Peer advocates for health: a community-based program to improve reproductive health knowledge and lifestyle choices among adolescent males.

Peer Advocates for Health is a community-based program to increase reproductive health knowledge and improve lifestyle choices among African American adolescent males. This study examines program impact on knowledge, clinic utilization, communication, and condom use among participants. PAH provided training, support, and employment experience to 75 African American males from 15 Chicago high schools, who reached 4,000 adolescents in their own communities, providing information and condoms. Mean age at intake was 15.9; all were in school, unmarried, and living at home. One-third reported never having sex: only one had fathered a child. After one year, knowledge, utilization of clinic services, and communication with partners and peers increased significantly. Condom use remained high, and condom self-efficacy increased. Results suggest that, to impact behaviors and lifestyles of high-risk adolescents, programs must provide not only education but also long-term follow-up and support in the context of everyday lives.

Keywords: adolescent males, community-based programs for males, reproductive health, condom use

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The 1990s brought a renewed awareness of reproductive health issues for males and an increased recognition of the roles and responsibilities of the male partner (Schulte & Sonnenstein, 1995). The globalization of HIV and AIDS during the past two decades has highlighted the importance of male sexual behavior and condom use in relation to the health of both partners (AVSC, 1999). The impact of male attitudes and behavior upon the reproductive health of both partners is especially critical among adolescent populations, particularly those adolescents who live in worlds with little structure and few resources. Increasingly, empirical research suggests that men who are informed and educated about reproductive health issues are more likely to support their partners' decisions about family planning and contraceptive methods (Grady, Tanfer, & Lincoln-Hanson, 1996: Fee & Youssef, 1993), yet access to reproductive health information and services is limited for many young men growing up in low-income, inner-city neighborhoods in the U.S. (Guttmacher Institute, 2002: Male Advocacy Network, 2002: Shultze & Sonenstein, 1995; Shirk, 1997). Unlike female adolescents, who generally access information and enter the health system with menstruation or pregnancy, adolescent males living in underserved neighborhoods may have contact with a healthcare provider once a year for a school physical or in a hospital emergency room (Male Advocacy Network, 2002). African American adolescent boys have been shown to be less knowledgeable about sexual health and have less positive attitudes about condoms than their female counterparts (St. Lawrence, 1993). Their source of reproductive information and gender norms is often the "street," where females tend to be viewed as "sexual targets" rather than partners in a healthy relationship.

THE PEER ADVOCATES FOR HEALTH PROGRAM

This paper describes "Peer Advocates for Health" (PAH), a community-based program designed to increase reproductive health knowledge and improve lifestyle choices among adolescent males recruited from inner-city neighborhoods in Chicago. Between 2000 and 2004, 75 African American males, ages 14-17, from 15 high schools on the south side of Chicago were enrolled in the program. This study examines the impact of PAH program participation on knowledge, clinic utilization, communication, and condom use among adolescent male participants. Peer Advocates for Health is a five-year demonstration project supported by the U.S. Department of Health and Human Services, Region V, Office of Family Planning. Broad goals of this pilot effort are, first, to determine if adolescent males from the south side of Chicago could be recruited to join a program that required a long-term commitment and group participation and, second, to design a program that meets the needs of these young men. The long-term goal is to utilize well-trained Peer Advocates as a mechanism for change, providing information and condoms to the broader community.

PAH is being implemented at a community health center that provides primary healthcare to families living in low-income communities on the south side of Chicago. The Peer Advocates program targeted two neighborhoods adjacent to the health center, Englewood and Woodlawn, where 40% of the families live in poverty, a majority of households (61%) are female-headed, only 63% of the people over 25 graduated from high school, and nearly one-quarter of the residents are unemployed (CDPH, 2004). Each of these factors--poverty, education, and employment--can directly impact access to healthcare (Sandman, Simantov, & An, 2000). Being a minority, being poor, and living in a female-headed household are all factors associated with risky behaviors and poor reproductive health outcomes for adolescent males (Blum, Beuhring, Shew, Bearinger, Sieving, & Resnick. 2000: Jemmott & Jemmott, 1992: Lindberg, Boggess, Porter, & Williams, 2000).

Current health status indices, coupled with limited access to healthcare, paint a bleak picture for adolescent males growing up in these neighborhoods. Life expectancy in Englewood (which is 98% African American) is 57 years, compared to 70 for the city of Chicago and 65 for the nation as a whole (CDPH, 1997). Non-Hispanic Blacks accounted for nearly 57% of HIV infections diagnosed in adults and adolescents in Chicago in 2001-2002 (Simpson & Benbow. 2003), and the rate of death from HIV infection is 21.4 for Blacks vs. 6.6 among non-Hispanic whites (Benbow, 2003). In 2001, HIV was the seventh leading cause of death for Black males in Chicago (Simpson & Benbow, 2003). The rates of AIDS cases in the two target communities are approximately twice the rates for the city of Chicago, while rates of other STDs are even higher in comparison (Kouvelis & Thomas, 2003; see Table 1).

At the community level, contraceptive behavior among adolescent couples is reflected in levels of teenage childbearing. In the Englewood and Woodlawn communities, 30% and 27%, respectively, of the live births are born to women under the age of 20 (Kouvelis & Thomas, 2003); 18% and 19%, respectively, are low-birthweight; and infant mortality rates are double those of the city of Chicago (20 and 25 per 1,000 live births, see Table 1; Kouvelis & Thomas, 2003). Such indices suggest that changes in reproductive health behavior among adolescent males could have significant impacts upon the health of young people in these inner-city neighborhoods.

To date, 75 African American adolescent males have participated in Peer Advocates for Health program activities. After six months of training. Peer Advocates are paid to make presentations to school and neighborhood groups or talk one-on-one with peers about issues related to male health. The current analysis examines the impact of PAH program participation on the reproductive health knowledge and lifestyle choices of young men who joined the program between June 2000 and June 2004. Given the intense training and follow-up provided by the Peer Advocates model, we hypothesized that reproductive health knowledge would increase among young men participating in the program and that utilization of clinic services, communication, and condom use would increase during the program year.

METHODS

PROGRAM MODEL

Design of the Peer Advocates program model and the implementation strategies for adolescent males were guided by a number of different theoretical frameworks. Rational behavior models and subsequent refinements of these models suggest that changes in knowledge are necessary, but not sufficient, for behavior change (Glanz, Lewis, & Rimer, 1997). These frameworks suggest that changes in attitudes, skill levels, and self-efficacy must also occur (Bandura, 1977). Both Life Transition and Stages of Change Models provided useful frameworks for designing reproductive health training for groups of young men who differ in age, learning ability, physical and emotional maturity, and sexual experience (Forrest, 1993: Prochaska, Redding, & Evers, 1997). The work of Jemmott and Jemmott (1990, 1992, 1996), among others, highlights the necessity of combining theory-based research with practice when developing innovative community-based interventions designed to reduce high-risk behaviors among African American male adolescents.

These frameworks, and more than 10 years of community-based program experience working with young people in Chicago, suggest that, to impact the behavior and lifestyles of inner-city adolescents, programs must provide not only information but also the long-term follow-up and support necessary to process and utilize this information for decision-making within the context of their own lives. This philosophy underlies training and support strategies utilized within the Peer Advocates program model.

Primary objectives of the Peer Advocates for Health program are:

* to increase reproductive health knowledge among adolescent male participants during the program year;

* to increase access and utilization of reproductive health clinic services among young men participating in the program; and

* to improve healthy lifestyle choices among program participants, especially communication and condom use.

The three major components of the Peer Advocates Program Model are (1) reproductive health training, (2) individual support, and (3) employment. PAH provides intense, long-term training through group participation and one-on-one support through a personal relationship with the Project Coordinator. After six months of training, participants are employed to work as Peer Advocates providing information, distributing condoms, and serving as role models in their own schools and communities.

TRAINING

Basic Training. Peer Advocates training begins with an initial eight-week basic training session held three days per week during the summer. Participants meet three afternoons per week for three hours for training that is supplemented by homework and field trips to a male clinic and Planned Parenthood. Participants are paid $6 per hour to attend training. At the end of Basic Training, each participant makes a formal presentation on one of the curriculum topics to an audience of participants, parents, and friends. Although difficult for some young men, making these formal presentations instills confidence and marks a transition to the next phase of Peer Advocates training.

Continued Training. Beginning in the fall, PAH Continued Training is carried out through weekly group meetings for the remainder of the program year. In addition to reproductive health issues, this Continued Training focuses upon building communication and decision-making skills and upon understanding the consequences of decisions in everyday life.

The Peer Advocates for Health Curriculum topics include Communication: Reproductive Anatomy and Physiology; Puberty/Home Clinic Partnership; Healthy Relationships; Conception/Contraception/Teenage Parenthood; Avoiding and Handling STDs, HIV/AIDS in Our Community: Real World Education and Employment. and Domestic Violence. The Peer Advocates curriculum built upon a reproductive health curriculum for adolescents developed working with community providers over the past 10 years. PAH participants have provided continual feedback regarding choice of curriculum topics and method of presentation. Over the past two years, more time and emphasis has been placed upon domestic violence and HIV/AIDS in the community--two very real issues in the lives of these young men. A variety of training techniques is used during the group sessions, including group discussion, role playing, scenarios, videos, and professional guest speakers. Because group membership is closed in June (no new members after the first week of training), these young men get to know each other intimately, and group participation becomes an important source of support for each participant.

INDIVIDUAL SUPPORT

Each young man who joins the Peer Advocates program receives ongoing, individual support through a personal relationship with the project coordinator.

The coordinator is an African American male who has devoted his career to working with young people, primarily in social service agencies and the Chicago public schools. The coordinator, a seven-loot African American former college basketball player who grew up on the south side of Chicago, relates directly to the young men and the issues they face with school, family, and the street. He serves as friend, mentor, confidant, and role model. The coordinator attends and participates in all weekly training sessions. In addition, he meets with the group two Saturdays per month for follow-up discussion of curriculum topics, field trips, and community outreach activities. The coordinator meets individually with each participant at least once a month and maintains close contact with his family through home visits and telephone calls. He monitors school performance and grades, finds tutors (or acts as a tutor himself), and advocates for these young men with school faculty and administrators. As illustrated by one participant's comment, "'Mr. S., I spent more time with you in the six months I been in this program than I have with my dad in my whole life," the coordinator becomes an important support in each young man's life.

EMPLOYMENT

Employment and job skills training are important components of the Peer Advocates program model. PAH program participants are paid an hourly stipend to attend training sessions and for doing community outreach activities in their own schools and communities. After six months of formal training and certification as a Peer Advocate for Health (based upon knowledge, participation, and attendance), participants are paid an hourly stipend ($7 per hour) to work in their own neighborhoods, making group presentations or talking one-one-one with their peers about adolescent health issues, including pregnancy and disease prevention, abstinence, contraceptive methods, condom use, STDs, and HIV/AIDS. Formal community presentations are planned and rehearsed during weekly meetings or on Saturdays. The trainer or the project coordinator accompanies Peer Advocates when they do group presentations and often facilitates discussion or answers audience questions following the presentation. In order to be paid, PAH participants must become temporary employees of the health center where the program is being implemented and must go through the formal hiring procedures for clinic employment, including application forms and drug testing. After the first year of training and program participation, the young men are eligible for summer employment at the health center. Over the past four years, 20 young men have been employed at the health center in a number of different departments, including administration, data entry, medical records, and storeroom. (Not all PAH participants were available for summer employment due to summer school or other jobs). A full week of job skills training is provided to each of these young men prior to beginning his clinic employment. Supervisors in each department worked with and assessed the performance of each young man who worked in the clinic through written evaluations of job performance. Employment in the clinic provides income but also a familiarity and personal relationship with a healthcare facility in the community and with the professional staff who work there.

In addition to providing a needed source of information and referral, Peer Advocates provide an important mechanism for condom distribution. Within the Peer Advocates program, condom distribution occurs at two levels: individual program participants and the broader south side community. Program participants receive condoms at each group meeting. Peer Advocates distribute condoms using "condom wallets," which are velour wallets holding two condoms and instructions. All Peer Advocates carry a supply of condom wallets that they distribute at school and in their neighborhoods. Condom distribution is generally done one-on-one with few formal distribution requirements other than discussion of correct usage.

RECRUITMENT AND RETENTION

In order to provide the level of support that staff feel is necessary for these adolescents, the number of participants is kept small, with a maximum of 25 young men accepted into the program each year. The initial challenge was to inform people about the project and to recruit 25 young men, ages 14-17, who were in school and living on the south side of Chicago. During the first year, the project coordinator made personal visits to 20 local high schools to talk with counselors and principals, posted flyers in the clinic waiting rooms, and asked for referrals from adolescents' physicians. These recruitment channels have been supplemented by word of mouth from former participants and their parents, and last year 75 young men applied for the 25 participant positions. To insure that both the young man and his parents understand the Peer Advocates for Health program, the project coordinator carries out a personal interview with the young man and his parent(s) prior to his joining the program.

PAH retention strategy includes an initial effort to explain the intensity of the training and the hard work and commitment that group participation and becoming a Peer Advocate requires, the rationale being that those young men who joined PAH for the money and who are not committed or willing to work will not contribute to the group or become effective health advocates in their own communities. The summer Basic Training "boot camp" is rigorous with intense training sessions, attendance and participation requirements, and homework. A dress code including no braids, no heavy gold crosses, no pants' crotches at the knee, and shirt and tie for formal presentations, is firmly enforced. Behavior that is disruptive to the group or training process entails specific consequences such as a "no excuse card," which translates to a pay dock or, if severe, expulsion from the program. Every year, about one-third of the new recruits either drop out due to the intensity of the training or scheduling conflicts or are asked to leave because of behavior problems or lack of group participation. However, those young men who remain in the program are serious about learning and about sharing their knowledge with their community.

MEASURES

Evaluation has been an integral and ongoing part of Peer Advocates program activity since the beginning. The participant level record-keeping system currently used for Peer Advocates was adapted from a system previously developed to evaluate a multi-state adolescent male health initiative (Mosena & Ruch-Ross, 1998). Pre- and post-tests were developed in conjunction with curriculum development; both were based on training materials previously used by the PAH team in another program for adolescents in Chicago.

Three existing scales were added to the PAH data systems in the second year of program effort. These included An Adolescent and Young Adult Condom Perception Scale (Hanna. 1999), a 15-item scale with an alpha coefficient of .82, and a 10-item reproductive health knowledge scale used in the National Longitudinal Survey of Adolescent Health (ADD Health) surveys. An eight-item contraceptive self-efficacy scale developed for use with a high-risk American Indian adolescent population (Chewning, 2001) and previously used by the PAH team in a program for adolescent mothers was also added. All scale scores are derived by summing items once coded in the appropriate direction.

DATA COLLECTION

Data collection activities carried out each year include written participant questionnaires completed at program intake, three months, six months, and 12 months (yearend). Attendance logs are used to document participant attendance at training sessions. Community outreach logs are completed by all Peer Advocates to record their work in the community and to document the number of people reached, the topic, and duration of each presentation or individual contact made. Employment records and supervisor assessment forms are used to document and evaluate Peer Advocate clinic employment. In addition to program impacts, these data provide process variables and a means of documenting stages of program development and implementation over time.

To supplement quantitative documentation of program activity and impact, every effort has been made to obtain qualitative feedback from both adolescent program participants and their parents. Parental Advisory groups meet quarterly for discussion and feedback and provide written evaluations at the end of each program year. Semi-structured group discussions are carried out with each group of young men at the end of summer training and after one year of program participation to determine "what they liked best and least about the program, what they would change, and what type of young man they thought should join the program." Because the number of participants each year is quite small, every effort is made to utilize both qualitative and quantitative data and to look at impacts across program years. Results of these data collection efforts and analyses of these program data are used for modification and refinement of the Peer Advocates program model and are not intended for generalization to other populations of adolescent males.

RESULTS

PARTICIPANT OUTCOMES

Changes in key outcome variables among PAH program participants will be reported. They include (1) reproductive health knowledge, (2) clinic utilization, (3) communication with partners, peers, and parents, and (4) condom use and attitude. Given the small number of new participants recruited into the program each year (n = 11 to 24), and due to program attrition and nonattendance of sessions when outcome assessments were collected, all four years of PAH groups are aggregated for the current analysis. Preliminary analyses supported this decision in that there were few meaningful differences among the participant groups across the four years. The sample size used for analyses differs with each outcome because questionnaires were distributed at different time points during the program year.

Changes in reproductive health knowledge among program participants were measured using percentage of correct responses on three sets of pre- and post-tests by curriculum topic. Post-tests were administered within one to two weeks after a topic was taught in a training session; thus there are 48-58 participants for this outcome. Improvements in healthy lifestyle choices are measured using participant responses to questions on clinic utilization, communication, and condom use, asked at intake and after six or 12 months of program participation. For communication about birth control with peers and partners, there are 12 months of completed questionnaires for 20 of the 75 young men. For condom use, there are three, six, or 12-month follow-up data for 68% (n = 51) of the young men. The three-to- 12-month data for this variable were aggregated since noncondom use was extremely low at all time points.

CHARACTERISTICS

During the first four years of the program, a total of 75 young African American men from 15 high schools in the Chicago south side area were initially enrolled into PAH. Mean age of all participants was 15.9 years: all were in school, grades 8-12; 52% lived in single-parent households: and two-thirds (65 %) reported they had already had sexual intercourse at the time they entered the program (see Table 2). Most of the sexually active participants reported use of a condom at last intercourse, but only a small proportion. 15%, (N = 12) had ever been to a clinic for condoms. STDs, or birth control information.

ATTRITION ANALYSES

Among the 75 young men who joined the Peer Advocates program during the past four years, more than half, 61%, remained in the program for 12 months or more. Although year-end data were collected on only 20 participants, attendance records show that 46 young men actually completed the program year. Due to the high attrition of participants and nonattendance at data collection sessions, analyses were conducted to compare key demographic and health variables by number of sessions attended. Results showed that those who attended fewer training sessions were not more likely to be from single-parent households, [chi square] (6, N = 75) = 1.66, p = .948. Number of sessions attended was also not related to condom attitudes and self-efficacy at baseline. However, young men who dropped out or were asked to leave the program during the first three months were older than those who remained in the program for six months or more. t (70) = 2.46, p = .016. They were also more likely to be sexually active than those who participated for a longer period, [chi square] (3, N = 74) = 12.14, p = .003, but they were as likely to have used condoms at their last sexual activity.

REPRODUCTIVE HEALTH KNOWLEDGE

During the first three months of PAH basic training, pre- and post-tests were administered for three curriculum topics. Puberty/Anatomy and Physiology, Contraception and HIV/AIDS/STDs. Pre-and post-tests consisted of 10-15 true/false questions for each topic. As expected, knowledge of reproductive health increases among young men exposed to PAH curriculum and training. As seen in Figure 1, paired-sample t-tests showed significant increases in pre- and post-instruction knowledge for each reproductive health topic: Puberty/Anatomy/Physiology, t (57) = -14.16, p = .000, Contraception, t (55) = -19.30, p = .000, and HIV/AIDS/STDs, t (47) = -12.48, p = .000.

[FIGURE 1 OMITTED]

CLINIC UTILIZATION

At baseline and six months, young men were asked if they had been to a clinic for condoms, STD information, birth control information, or "with girlfriend." As shown in Figure 2, paired-sample t-tests showed that visits to a clinic for reproductive health purposes (not physical exam) increased between baseline and six months, t (21) = -2.11,p = .047.

[FIGURE 2 OMITTED]

COMMUNICATION ABOUT BIRTH CONTROL

A series of ANOVAs with time of measurement (baseline, three-month, and 12-month) as a within-subjects factor were conducted based on 20 young men for whom 12-month follow-up data were available. Results show that frequency of talking with girlfriend or partner about birth control increased significantly, F(1.65.33.3) = 4.29, p = .03 (see Figure 3). Frequency of talking with friends about birth control also increased, F(1.78.33.9) = 19.2, p = .000) (see Figure 4). Interestingly, the frequency of conversation with parents about birth control did not change F (1.67.30.1) = 1.59, p = .22.

[FIGURES 3-4 OMITTED]

CONDOM USE AND ATTITUDE

Among PAH participants, condom use was very high at intake, and analyses did not show a significant change during the 12 months of program participation. We have three-, six-, or 12-month follow-up data for 68% (17 = 51) of the young men. For this analysis, we used the last available follow-up time point. Among these participants, 58.8% (11 = 30) started or continued to use condoms at follow-up: 3.9% (17 = 2) of the sexually active young men went from not using to using: and 7.8% (n = 4) reported not using a condom: 29.4% (n = 15) remained abstinent at follow-up.

Results also showed that attitude towards condom use did not change throughout the study period. However, the young men generally expressed positive attitudes toward condom use at all data points. Mean attitude was 4.2 (SD = .46 to .55) for all data points on a five-point scale with "5" as most positive. Finally, the main effect of time of measurement was significant for reproductive health self-efficacy, F(1.96, 37.3) = 5.02, p = .012. Reproductive health self-efficacy increased for our participants between baseline and 12 months of program participation (See Figure 5).

[FIGURE 5 OMITTED]

COMMUNITY OUTREACH

Peer Advocates for Health program activity is designed to impact not only the young men who are being trained but also the broader community in which they live. However, adequate assessment of community-level impact is beyond the scope and budget of this community-based pilot program. At the current level of program development, assessment of Peer Advocates community outreach activity is limited to documentation of the number, age, and gender of community residents reached and number of condoms distributed. Over the past 30 months, from late 2001 to early 2004. Peer Advocates documented talking about reproductive health issues with 4,419 individuals, both adolescents and adults, individually and in groups.

Both the type and level of Peer Advocates community outreach activity has increased in response to felt needs in the larger south side community. Initially, community outreach efforts centered upon Peer Advocate presentations to school classes and one-on-one discussion with peers. Peer Advocates now make presentations to a variety of groups including after-school programs, church groups, health fairs, youth conferences, and most recently a prom expo and a women's shelter. Beginning in 2002, monthly Let's Talk About It sessions were begun in which male Peer Advocates work directly with female Peer Educators and make coed presentations to middle school students and their parents. Over two years, these young men and women have worked together to make 19 co-ed presentations to 199 middle school children and 61 adults attending these monthly sessions.

An important part of Peer Advocates community outreach activity is condom distribution. Each year, Peer Advocates distribute between 2,000 and 3,000 condoms at their schools or in the neighborhoods. Last year, one Peer Advocate was the regular distributor for his football team, and another young man distributed 33 "condom wallets" on prom night at his local Catholic high school. In the past four years, Peer Advocates have distributed more than 10,000 condoms in their own communities.

DISCUSSION

Community-based program experience working intensely with adolescent males in inner-city Chicago strongly suggests that these young men will join the program, will come to group, and need and want information. When asked what they liked best about being in the Peer Advocates program, participants responded: "learning new things," "learning to be safe and communicating," and "the things we were learning can be applied to everyday life." Once these young men are trained as Peer Advocates, their willingness and level of enthusiasm for sharing their reproductive health knowledge with friends and family has surprised even the project staff. Each year only 12 to 15 Peer Advocates are active in their communities, but these young men have reached more than 4,000 other adolescents and adults living in a broad geographic area on the south side of Chicago. Along with information, Peer Advocates also provide a mechanism for distributing condoms to their communities--at school, in the locker room, at the prom, or wherever the need arises.

Analyses of four years of program data support the hypothesized outcomes among PAH program participants with significant changes in reproductive health knowledge reported among adolescent males in and across all four participant groups. After six months in the program, more than half of the young men had been to a clinic for reproductive health services, as compared to 15% at intake. Although year-end data are available for a very small number of participants, these participants report increased communication with partners and peers after 12 months of program participation. Condom self-efficacy increases, and use of condom at last intercourse remains high throughout the program year.

The small number of respondents for whom 12-month data are available is a serious limitation to the current study and results from both participant attrition, due to dropout or expulsion, and poor timing of data collection efforts that conflicted with sports and high school graduation. The intense training and strict rules for participation are both a strength and a weakness of the Peer Advocates program model. Each year, a large number of participants leave the program because they are not willing to meet these requirements. However, those young men who remain in the program are both committed and well prepared to become Peer Advocates and to represent the program in their own communities. Overall, during the four years of program activity, more than 60% of all PAH participants remained in the program for a year or more, and the impact of their participation in the Peer Advocates for Health program appears to be very positive both in terms of knowledge gained and willingness to share this knowledge with the broader community.

These impacts of Peer Advocates program participation on adolescent African American males in Chicago are similar to those reported for adolescents in Africa, where peer education programs are reported to be effective at improving knowledge and perceived self-efficacy and promoting attitudinal and behavior change among program participants (Brieger, Delano, Lane, Oladepo, & Oyedrian, 2001; Speizer, Tambashe, & Tegang, 2001; Lane, 1997). Likewise, the long-term goal of utilizing Peer Advocates as change agents in their own communities is supported by several studies reporting that outreach programs, especially involving condom distribution and STD/HIV prevention, have been successful in reaching other males and making valuable contacts in the community and, when attached to clinic services, have resulted in increased contraceptive compliance among teen clients (Herz, Olsen, & Reis, 1988; UNFPA; Mellanby, Newcombe, Rees, & Tripp, 2001).

Given the nature and characteristics of these south side neighborhoods, providing a mechanism for information and condom distribution that reaches adolescent males could have a significant impact on the young people and on the health of these communities. Peer Advocates is currently a small community-based demonstration project, and the ability to assess program impacts at the broader community level is very limited. A rigorous evaluation of both individual and community level impacts of Peer Advocates program activity should be the next phase of program development but will require substantially more resources and a longer time frame.

LESSONS LEARNED

A number of lessons have been learned in developing and refining the Peer Advocates program model. Four years of PAH program experience demonstrates that improving levels of reproductive health knowledge is relatively easy compared to changing attitudes and the normative context in which these young men live. Despite significant gains in reproductive health knowledge and six months of training and group participation, a large majority of the participants continue to report that "their friends would respect them if they got someone pregnant." Such responses suggest the normative influence of peers and the negative influence this context can have on decision-making and reproductive health behaviors. These responses strongly support our recommendation that, in addition to reproductive health education and training, adolescent programs must also provide the time and support necessary to process this new information and to incorporate reproductive health knowledge into the belief system and lifestyle choices of each adolescent.

Because project staff were developing a new program model and implementing this model for the first time in a community health center, they faced a number of obstacles at various stages of program development. Initially, recruitment of young men to participate in the program was a challenge, but this challenge was overcome by using several channels of recruitment and personal contacts. Continual changes in administration and clinic staff (five Executive Directors and four Medical Directors in four years) resulted in a constant need to explain the program and to advocate for training space and payment to the Peer Advocates at the health center. Initially, the per capita cost of training a small number of Peer Advocates was high, but when program costs are spread across the number of community residents reached by the Peer Advocates program, the cost per participant becomes less than a clinic visit and certainly less than the cost of a teen pregnancy. More accurate estimates of the cost-effectiveness of Peer Advocates program effort cannot be determined until more rigorous evaluation of community impacts is carried out. Financial support by DHHS, Region V, Office of Family Planning, made this type of local community-based project possible, but funding was not always sufficient to pay the Peer Advocates for all the hours they wished to work. Having too many trained adolescent males who want to work in their own communities as Peer Advocates for Health is a "positive problem" and speaks to both the need for and effectiveness of this demonstration effort.

Finally, a number of factors contributed to the effectiveness of this pilot effort and should provide guidelines for replication and expansion of the Peer Advocates program model. The project coordinator and the individual support he provides to each young man are critical because he spends the time necessary to know and meet the needs of each young man. Both the program's coordinator and the trainer, who is an African American female, possess high levels of expertise, an in-depth knowledge of the challenges faced by minority adolescents growing up in inner-city neighborhoods, and a deep commitment to providing the knowledge, skills, and support necessary to optimize the potential of each young man in the program. Parental support is also important, both in terms of supporting program goals and providing transportation to weekly meetings. In her year-end evaluation, one parent wrote:

"The focus is on the entire male and not just sex. Mr. S. [the project coordinator] is an excellent role model who supports these young men in their character, choices, and integrity as they become young men who can be a positive influence in their communities."

To date, the Peer Advocates for Health Program has directly served a relatively small number of participants. Nevertheless, both quantitative and qualitative analyses point to positive program impacts in the areas of knowledge gains and healthy lifestyle choices for these young men. Moreover, participants reach a substantial number of their peers in an intentional effort to have an impact in their own communities. Based upon the first four years of Peer Advocates program experience, the long-term potential for individual and community impacts is strong. Results of this study add to the growing body of literature that suggests that, to improve behavior and lifestyle choices among high-risk adolescent males, programs must provide not only reproductive health education but also the long-term follow-up and support necessary to utilize this information in the context of everyday lives.

Table 1
Demographic and Health Characteristics of Communities
in the Program Area, 1999-2000

Variable                                        Englewood  Hyde Park

Demographics
  Total population *                              40,222     29,920
  Males                                           18,207     14,479
  Females                                         22,015     15,441
  Ethnicity *
  Non Hispanic Black                              97.84%     37.73%
  Non Hispanic White                               0.44%     43.52%
  Hispanic                                         0.86%      4.11%
  Other                                            0.24%     11.84%
  Socioeconomic status
  Median household income ([double dagger])      $18,955    $35,991
  Below poverty line *                             43.8%      16.5%
  Below twice poverty line *                       67.5%      31.5%
  Poverty rate, children
  < 18 yrs ([double dagger])                       54.1%      14.0%
  Public assistance income
  (% households) ([double dagger])                 21.6%       2.3%
  High school graduates or higher
  (% population [greater than or equal to]
  25 yrs) ([double dagger])                        59.3%      92.7%
  Unemployment rate
  (% civil labor force) ([double dagger])          25.8%       7.3%
  Female-headed households ([double dagger])       60.6%      25.8%
Health
  Causes of death
  (per 100,000 pop) (#)
    All cancers                                      292        157
    Homicide (Assault)                                65         12
    HIV infection                                     31          4
    Heart disease                                    413        223
  STD cases (per 100,000 pop) (#)
  AIDS                                                55         30
    Gonorrhea                                      1,343        211
    Syphilis                                          15          0
    Chlamydia                                        990        231
Maternal and child health (#)
  Teen births (< 20yrs)                            29.7%      10.0%
  Low birth weight (< 2.5 kg)                      17.5%      10.3%
  No prenatal care                                  6.2%       2.1%
  Infant mortality rate
  (per 1000 live births)                            20.3       10.3

                                                              All
Variable                                        Woodlawn    Chicago

Demographics
  Total population *                              27,086  2,896,016
  Males                                           12,084  1,405,107
  Females                                         15,002  1,490,909
  Ethnicity *
  Non Hispanic Black                              94.21%     36.39%
  Non Hispanic White                               2.81%     31.32%
  Hispanic                                         1.06%     26.02%
  Other                                            0.99%      4.63%
  Socioeconomic status
  Median household income ([double dagger])      $18,266    $38,625
  Below poverty line *                             39.4%      19.4%
  Below twice poverty line *                       63.9%      39.3%
  Poverty rate, children
  < 18 yrs ([double dagger])                       48.7%      28.1%
  Public assistance income
  (% households) ([double dagger])                 16.4%       6.9%
  High school graduates or higher
  (% population [greater than or equal to]
  25 yrs) ([double dagger])                        67.7%      71.8%
  Unemployment rate
  (% civil labor force) ([double dagger])          19.8%      10.1%
  Female-headed households ([double dagger])       61.3%      31.8%
Health
  Causes of death
  (per 100,000 pop) (#)
    All cancers                                      236        223
    Homicide (Assault)                                56         21
    HIV infection                                     18         13
    Heart disease                                    446        330
  STD cases (per 100,000 pop) (#)
  AIDS                                                52         27
    Gonorrhea                                        897        402
    Syphilis                                          18         10
    Chlamydia                                        761        491
Maternal and child health (#)
  Teen births (< 20yrs)                            27.4%      17.1%
  Low birth weight (< 2.5 kg)                      18.6%      10.1%
  No prenatal care                                  5.5%       3.5%
  Infant mortality rate
  (per 1000 live births)                            24.7      11.5%

* Source: Chicago Department of Public Health (CDPH, 2004). Chicago
Community Health Profiles (Englewood, Hyde Park, and Woodlawn).
Chicago Health and Health Systems Project (Year 2000 data).

(#) Source: Kouvelis & Thomas, 2003, Community Area Health Inventory
1989-1999 Volume II, City of Chicago Department of Public Health,
Epidemiology Program Report (Year 1999 data).

([double dagger]) Source: Data spreadsheets compiled by the
Northeastern Illinois Planning Commission (NIPC, 2004) using data
from U.S. Census Bureau, 2000 Census of Population and Housing,
Summary File 1: June 2001 and Summary File 3: August 2002.

Note: Chicago has 77 community areas.

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Correspondence concerning this article should be sent to Pat W. Mosena, 5646 S. Kimbark Avenue, Chicago, Il. 60637. Electronic mail: Pat Mosena: [e-mail].

PAT W. MOSENA

Options for Youth

JOYCE HO

University of Chicago

JANICE ELY

DHHS Region V Office of Family Planning

HOLLY S. RUCH-ROSS

Consultant for Evaluation