AIDS Peer Education Program

The goal of this peer education program was to reduce the incidence of sexually transmitted diseases (STD) and AIDS among teenagers, by the postponement of sexual involvement or by condom use. A group of trained students (ages 15-16) created skits, videos, games and posters, then made presentations for their younger peers (ages 12-15).

Background

This peer education program was created in 1987 for a small multi-ethnic high school situated in the Montérégie region of Quebec (south of Montreal). Designed by the school's nurse and one of its biology teachers, it was so successful that by 1990 it had evolved into an annual program. In 1991, it was redesigned by the school nurse to incorporate a training program for peer educators. Following a positive evaluation (1996), the peer training program was further improved with support from a provincial research team and a pedagogical consultant from the Riverside School Board (1999). This revised program was named the Programme Express Protection (Protection Express Program: PEP).

The Protection Express Program was integrated into the regular curriculum for secondary 4 students (ages 15-16) in eleven schools as part of the programme d'Enseignement moral (Moral Education Program) or the programme de Formation personnelle et sociale (Personal and Social Development Program). This case study presents results for the after-school program only. An evaluation of the PEP Program on sexual behaviour was in progress in 1999-2001.

Setting Objectives

The objectives for this program were to decrease the incidence of sexually transmitted diseases and AIDS among high school students by the postponement of sexual involvement and condom use.

Getting Informed

Program managers conducted what was an extensive literature review, given that this program took place in 1999. Key findings are outlined below. Additional findings are described in the linked evaluation report. The literature review revealed that although 50% to 75% of adolescents in Quebec used condoms during their first sexual encounter, only 13% to 48% used them consistently. Between 2.0% and 6.4% of these teenagers engaged in sexual intercourse with an IV drug user. Impaired judgement associated with drug and alcohol abuse can lead to unprotected sex. Moreover, many teenagers lack the skills needed to properly evaluate risks, to plan and avoid high risk situations, or assertively make decisions (i.e. not give in to peer pressure).

The literature review also uncovered two important factors that effective AIDS education programs shared: they were based on theoretical models (research) and they used interactive teaching strategies that are adapted to the target population.

This peer education program was based on the Theory of Planned Behavior. According to this theory, the intention to adopt a given behavior is determined by three factors: personal attitudes toward the behavior, perception of behavior control and perceived social norms. Teenagers are more likely to have a positive attitude toward postponing sexual involvement if they perceive the following advantages to it: proves you respect each other; allows you to discover each other at your own rate; allows you to find out if you really love each other; is an intelligent, mature and responsible choice; is approved by parents; and offers complete protection from unwanted pregnancy, sexually transmitted diseases and AIDS. Teenagers are more likely to have a positive attitude towards condom use if they perceive the following advantages: that condom use is an intelligent, mature and responsible choice, can be fun to use, can prolong sexual pleasure by retarding ejaculation and provides excellent protection from unwanted pregnancy, sexually transmitted diseases and AIDS when used correctly.

Common barriers tied to postponing sexual involvement include: being alone with your partner, using drugs or alcohol, becoming highly aroused by foreplay, being asked to engage in intercourse and peer pressure. Common barriers tied to condom use include: feeling shy, lack of money to buy condoms; not knowing where to buy condoms; an inability to openly discuss use of condoms/convince partner to use them; use of drugs or alcohol; condoms not being handy when needed; existing use of oral contraceptives; and "forgetting" to use a condom in the heat of passion. The presentations performed by peer educators were planned to include all of these aspects.

Delivering the Program

The following is a description of the program as it was at the time of the first evaluation (1996). Sixteen student volunteers aged 15-16 were selected to act as peer educators to students aged 13-14. The volunteers were enrolled in a 40 hour training program administered after school by a school nurse and a teacher of Moral and Religious Education (MRE), who used a specifically developed teacher's guide.

The training program was interactive and covered a wide range of topics: sexually transmitted diseases and AIDS; living with AIDS; homosexuality and homophobia; sexuality from a physical, social, emotional and spiritual perspective; values; decision making processes; communication and refusal skills; lesson planning; and group animation techniques. The trainees also met with a person living with AIDS and visited a condom shop.

Two course credits were granted as an incentive to volunteers who successfully compleded the training. Volunteers were also given T-shirts to wear in the school, which identified them as peer educators (Norm Appeals). As a further incentive, participants were invited along with their parents to an end-of-program party where they received a plaque recognizing their contribution.

Once training was completed, the peer educators were grouped into teams of four or five. Each team was required to create two presentations - including skits, videos and posters - based on personal experiences but following a defined set of objectives and criteria. The presentations were usually performed by students at their own school. This helped ensure that the manners and idoms used - which could vary form school to school within a given community-were culturally appropriate (Vivid, Personalized Communication).

The fact that the presentations were performed by peers who were openly in favor of the postponement of sexual involvement and condom use sent a powerful message to other teens that these choices were not only important but socially acceptable (Norm Appeals).

Each team provided an educational intervention on abstinence to an MRE class, and one on condom use to a Biology class. In order to properly prepare each class - an important part of the intervention process - teachers annouced the presentations ahead of time; they explained the peer educators' role, emphasized the need for good behavior and encouraged student participation. To ensure that the presentations were suitable for each class, program organizers consulted with the class teachers beforehand.

During each presentation, the peer educators talked about the advantages of postponing sexual involvement and using condoms. They also enacted situations portraying the common barriers to the postponement of sexual involvement and to the use of condoms, and demonstrated strategies to overcome them (Vivid, Personalized Communication and Overcoming Specific Barriers).

Strategies for overcoming the barriers to the postponement of sexual involvement included: avoiding being home alone with a partner (e.g. finding fun things to do with your partner as part of a group); avoiding use of drugs and alcohol; being aware of one's level of sexual arousal and knowing when to stop (e.g. deciding ahead of time on a desired level of intimacy); communicating one's wishes in an affirmative manner with a partner; and resisting peer pressure.

Strategies for overcoming the barriers to condom use included: sharing the cost of condoms; going to the drugstore with friends; refusing to engage in sexual intercourse without a condom; avoiding drug and alcohol use; carrying a condom at all times; practicing using condoms correctly ahead of time; and using condoms even when the female partner was "on the pill" (Building Motivation Over Time).

The peer educators also created poster contests, handed out AIDS ribbons, and/or displayed traced outlines of students' hands to symbolize solidarity with people living with AIDS.

To promote the program elsewhere, peer educators performed their presentations for visitors (parents and students) during an open-house in their own school. Two videos were produced which showed the peer educators in action. These videos were shown to adminstrators and teachers in other schools. PEP's innovative approach and strong basis in educational theory - widely recognized as favorable qualities by educators - were highlighted.

Financing the Program

The following three year budget was created for the period 1996-2001:

EXPENDITURES	AMOUNT
Production of revised teacher’s guide, support and evaluation of the program in eight schools - full-time coordinator (for two years)	$128,000
Supplies (e.g. T-shirts, teacher's guide and student workbook,video cassettes, condoms), Guest Speakers and other resources	$7,000
Evaluation of PEP program	$144,573
Subtotal	$279,573
REVENUES
Contribution from the Conseil québécois de la recherche social (CQRS-	$30,000
Direction de la santé publique de la planification et de l'évaluation, Régie régionale de la santé et des services sociaux, Montérégie (in part via a grant from the Centre québécois de coordination sur le SIDA: CQCS (Quebec AIDS Coordination Center)	$105,000
Conseil québequois de la recherche sociale (Quebec research council)	$144,573
Subtotal	$279,573

Measuring Achievements

A self-administered questionnaire was completed by 70 students (70% of participants) both before and after the intervention. The questionnaire examined intentions about postponing sex and condom use as well as beliefs about the advantages and disadvantages of postponing sexual involvement and condom use. Finally perceived barriers to abstinence and condom use were also examined. This questionnaire was adapted from a validated instrument based on the Theory of Planned Behavior. A control group was used, composed of 74 students attending another high school in another city. The comparison group received the same questionnaire with no intervention. For ethical reasons, the peer educators later visited these students and provided the presentation. All questionnaires were coded to ensure confidentiality. 

In addition, three process evaluation methods were used. Two of these were used with the 70 students who received the educational intervention and completed both the pretest and the posttest questionnaires. One involved peer educators only.

1. During each presentation, an observer (teacher or nurse) checked off compulsory components as they were communicated by peer educators.

2. A self-administered questionnaire was used to evaluate students', teachers' and peer educators' appreciation of the program following each presentation. Qualitative data was also collected, using open ended questions included in this questionnaire. Students were asked to describe the presentation's key message(s), what they learned, what they most liked/disliked about the presentation, and comments or suggestions.

3. Personal comments from peer educators were gathered at the end of the program during a 50-minute group meeting. Peer educators were asked what they had learned through their involvement and whether or not this experience had changed them in any way.

Results

Students who completed the program had a more positive attitude towards abstinence and condom use and were more likely to intend to use condoms. Peer educators reported feeling more responsible, mature, self-confident and assertive as a result of their involvement in the program.

Contacts

Françoise Caron
Module maladies transmissibles
Direction de la santé publique, de la planification et de l'évaluation
Régie régionale de la santé et des services sociaux Montérégie
1255, Beauregard
Longueuil (Québec)
J4K 2M3

Tel: (450) 928-6777
Fax: (450) 928-3023

E-mail: f.caron@rrsss16.gouv.qc.ca

Notes

Last revised: December 6, 1999. The link to the program evaluation report was added in January 2021.