IQ, effortful control, and parental SES, both as confounders in these associations, and as predictors of educational level and drinking around age 14 (wave 2). In fixed effects models, lower education around age 14 predicted increases in drinking around 16. From age 19 onward, we found a tendency towards opposite associations, with higher education predicting increases in alcohol use. Alcohol use was not associated with subsequent changes in education. Childhood characteristics strongly predicted education around age 14 and, to a lesser extent, early drinking. We mainly found evidence for the social causation theory in early adolescence, when lower education predicted increases in subsequent alcohol use. We found no evidence in support of the health-related selection hypothesis with respect to alcohol use. By determining initial educational level, childhood characteristics also predict subsequent trajectories in alcohol use.

The Antecedents and Consequences of Interpersonal Communication during a School-based Health Intervention

School-based health interventions often have limited and inconsistent effects. Although interpersonal communication likely is important, hardly any studies have investigated interpersonal communication of students with their friends, classmates, and parents about the health programs and health behaviors in school-based health interventions. In a two-wave prospective study of 389 adolescents focusing on three health behaviors (i.e., alcohol use, snack intake, and exercise), we addressed two aims. Our first aim was to investigate how student evaluations of a school-based health intervention influenced interpersonal communication about health behaviors (i.e., valence and frequency of conversations). Findings showed that positively evaluating a school-based health intervention increased how often students talked about the intervention with friends, classmates, and parents, as well as how they discussed the three health behaviors. Our second aim was to investigate the influence of interpersonal communication with friends, classmates, and parents on predictors of health behaviors. We found for conversational frequency that frequently discussing health behaviors resulted in healthier (more positive) predictors of exercise, but also in unhealthier (more positive) predictors of snacking and drinking. Furthermore, findings showed that positively discussing exercising, and negatively discussing snacking and drinking, resulted in healthier predictors of these behaviors. Our findings show that it is important to understand the impact of post-intervention communication and that post-intervention communication with peers and parents about health behaviors are predictors of health behavior.

Effects of health education on adolescents' non-cognitive skills, life satisfaction and aspirations, and health-related quality of life: A cluster-randomized controlled trial in Vietnam

Objective

The effectiveness of health education on adolescents has been questioned, along with a growing body of empirical studies documenting the absence of behavioral changes after the intervention. However, evidence on its impact on other crucial health domains, besides health practices, is lacking. We evaluated the causal effects of a school-based health education program on adolescents’ multidimensional psychological health factors.

Design

A cluster-randomized controlled trial.

Methods

We conducted a cluster-randomized controlled trial involving 140 lower secondary schools in Vietnam. After stratifying by district, schools were randomized 1:1 to either treatment or control groups. Students enrolled in the treatment schools received monthly stand-alone health education in five topics by school teachers at the class level, but control group students did not receive any intervention. The primary outcomes of the study were students’ non-cognitive skills, life satisfaction, aspirations gap, and the Health-Related Quality of Life at five-month follow-up. We estimated the intention-to-treat effects with the panel fixed effects model using student panel data.

Results

Of the 6,477 students enrolled at baseline, 2,958 (92%) treated and 2,967 (91%) control students completed the follow-up survey five months after baseline data collection from October to December 2018. Compared with controls, health education led to improved treatment school students’ self-efficacy (p-value = 0.013), presumed life satisfaction five years from the present (p-value = 0.001), aspirations gap for a socially and mentally healthy future (p-value = 0.036), and the Health-Related Quality of Life (p-value = 0.036).

Conclusion

A school-based health education program enhanced students’ non-cognitive skills, life satisfaction and aspirations gap, and the Health-Related Quality of Life significantly. This study proposes essential psychological factors that should be taken into account when evaluating the effectiveness of a health education program in resource-limited settings.

Mental health support and training to improve secondary school teachers’ well-being: the WISE cluster RCT

Background

Health and Safety Executive data show that teachers are at heightened risk of mental health difficulties, yet few studies have attempted to address this. Poor teacher mental health may impact on the quality of support provided to young people, who also report increased mental health difficulties themselves.

Objective

To test the effectiveness of an intervention aiming to improve secondary school teachers’ well-being through mental health support and training.

Design

A cluster randomised controlled trial with embedded process and economic evaluations.

Setting

Twenty-five mainstream, non-fee-paying secondary schools in the south-west of England and South Wales, stratified by geographical area and free school meal entitlement, randomly allocated to intervention or control groups following collection of baseline measures (n = 12, intervention; n = 13, control) between May and July 2016.

Participants

All teachers in the study schools at any data collection. All students in year 8 (baseline) and year 10 (final follow-up).

Intervention

Each intervention school received three elements: (1) a 1-day mental health first aid for schools and colleges training session delivered to 8% of all teachers; (2) a 1-hour mental health session delivered to all teachers; and (3) 8% of staff trained in the 2-day standard mental health first aid training course set up a confidential peer support service for colleagues. Control schools continued with usual practice.

Main outcome measures

The primary outcome was teacher well-being (using the Warwick–Edinburgh Mental Wellbeing Scale). Secondary outcomes were teacher depression, absence and presenteeism, and student well-being, mental health difficulties, attendance and attainment. Follow-up was at 12 and 24 months. Data were analysed using intention-to-treat mixed-effects repeated-measures models.

Economic evaluation

A cost–consequence analysis to compare the incremental cost of the intervention against the outcomes measured in the main analysis.

Process evaluation

A mixed-methods study (i.e. qualitative focus groups and interviews, quantitative surveys, checklists and logs) to examine intervention implementation, activation of the mechanisms of change outlined in the logic model, intervention acceptability and the wider context.

Results

All 25 schools remained in the study. A total of 1722 teachers were included in the primary analysis. We found no difference in mean teacher well-being between study arms over the course of follow-up (adjusted mean difference –0.90, 95% confidence interval –2.07 to 0.27). There was also no difference in any of the secondary outcomes (p-values 0.203–0.964 in the fully adjusted models). The average cost of the intervention was £9103 (range £5378.97–12,026.73) per intervention school, with the average cost to Welsh schools being higher because of a different delivery model. The training components were delivered with high fidelity, although target dosage was sometimes missed. The peer support service was delivered with variable fidelity, and reported usage by teachers was low (5.9–6.1%). The intervention had high acceptability, but participants reported low support from senior leadership, and minimal impact on school culture.

Limitations

Participants and the study team were unblinded, self-report for the main outcome measures and inaccurate measurement of peer support service usage.

Conclusions

The Wellbeing in Secondary Education (WISE) intervention was not effective at improving teacher or student well-being, or reducing mental health difficulties, possibly because of contextual barriers preventing it becoming embedded in school life.

Future work

Identification of ways in which to achieve system-level change and sustained support from senior leaders is important for future school-based mental health interventions.

Trial registration

Current Controlled Trials ISRCTN95909211.

Funding

This project was funded by the National Institute for Health Research Public Health Research programme and will be published in full in Public Health Research; Vol. 9, No. 12. See the NIHR Journals Library website for further project information. Intervention costs were met by Public Health Wales, Public Health England and Bristol City Council.

Social norms as a predictor of smoking uptake among youth: a systematic review, meta-analysis and meta-regression of prospective cohort studies

BACKGROUND AND AIMS

Social norms towards smoking are a key concept in tobacco control policy and research. However, the influence and strength of different types of social norms on youth smoking uptake is unclear. This study aimed to examine, quantify and compare evidence of the longitudinal associations between different types of social norms towards smoking and youth smoking uptake (initiation and escalation).

METHODS

Systematic review searching four databases (MEDLINE, EMBASE, PsycInfo, CINAHL) from January 1998 to October 2020. Evidence synthesis via narrative review, meta-analysis pooling unadjusted associations (initiation only, due to heterogeneity in escalation outcomes) and meta-regression comparing effect sizes by norm type and study characteristics. Studies included observational prospective cohort studies using survey methodology with youth aged ≤24 years. Measurements included longitudinal associations between descriptive norms (perceived smoking behaviour) and injunctive norms (perceived approval/disapproval of smoking) among social network(s) and subsequent smoking initiation or escalation.

RESULTS

Thirty articles were identified. In the narrative review, smoking initiation (but not escalation) was consistently predicted by two norms: parental and close friend smoking. Associations between smoking uptake and other descriptive norms (smoking among siblings, family/household, partner, peers, adults) and all injunctive norms (perceived approval of smoking among parents, siblings, close friends/peers, partner, teachers, people important to you, the public) were less consistent or inconclusive. In the meta-analysis pooling unadjusted associations, 17 articles were included (n = 27 767). Smoking initiation was predicted by the following descriptive norms: smoking among parents [Odds Ratio (OR) = 1.88, 95% Confidence Interval (CI) = 1.56-2.28], close friends (OR = 2.53, 95% CI = 1.99-3.23), siblings (OR = 2.44, 95% CI = 1.93-3.08), family/household (OR = 1.55, 95% CI = 1.36-1.76) and adults (OR = 1.34, 95% CI = 1.02-1.75), but not peers (OR = 1.14, 95% CI = 0.92-1.42). Smoking initiation was also predicted by two injunctive norms, perceived approval of smoking among parents (OR = 1.74, 95% CI = 1.27-2.38) and the public (OR = 4.57, 95% CI = 3.21-6.49), but not close friends/peers (OR = 2.36, 95% CI = 0.86-6.53) or people important to the individual (OR = 1.24, 95% CI = 0.98-1.58).

CONCLUSIONS

In this systematic review (narrative and meta-analysis), descriptive norms of parents' and close friends' smoking behaviour appeared to be consistent predictors of youth smoking initiation, more so than the descriptive norms of more distal social networks and injunctive norms.

Impact of a National Peer-Led Training Program to Increase Brief Physical Activity Advice Given to Patients by Health Care Professionals

BACKGROUND

The benefits of physical activity for preventing and managing long-term health conditions are well established and health care professionals could promote physical activity to patients. The current study aims to evaluate the impact of the Clinical Champions Physical Activity Training Program.

METHODS

Health care professionals attend a one-off in-person training session delivered by a trained Clinical Champion. Attendees at the Clinical Champions Physical Activity Training Program were asked to complete a baseline survey prior to the training session and follow-up surveys 4 and 12 weeks posttraining.

RESULTS

A total of 5945 training attendees completed the baseline survey. A total of 1859 and 754 participants completed 4- and 12-week follow-up (31.3% and 12.7% response rate, respectively). Significant increases in confidence to deliver brief physical activity advice and knowledge of physical activity guidelines were reported at 12 weeks (P < .001). The perceived frequency of physical activity discussions with patients significantly increased (P < .001). Twelve weeks after training, fewer barriers in promoting physical activity were reported.

CONCLUSIONS

The evaluation of the Clinical Champions Physical Activity Training Program demonstrated an increase in knowledge of physical activity guidelines, levels of confidence, and frequency of delivery of brief physical activity advice to patients. Further research is required to determine if this impact translates into changes to patients' physical activity behavior.

Peer network studies and interventions in adolescence

Peer influence occurs across a wide variety of behavioral domains, which is an important reason for peer-led interventions: interventions in which peers are involved in the delivery of the program. These programs are promising in combatting undesirable behaviors (e.g. risk behavior) and promoting desirable behavior (e.g. healthy lifestyle), but it was shown recently that the effectiveness of these programs is modest at best and the mechanisms underlying programs' effectiveness are poorly understood. Research is needed that promotes understanding of the relative, cumulative, and interactive impacts of different types of peer relations and unpacks the various mechanisms underlying peer selection and influence. This has the potential to yield insights that advance theory and optimize peer-led interventions.