Effect of an adolescent peer-led health curriculum on peer educators and participants

Abstract

Objective:

To assess the effectiveness of an adolescent peer-led health curriculum in changing physical activity and fruit and vegetable social-cognitive and behavioural variables among Filipino American adolescents in Hawai’i for participants and peer educators.

Design:

Quasi-experimental design.

Setting:

One high school on Oahu, Hawai’i.

Method:

Filipino American adolescents aged 16–18 years from a grade 12 health class were recruited and trained as peer educators to deliver a health curriculum to grades 9–11 health classes over 8 months. We examined peer educators’ influence on physical activity and fruit and vegetable social-cognitive (knowledge, stage of change, self-efficacy and enjoyment) and behavioural variables (physical activity and consumption). Participants and peer educators completed baseline and follow-up questionnaires.

Results:

Compared with controls, intervention students showed an increase in physical activity knowledge and self-efficacy. Multiple regression analysis predicted higher physical activity knowledge and moderate-vigorous physical activity follow-up scores for members of the intervention group. A significant effect was found for physical activity stage of change and moderate-vigorous physical activity for peer educators over time. No significant effect was found for any fruit and vegetable variables.

Conclusion:

A peer-led health curriculum may be a viable method to change physical activity social-cognitive and behavioural variables in Filipino American adolescents and peer educators.

Keywords

Adolescent health Filipino adolescents health curriculum peer-led social-cognitive theory

Introduction

In 2010, 3.4 million Filipinos lived in the USA, with around three hundred and forty thousand of them (22.8% of the Hawai’i population) residing in the state of Hawai’i (US Department of Commerce Economics and Statistics Administration, 2010). Filipinos comprise the second-largest Asian subgroup in the USA and are 70% more likely to be obese compared to the overall Asian population (Office of Minority Health, 2020). They are among the most underrepresented populations in health research (Javier et al., 2007). According to Javier et al. (2007), Filipino American adolescents have a higher risk of being overweight and inactive than other ethnicities of the same age. With Filipino adolescents being among the most overweight and obese (Hawai’i Department of Health, 2017a, 2017b) ethnic groups in Hawai’i, it is important to research increasing health behaviour in this population.

Theory-based interventions can be an effective way to create health behaviour change. While there exist many health behaviour models, most focus only on predicting health habits (Bandura, 2004). Social-cognitive theory, one of the most utilised theories in health behaviour research, focuses on both predictors and principles to enable, guide and motivate people to adopt and promote health behaviours (Bandura, 2004). The premise is that behaviour change is made possible by a personal sense of control through mutually interacting cognitive, behavioural and environmental factors.

Adolescents and young people are strongly influenced by their social environment: peers, family, school and community (Chakraborty and Chakraborty, 2010). Filipino American adolescent intervention programmes need to acknowledge both cultural values and acculturation of the population to facilitate the development of tailored messages to improve health behaviours (Yang et al., 2014). In traditional Filipino culture, an individual is seen as part of the family and community, and actions are taken for these groups rather than for individual gain (Watkins and Gerong, 1997). High value is placed on harmony, conflict avoidance (Anderson, 1983) and education over engagement in sports (Abesamis et al., 2016). The cultural palate is high in salt (fish sauce, soy sauce and shrimp paste) and traditional foods such as lumpia, pancit, fried fish and roasted pork, served at special gatherings in large quantities, are generally high in fat (National Institute of Health and National Heart, Lung, and Blood Institute, 2010).

Second- and third-generation Filipino Americans may be more acculturated than first-generation Filipinos due to contact with other ethnicities, possibly changing their health behaviours (Chakraborty and Chakraborty, 2010). As Filipino’s assimilate, there is a decrease in traditionally healthy Filipino immigrants’ habits, such as physical activity (PA) and fruit and vegetable (FV) consumption, an increase in consumption of traditional dishes and the adoption of a high fat and sugar diet (Vargas and Jurado, 2016). In addition, Filipino American adolescents’ increase in assertiveness, due to acculturation into an ideology of individuality, challenges traditional Filipino family values creating a source of intergenerational conflict (Tompar-Tiu and Sustento-Seneriches, 1995) and reliance on peers for normative behaviour (Javier et al., 2007).

One approach to changing adolescent health behaviour involves peer-led initiatives. Peer educators (PEs) are individuals from the same population trained to educate peers from a similar background to themselves (Martin-Ginis et al., 2013). They can act as positive role models who directly affect their social environment and influence health behaviours (Story et al., 2002). Studies have shown peer-led initiatives can improve their peers’ self-efficacy, knowledge, attitudes and behaviours (Forneris et al., 2010; Stock et al., 2007; Story et al., 2002). No studies have been found using PEs to change Filipino American adolescent health behaviours.

PEs’ increased exposure to health topics through teaching and sharing their experiential knowledge could potentially change their health behaviours (Dennis, 2003). According to social-cognitive theory, cognitive factors, behaviours and the environment interact and reciprocate to create change (Bandura, 2004). This reciprocal determinism suggests PEs can influence their peers and vice versa, potentially reinforcing health behaviour changes. While studies (Mason-Jones et al., 2013; Stock et al., 2007; Taylor et al., 2000) have evaluated the effect of delivering education activities on PEs’ own behaviours, more studies are still needed.

Therefore, this study aimed to investigate the effectiveness of an adolescent peer-led health curriculum to change PA and FV social-cognitive and behavioural variables among Filipino American adolescents and PEs over an 8-month period in a school-based setting in Hawai’i. As a result of participating in the Health Action and Research Training (HART) project, it was hypothesised that Filipino American adolescents and PEs would increase their scores on PA and FV social-cognitive and behavioural variables.

Methods

Study design

The study was the intervention component of the HART project in the year 2014–2015. The project aimed to promote PA and nutrition through traditional classroom pedagogy, using PEs’ positive influence on participating young people. HART was a partnership between a Hawai’i high school, the Hawai’i Department of Education and the University of Hawai’i Office of Public Health Studies. The University of Hawai’i Institutional Review Board and the Hawai’i Department of Education approved all methods and procedures, including gaining parental consent and student assent prior to participation.

Ethical approval included the provision of training to PEs to ensure they were familiar and comfortable with the teaching materials, and they knew how to properly administer the questionnaire and learned about confidentiality and research ethics. One member of the research staff (M.A.T. or C.R.N.) was present to serve as a support during the teaching session for PEs. As part of the agreement with the Hawai’i Department of Education, the HART curriculum was designed around the prescribed high school health curriculum and lessons were implemented during regular class time.

The initial development of the HART project was informed by work in the same school by Geller et al. (2014). Pupils at the school were predominantly second- and third-generation Filipino American adolescents. Self-reports revealed that friends had a considerable influence on PA and that parents were the biggest influence on at-home food availability and accessibility. Pilot work to develop the HART curriculum took the form of a collaboration between researchers, recruited health teachers and Filipino American adolescents at the school to create eight lessons with activities that reflect Filipino American adolescents’ PA and nutrition interests locally.

For the present study, through a university–teacher participatory partnership, PEs and participants were recruited. The PEs (n = 19; baseline to follow-up) were recruited from a final year health class consisting of students enrolled in the school’s health and sciences college and careers academy. Recruitment was based on their in-depth understanding of the population, their ability to share experiential knowledge to support the needs of recipients and their role-modelling capabilities (Dennis, 2003; Martin-Ginis et al., 2013). Five health classes served as the intervention (n = 70) and four as the control (n = 44; quasi-experimental design). Only students who returned parental consent and signed student assent forms were included in the analysis. The classroom teacher provided non-participants with a supplemental activity during questionnaire administration.

Peer training and intervention

PEs were trained for 5 weeks on lessons 1 to 4 (October–November 2014) and then 5 to 8 (January–February 2015) two times a week during their health class. Training consisted of teaching PEs’ about the research protocol, the importance of measurement, what each lesson was about, activities for each lesson, strategies to get participants involved and practice teaching.

Lesson activities varied depending on PA and nutrition topics and addressed knowledge, individual motivation factors, skills and environment. The PEs provided examples for PA (e.g. dancing as a way to be physically active) and nutrition topics (e.g. using local FV to teach about eating the rainbow). Lesson topics, activities and homework are shown in Tables 1 and 2.

Table 1.

HART curriculum lessons 1–4.

Lessons 1–4	Nutrition		Physical activity
	Activity	Homework	Activity	Homework
Introduction to Nutrition and PA	Students complete the HART questionnaire. Introduce My Plate, teach different parts and provide examples. Create a healthy meal based on My Plate.	Create a nutrition pamphlet on the assigned section of My Plate.	Watch video on calories and energy balance – introduced different ways to be physically active. Group discussion on how to be physically active even with a busy schedule.	Try an activity that the student has not done before – complete worksheet on experience.
The Ingredients of Nutrition and PA	Learn parts of a food label and how to apply it.	Find four food items at home and compare using food label worksheet.	Introduce FITT and calorie balance. Students identify if activity is sedentary, moderate or active.	Apply FITT principle to PA and complete worksheet.
Eating the Rainbow and Variety in PA	Watch video eating the rainbow, learn recommended servings of FV and importance of eating a variety of FVs. Find FVs in assigned colour and complete worksheet.	Try a different colour FV every day using worksheet.	Delve deeper into different types of PA and ways to incorporate them into daily life. Calculate max heart rate and use pulse to know when doing MVPA.	Try a new MVPA, encourage a family member to join and complete worksheet.
Eating Out and Working Out	Learn the recommended dietary allowance for carbohydrates, fats and protein. Calculate needs based on a 2,200 calorie diet and research nutrition content from menu and present findings.	Practise healthy nutrition over holidays.	Discuss ways to be physically active over holidays. Share an at-home workout with the class.	Be active over the holiday.

PA: physical activity; HART: Health Action and Research Training; FITT: frequency intensity, time, type; FV: fruit and vegetable; MVPA: moderate-vigorous PA.

Table 2.

HART curriculum lessons 5–8.

Lessons 5–8	Nutrition		Physical activity
	Activity	Homework	Activity	Homework
Refresher on Nutrition and PA	Review nutrition from lessons 1–4. Compare food labels of different bags of chips.	Create a nutrition or PA poster to showcase on campus.	Review PA from lessons 1–4. Come up with a moderate and vigorous activity the student can do with someone or individually that week.
Encouraging Nutrition and PA in your community	How to support friends and family to create a healthy lifestyle. Explore the University of Hawai’i Foods website with healthier versions of popular Hawai’i food. Create a list of ways to help each other eat a more balanced diet.	A complete 2-day food journal and share a recipe from the University of Hawai’i website with family.	The PEs share local areas students can use for PA and ways to get the family involved. Create a list of ways to help each other be more physically active.	Complete a 2-day PA journal.
Making Small Changes for Nutrition and PA	Ways to gather support and how small changes help create success. Partner up, review food logs and come up with three small changes each can make.	Try small nutrition changes, journal for the next class.	How to make small changes to be physically active. Partner up, review PA logs and come up with three small changes each can make.	Try small PA changes, journal for next class. Find two flexibility and balance workouts to do at home and complete worksheet.
Positive Attitude for a Positive Life	Brief review of PA and nutrition.	Apply and share the nutrition knowledge they have learned.	Play HART Jeopardy on PA and nutrition. Students complete follow-up HART questionnaire.	Continue to be physically active and encourage others to be active as well.

PA: physical activity; PE: peer educator; HART: Health Action and Research Training.

All PEs signed consent and assent forms. They completed the questionnaire at the initial meeting with research staff and again after teaching lesson 8. After completing their training, PEs (groups of two to three) taught two to three health classes (grades 9–11) their assigned lesson (one lesson between November and December 2014 and one lesson between March and April 2015) and administered the questionnaire at the beginning of lesson 1 and end of lesson 8.

Measures

The HART questionnaire was informed by the HART curriculum and by the cognitive, behavioural and environment factors suggested by social-cognitive theory (Bandura, 2004).

Nutrition and PA knowledge questions were informed by findings from the initial development of the HART project (Geller et al., 2014) and reflected the content of the HART curriculum. Four true/false questions addressed nutrition (food groups, reading labels, FV and nutrition recommendations) and PA knowledge (intensities, type, energy balance and PA recommendations). Correct answers were summed. Face validity was confirmed by a doctoral-level judge (C.R.N.) and a master’s-level judge (a former doctoral student) who had developed and was familiar with the HART curriculum.

Stages of change questions assessed an individual’s readiness to participate in regular PA and consume FV. Participants were asked about participating in 60 minutes per day of moderate-vigorous PA (MVPA) for at least 5 days or more a week and readiness to consume four and a half cups or more of FV each day. Answers were classified based on the transtheoretical model’s five stages of change: precontemplation, contemplation, preparation, action and maintenance (Prochaska and Velicer, 1997). Stages of change for PA (Calfas et al., 1997) and FV (Di Noia et al., 2012) have been validated for adolescents.

Self-efficacy measured confidence to do PA and eat FV given 6 specific barriers for each.

PA barriers: (1) when it is raining; (2) under much stress; (3) do not have the time; (4) have to exercise alone; (5) do not have access to a place to exercise; and (6) when spending time with friends.

FV barriers: (1) eating at a restaurant; (2) hard to cut or peel; (3) hard to get to store; (4) had a hard day, and not feeling good; (5) cooking vegetables is difficult; and (6) FVs do not taste good.

Answers were provided on a 5-point Likert-type scale ranging from 1 (not at all confident) to 5 (completely confident). The mean of all items was used. The self-efficacy scales for PA (Wu et al., 2011) and FV (Hagler et al., 2005) are reliable and valid for use with adolescents.

Enjoyment of PA was assessed via 5 questions (enjoy it, makes the body feel good, get something good out of it, it is very exciting and it feels good) using a 5-point Likert-type scale with responses ranging from 1 (disagree a lot) to 5 (agree a lot) (Paxton et al., 2008). The mean of the items was used. This scale has been shown to provide a valid and reliable measure of enjoyment of PA by children (Latorre Román et al., 2014).

The adapted Leisure-Time PA Questionnaire (Godin and Shephard, 1985) was used to assess the number of days a week students performed strenuous, moderate and mild PA along with the average duration (0–60+ minutes) per day of each. The measure used has been shown to be reliable and valid with adolescents (Sallis et al., 1993).

Consumption of FV assessed how often in the past 7 days, 100% fruit juices, FV were consumed using three items from the youth risk behaviour surveillance system survey (Centers for Disease Control and Prevention, 2015). Responses included never, one to three times per week, four to six times per week, one time per day, two times per day, three times per day, and four or more times per day. These were recoded to reflect total consumption per day. The survey has been validated for use with adolescents (Brener et al., 2013).

Data analysis

Data analysis was conducted via SPSS 22.0 (SPSS Worldwide Headquarters, Chicago, IL). Demographics and descriptive variables were calculated. Missing data (M = 6.03%, SD = 3.47) appeared at random and thus was deleted pairwise. No dropouts were reported. Significance was set a priori at <.05.

A 2 × 2 (time × group) analysis of variance (ANOVA) was used to examine the intervention’s effect on participants and adolescents considered at-risk (i.e. not meeting the recommended guidelines for PA or FV consumption, thus being at increased risk for chronic diseases). An at-risk analysis was conducted with adolescents in the pre-action (precontemplation, contemplation, preparation) PA or FV stages of change. Stage of change was used as a criterion since it reflected students’ judgement of meeting recommended guidelines. A multiple regression analysis was also conducted controlling for baseline score, gender and age to identify factors predicting participants’ follow-up scores. PEs were assessed using a repeated-measures ANOVA for change over time in PA and FV variables.

Results

A total of 114 adolescents (70 intervention, 44 control) completed the questionnaire. Table 3 shows the distribution of PEs and participants by gender, age and case. Descriptive statistics with results for all variables are provided in Table 4. A significant interaction was found over time for PA knowledge, F(2, 98) = 14.71, p < .00, and self-efficacy, F(2, 97) = 1.27, p < .01, between groups. No significant interaction was found for other PA or FV variables.

Table 3.

Descriptive statistics.

	Peer educators	Intervention	Control
n (%)	19 (100)	70 (61.4)	44 (38.6)
Male participants, n (%)	5 (26.35)	7 (10)	9 (20.5)
Female participants, n (%)	14 (73.7)	63 (90)	35 (79.5)
Age (SD)	17 (0.52)	14 (0.85)	16 (0.55)
At-risk PA (%)		41 (56.2)	32 (43.8)
At-risk FV (%)		41 (56.9)	31 (43.1)

SD: standard deviation; PA: physical activity: FV: fruit and vegetable; n = number completed at follow-up.

Table 4.

Descriptive statistics for PA and FV variables.

Variables	Group	n	Baseline	Follow-up	F (df)	Sig.	$η_{p}^{2}$
			Mean (SD)	Mean (SD)
PA	Intervention	60	2.85 (0.80)	3.38 (0.71)	14.71 (98)	.00*	0.13
Knowledge	Control	40	3.03 (0.80)	2.80 (0.82)
	Total	100
PA	Intervention	60	3.37 (0.92)	3.58 (1.09)	0.12 (99)	.73	0.00
Stage of change	Control	41	2.90 (1.02)	3.05 (1.12)
	Total	101
PA	Intervention	60	2.87 (0.71)	3.15 (0.70)	1.27 (97)	.01*	0.01
Self-efficacy	Control	39	2.70 (0.68)	2.82 (0.74)
	Total	99
PA	Intervention	61	4.13 (0.60)	4.27 (0.70)	1.31 (99)	.25	0.01
Enjoyment	Control	40	4.14 (0.67)	4.11 (0.91)
	Total	101
MVPAminute/day	Intervention	60	30.71 (23.13)	33.90 (27.06)	0.77 (98)	.38	0.00
	Control	40	21.64 (21.14)	21.21 (18.95)
	Total	100
Nutrition	Intervention	60	3.65 (0.55)	3.77 (0.43)	0.33 (99)	.56	0.00
Knowledge	Control	41	3.60 (0.63)	3.80 (0.46)
	Total	101
FV	Intervention	61	3.39 (1.04)	3.57 (1.02)	0.04 (99)	.83	0.00
Stage of change	Control	40	3.07 (0.94)	3.30 (1.16)
	Total	101
FV	Intervention	59	3.15 (0.69)	3.13 (0.68)	0.95 (97)	.33	0.01
Self-efficacy	Control	40	2.75 (0.59)	2.90 (0.78)
	Total	99
FV	Intervention	61	2.86 (2.31)	3.43 (2.55)	0.01 (100)	.92	0.00
Consumption	Control	41	2.06 (2.04)	2.49 (2.10)
	Total	102

SD: standard deviation; PA: physical activity; MVPA: moderate-vigorous PA; FV: fruit and vegetable; n = number completed at follow-up.

Statistically significant, p < .05.

Table 5 shows multiple regression results for PA and FV variables. Each of the PA variables had a significant positive regression weight (p < .01). Baseline PA knowledge ( $\hat{β}$ = 0.22, SE = 0.09, p = .02), stage of change ( $\hat{β}$ = 0.63, SE = 0.10, p < .01), self-efficacy ( $\hat{β}$ = 0.49, SE = 0.09, p < .01), enjoyment ( $\hat{β}$ = 0.55, SE = 0.11, p < .01) and MVPA ( $\hat{β}$ = 0.67, SE = 0.08, p < .01) predicted follow-up scores. Group predicted higher PA knowledge ( $\hat{β}$ = 0.95, SE = 0.24, p < .01) and MVPA ( $\hat{β}$ = 20.04, SE = 6.13, p < .01) follow-up scores for the intervention, while sex predicted PA stage of change ( $\hat{β}$ = 0.59, SE = 0.59, p = .03) and age predicted MVPA ( $\hat{β}$ = 7.13, SE = 2.34, p < .01) follow-up scores. The FV multiple regression found stage of change, self-efficacy and consumption variables had significant positive regression weight (p < .01), while baseline FV stage of change ( $\hat{β}$ = 0.53, SE = 0.10, p < .01), self-efficacy ( $\hat{β}$ = 0.34, SE = 0.34, p < .01) and FV consumption ( $\hat{β}$ = 0.40, SE = 0.10, p < .01) predicted follow-up scores.

Table 5.

Multiple regression of PA and FV variables.

Dependent variable	Control variable	F (df)	Adjusted R²	Sig.	$\hat{β}$	SE	t	Sig.
PA Knowledge		5.82 (4, 95)	.16	.00*
	Baseline				0.22	0.09	2.34	.02*
	Group				0.95	0.24	3.87	.00*
	Age				0.16	0.10	1.71	.09
	Sex				0.02	0.21	0.10	.92
PA Stage of Change		13.75 (4, 96)	.34	.00*
	Baseline				0.63	0.10	6.41	.00*
	Group				0.36	0.31	1.16	.25
	Age				0.09	0.09	0.80	.43
	Sex				0.59	0.59	2.26	.03*
PA Self-efficacy		9.39 (4, 94)	.25	.00*
	Baseline				0.49	0.09	5.27	.00*
	Group				0.36	0.21	1.66	.10
	Age				0.06	0.08	0.73	.47
	Sex				0.13	0.18	0.68	.50
PA Enjoyment		6.96 (4, 96)	.19	.00*
	Baseline				0.55	0.11	4.78	.00*
	Group				0.41	0.23	1.74	.09
	Age				0.12	0.09	1.27	.21
	Sex				0.01	0.20	0.06	.96
MVPA		23.17 (4, 95)	.47	.00*
	Baseline				0.67	0.08	8.03	.00*
	Group				20.04	6.13	3.27	.00*
	Age				7.13	2.34	3.04	.00*
	Sex				9.79	5.33	1.84	.07
Nutrition Knowledge		1.40 (4, 96)	.02	.24
	Baseline				0.13	0.13	0.68	.10
	Group				0.23	0.14	1.59	.11
	Age				0.09	0.06	1.58	.12
	Sex				0.07	0.13	0.58	.56
FV Stage of Change		8.67 (4, 96)	.23	.00*
	Baseline				0.53	0.10	5.58	.00*
	Group				0.03	0.32	0.09	.93
	Age				0.03	0.12	0.22	.82
	Sex				0.23	0.28	0.80	.42
FV Self-efficacy		3.27 (4, 94)	.08	.01*
	Baseline				0.34	0.11	3.13	.00*
	Group				0.60	0.23	0.25	.80
	Age				0.03	0.09	0.31	.76
	Sex				0.16	0.20	0.80	.42
FV Consumption		4.70 (4, 97)	.13	.00*
	Baseline				0.40	0.10	3.81	.00*
	Group				1.01	0.76	1.34	.18
	Age				0.22	0.29	0.73	.46
	Sex				0.38	0.67	0.57	.57

SE: standard error; PA: physical activity; MVPA: moderate-vigorous PA; FV: fruit and vegetable. Group = Intervention versus Control.

Statistically significant, p < .05.

Descriptive statistics with results for at-risk for PA (41 intervention, 32 control) and FV (41 intervention, 31 control) variables are provided in Table 6. There was a significant interaction found for at-risk PA knowledge, F(1, 65) = 6.69, p < .01, between the groups. No significant interaction was found for other PA and FV variables.

Table 6.

Descriptive statistics with 2 × 2 ANOVA results for at-risk PA and FV variables.

Variables	Group	n	Baseline mean (SD)	Follow-up mean (SD)	F (df)	Sig.	$η_{p}^{2}$
PA Knowledge	Intervention	38	2.89 (0.86)	3.39 (0.72)	6.69 (65)	.01*	0.09
	Control	29	3.03 (0.82)	2.93 (0.80)
	Total	67
PA Stage of change	Intervention	38	2.76 (0.43)	3.24 (0.94)	0.66 (67)	.42	0.01
	Control	31	2.42 (0.56)	2.70 (1.01)
	Total	69
PA Self-efficacy	Intervention	37	2.68 (0.71)	3.00 (0.77)	0.56 (65)	.45	0.01
	Control	30	2.55 (0.66)	2.72 (0.69)
	Total	67
PA Enjoyment	Intervention	38	3.92 (0.60)	4.01 (0.69)	0.67 (66)	.41	0.01
	Control	30	4.06 (0.67)	3.97 (0.97)
	Total	68
MVPAminute/day	Intervention	37	20.04 (17.96)	23.63 (16.83)	0.23 (66)	.63	0.00
	Control	31	16.31 (14.89)	17.83 (18.14)
	Total	68
Nutrition Knowledge	Intervention	36	3.67 (0.58)	3.75 (0.44)	0.11 (63)	.74	0.00
	Control	29	3.62 (0.62)	3.76 (0.51)
	Total	65
FVStage of Change	Intervention	36	2.69 (0.67)	3.17 (1.00)	0.10 (62)	.75	0.00
	Control	28	2.57 (0.57)	2.96 (0.88)
	Total	64
FVSelf-efficacy	Intervention	34	3.09 (0.61)	3.04 (0.10)	1.55 (61)	.22	0.02
	Control	29	2.84 (0.43)	2.99 (0.67)
	Total	63
FVConsumption	Intervention	36	2.63 (2.29)	2.76 (2.17)	0.07 (63)	.79	0.00
	Control	29	1.70 (1.63)	1.67 (1.41)
	Total	65

ANOVA: analysis of variance; SD: standard deviation; PA: physical activity; MVPA: moderate-vigorous PA; FV: fruit and vegetable; n = number completed at follow-up.

Statistically significant, p < .05.

A total of 19 PEs (73.7% female participants) completed the HART questionnaire. Descriptive statistics with results for all variables are provided in Table 7. A significant effect was found for PA stage of change, F(1, 18) = 5.51, p < .05, and MVPA, F(1, 18) = 7.44, p < .01. No other significant effect was found.

Table 7.

PA and FV variables descriptive for peer educators.

Variables	n	Baseline	Follow-up	F (df)	Sig.	$η_{p}^{2}$
		Mean (SD)	Mean (SD)
PA Knowledge	19	3.05 (0.78)	3.21 (0.71)	0.58 (1)	.45	0.03
PA Stage of Change	19	3.47 (1.12)	3.84 (1.01)	5.51 (1)	.03*	0.23
PA Self-efficacy	18	3.35 (0.91)	3.50 (0.77)	0.44 (1)	.51	0.02
PA Enjoyment	18	4.81 (0.43)	4.75 (0.51)	0.56 (1)	.46	0.03
MVPA minute/day	19	24.81 (19.26)	42.06 (29.52)	7.44 (1)	.01*	0.29
Nutrition Knowledge	19	3.84 (0.37)	3.78 (0.53)	0.32 (1)	.58	0.01
FV Stage of Change	19	3.68 (0.94)	3.94 (0.77)	1.02 (1)	.31	0.05
FV Self-efficacy	17	3.20 (0.82)	3.36 (0.68)	0.63 (1)	.44	0.03
FV Consumption	19	3.07 (2.31)	3.73 (2.76)	1.93 (1)	.18	0.09

SD: standard deviation; PA: physical activity; MVPA: moderate-vigorous PA; FV: fruit and vegetable; n = number completed at follow-up.

Statistically significant, p < .05.

Discussion

The primary aim of this study was to investigate the effectiveness of an adolescent peer-led health curriculum to change PA and FV social-cognitive and behavioural variables among Filipino American adolescents and PEs in Hawai’i. It demonstrated that PEs can effectively promote health education to their peers, resulting in positive outcomes for both. To our knowledge, this is the first study to analyse Filipino American adolescents considered with at-risk health behaviours. The at-risk analysis is unique since it looks only at students who are not meeting PA and FV consumption recommendations. The study also demonstrated that a peer-led health curriculum can be achieved in a high school setting within a prescribed curriculum.

The peer-led curriculum improved PA knowledge, PA self-efficacy and at-risk PA knowledge in recipients of the curriculum. Other peer-led studies have found similar results for increased PA knowledge (Santos et al., 2014; Stock et al., 2007) and self-efficacy (Saksvig et al., 2005; Santos et al., 2014) in school-based interventions. The regression analysis findings that group differences predicted higher follow-up scores for PA knowledge and MVPA in recipients support that the peer-led curriculum creates positive behaviour change. Previous work in the same school by Geller et al. (2014) reported that friends had the biggest influence on PA. These findings provide evidence that peer-led health curricula may offer a viable way to change PA behaviour in Filipino American adolescents, especially those with at-risk health behaviours.

Self-efficacy is a key determinant in the social-cognitive theory since it directly affects health behaviour, is situation-specific and may vary concerning personal circumstances (Bandura, 1997). While confidence to perform PA increased for recipients, no significant effect was found for stage of change or MVPA in this adolescent population. According to the transtheoretical model, individuals at different stages may have different perceived self-efficacy and different levels of confidence in maintaining and overcoming barriers to exercise (Marcus et al., 1994). In traditional Filipino culture, high value is placed on education over PA (Abesamis et al., 2016) and only one credit of physical education is required for high school students in Hawai’i (Hawai’i Department of Education, 2016).

The study also demonstrated that PEs could progress through PA stage of change (preparation towards action) and increase MVPA while implementing a health curriculum. A study (Callaghan et al., 2002) with Chinese adolescents saw a similar increase in PA as stage of change increased. In the transtheoretical model’s processes of change, experiential (information generated by an individual’s own experiences and actions) and environmental (information generated by environmental events) increase in use from the preparation to the action stage (Prochaska and Marcus, 1993). A similar effect may be seen in social-cognitive theory in terms of how cognitive, behavioural and environmental factors interact and reciprocate to create change (Bandura, 2004). Self-efficacy is considered to be a critical part of behaviour change and has been found to increase from precontemplation to maintenance (Nigg and Courneya, 1998; Prochaska and Marcus, 1993). The present study, however, found no significant effect for PA self-efficacy increasing over time with stage of change. There was also no significant effect for PA knowledge or enjoyment.

The peer-led curriculum had no effect on any FV variables for participants or PEs. These findings are similar to those of a peer-led obesity prevention programme in schools in England (Bell et al., 2017). Given that these adolescents still live at home, they may have limited control over increasing their FV consumption (Bell et al., 2017). Students from a similar population to that in this study reported that parents had the biggest impact on at-home accessibility of food (Geller et al., 2014). Participants were also found to be only moderately confident for FV self-efficacy from baseline to follow-up. Having little control over food accessibility may directly impact both FV consumption and self-efficacy in this age group.

Future research might involve the addition of FV culinary classes to the curriculum to help increase FV self-efficacy and consumption. A study of Latino adolescents using culinary education as part of the intervention showed improvement in FV social-cognitive variables compared to controls (Gatto et al., 2012). The questionnaire might also expand beyond FV consumption to see how this influences other nutrition behaviours (e.g. skipping meals, fast food consumption, sugar-sweetened beverages). Consideration needs to be taken, though, on how these additional measures may affect the response burden. Also, the addition of four field tests (Cooper’s 12-minute run, push-up test, Berg balance scale, and sit and reach test) that cover PA taught in HART is recommended to strengthen confidence in measuring the effects of PA beyond self-report.

Limitations

There are several limitations to this study. First, the design was quasi-experimental, as the researchers were unable to assign classes randomly. Beyond this, data were collected by means of a self-report questionnaire, which could have led to reporting bias informed by social norms. Also, all the classes participating in the study were health curriculum classes. Finally, the lack of a control group for PEs and the study focusing only on Filipino American adolescents from one Hawai’i high school limits generalisability and findings.

Conclusion

In conclusion, this is the first study to analyse a peer-led PA and nutrition curriculum on changing social-cognitive and behavioural variables in Filipino American adolescents and PEs. The analysis provides researchers with valuable information on how to update the HART curriculum and questionnaire, strengthen its delivery, and involve more classes. The study findings suggest that a peer-led health curriculum is beneficial to Filipino American adolescents and PEs. Given currently limited research on changing Filipino American adolescents’ health behaviours, the study therefore adds to the literature even with limitations.

Footnotes

Author’s note

Michelle A Thompson is also affiliated with United States Army, Nutrition Clinic, Guthrie Ambulatory Health Care Clinic, Fort Drum, NY, USA.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article. The authors received financial support from the Hawai’i Medical Service Association grant.

ORCID iDs

Michelle A Thompson

Claudio R Nigg

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