Abstract objective: to evaluate the effectiveness of a pilot peer education sexually transmitted infection prevention program with male sex workers.
Design: process and results evaluation of pilot programs conducted in three London male escort agencies, using quasi-
Experimental design.
Target: staff of three London escort agencies, including 88 people who completed the questionnaire, five peer educators and 16 other men (
Including management)
Working in two of them.
Methods: peer education sexually transmitted infections prevention program managed by staff Program (WMP)
This is a sexual health service agency dedicated to male sex workers, which has been piloted in two escort agencies in London.
Five male sex workers participated in a two-day peer education training session.
They then returned to their respective agencies to spread information and condoms in an attempt to influence the code of conduct.
A results evaluation was conducted to assess changes in knowledge related to sexually transmitted infections, high-risk sexual behavior, and participation in sexual health services. A pre-
An intervention questionnaire to assess variables such as knowledge, sexuality and population information related to sexually transmitted infections was conducted in institution A and institution B and in institution C as A control.
Ten weeks after peer educators returned to their institution, the same questionnaire was conducted in the same institution.
During this period, the recommendation of peer educators to WMP was also recorded.
The process assessment includes interviews with peer educators and focus groups, as well as a diary of the completion of their experiences in this role.
Another 16 men work in these institutions (
Including managers and owners)
They were interviewed about their program experience.
Participants were also observed through regular outreach to agencies.
Results: there were 57 males who completed the questionnaire at time 1, and 44 males who completed the questionnaire at time 2.
Unfortunately, only 13 matches exclude any meaningful analysis of sexually transmitted infection-related knowledge and changes in sexual behavior.
The questionnaire provides an overview of men working in these institutions.
Of the 88 men who completed at least one survey, the majority were gay, when they were in their teens or 20 s.
Although there are some ranges in these categories, most of them belong to the "white" race.
I like to speak English best, and I am highly educated.
Relevant knowledge of sexually transmitted infections reveals a high level of understanding of HIV and hepatitis B, a moderate understanding of gonorrhoea, syphilis, condyloma acuminatum and herpes, and an understanding of non-
Specific urethritis (NSU)or chlamydia.
Sexual behavior shows that both men and women have a highly sexually active population of both paid and non-paidPaid Partners
For paying partners, especially anal sex, condom use is the highest.
The use of condoms when performing oral sex with all partners is not consistent, and the use of condoms when performing all types of sex with ordinary partners is lower than that with other partners.
A small number of men who have vaginal sex with paid and regular partners are less likely to use condoms.
Due to peer educators recommendation, 26 new patients were registered at WMP, accounting for 65% of all new contacts during the study.
The process assessment shows that while the training programme is considered appropriate and while peer educators consider the programme and its role to be successful, their experience with the role is difficult.
The role of management support is essential to support the programme.
The results did not confirm the hypothesis that "peers" were particularly effective educators.
While peers are considered appropriate to discuss certain aspects of the industry, many prefer to consult "professionals" on health-related issues ".
The concept of "peers" is problematic because most men attract "peers" from groups within the organization ".
Other restrictions on behavior, such as lack of power, particularly lack of management support or poverty, have a significant impact on behaviour that is not affected by peer educators.
Conclusion: This study illustrates the use of accurate
Experimental evaluation methods for this customer base.
It also shows the limitations of peer education based on information-provided health education models focusing on personal behavior change.
Suggestions were made for future interventions.
In the United Kingdom, 807 cases of HIV infection were reported, of which 366 were reported (61%)
It is considered to be gay.
1 There is no regular data on HIV prevalence among male sex workers in the UK, although a London study found that among male sex workers tested at a specialized sexual health service, 11% are HIV positive.
High levels of other sexually transmitted infections have also been identified in this population, which may also be important to promote HIV transmission.
However, the illegal and stigmatized nature of prostitution means that many male sex workers are reluctant to participate in general sexual health services, or do not disclose to employees that they are involved in sexual transactions if they wish.
Although sex workers themselves do not constitute a "risk group", five male sex workers are often associated with a range of risk behaviors such as injecting drug use, with a high rate of inconsistency in anal sex, 3,7 and condom use (
Although the reported rate is vary3)
Therefore, it may be important in STI transmission.
In addition, non-security behavior
Paid partners are very common, which may provide an important avenue for sexually transmitted infections.
8, 9 peer education has become a popular method of health intervention for male and female workers.
The study found that peer groups and social norms are important determinants of behavior of many groups (
See Fennell10 and rho11 for comments).
Similarly, the study also shows that social consensus and peer recognition of sexual behavior are one of the most important determinants of behavioral change.
As a result, peer education programmes have begun to leverage the skills of "indigenous" peer educators.
That is to say, individuals from "target groups" are considered key or core in social networks who are employed as health educators.
World Health Organization (WHO (WHO)
Guidelines for policies on control of sexual transmission of infections in prostitution construction workers and their partners are involved in transmission of infection prevention initiatives, suggesting current or previous
Sex workers are employed as educators and coordinators.
13. Peers and Johnston14 believe that peer education is particularly difficult to assess due to its loosely defined goals and emergency activities, and some reviews of peer education initiatives show that there are very few systematic assessments
10. 15 Milburn, in reviewing peer education initiatives with young people, found that many initiatives did not clearly define the theoretical content and warned of the difficulties of "artificially rebuilding the social process.
Campbell, 16, wrote an article on peer education for adolescents and safer sex, noting the limitations of peer education in addressing the constraints of behavioral change, especially in the community and
Rhodes11, however, believes that the existing assessment of peer education suggests that this is a more effective method of behavior change than an individual-based intervention.
Staff project (WMP)
Headquartered in St Mary's Hospital in London, professional sexual health services are provided for men selling sex products to men.
The project launched a pilot peer education initiative where men work off-site
Escort agencies that have sex in the premises carry out street prostitution in an attempt to reach harder-to-reach workers in new ways.
The initiative hopes to use the important role of peers to impart information and "models" of appropriate behaviour with the aim of: increasing sexual health knowledge, as knowledge of sexually transmitted infections has been shown to be an important prerequisite for safer sex in prostitution 17 reduction of high risk sex
That is, by encouraging regular screening in male work programs, the use of condoms is encouraged for anal, vaginal and oral health care.
WMP interventions are currently visiting a number of agencies, distributing condoms, discussing sexually transmitted infections and safe behaviour, and making appointments at WMP.
Eight people from two agenciesA and B)
Invited to attend a two-day training program.
The worker from the third agency, C, did not participate and this agency is a control agency.
Select institutions A and B for intervention as they are the largest and WMP is somewhat familiar with the network within them.
C institutions are smaller, and their social networks are not well known.
The reason the participants in the training programme were selected was that WMP knew that they were key players in the institutional network and had informally introduced patients to the program, working to prevent sexually transmitted infections.
Five men participated in the event.
The first day examined all aspects of HIV, information on sexually transmitted infections and the benefits of regular sexual health screening.
Personal growth and communication and negotiation skills were discussed the next day.
Peer Educators (PEs)
Took part in the actual role-playing practice.
After the completion of the training program, PEs returned to their respective institutions (
2 Institutions A and 3 institutions B)
Provide a range of health education materials, distribute condoms and spread the knowledge they have learned.
Unfortunately, two PEs (
One per agent)
Leaving the program, one working in private and the other completely leaving prostitution.
WMP continues to visit all agencies.
Evaluation methods this study began in October to December 1995 for a period of 10 weeks.
In order to assess the effectiveness of the programme in achieving its objectives, a process and results evaluation was conducted.
Due to the established nature of the employees of the institution, the experimental method for evaluation of results randomly assigned is not feasible. However, quasi-
Experimental methods and pre-
Intervention and post
Intervention measures and non-
They were randomly divided into experimental group and control group.
In addition to the existing health promotion activities, peer education interventions were provided to the two experimental groups.
The control group received only the existing health promotion.
A questionnaire was prepared to assess a range of aspects, including awareness of sexually transmitted infections and knowledge of transmission, prevention and treatment;
Sexual behavior;
Population Information.
The questionnaire was evaluated by an appropriate panel of experts with a structure and content effectiveness, and was piloted three times with the members of the subject group and revised accordingly.
The questionnaire included a briefing outlining ethical considerations, which were distributed to men working in institutions during existing regular visits.
The questionnaire was completed in the presence of the researchers, and once completed, it was returned in a sealed envelope.
The questionnaire was anonymous, although participants were asked to provide a "identifier" of the month, year, and town in which they were born in order to compare responses in the future.
At the end of the 10-week study period, the questionnaire was again distributed to men working in all three institutions. The pre-
Intervention and post
Condom use in intervention sexual health knowledge scores and related sex was compared in A and B, and institution C was used as A control.
In addition, the WMP recorded the number of new patients claiming to be registered for interaction with the PE.
At the end of the second day of the training programme, a focus group was held with PEs to assess the training situation.
During the intervention, peer educators were asked to complete the daily diary detailing the number and nature of their contacts with colleagues.
They were also asked to complete the weekly diary to record their programming experience over the past week.
Individual interviews were also conducted with PEs.
In addition, the two group meetings held during the intervention provided practical support and provided an opportunity to evaluate the programme.
Finally, at the end of the programme, a focus group was set up with PEs to reflect on the overall experience, successes and failures of the programme and suggestions for future initiatives.
In addition, interviews were conducted with the owner and manager of Institution A and the manager of institution B, in addition to 13 men working in two participating institutions recruited through the initial questionnaire.
WMP's monthly visits to various agencies, participation in a gathering of institutions a and informal discussions make it possible for Ethnographic Research and participant observation, especially for those who refuse to be interviewed, and try to solve the potential bias of the respondent's self-report.
The study was approved by ethics through the WMP at St Mary's Hospital in London.
The results did not know the exact number of men working at the institution each time, although it was observed that most workers had completed the questionnaire.
However, due to the rapid flow of men working in these three institutions, the proportion of samples still available at the time of the second management questionnaire is very small, as can be seen from Table 1.
In addition, during the study, some men changed the institutions and confused the distribution of groups.
These factors exclude any meaningful comparison of the questionnaire data for evaluation purposes.
1 View this table: View the inline View pop-up table 1 The number of men who completed the questionnaire at time 1 and time 2 However, the questionnaire data provides some knowledge of men working in these institutions
Eighty-eight men completed at least one survey.
The average age of respondents was 24.
Two of them were 17 years old, less than the agreed age for same-sex. Sixty six (75%)
Identified as gay, 11 years old (13%)
Two bisexuals2%)
As heterosexual, four (5%)as other (five (6%)missing)(
Due to rounding, the percentage does not add up to more than 100). Thirty two (37%)
Identified as "white English/Scotland/Wales", seven (8%)
As "white Irish", 29 years old (33%)
Such as "white others "(
Mainly other European Communities and South American countries). Three (3%)
Identified as "Black Africa", three (3%)as “black-
Caribbean and three (3%)
"Black Other ".
There are 1 Indian, 1 Chinese and 4 Chinese. 5%)
Men from "other" races (five (6%)missing).
Of the vast majority of respondents, 58 (66%)
I like to speak English and Spanish, Portuguese, French and Italian are other popular languages. Seventy six (86%)
The man has completed a secondary school or equivalent. Of these, 49 (64%)
Further qualifications, 19 (39%)
The level of these degrees.
As can be seen from Table 2, STI knowledge varies significantly due to infection.
The knowledge of HIV is particularly high and it is reported that this is predictable given the exposure to HIV prevention campaigns.
Hepatitis B is also high, probably due to targeted educational activities during the study, due to the hepatitis B panic in the institution.
Moderate knowledge of condyloma acuminatum, herpes, syphilis and gonorrhoea, but little knowledge of chlamydia and NSU.
View this table: View inline View pop-up table 2 median percentage score of STD knowledge the median of paid partners for the first 7 days is 6 (range 0–25). Forty nine (58%)
In the last 3 months and 5 months there has been a sexual relationship with a casual male partner (7%)
And a casual female partner. Forty nine (57%)
In the last 3 months and 6 months, the male has had sex with the normal male partner (7%)
With an ordinary female partner.
As can be seen from table 3, oral sex is the most common sex with paying partners, and more than half of them do not continue to use condoms.
Although the use of condoms is much higher, anal sex is also quite common, especially active.
While only half of people always use condoms, few people engage in vaginal sex.
Similarly, a small number of sex toys have been used, but condom use is high.
View this table: In day4 and 5 for the last 7 days, View the inline View pop-up table 3 showing sex and condom usage with paying partners, most men with leisure partners have low condom use.
Anal sex is also quite common, slightly higher than the number of paying partners who do not use condoms frequently.
A small number of people have had vaginal sex with regular sexual partners, and they all use condoms a lot.
The number of people who have used sex toys is similar, but two people don't always use condoms.
Sex with a regular partner is similar to casual sex, although anal sex is more common in the case of lower condom use.
A small number of men have vaginal sex with their regular partners, which is inconsistent with the use of condoms, and the use of sexual toys is also inconsistent.
View this table: view sex and condom use with a temporary partner in the past 3 months see this table: view inline View pop-up table 5 sexual behavior and condom use with regular partners in the past 3 months given the high rate of sometimes lost data, sexual behavior and condom use should be considered (see tables 3–5).
The recommendation of WMP showed that PE activity had a significant impact on the recruitment of new patients in WMP.
During the study, a PE referred 26 newly registered patients to the WMP, accounting for 65% of the new patients who visited during the period.
The training program was positively evaluated and all PEs felt they had enough skills to take on the new role.
Interviews, focus groups and diaries indicate that PEs find it beneficial for them to be involved in the project and believe that they have been successful in many ways, especially in terms of the success of their referrals and the improvement of their own knowledge and expertise.
WMP followed up with some suggestions from PEs --
For example, a hepatitis B information card, a condom bag with sexual health information, and an STI information card with photos (
Although these developments were not completed until the end of the study).
However, sometimes PEs feel unappreciated and supported in their institutions, and people who work in agency B are positively discriminated against (see below).
By the end of the study, all the workers left the institution, reflecting both the short nature of the work and their difficulties in their roles.
Management experience the management of the two intervention agencies varies in the experience of peer education programmes.
At Institution A, the managers and owners of the agency are fully supportive of the WMP and peer education program.
They provided important support for sports to work in the agency and encouraged new workers to meet with him.
In contrast, at agency B, the owner was hostile to the program and was concerned that encouraging the use of condoms would cost him business.
When the two PEs significantly affected the worker's decision to use a condom for oral sex, he fired anyone associated with them and subsequently made sure that PEs was barely working.
The intervention attempt by WMP failed.
Male interviews with men working in institutions show that "peers" are preferred and more effective sources of advice and information, only in some cases, only part of the sample is like this.
Some people interviewed said they would seek advice and information from their peers and thought that sometimes "peers" are better informed about their situation than external health professionals.
For example, the idea of sexually safer sex is best suited to people in the industry.
A large percentage of men, however, emphasize that health professionals are a more appropriate source of information/advice for most things.
It is believed that health professionals are only "professionals" with ethics, secrecy rules, etc ".
"For me, the people who wear a white suit or go to the hospital are professional or they won't be there.
To me, I mean everyone knows it's confidential, what's going on between you and me and in the hospital "(Peter)(
As this will provide identity information, no details about the man being interviewed are provided. )
Some men said that when discussing health issues with colleagues, there may be conflicts of interest with colleagues and concerns about secrecy.
Many people talk about the importance of talking to "outsiders.
"If you have an embarrassing question, then you want someone who is more like an outsider, no matter what you think. ” (Michael)
Contrary to the role of potential PEs, the role of health professionals is clearer to them: "They are [
Peer Educators]
They are not true to us.
Like we know you. WMP staff]
We are really there. ” (Peter)
In addition to the importance of health professionals, most people use the "gay" health education campaign as their favorite source of information.
With regard to the role of social norms and peer impact, it appears that there are informal and formal norms related to sexual behaviour and other elements of work practice in the institution.
Institution A has A formal internal rule that condoms are used for anal sex with clients.
Anyone found not to do so will be fired.
In addition, there is an informal norm between these people, which must be observed.
Despite the lack of management support, similar informal rules exist in agency B.
Although both institutions have group norms for the use of anal condoms, there are rumors that this specification has been violated with the support of the questionnaire data, which is largely relatedDiscussed below).
The impact of PEs on these sexual norms is difficult to assess.
According to factors such as lifestyle, nationality and language, there are many groupings within the organization that have a series of norms in themselves (
For example, it is related to the use of condoms, oral sex, kissing, and anal sex in some cases).
The social life of an institution is an important part of its operation.
It is from these groupings that people seem to identify "peers" more directly, as well as those who seek information and advice.
A number of other factors affected men's sexual behavior and provided obstacles to compliance with social norms.
Most people believe that the role of power in the industry is very important.
Many people talk about mind games and power struggles that often happen between customers and workers.
Similarly, the manager of one of the agencies talked about the need for customers to control sexual contact, saying it was one of the reasons why condom use was difficult.
Customers sometimes complain about using a condom or refuse a man on the grounds that he wants to use it.
Management support is critical in this case.
At Institution A, all the people interviewed thought they had the support of management to reject customers or sex.
Customers who are known to have taken out condoms are prohibited from entering the agency.
However, at agency B, for whatever reason, if three complaints were made against a person, he was dismissed.
All the men interviewed reported that they were economically tempted by unsafe sex.
It is reported that some people working in these institutions are suffering from extreme economic difficulties: "It is very difficult in London.
This is a very difficult city. . . .
You don't have insurance, you don't have social insurance that gives you money every week, you have to work. ” (Dan)
This is particularly relevant to illegal immigration.
For example, it is reported that the manager of agency B employs the following
Men of age and illegal immigrants, and made it clear to them that no other institution would do so.
It was noted that many illegal immigrants believed that they could not use medical services or were unwilling to do so because they were concerned that they would be tracked through medical records.
In general, the law also affects people's behavior, for example, to respond to management policies or customer behavior on institutional health and safety issues.
While most workers are aware of the risk of sexually transmitted infections caused by oral sex without condoms, in some cases, at "cost-
An analysis of the benefits of the extra money they can earn ".
On the failure of quasi-
The experimental design illustrates the inherent difficulty of using these methods to evaluate such a stigmatized group, "most boys work/rest/change institutions/work/return to old institutions, etc "(
Quote from fellow educators).
In terms of the effectiveness of peer education in increasing sexual health knowledge and reducing risky behaviour, the outcome assessment was inconclusive.
However, the questionnaire data provides photographs of men working in these institutions, which is important if appropriate targeting is required.
Most men are gay and are about 20 years old.
Although there are some ranges in these categories, most of them belong to the "white" race and prefer to speak English.
The level of education is high.
Since there are no specifications related to survey tools, it is difficult to determine the overall level of knowledge of science, technology and innovation.
However, the relative level of knowledge has found that the incidence of HIV and hepatitis B is high and there is a serious shortage in some areas.
The results showed that both men and women had a highly active population of both payments and non-paymentsPaid Partners
For paying partners, the use of condoms is the highest for anal sex, which confirms the qualitative data of anal sex norms.
Similarly, the use of condoms when performing oral sex with all partners is not as consistent as suggested during interviews with men.
It is not consistent with the use of condoms by ordinary partners, especially when anal sex.
These findings are consistent with the findings of de Graaf et al among male sex workers in the Netherlands, that is, as familiarity with the type of partner increases, condom use for penetrating sex decreases.
19 people who have vaginal sex with paying partners and regular partners are also less likely to use condoms, suggesting that although these numbers are small, the risk is considered low.
While these measures fail to account for changes in knowledge of sexually transmitted infections, sexual behaviour and condom use, it does show a significant increase in referrals to WMP, given the reluctance of many sex workers to access sexual health services, this is important.
The training programme itself appears to be sufficient to equip educators, and PEs itself believes that the programme and its role in it are successful, which is largely related to the referral process.
However, PEs needs a lot of support, especially if management is against it.
The results did not confirm the hypothesis that "peers" were particularly effective educators.
Interviews with the sample show that the medical industry and gay communities are generally more relevant to health education for these men compared to "sex worker peers.
Similarly, the impact of PEs on relevant social norms is also a complex process.
This process involves a broader concept of group members, social norms and peer relationships.
Management interventions and financial considerations provide significant obstacles to the impact of the programme.
The scope of management power is significantly affected by the physical environment and immigration status.
The impact of these factors illustrates the limitations of peer education based on information-provided health education models that focus only on changes in individual behavior.
11, 20 more forms of collective action, using 20 models of "social transformation" designed to enhance health by bringing about broader social change, may be more suitable for this group.
Conclusion The evaluation of the pilot project demonstrates the difficulty of peer education with this customer base.
Future peer education programs may need to take into account the various information needs and credible sources of information for specific subject groups, as this may vary.
Using the skills of many different "types" sex workers in peer education, it may be important to address different levels of social norms.
This may involve, for example, tapping into more common gay norms or attracting cultural backgrounds.
Health interventions may require strategies to promote collective recognition of consciousness.
This will require a community action model with ownership by the relevant groups.
Similarly, the role of power, material and structural factors in behavioral selection suggests that a broader approach is needed, such as involving managers and other participants in sexual industries such as clients, or address the impact of legislation on health and occupational safety.
The intervention budget should take into account the role of maintaining the momentum of initiatives and providing adequate support to peer educators.
Peer education is not a "cheap option" in this case ".
Finally, the study emphasizes the importance of considering the operating environment of peer education programmes and the objectives of specific groups.
Even information such as what a worker says "we don't get up very early" is important in organizing training programs or supporting meetings.
Similarly, the study involves men working in London institutions where prostitution may be found differently in other settings.
The authors would like to thank fellow educators and others involved in the study.
We would also like to thank Dr. Catherine Campbell and Dr. David Tomlinson for their help and advice in this work, as well as anonymous referees for their comments on the previous draft of this article.
Contributor: AZ and JG designed and managed the questionnaire and wrote the paper.
AZ designed and managed the diary, conducted qualitative work, and compiled statistical data.
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