Effective School Interventions in the UK - Literature review Example

?Effective school interventions in the UK Smoking tobacco among adolescents is increasingly becoming a matter of grave concern in both developed and developing countries across the world. There has been numerous intervention programs conducted by health care centers, but so far the success rate has not been encouraging. The idea is to promote intervention process that will create awareness among adolescents about the social, economic and health hazards of smoking. Current studies have proved peer-based interventions in schools can give significant success rates. Previous intervention The smoking trend among secondary school students has been explored by Ridout et al. (2008) in their article. The practice of using scare tactics was observed as an added inhibition to behavioral modifications and therefore it is no more a part of health education. However, psychosocial theories offer the concept that school based social approach can encourage students to avoid peer pressure and resist temptations arising from advertisements and social influence. The article mentioned the failure of European Union Program as an endeavour to create awareness among students about the negative social influence. The reason of failure was associated with the program’s non-inclusion of materials regarding health consequences. The attempt to create awareness regarding the negative impacts of smoking tobacco during early age was initiated by UK National Curriculum. This idea was given shape by incorporating “smoking prevention and cessation education” (Ridout et al., 2008, p.1039). A survey was conducted on 1789 students between 11 and 15 years regarding their smoking habits after experiencing smoking education. The lessons induced students to change their perspectives on smoking by learning the health issues as compared to social influence. The results of the survey revealed that 56% of the participants changed their smoking ideas due to the lessons, while 43% of former smokers quit smoking. “Multinomial logistic regression” (Ridout et al., 2008, p.1043) associated smoking habits of students with presence of non-smoking friends and family members around them. Therefore, although almost 75% of the participants claimed to have been positively influenced by the lessons, there was no evidence to prove the extent of the lessons’ influence. An important thing revealed by the survey is that health themes had better impact on students than social issue themes like peer influence. There is prevalence of inter-school variations on smoking patterns among students for which two reasons are attributed. First one is the student composition that varies between schools. For instance, a school having students from high socio-economic backgrounds will have low prevalence of smoking while students from low backgrounds will have more tendencies towards smoking. The second reason is that school environment has an impact on students irrespective of their social backgrounds. Stanton et al. (2005) in their article explored the impact of smoking on children, infants and fetus. It is a fact that even passive smoking has severe health impacts. Smoking by parents can induce adolescents to take up smoking, hence a “smoke-free home policy” (Stanton et al., 2005, p.590) can reduce smoking incidences among adolescents. Heavy smokers are more likely to have premature death which is a social concern, but the more serious issue is their reluctance to curtail their habit. The reasons behind this include covert and open persuasions by tobacco companies to peer pressure and prevalent smoking among family members. There is growing awareness of harmful impacts of passive smoking, however this does not reduce the chances of infants and children getting exposed to passive smoking. The authors explore the reports from smoke-free homes that say children are less likely to take up smoking if they are from smoke-free homes. Also, further studies have proved that adolescents from smoke-free homes show more inclination towards cessation than those who are from families of smokers. Another factor is parenting style, which means that parents who focus more on upbringing of children cause less possibility of smoking tendencies among adolescents. The need is to create awareness among parents by not only encouraging them to quit smoking but also telling them to discourage other family members to quit smoking. In spite of external factors like school environment, socio-economic status playing respective roles in smoking habits of adolescents, the most important factor is smoking in the family. However, group studies have shown that “baseline smoking status” (Aveyard et al., 2005, p.56) has a separate risk factor which indicates that adolescents make their choice regarding smoking for no specific reasons. Aveyard et al. (2005) have explored three areas like the extent of impact of variable pupil compositions, influence of unknown factors that induce non-smokers to initiate smoking or current smokers to continue smoking, and whether public heath can be included in a preventive program. The authors conducted a study on students from 89 urban and rural schools by providing them similar set of questionnaire in the interval of one year. The result showed that inter-school variations shape smoking patters, but differences in pupil composition concealed some of those variations. Further, it has been observed that unexplained differences between schools were also substantial factors. These differences were not results of variations in anti-smoking educations in schools, since the participant pupils’ smoking habits were not influenced by regular interventions from anti-smoking programs. The limitation of this study was that it could not investigate neighbourhood influence on students who attend same school and stay in same neighbourhood since the participant schools were widely dispersed. In UK, there are numerous education and health programs to create awareness about the negative impacts of smoking. The success rates of these endeavours have been high with signification decline in smoking rates. However, in recent years there has been increasing difficulties in reducing smoking rates; thus smoking behaviour has become a major public health issue. Several formal policies in Europe like banning smoking in public places have limited success. Although most smokers quit smoking in the long run, Twigg et al. (2009) focus on “core smokers” (Twigg et al., 2009, p.610) who either do not wish to quit or else their attempts to quit have failed. The characteristics of these core smokers are mostly determined by their socio-cultural backgrounds. Any cessations programs need to be modified emphasizing on the core smokers in order to generate further reduction in smoking habits. Ethnicity also has role in quitting as it is seen that South Asians in UK find it difficult to practice cessation. There is also neighbourhood impact like in people in socio-economically advantaged areas can more easily quit smoking. The reason behind this is lack of cessation programs in disadvantaged areas and people tending to escape from poverty by smoking. The core smokers are in particular need of assistance form public heath promotion centers and hence the approach should be to recognize the various factors of these “hard-to-engage” populations (Twigg et al., 2009, p.618). For the success of any health program, it is needed that people stay engaged with the program. Aveyard et al. (2003) reviewed the results of a study based on 8352 school pupils between 13 and 14 years. The participants were divided into two groups – one group who recognised the benefits of school-based health promotion interventions were considered as engaged and the rest were considered as disengaged. A traditional approach is determining specific risk factors for smoking and then using opposite and equal force to stop non-smokers from taking up smoking. Such an approach is based on the assumption that many adolescents are influenced by social factors and are more often coaxed into smoking against their will. It has been seen that individuals who were non smokers at the beginning of adolescence have become smokers by the end of their adolescent years. It is clear that no intervention program can satisfy every adolescent. However, those adolescents who do not find such programs useful may not have more possibility of becoming smokers than those who find such programs interesting and purposeful. Also, if disengagement is considered as sign of desire to smoke then it may indicate possibility of disengaged adolescents to become smokers later on in their lives. Thus disengagement can be a risk factor, but if an adolescent develops controlling power to refrain from smoking, then this risk factor can be eliminated. Therefore, the study reviewed in this article aims at examining whether disengagement is linked with smoking at 1 and 2 years follow up, and also whether disengagement is associated with desire to smoke. The results of the study showed that disengagement from anti-smoking intervention programs was an independent risk factor with no link with prevalent risk factors. Sensitivity analysis has eliminated the possibility of smoking as cause of disengagement. There was limited evidence to prove the impact of disengagement on those who have never smoked. However, it has been empirically proved that disengagement is not dependent on phase of changing smoking habit, but the impact of disengagement on each phase has not been clearly proven. Such limitations of concrete results were caused by evasive answers by pupils. Those who consider smoking as undesirable have the intention to underplay their smoking habits and overstate their engagement with intervention programs. The opposite response comes from those who consider smoking as socially desirable. This article on disengagement has another implication. It cannot be clearly known whether smoking causes disengagement or vice versa. Some previous studies have shown that pupils with smoking habits show a natural disrespect towards school based intervention programs. There are, however other studies that have proved that disengagement from schools induces smoking among never-smokers. A third implication of the above results relates to research programs. If health related behavior is influenced by social disengagements, and if impact of school disengagement cannot be reduced by health education, then the need is that research programs should focus more on school disengagement. In schools where intervention is practiced, almost all pupils go through the experience of the interventions but not all gets engaged. The assumption that pupils who recognized the benefits of school-based intervention i.e. engaged pupils, reduced their smoking trends is not supported by any evidence although majority gets engaged. However, if this assumption is admitted as true, then it must also be concluded that pupils who experienced intervention without getting engaged have started or continued with smoking. Hence, it cannot be known whether experience of intervention caused increasing smoking or whether individuals with low risk of smoking were inclined towards engagement. There is another explanation which states that pupils who are adamant to continue smoking do not allow interventions to affect them. Therefore, Aveyard et al. (2003) concluded that unless school-based smoking prevention programs take steps to encourage the disengaged pupils to become engaged, prevention has less possibility to become successful. Current intervention There is the need to measure the effectiveness of health promotion interventions in order to inform policy makers on how to allocate resources. Although RCT (randomized controlled trial) is the standard of health services research, its appropriateness is doubted by health promotion practitioners. The chief concern is that RCT needs fixed conditions like regular intervention, concrete results that can be statistically measured and uniform implementation of the intervention on specifically targeted subjects. Such pre decided conditions may not be available in complicated health promotion programs where “social and economical conditions vary considerably” (Audrey et al., 2006[1], p.366). Results derived from RCT cannot be considered useful and feasible for policy makers. A more accepted model examines the effectiveness under regular conditions. This model is a part of ASSIST (A Stop Smoking in Schools Trial). The function of this model was to measure the effectiveness of intervention in which 8 students between 12 and 13 years were trained to discourage smoking among peers through informal discussions. The result showed that such intervention process has more positive results in intervention schools than control schools. Audrey et al. (2006[1]) focused on effectiveness measurement and considered its potential to “affect the intervention’s delivery, receipt and outcome evaluation” (Audrey et al., 2006[1], p.366). In recent years, pragmatic trials have become more popular where intervention process is not disturbed, and the resultant outcomes are measured by quantitative research. It has been now determined that final results should be evaluated by an integral process. This will provide information about the implementation process of the intervention and how it has been accepted along with its pros and cons, and how results varied with different conditions. Three issues that have been considered as relevant to health promotion interventions are Hawthorne effect which means possible impacts of research method on final results, overlapping roles of team members and distinguishing between the intervention and its evaluation. For instance the intervention students mentioned earlier filled questionnaires regarding their opinion about the training process. The questionnaires were filled during the intervention process and required commitment which would have been missing had the questionnaires were filled at the end of the intervention process. Thus, although completing questionnaires became integral part of intervention process, it became impossible to assess the effectiveness of the intervention had there been no questionnaire completion sessions. As conclusion, the authors said that although a pragmatic trial is more widely accepted as it gives a fair reflection of intervention’s effectiveness; it is not without complexities that include necessity of additional research processes. So far, no intervention policies have been largely successful in preventing smoking among the adolescents. Indeed, in UK a major concern is the growing tendency of smoking among 11 to 16 year olds. The stress is usually imposed upon the teachers to implement intervention methods, but it has been seen (as mentioned in the previous article) that peer intervention proves to have better results. Even though it is imperative that a comprehensive evaluation is conducted of complicated public health interventions, it is however rare in the UK. Starkey et al. (2005) demonstrated “the feasibility of cluster RCTs of complex public health interventions in schools” (Starkey, 2005, p.43). It has also been explored in this article how the key issues in the designs can be utilized by proper implementation and by broadening the framework of questions used during the trial. The ASSIST intervention used 8 students who were nominated by their peers as they considered them more influential in intervention process. These students were trained to create awareness among their peers about social, economic and health hazards of smoking. This evaluation study was conducted over a period of two years in 59 schools in South East Wales and the West of England. At the end of 2 years, decisions were taken regarding recruitment of more peer supporters and modification of the intervention process. The major elements that were addressed in this evaluation were “development of positive working relation with schools, obtaining consent from participants, and collection of data from schools sensitively and successfully” (Starkey, 2005, p.48). Today, in every country, schools are emphasizing on smoking prevention programs to reduce smoking patterns in adolescents. However, regular reviews of such programs revealed the extremely limited success of the programs. The focus is now on peer-driven intervention processes, but since these are mainly confined in classrooms, their evaluation process so far has been limited. Campbell et al. (2008) evaluated the effective impact of peer-led anti-smoking intervention. Consumption of tobacco by adolescents is a major concern in most countries especially in America and Europe. Addressing the seriousness of the issue and accordingly taking preventive measures have become urgent in both developed and developing countries. Schools are considered as the most potential platform for such measures since adolescents remain associated with schools for a long period. One major cause of smoking is peer pressure that arises more often from the tendency of adolescents to socialize with like-minded people. However, it is also peer intervention that plays an important role in reduction of smoking (Campbell et al., 2008, p.1600). Evaluation study that was conducted in 59 schools in South East Wales and the West of England showed that peer training for the purpose of anti-smoking intervention has managed to reduce smoking in adolescents for 2 years after the intervention. Evidence from this study proved that many elements contributed towards the success of this intervention. Firstly, asking students to select among them as the most influential ones added to the trust level among students which in turn enhanced effectiveness of the intervention. Also, trainings were held in external venues and this created a sense of responsibility in the minds of the young people. Moreover, the success of such peer-driven interventions was proven when also applied in domains other than smoking. Although systematic evaluations have provided mixed results regarding effectiveness of school-based peer-driven interventions, the results presented in this article by Campbell et al. (2008) suggest that it will not be wise decision to completely abandon smoking prevention programs in schools. Today, many countries have made it obligatory for schools to include smoking awareness in their curriculums. So, the focus should not be on the viability of such interventions, but should be on the effective ways of implementation of the interventions. With the growing popularity of peer education as health promotion approach, the need is to evaluate its effectiveness. However, various studies have given mixed reports about its effective impact on young people. There is a general belief that “similarities between influencer and recipient increase the persuasiveness of any message” (Audrey et al. 2006[2], p.321). Therefore, the authors suggest that peer intervention approach should be encouraged as part of health promotion programs. This argument has been backed by “diffusion of innovation” theory (Audrey et al. 2006[2], p.321) which explains how awareness can be created in different communities through meaningful interpersonal communications. The ASSIST intervention trained students who were selected by their peers. The purpose of the training was to prepare the students to make informal conversation with peers to discourage smoking. From the results of this trial, it was found that some non-smokers became determined not to take up smoking after conversations with peer supporters. There were others who argued that such conversations have little impact since they have already made decisions not to smoke. For those young people who considering starting smoking, the conversations had positive impact as they became discouraged to smoke. The training also influenced the regular smokers among the peer supporters. The authors concluded that given the increasing smoking trends in young people, it is advisable to adapt this approach more widely. In UK, due to the growing trend of smoking in adolescents, emphasis is on making school-based intervention programs more widely acceptable. However, the curriculum does not allow much scope for teacher-based interventions. The effort is to minimize the pressure on teachers and curriculum space. Audrey et al. (2008) consider teachers’ perspective of student-based approach trained by external trainers. The intervention during which students were trained for the purpose proved to be successful in reducing smoking levels among peers. This also encouraged more schools to accommodate the intervention. This proves that the trial can be conducted generally in schools across UK. Through this trial several other elements were also emphasized like students were able to recognize influential peers, allowing all nominated students even if they are challenging to participate in the intervention, encouraging discipline among the participant students, and also taking care that behavioral standards of schools are not compromised (Audrey et al. 2008, p.87). Since most people take up smoking in adolescent years, therefore schools are considered as the most potential ground for intervention methods. This is because of the long association of adolescents with schools. Introducing smoking education based on health themes can create awareness about its negative impacts. Peer-led interventions are becoming more popular in UK schools because of its high success rate. Since students are selected by peers for training purpose, this has an added advantage of enhanced trust between peers. References Audrey, S. et al. (2006[1]). Meeting the challenges of implementing process evaluation within randomized controlled trials: the example of ASSIST. Health Education Research, 21(3), 366-377 Audrey, S., Holliday, J. & R. Campbell (2006[2]). It’s good to talk: Adolescent perspectives of an informal, peer-led intervention to reduce smoking. Social Science & Medicine, 63(2), 320-334 Audrey, S., Holliday, J. & R. Campbell (2008). Commitment and compatibility: Teachers’ perspectives on the implementation of an effective school-based, peer-led smoking intervention. Health Education Journal, 67(2), 74-90 Aveyard, P. et al. (2005). Is inter-school variation in smoking uptake and cessation due to differences in pupil composition? A cohort study. Health & Place, 11(1), 55-65 Aveyard, P. et al. (2003). The risk of smoking in relation to engagement with a school-based smoking intervention. Social Science & Medicine, 56(4), 869-882 Campbell, R. et al. (2008). An informal school-based peer-led intervention for smoking prevention in adolescence (ASSIST): a cluster randomised trial. Lancet, 371(9624), 1595-1602 Ridout, F., Charlton, A. & I. Hutchison (2008). Health risks information reaches secondary school smokers. Health Education Research, 23(6), 1039-1048 Stanton, H.J., Martin, J. & J.E. Henningfield (2005). The impact of smoking on the family. Current Paediatrics, 15, 590-598 Starkey, F. et al. (2005). Rationale, design and conduct of a comprehensive evaluation of a school-based peer-led anti-smoking intervention in the UK: the ASSIST cluster randomised trial. BMC Public Health, 5, 43-52 Twigg, L. et al. (2009). Smoking cessation in England: Intentionality, anticipated ease of quitting and advice provision. Social Science & Medicine, 68(4), 610-619 Read More