Peer education as a drug prevention strategy: what works?

Free interactive seminar and forum held on Tuesday 11 April 2006 at Angliss Conference Centre, Melbourne

This interactive seminar explored the effectiveness of peer education as a drug prevention strategy and what constitutes “evidence” when evaluating peer education programs.

Speakers

Peer education as a drug prevention strategy: Rationale and current research directions
Mr Netzach Goren, Senior Research Officer, Centre for Youth Drug Studies, Australian Drug Foundation

Evaluating peer education: Whose values and which “gold standard”?
Mr David McDonald, Consultant in Social Research and Evaluation and Visiting Fellow, National Centre for Epidemiology and Population Health, The Australian National University, Canberra

Putting the ART into peer pARTicipation: Using drama techniques in peer drug education
Ms Helen Cahill, Deputy-Director, Australian Youth Research Centre, The University of Melbourne
Mr Michael Waugh, Drama teacher, Williamstown High School
Year 10 drama students, Williamstown High School

Putting the peer into peer education: The experience of Australian drug-user organisations
Mr Damon Brogan and Ms Jennifer Kelsall, VIVAIDS

 

Peer education as a drug prevention strategy: rationale and current research directions

Mr Netzach Goren

The theoretical roots of peer education can be traced back to a number of social theories. These include:

• Bandura’s Social Learning theory
  This theory states that peer education equals social learning. Learning processes that occur within a social context take place through observation, imitation and modelling. This is the type of learning used by young people and is very important in terms of peer education.

• Social Identity theory
  This theory states that an individual has multiple “social identities”, derived from a sense of membership of a group. For example, individuals are more likely to be influenced by people from their group, than by those who are “out-group” members.

• Role theory
  This theory states that selected individuals will adapt to the role of group facilitator and will behave as is expected from a person in this position. It is also known that communication is less effective if there are significant cultural differences between the teacher/peer educator and students.

Rationale for peer education

There are many justifications for the use of peer group education.

• Credibility is one of the main issues in peer education. People are more likely to listen and adopt messages if they assume that the messenger is similar to them and faces the same concerns. Peer educators may possess increased credibility because:
  • They may use a similar language style (slang).
  • They tend to interact more with their peers.
  • They have a history of exchanging information with peers.

• Benefits of ongoing contact Ongoing contact between the peer educators and the targeted group can reinforce learning. Peer educators bring their knowledge to contexts other than the peer education context. This could have a significant impact in terms of drug education and the modelling of positive behaviour.
• Access to hard-to-reach populations Peer education projects are able to reach populations that are hard to reach because they can be set in different environments; for example, raves and clubs. Peer education does not entail the disclosure of sensitive information (for example, sexuality, drug use details) and can reach specific populations that would not be available within schools.
• Cost effective Peer education projects can be relatively inexpensive to operate because they don’t require input from health professionals. However, developing, designing and implementing a project is not necessarily inexpensive. If a project is perceived as a “cheap strategy” it may affect the quality of training, the quality of materials used and the level of satisfaction of the educators themselves.

Benefits for peer educators

The benefits of peer education for peer educators include:

• development of conflict resolution skills
• increased self esteem
• knowledge growth
• development of tolerance
• development of presentation and leadership skills.

Adverse effects for peer educators

Possible adverse effects on peer educators include:

• anxiety about the need to become an expert source of information
• lack of ongoing support
• lack of payment.

Peer education versus adult-led programs

Evaluation problems make direct comparison between peer education and other drug education programs difficult. However, the effects of these different types of programs are usually small. Knowledge acquisition seems to be similar in adult-led programs and peer-led programs. Overall, it has been shown that adult-led education has been more effective in didactic teaching, while peer-led programs are more effective in interactive teaching.

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Evaluating peer education: whose values and which “gold standard”?

Mr David McDonald

What the evaluation research tells us about peer education

A review of the effectiveness of peer-delivered health promotion interventions for young people by the Evidence for Policy and Practice Information and Co-ordinating Centre (1999) concluded that there is some evidence to support the effectiveness of peer-delivered health promotion for young people. However, due to a lack of methodologically sound studies and a limited evidence-base, it was concluded that the intuitive appeal of peer-delivered health promotion is not matched by much hard evidence. It was suggested that greater care should be taken in future to develop and test interventions, using sound methodological principles.

Mr McDonald suggested that this review approached the issue from a background that maintains that, unless there is evidence published in the scientific literature and unless the types of studies published in the literature are of a particular kind, we can’t say anything about peer education.

Values

The first issue to consider when evaluating a peer education program is values. Are values relevant and, if so, which values and whose values?

The researcher’s values influence the selection of research topics, research questions and research methods. However, it is not only the researchers that bring values to a peer education project, but also the practitioners, the peer educators themselves, managers, designers and funders.

There are three approaches to social science research and researcher values:

• positivist or instrumental: from the natural sciences, empirical observations of individual behaviour work to discover causal laws
• interpretive: approaches study meaningful social action from the point of view of the actors, the peer educators, rather than looking from the outside in
• critical: understand power structures and focus is on social justice, people’s wellbeing and human rights.

When talking about values it is important to identify the values that apply to the research, and many researchers don’t know how to answer this question. However, we can very safely look back 20 years to the Ottawa Charter for Health Promotion (International Conference on Health Promotion 1986) and see that the seven values to health promotion articulated there still seem to be relevant. Particularly the value that:

“Health promotion is the process of enabling people to increase control over, and to improve, their health … Health is, therefore, seen as a resource for everyday life, not the objective of living.”

This overarching value can be rolled out in terms of particular types of action. Ways of engaging in health promotion activities include:

• building healthy public policy
• creating supportive environments
• strengthening community action
• developing personal skills
• reorienting health services.

Evaluation and E-value-ation

Mr McDonald discussed the role of values and valuing in evaluation. Value is at the root of the concept of evaluation. The best-known definition of program evaluation is:

“The use of social research methods to systematically investigate the effectiveness of social intervention programs …” (Rossi, Lipsey & Freeman 2004)

There are three things wrong with this definition:

• In evaluation we use many methods other than social research methods (for example, financial audit or cost–benefit analysis).

• Effectiveness or goal attainment is not the only element evaluated. “Process” can also be evaluated.

• This definition says nothing about valuing or judging the worth of something.

The core of evaluation is valuing: determining the worth of something. When we do this, we confront the issue of the standards used to value something. It is important to take the values of the stakeholders into account. But whose values and which values should be used?

The leading proponent of this process of evaluation is Michael Scriven, who set out the following steps:

• Determine the criteria of merit.
• Construct standards.
• Measure.
• Compare results with standards.
• Make a judgement of merit or worth. (Scriven 1991)

This is an approach to evaluation that focuses explicitly on the value aspect—judging the work.

Types of evaluation in peer education

There are many evaluation models that can be used to evaluate peer education programs (Stufflebeam 2001; Wadsworth 1997).

The most common model is the goal attainment model, but it is just one of many. The problems with the goal attainment model include:

• over-runs and shortfall
• goal difficulty and importance
• side effects
• synthesising mixed results
• reasonableness of target levels
• ignoring process
• whose/which goals. (Davidson 2005)

Instead, think about the evaluation questions that you want answered, such as:

• concept and design (including program logic)
• implementation
• achievements—outcomes
• attribution—ascribing causality
• next steps.

Evidence

The kind of evidence used to determine the worth of something is usually gathered by a randomised controlled trial. The randomised controlled trial is the “gold standard” and assesses efficacy, which is defined as: “the extent to which a specific intervention, procedure, regimen or service produces a beneficial result under ideal conditions” (Last 1989).

Challenges to controlled trials as the “gold standard” for peer education evaluation include:

• The unit of intervention (typically individual behaviour change) is often an inappropriate measure. Measuring behavioural change tells us nothing about societal factors that shape people’s behaviour—community level change impacting on the social determinants of health and healthy behaviour.
• Doesn’t deal well with health promotion interventions, which are: multiple, complex, interacting, have long time frames.
• Health promotion focuses on process, not just outcomes. The ends do not justify the means.
• In much health promotion there are weak effects. For example, 5 per cent of people who receive the intervention may actually benefit from it but this is a substantial benefit from a societal point of view.
• Controlled experimentation explicitly excludes an understanding of context. In health promotion, it is important to understand and use context as a tool.

Efficacy versus effectiveness

Efficacy:

“The extent to which a specific intervention … or service produces a beneficial result under ideal conditions.”

contrasted with:

Effectiveness

“The extent to which a specific intervention … or service, when deployed in the field, does what it is intended to do for a defined population.” (Last 1989)

An example of an evaluation process that can be used to evaluate peer education programs is the RE-AIM (reach, efficacy, adoption, implementation and maintenance) model. The elements of this model are as follows:

• Reach—percentage of the target population that participated in the peer education program
• Efficacy—success rate if the program is implemented as per guidelines
• Adoption—percentage of settings that adopt the peer education program
• Implementation—extent to which the peer education program is implemented as intended
• Maintenance—extent to which the program is maintained over time (Glasgow, Vogt & Boles 1999).

This kind of broad model draws our attention to the importance of context and the range of approaches that can be taken.

Conclusion

• The evidence base for peer education is weak, but this probably reflects the types of research that are undertaken and published, more so than the on-the-ground outcomes of peer education.
• High-quality evaluation research, including controlled experiments, is essential in order to assess efficacy and improve our knowledge base.
• Other types of evaluation research, such as broader and effectiveness-focused evaluation (for example, reach, efficacy, adoption, implementation, maintenance), are needed.
• Focus on the features that are specific to health promotion evaluation (for example, social determinants, time, complexity, interaction).
• Think about the valuing part of evaluation (judging the worth of the peer education program against explicit standards).

References

Davidson EJ 2005 Evaluation methodology basics: The nuts and bolts of sound evaluation, Thousand Oaks: Sage Publications

Evidence for Policy and Practice Information and Co-ordinating Centre 1999 A review of the effectiveness and appropriateness of peer-delivered health promotion interventions for young people, London: University of London

Glasgow RE, Vogt TM & Boles SM 1999 “Evaluating the public health impact of health promotion interventions: The RE-AIM framework”, American Journal of Public Health, 89:9, pp. 1322–27, available at www.re-aim.org

International Conference on Health Promotion 1986, Ottawa Charter for Health Promotion, WHO/HPR/HEP/95.1, First International Conference on Health Promotion, Ottawa, 17–21 November

Last JM 1989 A dictionary of epidemiology, 2^nd edn, New York: Oxford University Press

Rossi PH, Lipsey MW & Freeman HE 2004 Evaluation: A systematic approach, 7^th edn, Thousand Oaks: Sage

Scriven M 1991 Evaluation thesaurus, 4^th edn, Newbury Park: Sage Publications

Stufflebeam DL 2001 “Evaluation models” in GT Henry (ed.) New directions for evaluation, no. 89, San Francisco: Jossey-Bass

Wadsworth Y 1997 Everyday evaluation on the run, 2^nd edn, St Leonards: Allen & Unwin

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Putting the ART into peer pARTicipation: using drama techniques in peer drug education

Ms Helen Cahill, Mr Michael Waugh and Year 10 drama students from Williamstown High School

When using peer drug education approaches in schools, it is important to consider the following factors:

• Keep in mind the evidence-base relating to effective drug education.
• The theoretical framework is a harm-minimisation approach.
• The peer education activity should promote a positive relational climate around learning and activity.
• Use engaging and interactive pedagogy to direct exploration of social and health issues. It’s no use if it is boring.
• Keep it relevant to the age, developmental stage and context of the young people involved.
• Debunk myths and misconceptions about risky drug use as the norm for young people.
• Promote critical thinking about influences conducive to risky drug use, such as the glamourising images found in the media.
• Promote active development of harm-prevention and harm-minimisation strategies.
• Ensure relevance to the cultural and contextual needs of the participants.
• The activity should be undertaken as part of a broader approach to the promotion of wellbeing in the school, community and family.

The students from Williamstown High School presented a workshop that demonstrated the use of interactive drama techniques to prompt thinking about decisions relating to drug use. The workshop moved beyond the focus on knowledge and skills to identify assumptions, needs and norms. In this session the students used a range of strategies and provided commentary on their engagement with the techniques.

The most important thing modelled in the work is the notion of providing active roles for young people. Positioning young people as a purposeful re/source involved in generating solutions (rather than as passive recipients who are the site of the “problem”). Promoting inclusive and respectful relationships in which diversity is acknowledged and embraced, and providing intellectual, relational and practical support.

This workshop exemplified the challenges of placing peer education within the context of the existing evidence base of drug education.

References

Cahill H, Murphy B & Kane C The Leading Education About Drugs (LEAD): Student participatory approaches, Melbourne: Australian Youth Research Centre for Department of Education Science and Training, available at www.dest.gov.au/sectors/school_education

Meyer L & Cahill H 2004 Principles for school drug education, Canberra : Australian Government Department of Education, Science and Training, available at www.dest.gov.au/NR/rdonlyres/60B9A2F3-BF3C-4A7E-90D7-AF5DD95EC97A/7601/PrincSchoolDrugEd.pdf

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Putting the peer into peer education: The experience of Australian drug-user organisations

Mr Damon Brogan and Ms Jennifer Kelsall

Since the early days of the HIV/AIDS epidemic in Australia, peer-based, drug-user organisations have designed and delivered a vast array of projects, campaigns and processes aimed at reducing HIV transmission and other drug-related harms. The concepts of “peer”, “community attachment” and “community action” have been fundamental to these processes. While much internal discussion and development of the idea of “peer education” has taken place within the network of Australian drug-user organisations, the major preoccupation has been internally focused, pragmatic and action-based. Drug user organisations such as VIVAIDS have been carrying out their type of peer education for more than 15 years.

The model of peer education developed by drug-user organisations is not a prescriptive model; it is about harm reduction for drug users.

Drug user organisations—origins

Drug user organisations had their origins in the 1970s, but increased in importance in the 1980s with the advent of AIDS, when people recognised a huge problem affecting a large population. The basic principles of peer education are that people affected by a problem are far more likely to listen to other people faced by the same problem.

Between 1989 and 1992, the Australian response to HIV increased and drug users were able to receive funding and form their own organisations. Drug user organisations are user-run and user-accountable.

User groups are agents of change in the following ways:

• A centre point of their activity is peer education. This builds on the recognition that users attach more credibility to people who share their values and experience. Adult education principles are applied.
• They encourage a change to safer behaviours through conviction and choice, not persuasion.
• They encourage community development and capacity building. Strategies are developed and implemented from accumulated knowledge, skills, access to information and networks.
• They provide advocacy through participation in social processes.

What is peer education?

The model of peer education for user groups is different from other interpretations of this concept. The term is broad enough to accommodate other models; however, the term can be misused and used to the exclusion of user-based organisations.

User organisations have a strong sense of ownership about peer education because it is the heart of these organisations. Avoiding an epidemic of AIDs came down to users educating themselves and each other and changing their drug use practices. This process involved peer education and providing users with the information and resources they needed.

Informal peer education existed before formal, funded programs. It is a natural process that occurs spontaneously among users. It uses the everyday interactions between peers rather than training workshops. Peers often do their best work when they are not working. The aim of peer education is to influence and harness these naturally occurring interactions.

Access

Due to the social stigma and illegality of injecting drug use, peer education is the only model with the potential to access and inform the vast array of users that would otherwise not be reached. In the process of scoring and using drugs together, drug users often only have each other to learn from. Trained peer educators may be not just the best people but also the only people who can do this job. Information delivered by health care professionals or the media seldom caters to the needs of drug users and they often receive less-than-optimal or humane treatment.

Sources of information for drug users

Professional	Peer
Doctors	Other users
NSPs	Friends
Health Centres	Dealers
Media	Drug user organisations, e.g. VIVAIDS, NUAA
Internet	WHACK! magazine
Research

Drug user organisations act as filters so that the right information is transmitted to users. Many of the principles used are drawn from adult education.

Principles of adult education

Peer education is based on the principles of adult education:

• Adults self-determine what they need to know.
• Adults test learning against their own beliefs and experiences.
• Adults seek relevance and immediate application.
• Adults have extensive knowledge and experience from which to draw.
• Adult learning tends to be problem and outcome focused.
• Adults share power with teachers and facilitators. (Gore 1995)

Examples of peer education programs

Example 1: Tribes (NSW Users and AIDS Association 1990–1995)

This program was based on the view that education campaigns designed and delivered by self-identifying members of peer networks could make an effective, cost-effective contribution to the reduction of drug-related harms. A number of diverse drug-using subcultures were identified (for example, ravers, bikies, Westies, Kooris, steroid users, young homeless users, leather dykes, Na-Nas [users in abstinence-based treatment]) and targeted and the campaign used the common currency of the tribe; for example, language, customs, rituals, attitudes to drug use, geographical connections. The process was of equal value to the “product”.

Example 2: SAVIVE CNP (Clean Needle Program 1992–2006)

The micro-community approach of Tribes lacked a cost-effective reach, so SAVIVE developed a utilitarian model of the intravenous drug user community as broad and heterogeneous, but united via a “deep and unique understanding of (illicit) injecting as an idea replete with cultural, social and psychological importance and impact”. The NSP was a platform for peer education and community development. The customers were equally important as the staff because the peer education continued when the users went back to their peer network. This program stressed ownership and modelling of safer behaviours by participants.

Example 3 Whack, VIVAIDS

Whack magazine is published by a drug-user organisation. It provides a voice for the community and an information source. Information is reviewed through peer-dominated processes. 

Model of peer education

Peer education aims to effect change at both individual and community levels. Despite differences in age, gender and ethnicity between users, the experience of injecting drug use cuts across boundaries, difficulties and barriers in communication.

Basic tenets of peer education

• People who are marginalised by society are often distrustful of education delivered through mainstream services.
• Subcultures develop rituals and language unique to that subculture.
• There is value in using the knowledge and expertise that already exists in a community or subculture.
• There is value in using existing networks to spread accurate information.
• There is value in using as a resource the interaction that occurs naturally in users’ everyday lives. (AIVL 1995)

Elements of effective peer education

• Peer education supports the sharing of knowledge within networks of users, respecting the knowledge and experiences they may already have.
• Peer education provides information that leads to safer drug use and emphasises the “why” rather than the “right” or “wrong” way to inject.
• Peer education encourages users to develop their own solutions and strategies.
• Peer education acknowledges the diversity of drug users and that they require information in a range of styles and formats.
• Peer education begins from an understanding of the social and situational aspects of drug use.
• Peer education provides information in a way that enables users to pass it on to their peers.
• Peer education shares power between users, rather than placing the trainer/facilitator in a position of authority.
• Peer education is based on mutual trust and respect.

Conclusion

Peer education involves a usage of pre-existing peer relationships that are specific and relevant to the health issue that you are trying to address. That means young people, because they are young people, are not necessarily peers when it comes to a health issue such as Alzheimer’s disease. Peer education involves ownership by participants (they are there because they want to be) and there is a relative equality of power, even when working with young people. It has diverse applications from one person talking to another person about things that affect their health to a structured workshop or a theatre production that then goes on to stimulate peer education. Peer education taps into pre-existing networks and dynamics. It is out in the real world and all user groups try to do is enhance natural existing dynamic relationships and interactions. Peer education does not only work with young people but with all types of groups.

Reference

Australian Injecting and Illicit Drug Users League (AIVL) 2006 A framework for peer education by drug-user organisations, Sydney: AIVL

Damon Brogan and Jennifer Kelsall used the AIVL document as background for their presentation with permission from AIVL.

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