1. Does peer-led education to promote safe sex, compared to
teacher-led education, change adolescents (12-19 years)
attitudes towards risky sexual behaviours?
By
Laud Dei
Brunel University
School of Health Sciences and Social Care
Changing Health Behaviours and Educating Communities

2. Outline
 Meaning of Acronyms Used
 Introduction
 Rationale
 Aim
 Search Strategy
 Setting
 Inclusion and Exclusion Criteria
 Selected Studies
 Limitations
 Conclusion
 Recommendations
 Questions
 References

3. Meaning of Acronyms Used
 AIDS Acquired Immune Deficiency Syndrome
 HIV Human Immunodeficiency Virus
 STD Sexually Transmitted Disease
 STI Sexually Transmitted Infection
 RCT Randomised Controlled Trial
 CBA Controlled Before and After Studies
 cRCT Cluster Randomised Controlled Trial
 UNAIDS Joint United Nations Programme on HIV/AIDS
 WHO World Health Organisation

4. Introduction
 The World Health Organisation (WHO) define adolescents as persons
between 10 and 19 years of age (WHO, 1998), but for the purposes of this
presentation, adolescents will be defined as persons between age 12 and 19
years.
 In many countries, regardless of the level of development or well-being, there
is the lack of information and services to protect youth from sexually
transmitted infections including HIV/AIDS (United Nations 2003).
 The most vulnerable groups within any population, who due to some
circumstances, for example peer-pressure, engage in a variety of risky sexual
behaviours and often are less likely to seek prevention, counselling, testing
and care are adolescents aged 12-19 years (WHO, 2006).

5.  In developing countries approximately 60% of new HIV infections occur
among 15–19 year-olds, and a similar proportion of pregnancies and births to
adolescents are unintended.
 In industrialized countries, the incidence of STIs among youth is increasing
(Darroch, Singh and Frost, 2001).
 In the U.S for example, sexual risk behaviour accounts for the majority of HIV
infections in youth, and has led to epidemic rates of STIs among 13 to 19 year
olds (Centre for Disease Control and Prevention, 2000).
 In the UK, adolescents aged 16-19 years were amongst the age group most at
risk of being diagnosed with a sexually transmitted infection, accounting for
65% of all chlamydia, 50% of genital warts and 50% of gonorrhoea infections
(Health Protection Agency, 2007).
Introduction cont’d

6. Age distribution of chlamydia and genital warts by sex, UK 2007
Source: Health Protection Agency Report, 2007

7. Source: UNICEF/MICS & Measure DHS, 1999-2001
Have heard of AIDSHave heard of AIDS
Have sufficient knowledge to protect themselvesHave sufficient knowledge to protect themselves
94
27
91
4
97
14
94
37
97
33
93
4 13
3
96
17
93
16
43
2
90
16
99
23
70
5
81
18
84
15
59
16
72
5
59
5
90
26
% of young women (aged 15–24) who have heard of AIDS and have sufficient
knowledge to protect themselves

8. Introduction cont’d
So how can adolescents be helped to take control of their lives?
 Peer education is currently one of the most widely adopted health
promotion strategies used with young people, and is almost universally
represented as effective (Price and Knibbs, 2008).
 It originated in British schools in the 19th century, with pupils appointed
as monitors to pass on what they had learned from their teachers to
younger classes (Parkin and McKeganey, 2000).
 They seek to utilise the positive aspects of adolescent peer groups by
helping them learn from each other.
 Researchers have confirmed that peer-led interventions are more effective
at changing young people’s behaviour than non-peer-led interventions
(Milburn, 1995).

9. Rationale
 Peer-led and teacher-led sex educations in schools are widely used as
behavioural change strategies to change adolescents attitudes towards early
sexual activity, and have been implemented by countries across the world, in
an effort to change their risky sexual behaviours.
 However, there is uncertainty regarding the effects of these interventions,
and hence the need to appraise their evidence-base.
Aim
 To compare peer-led education to promote safe sex to teacher-led sex
education, towards changing adolescents (12-19 years) attitudes towards
risky sexual behaviours.
Setting
 Due to the nature of the interventions being compared, and the age of the
participants, only studies performed in a school setting were considered the
most appropriate.

10. Search Strategy- Databases Searched
 Pubmed
 Cochrane
 Medline via OvidSP
 ERIC
 CINAHL Plus
 Web of Knowledge

11. Search Strategy Cont’d- Search Terms Used
1. Adolescent or Adolescence or Youth or Child or Pupil or Student or
School
2. ((Peer (support or education or counselling or educator or counsellor
or led)) or Peer-mentoring intervention
3. Sex Education or STD Control or STI Control or peer risk reduction
or safer-sex or unprotected sex or unprotected sexual intercourse or
unprotected sexual practice or unprotected sexual behaviour or
Condoms or Sexual Abstinence or Safe Sex
4. Combine 1 and 2 and 3

12. Search Strategy Cont’d- Inclusion and Exclusion Criteria
Number of Studies Generated
115 studies were generated 80 studies were excluded
35 studies were selected and screened 3 selected
Studies which included a wide range of participants, and included the 12-19
year olds, data related to this age group alone were considered.
Types of Studies Included
The following study designs were considered for inclusion:
Randomised Controlled Trials
Systematic Reviews
Controlled Before and After

13. Titles of Studies Selected
 Study 1:- Systematic Review of Interventions to Prevent the Spread of
Sexually Transmitted Infections, Including HIV, Among Young
People in Europe by Lazarus (2010)
 Study 2:- HIV prevention in Mexican schools: prospective
randomised evaluation of intervention by Walker et al (2006)
 Study 3:- Effectiveness of an HIV Prevention Program for Secondary
School Students in Mongolia by Rosario et al. (2006).

14. Population, Intervention, Comparison and Outcome (P.I.C.O) Formulation
 Population: Adolescents (12-19 years)
 Intervention: Peer-Led Education
 Comparison : Teacher- Led Education
 Outcome: Change in attitude towards risky sexual behaviour

15. Methodological Quality and Data Extraction
 CASP tools used were questions validated by Solutions for Public
Health (SPH).
 10 CASP questions for Randomised Controlled Trials (RCTs) and
Systematic Reviews (SR) were used to assess the methodological
quality and validity of selected studies.

16. Study 1:
Systematic Review of Interventions to Prevent the Spread of Sexually
Transmitted Infections, Including HIV, Among Young People in Europe by
Lazarus (2010)
 Objective
To examine the effectiveness of interventions seeking to prevent the spread
of sexually transmitted infections including HIV, among young people in
the European Union
 Selection Criteria
Randomised Controlled Trials (RCTs) and Evaluations of behaviour risk
interventions were searched. 40 articles were generated out of which 21
were eliminated. This included studies done in other European languages.
 Outcome Measure
 Changes in condom use
 Reduced/increased frequency of unprotected sexual intercourse
 Reduced/increased number of sexual partners
 Delayed/accelerated initiation of intercourse
 Taking STI test and/or using STI services

17. Study 1:
Systematic Review of Interventions to Prevent the Spread of Sexually
Transmitted Infections, Including HIV, Among Young People in Europe by
Lazarus (2010). Cont’d
 Results
Teacher Intervention
 1 out of 6 teacher interventions showed a behavioural change. 1215 student
from 10th
and 11th
grades were randomly assigned an intervention and control
groups
 Slight improvement in condom use only in the intervention group (baseline
22% vs follow-up 26%, P < 0.05)
Peer Intervention
 5 of 8 peer interventions were school based.
 3 studies report acceptability of the intervention
 2 peer-led studies reported some behavioural improvement.
Limitation(s)
 Designs used in most studies reviewed were inappropriate.

18. Study 2: HIV prevention in Mexican schools: prospective randomised
evaluation of intervention (Walker, 2006)
 Objective
 To assess effects of condom use and other sexual behaviour of an HIV
prevention programme at school that promotes the use of condoms with
and use without emergency contraception.
 Study Design
 Cluster Randomised Controlled Trials (cRCTs) of 40 public high schools
randomised into 3 arms in the state of Morelos in Mexico.
 Participating schools were selected using stratified random sampling.
 10th
to 12th
grades students ages 15-18 years randomly selected.
 10 of the 40 schools were randomised as control schools and continued
with biology based sex education.
 15 schools received the HIV education course with condom promotion
and 15 schools had the same course and a module on emergency
contraception and improved access to such contraception.

19. Study 2: HIV prevention in Mexican schools: prospective randomised
evaluation of intervention (Walker, 2006)
 106 teacher received a 40 hour training session for one week, for a 16
weeks sex education session.
 Sample size : 10,954 students at baseline. 9,372 students immediately
after intervention, (1,582 drop between baseline and first follow-up), and
7,308 students at one follow-up (2,064 drop between second follow-up
and third follow-up).
 Results
 Intervention did not affect reported condom use. Knowledge of HIV
improved in both intervention arms and knowledge of emergency
contraception improved in the condom promotion with contraception
arm. Reported sexual behaviour was similar in the intervention arms and
the control group.

20. Study 2: Limitation(s)
 Though teachers were trained and closely monitored, observations of
classes was limited.
 No measure of student attendance at the course.
 Although the course was intensive and longer than the recommended
14 hours (it was 30 hours), it was not followed up or reinforced the
after 1 year.
 Although the questionnaires were anonymous, confidential, and
completed in the presence of adults, privacy may not have been
optimal.
 Attrition at follow-up may have caused some loss of power

21. Study 3: Effectiveness of an HIV Prevention Program for Secondary
School Students in Mongolia by Rosario et al. (2006).
 Objective
 To evaluate the effectiveness of a 3-year human immunodeficiency virus
(HIV) prevention program for adolescents attending secondary school in
Mongolia.
 Method
 Design: Randomised Controlled Trial
 16-18 students were selected to complete a 3-day training in Reproductive
health; AIDS and STI transmission, symptoms and prevention and Safe
sex including how to use condoms.
 Intervention length 3 years. Age of participants- students 15-19 years
 45 participants were randomly selected from 8 schools using the random
number table.
 720 students in 10th
grade randomly selected with peer education
prevention program (Intervention). 647 students in 10th
grade randomly
selected from 8 schools without the peer education (Control).
 Intervention were already exposed to the intervention for 3 years

22.  Results
 Knowledge attitude and self-efficacy levels are statistically significantly
higher among students attending schools with peer education programs
relative to students from schools without such programs.
 Sexual practices were safer, though not statistically significant, likely due to
the small size of the sexually active subgroup.
 Students from schools where the peer education program was delivered by
small teams were statistically significantly more likely to engage in safer sex,
relative to their peers in schools without peer education programs.
Study 3: Effectiveness of an HIV Prevention Program for Secondary
School Students in Mongolia by Rosario et al. (2006). Cont’d

23. Limitation and Strengths of Study 3
 Limitation(s)
 Due to resource (money and time) constrains peer educators had only
3 days training.
 No control over which schools were selected to have the program and
unable to identify the factors used to determine in which schools the
program had been implemented.
 Strength(s)
 Intervention was done over a longer period (3-years)
 Researchers ensured that program and nonprogram schools were
matched on the basis of likely confounders
 Contamination was limited by excluding schools closer to the
intervention.

24. Conclusion for selected studies
 Study 1: Participants were more accepting of peer-led than teacher -led
interventions. Peer-led interventions were also more successful in
improving sexual knowledge.
 Both interventions influence on actual sexual behaviour were limited and
could not clearly reduce sexual risk behaviours.
 Study 2: The rigorously designed, implemented, and evaluated HIV
education course for teachers in public high schools did not reduce risk
behaviour, so such courses need to be redesigned and evaluated.
 Addition of emergency contraception did not decrease reported condom
use or increase risky sexual behaviour but did increase reported use of
emergency contraception.

25. Conclusion for selected studies- Cont’d
 Study 3: Study demonstrated that, after three years of delivery, grade 10
secondary school students were more knowledgeable, had less traditional
attitudes, and had a greater sense of their self-efficacy.
 Broader implementation of peer education programs in the school system
is justified as these programs have the potential to inform the students
about the risk factors associated with unsafe sexual practices.

26. Recommendations
 Even though knowledge may help improve health-seeking behaviour, long
term peer-led interventions are needed to effectively increase safer sex
among adolescents.
 The gap between baseline study and follow-up should be longer in peer-
led interventions, since behavioural change takes time.
 Peer education programs, particularly those that are managed by small
teams, appear effective in promoting safer sexual behaviours and should be
implemented more broadly.
 Additional studies needed to further confirm its viability.
 Peer-led strategies need to be reviewed to take place over a longer period
to change risky sexual behaviour among adolescents.

27. The End

28. Questions

29. References
 Critical Appraisal Skills Programme (CASP) Tools Available at:
http://www.unisa.edu.au/cahe/resources/cat/default.asp. Accessed 28/01/12
 Centre for Disease Control and Prevention (2000) U.S. HIV and AIDS cases reported through June 2000. HIV/AIDS
Surveillance Report. 2000;12:1–44
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Report.
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Medicine Vol.27, (3), 172-184

30. References
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