The European Journal of Public Health Advance Access originally published online on January 23, 2006
The European Journal of Public Health 2006 16(2):128-132; doi:10.1093/eurpub/cki162
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Infectious Diseases |
Peer education in HIV prevention: an evaluation in schools
Koula Merakou and Jenny Kourea-KremastinouDepartment of Public & Administrative Health, National School of Public Health, Athens, Greece
Correspondence: Koula Merakou, Department of Public & Administrative Health, National School of Public Health, 196 Alex. Avenue, 11521 Athens, Greece, tel: +301 6465982, fax: +301 6432258, e-mail: kmerakou{at}nsph.gr
Received March 21, 2003, accepted June 7, 2005
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Abstract |
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Background: In recent years a number of publications have come out about the peer education method used as a tool in HIV prevention for young people. Our survey aimed at testing the effectiveness of the peer education method in HIV prevention in high school settings through a pilot intervention. Methods: A peer education intervention took place in 10 high schools in Athens over a 1 year period. A cohort of 702 students was surveyed (n = 493 intervention group, n = 209 control group) from 13 high schools through anonymous questionnaires based on the KABPs model, pre- and post-intervention. The statistical package used was SPSS using the
2-test. Results: Compared with control students, the intervention students were slightly empowered: (i) to increase their personal responsibility; and (ii) to adopt a safer behaviour in sexual practice. Knowledge did not show any significant modification between the two groups. However, discrimination about certain groups of people, the attitude about condoms and initiation of sexual relations did not appear to be influenced. Conclusions: The peer education approach can influence the behaviour of young people regarding their personal protection from HIV infection. In order to test its effectiveness, peer education should be further evaluated as a health education method in HIV prevention in high schools, other youth settings and community interventions, where the aim is behavioural change.
Keywords: high school, HIV prevention, peer education, survey
Health education needs to go beyond traditional education methods, especially when it concerns young people. Preventive interventions that only provide information about HIV/AIDS have proved to be ineffective in changing risky behaviour.1,2 Other studies support the view that cognitive-behavioural interventions that focus on changing attitude and life skills development, in addition to information, may be more effective in modifying risky behaviour.3,4
Peer education appears to be a promising method in promoting risk-reduction behaviour among young people.5–7 Although, as a pedagogical method, peer education has a long history, it began being applied in health education and especially for HIV/AIDS prevention during the 1980s. In recent years, this method has been relatively popular in health education, perhaps because of the unquestioned positive component of the method, which is the interaction it brings between peers.
Peer education interventions for HIV/AIDS prevention are usually based on behavioural theories. The design of the intervention discussed here is based partly on the Theory of Diffusion of Innovations,8 which considers that an innovation can be new information, an attitude, a belief or a practice or any other object that is perceived as new by the individual or the community and can be diffused to a target group. An innovation is communicated through certain channels over time amongst members of a social system (here, the school). A central point in this theory is the use of opinion leaders as ‘change agents’. Peer educators are assumed to have this role by influencing not only those for whom the activities are organized (their peers), but also others of relevance in the peer's environment (family, friends, etc.) through an informal and diffusional effect.8,9 Behavioural change thus comes about through a process of formal or informal communication and modelling by trained peers.10 The intervention discussed here developed a process by which trained students (peer educators) informed, taught and encouraged their schoolmates (peers) to recognize the risk factors and protect themselves against HIV. Efforts were made for prevention to become a peer norm. The whole process was an innovative idea for the peers while the school system is appropriate for the diffusion of this innovation.
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Methods |
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The aim of this study was to test whether peer education is an effective method of HIV prevention in a high school setting. The initial hypothesis was whether the use of the specific method could change the knowledge, attitudes, beliefs and practices of the target population in relation to HIV/AIDS prevention. The students (aged 15–20 years old) of 10 high technical-professional schools located in the Athens area formed the intervention group and the students of three schools with similar characteristics formed the control group. Amongst the students of the 10 high-schools (intervention group) a peer education approach for HIV/AIDS prevention was implemented during one academic year (October 1997 to May 1998), while the students of the other three schools (control group) did not receive any HIV/AIDS prevention program or counselling during this period of time.
The intervention
The intervention program included three stages: recruitment and training of the peer educators, implementation of HIV prevention activities in schools on behalf of the peer educators and evaluation. The selection of the 10 high schools took place with the cooperation of the Ministry of Education. One to two teachers from each school were offered to participate in the project on a voluntary basis. Subsequently, a meeting with the teachers was arranged, where the objectives of the projects, the activities, their role in the project, the time schedule, etc., were explained to them and their commitment was assured. Following this, 15 students from each school who wished to undertake the peer educator role were selected by the teachers, while in cases where there were more than 15 volunteer students, a lottery was used (total 150 peer educators). The mean age was 17 years. For those under 18 years of age, written permission was obtained from their parents. Therefore, each intervention school team was consisted of 15 peer educators, one to two teachers in charge and the coordinator of the group, who was appointed by the project. The training of the peer educators, which occurred outside of school hours, proved to be more intensive, regarding both time and content, from the one scheduled in the initial design of the project. The total duration of the training was 60 h (36 h initial training during October–December 1997 and 24 h support training in field work during January–May 1998). The curriculum of the initial training included: (i) the history of HIV/AIDS, HIV transmission routes, prevention measures, demonstration of condom use, and care of HIV positive persons and AIDS patients, taught by doctors (2 h per meeting in plenary); and (ii) communication skills, self-esteem, decision-making skills, assertiveness and planning prevention activities in schools, taught by each school-team coordinator (4 h per meeting in group work). After completing the initial training, each school coordinator visited his/her ‘adopted school’ twice a month supporting the peer educators and offering feedback to the organizers of the project (total time 24 h). These visits helped especially in developing a very close and friendly relationship between the coordinators and the peer educators and contributed greatly to the evaluation process of the project as well. As the program continued, some peer educators dropped out, and finally eight to 10 peer educators per school remained.
Teachers were trained in a similar way to peer educators concerning HIV/AIDS prevention. Their initial regular training also included communication and motivation strategies with adolescents and non-intervention techniques in peer educators' initiatives in school. Their role was limited in facilitating peer educators' activities in school.
Materialization of the project in schools
After their training, the peer educators started working in their schools. Each peer educators' team followed a number of common activities in order to inform and sensitize their schoolmates. The common activities in all schools were:
- Teen-aids club. This was a kiosk that the peer educators set up in the schoolyard. It consisted of a large white umbrella with prevention messages written on it and a long table and chairs, where the peer educators sat and offered their services to their schoolmates who approached to the kiosk during the breaks. Numerous leaflets about HIV/AIDS and condoms were displayed on the table and distributed to the peers. Also, an HIV calendar containing photos and short texts about young people and HIV prevention was available that the peers could examine, read and write in something about HIV and AIDS. Also, a question box was put on the table where the peers, especially those who hesitated to ask questions personally, threw their questions anonymously; these were answered by the peer educators to the peers visiting the teen-aids club during the longest break of the day.
- A poster painted by the peer educators was reproduced and put around in many places inside and outside the school.
- A stamp produced by the peer educators with the message ‘AIDS is Not Allowed’, was put on all the materials they gave out.
- A hat or a T-shirt (some schools preferred to have a T-shirt and some others a hat) having typed on it the previously mentioned message. This activity was designed to promote a prevention message during their summer holidays on the beach by wearing the T-shirts or hats. These were delivered to the peers with the order that they be summer messengers.
- Teaching HIV/AIDS in class. With the permission and aid of their teacher-facilitator, the peer educators entered every classroom and gave a presentation on HIV/AIDS prevention and delivered material and condoms to their schoolmates. Then, they discussed with them and answered all the questions asked about HIV and sexual health matters (2 h in total).
- At the end of the school year, a festivity for the ‘Day Against AIDS’ was organized by each school where the local community was invited. This was a big celebration devoted to HIV prevention, which completed the year of the project.
Study design
To evaluate the outcome of the method, a questionnaire based on the WHO KABPs model was developed and translated in Greek. It consisted of 48 questions on knowledge, attitudes, beliefs and practices. In order to test its validity, the questionnaire was pre-tested on a representative group of 50 students and a focus group discussion, and the necessary corrections were made. It was completed by the students of the intervention schools (except the peer educators) and the students of the three control schools, before and after 6 months of the HIV prevention intervention.
The questionnaire was anonymous and was filled in by the same students of the 4th grade of the high schools on a voluntary basis. To maintain confidentiality whilst at the same time ensuring completion of the pre- and post-questionnaires by the same students a number was assigned to each student. The list of names and numbers was in the safe keeping of each class president and questionnaires were identified by number alone. The list was not available to the researchers, and was publicly destroyed after completion of the post-questionnaire.
The SPSS statistical package was used for analysis of the data and pre- and post-difference was examined using 2-test. The threshold for statistical significance was set at 0.05.
During the first phase, 600 students of the intervention group and 300 of the control group answered the questionnaires. The students who completed the questionnaires in the first phase but were not present in the second one (follow up phase), were excluded from the sample.
Thus, in total, 702 students (493 from the intervention group and 209 from the control group) answered the questionnaires in both phases, and these constituted the final population of the research.
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Regarding the knowledge items, the respondents had three options: yes, no, I do not know (Table 1). During the second phase of the research, knowledge of the control group regarding sexual transmission of HIV increased more than amongst the intervention group, as the items that HIV is transmitted through seminal fluid, vaginal fluids, and vaginal, anal and oral sex without condom (items 7–11).
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In items that referred to other general questions such as that HIV carriers have no symptoms or that a pregnant woman can infect her baby, the percentage of correct knowledge in the control group during this year decreased while an increase on the same items was observed in the intervention group (items 2 and 4).
As shown in Table 2, subjective knowledge about HIV/AIDS amongst the intervention group increased significantly (from 38.1% to 49.7%), while subjective knowledge of the control group decreased during this year (from 54.4% to 45.5%), although this difference was not statistically significant (item 1). Before the year of the intervention, 90.3% and 82.8% of the intervention students believed that drug users and men who have sex with men, respectively, were more likely to be at risk of HIV infection, while after the intervention both rates increased, to 95.7% and 87.6%, respectively. The responses of the control students to the same questions increased from 89% and 79.9% to 97.6% and 89.5%, respectively (items 2 and 3).
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The differences in beliefs and attitudes were bigger pre- and post-intervention amongst the intervention group, as more respondents believed that behaviour was the key to avoiding infection (66.1% to 75.1%) and that they did change behaviour because of AIDS (42.8% to 52.3%), as well as being more hesitant about making love without a condom with a person they desired (70.8% to 72%) (items 4–6).
However, the proportion of students of the intervention group who believed that ‘condoms make sex less enjoyable’ increased (from 37.1% to 38.7%), while the respective rate in the control group decreased during this year (from 47.4% to 44.5%) (item 7). The percentage of the intervention students who believed that condoms were more useful with occasional partners (one-night partner) compared with a stable partner remained almost stable (70.4% and 69.6%), while the corresponding rate in the control group evidenced a rise of 12 percentage units (64.6% and 76.6%) (item 8).
According to Table 3, the increase in the percentage of the students from the control group who answered that HIV carriers should be isolated and not work was higher during the second phase of the study, without this difference being statistically significant, than the respective percentage of the intervention group (items 4 and 5).
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As shown in Table 4, the peer education intervention did not discourage the initiation of sexual relations, as the percentage of the students who started sexual relations through this year was higher in the intervention group (item 1). However, the proportion of the intervention students who answered that they had at least one sexual relation without a condom with an occasional partner (one-night partner) was slightly reduced (from 19.5% to 18.5%), while the relevant rate in the control group increased (28.5% to 33.3%) (item 2). Finally, a slight increase was observed towards initiation and carrying of condoms used among the intervention students (13.8% to 14.5% and 25.7% to 28%, respectively), while the corresponding rates amongst the control students decreased (17.3% to 11.9% and 45.1% to 35.3%, respectively), although both these differences were not statistically significant (items 3 and 4).
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Discussion |
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Researchers have already reported the role of peer educators as an attitude and behaviour model that attracts their peers to imitate them,11 In addition to this, the activities of peer educators in settings such as schools over a 1-year period helps in establishing peer norms about healthy lifestyles, which support behaviour modification. Also, studies about AIDS prevention in adolescents have shown that peer-led programs improved students' attitudes and behaviour compared with students who did not receive such prevention education.12,13
In our study there was already a high level of accuracy in knowledge concerning the principal routes of HIV transmission and ways of prevention amongst both groups during the pre-intervention phase. From the beginning, both groups were aware of transmission routes, especially those related to sexual intercourse. The fact that the level of knowledge of the intervention group did not increase significantly during the year of the intervention compared with the control group may be explained by the assumption that the students perhaps did not entirely trust the peer educators as a reliable source of information, which might mean that horizontal sources of information lack credibility in the eyes of young people.10 The increase in the level of subjective knowledge amongst the intervention group has been also confirmed by another European study.10
After the intervention, the intervention students seemed to be better informed about HIV issues, but they still presented a discriminatory attitude and bias against drug users, men who have sex with men and HIV-positive people. However, this attitude increased more frequently in the control students. This may mean that although the method did not eliminate the discrimination against special groups of people, it at least prevented its spread.
The peer education intervention seemed to empower students to adopt a less risky sexual behaviour, as more students stated that they had made changes in their behaviour because of AIDS and that they would not have sex without a condom with someone they liked very much compared with the control group.
The attitudes of the students of the intervention group regarding condoms were of concern. Before the intervention, over a third believed condoms made sex less enjoyable and 70.4% stated that condoms were more useful with occasional partners. There was no trend towards greater condom acceptability as measured by these two questions in the intervention group; in these measures the control group did have a favourable trend regarding the belief that condoms made sex less enjoyable. The intervention group may have suffered from peer educators not having adequate training or experience to discuss condoms favourably and thoroughly with their peers. The control group, however, continued to believe that condoms were more useful with occasional partners (one-night partners) compared with stable partners. This finding lead us to the assumption that students did not consider HIV infection to be their problem when they had a steady relationship. However, according to a study,14 students of this age have usually short relationships (about 3 months) that they consider to be steady. The authors concluded that being monogamous within these short relationships is not an effective method of HIV prevention.
The finding that more students from the intervention group initiated sex during the intervention year contrasts with the findings from other studies which asserted that sex and HIV/AIDS prevention education did not increase sexual activities among high school students.15 This might be explained by the hypothesis that the students who started sexual relations during this year became both more familiar with this issue and were more influenced by the peer educators' main message of ‘safe sex’, instead of the social message of ‘delay sex’. However, during the intervention year, less students in the intervention group chose to have occasional sexual relations without a condom (one-night partners) and more students initiated and already had the condom that they used with them. Thus it could be assumed that they adopted a safer behaviour as a result of the intervention.
According to our findings, we could presume that the increase in the rate of the intervention students who reported changes in their behaviour because of AIDS, avoidance of one-night sexual relations without a condom as well as initiation and carriage of condoms is an encouraging assumption for the effectiveness of the method. However, the peer education method did not influence discrimination against drug users, men who have sex with men and HIV-positive people, as well as attitudes towards condoms and initiation of sexual relations. The results of the outcome evaluation of the program provided little support to our initial hypothesis that the peer education approach may have a substantial beneficial influence on risky behaviour concerning HIV prevention in young people. However, further research needs to be carried out to the same and other target groups, in other settings and on different health topics to validate its effectiveness.
We consider that the strengths of this project were that young people appeared to enjoy their participation in the program and found it easier to learn from peers than from teachers. Two other aspects that augmented the attractiveness of the program was the creation, on behalf of the peer educators, of fun social events, as well as the empowerment of the peers to discuss the issue of sexual matters and AIDS with their schoolmates openly using their own teenage language. Another important and innovative feature was the lectures given by the peer educators to each class as ‘teachers’ or ‘experts’, talking with their schoolmates about personal HIV risk reduction, communicating their new knowledge to them, listening to them and mainly providing a new role model as peer educators for such an important issue as AIDS prevention.
Finally, it is important to consider the methodological limitations that may have had an effect on the results. For example, the selection of peer educators by teachers: would it have been more effective if a sociogram, which is a useful tool for determining how a student interacts with peers and is viewed by his/her classmates, had been used to identify the peer educators?16 In addition, the results could have been influenced by other sources of information about HIV/AIDS prevention, such as mass media (television, radio, magazines, newspapers), family and friends, educational material such as posters, leaflets, etc., distributed to young people in many places in the city on 1 December (World AIDS Day), etc. Also, a shortcoming of the program, identified through the process evaluation, was that, 30% of the trained peer educators left the program, mainly, as they stated, because of a lack of time; however, other reasons could have existed for their leaving the program, i.e. a lack of motivation. Moreover, teachers in charge of the program and the head of the schools argued that these activities, implemented in one school year, were too much for the already constrained time of the school.
Key points
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Acknowledgments |
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We would like to address special thanks to the European Commission (DG – V) and the Hellenic General Secretarial for Youth for funding this pilot project. This project was funded by the EU (DG V) and the Hellenic General Secretariat for Youth.
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