Articol Review - Buda Adriana - Commitment and Compatibility Teachers' Perspectives On The Implementation of An Effective School-Based, Peer-Led Smoking Intervention

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Health Education Journal

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The online version of this article can be found at:
DOI: 10.1177/0017896908089387
2008 67: 74 Health Education Journal
Suzanne Audrey, Jo Holliday and Rona Campbell
effective school-based, peer-led smoking intervention
Commitment and compatibility: Teachers' perspectives on the implementation of an
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74 Health Education Journal 67(2) 2008 7490
Commitment and compatibility: Teachers
perspectives on the implementation of an
effective school-based, peer-led smoking
intervention
Suzanne Audrey
a
, Jo Holliday
b
and Rona Campbell
a
Abstract
Objective Although current UK policy argues that schools have a key
role in raising health standards, emphasis on the core curriculum
restricts teachers opportunities to undertake health promotion activ-
ities. The challenge is to design effective health promotion interventions
that minimize pressures on teaching staff and curriculum space. Here
we consider teachers perspectives of an effective peer-led, school-based
smoking intervention, implemented by external trainers.
Design The intervention, during which inuential Year 8 students iden-
tied through a whole-year peer nomination process were trained to
reduce smoking uptake through informal interactions with students in
their year group, was evaluated by a pragmatic randomized con trolled
trial (ASSIST: A Stop Smoking In Schools Trial). An integral process
evaluation examined the context, implementation and receipt of the
intervention.
Setting Thirty secondary schools in south-east Wales and the west of
England.
Health Education Journal copyright SAGE 2008 www.sagepublications.com
[DOI: 10.1177/0017896908089387]

a
Department of Social Medicine, University of Bristol, UK.
b
Cardiff Institute of Society Health and Ethics, School of Social Sciences, Cardiff
University, UK.
Correspondence to: Dr Suzanne Audrey, Research Associate, University of Bristol,
Department of Social Medicine, Canynge Hall, Whiteladies Road, Bristol BS8 2PR, UK.
Suzanne.Audrey@bristol.ac.uk
Commitment and compatibility
Health Education Journal 67(2) 2008 7490 75
Methods Teachers in all intervention schools completed questionnaires at
key stages of the intervention. Semi-structured interviews were under-
taken in four schools at baseline and immediately post-intervention.
The method of constant comparison, derived from grounded theory,
was used throughout the analysis.
Results The intervention was successfully implemented in a wide range
of schools; recruitment and retention rates were good; and outcome data
showed a reduction in smoking levels. Some teachers expressed concern
about the participation of challenging students, external trainers setting
standards of discipline, and communication over timetabling.
Conclusion Overall, teachers showed commitment to the ASSIST interven-
tion and felt it was compatible with the Year 8 curriculum. If implemented
more widely, the importance of peer nomination should be stressed.
Key words: adolescent smoking, health promotion, peer-led, schools, teacher perspectives
Introduction
Current UK policy documents advocate that schools have a key role in raising both the
educational and health standards of the nation
1
. However, in the school context, health
and education agendas are likely to be in competition
24
. Health education is included
in the curriculum as a cross curricular theme
5
but the pressurized school culture in
the UK, with its emphasis on core subjects and examination league tables, may restrict
the opportunity for teachers to engage in meaningful health promotion activities
with their students
6,7
. In relation to smoking prevention, there is an acknowledged
lack of rigorously evaluated studies and this has called into question the effectiveness
of school-based interventions
810
. Furthermore, while arguments in favour of health-
promoting schools may be convincing and attractive, schools are more likely to be
judged by the academic achievements of their students than by their ability to reduce
health problems
4
.
Nevertheless, the school environment is conducive to health promotion pro-
grammes aimed at young people because of the potential to access the target group
over several years. The challenge is to design and implement effective health promo-
tion interventions that minimize the pressures on teaching staff and curriculum space.
A number of factors have been identied as inuencing the successful implementation
of health promotion interventions in schools. These include: the schools capacity to
plan for and support the intervention; the degree to which the intervention is seen
as useful and relevant to the goals of the school; and the level of support from senior
management, classroom teachers and key contacts who may champion the interven-
tion within the school
6,1114
.
In relation to intervention design, peer education is heralded as a promising
approach but concerns have been raised that peer educators tend to be female high
S Audrey et al
achievers who volunteer, or are invited by teaching staff, to take on responsible roles in
the school and who are encouraged to adopt a didactic, classroom-based approach
1518
.
This model usually requires teacher supervision with allocated curriculum and class-
room space. It also raises questions about the ability of the peer educators to inu-
ence males, low achievers, and disaffected young people. ASSIST (A Stop Smoking
In Schools Trial) aimed to overcome these problems with an innovative school-based
intervention that combined peer education with diffusion of innovation theory
19,20
.
Inuential Year 8 students, nominated by their peers, were trained by external health
promotion trainers to reduce smoking uptake through informal conversations with
other students in their year group
21
. The intervention was rigorously evaluated through
a pragmatic cluster randomized controlled trial involving 10,730 students at baseline
in 59 secondary schools in south-east Wales and the west of England
22
. Thirty schools
were randomly assigned to receive the ASSIST intervention, and 29 were assigned to
the control group. The intervention
21
, study design
22
and perceptions of the young
people concerned
23
are described in detail elsewhere. In this article we focus on the
schools and teaching staff.
ASSIST activities in the schools
The stages of the ASSIST trial and intervention are summarized in Table 1. Data on
smoking behaviour and attitudes were collected from students in all schools at the
Year 8 baseline, immediately post-intervention, and when the students were in Years
9 and 10.
At baseline, Year 8 students were also asked to complete a peer nomination ques-
tionnaire to identify students in their year group whom they respected, looked up
to and regarded as good leaders. The nominations were tallied and a list of approxi-
mately 17.5 per cent of students with the highest scores was faxed to the schools. These
inuential students were invited to a recruitment meeting at which the role of a peer
supporter was outlined and discussed, and they were invited to undertake training.
Students who agreed, and had parental permission, to train as peer supporters were
taken out of school for a two-day training event run by a team of health promotion
trainers and youth workers. During the following 10 weeks, the peer supporters were
asked to intervene in informal situations and encourage other Year 8 students not to
smoke and to record their experiences in simple diaries. They were encouraged and
supported by ASSIST trainers at four school-based follow-up sessions. When the inter-
vention ended, the diaries were collected and the peer supporters were presented with
certicates and gift vouchers to acknowledge their efforts.
The responsibilities of participating schools
The responsibilities of participating schools were discussed in advance with a mem-
ber of the schools senior management team and a designated contact teacher. Schools
were asked to give access to Year 8 students in order to carry out the peer nomination
TABLE 1 Stages of ASSIST (A stop smoking in schools trial)
Outcome data collection Intervention activities
Baseline smoking behaviour Peer nomination Completion of questionnaire by all
questionnaire salivary Year 8 students to identify
cotinine sample [Year 8] influential peers. 17.5% of year
group with most nominations
invited to recruitment meeting.
Recruitment Recruitment meeting with nominees
to explain peer supporter role and
invite them to attend training.
Training Two-day out-of-school training
course.
Diffusion of smoke- 10-week period in which peer
free message supporters had conversations
with other Year 8 students about
smoking and kept a record in
their diary.
Support Four follow-up sessions in school
during 10-week period where
trainers provided
encouragement and advice.
Acknowledgement Presentation of certificates to all
peer supporters.
Presentation of gift vouchers
to peer supporters who
handed in their diary.
Post-intervention smoking
behaviour questionnaire
salivary cotinine sample
[Year 8]
One-year follow-up smoking
[Year 9]
Two-year follow-up smoking
[Year 10]
procedure; inform the selected students and arrange for them to attend the recruit-
ment meeting; provide a member of staff to accompany the students to the off-site
training event; arrange for the trained peer supporters to attend four school-based fol-
low-up sessions; and arrange for students to receive their certicates and gift vouch-
ers. The school contact was also responsible for liaison with teachers whose lessons
would be disrupted by the withdrawal of the selected students.
Additional tasks related to the outcome evaluation and included circulating
ASSIST information to school governors, teachers and parents; collecting parental
S Audrey et al
refusal forms and supplying lists of students taking part in the study, including details
of special educational needs; and organizing timetables and venues for the baseline,
post-intervention, Year 9 and Year 10 data collections. Further tasks related to the pro-
cess evaluation (see below).
Impact on smoking levels
Of those providing one-year follow-up data, 38.1 per cent were in the high-risk group
of occasional or experimental smokers at baseline. The proportion of these students
reporting weekly smoking at one-year follow-up was 18.2 per cent lower (p 0.045)
in intervention schools than control schools (Table 2), and this reduction in self-
reported smoking amongst the high-risk group was supported by analysis of salivary
cotinine
23,24
.
The promising results have led to plans for the broader implementation of the
ASSIST intervention in secondary schools in Wales and Bristol. It is important to remem-
ber that the intervention has been shown to be effective as implemented during the trial,
and that deviations from the original protocol should be avoided. Schools are more likely
to engage with the intervention, and deviations from the protocol are less likely to occur,
if the programme has the support of teachers and is compatible with the school context.
In this article, therefore, we consider teachers perspectives of the intervention.
Methods
The school sample
ASSIST information sheets were sent to 223 head-teachers of secondary schools
in south-east Wales and the west of England. Of these, 127 expressed an interest,
TABLE 2 Self-reported weekly smoking at one-year follow-up
Smoking status at Smoking prevalence at one-year
baseline follow up
Percentage Intervention Control
Self-reported smoking of students schools schools Relative
status (95% CI) (95% CI) reduction risk p-value*
High-risk group 38.1% 18.8% 23.0% 18.2% 0.045
(occasional/ (n 3483) (15.7, 22.4) (19.9, 26.6)
experimenters)
Never smoked 57.3% 2.4% 3.1% 24.2% 0.20
(n 5240) (1.7, 3.2) (2.3, 4.1)
Regular (weekly) 4.7% 74.9% 76.9% 2.6% 0.68
smokers (n 424) (68.5, 80.3) (70.5, 82.2)
* p-values from multivariable random effects logistic regression models adjusted for school-level
stratifying variables.
TABLE 3 Characteristics of schools in the ASSIST trial
Characteristic Intervention Control
State funded 28 28
Fee-paying 2 1
Comprehensive 28 28
Independent 2 1
Single sex 2 1
Denominational 2 1
Welsh medium 1 2
19% students with free school 14 12
meal entitlement
199 students in Year 8 13 14
considerably more than were required for the purposes of the study. A stratied ran-
dom sampling procedure was used
22
to ensure that a representative 59 schools were
nally recruited (Table 3).
Process evaluation
A detailed process evaluation was incorporated in the trial to examine the context,
implementation and receipt of the intervention. The design of the process evaluation
and the challenges of implementing process evaluation within the ASSIST randomized
controlled trial, are described in detail elsewhere
25
. Two researchers, one based in
Bristol and the other in Cardiff, were primarily responsible for collecting and analy-
sing process data. They were monitored and supported by a sub-group of the research
team.
To examine the teachers perceptions of the intervention, data were collected
from all intervention schools through self-complete questionnaires. In addition, semi-
structured interviews were conducted in four intervention schools purposively selected
on the basis of size (fewer or more than 200 students in Year 8), free school meal enti-
tlement (as a proxy for level of deprivation) and geographical location (England or
Wales). The key stages, data collection methods, and number of respondents are sum-
marized in Table 4.
Questionnaires were completed by the school contact, or by teachers who were
present at a given stage of the intervention. Open-ended questions and free text boxes
enabled teachers to use their own words when prompted about specic aspects of the
intervention, and to add any additional comments they considered to be relevant. Semi-
structured interviews were conducted at baseline and immediately post-intervention
with at least two members of staff, including a member of the senior management
team and the designated school contact, in four interventions schools that were purpos-
ively selected on the basis of size, level of deprivation and geographical location.
All interviews were taped and fully transcribed, and free text responses from
self-complete questionnaires were reproduced in full on summary sheets to facilitate
S Audrey et al
TABLE 4 Data sources to examine teachers perceptions of the ASSIST
intervention
Method and
Stage Source numbers Key information
Peer Teachers in 30 Self-complete Opinion of general
supporter intervention schools questionnaires arrangements at
recruitment involved in organizing (27 from 27 each stage.
the peer supporter schools) Compatibility of the
recruitment meeting Semi-structured intervention with the
Contact staff in four interviews school timetable,
intervention schools (a) baseline (8) curriculum, health
selected for in-depth (b) post- education, smoking
process evaluation intervention (10) policies. Impact on
students who were
Peer Teachers in 30 inter- Self-complete selected, or not selected,
supporter vention schools who questionnaires as peer supporters.
training accompanied students (31 from Attitudes towards peer
to the training event 25 schools) education in general,
Contact staff in four Post-intervention and ASSIST in
intervention schools semi-structured particular.
selected for in-depth interviews (10) Suitability of selected stu-
process evaluation dents to undertake role
of peer supporter.
Follow-up Contact staff in four Post-intervention Style and content of the
sessions intervention schools semi-structured intervention.
selected for in-depth interviews (10) Whether the training
process evaluation and support equipped
students to perform the
role of peer supporter.
Awareness of, and
opinions about, peer
supporters operating in
the school.
Characteristics of four intervention schools in which in-depth process evaluation
was undertaken
South-east Wales West of England
269 Year 8 students 232 Year 8 students
4.8% free school meal entitlement 21.8% free school meal entitlement
130 Year 8 students 159 Year 8 students
25.9% free school meal entitlement 6% free school meal entitlement
comparison. The data were examined using the framework method of data manage-
ment
26
. This involved repeated reading, coding and identifying themes, and sorting
and charting the material according to key issues. While it cannot be presumed that
interview data from four schools are representative of all schools participating in the
intervention, data from the self-complete questionnaires administered in all inter-
vention schools do support the more detailed views expressed by those teachers who
were interviewed. Quotations used in this article were chosen because they represent
common attitudes or illustrate the breadth of opinions. In reporting the data here,
respondents are distinguished by their position in the school, data collection method,
and anonymized school identier.
Results
Recruitment, retention and response rates
A number of challenges have been identied when undertaking research in schools,
including difculties in recruiting and retaining school participants
2729
and reluc-
tance amongst teachers to return questionnaires
30
. We begin, therefore, by considering
ASSIST recruitment, retention and response rates.
The high level of interest from schools approached to take part in the trial
has already been noted, with more than 50 per cent indicating that they wanted
to participate. Once recruited, no school withdrew from the intervention. Training
and follow-up sessions were successfully conducted in all intervention schools and
teachers responded well to requests to complete questionnaires at key stages of the
intervention, and to participate in interviews at selected schools. Recruitment and
retention rates of peer supporters were also high with 85 per cent (835 of 978) of
those originally nominated attending the training event and agreeing to continue in
the role. Peer supporter attendance at follow-up meetings did not fall below 86 per
cent, and 82 per cent of peer supporters handed in a diary
21
. These ndings suggest
that the schools were generally willing and able to accommodate the intervention.
The commitment to, and compatibility of, specic aspects of the intervention in the
school context will be considered next.
Commitment
The ASSIST intervention model was based on two important features: recruitment
of inuential students who were nominated by their peers, and implementation by
external trainers rather than school teaching staff. Here we consider teachers percep-
tions of these key features, illustrated by quotations in Figure 1.
Peer nomination The peer nomination process resulted in the inclusion
of some challenging young people in the list of potential peer supporters. Although
schools were encouraged to allow all nominated students to take part in the train-
ing, it was agreed that teachers could remove students from the list of nominees if
S Audrey et al
FIGURE 1 Teachers commitment to key elements of the ASSIST intervention
Perceived benefits Concerns
Peer I was really encouraged that there We ran with it because we just
nomination was a mix of streetwise, dominant wanted to see what it was like.
kids, some are bullies, some pupils But no, it wouldnt necessarily
are scared stiff of them. But you have been the list of kids I would
also have hardworking sensitive have come up with if I was
kids. There is a real mix. nominating a group for an activity
(Head of Year 8, baseline like that.
interview, school i2) (Guidance coordinator, post-
intervention interview, school i13)
The feedback that Ive had from
staff is that it was a very good I feel quite strongly that
cross-section. They thought it the children chosen tended
was very good. So you obvi- to be the naughtier ones I
ously, it is very, very important dont think they have listening
to get the leaders within each skills. I worry that their imma-
sort of little group within the turity and arrogance may have
year, if you see what I mean. been worsened by being
(Head of Year 8, baseline singled out as respected
interview, school i17) people in their year group.
Having said this, some of
People react in one or two ways them reacted well and will do
when a teacher is talking well as peer supporters.
about an issue. They will say (Teacher self-complete
I am not going to listen to this questionnaire, school i3)
or I have got to listen to this as
the teacher is saying it, rather I think you need to look at how
than I want to do this because you choose your peer
it is right. So on some of these supporters I think that
issues I think it is a very maybe some teacher interven -
positive move to have the peer tion, perhaps, they could say
group involved because they to you Oh, such person is a
are nearer to the situation and waste of space, you know, he
to the views of children around. wont stay the course.
(Acting head of religious (PHSE coordinator, post-
studies, post-intervention intervention interview,
interview, school i19) school i19)
Implemen- I was very impressed by the I do feel I was unsure how (and
tation by arrangements and found the whether) I was supposed to be
external programme was organized very involved. I would have liked
trainees effectively. The staff were very to have been informed about the
friendly and provided very good content beforehand. I think the
activities aimed at this age group. idea that I was not a teacher for
(Continued )
FIGURE 1 (Continued)
(Teacher self-complete the day, whilst being
questionnaire, school i6) important perhaps for trust, sent
mixed messages about respect
If they made a comment in the and authority.
lesson, I think a lot of them (Teacher self-complete
feel that the teacher would questionnaire, school i3)
judge them for being, Oh
well, all right then, I know I felt my role was unclear in imposing
that so-and-so and so-and-so ground rules and enforcing
smokes twenty a day or what- discipline. Hence they got
ever. I think to have an outside away with a lot more
agency was a good idea. than I would have tolerated
(Assistant guidance team in the classroom. But this
leader, post-intervention is the dilemma. They have
interview, school i13) volunteered to be peer
supporters and if they are
The value of your project was given a hard time, disciplined
that you were running it and during the training, the
you were organizing it, taking danger is that they will
the onus off us because there withdraw support.
are so many other things to cope (Teacher self-complete
with, new initiatives, you know. questionnaire, school i2)
(PHSE coordinator, post-
they had serious concerns. In some cases, teachers suggested that the young people
were not suitable to represent the school or that they did not deserve the privilege of
participating in the intervention because of a history of truancy or disruptive behav-
iour. Approximately 3 per cent (33 of 978) of nominated students were withdrawn
from the lists of nominees by teachers, but the majority of schools accepted the peer
nomination process as an important aspect of the intervention.
Some teachers indicated that, although they would have chosen a different
group of students to undertake peer-led health promotion, they were prepared to
allow nominated students to participate. Others had more serious concerns and sug-
gested that, given a free hand, they would have made signicant changes to the list
of nominees. Nevertheless, despite some misgivings, the majority of school contacts
recognized the importance of the peer nomination process and gave active support
to its implementation. This resulted in the recruitment of peer supporters who were
balanced in terms of gender and broadly representative of their peer group (Table 5).
Implementation by external trainers The ASSIST intervention was imple-
mented by a team of health promotion trainers and youth workers with a variety of
backgrounds and skills. Schools were asked to provide a teacher to accompany students
S Audrey et al
TABLE 5 Characteristics of ASSIST peer supporters (baseline)
Peer supporters
n 835
All Year 8 students in
intervention schools
n 5358
Gender Male 50%
Female 50%
Male 51%
Female 49%
Ethnicity White 90%
Minority ethnic group 8%
No response 3%
White 89%
Minority ethnic group 6%
No response 5%
Self-reported smoking Never 50%
High-risk 42%
Regular 5%
No response 4%
Never 54%
High-risk 37%
Regular 5%
No response 5%
Intentions at age 16 Stay on at school 49%
College or training 30%
Get a job 11%
Other/no response 14%
Stay on at school 45%
College or training 29%
Get a job 14%
Other/no response 17%
Note: Some students gave multiple responses for their intentions at age 16. Other totals exceeding
100% are due to rounding.
to the training event, but these teachers were asked to adopt a relatively passive role
unless serious disciplinary issues arose. Teacher self-complete questionnaires revealed
that the vast majority felt the training was well organized, interesting and appropriate
for their students. Some teachers indicated that they felt uncomfortable with their role,
particularly in relation to discipline, but their remarks also suggest that they understood
the rationale behind their perceived lack of authority in relation to the intervention.
Overall, teachers welcomed the fact that the training was delivered by exter-
nal trainers, suggesting that it created additional interest amongst the students and
acknowledging that students might experience difculties in discussing smoking
behaviour with teachers. Teachers also welcomed the use of outside trainers to relieve
the burden on teaching staff.
Compatibility
The quotations in Figure 2 illustrate that, although there were some concerns, the
intervention appeared to be broadly compatible with the ethos and timetable of partici-
pating schools. Student smoking was perceived to be a difcult issue and, because they
were unclear how to address the problem effectively, staff appeared to welcome the
opportunity to test a new initiative. Schools also appeared receptive to a peer educa-
tion model that would complement their attempts to promote condence and a sense
of responsibility in their students.
A degree of disruption to the school timetable was inevitable as students were
taken out of classes to participate in activities associated with the intervention and its
Smoking
education
We discuss and we sort of run out
of ideas really, when it comes
to the smokers on the field and
to what degree punishing them,
writing letters home, informing
parents. All that stuff is a bit, its
negative and not very effective.
So to have an approach which
is more thought out, and more
involving kids, involving pupils
being more active and spreading
the message, yeah, its good.
(Head of Year 8, post-intervention
interview, school i2)
I am hoping that we are going to
have a knock-on effect from it as
these children work through 9 and
10 and into 11. At the moment we
do have a smoking problem and
I think every school in the country
probably does, but I think it is
raising the childrens awareness.
(PHSE coordinator, baseline
I think that some [peer supporters]
are still apprehensive about
broaching the subject with their
peers but hopefully once they get
going they will be OK.
(Teacher self-complete
questionnaire, school i9)
Knowing one or two of the students,
I wonder if they will make full use
of the knowledge learned.
(Teacher self-complete
questionnaire, school i14)
Dealing with conflict may be an
issue for some. I fear some may go
in quite assertively. (Teacher self-
complete questionnaire, school i7)
FIGURE 2 Compatibility of ASSIST intervention with school ethos and
organization
Student
development
Its denitely the ethos of the school
to let pupils take responsibility for
themselves.
(Deputy head of year, baseline
Health education might be the
particular message but I think it
ts in to a much broader spectrum
about education in general,
about giving kids condence
with information to actually go
and talk to other people and put
forward a point of view.
(Guidance coordinator, baseline
We did have one or two problems
with some of them bucking the
system and truanting when they
were meant to be at the peer
support meetings.
(PHSE coordinator, post-
I mean theres issues about, but
theyre general school issues
anyway, about pupils missing
lessons. But in this particular
instance its not been a great
problem because Year 8 is not
necessarily seen as a crunch
year.
(Guidance coordinator, post-
(Continued )
S Audrey et al
Timetable
and
curriculum
I would say that the disruption has
been minimal because that is how
we tried to do it, that we werent
hitting every maths group, for
example, each time they came in
for their training.
(Head of PHSE, post-intervention
For this, as a year, its not so
onerous for them. As staff, Year
8, theres no pressure on it,
whereas with Year 9 weve got
SATs to aim for, weve got mock
SATs and so on, and obviously
into Year 10 and 11 youve got
GCSEs. So its the better year for
them to go for.
(Pastoral deputy head, baseline
To rearrange, perhaps if there was
a test on and they needed to be
seen, and so on and so forth,
does pose a problem for some
pupils It is making a comment
about life in school at the moment.
There seems to be one thing after
another, after another. Now
that has an effect on staff and it
certainly has an effect on pupils
too.
(Acting head of religious studies,
post-intervention interview, school
i19)
Some of its down to them [teachers]
not listening and not taking it on,
you know. It was discussed. We
explained it. We talked about
it at team meetings before we
embarked on it. I guess for some
people it was like one more thing
They just want to know where
they have to be, when and what,
and some of the ner detail of the
project has ltered out.
(Head of Year 8, post-intervention
FIGURE 2 (Continued)
evaluation. On a practical level this highlighted the importance of good communication
between the ASSIST team and designated school contacts, and between teachers within the
schools. In terms of the school curriculum, teaching staff prioritized the core subjects and
were acutely aware of the current emphasis on examinations and league tables. However,
it was suggested that Year 8 (when students are aged 12 to 13 years) was particularly suit-
able for an intervention of this kind because students were not embroiled in SATs (stand-
ard attainment tests) or GCSE (general certicate of secondary education examinations).
Discussion
In this article we have considered teachers perceptions of the ASSIST intervention in
which inuential Year 8 students were successfully trained to reduce smoking levels
amongst their peers. The favourable recruitment and retention rates suggest that
schools were interested in and able to accommodate the intervention. Furthermore,
the range of schools involved in the trial gives grounds for condence that the results
are generalizable to schools across the UK.
The promising results of the outcome evaluation have prompted plans for the
broader implementation of the ASSIST intervention in secondary schools in Wales
and Bristol. Evidence from the process evaluation suggests that, outside of the trial
context, it will be necessary to emphasize the importance of several core elements of
the intervention to maximize diffusion of the health promotion message. These are:
allowing students to identify inuential members of their year group; permitting the
nom inated students, even those who appear challenging or disaffected, to participate
in the intervention; and establishing standards of discipline that encourage the active
participation of a broad range of young people, whilst reassuring teaching staff that
the schools behavioural standards are not being undermined.
During the trial, tensions emerged in relation to organizing activities within the
school environment and in ensuring good communication between teachers over dis-
ruption to the normal teaching routine. In practice, both contact staff and classroom
teachers are unlikely to have differentiated between the intervention and its evaluation
when considering the degree of disruption involved. Outside of the trial context, which
would eliminate the need to arrange several outcome data collection sweeps across the
entire year group, the levels of disruption would be signicantly reduced. Furthermore,
teachers acknowledged that Year 8 was suitable for an intervention of this kind because
examinations were not imminent, and it complemented the broader curriculum by
encouraging a sense of responsibility and developing transferable skills such as team-
work and effective communication.
The ASSIST intervention has been rigorously evaluated as part of a pragmatic
randomized controlled trial and has been shown to reduce smoking uptake. Given
the lack of evidence for the effectiveness of other approaches, we believe it has much
to offer. We have identied some areas of tension but overall we believe the interven-
tion was acceptable to teaching staff and compatible with the school context. Schools
appeared willing to accommodate a degree of disruption and to show commitment
and enthusiasm in working with health promotion trainers to tackle smoking levels
amongst their students. Furthermore, the ASSIST model, with its emphasis on infor-
mal peer education outside of the classroom and the use of external trainers, reduces
the degree of competition for teacher time and curriculum space. As such, the model
offers an effective and practicable approach to smoking education and, perhaps, to
other school-based health promotion initiatives in the UK.
Acknowledgements
We would like to thank all the students and teachers who participated in ASSIST. We
are grateful to Professor Roisin Pill, Dr Fenella Starkey and several anonymous referees
for their valuable comments on earlier drafts. Dr Nina Parry-Langdon led the design
of the process evaluation. This trial was made possible by funding from the Medical
S Audrey et al
Research Council following a successful feasibility study headed by Professor Mick
Bloor
31
. Medical Research Council (grant number G9900538).
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