‘They treated us like one of them really’: Peer education as an approach to sexual health promotion with young peopleDr Simon ForrestSchool of Medicine & HealthDurham University

Simon.forrest@durham.ac.uk

Overview

Explore the evidence base for the efficacy and effectiveness of peer education involving young people

Explore the potential strengths and weaknesses of peer education with young people.

Identify some of issues and outcomes associated with peer-led programmes

BackgroundMonitorial system (Lancaster and Bell)

Management of large, mixed aged groups

Peer tutoring (Vygotsky, 1962)Learning support

Peer education (Clements and Buczkiewicz, 1993; Charleston et al., 1998; Svenson, 1998; Jaquet et al. (1996)

Effecting change in attitudes, values, knowledge, awareness and behaviour through the benign influence of members of the group

Peer involvement Approaches

Mediation(bringing

bullies and victims

together to resolve

disputes

Counselling(structured provision of advice and counselling

Mentoring(older peers guiding and supporting

younger peers)

Peer Counselling(one-to-one work between

peers)

Peer Education(one peer working with a

group)

Peer Projects(groups of peers working

with groups )

Befriending(offering

support and friendship in

everyday interaction)

Pedagogic(Presentation within formal

education settings )

Outreach(Information/skills

sharing and discussion in social

settings)

Diffusional(Information /skills disseminated via spontaneous and

unstructured discussion between

peers

Community-based(Change affected by

the formation of coalitions based

within communities)

Models and methods

Rationale for peer-led approaches

Mobilising communities to design and implement interventions which are responsive and receptive to social and local norms and factors

Potentially ‘long’ reach to vulnerable and inaccessible groups

‘Edgy’ and ideological congruent with challenges to ‘top down’ health promotion

6

Theoretical basesTheories of health-related behaviour

Knowledge, attitudes, self-efficacy, etc.

Social learningInternalisation, age/status similarity

etc.

DiffusionTransmission of new ideas through

(sub)cultures

Does it work?Harden et al., (1999, 2001) critically examined the claim that peer education is a more

effective and appropriate way of promoting young people’s health than other traditional approaches.

Mellanby et al., (2000)reviewed of studies comparing comparing peer-led and adult-

led health education in schools Stephenson et al., (2004)Reported results of a randomised controlled trial comparing

peer and teacher-led SRE impact on sexual knowledge, attitudes and behaviour among

Borgia et al., (2005)Reported results of an evaluation of the effectiveness of

peer education compared to teacher-led in AIDS prevention

Results (Harden et al & Mellanby et al.)

Small numbers of rigorous studies, most in the USA, most school based, targeting range of behaviours

Harden et al (1999,2001)

12 studies of which

7 showed that peer education changed young people’s behaviour

4 more studies showed either an increase in knowledge, positive shifts in attitudes, behavioural intentions or self-efficacy.

Mellanby et al., (2000)

13 studies of which

7 found peer eds. more effective than teachers in the long term

4 found no difference between peer educators and teachers.

When peer-led and teachers both compared to other programmes:

Peer-led more impact in 9 studiesTeacher-led more impact in 4 studies

Results (Borgia et al & Stephenson et al)

Borgia et al (2005)

5 sessions 10 hours participative learning covering sex and drugs; values, decision-making, communication, condom use

Delivered by 9th graders – 7th graders (14/15 – 12/13 yr old

• Positive outcomes for knowledge, attitudes and behaviours for both groups.

• Higher HIV knowledge among peer-led group.

Stephenson et al (2004)

3 sessions 1 hours participative learning covering sex values, decision-making, communication, condom use

Delivered by yr12 – yr9 (16/17 – 13/14 yr old

• Higher satisfaction in peer-led groups• Girls in peer-led less likely to have sex by 16 years

old, and see delaying sex as positive• Knowledge about STI prevention and HIV higher

in peer-led group• No overall difference in condom use, sexual

regret, pregnancy, relationships quality

Research limitationsDifferent kinds of intervention (duration, intensity,

different intervention groups and peer eds. Differences in topics, methods)

Different comparators and equally successful comparators

Peer led works for some groups (girls and young women = outcomes young men = satisfaction))

Sufficient length of follow-up

Expecting too much of interventions and unable to overcome socio-cultural factors

Why might peer-led approaches be useful?

Young people relate to peer educatorscredible, relaxed, non-judgmental, respectful of confidences

Accessible and effective methodsMore active and participatory

Peer educators’ developmentIncreases in knowledge, attitudinal change, relationship competence, and confidence

‘Long reach’ of peer ed.Provides access to individuals and groups hard for traditional means to reach

What are the challenges?Gender and sexuality issues (Fox et al., 1993; Schonbach, 1995; Strouse

et al., 1990) Recruiting young men;Breaking expectations about gender rolesHeterosexuality and group dynamics

Diffusional limits (Frankum, 1998)Peer eds can find it difficult to get beyond immediate social circles

Organisational friction Peer ed. may conflict with dominant pedagogy, structure and

relationships

CostFinancial and labour costs may be high

ConclusionsWe can a qualified ‘yes’ to the question of whether

peer education is effective as approach to health promotion BUT maybe no more effective than other approaches for behavioural outcomes

Has some other characteristics and potential advantages which may make it attractive as an intervention

Needs a supportive context, organisational culture , time and energy

Peer educators may be the primary target audience

ResourcesResources

Forrest, S. and Lynch, J. (2002) SRE and peer support, Peer Support Forum Briefing Paper, London: Sex Education Forum. http://peersupport.ukobservatory.com

Entre Nous: The european magazine for sexual and reproductive health No 56 2003, https://www.euro.who.int/document/ens/en56.pdf

Europeer UK, https://projects.exeter.ac.uk/europeeruk/index.htm

Scottish Peer Education Network (SPEN) http://www.fastforward.org.uk/peernetwork.html

ReferencesBorgia et al., (2005) Is peer education the best approach for HIV prevention in schools?

Findings from a randomized controlled trial, Journal of Adolescent Health 36: 508-516Charleston S, Oakley A, Johnson A, Stephenson J, Brodala A, Fenton K, Petruckevitch A (1998)

Report on a pilot study for a randomised controlled trial of peer-led sex education in schools. Social Science Research Unit, Institute of Education, London.

Clements I, Buczkiewicz M (1993) Approaches to peer-led health Fox J, Walker B, Kusher S (1993) 'It's not a bed of roses'; Young mother's education project

evaluation report. Norwich: Centre for Applied Research in Education, University of East Anglia.

Frankham J (1998) Peer Education: the unauthorised version. British Educational Research Journal, 24(2): 179-193.

Harden, A., Oakley, A. and Oliver, S. (2001) Peer-delivered health promotion for young people: A systematic review of different study designs, Health Education Journal 60(4): 339-353

Jacquet S, Robertson N, Dear C (1996) The Crunch. Fast Forward Positive Lifestyle Ltd.Mellanby, A.R., Rees, J.B. and Tripp, J. H. (2000) Peer-led and adult-led school heath

education: a critical review of available comparative research, Health Education Research 15(5): 533-545

Schonbach K (1995) Health promotion and peer involvement for youth. Themen and Konzepte, Berlin.

Stephenson et al., (2004) Pupil-led sex education in England (RIPPLE study): cluster-randomised intervention trial, The Lancet 364: 338-346

Strouse JS, Krajewski LA, Gillin SM (1990) Utilzing undergraduate students as peer discussion facilitators in human sexuality classes. Journal of Sex Education and Therapy, 16(4): 227- 235.

Svenson,G. (1998) European guidelines for youth AIDS peer education. Lund, Sweden: University of Lund. http://www.europeer.lu.se

Vygotsky LS (1962) Thought and language. MIT Press, Cambridge, MA.