Health Education Research, Vol. 15, No. 5, 533-545,
October 2000
© 2000 Oxford University Press
Peer-led and adult-led school health education: a critical review of available comparative research
Department of Child Health, University of Exeter, Exeter EX2 5SQ, UK
 |
Abstract |
|---|
 Top Abstract IntroductionMethodsResultsDiscussionConclusionsReferences |
|---|
Peer-led health education in school is widely used. Advocates suggest it is an effective method based on the belief that information, particularly sensitive information, is more easily shared between people of a similar age. Critics suggest that this is a method not based on sound theory or evidence of effectiveness. This review evaluates school-based health education programmes which have set out to compare the effects of peers or adults delivering the same material. The identified studies indicated that peer leaders were at least as, or more, effective than adults. Although this suggests that peer-led programmes can be effective, methodological difficulties and analytical problems indicate that this is not an easy area to investigate, and research so far has not provided a definitive answer.
|
Introduction |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionConclusionsReferences |
|---|
This paper reviews published studies which compare peer-led with adult-led delivery of the same school-based health education programme under experimental conditions.
Peer-led health education has been advocated as a potentially effective method of providing health education in schools [e.g. (Health Education Authority, 1993
)]. The term `peer educators' generally refers to students delivering an educational programme who are of similar, or slightly older, age than the students receiving the programme. A rationale for using peer-educators relates to the social influences theoretical model, based on the theories of social learning (Bandura, 1976, 1986), social inoculation (McGuire, 1964) and social norms (Baric, 1977). These theories relate to the observation that `... friends seek advice from friends and are also influenced by the expectations, attitudes and behaviours of the groups to which they belong' (Lindsey, 1997).
Underlying this is a concept that peer influence may be stronger than that of adults such as teachers or `experts'.
As a technique in education it is not new, the `monitorial system' was used in the 1800s as a cheap method of giving information to pupils in English and French elementary schools (Hopkins, 1979). Peer-led education has been used extensively to meet a variety of educational objectives, such as tutoring of reading (Devin-Sheehan et al., 1976), and peers have been used in a wide variety of health-related initiatives (Vriend, 1969; Davis et al., 1977; Baldwin, 1978; McCue and Afifi, 1996). Peers have used many and diverse methods including presenting lectures/lessons, drama productions, supporting resource centres, operating hot-lines and one-to-one counselling (Lindsey, 1997). Peer-led education is not confined to school-age students, and projects have involved nurse tutoring (Costello, 1989) and even geriatric services (Weinrich et al., 1993).
Although peer-education may appear attractive it has `often been embraced with uncritical enthusiasm, and the problems and difficulties overlooked' (Health Education Authority, 1993). Currently there is a lack of good evaluation, particularly of outcomes (Milburn, 1995; Orme and Starkey, 1999), and peer education has been criticized as being dogma based on faith rather than sound principles (Frankham, 1998). Peer-led education may be exciting and novel, and requested by younger teenagers, but there needs to be evidence for effectiveness before this process can be recommended for standard health education: `health educators must carefully assess how to use peer educators to enhance their health promotion and disease prevention efforts' (Lindsey, 1997).
The logistics of training and programme delivery are considerable. Schools may not have convenient time when peer-leaders and students can be put together. Changes in the timetable such as additional assemblies, work experience and even fire-drill or fire alarms going off `inadvertently' all combine to prevent the full implementation of programmes since it may be impossible to rearrange sessions. Peer-leaders' exams, illness and occasional over-exuberant extracurricular activities add to the difficulties. Some peer-leaders may not attend the same school as the students and they may require transportation, this often means one of the adult support staff driving them between destinations.
In a school-based programme the content and style of peer-led sessions can be affected by factors outside their control. Peer-leaders may be selected and trained for specific tasks, but as with any individuals what happens in classroom sessions is less easily predicted (Frankham, 1998). Peer-leaders working in schools are working in a social environment with written and other ill-defined rules and regulations. If the peer-leaders are, or have recently been, students at the school this may complicate their roles further and teachers may find this difficult. Peer-leaders may assume a semi-expert position, having been trained in specific areas, while teachers may be more used to dealing with them as children. A peer-leader's history in the school and their own disciplinary past may affect how they are perceived (Phelps et al., 1994). Teachers passing classrooms where events may seem less controlled than normal lessons may intervene with unpredictable results.
This report has not reviewed `peer helping', co-facilitation or peer counselling. We have taken the term `peer-educators' to refer to students delivering an educational curriculum who are of similar, or slightly older, age than the students receiving the programme. Two previous reviews which examined the effect of substance abuse prevention interventions suggested that those led by peers had greater effects on attitudes and behaviour (Tobler, 1986; Bangert-Drowns, 1988). However, these reviews have included peer-led or adult-led interventions between studies conducted at different times, using different methods and with different ages of students. This study evaluates health education interventions which set out to compare effects of peer or adults delivering similar material within a single study during normal school time.
|
Methods |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionConclusionsReferences |
|---|
The electronic databases Medline (United States National Library of Medicine) from 1966 to 1999, ERIC (Educational Resources Information Centre) from 1981 to 1999, BIDS (Bath Information and Data Services) from 1981 to 1999 and PsycLit from 1967 to 1999 were searched. A systematic search was made of these databases including the terms `peer(s) or `same age' in combination with `trial(s) or experiment(s)' or `health (education)' and `school or college'.
The abstract texts from these results were examined for publications of studies involving health education or promotion. Further references were obtained from publications. Additionally, workers in this country involved in peer education were approached for information about published material.
Studies were included if they were carried out in normal school time, and provided comparisons of adult and peer delivery of similar health education programmes.
|
Results |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionConclusionsReferences |
|---|
Thirteen studies detailing comparative trials of peer-led and adult-led education in schools were found, 10 carried out in North America, one in Finland, one in Australia and one an international collaboration. Details of the studies are given in Table I.
|
Nine studies involved substance use prevention (mostly smoking), one alcohol education, one sexual health, one oral health and one testicular cancer. Two reports by Botvin et al. (Botvin et al., 1984
, 1990) were results from the same study published with data from immediate post-testing, and then with further intervention and data collection after 1 year. The reports by Murray et al. (Murray et al., 1987) and Luepker et al. (Luepker et al., 1982) represent the longer-term follow-up of earlier studies (Arkin et al., 1981; Murray et al., 1984). Shean et al. (Shean et al., 1994) carried out a 5-year follow-up of 37% of the original sample described by Armstrong et al. (Armstrong et al., 1990). All the trials included in the tables compared adult-led and peer-led interventions, some with additional controls receiving no intervention. Seven are described as randomized control trials.
No published trials or evaluations of effectiveness were found from studies carried out in British schools, although one publication gave preliminary details of a study in progress (Stephenson et al., 1998). A study described by Lester et al. (Lester et al., 1997) compared peer and adult instruction in resuscitation training, but has not been included in this review since this was not personal health education and peers provided instruction alongside adults who led the session. A further study by Kirby et al. (Kirby et al., 1997) evaluated peer-led and adult-led sex education in separate arms of a randomized control study. This study found no effect from either intervention. However, no comparative analysis was made between the interventions and the study has not been included in this review.
Knowledge and attitudes
Seven studies reported evaluations of knowledge gains and attitudes, either anti-substance or attitudes towards stopping use. There was only one study, relating to testicular cancer education, where the peer-led students gained less knowledge than the adult-led group. In the other studies peer-led students gained as much knowledge (Clarke et al., 1986; Perry et al., 1989) or more than the adult-led group (Jordheim, 1976; Botvin et al., 1984, 1990; Laiho et al., 1993). None of the studies reported that adults were more effective in altering attitudes, but three showed peers to be more effective (Botvin et al., 1984, 1990; Laiho et al., 1993).
Health-related behaviour
Table II summarizes the behavioural effects stratified by the level of evidence (Stevens et al., 1995). Table II includes only those trials which have demonstrated some behavioural effect, either of one or both types of intervention, when compared to each other or a control group.
|
Eleven studies reported behavioural comparisons between adult-led and peer-led interventions with seven finding peer led more effective than adult led. One study found adult led more effective than peer led in males but the difference was not sustained at longer follow-up. Four studies found no significant difference between interventions. All 11 studies compared both peer-led and adult-led interventions with controls, finding peers more effective than controls in nine (one in females only) and adults more effective than controls in four. One adult-led group reported a negative effect on alcohol use compared to controls (Botvin et al., 1990
); no other studies reported negative results significant at the 5% level.
The majority of these studies compared same-age peer leaders with adults (whose ages were not given). In one study using a `college' student, who was presumably older than the intervention students, a lower degree of knowledge gain was noted compared to the adult taught students. However, in two studies reporting behavioural effect (Botvin et al., 1984, 1990; Clarke et al., 1986) slightly older peers were as effective as the same-age peers in the remaining studies. Similarly there was no evidence of difference between studies using external adults or normal schools' teachers (see Table II
).
Quality of evidence
The published studies found in this review concentrated on the measurement of the outcomes of knowledge, attitudes and behaviour. Although a description of programme content is given (Table II), details are lacking about the comparability of the extent of training, style of programme delivery and adherence to planned structure for the sessions. It is therefore not possible from these publications to assess the effects in relation to the quality of the programmes themselves.
In common with many school health education programmes (Kirby, 1984), several of the interventions described difficulty in adhering to the original experimental design. In one study, one of the schools was permanently closed during the follow-up (Luepker et al., 1983), one of the control schools in the international alcohol education programme started teaching the active intervention and another school was closed by floods (Perry et al., 1989); in another study, Laiho states that one group of teachers forgot to administer some of the questionnaires (Laiho et al., 1993).
Data collection and outcome measures
All studies used questionnaires to evaluate outcomes. In three studies the questionnaires were administered by the research team or other outsiders (Johnson et al., 1986; Perry et al., 1989; Best et al., 1996), in one by teachers (Laiho et al., 1993) and in the remainder the data collection methods were not stated. In addition to questionnaires, in seven smoking prevention studies saliva samples were collected. In two experiments these were used to measure thiocyanate levels which may indicate recent smoking (Luepker et al., 1983; Clarke et al., 1986), although the results were given in only one (Luepker et al., 1983). In five experiments they were used as a `bogus pipeline' (Botvin et al., 1984; Johnson et al., 1986; Murray et al., 1987; Armstrong et al., 1990; Telch et al., 1990)—the aim of this method is to encourage accurate self-reporting by suggesting that analysis of saliva samples can be done to corroborate answers without actually performing the analysis (Askers et al., 1983).
Six of the studies gave numbers in each intervention type (Jordheim, 1976; Murray et al., 1987; Armstrong et al., 1990; Telch et al., 1990; Laiho et al., 1993; Prince, 1995), two gave numbers in groups of interventions (Clarke, 1986; Perry, 1989) and five gave only overall numbers in the study (Luepker et al., 1983; Botvin et al., 1984, 1990; Johnson et al., 1986; Best et al., 1996).
Analysis
All the studies presented results and analysis based on individual student's response to the intervention and were based on students present at times of evaluation (rather than an `intention to treat' analysis). The reported studies described several different methodologies for considering pre-test and post-test data. In one study on dental hygiene, knowledge and attitude pre-test values were not measured (Laiho et al., 1993) and in two where no difference in pre-test was found these scores were not included in outcome analysis (Jordheim, 1976; Best et al., 1996). In six studies, results at post-test were given for groups of students dependent on their pre-test scores on the target behaviour, e.g. non-smokers at pre-test (Luepker et al., 1983; Clarke et al., 1986; Armstrong et al., 1990; Johnson et al., 1990; Telch et al., 1990; Prince, 1995). In some of the studies pre-test results were markedly different across the groups. Clarke reported that pre-intervention smoking prevalence was 2% in the adult-led group and 13% in the peer-led group, and post-test results were presented for comparative reduction in smoking prevalence (Clarke et al., 1986). In three studies pre-intervention values were used as covariates in an analysis of variance, although it was not entirely clear whether the intervention pre-test values, and therefore matched schools, were different (Botvin et al., 1984, 1990; Perry et al., 1989). In the largest smoking prevention study (Murray et al., 1987) pre-intervention details were given and included in the analysis.
Attrition
In any study measuring pre- and post-intervention variables, missing individuals present problems, particularly when the follow-up time extends over several years. Johnson et al. (Johnson et al., 1986) noted an attrition of 65% at the end of the intervention, Luepker et al. (Luepker et al., 1983) around 50%, Best et al. (Best et al., 1996) 42%, Armstrong et al. (Armstrong et al., 1990) 36%, Telch et al. (Telch et al., 1990) 19%, and Botvin et al. (Botvin et al., 1990) noted 24% missing at the final assessment and greater attrition amongst certain groups, such as alcohol users, and Prince (Prince, 1995) reported that 17% did not complete the study. Three studies gave comparative numbers missing between interventions: Laiho et al. (Laiho et al., 1993) where due to non-collection of questionnaires 50% were missing in the control group; Murray et al. (Murray et al., 1987) where attrition was stated (ranging from 13.2 to 30.8%) and accounted for in the analysis; and Armstrong et al. (Armstrong et al., 1990) where attrition was very similar in all groups. The remaining studies did not mention attrition (Botvin et al., 1984; Clarke et al., 1986; Perry et al., 1989).
In addition, students are not always in school either for the intervention or the questionnaires, but only two studies mentioned non-attendance [Luepker et al. (Luepker et al., 1983) around 8% and Clarke et al. (Clarke et al., 1986) 1–5%], although Murray et al. (Murray et al., 1987) noted that 93% of students on roll completed the pre-intervention questionnaire.
Theoretical basis
Three of the studies were based on traditional information teaching methods (Jordheim, 1976; Laiho et al., 1993; Best et al., 1996). The remainder of the studies stated that the health education programmes were related to a social influences model. This applies to all the studies which measured health behaviour outcomes. These studies describe dealing with social pressures and developing counteractive techniques to combat pressure. Although details are given for some of the content, insufficient information was given to allow an assessment of the outcome in relation to the application of specific theoretical components.
|
Discussion |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionConclusionsReferences |
|---|
This review identified 13 experimental study comparisons of peer-led and adult-led health education programmes in schools. The results in Table II
indicate that in the majority of trials that reported any behavioural effects of the intervention, peer-led interventions were at least as, or more, effective than adult-led interventions. In the one randomized trial that reported fewer boys starting smoking in the adult-led group, these results were not sustained in multivariable analysis adjusting for factors such as family smoking levels (Armstrong et al., 1990) and not sustained in longer-term follow-up (Shean et al., 1994).
It is likely that trial publications are markedly biased towards studies with positive and significant outcomes (Dickersin, 1990). One additional study (Guthrie et al., 1996) has published methodology but results appear not to have been published. There were many (more than 50) educational interventions which have used peer-led components; however, only comparative studies were investigated for evidence of effectiveness. There have been other comparative investigations using peers and experts in, for example, clinic settings (Quirk et al., 1993). The absence of UK research publications may reflect a difference in approach to health education evaluation and the nature of the results collected. The emphasis is less on the need to evaluate the behavioural effects than to assess important educational aspects of health education in Britain (Rivers and Aggleton, 1993; Tones, 1996). The identification of two studies in progress, one our own, may indicate a change in attitudes toward school health education evaluation.
A fundamental question in assessing these reports is whether the studies are comparing equivalent procedures. Peer-led education was probably not the norm in any school, even in health education. Although these studies have evaluated new programmes in schools, the peer-led component is likely to be regarded as more `novel' and there may be more effort given to the accuracy of implementation. It is also not clear exactly how the programmes described relate to the theories included in a social influences model. The poor implementation of the adult-led comparative programme was raised (Botvin et al., 1984, 1990). The findings in some of the studies that students receiving the adult-led component were actually worse informed at post-intervention than pre-intervention (Jordheim, 1976) or had negative behavioural outcomes compared to controls with no intervention ( Botvin et al., 1990) questions the style and methods used by the adults. In the second study by Botvin et al. (Botvin et al., 1990), a `restricted sample' analysis of groups which had received a `high fidelity' adult-led intervention did have lower substance use than controls, and, although not analysed in the paper, there appears not to have been significant differences between this group and the peer-led group. It is possible that some adult-led health education relies too heavily on didactic teaching methods previously shown to have poor effects (Kirby, 1984; Rundall and Bruvold, 1988). Thus it may sometimes be the methodology rather than the deliverer of the programme which is being tested. It has been suggested that peer-leaders are easier to train than adult teachers because they `possess fewer preconceived notions' (Perry, 1989) and since they change from year to year their novelty is less likely to wear off. However, none of these programmes have evaluated either adult-led or peer-led interventions delivered over several years or as part of a service rather than research programme. Thus even if it is accepted that peer-educators are probably more effective than adults in achieving positive results, it is still unclear whether the results can be sustained.
Unit of analysis
The results presented in the reviewed publications are based on the individual results of students in schools. It has been argued that since the school and not the student is the unit of allocation in such interventions (Murray and Hannan, 1990), the school should be the unit of analysis. The reasoning is that `intact social groups such as schools often display measurable intraclass correlation across a variety of measures' (Rooney and Murray, 1996). Thus using the individual misleadingly increases the power of a study and increases the likelihood of type I error. Within the reviewed studies, four made reference to the unit of analysis: Murray et al. (Murray et al., 1987) commenting on the results suggested `they are not as valuable perhaps [as using the school as the unit of analysis] but they can provide additional evidence in support of particular interventions'. Perry et al. (Perry et al., 1989) found that using the school as the unit of analysis reduced the significance of all of the findings to above the 5% level. Botvin et al. (Botvin et al., 1990) suggested `there is no easy solution to this problem'. Armstrong et al. (Armstrong et al., 1990) discussed using the class as the unit of analysis, but decided against this considering that the mixing of classes over time would reduce the intra-class correlation, that using the individual would make the results more easily interpreted and that since the school identifier had been removed inadvertently from the data, this prevented such analysis.
To deal with the problem of the unit of analysis, various methods have been used to compensate for intra-class correlation. These methods are used to correct (inflate) the variance of the measured effects and reduce the overestimate of the population effect. Using this method in a meta-analysis of smoking prevention, Rooney and Murray (Rooney and Murray, 1996) found that the overall effects may be insufficient to suggest that these interventions have much health benefit and this has been confirmed in a prospective study of smoking prevention (Nutbeam et al., 1993).
Effect size
Although several of the studies reviewed have produced highly significant results in terms of probability values, it is not possible to determine from these data what would be the expected benefit in health gain from introducing a peer-led or adult-led health intervention into a specific population. Further studies or further examination of the data would be required before health gain could be quantified or an assessment of cost-effectiveness be determined.
|
Conclusions |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionConclusionsReferences |
|---|
The evidence from the studies reviewed suggests that peer-led education may be more effective, resulting in greater positive changes in health behaviour, than adult-led interventions, although the analytical and methodological problems of these studies indicate that the case is not entirely proven. The complexity of school-based studies and the requirement for very large sample sizes to address the problems of the unit of allocation make it difficult to implement or obtain funding to answer this specific question.
Peer-led education is not easy to establish and sustain. Providing teenagers with sufficient factual information to become experts in health-related problems is probably impractical and would take up too much of their own educational time. It may be more appropriate for the majority of this factual information to be delivered by adults, with peer-leaders concentrating more on the social factors related to health. It is not known how peer-led and more usual adult/teacher-led programmes can be used together effectively in school health education. This review has focussed only on peer-led and adult-led experimental comparisons using similar interventions. There are issues around the suitability of the material for use by both groups, e.g. ethical considerations about the use of material suitable for youth to youth that would be inappropriate for adult to youth. Although there are research problems, there is a need to determine the strengths and weaknesses of the approaches and the specific areas where peer-led health education is most effective and therefore should be targeted. Further information is also required on the application of specific health education theories and their effectiveness in deriving either peer-led or adult-led programmes. To determine relative effectiveness between peer and adult educators requires isolating the `educator' from the programme. Any new comparative research in this area should take into account the necessity of describing how peer-led and adult-led sessions differ in content and style, how programmes are introduced into schools, and the training given to those delivering the programme. There is also a need to determine whether an effective peer-led educational programme can be sustained outside of research programmes within the normal school curriculum structure. When these questions have been answered we will be able to assess whether the theoretical advantages of the use of peers in rendering health education more effective can be carried out in practice.
|
References |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionConclusionsReferences |
|---|
Arkin, R. M., Roemhild, H. F., Johnson, C. A., Luepker, R. V. and Murray, D. M. (1981) The Minnesota smoking prevention program. Journal of School Health, 51, 611–616.
Armstrong, B. K., de Klerk, N. H., Shean, R. E., Dunn, D. A. and Dolin, P. J. (1990) Influence of education and advertising on the uptake of smoking by children. Medical Journal of Australia, 152, 117–124.[Web of Science][Medline]
Askers, R. L., Massey, J., Clarke, W. and Lauer, R. M. (1983) Are self-reports of adolescent deviance valid? Biochemical measures, randomized responses, and the bogus pipeline in smoking behavior. Social Forces, 62, 234–251.
Baldwin, B. A. (1978) Moving from drugs to sex: new directions for youth-oriented peer counselling. Journal of American College Health Association, 27, 75–78.
Bandura, A. (1976) Social Learning Theory. Prentice-Hall, Englewood Cliffs, NJ.
Bandura, A. (1986) Social Foundations of Thought and Action. Prentice-Hall, Englewood Cliffs, NJ.
Bangert-Drowns, R. L. (1988) The effects of school-based substance abuse education—a meta analysis. Journal of Drug Education, 18, 243–265.[Web of Science][Medline]
Baric, L. (1977) Harrison A. Social pressure and health education. Journal of The Institute of Health Education, 15, 12–18.
Best, D. L., Davis, S. W., Vaz, R. M. and Kaiser, M. (1996) Testicular cancer education: a comparison of teaching methods. American Journal of Health Behavior, 20, 229–241.
Botvin, G. J., Baker, E., Filazzola, A. D. and Botvin, E. M. (1990) A cognitive-behavioral approach to substance abuse prevention: one-year follow-up. Addictive Behaviors, 15, 47–63.[Web of Science][Medline]
Botvin, G. J., Baker, E., Renick, N. L., Filazzola, A. D. and Botvin, E. M. (1984) A cognitive-behavioral approach to substance abuse prevention. Addictive Behaviors, 9, 137–147.[Web of Science][Medline]
Clarke, J. H., MacPherson, B., Holmes, D. R. and Jones, R. (1986) Reducing adolescent smoking: a comparison of peer-led, teacher-led, and expert interventions. Journal of School Health, 56, 102–106.
Costello, J. (1989) Learning from each other: peer teaching and learning in student nurse training. Nurse Education Today, 9, 203–206.[Medline]
Davis, A. K., Weener, J. M. and Shute, R. E. (1977) Positive peer influence: school-based prevention. Health Education, 8, 20–22.
Devin-Sheehan, L., Feldman, R. S. and Allen, V. L. (1976) Research on children tutoring children: a critical review. Review of Educational Research, 46, 355–385.
Dickersin, K. (1990) The existence of publication bias and risk factors for its occurrence. Journal of the American Medical Association, 263, 1385–1389.
Frankham, J. (1998) Peer education: the unauthorised version. British Educational Research Journal, 24, 179–192.
Guthrie, B. J., Wallace, J., Doerr, K., Janz, N., Schottenfield, D. and Selig, S. (1996) Girl talk: development of an intervention for prevention of HIV/AIDS and other sexually transmitted diseases in adolescent females. Public Health Nursing, 13, 318–330.[Web of Science][Medline]
Health Education Authority (1993) Peers in Partnership. Health Education Authority, London.
Hopkins, E. (1979) A Social History of the English Working Classes 1815–1945. Edward Arnold, London.
Johnson, C. A., Hansen, W. B., Collins, L. M. and Graham, J. W. (1986) High-school smoking prevention: results of a three-year longitudinal study. Journal of Behavioural Medicine, 9, 439–452.
Jordheim, A. (1976) A comparison study of peer teaching and traditional instruction in venereal disease education. Journal of the American College Health Association, 24, 286–289.[Web of Science][Medline]
Kirby, D., Korpi, M., Barth, R. P. and Cagampang, H. H. (1997) The impact of the Postponing Sexual Involvement curriculum among youths in California. Family Planning Perspectives, 29, 100–108.[Web of Science][Medline]
Kirby, D. (1984) Sexuality Education: An Evaluation of Programs and their Effects. Network Publications, Santa Cruz, CA.
Laiho, M., Honkala, E., Nyyssönen, V. and Milen, A. (1993) Three methods of oral health education in secondary schools. Scandinavian Journal of Dental Research, 101, 422–427.[Web of Science][Medline]
Lester, C., Donnelly, P. and Weston, C. (1997) Is peer tutoring beneficial in the context of school resuscitation training? Health Education Research, 12, 347–354.
Lindsey, B. J. (1997) Peer education: a view point and critique. Journal of the American College of Health, 45, 187–189.
Luepker, R. V., Johnson, C. A., Murray, D. M. and Pechacek, T. F. (1983) Prevention of cigarette smoking: three-year follow-up of an education program for youth. Journal of Behavioural Medicine, 6, 53–62.
McCue, M. and Afifi, L. A. (1996) Using peer helpers for tuberculosis prevention. Journal of the American College of Health, 44, 173–176.
McGuire, W. J. (1964) Inducing resistance to persuasion: some contemporary approaches. Advances in Experimental Social Psychology, 1, 191.
Mellanby, A. R. (1997) Peer-led sex education. MPH Dissertation, University of Wales.
Milburn, K. (1995) A critical review of peer education with young people with special reference to sexual health. Health Education Research, 10, 407–420.
Murray, D. M. and Hannan, P. J. (1990) Planning for the appropriate analysis in school-based drug-use prevention studies. Journal of Consulting and Clinical Psychology, 58, 458–468.[Web of Science][Medline]
Murray, D. M., Luepker, R. V, Johnson, C. A. and Mittelmark, M. B. (1984) The prevention of cigarette smoking in children: a comparison of four strategies. Journal of Applied and Social Psychology, 14, 274–288.
Murray, D. M., Richards, P. S., Luepker, R. V. and Johnson, C. A. (1987) The prevention of cigarette smoking in children: two- and three-year follow-up comparisons of four prevention strategies. Journal of Behavioral Medicine, 10, 595–611[Web of Science][Medline]
Murray, D. M., Davis-Hearn, M., Goldman, A. I., Pirie, P. and Luepker, R. V. (1988) Four- and five-year follow-up results from four seventh-grade smoking prevention strategies. Journal of Behavioral Medicine, 11, 395–405[Web of Science][Medline]
Nutbeam, D., Macaskill, P., Smith, C., Simpson, J. M. and Catford, J. (1993) Evaluation of two school smoking education programmes under normal classroom conditions. British Medical Journal, 306, 102–107.
Orme, J. and Starkey, F. (1999) Peer drug education: the way forward? Health Education, 1, 8–16.
Perry, C. (1989) Prevention of alcohol use and abuse in adolescence: teacher vs peer led intervention. Crisis, 10, 52–61.[Medline]
Perry, C. L., Grant, M., Ernberg, G., Florenxano, R. U., Langdon, M. C., Myeni, A. D., Waahlberg, R., Berg S., Andersson, K., Fisher, K. J., Blaze-Temple, D., Cross, D., Saunders, B., Jacobs, D. R. and Schmid, T. (1989) WHO collaborative study on alcohol education and young people: outcomes of a four-country pilot study. International Journal of the Addictions, 24, 1145–1171.[Web of Science][Medline]
Phelps, F. A., Mellanby, A. R., Crichton, N. J. and Tripp, J. H. (1994) Sex education: the effect of a peer programme on pupils (aged 13–14 years) and their peer leaders. Health Education Journal, 53, 127–139.
Prince, F. (1995) The relative effectiveness of a peer-led and adult-led smoking intervention program. Adolescence, 30, 187–194.[Web of Science][Medline]
Quirk, M. E., Godkin, M. A. and Schwenzfeir, E. (1993) Evaluation of two AIDS prevention interventions for inner-city adolescent and young adult women. American Journal of Preventive Medicine, 91, 21–26.
Rivers, K. and Aggleton, P. (1993) Participation and information—why young people need more than the `facts' in HIV and AIDS education. Hygie, 12(2), 22–5.
Rooney, B. L. and Murray, D. M. (1996) A meta-analysis of smoking prevention programs after adjustment for errors in the unit of analysis. Health Education Quarterly, 23, 48–64.[Web of Science][Medline]
Rundall, T. G. and Bruvold, W. H. (1988) A meta-analysis of school-based smoking and alcohol use prevention programs. Health Education Quarterly, 15, 317–334.[Web of Science][Medline]
Shean, R. E., de Klerk, N. H., Armstrong, B. K. and Walker, N. R. (1994) Seven year follow-up of a smoking-prevention program for children. Australian Journal of Public Health, 18, 205–208.[Web of Science][Medline]
Stephenson, J. M., Oakley, A., Charleston, S., Brodala, A., Fenton, K., Petruckevitch, A. and Johnson, A. M. (1998) Behavioural intervention trials for HIV/STD prevention in schools: are the feasible? Sexually Transmitted Infections, 74, 405–408.[Abstract]
Stevens, A., Colin-Jones, D. and Gabbay, J. (1995) `Quick and clean': authoritative health technology assessment for local health care contracting. Health Trends, 27, 37–42.[Medline]
Telch, M. J., Miller, L. M., Killen, J. D., Cooke, S. and Maccoby, N. (1990) Social influences approach to smoking prevention: the effects of videotape delivery with and without same-age peer leader participation. Addictive Behaviors, 15, 21–28.[Web of Science][Medline]
Tobler, N. S. (1986) Meta-analysis of 143 adolescent drug prevention programs: quantitative outcome results of program participants compared to control or comparison group. Journal of Drug Issues, 16, 537–567.[Web of Science]
Tones, K. (1996) The health promoting school: some reflections on evaluation. Health Education Research, 11, 1.
Vriend, T. J. (1969) High-performing inner-city adolescents assist low-performing peers in counselling groups. Personnel Guidance Journal, 48, 897–904.
Weinrich, S. P., Weinrich, M. C., Stromborg, M. F., Boyd, M. D. and Weiss, H. L. (1993) Using elderly educators to increase colorectal-cancer screening. Gerontologist, 33, 491–496.[Abstract]
Received on August 5, 1999; accepted on January 25, 2000
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  M.-L. Wong, R. K.-W. Chan, D. Koh, H.-H. Tan, F.-S. Lim, S. Emmanuel, and G. Bishop Premarital Sexual Intercourse Among Adolescents in an Asian Country: Multilevel Ecological Factors Pediatrics, July 1, 2009; 124(1): e44 - e52. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 T. A. Meyer and J. Gast The Effects of Peer Influence on Disordered Eating Behavior The Journal of School Nursing, February 1, 2008; 24(1): 36 - 42. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. Stock, C. Miranda, S. Evans, S. Plessis, J. Ridley, S. Yeh, and J.-P. Chanoine Healthy Buddies: A Novel, Peer-Led Health Promotion Program for the Prevention of Obesity and Eating Disorders in Children in Elementary School Pediatrics, October 1, 2007; 120(4): e1059 - e1068. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 D. Swart, S. Panday, S P. Reddy, E. Bergstrom, and H. de Vries Access point analysis: what do adolescents in South Africa say about tobacco control programmes? Health Educ. Res., July 1, 2006; 21(3): 393 - 406. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
H. de Vries, F. Dijk, J. Wetzels, A. Mudde, S. Kremers, C. Ariza, P. D. Vitoria, A. Fielder, K. Holm, K. Janssen, et al. The European Smoking prevention Framework Approach (ESFA): effects after 24 and 30 months Health Educ. Res., February 1, 2006; 21(1): 116 - 132. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. Hanewinkel and M. Asshauer Fifteen-month follow-up results of a school-based life-skills approach to smoking prevention Health Educ. Res., April 1, 2004; 19(2): 125 - 137. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
F. Caron, G. Godin, J. Otis, and L. D. Lambert Evaluation of a theoretically based AIDS/STD peer education program on postponing sexual intercourse and on condom use among adolescents attending high school Health Educ. Res., April 1, 2004; 19(2): 185 - 197. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S. Audrey, K. Cordall, L. Moore, D. Cohen, and R. Campbell The development and implementation of a peer-led intervention to prevent smoking among secondary school students using their established social networks Health Education Journal, January 1, 2004; 63(3): 266 - 284. [Abstract] [PDF]
|
|
|
|
|
|
H. de Vries, A. Mudde, S. Kremers, J. Wetzels, E. Uiters, C. Ariza, P. D. Vitoria, A. Fielder, K. Holm, K. Janssen, et al. The European Smoking Prevention Framework Approach (ESFA): short-term effects Health Educ. Res., December 1, 2003; 18(6): 649 - 663. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M K Hunt, P Fagan, R Lederman, A Stoddard, L Frazier, K Girod, and G Sorensen Feasibility of implementing intervention methods in an adolescent worksite tobacco control study Tob. Control, December 1, 2003; 12(90004): iv40 - 45. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
B. Jansson, C. Boldeman, H. Dal, and H. Ullen Skin cancer prevention in early childhood: An evaluation of a health education intervention among students in a preschool vocational programme Health Education Journal, January 1, 2003; 62(3): 198 - 209. [Abstract] [PDF]
|
|
|
|
|
|
A. R. Mellanby, R. G. Newcombe, J. Rees, and J. H. Tripp A comparative study of peer-led and adult-led school sex education Health Educ. Res., August 1, 2001; 16(4): 481 - 492. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||