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Multicultural Health
and Support Service
Peer Education
Project Evaluation
B u r n e t I n s t i t u t e
C e n t r e f o r P o p u l a t i o n
H e a l t h
Carol El-Hayek, Jane Howard,
Hilary Veale
Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 1
Contents
Abbreviations..........................................................................................................................................2
Acknowledgements.................................................................................................................................2
Preface ....................................................................................................................................................3
The Peer Education Project.................................................................................................................3
Peer Education Project Aims...........................................................................................................4
Description of the Peer Education project......................................................................................4
Executive Summary.................................................................................................................................6
Background to evaluation.......................................................................................................................8
Objectives ...........................................................................................................................................8
Methods..............................................................................................................................................8
Results.....................................................................................................................................................9
Education and Training ...................................................................................................................9
Reach of MHSS..............................................................................................................................12
Sustainability.................................................................................................................................13
Emerging themes..................................................................................................................................14
Community benefit.......................................................................................................................14
Community engagement ..............................................................................................................14
Community ownership..................................................................................................................14
Specialised skills............................................................................................................................15
Discussion..............................................................................................................................................15
Peer Education project objectives ................................................................................................15
Strengths and enablers .................................................................................................................16
Project challenges.........................................................................................................................17
Recommendations............................................................................................................................17
Limitations of this evaluation ...........................................................................................................18
References ............................................................................................................................................19
Appendix 1. Participant Selection and recruitment..............................................................................20
Appendix 2. Example of flyer advertising PE opportunity ....................................................................21
Appendix 3. MHSS brochure (English). .................................................................................................22
Appendix 4. Summary table for the eight peer education groups. ......................................................24
Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 2
Abbreviations
BBV Blood borne viruses
CALD Culturally and linguistically diverse
CEH Centre for Culture, Ethnicity and Health
CERSH Centre for Excellence in Rural Sexual Health
HIV Human Immunodeficiency Virus
MHSS Multicultural Health and Support Service
NRCH North Richmond Community Health
PE Peer educator
SRH Sexual and reproductive health
STI Sexually transmissible infections
VACCHO Victorian Aboriginal Community Controlled Health Organisation
Acknowledgements
The Surveillance and Evaluation team from the Burnet Institute would like to acknowledge the work
undertaken by the Multicultural Health Service and Support program and the many organisations in
the government, community, health and medical, academic and scientific sectors toward reducing
the impact of HIV, viral hepatitis and STI in Victoria.
Many people have contributed to this evaluation and report. We express our thanks to the many key
informants and community members who gave their time and valuable insights to support the
evaluation. We would like to extend a special thank you to Chiedza Malunga from MHSS, for her
assistance in providing invaluable input and time while on maternity leave.
Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 3
Preface
It is acknowledged that culturally and linguistically diverse (CALD) communities are vulnerable with
respect to stressors faced in their countries of origin and that these can impact negatively upon
health outcomes [1, 2]. For example, a sensitive area for CALD communities is sexual health, with
stigmatisation and invisibility complicating delivery of sexual health messages [3, 4]. In addition,
there are perceptions of low personal relevance often as a result of the intense health screening
received before entry to Australia for some CALD populations leading to a false sense of security
regarding the risk to them from BBVs or STIs[3]. As a result CALD populations have been identified as
a priority population in the Sixth National HIV Strategy 2010 – 2013 [5].
The Multicultural Health and Support Service (MHSS) is a state-wide health promotion service with a
focus on blood-borne viruses (BBVs) and sexually transmissible infections (STIs) within migrant and
refugee communities. It is a program operating from within the Centre for Culture, Ethnicity and
Health (CEH), and is funded by the Victorian Government Department of Health.
Beginning in 2011, MHSS designed and implemented Phase 1 of a Peer Education project to
Victoria’s Karen and Liberian com munities. These migrant populations are among the top 20 fastest
growing migrant populations in Australia [6]. Since the 2006 census Liberian born migrants have
increased 75% Australia wide, with Victoria having the third largest population[7] and the Burmese
migrant population has increased 191% in Victoria [8]. This project involved the delivery of a
culturally appropriate and needs-based curriculum in a series of group sessions by trained volunteers
from within the community. The Peer Education project consisted of two phases, to be delivered
over two years, the first being piloted within the Karen and Liberian communities.
The application of peer education to improve sexual health knowledge in migrant populations in
Western countries has been shown to be effective in changing knowledge and behaviours [9]. Peer
education can be defined as a way of communicating specific health information via a range of
methodologies, e.g. advocacy, counselling, facilitated discussions, drama, distribution of materials,
providing support [10]. It is often used to facilitate change at an individual level (changing
knowledge, beliefs, behaviours or attitudes), group level (shifting cultural norms) and collective level
(shifting the health motivations of CALD communities) [10, 11]. Peer education has gained in
popularity for implementing health promotion interventions, such as those targeting sexual health
knowledge, in many at-risk populations [9, 12-15].
The Peer Education Project
MHSS designed the Peer Education project to address the language and cultural barriers experienced
by migrant and refugee communities when accessing appropriate BBV/STI health services. The
project was intended to address broader determinants of health affecting the ability of community
members to navigate the healthcare system and access appropriate care.
Previously, MHSS’s primary mode of delivering sexual and reproductive health (SRH) messages to
CALD communities was via community workers delivering education sessions usually by invitation.
The Peer Education approach represented a shift for MHSS in the way it traditionally worked in
health promotion; moving away from using community workers to deliver sexual health messages,
to utilising community members themselves as peer educators to deliver those messages. In
consultation with a reference group, comprising experts in the area of peer education, MHSS
devised an alternative model for delivery of SRH messages.
Initial community consultations determined what issues were perceived as important by the target
communities. This information was used to guide the development of the project’s educational
content and how it was delivered. The basis of the model was the recruitment of volunteer peer
Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 4
educators (PEs) from the target communities whom having completed their training would
subsequently deliver four to six education sessions to members of their respective community.
Peer Education Project Aims
The Peer Education project had two broad aims:
1. To increase the educational capacity and reach of the MHSS program enabling closer and more
effective engagement with priority CALD communities affected by or vulnerable to BBV/STI; and
2. To create a sustainable program of culturally authentic volunteer-based peer education through
consultation and collaboration with priority CALD communities
Description of the Peer Education project
Volunteer peer educators (PEs) were recruited through a formal process, beginning with the
positions being advertised in the Liberian and Karen communities (see Appendix 2 for an example).
For the first phase, eight Liberian and nine Karen PEs were formally recruited through a written
application and interview process. This method was chosen specifically to provide additional
professional skills and experiences to the PEs. PEs were selected based on their experience and
qualifications or endorsement by community members, as well as their language skills, commitment
and enthusiasm for the project. The majority of the PEs selected were already actively volunteering
within their communities and this project enabled them to develop their skill base and have these
formally recognised.
The project was overseen by a dedicated project officer with extensive CALD experience who was
employed full time at MHSS. The project officer role was supported by an external reference
committee, other experienced community workers (MHSS staff) and community worker student
interns. The role of the project officer included delivery of training to PEs and providing additional
support while they prepared and conducted their Peer Education sessions.
The recruited PEs committed to a six month period that involved intensive training delivered by the
project officer. The training for the Karen and Liberian communities was conducted separately, with
Karen PEs receiving their training over five evenings and the Liberians over two half-days for a 2-4
week period. During the training period, PEs acted as community consultants with respect to the
development of culturally appropriate and needs-based curricula. Continued consultation with PEs
culminated in the peer education manual which utilised interactive teaching strategies, for example
verbal, visual and hands-on activities and was used to deliver six peer education sessions to
community members.
Once trained, the PEs were subsequently required to deliver four to six education sessions to
community members. The project officer was available to PEs if needed. Once each session had been
delivered the project officer conducted formal follow-up telephone calls with all the PEs.
Based on a risk assessment conducted during project development, attendance numbers for each
Peer Education session was capped at 10 participants per two PEs. The one exception was a Geelong
Karen group, which had three PEs for 10 participants. There were four Karen groups and four
Liberian groups with PEs deciding how and where to deliver their community sessions, based on
what they felt were appropriate for their group profile and dynamic, and for logistical reasons.
Sessions were conducted in a range of community settings following an outreach model of service
and education delivery, e.g. homes or community halls, and the order of the material covered was
based on the identified group needs.
For the purpose of maintaining the health and wellbeing of everyone involved, reducing barriers for
attendance, addressing cultural expectations and promoting a level of safety and trust for
community participants, catering and childcare were provided on site by MHSS for each Peer
Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 5
Education session. The project officer was responsible for organising catering and childcare for every
session with MHSS providing the funds.
Participant feedback regarding content and relevance was to be collected orally at the conclusion of
each session, with PEs recording responses. An evaluation of the education sessions overall was
conducted orally at the final session with one PE asking a number of questions of the community
participants and the second PE taking handwritten notes of responses.
Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 6
Executive Summary
Beginning in 2011, the Multicultural Health and Support Service (MHSS) designed and implemented
the first phase of a new sexual health promotion initiative to Victoria’s Karen and Liberian
communities. The Peer Education project involved the delivery of a culturally appropriate and needs-
based curriculum in a series of group sessions by volunteers from within the community. The Peer
Education project had two aims:
1. To increase the educational capacity and reach of the MHSS program enabling closer and more
effective engagement with priority CALD communities affected by or vulnerable to BBV/STI; and
2. To create a sustainable program of culturally authentic volunteer-based peer education through
consultation and collaboration with priority CALD communities.
Evaluation objectives
The purpose of this evaluation was to assess the extent to which the MHSS Peer Education project
met its aims during Phase 1 and provide recommendations for future iterations. The specific
objectives of this evaluation were to:
1. Analyse the education and training provided through the Peer Education project
2. Describe the reach of MHSS through the Peer Education project
3. Discuss the sustainability of the Peer Education project
4. Provide recommendations
Methods
An advisory group was established for the evaluation in order to identify key informants, provide
project documentation, and advise on methods of recruitment and conduct with community
members. The evaluation involved document reviews, key informant interviews, and focus group
feedback. A thematic analysis was conducted to identify emerging themes on which
recommendations were based. Evaluation methodology was approved by The Alfred Research and
Ethics Unit.
Findings
An indicator of the success of the Peer Education project was that Peer Educators (PEs) unanimously
stated the training and support they received enabled them to confidently deliver BBV/STI education
sessions to members of their communities, and that they gained both personally and professionally
from the experience. Community feedback was that the information they received from attending
the sessions was relevant at both an individual and community level. Attendance and session
evaluation data collected by PEs was incomplete. Both these findings are indicative of the project’s
strengths in addressing both the normative and felt needs of the Karen and Liberian communities.
The reach of the project was evidenced by: 1) The attendance of 85 individuals (full capacity) from
the targeted communities at the education sessions in a period of less than six months, and 2) the
demonstrated potential and enthusiasm for the trained PEs to further integrate the project into their
communities. Through the PEs, MHSS have established a connection and presence within both
communities. In addition, other organisations have utilised MHSS’s connections with the Karen and
Liberian communities for further interventions.
It is too early at this point in the project life cycle to measure the sustainability of the project
however several program strengths potentially contributing towards sustainability were
demonstrated. These included the effective partnerships between MHSS allowing for the through
which MHSS was able to provided organisational support to the target communities as well as the
achievement of community interest and engagement. Through this partnership MHSS for the
delivery of peer education sessions by trained PEs.
Sustainability could be strengthened through continued engagement or employment of PEs and
exploring sector partnerships.
Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 7
Recommendations
To build on the strengths of the current program, and to ensure sustainability, it is recommended
that MHSS consider the following:
1. Develop a program that will provide effective support and supervisory structures for a formal
partnership with the trained volunteer PEs.
2. Continue to extend the capacity of PEs by introducing additional skills training where
appropriate and integrating professional development opportunities into the PE model.
3. Explore ways to integrate or link the delivery of peer education sessions with existing local social
and clinical services and explore long term partnership opportunities.
4. Methodology and tools for project data collection should be improved and planned ahead of
each phase of the project.
5. Develop strategies to integrate data and feedback into an ongoing improvement process within
the organisation.
Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 8
Background to evaluation
The Burnet Institute was contracted by MHSS to conduct an independent evaluation of Phase 1 of
the Peer Education project. Community focus groups and planning for Phase 2 of this project has
begun within the Ethiopian and Chin communities.
Objectives
The purpose of this evaluation was to assess the extent to which the MHSS Peer Education project
met its aims during Phase 1 and provide recommendations for future iterations. The specific
objectives of this evaluation were to:
1. Analyse the education and training provided through the Peer Education project
2. Describe the reach of MHSS through the Peer Education project
3. Discuss the sustainability of the Peer Education project
4. Provide recommendations
Methods
An advisory group was established for the evaluation in order to identify key informants, provide
peer educator (PE) contact details and project documentation, and advise on methods of
recruitment and conduct with community members. The evaluation was approved by The Alfred
Research and Ethics Unit and involved the following methods:
1. Document review
Review of project documentation included existing internal evaluation documents; records of
participation; minutes of meetings; educational and training materials used by the PEs; project
reports; PE recruitment documents (position description and acceptance/rejection letters); and,
staff self-reflective documents. De-identified demographic data from attendance records of
education sessions and final session evaluation notes taken by PEs were also examined.
2. Key informant interviews
Face-to-face and telephone interviews were conducted with PEs and key project informants
including MHSS staff members, and a member of the original advisory group for the Peer
Education project. Extensive notes were taken during interviews as well as audio recordings.
Following the conclusion of each interview, PEs received a $50 gift voucher as reimbursement
for their time and any expenses related to being interviewed.
3. Focus group session
A focus group session was conducted for five Karen community participants. Participants were
recruited by a PE; they received an information sheet prior to commencing and gave verbal
consent to participate. At the conclusion of the focus group session, each participant received a
$20 cash reimbursement for attending. One of the focus group participants acted as interpreter
for the rest of the group. The focus group informed evaluation objectives 1 and 2. No focus
group session was held for Liberian community participants.
4. Thematic analysis
Qualitative data were analysed to identify key themes and their relationship to the project
objectives. This analysis also informed the recommendations.
Data collection from informants ceased when no new themes emerged. For further detail on
participant selection and recruitment refer to Appendix 1.
A draft of the final report was presented to MHSS for review and comment with a face-to-face
presentation of project findings.
Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 9
Results
This section describes the data collected in the key informant interviews and focus group session
with community participants. Questions focused mainly on the project model; the PE’s experience of
the training and education received and delivered; perceived relevance of session structure and
content by PEs and community participants; what PEs and community participants learnt; benefits
gained (for both PEs and community participants) and areas for improvement.
In addition, feedback notes recorded by the PEs during and after the education sessions were
examined, even though incomplete. The project officer reported that there was difficulty achieving
full compliance by PEs in returning required evaluation documents which included attendance
records, dates sessions held, complete session notes and a final verbal evaluation.
Education and Training
The peer education model was designed to be a structural intervention addressing the contextual
causes (language, culture, knowledge, confidence) that create barriers to accessing appropriate
health care by affected communities. This was achieved via the delivery of interactive group sessions
facilitated by volunteer PEs. The education sessions were designed to be accessible across all ranges
of educational backgrounds; easy to understand and engage with. As such, the content and structure
of the peer education sessions followed a low literacy format utilising narrative storytelling in a
culturally appropriate and sensitive manner.
The model was dependent on building the capacity and knowledge of the volunteer PEs to enable
them to reduce BBV/STI vulnerability at an individual level. Following intensive training and
curriculum development the volunteer PEs were responsible for organising and running four to six
two-hour peer education sessions for their community members in their preferred language and
setting.
Peer educator experience
Of the 17 PEs recruited, eight were interviewed for this evaluation and were asked specifically about
the training, preparation, tools and support they received in order to deliver their peer education
sessions. All eight, four from each community, stated that they felt confident delivering the
education sessions and the training and support they received from the project officer was without
fault. Part of the ongoing support they received was having telephone access to the project officer
before, during and after their sessions.
“Yes, it gave me the skills, although I knew like, about them, I didn’t know how to go into the
community and talk about, you know, things like that because those things are sensitive to
people ... it becomes sensitive, …especially for our African background ... So we learn the skills to
speak to people in our African community how to approach them about these things that we
consider to be sensitive.”
“every area for me was correct, yeah, we learnt everything that we needed to know...every area
was talked about, there was no hiccups where we thought, ah, I don’t have much understanding,
how do I answer this question...it was all great”
Based on the risk assessment done by MHSS prior to the project commencing, PEs worked in pairs
when delivering the community education sessions. PEs were comfortable facilitating discussions
around BBV/STI and did not perceive any gaps in their preparation.
“I was happy with the training ... I’m not good at speaking but I did my best, the training was very
good”
“Yes, definitely ... I became pretty much an educator about how to pass on communication, how
to pass on information about different needs to a group of people”
Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 10
All of the PEs interviewed responded positively when asked whether they felt that being a part of
this project and a PE benefited them. The training received and experience gained during the
development and delivery of sessions throughout the project had many benefits for them
professionally. In addition, they expressed feeling more confident when talking about SRH issues
with people in their community because they had learned the necessary techniques.
“Well the training you know…the training I received was very much an eye opener especially
about how to work in groups, how to conduct a meeting ... different ways of communicating,
passing on information to a group of people”
“… it was about getting people to comprehend an idea through different means, different
activities ... valuable information to them”
Many stated that their own knowledge of BBV/STIs had improved following the training and
reported that their training helped them personally to understand SRH issues better. All PEs felt very
strongly about contributing to their communities and sharing the knowledge they had learnt through
their training.
“I feel like good ... like to do something for my community, to contribute to the community ...
it has also helped me to learn and to understand more ... each one, each individual problem
... most of us in similar situation”
“The training was most helpful to me, my community my friends ... in my culture we don’t
like to talk about sex ... this is the first time we talk about sex”
In addition to the training and experience gained, the PEs were given professional development and
support in other ways. MHSS contributed towards a personal long term goal rather than cash
payments, for example a laptop or driving lessons in appreciation for their commitment to delivering
the peer education sessions. The PEs also received feedback and assistance with generating
professional resumes that formally acknowledged their teaching and group facilitation skills as
trained peer educators.
When asked about areas for improvement for future training, PEs made two suggestions: 1)
inclusion of more audio-visual content during training that could accommodate different learning
styles; and 2) the addition of doctor-patient scenarios to the manual used for the education sessions.
None of the interviewed PEs felt that there were any deficiencies in their training in relation to
feeling equipped to facilitate peer education sessions.
Community experience
Overall attendance by community participants across the six sessions was reported by PEs to be
consistent; any absence was not attributed to lack of interest but rather illness or work and family
commitments. The session dates and attendance records were incomplete therefore it was not
possible to verify consistency of attendance by all participants in each group; however feedback
from the Karen focus group and the project officer did support the PEs statements.
To create a more culturally appropriate and safe environment, catering and childcare were provided
at all sessions. PEs also accommodated their participants by holding sessions at different days and
times. Evidence of the appreciation for the session settings was found in the notes taken by PEs
during the evaluation when they asked community participants what they liked about the sessions:
“The food”
“Childcare helped us concentrate”
“The kids were well looked after and kept quire [sic] and away for the session”
Based on PE input and community consultation, the sessions did not solely deliver sexual health
messages; they were embedded within stories dealing with other pertinent issues such as family
troubles and unemployment. Community participants unanimously voiced that the content of the
sessions and how they were delivered was relevant to them. As found in our examination of final
Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 11
session evaluation notes, the use of narrative story telling approaches delivered by the PEs in
contextually relevant ways resonated with participants.
“I found the activities fun and educative.”
“[We] know more about diseases; know… more about how to protect ourselves.”
“The topic were meaningful and useful”
Many community participants reported increased knowledge around accessing health services. They
indicated that the information was useful and relevant to them, especially regarding knowing where
to go, and what to do. The interpreter for the focus group stated on behalf of one Karen woman
when asked what she learned:
“She remembers about [if] ever get HIV or something like that kind of disease, where to go, how
to get help”
There were many expressions of increased confidence regarding helping family and friends with
medical issues and many references from community participants expressing a desire to share the
material they had learned with others. Through an interpreter, examples of responses from the
Karen focus group when asked about the benefits of having attended the sessions were:
“…so that we can help each other”
“We want to know all about health…or some other information within our communities and so
that if we knew more about that we can help others”
“Especially…. about the kid[s], the youth, [if] they have problem[s], how can we fix and how can
we help them?”
One PE interviewed gave an example of a married couple attending the education sessions who
learned that it was okay to use condoms within a marriage. Other evidence of community
participants retaining the information delivered in the sessions were found in the evaluation session
notes recorded by PEs:
“We learn about health and about family and other kids and youth and drugs and sexual things,
use condoms and about how to apply job and how to write resume, yeah it was helpful”
“More in depth understanding about the different types of health issues, how to protect
ourselves, how to get treated, and where to seek help and support”
Resources were provided for the community participants at the education sessions where BBV/STI
issues were discussed including an MHSS brochure (Appendix 3), condoms and lubricant. There was
no record of whether these were taken by the community participants; however there were some
comments recorded by PEs for the final session evaluation documents that more resource material
to take home would be valued. Another consideration when interpreting the evaluation session data
regarding the community’s experience is the incomplete nature of participant responses recorded by
PEs.
When asked about areas for improvement for the education sessions during the final session
evaluation, community participant feedback (as recorded by PEs) included: 1) more sessions so that
those who could not attend some sessions did not miss out; 2) more handouts to take away at the
end of sessions; and 3) to include some audio-visual material.
Two additional comments made at the Karen community focus group regarding session content
were: 1) information about how they can assist family still in Burma to migrate to Australia; and 2) to
cover more issues affecting their youth (sex, drugs, and alcohol).
Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 12
Summary
The training received by PEs enabled them to successfully deliver peer education sessions to
community participants
PEs received professional development and valuable content knowledge from their training
Community participants perceived the session content and delivery to be relevant and engaging
Community participants believed sessions improved their confidence and knowledge regarding
accessing appropriate health care when needed
Attendance and session evaluation data were incomplete
Reach of MHSS
It was not possible to quantify the full extent of MHSS’s reach within the scope of this evaluation,
however, the information obtained from session evaluation documents, the focus group and
interviews with key informants provided the following evidence for community reach.
Direct reach
Phase 1 of the Peer education project was successfully conducted with sessions for eight groups
(four Karen and four Liberian) reaching 85 community members in total. As peer education sessions
were delivered by at least two PEs with session attendance capped at ten participants per group, the
project reached its maximum attendance.
The Liberian peer education sessions were mixed gender and the participants ranged in age from
17–36 years. The Karen peer education sessions also consisted of mixed gender but included a
dedicated youth group (18–22 years) alongside other groups of older participants (24–45 years).
Years in Australia for participants ranged from one to seven. Although only confirmed through
interviews with PEs, attendance was consistent across all sessions for all groups. All groups had more
women attending than men with the exception of one. Refer to Appendix 4 for a summary table of
available information summarised for each of the eight peer education groups.
As planned, the peer education sessions were held in locations where the Liberian and Karen
migrant communities have been settled. The Liberian groups held their sessions in Sunshine,
Thomastown, St Albans and Truganina (rural-urban fringe). The Karen groups were held in Werribee,
Geelong and Hoppers Crossing. This is likely to have enabled participation by the targeted
community members.
In addition, the trained PEs are a valuable resource for MHSS. They learned to deliver accurate and
culturally sensitive information on sexual health and gained skills in teaching and group facilitation.
MHSS now has connections with the PEs from the Karen and Liberian communities which are
communities they had previously had little or no contact with.
Indirect reach
Through the Peer Education project, MHSS’s presence has also improved more broadly within these
communities. This evaluation saw a number of examples of MHSS being used as a resource and
support for community members. These include a request for an information session delivered to
the Karen community on SRH; a Karen worker who moved to regional Victoria - where there is a
large Karen community - requested a box of condoms to distribute; one Karen PE has attended
further sexual health education sessions held by MHSS; and a Liberian PE has contacted MHSS asking
for more sessions to be given in her community.
Since Phase 1 of the Peer Education project a number of other organisations have used MHSS as a
connection between these organisations and the communities. For example, Cancer Council Victoria
Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 13
asked MHSS to assist them in promoting a pap screening intervention to the Karen community in
Geelong and Werribee. Another example was the development of a sexual health teaching video
jointly with Deakin University, the Centre for Excellence in Rural Sexual Health (CERSH) and the
Victorian Aboriginal Community Controlled Health Organisation (VACCHO).
An underlying principle of the Peer Education project was that through the community led education
sessions more people in the Karen and Liberian communities would “know someone who knows”.
Aside from the examples above of community awareness for MHSS, a demonstration of community
reach is one married couple, who are both trained PEs, reporting that they have continued to engage
with their community by delivering sessions on prevention of violence against women.
Summary
Maximum attendance was achieved with 85 community members participating in the education
sessions delivered locally to them
Through the PEs, MHSS has established a connection and presence within both communities
Other organisations have utilised MHSS’s connections with the Karen and Liberian communities for
other health promotion interventions
There is evidence of PEs continuing to educate the communities with the support of MHSS
Sustainability
The presence of the trained PEs provides an ongoing link between MHSS and the community (a
visible presence), the PEs are able to advocate on behalf of MHSS as well as providing a resource for
community members and ultimately community ownership through consultation and
representation. For example, interviewed project key stakeholders mentioned that the employment
of two of the Liberian PEs by MHSS has strengthened MHSS’s relationship with that community.
Strong relationships with the community via PEs who are evidently still positively engaged with the
service is important in achieving a sustainable volunteer-based peer education program.
Another example of the formation of relationships as a result of the project is the presence of skilled
PEs in each of these communities; they are a valuable resource that did not exist prior to this
project. These PEs can act as an important link between their community and healthcare and social
support services. In addition they have the potential to continue to engage with their fellow
community members in talking about health and education as has already been demonstrated.
Other aspects of sustainability are partnerships with local health services. Leveraging off the
unforseen relationships that were established through the initial phase of the project will be of
benefit to maintaining community presence and improving the health of community members.
Summary
It is too early at this point in the project life cycle to gauge the sustainability of the project however
the project fulfils several factors that will potentially contribute to sustainability:
Demonstrated effective relationships and partnerships between MHSS and the PEs and their
respective communities
Supportive context for practice where MHSS was able to provide organisational support to these
communities for the delivery of peer education sessions by trained PEs; and
Partnerships with other local health organisations delivering health promotion in CALD
communities
PEs remain positively engaged with education of their community, providing opportunity for MHSS
Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 14
Emerging themes
Community benefit
It is clear from the data collected that both PEs and community participants have a high degree of
satisfaction with what they have learned, and that they wish for the sessions to be continued. There
is obvious enthusiasm for giving back to the community and sharing knowledge. PEs and community
participants have benefited from their involvement in the project, whether through training and
professional development or through attending peer education sessions as a community member.
They have expressed more confidence in their health literacy in relation to knowing how and where
to seek help and how to communicate around BBV/STI issues and sensitive health topics.
Community engagement
A key feature of this project was community engagement. MHSS held initial consultation sessions
with community representatives during the development of the project. This enabled them to form
initial relationships with community members, and to raise awareness of their organisation and
planned Peer Education project. Importantly, it also presented the opportunity for community
members to express their priorities and contribute to the design and content of the peer education
project. This contribution then carried on to the recruited PEs who developed the content and
delivery methods of the education sessions.
Once PEs delivered their education sessions there was no formal expectation of continued
involvement with the project or with MHSS. Interviewed MHSS staff indicated that it was always
intended that the PEs would deliver a defined number of sessions to their communities, and that the
decision for ongoing involvement would be left to the individual PEs. There was some evidence from
the interviewed PEs that a few had remained involved with MHSS with the majority indicating that
they had not.
When asked whether PEs felt as though they had a current connection with MHSS, most replied that
they did not. MHSS made efforts to maintain contact with PEs through semi-regular emails and
telephone calls, however there was perceived disconnect between the felt experience of PEs and the
effort by MHSS to try to maintain a connection. Some of this may be partly due to recall by
interviewed PEs when asked to describe MHSS efforts, delays caused by staff turnover or difficulty
replacing the project officer, PE contact details may have changed and other PE work/life
commitments.
Community ownership
Interviews with MHSS staff and a review of project documentation indicated that community
ownership was a key feature envisaged for this project. To date, community ownership has taken
the form of: direct consultation with community members and community representation from PEs
during project development and delivery; PE involvement with the development of the session
content; PEs’ autonomy regarding how, when and where they delivered their sessions; and the
ongoing presence of the trained PEs within their communities.
Beyond the completion of the sessions however, the way in which the community would maintain
ownership was not formally articulated. For example, the PE position description does not describe
how a continued relationship with MHSS would be maintained nor does it clearly define any ongoing
involvement of the PE (i.e. what would be expected of the PE and what MHSS’s role would be).
However, despite this there were clear demonstrations of community ownership with some PEs
taking the initiative to continue to engage with MHSS as well as their own communities through the
delivery of further education sessions while supported by MHSS.
Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 15
Specialised skills
The role of project officer was a 1.0 EFT high-level position with many responsibilities which included
being key contact person and trainer for all the PEs throughout their training, session delivery and
beyond. The project officer for Phase 1 of the Peer Education project had the capacity to meet all
the responsibilities required of this role and was well-liked by the PEs, and delivered exemplary
support throughout. Support for this role came from internal (student interns, senior project officer,
senior community worker and MHSS Manager) and external sources (the project reference group).
With this support the project officer reported feeling able to provide the level of assistance and
monitoring of PEs required for implementing the project.
When the project officer role became vacant, the responsibility for ongoing contact with PEs passed
onto other MHSS staff and the ability of MHSS to maintain an active continued connection with PEs
was impacted. Finding suitable candidates with the requisite experience and knowledge of working
with CALD communities and implementing community-based interventions is a challenge for small
organisations. Migrant workers, who are best placed to deliver community education, have complex
personal issues themselves which come from resettlement and cultural expectations. Employing a
suitable worker requires intensive provision by MHSS of appropriate support, mentoring, up-skilling
and opportunity.
Discussion
MHSS has successfully delivered BBV/STI education to two refugee and migrant communities using a
peer education approach. Indicators for the success of this project were that all of the PEs
interviewed reported that their training was excellent, as was the support provided to them. PEs felt
they had gained invaluable work experience through being involved with this project and facilitating
peer education sessions. The education sessions reached maximum capacity with 85 community
members participating. The feedback from community participants was predominantly positive and
value was given to the education they received and how it was delivered.
MHSS as the lead organisation initiated a coalition between themselves as professionals and
community members as peer educators. In doing this the organisation has contributed to
sustainability of community health promotion projects. In addition, MHSS has demonstrated stability
through its program being established within CEH; credibility through their work with CALD
communities in Victoria; and as an ongoing Department of Health funded program they have access
to resources. These have been documented as the three key features necessary to maintain
presence and increase sustainability in health promotion [16].
Peer Education project objectives
This Peer Education project aimed to strengthen participating communities’ capacity to address their
health and social support needs through disseminating information and promoting the availability of
MHSS as a resource and support service. The commitment of PEs to deliver the education sessions
and the consistent attendance by community participants over the course of sessions suggests that
the project related to the individual needs in culturally appropriate ways.
Another of the main objectives of the Peer Education project was to increase the reach of MHSS
enabling closer and more effective engagement with priority CALD communities affected by or
vulnerable to BBV/STI. Evidence that MHSS increased its educational capacity and reach was
demonstrated not only by the delivery of the education sessions to 85 community members across
both Liberian and Karen communities including 18 trained PEs who know more about SRH issues and
are now trained group facilitators.
Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 16
These outcomes indicate increasing educational capacity and reach of MHSS into these
communities.
The third main objective for the project was to create a sustainable program of culturally authentic
volunteer-based peer education through consultation and collaboration with priority CALD
communities. There are several factors that contribute to sustainable health promotion programs
and long term community engagement is key. The recognition by MHSS that community members
are the ‘experts’ of their lives by engaging community in the Peer Education project from conception
has contributed to this.
There have also been many positive and unforseen outcomes of the Peer Education project which
will assist in reaching the objective of sustainability for the program. MHSS has incidentally
developed relationships and partnerships with community members and other organisations; they
have employed two Liberian PEs as health educators retaining their credibility as PEs within the
community[18]; and they have target populations willing to be engaged as well as PEs who are still
positively involved. MHSS has a strong emphasis on building community and individual capacity of
CALD individuals and their ability to provide organisational support (PE training, provision of peer
educators manual) also contributes towards sustainability [17].
While there is evidence of many factors that will contribute to program sustainability, there is a lack
of clear articulation by MHSS for how sustainability will be reached. For example, what form will
community ownership take, how will ongoing connections with trained PEs be maintained. A clear
definition needs to exist with planned actions and measured outcomes.
Strengths and enablers
One of the strengths of this project was MHSS’s ability to be flexible in how they developed the
curricula for the community education sessions to ensure that they addressed the normative as well
as the felt needs of the Karen and Liberian communities. This meant that the education sessions did
not just deliver BBV/STI education material but addressed other pertinent issues such as family
dysfunction and unemployment. Approaching the Peer Education project this way ensured that
content was relevant to the communities, and likely contributed to the engagement of the
participants.
Another strength of the project was the recruitment of PEs who were already active within their
communities which is an acknowledged factor contributing towards successful peer education
programs [18, 19]. In addition, the project’s success was facilitated by the dedication and
commitment of PEs, the enthusiasm and commitment of the project officer and the higher level
organisation support given by MHSS. This also suggests that the training received by PEs enabled
them to successfully facilitate these sessions.
Additional enablers for the success of this project were the consultative curriculum development
process used by MHSS in developing and implementing the Peer Education project and employing a
dedicated project officer. PEs contributed towards the development of the curricula for the peer
education sessions so that it was culturally and contextually relevant. The PEs benefitted
professionally through formal recognition of the training they received.
The project officer had several support structures available, which ensured that the role could
deliver on project commitments and additionally, provide support for PEs while they delivered their
education sessions (e.g. the project officer was contactable before, during and after each education
session held). The dedicated role of the project officer was a practical necessity that brought an
intimate knowledge of the project and strong relationships with PEs and community members.
Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 17
Project challenges
A central challenge to project sustainability is the resource intensive nature of peer education
programs. They require: a dedicated project officer; provision of high-quality training for the PEs;
support for PEs; resource development (i.e. development of curricula for different populations);
project monitoring takes time, effort and funding; and, compensation for the time and energy PEs
put into delivering their education sessions. As such these project are reliant upon funding for
continued operation [19, 20].
It is also a challenge for small agencies to recruit experienced high level workers with sound CALD
practice and experience and to build capacity of CALD workers. MHSS was successful in attracting
committed and competent volunteers to be trained as PEs and retaining them is beneficial in terms
of maximising resources and leveraging off existing knowledge and experience.
With any peer education project retention of trained PEs is an issue, particularly as this role is often
a transitional one[18]. Additionally new migrants continually arrive which also impacts on the
project and MHSS’s ongoing presence within these communities. To ensure the potential for ongoing
community ownership and longevity a formalised partnership between the PEs and MHSS is
necessary.
Common to many peer education programs this project has experienced difficulties in collecting
data for evaluation [13, 19, 21]. The PEs had varying levels of literacy and time to dedicate to
documenting the sessions, possibly affecting their motivation to complete reports. There was also
no documentation of material taken by community members (e.g. number of condoms, MHSS
brochures) at end of session which could have given us some idea of the relevance to participants or
their interest in these.
Recommendations
MHSS should capitalise on the training, engagement and enthusiasm of PEs, especially given the
resources expended in recruitment, training and support. There was no formal governance or
planned structure for how the relationship between MHSS and the trained PEs would continue after
the PEs had delivered their expected number of sessions, however some have gone on to paid
employment with MHSS or continue volunteer peer education within their communities. For the
purpose of sustainability without the cost of re-establishing the Peer Education project within these
growing communities, a formal, structured and supported program that extends beyond the training
and delivery of education sessions is essential.
Recommendation 1: Develop a program that will provide effective support and supervisory
structures for a formal partnership with the trained volunteer PEs.
There was a clear perception by MHSS that the training received by the PEs would give them formal
qualifications that could be used as pathways to further education and/or employment. It is possible
that by extending the skills of PEs to include project development, management or evaluation, for
example, MHSS would continue to attract recruits to ensure ongoing reach of the program.
Recommendation 2: Continue to extend the capacity of PEs by introducing additional skills
training where appropriate, and integrating professional development opportunities into the PE
model.
Characteristics of successful peer education programs often include an integrated approach where
the PEs and session delivery are linked with local clinical, counselling and youth services, addressing
place-based disadvantage. The evidence suggests that peer education is most effective when these
partnership structures are in place [13, 22]. The PEs themselves could become ambassadors or
consultants on behalf of MHSS in in their continued peer education [22]. These partnerships will help
Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 18
to raise local sector awareness of MHSS and increase BBV/STI related health knowledge among
community members and potentially their access to health care.
Recommendation 3: Explore ways to integrate or link the delivery of peer education sessions
with existing local social and clinical services and explore long term partnership opportunities.
In line with national BBV/STI control strategies, the Peer Education project is designed to improve
knowledge among priority populations around potential risk and access to healthcare. It is important
that relevant data are captured to measure the extent to which MHSS efforts address these
strategies. Capturing feedback from participants and stakeholders is also important for ongoing
improvement of the project itself. Throughout the Peer Education project there were missed
opportunities for data collection and/or areas where data collection could be improved.
Recommendation 4: Methodology and tools for project data collection should be improved and
planned ahead of each phase of the project.
Another advantage of data collection is the knowledge gained by MHSS that will allow an ongoing
improvement process taking feedback into account and providing the basis for discussion and
reflection. New findings and lessons learned can then be shared with all staff of CEH involved in
health promotion or community engagement.
Recommendation 5: Develop strategies to integrate data and feedback into an ongoing
improvement process within the organisation.
Limitations of this evaluation
A number of limitations may have impacted on the ability to evaluate the education, reach and
sustainability of this project. The scope of this evaluation and availability of collected project data
was such that sustainability of the project was inferred. As it is still early in the project life-cycle its
sustainability may become more evident over time.
The first is the lack of complete records for sessions. However, this limitation must be taken in
appropriate context. A verbal account is a common approach taken for peer education programs
dealing with marginalised populations where listening to participants comments (solicited and
unsolicited) is contextually and culturally appropriate [13].
Secondly, there was no way of directly measuring what community members attending sessions
learnt and what knowledge or assistance they may have passed onto other community members.
Thirdly, the commencement of this external evaluation was one year following PEs completing their
peer education sessions. The passing of time has potentially introduced recall issues for PEs
regarding their experiences[15].
Finally, there was no focus group from the Liberian community, which meant that only 5/85
community participants gave direct feedback for this evaluation. However the feedback sourced
from the document review was very much in agreement with the output from the focus group
discussion.
It is important to stress that projects like this peer education one will not necessarily yield definitive
outcomes (e.g. increased BBV/STI testing, or changes in numbers of people accessing health
services) early in the project life cycle. Many of the benefits such as improved health literacy and
access, and community engagement, although very important, are not easily quantifiable and are
difficult to demonstrate. These contextual constraints do not lessen the credibility of the evaluation
approach used for this report or conclusions reached [15].
Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 19
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2. Institute for Community, E.a.P.A., Review of Current Cultural and Linguistic Diversity and Cultural Competence
Reporting Requirements, Minimum Standards and Benchmarks for Victoria Health Services Project: Literature
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3. McNally, S. and S. Dutertre, Access to HIV prevention information among selected culturally and linguistically
diverse (CALD) communities in Victoria. 2006, The Australian Research Centre in Sex, Health and Society, La
Trobe University.
4. Hawke, E., Exploring sexual health issues of the culturally and linguistically diverse communities in
Wollongong, Healthy Cities Illawarra Inc, Editor. 2005.
5. DoHA, Sixth National HIV Strategy 2010-2013, D.o.H.a. Ageing, Editor. 2010.
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http://blog.id.com.au/2011/australian-demographic-trends/australia-newest-migrants/.
7. Department of Immigration and Citizenship (DIAC), Community Information Summary. Liberia-born. 2013,
Commmunity Relations Section of DIAC,.
8. Office of Multicultural Affairs and Citizenship, Victorian community Profiles: 2011 census Burma (Republic of
the union of Myanmar)-born, Victorian Multicultural Commission, Editor. 2013.
9. Drummond, P.D., et al., Using peer education to increase sexual health knowledge among West African
refugees in Western Australia. Health Care Women Int, 2011. 32(3): p. 190-205.
10. Kerrigan, D., UNAIDS Best Practice Collection. Peer education and HIV/AIDS: Concepts, uses and challenges, S.
UNAIDS Geneva, Editor. 1999.
11. Triandis, H.C. and M.J. Gelfand, Converging measurement of horizontal and vertical individualism and
collectivism. Journal of personality and social psychology, 1998. 74(1): p. 118.
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Educ Res, 2000. 15(1): p. 85-96.
13. Jaworsky, D., et al., Evaluating Youth Sexual Health Peer Education Programs: Challenges and Suggestions for
Effective Evaluation Practices. 2013. Vol. 1. 2013.
14. Mikhailovich, K. and K. Arabena, Evaluating an indigenous sexual health peer education project. Health
Promot J Austr, 2005. 16(3): p. 189-93.
15. Newland, J. and C. Treloar, Peer education for people who inject drugs in New South Wales: Advantages,
unanticipated benefits and challenges. Drugs: education, prevention and policy, 2013(0): p. 1-8.
16. Vermeer, A.J.M., et al., Factors influencing perceived sustainability of Dutch community health programs.
Health Promotion International, 2013.
17. Harris, N. and M. Sandor, Defining sustainable practice in community-based health promotion: a Delphi study
of practitioner perspectives. Health Promot J Austr, 2013. 24(1): p. 53-60.
18. Cupples, J.B., A.P. Zukoski, and T. Dierwechter, Reaching young men: lessons learned in the recruitment,
training, and utilization of male peer sexual health educators. Health Promot Pract, 2010. 11(3 Suppl): p. 19S-
25S.
19. Lambert, S.M., et al., Effective peer education in HIV: defining factors that maximise success. Sexual Health,
2013. 10(4): p. 325-331.
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Australasia, 2010. 10(2): p. 36.
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approaches to changing nutrition environments. J Am Diet Assoc, 2007. 107(2): p. 301-5.
22. Walker, R., Literature review of sexual health and blood bourne virus education and peer influence programs
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Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 20
Appendix 1. Participant Selection and recruitment
Stakeholder Stakeholder
definition
Sampling Number
recruited
Notes
Reference
group
member
External
expert/s on
peer
education
who had a
relationship
with the
project
(n=10)
Reference group
members were
identified by
MHSS staff
1 A face-to-face interview was
held.
Peer
educator
Volunteers
recruited and
trained by
MHSS to
undertake
peer
education
activities
(n=17)
Peer educator
contact details
were provided by
MHSS. Contact
was made by
telephone
8
(4 Karen and
4 Liberian)
The phone lines/numbers for
a few peer educators had
become disconnected and
they could not be contacted.
Two peer educators were
interviewed face-to-face.
Access to PEs was also
complicated by the passage of
time that has elapsed since
they delivered their peer
education sessions (1 year)
Staff Current
MHSS staff
directly
involved with
project
(n=2)
Staff asked to
participate by
the evaluator
2 One telephone and one face-
to-face interview was held.
Community
participants
People who
attended the
education
sessions held
by the peer
educators
(n=85, verbal
confirmation
by project
officer)
4 peer educators
(2 Karen and 2
Liberian) were
asked to contact
people who had
attended their
sessions and
recruit them to
the evaluation
5
(Karen)
One Karen peer educator was
successful in recruiting
community participants for
the evaluation (a group focus
session was held for the 5
participants).
Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 21
Appendix 2. Example of flyer advertising PE opportunity
Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 22
Appendix 3. MHSS brochure (English).
Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 23
Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 24
Appendix 4. Summary table for the eight peer education groups.
Peer facilitator groups
Group 1 Group 2 Group 3 Group 4 Group 5 Group 6 Group 7 Group 8
Group demographics (Attendance)
Women 6 - 8 8 - 3 - 7
Men 5 - 2 - - 8 - 2
Age range 24 - 45 - 18 – 22 30 - 40 - 18 – 22 - 17 - 36
Number of
people
attending who
have children
3 - 0 - - 3 - -
Number of
years in
Australia
(range)
1 - 6 - 1 – 6 - - 2 ½ - 7 - -
Number of
attendees for
each session
(if given,
range)
8 - 9 - - - - - - -
Dates sessions
held (if given)
26-08-12
02-09-12
09-09-12
16-09-12
- - 18/08/12 - - -
08/09/12
15/09/12
Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 25
Peer facilitator groups
Group 1 Group 2 Group 3 Group 4 Group 5 Group 6 Group 7 Group 8
Paul’s story (about to drop out of high school)
Page 19 ‘’So
what?’’
General
comments
about
encouragemen
t and options
General
comments
about
encouragemen
t and who to
contact
General
comments
about
encouragemen
t and who to
contact
No comments General
comments
about
encouragemen
t and what can
do
General
comments
about
encouragemen
t and what can
do
General
comments
about
encouragemen
t and what can
do
General
comments
about
encouragemen
t and what can
do
Nick’s story (unemployed for 18 months)
Page 23 “Now
what?”
Volunteer
Get work
experience
Get help for
resume
Support and
encourage to
change his life
Pray for him
Look for work
for him
(M2) where
would you go
to get help for
family
violence?
Can go back to
school
Get drunk
Family
problem
Ask parents for
money
Encourage to
volunteer
Check health
Seek ideas
from others
General
comments
about negative
stereotyping
of
unemployed/
migrants
Summary of
feelings
(suicide,
depressed,
anger, violent)
Encourage to
volunteer
Self-evaluation
Get more
training
Encourage to
volunteer
See career
counsellor
Do
apprenticeship
Take classes
(literacy/nume
racy)
Volunteer
Work
experience
Do resume
Choose
suitable job
Keep trying
Volunteer
Get work
experience
Get help for
resume
Make sure
have good
relationship
with referees
Session 1 group evaluation
Page 25
What would
you be happy
Good to help
young people
Beneficial for
Very good
session
We know
(M1) work
together
(M1) family
Be more open
minded about
volunteering
Refer them to
services/netw
orks
This session
made some of
the attendees
start thinking
No comments No comments
Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 26
Peer facilitator groups
Group 1 Group 2 Group 3 Group 4 Group 5 Group 6 Group 7 Group 8
to tell your
friend about
the session?
both young
and old,
volunteering
good
Get ideas from
as many
people as you
can
Session is good
We can
encourage
young people
about
educational
and job
pathways
more
information
Found the
session very
helpful, about
supporting
each other in
the
community
Others should
most definitely
come along,
friends/family
Thankful to
leader for
organising
education
session
problem
(M1) homeless
To kill
To be die
Ask friend for
job
They don’t
have job
Get ideas from
family/friends
Be pro-active
Let others in
your
community
know if you
are struggling
When working
must leave any
issues/proble
ms may have
at
home/persona
lly – don’t
bring them to
work
Encourage
critical
thinking
Discuss
options
(volunteering
etc)
Try to be
positive and
motivated
Keep up-to-
date with
technology
Be role model
Be pro-active
about their
current
situation
It informed
them about
different
situations in
the
community
It taught them
how work in
small groups
Page 26
If someone in
your family
was in the
situation do
you think you
could help
them? Please
tell us one
Tell people
about the
options
(VCAL/TAFE)
that are out
there
Support
family/friends,
encourage
Advise them
Encourage
them
Tell friends
that if have
problems
don’t need to
be upset, we
all have
No comments Go and talk to
community
leader
Some people
are reluctant
to seek help
from other
friends/comm
unity
Encourage
them
Try to
motivate and
be a role
model
Refer to
services/netw
orks
Try to give
people as
much support
as possible
Help in any
way you can
No comments No comments
Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 27
Peer facilitator groups
Group 1 Group 2 Group 3 Group 4 Group 5 Group 6 Group 7 Group 8
thing you
would do for
them.
them
Seek help so
can assist your
child with their
problem
Get special
tuition to help
with study
problems – we
need to
support each
other
I want my
friends to
come, this is a
good session
This session
made me
understand
about friends
and
community
organisations
If people who
work at
community
organisations
aren’t
friendly/helpfu
l people won’t
go to them for
help
Take action,
get support
Session 2
Lee’s story (young 16 old male, mother finds condom in his room)
Page 33
“Options”
Talk privately
Get father to
have talk
Discipline
Protect family
dignity
Too young to
be using
condoms
Mother should
teach him (sex
ed?) for his
future
He should
repent and
listen to
Father should
have a talk
with his son
Father is afraid
to talk with
son privately
about sex
No comments Counselling
Sex education
Social worker
Get more
condoms
Could hide his
condoms
elsewhere
The mother
could give him
some sex
education
The mother
could give
advice about
No comments Seek social
worker help
Mother should
have a serious
discussion with
son
Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 28
Peer facilitator groups
Group 1 Group 2 Group 3 Group 4 Group 5 Group 6 Group 7 Group 8
parents
Encourage
having sex at a
young age
The mother
could provide
condoms
Lisa and Alex’s story (young relationship, woman pregnant)
Page 39
“Options”
Discuss with
one another
Prepare for
child
Consider
abortion
Talk with
parents
Seek advice
Look after the
baby
Prevent the
health (?)
Take care of
the child and
go back to
study later –
never too late
for study
(M1) talk to
father (i.e.
man-to-man)
Protect name
of family
Parent(?)
afraid to talk
with son
Use
contraceptive/
condom
Encourage to
get married
Parents to talk
about sex(?)
(M2) talk with
both families
(M2) go to
GP/hospital
Consider
abortion
She can go to
youth resource
centre
Seek help from
a
counsellor/soci
al worker
Ask for help
from parents
She can have
baby and then
go back to
school
Consider
abortion
Relationship
counsellor
See GP for
regular health
check
Consider
adoption
Family support
Peer support
Consider
abortion
Young man
could dropout
of school to
support family
They could
seek
counselling
Get centrelink
support
Have the baby
– don’t
consider an
abortion
Be happy
Prevent future
pregnancy
Have the baby
– don’t
consider an
abortion
Be happy,
knows father
of child
Prevent future
pregnancy
Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 29
Peer facilitator groups
Group 1 Group 2 Group 3 Group 4 Group 5 Group 6 Group 7 Group 8
(M2) The girl
could discuss
with the boy
Session 2 group evaluation
Page 40
What would
you be happy
to tell your
friend about
the session?
Educate your
child about
how to use a
condom
Treat with
respect, do not
use anger –
otherwise
child will lie
and not want
to cooperate
with us
Have a
discussion
Happy to share
this session
with friend
Condoms can
protect you
Good session
We know
more
information
(M1) use
condom t
protect
yourself
(M2)
encourage
them (to?)
(M2) Let them
know where
they can seek
help, take
them there
(M2) tell your
friend to go to
the GP
Share ideas
with friends
Be open
minded
Take more
action
This kind of
session is very
helpful for our
community
and if held
again would
bring more
friends
Have
protected sex
Go to family
planning
Teenage
pregnancy is
not the end of
life/career/fut
ure
Get sex
education
Sessions are
educative/info
rmative
They help
prepare you
Follow your
goal
Motivate you
No comments No comments
Page 41
If someone in
your family
was in the
situation do
you think you
could help
Encourage
them
Link them with
service
providers/orga
nisations
Encourage
them to see a
counsellor
(M1)
everything
(M2) make
them feel they
can trust you
and listen to
what they are
Yes, I feel that
I could help
them and
suggest they
see a project
officer at
MHSS
Support them
(emotionally
and financially)
Ask their
opinion about
pregnancy
Give
encouragemen
t and support
Tell them
where they
can go for help
(MHSS/service
No comments No comments
Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 30
Peer facilitator groups
Group 1 Group 2 Group 3 Group 4 Group 5 Group 6 Group 7 Group 8
them? Please
tell us one
thing you
would do for
them.
Help them to
take care of
the child
Advise them to
seek
counselling/m
edical help
Talk with them
about taking
responsibility
for child so
parent can go
to school/work
saying without
judgement
(M2) Guide
and direct
them
Listen to them
without
judgement
Will give them
name of
contact (NB.
Phone number
given in
brackets-
94189916, this
was the MHSS
peer education
project
officer’s office
number)
Find a
community
leader/organis
ation that can
help
Ask if ready to
have baby
Meet parents
Seek medical
check-up
Consider
abortion
Depends on
family
background
providers)
Financial
management
Session 3
Mary’s story (Living with HIV)
Page 48
“Options”
Talk with
others
Learn more
about HIV
Learn how to
stop
transmission
Find someone
who can help
Find out who
to ask in the
community
See a GP
Get tested and
(M1) shame
(M1) cannot
sleep
(M1) kill
themselves
(depression)
(M1) they
No comments Seek advice
Speak to
counsellor
Be positive
See a religious
person
Get medical
advice
See a
counsellor or
social worker
(e.g. at MHSS)
Speak with
Keep her
illness secret
Stay positive
Take her
medical
treatment
Eat healthy
Seek help from
a counsellor or
social worker
Get support
from family
Seek medical
help
Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 31
Peer facilitator groups
Group 1 Group 2 Group 3 Group 4 Group 5 Group 6 Group 7 Group 8
Seek
counselling
Get medical
check
get treatment
if needed
Find
information
about HIV and
treatment(?)
on internet
don’t tell
anyone
(M1) see GP
(M1) speak
with
family/best
friend
your pastor
Have
protected sex
Use sex toys
Have safe sex
to prevent
spreading
disease
Talk to
someone just
to relieve
stress
Ben and Kelly’s story (Hepatitis B)
Page 54
“Options”
Discuss with
others
Seek medical
advice
See Chiedza or
any MHSS
worker
Get vaccinated
See Hep B
specialist
See Hep B GP
Get vaccinated
Tell partner to
trust him
Find someone
in community
who can help
Search for Hep
B information
Visit
community,
GP, pastor,
hospital
Socialise with
friends
(M2)
encourage
them to
discuss
problem with
each other
(M2) Tell
partner the
truth
(M2) Get
treated and
take
medication
(M2) see GP
for help and
advice
(M2) both get
Has to tell
partner before
getting
married
Has to know
cannot donate
blood
Must see GP
regularly and
take
medication
As
friends/family
advise to take
medication
Visit them
He could be
treated
He could die
He could lose
relationship
He could get
counsellor
Family could
stigmatise
Seek
treatment
They could go
to counselling
Tell partner
Kelly might
leave Ben
No comments Seek help from
a GP
Practice safe
sex so partner
does not get
Hap B
Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 32
Peer facilitator groups
Group 1 Group 2 Group 3 Group 4 Group 5 Group 6 Group 7 Group 8
Hold
information
sessions in
community
health check
before
marrying
Make sure not
excluded from
community/so
cial events
Session 3 group evaluation
Page 55
What would
you be happy
to tell your
friend about
the session?
There is good
information
about HIV and
hepatitis B
available
There is help
for these
diseases
Don’t be afraid
to seek
medical advice
Don’t be afraid
of these
diseases
It is a good
session to
share with
friends
We know
more about
disease and
where to get
help
(M2) go to GP
and get health
check
(M2) direct
your friend to
seek help
(M2) Tell
friends what
learnt at
session and
they might in
turn tell others
(M2) have to
trust partner
before getting
married
(M2) see
MHSS
(M2) if your
friends have
disease/illness
Helpful for us
as well as
community
Learnt about
liver disease
and how it is
transmitted
How to have
safe sex to
protect
yourself and
loved ones
Hep B a scary
disease
Saw female
condom –
something
never seen
before
Hep B is a
dangerous
disease
Can be
contracted in
many ways
There is stigma
associated
with having it
It’s
manageable
Awareness
about
different STIs
Session
educative and
informative
Gives young
people
opportunity to
come together
No comments No comments
Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 33
Peer facilitator groups
Group 1 Group 2 Group 3 Group 4 Group 5 Group 6 Group 7 Group 8
tell them they
can trust you
and can guide
them to who
can help them
the most
Page 56
If someone in
your family
was in the
situation do
you feel you
could help
them?
Encourage
them to seek
help
Tell them to be
careful about
what they eat
There are
options to
tackle issue
Be
positive/optim
istic/cheerful
Educate them
about AIDS &
Hep B
Support them
Encourage
them to get
help and to
protect others
Visit them
(M2)
emotional
support
(M2) go to GP
(M2) don’t
gossip
(M2) reassure
them
(M2) tell them
there is help
available
Advise them to
see GP
regularly
Comfort them
and show
them they are
not excluded
Ask to come to
community
events
Go out socially
with them
It’s
manageable
Ask the person
to see a GP
Advise
him/her to
practice safe
sex so don’t
spread disease
Keep
encouraging
them
Spend time
with them
Seek out
information
for them that
could help
Refer to
counsellor/MH
SS worker
No comments No comments
Session 4
Lara and Bob’s story (STI message)
Page 63
“Options”
Get medical
check and test
blood
Encourage
Support
(M2) choose a
GP you are
comfortable
Before go to
GP look up
information on
See a GP
See a
Seek medical
advice, get
treatment
No comments Go and speak
with GP
Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 34
Peer facilitator groups
Group 1 Group 2 Group 3 Group 4 Group 5 Group 6 Group 7 Group 8
See
GP/specialist
See Cheidza or
MHSS worker
Go to
community
health centre
Get sexual
health check
Find someone
in community
who can help
Visit GP often
Get tested
talking to
(M2) get
treated often
(M2) if cannot
speak English
can ask for an
interpreter
(M2) tell
family and
friends can
trust
(M2) look for
information
online
the internet
Advise to go to
GP and get
treated
Do not gossip
about them,
do not leave
them alone
Make sure
included in
family/commu
nity social
events
relationship
counsellor
Family
violence and
divorce
Seek
counselling
Talk with a
trusted friend
Speak with a
community
health worker
(MHSS)
Encourage one
another
Session 4 group evaluation
Page 66
Would you be
happy to tell
your friend
about the
session?
How to use
condom
Where to get
medical help
Get medical
check
A good
session, now
know more
about how to
prevent
pregnancy and
disease by
using condoms
We are happy
to tell
friends/family
(M2) know
how to protect
yourself from
STis
(M2) get
tested for STIs
(M2) know
where to seek
help
(M2) personal
Learnt about
growths and
how spread
That
husband/wife
must be open
minded
Use condoms
If friends say
they have
Encourage
them to look
after
themselves
To have safe
sex
Get educated
Session helped
us to learn
about growths
that can be
sexually
transmitted
Session
informative
and educative
Learnt about
protection and
No comments No comments
Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 35
Peer facilitator groups
Group 1 Group 2 Group 3 Group 4 Group 5 Group 6 Group 7 Group 8
about session hygiene
(M2) clean
yourself after
sex
(M2) both get
STI test before
marry
(M2)use
condoms
correctly
(m2) if you
think/know
you have STI
get tested and
treated
immediately
(M2) not all
STIs have
symptoms, if
you are
sexually active
make sure you
get tested
these would
recommend
going to the
GP
It was
worthwhile
coming to this
sessions had
never heard
about these
kinds of things
before
safe sex
Page 67
If someone in
your family
Seek
counselling
from
professionals
Know we know
where to get
help we can
encourage
(M2)
encourage the
person to see
a GP, get
No comments Seek medical
advice
See a
Advise them to
see a GP
Find
No comments No comments
Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 36
Peer facilitator groups
Group 1 Group 2 Group 3 Group 4 Group 5 Group 6 Group 7 Group 8
was in the
situation do
you feel you
could help
them?
Go and get
medical help
Encourage and
comfort them
See
GP/specialist
Give
information
about STI
them to see a
GP and
support
services (e.g.
MHSS, GP etc)
tested and
treated
(M2) be
supportive
(M2) use
condoms
(M2) tell tehm
about helath
facts
(M2) there is
an advantage
to seeing a GP
(M2) family
needs to be
trusted
counsellor
See a MHSS
worker
Get treated
See GP, take
antibiotics
information
that can help
them
Support them
Refer them to
MHSS or
sexual health
services
Final comments (manual)
Page 68 No comments Limit number
Cancer
Hepatitis
Heart attack
Leukaemia
Discharge
(M2) Hepatitis
B and other
Hepatitis’s
(M2) STI
(M2)
education
No comments No comments No comment No comments No comments
Final Electronic only Hardcopy and Hardcopy and Electronic only Electronic only None available Electronic only None available
Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 37
Peer facilitator groups
Group 1 Group 2 Group 3 Group 4 Group 5 Group 6 Group 7 Group 8
evaluation
questionnaire
(celebration
session)
electronic
copy
electronic
copy
Other
comments
Reports all
done
electronically,
notes for all
activities.
There were
two manuals
returned to
MHSS (M1 and
M2)
First session
notes typed
out
(18/08/12),
rest are from
manual
There is a
group
evaluation
page which is
probably the
final
evaluation in
electronic PF
notes

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Peer education Evaluation_BurnetInstitute April 2014

  • 1. Multicultural Health and Support Service Peer Education Project Evaluation B u r n e t I n s t i t u t e C e n t r e f o r P o p u l a t i o n H e a l t h Carol El-Hayek, Jane Howard, Hilary Veale
  • 2. Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 1 Contents Abbreviations..........................................................................................................................................2 Acknowledgements.................................................................................................................................2 Preface ....................................................................................................................................................3 The Peer Education Project.................................................................................................................3 Peer Education Project Aims...........................................................................................................4 Description of the Peer Education project......................................................................................4 Executive Summary.................................................................................................................................6 Background to evaluation.......................................................................................................................8 Objectives ...........................................................................................................................................8 Methods..............................................................................................................................................8 Results.....................................................................................................................................................9 Education and Training ...................................................................................................................9 Reach of MHSS..............................................................................................................................12 Sustainability.................................................................................................................................13 Emerging themes..................................................................................................................................14 Community benefit.......................................................................................................................14 Community engagement ..............................................................................................................14 Community ownership..................................................................................................................14 Specialised skills............................................................................................................................15 Discussion..............................................................................................................................................15 Peer Education project objectives ................................................................................................15 Strengths and enablers .................................................................................................................16 Project challenges.........................................................................................................................17 Recommendations............................................................................................................................17 Limitations of this evaluation ...........................................................................................................18 References ............................................................................................................................................19 Appendix 1. Participant Selection and recruitment..............................................................................20 Appendix 2. Example of flyer advertising PE opportunity ....................................................................21 Appendix 3. MHSS brochure (English). .................................................................................................22 Appendix 4. Summary table for the eight peer education groups. ......................................................24
  • 3. Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 2 Abbreviations BBV Blood borne viruses CALD Culturally and linguistically diverse CEH Centre for Culture, Ethnicity and Health CERSH Centre for Excellence in Rural Sexual Health HIV Human Immunodeficiency Virus MHSS Multicultural Health and Support Service NRCH North Richmond Community Health PE Peer educator SRH Sexual and reproductive health STI Sexually transmissible infections VACCHO Victorian Aboriginal Community Controlled Health Organisation Acknowledgements The Surveillance and Evaluation team from the Burnet Institute would like to acknowledge the work undertaken by the Multicultural Health Service and Support program and the many organisations in the government, community, health and medical, academic and scientific sectors toward reducing the impact of HIV, viral hepatitis and STI in Victoria. Many people have contributed to this evaluation and report. We express our thanks to the many key informants and community members who gave their time and valuable insights to support the evaluation. We would like to extend a special thank you to Chiedza Malunga from MHSS, for her assistance in providing invaluable input and time while on maternity leave.
  • 4. Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 3 Preface It is acknowledged that culturally and linguistically diverse (CALD) communities are vulnerable with respect to stressors faced in their countries of origin and that these can impact negatively upon health outcomes [1, 2]. For example, a sensitive area for CALD communities is sexual health, with stigmatisation and invisibility complicating delivery of sexual health messages [3, 4]. In addition, there are perceptions of low personal relevance often as a result of the intense health screening received before entry to Australia for some CALD populations leading to a false sense of security regarding the risk to them from BBVs or STIs[3]. As a result CALD populations have been identified as a priority population in the Sixth National HIV Strategy 2010 – 2013 [5]. The Multicultural Health and Support Service (MHSS) is a state-wide health promotion service with a focus on blood-borne viruses (BBVs) and sexually transmissible infections (STIs) within migrant and refugee communities. It is a program operating from within the Centre for Culture, Ethnicity and Health (CEH), and is funded by the Victorian Government Department of Health. Beginning in 2011, MHSS designed and implemented Phase 1 of a Peer Education project to Victoria’s Karen and Liberian com munities. These migrant populations are among the top 20 fastest growing migrant populations in Australia [6]. Since the 2006 census Liberian born migrants have increased 75% Australia wide, with Victoria having the third largest population[7] and the Burmese migrant population has increased 191% in Victoria [8]. This project involved the delivery of a culturally appropriate and needs-based curriculum in a series of group sessions by trained volunteers from within the community. The Peer Education project consisted of two phases, to be delivered over two years, the first being piloted within the Karen and Liberian communities. The application of peer education to improve sexual health knowledge in migrant populations in Western countries has been shown to be effective in changing knowledge and behaviours [9]. Peer education can be defined as a way of communicating specific health information via a range of methodologies, e.g. advocacy, counselling, facilitated discussions, drama, distribution of materials, providing support [10]. It is often used to facilitate change at an individual level (changing knowledge, beliefs, behaviours or attitudes), group level (shifting cultural norms) and collective level (shifting the health motivations of CALD communities) [10, 11]. Peer education has gained in popularity for implementing health promotion interventions, such as those targeting sexual health knowledge, in many at-risk populations [9, 12-15]. The Peer Education Project MHSS designed the Peer Education project to address the language and cultural barriers experienced by migrant and refugee communities when accessing appropriate BBV/STI health services. The project was intended to address broader determinants of health affecting the ability of community members to navigate the healthcare system and access appropriate care. Previously, MHSS’s primary mode of delivering sexual and reproductive health (SRH) messages to CALD communities was via community workers delivering education sessions usually by invitation. The Peer Education approach represented a shift for MHSS in the way it traditionally worked in health promotion; moving away from using community workers to deliver sexual health messages, to utilising community members themselves as peer educators to deliver those messages. In consultation with a reference group, comprising experts in the area of peer education, MHSS devised an alternative model for delivery of SRH messages. Initial community consultations determined what issues were perceived as important by the target communities. This information was used to guide the development of the project’s educational content and how it was delivered. The basis of the model was the recruitment of volunteer peer
  • 5. Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 4 educators (PEs) from the target communities whom having completed their training would subsequently deliver four to six education sessions to members of their respective community. Peer Education Project Aims The Peer Education project had two broad aims: 1. To increase the educational capacity and reach of the MHSS program enabling closer and more effective engagement with priority CALD communities affected by or vulnerable to BBV/STI; and 2. To create a sustainable program of culturally authentic volunteer-based peer education through consultation and collaboration with priority CALD communities Description of the Peer Education project Volunteer peer educators (PEs) were recruited through a formal process, beginning with the positions being advertised in the Liberian and Karen communities (see Appendix 2 for an example). For the first phase, eight Liberian and nine Karen PEs were formally recruited through a written application and interview process. This method was chosen specifically to provide additional professional skills and experiences to the PEs. PEs were selected based on their experience and qualifications or endorsement by community members, as well as their language skills, commitment and enthusiasm for the project. The majority of the PEs selected were already actively volunteering within their communities and this project enabled them to develop their skill base and have these formally recognised. The project was overseen by a dedicated project officer with extensive CALD experience who was employed full time at MHSS. The project officer role was supported by an external reference committee, other experienced community workers (MHSS staff) and community worker student interns. The role of the project officer included delivery of training to PEs and providing additional support while they prepared and conducted their Peer Education sessions. The recruited PEs committed to a six month period that involved intensive training delivered by the project officer. The training for the Karen and Liberian communities was conducted separately, with Karen PEs receiving their training over five evenings and the Liberians over two half-days for a 2-4 week period. During the training period, PEs acted as community consultants with respect to the development of culturally appropriate and needs-based curricula. Continued consultation with PEs culminated in the peer education manual which utilised interactive teaching strategies, for example verbal, visual and hands-on activities and was used to deliver six peer education sessions to community members. Once trained, the PEs were subsequently required to deliver four to six education sessions to community members. The project officer was available to PEs if needed. Once each session had been delivered the project officer conducted formal follow-up telephone calls with all the PEs. Based on a risk assessment conducted during project development, attendance numbers for each Peer Education session was capped at 10 participants per two PEs. The one exception was a Geelong Karen group, which had three PEs for 10 participants. There were four Karen groups and four Liberian groups with PEs deciding how and where to deliver their community sessions, based on what they felt were appropriate for their group profile and dynamic, and for logistical reasons. Sessions were conducted in a range of community settings following an outreach model of service and education delivery, e.g. homes or community halls, and the order of the material covered was based on the identified group needs. For the purpose of maintaining the health and wellbeing of everyone involved, reducing barriers for attendance, addressing cultural expectations and promoting a level of safety and trust for community participants, catering and childcare were provided on site by MHSS for each Peer
  • 6. Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 5 Education session. The project officer was responsible for organising catering and childcare for every session with MHSS providing the funds. Participant feedback regarding content and relevance was to be collected orally at the conclusion of each session, with PEs recording responses. An evaluation of the education sessions overall was conducted orally at the final session with one PE asking a number of questions of the community participants and the second PE taking handwritten notes of responses.
  • 7. Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 6 Executive Summary Beginning in 2011, the Multicultural Health and Support Service (MHSS) designed and implemented the first phase of a new sexual health promotion initiative to Victoria’s Karen and Liberian communities. The Peer Education project involved the delivery of a culturally appropriate and needs- based curriculum in a series of group sessions by volunteers from within the community. The Peer Education project had two aims: 1. To increase the educational capacity and reach of the MHSS program enabling closer and more effective engagement with priority CALD communities affected by or vulnerable to BBV/STI; and 2. To create a sustainable program of culturally authentic volunteer-based peer education through consultation and collaboration with priority CALD communities. Evaluation objectives The purpose of this evaluation was to assess the extent to which the MHSS Peer Education project met its aims during Phase 1 and provide recommendations for future iterations. The specific objectives of this evaluation were to: 1. Analyse the education and training provided through the Peer Education project 2. Describe the reach of MHSS through the Peer Education project 3. Discuss the sustainability of the Peer Education project 4. Provide recommendations Methods An advisory group was established for the evaluation in order to identify key informants, provide project documentation, and advise on methods of recruitment and conduct with community members. The evaluation involved document reviews, key informant interviews, and focus group feedback. A thematic analysis was conducted to identify emerging themes on which recommendations were based. Evaluation methodology was approved by The Alfred Research and Ethics Unit. Findings An indicator of the success of the Peer Education project was that Peer Educators (PEs) unanimously stated the training and support they received enabled them to confidently deliver BBV/STI education sessions to members of their communities, and that they gained both personally and professionally from the experience. Community feedback was that the information they received from attending the sessions was relevant at both an individual and community level. Attendance and session evaluation data collected by PEs was incomplete. Both these findings are indicative of the project’s strengths in addressing both the normative and felt needs of the Karen and Liberian communities. The reach of the project was evidenced by: 1) The attendance of 85 individuals (full capacity) from the targeted communities at the education sessions in a period of less than six months, and 2) the demonstrated potential and enthusiasm for the trained PEs to further integrate the project into their communities. Through the PEs, MHSS have established a connection and presence within both communities. In addition, other organisations have utilised MHSS’s connections with the Karen and Liberian communities for further interventions. It is too early at this point in the project life cycle to measure the sustainability of the project however several program strengths potentially contributing towards sustainability were demonstrated. These included the effective partnerships between MHSS allowing for the through which MHSS was able to provided organisational support to the target communities as well as the achievement of community interest and engagement. Through this partnership MHSS for the delivery of peer education sessions by trained PEs. Sustainability could be strengthened through continued engagement or employment of PEs and exploring sector partnerships.
  • 8. Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 7 Recommendations To build on the strengths of the current program, and to ensure sustainability, it is recommended that MHSS consider the following: 1. Develop a program that will provide effective support and supervisory structures for a formal partnership with the trained volunteer PEs. 2. Continue to extend the capacity of PEs by introducing additional skills training where appropriate and integrating professional development opportunities into the PE model. 3. Explore ways to integrate or link the delivery of peer education sessions with existing local social and clinical services and explore long term partnership opportunities. 4. Methodology and tools for project data collection should be improved and planned ahead of each phase of the project. 5. Develop strategies to integrate data and feedback into an ongoing improvement process within the organisation.
  • 9. Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 8 Background to evaluation The Burnet Institute was contracted by MHSS to conduct an independent evaluation of Phase 1 of the Peer Education project. Community focus groups and planning for Phase 2 of this project has begun within the Ethiopian and Chin communities. Objectives The purpose of this evaluation was to assess the extent to which the MHSS Peer Education project met its aims during Phase 1 and provide recommendations for future iterations. The specific objectives of this evaluation were to: 1. Analyse the education and training provided through the Peer Education project 2. Describe the reach of MHSS through the Peer Education project 3. Discuss the sustainability of the Peer Education project 4. Provide recommendations Methods An advisory group was established for the evaluation in order to identify key informants, provide peer educator (PE) contact details and project documentation, and advise on methods of recruitment and conduct with community members. The evaluation was approved by The Alfred Research and Ethics Unit and involved the following methods: 1. Document review Review of project documentation included existing internal evaluation documents; records of participation; minutes of meetings; educational and training materials used by the PEs; project reports; PE recruitment documents (position description and acceptance/rejection letters); and, staff self-reflective documents. De-identified demographic data from attendance records of education sessions and final session evaluation notes taken by PEs were also examined. 2. Key informant interviews Face-to-face and telephone interviews were conducted with PEs and key project informants including MHSS staff members, and a member of the original advisory group for the Peer Education project. Extensive notes were taken during interviews as well as audio recordings. Following the conclusion of each interview, PEs received a $50 gift voucher as reimbursement for their time and any expenses related to being interviewed. 3. Focus group session A focus group session was conducted for five Karen community participants. Participants were recruited by a PE; they received an information sheet prior to commencing and gave verbal consent to participate. At the conclusion of the focus group session, each participant received a $20 cash reimbursement for attending. One of the focus group participants acted as interpreter for the rest of the group. The focus group informed evaluation objectives 1 and 2. No focus group session was held for Liberian community participants. 4. Thematic analysis Qualitative data were analysed to identify key themes and their relationship to the project objectives. This analysis also informed the recommendations. Data collection from informants ceased when no new themes emerged. For further detail on participant selection and recruitment refer to Appendix 1. A draft of the final report was presented to MHSS for review and comment with a face-to-face presentation of project findings.
  • 10. Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 9 Results This section describes the data collected in the key informant interviews and focus group session with community participants. Questions focused mainly on the project model; the PE’s experience of the training and education received and delivered; perceived relevance of session structure and content by PEs and community participants; what PEs and community participants learnt; benefits gained (for both PEs and community participants) and areas for improvement. In addition, feedback notes recorded by the PEs during and after the education sessions were examined, even though incomplete. The project officer reported that there was difficulty achieving full compliance by PEs in returning required evaluation documents which included attendance records, dates sessions held, complete session notes and a final verbal evaluation. Education and Training The peer education model was designed to be a structural intervention addressing the contextual causes (language, culture, knowledge, confidence) that create barriers to accessing appropriate health care by affected communities. This was achieved via the delivery of interactive group sessions facilitated by volunteer PEs. The education sessions were designed to be accessible across all ranges of educational backgrounds; easy to understand and engage with. As such, the content and structure of the peer education sessions followed a low literacy format utilising narrative storytelling in a culturally appropriate and sensitive manner. The model was dependent on building the capacity and knowledge of the volunteer PEs to enable them to reduce BBV/STI vulnerability at an individual level. Following intensive training and curriculum development the volunteer PEs were responsible for organising and running four to six two-hour peer education sessions for their community members in their preferred language and setting. Peer educator experience Of the 17 PEs recruited, eight were interviewed for this evaluation and were asked specifically about the training, preparation, tools and support they received in order to deliver their peer education sessions. All eight, four from each community, stated that they felt confident delivering the education sessions and the training and support they received from the project officer was without fault. Part of the ongoing support they received was having telephone access to the project officer before, during and after their sessions. “Yes, it gave me the skills, although I knew like, about them, I didn’t know how to go into the community and talk about, you know, things like that because those things are sensitive to people ... it becomes sensitive, …especially for our African background ... So we learn the skills to speak to people in our African community how to approach them about these things that we consider to be sensitive.” “every area for me was correct, yeah, we learnt everything that we needed to know...every area was talked about, there was no hiccups where we thought, ah, I don’t have much understanding, how do I answer this question...it was all great” Based on the risk assessment done by MHSS prior to the project commencing, PEs worked in pairs when delivering the community education sessions. PEs were comfortable facilitating discussions around BBV/STI and did not perceive any gaps in their preparation. “I was happy with the training ... I’m not good at speaking but I did my best, the training was very good” “Yes, definitely ... I became pretty much an educator about how to pass on communication, how to pass on information about different needs to a group of people”
  • 11. Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 10 All of the PEs interviewed responded positively when asked whether they felt that being a part of this project and a PE benefited them. The training received and experience gained during the development and delivery of sessions throughout the project had many benefits for them professionally. In addition, they expressed feeling more confident when talking about SRH issues with people in their community because they had learned the necessary techniques. “Well the training you know…the training I received was very much an eye opener especially about how to work in groups, how to conduct a meeting ... different ways of communicating, passing on information to a group of people” “… it was about getting people to comprehend an idea through different means, different activities ... valuable information to them” Many stated that their own knowledge of BBV/STIs had improved following the training and reported that their training helped them personally to understand SRH issues better. All PEs felt very strongly about contributing to their communities and sharing the knowledge they had learnt through their training. “I feel like good ... like to do something for my community, to contribute to the community ... it has also helped me to learn and to understand more ... each one, each individual problem ... most of us in similar situation” “The training was most helpful to me, my community my friends ... in my culture we don’t like to talk about sex ... this is the first time we talk about sex” In addition to the training and experience gained, the PEs were given professional development and support in other ways. MHSS contributed towards a personal long term goal rather than cash payments, for example a laptop or driving lessons in appreciation for their commitment to delivering the peer education sessions. The PEs also received feedback and assistance with generating professional resumes that formally acknowledged their teaching and group facilitation skills as trained peer educators. When asked about areas for improvement for future training, PEs made two suggestions: 1) inclusion of more audio-visual content during training that could accommodate different learning styles; and 2) the addition of doctor-patient scenarios to the manual used for the education sessions. None of the interviewed PEs felt that there were any deficiencies in their training in relation to feeling equipped to facilitate peer education sessions. Community experience Overall attendance by community participants across the six sessions was reported by PEs to be consistent; any absence was not attributed to lack of interest but rather illness or work and family commitments. The session dates and attendance records were incomplete therefore it was not possible to verify consistency of attendance by all participants in each group; however feedback from the Karen focus group and the project officer did support the PEs statements. To create a more culturally appropriate and safe environment, catering and childcare were provided at all sessions. PEs also accommodated their participants by holding sessions at different days and times. Evidence of the appreciation for the session settings was found in the notes taken by PEs during the evaluation when they asked community participants what they liked about the sessions: “The food” “Childcare helped us concentrate” “The kids were well looked after and kept quire [sic] and away for the session” Based on PE input and community consultation, the sessions did not solely deliver sexual health messages; they were embedded within stories dealing with other pertinent issues such as family troubles and unemployment. Community participants unanimously voiced that the content of the sessions and how they were delivered was relevant to them. As found in our examination of final
  • 12. Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 11 session evaluation notes, the use of narrative story telling approaches delivered by the PEs in contextually relevant ways resonated with participants. “I found the activities fun and educative.” “[We] know more about diseases; know… more about how to protect ourselves.” “The topic were meaningful and useful” Many community participants reported increased knowledge around accessing health services. They indicated that the information was useful and relevant to them, especially regarding knowing where to go, and what to do. The interpreter for the focus group stated on behalf of one Karen woman when asked what she learned: “She remembers about [if] ever get HIV or something like that kind of disease, where to go, how to get help” There were many expressions of increased confidence regarding helping family and friends with medical issues and many references from community participants expressing a desire to share the material they had learned with others. Through an interpreter, examples of responses from the Karen focus group when asked about the benefits of having attended the sessions were: “…so that we can help each other” “We want to know all about health…or some other information within our communities and so that if we knew more about that we can help others” “Especially…. about the kid[s], the youth, [if] they have problem[s], how can we fix and how can we help them?” One PE interviewed gave an example of a married couple attending the education sessions who learned that it was okay to use condoms within a marriage. Other evidence of community participants retaining the information delivered in the sessions were found in the evaluation session notes recorded by PEs: “We learn about health and about family and other kids and youth and drugs and sexual things, use condoms and about how to apply job and how to write resume, yeah it was helpful” “More in depth understanding about the different types of health issues, how to protect ourselves, how to get treated, and where to seek help and support” Resources were provided for the community participants at the education sessions where BBV/STI issues were discussed including an MHSS brochure (Appendix 3), condoms and lubricant. There was no record of whether these were taken by the community participants; however there were some comments recorded by PEs for the final session evaluation documents that more resource material to take home would be valued. Another consideration when interpreting the evaluation session data regarding the community’s experience is the incomplete nature of participant responses recorded by PEs. When asked about areas for improvement for the education sessions during the final session evaluation, community participant feedback (as recorded by PEs) included: 1) more sessions so that those who could not attend some sessions did not miss out; 2) more handouts to take away at the end of sessions; and 3) to include some audio-visual material. Two additional comments made at the Karen community focus group regarding session content were: 1) information about how they can assist family still in Burma to migrate to Australia; and 2) to cover more issues affecting their youth (sex, drugs, and alcohol).
  • 13. Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 12 Summary The training received by PEs enabled them to successfully deliver peer education sessions to community participants PEs received professional development and valuable content knowledge from their training Community participants perceived the session content and delivery to be relevant and engaging Community participants believed sessions improved their confidence and knowledge regarding accessing appropriate health care when needed Attendance and session evaluation data were incomplete Reach of MHSS It was not possible to quantify the full extent of MHSS’s reach within the scope of this evaluation, however, the information obtained from session evaluation documents, the focus group and interviews with key informants provided the following evidence for community reach. Direct reach Phase 1 of the Peer education project was successfully conducted with sessions for eight groups (four Karen and four Liberian) reaching 85 community members in total. As peer education sessions were delivered by at least two PEs with session attendance capped at ten participants per group, the project reached its maximum attendance. The Liberian peer education sessions were mixed gender and the participants ranged in age from 17–36 years. The Karen peer education sessions also consisted of mixed gender but included a dedicated youth group (18–22 years) alongside other groups of older participants (24–45 years). Years in Australia for participants ranged from one to seven. Although only confirmed through interviews with PEs, attendance was consistent across all sessions for all groups. All groups had more women attending than men with the exception of one. Refer to Appendix 4 for a summary table of available information summarised for each of the eight peer education groups. As planned, the peer education sessions were held in locations where the Liberian and Karen migrant communities have been settled. The Liberian groups held their sessions in Sunshine, Thomastown, St Albans and Truganina (rural-urban fringe). The Karen groups were held in Werribee, Geelong and Hoppers Crossing. This is likely to have enabled participation by the targeted community members. In addition, the trained PEs are a valuable resource for MHSS. They learned to deliver accurate and culturally sensitive information on sexual health and gained skills in teaching and group facilitation. MHSS now has connections with the PEs from the Karen and Liberian communities which are communities they had previously had little or no contact with. Indirect reach Through the Peer Education project, MHSS’s presence has also improved more broadly within these communities. This evaluation saw a number of examples of MHSS being used as a resource and support for community members. These include a request for an information session delivered to the Karen community on SRH; a Karen worker who moved to regional Victoria - where there is a large Karen community - requested a box of condoms to distribute; one Karen PE has attended further sexual health education sessions held by MHSS; and a Liberian PE has contacted MHSS asking for more sessions to be given in her community. Since Phase 1 of the Peer Education project a number of other organisations have used MHSS as a connection between these organisations and the communities. For example, Cancer Council Victoria
  • 14. Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 13 asked MHSS to assist them in promoting a pap screening intervention to the Karen community in Geelong and Werribee. Another example was the development of a sexual health teaching video jointly with Deakin University, the Centre for Excellence in Rural Sexual Health (CERSH) and the Victorian Aboriginal Community Controlled Health Organisation (VACCHO). An underlying principle of the Peer Education project was that through the community led education sessions more people in the Karen and Liberian communities would “know someone who knows”. Aside from the examples above of community awareness for MHSS, a demonstration of community reach is one married couple, who are both trained PEs, reporting that they have continued to engage with their community by delivering sessions on prevention of violence against women. Summary Maximum attendance was achieved with 85 community members participating in the education sessions delivered locally to them Through the PEs, MHSS has established a connection and presence within both communities Other organisations have utilised MHSS’s connections with the Karen and Liberian communities for other health promotion interventions There is evidence of PEs continuing to educate the communities with the support of MHSS Sustainability The presence of the trained PEs provides an ongoing link between MHSS and the community (a visible presence), the PEs are able to advocate on behalf of MHSS as well as providing a resource for community members and ultimately community ownership through consultation and representation. For example, interviewed project key stakeholders mentioned that the employment of two of the Liberian PEs by MHSS has strengthened MHSS’s relationship with that community. Strong relationships with the community via PEs who are evidently still positively engaged with the service is important in achieving a sustainable volunteer-based peer education program. Another example of the formation of relationships as a result of the project is the presence of skilled PEs in each of these communities; they are a valuable resource that did not exist prior to this project. These PEs can act as an important link between their community and healthcare and social support services. In addition they have the potential to continue to engage with their fellow community members in talking about health and education as has already been demonstrated. Other aspects of sustainability are partnerships with local health services. Leveraging off the unforseen relationships that were established through the initial phase of the project will be of benefit to maintaining community presence and improving the health of community members. Summary It is too early at this point in the project life cycle to gauge the sustainability of the project however the project fulfils several factors that will potentially contribute to sustainability: Demonstrated effective relationships and partnerships between MHSS and the PEs and their respective communities Supportive context for practice where MHSS was able to provide organisational support to these communities for the delivery of peer education sessions by trained PEs; and Partnerships with other local health organisations delivering health promotion in CALD communities PEs remain positively engaged with education of their community, providing opportunity for MHSS
  • 15. Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 14 Emerging themes Community benefit It is clear from the data collected that both PEs and community participants have a high degree of satisfaction with what they have learned, and that they wish for the sessions to be continued. There is obvious enthusiasm for giving back to the community and sharing knowledge. PEs and community participants have benefited from their involvement in the project, whether through training and professional development or through attending peer education sessions as a community member. They have expressed more confidence in their health literacy in relation to knowing how and where to seek help and how to communicate around BBV/STI issues and sensitive health topics. Community engagement A key feature of this project was community engagement. MHSS held initial consultation sessions with community representatives during the development of the project. This enabled them to form initial relationships with community members, and to raise awareness of their organisation and planned Peer Education project. Importantly, it also presented the opportunity for community members to express their priorities and contribute to the design and content of the peer education project. This contribution then carried on to the recruited PEs who developed the content and delivery methods of the education sessions. Once PEs delivered their education sessions there was no formal expectation of continued involvement with the project or with MHSS. Interviewed MHSS staff indicated that it was always intended that the PEs would deliver a defined number of sessions to their communities, and that the decision for ongoing involvement would be left to the individual PEs. There was some evidence from the interviewed PEs that a few had remained involved with MHSS with the majority indicating that they had not. When asked whether PEs felt as though they had a current connection with MHSS, most replied that they did not. MHSS made efforts to maintain contact with PEs through semi-regular emails and telephone calls, however there was perceived disconnect between the felt experience of PEs and the effort by MHSS to try to maintain a connection. Some of this may be partly due to recall by interviewed PEs when asked to describe MHSS efforts, delays caused by staff turnover or difficulty replacing the project officer, PE contact details may have changed and other PE work/life commitments. Community ownership Interviews with MHSS staff and a review of project documentation indicated that community ownership was a key feature envisaged for this project. To date, community ownership has taken the form of: direct consultation with community members and community representation from PEs during project development and delivery; PE involvement with the development of the session content; PEs’ autonomy regarding how, when and where they delivered their sessions; and the ongoing presence of the trained PEs within their communities. Beyond the completion of the sessions however, the way in which the community would maintain ownership was not formally articulated. For example, the PE position description does not describe how a continued relationship with MHSS would be maintained nor does it clearly define any ongoing involvement of the PE (i.e. what would be expected of the PE and what MHSS’s role would be). However, despite this there were clear demonstrations of community ownership with some PEs taking the initiative to continue to engage with MHSS as well as their own communities through the delivery of further education sessions while supported by MHSS.
  • 16. Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 15 Specialised skills The role of project officer was a 1.0 EFT high-level position with many responsibilities which included being key contact person and trainer for all the PEs throughout their training, session delivery and beyond. The project officer for Phase 1 of the Peer Education project had the capacity to meet all the responsibilities required of this role and was well-liked by the PEs, and delivered exemplary support throughout. Support for this role came from internal (student interns, senior project officer, senior community worker and MHSS Manager) and external sources (the project reference group). With this support the project officer reported feeling able to provide the level of assistance and monitoring of PEs required for implementing the project. When the project officer role became vacant, the responsibility for ongoing contact with PEs passed onto other MHSS staff and the ability of MHSS to maintain an active continued connection with PEs was impacted. Finding suitable candidates with the requisite experience and knowledge of working with CALD communities and implementing community-based interventions is a challenge for small organisations. Migrant workers, who are best placed to deliver community education, have complex personal issues themselves which come from resettlement and cultural expectations. Employing a suitable worker requires intensive provision by MHSS of appropriate support, mentoring, up-skilling and opportunity. Discussion MHSS has successfully delivered BBV/STI education to two refugee and migrant communities using a peer education approach. Indicators for the success of this project were that all of the PEs interviewed reported that their training was excellent, as was the support provided to them. PEs felt they had gained invaluable work experience through being involved with this project and facilitating peer education sessions. The education sessions reached maximum capacity with 85 community members participating. The feedback from community participants was predominantly positive and value was given to the education they received and how it was delivered. MHSS as the lead organisation initiated a coalition between themselves as professionals and community members as peer educators. In doing this the organisation has contributed to sustainability of community health promotion projects. In addition, MHSS has demonstrated stability through its program being established within CEH; credibility through their work with CALD communities in Victoria; and as an ongoing Department of Health funded program they have access to resources. These have been documented as the three key features necessary to maintain presence and increase sustainability in health promotion [16]. Peer Education project objectives This Peer Education project aimed to strengthen participating communities’ capacity to address their health and social support needs through disseminating information and promoting the availability of MHSS as a resource and support service. The commitment of PEs to deliver the education sessions and the consistent attendance by community participants over the course of sessions suggests that the project related to the individual needs in culturally appropriate ways. Another of the main objectives of the Peer Education project was to increase the reach of MHSS enabling closer and more effective engagement with priority CALD communities affected by or vulnerable to BBV/STI. Evidence that MHSS increased its educational capacity and reach was demonstrated not only by the delivery of the education sessions to 85 community members across both Liberian and Karen communities including 18 trained PEs who know more about SRH issues and are now trained group facilitators.
  • 17. Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 16 These outcomes indicate increasing educational capacity and reach of MHSS into these communities. The third main objective for the project was to create a sustainable program of culturally authentic volunteer-based peer education through consultation and collaboration with priority CALD communities. There are several factors that contribute to sustainable health promotion programs and long term community engagement is key. The recognition by MHSS that community members are the ‘experts’ of their lives by engaging community in the Peer Education project from conception has contributed to this. There have also been many positive and unforseen outcomes of the Peer Education project which will assist in reaching the objective of sustainability for the program. MHSS has incidentally developed relationships and partnerships with community members and other organisations; they have employed two Liberian PEs as health educators retaining their credibility as PEs within the community[18]; and they have target populations willing to be engaged as well as PEs who are still positively involved. MHSS has a strong emphasis on building community and individual capacity of CALD individuals and their ability to provide organisational support (PE training, provision of peer educators manual) also contributes towards sustainability [17]. While there is evidence of many factors that will contribute to program sustainability, there is a lack of clear articulation by MHSS for how sustainability will be reached. For example, what form will community ownership take, how will ongoing connections with trained PEs be maintained. A clear definition needs to exist with planned actions and measured outcomes. Strengths and enablers One of the strengths of this project was MHSS’s ability to be flexible in how they developed the curricula for the community education sessions to ensure that they addressed the normative as well as the felt needs of the Karen and Liberian communities. This meant that the education sessions did not just deliver BBV/STI education material but addressed other pertinent issues such as family dysfunction and unemployment. Approaching the Peer Education project this way ensured that content was relevant to the communities, and likely contributed to the engagement of the participants. Another strength of the project was the recruitment of PEs who were already active within their communities which is an acknowledged factor contributing towards successful peer education programs [18, 19]. In addition, the project’s success was facilitated by the dedication and commitment of PEs, the enthusiasm and commitment of the project officer and the higher level organisation support given by MHSS. This also suggests that the training received by PEs enabled them to successfully facilitate these sessions. Additional enablers for the success of this project were the consultative curriculum development process used by MHSS in developing and implementing the Peer Education project and employing a dedicated project officer. PEs contributed towards the development of the curricula for the peer education sessions so that it was culturally and contextually relevant. The PEs benefitted professionally through formal recognition of the training they received. The project officer had several support structures available, which ensured that the role could deliver on project commitments and additionally, provide support for PEs while they delivered their education sessions (e.g. the project officer was contactable before, during and after each education session held). The dedicated role of the project officer was a practical necessity that brought an intimate knowledge of the project and strong relationships with PEs and community members.
  • 18. Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 17 Project challenges A central challenge to project sustainability is the resource intensive nature of peer education programs. They require: a dedicated project officer; provision of high-quality training for the PEs; support for PEs; resource development (i.e. development of curricula for different populations); project monitoring takes time, effort and funding; and, compensation for the time and energy PEs put into delivering their education sessions. As such these project are reliant upon funding for continued operation [19, 20]. It is also a challenge for small agencies to recruit experienced high level workers with sound CALD practice and experience and to build capacity of CALD workers. MHSS was successful in attracting committed and competent volunteers to be trained as PEs and retaining them is beneficial in terms of maximising resources and leveraging off existing knowledge and experience. With any peer education project retention of trained PEs is an issue, particularly as this role is often a transitional one[18]. Additionally new migrants continually arrive which also impacts on the project and MHSS’s ongoing presence within these communities. To ensure the potential for ongoing community ownership and longevity a formalised partnership between the PEs and MHSS is necessary. Common to many peer education programs this project has experienced difficulties in collecting data for evaluation [13, 19, 21]. The PEs had varying levels of literacy and time to dedicate to documenting the sessions, possibly affecting their motivation to complete reports. There was also no documentation of material taken by community members (e.g. number of condoms, MHSS brochures) at end of session which could have given us some idea of the relevance to participants or their interest in these. Recommendations MHSS should capitalise on the training, engagement and enthusiasm of PEs, especially given the resources expended in recruitment, training and support. There was no formal governance or planned structure for how the relationship between MHSS and the trained PEs would continue after the PEs had delivered their expected number of sessions, however some have gone on to paid employment with MHSS or continue volunteer peer education within their communities. For the purpose of sustainability without the cost of re-establishing the Peer Education project within these growing communities, a formal, structured and supported program that extends beyond the training and delivery of education sessions is essential. Recommendation 1: Develop a program that will provide effective support and supervisory structures for a formal partnership with the trained volunteer PEs. There was a clear perception by MHSS that the training received by the PEs would give them formal qualifications that could be used as pathways to further education and/or employment. It is possible that by extending the skills of PEs to include project development, management or evaluation, for example, MHSS would continue to attract recruits to ensure ongoing reach of the program. Recommendation 2: Continue to extend the capacity of PEs by introducing additional skills training where appropriate, and integrating professional development opportunities into the PE model. Characteristics of successful peer education programs often include an integrated approach where the PEs and session delivery are linked with local clinical, counselling and youth services, addressing place-based disadvantage. The evidence suggests that peer education is most effective when these partnership structures are in place [13, 22]. The PEs themselves could become ambassadors or consultants on behalf of MHSS in in their continued peer education [22]. These partnerships will help
  • 19. Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 18 to raise local sector awareness of MHSS and increase BBV/STI related health knowledge among community members and potentially their access to health care. Recommendation 3: Explore ways to integrate or link the delivery of peer education sessions with existing local social and clinical services and explore long term partnership opportunities. In line with national BBV/STI control strategies, the Peer Education project is designed to improve knowledge among priority populations around potential risk and access to healthcare. It is important that relevant data are captured to measure the extent to which MHSS efforts address these strategies. Capturing feedback from participants and stakeholders is also important for ongoing improvement of the project itself. Throughout the Peer Education project there were missed opportunities for data collection and/or areas where data collection could be improved. Recommendation 4: Methodology and tools for project data collection should be improved and planned ahead of each phase of the project. Another advantage of data collection is the knowledge gained by MHSS that will allow an ongoing improvement process taking feedback into account and providing the basis for discussion and reflection. New findings and lessons learned can then be shared with all staff of CEH involved in health promotion or community engagement. Recommendation 5: Develop strategies to integrate data and feedback into an ongoing improvement process within the organisation. Limitations of this evaluation A number of limitations may have impacted on the ability to evaluate the education, reach and sustainability of this project. The scope of this evaluation and availability of collected project data was such that sustainability of the project was inferred. As it is still early in the project life-cycle its sustainability may become more evident over time. The first is the lack of complete records for sessions. However, this limitation must be taken in appropriate context. A verbal account is a common approach taken for peer education programs dealing with marginalised populations where listening to participants comments (solicited and unsolicited) is contextually and culturally appropriate [13]. Secondly, there was no way of directly measuring what community members attending sessions learnt and what knowledge or assistance they may have passed onto other community members. Thirdly, the commencement of this external evaluation was one year following PEs completing their peer education sessions. The passing of time has potentially introduced recall issues for PEs regarding their experiences[15]. Finally, there was no focus group from the Liberian community, which meant that only 5/85 community participants gave direct feedback for this evaluation. However the feedback sourced from the document review was very much in agreement with the output from the focus group discussion. It is important to stress that projects like this peer education one will not necessarily yield definitive outcomes (e.g. increased BBV/STI testing, or changes in numbers of people accessing health services) early in the project life cycle. Many of the benefits such as improved health literacy and access, and community engagement, although very important, are not easily quantifiable and are difficult to demonstrate. These contextual constraints do not lessen the credibility of the evaluation approach used for this report or conclusions reached [15].
  • 20. Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 19 References 1. Henderson, S. and E. Kendall, Culturally and linguistically diverse peoples’ knowledge of accessibility and utilisation of health services: exploring the need for improvement in health service delivery. Australian Journal of Primary Health, 2011. 17(2): p. 195-201. 2. Institute for Community, E.a.P.A., Review of Current Cultural and Linguistic Diversity and Cultural Competence Reporting Requirements, Minimum Standards and Benchmarks for Victoria Health Services Project: Literature Review, D.o. Health, Editor. 2009. 3. McNally, S. and S. Dutertre, Access to HIV prevention information among selected culturally and linguistically diverse (CALD) communities in Victoria. 2006, The Australian Research Centre in Sex, Health and Society, La Trobe University. 4. Hawke, E., Exploring sexual health issues of the culturally and linguistically diverse communities in Wollongong, Healthy Cities Illawarra Inc, Editor. 2005. 5. DoHA, Sixth National HIV Strategy 2010-2013, D.o.H.a. Ageing, Editor. 2010. 6. .idblog. Australia’s newest migrants – where are they coming from? 2011 1 Feburary 2014]; Available from: http://blog.id.com.au/2011/australian-demographic-trends/australia-newest-migrants/. 7. Department of Immigration and Citizenship (DIAC), Community Information Summary. Liberia-born. 2013, Commmunity Relations Section of DIAC,. 8. Office of Multicultural Affairs and Citizenship, Victorian community Profiles: 2011 census Burma (Republic of the union of Myanmar)-born, Victorian Multicultural Commission, Editor. 2013. 9. Drummond, P.D., et al., Using peer education to increase sexual health knowledge among West African refugees in Western Australia. Health Care Women Int, 2011. 32(3): p. 190-205. 10. Kerrigan, D., UNAIDS Best Practice Collection. Peer education and HIV/AIDS: Concepts, uses and challenges, S. UNAIDS Geneva, Editor. 1999. 11. Triandis, H.C. and M.J. Gelfand, Converging measurement of horizontal and vertical individualism and collectivism. Journal of personality and social psychology, 1998. 74(1): p. 118. 12. Backett-Milburn, K. and S. Wilson, Understanding peer education: insights from a process evaluation. Health Educ Res, 2000. 15(1): p. 85-96. 13. Jaworsky, D., et al., Evaluating Youth Sexual Health Peer Education Programs: Challenges and Suggestions for Effective Evaluation Practices. 2013. Vol. 1. 2013. 14. Mikhailovich, K. and K. Arabena, Evaluating an indigenous sexual health peer education project. Health Promot J Austr, 2005. 16(3): p. 189-93. 15. Newland, J. and C. Treloar, Peer education for people who inject drugs in New South Wales: Advantages, unanticipated benefits and challenges. Drugs: education, prevention and policy, 2013(0): p. 1-8. 16. Vermeer, A.J.M., et al., Factors influencing perceived sustainability of Dutch community health programs. Health Promotion International, 2013. 17. Harris, N. and M. Sandor, Defining sustainable practice in community-based health promotion: a Delphi study of practitioner perspectives. Health Promot J Austr, 2013. 24(1): p. 53-60. 18. Cupples, J.B., A.P. Zukoski, and T. Dierwechter, Reaching young men: lessons learned in the recruitment, training, and utilization of male peer sexual health educators. Health Promot Pract, 2010. 11(3 Suppl): p. 19S- 25S. 19. Lambert, S.M., et al., Effective peer education in HIV: defining factors that maximise success. Sexual Health, 2013. 10(4): p. 325-331. 20. Lobo, R., et al., Evaluating peer-based youth programs: Barriers and enablers. Evaluation Journal of Australasia, 2010. 10(2): p. 36. 21. Johnson, D.B., L.T. Smith, and B. Bruemmer, Small-grants programs: lessons from community-based approaches to changing nutrition environments. J Am Diet Assoc, 2007. 107(2): p. 301-5. 22. Walker, R., Literature review of sexual health and blood bourne virus education and peer influence programs and best proactice models, including a review of technology and media opportunities, Youth Affairs Council of Western Asutralia, Editor. 2010. 23. Medley, A., et al., Effectiveness of peer education interventions for HIV prevention in developing countries: a systematic review and meta-analysis. AIDS Educ Prev, 2009. 21(3): p. 181-206.
  • 21. Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 20 Appendix 1. Participant Selection and recruitment Stakeholder Stakeholder definition Sampling Number recruited Notes Reference group member External expert/s on peer education who had a relationship with the project (n=10) Reference group members were identified by MHSS staff 1 A face-to-face interview was held. Peer educator Volunteers recruited and trained by MHSS to undertake peer education activities (n=17) Peer educator contact details were provided by MHSS. Contact was made by telephone 8 (4 Karen and 4 Liberian) The phone lines/numbers for a few peer educators had become disconnected and they could not be contacted. Two peer educators were interviewed face-to-face. Access to PEs was also complicated by the passage of time that has elapsed since they delivered their peer education sessions (1 year) Staff Current MHSS staff directly involved with project (n=2) Staff asked to participate by the evaluator 2 One telephone and one face- to-face interview was held. Community participants People who attended the education sessions held by the peer educators (n=85, verbal confirmation by project officer) 4 peer educators (2 Karen and 2 Liberian) were asked to contact people who had attended their sessions and recruit them to the evaluation 5 (Karen) One Karen peer educator was successful in recruiting community participants for the evaluation (a group focus session was held for the 5 participants).
  • 22. Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 21 Appendix 2. Example of flyer advertising PE opportunity
  • 23. Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 22 Appendix 3. MHSS brochure (English).
  • 24. Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 23
  • 25. Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 24 Appendix 4. Summary table for the eight peer education groups. Peer facilitator groups Group 1 Group 2 Group 3 Group 4 Group 5 Group 6 Group 7 Group 8 Group demographics (Attendance) Women 6 - 8 8 - 3 - 7 Men 5 - 2 - - 8 - 2 Age range 24 - 45 - 18 – 22 30 - 40 - 18 – 22 - 17 - 36 Number of people attending who have children 3 - 0 - - 3 - - Number of years in Australia (range) 1 - 6 - 1 – 6 - - 2 ½ - 7 - - Number of attendees for each session (if given, range) 8 - 9 - - - - - - - Dates sessions held (if given) 26-08-12 02-09-12 09-09-12 16-09-12 - - 18/08/12 - - - 08/09/12 15/09/12
  • 26. Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 25 Peer facilitator groups Group 1 Group 2 Group 3 Group 4 Group 5 Group 6 Group 7 Group 8 Paul’s story (about to drop out of high school) Page 19 ‘’So what?’’ General comments about encouragemen t and options General comments about encouragemen t and who to contact General comments about encouragemen t and who to contact No comments General comments about encouragemen t and what can do General comments about encouragemen t and what can do General comments about encouragemen t and what can do General comments about encouragemen t and what can do Nick’s story (unemployed for 18 months) Page 23 “Now what?” Volunteer Get work experience Get help for resume Support and encourage to change his life Pray for him Look for work for him (M2) where would you go to get help for family violence? Can go back to school Get drunk Family problem Ask parents for money Encourage to volunteer Check health Seek ideas from others General comments about negative stereotyping of unemployed/ migrants Summary of feelings (suicide, depressed, anger, violent) Encourage to volunteer Self-evaluation Get more training Encourage to volunteer See career counsellor Do apprenticeship Take classes (literacy/nume racy) Volunteer Work experience Do resume Choose suitable job Keep trying Volunteer Get work experience Get help for resume Make sure have good relationship with referees Session 1 group evaluation Page 25 What would you be happy Good to help young people Beneficial for Very good session We know (M1) work together (M1) family Be more open minded about volunteering Refer them to services/netw orks This session made some of the attendees start thinking No comments No comments
  • 27. Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 26 Peer facilitator groups Group 1 Group 2 Group 3 Group 4 Group 5 Group 6 Group 7 Group 8 to tell your friend about the session? both young and old, volunteering good Get ideas from as many people as you can Session is good We can encourage young people about educational and job pathways more information Found the session very helpful, about supporting each other in the community Others should most definitely come along, friends/family Thankful to leader for organising education session problem (M1) homeless To kill To be die Ask friend for job They don’t have job Get ideas from family/friends Be pro-active Let others in your community know if you are struggling When working must leave any issues/proble ms may have at home/persona lly – don’t bring them to work Encourage critical thinking Discuss options (volunteering etc) Try to be positive and motivated Keep up-to- date with technology Be role model Be pro-active about their current situation It informed them about different situations in the community It taught them how work in small groups Page 26 If someone in your family was in the situation do you think you could help them? Please tell us one Tell people about the options (VCAL/TAFE) that are out there Support family/friends, encourage Advise them Encourage them Tell friends that if have problems don’t need to be upset, we all have No comments Go and talk to community leader Some people are reluctant to seek help from other friends/comm unity Encourage them Try to motivate and be a role model Refer to services/netw orks Try to give people as much support as possible Help in any way you can No comments No comments
  • 28. Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 27 Peer facilitator groups Group 1 Group 2 Group 3 Group 4 Group 5 Group 6 Group 7 Group 8 thing you would do for them. them Seek help so can assist your child with their problem Get special tuition to help with study problems – we need to support each other I want my friends to come, this is a good session This session made me understand about friends and community organisations If people who work at community organisations aren’t friendly/helpfu l people won’t go to them for help Take action, get support Session 2 Lee’s story (young 16 old male, mother finds condom in his room) Page 33 “Options” Talk privately Get father to have talk Discipline Protect family dignity Too young to be using condoms Mother should teach him (sex ed?) for his future He should repent and listen to Father should have a talk with his son Father is afraid to talk with son privately about sex No comments Counselling Sex education Social worker Get more condoms Could hide his condoms elsewhere The mother could give him some sex education The mother could give advice about No comments Seek social worker help Mother should have a serious discussion with son
  • 29. Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 28 Peer facilitator groups Group 1 Group 2 Group 3 Group 4 Group 5 Group 6 Group 7 Group 8 parents Encourage having sex at a young age The mother could provide condoms Lisa and Alex’s story (young relationship, woman pregnant) Page 39 “Options” Discuss with one another Prepare for child Consider abortion Talk with parents Seek advice Look after the baby Prevent the health (?) Take care of the child and go back to study later – never too late for study (M1) talk to father (i.e. man-to-man) Protect name of family Parent(?) afraid to talk with son Use contraceptive/ condom Encourage to get married Parents to talk about sex(?) (M2) talk with both families (M2) go to GP/hospital Consider abortion She can go to youth resource centre Seek help from a counsellor/soci al worker Ask for help from parents She can have baby and then go back to school Consider abortion Relationship counsellor See GP for regular health check Consider adoption Family support Peer support Consider abortion Young man could dropout of school to support family They could seek counselling Get centrelink support Have the baby – don’t consider an abortion Be happy Prevent future pregnancy Have the baby – don’t consider an abortion Be happy, knows father of child Prevent future pregnancy
  • 30. Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 29 Peer facilitator groups Group 1 Group 2 Group 3 Group 4 Group 5 Group 6 Group 7 Group 8 (M2) The girl could discuss with the boy Session 2 group evaluation Page 40 What would you be happy to tell your friend about the session? Educate your child about how to use a condom Treat with respect, do not use anger – otherwise child will lie and not want to cooperate with us Have a discussion Happy to share this session with friend Condoms can protect you Good session We know more information (M1) use condom t protect yourself (M2) encourage them (to?) (M2) Let them know where they can seek help, take them there (M2) tell your friend to go to the GP Share ideas with friends Be open minded Take more action This kind of session is very helpful for our community and if held again would bring more friends Have protected sex Go to family planning Teenage pregnancy is not the end of life/career/fut ure Get sex education Sessions are educative/info rmative They help prepare you Follow your goal Motivate you No comments No comments Page 41 If someone in your family was in the situation do you think you could help Encourage them Link them with service providers/orga nisations Encourage them to see a counsellor (M1) everything (M2) make them feel they can trust you and listen to what they are Yes, I feel that I could help them and suggest they see a project officer at MHSS Support them (emotionally and financially) Ask their opinion about pregnancy Give encouragemen t and support Tell them where they can go for help (MHSS/service No comments No comments
  • 31. Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 30 Peer facilitator groups Group 1 Group 2 Group 3 Group 4 Group 5 Group 6 Group 7 Group 8 them? Please tell us one thing you would do for them. Help them to take care of the child Advise them to seek counselling/m edical help Talk with them about taking responsibility for child so parent can go to school/work saying without judgement (M2) Guide and direct them Listen to them without judgement Will give them name of contact (NB. Phone number given in brackets- 94189916, this was the MHSS peer education project officer’s office number) Find a community leader/organis ation that can help Ask if ready to have baby Meet parents Seek medical check-up Consider abortion Depends on family background providers) Financial management Session 3 Mary’s story (Living with HIV) Page 48 “Options” Talk with others Learn more about HIV Learn how to stop transmission Find someone who can help Find out who to ask in the community See a GP Get tested and (M1) shame (M1) cannot sleep (M1) kill themselves (depression) (M1) they No comments Seek advice Speak to counsellor Be positive See a religious person Get medical advice See a counsellor or social worker (e.g. at MHSS) Speak with Keep her illness secret Stay positive Take her medical treatment Eat healthy Seek help from a counsellor or social worker Get support from family Seek medical help
  • 32. Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 31 Peer facilitator groups Group 1 Group 2 Group 3 Group 4 Group 5 Group 6 Group 7 Group 8 Seek counselling Get medical check get treatment if needed Find information about HIV and treatment(?) on internet don’t tell anyone (M1) see GP (M1) speak with family/best friend your pastor Have protected sex Use sex toys Have safe sex to prevent spreading disease Talk to someone just to relieve stress Ben and Kelly’s story (Hepatitis B) Page 54 “Options” Discuss with others Seek medical advice See Chiedza or any MHSS worker Get vaccinated See Hep B specialist See Hep B GP Get vaccinated Tell partner to trust him Find someone in community who can help Search for Hep B information Visit community, GP, pastor, hospital Socialise with friends (M2) encourage them to discuss problem with each other (M2) Tell partner the truth (M2) Get treated and take medication (M2) see GP for help and advice (M2) both get Has to tell partner before getting married Has to know cannot donate blood Must see GP regularly and take medication As friends/family advise to take medication Visit them He could be treated He could die He could lose relationship He could get counsellor Family could stigmatise Seek treatment They could go to counselling Tell partner Kelly might leave Ben No comments Seek help from a GP Practice safe sex so partner does not get Hap B
  • 33. Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 32 Peer facilitator groups Group 1 Group 2 Group 3 Group 4 Group 5 Group 6 Group 7 Group 8 Hold information sessions in community health check before marrying Make sure not excluded from community/so cial events Session 3 group evaluation Page 55 What would you be happy to tell your friend about the session? There is good information about HIV and hepatitis B available There is help for these diseases Don’t be afraid to seek medical advice Don’t be afraid of these diseases It is a good session to share with friends We know more about disease and where to get help (M2) go to GP and get health check (M2) direct your friend to seek help (M2) Tell friends what learnt at session and they might in turn tell others (M2) have to trust partner before getting married (M2) see MHSS (M2) if your friends have disease/illness Helpful for us as well as community Learnt about liver disease and how it is transmitted How to have safe sex to protect yourself and loved ones Hep B a scary disease Saw female condom – something never seen before Hep B is a dangerous disease Can be contracted in many ways There is stigma associated with having it It’s manageable Awareness about different STIs Session educative and informative Gives young people opportunity to come together No comments No comments
  • 34. Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 33 Peer facilitator groups Group 1 Group 2 Group 3 Group 4 Group 5 Group 6 Group 7 Group 8 tell them they can trust you and can guide them to who can help them the most Page 56 If someone in your family was in the situation do you feel you could help them? Encourage them to seek help Tell them to be careful about what they eat There are options to tackle issue Be positive/optim istic/cheerful Educate them about AIDS & Hep B Support them Encourage them to get help and to protect others Visit them (M2) emotional support (M2) go to GP (M2) don’t gossip (M2) reassure them (M2) tell them there is help available Advise them to see GP regularly Comfort them and show them they are not excluded Ask to come to community events Go out socially with them It’s manageable Ask the person to see a GP Advise him/her to practice safe sex so don’t spread disease Keep encouraging them Spend time with them Seek out information for them that could help Refer to counsellor/MH SS worker No comments No comments Session 4 Lara and Bob’s story (STI message) Page 63 “Options” Get medical check and test blood Encourage Support (M2) choose a GP you are comfortable Before go to GP look up information on See a GP See a Seek medical advice, get treatment No comments Go and speak with GP
  • 35. Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 34 Peer facilitator groups Group 1 Group 2 Group 3 Group 4 Group 5 Group 6 Group 7 Group 8 See GP/specialist See Cheidza or MHSS worker Go to community health centre Get sexual health check Find someone in community who can help Visit GP often Get tested talking to (M2) get treated often (M2) if cannot speak English can ask for an interpreter (M2) tell family and friends can trust (M2) look for information online the internet Advise to go to GP and get treated Do not gossip about them, do not leave them alone Make sure included in family/commu nity social events relationship counsellor Family violence and divorce Seek counselling Talk with a trusted friend Speak with a community health worker (MHSS) Encourage one another Session 4 group evaluation Page 66 Would you be happy to tell your friend about the session? How to use condom Where to get medical help Get medical check A good session, now know more about how to prevent pregnancy and disease by using condoms We are happy to tell friends/family (M2) know how to protect yourself from STis (M2) get tested for STIs (M2) know where to seek help (M2) personal Learnt about growths and how spread That husband/wife must be open minded Use condoms If friends say they have Encourage them to look after themselves To have safe sex Get educated Session helped us to learn about growths that can be sexually transmitted Session informative and educative Learnt about protection and No comments No comments
  • 36. Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 35 Peer facilitator groups Group 1 Group 2 Group 3 Group 4 Group 5 Group 6 Group 7 Group 8 about session hygiene (M2) clean yourself after sex (M2) both get STI test before marry (M2)use condoms correctly (m2) if you think/know you have STI get tested and treated immediately (M2) not all STIs have symptoms, if you are sexually active make sure you get tested these would recommend going to the GP It was worthwhile coming to this sessions had never heard about these kinds of things before safe sex Page 67 If someone in your family Seek counselling from professionals Know we know where to get help we can encourage (M2) encourage the person to see a GP, get No comments Seek medical advice See a Advise them to see a GP Find No comments No comments
  • 37. Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 36 Peer facilitator groups Group 1 Group 2 Group 3 Group 4 Group 5 Group 6 Group 7 Group 8 was in the situation do you feel you could help them? Go and get medical help Encourage and comfort them See GP/specialist Give information about STI them to see a GP and support services (e.g. MHSS, GP etc) tested and treated (M2) be supportive (M2) use condoms (M2) tell tehm about helath facts (M2) there is an advantage to seeing a GP (M2) family needs to be trusted counsellor See a MHSS worker Get treated See GP, take antibiotics information that can help them Support them Refer them to MHSS or sexual health services Final comments (manual) Page 68 No comments Limit number Cancer Hepatitis Heart attack Leukaemia Discharge (M2) Hepatitis B and other Hepatitis’s (M2) STI (M2) education No comments No comments No comment No comments No comments Final Electronic only Hardcopy and Hardcopy and Electronic only Electronic only None available Electronic only None available
  • 38. Evaluation of MHSS Peer Education Project: Centre for Population Health, Burnet Institute 37 Peer facilitator groups Group 1 Group 2 Group 3 Group 4 Group 5 Group 6 Group 7 Group 8 evaluation questionnaire (celebration session) electronic copy electronic copy Other comments Reports all done electronically, notes for all activities. There were two manuals returned to MHSS (M1 and M2) First session notes typed out (18/08/12), rest are from manual There is a group evaluation page which is probably the final evaluation in electronic PF notes