A process evaluation of the implementation of ASSIST in Scotland

Chapter 5: Post-delivery of ASSIST

This chapter describes findings post-delivery of ASSIST, in particular the benefits of being a peer supporter; message diffusion; smoking status; and views on future application of the ASSIST model.

5.1 Message Diffusion and Impact

Delivery of ASSIST centres on peer-to-peer informal message diffusion, which expects students to have conversations with their peers to spread anti-smoking social norms. This section of the report examines perceptions on the extent to which this happened, based on the data available from the study.

Stakeholders, school leads, site co-ordinators and trainers were sceptical (some less so than others) about diffusion of key messages via informal conversations, which mainly centred on how many conversations actually took place. There were two explanations for this. First, the point was made that smoking in schools nowadays is not 'a big issue' so opportunities may be limited. This implies that peer supporters would only speak to smokers which is not the objective of ASSIST (smoking prevention by reinforcing smoking harm is also a key objective of the programme). They also acknowledged that just because they were not aware of informal conversations taking place this does not mean they are not happening.

"Just because they're not filling in the diaries, they might still be covering the conversations." (School lead 5, follow-up)

Second, there was a perception that peer supporters may be more likely to have conversations with parents or family members than their peers. Findings from peer supporters support this view with several mentioning that they had engaged in conversations with other people outside of their year group such as their parents or other family members, but not with their peers. Some peer supporters felt they had really made a difference to their families' health because it had resulted in them cutting down or trying to stop smoking altogether. While others reported being dismissed by parents who felt that they were already aware of the dangers of smoking.

The student survey indicated that conversation recall with peer supporters was low with 9% (n=145) of respondents answering yes, when asked if a peer supporter had spoken to them about smoking.

Why did so few conversations with peer supporters take place or were recalled? There are a number of potential explanations for this. First, smoking rates in Scotland are now so low in this age group overall, that young people may have not felt the topic was immediately relevant to them or their peers. Just 1.6% of pupils (n=33) reported that they smoked one or more cigarettes per week increasing slightly to 1.8% (n=38) at follow-up (see Table A3), and this is consistent with national surveys. If so very few young people are smoking, then it is understandable that few conversations on the topic were taking place. Even though ASSIST does not intend for conversations only to take place with smokers, this very low prevalence may well have affected when and with whom conversations took place.

A priority group for conversations are young people who are not already regular smokers, but are at risk of smoking uptake, particularly those who are experimenting with cigarettes or considering experimenting. We did not assess smoking susceptability but we did ask about experimenting with smoking. Only 12 of the 145 students who reported a conversation with a peer supporter had experimented with smoking (had tried smoking once or used to smoke sometimes but not now). Thus we do not have any evidence that the conversations that did take place were targeted at the most 'at risk' group.

Secondly, there may be methdological reasons for why so few conversations were recalled. The data collection mode was a self-complete survey, so there is a possibility that by the time they completed it, young people may simply not have remember conversation(s) with a peer supporter or may not have known that they had spoken with a peer supporter. Some weight is added to this argument when reviewing answers to a different survey question - 'How many conversations have you had with friends from school about smoking in the last week?' Between baseline and follow-up there was significant increase in the number of conversations (p<0001, see Table A4), with 18% reporting smoking conversations at baseline and 26% at follow-up. These data suggest that smoking conversations in general between students (albeit not necessarily facilitated by peer supporters) had increased over the intervention period.

When conversations with peer supporters who had received ASSIST training did happen, feedback from the student survey suggests that the majority took place face-to-face (87% n=125), and during school hours (63% n=94). Similar findings came from student focus groups with students reporting that most conversations took place in school. The main reason students communicated face-to-face (rather than by text or social media) was because it let them see facial expressions and body language and they would also find it hard to bring up facts about smoking via text or social media. Non-peer supporters were able to recall some of the conversations they had with peer supporters which included various facts:

"Like, I remember one person was saying like cigarettes are like as addictive as cocaine or something like that."

"And then there was like £17.50 to smoke like so many cigarettes in a week or something like that."

"Yeah and it's like every cigarette you smoke takes seven minutes off your life and stuff like that." (Student, school 5)

However, some students who were not selected to be a peer supporter mentioned that they had not been approached by a peer supporter because they were not part of that person's particular friendship group. These students also felt that the fact that the peer supporters had got out of school for two days was more important to them than actually talking about smoking because they had heard them boasting to their friends about going away for the training.

5.2 Benefits of being a Peer Supporter

School leads were very positive regarding the wider opportunities that becoming a peer support held for students, recognising that ASSIST was not just about smoking prevention. Comments centred on personal and transferable skills which would not only help them in school but also when they moved onto higher education or employment. Perceived skills included: improved self-confidence; self-esteem; self-worth; leadership; working as a team; communication; social skills and new friendships. There was also a view that taking part in ASSIST may encourage students to sign up for other activities within the school, especially the quieter students who do not normally put themselves forward. It was also noted that, particularly in first year, it helped create a greater level of cohesion as peer supporters got to know their peers a bit better. This was especially true in one school that had seen eight primary schools merge to form S1. Finally, there was a perception that peer supporters had acquired a considerable amount of knowledge about cigarettes, especially the tobacco industry, which will benefit not just them and the school, but also their family and communities.

"… they were speaking to folk in their clubs and their wee youth groups so I suppose you get a range of ages in there, so you did get that and as I say it was granny, grandads, mums and dads that were getting it you know, it was their family members so I dare say it was their big sisters and big brothers in there as well."

Q: "So the clubs and the youth group, was that within the school or was that out-with the school?"

"No that was outside, outside in the community." (School lead 3, follow up)

Similar views were held by peer supporters who stated that one of the benefits of being involved in the programme was that it allowed them to make friends and grow closer to other students who had attended the two day training course. Many also mentioned how the programme had helped to make them more confident when speaking to other people and improved their communication skills.

Some students believed that being a peer supporter might also be a useful thing to add to their CV. They were proud of their achievements and believed it was something which would be of great use to them in the future.

Stakeholders could also see the positive outcomes of ASSIST for peer supporters in terms of life skills e.g. personal and social skills.

"When you hear about it, that they [peer supporters] get something really positive out of it which must be worthwhile. So I think that is, and I am talking about self-esteem, self-confidence, those personal qualities that people are getting out of it I think is really worthwhile." (Stakeholder 11)

However, it was suggested that peer supporters would benefit further if their contribution was recognised by a national award, which could help them in the future to apply for jobs or further education opportunities.

"But I think a big part should be how it ties in with Saltire [youth volunteering initiative], what awards, and youth achievement awards, I think we could be better at that." (Stakeholder, 6)

5.3 Trainer Reflections on Implementation

As would be expected, trainer confidence to deliver ASSIST increased over the course of the pilot, with self-perceived scoring of their confidence increasing between baseline and follow-up.

"I think I would probably; I'd definitely be up [score for level of confidence] from before, because you are always a bit nervous about doing things for the first time. And now having done it twice I do feel a lot more confident." (Trainer, Site 2)

The perceived usefulness of the 'train the trainer' training during baseline interview was largely maintained at follow-up though some felt the training could be improved by providing additional instruction on how to conduct follow-up sessions and, depending upon the occupational background of the trainer, behaviour management and tobacco related knowledge.

Overall, trainers' experience and satisfaction with being involved in ASSIST appeared to vary according to the extent and nature of their role which was often linked to the way in which the programme was implemented in different sites. For example, trainers who were employed as part of a dedicated team and involved in all aspects of delivery, appeared to exhibit greater satisfaction with their role.

"If you were doing this on top of another [job], certainly if I only worked part time and I've got ten schools, you couldn't do it, but because we are specifically for the ASSIST project. I think that's one of the main reasons it's ran so smoothly for me, it's the focus of my work." (Trainer, Site 1)

In contrast, trainers who took on the role part time alongside other working commitments and/or were employed on short term fixed contracts with input into the programme limited to delivery only, appeared less satisfied with their involvement.

"My job is on a fixed term contract, so it runs from year to year. But everyone wants a permanent job, so when your fixed term contract comes up for renewal, which might not be renewed, then you are obviously going to be looking for other posts." (Trainer, Site 3)

5.4 Future Application of ASSIST Model

Participants reflected on the future direction of ASSIST in Scotland in two main ways - strategic (factors that will influence funding beyond the pilot) and operational (what do schools plan to do?).

5.4.1 Strategic Perspective

As would be expected, the key factor influencing future delivery of ASSIST beyond the pilot is funding. Stakeholders acknowledged the cost in delivering a licensed programme like ASSIST and the considerable challenges NHS Boards and Local Authorities will face to securing future funding for delivery. This was especially pertinent because ASSIST currently focuses solely on smoking and does not address other risk taking behaviours, with some commenting that in the current context of extremely low smoking prevalence rate in adolescents perhaps the programme is becoming less relevant?

"It's an expensive programme and you've got, it's got to address a need that is there, an identified need. Now if your need is not there, why would they spend that level on a programme particularly on one topic area? I don't think it is the best way forward. Especially targeting it at an age group where there is, you wouldn't identify that as a specific need. I think it would be better to look at something that is maybe more health improvement, a generic focused programme, and I think peer education is a brilliant way of working but to just focus it on tobacco I think is too narrow." (Stakeholder 11)

Linked to this were questions around the frequency of message diffusion, wider budget cuts and how this will effect ongoing partnership working to deliver ASSIST.

"I think there are interesting questions even if there is a commitment to fund at whatever level. Questions that other people have been raising, about prevalence rates being so low, so in practice, if the implications of that is the peer educators are struggling to have the conversations, I think that has to be looked at quite seriously…… And there is a real challenge in Local Authorities just now about CLD [Community Learning and Development] - seems to be getting decimated. Which for youth health promotion generally is a real serious concern, not just DECIPHer-ASSIST and tobacco. They have a long tradition of delivering work that is focussed on young people's health and well-being. The NHS doesn't have the skills, the capacity, the position, to deliver that work. So without CLD youth work sector to work in partnership with, I think that we will struggle." (Stakeholder, 7)

The counter argument against diverting funds away from ASSIST to other health promotion activities is associated with a need to maintain the current provision to prevent prevalence going up.

"I would take the other view which is actually you need to maintain the investment at that age which is a key transition from primary to secondary. In order to meet the target of reducing prevalence at 15 down to 2%, but really we need to also have the adult rate reduced to a significantly lower level to allow us to think that actually we could, an approach like ASSIST is no longer necessary." (Stakeholder, 1)

5.4.2 ASSIST Existing Evidence Base

The evidence base to support ASSIST is 13 years old. Stakeholders made reference to this and there was a strong view that the existing evidence base is now outdated and there is a clear need to not only update the existing RCT findings but also to follow schools and peer supporters longer term to see what impact (if any) ASSIST has had.

There were also contextual issues that were raised, most notably on e-cigarettes and vapourisers which have made clarification of current smoking prevention messages more complex. The existing RCT of ASSIST was conducted well before e-cigarette experimentation amongst adolescents was occurring.

"I think the other issue as well is that ASSIST, I mean it's been slightly updated but the whole kind of emergence of e-cigarettes and you can't, it doesn't deal with those, for good reason because they weren't part of the RCT, but they are the real - you know that has been a game changer in terms of people's behaviours, and I don't know going forward whether you would need to adapt a programme that actually took into account those things like e-cigarettes." (Stakeholder 10).

5.4.3 Operational Perspective

It was common for schools to report that they had received more than one cycle
of ASSIST and would be keen to receive more in the future, suggesting that the programme was viewed positively and imposed little burden on schools.

Schools leads could see potential to apply the ASSIST model to other types of health behaviour change such as alcohol or drugs, (with one school commenting that they had used the peer approach to tackle energy drinks) but wondered if the age range would need to change (i.e. older students). Comment was made around the potential for saturation - i.e. the reason it works so well is because it is new to the school and different. Using the same approach in a different area may dilute impact if students become disengaged. It should be clarified that school leads were asked this question to ascertain their views on the peer support model and theory underpinning ASSIST. For reasons discussed in the background chapter (i.e. ASSIST is an evidence based, licensed programme) there was no expectation that schools attempt to apply or adapt the model, as this would require further research and development. Peer supporters and students expressed doubts about the applicability of the ASSIST model to sexual health as they felt that would be too embarrassing for the students to talk about with each other.

Baseline interviews from school leads highlighted an interest in using the skills the peer supporters had been given through ASSIST, although the precise detail of what this may look like was lacking, which is to be expected because ASSIST had yet to be delivered in their schools. At follow-up it was perhaps still too early to assess what schools had done with the resources they had been given. School leads were still vague about what they would like to do or could do rather than describing explicit actions. There was a sense of a willingness not to let the opportunities from ASSIST 'fizzle out' but also an expectation of further input from the trainers to drive this forward. As illustrated below when the school lead was asked if the school had any plans to use the peer supporter in the future.

"Yes. How we would do that, I haven't really thought through. I don't know if there's going to be any more input from the actual ASSIST team about how we might follow on with it or not?"

"You don't know, do you, if ASSIST will do anything more specific with us?" (School lead 4, follow-up)

Suggestions included having something at the end of the ASSIST delivery period to raise the profile of ASSIST in the school. This included creating a game; video; drama or radio show; having a slot in the annual school health week; peer supporters contributing to the student council newsletter; or incorporating some of the ASSIST activities into PSE classes. Another suggestion was putting ASSIST schools in touch with one another so that they could learn from one another in regard to next steps i.e. how they could use the peer supporters in other areas or adapt the model in some way to tackle other health behaviour change or problems within the school (litter for example).

Students believed that the ASSIST model could be applied to other health behaviours such as drugs, alcohol and violence. It was also mentioned that it might be useful to spread anti-bullying messages. Most trainers were also very positive about the potential benefits of using ASSIST to tackle various other behaviours with sexual health education being a frequently mentioned, possible topic.