The prevalence of sexual risk behaviors among teenagers and young adults demands continued attention. Eighty five percent of the teenage pregnancies that occur each year are unintended.¹ Each year, about three million teens contract a sexually transmitted disease (STD).² While condom use rates are rising, only 54 percent of sexually active, in-school teens report consistent use.³ Finding effective ways to educate and motivate young people to avoid sexual risk behaviors is an ongoing challenge. Peer education*, with its grounding in social learning theory, draws upon the resources and existing social networks of young people to engage them in disease and pregnancy prevention among their peers. Peer education is experiencing a boom in popularity as programs are established in schools and universities, clinics, youth serving organizations, community based groups, and religious institutions.

Overwhelming amounts of anecdotal evidence vouch for the positive effects of peer education. Even more significantly, preliminary research indicates the promise and exciting possibilities of peer education. Despite the compelling stories and promising research, however, more scientific evaluation is needed. Specifically, more impact evaluation data must be collected and analyzed before peer education can be unequivocally touted as an effective prevention method.

While the goals of peer education programs may be similar, the philosophies and methods guiding such programs are often very different. Currently, centralized monitoring does not exist for the hundreds of peer education initiatives being implemented. Assistance in designing programs can be expensive and hard to find. As with any approach, certain programs will be more successful than others. This monograph presents a synthesis of elements of the most promising prevention strategies identified and used by peer led sexual health programs.^4,5,6,7,8 By using the existing body of knowledge, program funders, planners, coordinators, and administrators can make the best use of scarce prevention dollars and maximize the positive benefits of programs for peer educators, their audiences, and the sponsoring organizations.

Designing the Program

• Begin with a clearly defined target population. Consider age, gender, race/ethnicity, sexual orientation, socioeconomic factors, neighborhoods, whether the youth are in or out-of-school, etc. If data is available from local health departments, consider which groups of youth appear to have the highest rates of STDs or unintended pregnancy when targeting the intervention. Research other existing programs, and look for underserved members of the community.
• Include members of the defined population from the beginning of the planning process. This means youth. Their participation will ensure that the program is a product of the community, helping create a feeling of ownership in the program and its goals rather than that it has been foisted upon the community by 'outsiders.' Youth must be invited not merely as tokens but as full participants. Young people should be present from the beginning, and their opinions and suggestions considered seriously. Meetings should be after school, accessible by public transportation or with transportation provided. Snacks and, perhaps, childcare can also help to keep young representatives participating.
• Set a clearly defined program with realistic goals and objectives. One program cannot address all the issues facing teens, and a group of ten teenagers will not be able to reduce rates of STDs or pregnancy in a state, county, or town in six months. However, ten teenagers could present 12 workshops to 200 students over a period of 9 months and host a health fair that reaches 350 students or, over the period of 6 months, implement a curriculum in 10 health classes at the local high school, reaching 70 students. A time period and the number of people to be reached for each objective will help define the program and target population as well as ensure measurable goals and objectives.
• Plan realistically for evaluation in the time line and budget. Whether a detailed process evaluation or a long-term impact evaluation, it must be planned from the beginning, or data gathered will be partial and inconclusive. The quantifiable objectives developed for the program will define the data to be gathered. Changes in knowledge will be measured by pre- and post-testing peer educators and participants. Process evaluation data may include numbers and characteristics of program activity participants, post-workshop satisfaction measures, focus groups data from workshop participants, and peer educator journal entries recording activities and referrals. Evaluation is a worthy investment. Demonstrating success encourages funders to support the program. Process evaluation allows ongoing assessment program strengths and weaknesses.
• Find the right person or people to coordinate the program. Much of the success of a peer education program will rest on the program coordinator(s) who must understand youth and enjoy working with them. The coordinator must also be comfortable with the goals and objectives of the program. The coordinator should display a non-judgmental perspective while establishing high standards of expectation for program participants.

Implementing the Program

• Recruit peer educators from a broad base of potential candidates. Consider opinion leaders within the defined population, but look also for those who strongly believe in the program's goals and objectives and want to help achieve them. Some of the most effective peer educators do not initially appear to be ideal candidates. Successful recruiters will search out young people, rather than simply expecting them to respond to a flyer or notice. Enlist teachers and other community and agency staff to make recommendations and to publicize the program among their youth.
• Decide what incentives the program will provide for the peer educators. Some programs offer school credit or volunteer service hours. Local merchants may be willing to donate shirts, snacks, or discount coupons. Other programs build peer educator wages into their budgets. Programs that do not pay the peer educators may attract a limited or non-representative group of candidates.
• Provide sufficient training for the peer educators. Skills development is as crucial as knowledge. Training empowers peer educators to recognize when to refer a peer to a professional. The training should model the supportive and interactive techniques that peer educators themselves will use. Successful programs will have ongoing training for the peer educators, times to practice existing skills and to develop new ones.
• Select a curriculum to maximize interactive and experiential learning. Peer education works best when young people work with one another to learn new things or to develop new skills. Youth lectures are no more effective than adult lectures. Peer educators should be trained in facilitating and processing as well as in giving clear directions. Peer educators gain ownership of the program when they play a role in deciding which activities to use or in designing new ways to present the information.
• Remember that research shows peer education to be most effective when part of a comprehensive initiative. Link peer educators with school nurses, 'youth friendly' local clinics, community agencies, and programs with similar goals. Ensure that peer educators know when and where to refer another young person. A local health professional from a teen clinic or other 'youth friendly' health provider may serve as an advisor to the peer educators and program staff and as a link to health services.
• Monitor the peer educators' work. After the initial training, peer educators will need ongoing supervision of their work and training. Peer educators should keep a log of informal activities. Monitoring will highlight skills or knowledge that need strengthening. Feedback will also help the young people become more skillful and effective educators.
• Provide ongoing encouragement and support. Peer educators work hard and their work is not always easy. Positive feedback and support will help keep trained youth involved, as will encouraging them to support each other and providing occasional incentives, such as pizza parties or small trips.
• Expect attrition and have a formal structure for recruiting and training new peer educators. Youth have many competing interests; some may decide they do not enjoy being peer educators. Exit interviews will help gauge whether they are leaving for personal or programmatic reasons. Involving current peer educators in the recruitment and training of new peer educators will also empower them and help them develop new skills.
• Provide opportunities for peer educators to give feedback about the program, its activities, and their own performance. The peer educators usually know what they need to become more effective and to enjoy their work more.
• Finally, promote the program. Develop literature showcasing services and highlighting accomplishments. Positive stories from the peer educators and feedback from workshop participants will enliven databased reports. These materials will increase visibility and encourage potential funders to invest in to peer education program.

Written by Jane Norman, February 1998

Sources for Information, Technical Assistance, and Curricula

Guide to Implementing TAP: Teens for AIDS Prevention

A step-by-step guide to developing and implementing an HIV prevention peer education program in schools and communities. The guide is available online. For ordering information, contact 2000 M Street NW, Suite 750, Washington, DC 20036; or call 202.419.3420.

Peer Education… a Little Help from Your Friends: A How-To Manual

Developed by Planned Parenthood Centers of Western Michigan, this 40-hour comprehensive health training provides a multitude of original as well as adapted ideas, activities, and materials. For ordering information, contact Planned Parenthood Centers of West Michigan, 425 Cherry SE, Grand Rapids, MI 49503; or call 616/774-7005.

Healthy Oakland Teens

A school-based, peer-led AIDS prevention program for junior high school students. Evaluation showed that students who received AIDS prevention counseling from their peers were significantly less likely to engage in potentially risky vaginal intercourse than students who were not involved in the peer-led counseling. The curriculum is available via the Center for AIDS Prevention Studies Web site, along with a Knowledge, Attitudes, Behavior, Belief questionnaire for use with teens and pre-teens. URL: http://www.caps.ucsf.edu/capsweb/hotindex.html. Contact Center for AIDS Prevention Studies, 74 New Montgomery, Suite 600, San Francisco, CA 94105; or call 415/597-9100.

Peer Facilitator Quarterly

The official publication of the National Peer Helpers Association. For subscription information, contact the National Peer Helpers Association, PO Box 10627, Gladstone, MO 64188-0627; or call 877/314-7337.

PeerHelp: A New LISTSERV for Peer Helper Programs and Training

Created to help those interested in peer helping share information such as ideas, techniques, and resources this requires access to electronic mail. For more information or to subscribe, contact Dr. Russell Sabella, School of Education, University of Louisville, Louisville, KY 40292: or call 502/852-0625; E-mail: This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

References

* A note about terminology: although many people use the terms peer helping, peer tutoring, peer counseling, and peer education interchangeably, they represent different concepts and different goals. For the purposes of this document, peer education refers to sexual health workshops given by and for adolescents.

1. Trussell J. Koenig J. Stewart F. et al. Medical care cost savings from adolescent contraceptive use. Fam Plann Perspect 1997:29:248.
2. Alan Guttmacher Institute. Sex and America's Teenagers. New York, NY: The Institute, 1994.
3. Kann L, Warren CW, Harris WA, et al. Youth Risk Behavior Surveillance, United States. 1995. MMWR CDC Surveillance Summaries 1996:45(SS-4): 1 -84.
4. Holtgrave D, Qualls N. Curran J. et al. An overview of the effectiveness and efficiency of HIV prevention programs. Public Health Reports 1995:110:134-146.
5. Janz N. Zimmerman M, Wren P. Evaluation of 37 AIDS prevention projects: successful approaches and barriers to program effectiveness. Health Educ Q 1996:23:80-97.
6. Kirby D. No Easy Answers: Research Findings on Programs to Reduce Teen Pregnancy. Washington, DC: National Campaign to Prevent Teen Pregnancy, 1997.
7. HIV Education and Prevention Working Group. What are the Characteristics of HIV Education and Prevention Programs that 'Work' and 'Do Not Work'? HIV Education Prevention Working Group Meeting August 7, 1991. San Francisco, CA: Office of AIDS, California Dept. of Health Services, 1991.
8. Davis L. Components of Promising Teen Pregnancy Prevention Programs. [Issues at a Glance] Washington, DC: Advocates for Youth, 1996.