Process evaluation results

Parts of this chapter have been reproduced with permission from Willis et al.1 and Jago et al.2 These are Open Access articles distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: https://creativecommons.org/licenses/by/4.0/. The text below includes minor additions and formatting changes to the original text.

The aim of this process evaluation was to understand how the intervention was delivered, whether or not it was delivered as intended, whether delivery or receipt differed by setting and what factors affected delivery fidelity. A mixed-methods process evaluation was conducted, and the findings are structured to address (a) fidelity and quality of intervention delivery, (b) receipt of the intervention and the experience of being a peer supporter, (c) perceived intervention effects and (d) school context. Quantitative data comprise questionnaire data, attendance records and observations of the intervention delivery. Qualitative data comprise interviews with school contacts and trainers and focus groups with peer supporters and non-peer supporters at each intervention school. In addition, interviews were conducted with public health commissioners, education leads, and regional and national organisations to explore potential implications for public health policy and practice.

Quantitative data provision

All intervention sessions were observed by a member of the research team. In total, 158 (95.18%) and 137 (82.53%) peer supporters completed the evaluation questionnaire following the 2-day and top-up day training, respectively. Peer supporters reported the type and frequency of peer supporting that they had undertaken (as a measure of fidelity) at the top-up day and at the end of the 10-week intervention period (by mail). In total, 132 (79.52%) peer supporters provided this information at the 5-week time point, but only 23 (13.86%) responded at 10 weeks. Therefore, these data cannot be used to make representative statements about peer supporter fidelity at week 10.

Qualitative data provision

Peer supporter and non-peer supporter focus groups and school contact interviews were completed in all 10 intervention schools. Quotations have been anonymised and are presented by informant group and school identification number (ID) or trainer ID [e.g. peer supporter (PS) 7, non-peer supporter (NPS) 2, school contact (SC) 10, trainer G].

Fidelity and quality of intervention delivery

School and participant recruitment

There were no stated barriers to taking part in the project for girls or school contacts. However, in two schools, the consent rate was low (46.27% and 52.78%) compared with the average consent rate of 88.58% in the other 18 schools. Very few non-consenting girls provided a reason for not taking part and so there are few pupil data to understand this issue. However, in one school with a low consent rate, the school contact described a pupil mind-set within the school that deterred girls from putting themselves forward for opportunities because of a lack of confidence and fear of the unknown.

Train the trainers

The trainers perceived their training for the intervention to be comprehensive, enjoyable and successful in preparing and motivating them to deliver the content to the peer supporters in line with the theoretical principles of SDT. The format, delivery style and bonding time with the other trainers were praised, as well as the opportunity to check understanding and ask questions about delivery style:

The trainers [who delivered the train the trainers] were really good. I think it was really effective, us pretending to be the girls, because you got to go through every activity, how it would be run, and then you can, kind of, go through it in your head, things that might be changed, or things you think that they would pick up quicker or need more time on. I think it was good to go through the theory side of it, to understand that, and I think enough time was spent on that.

The importance of being trained in broader teaching techniques was highlighted, including reading the audience, relating the activities to the peer supporter role and emphasising key objectives:

. . . you guys were saying it over and over again, ‘this is the one thing I want you to summarise. Make sure that everything you’re doing is in the context of peer supporting’ . . . But I had your voices in my head saying ‘always bring it back to the peer supporting’ . . .

Using the peer supporter training resources at the train-the-trainers event was an important learning aid. The resources and delivery aids were rated ‘excellent’ for all training days (see Appendix 5).

Spending 1 full day on the material for each of the peer supporter training days was praised by trainers as it gave them the time to focus on the content for each day. Two trainers would have liked the top-up day content to be covered closer to the actual delivery of the top-up days to maintain trainer confidence:

I think that it was the right amount of time. Also good for it to mirror the amount of time that we would have with the girls. So we had quite a real-life experience of what they would be doing, so that’s good.

Peer nomination

Outcome of peer nomination

Although some peer nominations came as a surprise to school contacts because the girls were ‘less sporty’ or shy, and several were known for disruptive behaviour, most peer supporters were described as the confident, influential, kind, sporty and supportive girls in their year. It was believed that some peer supporters already upheld the key principles of the peer supporter role and encouraged their peers to be active. In certain schools, they were described as conscientious and future leaders in their school, suggesting that the process successfully selected appropriate peer supporters in most schools.

Representation of the year group among the peer supporters varied between schools. In some schools, most peer supporters were part of the same friendship group, whereas, in others, peer supporters represented a range of friendship groups. Most non-peer supporters had a friend who was a peer supporter or at least knew a peer supporter. Therefore, the process yielded a potentially representative sample.

Consenting to be a peer supporter

Consent rates and reasons for not signing up to be a peer supporter are reported in Chapter 3, Peer supporter recruitment. Peer supporters felt that there were few barriers to opting to be a peer supporter. The two most common drivers for agreeing to become a peer supporter were to be able to help and motivate others to become more active, and to be more active themselves.

Peer supporters at three schools were motivated by receiving nominations that indicated support from their peers, highlighting the perceived value of a peer-nomination process:

It wasn’t like your teacher picked you. It was that people within your year thought you were fit for the role, and that made you feel better about yourself and want to do it more because your friends and people around you thought that you could do it.

Impact of not being nominated as a peer supporter

Most peer supporters and non-peer supporters felt that not being nominated did not have a negative impact:

. . . nobody really seemed annoyed, which, I think, is good.

I wasn’t really bothered to be fair because it’s one of those things.

However, a few peer supporters believed that some non-peer supporters felt annoyed or disappointed that they were not nominated because they saw themselves as more active than some of the girls who were peer supporters. This was echoed by some school contacts:

When I was talking to my friends about it, some of them, two of them, seemed a bit annoyed. That’s people that were a bit more active than me.

You could hear them saying ‘oh, why can’t we do that?’ or ‘we’re not on that’ . . . They weren’t that upset, but I just think it was just something that they might have liked to have been involved in.

This view was not reflected in non-peer supporter focus groups, although some girls did speculate that others may have been jealous. Some did want to be a peer supporter, but did not mind that they did not get nominated; only one member of a non-peer supporter focus group from one school felt annoyed and thought it was unfair.

Peer supporter training

Attendance

Table 32 shows that 84.33% of consented peer supporters attended all 3 days of training (ranging from 66.67% to 100.00% across all schools). In six schools, all peer supporters attended both training days 1 and 2. The school with the lowest mean attendance was affected by absence for a school event on the top-up day. Conflict with important lessons was another reason for non-attendance in some schools. Two girls dropped out of the training because they no longer wanted to be a peer supporter.

Training logistics

School contacts were happy that the training logistics were arranged by the trial team as it minimised the amount of work required by the school – a crucial factor in achieving buy-in from schools. School contacts found the process ‘easy’ because the trial team communicated clearly and worked around the needs of the school:

I think with school staff, if it’s going to work, it needs to be as minimal as you can make it. So the fact that you guys did all of that made my life loads easier . . .

The duration and number of breaks throughout the training days were acceptable to peer supporters and trainers. Peer supporters liked the food, but would have preferred more simple sandwiches and crisps from the options available.

Training structure

Eighty-five per cent of peer supporters rated the length of training as acceptable (Table 33). The qualitative data support this and suggests that most peer supporters and school contacts felt that the structure (2 consecutive days, followed by a top-up day after 5 weeks) of the training was also appropriate, allowing the peer supporters to take on board information and feel prepared:

It wasn’t too long. It stuck with the school day, so they were happy to be able to leave at the same time as everyone else . . . it was like a normal school day.

I think the fact that we had 2 days, one after the other, just made it easier for us to understand stuff.

Training content

Stakeholders felt that there were no gaps in the peer supporter training content, it flowed well and had a suitable format with a good balance of interactive, active and quieter writing activities built in:

There was a range of different things. We did some desk work on what we needed and then we did some fun games and getting to know each other, it was a good fun day, or 2 days . . .

I thought it was really varied. Sometimes, they were sat down, watching a video and doing stuff on worksheets. Then, other times, they were really active.

Conversely, some peer supporters felt this balance was in favour of sitting and writing, which they viewed as negative. The overarching opinion was that more games would have increased peer supporter enjoyment. The second most common suggestion was to make the training more active overall:

Sometimes, trainers found it hard striking this balance:

They were like ‘we’re peer supporting and trying to get people to be active, but we’re not very active in terms of activities,’ which is fine, because they need to get the content across as well . . . Sometimes, there’s just no pleasing them.

Peer supporters and school contacts agreed that the training was pitched at the right level and was relevant to the aims of the project. However, some peer supporters felt that there was a lot of information to take on board, which made the days tiring:

I think the training, as such, and the training the girls had was very detailed. It was all relevant. I think the girls enjoyed that.

I think, in the training, they threw a lot of information at us. There was a lot thrown at us, and it’s a lot to take in to be honest, over the 2 days.

Some school contacts felt that it would not suit older age groups, but would work well with Year 8:

I think, for that year group, it was probably . . . I don’t think you’d be able to do it with any older year group, but maybe Year 8s would benefit from it as well.

To some extent, all stakeholders thought that some of the training content was repetitive, particularly during the top-up day (see Chapter 5, Top-up day). Although practising peer supporter scenarios was enjoyable and aided learning, these activities were repeated too often:

. . . it felt like the second day was just going over what we’d done on the first day.

Some trainers thought that this repetition was needed to reinforce information, as one trainer said that the peer supporters had forgotten a lot between the 2-day and the top-up day training:

I think all the activities were really good. I think day 2 is a little bit repetitive, but it’s also a good thing because they really do need to understand. I think it does take them a whole day to really get to grips with the conversations.

Training venues

Off-site venues to hold the peer supporter training that were within a mile of the school were secured for 8 out of 10 schools. In most cases, the venue was at a convenient location and was a suitable size with appropriate facilities. However, Table 33 shows that overall satisfaction mean score ± SD with the venue was low: mean score ± SD 2.79 ± 1.09 (maximum score 5). Low scores at schools 5, 7 and 15 were due to the space being too small and/or there being little/no outdoor space. Having a ‘breakout’ space or somewhere to be outdoors was important, as peer supporters did not like to feel ‘cooped up like a chicken’ (PS 16). Trainers rated the suitability (mean score ± SD 2.80 ± 0.89) and quality of facilities (2.55 ± 1.00) as ‘very good’ (maximum score 4; see Appendix 5). Despite the training spaces being more suitable on the top-up day, the quality decreased quite substantially (mean score ± SD 1.89 ± 1.02); this was probably due to difficulties in securing suitable venues.

All interviewed stakeholders felt that having the training off-site was important and preferable; it made it feel ‘more special’ (SC 14), promoted a better learning environment, meant that the peer supporters could be themselves and provided a break from school. In the two schools that hosted the intervention on-site, it was reported that peer supporters were often distracted, which led to disruptive behaviour. The ideal venue was described as off-site, with access to outdoor space, and the size of a sports or village hall:

I think we would have enjoyed it a bit more if it was in a different [venue], because, I think, it’s like, when you go out, you can take it more seriously.

Despite school contacts understanding the importance of having an off-site venue, some still suggested that it would be more convenient to hold training at school because of the school policies on organising trips off-site (which differed between schools). Some schools required 6 weeks’ notice, others a detailed risk assessment of the intended venue or additional parental consultation, and some schools were unable to release a member of staff to act as a chaperone for the training. This presented challenges for three school contacts and was the main reason for on-site delivery in schools 7 and 10.

The delivery of the peer supporter training on-site at school 10 demonstrated how this approach can negatively affect the intervention. Safeguarding procedures at this school meant that trainers could not leave the room reserved for the training, but the girls could. On day 1, this led to the peer supporters leaving the training venue during breaks without supervision (some for meetings with teachers, others to collect equipment), which resulted in peer supporters being distracted from the training and causing disruption to lessons in school:

Having worked in several schools, it did feel a little bit like the administration of that school was interfering a bit and trying to hold us back from what we were doing.

The disruption prompted complaints from school staff about the peer supporters not being in uniform (although this was part of PLAN-A) and the disturbance to lessons. This led to the school contact interrupting the peer supporter training to discipline the peer supporters. She spoke to the girls in a demeaning way and made an example out of one of the peer supporters for the clothes she was wearing (this girl subsequently dropped out of the training). The girls were told by the school to wear uniform or PE kit for the rest of the training. This incident led to feelings of defiance from the peer supporters and made the trainers uncomfortable and led them to feel that the peer supporters had lost trust in them:

. . . going back to the initial 2 days is when there was that bit of upset with the school, they seemed to lose a bit of trust in us, I think.

One trainer felt that this incident could have been prevented if they were more explicit with the peer supporters about the boundaries, especially with the training being on-site. As a result, the peer supporters became disengaged and harder to manage:

. . . the real disruption happened on day 1. When they came back for day 2, we’d kind of lost them already at the beginning of the day.

The top-up day delivery in school 10 was also restricted to one half-day because of an unforeseen school request for girls to be released early to receive exam results, an issue that would probably not have occurred off-site. The school contact was aware that the top-up day was cut short, compromising fidelity to the peer supporter training session plans. Observation data confirmed that the training was delivered in full in all other schools:

I know that ours was cut short, because the top-up day didn’t work fully . . .

Delivery of the peer supporter training

Delivery in pairs

Having two trainers deliver the training had certain advantages in that each trainer acted as a form of support for the other and trainers had different delivery styles:

I normally, just, as an individual, tend to be a bit more concise and a bit more to the point . . . [Trainer name], on the other hand, I was paired with quite a lot, tends to do the other way around. So we were a good balance.

It was preferable to have the same pair of trainers deliver the training at multiple schools, as this allowed trainers to adapt to each other’s teaching styles, to build a rapport with each other and, therefore, to optimise delivery. However, each of the trainers delivered with more than one partner and reported being well prepared to adapt as long as they had time to discuss who would lead which activities ahead of time:

I thought [when working with a different trainer] ‘oh no, I’ve got a good thing with [trainer name], we get the timings,’ you know, ‘we’ve got it perfectly’. But, actually, we all were so well-practised and informed from the training days that I think we knew how it would work anyway, and it just all flowed together really well . . .

Where possible, the same trainer pair delivered all 3 days of training in a school. Where this was not the case (i.e. in four schools), a different trainer stood in for the top-up day. Although it was desirable for the same pair to deliver the top-up day training to maintain consistency and take advantage of the rapport already established with the peer supporters, it was felt that having at least one of the same trainers was sufficient to ensure continuity from the 2-day training:

I think it’s important to have at least one of the same trainers on the top-up day. But I don’t think it’s a massive problem if the second trainer is not the same person.

Group size

In two schools, the number in the peer supporter group exceeded 20 (n = 26 and 22). Larger groups challenged the quality of delivery, how activities were delivered and the girls’ confidence in participating in discussions. No trainers mentioned any delivery challenges associated with smaller groups:

It [a large group] just felt like crowd control rather than being able to deliver it and being happy with our own delivery. I certainly wasn’t.

Delivery of content

Observation data indicated that, in general, there was good fidelity to the intervention content. Training activities were delivered in line with each of the objectives, at least ‘to some extent’ (Figure 13). The exceptions were the top-up day training in school 10, which was not delivered as intended (see Chapter 5, Training venues), and school 17, where the peer supporters’ level of engagement was low.

FIGURE 13 Average observed fulfilment of manualised activity objectives per school for all training days. 0 = not at all, 1 = a little, 2 = to some extent, 3 = mostly/all. (Figure not reproduced here; see the original article.)

Trainers felt that key aspects of the training were achieved throughout both training sessions across all schools (see Appendix 6). The lowest scoring aspect for both the 2-day and top-up training was how well the training enhanced the peer supporters’ interpersonal skills (mean ± SD score 2.15 ± 0.75 and 2.22 ± 0.55, respectively; maximum score 3). Peer supporters at school 17 scored the lowest across all aspects, particularly in the success of the training in enhancing interpersonal skills (2-day training, 0.50 ± 0.71; top-up training, 2.00 ± 0.00) and helping the peer supporters understand their role (2-day training, 0.50 ± 0.71; top-up training, 1.00 ± 0.00). However, both aspects improved after the top-up day. All trainers reported finding the delivery of the training an enjoyable and rewarding experience.

Supportive learning environment

Observation and focus group data indicated that, overall, the trainers were successful in creating a supportive environment for learning. They achieved this by managing the pace of delivery, making the content clear and relatable, and checking understanding. This also enabled them to respond to arising topics and develop a person-centred approach to delivery:

I think they went through everything quite thoroughly because every time we went back they would quiz us on what we would learnt before. And then, if we couldn’t really remember stuff, they would refresh us.

The trainers’ enthusiasm and friendly manner were key in fostering this environment, as well as making the girls feel confident to share their ideas and opinions:

I think because they were really interested in what they were teaching us, it made it easier to learn about it.

Peer supporters from schools 10 and 16 perceived that the activities were not well linked and that the trainers ran out of ideas. Specifically, they felt that the trainers were not well prepared or did not work well together, and they made the training feel like it dragged. For school 10, this may, in part, be explained by the fact that this was the first peer supporter training that the trainers delivered (see Chapter 5, Adaptation):

. . . we did very separate tasks, but we didn’t actually link them together much . . . If everything we did was linked in together, it would show us what we’re supposed to do.

I don’t know if this was new to them as well. It just seemed like, at some points, they didn’t know, in terms of, we would just be sat there, going to do something and they’d just, like, stare and it would just be silent for about 2 minutes and we didn’t know what to do.

Adaptation

Trainers noted that there was considerable variation between the groups of peer supporters in terms of confidence levels, engagement and understanding, and reported successfully tailoring activities to the individuals’ and groups’ needs. The activities that were affected the most by these aspects involved role play:

You can see it [losing concentration] happening at the time and maybe adapt, if you are quick enough, get the activity to be a little bit more active and move things around.

. . . we did try and get across to them that these conversations and the scenarios, that we weren’t getting them to act. It wasn’t about acting, it was trying to be normal conversations that you would have. Some of them, I think, did feel a little bit nervous about standing up in front of the groups and reading out their scripts or acting it out.

Being able to modify activities effectively relied on the trainers’ ability to read the room, an ability that developed over time, as well as a more natural approach to delivery. Some trainers reported feeling quite nervous for their first session, which may have contributed to the initial scripted style of delivery. This also influenced the trainers’ ability to support the needs of the peer supporters (see Chapter 5, Challenges of delivering the peer supporter training in line with self-determination theory):

. . . it was just lack of experience and lack of confidence and that [being able to adapt the training] was OK. I was quite, sort of, like ‘we need to get this done,’ you know, ‘this is what we need to deliver’ and I need to do it. Sticking by the rules . . . if we had noticed that they were getting a bit frustrated and bored and we’d moved on, that probably would have been better. So that was a learning thing for us.

Fidelity to self-determination theory

Self-determination theory39 was woven throughout the intervention design: in the delivery style coached to the trainers, the content of the peer supporter training and the recommended peer-supporting techniques.52 A crucial component of the theoretical underpinning was the promotion and support of the three inherent psychological needs: autonomy, relatedness and competence. The subsequent section utilises qualitative focus group data and questionnaire data to assess fidelity to the theoretical principles behind the design, and reports the perceived challenges to delivery of the intervention in line with SDT.

Needs supportiveness of trainers and peer supporters’ perceptions of need support

There was evidence from focus groups, interviews, questionnaire data and intervention observations that all trainers were successful in delivering the training in line with SDT: they supported the peer supporters’ autonomy, belonging and competence using a variety of techniques.

Autonomy support

The quantitative perceptions of the trainers’ provision of autonomy support were similar for both the 2-day and top-up training (Table 34), showing that peer supporters felt that, overall, the trainers were supportive of autonomy at all of the training days.

Observation records confirm that trainers provided choice as to how certain aspects of the peer supporter training should be run by involving peer supporters in decision-making about the topics covered, game rules, activity length, working groups and timing/duration of breaks. This was largely supported by qualitative data:

They said very clearly from the start ‘How do you want to be treated? How can we get your attention?’. It wasn’t like school. It was very much from that moment ‘You’re part of this, it’s a two-way thing’. That had an impact on the girls and their involvement.

They didn’t try and control us.

Observation data indicated that girls were primarily offered options; however, sometimes opportunities to involve girls in decision-making were missed. Several girls felt that they had little choice; however, others understood that, given the nature of the training, the trainers gave them choice when the opportunity arose and it was appropriate:

I think everything we had the opportunity to have a say in, like, what we did, because we couldn’t lead it because we didn’t know what to do. They had to take some form of leadership and they did. But anything we could get a say in, we did . . .

Trainers supported learning by encouraging the peer supporters to share their opinions and views, as well as recognising when to adapt the training to the needs of the peer supporters, giving clear rationale for changes:

So, giving them the choice on what they could do helped. You know, ‘so we can move onto the next activity because you are doing really, really well or we can have a little break or a slightly longer break if we carry on with this activity’.

Two trainers felt that failure to do this undermined the peer supporters’ autonomy. Observation data corroborate the belief that, in the occasional instances when only one opinion was gathered or prescriptive language was used, autonomy was undermined, although it was unclear whether or not this affected engagement:

Actually, I think that was one of the mistakes that [trainer name] and I made in [school name], was that, although we did mix it up and we gave them some breaks, we didn’t actually involve them in that process.

Relatedness support

In creating an open, relaxed and supportive atmosphere, the trainers helped the peer supporters feel that they could share and talk freely, allowing the girls to bond with each other and with the trainers. Common approaches to achieving this included being friendly and inclusive, joining in with activities, showing personal interest in peer supporters’ lives to build rapport, using personal experience to relate to the peer supporters, addressing concerns directly using supportive language and learning the girls’ names:

I think they didn’t try and act like teachers, they just acted themselves and just communicated with us as if we’re just all the same.

I just think, yes, building that rapport on that first day, just those little bits of first names, and giving them the options, yes, I would say worked well.

Comments from school contacts suggested that the trainers worked with the peer supporters, communicating with them on the same level rather than talking down to them and teaching them like children. This finding was supported by a trainer who reported that she fostered ‘friendship’ rather than a teacher–pupil relationship:

They [the peer supporters] didn’t feel like you [the trainers] were there to teach them. I think they thought you were there to actually work with them, rather than talk down to them . . .

They just then didn’t treat us like teachers. I think they saw us a bit more like peers, a little bit more, because we weren’t in uniform, we weren’t in anything like that, and we weren’t in their school.

Collectively, the trainers were described as non-judgemental, good listeners, interested and relatable:

. . . they were trying to relate to us, it was quite easy for us to talk about stuff with them.

However, peer supporters from two different schools felt that they did not bond with one of the trainers. At one school, it was felt that the trainer’s body language made her seem unapproachable. No clear reason was given for the lack of rapport with the trainer at the other school:

She always had this look on her face: if we looked over to her, she’d have this stern face, and it wouldn’t make someone approach you, because you’re like ‘oh, they’re a bit, don’t want to be there.’

Observation data suggested that, in a few instances, trainers could have used names more often, to strengthen relatedness and rapport; however, relatedness was actively undermined on only two occasions, when the actions of the school contacts compromised the peer supporters’ relationship with the trainers. These occasions were the incident in school 10 (see Chapter 5, Training venues) and when the school contact at school 17 spoke to the peer supporters in a negative way about the trainers:

We said [to the school contact] ‘Do you mind if we finish early, because,’ and I didn’t even say this, but, ‘they’re not very engaged’ . . . She went to the girls and, basically, started talking about us in a very negative way, and saying ‘they’re saying that you have to finish early,’ like, ‘They can’t be bothered to keep you here for as long as’ . . . That was early on in the day as well. So then, obviously, the girls then were a bit annoyed with us . . . So, that really didn’t help the day . . .

The training was successful in helping the peer supporters relate to other pupils/peers and build a sense of empathy for those who do not like being active or who found it hard. One school contact felt that this was helped by the fact that some peer supporters were inactive themselves:

. . . just seeing how, perhaps, other people might think or how they can help them to be more positive, I think will just naturally, hopefully, be something they take as part of them into the future.

It has given me a new point of view and perspective to other people’s lives and the barriers and boundaries they could put up and make me understand more about other people.

Competence support

Observation data showed that the trainers were helpful and aided learning by answering questions, fully explaining activities and linking them to the role of a peer supporter, as well as adapting activities when the peer supporters were struggling (see Chapter 5, Adaptation). They often prompted girls to find their own solutions to questions and praised their attempts:

. . . they’d explain it really well so we knew what they were saying.

It’s difficult when you are explaining things but trying to prompt them to be the ones that are giving the information and talking. I think that was key.

Trainers also worked closely with small groups and provided targeted support, set achievable targets and used progression in activities. This contributed to the peer supporters feeling well prepared to perform their role outside of the training:

Giving some more small and achievable realistic kinds of ideas of what they could do to peer support.

Trainers would reiterate to the peer supporters why they were nominated by helping them recognise the qualities in themselves that made them good peer supporters; this was supported by the content of the training:

. . . that constant reminder that it’s really important, it’s really a great thing you’re about to do. I tried to say that ‘you’re so special, you’re so fortunate, you’ve been chosen, you’ve got the skills; you’re in such a great position to help your friends’.

In hindsight, trainers felt that they could have done more to support some aspects, including greater focus on how peer supporters had been carrying out their roles, who they could support and trying to relate the training activities to their peer supporter role more. Observation data suggested that isolated cases of failing to relate a skill or activity to the peer supporter role were the only examples of undermined competence in the training:

I think we just could work a little bit more on . . . competence . . . So, just like I said, try and highlight the small things that they’re doing, so they really do genuinely feel that they can be a peer supporter and it’s actually quite easy, or it can be.

Peer supporters from two schools felt that the pace of training was too fast (see Chapter 5, Top-up day), which hampered their learning.

Challenges of delivering the peer supporter training in line with self-determination theory

Delivering the training across multiple schools challenged trainers’ ability to remember all of the peer supporters’ names, which compromised their ability to build rapport quickly:

I tried really hard to use everyone’s names, but it was quite difficult because you were going into different schools.

Supporting the peer supporters’ psychological needs during the trainers’ first delivery was a challenge because they needed to follow the ‘session plan guide’ closely and found it harder to respond to cues from the peer supporters (e.g. when to move on; see Chapter 5, Adaptation). This challenge diminished as they delivered more sessions:

In the first one [school], I was desperately worried about keeping to time and everything being perfect . . . and then you just realised that it doesn’t work that way. There’s nothing really that you can do about it apart from . . . be sensitive to the fact that actually, they are tailing off now and they need 5 minutes [a break] . . . delivering something where they are not engaged is just as good as not delivering it at all. So for the second, third and fourth deliveries, not that we were kind of lax, but you just were a bit more organic about things.

Large groups and disruptive behaviour challenged the boundaries of managing the group, and building relationships and a supportive environment:

I think the bigger the group, the harder it is. Just for that quality of conversation and quality of engagement with the exercise . . . You can create more of a cohesive, supportive environment, maybe, with less people. Less potential for disruption and all of those sorts of things.

One trainer felt that delivering the training in school or with a teacher present made it difficult to give the peer supporters autonomy over the training:

Again, it goes back to them being at school, having teachers there and it just felt very, very scripted. They didn’t have much choice. We weren’t able to move them around in groups because of the space and so, yes . . . the idea that they have autonomy, it didn’t really, that wasn’t exercised in the group, certainly.

Peer supporter autonomy support

There was evidence that peer supporters at one school thought carefully about how to approach conversations with peers, approaching conversations in a way that was more collaborative and less didactic:

You don’t want to seem, kind of, superior than them, saying, like, ‘You need to do this’. Most of us probably didn’t know that we had to do that in the first place. So when we started doing it and encouraging people, ‘Come on, I’m doing it, let’s do it together’ . . .

There was little evidence from non-peer supporters on the extent to which the peer supporters were supportive of autonomy. Some non-peer supporters described being encouraged to be active, but in a less autonomy-supportive style; others felt that peer supporters had been supportive:

They’re a lot more supportive in PE, I think, like cheering you on and stuff and trying to make you get more active.

Non-peer supporters in school 1 felt that the peer supporters had not been supportive and had not considered what their peers might enjoy or their preferences for being active:

I would have liked it if they asked you ‘Are you doing anything fitness-wise outside of school?’ and then actually have a conversation with you about it . . . maybe one of them could have come up to me and helped me out with it and be like ‘you’re doing all right’ and everything like that, but they didn’t.

Overall, the extent to which the peer supporters in all schools used autonomy-supportive approaches was unclear; however, the fact that one school demonstrated a considered approach indicated that the training did promote an autonomy-supportive approach.

Receipt of the intervention and the experience of being a peer supporter

Peer supporters reflected positively on their experience, with many enjoying their role. In particular, they enjoyed learning about the importance of physical activity, the skills the training provided them with that improved their communication with others and being able to help their peers. Peer supporters also reported feeling proud to be a peer supporter and having a sense of reward when helping their peers:

I love being a peer supporter.

Views on trainers

Most of the peer supporters liked the trainers, and both the peer supporters and school contacts thought that they were nice, friendly, helpful (see Table 33), approachable, non-judgemental and ‘found a way to make us have a laugh’ (PS 14):

I think they were really, like, nice and if you ever had anything to talk about and they’d be open to listen, and that was nice.

They were just really relaxed and had that relaxed atmosphere and it was something they had to do, but they approached it really well and it was never forced.

I thought they were great . . . they built up a really nice rapport with all of the students that were there which, again, for our students, is quite important.

The fact that the trainers were relatable and from different backgrounds to those the girls were used to (e.g. teachers and sports coaches) helped them to engage with the peer supporters:

I think that relationship [peer supporter and trainer] worked really well because, obviously, they’re going to be more engaged if it’s people that they can relate to . . . So that, obviously, had the girls interested from the beginning.

Only a small number of peer supporters from three different schools made negative remarks about the trainers. These involved perceptions about the body language, temperament and interpersonal connection with a trainer:

Receipt of content

Peer supporters felt that the training was active, relaxed and included a wide variety of activities, making it more enjoyable and engaging than peer supporters had expected:

Yes, it wasn’t classroom work where you sit there and you have to write it. It was more, everyone was moving and active.

Most peer supporters found the 2-day training interesting (mean score ± SD 3.15 ± 0.83; maximum score 4) across all schools. However, peer supporters from schools 5, 7, 10 and 15 perceived the training to be less interesting than peer supporters at other schools, with mean scores of < 3 (see Table 33). The trainers’ ratings indicated agreement with the peer supporters that the peer supporters at schools 7 and 10 may have lacked interest in the training (see Appendix 7); however, the trainers felt that peer supporters at school 17 had very little interest in both the 2-day (mean score ± SD 0.00 ± 0.00) and top-up day (mean score ± SD 1.00 ± 0.00) training (maximum score: 3), which contradicted the peer supporter’s rating of their interest (mean score ± SD 3.67 ± 0.49).

Overall, the training was perceived to be successful in increasing the peer supporters’ knowledge and understanding of physical activity and preparing the peer supporters to carry out their role. Role play using realistic scenarios and practising peer support were particularly valuable:

I thought we were very prepared, well, we were prepared as we could be for what was going to happen. We done loads of different scenarios.

. . . we’ve learnt how to bring it up and how to apply it to people we may know.

As in the feasibility trial,52 peer supporters and trainers perceived both the ‘peer supporter booklet’ and post box as useful to have in the training days, but they were not widely used.

Enjoyment

Most peer supporters enjoyed the training days (Figure 14); this is concurrent with the trainers’ perceptions (see Appendix 7). Enjoyment increased from day 1 to day 2 and was similar between day 1 and the top-up day. Enjoyment scores were low on all 3 days in schools 10 and 15, and on day 1 and the top-up day in school 7. For school 10, this may reflect the delivery issues that were encountered.

FIGURE 14 Peer supporter enjoyment of the training on day 1, day 2 and the top-up day. 1 = not at all, 5 = a lot. (Figure not reproduced here; see the original article.)

The informal environment, the practical/active activities, being able to learn something new, and the novelty of the training all contributed to their enjoyment:

. . . it was very relaxed and it wasn’t a very formal setting and I really liked that.

[When asked what they most enjoyed] Probably like the activities and stuff like that, because we actually got to practise it [peer support] as well, which really helped.

A small number of peer supporters also liked the activities that involved teamwork because it allowed them to bond, which they would not have experienced outside the training:

[The] training days were really enjoyable, especially when you got on a break and you got to socialise with people that you wouldn’t normally even see around school and get to chat with, which is really nice.

Peer supporters highlighted their enjoyment of the level of autonomy they were given throughout the training, having ‘freedom of speech’ (PS 5) and being given ownership of the tasks, which demonstrated fidelity to the training and its theoretical basis:

. . . it gave you a chance to speak to everyone and find out everyone’s different opinion on the situation.

The peer supporters enjoyed the games on all of the training days (see Table 33); however, specific activities were commonly raised as particularly enjoyable across evaluation methods: the ‘listening train’, ‘self-esteem tree’, ‘like a girl’ and ‘peer supporter pyramid’. These activities set a positive tone and focused on building self-esteem and confidence, something which the girls said that they did not often consider when thinking about themselves or their peers.

Peer supporter attitude and engagement

The observed quantitative ratings showed good engagement across each training day in 8 out of 10 schools (mean ± SD: day 1 training, 2.43 ± 0.64; day 2 training, 2.39 ± 0.30; top-up day, 2.47 ± 0.69; maximum score 3). The trainers felt that the peer supporters were somewhat engaged (mean ± SD: 2-day training, 2.30 ± 0.80; top-up training, 2.39 ± 0.78) and involved (mean ± SD: 2-day training, 2.55 ± 0.51; top-up training, 2.61 ± 0.61; maximum score 3) (see Appendix 7). Observations and trainers agreed that the engagement levels of peer supporters in schools 7, 10 and 17 were low.

Across all schools, the school contacts thought that the peer supporters had a positive attitude towards the training. However, trainers made it clear that this varied greatly by school. Some peer supporters were excited and felt privileged to be there, were ready to learn, behaved well, and were focused and enthusiastic during activities. Others were uninterested and did not take it seriously, and some saw it as an opportunity to not attend school; engaging girls with these perspectives was a challenge:

They [PSs at school 10] just weren’t engaged at all. From the beginning, you could just tell there was nothing there . . . It was such a different experience at [school 4]. We couldn’t have got more different [girls]. From the minute they walked in the room they seem excited to be there. They sat down and they were giving you eye contact and they were looking, and they were ready to learn. It was a different group of girls completely.

Two trainers suggested that the variation in attitude was partly because of age, and that older peer supporters were more likely to lack engagement. Reinforcing the school contacts’ view that the intervention would work well in younger year groups (see Chapter 5, Training content), trainers who had also delivered the intervention in the feasibility trial drew parallels between the different attitudes of the girls in the trials:

The first thing is that I was struck by the difference in the age that they are, in what that brought, just inherently. When I did it 3 years ago [during the feasibility trial] it was with Year 8 girls, and this time it was Year 9 girls. [There was] another level of being ever so slightly removed or slightly aloof to it . . . There was just a slightly different level of engagement. It felt like there was, perhaps, a little percentage of innocence that had been lost in that one year group.

Overall, the trainers and school contacts felt that there was a good level of engagement from the peer supporters, although this fluctuated during the training days:

I think there’s always a slight nervousness of not quite knowing what they’re going to be doing and a slight . . . Always, by the end of day 1, they’re a bit louder and more confident.

The interactive nature and variety of the activities (i.e. game-like activities, debate/discussion and teamwork), the relaxed manner and enthusiasm of the trainers, the degree of autonomy and the sense of responsibility that having the role of peer supporter provided the girls with were highlighted as factors that increased engagement and enjoyment:

. . . they enjoyed being trained up as a bit of a leader and being given a bit of responsibility.

Top-up day

The top-up day was perceived as important because it reinforced the 2-day training and prompted continued peer support. Alongside reinforcing their peer supporter skills and addressing how to deal with challenging scenarios, the peer supporters valued the opportunity to ask questions and share their experiences of peer supporting up to that point:

I think it was definitely something that was needed. There were some guys that had tried to peer support and had come up against a couple of problems and so having that space to discuss it . . .

I like the top-up day because if you didn’t know how to deal with a certain situation you could ask, so it meant if there was an issue in the weeks before, you weren’t just left on your own. You could talk to somebody else about how to deal with that in the future.

The peer supporters’ understanding of their role was broadly similar after the 2-day (mean ± SD 3.75 ± 0.45) and top-up day (mean ± SD 3.80 ± 0.46) training (maximum score 4), and they learned new information (see Table 33). However, all stakeholders agreed that there was not enough top-up day content and that it was repetitive and not active enough. The data in Appendix 8 support this, showing that activities were delivered faster than planned on the top-up day. One school suggested that all content could fit in 2 days, which should be spread out:

The only thing I would say about the top-up day was it felt like there wasn’t quite enough content to fill the time.

Evidence of peer support: fidelity to diffusion of innovations theory

Evidence of peer-supporting activities was obtained using a self-report questionnaire (see Appendix 9) and discussed in focus groups. The most commonly cited types of support offered (‘often’ or ‘very often’) were being active with friends (62.12%), being an active role model (48.48%) and inviting friends to be active with them (43.94%):

I was sort of saying that ‘I really want to do more sports clubs, do you want to join with me?’. So making it not about them, like they’re doing something wrong, so it was about me, ‘will you come with me?’. It’s a technique we learnt at the training.

Some peer supporters reported using facts in conversations (others felt that this approach might bring an awkwardness to conversations; see Chapter 5, Challenges to being a peer supporter), which shocked some non-peer supporters, as well as encouraging their friends to be active by making physical activity fun:

Finding a fun way to do it, so, I find peer supporting – well, I don’t really call it that. I’ll make it into a game, so if we’re going to do running in PE, we’ll go on a mad one, like running around the field and we’re actually being active, but you don’t realise it. It’s a way of disguising it.

I think people were quite shocked when they found out you need like an hour a day. They were like ‘that’s so much’ and I was like ‘I know, you need to get running,’ and things like that which are shocking facts that nobody really knows.

Peer supporters preferred to adopt a subtle approach to their encouragements and felt that peer supporting was quite natural and aligned with their identity:

. . . being quite subtle about it [peer supporting] . . . So not letting them know there’s a reason why you’re telling them all of this.

Sometimes it’s like a natural thing you do, to help them to do PE or try and encourage them to do it. It’s like part of who you already are, to try and encourage people as it is.

When asked about the types of support provided and the number of friends they had supported, being active with friends was again the most prevalent type of support (40.15% reported providing this type of support to four or more friends); however, the strategy with the second largest reach was talking to friends about the benefits of being active (28.03% reported providing this type of support to four or more friends). The least popular types of support offered by peer supporters were those that involved encouraging friends to adopt more or new activities.

Peer supporters encouraged participation in sports, active travel, walking, running, cycling, after-school clubs and going to the gym. At least one non-peer supporter in the focus groups in each of the seven schools indicated that the peer supporters had been encouraging or supportive in these activities (see Chapter 5, Peer supporter autonomy support) or by using the strategies mentioned above:

. . . me and my friend were going to get the bus to go out, but then I convinced her to walk with me . . .

My friend, she talks about being active more now than before she went [to the training]. She wanted me to run with her to work so she could get more active . . .

Peer supporting was made easier when peer supporters were in one-on-one situations with close friends and during PE. Several peer supporters expressed the importance of trust and identifying when conversations needed to be confidential:

I only really stick to my close friends, so I just basically say what I know they can take.

I feel like if someone came to you about something, you would want that to be kept to yourself because they come to you about something, you don’t want to then tell other people. That person purposely came to you because they trust you.

Other peer supporters felt that working together to encourage their peers to be active was a form of support for each other, boosting their confidence. This was perceived to hold more persuasive power when convincing peers to be active:

. . . when you’re in a friendship group and you’re bringing something up, if the peer supporter is there they can help that plan go forward if the person . . . they can go along with it, I guess, and help you push it . . .

Although we have clear evidence of peer supporters’ attempts at encouraging physical activity among their peers, conflicting accounts from various stakeholders also suggest that peer supporter activity was inconsistent. Almost every school had peer supporters who reported that they had performed no peer supporting, with the majority of peer supporters in school 17 stating that they had done ‘not a lot’ (PS 17) to get messages to friends about being active. This is a direct contradiction of the results from the peer support fidelity questionnaire (see Appendix 9):

I haven’t done any [peer supporting].

The non-peer supporters across all intervention schools gave the overarching impression that most peer supporters had not undertaken any work to carry out their role, or at least that they had not witnessed ‘active’ peer supporting by their friends. Some suggested that the peer supporters forgot about the project after the training. The non-peer supporters felt that the peer supporters should have done more to support their friends:

If anything, you wouldn’t notice that they’re trying to be supportive with you because, like, if they’ve been trained to be supportive with sport and anything else, they just genuinely have not been supportive at all. I know for a fact that one of my mates, like, [PS name], she just hasn’t been supportive of anything.

. . . I just don’t think they put any effort into trying to get people who aren’t as active or aren’t as sporty, to try and encourage them to do anything, which I thought was going to be part of it . . . I haven’t seen them making a real effort to try and encourage a broader spectrum of pupils.

On the other hand, it could be argued that the application of a more subtle approach to peer supporting, in line with the training that the peer supporters had received, would preclude the non-peer supporters from noticing some peer supporter activity:

They wouldn’t worry because they don’t realise, which is quite good, because it’s just like having a conversation.

Many trainers and school contacts questioned whether or not some peer supporters had done anything to support their peers to be active. Trainers believed that, despite peer supporters providing realistic examples of peer support during the top-up day, some examples may have given the impression that they had provided peer support more than was in fact the case. Most school contacts suspected that this could be true, but believed that the majority of peer supporters would have tried to embrace their role using the strategies from the PLAN-A training:

And then it comes to the top-up day and it was like ‘How have you got on?’. Hadn’t done a thing. Hadn’t done a thing.

I think some of them had [peer supported]. I think some of them probably just said stuff because they knew they had to. But some stuff, like, they couldn’t have just thought that up on the spot.

However, it was also suggested that many peer supporters were supporting their peers naturally, without realising they were doing so; it was only through discussion with the trainers at the top-up day that peer supporters realised how they had been peer supporting:

I didn’t realise I was doing it, but I was being a peer supporter, but I wasn’t consciously thinking ‘Oh, I need to do it and then go and write it in my book’ . . . I didn’t make a conscious decision to go and peer support, I was just doing it more naturally.

Others had said ‘we haven’t done anything. We haven’t done anything and we are desperately guilty about it’. Then, actually, when you tweaked a little bit more, they had actually done a few things, they just hadn’t considered that to be peer supporting.

Aside from supporting peers, some peer supporters provided support to their family members more than their friends at school, potentially because they felt more comfortable doing so. It was unclear if, by peer supporting their family, they felt that their role was being executed and, therefore, did not attempt to encourage their peers at school:

I tried to, I think, once with my sister, and I ended up making her walk around [place name] with me. But she enjoyed it, which I guess is the only time it really worked. That’s because I think it’s family.

Some of them talked, specifically, about things they’d done with family. There were a couple that had talked quite specifically about that, and maybe because they were the examples that they could remember, or they might have been the times when they felt comfortable to try it out a bit more.

Challenges to being a peer supporter

Challenges to providing peer support included not having the opportunity to do so, peer resistance, a lack of confidence or time, and the distance between home and school.

Peer supporters suggested that a principal barrier was the lack of convenient opportunities to provide support. If their friendship group did not talk about being active or their friends did not express a desire to be more active, the girls felt reluctant to raise the issue for fear of it sounding contrived. This often led to the peer supporters forgetting to peer support, as it was not at the forefront of their minds:

The situation hasn’t really come up [to be able to peer support], but if it did, I think we would be quite prepared because, obviously, we did lots of different situations.

It’s like, how to go up to someone and say that they need to be more active without it being taken the wrong way. They’re going to take it the wrong way.

Peer supporters found their role particularly difficult, and sometimes disheartening, when peers were stubborn, resistant to suggestions or did not listen. School contacts added that attempts to support could be construed as patronising unless approached carefully and with a co-participation angle:

Some of them can be stubborn and they just think, ‘I’ll do it my way, I don’t need your help.’

. . . every other time I asked somebody I got told ‘no’. They said they’d rather do something like watch Netflix [Netflix, Inc., Los Gatos, CA, USA] or play a game or something like that. And it was really frustrating. It made me want to give up, but I didn’t.

Peer supporters expressed concern that starting conversations with non-peer supporters, and especially citing facts about physical activity, would seem contrived and be received poorly. This deterred some from trying this approach. Despite fears of causing offence, there was no evidence that this happened:

I think they’d find it a bit offensive, like, ‘Whoa, why are you saying that to me?’

. . . if I have a conversation about how not everyone is going to exercise, you can still do an hour a week, I think people just, kind of, get a bit annoyed.

Lacking confidence to be a peer supporter or be active themselves held some peer supporters back from overcoming these barriers with their friends. Trainers also noted that confidence in different situations was a concern for many of the girls:

A lot of them still had that barrier [to peer supporting], they said ‘well, my friends still don’t want to do it’ and even though we’d gone through it so much in the first 2 days. So, it just felt like the barriers were that much harder to overcome, or they didn’t have the confidence to try and overcome them, maybe.

. . . they all felt that these stereotypes were in existence, but having the confidence and the tools to actually challenge people about it they lacked.

Trainers felt that some peer supporters did not understand the informal nature of peer supporting, instead believing that peer supporting was a structured, planned event, making them feel like they did not have time to peer support:

I think they still sort of felt, like, that they were required to have these big conversations with facts in and they felt a bit uncomfortable. They felt a bit silly.

I suppose, just the time seemed to be a massive issue. Obviously, this time of year was probably a difficult one for some of them. They’ve got exams or they’ve got other stuff going on. Weirdly, they didn’t feel like they could fit it into their day . . . But that was the common worry and anxiety.

Some peer supporters in school 14 felt that living far from school made it difficult to support their friends. In other schools, girls could suggest active travel or co-participation, whereas peer supporters in school 14 felt that those options were not available to them. The school contact agreed that this limited peer-supporting opportunities within the school:

I live in the middle of nowhere with no city or town anywhere near me. None of my school friends live there, so it’s quite difficult to bring out those conversations because they’re like ‘Shall we do parkrun [parkrun Ltd, London, UK]’ because I’ve got some of my friends to do parkrun on like Saturdays and things. That’s about it. There are no buses where I live on Sundays and it’s just quite difficult.

Other challenges included finding it more difficult to peer support around boys, having a limited friend network and having friends that were already active:

. . . it’s almost as if I spoke to all my friends that I talked to and I spoke to all of them about it at the lunch table or on the way home and then that was it. There was nothing else I could really do, because I’d already tried doing it.

Overcoming the challenges to peer supporting could have been made easier by working together, but this was difficult if they were the only peer supporter in their social circle (Chapter 5, Outcome of peer nomination, reports that the desired reach of peer nomination was not achieved in all schools):

It was quite difficult for me because I only had one other person in my form who was doing it and I don’t really speak to her very much because she’s not one of my close friends. So it was more difficult to – obviously, it would have been a bit weird if one of us just to go to the other person’s friendship group or something like that because then it would make it more noticeable and obvious.

Perceived intervention effects

Effect on peer supporters

Impact of being nominated

The nomination method was praised by peer supporters and school contacts because it was conducted by peers rather than teachers. This meant that the girls who were nominated had a higher sense of peer endorsement and it increased their self-esteem/confidence, especially for those who did not expect the nomination:

It wasn’t like your teacher picked you. It was that people within your year thought you were fit for the role, and that made you feel better about yourself.

Impact of the training

Peer supporters from all schools understood their role after the 2-day (mean score ± SD 3.75 ± 0.45) and top-up day (mean score ± SD 3.80 ± 0.46; maximum score 4) training sessions (see Table 33). Some peer supporters reported becoming more active as a result of a greater awareness of their own physical activity levels:

I’ve become more aware of how much I have to do, and not just telling others.

I’ve also been doing more exercise since I’ve learnt all the facts and things like that. I think it’s influenced me as well.

The training also positively impacted peer supporters’ confidence, communication and social skills, resulting in a more empathetic approach to their peers:

. . . a lot of them were saying that they just felt more self-confident in themselves.

The girls, from my point of view, came out of that knowing exactly what they should be doing, exactly how to support and support in a nice manner, rather than just holding that everybody has to do more exercise. So, the training side of the peer supporters worked really well.

I feel like I’ve learnt how to communicate with people and how to support people better than I already could.

. . . now I’ve learned how to go with a nicer approach and more advise people and be like ‘come on, I understand, let’s do it together’.

However, after the training, confidence to pass positive physical activity messages to their friends varied between schools, and in half of the schools the average score was lower after the top-up day (see Table 33).

Finally, training strengthened peer connections and helped the girls to develop as leaders:

There’s probably little groups that don’t actually know each other. So it was nice that they got to interact because that’s maybe something that they don’t necessarily do while they’re at school.

I think it helped them develop, almost, their leadership skills, in a way. It helped develop them as role models.

Impact of being a peer supporter

The act of being a peer supporter impacted the girls in different ways depending on their experience; however, many reported that it motivated them to keep active. It also helped them to develop broader transferable skills, such as kindness, empathy and the ability to build new relationships. School contacts felt that the training fostered social maturity:

I feel like I’m doing more sport. Obviously, I did stuff before, but I feel like I’m more conscious, ‘oh, I haven’t done anything today, I need to go for a walk’.

Another one [impact of being a peer supporter] is building a relationship, because I wasn’t really close to this girl in my science class. And then I was like ‘do you want to go swimming?’ just out of the blue. And then we ended up going swimming, and we built a decent sort of friendship.

Although non-peer supporters believed that they had not witnessed peer supporting in action, there were some indications that they had seen changes in the peer supporters. They felt that their attitudes towards being active themselves had changed in that they wanted to be more involved in active opportunities and their confidence had increased. Non-peer supporters from one school said that the peer supporters had started to interact with girls they did not know before:

In PE, say for sports day, they’re volunteering for more things and stuff and they’re more active in PE.

She [a peer supporter] wasn’t confident contacting people out there and stuff like that. And now that, after PLAN-A, I feel like she contacts more people and she’s more active with people and stuff.

The non-peer supporters in the other half of schools said that they had not noticed any changes in the peer supporters, particularly those who were already active:

The people that you took there are group of them who are quite sporty already, so they just stayed as they were . . .

Effect on other girls in Year 9

Many peer supporters felt that they were successful at encouraging and supporting their friends to be active and could give examples of how they did this (see Chapter 5, Evidence of peer support: fidelity to diffusion of innovations theory).

Some peer supporters felt that many non-peer supporters were more open to being active and enjoyed physical activity more. Two school contacts agreed that Year 9 girls were now more engaged and supportive of each other in PE:

I think we’ve definitely seen an increase in engagement in lessons. I think they’ve [all Year 9 girls] all been a lot more supportive . . . they’ve all been so supportive of each other and cheering each other on. Some of them have run extra laps with the slow ones, to keep them going, which would never have happened before we did this at all.

Non-peer supporters at school 7 felt that girls in their year may have become more confident in PE and in front of boys since the intervention began:

Non-peer supporters at another school said that there is now less pressure to be good at PE. A small number of non-peer supporters and school contacts from different schools reported uptake of new activities since the intervention began, including walking, running, going to the gym and being outside together, as well as increased sign-up to school clubs. Nevertheless, they were unsure whether this was due to PLAN-A or seasonal variation. Conversely, many non-peer supporters stated that they had not started new physical activity since the intervention began:

[When asked how girls’ confidence has changed in PE after PLAN-A] it’s just that we don’t feel that we have to do well in PE. That might be a teacher or it might be just in general, the people. We don’t feel like we’re pressured to be amazing sports people.

After you did PLAN-A, a lot more girls will go to the gym or try it and a lot of people liked it, so they kept on going back.

I know there are a few Year 9 girls that now want to join the cricket after school as well, but then I don’t know whether that’s just because it’s warm weather now and they’re a lot happier to be outside than inside.

Some peer supporters were unable to or did not carry out their role and were therefore unsure whether or not they had had any impact on their peers. Some peer supporters who did peer support did not think they had any impact and did not notice any changes in physical activity. Any impact they may have had was described as not significant or long-lasting. Some attributed this to the fact that non-peer supporters were unaware of the project and what the peer supporters were trying to do:

Not really [been successful in encouraging others to be active], just because it’s quite hard to just go up to someone and start the conversation with them if you’re not sure why they have that barrier.

I’ve had some success, but it’s not been an overwhelming amount where people have suddenly gone up the amount of activity they’ve done. It’s normally a one-time thing that happens. And then it doesn’t happen again.

At most schools, peer supporters going to the training days initially sparked interest among non-peer supporters, but this diminished with time. Most non-peer supporters did not know why certain girls went away for the training unless the peer supporters told them, which they found hard to explain or understand:

I think some people do know where we went, because when they go ‘Where’d you go?’ some of us went ‘Well, we did this, and these are the facts,’ but I think they just forgot about it over time.

Some school contacts corroborated non-peer supporter claims that taking part in data collection, specifically wearing the accelerometers, made them more aware of and thus increased their physical activity:

I think when we used the belts, definitely. I think when the belts came in, the girls were actively thinking ‘Actually, I’m being tracked, and I’m not doing very much’. I think that would’ve helped participation. I really liked that side of it.

The consensus from non-peer supporters was that the intervention had no social effects, stating that there were no differences in friendship groups or how they interacted. However, comments from school contacts challenged this view, as some felt that conversations between different girls had increased:

We didn’t really have a change in our friendship group.

I think a social one in terms of them having the conversations. The freedom between the PLAN-A students and the non-PLAN-A students to have those conversations.

Overall, all stakeholder groups were uncertain about whether the intervention had resulted in any social or attitude changes in other girls in Year 9, although this would be difficult to detect or measure robustly in any case. None had observed pervasive changes in attitude towards, confidence in or talking about physical activity since taking part in PLAN-A:

School context

School attitude, curriculum and policies

The project aligned with key aims within the PE departments of most schools around improving participation and leadership and was therefore considered a priority within PE in those schools. In several schools, PLAN-A aligned with the school ethos, as healthy lifestyles and physical activity were embedded in their school values; however, only one school (school 14) saw supporting the project as a school-level priority:

In terms of the PE department, our aim is to make sure we’re giving the skills and the confidence to all of our students to, hopefully, instil life-long involvement in physical activity and healthy lifestyles.

It was ideal and it brought in everything that we want to push forward to the girls, with the added bonus that, actually, if it did work, which you guys decide, we get the added bonus of increased fitness and health of our girls as well, so it was perfect.

In one school, the project was not seen as a priority because lessons and exams were of higher importance:

It wasn’t really very high in our priorities as a department or a school. Yes, the day-to-day running of lessons and exam results and things like that were a higher priority.

In school 10, the leadership’s attitude to the trial as a whole was described as ‘poor’ (SC 10) by the school contact, which they contextualised by explaining that the senior leadership team (SLT) had not properly read the trial information and did not fully understand what was required of the school or the benefits to the participants:

Maybe, the head teacher and SLT, I don’t think they fully understand the benefits and what you’re trying to get out of it.

Just because they lost the paperwork. I don’t even know who actually signed all the paperwork and who, actually, was the first person. Because our staff turnover last year was really high. I reckon at least three other people who took it forward to SLT have probably left.

Appendix 10 shows that school policy scores (with higher scores indicating that the policy is more supportive of physical activity) were largely similar between intervention (mean score ± SD 7.50 ± 1.51) and control schools (mean score ± SD 7.40 ± 2.62; maximum score 12). However, three schools (control, n = 2; intervention, n = 1) received very low policy scores (i.e. ≤ 6).

Appendix 11 shows the level of physical activity throughout the wider curriculum of each school. The mean score ± SD for the control schools (3.80 ± 1.62) was marginally higher than that in the intervention schools (3.20 ± 1.62; maximum score 8); however, the difference was small and there was high school-to-school variability, so any difference between arms would not have been consistent across all schools in each arm.

Physical activity provision

School environment audit data (see Appendix 12) that examined the facility provision at each school to support active travel, sports and general play (see Chapter 2, School context) were highly variable between schools, but did not show meaningful differences between the intervention (mean score ± SD 81.90 ± 12.61) and control group (mean score ± SD 84.55 ± 15.00; maximum score = 164). Comparing baseline school-level physical activity data with physical activity provision scores showed that a low score for physical activity provision (e.g. schools 12 and 17) appeared to be crudely associated with low levels of physical activity (Figure 15).

FIGURE 15 School-by-school comparison of facility provision scores over baseline MVPA minutes. (Figure not reproduced here; see the original article.)

No schools took part in any other physical activity research projects during this trial, and just three (control, n = 2; intervention, n = 1) had any involvement with local initiatives that might have influenced physical activity behaviours (see Appendix 13). Termly changes to PE provision or extracurricular opportunities between T0 and T1 were balanced between trial arms; however, four control schools described a change in the focus of PE for girls, moving away from competitive sport and towards well-being and health. School contacts in those schools described a gender-specific consideration not just for what girls enjoyed, but also for what would motivate them to continue to be active beyond school. No intervention schools reported a similar change:

We also look at modern influences such as the interest girls have in exercise to music and dance. So, ‘Fitness Marshall’- and ‘Body Pump’-type exercises have been incorporated into the health and fitness sessions of our PE curriculum. For one of their 2-hour PE lessons, there is a ‘mass fitness activity’ that has been influenced by modern fitness trends, such as HIIT [high-intensity interval training] or exercise to music, with the aim of inspiring them to exercise once they leave school.

Public stakeholder interviews

Intervention weaknesses

When asked about potential factors limiting the effectiveness of school-based, individual-level interventions to increase physical activity in young people, respondents described a range of interconnected factors. These stemmed from the school as the setting, because the priorities of individual schools do not necessarily allow space for an agenda that facilitates increases in physical activity or a culture that promotes it throughout the school:

I think, obviously, the pressures upon schools in terms of standards, progress and achievements, obviously, has a significant factor as well, when it comes to making decisions on what schools prioritise and what resource they put behind that.

Additional issues were highlighted, including failure to consult the end user and engage parents in design stages, and a lack of wider support for change:

We’ve made the mistake for years of putting on activities for young people, as opposed to understanding what the needs of the young people are and delivering what they want.

There was an overall view that many individual-level interventions were reliant on isolated champions, were implemented in environments in which physical activity was not a priority and failed to consider the scaffolding that is necessary for sustained change within and outside of school.

Whole-school approach considerations

The consensus among stakeholders was that adoption of a whole-school approach to promoting physical activity is contingent on sympathetic school leadership, with leaders needing to be convinced of the value of the approach for their school and students. Of primary concern to school leadership is the criteria that the Office for Standards in Education, Children’s Services and Skills (Ofsted) in the UK use to evaluate schools, so several stakeholders recommended aligning school assessment criteria with well-being outcomes to increase adoption of whole-school approaches to physical activity:

. . . if you’re going to have a whole-school approach, it has to relate to those wider measures for schools to really buy into it, certainly at senior level.

Stakeholders reported that any whole-school approach must work around school-specific challenges at the point of implementation, including, but not limited to, resource issues, staff capacity and confidence to adapt lessons, and pressure to deliver against existing Ofsted criteria. Consultation in design is therefore vital to creating a flexible and sustainable offer for schools that meets the needs of their community and is deliverable by their staff:

. . . making sure we can be as flexible as possible for schools, to enable them to take an approach that best suits their circumstances.

Culture change within schools was discussed at length and framed as both a crucial component in any whole-school approach and the main objective of the approach itself. All respondents agreed that there must be a united approach within the school to create culture change, but that the support and cooperation of the wider community around each school is also crucial to creating an environment in which behaviour change could be maintained:

Because if your environment and your structures and your attitudes aren’t changing, I’m not sure you get any real meaningful change either.

Research used and needed

The interviews highlighted that the use of research differed by organisation, and some stakeholders expressed a lack of confidence to source and apply high-quality relevant research to underpin intervention design or evaluation. Providing robust research that was easily accessible and linked physical activity to measurable educational outcomes was highlighted as a key need:

I need to present data that shows that engagement has produced that educational outcome that has improved their chances of educational success or social mobility . . .

Respondents reported that case studies are a preferred research model for schools to see if and, crucially, how programmes work in practice. This is an important finding as the majority of research focuses on summary data and does not follow the case-study approach. There is an appetite for a united approach between research institutions and public-sector organisations to co-produce useful evidence to drive the physical activity agenda forward:

I think there has got to be a more coordinated approach to influence the government as well. I think we need to be looking at potential policy recommendations and initiatives . . .

Impact of COVID-19 and post-COVID considerations

At an unprecedented level, schools have had to change how they operate in the face of the COVID-19 pandemic. Respondents felt that these changes had reduced the opportunities to be active at school and added barriers, thereby exacerbating existing health inequalities and increasing the complexity of implementing school-based physical activity interventions of any kind. It was also felt, however, that the importance of physical activity for well-being had been highlighted during this time and that this should be harnessed to encourage uptake from schools by reframing the benefits of physical activity to aid post-COVID recovery and linking it with school attainment objectives:

I suppose, the opportunity, you can argue, is to reframe the role of physical activity as a real positive in terms of what we’re trying to do now within schools.

Post COVID, virtual physical activity offers could be used as a strategy for schools and organisations to engage a broader range of pupils and address provision inequalities:

We’re always going to run a virtual element because we’re attracting children that wouldn’t do that in a team.

Summary of process evaluation key findings

This chapter has provided a lot of information about the delivery and receipt of the PLAN-A intervention. Table 35 presents the key findings of the process evaluation.

Comparison with the PLAN-A feasibility trial

There were several differences between the process evaluation of the feasibility trial55 and the definitive trial of the PLAN-A intervention. We think that it is useful to present the data that might inform our understanding of these differences, as well as the perspectives of one researcher (KW) who observed intervention delivery and two trainers who delivered the intervention in both trials.

The two trials produced very similar results in terms of dose, fidelity and quality of intervention delivery, suggesting that the intervention is scalable. However, certain factors in the definitive trial may have led to differences in how the intervention was received compared with how it was received in the feasibility trial.52 The principal difference between the two trials was the age of the participants: girls were in Year 8 (i.e. aged 12–13 years) in the feasibility trial and in Year 9 (i.e. aged 13–14 years) in the definitive trial. The transition to the General Data Protection Regulations (GDPR)97 between the two trials meant that the consenting procedures and age of participants had to change to be GDPR compliant. This presented a conflict between the theoretical underpinning of the intervention (i.e. DOI, effectively, that the trial is conducted within a naturally occurring social network, e.g. a school year group) and the GDPR rules on use of opt-out consent.97 To use an informed, opt-out consenting procedure, girls had to be aged 13 years and, therefore, in Year 9. Trainers and researchers alike felt that this had a significant impact on delivery factors and receipt of the intervention.

In the definitive trial, 9.58% fewer girls consented to be a peer supporter than in the feasibility trial52 (86.91% vs. 96.49%, respectively). The main reason for this was not wanting to miss important lessons. This may be a product of Year 9 participants (and their parents) placing greater emphasis on academic focus. Being slightly older, the peer supporters in the full trial were able to understand activity explanations and grasp the key purpose of the training more quickly than the younger peer supporters in the feasibility trial.52 The trainers who had delivered the intervention in both trials suggested that this may have led to the peer supporters perceiving the training as repetitive and lacking sufficient content. By contrast, during the pilot phase of the feasibility trial,52 refinements were made based on participant feedback to ensure key themes and activities were reiterated. A perception that activities were repetitive may have contributed to reduced engagement and interest during the training in the definitive trial, which was found to be an issue in some schools.

Being 1 year older also seemed to impact the girls’ attitude to the project. Year 9 peer supporters appeared to be slightly more indifferent during the training than those in Year 8, as if they did not want to be seen as too ‘keen’ or to care too much about the training for fear of appearing ‘uncool’. Despite being interested in what they were learning, they appeared to lack the motivation to overcome the barriers to peer supporting, that is when their peers were stubborn or resistant; the peer supporters in Year 8 seemed more invested, and more willing to follow the trainer’s instruction and carry out their peer supporter role.

Year group sizes were larger in the schools in the definitive trial than in the feasibility trial52 (mean 92.05 vs. 75.16, respectively), which could be a result of delivering across more schools (20 vs. 6, respectively) and/or Year 9 being an intake year for many secondary schools. This resulted in larger peer supporter groups in the definitive trial than in the feasibility trial.52 This was a key challenge to delivery for the trainers in the full trial, mainly through challenges to behaviour management that undermined the quality of delivery. It was also difficult to find community training venues that were large enough, which presented challenges with regard to space constraints.

The training being held on site in one school in the feasibility trial presented challenges of frequent disruption from other pupils and peer supporters being able to leave for other school commitments.52 In the two schools that delivered on site in the full trial, these challenges were similar, yet more pronounced, with the addition of more disruptive behaviour from the peer supporters. This could also be related to the older age group, as they may have been more confident and familiar in their school setting to behave in such a manner.