Sex Health. 2013 Aug;10(4):325-31.

Effective peer education in HIV: defining factors that maximise success.

Lambert SM, Debattista J, Bodiroza A, Martin J, Staunton S, Walker R.

School of Medicine, The University of Queensland, Brisbane, Qld 4072, Australia.

 

Abstract

Background: Peer education is considered an effective health promotion and education strategy, particularly to populations traditionally resistant to conventional forms of health information dissemination. This has made it very applicable to HIV education and prevention, where those who are affected or at risk are often amongst the most vulnerable in society. However, there still remains uncertainty as to the reasons for its effectiveness, what constitutes an effective methodology and why a consistent methodology can often result in widely variable outcomes.

Method: Between 2008 and 2010, three separate reviews of peer education were undertaken across more than 30 countries in three distinct geographical regions across the globe. The reviews sought to identify determinants of the strengths and weaknesses inherent in approaches to peer education, particularly targeting young people and the most at-risk populations.

Results: By assessing the implementation of peer education programs across a variety of social environments, it was possible to develop a contextual understanding for peer education’s effectiveness and provide a picture of the social, cultural, political, legal and geographic enablers and disablers to effective peer education. Several factors were significant contributors to program success, not as strategies of methodology, but as elements of the social, cultural, political and organisational context in which peer education was situated.

Conclusion: Contextual elements create environments supportive of peer education. Consequently, adherence to a methodology or strategy without proper regard to its situational context rarely contributes to effective peer education.

PMID: 23725575

 

Supplement

Peer education has become an internationally accepted tool for disseminating information and behavioural skills to populations that are traditionally resistant to conventional forms of health education and promotion. This has made it particularly relevant for HIV prevention where strategic targeting of the most at-risk populations (MARP) is prioritised. However, despite peer education being a widely utilised strategy, there is ongoing debate concerning its effectiveness, the theoretical frameworks  that underpin it and the factors that maximise program success.

In addition to this lack of consensus as to what constitutes effective peer education, there is uncertainty as to why that effectiveness can appear to vary across settings. To better understand why peer education programs can vary in effectiveness, it is important to consider such programs, not as formula-based interventions that can be replicated by methodology alone, but as contextually-based interventions, where effectiveness is dependent upon considering methodology within a context of social, legal, cultural, geographical, political and economic determinants. By considering the range of determinants, it is possible to develop a contextual understanding for peer education’s effectiveness.

We were involved in three separate reviews of peer education programs conducted at national and regional levels covering more than 30 countries. The reviews sought to identify determinants of the strengths and weaknesses inherent in approaches to peer education, particularly targeting young people and MARP, and did not seek to evaluate methodology of specific programs. Our paper provides a summary of those reviews and observations across several countries, and identifies a number of social, cultural, political, legal and geographic determinants as enablers and disablers to effective peer education. Our paper investigates peer education programs, not as independent interventions, but as ‘interventions-in-context’.

Our key informant-driven review of peer education programs identified 10 contextual themes from which a series of enabling and disabling factors can be drawn:

  • Support and collaborative relationships
  • Governance and quality assurance
  • Integrated approaches
  • Defining and engaging the target community
  • Recruitment and retention
  • Skill development and capacity building
  • Coordination
  • Referral systems
  • Monitoring
  • Evaluation

These determinants of effective peer education have been previously identified however many studies of peer education do not report on implementation issues or in a manner that allows for comparison with other interventions. In synthesising the results of our various international reviews, we have attempted to identify common contextual enablers and disablers of implementation across a multiplicity of interventions.

Peer education has been promoted as being well suited for accessing MARP, particularly those communities that are highly stigmatised: sex workers,  men who have sex with men and injecting drug users. However despite the in-principle support given to peer-based methodologies targeting MARP within various national strategies, our international reviews have identified significant issues with planning, coordinating, evaluating and networking programs targeting MARP. Using the 10 contextual themes described previously, several enabling elements, specific to the needs of MARP were identified in the course of our reviews as prerequisite to effective peer education in almost all countries:

  • a need to develop policies and legislation that create a supportive environment for MARP and the organisations that seek to work with them;
  • a need to address issues of stigma and discrimination;
  • a need to develop the capacity and skills of NGOs to engage, consult and work with MARP, given the reluctance or inability of many governments to undertake this work;
  • a need to create an environment conducive to public debate, discussion and awareness regarding the issues for MARP and to engage representatives of those marginalised populations in those discussions;
  • a need for identifying the demography, knowledge, attitudes and practices of MARP through sound research.

However, in many of the countries reviewed, there was evidence of significant cultural, social and legal challenges to the acceptance of MARP within the wider community and therefore an inability to facilitate these enabling factors. Consequently, the delivery of peer education without consideration of the context for these interventions limits the prospect of success, even if the methodology closely accords with published literature.

Nonetheless, in the face of marginalisation, stigma and, at times, legal sanction, some countries demonstrated strategies that contributed to effective peer education. Again, these strategies reflected the enabling elements drawn out by our analysis:

  • involving community leaders and local authorities with culturally sensitive training, based on empirical evidence and surveillance, and engaging their support;
  • developing the capacity of relevant NGOs to undertake outreach and training of MARP;
  • providing opportunities for the direct engagement of MARP and enlisting their support as partners;
  • creating clinical environments that are free of stigma and discrimination, and creating confidential, safe spaces;
  • solid knowledge, attitudes and practices, and epidemiological research to establish a need and base line for the monitoring of trends.

These enabling elements for successful peer education reflect the principles of health promotion outlined in the Ottawa Charter that seek to engender partnership with, engagement with and capacity building of affected communities and the development of personal skills. Instinctively, good peer education reflects good health promotion. Our review of peer education programs across three distinct regions of the world identified commonalities for those enablers and disablers of effective peer education. Several factors were significant contributors to program success, not as strategies of methodology, but as elements of the social, cultural, political and organisational context in which peer education was situated.

These contextual elements created environments supportive of peer education and our study of peer education as applied across diverse cultures clearly demonstrated that adherence to a methodology without proper regard to its situational context is rarely a successful journey.

 

Acknowledgements

Thanks are expressed to the other members of the team involved in evaluation of the Y-PEER network, Oluyombo Onafowokan and Chris Statham. Thanks are expressed to the many Y-PEER and the SPC contacts made during this review process – peer educators, focal points, fellows, coordinators and international trainers. Thanks also to the many UN and SPC agency staff who assisted with the organisation, logistics and implementation of this evaluation process, including participation in nterviews and meetings, especially UNFPA country representatives, the IV & STI Section of the SPC’s Suva Office and contacts for Y-PEER networks. Finally, thanks are expressed to the many individuals from collaborating and partner organisations who took the time to provide information for these reviews.

 

Contact

Dr Joseph Debattista

Sexual Health, HIV & Hepatitis Coordinator

Sexual Health & HIV Service

Metro North Hospital & Health Service

270 Roma Street Brisbane Q 4000

P +61 (0) 404136457

Email: Joseph.Debattista@health.qld.gov.au

 

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