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Beyond the clinic walls: empowering young people through Youth Peer Provider programmes in Ecuador and Nicaragua
FEATURE
Beyond the clinic walls: empowering young people through Youth Peer Provider programmes in Ecuador and Nicaragua Claire Tebbets,a Dee Redwineb a Senior Programme Learning Officer, Planned Parenthood Global, Planned Parenthood Federation of America, New York, NY, USA. Correspondence: [email protected] b Regional Director, Latin America, Planned Parenthood Global, Planned Parenthood Federation of America, Miami, FL, USA
Abstract: Youth in Latin America experience high rates of teen pregnancy and sexually transmitted infections, but traditional health services are not meeting their health care needs. Youth require access to tailored health care and information to make informed, healthy decisions. To break down barriers to these vital sexual and reproductive health services, Planned Parenthood Global, a division of Planned Parenthood Federation of America, developed a Youth Peer Provider model which has been implemented in Latin America since the early 1990s. The model goes beyond peer education to train Youth Peer Providers under age 20 to provide condoms, oral contraceptive pills, emergency contraception, injectable contraceptives, and sexual and reproductive health information to their peers. Peers with needs beyond Youth Peer Providers’ capacity are referred to health professionals offering youth-friendly services. Survey results reveal high levels of contraceptive use among those served by the Youth Peer Providers: 98% of sexually active survey respondents wishing to avoid pregnancy report contraceptive use at least five years after joining the programme. Results of qualitative programme evaluations highlight higher self-esteem, stronger communication and decision-making skills, close relationships with friends and family, more interest in school, understanding of responsibility in relationships, and other positive outcomes among programme participants. © 2013 Reproductive Health Matters Keywords: adolescents and young people, community-based programmes and interventions, contraception, peer education Around the world, young people encounter barriers to realising their human rights, including the right to sexual and reproductive health.1–3 Sixteen million young women aged 15–19 give birth annually, including two million in Latin America.4,5 Ninety-five per cent of births to young women aged 15–19 were in low- and middle-income countries in 2008,5 and young people aged 15–24 accounted for approximately 60% of all sexually transmitted infections in 2005.6 In developing regions as a whole, two-thirds of unsafe abortions that occurred in 2004 were among women aged 15–30 and 14% among women under age 20,7 yet only half of sexually active young women in Latin America who did not wish to become pregnant were using a modern contraceptive method in 2007.8 Young people experience obstacles to health care and information due to their age. While many youth have easy access to information through the internet, others in low-and middle-
income countries, particularly those living in rural areas and urban slums do not, and often do not know where to find information or services. They do not trust that services at health centres will be confidential, that they will be treated well, or that staff will understand or address their needs. Transportation to health centres and the cost of services can be prohibitive. Community disapproval of young people’s sexual activity creates further obstacles.5,9,10 As a result, information and services are needed, to help young people make informed and healthy decisions, and prevent unintended pregnancy and sexually transmitted infections. 1,3,11–13 Young people should also have access to the full range of contraceptive methods; the World Health Organization does not exclude adolescents from eligibility for any method.14 Peers exert significant influence on young people’s decision-making around sexual and reproductive
Contents online: www.rhm-elsevier.com
Doi: 10.1016/S0968-8080(13)41693-2
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health.15 Research from around the world has found that youth who receive peer education boast improved knowledge, attitudes and behaviours regarding sexual and reproductive health, and that peer educators are crucial to programme success.16–21 Youth who discuss sexual and reproductive health with peers are more likely to display positive health-seeking behaviours than youth who discuss it with adults. Sexually active young people are also far more likely to discuss sexual and reproductive health with peers than adults,17 and more open to discussing genderrelated issues when presented the topic by peers.22 Peer education can increase knowledge on sexual and reproductive health among marginalised youth in as little as three months,16 and have a positive effect on self-esteem around sexual health.20 As a result, young people are uniquely positioned to act as resources for their peers. For all these reasons, Planned Parenthood Global developed and supported the implementation of the Youth Peer Provider programme model.
Some history and current implementing organisations The Youth Peer Provider programme model has been implemented in Latin America since the early 1990s. At that time, Planned Parenthood Global, a division of Planned Parenthood Federation of America, supported peer education programmes managed by a number of local non-governmental organisations (NGOs). However, neither Planned Parenthood Global nor their partners saw an increase in contraceptive use among youth as a result. Planned Parenthood Global therefore developed the Youth Peer Provider model and supported a partner organisation in Mexico to pilot a programme that moved beyond traditional peer education and integrated contraceptive provision into their programming. Over the past 20 years, the model has been implemented with 16 organisations in Latin America and has grown to offer a range of contraceptives and to reach youth in low-resource areas across Latin America and parts of Africa. The model has been tailored to meet the needs of marginalised groups ranging from rural, indigenous youth to youth in urban slums. Today, Planned Parenthood Global supports seven NGOs in Latin America to manage Youth Peer Provider programmes to increase access to sexual and reproductive health care and infor144
mation for youth in Ecuador (1), Nicaragua (1), Guatemala (2), and Peru (3). This article will focus on the two organisations with the longeststanding programmes. In Nicaragua, the Luisa Amanda Espinoza Association of Nicaraguan Women (AMNLAE) manages a network of community centres offering social support services to women since the 1980s. In 2011, 7,484 young people received services through their Youth Peer Provider programme. The programme reaches a substantial proportion of sexually active youth in participating communities. AMNLAE provides contraceptive methods to approximately 18% of adolescents in these communities, and education to approximately 60%.23 In Ecuador, CEMOPLAF (Family Planning and Health Care Centres) has been one of the country’s foremost providers of family planning services since its inception in 1974, and offers services and information at 26 centres in 11 provinces. In 2011 CEMOPLAF served 7,986 young people through the programme’s 21 sites. In rural areas and smaller cities, the programme reaches up to 35% of adolescents with contraceptive counselling and methods and up to 95% with education. The programme serves 1% or less of youth in large cities like Quito; in these cities the reach is substantially higher in the specific sectors the programme covers, but limited data preclude estimates.24 Both organisations focus exclusively on reaching low-income and otherwise marginalised youth. In many communities, particularly remote, rural communities, they provide the only access to contraceptives, and for urban youth from disadvantaged sectors, similarly, the only accessible and affordable services. While some young people in urban areas seek services through the public health system or the private sector, youth-friendly services are rarely available.
Programme model: beyond peer education This programme model goes one step beyond peer education to train young people under 20, dubbed Youth Peer Providers, to provide contraceptive methods and sexual and reproductive health information to peers in their communities. In Ecuador, CEMOPLAF’s health centres are the focal points for the programme; staff carry out trainings and stock supplies there. In Nicaragua, in communities where AMNLAE has a community centre, staff there do the same. In communities with no centre, staff establish a separate training
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space: a local school or community centre or a Youth Peer Provider’s home. Each programme has dedicated staff, including Programme Directors and Site Coordinators. Programme Directors oversee operations from the organisations’ headquarters and make regular visits to sites to monitor programme activities, train staff and assess quality of care. At each site, one Site Coordinator is responsible for recruiting, training and supervising Youth Peer Providers, and carries out educational activities in communities. In Ecuador, Coordinators are full time health centre staff, including nurses, educators and counsellors, who dedicate at least half their time to the programme. In Nicaragua, AMNLAE employs part-time Coordinators. Their Program Directors provide more frequent site supervision, up to monthly, as Coordinators are not health professionals. Coordinators and Youth Peer Providers invite new youth into the programme. Both conduct educational activities at local schools and in the community, and invite young people demonstrating interest to become involved. Both seek out out-of-school youth through sports, youth and community groups to ensure their inclusion. Youth Peer Providers also invite interested classmates, friends, and family. In 2011, CEMOPLAF managed 231 Youth Peer Providers, with an average of 12 per site. AMNLAE managed 198, averaging 20 per site. Primary selection criteria for Youth Peer Providers are interest in and commitment to offering services and information to peers. Other criteria include personal initiative, interpersonal and communication skills, responsibility, and sufficient time to dedicate to programme activities. Most Youth Peer Providers report participating to learn about sexual and reproductive health and to help peers avoid unplanned pregnancies and sexually transmitted infections. Youth Peer Providers share similar demographic characteristics with the youth they serve. Younger Youth Peer Providers tend to serve younger adolescents, while older ones serve older adolescents. Similarly, male Youth Peer Providers more often serve male peers, while females serve female peers. As a result, both organisations maintain a balance of age and sex among Youth Peer Providers to ensure they are meeting the needs of participating communities. Coordinators train and supervise Youth Peer Providers. Both organisations have standard training manuals, but the process is tailored to meet
the needs of each site. The most common protocol is that youth receive several weeks of training before offering condoms and basic information to peers, but additional training before offering other methods, counselling and community education. All training curricula include modules on: contraceptive methods, including mechanism of action, side effects, and contraindications; contraceptive counselling; sexually transmitted infections; responsible parenthood; teen pregnancy; sexuality; puberty; gender; family and intimate partner violence; self-esteem; alcohol and drugs; communication, public speaking and group facilitation skills; contraceptive data collection; and caseload management. To ensure quality of care, Youth Peer Providers receive ongoing supervision and refresher training from Coordinators. In Ecuador, youth convene for weekly or bi-weekly meetings. In Nicaragua, they meet monthly as a group and individually with Coordinators in the interim. During meetings, Coordinators at both organisations offer training, discuss issues that arise during counselling sessions, review contraceptive records to monitor volume and follow-up, and restock contraceptives. Contraceptive methods are provided free to Youth Peer Providers. They also receive minimal monetary compensation, as well as jackets, hats, or other programme attire. Some sites offer occupational skills training or seed grants to finance income-generating activities. These incentives are essential factors for retention in the programme.
Services provided 2007–2011 In Ecuador, CEMOPLAF’s Youth Peer Providers provided 27,418 young people with contraceptive services from 2007 to 2011. Table 1 illustrates the demographic breakdown of these youth. In 2011, each Youth Peer Provider served 48 peers on average (ranging from 24 to 119). In Nicaragua, AMNLAE’s Youth Peer Providers served 28,088 youth from 2007 to 2011. In 2011, each one served an average of 37 peers (ranging from 15 to 60). All Youth Peer Providers offer condoms and oral contraceptive pills, highlighting the importance of condoms to prevent sexually transmitted infections. At several programme sites, Youth Peer Providers are trained to offer injectable contraceptives and refer peers out for administering it. At CEMOPLAF, they also offer emergency contraception. All methods offered are available without prescription at pharmacies. Youth Peer Providers 145
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refer peers with questions beyond their expertise to medical professionals, and Coordinators oversee quality of care. Youth Peer Providers receive suggested prices for methods from Coordinators. Prices are always lower than comparable products at pharmacies or private health centres, although pricing structures vary by organisation and site. Methods are always offered free when youth cannot pay. Youth Peer Providers do not seek out peers to offer methods. They make themselves available to peers as trusted resources by introducing themselves in classes and community meetings, and interested youth approach them. “Despite that fact that I am a father, I did not understand the responsibilities parenthood carried with it [until I joined the youth programme]. I thought it meant having sex and that was it. When my now wife told me we would be having a child, I was surprised and did not know how to take on that responsibility. I looked for support and advice, but there was no one in my family to give me either. I could not tell them, because then what would they think of me? I thought if I told my friends they would make me feel bad. In the end I called my friend at CEMOPLAF, and told him with embarrassment. I liked the way he began to counsel me. Little by little he helped me to understand and recognize my responsibilities... and it improved me as a person.” (Male programme client, 18 years old) Youth Peer Providers carry contraceptive methods in their backpacks and meet peers at any conve146
nient time and place, often during the school day, or at places like football practice or in one of their homes. They offer comprehensive information on contraceptive options, including advantages, disadvantages, and mechanisms of action, as well as on prevention of sexually transmitted infections, in an age-appropriate and culturally relevant manner. Young people electing a method are screened for contraindications and receive additional information and their first month’s supply on the spot. Follow-up occurs at least once monthly, and often considerably more, regardless of the method. Many Youth Peer Providers report seeing the young people they serve daily, at school or in their neighbourhoods. During follow-up visits, Youth Peer Providers inquire about side effects, confirm correct usage, answer questions, and resupply methods. Initial visits can last up to half an hour or more depending on the prior knowledge of the young person. Follow-up visits range from a few minutes for a quick check-in to half an hour or more to answer questions or concerns. Youth Peer Providers generally meet peers individually, although occasionally partners are present. When peers have questions or concerns beyond the skill level of Youth Peer Providers, they are referred to health professionals. In Ecuador, youth are referred to CEMOPLAF health centres, where staff are trained in youth-friendly services. These address the specific needs of young people, recognizing their rights to information, to make their own decisions and to enjoy their sexuality in a healthy way. Youth-friendly health centres offer convenient schedules and locations, comfortable and age-appropriate spaces, and manageable administrative processes. Staff treat young people with trust and respect and maintain their confidentiality.25 In Nicaragua, Coordinators develop relationships with local providers, and youth are referred there. Generally, Coordinators lead educational activities for parents and teachers, while Youth Peer Providers lead activities for students and community groups. In 2011, CEMOPLAF reached 50,559 community members through information, education and communication activities, and AMNLAE, 52,440. All educational activities and materials are adapted to their audiences, by literacy level and social and cultural background. Materials contain images of local populations, utilise local languages, and link sexual and reproductive health to locally relevant topics.
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“Thanks to CEMOPLAF, my son did not get married quickly, as his other brothers did... My life would have been different if I had had condoms and pills when I was young… My [youngest] son knows about condoms, because if he did not, he would have already married… He wants to work and study and only then, later, have a wife. I would have wanted my other six children to be that way.” (Father) Activities are tailored to meet community needs. In urban areas, they are conducted in schools, community centres, or football arenas, and in rural areas, at local markets, community service events, or people’s homes. Activities include in-school workshops for youth, teacher training, discussion groups for parents, door-to-door home visits, educational booths at community events, outreach at sports games or community service events, street theatre, dance expositions, and puppet shows. Most activities are held for groups, but Youth Peer Providers also offer small group or one-on-one education. Organisations utilise radio programming to reach broader audiences; youth record and broadcast public service announcements and short segments about sexual and reproductive health. In Ecuador, where mobile technology is inexpensive and widespread, CEMOPLAF employs some mobile and computer-based technologies. Youth can text, call or e-mail trained staff for answers to pressing questions. Additionally, the organisation has utilised online chat rooms and social networking to disseminate information. Organisations engage Youth Peer Providers in advocacy. In Nicaragua, AMNLAE coordinated young people to participate in local and national summits to ensure their representation in political dialogue. In Ecuador, Youth Peer Providers in Latacunga receive extensive training on human rights and participated in a virtual exchange of youth advocates around the world.
Challenges and lessons learned As with any programme model, challenges exist. A primary challenge is sustainability, given that services are provided free or at greatly reduced prices. At CEMOPLAF the youth programme attracts new clients to health centres, generating income to cover programme costs, and expenses are integrated into health centre budgets. AMNLAE provides loans to sites to start small businesses, which offset some, but ultimately few, costs. Sites 148
have started businesses ranging from internet cafés to used bookstores, staffed by Youth Peer Providers. Net profit is invested in the programme. Experience has shown that sustainability is more feasible in an organisation that, like CEMOPLAF, can generate income through the programme. Garnering support from organisational leaders is vital. At CEMOPLAF, supportive health centre directors foster thriving programmes, while sites with unsupportive directors struggle and often fold. Successful strategies to cultivate support include education about the programme prior to implementation and demonstrating the benefit to health centres’ revenue. Appropriate staffing is key to programme success. CEMOPLAF found that successful Coordinators are dedicated to working with youth. Lacking this commitment, Youth Peer Providers do not feel supported, and attrition rates are high. Organisations must strike a balance between financial sustainability and adequate staffing. At most CEMOPLAF sites, Coordinators have responsibilities outside the programme. As a result, many report not having sufficient time to carry all of their responsibilities. At AMNLAE sites, Coordinators are part-time due to limited budgets, and staff only have time for monthly training activities. Youth Peer Providers report to Coordinators and Planned Parenthood Global a desire for more frequent trainings and meetings, but sustainable staffing solutions remain to be found. Additional budget allocated to staffing and realignment of job responsibilities are possibilities. Coordinator and Youth Peer Provider turnover presents another challenge. Programme Directors report that when programme staff leave their positions, Youth Peer Providers also leave the programme. Similarly, when Youth Peer Providers leave, their peers are often lost to follow-up. Both organisations strive to ensure youth feel more invested in the programme than in any one staff person. In Nicaragua, Coordinators form personal relationships with Youth Peer Providers and their peers. Inviting youth to participate in educational and other events encourages continued involvement. Similarly, Coordinators in Ecuador found that forging relationships between Youth Peer Providers, their peers and health centre staff encourages them to return. Further efforts are needed to improve programme continuation. Monitoring young people’s satisfaction with services and information they receive from Youth Peer Providers is challenging, as many prefer to
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remain anonymous. Currently most supervision of Youth Peer Providers is carried out by monitoring contraceptive records and assessing their skill through educational activities. CEMOPLAF is piloting a system whereby Youth Peer Providers ask peers to complete annual satisfaction surveys. At AMNLAE, additional ad hoc monitoring is possible due to personal relationships Coordinators have with youth. Experience has shown that Coordinators need to be more involved in the relationship from the beginning where possible, while still maintaining confidentiality. New strategies are needed to facilitate this process. Both financial and logistical barriers present challenges to securing contraceptive commodities, and irregular supply negatively affects contraceptive usage. In 2008–2009 volume at CEMOPLAF dropped precipitously when new customs regulations led to a shortage of oral contraceptive pills. Investment in commodity procurement is essential to programme success. Community buy-in also represents a challenge. Schools, parents, community leaders and religious entities have all expressed concerns about the programme model in certain communities. Both organisations have confronted this by working closely with these groups to foster understanding of the programme and sexual and reproductive health more broadly. In rural areas, CEMOPLAF has collaborated with trusted organisations to facilitate implementation, as well as conducted door-to-door home visits before starting contraceptive services. A final lesson learned is that contraceptive access through the programme is essential; peer education alone does not eliminate barriers to obtaining methods. “What’s the point of all this information on how to use them if I don’t have them to use? It would just be a lot of talk on the street but not much else.” (Young contraceptive user) “There’s no value in just talking, talking, talking.” (Youth Peer Provider) “I think it’s ideal that it’s the contraceptive and the information... It’s easier and more accessible for the young people. That way they can also put into action the learning they’ve received.” (Mother)
Programme evaluations Information in this article draws upon ten years of programme monitoring and evaluation, focus-
ing on three evaluations. First, in 2004, Planned Parenthood Global conducted an evaluation of both CEMOPLAF and AMNLAE Youth Peer Provider programmes to identify long-term benefits of programme participation, specifically health behaviours and outcomes. Youth Peer Providers at six sites conducted structured interviews using a 33-item survey on contraceptive use and history of pregnancies and births. 597 respondents were randomly selected from contraceptive users with records going back to five years prior. They had participated in the programme for an average of three years. Second, from 2007–2009, CEMOPLAF carried out an evaluation of their programming across Ecuador utilising the Most Significant Change Technique,26 collecting 92 interviews in a qualitative, participatory evaluation process to assess programme impact. The survey tool comprised six questions: how participants became involved in the programme, what their current participation entailed, the changes they saw resulting from the programme, which was the most significant, why, and what recommendations they had for the programme. Third, in 2010, Planned Parenthood Global conducted 15 in-depth interviews covering participants’ assessments of CEMOPLAF’s strengths, weaknesses, and impacts, and operational issues including supervision and training.27 Given the similar methodologies and response categories of the second and third evaluations, their results were combined for analysis. The 107 respondents included current and past Youth Peer Providers, youth receiving counselling and methods through the programme, students receiving regular trainings from Youth Peer Providers or Coordinators, parents of programme participants, organisational staff, staff at participating schools, and other young people. Both evaluations comprised purposive samples and utilised convenience sampling. Findings: 2004 survey The 2004 survey revealed high levels of contraceptive use among young people previously served by Youth Peer Providers (Table 2). Threequarters of survey respondents were sexually active, and 95% of those sexually active reported current contraceptive use. Among those who did not want to become pregnant at the time of the survey, this increased to 98%. These levels are very high relative to comparable data available. In the general population in 149
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half (49%) named one or more specific areas in which programme participants’ knowledge increased, including pregnancy prevention, contraceptive methods, sexual transmitted infections, HIV, sexuality, and anatomy. Many respondents indicated this knowledge enabled youth to be responsible about their health, particularly through protection from sexually transmitted infections and unintended pregnancy. “Previously I knew absolutely nothing about condoms or pills, and now I can protect myself.” (Male high school student) The second most common programme impact mentioned was personal growth, named by 42% of respondents. Programme participants matured emotionally and intellectually, became more responsible, and made better decisions, including related to sexual and reproductive health behaviours, alcohol and drug use, and participation in gangs. “In these four years I have [watched] them, I have seen them grow not only physically, but also in their emotional and intellectual maturity, in being responsible, and in behaving responsibly.” (CEMOPLAF staff member) Nicaragua in 2001, 63% of sexually active 15–24 yearolds utilised a modern contraceptive method.28 In the general population in Ecuador in 2004, 64% of youth 15–24 years old living with a partner utilised a modern contraceptive method.29 Three-quarters of survey respondents had ever utilised a condom to prevent sexual transmitted infections, which also compared favourably to the general population. In Nicaragua, less than one-quarter of women under 30 had ever used a condom.28 Findings: qualitative evaluations Ecuador 2007–10 The impact of the CEMOPLAF programme on contraceptive use was supported by the qualitative evaluations, where six per cent of respondents noted, unprompted, a decrease in teen pregnancy in their communities as a result of the Youth Peer Provider programme.
Twenty-two per cent of respondents mentioned increased self-esteem, self-confidence, and leadership skills of youth involved in the programme. Many programme participants noted that they had had low self-esteem going into the programme, but that their participation led them to value and respect themselves. “One of the most important changes was really getting to know myself and improve my selfesteem… I did not believe in myself, and above all, I hated myself. At CEMOPLAF they taught me not only what a contraceptive is, they taught me to love myself and respect my body, my feelings, and above all, my thoughts.” (Female Youth Peer Provider)
“I saw [the change] in the high school… my daughter and the girls in her class graduated, and none of them were pregnant – although they had active sex lives.” (Mother)
Twenty-three per cent of respondents reported that programme participants improved their communications skills, both around sexual and reproductive health issues and in general. Youth reported being more open and expressive and more comfortable talking about sexuality. Participation in the programme also led young people to respect others, according to 11% of respondents.
The most common programme impact mentioned by respondents was increased knowledge. Nearly
“I have learned to live with other people, to respect others’ comments and ideas… because we are all
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people and we should respect one another.” (Male Youth Peer Provider) An important number of respondents highlighted the improvement in young people’s relationships with their family (27%) and friends (17%). Youth and their families saw increased trust and support within their family relationships, and programme participants experienced strengthened bonds with their friends. “When I entered the programme I had a lot of family problems. In my house no one listened and everything was solved with violence. I started drinking, and I didn’t have a good friend or anyone who understood my situation. When I entered the programme out of curiosity, I discovered there was a space where I could be myself and be understood and understand why I was the way I was, and that was how the programme became my home and the other youth became my family… There are many youth who aren’t understood in our homes and the programme is a fundamental tool to help them grow.” (Male Youth Peer Provider) Several respondents (7%) noted that young people who participated in the programme became more involved in school. They began to speak up more in class and focus more on their studies. Five per cent of participants noted improved relationships between teachers and students who participated in the programme. Ongoing programme monitoring and evaluation reveal that many effects of the model are longer term than what is captured through typical evaluation mechanisms. Five percent of respondents mentioned that programme participants had greater professional aspirations as a result of participation. Many have assumed leadership positions within NGOs, the government and international organisations, and work in sexual and reproductive health and other social justice issues as many as 15 years after contact with the programme.
knowledge and skills gained through participation, including decision-making and communication skills, can influence protective behaviours. The maturity, self-esteem and self-confidence participants develop can contribute to health-seeking and positive health outcomes.30 The impact of the programme is broader than originally anticipated, reaching young people directly involved with the programme but also their communities. Participation seems to foster stronger relationships between young people and their friends, family and teachers, and greater respect and better communication within those relationships. These factors can positively impact young people’s sexual and reproductive health by reducing barriers to information and care. Given the wideranging potential for positive outcomes of these programmes, we believe they should be expanded to new areas and new organisations. Lessons learned through Youth Peer Provider programme implementation can also help to strengthen existing programmes* aimed at improving adolescent access to sexual and reproductive health information and services. Acknowledgements We would like to acknowledge the staff at AMNLAE and CEMOPLAF for their tireless work in Latin America, and Planned Parenthood Global staff, past and present, for supporting these efforts. In particular, we would like to thank Teresa de Vargas, Elsa Racines, Adaly Ordoñez, and Martha Ambota for their ongoing commitment. We would like to thank Diana Santana for her significant contributions to this paper, and Kelley Carnwath, Ellen Clancy, Jessica Getz, Alana Ortez, Heather Sayette, and Wendy Sheldon for assistance in technical support, monitoring and evaluation.
Conclusions The Youth Peer Provider model offers young people access to vital health information and services and presents an important opportunity to improve young people’s sexual and reproductive health in Latin America and beyond. Programme evaluations provide strong evidence that programme participation leads to healthy behaviours, including contraceptive use. Increased
*Planned Parenthood Global developed a Youth Peer Provider Programme Replication Manual that provides in-depth guidance and comprehensive training materials for organisations considering implementing the programme: www. plannedparenthood.org/images/PP_Global_YPP_Manual.pdf.
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12. Kirby D, Laris BA, Rolleri L. Impact of sex and HIV education programmes on sexual behaviors of youth in developing and developed countries. Research Triangle Park: Family Health International/ YouthNet; 2005. 13. Goicolea I, Coe AB, Hurtig AK, et al. Mechanisms for achieving adolescent-friendly services in Ecuador: a realist evaluation approach. Global Health Action 2012;5. 14. World Health Organization Department of Reproductive Health. Medical eligibility criteria for contraceptive use. 4th ed. Geneva: WHO; 2010. 15. Saavedra M. Young people in Bogota, Colombia develop their own strategies to prevent risky sexual behavior. SIECUS Report 1996;24(3):10–12. 16. Li S, Huang H, Cai Y, et al. Evaluation of a school-based HIV/AIDS peer-led prevention programme: the first intervention trial for children of migrant workers in China. International Journal of STD & AIDS 2010;21: 82–86. 17. Wolf RC, Pulerwitz J. The influence of peer versus adult communication on AIDS-protective behaviors among Ghanaian youth. Journal of Health Communication 2003;8(5):463–74. 18. Brieger WR, Delano GE, Lane CG, et al. West African Youth Initiative: outcome of a reproductive health education programme. Journal of Adolescent Health 2001;29(6):436–46. 19. Speizer I, Tambashe BO, Tegang SP. An evaluation of the “Entre Nous Jeunes” peer educator programme for adolescents in Cameroon. Studies in Family Planning 2001;32:339–51. 20. Peña R, Quintanilla M, Navarro K, et al. Evaluating a peer intervention strategy for the promotion of sexual health-related knowledge and skills in 10- to 14-year-old girls. Findings from the “Entre amigas” project in Nicaragua. American Journal of Health Promotion 2008;22(4):275–81. 21. Perez F, Dabis F. HIV prevention in Latin America: reaching youth in Colombia. AIDS Care 2003;15(1): 77–87. 22. Re MI, Pagani L, Bianco M. Assessing workshops on sexuality with Argentinian youth. AIDS STD Health Promotion Exchange 1996;(3):13–15. 23. Instituto Nacional de Información para el Desarrollo. Cifras municipals. Managua: INIDE; 2008. www.inide. gob.ni/censos2005/CifrasMun/tablas_cifras.htm. 24. Instituto Nacional de Estadística y Censos. Banco de Información. Ecuador; 2011. www.inec.gob.ec/ estadisticas/?option=com_content&view=article&id= 109&Itemid=88.
C Tebbets, D Redwine. Reproductive Health Matters 2013;21(41):143–153 25. Nelson K, MacLaren L, Magnani R. Assessing and planning for youth friendly reproductive health services. Workbook No.1: Planning for an assessment & collecting data. Washington, DC: Pathfinder International; 2000. 26. Davies R, Dart J. The ‘Most Significant Change’ (MSC) technique: a guide to its use. www.mande.co.uk/ docs/MSCGuide.pdf. 27. Planned Parenthood Global. Youth Peer Provider Replication Manual. New York, NY; 2011.
28. Encuesta Nicaragüense de Demografía y Salud 2001. Managua: Instituto Nacional de Estadísticas y Censos, Ministerio de Salud; 2002. 29. Encuesta Demográfica y de Salud Materna e Infantil 2004. Quito: Centro de Estudios de Población y Desarrollo Social; 2005. 30. Lipovsek V, Karim AM, Gutiérrez EZ, et al. Correlates of adolescent pregnancy in La Paz, Bolivia: findings from a quantitative-qualitative study. Adolescence 2002;37(146):335–52.
Résumé En Amérique latine, les jeunes enregistrent des taux élevés de grossesse et d’infections sexuellement transmissibles, mais les services de santé traditionnels ne répondent pas à leurs besoins. Ils doivent avoir accès à des informations et des soins de santé adaptés pour prendre des décisions saines et judicieuses. Pour lever les obstacles à ces services essentiels de santé sexuelle et génésique, Planned Parenthood Global, une division de Planned Parenthood Federation of America, a élaboré un modèle de jeunes pairs qui est mis en œuvre en Amérique latine depuis le début des années 90. Le modèle va au-delà de l’éducation des pairs pour apprendre aux prestataires de moins de 20 ans à distribuer des préservatifs, des pilules contraceptives orales, une contraception d’urgence, des contraceptifs injectables et une information de santé sexuelle et génésique à leurs pairs. Les jeunes dont les besoins dépassent les capacités des pairs prestataires sont aiguillés vers des professionnels de la santé qui assurent des services adaptés aux jeunes. Les enquêtes révèlent de hauts niveaux d’utilisation des contraceptifs parmi la population desservie par ces pairs: 98% de répondants sexuellement actifs souhaitant éviter une grossesse ont indiqué qu’ils utilisaient un contraceptif au moins cinq ans après avoir rejoint le programme. Les évaluations qualitatives du programme mettent en évidence une meilleure estime de soi, des aptitudes plus solides à la communication et à la décision, d’étroites relations avec les amis et la famille, davantage d’intérêt pour l’école, une compréhension de la responsabilité dans les relations et d’autres résultats positifs parmi les participants du programme.
Resumen En Latinoamérica existen altas tasas de embarazo e infecciones de transmisión sexual en la adolescencia. Los servicios tradicionales de salud no están atendiendo las necesidades de salud de los jóvenes, quienes necesitan acceso a información y servicios de salud adaptados a sus necesidades para poder tomar decisiones informadas y saludables. Para eliminar las barreras a estos servicios vitales de salud sexual y reproductiva, Planned Parenthood Global, una división de Planned Parenthood Federation of America, creó un modelo de Proveedores Pares de Jóvenes, el cual comenzó a aplicarse en Latinoamérica a principios de la década de los noventa. El modelo va más allá de la educación de pares para capacitar a Proveedores Pares de Jóvenes menores de 20 años para que sumistren a sus pares condones, píldoras anticonceptivas orales, anticoncepción de emergencia, anticonceptivos inyectables e información sobre salud sexual y reproductiva. Pares con necesidades más allá de la capacidad de estos proveedores reciben referencias a profesionales de la salud que ofrecen servicios amigables para la juventud. Los resultados de una encuesta revelan altos niveles de uso de anticonceptivos entre jóvenes atendidos por Proveedores Pares de Jóvenes: el 98% de las personas encuestadas que mantienen relaciones sexuales y desean evitar embarazos informaron continuar usando anticonceptivos por lo menos cinco años después de inscribirse en el programa. Entre los resultados de las evaluaciones cualitativas del programa se destacan mayor autoestima, mejores habilidades de comunicación y toma de decisiones, relaciones cercanas con amistades y familiares, más interés en la escuela, entendimiento de la responsabilidad en relaciones y otros resultados positivos entre los participantes.
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Beyond the clinic walls: empowering young people through Youth Peer Provider programmes in Ecuador and Nicaragua Claire Tebbets,a Dee Redwineb a Senior Programme Learning Officer, Planned Parenthood Global, Planned Parenthood Federation of America, New York, NY, USA. Correspondence: [email protected] b Regional Director, Latin America, Planned Parenthood Global, Planned Parenthood Federation of America, Miami, FL, USA
Abstract: Youth in Latin America experience high rates of teen pregnancy and sexually transmitted infections, but traditional health services are not meeting their health care needs. Youth require access to tailored health care and information to make informed, healthy decisions. To break down barriers to these vital sexual and reproductive health services, Planned Parenthood Global, a division of Planned Parenthood Federation of America, developed a Youth Peer Provider model which has been implemented in Latin America since the early 1990s. The model goes beyond peer education to train Youth Peer Providers under age 20 to provide condoms, oral contraceptive pills, emergency contraception, injectable contraceptives, and sexual and reproductive health information to their peers. Peers with needs beyond Youth Peer Providers’ capacity are referred to health professionals offering youth-friendly services. Survey results reveal high levels of contraceptive use among those served by the Youth Peer Providers: 98% of sexually active survey respondents wishing to avoid pregnancy report contraceptive use at least five years after joining the programme. Results of qualitative programme evaluations highlight higher self-esteem, stronger communication and decision-making skills, close relationships with friends and family, more interest in school, understanding of responsibility in relationships, and other positive outcomes among programme participants. © 2013 Reproductive Health Matters Keywords: adolescents and young people, community-based programmes and interventions, contraception, peer education Around the world, young people encounter barriers to realising their human rights, including the right to sexual and reproductive health.1–3 Sixteen million young women aged 15–19 give birth annually, including two million in Latin America.4,5 Ninety-five per cent of births to young women aged 15–19 were in low- and middle-income countries in 2008,5 and young people aged 15–24 accounted for approximately 60% of all sexually transmitted infections in 2005.6 In developing regions as a whole, two-thirds of unsafe abortions that occurred in 2004 were among women aged 15–30 and 14% among women under age 20,7 yet only half of sexually active young women in Latin America who did not wish to become pregnant were using a modern contraceptive method in 2007.8 Young people experience obstacles to health care and information due to their age. While many youth have easy access to information through the internet, others in low-and middle-
income countries, particularly those living in rural areas and urban slums do not, and often do not know where to find information or services. They do not trust that services at health centres will be confidential, that they will be treated well, or that staff will understand or address their needs. Transportation to health centres and the cost of services can be prohibitive. Community disapproval of young people’s sexual activity creates further obstacles.5,9,10 As a result, information and services are needed, to help young people make informed and healthy decisions, and prevent unintended pregnancy and sexually transmitted infections. 1,3,11–13 Young people should also have access to the full range of contraceptive methods; the World Health Organization does not exclude adolescents from eligibility for any method.14 Peers exert significant influence on young people’s decision-making around sexual and reproductive
Contents online: www.rhm-elsevier.com
Doi: 10.1016/S0968-8080(13)41693-2
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health.15 Research from around the world has found that youth who receive peer education boast improved knowledge, attitudes and behaviours regarding sexual and reproductive health, and that peer educators are crucial to programme success.16–21 Youth who discuss sexual and reproductive health with peers are more likely to display positive health-seeking behaviours than youth who discuss it with adults. Sexually active young people are also far more likely to discuss sexual and reproductive health with peers than adults,17 and more open to discussing genderrelated issues when presented the topic by peers.22 Peer education can increase knowledge on sexual and reproductive health among marginalised youth in as little as three months,16 and have a positive effect on self-esteem around sexual health.20 As a result, young people are uniquely positioned to act as resources for their peers. For all these reasons, Planned Parenthood Global developed and supported the implementation of the Youth Peer Provider programme model.
Some history and current implementing organisations The Youth Peer Provider programme model has been implemented in Latin America since the early 1990s. At that time, Planned Parenthood Global, a division of Planned Parenthood Federation of America, supported peer education programmes managed by a number of local non-governmental organisations (NGOs). However, neither Planned Parenthood Global nor their partners saw an increase in contraceptive use among youth as a result. Planned Parenthood Global therefore developed the Youth Peer Provider model and supported a partner organisation in Mexico to pilot a programme that moved beyond traditional peer education and integrated contraceptive provision into their programming. Over the past 20 years, the model has been implemented with 16 organisations in Latin America and has grown to offer a range of contraceptives and to reach youth in low-resource areas across Latin America and parts of Africa. The model has been tailored to meet the needs of marginalised groups ranging from rural, indigenous youth to youth in urban slums. Today, Planned Parenthood Global supports seven NGOs in Latin America to manage Youth Peer Provider programmes to increase access to sexual and reproductive health care and infor144
mation for youth in Ecuador (1), Nicaragua (1), Guatemala (2), and Peru (3). This article will focus on the two organisations with the longeststanding programmes. In Nicaragua, the Luisa Amanda Espinoza Association of Nicaraguan Women (AMNLAE) manages a network of community centres offering social support services to women since the 1980s. In 2011, 7,484 young people received services through their Youth Peer Provider programme. The programme reaches a substantial proportion of sexually active youth in participating communities. AMNLAE provides contraceptive methods to approximately 18% of adolescents in these communities, and education to approximately 60%.23 In Ecuador, CEMOPLAF (Family Planning and Health Care Centres) has been one of the country’s foremost providers of family planning services since its inception in 1974, and offers services and information at 26 centres in 11 provinces. In 2011 CEMOPLAF served 7,986 young people through the programme’s 21 sites. In rural areas and smaller cities, the programme reaches up to 35% of adolescents with contraceptive counselling and methods and up to 95% with education. The programme serves 1% or less of youth in large cities like Quito; in these cities the reach is substantially higher in the specific sectors the programme covers, but limited data preclude estimates.24 Both organisations focus exclusively on reaching low-income and otherwise marginalised youth. In many communities, particularly remote, rural communities, they provide the only access to contraceptives, and for urban youth from disadvantaged sectors, similarly, the only accessible and affordable services. While some young people in urban areas seek services through the public health system or the private sector, youth-friendly services are rarely available.
Programme model: beyond peer education This programme model goes one step beyond peer education to train young people under 20, dubbed Youth Peer Providers, to provide contraceptive methods and sexual and reproductive health information to peers in their communities. In Ecuador, CEMOPLAF’s health centres are the focal points for the programme; staff carry out trainings and stock supplies there. In Nicaragua, in communities where AMNLAE has a community centre, staff there do the same. In communities with no centre, staff establish a separate training
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space: a local school or community centre or a Youth Peer Provider’s home. Each programme has dedicated staff, including Programme Directors and Site Coordinators. Programme Directors oversee operations from the organisations’ headquarters and make regular visits to sites to monitor programme activities, train staff and assess quality of care. At each site, one Site Coordinator is responsible for recruiting, training and supervising Youth Peer Providers, and carries out educational activities in communities. In Ecuador, Coordinators are full time health centre staff, including nurses, educators and counsellors, who dedicate at least half their time to the programme. In Nicaragua, AMNLAE employs part-time Coordinators. Their Program Directors provide more frequent site supervision, up to monthly, as Coordinators are not health professionals. Coordinators and Youth Peer Providers invite new youth into the programme. Both conduct educational activities at local schools and in the community, and invite young people demonstrating interest to become involved. Both seek out out-of-school youth through sports, youth and community groups to ensure their inclusion. Youth Peer Providers also invite interested classmates, friends, and family. In 2011, CEMOPLAF managed 231 Youth Peer Providers, with an average of 12 per site. AMNLAE managed 198, averaging 20 per site. Primary selection criteria for Youth Peer Providers are interest in and commitment to offering services and information to peers. Other criteria include personal initiative, interpersonal and communication skills, responsibility, and sufficient time to dedicate to programme activities. Most Youth Peer Providers report participating to learn about sexual and reproductive health and to help peers avoid unplanned pregnancies and sexually transmitted infections. Youth Peer Providers share similar demographic characteristics with the youth they serve. Younger Youth Peer Providers tend to serve younger adolescents, while older ones serve older adolescents. Similarly, male Youth Peer Providers more often serve male peers, while females serve female peers. As a result, both organisations maintain a balance of age and sex among Youth Peer Providers to ensure they are meeting the needs of participating communities. Coordinators train and supervise Youth Peer Providers. Both organisations have standard training manuals, but the process is tailored to meet
the needs of each site. The most common protocol is that youth receive several weeks of training before offering condoms and basic information to peers, but additional training before offering other methods, counselling and community education. All training curricula include modules on: contraceptive methods, including mechanism of action, side effects, and contraindications; contraceptive counselling; sexually transmitted infections; responsible parenthood; teen pregnancy; sexuality; puberty; gender; family and intimate partner violence; self-esteem; alcohol and drugs; communication, public speaking and group facilitation skills; contraceptive data collection; and caseload management. To ensure quality of care, Youth Peer Providers receive ongoing supervision and refresher training from Coordinators. In Ecuador, youth convene for weekly or bi-weekly meetings. In Nicaragua, they meet monthly as a group and individually with Coordinators in the interim. During meetings, Coordinators at both organisations offer training, discuss issues that arise during counselling sessions, review contraceptive records to monitor volume and follow-up, and restock contraceptives. Contraceptive methods are provided free to Youth Peer Providers. They also receive minimal monetary compensation, as well as jackets, hats, or other programme attire. Some sites offer occupational skills training or seed grants to finance income-generating activities. These incentives are essential factors for retention in the programme.
Services provided 2007–2011 In Ecuador, CEMOPLAF’s Youth Peer Providers provided 27,418 young people with contraceptive services from 2007 to 2011. Table 1 illustrates the demographic breakdown of these youth. In 2011, each Youth Peer Provider served 48 peers on average (ranging from 24 to 119). In Nicaragua, AMNLAE’s Youth Peer Providers served 28,088 youth from 2007 to 2011. In 2011, each one served an average of 37 peers (ranging from 15 to 60). All Youth Peer Providers offer condoms and oral contraceptive pills, highlighting the importance of condoms to prevent sexually transmitted infections. At several programme sites, Youth Peer Providers are trained to offer injectable contraceptives and refer peers out for administering it. At CEMOPLAF, they also offer emergency contraception. All methods offered are available without prescription at pharmacies. Youth Peer Providers 145
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refer peers with questions beyond their expertise to medical professionals, and Coordinators oversee quality of care. Youth Peer Providers receive suggested prices for methods from Coordinators. Prices are always lower than comparable products at pharmacies or private health centres, although pricing structures vary by organisation and site. Methods are always offered free when youth cannot pay. Youth Peer Providers do not seek out peers to offer methods. They make themselves available to peers as trusted resources by introducing themselves in classes and community meetings, and interested youth approach them. “Despite that fact that I am a father, I did not understand the responsibilities parenthood carried with it [until I joined the youth programme]. I thought it meant having sex and that was it. When my now wife told me we would be having a child, I was surprised and did not know how to take on that responsibility. I looked for support and advice, but there was no one in my family to give me either. I could not tell them, because then what would they think of me? I thought if I told my friends they would make me feel bad. In the end I called my friend at CEMOPLAF, and told him with embarrassment. I liked the way he began to counsel me. Little by little he helped me to understand and recognize my responsibilities... and it improved me as a person.” (Male programme client, 18 years old) Youth Peer Providers carry contraceptive methods in their backpacks and meet peers at any conve146
nient time and place, often during the school day, or at places like football practice or in one of their homes. They offer comprehensive information on contraceptive options, including advantages, disadvantages, and mechanisms of action, as well as on prevention of sexually transmitted infections, in an age-appropriate and culturally relevant manner. Young people electing a method are screened for contraindications and receive additional information and their first month’s supply on the spot. Follow-up occurs at least once monthly, and often considerably more, regardless of the method. Many Youth Peer Providers report seeing the young people they serve daily, at school or in their neighbourhoods. During follow-up visits, Youth Peer Providers inquire about side effects, confirm correct usage, answer questions, and resupply methods. Initial visits can last up to half an hour or more depending on the prior knowledge of the young person. Follow-up visits range from a few minutes for a quick check-in to half an hour or more to answer questions or concerns. Youth Peer Providers generally meet peers individually, although occasionally partners are present. When peers have questions or concerns beyond the skill level of Youth Peer Providers, they are referred to health professionals. In Ecuador, youth are referred to CEMOPLAF health centres, where staff are trained in youth-friendly services. These address the specific needs of young people, recognizing their rights to information, to make their own decisions and to enjoy their sexuality in a healthy way. Youth-friendly health centres offer convenient schedules and locations, comfortable and age-appropriate spaces, and manageable administrative processes. Staff treat young people with trust and respect and maintain their confidentiality.25 In Nicaragua, Coordinators develop relationships with local providers, and youth are referred there. Generally, Coordinators lead educational activities for parents and teachers, while Youth Peer Providers lead activities for students and community groups. In 2011, CEMOPLAF reached 50,559 community members through information, education and communication activities, and AMNLAE, 52,440. All educational activities and materials are adapted to their audiences, by literacy level and social and cultural background. Materials contain images of local populations, utilise local languages, and link sexual and reproductive health to locally relevant topics.
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“Thanks to CEMOPLAF, my son did not get married quickly, as his other brothers did... My life would have been different if I had had condoms and pills when I was young… My [youngest] son knows about condoms, because if he did not, he would have already married… He wants to work and study and only then, later, have a wife. I would have wanted my other six children to be that way.” (Father) Activities are tailored to meet community needs. In urban areas, they are conducted in schools, community centres, or football arenas, and in rural areas, at local markets, community service events, or people’s homes. Activities include in-school workshops for youth, teacher training, discussion groups for parents, door-to-door home visits, educational booths at community events, outreach at sports games or community service events, street theatre, dance expositions, and puppet shows. Most activities are held for groups, but Youth Peer Providers also offer small group or one-on-one education. Organisations utilise radio programming to reach broader audiences; youth record and broadcast public service announcements and short segments about sexual and reproductive health. In Ecuador, where mobile technology is inexpensive and widespread, CEMOPLAF employs some mobile and computer-based technologies. Youth can text, call or e-mail trained staff for answers to pressing questions. Additionally, the organisation has utilised online chat rooms and social networking to disseminate information. Organisations engage Youth Peer Providers in advocacy. In Nicaragua, AMNLAE coordinated young people to participate in local and national summits to ensure their representation in political dialogue. In Ecuador, Youth Peer Providers in Latacunga receive extensive training on human rights and participated in a virtual exchange of youth advocates around the world.
Challenges and lessons learned As with any programme model, challenges exist. A primary challenge is sustainability, given that services are provided free or at greatly reduced prices. At CEMOPLAF the youth programme attracts new clients to health centres, generating income to cover programme costs, and expenses are integrated into health centre budgets. AMNLAE provides loans to sites to start small businesses, which offset some, but ultimately few, costs. Sites 148
have started businesses ranging from internet cafés to used bookstores, staffed by Youth Peer Providers. Net profit is invested in the programme. Experience has shown that sustainability is more feasible in an organisation that, like CEMOPLAF, can generate income through the programme. Garnering support from organisational leaders is vital. At CEMOPLAF, supportive health centre directors foster thriving programmes, while sites with unsupportive directors struggle and often fold. Successful strategies to cultivate support include education about the programme prior to implementation and demonstrating the benefit to health centres’ revenue. Appropriate staffing is key to programme success. CEMOPLAF found that successful Coordinators are dedicated to working with youth. Lacking this commitment, Youth Peer Providers do not feel supported, and attrition rates are high. Organisations must strike a balance between financial sustainability and adequate staffing. At most CEMOPLAF sites, Coordinators have responsibilities outside the programme. As a result, many report not having sufficient time to carry all of their responsibilities. At AMNLAE sites, Coordinators are part-time due to limited budgets, and staff only have time for monthly training activities. Youth Peer Providers report to Coordinators and Planned Parenthood Global a desire for more frequent trainings and meetings, but sustainable staffing solutions remain to be found. Additional budget allocated to staffing and realignment of job responsibilities are possibilities. Coordinator and Youth Peer Provider turnover presents another challenge. Programme Directors report that when programme staff leave their positions, Youth Peer Providers also leave the programme. Similarly, when Youth Peer Providers leave, their peers are often lost to follow-up. Both organisations strive to ensure youth feel more invested in the programme than in any one staff person. In Nicaragua, Coordinators form personal relationships with Youth Peer Providers and their peers. Inviting youth to participate in educational and other events encourages continued involvement. Similarly, Coordinators in Ecuador found that forging relationships between Youth Peer Providers, their peers and health centre staff encourages them to return. Further efforts are needed to improve programme continuation. Monitoring young people’s satisfaction with services and information they receive from Youth Peer Providers is challenging, as many prefer to
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remain anonymous. Currently most supervision of Youth Peer Providers is carried out by monitoring contraceptive records and assessing their skill through educational activities. CEMOPLAF is piloting a system whereby Youth Peer Providers ask peers to complete annual satisfaction surveys. At AMNLAE, additional ad hoc monitoring is possible due to personal relationships Coordinators have with youth. Experience has shown that Coordinators need to be more involved in the relationship from the beginning where possible, while still maintaining confidentiality. New strategies are needed to facilitate this process. Both financial and logistical barriers present challenges to securing contraceptive commodities, and irregular supply negatively affects contraceptive usage. In 2008–2009 volume at CEMOPLAF dropped precipitously when new customs regulations led to a shortage of oral contraceptive pills. Investment in commodity procurement is essential to programme success. Community buy-in also represents a challenge. Schools, parents, community leaders and religious entities have all expressed concerns about the programme model in certain communities. Both organisations have confronted this by working closely with these groups to foster understanding of the programme and sexual and reproductive health more broadly. In rural areas, CEMOPLAF has collaborated with trusted organisations to facilitate implementation, as well as conducted door-to-door home visits before starting contraceptive services. A final lesson learned is that contraceptive access through the programme is essential; peer education alone does not eliminate barriers to obtaining methods. “What’s the point of all this information on how to use them if I don’t have them to use? It would just be a lot of talk on the street but not much else.” (Young contraceptive user) “There’s no value in just talking, talking, talking.” (Youth Peer Provider) “I think it’s ideal that it’s the contraceptive and the information... It’s easier and more accessible for the young people. That way they can also put into action the learning they’ve received.” (Mother)
Programme evaluations Information in this article draws upon ten years of programme monitoring and evaluation, focus-
ing on three evaluations. First, in 2004, Planned Parenthood Global conducted an evaluation of both CEMOPLAF and AMNLAE Youth Peer Provider programmes to identify long-term benefits of programme participation, specifically health behaviours and outcomes. Youth Peer Providers at six sites conducted structured interviews using a 33-item survey on contraceptive use and history of pregnancies and births. 597 respondents were randomly selected from contraceptive users with records going back to five years prior. They had participated in the programme for an average of three years. Second, from 2007–2009, CEMOPLAF carried out an evaluation of their programming across Ecuador utilising the Most Significant Change Technique,26 collecting 92 interviews in a qualitative, participatory evaluation process to assess programme impact. The survey tool comprised six questions: how participants became involved in the programme, what their current participation entailed, the changes they saw resulting from the programme, which was the most significant, why, and what recommendations they had for the programme. Third, in 2010, Planned Parenthood Global conducted 15 in-depth interviews covering participants’ assessments of CEMOPLAF’s strengths, weaknesses, and impacts, and operational issues including supervision and training.27 Given the similar methodologies and response categories of the second and third evaluations, their results were combined for analysis. The 107 respondents included current and past Youth Peer Providers, youth receiving counselling and methods through the programme, students receiving regular trainings from Youth Peer Providers or Coordinators, parents of programme participants, organisational staff, staff at participating schools, and other young people. Both evaluations comprised purposive samples and utilised convenience sampling. Findings: 2004 survey The 2004 survey revealed high levels of contraceptive use among young people previously served by Youth Peer Providers (Table 2). Threequarters of survey respondents were sexually active, and 95% of those sexually active reported current contraceptive use. Among those who did not want to become pregnant at the time of the survey, this increased to 98%. These levels are very high relative to comparable data available. In the general population in 149
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half (49%) named one or more specific areas in which programme participants’ knowledge increased, including pregnancy prevention, contraceptive methods, sexual transmitted infections, HIV, sexuality, and anatomy. Many respondents indicated this knowledge enabled youth to be responsible about their health, particularly through protection from sexually transmitted infections and unintended pregnancy. “Previously I knew absolutely nothing about condoms or pills, and now I can protect myself.” (Male high school student) The second most common programme impact mentioned was personal growth, named by 42% of respondents. Programme participants matured emotionally and intellectually, became more responsible, and made better decisions, including related to sexual and reproductive health behaviours, alcohol and drug use, and participation in gangs. “In these four years I have [watched] them, I have seen them grow not only physically, but also in their emotional and intellectual maturity, in being responsible, and in behaving responsibly.” (CEMOPLAF staff member) Nicaragua in 2001, 63% of sexually active 15–24 yearolds utilised a modern contraceptive method.28 In the general population in Ecuador in 2004, 64% of youth 15–24 years old living with a partner utilised a modern contraceptive method.29 Three-quarters of survey respondents had ever utilised a condom to prevent sexual transmitted infections, which also compared favourably to the general population. In Nicaragua, less than one-quarter of women under 30 had ever used a condom.28 Findings: qualitative evaluations Ecuador 2007–10 The impact of the CEMOPLAF programme on contraceptive use was supported by the qualitative evaluations, where six per cent of respondents noted, unprompted, a decrease in teen pregnancy in their communities as a result of the Youth Peer Provider programme.
Twenty-two per cent of respondents mentioned increased self-esteem, self-confidence, and leadership skills of youth involved in the programme. Many programme participants noted that they had had low self-esteem going into the programme, but that their participation led them to value and respect themselves. “One of the most important changes was really getting to know myself and improve my selfesteem… I did not believe in myself, and above all, I hated myself. At CEMOPLAF they taught me not only what a contraceptive is, they taught me to love myself and respect my body, my feelings, and above all, my thoughts.” (Female Youth Peer Provider)
“I saw [the change] in the high school… my daughter and the girls in her class graduated, and none of them were pregnant – although they had active sex lives.” (Mother)
Twenty-three per cent of respondents reported that programme participants improved their communications skills, both around sexual and reproductive health issues and in general. Youth reported being more open and expressive and more comfortable talking about sexuality. Participation in the programme also led young people to respect others, according to 11% of respondents.
The most common programme impact mentioned by respondents was increased knowledge. Nearly
“I have learned to live with other people, to respect others’ comments and ideas… because we are all
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people and we should respect one another.” (Male Youth Peer Provider) An important number of respondents highlighted the improvement in young people’s relationships with their family (27%) and friends (17%). Youth and their families saw increased trust and support within their family relationships, and programme participants experienced strengthened bonds with their friends. “When I entered the programme I had a lot of family problems. In my house no one listened and everything was solved with violence. I started drinking, and I didn’t have a good friend or anyone who understood my situation. When I entered the programme out of curiosity, I discovered there was a space where I could be myself and be understood and understand why I was the way I was, and that was how the programme became my home and the other youth became my family… There are many youth who aren’t understood in our homes and the programme is a fundamental tool to help them grow.” (Male Youth Peer Provider) Several respondents (7%) noted that young people who participated in the programme became more involved in school. They began to speak up more in class and focus more on their studies. Five per cent of participants noted improved relationships between teachers and students who participated in the programme. Ongoing programme monitoring and evaluation reveal that many effects of the model are longer term than what is captured through typical evaluation mechanisms. Five percent of respondents mentioned that programme participants had greater professional aspirations as a result of participation. Many have assumed leadership positions within NGOs, the government and international organisations, and work in sexual and reproductive health and other social justice issues as many as 15 years after contact with the programme.
knowledge and skills gained through participation, including decision-making and communication skills, can influence protective behaviours. The maturity, self-esteem and self-confidence participants develop can contribute to health-seeking and positive health outcomes.30 The impact of the programme is broader than originally anticipated, reaching young people directly involved with the programme but also their communities. Participation seems to foster stronger relationships between young people and their friends, family and teachers, and greater respect and better communication within those relationships. These factors can positively impact young people’s sexual and reproductive health by reducing barriers to information and care. Given the wideranging potential for positive outcomes of these programmes, we believe they should be expanded to new areas and new organisations. Lessons learned through Youth Peer Provider programme implementation can also help to strengthen existing programmes* aimed at improving adolescent access to sexual and reproductive health information and services. Acknowledgements We would like to acknowledge the staff at AMNLAE and CEMOPLAF for their tireless work in Latin America, and Planned Parenthood Global staff, past and present, for supporting these efforts. In particular, we would like to thank Teresa de Vargas, Elsa Racines, Adaly Ordoñez, and Martha Ambota for their ongoing commitment. We would like to thank Diana Santana for her significant contributions to this paper, and Kelley Carnwath, Ellen Clancy, Jessica Getz, Alana Ortez, Heather Sayette, and Wendy Sheldon for assistance in technical support, monitoring and evaluation.
Conclusions The Youth Peer Provider model offers young people access to vital health information and services and presents an important opportunity to improve young people’s sexual and reproductive health in Latin America and beyond. Programme evaluations provide strong evidence that programme participation leads to healthy behaviours, including contraceptive use. Increased
*Planned Parenthood Global developed a Youth Peer Provider Programme Replication Manual that provides in-depth guidance and comprehensive training materials for organisations considering implementing the programme: www. plannedparenthood.org/images/PP_Global_YPP_Manual.pdf.
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12. Kirby D, Laris BA, Rolleri L. Impact of sex and HIV education programmes on sexual behaviors of youth in developing and developed countries. Research Triangle Park: Family Health International/ YouthNet; 2005. 13. Goicolea I, Coe AB, Hurtig AK, et al. Mechanisms for achieving adolescent-friendly services in Ecuador: a realist evaluation approach. Global Health Action 2012;5. 14. World Health Organization Department of Reproductive Health. Medical eligibility criteria for contraceptive use. 4th ed. Geneva: WHO; 2010. 15. Saavedra M. Young people in Bogota, Colombia develop their own strategies to prevent risky sexual behavior. SIECUS Report 1996;24(3):10–12. 16. Li S, Huang H, Cai Y, et al. Evaluation of a school-based HIV/AIDS peer-led prevention programme: the first intervention trial for children of migrant workers in China. International Journal of STD & AIDS 2010;21: 82–86. 17. Wolf RC, Pulerwitz J. The influence of peer versus adult communication on AIDS-protective behaviors among Ghanaian youth. Journal of Health Communication 2003;8(5):463–74. 18. Brieger WR, Delano GE, Lane CG, et al. West African Youth Initiative: outcome of a reproductive health education programme. Journal of Adolescent Health 2001;29(6):436–46. 19. Speizer I, Tambashe BO, Tegang SP. An evaluation of the “Entre Nous Jeunes” peer educator programme for adolescents in Cameroon. Studies in Family Planning 2001;32:339–51. 20. Peña R, Quintanilla M, Navarro K, et al. Evaluating a peer intervention strategy for the promotion of sexual health-related knowledge and skills in 10- to 14-year-old girls. Findings from the “Entre amigas” project in Nicaragua. American Journal of Health Promotion 2008;22(4):275–81. 21. Perez F, Dabis F. HIV prevention in Latin America: reaching youth in Colombia. AIDS Care 2003;15(1): 77–87. 22. Re MI, Pagani L, Bianco M. Assessing workshops on sexuality with Argentinian youth. AIDS STD Health Promotion Exchange 1996;(3):13–15. 23. Instituto Nacional de Información para el Desarrollo. Cifras municipals. Managua: INIDE; 2008. www.inide. gob.ni/censos2005/CifrasMun/tablas_cifras.htm. 24. Instituto Nacional de Estadística y Censos. Banco de Información. Ecuador; 2011. www.inec.gob.ec/ estadisticas/?option=com_content&view=article&id= 109&Itemid=88.
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Résumé En Amérique latine, les jeunes enregistrent des taux élevés de grossesse et d’infections sexuellement transmissibles, mais les services de santé traditionnels ne répondent pas à leurs besoins. Ils doivent avoir accès à des informations et des soins de santé adaptés pour prendre des décisions saines et judicieuses. Pour lever les obstacles à ces services essentiels de santé sexuelle et génésique, Planned Parenthood Global, une division de Planned Parenthood Federation of America, a élaboré un modèle de jeunes pairs qui est mis en œuvre en Amérique latine depuis le début des années 90. Le modèle va au-delà de l’éducation des pairs pour apprendre aux prestataires de moins de 20 ans à distribuer des préservatifs, des pilules contraceptives orales, une contraception d’urgence, des contraceptifs injectables et une information de santé sexuelle et génésique à leurs pairs. Les jeunes dont les besoins dépassent les capacités des pairs prestataires sont aiguillés vers des professionnels de la santé qui assurent des services adaptés aux jeunes. Les enquêtes révèlent de hauts niveaux d’utilisation des contraceptifs parmi la population desservie par ces pairs: 98% de répondants sexuellement actifs souhaitant éviter une grossesse ont indiqué qu’ils utilisaient un contraceptif au moins cinq ans après avoir rejoint le programme. Les évaluations qualitatives du programme mettent en évidence une meilleure estime de soi, des aptitudes plus solides à la communication et à la décision, d’étroites relations avec les amis et la famille, davantage d’intérêt pour l’école, une compréhension de la responsabilité dans les relations et d’autres résultats positifs parmi les participants du programme.
Resumen En Latinoamérica existen altas tasas de embarazo e infecciones de transmisión sexual en la adolescencia. Los servicios tradicionales de salud no están atendiendo las necesidades de salud de los jóvenes, quienes necesitan acceso a información y servicios de salud adaptados a sus necesidades para poder tomar decisiones informadas y saludables. Para eliminar las barreras a estos servicios vitales de salud sexual y reproductiva, Planned Parenthood Global, una división de Planned Parenthood Federation of America, creó un modelo de Proveedores Pares de Jóvenes, el cual comenzó a aplicarse en Latinoamérica a principios de la década de los noventa. El modelo va más allá de la educación de pares para capacitar a Proveedores Pares de Jóvenes menores de 20 años para que sumistren a sus pares condones, píldoras anticonceptivas orales, anticoncepción de emergencia, anticonceptivos inyectables e información sobre salud sexual y reproductiva. Pares con necesidades más allá de la capacidad de estos proveedores reciben referencias a profesionales de la salud que ofrecen servicios amigables para la juventud. Los resultados de una encuesta revelan altos niveles de uso de anticonceptivos entre jóvenes atendidos por Proveedores Pares de Jóvenes: el 98% de las personas encuestadas que mantienen relaciones sexuales y desean evitar embarazos informaron continuar usando anticonceptivos por lo menos cinco años después de inscribirse en el programa. Entre los resultados de las evaluaciones cualitativas del programa se destacan mayor autoestima, mejores habilidades de comunicación y toma de decisiones, relaciones cercanas con amistades y familiares, más interés en la escuela, entendimiento de la responsabilidad en relaciones y otros resultados positivos entre los participantes.
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