Adolescents encouraging healthy lifestyles through a peer‐led social marketing intervention: Training and key competencies learned by peer leaders

Abstract Background Adolescents who participate as peer leaders can benefit and acquire competencies from their peer leadership experience. Objectives To identify the competencies gained by adolescents who participated as peer leaders in a healthy lifestyle study and to determine whether the training characteristics were related to improvement in competencies. Design The present study was part of the European Youth Tackling Obesity (EYTO) project, a multicentre social marketing intervention involving four European countries. Setting and Participants Eighteen peer leaders (aged 13–15 years, three or five leaders per country) from disadvantaged neighbourhoods received training in designing and implementing activities for their peers. Measures The peer leaders' confidence, experience and interest in 11 tasks related to lifelong learning competencies were assessed with questions rated on a colour scale at baseline and at the end of the study. Results The peer leaders demonstrated improvements in experience, confidence and interest in different tasks, such as research, website or logo design, oral presentations, social media use and collaboration with people from other countries. They increased their confidence in management tasks (p = 0.03) and their confidence and experience in communication tasks (p = 0.01). The peer leaders from Spain and Portugal had greater improvements than those from the other countries. Conclusion The peer leaders improved their confidence in management tasks and their confidence and experience in communication tasks. Slight differences were detected in improvement in competencies by country, likely due to the differences in the peer training applied. Recommendations for peer leader training are proposed, although these results should be verified with larger sample size. Patient or Public Contribution The peer leaders contributed to the design and implementation of the training and intervention.


| INTRODUCTION
Risk behaviours adopted during adolescence influence noncommunicable diseases in adulthood. 1 For this reason, investment in adolescents' capabilities is vital for the UN's Sustainable Development Agenda, considering that investment in health and education generates a large economic and social return and transforms adolescents' lives. 2 Encouraging healthy lifestyles among adolescents is a challenge that requires the successful implementation of educational methodological strategies 3 because, at this stage, healthy lifestyles are affected not only by family influences but also as they are in preschoolers; for example, school and peer influences on lifestyles become more important during the childhood and adolescence. 4 In this context, peer-led programmes have emerged as an educational strategy that involves the effective transmission of information and behaviours between peer leaders as educators and their peers. 5 As a result, adolescent peer leaders solve their own issues, support their peers 6 and act as lifestyle mentors through actions performed in their daily lives. 7 In particular, youth peer-led interventions have shown greater positive results than adult-led interventions with respect to improving the diets of and/or the amount of physical activity [8][9][10] of youths in the promotion of healthy lifestyles and the prevention of risky behaviours. [11][12][13] To demonstrate the effectiveness of peer-led programmes designed to improve the lifestyles of adolescents, it is necessary to elucidate the skills and competencies achieved during training by peer educators. 14 Moreover, this type of programme goes beyond changing only lifestyles, having been demonstrated to increase student connectedness to the self, others and school for both peer educators and peer education receivers. 14 In addition, this increase in connectedness has been associated with academic performance improvement. 15 A peer leader is a person who shares similar status and experiences to those whom they are leading, 16 and can be considered a health educator after training. According to the World Health Organization (WHO), a health educator assesses community needs; plans, implements and assesses the effectiveness of health education programmes; coordinates the provision of health education services; acts as a resource person in health education; and reinforces health communication. 17 Peer leaders create a favourable environment and implement different tactics or strategies to promote student participation and facilitate sessions. 18 Peer leaders can carry out interventions with similar fidelity to adult educators, as demonstrated in the Peer-Led Asthma Self-Management Program for Adolescents (PLASMA), 19 and the students who attended peer-led training demonstrated significant improvements in basic first aid skills, such as cardiopulmonary resuscitation and defibrillation. 20 The results obtained in the PLASMA study, are not only for the recipients of the training; for example, peer leaders who participated in this study improved their knowledge about asthma, their quality of life and their control about asthma. 21 Although there have been published studies and systematic reviews showing improvements in communication skills, confidence and knowledge, 20-23 only some of them presented results about the benefits of being a peer leader. 24,25 For this reason, more studies are needed to delve into the benefits for leaders.
A peer-led strategy among adolescents was the methodological keystone of the European Youth Tackling Obesity (EYTO) project, a multicentre social marketing intervention that involved the United Kingdom (UK), Spain, Portugal and the Czech Republic (CZ). Each of the four participating countries acted autonomously and recruited five peer leaders from low-income neighbourhoods. These leaders designed and implemented activities for interventions focusing on encouraging healthy lifestyles among their high school adolescent peers over a period of 2 academic years, spanning 12 months. All four interventions had five requirements 10 : (1) encourage healthy lifestyles; (2) implement social marketing as a methodological base; (3) implement a peer-led educational strategy; (4) involve young people in the decision-making processes; and (5) use social media as the main communication channel among adolescents. Since each country acted autonomously despite having the same five requirements, four separate interventions were developed, with differences in type, place and/or social media used.
In this context, the hypothesis was that the training of peer leaders would influence their competencies acquired during the training process and the implementation of the intervention. Thus, the purpose of the present study was to identify the competencies achieved by adolescents who participated as peer leaders by designing and implementing activities that encouraged healthy lifestyles among their peers over a period of 12 months in the four EYTO participant countries. Additionally, the study aimed to determine whether the training characteristics were related to the improvement of the competencies of peer leaders, to make recommendations for effective adolescent peer leader training and to propose interventions that encourage healthy lifestyles.

| MATERIALS AND METHODS
The present study was part of the EYTO project, a multicentre social marketing intervention involving four European countries: the UK, Spain, Portugal and CZ. The project followed the principles of the Declaration of Helsinki and the Good Clinical Practice Guidelines of the International Conference on Harmonization (ICH GCP). Portugal, CZ and the UK did not conduct any scientific assessment. However, Spain completed a study based on a parallel-cluster, randomized, controlled, school-based, peer-led social marketing intervention that was approved by the Ethics Committee (ref: 14-04-24/4proj2) and was registered at clinicaltrials.gov (NCT02157402). 10

| Subjects
The initial study sample of peer leaders consisted of 20 adolescents aged 13-15 years old who lived in disadvantaged neighbourhoods.
The sample included five adolescents from each of the four countries who had been trained as peer leaders to implement the EYTO project and had been given the title of an adolescent challenge creator. 10 The peer leaders were selected from a youth centre, a scout meeting, a community event and high schools depending on the country from which they were recruited (considering the availability and expertise of each country participant), that is, the UK, Portugal, CZ or Spain, respectively. The inclusion criteria were based on the knowledge of the head of the scout group, communication experts or high school teachers regarding the leadership characteristics and enthusiasm of the students that would support their involvement in a project of this nature. Additionally, English language skills were important since peer leaders needed to be able to communicate with peer leaders from other countries. 10

| Peer leader training
The training process of the peer leaders was designed according to the Association of American Colleges and Universities (AAC&U) and included the acquisition of adolescent skills through frequent interactions with peer coaches and other peer leaders. 26 The EYTO training consisted of two stages over 12 months, as shown in Figure 1.

| Data collection: Peer leader training and learning competencies
Initially, two focus groups were conducted based on a guided interview using qualitative semistructured questions. This guided interview allowed for the collection of data regarding the perceptions, attitudes, experiences and beliefs of the participants. 27 Additionally, in the focus groups, the peer leaders were questioned about what they had gained in terms of self-confidence, communication skills, and marketing and organization skills, as well as what they had learned regarding healthy lifestyles and encouraging others to follow them. 28 During the focus groups, which were conducted by external project researchers, the 20 peer leaders (three or five leaders from each of the participating countries) were interviewed in their respective countries at baseline (June 2014) and at the end of the project (December 2015). The general results of the focus groups were published in the final evaluation report of the EYTO project. 28 The data assessed in the present study were based on the skills of the peer leaders identified in the focus group and included their degree of confidence in developing tasks, their experience and knowledge required to complete the tasks, and their degree of interest in developing and implementing the tasks. 29 The data led to the identification of 11 specific tasks related to the key competencies that all individuals need for personal fulfilment, development, employment, social inclusion and active citizenship. 29 Accordingly, the 11 specific tasks to assess the peer leaders' skills were created based on the WHO health educators' definitions as follows 17 : (1) organize an event, for example, a cooking contest, exhibition or gymkhana; (2) evaluate the event activities; (3) design a poster; (4) design a website; (5) design a logo; (6) design a graphic; (7) draft written material to be disseminated to many people; (8) give an oral presentation to a large audience; (9) use social media to communicate a message (through texts, pictures, videos, posters and other formats); (10) engage in a project with unfamiliar people and (11) work with people from other countries.
The quantitative data regarding the 11 tasks were obtained by asking peer leader-specific questions (Table S1). With respect to the evaluation, each of the 11 tasks was presented in a questionnaire administered to the peer leaders, whereby the peer leaders used stickers to indicate their levels of confidence, experience and interest; specifically, green indicated yes or very much, yellow indicated yes or somewhat and red indicated no or not at all. The results only included the adolescents who answered the questions with a green sticker.

| Statistical analysis
Categorical variables are presented as percentages (%), and continuous variables are presented as the mean ± standard deviation (±SD). Fisher's exact test was used, due to the small sample size, to detect significant changes in outcomes (confidence, experience and interest) from baseline to the end of the study for each of the 11 project tasks. 30 Additionally, the t-test was used to detect significant changes in the task subgroups (management, design and communication). All of the results were separated according to confidence, experience and interest based on the baseline versus end-of-study results and were independently analysed. All of the analyses were performed using IBM SPSS statistics software, version 27.

| RESULTS
Although 20 peer leaders were recruited to participate in the EYTO project, two peer leaders from the UK did not finish the study because they decided not to continue participating in the EYTO study.
Hence, the end-of-study analyses included 18 peer leaders from the four participating countries, specifically, five each from Spain, CZ and Portugal and three from the UK. Table 1 Table 1).

| Experience, confidence and interest of peer leaders in the 11 tasks
Regarding experience, peer leaders from two countries demonstrated some growth. For example, peer leaders from Spain presented increased experience in using social media (0%-100%; p = 0.008), while those from Portugal demonstrated increased experience in website design (0%-80%; p = 0.048) and logo design (20%-100%; p = 0.048), as well as oral presentations (0%-100%; p = 0.008). Conversely, peer leaders from the UK and CZ did not significantly increase their experience in any specific task. With respect to confidence at the country-by-country level, Spain's peer leaders demonstrated growth in website design (20%-100%;     29 Peer-led implementation in other populations, such as medical students, showed that explaining concepts to peers improves the communication skills of peer educators, 32 is an important skill for working in groups and is one of the emphasized skills for jobs in the digital age. 33 Adolescence is a good time to learn certain skills, for example, communication because it is known that nonverbal and verbal communication techniques will be important for adolescents' futures in job interviews. 34 Additionally, better communication skills and free time management are also associated with greater motivation in students. 35 The peer leader key competencies assessed in this study were more accurate than those reported in other health interventions that evaluated only the skills gained by the participants. 27 For example, the American nonprofit NutriBee, which performed a communitybased high school adolescent peer leader (13-18 years old) online nutrition intervention, encouraged 10 healthy diet behaviours in middle school students (10-12 years old). 27 NutriBee peer leaders improved their skills, such as helping others while doing what they enjoyed and being a resource and coach; at the same time, they further developed their personal interests and career paths. 36 Additionally, it was shown that peer leaders who participated in peerled team learning in an engineering course improved their selfconfidence and interest in teaching, although at the beginning of the course, they were apprehensive, worried and unsure. 37 These acquired competencies were similar to those of the peer leaders in the EYTO project; however, the EYTO project achieved broader results.

| Project evaluation
To our knowledge, the literature on skills gained by peer leaders trained as health educators is scarce. In this context, in one study, peer leaders reported achieving communication, organizational, time management and presentation skills due to their peer-advising experience. Moreover, the authors of this publication commented that the peer leaders improved their ability to make presentations, conduct individual advising sessions, engage in public speaking and work with others. 38 However, the study did not include the necessary data to confirm these results. Therefore, it is impossible to compare our results with this study. In a recent study, peer education revealed a confidence improvement of ongoing support on peer leader adolescents while they were motivated to make healthy lifestyle choices and to share their knowledge and experience. 39 The   Figure 2), as well as suggestions for improving the 11 tasks ( Figure 3).
This study has certain limitations. First, since the number of peer leaders was small, it was difficult to obtain conclusive results. Thus, the findings on the confidence, experience and interest in developing and implementing these tasks among the three or five peer leaders per country should be verified through an intervention that includes a greater diversity of peer leaders from more diverse environments to evaluate the generalizability of the results. Moreover, the assessments of these tasks, as well as the methods of the assessments, should also be validated. Despite its limitations, the present study contributes to the research by presenting a novel methodology that has great potential in the field of health promotion. At the same time, the study serves as a guide to determine the aspects that should be strengthened in the future to identify the best methodology to obtain successful results.
In conclusion, the peer leaders improved their confidence in management tasks and their confidence and experience in communication tasks. Slight differences were detected in competencies improved by country, likely due to the dissimilarities among peer training applied.
Recommendations for peer leader training were proposed, although these results should be verified with larger sample size.