Abstract
Peer-led intervention is one of the
beneficial approaches for preventing adolescents from health risk behavior. So,
peer-led intervention may help to prevent adolescents from smoking cigarettes
but impact of such intervention has not been studied well. Therefore, this
study was conducted to investigate the
effect of peer-led intervention to prevent adolescents from smoking behavior. Pub
MED, PschyINFO, EMBASE, Google scholar and Cochrane Library were searched from
march to June, 2016 with set criteria in review protocol and only randomized
control trials were included. Screening and data extraction were conducted and
data from eligible studies were pooled. Number of studies included after full
text review was three. Three eligible studies' data were extracted and further
analyzed for risk of bias in Revman 5. Three studies targeting smoking behavior
was pooled which represent 25,864 adolescents. Meta analysis revealed
that odd ratio of smoking were lower in those receiving peer-led
intervention compared to with not receiving peer-led intervention. Peer-led
intervention may be effective in prevention of cigarette smoking among adolescents
therefore it can play significant role in prevention of smoking behavior.
Keywords:
Peer-led, smoking, behavior, adolescents, intervention
Introduction
Smoking
is one of the major health risk behaviors in adolescents. According to the World
Health Organization (WHO, 2016) the prevalence
of tobacco use among adolescents aged 13-15 years is: 8.3% (female) and 18.2%(male)
globally, 7.2(female) and 21(male) in South East Asia, 13.8(female) and
17(male) in United States. At the same time, 80 percent of more than 1 billion
smokers worldwide live in low and middle income countries where the burden of
tobacco related illness and death is heaviest (WHO, 2016) .
Smoking is one of the leading causes of morbidity and mortality (US Department of Health and Human Services, 2014) . In adolescents, smoking
causes asthma and other respiratory diseases, and is well known as a risk
factor for lung cancer in later life (The Cancer Council, 2016) . Both the
government commitment and public awareness interventions have shown promise in
preventing smoking in adolescents worldwide.
Over 1.3 billion people, or 18% of
the world's population, are protected by comprehensive national smoke-free laws (WHO, 2016) .
Despite efforts in smoking prevention, smoking behavior in adolescents has been
increasing and it is considered as one of the major threats for adolescent
health. According to the WHO, in Nepal, the prevalence of tobacco use among
adolescents aged 13-15 years are; 5.3(female) and 13(male) was increased to
16.4(female) and 24.6(male) in 2011. Altogether 90 percent of smokers have started
smoking by the age of 18 and 99 percent have started by the age of 26 (US
department of health and human services, 2016). This indicates the importance
of smoking prevention programs or interventions during adolescence. Peers are
major social agents who influence the adolescents' behavior. They have similar
values, ages, status and behaviors, and can share information and teach each
other. So, peer-led interventions are considered as one of the major
intervention strategies to reduce the health risk behavior among adolescents
worldwide.
Peers have great influence on
positive and negative behavior of the adolescents. In peer-led interventions,
peer education is used to influence peers in a positive way to improve health risk
behavior(Raji, Abubakar, Oche, Kaoje, & Isah, 2014). Peer educators are generally
of similar or slightly older age than the students receiving educational
program(Mellanby, Newcombe, Rees, & Tripp, 2001). Peer educators are more
likely to influence peers because they are usually less judgmental and credible
to their peers and such intervention involving peers can access the hidden
populations (Ye, et al., 2014). In most
of the interventions, peer educators may act as a role model, innovator, and
educator to change the health risk behavior of adolescents and solve health
problems in partnership. The peer-led approach is quite popular in major health
interventions related to HIV and AIDS, family planning and drug prevention.
Peer education program in HIV prevention in low and middle income countries
demonstrated that some success in changing community attitudes and norms but
effects on other sexual behaviors and STI rates were equivocal (Tyndale &
Barnett, 2010) . Both
peer-led and adult-led interventions are generally have their own place in
effective sex education but the main challenge is which area should be dealt
with peer-led intervention to get maximum benefit. Peer-led education is less
effective in communicating factual information in one hand but in other hand it
is more effective in dealing with teenage relationship and setting conservative
norms(Mellanby et al., 2001). Peer-led interventions need
more time to train peer and need more effort to fix the venue for peer
education(Macarthur, Sean, Deborah, Matthew, & Rona, 2016).
There are a number of types of peer-led
interventions to prevent adolescents from smoking behavior. Each of these peer-led
interventions uses different theory and principles. So, in this context, it is
important to provide best possible evidences on peer-led interventions out of
many interventions applied in smoking prevention programs worldwide. In this
meta analysis, peer-led intervention means all the smoking prevention
interventions which involved peers to delivery of smoking prevention activities
directly or indirectly to adolescents.
Till date, most of the systematic
reviews were done on teacher-led school based programs and only very few
systematic review were conducted on peer-led interventions. Most of the
peer-led reviews were conducted to find the effect of peer-led interventions on
multiple risk behaviors including alcohol, drug besides smoking behavior. The main objective of this study is to assess
the effectiveness of peer-led interventions for preventing adolescents (aged
13-19) from smoking. So, the set hypothesis for this study was peer-led
interventions are more effective in preventing adolescents from smoking.
Methods
The protocol of systematic
review is prepared on the basis of question provided by the university. Then,
it was sent to university professor for approval. After getting on approval on
protocol from the university, review started. The primary objective of the
review was to identify and review the effect of peer-led intervention in
preventing adolescents aged 10-19 years from smoking behavior. This age group
was chosen based on the WHO definition of adolescents and because many young
people start smoking behavior below the age of 20.
Criteria for Considering Studies
The review included only randomized control trials (RCTs). Only articles
published after 2005 were included. Moreover, papers published in non-English
language and grey literature were also excluded. Only published journal papers
were included in the study. The studies were considered on the basis of
population, intervention, comparison, outcomes and context(PICOC).
Population(P). All the studies that included young people aged between 10-19 who were
currently studying in school/college were included but out of school or college
adolescents were not included in this meta analysis.
Intervention(I).
Peer-led intervention means all the smoking prevention interventions which
involved peers in the delivery of smoking prevention activities directly or
indirectly to adolescents.
Comparison(C)
: The studies assessed the effectiveness of the interventions on the basis of
comparison between intervention and control group. The comparison was done on
the basis of program intervention such as peer-led discussion and interaction
program after peer-led intervention such as peer-led video show, lecture,
poster, pamphlets, advocacy. Interventions with less than 6 months follow up period
were excluded in selection process.
Outcomes(O).
The primary outcome was smoking prevalence, which was measured as the number of
new smokers and/or number of quitters. Only studies that had at least 6 months
follow up period were considered.
Context(C). Study included only peer-led interventions and
it excluded multi-component interventions where one of the components was
peer-led intervention.
Search Methods for Identification of Studies
A systematic literature search was
performed to identify published randomized control trials(RCTs). Keywords and
synonyms were identified through Google scholar and Pub Med limited search. The
keywords and synonyms identified were used in extensive literature search in
respective database. The basic search was done with major key words
"adolescent", "Peer*", "smoking","
tobacco", "prevent*", “intervention".
The search was done systematically by
using four electronic databases namely "Pub Med", "PsycINFO
","EMBASE" and "Cochrane library". Furthermore, search
was also carried out through search engine "Google scholar". Boolean
operators were used during searching process. Search process was presented in
PRISMA's recommended flow chart (Stovold, Beecher, Foxiee, & Noel-Storr, 2014) . Duplicates were
removed from total identified articles from above mentioned database and search
engine step by step.
Identified titles were reviewed and
relevant articles were selected for further screening or abstract review.
Screening of abstract was done based on predefined inclusion and exclusion
criteria. After reviewing abstract, full articles from relevant studies were
retrieved. Critical appraisal of full text articles was carried out among the
selected articles in abstract review. Reasons for exclusion of full text articles
were presented in flow chart in each step. Articles which met the inclusion
criteria were retained for full analysis. The reference lists of selected
articles further were searched for more relevant articles. Any confusion while
selecting articles was resolved by discussion with study mentor of this meta
analysis.
Figure 1
Preferred Reporting Items for Systematic
Reviews PRISMA
Flow diagram
|
Record
identified through database searching (n=4036):
Cochrane
library (n=69)
Pub
Med(n=39)
PschyINFO(n=566)
EMBASE(n=412)
Google
Scholar(n=2950)
|
|
Result
after title screening
n=618
|
|
Result
after abstract screening
n=577
|
|
Result
after duplicate and non English
screening for full text review
n=13
|
|
Full
text article excluded (n=6)
1.
Only protocol available(n=1)
2.
Study under same sample (n=2)
3.Not
specific and data was not enough for systematic review(n=1)
4.
Contents was not specific to peer-led intervention(n=1)
5.
Content was more specific to cost effectiveness (n=1)
|
|
Studies
included in quantitative analysis
n=6
|
|
Studies
selected in quantitative analysis
n=3
|
|
2 studies selected for meta analysis (Lotrean et al., 2010)
&(Campbell et al., 2008)
|
|
Three multi -components studies were
removed
|
|
Study which used "linear rate of
change" removed after communication with researchers who were unable
to give primary data i.e. number or percentage of new smoker in control and
experimental group (Perry et al., 2009)
|
Data were extracted by using Review
Manager 5.3(RevMan) for each included study. Data were extracted for all
included studies on study design, age of participants, gender of participants,
intervention duration and follow up, brief overview of peer-led intervention
and details of control group as in table 1. Data were extracted for never
smoker. Both base line and follow up data were collected for both intervention
and control groups. Confusion were solved by discussion with study mentor.
Table 1
Table
of included studies
Studies at step II of selection process
|
|||
Author
|
(Lotrean et al., 2010)
|
(Campbell et al., 2008)
|
(Perry et al., 2009)
|
Location
|
Romania
|
United
Kingdom & Wales
|
India
|
Sample
size
|
1071
students
|
10730
students
|
14063
|
Age
of participants
|
13-14
|
12-13
|
6th
and 8th graders
|
Behavior
|
Smoking
|
Smoking
|
Tobacco
smoking & chewing
|
Setting
|
school
|
School
|
School
|
Interventions
|
School
based smoking prevention program with video and peer-led discussion
|
A
stop smoking in school trial program, peer supporters during informal
interaction outside classroom encourage their
peers not to smoke
|
Peer-led
classroom activities along with Peer-led activism, poster hanging and post
cards to parents
|
Theoretical
model
Intervention
modality
Peer
selection modality
Research
design
Duration
of intervention
Follow
up
|
Social
cognitive theory, Integrated model of change, social influence approach
5weekly
video sessions of 45 minutes each. The program consist of theme introduction
in class on video, activities, peer-led small groups discussion, home
activities
Selection
procedure for peer leaders was not mentioned clearly but teacher coordinated
the lessons, assisted peer leaders and stimulate the students to participate.
Both teachers and peer leaders have one hour information session before the
beginning of the activities on content and characteristics of the program
Non-equivalent
control group pretest-posttest quasi-experimental research design
5
weeks
9
months
|
Diffusion
of innovation
10
week intervention during which peer supporters undertook informal
conversation about smoking with their peers when travelling to and from
school, in breaks, at lunch time and after school in their free time and logged the
conversation in diary
Recruitment
meeting held with peer nominees to explain the role of peer supporter,
question answer and obtain agreement
to attend the training course. Two days training course held out of
school, facilitated by team of external trainer which aimed to provide short
term risk to young people of smoking behavior
Equivalent
time sample quasi-experimental research design
10
weeks
1,2
& 3 years period
|
Social
cognitive theory
7
peer-led classroom activities as the main intervention for 6th and 8th
graders. Besides this peer led activism outside classroom and posters were
hung and post cards were sent to parents
No
clear pear leader selection procedure mentioned. Sets of manuals were
provided to teachers and peer leaders
Equivalent
time sample quasi experimental research design
Approximately
4 months of each school year
1and
2 year period
|
Findings
|
A
post test results indicated weekly smoking on set was 4.5 percent in
experimental group verses 9.5 percent in control group. More than double new smoker
in control group than in experimental group
|
The
odds ratio of being a smoker in intervention compared with control school was
0.75(95% CI, 0.55-1.01) immediately after intervention(n=9349 students),
0.77(0.59-0.99) at one year follow up(n=9147 students) and 0.85(0.72-1.01) at
two year follow up(n= 8756 students)
Intervention
was fruitful in reducing smoking
prevalence in adolescents
|
Cigarette
smoking linear rate of change was 1.37(95% CI, 0.72-2.02) in control group
and 0.46(95% CI, -0.19-1.11) in intervention group
More
students in control group smoked cigarette &bidis than students in the intervention group
|
Results
Figure
1 shows the total number of studies identified, screened and reviewed. It shows
the reason of exclusion of each excluded study after review of full articles. A
total of 4036 articles were identified by database search and through Google
scholar. The total number of articles after title screening was 618 which further screened by abstract
review. Altogether 577 articles were identified for abstract review. After
removal of duplicate and non English articles
in abstract review process the total of 34 articles were selected. From
34 articles, finally 12 articles were selected for full text review. Six
articles were selected after full text review of 12 articles. At this stage
articles were excluded mainly due to the following reasons: Only protocol available,
study were conducted in same sample, not enough data was available for
systematic review, contents was not specific to peer-led interventions and
contents was more specific to cost effectiveness. After further full review of
six articles, three multi component studies were excluded. Finally, three
studies were selected for quantitative analysis. Out of three articles two
studies used the number of smokers as measurement units but one study used
linear rate of change to calculate intervention effect. Authors of this
articles were contacted for primary data to calculate odd ratio. Authors were
unable to provide primary data of this study. Finally, two studies were
selected for meta analysis.
Table 1 summarizes the
characteristics of the included studies. Selected three studies were conducted
in Romania, UK & Wales and India. Out of three studies the first study
included adolescents aged between 13-14, while second study included student aged
between 12-13 and third study included students from grade 6 and 8 without mentioning their
age. All included studies were targeted to tobacco smoking. Included studies
were school based intervention which didn't cover out of school adolescents.
All the studies were heterogeneous in nature where duration of intervention
varied from one year to three years. Follow up period for all three studies
were nine months to three years. Meta analysis of the studies’ outcomes from nine
months to twelve months was conducted.
A post test results indicated weekly smoking
on set was 4.5 in experimental group verses 9.5 percent in control group in
first study. More than double new smoker in control group than in experimental
group. The first included study showed that
more than double new smoker in control group than in experimental group(Lotrean et al., 2010).
In second study, the odd ratio of
being a smoker in intervention compared with control school was 0.75(95% CI,
0.55-1.01) immediately after intervention (n=9349 students), 0.77(0.59-0.99) at
one year follow up(n=9147 students) and 0.85(0.72-1.01) at two year follow
up(n= 8756 students). Therefore, the study showed that intervention was
fruitful in reducing smoking prevalence in adolescents in experiment group (Campbell et al., 2008).
In third study, Cigarette smoking
linear rate of change was 1.37(95% CI, 0.72-2.02) in control group and 0.46 (95%
CI, -0.19-1.11) in intervention group More students in control group smoked
cigarette & bidis than students
in the intervention group. The study showed that more students in control group
smoked cigarette and bidis than
students in intervention group(Perry et al., 2009).
Forest Plot
showing results for effectiveness of smoking prevention program in experimental
and control group
Figure
3 shows the effectiveness of peer led interventions by showing number of new
smokers in follow up period in experimental and control group. Data were pooled
for two main studies. In first study AR1(Lotrean et al., 2010)number of new
smokers is higher in control group than experimental group with odd ratio
0.46(0.28,0.76) at 95% CI in fixed effect model. Similarly, in second study AR2(Campbell et al., 2008) number of new
smokers is lower in experimental group with odds ratio 0.84(0.73,0.97) at 95%
CI in fixed effect model. Though the sample size of the AR1 was small, the
study demonstrates a significant effect favoring the intervention, which is
greater than for AR2. The diamond of the forest plot shows that, overall, peer
led intervention is an effective approach in smoking prevention for adolescents.
The total effect shows odd ratio of 0.80(0.70-0.92) at 95% CI. As the overall
odds ratio is less than 1, this indicates that such an intervention is
effective in preventing adolescents to initiate smoking. Among the two studies,
, I2=81%, chi2=5.20 df=1(p=0.02) which shows high statistical heterogeneity.
Discussion
Critical Appraisal
Risk
of bias was assessed using the Cochrane tool (Higgins & Greens, 2011) . Cochrane tool was
used to check the low, high and unclear risk of bias. The major risk of bias
considered in the reviews were selection bias(Random sequence generation and
allocation concealment), performance bias(blinding of participants and
personnel), detection bias(blinding of outcome assessment), attrition
bias(Incomplete outcome data), reporting bias(selective reporting) and other
biases. Risk of bias analysis was done for three studies namely study 1 (Lotrean, Dijk, Mesters, Ionut, & De Vries, 2010), Study 2(Campbell et al., 2008) and study 3 (Perry, Stigler, Arora, & Reddy, 2009) shown in figure
2.
Figure 2
Review author judgments about each risk of
bias item presented as percentages across all included studies.
Selection Bias
Random sequence generation. Altogether 10 schools randomly
assigned and by tossing coins, the two groups randomly assigned as experimental
and control group so there is low risk of selection bias due to random sequence
generation in study 1(Lotrean et al., 2010).
Study 2(Campbell et al., 2008) also showed low risk of selection bias as in this study stratified
block randomization was done.
Study 3 (Perry, Stigler, Arora, & Reddy, 2009) showed unclear random
sequence generation process but it highlighted about group randomized
trial." As a means of ensuring representativeness, schools within each
city were matched according to type of school and then randomly assigned to
receive the tobacco use intervention program". The article did not mention
the clear procedure of randomization.
Allocation
concealment. In study 1 (Lotrean et al., 2010),
participants and Investigators could not foresee the assignment because all the
names were kept in box and the investigator took the number by lottery and two
created groups were named control and experiment group by tossing coin so there
is low risk of selection bias due to allocation concealment. Actual blinding
was not possible in this study. The study 2(Campbell et al., 2008) stated that the schools were
allocated using randomly ordered list of schools for each stratum. It had low
risk of selection bias due allocation concealment. For conceal allocation,
another investigator was at different location and was unaware of school was
next to randomize and random number generator was used to establish the group
allocation of next school, which communicate to first investigator by
telephone. in study 3(Perry et al., 2009) stated that " Student response by the
use of unique identification tag that was not recognizable to students or
school staff over time so allocation concealment was probably done and
therefore had low risk of selection bias.
Performance Bias
If the participants were asked their
view whether they stop smoking in future, many of them might say yes during
self administered data collection, this might not be due to intervention effect
but due to the participants knowledge about the intervention intention so there
was high risk of performance bias due to lack of blinding of participants and
personnel in study 1(Lotrean et al., 2010). As in previous study, Study
2 (Campbell et al., 2008) also showed actual blinding
of participants and personnel was not possible in this study so it has high
risk of performance bias. If the participants were asked their view regarding
whether they stop smoking in future as the intervention itself named as "A
stop smoking in school trial". Many of them might say yes during self
administered data collection, this might not be due to intervention effect but
due to the participants prior knowledge about the intervention intention.
Study 3 (Perry et al., 2009) showed high risk of
performance bias. Students, peers and teachers were aware about program
intention so, in self administered questions when ask about their intention and
prevalence they will answer as they wanted to stop smoking so, blinding of
participants and personnel in this case was not be possible. No bio chemical
analysis of tobacco use was done due to expense of obtaining and analyzing such
data.
Detection bias
Study
1(Lotrean et al., 2010)showed
high risk of detection bias as blinding of outcomes assessment was not
possible. Double blinding was not possible as the peer educators and trainer
were trained and got manual. Students expressed their view in self administered
questionnaire. So, participants might had knowledge about intervention
intention students subconsciously answered questions according to program
intention. They had prior knowledge
of getting educational intervention.
Study 2 (Campbell et al., 2008) had low risk of detection
bias due to blinding of outcome assessment. "Comparison of self reported
data and concentration of salivary cotinine shows 1% of students who reported
not smoking had salivary cotinine concentration greater than 15ng/ml at 1 year
follow up" this indicate the study not only collected outcome assessment
through self administered questionnaire where probability of answering on the
basis intervention intention was reduced by cross validation with saliva test.
Study 3(Perry et al., 2009) did not mention about double
blinding. Double blinding was not possible as the peer educators and supervisor
teachers were trained and got standardized protocol on how to educate students.
Students were expressed their view in self administered questionnaire during
baseline, midline and end line. So, participants had knowledge about intervention
intention so students generally subconsciously answered according to program
intention. Blinding of outcome assessment might not possible. So, this study
had high risk of detection bias.
Attrition Bias
Study
1(Lotrean et al., 2010)
had low risk of attrition bias due to complete outcome data. " Dropout
rates were similar(p>0.05) in both condition, 11 % in experiment group and 9.8%
in control group" which was mostly by absenteeism and change of schools by
some students. Similarly, study 2 (Campbell et al., 2008) also showed low risk of
attrition bias." Two schools withdrew after randomization, one from the
control group and one from the intervention group because of changes in
decision by school management and replacement was done by each school one from
each strata in the list" In 1 year follow up 93% students in control group
and 96% student in intervention group participated; In 2 year follow up 90%
students in control group and 94% students in intervention group participated
which showed the dropout percentage seems not so high. Study 3(Perry et al., 2009) showed high risk of attrition
bias. Follow up data from 2 of Delhi schools(1- intervention, 1- control
school) was not obtained due to time constraint at these school. Three
additional school in Delhi( 2 control and one intervention school) would not
allow their 10th grader to be surveyed because of ensuing exams
Reporting Bias
Study 1(Lotrean et al., 2010) had unclear risk of reporting
bias. It measured behavioral outcomes and the secondary outcomes like
attitudes, social influence, self efficacy and intention to smoke in future but
study 2 (Campbell et al., 2008) showed low risk of reporting
bias due to selective reporting. It
reported that outcomes as expected in four major time periods in
baseline, immediately after intervention, at one year follow up and at two year
follow up and measured outcome data were reported as planned. Study 3(Perry et al., 2009) reported outcome data of
three major period i.e. before the
beginning of intervention, midpoint of intervention and after the completion of
intervention so it had low risk of
reporting bias.
Peer-led intervention generally
pillars on two major theories: social cognitive and diffusion of innovation
theory. Individual behavior is the result of interaction among cognition,
behavior, environment and physiology. Learning by observing peers behavior and
lifestyles which may lead to the particular behavior which become more
pronounce when it is also goal directed. Adopted behavior eventually becomes
self regulated behavior and its persistence depends on reinforcement and
punishment for that particular behavior. The intervention generally use the
process through which new ideas and products for enhancing particular behavior
known and make available for young people leads to diffusion in the society.
In this study, the impact of
peer-led intervention on smoking behavior is quantified. The findings of the
study showed that peer-led intervention can play a significant role in
prevention of smoking behavior among adolescents. The pooling of two main
studies including 11801 adolescents aged 12-14 adolescents suggests that number of new smoker in experimental or
intervention group was less in comparison to number of smoker in control or the
without intervention group. The odds of becoming a new smoker were lower among
those who received a peer-led intervention compared to control group( OR=0.80,
95% CI=0.70-0.92). This result is only based on two studies, as a third study
that was relevant reported data using a different method. Importantly, the
results of the third study are in broad agreement with the meta-analysis,
further strengthening the findings of this systematic review.
The systematic review of the studies
suggested that peer-led interventions may be effective in preventing smoking
behavior among adolescents but the evidence base is limited because of the high
heterogeneity in included studies. Similarly, one of the systematic review on
effectiveness of peer-led interventions to prevent tobacco, alcohol and/or drug
use among young people aged 11-21 years also highlighted that most of the
included studies on peer-led intervention were of low quality small studies
which limited the evidence base of review(Macarthur et al., 2016).
Out of three studies, two studies
were based on equivalent time series quasi experimental design where selection
of control and experimental group was done randomly only within group and
pre-post test was done before the experiment and at different time intervals.
One study was based on non-equivalent pre-post test quasi experimental design
where selection of control and experimental and control group was done randomly
within group but both groups were not tested for equivalency by any scientific
method.
Limitation of Study
The major limitation of this study
was heterogeneity of the data due to differences in effect size, intervention
modality and follow up period. In this review, the process of peer-led intervention implementation was very
different, one of the studies conducted used formal school setting for the
intervention while other used informal out of class informal interaction for
peer-led interventions which increased the heterogeneity among included
studies. The scope of analysis was limited by exclusion of one of the major
studies with sample size of 14063 because the authors of the study were unable
to provide data on number of new smoker in intervention and control group. The
authors used linear rate of change and base line data for control and
intervention group(Perry et al., 2009) which was not
compatible with data of other two studies but the result of third study also
showed effectiveness of peer-led intervention in prevention of smoking behavior
among adolescents. Therefore, this study was included in systematic review
process and it was not included in meta analysis due to lack of primary data
for the analysis during forest plot analysis.
Furthermore, the study was limited
due to exclusion of many studies due to their multi components nature where the
peer-led intervention was one of the components besides other components. The
study was conducted by single author as course assignment. The risk of bias
might be higher in this study in comparison to other studies in which
screening, critical appraisal and data extraction is done in duplicate. However,
inclusion of studies was carried out by getting consensus from the mentor of
this study.
Conclusion and Implication
The findings shows
peer-led intervention can play a significant
role in prevention of smoking behavior among adolescents based on social
cognition and diffusion of innovation theory. Adolescents knowledge acquisition
is directly related to observing peers' behavior and sharing experiences with
peers during school and out of school time. Therefore, the interventions which
involves peers can lead to positive health behavior than adult-led
interventions because adolescents usually feel more comfortable with peers than
with adult like teachers, parents, social workers. Moreover, innovations in
peer-led interventions can lead to seek more information which eventually
result in decision, information and confirmation to adopt new desired behavior.
Only a few systematic
reviews have been conducted in the past on the effectiveness of peer-led interventions
as part of a multi-component intervention in relation to risk behavior in
adolescents, but none have examined the effectiveness of peer-led interventions
on their own for smoking in adolescents. This study has found that peer-led
interventions are effective in preventing smoking behavior among adolescents,
however, the scope of this study is limited by its total small sample size and
high heterogeneity among included studies. Therefore, to draw the conclusion on
effectiveness of peer-led interventions
on smoking behavior of adolescent, more robust and rigorous randomized control
trials in wide range of geography and adolescents population was needed.
Moreover, the more homogenous studies and large number of such studies can add
more value to draw the conclusion on effectiveness of the peer-led intervention
in reducing risk behavior among adolescents. Therefore, future randomized
control trials with homogenous program modality can help to inform future
peer-led interventions strategy and program implementation in reducing risk
behavior among adolescents.
References
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Bloor, M., Parry-Langdon, N., … Moore, L. (2008). An informal school-based
peer-led intervention for smoking prevention in adolescence (ASSIST): A cluster
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