article 2

Evidence Based Practice and Policy Reports

A Structured Peer-Mentoring Method for Physical Activity Behavior Change Among Adolescents

Laureen H. Smith, PhD, RN1, and Rick L. Petosa, PhD2

Abstract

Despite national guidelines for regular physical activity, most adolescents are not physically active. Schools serve an estimated 60 million youth and provide an educational environment to meet the current physical activity guidelines. The obesity epidemic and chronic disease comorbidities associated with physical inactivity are not likely to be reversed without a strong contri- bution from local schools. This article describes how a structured peer-mentoring method provides a feasible, flexible, and tailored means to meet the current guidelines for best practice in a school setting. Structured peer mentoring using trained high school mentors to support behavior change in younger peers is an innovative method to meeting the School Health Guidelines to Promote Healthy Eating and Physical Activity. Through structured peer mentoring, adolescents are provided con- sistent social support in a caring and personalized manner. This support builds skills and competencies enhancing self-efficacy to sustain a lifetime of physical activity behavior.

Keywords

exercise, mentoring, obesity, best practices/practice guidelines, health education, school nursing

Despite national guidelines for regular physical activity,

most adolescents are not physically active (Centers for Dis-

ease Control and Prevention [CDC], 2011). Current guide-

lines and scientific evidence for best practices to prevent

obesity and obesity comorbidities such as heart disease, can-

cers, and diabetes recommend at least 60 min of moderate to

vigorous daily physical activity (CDC, 2011; Institute of

Medicine, 2012). A review of 50 studies focused on youth

concluded that regular physical activity improves academic

achievement, academic behavior, and cognitive skills

including concentration and memory (CDC, 2010). Despite

these health and academic benefits, recent data suggest that

only 27% of high school students reported 60 min of daily physical activity every day during the past week, while 14% reported no physical activity in the past week, and less than

half (48%) of high school students attend any physical edu- cation classes in the average week (CDC, 2010, 2013).

These data indicate that most adolescents are not meeting

the recommended daily physical activity guidelines. With

one in three school-aged youth currently overweight or

obese (Ogden, Carroll, Kit, & Flegal, 2014), obesity preven-

tion through improving physical activity is a top priority

(American Academy of Pediatrics, 2006; U.S. Department

of Health and Human Services [USDHHS], 2008).

Schools serve an estimated 60 million youth and provide

a critical setting to build the foundation of skills needed to

help youth meet the current physical activity guidelines

(U.S. Department of Education, National Center for Educa-

tion Statistics, 2015). Most children attend either public or

private schools and spend the majority of their waking hours

in school settings. At the same time, schools are facing

increasing demands on instructional time for core subject

areas to improve standardized test scores (Corcoran & Silan-

der, 2009; Farbman, 2015; Fleischman & Heppen, 2009). As

a result, physical education classes, recess, and activity

breaks are frequently reduced or eliminated during the

school day. In 2006, only 2% of high schools provided daily physical education for students in all grades (Lee, Burgeson,

Fulton, & Spain, 2007). As recently as 2013, only 20% of 12th-grade students attended daily physical education

classes, far below recommendations (CDC, 2013).

Most schools rely on health education and/or physical

education programs delivered by teachers to provide the

skills and motivation for adolescents to engage in physical

activity. In general, these school-based programs have not

1 College of Nursing, The Ohio State University, Columbus, OH, USA 2 College of Education and Human Ecology, The Ohio State University,

Columbus, OH, USA

Corresponding Author:

Laureen H. Smith, PhD, RN, College of Nursing, The Ohio State University,

240 Newton Hall, 1585 Neil Avenue, Columbus, OH 43210, USA.

Email: [email protected]

The Journal of School Nursing 2016, Vol. 32(5) 315-323 ª The Author(s) 2016 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1059840516644955 jsn.sagepub.com

resulted in sustainable behavior change. Consequently,

school nurses and other health professionals serving

school-aged youth frequently seek alternative solutions to

promote behavior change and impact health outcomes. The

purpose of this article is to describe a structured peer-

mentoring method to impact physical activity behavior

change among adolescents. Structured peer mentoring using

trained high school mentors to lead and support the behavior

change in younger peers is a responsive and tailored method

to meeting the School Health Guidelines to Promote Healthy Eating and Physical Activity.

Literature Review

During adolescence, teenagers spend less time with family

members and more time with peers. The powerful influence

that peers have on role modeling and supporting behaviors

of others in their peer group is well recognized (Karcher,

2009; Substance Abuse and Mental Health Services Admin-

istration [SAMHSA], 2014). Adolescents tend to view their

own peers as being more credible, having a better under-

standing of the concerns of young people, have a sense of

responsibility to their friendship group, and are more likely

to model the behaviors of peers than adults (DuBois &

Karcher, 2014; Karcher, 2009; Smith, 2011).

Peer-mentoring programs have been utilized to

strengthen interpersonal connectedness between adoles-

cents, their friends, and schools (Karcher, 2012). Peer men-

toring further strengthens connectedness to oneself both now

and in the future (Karcher, 2012). Feeling a sense of con-

nected to others can be best understood as what one does and

does not care about such as friendship groups and school

friendship networks. Peer mentors build and strengthen

social networks while enhancing school connectedness for

adolescents.

Social networks are links between people that provide

social support (Keller & Blakeslee, 2014). Social networks

among peers provide emotional, informational, and apprai-

sal support that creates a sense of psychological safety

within the peer group, resulting in higher motivation to

change behavior and sustain behavioral change. Learning,

behavior self-efficacy, and behavior change are facilitated

when people have a sense of psychological safety or the

perception that attempts to change behavior can occur with-

out fear or embarrassment (Heaney & Israel, 2008). For

adolescents, advantages of peer mentoring include enhanced

learning and behavioral change support resulting from the

perceived social support and psychological safety promoted

by peer-to-peer mentoring.

Structured Peer Mentoring to Support Physical Activity

Recent developments in program-based peer mentoring have

resulted in the emergence of structured mentoring programs

to promote behavior change (Karcher & Hansen, 2014).

Structured peer mentoring programs are goal directed and

skill building (Karcher & Hansen, 2014). Strengths of struc-

tured peer-mentoring programs are that the mentee learns

behaviors from the role modeling, personalized support for

behavior change, and guidance provided from peer mentors

(Hamilton & Hamilton, 1992). In structured peer mentoring,

a clearly defined curriculum is delivered on a regular sched-

ule. Structured peer mentoring retains the social support and

developmental benefits of peer mentoring while adding

behaviorally focused instruction.

There are numerous advantages to the use of peer mentors

in structured mentoring programs promoting physical activ-

ity among adolescents. Peer mentors empower teens by the

strengthened social network and social support to plan, reg-

ulate, and evaluate their personal activity plan, thus building

self-efficacy to engage in regular activity. Peer mentors can

focus on unique healthy lifestyle challenges to engaging in

regular physical activity such as a lack of organized sports

and recreational facilities prevalent in many low-resource

areas. Peer mentors provide personal support and guidance

to these overcoming environmental, social, and psychologi-

cal barriers, leading to improved adherence to physical

activity and increased peer resources to sustain physical

activity. Serving as role models, peer mentors improve their

own lifestyle behaviors, providing a dual effect of the inter-

vention (SAMHSA, 2014; Smith & Holloman, 2013).

Through structured peer mentoring, physical activity

behavior as a social norm is strengthened by connectedness

with others who care about being physically active. Out-

come expectations or the perceived value one has about

engaging in physical activity is enhanced by engagement

with one’s mentor and peer social group or network.

Because teenagers prefer informal sharing of information

among friends and peer groups, receiving structured physi-

cal activity and exercise information from those closer in age

via structured peer mentoring capitalizes on this innate pre-

ference during the adolescent years. For adolescents lacking

exercise self-efficacy, the social support, guidance, and role

modeling provided through structured peer mentoring and

the broader friendship social networks resulting from men-

toring groups strengthens their personal beliefs about their

own capacity to begin and ultimately sustain daily physical

activity and exercise.

Health educators and school-based health education pro-

grams have used Social Cognitive Theory (SCT) to develop

robust programs leading to behavioral change among indi-

viduals. Two of the most important lessons that SCT stresses

in structured peer mentoring are that age-appropriate cogni-

tive development allows for self-reflection and an awareness

of what others are thinking (Noam, Malti, & Karcher, 2014).

SCT also recognizes that human behavior is shaped by a

dynamic interaction between the individual and the environ-

mental influences (McAlister, Perry, & Parcel, 2008).

Broadly speaking, structured peer mentoring to support

physical activity addresses SCT key constructs of psychoso-

cial determinants, self-regulation, and environmental

316 The Journal of School Nursing 32(5)

determinants affecting individual behavior change. Psycho-

social determinants include outcome expectancies and exer-

cise self-efficacy. Outcome expectations correspond to

social norms and are a function of a social outcome or how

a person will feel about them if they exercise or do not

exercise (McAlister et al., 2008).

Self-regulation includes goal setting, self-monitoring,

overcoming barriers, time management, self-reward, and

social support. For mentors and mentees, establishing,

experiencing, and strengthening important relationships

through the mentoring process and program helps develop

stronger social skills, build exercise self-efficacy, and over-

come perceived barriers by personalized empathy, praise,

and attention (Karcher, 2012). Through personal praise and

support from a mentor, mentees set more realistic goals, self-

monitoring plans, and time management plans to engage in

physical activity. Social perspective taking common during

adolescence, one of collaboration and acting out of shared

needs and concerns for ‘‘us,’’ helps to strengthen interperso-

nal negotiation strategies that help mentees achieve realistic

goal setting, self-regulation strategies, and time manage-

ment skills (Selman & Schultz, 1990). Social perspective

taking further strengthens the ongoing structured peer-

mentoring relationships (Karcher, 2012).

Structured peer mentoring provides mentees with oppor-

tunities to interact with others outside their immediate peer

group or neighborhood. By using peer mentors from the

same local community, personal plans to overcome barriers

and challenges such as the lack of exercise equipment at

home, the lack of recreational facilities, or taking advantage

of opportunities present while at school are jointly devel-

oped. These personal plans are useful for sustaining goal-

directed physical activity behavior change. In addition,

through peer mentoring, engaging in physical activity may

be a form of interpersonal connectedness with peer mentors,

groups, and friendship networks while at school or in the

community that leads to sustainability of the behavior over

time.

Although SCT recognizes how the external environment

shapes behavior, emphasis is also placed on how the indi-

vidual’s personal ability to alter environments to suit pur-

poses they devise for themselves such as altering

environments to engage in physical activity (McAlister

et al., 2008).

External environments are one’s home, neighborhood,

and school. Students actively seek and create supportive

environments that provide opportunities for physical activ-

ity. Structured peer-mentoring programs empower youth by

providing them with resources missing from their neighbor-

hoods and communities (Deutsch, Lawrence, & Henneber-

ger, 2014) SCT has been used extensively for determinants

of physical activity and was used to guide the development

of our proposed method (see Figure 1) to impact physical

activity behavior change (Hortz & Petosa, 2006; Plotnikoff,

Costigan, Karunamuni, & Lubans, 2013).

A School-Based Structured Peer-Mentoring Method

Developed in collaboration with school partners and stake-

holders in rural underresourced and underserved commu-

nities, our structured peer-mentoring method to promote

physical activity was developed and tested over the course

of six intervention studies completed over the past 15 years

(see Table 1). Funded primarily by the National Institutes of

Health and the Centers for Disease Control and Prevention,

the authors conducted two studies testing the feasibility,

acceptability, and outcomes resulting from training peer

mentors to deliver a school-based health curriculum to youth

and four studies to develop and refine a physical activity

curriculum.

These six studies revealed that SCT and specifically self-

regulation, social support, and behavioral self-efficacy vari-

ables are strongly related to moderate and vigorous physical

activity (Hortz & Petosa, 2008; Winters & Petosa, 2001).

The use of trained peer mentors lead to physical activity

behavior change and better health outcomes in mentees,

compared to the same curriculum being delivered to class-

room teachers (Smith, 2011; Smith & Holloman, 2013).

Mentored groups achieved improved blood pressure and

body mass index outcomes, compared to teacher-led groups

(Smith, 2011). The structured peer-mentoring method

increased self-regulation of physical activity, and a

10-lesson dose led to the greatest improvement in moderate

and vigorous daily physical activity, compared to a shorter

eight-session delivery (Stevens & Petosa, 2006). Reinforce-

ment activities via homework assignments provide weekly

consistency of skills and focus on the application and refine-

ment of self-regulation skills applied to the initiation and

maintenance of physical activity.

Implementing a Structured Peer-Mentoring Program

Based on our experience, we offer the following general

steps to consider when establishing a structured peer-

mentoring program (see Figure 2). The first step is to secure

a health behavior change curriculum. The curriculum should

have clear behavioral objectives and provide concise infor-

mation to support motivation to change physical activity.

The curriculum should employ behavioral strategies and

skills deemed valuable to personal health behavior change.

Planned educational activities should be designed to take

advantage of the strengths of peer mentoring. Specifically,

activities should emphasize social interaction, personal tai-

loring, and continuous review of personal progress during

the behavior change progress.

The next step is to consider school infrastructure and

support. Meeting space and time of day are important. Sup-

port staff will be needed, such as a school coordinator, liai-

son, and administrative helpers. The projected size of the

program and budgetary decisions need to be considered

early on. Schools should plan for the projected number of

peer mentors and mentees. One driving force that impacts

Smith and Petosa 317

these early decisions is transportation. Peer mentors and

mentees must be able to get to and from the school for

sessions or meetings. Transportation issues that result in

missed meetings can be hurtful to the mentor–mentee rela-

tionship and problematic for achieving program goals. To

overcome these concerns, many schools incorporate the

mentoring program into the regular school day during study

hall periods, lunch periods, or a regular class period such as a

health class.

Because peer mentors work directly with mentees, there are

certain characteristics that will help them thrive in the mentor

role. Important traits for peer mentors include strong interper-

sonal skills, strength of character, empathy of others, suppor-

tive and flexible, commit to projects and people, skilled in

making friends, good communication, strong listening skills,

strong problem-solving skills, and has fun with others in struc-

tured and unstructured settings (Karcher, 2012). The best peer

mentors may not be those who are already the ‘‘high achie-

vers’’ or those who are most successful in school.

It might be beneficial to seek out possible peer mentors as

students who are high-quality students who have less

competing interests or outside obligations that might

embrace the opportunity to participate as a mentor and ben-

efit from the experience. Many successful peer mentors have

been those who receive average or passing grades but regu-

larly attend school. Consistent attendance in school indicates

a consistent presence in and connectedness to school; stu-

dents who regularly attend school might be better equipped

to build stronger relationships with their mentees (Karcher,

2012).

Other factors to consider are age and year in school.

Ideally, a peer mentor should be about 2 years older than

their assigned mentee. This gap is considered important for

maintaining boundaries in the relationship (Karcher, 2012).

We have found that, due to competing demands and school

adjustment concerns, 10th and 11th graders typically make

ideal peer mentors for mentoring programs taking place dur-

ing the academic year.

In order to build trust and positive relationships with their

mentees, most prospective peer mentors are typically out-

going and social. They are often described by others as having

a positive outlook, wanting to help others, and empathic. It

Delivery Method Social Cognitive Theory Concepts Behavioral Outcome

Daily Physical Activity

PSYCHOLOGICAL DETERMINANTS

PA Outcome Expectations

SELF REGULATION

PA Self Monitoring

Behavioral Goal Setting

Planned Social Support Actual Social Support

ENVIRONMENTAL DETERMINANTS

Perceived Neighborhood Environment for PA

Self-Efficacy for PA

Self-reward for PA

Time Management

Overcoming Barriers

Perceived Home Environment for PA

Peer Mentor Delivery

Figure 1. Structured peer-mentoring method with social cognitive theory concepts to impact physical activity.

318 The Journal of School Nursing 32(5)

Table 1. Preliminary Studies for Structured Peer-Mentoring Method for Physical Activity.

Authors (year) Sample, Setting, Design Variables of Interest Key Results

Smith (2011) n ¼ 72 children n ¼ 35 peer mentors 8-session curriculum School-based (after-school) Pretest–posttest design Attention control and intervention group

comparisons

Physical Activity (PA) Attitudes Self-Efficacy toward PA Perceived support for PA Intention to be PA Body mass index (BMI)

percentile

Mentor Group: Mean change in BMI %—0.38. Improved: Attitudes toward PA (þ0.29) Self-efficacy toward PA (þ1.50) Perceived support to be PA (þ0.74). Peer mentors delivering curriculum is feasible. Attention control: Mean change in BMI% was þ0.07. Mean decreases in variables of interest

Smith and Holloman (2013)

n ¼ 160 children n ¼ 32 peer mentors 8-session curriculum School-based randomized controlled trial

(RCT) 8-session curriculum School-based comparison group was teacher

led Pretest–posttest design

Dietary behaviors PA behaviors Blood pressure (BP) BMI Mediators: nutritional

knowledge, attitudes, perceived support, self- efficacy, intentions

Mentor group: Increased PA behavior (p ¼ .04). Marginal decrease in BMI (p ¼ .06) Medium effect size (ES): Current Eating Behavior (ES ¼ .57). Improved diastolic BP (ES ¼ .56). Perceived Support (ES ¼ .60). Teacher group. No improved behavioral or health outcomes Other comparisons: High retention rates (92%) Greater number of sessions attended resulted

in better outcomes Hortz et al.

(2009) n ¼ 15 Appalachian high schools with 602 9th

graders and 422 12th graders included Needs Assessment to compare to current

physical activity guidelines. Descriptive, cross-sectional study

PA behavior over the past 7 days

Only 13.9% engaged in vigorous PA at least 3 days/week.

Only 37% engaged in moderate PA at least 5 days/ week.

For students meeting current guidelines, 14% did so through organized sports and 12% used physical education classes

Winters and Petosa (2001)

n ¼ 143 students in Appalachian high schools. Two group RCT, pretest and posttest design

Frequency of PA Self-regulation of PA Social situation for PA PA outcome expectations PA self-efficacy

10-session dose led to best outcomes. Teacher retention rate was 100%. Program increased self-regulation.

Comparisons: Intervention group increased PA from 1.29

days/week to 2.35 days/week (p < .01). Comparison group PA decreased from pretest to posttest (p ¼ .05)

Hortz and Petosa (2008)

n ¼ 363 students in two rural Appalachian high schools; two group-controlled, 10- session intervention trial with pretest and posttest design

Rates of moderate and vigorous physical exercise

Gender comparisons Self-regulation Social situation

At baseline, rate of exercise was low in both the groups. Nearly all students did not meet recommended daily exercise requirements.

Intervention group: Increased moderate PA by 2.05 days/week

(p ¼ .025). Intervention increased self-regulation skills

and social situation. Control group: 10% decrease in daily exercise. Other comparisons: No gender differences, regardless of group

Stevens and Petosa (2006)

n ¼ 4 Appalachian high schools with 422 participating students; nonequivalent comparison group design (3 intervention school/1 comparison school). Nine-session PA curriculum. Eligible students were those who did not engage in sports or sports teams

Rates of weekly PA (moderate and vigorous)

Self-regulation Social Support

Teacher noncompliance with intervention protocols led to the loss of 26 participants.

Intervention: Explained greater portion of variance at two

of the three intervention schools. Intervention was partially effective at impacting moderate PA supporting need for 10 sessions. Regression models explained 24–78% of variance within intervention schools. Self-regulation and social support mediated changes in PA. No changes in vigorous PA found

Smith and Petosa 319

would also be important to seek possible peer mentors who

feel a strong sense of connectedness to their friends and

school. One indicator of connectedness to one’s schools is

overall performance in school.

How you recruit peer mentors will depend on the size and

scope of your program. It is best to start small with 10–15

peer mentors matched with one to two mentees each. As

with any newly implemented program, expect some glitches

along the way so starting small will facilitate a smoother

program implementation. Some suggestions for recruitment

include information sharing at parent orientation events,

brochures and posters in school, school announcements,

in-class announcements, and personal outreach to targeted

students. A key component of peer mentor recruitment is to

have each prospective peer mentor complete a Mentor

Application. The Mentor Application should include contact

information, preferred mentoring day and time, preferred

gender match, what is unique about them, why they want

to be a mentor, their hobbies and interests, activities they

like to do, favorite subjects in school, and their least favorite

subjects in school. In addition, you may ask for a reference

from a teacher, coach, or counselor as part of the application.

This application may be used as a tool to match program

participants to mentors as well as screen potential mentors

for selection.

Training and supervision are critical components of peer

mentoring. Training begins with prematch activities but con-

tinues during the program at regular meetings with mentors,

such as brief debriefing sessions as well as guidance and

support during mentoring sessions. To be effective peer

mentors, teens need training on how to be supporting men-

tors as well as curriculum content training. Peer mentor

training should be structured to cover important program

responsibilities and how to build and sustain an effective

mentoring relationship with a mentee. To assure program

effectiveness, the main role of peer mentors is to consis-

tently attend all program sessions and actively participate

in program activities with their assigned mentees. These

critical responsibilities build the trusting relationship that

is necessary for successful peer mentoring program delivery.

Other mentor program responsibilities include informing

program staff if unable to attend a session (in advance),

staying on task, being respectful, modeling behaviors, focus-

ing on the mentee by giving the mentee their full attention

during the sessions, helping mentee complete program activ-

ities, and report on activities or provide feedback during

debriefing sessions.

Peer mentors should also be trained on whom to seek out

for assistance during and after any session for help and gui-

dance. Important mentoring topics to discuss during mentor

training include what is mentoring; how to be a good lis-

tener, how to handle crises or the unexpected, how to break

the ice, and getting their mentee to share; building trust;

offering praise and reinforcement; offering constructive crit-

icism; conflict resolution; problem-solving steps; and transi-

tion of the mentoring relationship or saying good-bye

(Karcher, 2012).

Once mentoring training is completed, peer mentors

should be trained on the school’s specific physical activity

program and its delivery. To strengthen program fidelity,

peer mentors should be provided detailed and structured

outlines of each lesson or session’s activities including

instructions, materials needed, and time allocated to com-

plete the activity. In addition, a brief meeting with the peer

mentors prior to each lesson or session to problem solve or

answer any questions about the planned activities is essen-

tial. We have found that a brief 10- to 15-min debriefing

meeting at the conclusion of each mentoring session for

program staff to meet with the peer mentors is beneficial.

During these debriefing sessions, the peer mentors may

share program delivery challenges, share program delivery

successes, offer suggestions for improvement, and provide

guidance and support to other peer mentors. The debriefing

meetings may be a time when program staff may log any

community service credit or provide any incentive payment

(if provided).

Peer mentors should be supportive of other peer mentors.

As part of a budding social network, many mentoring groups

1. Select a (Health) Curriculum or Program Behavior objectives, Skill-building, Social Support

2. Plan for Needed Infrastructure and Support Meeting Space, Time of Day, Supervision, Program Size

3. Mentor Selection – Personal Skills Interpersonal Skills, Empathy, Supportive, Flexible,

Commitment, Strong Listening Skills, Good Communication, Strong Problem-Solving Skills, Social

4. Mentor Selection – Practical Considerations School Attendance, Age, Gender, Competing Demands,

Other Interests, Teacher or Staff Recommendations 5. Implementation

Mentor Application, Personal Outreach to students, Outreach at Parent and Student Events, School Announcements, Brochures, Posters

6. Start Small for Success 10-15 mentors matched with 1-2 mentees each.

7. Training and Supervision Training on curriculum and how to be a supportive

mentor Regular de-briefing sessions, guidance, and support

8. Consistency is Key Structured Peer Mentoring works best with the same

mentor-mentee pairs for all curricular sessions Mentors should participate in program activities with

mentees Build in activities for the larger mentoring groups to do

together 9. Make a Transition Plan (End of Program)

Reflect on time Mentor-Mentee together and provide closure

Time to Celebrate and Recognition for Completion

Figure 2. Steps to implement a school-based structured peer- mentoring program.

320 The Journal of School Nursing 32(5)

meet in a large school space together, such as a gymnasium

or a cafeteria. Seeing the presence of other mentoring groups

offers a sense of security to both peer mentors and mentees.

Having all mentoring groups meet in the same large space

also facilitates guidance and supervision by program staff.

We have found that in a large school space, it is best to ask

mentor–mentee triads/dyads to work together and at a dis-

tance from other groups while remaining visible to other

groups. Larger groupings may lead to distractions among all

within the room and hinder implementation of the program

as well as program fidelity.

Peer mentors or mentees may not be able to attend every

session; a plan to handle absenteeism of both mentors and

mentees should be drafted. If a peer mentor is absent, you

may place their assigned mentees with other mentors for the

session. If a peer mentor’s assigned mentees are absent, you

can ask the mentor to assist other mentoring groups or be a

program assistant or lead mentor for the session. As program

assistant or lead mentor, they would help all groups or pro-

gram staff in facilitating program delivery. Strategies to

enhance program attendance include offering a refresh-

ments; planning activities that span several sessions; and

integrating activities from other curricula such as health,

science, or math. Since many students seek community ser-

vice opportunities, many schools now require a requisite

number of community service hours for graduation. Offering

community service hours to peer mentors should be consid-

ered. Community service hours strengthen college applica-

tions, job applications, and professional resumes. Often

students who served as mentors are recruited based on the

professional development and leadership experience gained

from mentoring others.

Finally, a transition plan should be established. We have

found that how the structured mentoring ends is critical.

The transition plan should provide both the peer mentors

and the mentees an opportunity to reflect on their relation-

ship and walk away with positive feelings and memories.

This phase should provide closure and opportunities for

learning for both parties (Karcher, 2012). Many programs

build in an end of program Celebration Session to allow for

closure.

Implications for the School Nurse

Considering all causes of morbidity and mortality in the

United States, modifiable behaviors are the leading cause

of comorbidities of Americans. Two behaviors, physical

inactivity and unhealthy eating, are largely responsible for

the rapid rise in and prevalence of overweight and obesity

among our school-age youth. In addition to substantial

well-documented health disparities, overweight and obese

youth have a higher prevalence of school problems includ-

ing poor social skills, poor academic performance, and

mental health concerns such as anxiety, depression, and

suicide attempts (Carey, Singh, Brown, & Wilkinson,

2015; Serrano-Gonzalez, McConnel, Bokhary, Oden, &

Lopez, 2015). Sedentary behaviors, specifically increased

screen time, have been shown to have detrimental effects

on the cognitive outcomes of youth such as language skills,

memory, and spatial cognition (Carson et al., 2015). With

increasing demands placed on today’s schools, the school

nurse’s role has evolved to encompass the responsibility for

teaching much of the health and physical education curri-

culum once completed by traditional teachers. School

nurses assume this role often while serving several schools

within district or locale. Consequently, others within the

school community such as health coaches, health assis-

tants, and administrative support are often taught and led

by school nurses to address many health needs with the

schools.

Older teens as trained peer health mentors may be a

feasible and resourceful approach that school nurses may

adapt to meet the needs of their schools. In addition, a

structured peer-mentoring approach to curricular delivery

overcomes several barriers to behavioral change and has

many innate benefits to both the mentors and the mentees.

In focusing on physical activity behaviors, our experience

of working in underresourced areas suggests that many

students will not have access to traditional exercise and

fitness facilities characteristic of many urban and suburban

settings. Lack of transportation and distance to facilities are

barriers. Therefore, forms of activity that can readily be

done in school, neighborhood, and home environments are

best achieved through friendship networks and peer groups

cultivated through peer mentoring. With peer mentors,

engaging in physical activity may be a form of interperso-

nal connectedness to peer mentors, groups, and friendship

networks that leads to sustainability of the behavior over

time. Although the behavioral focus of our method is

physical activity behavior, school nurses may establish a

structured peer-mentoring program to address other health-

related topics of importance to their individual school or

school district.

Conclusion

The structured peer-mentoring method described in this arti-

cle provides a promising approach that provides flexibility

while at the same time the rigors of an evidence-based and

sound theoretical foundation to better engage adolescents in

physical activity. Through peer mentoring, adolescents are

provided intense social support in a caring and personalized

manner. This support builds self-efficacy, competence, and

skills needed to develop, maintain, and sustain a lifetime of

physical activity behavior.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect

to the research, authorship, and/or publication of this article.

Smith and Petosa 321

Funding

The author(s) disclosed the following financial support for the

research, authorship, and/or publication of this article: The method

reported in this publication was supported by the Eunice Kennedy

Shriver National Institute of Child Health and Human Development

of the National Institutes of Health under Award Number

R01HD080866. The content is solely the responsibility of the authors

and does not necessarily represent the official views of the National

Institutes of Health.

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Author Biographies

Laureen H. Smith, PhD, RN, is an associate professor at College

of Nursing at The Ohio State University.

Rick L. Petosa, PhD, is a professor at College of Education and

Human Ecology at The Ohio State University.

Smith and Petosa 323