Using Peer Promoters in Reproductive
Health Programs for Youth
Reproductive health programs for young adults that use peer promoters typically involve education and/or counseling activities in which the educator/counselor has background characteristics similar to those of the young clients. Peer educators/counselors are not professionals, but they are trained to assist young people who need reproductive health information and services. Peer educators receive special training in decision-making, in making client referrals, or in providing commodities or services. In recognition of the work they do in motivating young people to obtain the information and services they need, peer educators/counselors are sometimes called "peer promoters."*
Peer promoters usually work with participants in one-to-one or small
group settings. But they often have other responsibilities. They make presentations in
front of large groups, represent the organizations they work for on boards and councils,
and consult with program managers. Peer projects are often part of larger programs that
have added a youth-to-youth outreach component. At times, however, they operate as
What are the advantages and benefits of peer programs? 1, 5, 6, 16
Peer programs build on evidence that young people already get a great deal of information from their peers.
Young people relate well to people similar to them in age, background, and interests.
The cultural similarity of peer promoters helps ensure that the language and messages used are relevant and appropriate.
Peer-led programs can change social and community norms to support risk-reducing behavior.
Peer programs allow for the direct involvement of young people in their own programs.
Peer programs can be implemented economically.
Peer programs often reach not only the peer group but also the peer promoters' relatives and neighbors.
Peer promoters often gain long-term benefits from their experiences. These include an ongoing commitment to responsible reproductive health behavior, leadership potential, useful employment experience, and personal development.
What criteria are commonly used when selecting young people to become
Not all reproductive health programs employ strict criteria when choosing peer promoters. Nevertheless, many programs have developed a set of characteristics that go beyond age, education, occupation, sex, and other background variables. Because all programs are different, the criteria that are used vary according to the tasks the promoter will be expected to perform. Here is a list of some of the most important characteristics considered desirable in a peer promoter. The list has been compiled from review of a broad range of projects:5, 6, 10, 11, 13, 14, 16
A demonstrated interest in working with peers and in the community.
The ability to be respectful, non-judgmental, and to maintain client confidentiality.
Acceptability among the young people who will be reached by the promoter.
The ability to establish good relations with individuals and within a group.
The ability to serve as a role model and to exercise leadership.
The ability to deal with relevant information and program content.
A commitment to family planning and to positive reproductive health practices.
Is there evidence that peer programs are successful?
The West African Youth Initiative in Nigeria and Ghana, uses peers to provide reproductive health and sexuality information and counseling to young males and females aged 12-24. Evaluation indicates significant positive effects on program participants knowledge, perceived self-efficacy, and behavior. A post-intervention survey found that after about 18 months of program activities, the target population showed increases in knowledge and in the use of modern contraceptive methods, when compared to the baseline survey. Compared to a control group, the experimental group showed greater feelings of confidence in saying "no" to sex, in asking a partner to use condoms, and in buying contraceptives. More young people in the experimental group than in a control group reported that they had taken protective measures against STDs/HIV. These included abstinence, limiting the number of sexual partners, and the use of condoms.9
In a CARE project in Kenya, Community Resources for Under 18's on STDs and HIV (CRUSH), survey results indicated that when compared to a control group of non-participants, the target group of out-of-school youth aged 12-18 displayed better knowledge, more positive attitudes, and signs of behavioral changes toward STD/HIV prevention following a peer-to-peer educational intervention.4
In a Thai factory-based setting, single female adolescent workers involved in a peer-led education program demonstrated the most significant improvements in both knowledge and enabling skills when compared to their counterparts reached by either adult health educator-led sessions or by sessions employing materials only. The program participants improved their skills in being able to discuss contraception with their partner, as well as their ability to assume responsibility for practicing contraception. The peer-led group also exhibited the most pronounced increase in perceiving themselves as potentially vulnerable to contracting the HIV infection, but the lowest level of fear because they had learned how to protect themselves.3
Several peer projects have also found impacts on the peer promoters themselves:
In the Jamaica Red Cross "Together We Can" Project, peer educators showed significant gains in knowledge about HIV transmission and about where young people can go to find help with STDs. Most of the peer educators also intended to delay their first or subsequent sexual encounters and to use condoms when sexually active.14
A major study of 21 AIDSCAP projects found that 95% of peer educators had made changes in their own life and behavior, 31% were practicing safer sex and/or were using condoms, 20% had reduced their number of sexual partners, and 19% had changed their own attitudes.6
Peer promoters working in PROJUVE, a youth project in Mexico, had significantly changed in both attitudes and behavior. And 97% of those who were sexually active reported that they used contraception. In addition, the promoters were found to have a very strong knowledge of contraceptive methods and STDs. 10
What are the lessons learned from peer programs?
Many young people prefer to receive reproductive health information from peers rather than from adults.5, 6
The involvement of peer promoters significantly increases referrals for contraceptive services at a fixed site.2, 7, 11
Peer promoters need to be selectively recruited, adequately trained, supervised, and supported.1, 5, 6, 10
Interactive training improves project outcomes.4, 5, 12
Peer counseling requires more complex training and supervision than peer education.6, 13
Turnover is a common problem in peer programs but it can be partially addressed by careful selection, the use of contractual agreements, and by good support, reinforcement, compensation, or other rewards.2, 8
Are peer programs cost-effective?
In some instances peer outreach workers have been engaged to increase the utilization of a fixed-site clinic. In at least one of these effortsMexfam's Gente Jovenwhen peer promoters were found to be more cost-effective, youth centers were closed down and entirely replaced by the peer education component.11
Although much more remains to be examined in terms of costs of recruitment, supervision, and sustainability, a few studies have compared costs of different models, including peer outreach:
In a study conducted by the Population Council in Mexico, Prosuperación Familiar Neolonesa (PSFN) used two alternative strategies to provide young adults with sex education and family planning. In a comparison of the two, the peer outreach programthe Community Youth Programwas able to reach young adults at one-third the cost per active contraceptive user of the Integrated Youth Centers.15
Another study compared two peer promotion projects: PROJUVE in Mexico and El Camino in Guatemala. While both provided information in informal settings and referred young people to their base clinics where necessary, PROJUVE, whose promoters distributed contraceptives directly, proved more cost-effective than El Camino, which depended on referrals to its multiservice clinic.10
1AIDSCAP. How to Create an Effective Peer Education Project. FHI. Undated.
2Bartling H, Cameron H, Cronk B, et al. Assessing the Evaluation Process: Adolescent Peer Counseling in Latin America. Report prepared for IPPF/WHR and the Applied Workshop in Economic and Political Development of the School of International and Public Affairs, Columbia University. 1996.
3Cash K, Anasuchatkul B. Experimental Educational Interventions for AIDS Prevention among Northern Thai Single Migratory Female Factory Workers. ICRW Report-in-Brief. Women and AIDS Research Program. ICRW, 1993.
4Chege I, Avarand , Ngay A. Final Evaluation Report. Communication Resources for the Under 18s on STDs and HIV (CRUSH) Project, 1995.
5Fee N, Youssef M. Young People, AIDS and STD Prevention: Experience of Peer Approaches in Developing Countries. (Draft). Global Programme on AIDS. WHO, 1993.
6Flanagan D, Williams C, Mahler H. Peer Education in Projects Supported by AIDSCAP: A study of 21 projects in Africa, Asia and Latin America. AIDSCAP. 1996.
7International Planned Parenthood Federation (IPPF). Understanding Adolescents. An IPPF Report on Young People's Sexual and Reproductive Health Needs. IPPF, 1994.
8International Planned Parenthood Federation/Western Hemisphere Region (IPPF/WHR). Responding to the Challenge: Preventing Unwanted Teenage Pregnancy in Latin America and the Caribbean. A project paper on five years of funding from the William and Flora Hewlett Foundation. IPPF, 1995.
9Lane C. Peer Education: Hopes and Realities/The West African Youth Initiative. Presented at a John Hopkins University/CEDPA Symposium, "The Young and the Restless," Washington, DC. April 1997.
10Lobo EJ. A Study of Youth Promoter Programs Aimed at Adolescent Family Planning in Latin America. Prepared for Pathfinder Fund. Undated.
11Marques M. Gente Joven/Young people: A Dialogue on Sexuality with Adolescents in Mexico. Quality/Calidad/Qualité. The Population Council. No. 5. 1993.
12Merritt AP, Raffaelli M. Creating a Model HIV Prevention Program for Youth. The Child, Youth, and Family Services Quarterly 16(2). American Psychological Association, 1993.
13Perry CL, Sieving R. Peer Involvement in Global AIDS Prevention among Adolescents. Unpublished review commissioned by the Global Programme on AIDS. WHO, 1991.
14Randolph SM. Evaluation of the Jamaica Red Cross Society's "Together We Can" HIV/AIDS Peer Education Project. Submitted to the American Red Cross National Headquarters and Jamaica Red Cross Society, 1996.
15Townsend JW, Dias de May E, Sepulveda Y, et al. Sex Education and Family Planning Services for Young Adults: Urban Strategies in Mexico. Studies in Family Planning 18(2):103-108 (1987).
16World Health Organization/United Nations Population Fund/United Nations Childrens Fund (WHO/UNFPA/UNICEF). Programming for Adolescent Health. Discussion paper prepared for the WHO/UNFPA/UNICEF study group on programming for adolescent health. 29 November-4 December 1995. Saillon, Switzerland. 1995. ] The In Focus series summarizes for professionals working in developing countries some of the program experience and limited research available on young adult reproductive health concerns. This issue was prepared by Judith Senderowitz and was reviewed by the FOCUS Editorial Board, some outside experts, and the staff of the FOCUS Program.