Topping, Keith J.

English

Peer education and peer counselling have existed as complements to intervention for health and wellbeing by doctors, nurses and other professional staff for many decades, but only in recent times has effectiveness research become satisfactory. These methods have potential advantages in penetrating contexts where professionals cannot, but this means establishing effectiveness is complex. This study evaluates 58 reviews (narrative and systematic reviews and meta-analyses) on this issue. In peer education, many reviews of sexual health and of HIV/AIDS interventions were found, with smaller numbers of reviews of certain medical conditions and the prison context. In peer counselling, reviews of breast-feeding and mental health were evident. Earlier reviews tended to complain of lack of research; later reviews established knowledge gains but no gains in attitudes; still later reviews discovered both knowledge and attitude gains; and most recently there was evidence of knowledge, attitude and behaviour gains. Peer education and counselling are effective in certain areas (but effectiveness is unknown in other areas), and then only if projects are well managed and the cultural context taken into account. Action implications for research, practice and policy were suggested

University of Dundee Online Publications

                                                                    University of DundeePeer-Led Interventions in Health and Well-BeingTopping, Keith J.DOI:10.35841/2471-9854-8.6.146Publication date:2022Licence:CC BYDocument VersionPublisher's PDF, also known as Version of recordLink to publication in Discovery Research PortalCitation for published version (APA):Topping, K. J. (2022). Peer-Led Interventions in Health and Well-Being: A Review of Effectiveness. ClinicalPsychiatry, 8(6), [146]. https://doi.org/10.35841/2471-9854-8.6.146General rightsCopyright and moral rights for the publications made accessible in Discovery Research Portal are retained by the authors and/or othercopyright owners and it is a condition of accessing publications that users recognise and abide by the legal requirements associated withthese rights. • Users may download and print one copy of any publication from Discovery Research Portal for the purpose of private study or research. • You may not further distribute the material or use it for any profit-making activity or commercial gain. • You may freely distribute the URL identifying the publication in the public portal.Take down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Download date: 23. Sep. 2022ABSTRACT Peer education and peer counselling have existed as complements to intervention for health and wellbeing by doc- tors, nurses and other professional staff for many decades, but only in recent times has effectiveness research become satisfactory. These methods have potential advantages in penetrating contexts where professionals can- not, but this means establishing effectiveness is complex. This study evaluates 58 reviews (narrative and systematic reviews and meta-analyses) on this issue. In peer education, many reviews of sexual health and of HIV/AIDS inter- ventions were found, with smaller numbers of reviews of certain medical conditions and the prison context. In peer counselling, reviews of breast feeding and mental health were evident. Earlier reviews tended to complain of lack of research; later reviews established knowledge gains but no gains in attitudes; still later reviews discovered both knowledge and attitude gains; and most recently there was evidence of knowledge, attitude and behaviour gains. Peer education and counselling are effective in certain areas (but effectiveness is unknown in other areas), and then only if projects are well managed and the cultural context taken into account. Action implications for research, prac- tice and policy were suggested. Keywords: Peer education; Peer counselling; Peer support; Knowledge; Attitude; Behaviour; Effectiveness   Clinical Psychiatry ISSN: 2471-9854   Peer-Led Interventions in Health and Well-Being: A Review of Effec- tiveness Keith J. Topping* Department of Educational and Social Research, University of Dundee, Scotland  INTRODUCTION From where does the lay person obtain medical information about diagnoses and treatments? Obviously, from doctors and nurses in hospitals and GP surgeries and from patient information leaflets and the websites of national health services and relevant medical charities. But also, from wider searches on the internet,  and here the accuracy of the information begins to decline also by talking to their friends and relatives even worse, from social media, with its deluge of misinformation. However, in developing countries, economically disadvantaged people most at risk might have no access to the internet and/or be unable to read, as well as having limited access to doctors and nurses. Even in developed countries, some at risk populations are hard to reach at least as far as professional intervention is concerned. For these groups, peer education, peer counselling, peer support and other peer-led interventions have been used for many years with training and monitoring for the peer leaders. Peer education is defined here as “peers offering credible and reliable information about sensitive life issues and the opportu- nity to discuss this in an informal peer group setting” [1]. Peer counselling is defined as “people from similar groupings who are  not professionals who help to clarify life problems and identi- fy solutions by listening; clarifying; feeding back; summarizing; questioning and being positive, supportive and reassuring, then helping plan, organize and problem solve” [1]. Peer education and peer counselling are located in primary and secondary schools, in further and higher education, in work train- ing and the workplace, and in various community settings. Such methods go well beyond formal teaching, penetrating where professionals cannot enter, but also offering a degree of ap- proachability that professionals sometimes lack. Of course, this feature renders them inherently difficult to manage and evalu- ate. Nonetheless, there is evidence that peer counselling can be as effective as professional counselling, and such evidence has existed in the literature for years [2,3]. Many peer education and   Received: 14-June-2022 Manuscript No: IPCP-22-13747 Editor assigned: 16-June-2022 PreQC No: IPCP-22-13747(PQ) Reviewed: 30-June-2022 QC No: IPCP-22-13747 Revised: 05-July-2022 Manuscript No: IPCP-22-13747(R) Published: 12-July-2022 DOI: 10.35841/2471-9854-8.6.146 Corresponding author Keith J. Topping, Department of Educational and Social Research, University of Dundee, Scotland, Email: k.j.topping@dundee.ac.uk Citation Topping KJ (2022) Peer-Led Interventions in Health and Well-Being: A Review of Effectiveness. Clin Psychiatry. 8. 146 Copyright ©2022 Topping KJ. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited  © Under License of Creative Commons Attribution 4.0 License This article is available in: https://www.primescholars.com/clinical-psychiatry.html  Volume 08 • Issue 06 • 146 Open access Research Article Topping KJ. Page 80 Volume 08 • Issue 06 • 146   peer counselling programs target helper gains as well as gains for  the helped, since to be a helper can be more therapeutic than being helped. METHODOLOGY Peer education, peer counselling and peer support for health and well-being were subject to a systematic review, particular- ly looking for existing reviews of the literature. Search keywords were: “peer education” “peer counselling” or “peer counselling”  or “peer support” and health or well-being or wellbeing. Four da- tabases were searched: ERIC, Scopus, Web of Science and Google Scholar (the latter three including papers from medicine). Crite- ria for inclusion were: the paper was a peer-reviewed journal ar- ticle, in the English language, and was a review of quantitative and/or qualitative data. No date limits were set. 58 reviews were located from 1974 through 2022, most from 2000-2022. Some of these were narrative reviews, most were systematic analyses, Table 1: Categorization of the Review Studies by Type of Problem and a few were meta-analyses. Some of these reviews reported on young people, some on adults, and some on a mixture. Later reviews were more likely to feature randomized controlled trials (RCTs) or be exclusive to RCTs, but study quality and the age of the review were only loosely related. A minority of the reviews gave Effect Size (ES), Mean Standard Deviation (MSD) and Odds Ratios (OR), Risk Ratios (RR) or other quantitative measures of impact. RESULTS Peer education reviews were located in six categories; peer coun- selling and support reviews in three categories. These categories are contestable but serve to facilitate reader access. Table 1 sum- marises the overall pattern. Study quality was highest for peer education in HIV/AIDS and Social Problems; weakest in the peer education General category.   Type of Problem Total Number of Reviews       Sexual Health 10      HIV/AIDS 10  Social Problems(drug abuse, obesity, physical activity, smoking, alcohol 7 abuse, cannabis abuse) Medical Conditions(diabe- tes, asthma, spinal cord 5 injury, cardiac)  Number of Types of Re- view: Narrative, System- atic or Meta-Analysis * Peer Education Narrative 5 Systematic 5 Meta-analysis 1 Narrative 4 Systematic 4 Meta-analysis 3 Narrative 4 Systematic 4 Meta-analysis 3 Systematic 5  Meta-analysis 3  Narrative 1 Systematic 3 Meta-analysis 1  Number of Studies with Effect Sizes or Equivalent, Effect Sizes or Equivalent  where given      1 0.27     2.28, 0.37, 1.92, 1.22 3.19, 3 2.66, 0.50, 0.82 1.07, 1.06, 6.24 (mean=1.94)  0.16, 0.72, 0.24 0.78, 0.12 4 1.05, 0.24, 0.75, 0.20 0.78, 0.80, 0.70 (mean=0.55)   1 0.70, 1.36 (mean=1.03) Prisons(HIV, risk behaviour) 3 Systematic 3 0 Narrative 8 General(physical activity, smoking, condom use)    Mental Health(depression, suicide) 14 Systematic 5 Meta-analysis 1 Peer Counselling and Support Narrative 1 4 Systematic 2 Meta-analysis 1 1 −0.50, 2.86 (mean=1.18)     2 0.59, 0.10 0.86, 0.19, 0.23 (mean=0.39) Breast-Feeding(increase, reduce diarrhoea) Medical Conditions(breast Systematic 2 3 0 Meta-analysis1 Systematic 2 cancer, colorectal cancer 2 screening) cancer screening) 0 Meta-analysis1 *Some studies included more than one type of review, so numbers may not match Topping KJ. Page 81 Volume 08 • Issue 06 • 146   Peer Education The first reviews in sexual health complained of lack of evidence,  or reported the evidence was not positive. Later reviews were troubled by the lack of impact on behaviour despite evidence of knowledge gains. The latest reviews gave better evidence on ef- fects, in knowledge gains, attitude gains and behaviour change. There was some evidence that peer education was more effec- tive with women than men. The pattern was less positive in de- veloping countries, and cultural attitudes could present difficul- ties, although Turkey showed excellent results. More than half the literature on peer education for HIV/AIDs comes from developing countries, where the problem is much greater in relation to population size, and relevant resources less accessible. However, in developing countries there is evidence of knowledge gain, but also of behavioural gains in at least some behaviour (including condom use, number of sex partners, and reduced equipment sharing). Nonetheless, other behavioural ef- fects were less certain (e.g. acquisition of STIs). Recent studies [4,5] showed peer education increased HIV testing and condom use, decreased unprotected sex and equipment sharing, de- creased HIV infection rates, increased viral suppression and in- creased retention in care, with effects lasting from 3-24 months. Orienting to peer education in the context of social problems, peer-led sessions about drug abuse were effective; more effec- tive than sessions led by professionals. Participants yielded ev- idence of decreased substance use and increases in a range of recovery outcomes. Turning to the issue of obesity, knowledge of healthy eating, pos- itive attitudes to healthy eating, positive intentions, measures of diet, circumference of the waist, total weight and body mass index (BMI) all improved as a result of peer education. Programs were liked by students, parents and staff. However, the evidence on longer term change (three months to two years) was more disappointing. Peer education programmes focusing on increasing physical ac- tivity showed significant gains. School based programmes to pre- vent or reduce smoking in adolescents in developing countries showed increased knowledge plus behavioural change. Sessions led by peers were seen as more enjoyable and credible and were preferred. Again, peer education was more effective than profes- sional education. Turning to the abuse of alcohol, abuse was lower among the peer-led intervention group compared with controls. Three of these studies also indicated impact on use of cannabis. Consid- ering peer education in various medical conditions, a minority of studies of adults with type 2 diabetes gave positive effects, one of the few more negative findings. However, for patients with asthma peer education improved lung function and life quality. Peer education with patients with spinal cord injury showed high success. A broader review of peer education showed mixed re- sults but good effectiveness with diabetes and cardiac patients. Peer-led physical activity projects for young people had mostly positive outcomes. Peer education in prisons could positively affect attitudes, knowledge and behavioural intention regarding HIV, while reducing risky behaviour and increasing HIV test rates.  Prisoners preferred peer education to professional delivery and it  was as effective. Taking the role of peer educator was consistent- ly associated with positive outcomes. However, the evidence was mixed for impact on injecting practice and drug use. Turning to the “General” category, the older reviews were weak,  only one study [6] noting any behavioural change? Even later, some reviews offered almost no evidence on knowledge, attitude or behaviour change. Three even later studies showed mixed re- sults, a minority showing behavioural change effects, although impact on knowledge and attitudes were more frequent. Howev- er, the three most recent reviews showed more positivity, report- ing knowledge change but additionally widespread behaviour changes, for example in physical activity, smoking and condom use. However, in this section review positivity showed very little relationship to the age of the review, which was more the case in other sections. Peer Counselling and Support Regarding peer counselling and/or support on general mental health, an early review had mixed results, but a later review found that hospitalization rates reduced and recovery improved. Other studies showed peer counselling relieved depression and decreased suicide rates. Regarding breastfeeding, effects were positive: breast feeding increased and baby diarrhoea reduced (although in Uganda diarrhoea stayed the same). High income young mothers showed some positive effects of peer counselling on exclusive breast feeding, but many also used baby formula. In medical conditions, peer counselling and/or support had positive effects on most breast cancer patients. In ethnic minorities, peer support raised awareness and intention to undergo colorectal cancer screening, and increase actual implementation of screen- ing. DISCUSSION Although the quality of reviews has generally improved, there is still much heterogeneity between studies and reviews, and little evidence of implementation integrity or fidelity of programmes. Furthermore, few reviews contained much evidence of longer term sustainability of programs over time. Where follow up ex- isted, it was generally only for three to six months. Additionally, most reviews assumed a narrow medical model of diagnosing a problem and then seeking to remediate it, being reactive to spe- cific problems, with little evidence of more preventive or pro-ac- tive measures. The developing physical activity studies were an exception to this. Review quality was very various, showing something of a ten- dency for later reviews to be better, but this was not even. The HIV/AIDS section was especially strong and later reviews were stronger. Obesity reviews were also especially strong and later reviews stronger. Mental Health reviews were also strong and lat- er reviews stronger. However, in other areas, fewer reviews were strong, irrespective of the quantity of reviews, with little or no relationship to publication date. Some areas had no strong stud- ies (Smoking and Prisons). The evidence suggests that peer education; peer counselling and peer support could be extended and researched in a number of areas, including those listed above, but not only those. Studies reported that peer education was more effective than profes- sional education and preferred by clients (e.g. in smoking, drug abuse and prisons), and further comparisons of this contrast would be useful. The implications of this are that some medical professionals might be partially re-tasked to train, supervise and Topping KJ. Page 82 Volume 08 • Issue 06 • 146   monitor peer-led projects. Additionally, some peer education and counselling projects are led by youth and community work- ers, who should be interested in these results. Programme quality depends on program structure, manage- ment, initial training, supervision, support, monitoring and reten- tion. These are all factors which require planning and resourcing. Monitoring of implementation fidelity or integrity has been rare and should be reported in future studies. Much more attention to longer term follow up (up to two years) is needed, and should be attended to despite the apparent difficulties. Cost-effective- ness is also important peer education and counselling are not free when all the costs of implementing a quality programme are considered [7]. CONCLUSION Peer education and peer counselling now have good evidence of effectiveness in terms of knowledge and attitude gains and be- haviour change, but only in certain areas, and research should be generalized to more areas of activity. The methods are fea- sible and in principle, the method is effective, but problematic to manage and/or quality control, much activity happening out- side of observable contexts. Before starting any new programme, serious consideration of organizational factors is necessary and these then need to be managed. New programmes will need to be carefully organized, delivered, monitored and evaluated. Fur- ther information about this research is available on open access. FUNDING This work was not supported by any funding. COMPETING INTERESTS There are no competing interests. REFERENCES 1. Topping KJ, Ehly S (1998) Peer-assisted learning. Lawrence erlbaum: Mahwah, nj and london. 2. Toseland RW, Smith GC (1990) Effectiveness of individual counseling by professional and peer helpers for family care- givers of the elderly. Psychol Aging. 5(2):256-63. 3. Zunker V, Brown W (1966) Comparative effectiveness of stu- dent and professional counselors. Pers Guid J. 44: 738-743. 4. Berg RC, Page S, Øgård-Repål A (2021) The effectiveness of peer-support for people living with HIV: A systematic review and meta-analysis. PLoS One. 16(6):e0252623. 5. Hu J, Wu Y, Ji F, Fang X, Chen F (2020) Peer support as an ideal solution for racial/ethnic disparities in colorectal can- cer screening: Evidence from a systematic review and me- ta-analysis. Dis Colon Rectum. 63(6):850-858. 6. Mellanby AR, Rees JB, Tripp JH (2000) Peer-led and adult-led school health education: A critical review of available com- parative research. Health Educ Res. 15: 533-545. 7. Topping KJ (2022) Peer education and peer counselling for health and well-being: A review of reviews. Int J Environ Res Public Health. 19(10):6064. 

Peer-Led Interventions in Health and Well-Being:A Review of Effectiveness

                                                                    University of DundeePeer-Led Interventions in Health and Well-BeingTopping, Keith J.DOI:10.35841/2471-9854-8.6.146Publication date:2022Licence:CC BYDocument VersionPublisher's PDF, also known as Version of recordLink to publication in Discovery Research PortalCitation for published version (APA):Topping, K. J. (2022). Peer-Led Interventions in Health and Well-Being: A Review of Effectiveness. ClinicalPsychiatry, 8(6), [146]. https://doi.org/10.35841/2471-9854-8.6.146General rightsCopyright and moral rights for the publications made accessible in Discovery Research Portal are retained by the authors and/or othercopyright owners and it is a condition of accessing publications that users recognise and abide by the legal requirements associated withthese rights. • Users may download and print one copy of any publication from Discovery Research Portal for the purpose of private study or research. • You may not further distribute the material or use it for any profit-making activity or commercial gain. • You may freely distribute the URL identifying the publication in the public portal.Take down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Download date: 17. Aug. 2023ABSTRACT Peer education and peer counselling have existed as complements to intervention for health and wellbeing by doc- tors, nurses and other professional staff for many decades, but only in recent times has effectiveness research become satisfactory. These methods have potential advantages in penetrating contexts where professionals can- not, but this means establishing effectiveness is complex. This study evaluates 58 reviews (narrative and systematic reviews and meta-analyses) on this issue. In peer education, many reviews of sexual health and of HIV/AIDS inter- ventions were found, with smaller numbers of reviews of certain medical conditions and the prison context. In peer counselling, reviews of breast feeding and mental health were evident. Earlier reviews tended to complain of lack of research; later reviews established knowledge gains but no gains in attitudes; still later reviews discovered both knowledge and attitude gains; and most recently there was evidence of knowledge, attitude and behaviour gains. Peer education and counselling are effective in certain areas (but effectiveness is unknown in other areas), and then only if projects are well managed and the cultural context taken into account. Action implications for research, prac- tice and policy were suggested. Keywords: Peer education; Peer counselling; Peer support; Knowledge; Attitude; Behaviour; Effectiveness   Clinical Psychiatry ISSN: 2471-9854   Peer-Led Interventions in Health and Well-Being: A Review of Effec- tiveness Keith J. Topping* Department of Educational and Social Research, University of Dundee, Scotland  INTRODUCTION From where does the lay person obtain medical information about diagnoses and treatments? Obviously, from doctors and nurses in hospitals and GP surgeries and from patient information leaflets and the websites of national health services and relevant medical charities. But also, from wider searches on the internet,  and here the accuracy of the information begins to decline also by talking to their friends and relatives even worse, from social media, with its deluge of misinformation. However, in developing countries, economically disadvantaged people most at risk might have no access to the internet and/or be unable to read, as well as having limited access to doctors and nurses. Even in developed countries, some at risk populations are hard to reach at least as far as professional intervention is concerned. For these groups, peer education, peer counselling, peer support and other peer-led interventions have been used for many years with training and monitoring for the peer leaders. Peer education is defined here as “peers offering credible and reliable information about sensitive life issues and the opportu- nity to discuss this in an informal peer group setting” [1]. Peer counselling is defined as “people from similar groupings who are  not professionals who help to clarify life problems and identi- fy solutions by listening; clarifying; feeding back; summarizing; questioning and being positive, supportive and reassuring, then helping plan, organize and problem solve” [1]. Peer education and peer counselling are located in primary and secondary schools, in further and higher education, in work train- ing and the workplace, and in various community settings. Such methods go well beyond formal teaching, penetrating where professionals cannot enter, but also offering a degree of ap- proachability that professionals sometimes lack. Of course, this feature renders them inherently difficult to manage and evalu- ate. Nonetheless, there is evidence that peer counselling can be as effective as professional counselling, and such evidence has existed in the literature for years [2,3]. Many peer education and   Received: 14-June-2022 Manuscript No: IPCP-22-13747 Editor assigned: 16-June-2022 PreQC No: IPCP-22-13747(PQ) Reviewed: 30-June-2022 QC No: IPCP-22-13747 Revised: 05-July-2022 Manuscript No: IPCP-22-13747(R) Published: 12-July-2022 DOI: 10.35841/2471-9854-8.6.146 Corresponding author Keith J. Topping, Department of Educational and Social Research, University of Dundee, Scotland, Email: k.j.topping@dundee.ac.uk Citation Topping KJ (2022) Peer-Led Interventions in Health and Well-Being: A Review of Effectiveness. Clin Psychiatry. 8. 146 Copyright ©2022 Topping KJ. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited  © Under License of Creative Commons Attribution 4.0 License This article is available in: https://www.primescholars.com/clinical-psychiatry.html  Volume 08 • Issue 06 • 146 Open access Research Article Topping KJ. Page 80 Volume 08 • Issue 06 • 146   peer counselling programs target helper gains as well as gains for  the helped, since to be a helper can be more therapeutic than being helped. METHODOLOGY Peer education, peer counselling and peer support for health and well-being were subject to a systematic review, particular- ly looking for existing reviews of the literature. Search keywords were: “peer education” “peer counselling” or “peer counselling”  or “peer support” and health or well-being or wellbeing. Four da- tabases were searched: ERIC, Scopus, Web of Science and Google Scholar (the latter three including papers from medicine). Crite- ria for inclusion were: the paper was a peer-reviewed journal ar- ticle, in the English language, and was a review of quantitative and/or qualitative data. No date limits were set. 58 reviews were located from 1974 through 2022, most from 2000-2022. Some of these were narrative reviews, most were systematic analyses, Table 1: Categorization of the Review Studies by Type of Problem and a few were meta-analyses. Some of these reviews reported on young people, some on adults, and some on a mixture. Later reviews were more likely to feature randomized controlled trials (RCTs) or be exclusive to RCTs, but study quality and the age of the review were only loosely related. A minority of the reviews gave Effect Size (ES), Mean Standard Deviation (MSD) and Odds Ratios (OR), Risk Ratios (RR) or other quantitative measures of impact. RESULTS Peer education reviews were located in six categories; peer coun- selling and support reviews in three categories. These categories are contestable but serve to facilitate reader access. Table 1 sum- marises the overall pattern. Study quality was highest for peer education in HIV/AIDS and Social Problems; weakest in the peer education General category.   Type of Problem Total Number of Reviews       Sexual Health 10      HIV/AIDS 10  Social Problems(drug abuse, obesity, physical activity, smoking, alcohol 7 abuse, cannabis abuse) Medical Conditions(diabe- tes, asthma, spinal cord 5 injury, cardiac)  Number of Types of Re- view: Narrative, System- atic or Meta-Analysis * Peer Education Narrative 5 Systematic 5 Meta-analysis 1 Narrative 4 Systematic 4 Meta-analysis 3 Narrative 4 Systematic 4 Meta-analysis 3 Systematic 5  Meta-analysis 3  Narrative 1 Systematic 3 Meta-analysis 1  Number of Studies with Effect Sizes or Equivalent, Effect Sizes or Equivalent  where given      1 0.27     2.28, 0.37, 1.92, 1.22 3.19, 3 2.66, 0.50, 0.82 1.07, 1.06, 6.24 (mean=1.94)  0.16, 0.72, 0.24 0.78, 0.12 4 1.05, 0.24, 0.75, 0.20 0.78, 0.80, 0.70 (mean=0.55)   1 0.70, 1.36 (mean=1.03) Prisons(HIV, risk behaviour) 3 Systematic 3 0 Narrative 8 General(physical activity, smoking, condom use)    Mental Health(depression, suicide) 14 Systematic 5 Meta-analysis 1 Peer Counselling and Support Narrative 1 4 Systematic 2 Meta-analysis 1 1 −0.50, 2.86 (mean=1.18)     2 0.59, 0.10 0.86, 0.19, 0.23 (mean=0.39) Breast-Feeding(increase, reduce diarrhoea) Medical Conditions(breast Systematic 2 3 0 Meta-analysis1 Systematic 2 cancer, colorectal cancer 2 screening) cancer screening) 0 Meta-analysis1 *Some studies included more than one type of review, so numbers may not match Topping KJ. Page 81 Volume 08 • Issue 06 • 146   Peer Education The first reviews in sexual health complained of lack of evidence,  or reported the evidence was not positive. Later reviews were troubled by the lack of impact on behaviour despite evidence of knowledge gains. The latest reviews gave better evidence on ef- fects, in knowledge gains, attitude gains and behaviour change. There was some evidence that peer education was more effec- tive with women than men. The pattern was less positive in de- veloping countries, and cultural attitudes could present difficul- ties, although Turkey showed excellent results. More than half the literature on peer education for HIV/AIDs comes from developing countries, where the problem is much greater in relation to population size, and relevant resources less accessible. However, in developing countries there is evidence of knowledge gain, but also of behavioural gains in at least some behaviour (including condom use, number of sex partners, and reduced equipment sharing). Nonetheless, other behavioural ef- fects were less certain (e.g. acquisition of STIs). Recent studies [4,5] showed peer education increased HIV testing and condom use, decreased unprotected sex and equipment sharing, de- creased HIV infection rates, increased viral suppression and in- creased retention in care, with effects lasting from 3-24 months. Orienting to peer education in the context of social problems, peer-led sessions about drug abuse were effective; more effec- tive than sessions led by professionals. Participants yielded ev- idence of decreased substance use and increases in a range of recovery outcomes. Turning to the issue of obesity, knowledge of healthy eating, pos- itive attitudes to healthy eating, positive intentions, measures of diet, circumference of the waist, total weight and body mass index (BMI) all improved as a result of peer education. Programs were liked by students, parents and staff. However, the evidence on longer term change (three months to two years) was more disappointing. Peer education programmes focusing on increasing physical ac- tivity showed significant gains. School based programmes to pre- vent or reduce smoking in adolescents in developing countries showed increased knowledge plus behavioural change. Sessions led by peers were seen as more enjoyable and credible and were preferred. Again, peer education was more effective than profes- sional education. Turning to the abuse of alcohol, abuse was lower among the peer-led intervention group compared with controls. Three of these studies also indicated impact on use of cannabis. Consid- ering peer education in various medical conditions, a minority of studies of adults with type 2 diabetes gave positive effects, one of the few more negative findings. However, for patients with asthma peer education improved lung function and life quality. Peer education with patients with spinal cord injury showed high success. A broader review of peer education showed mixed re- sults but good effectiveness with diabetes and cardiac patients. Peer-led physical activity projects for young people had mostly positive outcomes. Peer education in prisons could positively affect attitudes, knowledge and behavioural intention regarding HIV, while reducing risky behaviour and increasing HIV test rates.  Prisoners preferred peer education to professional delivery and it  was as effective. Taking the role of peer educator was consistent- ly associated with positive outcomes. However, the evidence was mixed for impact on injecting practice and drug use. Turning to the “General” category, the older reviews were weak,  only one study [6] noting any behavioural change? Even later, some reviews offered almost no evidence on knowledge, attitude or behaviour change. Three even later studies showed mixed re- sults, a minority showing behavioural change effects, although impact on knowledge and attitudes were more frequent. Howev- er, the three most recent reviews showed more positivity, report- ing knowledge change but additionally widespread behaviour changes, for example in physical activity, smoking and condom use. However, in this section review positivity showed very little relationship to the age of the review, which was more the case in other sections. Peer Counselling and Support Regarding peer counselling and/or support on general mental health, an early review had mixed results, but a later review found that hospitalization rates reduced and recovery improved. Other studies showed peer counselling relieved depression and decreased suicide rates. Regarding breastfeeding, effects were positive: breast feeding increased and baby diarrhoea reduced (although in Uganda diarrhoea stayed the same). High income young mothers showed some positive effects of peer counselling on exclusive breast feeding, but many also used baby formula. In medical conditions, peer counselling and/or support had positive effects on most breast cancer patients. In ethnic minorities, peer support raised awareness and intention to undergo colorectal cancer screening, and increase actual implementation of screen- ing. DISCUSSION Although the quality of reviews has generally improved, there is still much heterogeneity between studies and reviews, and little evidence of implementation integrity or fidelity of programmes. Furthermore, few reviews contained much evidence of longer term sustainability of programs over time. Where follow up ex- isted, it was generally only for three to six months. Additionally, most reviews assumed a narrow medical model of diagnosing a problem and then seeking to remediate it, being reactive to spe- cific problems, with little evidence of more preventive or pro-ac- tive measures. The developing physical activity studies were an exception to this. Review quality was very various, showing something of a ten- dency for later reviews to be better, but this was not even. The HIV/AIDS section was especially strong and later reviews were stronger. Obesity reviews were also especially strong and later reviews stronger. Mental Health reviews were also strong and lat- er reviews stronger. However, in other areas, fewer reviews were strong, irrespective of the quantity of reviews, with little or no relationship to publication date. Some areas had no strong stud- ies (Smoking and Prisons). The evidence suggests that peer education; peer counselling and peer support could be extended and researched in a number of areas, including those listed above, but not only those. Studies reported that peer education was more effective than profes- sional education and preferred by clients (e.g. in smoking, drug abuse and prisons), and further comparisons of this contrast would be useful. The implications of this are that some medical professionals might be partially re-tasked to train, supervise and Topping KJ. Page 82 Volume 08 • Issue 06 • 146   monitor peer-led projects. Additionally, some peer education and counselling projects are led by youth and community work- ers, who should be interested in these results. Programme quality depends on program structure, manage- ment, initial training, supervision, support, monitoring and reten- tion. These are all factors which require planning and resourcing. Monitoring of implementation fidelity or integrity has been rare and should be reported in future studies. Much more attention to longer term follow up (up to two years) is needed, and should be attended to despite the apparent difficulties. Cost-effective- ness is also important peer education and counselling are not free when all the costs of implementing a quality programme are considered [7]. CONCLUSION Peer education and peer counselling now have good evidence of effectiveness in terms of knowledge and attitude gains and be- haviour change, but only in certain areas, and research should be generalized to more areas of activity. The methods are fea- sible and in principle, the method is effective, but problematic to manage and/or quality control, much activity happening out- side of observable contexts. Before starting any new programme, serious consideration of organizational factors is necessary and these then need to be managed. New programmes will need to be carefully organized, delivered, monitored and evaluated. Fur- ther information about this research is available on open access. FUNDING This work was not supported by any funding. COMPETING INTERESTS There are no competing interests. REFERENCES 1. Topping KJ, Ehly S (1998) Peer-assisted learning. Lawrence erlbaum: Mahwah, nj and london. 2. Toseland RW, Smith GC (1990) Effectiveness of individual counseling by professional and peer helpers for family care- givers of the elderly. Psychol Aging. 5(2):256-63. 3. Zunker V, Brown W (1966) Comparative effectiveness of stu- dent and professional counselors. Pers Guid J. 44: 738-743. 4. Berg RC, Page S, Øgård-Repål A (2021) The effectiveness of peer-support for people living with HIV: A systematic review and meta-analysis. PLoS One. 16(6):e0252623. 5. Hu J, Wu Y, Ji F, Fang X, Chen F (2020) Peer support as an ideal solution for racial/ethnic disparities in colorectal can- cer screening: Evidence from a systematic review and me- ta-analysis. Dis Colon Rectum. 63(6):850-858. 6. Mellanby AR, Rees JB, Tripp JH (2000) Peer-led and adult-led school health education: A critical review of available com- parative research. Health Educ Res. 15: 533-545. 7. Topping KJ (2022) Peer education and peer counselling for health and well-being: A review of reviews. Int J Environ Res Public Health. 19(10):6064. 

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Peer-Led Interventions in Health and Well-Being:A Review of Effectiveness

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