P r e v e n t i v e m e d i c i n e
Peer programs in STI prevention
Peer programs in prevention of sexually
transmitted infections
M. Ebert
- S u m m a r y
For the past five years it was attempted to educate teenagers about reproductive health and sexually transmitted diseases including HIV/AIDS by using the Project Virus. The program is a peer program run by medical students and encompasses the entire country of Slovenia.
Project Virus implements workshops on healthy and safe sex. Workshops are performed in elementary and secondary schools across Slovenia. The project has initiated over 500 workshops and has reached approximately 14,000 young people between the ages of 13 and 20. The method used in the program is called peer education - young people teaching young people. The goal is to create positive behavioral changes that will lead to healthier and safer sex.
Project Virus also focuses on educating peer counselors through national and international workshops. The project is active in the annual World AIDS Day, held December 1 of each year. Project Virus initiates the Stop HIV/AIDS action, held just before summer every year. Project Virus educates and counsels individuals also through web page www.slomsic.org/aids. peer program
KEY WORDS
peer education, STI, HIV, AIDS, sexual education
Introduction
Sexual education is a lifelong process and a fundamental part of every person's socialization. For every young person, especially adolescents, it is imperative to have access to accurate, accessible and age-appropriate information about their sexuality and their sexual health.
Peer education is a specific teaching practice used with good results in sexual education of adolescents. Usually it is age related - young people to young people. Since the emergence of diseases like AIDS, sexual edu-
cation has become more crucial than ever. Young people (age between 10-25 years) are one of the most vulnerable groups to contract sexually transmitted infections (STI), including HIV. Every year one in 20 young people worldwide contracts STI and over 50% of newly infected with HIV are between 15-25 years old (1). Reasons are various, including lack of information, lack of interest, shame and taboos still prevailing in our society.
An international survey in 1997 carried out by International Planned Parenthood Federation found that one
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in three young people found it difficult or impossible to discuss sexual matters with adults. Young people often find it easier to talk about sexuality with a friend or someone closer to their own age. Young peer educators are more readily accepted as workshop facilitators than any other experts. Trained peer educators can also ensure that activities and information will be appropriate and relevant to peers. Moreover, in a study that compared peer led vs. adult led sexual education in teenagers suggested that, teens may be more likely to see HIV/AIDS as a personal danger and take the massage more serious, when education is presented by peer educators (2, 3).
Additionally, peer educators are usually volunteers, so peer programs can be economically easier accessible.
Materials and methods
Peer programs are designed to fit the needs of a young audience with the goal of improving the knowledge they already have. The main goal of peer education is to achieve a behavioral change that would promote healthier and safer sex. Peer education workshops follow the message of the Chinese proverb: Tell me and I will forget, show me and I will remember, involve me and I will understand. It is not enough to only pass on the information to peers. It is important to make them understand and implement the knowledge in their lives. It is not enough to offer a condom, if they don't know how to use it. And it is not enough to know how to use a condom if in a moment of passion one is afraid to ask one's partner to use it. Only carefully designed programs will offer the satisfactory results and help to educate confident teenagers with self respect and respect of their health.
Workshops about healthy and safe sexuality are dynamic structure of games, group work, discussions, demonstrations, video presentations, writings, drawings, even music and role-playing (4). Facilitators are trained to be open minded and relaxed, to encourage open discussions about any matter concerning sexuality.
Results
Project Virus is a Slovenian educational, preventive health program that includes several activities all through the year. The main purpose of the program is spreading the idea of healthy and safe sexuality in all age groups and in various communities. The approach is universal, serving the different needs of specific groups. Our main task is to promote a common usage of condoms, but at the same time stressing the importance of family values and trust in partnership.
A major part of Project Virus represent peer education workshops on healthy and safe sex. Workshops
are basically designed for teenagers, 13 - 20 years old. Slovenian teenagers become sexually active in general after the age of 14 years. 50% of Slovenian high school students are sexually active by 18, 5 (mean value for girls 18.4 years, for boys 19.0 years) (5). At the age of 14, almost all young people know about condoms, however the study does not clarify, if they know how to use them correctly (6). At first intercourse 71% of them use condoms, in following sexual contacts this percentage gets lower to 65%. The second most used "contraception" among high school students is interrupted intercourse (19%); contraception pills are on third place (13%).
Project Virus offers the schools several programs considering basic knowledge of teenagers and time available for sexual education. Workshops offered are: basic workshop (2 hours), advanced workshop (2 hours), 4 hours workshop, 10 hours workshop. The main goal of workshops is to help young people develop the knowledge, autonomy and skills, such as communication, decision-making and negotiation. The program includes basic information about anatomy and physiology, reproductive organs, puberty, contraception, pregnancy, abortion and STIs, including HIV/AIDS. It approaches sexuality as a natural, integral and positive part of life, and covers all aspects of becoming and being a sexual, gendered person. It promotes gender equality, self-esteem and respect for the rights of others. At the end of every workshop each individual gets a packet of information and condoms. Correct usage of condoms is demonstrated and later preformed by participants. Before leaving SOS phone lines and useful Internet sites are suggested for any questions left unanswered.
These workshops are performed allover Slovenia. Still most of the activities are centralized in the capital due to the sponsorships of the city government of Ljubljana. Workshops in the capital are free of charge for all schools in the region.
In the last five years over 500 workshops were carried out and reached around 14,000 teenagers between the ages of 13-20. An intensive evaluation of the program unfortunately has not yet been completed. Feedback from schools, school employees and students has been excellent. Every year we have more requests for workshops than we can supply. A major limitation is the number of trained, active volunteers. The majority being medical students, have every day school obligations and their time is limited. Anyway, project tries to keep on with quality and quantity of work over the years.
Discussion
While peer education worldwide continues to grow in popularity, implementation has far outpaced evaluation of these programs. Most peer education programs
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include at least some kind of an evaluation. Most programs including Project Virus track the number of peer educators recruited and trained, the number of teens reached by the program, and the number and types of activities in which peer educators participate. Many also solicit the audience's evaluation of peer education presentations. The evaluation helps the plan coordinators and peer educators to find out, if the program is operating as intended. This type of evaluation does not, however, help to determine whether the program achieved its primary goal.
When the providers of funding, program coordinators or peer educators want to know whether a program is achieving its goals in increasing the knowledge or influencing the attitudes of its audience, short-term outcome evaluations have to be carried through. One common method of outcome evaluation involves administering pre- and post-test questionnaires as well as follow-up surveys. However, determining the long-term
impact of peer education requires a more thorough, methodologically rigorous evaluation. It is usually costly, time-consuming and may require a professional expertise beyond that of the program's staff. These difficulties help to explain why few peer education programs have been evaluated for their long-term impact.
Conclusion
Despite the shortage of well-designed evaluations, a review of the literature suggests positive findings from outcome evaluations (7, 8, 9). Peer programs do promote healthier sexuality-related attitudes and behavior in young people, including increasing knowledge and condom use and reducing unprotected sexual intercourse. Peer education should be promoted whenever designing comprehensive sexual education programs.
R E FE R E N C E S
1.	Annon. UNAIDS/WHO report. AIDS epidemic update: December 2002.
2.	Rickert VI, Jay MS and Gottlieb A. Effects of a peer-counseled AIDS education program on knowledge, attitudes and satisfactions of adolescents. J Adolesc Health, 1991, 12: 38-43.
3.	Charles S, Oakley A, et al. Report on a pilot study for randomized controlled trial of peer-led sex education in schools. Institute of Education University of London. 1997.
4.	Dibb L, Warwick M. Health connections. An essential guide to training for sexual health education. Oxford. West London Health Promotion Agency, 1996.
5.	Pinter B. Sexual behavior of secondary-school students in Ljubljana. Slov Pediatr, 1995; 4: 13-6.
6.	Brcar Štrukelj P. Spolno vedenje slovenskih osmošolk in osmošolcev: poročilo o raziskavi. Inštitut za varovanje zdravja, Ljubljana, 1997.
7.	Bourdon B, Tiemey S, Huba GJ et al. Health Initiatives for Youth: a model of youth adult partnership approach to HIV/AIDS service. J Adolesc Health, 1998, 23: S71-S82.
8.	Ekstrand M, Siegel D, Nido V et al. Peer led prevention delays sexual debut among junior school students. Presentation on the XI International Conference on AIDS, Vancouver, Canada, 1996.
9.	Freudo R. Vining Bethea S. Shulman L et al. Bridgeport's Teen Outreach and Primary Service (TOPS) project: a model for raising community awareness about adolescent HIV risk. J Adolesc Health, 1998, 23: S49 -S58.
A U T H O R 1 A D D R E S
S Maja Ebert, MD, Project VIRUS, Slovenian Medical Students' International S Committee, K[MF, Medical Faculty, University of Ljubljana, Korytkova 2, 1000 Ljubljana, Slovenia, e-mail: majaebert@email.si
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