Limited effectiveness of the peer education intervention
We observed limited effectiveness of the peer education intervention in increasing knowledge, changing attitudes and reducing sexual risk behavior. The intervention did not seem to effectively alter sexual risk behavior. Knowledge of HIV protection modes did increase somewhat, but the increase was actually larger in the control group. We could not find a sound explanation for this observation. On the other hand, the intervention did significantly reduce enacted stigma. This could indicate that the peer education program succeeded in creating a more positive, less stigmatizing climate, pulling it out of the taboo sphere.
The results are comparable to other evaluation studies of peer education interventions for youth. Individual and review studies have shown that peer education interventions do not completely succeed in their main objective, i.e. reducing sexual risk behavior
]. The most recent review on the effectiveness of peer education HIV prevention interventions
] identified four evaluations of peer education interventions in sub-Saharan Africa that reported on self-reported behavior using a quasi-experimental design
], not showing compelling evidence that peer education works for young people in this context. A literature study on the effectiveness of all types of HIV prevention interventions for young people in sub-Saharan Africa done in 2006 and recently updated indicated weak evidence that peer-led interventions are effective and recommended against scale-up
We are aware of several limitations of this study. First, since the intervention was planned to be implemented in all schools in one district in Rwanda it was not possible to randomize schools for participation in the intervention. Moreover, the intervention district was chosen because of its lower socio-economic status and its need for the intervention. Unsurprisingly, we found socio-demographic and behavioral differences between intervention and control students at baseline. To counter these differences, we adjusted for propensity scores in all analyses. Second, all schools, both in the intervention and control site, were asked if other HIV prevention interventions were taking place in the schools. Even if this was not the case, it cannot be excluded that regional or national prevention campaigns intervened with the interventions, that interventions with lingering effects had been implemented prior to the evaluation, or that in some schools teachers might be more actively involved in spreading HIV prevention messages, e.g. in biology classes. Third, we operated from the assumption that the messages of the intervention would reach, one way or another, all students in the schools. The interventions were freely accessible for all students of the intervention schools. However our analysis showed that a large number of students did not participate in the intervention at all, while only a few participated very actively. Nevertheless, differences in outcomes among students with low and high participation levels were negligibly small. Finally, even though we have regular reports of peer educators’ activities and paid several visits to the schools, we were not present during all the activities and therefore cannot ascertain the quality of all activities in each school.
Reasons for observed limited effectiveness
Based on our evaluation study and existing literature we identified several factors that can help to explain the limited impact of this intervention, in particular, and of peer education for young people in general. These factors are associated with: 1) the implementation of the intervention; 2) the design of the intervention; 3) the underlying assumptions of peer education for young people; 4) appropriate indicators of sexual behavior of young people.
Factors associated with the implementation of the intervention
The intervention studied in this paper was limited by implementation issues, partly explaining the lack of effectiveness. During the second half of the intervention internal problems arose in the organization, leading to limited monitoring and follow-up of the peer educators, and failure to provide the second round of training for the peer educators
]. Consequently, in the second part of the intervention, we observed a reduction in the number of activities organized by the peer educators in all schools. In the activity reports of the second part of the intervention, more peer educators requested additional support of the intervention coordinator. However, if this was the only reason for the lack of effectiveness, we would have seen better results after the first part of the intervention.
Factors associated with the design of the intervention
Notwithstanding that the intervention discussed in this paper was thoroughly developed, based on previous experience, peer education manuals and with the input from expert organizations, there were some lacunas in the intervention design.
The objectives of the intervention are very broad (to reduce sexual risk behavior and to promote sexual and reproductive health in the secondary school communities), as is the case in many other peer education interventions, e.g.
], while the methodologies used are rather limited (informative, sensitizing methodologies such as theatre, songs, counseling). It has been amply demonstrated and discussed that increasing knowledge alone will not change sexual behavior
], since sexual behavior is also determined by a number of other factors. For example, we cannot expect young people to use more condoms by only talking about condoms and not providing them in the schools.
Furthermore, the intervention focuses on the individual, while sexual behavior is influenced by a large number of factors on different levels: personal, inter-personal, institutional, socio-cultural, structural (e.g. the socio-ecological model of Bronfenbrenner
]). Behavior change can only be reached by tackling all these levels. Mason-Jones
] explained after evaluating the lack of effectiveness of a peer education program: “It may be that social factors are so influential that an individualized health education program cannot hope to make changes”.
It is our conviction that we set the expectations of peer education interventions too high. It would be more realistic to recognize these interventions in their true value in contributing to a more positive, less stigmatizing climate, and to complement them with other types of interventions, such as youth-friendly services, condom distribution, community involvement and structural approaches.
Factors associated with peer education as a prevention strategy
Since many Rwandan school-going youth stay in a boarding school and only return to their families two or three times a year, they have no other option than to rely on peers or teachers for HIV/SRH information. However, this does not mean they want to rely on them. In our study students were asked to indicate the two main channels through which they would prefer to receive information on HIV: friends ranked sixth as a preferred source of information, after radio, parents, television, teachers and medical experts (docters/nurses).
This finding is supported by studies from other countries. Young people in Uganda prefer receiving HIV information from formal sources. They rank friends last and mass media and teachers first as preferred prevention sources
]. In Cameroon a study among urban youth shows that only 3% of respondents named their friends as people whose opinion they value, while 93% mentioned family members
]. A study among Canadian youth demonstrated that, although they indicate friends as their main source, young people prefer receiving sexual health information from professionals
]. A study from the United Kingdom stressed the important role of parents in sex education, and showed that young people prefer to be taught about sexual health by health professionals
Peer education implies that certain members of a group (peer educators) can be influential in convincing their peers to change their behavior. The strategy has proven successful in other fields of health promotion (e.g.
]). However, when it comes to HIV prevention among young people, not disregarding the capacities they have, it is a very tall order to expect a young person – possibly discovering his/her sexuality him/herself - to act as an expert and guide, counsel, teach and advise peers on a personal, sensitive and complex issue as sexuality. Furthermore, when it comes to young people, the notion of ‘peer’ oftentimes refers to someone of the same age. This is a very simplistic notion: even though they might be of approximately the same age, this does not mean they have a similar background, similar experiences, similar values and norms
]. Besides personal characteristics, a peer educator’s credibility is determined by their own behavior and by how they transmit messages. A study of a peer education drug prevention intervention found that young people value experience-based and message-based credibility more than the peer educators’ personal characteristic (
Factors associated with the evaluation of the intervention
The ultimate goal of HIV prevention interventions is a reduced incidence of HIV in young people. While directly measuring HIV incidence is often not possible, the envisaged intervention effect is operationalized by measuring self-reported sexual behavior. To this end, in this and many other evaluation studies, internationally recognized indicators are used: ‘condom use at last sex’ (if this increases the intervention is considered successful), ‘recent sexual activity’ (if this decreases, the intervention is considered successful), the ‘number of sexual partners in the last 6
months’ (if this decreases the intervention is considered successful). We argue that these indicators might not be adequate to measure the actual risks taken by the respondents. By using these indicators individually and by neglecting the relationships or context in which these sexual activities take place, these indicators ignore that young people can have healthy sexual relationships. For example, the indicator ‘condom use at last sex’ might hide an increase in young people that are in a monogamous relationship, and decide not to use a condom after a negative HIV test. Or why would having a large number of sexual partners be negative for one’s sexual health, if the sexual intercourse is consensual and protected? An indicator that would appropriately measure sexual risk behavior should include aspects of exposure (relationship and partner characteristics), transmission (type of sex and protective measures), and preferably also infectiousness (HIV infection and stage of infection of the partners). The development of such contextualized, composite sexual behavioral measures is essential to measure the real risks young people are taking, hence to determine the real effectiveness of HIV prevention interventions. Our intervention did control for individual characteristics influencing sexual behavior (alcohol use and sexual self-concept), but did not control for relational and contextual characteristics.