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Promising practice details

Positive Peers: capitalising on young people’s friendship groups, Tower Hamlets

Themes this local practice example relates to:

  • Youth
  • General resources

Priorities this local practice example relates to:

    Basic details

    Organisation submitting example

    London Borough of Tower Hamlets, Youth and Connexions Service, Peer Education Team

    Local authority/local area:

    Tower Hamlets

     

    The context and rationale

    Background details to your example

    Summary
    Positive Peers is a peer education project for schools. The project supports students in ‘distress’ (this can be categorised as young people suffering from anxiety, worry, fear etc) by establishing a network of Trained Peer Supporters who have been equipped with the necessary skills and knowledge to engage in discussion and provide structured support. The aim of the peer work intervention is to help young people to become more informed, engaged and make healthier and better choices. The programme encourages young people to be 'active stakeholders' in their immediate environment, as well as adding to their own personal development,

    Background
    When people are worried, they typically turn to their peers first, not professionals, for help. The rationale behind peer work is that peers are a more trusted and credible source of information, as they share similar experiences and are therefore better placed to provide relevant, meaningful, explicit and honest information.

    The project builds on the growing evidence base about the effectiveness of peer work. Many pupils want to be involved in helping and offering support to their peers (Sharp, Sellors and Cowie, 1994). It is thought that peer work programmes draw and build on the positive, supportive and altruistic aspects of young people’s peer culture and are a natural extension of young people’s willingness to act in cooperative and friendly towards each others, albeit of a more structured kind (Baginsky, 2004). Sharp and Cowie (1998) state that children and young people have a strong desire to help other young people they see in distress.

    The driver for taking this innovative approach was two-fold.
    1. Teenage pregnancy and Sexually Transmitted Infections (STIs): to reduce underage teenage conceptions and social exclusion experienced by teenage parents and their children. Within this strategy the government set a number of targets, including a 50% reduction in under 18 conceptions by 2010. This was within a broader strategy to improve sexual health and contribute to the national target to increase the participation of teenage parents in education, training and employment to 60% by 2010. Tower Hamlets signed up to a 55% reduction in under 18 conception rates by 2010, from a 1998 baseline. Teenage conception trends in Tower Hamlets were higher than those in England and have plateaued between 2007 – 2010 and efforts had to be intensified to ensure the local 55% reduction target.

    2. Smoking prevention: smoking is the largest single cause of preventable illness in the UK, but whilst adult smoking prevalence has been falling, smoking amongst teenagers has risen over the last decade. Much money, time and effort is spent on anti-smoking programmes in UK schools, yet there is no rigorous evidence to support the effectiveness of any of these programmes. The study ran from 2001 and the final report was published in the Lancet in 2008.
    Known as ASSIST, the intervention was funded by a grant of £1.5m from the Medical Research Council, Cardiff Institute of Society, Health and Ethics, and Department of Social Medicine at the University of Bristol. The project aims to test the effectiveness of the intervention using a pragmatic cluster randomised trial research design. Students were followed up for two years to see whether smoking prevalence in the intervention schools was lower than that in the schools which did not receive the training. In addition, the study involved a substantial component of process evaluation, as well as a health economics analysis to assess the gains of the intervention against the costs of achieving them. This is a licensed programme from Decipher ASSIST.

    References
    Baginsky, M. (2004). Peer support: Expectations and realities. Pastoral Care, 22 3–9.

    Sharp, S. and Cowie, H. (1998). Counselling and supporting children in distress. London: Sage Publications.

    Sharp, S., Sellors, A. and Cowie, H. (1994). Time to listen: setting up a peer counselling service to help tackle the problem of bullying in schools. Pastoral Care in Education, 12(2), 3-6.

     

    The practice

    Further details about the practice

    National Research Foundation (NRF) funding was sought by LBTH and NHS Tower Hamlets in 2007 in order to run a pilot of the ASSIST approach in 4 schools. Following initial favourable results, additional funding was obtained through mainstream commissioning budget to extend the project to all secondary schools in Tower Hamlets.

    The Youth Service leads on the project and chose the route of empowering young people to be ambassadors to their peers (Diffusion of Innovation Theory). In doing so, 700 Health Champions (Peer Supporters) were trained. The Health Champions are nominated by their peers as being influential and respected in the community and schools. The idea was that young people will respond to other young people better than they would do to adults, particularly around the issue of health and relationships.

    Relationships with schools were built through emails and phone calls to impart information about the programme and its effectiveness; this led to initial meetings and regular updates. The Head Teachers’ Bulletin (a weekly bulletin sent to all Head Teachers in the borough) was also useful to inform schools’ senior management teams about the new intervention. Meetings with a number of people were necessary in some schools and included school nurses, PSHE Coordinators, Heads of Years and Deputy Heads.
    • One objective is to train 18% of year 8 pupils as Peer Supporters. In a year with 200 students this would be 35 Peer Supporters. This is based on research which shows that at least 15% of the population needs to be reached for the intervention to be effective.
    • The peer supporters are selected based on their peer influence and popularity. A selection questionnaire is administered where each student can nominate up to five names for the three questions and the results are used to identify the most influential students. Negotiations with the school take place about whether there are any young people who should be excluded from being a peer supporter.
    • At the same time as the selection questionnaire, students are asked to complete a survey about their smoking/Sex and Relationship Education (SRE) knowledge and attitudes. This information is used to collect baseline data This will take in total about 15 - 20 minutes and is best undertaken in tutor groups. The questionnaire and survey is best conducted as closely as possible in exam-style conditions to ensure that the results are valid.
    • The selected Peer Supporters are invited to a briefing session, which is held in the school. This is an opportunity for them to find out more about the programme before committing to it.
    • The Peer Supporters receive two days of training in smoking prevention and peer support (communication) skills. The training is provided by skilled and trained staff from Tower Hamlets Council and Partners. The training days are during school days and are held off-site from the school. A coach is provided to transport the young people from the school to the venue and back again at the end of the day. Funding for a supply teacher is provided if necessary.
    • Following the training, the Peer Supporters speak to their friends about smoking prevention and its impacts (information which they have learnt on the training days) during their break times and other informal times in and out of school. Their progress is tracked during the 10 weeks following their two day training; this is achieved by keeping diaries to record the conversations that they have had. A group involving the Peer Education Team meets three times during the 10 weeks to reflect on progress.
    • Three months after the programme, and then one year later, the survey on smoking knowledge and attitudes is conducted again to measure the change since the previous surveys and the longer term impact.

    This particular peer work model works well because it puts students at the heart of decision-making because the process allows them to nominate their representatives. It has been the case that most teachers (given the choice) would probably choose ‘gifted and talented’ high achievers and/or generally well behaved students to take part in projects. However, that does not give a true or fair representation of the other students who make up the school’s student community. Young people on this programme have a direct input and impact on the whole range of students.

    More details on the two day training course
    The ASSIST training course is a non-residential, two-day course. Transport is provided for the students from school to the training venue and back on both days. This allows students to attend registration at the start of the day and students are returned to school by the end of the school day. Students are provided with breakfast, lunch and tea.

    The aim of the training course is to give peer supporters the knowledge, skills and confidence to discuss the risks of smoking in informal, non-confrontational and supportive environments, and in so doing to prevent smoking amongst their peers.

    The activities used in the training programme are divided into three broad categories of information giving, communication skills and personal development. The programme is devised as a student-centred experiential learning process. Discussion and debate is encouraged. Games and group dividing activities are interspersed throughout the programme to energise, calm or reward the students as appropriate. The day is packed with no less than 15 fun activities, and some notable activities are shown below:

    Day 1 – Facts and myths about smoking

    Personal shield
    - to develop self esteem and confidence
    - to encourage peer supporters and trainers to get to know each other
    - to reflect on ways peer supporters can use their existing skills in their new role.

    Ready, steady, cook
    - to illustrate the ingredients of a cigarette using a format that will attract the attention of the peer supporters
    - to discuss the poisonous nature of some of constituents of a cigarette.

    Why do people smoke?
    - to reflect on the different reasons people have for choosing to smoke
    - to reach an understanding of the reasons why giving up smoking may be difficult.

    Information islands
    - to find information that is interesting and important to Year 8 students
    - to encourage peer supporters to memorise a piece of information that will be useful in conversations
    - to collate a wide range of facts on the topic of smoking.

    Day 2 - Communication skills

    Skills of a peer supporter: Diamond 9
    - to reflective on the skills needed to be a successful peer supporter
    - to prioritise the skills they think are most important using a ranking system.

    Problem solving
    - to provide peer supporters with ways of coping in difficult situations that may arise in their roles as peer supporters
    - to build confidence in the peer supporters’ ability to deal with these situations.

    Values continuum
    - to explore attitudes and values about smoking among peer supporters.

    Influences on attitudes and values
    - to explore the idea that young people are exposed to a variety of influences in everyday life and that some of these influences may affect whether or not they take up smoking.

    Partners involved
    Tower Hamlets Public Health previously of NHS Tower Hamlets fund the programme
    10 voluntary sector organisations (Youth and Community Centres)
    20 Secondary schools
    Options Sexual Health Service



     

    Evidence and evaluation - making a difference to children, young people and families

    Evidencing your practice has made a difference to children, young people and families

    Measurement
    In order to maintain an independent evaluation and assess the impact of the programmes, a Luton based company with experience of delivering SRE interventions and research write-up was contracted to run a number of focus groups and report on the results.

    A SRE based group from Devon with a wide remit of health related work was also contracted to produce the pre- and post- questionnaire data analysis using SPSS ((statistical analysis package).

    The cohort size comprised:
    12 schools taking part in the ASSIST intervention (360 students trained as peer supporters)
    8 school taking part in the SRE in Schools intervention (200 students trained as Peer Supporters)
    8 youth organisations (100 young people trained as Peer Supporters).

    SRE: In three of the four categories (Relationships, Rights and Responsibilities, Condoms and Contraception, STls Knowledge) there has been a highly significant positive impact. Overall, this represents a very considerable achievement and, with positive shifts ranging from 5% to 12%, could make a significant contribution to improving the sexual health of young people in Tower Hamlets. All of the young people (peer supporters) spoke confidently about sex and relationships, as a result of the training, and enjoyed the activity-based programme. Knowledge and information gained in the training varied across the groups. Most seemed to know where they could go to access contraceptive services, for example. The independent report also identified a very strong case for continuing to use a peer-led intervention.

    Smoking: From the independent reports and analysis, it was concluded that the peer intervention has had a positive impact on a significantly large number of variables. The programme had a negative impact on a sufficiently small number of variables as to have had no deleterious effect… ‘we would conclude that this intervention is likely to have a positive effect on the uptake of smoking amongst young people, but would recommend a more systematic and balanced approach to gathering data for the purposes of evaluation.’

    The local picture
    A survey of Year 8 pupils (12-13 years old) in four Tower Hamlets secondary schools in 2008 found that 4% of pupils smoked cigarettes at the time of the survey, while 80% had never smoked a cigarette (1). A further survey in 2009 suggested regular smoking rates of 4% at the beginning of the academic year and 6% by the end of the year (2).

    White pupils are more likely to smoke than pupils of Black or Mixed ethnicity, and smoking is also more likely among pupils in receipt of free school meals, an indicator of low family income. Regular smoking is associated with other risk-taking behaviours such as drinking alcohol, drug use, truancy and exclusion from school.

    The ethnicity and gender characteristics of young smokers in Tower Hamlets are likely to differ from the national picture due to the nature of the Tower Hamlets population as reflected in adult smoking patterns. 27% of adults in Tower Hamlets currently smoke compared to 23% nationwide, but Bangladeshi men are much more likely to smoke (45%) whereas only a small proportion of Bangladeshi women smoke (5%) (3). 62% of young people in the 10-14 year old population are of Bangladeshi origin while 16% are defined as ‘white’.

    Research suggests that differences in influences and motivation for smoking in young people also relate to the cultural differences between the Bangladeshi community and that of white British people. Male smoking is a social norm in Bangladeshi culture (4). Also, among ‘third generation’ Bangladeshi girls, there appear to be some young women for whom smoking may be seen as a way to escape their cultural restrictions and fit in with ‘western’ culture.

    37% of Tower Hamlets adult smokers began smoking when they were under 16 years old. 6% of respondents aged 16-24 report they smoke a shisha and around one in five households have children who are exposed to smoke most days (21%) (5).

    Rates of illicit underage sales of tobacco products are higher in Tower Hamlets than the average for London. In 2009/10, 27.9% of attempted purchases resulted in a sale, compared to 15% for London as a whole.

    What we know from young people
    NHS Tower Hamlets commissioned research in 2008 in order to inform work to reduce uptake of smoking in young people (6). Six focus groups were conducted, 3 with young people, 1 with parents and young people, 1 with parents and 1 with teachers.

    Young people’s knowledge, attitudes and beliefs

    Smoking
    Young people acknowledge smoking is a problem for peers of their age and see the link between smoking and ill health. However they are more concerned with the social aspects and physical appearance. They associate smoking with:
    - Being ‘tough’ or ‘cool’ varying from intimidation and fear to admiration;
    - Exercising their right of choice; demonstrating autonomy/independence;
    - Facilitating social interaction – a social norm;
    - Appearing more adult; and
    - Look at parents, teachers and celebrity role models.

    Some see smoking as a way of coping – dealing with stress and girls, in particular, make references to reducing appetite for eating.

    Life stage – teenage transition through adolescence
    - Young people like to form their own views, not take on board those received from ‘authority'.
    - They start to move away from parents’ and teachers’ influence and place more importance on peer views and approval.
    - Their self-perception becomes one of maturity: ‘an adult’ not a ‘child’.
    - They seek fun, social benefits, enjoying attention and ‘cause’.
    - And become questioning, challenging, rebellious, and streetwise.
    - They live in ‘the now’ and have less concern for the distant future.

    Those excluded from social groups associated with smoking are crowded out of spaces such as parks and even street corners. Smoking is associated with a tough image that both boys and girls see as protective. Their main anxieties are about physical safety and those who smoke are seen as tough enough to be safe. Smoking, which is prohibited to younger children, is a symbol of teenage identity for some; it is easy to get hold of cigarettes - some stores sell them to children outright, but the main source is older teenagers.

    Evidence of making a difference
    Given the challenge of detecting statistically significant changes at the school level we sought to ensure that the delivery model of the programme remained true to that of the original. The programme has recently been very favourably quality assured by Decipher Impact. Analysis of pre- and post- ASSIST (peer led smoking prevention intervention) questionnaires in 7 participating schools and 1 control school suggests that the intervention has had a preventative effect on the adoption of pro-smoking attitudes and has led to a decrease in the amount of smoking that young people thought was going on around them. There was no significant increase in reported levels of smoking in the intervention schools compared to a significant increase in the control school. The analysis also suggested that the intervention made it more possible for pupils to hang on to their convictions that they could resist when offered cigarettes. In summary, the analysis suggests that the intervention is likely to have a positive effect on the uptake of smoking amongst young people (7).

    Any programme aiming to reduce smoking among young people can only be successful if it is part of a broader tobacco control policy and so there needs to be ongoing work to tackle the supply side issues. An example of this is the LBTH Trading Standards report which found that the rate of underage sales in the Borough has fallen from 38% in 2008/09 to 27.9% in 2009/10 indicating that the policy of advice and test purchasing/prosecution appears to be working. Targeted enforcement on shisha premises frequented by young people has seen the number of shisha premises reduce from 30 to 13.

    References

    1. Stopping young people starting smoking in Tower Hamlets (2008). Barkers Social Marketing report for NHS Tower Hamlets.
    2. Health Behaviour Group analysis of ASSIST questionnaires for NHS Tower Hamlets.
    3. Ipsos Mori Social Research Institute (2009). Tower Hamlets Health and Lifestyle Survey.
    4. Healthy Lifestyle Behaviours: Minority ethnic group estimates at sub-national level in England, 2004. Health and Social Care Information Centre, Lifestyles Statistics
    5. Ipsos Mori Social Research Institute (2009). Tower Hamlets Health and Lifestyle Survey.
    6. Stopping young people starting smoking in Tower Hamlets (2008). Barkers Social Marketing report for NHS Tower Hamlets.
    7. Health Behaviour Group analysis of ASSIST questionnaires for NHS Tower Hamlets.

     

    Sustaining and replicating your practice

    Helping others to replicate your practice

    Barriers and challenges

    Staffing: there is a need to recruit staff on an annual basis to keep with the demand of the programme and in meeting the challenge of retention. All staff are on a zero hour contract and thus maintaining a consistent level of working hours becomes difficult. Having a pool of staff and assigning ‘lead workers’ helps to mitigate against this.

    SRE: It was difficult to fine tune the SRE training manual so it would engage young people. We had to make it fun, interactive and educational. We overcame these issues by looking at several examples of SRE materials from across the country and compiled the best practice to create our manual. This exercise has been supported by the young people who were involved in the consultation and helped create the resources.

    It was acknowledged that the questionnaires exploring young people’s knowledge and attitudes about SRE were not sensitive enough and some questions needed to be better tailored to young respondents. To remedy this, the questions were rephrased so they were more user-friendly. Amendments were made after consulting with young people, schools teachers and parents.

    Smoking: It was initially difficult to get the peer advisors to complete diaries recording their conversation, whilst others forgot or lost their dairies. To counter the issues, each young person was given a £10 voucher on full completion of the programme and return of the diaries. Checks were made to ensure that the diaries were not filled in in one go and some level of authenticity was there.

    Schools were not always keen to let students and teachers out of school for two days. We were able to provide a grant to schools so that they could offset any staff cost i.e. supply teacher and use of the grant for supporting activities in school.

    Cost
    SRE Community: £1500 per organisation
    SRE Schools: £2000 per school
    Smoking prevention: £3000 per school

    The programme started off costing at least 40% more than the above figures. Over time we found more streamlined ways of working, negotiating with partners and generally making cost savings to be able to bring it down to a more reasonable price.

    Must do
    Build and strengthen relationships with schools: the programme works best when it builds on existing good relationships with schools. The Youth and Connexions service at Tower Hamlets was able to build on the positive reputation they have amongst senior school staff to establish buy-in and cooperation from schools. This can only be achieved by maintaining dialogue with schools and building relationships with key Youth, Community Workers or Teachers.

    A robust assessment tool: a key factor of the intervention was being able to quantify and capture data for a positive shift in attitude, skills and knowledge of the recipients. This was achieved by creating unique questionnaires dedicated to each of the programmes which are read by a computer to measure pre- and post-intervention data. This helps to analyse where there has been a high level of positive shift and where it has not been so effective.

    Independent evaluation/reporting: in order to build a strong case for the effectiveness of a peer education approach and provide an un-biased finding of the work, it was important to use independent specialists in the field of statistics to write the final report.

    Administration support: the programme requires co-ordination with a number of schools and youth clubs and it is essential that an officer can lead on administrative tasks such as room booking.

    Core leadership behaviours
    Eight core behaviours have been identified as part of successful elements of leadership (see National College for Leadership of Schools and Children’s Services/C4EO (2011). Resourceful leadership: how directors of children’s services improve outcomes for children. Full report. Nottingham: NCSL. The behaviours that apply to this example are shown below.

    1. The ability to create and sustain commitment across a system. Tower Hamlets Youth and Community Service firmly believes in the unified approach to the work we deliver. In doing so, motivation and strategic thinking are paramount. As a result aligning staff values towards a common goal ensures meaningful outcomes to innovative work.

    2. The ability to simplify. When working with young people we ensure that learning is not made overly complicated and so ideas are kept simple and message clear. Complex health debates need to be kept at strategic levels and engagement with customers to be effective.

    3. The ability to learn continuously. In providing a platform for continuous personal and professional development, Tower Hamlets Youth Service thrives on a motivated and knowledgeable staff team. Reflective Practice and a strong evaluation base are key to building efficiency.

    C4EO Golden Threads

    Culture not structure – learning together. The Youth Service is a keen advocate of building a strong culture in which young people are active stakeholders in the services they receive. As such, staff at every level ensures that young people are given a voice and decision making powers.

    Prove it – making change happen. Evaluation plays a significant part in all our peer education programmes. We ensure that is of a high quality and independently achieved. In doing so, we have a database which is able to track changes in categories of Knower, Skills and Attitude of our young people.

    From good to great – leadership, vision and embedding is key. Strong leadership and a clear vision are paramount in achieving outstanding results. The Youth Service has not only delivered its outcomes but also has set a model of good and innovative practice. Leadership is also key in helping projects to evolve rapidly and harness learning from others.

    Further information as detailed below is available from the C4EO team at the NFER

    A smoking prevention initiative in secondary schools (ASSIST). A peer led Intervention. Report 11/12.

    ASSIST - A Peer led Smoking Prevention training for Year 8 pupils in Tower Hamlets Secondary Schools. Final report 09/10.

    Draft report on key findings on the impact of a peer education programme promoting sexual health in community settings in Tower Hamlets: A qualitative study. Stephen Maynards Associates, 2009.

    Quality Assurance Feedback, Tower Hamlets, 24th and 25th April 2012.

    Report on Peer led SRE. Intervention in the community in Tower Hamlets (includes target and peer leader youth),2011.

    Report prepared by the Health Behaviour Group on the findings of the ASSIST questionnaire. Report 04/11.

    Sex and Relationship Education in Schools. A peer led intervention. Report 10/11.

    Teenage pregnancy: Factsheet. Tower Hamlets Joint Strategic Needs Assessment 2010-2011.

    Tobacco Use and Young People: Factsheet. Tower Hamlets Joint Strategic Needs Assessment 2010-2011.


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