The effect of peer education based on adolescent health education on the resilience of children and adolescents: A cluster randomized controlled trial

facing adolescent problems has also been significantly improved (see S1 File). In addition, we also tested the peer educators’ learning of knowledge and skills related to peer education through interactive games, and the results showed that peer educators initially had the ability to carry out peer education activities. According to the theory of knowledge, attitudes, and practices (KAP) in behavior change models, knowledge is the foundation, attitude is the moti- vation and behavior is the goal. Knowledge improvement and attitude change contribute to the formation of individual behavior and skills [46]. It is suggested that the training of knowl- edge and attitude of adolescence and knowledge and skills of peer education activities can help peer educators to develop a healthy lifestyle and develop their ability to carry out peer educa- tion activities. After the peer education training course, peer educators used the knowledge and skills learned in the training course and materials provided by the research group to carry out inter- vention activities for each class. Regarding the forms of peer education, a knowledge quiz game, group discussion, sitcom performance, self-designed poster exhibition and so on were used to conduct activities, with the provision of knowledge quiz software, group discussion cases and analysis results, role-playing scripts, and adolescence-related health education slides. Peer educators spent the class meeting or spare time conducting activities among their peers

and were required to record key information of every activity, such as the number of partici- pants, context of activity, and satisfaction and advice of participants. Importantly, the content and format we selected is unique and has never been carried out in the primary and secondary schools of the district and county. Additionally, educators had to perform at least 2 activities per month. During the intervention, peer education activities were tracked and documented by psychologists and research members through online interviews or field visits. Then, we con- ducted secondary training on October 2,018 to intensify relevant knowledge and teach them how to cope with stress and negative events. During the 1-year intervention, we performed supervision twice per semester to evaluate the process of peer education activities and to collect activity records. With respect to the content of peer education sessions, based on the "Six Strategies Training Program" by Henderson and Milstein [47] and the key life period in which adolescents are transitioning from child to adult, physiological knowledge, psychological health education, and health lifestyles were included as the targeted intervention content. Physiological health education involves growth spurts, development of secondary sexual characteristics, acne treat- ment, treatment of breast development, menstruation, dysmenorrhea for girls, treatment of beard growth and seminal emission, and cleaning of the private parts. Psychological health

education includes the process of psychological development during adolescence and the treat- ment of psychological problems such as tension, anxiety and conflicts with parents, teachers, and peers; a healthy lifestyle involves a balanced diet, reasonable exercise, and good sleep. Measurements Psychological resilience was assessed through the Resilience Scale for Chinese Adolescents (RSCA) by Yueqin Hu [48] according to Chinese culture, which included 27 items and 5 fac- tors (F1-F5). F1- Target focus, which means sticking to goals, making plans and focusing on problem-solving in difficult situations; F2—Emotional adjustment, which refers to the control and adjustment of emotional fluctuations and pessimism in difficult situations; F3—Positive cognition refers to a dialectical and optimistic attitude towards adversity; F4—Family support, which refers to the tolerance, respect and supportive attitude of family members; F5- Interper- sonal assistance, which means that individuals can obtain help or vent their emotions through meaningful interpersonal relationships. All items were scored on a 5-point scale. The PLOS ONE The effect of peer education based on adolescent health education on resilience of children and adolescents PLOS ONE | https://doi.org/10.1371/journal.pone.0263012 February 2, 2022 6 / 18