Peer educators – recruitment and support
Two types of peer educators were recruited to the GUSO programme: those who were based in their communities, including schools, whose primary role was to provide SRH information and education to other young people; and youth peer providers7 who were based in participating health facilities and supported young people’s access to health services.
Recruitment methods varied, with some peer educators being recruited through community leaders, such as chiefs, friends, family or community health workers because they showed one or more desired qualities, including friendliness, leadership skills and/or specific technological abilities. Other peer educators said they thought that they were recruited because they were struggling with issues pertinent to the programme, such as teenage pregnancy or drug use, whilst yet others responded to advertisements. Some participated in an interview process while others did not.
How we recruited was [different] at different levels. Because the peer provider model was new, we wanted to leverage a platform that we had. So, we did engage community focal persons who engaged their community health extension workers to help in recruitment. We were able to have peers – or boys and girls – who were from the geographical surroundings of facilities. We had a pool, and we interviewed some. They understood what kind of volunteer work they got into. We reviewed the pool based on: whether just visiting or full time for at least 1 year; whether they wanted to venture into SRH volunteership [most of them had SRH as a new concept]; and for those who were minors, below 18, we had to ask if their guardians were comfortable. (GUSO staff member, Kisumu)
Gender was only taken into consideration insofar as an equal number of girls and boys were recruited as peer educators. Recruitment could therefore be described as gender aware, based on the premise that gender would be important in influencing young people’s receptivity to information and outreach: ‘They were looking for gender equality so that females could talk to females and males to males.’ (Peer educator, Siaya)
Training and support
The amount and content of training and support provided to peer educators varied widely. Twenty-two of the 24 peer educators reported receiving training to some degree; most of the training was geared towards preparing them to provide SRH information, education and/or services to other young people. However, peer educators reported varying training duration, from three days to five weeks. All peer educators reported receiving support in terms of supervision and technical updates during their work.
I was trained for one week and two days additional training as a peer provider at the facility by the facility in-charge. I have also been trained on monitoring and evaluation, youth friendly services and meaningful youth participation. I was trained by KMET on ASRH, community health messaging, and referrals. HIV, STIs, drugs and substance abuse, alcohol abuse, referral channels, and comprehensive abortion care. I am supervised by the facility in charge at the facility and by the project officer when we go for outreach. I have received refresher training on the same topics and additionally COVID 19, including how it has affected referrals that young people seek from the community. (Peer educator, Kisumu)
[We received training for] five weeks [on] how to control HIV/AIDS/ contraceptives/use of condoms and setting personal goals. (Peer educator, Siaya)
The topics covered in training also varied widely, with contraception and HIV prevention being the most commonly cited; menstrual hygiene, gender-based violence, and substance abuse and other topics were mentioned by a few peer educators. Many described being trained in how to conduct outreach work, speak to other young people effectively, and provide referrals to SRH services. All the peer providers and some community-based peer educators also received training in service provision – primarily counselling on issues such as contraception and pregnancy, HIV testing and counselling, and mental health.
Just over half of all the peer educators mentioned receiving refresher training or content related ‘updates’ throughout the time with the programme. Most peer educators described receiving a significant amount of supervision and support from the organisation with which they worked, including monthly meetings with supervisors in some cases. Those working in health facilities were most likely to mention supportive supervision.
Compensation of peer educators varied widely. Some reported receiving only travel cost reimbursement, while others received monthly stipends. Some peer educators reported that they received incentives such as t-shirts, caps, notepads and/or pens. In the case of one programme partner, peer educators had been recruited through a separate programme that paid their school fees, and this caused a degree of confusion as to whether their peer education activities were a required activity to continue receiving that benefit. Finally, several stakeholders recognised the importance of compensation of some kind for peer educators to continue to motivate them and ensure their participation:
Motivating peer providers is very important as they are the lifeline of the programme at the community level. They help reach many youths. (Nurse, Siaya)
Peer educator contributions
When asked whether GUSO measurements adequately captured peer educators’ contributions to the programme, no study participants answered affirmatively and many recognised gaps in how peer education was measured. Among other things, study participants wished that there had been data to illustrate peer educators’ contributions to decreasing unsafe abortion; the creation of SRHR related social media content; changes in cultural beliefs; reductions in school dropouts; ensuring commodity availability and avoiding stockouts; reductions in teenage pregnancy; and reductions in parent-child conflict, amongst others.
Access to information and education
Monitoring data reveals that over 7,600 people were trained to provide SRHR education and information to young people in Kenya; however, it is not known how many of these were peer educators (GUSO Kenya Citation2021). Peer educators were trained to provide information and education through a variety of channels, including one-to-one, informal interactions and more formal group sessions in school and at community events.
Every peer educator interviewed stressed the importance of sharing information with other young people, with many seeing this as the most important part of their role. Importantly, peer educators expanded on the reach and content of what they provided, going above and beyond their prescribed roles and responsibilities. For example, many described taking on personal responsibilities for the well-being of young people in their communities. Being seen as a role model and mentor in the community was a badge of honour. Other young people as well as parents and community leaders asked them for advice outside of their ‘working hours’ (FGD4) – tasks that likely went undocumented through the formal reporting channels. Programme participants described being given ‘guidance’ by peer educators to help make informed decisions about life matters (FGD4).
In schools we do group talks based on the ages. We address emerging issues based on questions raised. We form health groups within the schools and the students select a leader of the health group whom we reach [out to] for any updates, especially requirements for more health talks. (Peer educator, Kisumu)
The content of the information provided by peer educators went beyond the SRHR topics included in their training. Much of it could be described as general life coaching or counselling on relationships with parents; teenage behaviour; peer pressure; drug use; friendships; life goals; education and more. One peer educator shared:
I have spoken with teenage mothers on how to take care of themselves, how to relate in community and to their parents to reduce conflicts, addressing issues of unsafe abortion, problems of drug and substance abuse and avoiding bad company.’ (Peer educator, Siaya)
Informing young people about available SRH services was another part of peer educators’ role. Many said that making referrals and/or escorting young people to health facilities was of crucial importance to ensuring that they are able to act on the SRH information received. One peer educator described the linking role that she played between information, services and enabling environment as follows:
‘I help provide a conducive environment for youth to be able to access services. I provide a link for the youth who are referred to the facility and I give basic counselling before services uptake. I provide referrals [and] escorts for young people for health services at the facility’ (Peer educator, Siaya).
Monitoring data indicated that over 615,000 young people were reached with information or education during the five years of the programme, although data on the percentage of these reached by peer educators is not available.
SRH service utilisation and quality assurance
Peer educators helped increasing the utilisation of youth-friendly SRH services8 through community outreach, awareness raising and referrals for young people as well as by directly providing services to young people. They also monitored service quality and participated in formal and informal quality assurance processes.
During community outreach, peer educators’ efforts were focused heavily on raising awareness of the availability of SRH services for young people as well as how youth-friendly the services were. This was needed in order to overcome preconceived ideas amongst young people about the SRH services: ‘The youth used to have a mentality that some nurses were bad … We connect the youth to the health providers who have changed their attitudes towards youth and become more supportive. Youth now feel free to come and get health services at the facility.’ (Peer educator, Siaya)
Some peer educators, such as those working with KMET, were trained as peer providers and were able to provide contraceptive and counselling services to young people themselves. Others simply referred young people to the youth-friendly services in their area. Yet others personally escorted young people to the services, ensuring they knew where to go. Furthermore, many peer educators participated in HIV testing and cervical cancer screening drives in their communities, ensuring the inclusion and participation of young people.
With respect to quality assurance, peer educators provided feedback from young people to service providers that allowed improvements and adjustments to be made . At the health facility level, peer educators were the ‘eyes and ears’ of young people, with many indicating that they made ‘regular visits’ to check on the quality of services provided to young people: ‘We ask about services which are not being provided to the youth and communicate the same to TICH which comes to help and improve the quality and range of services offered’ (Peer educator, Siaya). Another peer educator in Siaya described how he regularly asked health facilities’ staff members how they were providing services to young people, ensuring that they were making use of the dedicated youth room. Two other peer educators mentioned encouraging health providers to be friendly, maintain confidentiality and use polite language when speaking to young people (Siaya). Yet others helped clinics become more ‘attractive’ to youth by planting trees and designating corners or rooms specifically for young people, to make them feel comfortable.
Monitoring data for the GUSO programme reveal that over 3 million direct and indirect SRH services were provided to young people during the five year implementation period across Kenya (GUSO Kenya Citation2021). As with information and education, figures that isolate peer educators’ contributions are not available. The endline evaluation of the GUSO programme in Kenya showed increases in young people’s utilisation of the following services in the implementation areas: male circumcision, child protection, STI testing, counselling for sexual violence, and voluntary counselling and testing for HIV (Kok et al. Citation2021).
One of the five GUSO outcome areas was ‘improved socio-cultural, political and legal environment’ (for SRHR). The programme did not measure peer educators’ contributions in relation to this outcome. However, this study found that peer educators worked to increase the support and involvement of important stakeholder groups and, as a result, were able to share their ideas more freely.
In particular, peer education increased community support for youth SRHR and support for the provision of SRH information, education and services for young people, as well as collaboration between different community actors, such as parents, churches, teachers, police officers, paralegal workers, school administrators, health management committees, local provincial administration and parents. Whilst some actors were resistant to the GUSO programme at first, they eventually changed their minds:
‘Some churches didn’t allow [SRH education], but through our efforts, now they are giving us that platform, that is a great achievement’ (GUSO staff member, Kisumu).
As a result of greater acceptance from their communities, peer educators gained access to platforms through which they could highlight issues of importance to them, including adolescent sexuality; teenage pregnancy; unsafe abortion; return to schools for pregnant girls and young mothers; drug use; justice for survivors of sexual violence; and reduction in child marriage. New spaces opened up for young people to voice their concerns, including policy-making forums and new decision-making opportunities within the GUSO implementing partners (Peer educator, Siaya).
Parents and the community were initially not very supportive of the programme, but now having seen the positive changes in behaviours of youth in the community, they are supportive. Issues of drug abuse used to cause a lot of dropout and idle youth in the community but this has changed … (Peer educator, Kisumu)
We speak during public meetings, and we have gained acceptance and conduct dialogue on issues that were previously difficult to discuss such as adolescent sexualilty and teenage pregnancies. (Peer educator, Siaya)
Peer educators tackled sensitive issues, increasing openness to discussion amongst stakeholders in the community and gaining support for engaging with such concerns. One adult stakeholder shared the following: ‘Unlike in the past, peer educators are able to address sensitive topics in the community such as teenage pregnancy and unsafe abortion’ (Local government representative, Siaya).
Organisational and programmatic strengthening
Strengthening the Kenya SRHR Alliance was the first outcome area of the GUSO programme in Kenya. However, peer educators’ contribution to this element of work was not measured. Our study findings highlight how peer educators not only brought enhanced visibility to implementing organisations but, also, taught them what being accountable to young people meant in practice.
Adult stakeholders interviewed credited peer educators with bringing greater visibility to the work of their organisations, making them more credible and known about for their ability to reach youth. Programme participants agreed, with one group saying that there were ‘more partnerships with the community’ as a result of peer educators’ innovative activities [FGD3]. Several peer educators noticed a shift in how supportive organisations were for youth, with one commenting: ‘[The partner organisation] has become more supportive of youth’ (Peer educator, Kisumu). According to one peer educator, implementing GUSO partners saw ‘an increase in youth participation in [their] programme activities and in the community’ (Peer educator, Siaya).
Apart from strengthening organisations, peer educators were recognised as strengthening the GUSO programme as a whole. Peer educators were seen, and saw themselves, as links between various components of the programme, including services, information/outreach, advocacy, youth participation, advocacy and monitoring and evaluation. At the county level, a government stakeholder noted the importance of linkages created with peer educators:
‘We were constantly ensuring, for every meeting at county level, [that] youth peer providers were there to represent the programme – at stakeholder meetings, county meetings that needed young people’s voices’ (GUSO staff member, Kisumu).
Another stakeholder observed that peer education not only expanded the reach of the programme within communities but, also, provided a way to sustain efforts beyond the life of the programme:
[Peer educators] contributed to more sustainable programming. Use of youth in provision of information and linkage to services at the community has a lasting impact on the youth themselves and community at large. They provided extra human resources that TICH could not afford, to reach all the areas within the project time. Using community own resource persons is more sustainable for programs. We are now more focused in supporting youth to take leadership in programming and to better understand the dynamics in youth programming. (GUSO staff member, Siaya)
Gender norm transformation
Study participants reported many examples of changes in gender norms brought about by peer education. These included greater value being placed on girls’ education, including for pregnant girls and young mothers; greater acceptance of girls desiring relationships; positive views of girls who do not follow traditional gender roles; encouragement for the sharing of responsibilities between boys and girls; and community mobilisation to encourage reporting and prosecution in cases of sexual violence.
It is true, it has changed a lot. Before, ladies and girls were regarded like people who were not meaningful in society …. Get married and that’s just our life, and now we are very concerned with girls’ education, a lady who is empowered …. can have strong health and life. (GUSO staff member, Kisumu)
More girl[s are] empowered to say no (to unwanted sexual advances). The belief that a girl should be [a] housewife has changed. They too can get jobs and work. Before, girl children could not speak out with parent[s] on SRH, but now they are free to talk …. Sharing ideas in the community was difficult but through GUSO we are free to express ourselves. (Peer educator, Siaya)
Study participants mentioned change in relation to the reporting of sexual violence in their communities. One peer educator explained: ‘I think it is a bit easier now to get community support for arrests of defilements perpetrators especially among relatives.’ [PE10] Young programme participants also mentioned how peer educators were working with chiefs and village headmen to ensure that sexual violence cases were reported to the police; the latter spoke of knowing the steps to follow in the case of rape and how to speak out as a result of interacting with GUSO peer educators (FGD1). One peer educator also mentioned working with county level officials to develop a new sexual and gender-based violence policy (Peer educator, Kisumu).
Youth economic empowerment
By working together, peer educators found unity of purpose, leveraging the network created as an opportunity to create economic opportunities for themselves and other young people. Peer educators in Siaya and Kisumu Countiesd formed small groups called chamas that evolved into community welfare services, saving schemes and business groups. Some chamas initiated enterprises that made and sold baked food, sanitary towels and jewellery, whilst others started grocery and tree seedling planting businesses. Two peer educators explained how they had been able to establish their businesses using the allowances they received as peer educators. To ensure viability, one stakeholder described how ‘peer educators [had] engaged local politicians and secured sponsorship for income generating activities such as setting up a small gasoline station’ (GUSO staff member, Siaya).
The ripple effects of this entrepreneurship were evident at various levels of the community. Peer educators engaged other young people in these economic endeavours, thus expanding their collective economic power. During one focus group discussion, a participant commented how by ‘making necklaces, sanitary towels and small grocery business, youth are becoming more independent and charting their own future’ [FGD1]. Peer educators also reported an increased ability to support their families, including paying for their own or siblings’ school fees, accumulating savings, enhancing their social status, and gaining recognition for being role models.
Confidence, life goals and employability
Study findings suggest increased self-confidence amongst both programme participants and peer educators as a result of their participation in the GUSO programme. This in turn contributed to changes in life goals and aspirations as well as job opportunities.
For programme participants, changes were shaped by participation in activities such as sport and drama, which enhanced their self-esteem, as well as enhanced awareness of their own health and rights (FGD1). One group of participants observed that after engaging with peer educators, they were better equipped to deal with peer pressure (FGD1).
Many peer educators also experienced increases in confidence. Factors that contributed to this included training, volunteer experience, being seen as role models, and public speaking engagements.
I was green at recruitment but with training received, and experience gained, I have been capacity built and am now able to teach and provide information to the youth. It has boosted my role at the facility, and I now hope to be a doctor one day. (Peer educator, Siaya)
Changes were also witnessed in peer educators’ employability beyond their own communities. One stakeholder described how some GUSO peer educators transitioned to take up more responsibilities including jobs elsewhere in Kenya:
For me, the peer educators I worked with are now running programmes. I was in a conference with one of my peer educators, and the way she was articulating issues made me feel that the peer educators, if empowered and mentored, can deliver. … I have been able to witness peer educators [running] programmes. They are in full-time employment. One works with M-TIBA9; one is a county commissioner; and another one (works) with Family Health Options Kenya. There is one in Nairobi with an organisation. [Peer education] has been providing them with a platform that puts them on a career path. (GUSO staff member, Kisumu)