Title: An exploratory study to test STASH, a peer-led intervention to prevent and reduce STI transmission and improve sexual health in secondary schools
Funder: Chief Scientist Office, Scotland

Abstract: Rationale: Young people in the UK are at highest risk of STIs and report higher levels of unsafe sex than any other age group. Their elevated risk has been linked to lack of awareness, insufficient knowledge of how to protect themselves, and social norms which denigrate safer sexual behaviour and undermine the quality of intimate relationships. Research suggests that involving peer supporters in intervention delivery is acceptable to students and effective in reducing risk behaviours via ‘diffusion of innovation’, particularly where peer supporters are influential role models, chosen by peers. Interventions in which peer supporters work informally within their social networks offer a useful alternative to peer-led didactic teaching, which has shown limited effects. To date, there have been no UK school-based studies in which peer supporters utilise social media, despite research from elsewhere suggesting their potential. Intervention: Building on learning from ASSIST (an effective peer-led anti-smoking intervention), we will identify and recruit the most influential students in fourth year (S4) of secondary schools (aged 14 to 16) in Scotland. These students will attend a two-day training run by specialist trainers. Over a defined period (between 4 and 10 weeks) they will use social media and face-to-face interaction to diffuse information, norm change and support for healthy sexual behaviour among their peers. They will be supported – through regular meetings and via social media – by the professionals who trained them. Participants and methods: Stage one involves formative evaluation of the intervention, including expert and student panels to advise on intervention design, as well as piloting of the intervention and evaluation instruments in one school. In stage two the revised intervention will be tested via an exploratory study in 6 schools, with staged implementation and comparison with the previous cohort of S4 students (controls). We will undertake a process evaluation in 6 schools based on: structured observation and evaluation of training; web-based questionnaire for peer supporters; interviews and focus groups with peer supporters, student participants, trainers, teachers and parents; and social network analysis. Measures: The main outcome is attainment of progression criteria to a potential subsequent full trial. The primary intervention outcome is frequency of unprotected sex. We will also assess the feasibility and acceptability of linkage to NHS data on STI diagnosis as a longer-term outcome. Secondary outcomes include: self-reported STI diagnosis, testing and symptoms; sexual behaviour; relationship quality; adherence to targeted behavioural norms; perceptions about the behaviour of others; knowledge of STI risk; awareness and use of local sexual health services; STI prevention skills; beliefs about capabilities. Process measures include feasibility, fidelity, acceptability and reach of the intervention, for example the proportion of nominated peer supporters who agreed to participate. We will assess the perceived value of peer supporters among students, the level of exposure to the intervention, and acceptability to teachers. We will also record the key costs of intervention adaptation, implementation and maintenance and we will assess the feasibility of measuring sexual quality of life and information on sexual health related health care resource use.

Lay abstract: Background: Young people in the UK report higher levels of unsafe sex than any other age group. As a result, they are at highest risk of getting, and passing on, sexually transmitted infections. Young people often lack awareness of the risks or are unsure how to protect themselves. They are also vulnerable to social pressure from friends and peers who seem more sexually experienced, and to popular beliefs that safer sex behaviour is ‘uncool’. Youth peer-led interventions often involve peers 'teaching' friends or younger children. Peer educators often volunteer themselves for this role or are chosen by teachers; this type of selection tends to result in young people who are committed to school and who may find it difficult to relate to students who are disengaged and at highest risk. An alternative is to recruit young people from among those voted as most influential by their peers, and to train them not as peer educators but as peer supporters. These individuals then act as role models who change behavioural norms through social networks and other mechanisms of influence. This has been tried, with success, in a school-based anti-smoking intervention called ASSIST. Early research on the use of social media in promoting healthy behaviour is promising. Most UK teens are connected to online social networks; messages can spread rapidly; and social media provides an alternative to talking about sex directly, something many youth find embarrassing. The intervention: We will build on components found to work well in ASSIST: recruiting influential peers, allowing knowledge and attitudes to spread via social networks and using professionals to train peer supporters. However, this intervention focuses on sexual health, an older target group and utilises social media to spread messages. Students, experts in sexual health, teachers and parents will contribute to the intervention design. We will identify and recruit the most influential students in fourth year (S4) of secondary schools in Scotland. These students will attend a two-day training run by specialist trainers. Over a defined period (between 4 and 10 weeks) they will use social media and face-to-face interaction to influence sexual norms and behaviour among their peers. They will be supported – through regular meetings and via social media – by the professionals who trained them. Testing whether the intervention works: The main aim of the study is to find out whether the intervention is feasible, acceptable and implemented as intended. Following a pilot test in one school, we will implement the intervention in a further 6 schools, using the previous cohort of S4 students as controls; these students will move to S5 before the intervention starts and will therefore not be exposed to it. We will examine how the intervention was implemented by evaluating activities, and by talking to students, teachers and parents about their experience of being involved. We are interested in whether the intervention improves attitudes, knowledge, and risk-reduction skills, and whether these, in turn, delay first sex, increase condom use and improve the quality of sexual relationships. The study is not big enough to tell us whether the intervention worked, but will let us to assess whether it is worth doing a larger trial, and if yes, how we should go about doing this. Peer supporters will present the findings to their year group, teachers, and other professionals, and we will write up the results for academic and policy audiences. If the intervention is successful, we will seek funds for a full-scale trial.

Research activity codes: 3.1 PRIMARY PREVENTION INTERVENTIONS TO MODIFY BEHAVIOURS OR PROMOTE WELL-BEING
Health categories: INFECTION;REPRODUCTIVE HEALTH AND CHILDBIRTH