art & science sexual health
Using peer education projects to prevent HIV/AIDS in young people Campbell S (2005) Using peer education projects to prevent HIV/AIDS in young people. Nursing Standard. 20,10, 50-55. Date of acceptance: December 6 2004.
This article discusses the use of peer education to reduce sexually transmitted infections, including human immunodeficiency virus/acquired immunodeficiency syndrome, in young people. I t describes experiences gained from a peer education project for young people in Uganda,
Author Sue Campbell is a freelance writer in Kampala, Uganda, Email: Masc(@)utlonline.co,ug
AIDS; Health education; Peer education
These keywords are based on the subject headings from the British Nursing Index, This article has been subject to double-blind review. For related articles and author guidelines visit our online archive at www.nursing-standard.co.uk and search using the keywords.
MORE THAN half of people newly infected with the human immunodeficiency virus (HIV) worldwide are aged 15-24 years (United Nations Children’s Fund (UNICEF) etal 2002). Empowering young people with the basic human right of reproductive choice is, therefore, critically important.
Over the past decade there has been a growing interest in involving young people as peer educators in health education in the UK, particularly in the area of sexual health (Health Education Board for Scotland (HEBS) 2003), Peer education approaches offer the possibility of changing behaviour and increasing knowledge to prevent HIV, This article explains what a peer education approach is and gives guidance on how to develop a project focused on young people. Although the author’s experience of developing peer education projects in Uganda for HIV prevention is discussed, some of the principles can be transferred to working with young people in the UK,
Young people are at the centre of the global HIV and acquired immunodeficiency syndrome (AIDS) pandemic. They are also a key human resource for the future wellbeing of communities. Each day nearly 6,000 young people aged from
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15-24 years become infected with HIV (UNICEF etal2002). Educating young people about HIV, and teaching them skills in negotiation, conflict resolution, critical thinking, decision-making and communication improve their self-confidence and ability to make informed choices, for example, postponing sex until they are mature enough to protect themselves from HIV, other sexually transmitted infections (STIs) and unwanted pregnancies (UNICEF ef a/2002).
In 2003, an estimated 4,1 per cent of adults in Uganda and 0,2 per cent in the UK were living with HIV/AIDS (Joint United Nations Programme on HIV/AIDS (UNAIDS) 1999, UNAIDSAJNICEFAVorld Health Organization (WHO) 2004), Factors that encourage the spread of HIV/AIDS among young people in Uganda include (Government of Uganda 1999):
• Sociocultural issues, including attitudes among peer groups about early and risky sexual behaviour, and service providers’ attitudes about adolescents’ sexuality,
• Practical issues, such as the availability of condoms and information,
• Economic factors that encourage young people to engage in sexual practices that put them at risk of developing an infection,
To be most effective, prevention approaches should be tailored to the needs of particular groups, such as young people, and address predisposing factors to the spread of HIV/AIDS, such as the lack of condom use.
Peer refers to a person of the same age, status or ability as another specified person (Pearsall 1999), Peer education is a popular concept that implies an approach, a communication channel, methodology, philosophy and strategy. In practice, peer education has encompassed a range of definitions and interpretations about who is a peer and what is education, for example, advocacy, counselling, drama, lecturing,
distributing materials, making referrals to services or providing support (UNAIDS 1999),
The theoretical base of peer education is behavioural theory, assuming that people make change based on progressive steps of understanding and internalising the relevance to their own situation (0stergaard 2003), Peer education typically involves training and supporting members of a given group to effect change among members of the same group. These can be changes in knowledge, attitudes, beliefs and behaviour at an individual level, and stimulating collective action that can bring about change at a policy and programme level.
The Baaba project – a Baaba is a respected elder sibling in the local Luganda dialect – is a peer-led HIV/AIDS prevention programme for street children in Uganda, It is facilitated by GOAL, an international non-governmental organisation (NGO), Street children as a group are generally vulnerable and difficult to reach. An estimated 4,000 young people live on the streets of Kampala and are the most visible of Uganda’s marginalised youth. Social breakdown and poverty resulting from the HIV/AIDS epidemic have contributed to the existence of street children in Uganda, Urbanisation, conflict and the breakdown of traditional family structures are also responsible (Ministry of Gender, Labour and Social Development 1999), Other health problems include skin infections, respiratory infections, diarrhoeal diseases and malaria (GOAL Uganda 2001),
The Baaba project seeks to integrate HIV/AIDS prevention into mainstream interventions for street children, such as provision of shelter, food and basic education and health care, and into the activities of other agencies that influence the health and welfare of street children and young people. The project involves a life skills approach to tackle HIV/AIDS prevention and issues such as drug misuse and rape. It is based on social learning theory (Bandura 1986), which emphasises self-efficacy – belief in the ability to change behaviour – and beliefs about the outcome of changing behaviour, for example, the belief that using condoms will prevent HIV,
The aim ofthe peer education approach is to develop the confidence, capacities and leadership skills of the young people who are trained as peer educators. This can be achieved by running project activities, training to be trainers, project planning and management training, occupying respected and responsible positions among their peers, and working as information providers on sexual and reproductive health issues.
Peer education can take place individually or in small groups in a variety of settings, including schools, clubs, religious settings, workplaces, on the street or in a shelter, or wherever young people
gather. It can be used with a variety of populations and age groups. In the past decade, peer education has been used extensively in HIV/AIDS prevention and reproductive health programmes around the world (Population Services International (PSI) 2000, Neukom and Ashford 2003),
Studies show that young people frequently turn to their peers for information and advice. These interactions tend to be more frequent, intense and diverse than those with other people, and they also provide an arena for support and modelling (HEBS 2003), The peer education approach is culturally appropriate, community- based, accepted by the target audiences and can also be economical (Family Health International/AIDS Control and Prevention Project (FHI/AIDSCAP) 1996),
Peer education has the advantage of perceived credibility of peer educators in the eyes of their target group. Young people exposed to peer education often praise this approach because it is reached through a shared background between the educator and his or her audience. Themes of interest for students, team members and others might include: musical tastes, popular celebrities, use of language and family themes – such as the struggle for independence and fitting into culturally accepted norms and values. Another advantage of peer education is that young peer educators are less likely to be seen as authority figures preaching about how others should behave. Rather, peer education is perceived more like receiving advice from a friend who is ‘in the know’, A successful peer educator is viewed by his or her peers as someone who has similar concerns, is trying to help out, and has an understanding of what it is like to be a young person (Stakic et al 2003),
Peer education advocates the right of young people to participate in processes that affect them and to access the information and services they require to protect their health. Young people represent a key resource in mobilising an expanded and effective response to the HIV/AIDS epidemic. Their energy, charisma, creativity and urge to learn and adopt new ways can bring insight and inspiration to programmes that listen to what they say.
Peer education can be a useful and productive approach to health promotion. However, it is not appropriate in all situations. It can be useful in targeting groups that are traditionally hard to reach, such as those who are alcohol and/or substance misusers and street children. It is also
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art & science sexual health Recruitment and selection
useful in reaching other marginalised groups, such as homosexuals or commercial sex workers. It can reach those who are in or out of school, college or university. It can work in projects to address bullying in school or assist in promoting sexual health. Peer education can also be used with information and communication technologies, such as internet-based counselling services or telephone help lines.
The identification of target groups should always be based on the identification of the specific needs of young people, preferably through baseline surveys and needs assessment studies in the proposed project sites (International Planned Parenthood Federation (IPPF) 2001), It is essential to make enquiries about the profile of the intended health education audience before deciding whether to deploy peer educators. There are a number of questions that should be addressed in a needs assessment (Box 1),
Questions to ask in a needs assessment of a proposed project site
• What are the goals of the project?
• Who is the target audience?
• Are there people in the target group who have the time, interest and ability to work as peer educators?
• What will the peer educators need to do?
• What resources will the peer educators need to conduct these activities?
• Can the project provide these resources?
• How large is the target group?
• How many peer educators are required to reach this group?
• Can the project train and support that many peer educators?
• Will the peer educators need incentives and, if so, what? Can the project provide them?
• Can the peer educators be supported with supervision, refresher training and incentives over the long term? Is there a budget for this?
• How many staff members will be required to support the project?
• What other activities will the peer education strategy complement?
* Have there been or are there any other similar projects going on in your area? This is important to avoid duplication and confusion.
(Adapted from FHI/AIDSCAP 1996)
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The recruitment and selection of peer educators should not be the responsibility of project managers only. The selection process should involve the relevant stakeholders to increase the acceptability of peer educators either in schools or the community (IPPF 2001), There are certain qualities to look for when selecting peer educators (Box 2), Another way to identify candidates for peer educators is to observe a group’s behaviour and then identify its natural opinion leaders (FHI/AIDSCAP 1996),
The Baaba project involves 170 trained peer educators, or Baabas, who plan and implement HIV/AIDS prevention activities with partner NGOs, on the streets and in surrounding communities. There are currently 12 NGOs participating in the Baaba project across Uganda, Partner NGOs provide activities for street children and are trained by GOAL to work on the Baaba project. Other organisations can become partners in the Baaba project if they (GOAL Uganda 2003):
• Work to meet the short and long-term needs of street children and youth,
• Are committed to the long-term development and rehabilitation of street children and youth,
• Recognise that street children and youth are at risk of contracting HIV/AIDS,
• Currently lack the capacity to confront HIV/AIDS issues for street children and youth.
Ten to 20 young people are elected as Baabas by their peers. The NGO director appoints a link staff member to supervise the Baabas and act as a link between them and GOAL, At project level, activities are co-ordinated and facilitated by a GOAL team, comprising a manager, three peer trainers/counsellors and two volunteers. The team provides capacity building and ongoing supervision support, organises inter-NGO events and co-ordinates advocacy activities.
Training topics and activities
Initial training, of seven to ten days and focusing on theoretical and practical issues, is an important element of a successful peer education programme. The initial training is important to equip them with the necessary skills, knowledge and motivation (IPPF 2001), The choice of training will depend on the objectives and activities of the project and the results of the needs assessments. Peer educators may:
• Provide one-to-one counselling or information, either formally or informally,
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• Provide formal or informal information or counselling in a group setting,
• Facilitate outreach programmes for target audiences in the general population,
• Reach audiences through a variety of interactive strategies, such as small group presentations, role play or games,
• Staff outreach offices, telephone help lines and resource centres to provide peer educators with health information and take part in self-assessments,
• Act in drama groups with role model problem-solving skills woven into scenarios that are recognisable as actual health risks to peers (HEBS 2003),
• Refer to service providers.
Experience in counselling young people has shown that information alone does not lead to a change in behaviour and, increasingly, there is recognition that young people should be equipped with the necessary skills to sustain behaviour change. Learning life skills, such as conflict resolution and negotiation, helps young people to relate to one another as equals, work in groups, build self-esteem, resolve disagreements peacefully and resist both peer and adult pressure to take unnecessary risks (UNICEF etal 2002), Thus training in life skills is important in all peer education programmes.
Frequent additional training and refresher courses in sexual and reproductive health and communication are necessary to ensure quality in peer educators’ work and keep them motivated and committed (IPPF 2001), Training should use as many different participatory techniques as necessary, for example, group discussions, role play, music, dance and drama and puppetry to increase understanding.
In the Baaba project, training and peer education activities are based on participatory learning tools,Objectives ofthe peer education and life skills component ofthe project are:
• Increased knowledge and skills of Baabas in promoting the sexual and reproductive health of street children and young people in and outside NGOs,
• Street children and young people accessing ‘street friendly’ sexual and reproductive health services, counselling, prophylaxis and protection through an effective NGO, Baaba network and referral system,
• Increased knowledge of sexual and reproductive health among street children and young people,
Activities run by the Baaba project include:
• Prevention clubs – focusing on information, education and communication activities to prevent HIV – seminars, sport and street outreach run by Baabas,
• Referral systems established through ‘street- friendly’ service providers,
• Condom distribution by Baabas and GOAL,
• Puppetry and drama.
Trainers include nominated teachers to assist with the school-based clubs and other community members. Links are made with the various clubs by displaying pertinent information on notice boards and through end of year festivals, when all the partner organisations get together and put on a joint concert. Encouragement is given for people living with HIV/AIDS to meet staff and members of the AIDS awareness clubs to share information and answer questions, AIDS awareness clubs develop their own topics for discussion and examples include: family life education, training in life skills, risk reduction, sexual and reproductive health rights, condom negotiation and distribution, coping with AIDS in the home, running a club, and music, dance and drama training, A manual was developed with the participation of the clubs. Condoms are available through the clubs.
Qualities to look for in potential peer educators for a sexual health project
• Ability to communicate clearly and persuasively with peers.
• Good interpersonal skills, including listening skills,
• A sociocultural background similar to that of the target audience – may include age, sex and social class.
• Accepted and respected by their peers.
• A non-judgemental attitude.
• Strong motivation to work towards human immunodeficiency virus (HIV) risk reduction.
• Care, compassion and respect for people affected by HIV and acquired immunodeficiency syndrome (AIDS).
• Self-confidence and potential for leadership.
• Pass a practical, knowledge-based exam at the end of training.
• Time and energy to devote to this work.
• Potential to be a safer-sex role model for their peers.
• Able to get to the location of the target audience.
• Able to work irregular hours.
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art & science sexual health
Supervision and support
Support for peer educators includes (GOAL Uganda 2003):
• Regular in-service meetings,
• Additional educational materials for peer educators’ own use, for example, a handbook or manual,
• Information, education and communication materials and condoms for distribution to peers,
• Certificates, badges, T-shirts, bags or hats to identify them as trained peer educators and acknowledge their contribution to the project,
• Supervisor availability to help peer educators deal with discouraging or difficult experiences,
• Information booklets that provide answers to commonly asked questions,
V Special activities just for fun,
• Links with other community groups,
• Referral book that allows educators to send peers to other available resources,
• Opportunities for established peer educators to teach and mentor new peer educators.
Supervision helps to ensure that the peer educators are doing a good job and there are various ways to supervise peer educators.
Monitoring and evaluation
The monitoring and evaluation of peer education projects should be carefully planned. Monitoring This should include field visits, activity reports, regular meetings, focus group discussions and qualitative surveys with young people and peer educators to assess progress and what needs to be done to improve the project (IPPF 2001), Peer education can include various activities and there appears to be no systematic evaluation ofthe effects of each ofthe activities (HEBS 2003), Consequently, there is little detailed understanding ofthe processes involved in such interventions and a lack of evidence about their effectiveness. Therefore, when setting up a peer education programme there is no clear guidance about issues, such as timing, recruitment, nature ofthe targeted behaviour, status of peers, effects on participants, social contexts and social processes. Evaluation This must be tailored to the realities ofthe time that is available. As with other health
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education activities, outcomes may vary depending on the timing ofthe assessment. With peer education it is also possible that the motivation ofthe peer educators may vary over time, depending in part on changes in their own life circumstances (HEBS 2003), The length of each project will vary depending on its target group and the objectives but often youth projects require long-term commitments. As the peer educators get older they will inevitably drop out ofthe project and others will have to be brought in to replace them. Often the targeted ‘problem’ will not disappear and will affect the next age group of children.
The Baaba project has used regular reviews of project, NGO staff and Baabas and their peers to evaluate its activities. The project also conducted a knowledge, attitudes and practice survey of street children as part ofthe baseline needs assessment and after two years of project implementation. These all demonstrated improvement and led to the development of a second phase of the project.
True participation is a partnership in which young people and adults have agreed responsibilities. Energetic, enthusiastic and creative young people are a tremendous resource in all areas of HIV prevention and care. Their input is invaluable to programme design and outreach, ensuring that prevention and care efforts are meaningful to young people, that information is communicated through effective channels and that the messages conveyed are relevant to their everyday lives (UNICEF efa/2002).
Involving young people in prevention efforts not only educates them about HIV but also gives them a sense of responsibility and pride. Participation of peer educators and other young people in the planning process and development of action plans is essential for successful programme implementation, A weekly or monthly activity plan, as well as clearly defined targets, are key elements to ensure that peer educators know what is expected of them (IPPF 2001),
Adults should ensure that young people are informed, trained, motivated and supported in all of their HI V prevention efforts, according to their ability and as the project evolves. Young people should demonstrate commitment, be reliable and active contributors. It is also important when working with young people that they are regarded as part of the solution and not the problem.
There is a lack of research, particularly in the UK, that evaluates the various components of peer
education projects. The inherent difficulties with evaluation of such projects remain challenging. Projects do not exist in isolation so it is difficult to identify the impact of the project and to demonstrate that a specific intervention resulted in behaviour change because there are other influences in the environment or possible contributing factors. Although an increase in knowledge is often used as a measure of impact, the objective of behaviour change is more difficult to measure, and an increase in knowledge does not necessarily lead to a change in behaviour.
A high attrition rate of peer educators can be a positive result because it may mean that the peer educators have left their previous negative behaviours such as substance misuse and are now concentrating on their academic career. It should also be noted than no single intervention is likely to bring about sustained behaviour change (Berlin and Hornbeck 2003).
In formulating youth programmes, the peer education component has to be integrated with other aspects of a youth project, and be part of an overall project philosophy. A single theatre performance may motivate a teenager or pre-teen to consider or adopt safer sexual options, but it cannot ensure that that this will be sustained. Parental, school and community involvement are crucial to sustain behaviour change (Berlin and Hornbeck 2003).
Working in an established system can also have limitations, such as having to fit your activities into a structured school curriculum. A peer education project requires a dynamic staff member to work with the young people and ensure that they remain motivated. A project should also be long term because many ofthe attributes required, such as self-esteem, take time to develop. Other difficulties encountered may have no right or wrong answers.
and need to be discussed with colleagues and the project participants to consider what is appropriate for a particular setting. This includes issues such as:
• Should the peer educators be paid?
• Should the peer educators only provide information, leaving the counselling and support activities to professional staff?
• Should the peer education project be linked formally with other health projects?
Because peer educators often receive little or no pay, the Baaba project had to find ways of ensuring the commitment of the Baabas. Various incentives have been used, such as designing and printing T- shirts and bags for the peer educators, regular supervision and support with refresher training, inter-club competitions and festivals. Peer educators are supplied with adequate educational materials and tools, for example, samples of contraceptives or flipcharts. Training the trainers has also been initiated to increase the number of peer educators and to compensate for those who drop out. The development of a manual will help to ensure that training of trainers and support and follow-up are of high quality.
Peer education can be a useful approach when working with young people. With a thorough needs assessment and the participation ofthe young people, an effective project to change negative behaviour or maintain positive behaviour can be developed and implemented, provided this is integrated with other activities. Adequate monitoring and evaluation should be included from the start of the project to help avoid difficulties at a later stage NS
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