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Moving beyond peer education: using peer advocates to increase condom availability on college campuses.

Unintended pregnancies and sexually transmitted infections (STIs) inherently affect America's youth biologically, economically, socially, culturally, and psychologically. Recent epidemiological surveillance data indicate that an estimated 65 million Americans are infected with a viral sexually transmitted infection (STI; ASHA, 1998). About half of all new STIs occur in young adults between the ages of 15 and 24 (Weinstock. Berman. & Gates. 2004). Currently, 60.1 million women between the ages of 15 and 44 use some form of contraception, and 93% of those who are sexually active use contraceptive strategies to prevent unintended pregnancies (Misra, 2001). Despite comprehensive efforts to increase effective contraceptive and STI prevention products over the last 40 years, nearly half of the pregnancies in 1994 in the United States were unintended, 54% of which ended in abortion (Henshaw. 1998). Demographic variables such as age, gender, and ethnicity appear to be relevant factors in assessing prevalence and incidence rates associated with STIs and unintended pregnancy (Kaiser Family Foundation. Hoff, Greene, & Davis. 2003).

The collegiate environment is commonly associated with increased autonomy and greater availability of and access to alcohol and sexual partners. Results of the 2004 American College Health Association--National College Health Assessment, conducted by the American College Health Association, indicates that 79% of college females and 81% of college males have consumed alcohol on one or more of the last 30 days (ACHA. 2004). According to the 1995 National College Health Risk Behavior Survey, 86.1% of college students have had sexual intercourse during their lifetime, 34.5% have had six or more partners, and 35.1% report that they have been pregnant or gotten someone pregnant (CDC. 1997). Additional findings reveal that oral contraception is the most prevalent form of pregnancy prevention methodology used by students during vaginal intercourse, followed by male condoms (ACHA).

Traditionally, research conducted on condom effectiveness has been limited simply to overall usage rates instead of correct and consistent use. Researchers at Indiana University and the Kinsey Institute for Research in Sex. Gender, and Reproduction have conducted several empirical studies with collegiate samples that have attempted to overcome these limitations.

One investigation conducted by Crosby and colleagues (2003) utilized a convenience sample of 260 undergraduate students enrolled in health courses at a large Midwestern university, including both males (n=118) and females (n=I42). The investigators assessed the frequency of eight condom use errors and seven potential condom problems that occurred by the participants and/or their sexual partners. The only inclusion factor was the participation in a sexual act (defined as putting the penis in the mouth, vagina, or rectum) with a condom during the previous three-months. Results indicated that 48.9% of the participants reported not having a condom available when needed, 38% applying a condom after sex had begun. 19.1 % using a condom that was stored in a wallet, 16.0% using a condom that was not lubricated, 14.1% experiencing a condom break during use, and 11.2% opening a condom package with a sharp tool.

A similar investigation was conducted on college women who apply male condoms to their male partners (Sanders, Graham, Yarber, & Crosby, 2003). A convenience sample of 102 undergraduate women was recruited through health science and psychology courses that did not include condom instruction at a large Midwestern university. Results indicate that 82.7% did not check the condom for visible damage. 71.3% did not check the expiration date, 51.1% put the condom on a male partner after sex had begun, 47.9% wanted to use a condom but did not have one available, and 29.6% put the condom on upside down and flipped it over to apply the condom in the correct direction. Despite the common occurrences of these problems, 84.3% of the sample reported they had received some form of condom education.

The results of these two studies and national trends associated with STIs and unintended pregnancy among young adults demonstrate the need for more effective condom education programs as well as advocacy programs specifically designed to increase condom availability to high-risk populations.

Peer-based health promotion programs have become more prevalent within colleges and universities in recent years. Programs using peers in teaching roles have been reported since 1957, and estimates indicate that approximately three-fourths of colleges and universities have a peer counselor program (Salovey & D'Andrea, 1984). Based on the previous success of various peer-based primary prevention programs, it was hypothesized that peer advocacy programs could be implemented to increase condom availability to the student population via peer distribution of free latex male condoms and brochures related to reducing high-risk sexual behaviors at bars and restaurants near campus. The primary purpose of this article is to outline two successful peer-based condom distribution programs at large universities with similar physical and social environments.

Sexual Health Peer Advocacy Programs

The University of North Carolina at Chapel Hill

The Center for Healthy Student Behaviors (CHSB), located within the James A. Taylor Student Health Services on the University of North Carolina at Chapel Hill (UNC-CH) campus, sponsors several sexual health peer advocacy initiatives, including STI/HIV prevention and sexual assault prevention programs. Traditionally, the primary role of the peers is to design and implement awareness events in conjunction with national/international campaigns (e.g., World AIDS Day, The White Ribbon Campaign, and National Condom Day), conduct fundraisers for the local rape crisis center, advocate for more comprehensive HIV/AIDS services in the U.S. and around the world, and distribute safer sex products.

Each year, the program coordinator recruits volunteers by posting informational fliers at the Student Health Services, the School of Nursing, the School of Social Work, the School of Medicine, and the School of Public Health. Under the supervision of the CHSB program coordinator and human sexuality educators, peers travel to nearby bars and restaurants on World AIDS Day (December I) and National Condom Day (February 14) to distribute "safer sex packets." Each packet includes two male latex condoms and a pamphlet that provides information about HIV testing, pregnancy prevention, abstinence, emergency contraception, sexual assault prevention, alcohol consumption, and gay, lesbian, bisexual, transgender, and queer services in the community.

To promote the program and increase their visibility, peers wear T-shirts specifically designed for the event. Volunteers in the program are required to complete a one-hour training program that outlines mandatory rules for program participation. Peers are prohibited from consuming alcohol prior to entering the establishments and during their visit to each location. Only students who are 21 and older are allowed to participate, and the peers are instructed to change their T-shirts should they choose to drink after the distribution of safer sex packets is completed. Peers are required to travel in groups of at least two members and are traditionally paired by gender (i.e., each group has one male peer and one female peer). This strategy creates a safer environment for the peers, may decrease the likelihood of harassment of the peers by patrons, and provides support in the unlikely event of an emergency.

After completing the training session, the peers routinely travel to approximately 20 bars and restaurants located near the UNC-CH campus. When the program was initiated five years ago, the program coordinator contacted several businesses prior to the planned distribution date to outline the program and seek approval to enter their establishments. However, given the success of the program over the years, both the business owners and their patrons (who are often students) have come to expect the peers and welcome them upon entering. Hence, the program coordinator no longer contacts business owners before initiating the program but requests verbal permission to distribute the packets upon arrival.

On average, the peers distribute approximately 2,500 packets containing 5,000 condoms per year. The program's success lies in its ability to reach a large number of students who might not otherwise receive condoms or preventative sexual health materials at the Student Health Service. In addition, the program allows the peers to participate in a program where they have the opportunity to develop and maintain ownership. Similarly, many peers participate in the condom distribution program that may not be able to participate in more time-consuming efforts or those requiring more specialized talents (e.g., peer-sponsored entertainment venues and ongoing peer education programs).

Indiana University at Bloomington

Using a consultant from the UNC-CH program, the Indiana University at Bloomington (IUB) Raising Awareness of Interactions in Sexual Encounters (RAISE) peer advocacy group piloted a similar program in the spring of 2005. Sponsored by the Office of Women's Affairs, the RAISE program has been conducting sexual assault prevention peer theater and sexual communication advocacy programs since 1988. Collegiate programs that utilize sexual assault prevention events often face significant barriers to program implementation, particularly when attempting to reach their target populations. For example, students may be hesitant to attend outreach programs that they perceive as "scare tactics," "male-bashing," or sex-negative in nature. The RAISE volunteers have overcome this challenge by creating a peer theater program that is interactive, exciting, and generated to reach both men and women. This year, the program was extended to include "Condoms at the Club," an outreach activity that was designed to increase condom availability and decrease sexual assault among students. Given the association between alcohol consumption, high-risk behavior, and sexual assault (Zenilman et al., 1994; Ullman, Karabatsos, & Koss, 1999), it was hypothesized that entering the local restaurants and bars would grant the peers increased access to target populations that may not otherwise have been accessible.

In April 2005, under the supervision of the RAISE program coordinator, 15 peers participated in the program which was modeled after the UNC-CH's guidelines. Prior to the implementation of the program, the program coordinator contacted six bars and restaurants located near campus via telephone; all of the managerial staff contacted verbally agreed to allow the peers to enter their establishment.

The program coordinator created T-shirts with the logo "RAISE" on the front and "Good Sex is Consensual and Safe" on the back. Because many of the RAISE volunteers were freshmen or sophomores, it was decided that peers under the age of 21 would be included in the program. It was designated that those under 21 would enter restaurants/businesses that do not have a minimum age requirement, and approach students roaming outside the bars. Peers who were 21 and older were designated to locations that require a minimum age of 21 for entrance.

The session was conducted on a Friday night during the spring semester. Overall, 500 packets were distributed, including 1,000 male latex condoms and brochures outlining effective sexual communication and sexual assault prevention strategies. Debriefing sessions with the peers revealed that more packets could have been distributed given the large number of students visiting the establishments on that particular evening.

Recommendations for Successful Implementation

Based on the above experiences in the field, the following recommendations may be useful for peer professionals in creating a safer sex distribution program:

Assess Your Campus Climate Conducting a needs assessment on campus is essential for any effective peer-based intervention. Ideally, peer professionals can conduct an informal evaluation of the sexual risk behaviors of the target population and implement interventions accordingly. This is particularly relevant for peer-based condom distribution programs. If the ideology of an institution (e.g.. religious affiliation) or the student body does not support the program, it is less likely to be effective.

Screen the PeersIt is important to screen peers prior to implementing the program. Peers should be chosen based on their support of the institution's mission and the ability to appropriately serve as ambassadors for the program. Peers who do not adhere to the program's mission and agree to follow the program's guidelines should be prohibited from participation. In addition, students who have consumed alcohol on the day of the event should not be included in the events.

Recruit Male and Female Peers Ideally, both male and female peers should be recruited to participate in the program. Regardless of their gender, peers should always travel in small groups to ensure their safety.

Pilot the Program Before allocating extensive resources to the program, a pilot program should be conducted. Evaluating this pilot program will provide the program coordinator with useful information concerning the program's success and potential alterations for future implementation. In addition, this may help alleviate concerns from administrators and provide useful information about the social ecology of the campus.

Conduct a Debriefing Session After the program has been implemented, the coordinator should conduct a debriefing session with participating peers. This will allow peers to share their experiences and provide process evaluation for the program.

Create Highly Visible T-shirts Having uniform T-shirts allows the peers to promote the program, even after the event, and increase visibility within the community. In addition, highly visible shirts allow the peers to visually scan their environment and easily locate fellow peers in the event of an emergency.

Use Effective Safer Sex Products

When purchased in bulk, condoms are extremely affordable making peer-based condom programs cost-effective. However, some companies sell condoms that are near expiration at reduced rates. Program coordinators should select condoms that have been recently manufactured, do not contain Nonoxynol-9, are coated with a water-soluble lubricant, and rank high on recent consumer reports. Safer sex products should be accompanied by up-to-date and accurate information regarding correct and consistent use of latex condoms.

Frequently Asked Questions

Over the last three years of the above mentioned programs, several recurring themes and questions have emerged. The following represent common questions and appropriate responses that may be encountered when implementing a safer sex distribution program:

1. Will condom distribution facilitate more sexual behaviors among students?

An empirical evaluation of a condom distribution program among adolescents by Kirby and colleagues (1999) indicates that the implementation of a program "does not hasten the onset of sexual intercourse." Additional studies conducted by Guttmacher and colleagues (1997) and Schuster and colleagues (1998) indicate that increasing condom availability may increase condom use without changing sexual activity rates.

2. Will the peers be putting themselves in danger by entering the establishments?

Participants in both programs have never experienced any form of hostility, harassment, or threat to their safety while visiting the establishments. The program coordinators specifically selected establishments that are routinely visited by the student population, minimizing the contact between the peers and non-student community members. We believe this facilitates the acceptance of the peers by individuals with similar sociodemographic characteristics. During the training sessions, the peers are provided with strategies for overcoming potentially dangerous scenarios. For example, peers are required to travel in small groups, ideally with at least one male peer per group. When entering the establishments, the peers are trained to be conscious of the location of the bar's bouncers, managers, bartenders, and servers. In the event of an emergency or threatening situation, the peers have been instructed to leave the establishment or, if in immediate danger, to report immediately to the nearest establishment employee.

3. Will the bar patrons take the condoms and discard the pamphlets, hence littering the establishment?

The peers commonly observe bar patrons reading the brochures and prevention materials shortly after receiving them. However, it is reasonable to assume that some patrons will use the condoms but disregard the informational materials. It is our hypothesis that the distribution of the condoms and the informational materials may provide a cue to action for safer sex practices, sexual communication, and/or lifestyle assessment for a significant portion of the target population. To reduce the risk of littering of the prevention materials, the condoms are placed within small plastic bags, making it easy to carry both the condoms and the brochures. Bars or restaurants have never complained or expressed frustration about patrons inappropriately littering with the brochures or the condoms.

4. Will the program be criticized by campus administrators?

Procuring administrative support for all peer-based programs before their implementation is essential. In our experience, administrators within peer-based agencies prefer to be a part of the planning process, or at minimum, require a debriefing on the program before its implementation. Given the administrators' leadership roles on campus, it may be essential to have their commitment to overcoming any outside threats to the program. We recommend conferring with all administrators who might influence the program such as university health service administrators, health care providers, women's center representatives, or any other agencies or centers that collaborate with the program. Giving administrators a detailed overview of the program's rationale and implementation plan is warranted; they must also be informed of any updates made to the program over time.

5. Will the campus community support the program?

Post-program debriefing sessions reveal that a majority of the students accepted the safer sex packets when offered. The program is terminated when the peers distribute all of the packets provided, usually within one or two hours. On many occasions, the peers report the need for more packets to keep pace with student demand. In addition, the peers are trained for the appropriate response to refusal of materials. When patrons refuse the packets, the peers are trained to reply, "Thank you. Have a safe evening." Neither program has ever received a complaint of harassment from a patron. The debriefing sessions are helpful in that they reveal the excitement and interest on the part of the peers and the patrons. The implementation of process and impact evaluation procedures can ensure that the program was implemented according to the coordinator's intentions and the results beneficial to the students. However, if the social ecology of the campus does not support the program, it should be discontinued. Fundamentally, if the target population disagrees with the prevention strategy, a new methodology must be considered.

Conclusion

The implemented programs described above demonstrate that peers can be successfully utilized in condom distribution programs at colleges and universities. Given the overall number of students reached, peers can be effective in reducing difficulties associated with reaching target populations within the collegiate environment. The programs outlined can be used in the decision-making process and programmatic endeavors at similar colleges and universities. Given the severity of sexuality-related problems of young adults, additional peer-based innovations that reflect the interest of both the target population and the peer are vital.

References

American College Health Association. (2004). American College Health Association-National College Health Assessment (ACHA-NCHA) Web Summary. Retrieved May 1, 2005, from http://www.acha.org/projects programs/ nchasampledata mbrs.cfm. 2004.

American Social Health Association. (1998). Sexually transmitted diseases in America: How many cases and at what cost? Research Triangle Park, NC: American Social Health Association.

Centers for Disease Control and Prevention. (1997). Youth risk behavior surveillance: National college health risk behavior survey-U.S., 1995. Morbidity & Mortality Weekly Report, 46(6), 1-54."

Crosby, R., Sanders S., Yarber W., & Graham, C. (2003). Condom-use and problems; A neglected aspect of studies assessing condom effectiveness. American Journal of Preventive Medicine, 24(4), 367-370.

Guttmacher, S., Lieberman, L., Ward, D., Freudenberg, N., Radosh, A., & Des Jarlais, D. (1997). Condom availability in New York City public high schools: Relationship to condom use and sexual behavior. American Journal of Public Health, 87, 1427-1433.

Henshaw, S. (1998). Unintended pregnancy in the United States. Family Planning Perspectives, 30( I), 24-29.

Kaiser Family Foundation, Hoff, T., Greene, L., & Davis, J. (2003). National Survey of Adolescents and Young Adults. Sexual Health Knowledge, Attitudes, and Experiences. Menlo Park, CA: The Henry J. Kaiser Family Foundation.

Kirby, D., Brener, N. D., Brown, N. L., Peterfreund, N.. Hillard, P.. & Harrist, R. (1999). The impact of condom distribution in Seattle schools on sexual behavior and condom use. American Journal of Public Health, 89(2), 182-187.

Misra. D. (2001). Women's health data book: A profile of women's health in the United States (3rd ed.) Washington, D.C.: Jacobs Institute of Women's Health and the Henry J. Kaiser Family Foundation.

Salovey, P., & D'Andrea, V. J. (1984). A survey of campus peer counseling activities.

Journal of American College Health, 32(6), 262-265.

Sanders. S.. Graham. C, Yarber, W., & Crosby, R. (2003). Condom use errors and problems among young women who put condoms on their male partners. Journal of the American Medical Women's Association, 58, 95-98.

Schuster. M., Bell, R., Berry, S., & Kanouse, D. (1998) . Impact of a high school condom availability program on sexual attitudes and behaviors. Family Planning Perspectives, 50(88), 67-72.

Ullman, S. E" Karabatsos, G" & Koss, M. P. (1999) . Alcohol and sexual assault in a national sample of college women. Journal of interpersonal Violence, 14(6), 603-625.

Weinstock, H.. Berman, S., & Cates. W., Jr. (2004). Sexually transmitted diseases among American youth: Incidence and prevalence estimates, 2000. Perspectives on Sexual and Reproductive Health. 36, 6-10.

Zenilman, J. M., Hook, E. W, III, Shephard, M" Smith, P.. Rompalo, A. M., & Celentano, D. D. (1994). Alcohol and other substance use in STD clinic patients: Relationships with STDs and prevalent HIV infection. Sexually Transmitted Diseases. 2/(4). 220-225.

Scott M. Butler, MS, CPPE is a member of the NAPP Board of Directors and is currently a PhD student and graduate instructor at Purdue University in West Lafayette, IN. Inquiries can be sent to him at 2303 Osage Ct # 18, Lafayette, IN 47909. smbutler@purdue.edu.

Rose M. Hartzell, MS, CHES is currently a PhD student, Doctoral Academy Fellow, and graduate instructor in the Department of Health Science at the University of Arkansas at Fayetteville.

Sarahmona Przybyla, MPH is currently a PhD student and graduate course instructor in the Department of Health Behavior and Health Education at the UNC-Chapel Hill School of Public Health and a human sexuality educator at the Center for Healthy Student Behaviors located on the UNC-Chapel Hill campus.

Lindsey B. Bickers Bock, MPH is currently a Health Education Specialist and Coordinator of the Healthy Devils Peer Education Program at Duke University in Durham, NC.
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Author:Butler, Scott M.; Hartzell, Rose M.; Przybyla, Sarahmona; Bock, Lindsey B. Bickers
Publication:Perspectives in Peer Programs
Date:Mar 22, 2006
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