Hadia Mohamed Balla Abass
Peer education and avoidance of risky sexual behaviour.
Concepts, examples and experiences from Sudan and Egypt.
A literature review
Thesis submitted for the Master degree in International Social
Welfare and Health Policy
Spring 2010
Faculty of Social Science
Oslo University College
1
Acknowledgements
First of all I would like to thank Allah, and then my supervisor Frank Meyer for supporting
me and giving me continuous feedback, constant help, and valuable contributions during the
entire period of writing my master’s thesis.
Secondly I would like to thank my family who always supported me and encouraged me
while being away from them. Also, I would like to thank my friends who always encouraged
me including Walaa, Mai, Jenifer, Prakash, Nahla, Afra. And to Helle my colloquium leader,
and also to the English man, Karl Robb “neighbour” and Kristin who helped me corrects
English language.
Last, but not least I would like to thank the International Office at Oslo University College
who selected me to be one of their students and accepting me to come to study here in
Norway. This has turned out to be a fruitful and lovely year in my life.
My greatest thanks go to Anne Moegster, Marte and Heidi.
Thank you all
Hadia
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Abstract
This thesis is a literature review which aims to describe and understand peer education
programs, adolescent sexuality, sexual behaviour and reproductive health in Sudan and
Egypt. Adolescent sexuality is the focal point of my thesis, as well as the widespread
adoption and acceptance of peer education programs in several countries, including Eastern
Europe, Central Asia, Africa and Arab states. The thesis reviews several studies done in
different countries; however, the main focus is on Sudan and Egypt.
The aim is to give an overview of theories about and of the practices of peer education
programs in relation to adolescent sexual behaviour. Most adolescents usually ignore relevant
knowledge on reproductive health because they don’t receive education about sexuality from
their families or school, much due to the fact that these issues are culturally sensitive.
Therefore, the adolescents seek information from their peers outside their families. Certain
countries have introduced peer education programs, which have then been adopted by
different communities in those countries. Today, peer education programs are adopted in
many countries that are in need of such programs.
3
Abstract
I
Acknowledgement
Ii
Table of contents
Iii
List of figures
Iv
List of tabeles
Iv
Chapter one
1
Introduction
1
1.1
Research question and rationale
2
1.2
Thesis structure
2
Chapter two
2
Methodology and research design
4
Chapter three
3
Literature review
8
3.1
Adolescent sexuality: knowledge and practices
8
3.1.1
Barriers to accessing appropriate information
9
3.1.2
The role of parents and family dynamics in youth sexual behaviour
10
3.1.3
Adolescents and sexual reproductive risks
11
3.1.4
Peer education and adolescent sexual behaviour/ reproductive health
12
3.1.5
Sexual reproductive health rights framework
13
3.2
Definition of peer education related concepts
14
3.3
How does peer education work and what is the role of behavioural 18
theory in peer education programs?
3.3.1
Behavioural theories
19
3.4
Advantages of peer education
22
3.5
Evidence of the impact of peer education programs globally
23
4
Chapter four
4
Peer education in Sudan and Egypt
26
4.1
Sudan’s experience with peer education
26
4.2
Egypt’s experience with peer education
29
4.3
Comparison between Sudan’s and Egypt’s experience with peer 30
education
Chapter five
5
Conclusion
References
5
Chapter One
In this chapter I will give a brief introduction to the peer education program, an overview of
the research questions and rationale, an outline of the thesis structure, and a description of the
methodology and research design.
1. Introduction
The type of peer education that is the subject of this thesis can be defined as a process of
teaching peers about a specific kind of information. The main purpose of such education is to
prevent the transmission of the Human Immunity Virus/ Acquired Immunity Deficiency
Syndrome (HIV/AIDS). The first network for peer education started with youth.
The Youth Peer Education Network is a program funded by the US government and includes
several networks such as FHI, UNICEF, Youth Network and others. The United Nation’s
Fund for Population Activities (UNFPA) leads this global effort, and the program now exists
in many countries in Eastern Europe, Central Asia, the Arab States and Africa” (UNFPA,
2005).
In 2004 the UNFPA and the Planned Parenthood Federation of America (PPFA) established
the Peer education program in Sudan, which is a branch of the Y-peer network. The program
activities are carried out in collaboration with local non-governmental organizations (NGOs).
The Sudanese Community Development Association (CAFA) is one of the associations/
NGOs that participate in the program. CAFA mainly works with Reproductive Health (RH)
and family planning (FP) methods in Sudan, and recently started working with peer education
programs. The association has carried out peer education activities since 2005 with
adolescents as a target group. The main issues of these initiatives have been the training of
peer educators in relation to RH, Family Planning (FP), Female Genital Mutilation (FGM),
HIV/AIDS and Sexual Transmitted Disease (STDS). As of yet, there is not much evaluation
done regarding the behavioural impact of these initiatives.
The expansion of peer education programs to several countries and from one community to
another, lead the education process and the recruitment of participants or the peer who
serves as peer educators for other future peers. In this way, peer education programs are
meant to set off a chain reaction, in which the programs spread from peer to peer,
neighborhood to neighborhood, community to community.In this thesis, I will begin with
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providing an overview about adolescents’ knowledge about sexuality, their sexual practices
and the sexual reproductive risks facing them. I will also describe the barriers to accessing
appropriate information about and to the rights to access sexual knowledge. Then, I will
present a background about peer education and outline the basic concepts and the theories of
the program. The main focus of the thesis will be on the peer education process and the
adolescents’ issues related to RH and HIV/AIDS, as well as on peers and their role in
distributing sexual and reproductive knowledge.
1.1 Research question and rationale
In this chapter I will give an overview and some specification of the research question and the
rationale for selecting this topic.
My main research questions are: What is the process of peer education? How does it work?
What is its impact on the sexual behaviour of adolescents? I will start with providing an
overview of adolescents’ sexuality, and then I will discuss peer education programs and
present several studies done in this field worldwide. Lastly, I will reflect the experiences of
CAFA in Sudan and the experiences with peer education programs in Egypt in order to
provide a comparison of the two countries regarding the factors that facilitated the
implementation/ success of the programs.
I have two reasons for choosing this topic: firstly, I consider peer education useful for young
people because I worked as peer educator myself, and I enjoyed the program and felt that it
was useful for me and my colleagues. My experience with the peer education program let me
to be more curious about the theoretical and pedagogical implications of peer education; why
was it an appropriate and efficient instrument to improve and enhance the sexual reproductive
health (SRH) and to combat HIV/AIDS? And how did it work so well among the youth?
Secondly, the training provided by CAFA may help changing attitudes and prevent
HIV/AIDS among youth.
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1.1.2 The structure of the thesis
The thesis is structured as follows:
In chapter one I introduce the reader briefly to youth peer education programs and to
my research questions. Also, I will give an overview of the thesis structure and the
methodology and research design of my thesis. I will describe adolescents’ sexuality
peer education programs and the use of the comparative method in order to contrast
Sudan’s and Egypt’s experience with peer education; the focus will be on the different
experiences in the two countries.
In chapter two, I will give an overview to the basic concepts related to peer education
programs and how peer education works, relevant behavioural theories, and key
theoretical aspects of peer education. This will provide the reader with a better
understanding of peer education programs and adolescents’ knowledge about sex and
sexual practices. In chapter three I will describe how peer education programs address
adolescents’ sexual behaviour, reproductive issues, adolescents’ rights to health
services, and STD and HIV/AIDS prevention. Moreover, I will present evidence
related to the advantages of the program.
In chapter four I will provide a comparison between the experiences of peer
education in Sudan and Egypt, and I will also give an overview of the challenges
facing the programs in Sudan and Egypt. Finally, I will discuss how peer education
might be used as a tool to escape a viscous circle.
In chapter five I will discuss the resistance against peer education programs and the
criticism related to the programs.
Chapter six will present a brief conclusion.
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1.2 Methodology and Research design
My study is a descriptive study, in which I will describe adolescents’ sexuality and the
process of peer education implementation and adoption as well as its influence on
adolescents’ sexual knowledge and behaviour The implementation and adoption of peer
education will be described by exploring the comparison between the two countries Sudan
and Egypt, through variables that capture differences and similarities, also including such
aspects as culture, language, education and health issues. When I describe adolescents’
sexuality I will look at the adolescents’ reproductive health, their rights to access knowledge
about sexuality and reproductive health and the barriers of getting appropriate information
about these issues.. In addition, I look at the role of parents and family dynamics in relation to
adolescents’ sexuality.
The literature review of my research is a collection of data from different sources of books,
articles, magazines, websites, and different documents, reports, paper and projects written by
UNFPA, UNAIDS, UNESCO, AIDSCAP, WHO, The population council and CAFA. Also, I
have used Google Scholar, BIBSYS, and EBSCO as search engines. The data from all these
resources are combined to provide different points of view and to bring new insight highlight
the cases of peer education in Sudan and Egypt and explain the theoretical background of
peer education programs and adolescents’ sexuality.
The methodology that I am going to use is a “comparative method of differences and
similarities” which is a type of comprehensive comparison. To conduct this comparison, I
will be analyzing the secondary data which I collected from the different sources of literature
review, including the documents and reports from Sudan and Egypt.
Since the 1960s the field of comparative social policy has grown dramatically, in terms of the
number of studies being undertaken, the types of approaches used and the number of
countries included in the studies. Recent studies have paid a greater attention to the diversity
of the communities being studied and the importance of analyzing the context, processes and
the outcome of social policies in different countries and their impact on different groups
(Clasen, Jochen, 1999).
In social sciences an observed phenomenon is compared against a certain point of reference,
which is either explicitly or implicitly assumed. This comparison allows differences and
similarities to be analyzed, interpreted and evaluated. In this sense, the social sciences might
9
be considered as ultimately comparative. In my thesis I’ll compare the cases of Egypt and
Sudan and their experiences with peer education. In Sudan my case is based on CAFA and
other organizations which started the work of peer education programs and contributed to
distributing it to other places. The case of Egypt is based on the Y-peer Egypt network and
the collaboration of other organizations that help in the building of the program.
The analyst in comparative social policy should provide a clear explanation about the ways in
which he or she conceives countries as units of analysis. The comparison conducted might be
made between two or more countries, for example, all member states of the UN. Dependent
on the specific aim of a comparative study, sub national entities e.g. localities and local
authorities or supranational organizations such as African union might be considered as a
more appropriate unit of analysis (Kennett Patricia, 2004).
According to Landmann (2003) the comparative method that uses the comparison between
few countries is primarily based on John Stuart Mills Method of agreement and Method of
differences (Landmann, 2003).
The comparison of similarities and differences is designed to uncover what is common
between each country and relate it to the outcome of the program in the two countries. By
collecting data on different issues concerning the program of peer education in the two
countries of Egypt and Sudan, and comparing the similarities and differences between them,
it might be possible to give a fuller explanation of what is similar and what is different in
each of them (Landmann, 2003).
This method of comparison highlights complexity, diversity and uniqueness, and provides a
basis for interpreting cases historically (Ragin, 1989). According to Ragin, the best method is
to look at the similarities and differences among few cases.
According to Kjelstadli, who refers to John Stuart Mill, the comparisons that aim at finding
causal explanations can be made in two different ways, either the Method of agreement, (in
spite of all differences) or the Method of difference (in spite of all similarities). The first
method concentrates on finding the similarities and the later one focuses on the differences.
When the method of agreement or similarities is used; the focus will be on what is common,
“the similar variables” in the different cases. However, even if the main focus is on
similarities, differences will also be reflected (Clasen, 1999).
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The following table illustrates the particular pattern of similarities and differences in the
Method of difference:
Table one:
Method of agreement:
Variables
Case 1
Case 2
A
D
B
E
C
F
X
X
Differences
Decisive agreement
Decisive agreement
Phenomenon
Y
Y
In the method of difference the focus is on the differences; which are the different variables
that can be regarded as the causes/ or different outcomes in spite of similarities. Many
variables can be similar, but the emphasis will be on identifying the different variables that
can be related to the different outcomes (Landmann, 2003).
The following table illustrates the particular pattern of similarities and differences in the
method of difference:
Table two:
Method of Difference:
Variables
Positive
Negative
case
case
A
A
Similarities
11
B
B
C
C
X
Not X
Decisive differences
Decisive differences
Phenomenon
Y
Not Y
In this thesis I will use the Method of differences in order to compare the implementation,
adoption and the development of peer education program in the countries of Egypt and
Sudan. My cases display variables that are different as well as those that similar to show the
differences and similarities in the progress and the development of peer education programs.
The different aspects are covered by literature with diverse methodological approaches. In the
end, I will give a brief comparison between the two countries in terms of how they have
adopted peer education programs, how these programs have progressed, and I will also
consider the differences and similarities between the programs.
My study compares the differences and similarities in each country in order to take the
similar and different variables and try to compare them within each country and relate them
to the adoption and implementation of the programs, in which the variables are trying to
explain the differences and similarities in the program, which may present the reason for the
different development.
In the method of differences, there are positive and negative cases. One of the countries has a
different variable which leads to a different outcome and to better implementation of peer
educational programs. I will discuss this in chapter four in which I define “X” and “not X”
and “Y” and “not Y” and suggest an explanation for the different outcomes of the
programs.In the positive case, which is represented by Egypt, X is defined by several
variables, including a longer history of peer education as an applied strategy, in addition to
the non-existence of conflicts, war, wider awareness and better teaching methods and
materials. While “not X” in the negative case is represented by Sudan in which “not X” is
defined by peer education programs not being an applicable strategy because of the presence
of conflicts, war, different ethnicities and ethnic groups. These differences produce different
outcomes in the two countries.
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Chapter Two
In this chapter I will give an overview of the literature related to peer education concepts,
how peer education programs work, the role of behavioural theories for the programs, as well
as adolescent sexual activity, and the barriers to accessing appropriate information about
sexuality and reproductive health for adolescents.
2. Basic concepts of peer education
According to UNAIDS, peer education is a popular concept that implies an approach, a
communication channel, a methodology, a philosophy, and a strategy. In peer education,
peers undertake a formal or informal way of educating people, in turn those people are
expected to convey or diffuse this information to the other peers (UNAIDs, 1999).
In practice, peer education has taken different definitions and explanations in terms of who is
a peer, who is a peer educator, who is the target group, where it occurs or takes place, and
what type of education it is, and whether there is a special curriculum for teaching peers. All
these questions discussed in this chapter.
The peer education programs studied in this thesis use multiple approaches that diffuse a
message about reproductive health, including mass media, interpersonal communication and
community mobilization programs. This approach is most successful when information and
education are provided interactively and linked to each other (UNAIDs, 1999).
Most adolescents are eager to learn about reproductive health and want advice in handling
their personal problems. Mass media entertainment (radio, TV, music, films, and books) can
be a cost-effective way to communicate information, which in turn can be an influential
factor upon knowledge, attitude and behaviour (Baldwin, 1995).
2.1 Who is a Peer?
According to the Population Council, a peer is defined as a person who is of “equal standing
with another; one belonging to the same societal group, especially based on age, grade or
status” (Population Council, 2003).
Many factors, such as similar age, background and interests, can explain why peers are
effective disseminators of knowledge and information. The fact that peers can convey
information in a manner in which adolescents are able to understand and relate to might
13
contribute to a change in norms, attitudes and behaviours. According to the WHO in a study
of 21 projects worldwide, it was reported that 95% of the peer educators had themselves
changed their own behaviour (WHO, 2002).
2.2 How peer education works
In this section, I will give an overview of the peer educator and his or her role and the ways
in which he or she gives information to peers. I will also describe different settings in which
peer education take place. Moreover, I will mention behavioural theories and their place in
peer education, as well as the evidence related to the benefits of peer education programs.
2.2.1 What does the peer educator do and what kind of education can they provide?
The main task of a peer educator is to diffuse information to other peers. Normally this is
achieved by organizing numerous and varied activities, such as arranging exhibitions, poster
sessions, role-plays and debate competitions, stage dramas or musical productions, in order to
inform their target group in an appropriate and understandable way. This work can entail
positive results by making the peer educator leave their previous risky behaviours and
concentrating on another career (Campbell S, 2005).
According to UNESCO, the peer educators realize that for their efforts to be successful they
need to involve their peers actively, they need to be interested and eager to know about peer
education. This can be achieved by providing interesting lectures and through using different
teaching aids such as group discussion, drama, pamphlet distribution, etc. Their activities
always focus on one or two issues, which are most relevant for a given age group. For
instance, health and hygiene information would be considered more appropriate for the
younger people, while information on HIV/AIDS and contraception would be appropriate for
older youth (UNESCO, 2003).
According to UNFPA, the training model of peer education is a pyramid of educating and
empowering peers to pass on knowledge, skills, and practical exercises that build on a system
of continuous training composed of three stages:
The first stage is specialized training, in which peers receive the basic information related to
reproductive health. The second stage is the training of trainers, which starts when peers
begin to train others and convey the information and knowledge, they received from others.
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The last stage of the pyramid is the training of peer educators in which a peer becomes an
educator for others. At this stage, they use manuals that are produced by UNFPA to provide
guidelines for training peers and to propose ideas for activities that could be carried out in
peer education projects with young people (UNFPA, 2005).
2.2.2 The role of the peers
The peer group is an important factor in the development of adolescents. It has an effect on
attitudes toward as well as on decisions about sex. Furthermore, adolescents are most likely
to receive their knowledge about sexual health issues from their peers. However, The
pressure to engage in sexual activity is increased; therefore the adolescent's peer group
attitude about sex influences the attitudes and behaviour of teenagers (UNFPA, 2009).
Although the research based on peer communication and adolescents’ sexual behaviour is
limited, there is evidence that adolescents’/peer experience with condoms, is associated with
more consistent condom use,
Despite health education and advice about preventive
methods, the need of safe sex and the values of condom use in preventing HIV/AIDS, many
people in high-risk groups are still continuing to reject them. This might be related to
different cultures and religious perspectives (Helman, Cecil G. 2007).
There is also empirical evidence that suggests that adolescents who communicate with their
peers are more likely to use condoms. Therefore, it is reasonable to expect that conversations
among adolescent peers about sex would play a critical role in sexually risky behaviour
among adolescents (UNFPA, 2009).
2.2.3 Where does peer education occur?
Peer education can occur in a variety of formal and informal settings, such as in school and
out of school, clubs, on the street or in a cafeteria, in companies or factories while workers
are on break, or in women gatherings, student housing, or among commercial sex workers
and prostitutes, as its reported by UNESCO. It is important that peer education takes place in
what is perceived as a real life environment, and not just in a classroom with abstract
discussions and an arsenal of facts (UNESCO, 2003).
In Sudan, peer education about adolescent sexuality, reproductive health, and safe-sex
practices take places pin associations, during breaks in schools and universities, or in groups
15
of people who are near to each other in age. These are considered more suitable places for
them to feel free in asking private questions about their sexual health and problems rather
than doing it in school or at home because sexuality is considered a culturally sensitive issue,
as mentioned earlier.
2.3 How does peer education work and what is the role of behavioural theory in peer
education programs?
In the following paragraphs I will briefly present the most important and influential theories
related behavioural change and behaviour change theories:
I will start this theoretical overview with a brief outline of the concept of behaviour as well as
a summary of the major theories related to behaviour change. For the purposes of my thesis, I
find it most useful to focus on the concept of behaviour as it relates to behaviour change, and
even more specifically, behaviour change as it relates to sexual behaviour connected to the
threat of diseases, such as HIV/AIDS.
According to Gohen (1998), behaviour is determined by “the phenomena of experience rather
than by external, objective and physically described reality.” Also, risky behaviour is defined
as those behaviours undertaken volitionally, whose outcome remains uncertain with a
possibility of an identifiable negative health outcome. The degree of volition in high risk
behaviour may be discussed, as there are external factors as well as an underlying internal
factor that may highly influence behaviour.
Behaviour change is the cornerstone of HIV prevention. More than 70 percent of premature
adult deaths are linked to behaviours begun in adolescence, such as smoking and risky sexual
behaviour (Kelly & Lwis, G. 2001).
Peer education can have a powerful influence on behaviour. Risky behaviours can be initiated
in order to gain acceptance or respect from the peer group. Particularly during adolescence,
the peer group has strong influence on the development of sexuality and the pattern of sexual
behaviour (Kelly & Lwis, G. 2001).
Because there is still no vaccination against or cure for HIV/AIDS, most health organizations
argue that the best cure is to change behaviour. In fact, currently this is the only means to halt
the epidemic. Behaviour change might be effected through information, education and
communication intervention (IEC). The latter is the strategy which is mostly used in and with
16
peer education. Peer education programs also advocate abstinence, being faithful and using
condoms (ABC) (UNAIDs, 2008).
2.3.1 Behavioural theories
It is important to understand where peer education comes from and how this concept relates
to theories of behaviour change and the reduction of sexually risky behaviours.
I am going to mention the most suitable and applicable theories from the view of people who
have used such theories in relation to the development of peer education programs.
According to UNAIDS, peer education is one of the behavioural change strategies that are
drawn from and based on several well-known behavioural theories. These theories hold that
peer educators can act as an influencing factor for behaviour change among their peers not
because these educators present scientific evidence, but because they present the subjective
judgment of close, trusted peers who have adopted changes and who act as persuasive role
models for change. This assumes that people may change based on progressive steps of
understanding and the ability to internalize the relevance of the experiences of the peer
educators to their own situation (UNAIDs, 1999).
The first theory is Bandura’s social learning theory. He says that people learn from others
through observation, imitation, and modelling. According to this theory, people serve as
models of human behaviour able to produce behavioural change in certain individuals based
on the individual’s value and interpretation system. This theory has often been called a bridge
between behaviourist and cognitive learning theories because it encompasses attention,
memory, and motivation (Bandura, 1986).
From the perspective of psychology this theory of observation is the best way of learning
from others. In my opinion, this theory is suitable and applicable to peer education program
because it includes a behaviour-change strategy which is based on both individual cognitive
as well as group empowerment and collective action theories.
The second theory is that of reasoned action which has been developed by Fishbein. This
theory states that the individual’s perception of social norms and beliefs plays an important
role in influencing behaviour change. Both the subjective beliefs of an individual and his or
her normative beliefs are changed when new behaviour is adopted (Fishbein & Ajzen, 1975).
17
The immediate determinant of a given behaviour is the intention to perform that behaviour,
when the intent is changed; the person’s behaviour is also changed. The change in intention,
in other words, performs the change in behaviour.
According to a study assessing the impact of a peer education intervention to reduce sexually
risky behaviours in “gay” bars in Glasgow, such interventions programs improved
knowledge, raised awareness, contributed to behaviour change and the use of health services
(Lisa M, etal, 2001).
Thus, in order to change behaviour, one must attempt to change the intentions to perform
such behaviours. In order to change such intentions, it is necessary to focus on attitudes
toward the behaviour, or any other attitude can be the changed, by influencing the primary
belief about the attitude object or the evaluation of its attribute, as is shown in the study done
by Fishbein & Ajzen, 1975. This study argued that the best predictor of a person’s behaviour
is located in his or her intention to perform the behaviour irrespective of the nature of the
behavioural criteria situation and time.
Much timely research has attempted to demonstrate the utility of the concept of attitude by
showing that people who behave in different ways also differ in their attitude. The finding
that group known to differ in their behaviour also differ in their measured attitude,
nevertheless, was taken as evidence confirming the assumption of a close link between
attitude and behaviour, Also, behaviour can be measured at different levels of speciality and
it is important to distinguish between different types of behaviour, as there can be single and
multiple acts of behaviour. (Fishbein & Ajzen, 1975).
Since much behaviour is under volitional control, most behaviour can be accurately predicted
from an appropriate measure of the individual intention to perform the behaviour in question.
The intention has to be measured at the same level of speciality as the behavioural criterion
and also the measure of intention must reflect the time the behaviour was performed (Kelly &
Lwis, G. 2001).
The understanding of a person’s behaviour, however, requires more than just knowledge of
his or her intention. It is not very illuminating to discover that people usually do what they
intend to do. It is necessary to realize that behavioural observation is nothing more or less
than one kind of data utilized by behavioural scientists (Fishbein & Ajzen, 1975).
18
The following figure gives an overview of the theory:
Figure one
The third theory is the theory of diffusion of innovation proposed by Rogers. He states that
certain individual ideas and opinions can play an important role in changing other individual
behaviours through diffusion of information to others by influencing group and community
norms. I think this theory is the best way for diffusing and distributing knowledge through
peers to others in the community (Rogers, 1983).
According to Rogers, a common problem for many individuals and organizations is how to
speed up the rate of diffusion of innovation. Thus, we see that the diffusion of innovation is a
social process even more than a technical matter. So, I am first going to define what diffusion
is means and also explain how it might be successful in peer education programs.
Diffusion is defined as the process in which an innovation is communicated through a certain
channel, over time among the member of a social system. It is a special kind of
communication in that the message is concerned with new ideas (Roger, 2003).
Communication is defined as a process through which participant create and share
information with one another in order to reach an understanding.
Diffusion, then, is a special type of communication in which the message is about a new idea.
It is also about the new idea’s effects on a given society in which an alteration in the structure
and function in social system may occur when the new idea is adopted or rejected. This new
19
idea, in other words, might lead to social change. Here, peer education can be an effective
way to diffuse new ideas because people tend to trust individuals who are similar to them
when it comes to the social groups, interests, employment and living conditions.The
similarities make an obvious effect of human communication and the transfer of ideas, which
most frequently occur between two or more individuals who are similar or belong to the same
group (Roger, 2003).
According to an examination by Fougner et al. (2008) of an award winning peer tutoring
programme at Oslo University Collage, based on socio-cultural theories of learning, peer
tutoring increases the students’ learning, and is much important and more effective than
knowledge transfer from teacher to student, based on cognitive pedagogic.
Fougner et al. (2008) advocate the dialogical concepts in which meaning and understanding
cannot be transferred directly; however meaning and understanding can be developed and
built in a process of dialogical questions and collaboration within groups of peer students
communicating with each other. Hence, the dialog can be used to facilitate cultural change.
Arguments exchanged in an ongoing dialogue between people create different perspectives
which support the learning process. Fougner et al. also use the notion of a pedagogy of
possibility which helps in giving peers the opportunity to express themselves and
communicate effectively with other people.
2.4 Adolescent sexuality: knowledge and practices
Falola, (2004) states that adolescence is generally understood as the period between the ages
of 15 to 19, with some scholars referring to it as up to age 24. It is also referred to as the
juvenile period between the onset of puberty and adulthood. The term young adult is the most
apt term for this age group, and without doubt, the many biological, psychological, and
behavioural change which mark this age, make this a concept that is continually dynamic and
fluid in its change.
Adolescents also represent our future generation. Therefore, their knowledge of sexuality
should come from reliable sources of information. Globally, every one in 20 adolescents
contracts a sexuality transmitted disease and one out of four adolescent girls experience
unsafe abortions. Hence, we have an ethical duty to do what is necessary to prevent this
20
suffering and devastation through distributing the needed knowledge and information related
to health, reproductive health and sexual issues (Williamson, 2000).
Currently, the world and particularly Africa, has its largest generation of youth ever. More
than 1.5 billion people globally are between the ages of 10 and 25. This largest-ever
generation of adolescents is approaching adulthood in a world their elders could not have
imagined. So most of these young people are lacking appropriate information and knowledge
about sexuality and sexually transmitted diseases are highly prevalent among adolescents
(UNFPA, 2007).
Nowadays, adolescents and young adults constitute the future. Their energy, leadership and
wisdom will shape the world during this new century. Consequently, developing effective
strategies and programs to promote the reproductive health of young adults is a vital concern,
especially in developing countries (Williamson, 2000).
Also according to the UNFPA fact sheet, more than 1.3 billion, one in five people alive today
are adolescents aged from 10-19. 85 percent of them are living in developing countries, in
which the young people represent an enormous potential resource.
Most of these adolescents lack power and face many risk factors which expose them to be
more vulnerable to sexual coercion. This is especially true for adolescent girls, who are more
vulnerable to multiple risk factors, including drug and substance abuse, depression, ignorance
about contraception and early sexual initiation. The age of first sexual experience can be low,
ranging from 9-13 years for boys, and 11-14 years for girls. About 16 million adolescent of
these girls aged 15-19 become pregnant and give birth each year, accounting for more than 10
per cent of all births worldwide. Nowadays, adolescent pregnancy correlates with lower
educational levels for girls.
Research indicates that educating these young adolescents through peer education programs
can provide them with health education and information about sexual reproduction, which
may lead them to develop their life skills and safeguard their sexual health and wellbeing
(UNFPA, 2009).
21
Globally in 2005, at least 90 % the young men and women between the ages of 15 and 24,
have access to information, education, including peer education programs and specific
information related to HIV/AIDS, as well as the services necessary to develop their life skills
and to reduce their vulnerability to HIV/AIDS infection. Parents and health-care providers
are also often involved in this preventive work. By 2010, the percent of young men and
women with access to information about HIV/AIDS is expected to increase to 95 percent
(UNFPA, 2009).
There are notable gender differences. Males tend to be more affected by conversations with
peers, while females tend to be more influenced by conversations with their parents.
Furthermore, it was found that both female and male adolescents’ sexual behaviour and
condom-use could be affected by parental communication about sex and condoms (David,
2000).
In addition, we must not forget discrimination on grounds such as sex, marital status race, age
and class. We should also keep in mind the individual’s right to equality: people have the
right to privacy and freedom from sexual violence and coercion, therefore defining
reproductive health and sexuality not only as a health issue, but also as a matter of social
justice.
In May 2002, the UN general assembly staged a special session on children. During this
session, the U.S. administration allied itself with Iraq, Iran, Libya, Sudan, Syria and the
Vatican in a proposal that in effect would have prevented young people from receiving
information about sexual abuse, birth control, condoms, and reproductive health care,
including HIV/AIDS prevention. Their initiative failed, but in the past four years, such
ideologies have found other to advance their agenda and impose their beliefs on the world’s
most vulnerable young women and men (UNAIDs, 2008).
2.5 Barriers to accessing appropriate information
Adolescence signifies the onset of physical/sexual maturation and the body’s reproductive
capacity. Young people have a need and right to know about their bodies and to be educated
and informed about their bodies and their sexual heath, yet they face many social, political
and community barriers to receiving and gaining access to appropriate information. Sex is
often a challenging and difficult issue for both youth and adults to discuss (Kelly, 2000).
22
Making choices and decision about sexual activity during the teen-age years can have
immediate and lasting implications for an individual’s overall health outcome. How teenagers
make decisions about relationships, about abstaining or participating in sex can be influenced
by numerous factors, for instance, parents, peers, media, access to education and health
services and a host of other factors.
Adolescents receive information about sexuality and reproductive health from a variety of
sources. Although parents and trusted adults have traditionally been the sources of this
information, there is evidence that a large proportion of young people increasingly rely on
their peers or entertainment or news media to get relevant information.
According to Elizabeth (2000), Adolescence period is mounted with embarrassment or shame
which may make young people reluctant to seek information from adults or even their
parents. It is considered to be a taboo in some cultures and traditions to ask frankly or
explicitly about sexuality. Therefore, it is not only shameful or embarrassing but also people
might think that those who ask might get engaged in premarital sexual relationships. Girls
and specially married adolescent girls may be isolated from peers and from institutions where
they otherwise access information, counselling or services (Elizabeth, 2000).
This argument is supported by a mini-survey conducted at Khartoum State by the Sudan
Fertility Care Association (SFCA, 2002). It documents that a group of young respondents
aged 10-14 years and a group aged 15-18 years refused to talk about sexuality and sexual
organs, considering it taboo. At the same time, the survey shows that there is no specific
curriculum or educational program targeting the reproductive health of adolescents and youth
(PPFA - UNICEF – SNAP, 2006).
In many cultures adolescents are not considered sexually active before marriage, even though
they in fact often are sexually active before matrimony. Accordingly, information and
services maybe withheld from them. Health providers, teachers and other potential sources of
support may discourage their questions or lack adequate training to deal with them
appropriately (Kelly, 2000).
2.6 The role of parents and family dynamics in youth sexual behaviour
Numerous factors have been found to influence adolescents’ knowledge about and attitude
towards sexuality as well as their sexual practices, For instance, parent-child communication
23
can lead to increased knowledge about and awareness of sexuality. It may also lead to a more
conservative sexual attitude. Research that has measured the relation between parent-child
closeness and sexual behaviour indicates that the parent-adolescent relationship, particularly
that between mother and daughter, made a considerable impact on adolescent sexual
behaviour (Dmchak, 2000).
The role of parents in the life and decision-making processes of youth is often
underestimated. However, parents play a crucial role and exert a significant influence upon
the choices young people make about sex. A long standing body of literature documents that
adolescents who communicate with their parents and their peers about sex are less likely to
engage in risky sexual behaviour than adolescents who do not have such communication
(Hussein, 2002).
Overall, the majority of research indicates that adolescents whose parents and peers talk to
them are less vulnerable to sexual diseases and more likely to delay their sexual onset. When
these adolescent are sexually active, they have fewer sexual partners than the adolescents
with less communication. However, the difference in adolescents’ preferences for such
communication has been observed. According to Dmchak, 61% of adolescents are most
likely to seek information about sexuality from their peers, while 32% seek information from
their parents. 43% of adolescents express a strong desire to have more information about
how to talk to their parents about sex (Dmchak,S 2000).
2.7 Adolescents and sexual reproductive risks
In recent years, increasing attention has been placed on the need to integrate a gender-based
approach. This is due to the generally lower status of women which leads to their
subordination and restricted opportunities which may expose them to risks. Men, on the other
hand, are often influenced by societal pressures that can make it difficult for them to adopt
protective behaviour, both for themselves and their sexual partner.
These factors are combined for adolescents who face additional restrictions due to their
young age. For instance, in some developing countries, young women often have less
decision-making power because they tend to have an older male partner who might dominate
them. In addition, parents may also strictly control their possibilities of accessing such items
as contraceptives and condoms (Igra & Irwin, 1996).
24
Young men, who like young women, are in the phase of establishing their sexual and gender
identities, face various pressures regarding the exercise of their sexuality, not only from
society at large (parent, religion, media), but also most importantly from their peers.
Thus, some adolescents lack information concerning contraceptive methods as well as access
to contraceptives. As a consequence, 10% of the world’s births are teenage mothers from
areas that have a high prevalence of HIV, and the proportion of pregnant women between the
ages of 15 and 19 infected by HIV/AIDs is on the rise (Dmchak S, 2000).
Combining age-appropriate sexual health information with activities to help develop
communication and negotiation skills can help young people who are not already sexually
active in delaying the onset of sexual activity. In developing countries, youth frequently leave
school at an early age, and this fact can be regarded as one of the causes that leads to risky
sexual behaviour. However, providing sexual education in school to young adolescents may
be the best opportunity these youths have to learn about and build skills related to their sexual
health. Youth in this age group who already are sexually active may develop the knowledge,
skills and motivation necessity to practice safer sexual behaviour (Igra & Irwin, 1996).
25
Chapter Three
In this chapter I will provide information about peer education and adolescents’ sexual
behaviour. I will also outline the sexual reproductive health rights framework; explain the
role of peer educator programs in preventing STDs and HIV/AIDS, and present evidence of
the relative effectiveness of peer education programs.
3. Peer education and adolescent sexual behaviour/ reproductive health
Peer education has become one of the most common approaches in addressing adolescent
sexual behaviour and reproductive health in recent years. Peer education is a strategy that
involves the use of members of a given group to affect change among other members of the
same group. Increasingly, program evaluations have been published, documenting the impact
on peer educators themselves in such areas as increased knowledge and the adoption of safer
sex practices, In short, these evaluations suggest that peer education programs change both
attitudes and behaviours (Baldwin, 1995).
A study of Russian adolescents’ knowledge about HIV/AIDS, documents that among 370
high schools students, only 25% of the girls and 35% of the boys knew that condoms should
be used only once, and 38% of the students incorrectly believed that condoms could be
washed and used several times. A survey among 948 public school students in Santiago
reflected that 57% of the boys and 59% of the girls expressed that a condom could be reused,
76% claimed not to know the fertile or infertile times of the female menstruation cycle.
However, after participating in peer education programs these students’ knowledge was
increased regarding the sexual and reproductive health (Elizabeth, 2000).
These tendencies are also found in a survey conducted among 1.800 males between the ages
of 15 and 19 in the United States. Among those who had participated in a peer education
program about HIV/AIDS and family planning, there was a decrease in the number of sexual
partners and an increase in consistent use of condoms (Baldwin, 1995).
Also, a study of a sex education program in South Africa based on peer education methods
found that youth want more information, including help with decision-making and coping
skills in addition to the opportunity for individual counselling with someone they trust, such
as peers (Kelly, K 2000).
26
According to young researchers from Zambia, the formation of group discussions through
peer education programs in schools, clubs and communities offered the young people
valuable information about HIV/AIDS through discussions, drama performances and
distribution of brochures and booklets (UNFPA, 2009).
Lastly, according to Kathryn (2000), in the UK, peer education has become an increasingly
popular way of carrying out health promotion work with young people but the evaluation of
its effectiveness remains unpublished (Kathryn, 2000).
The world health organization (WHO) recently published a review of 1.050 scientific articles
on sex education programs. A researcher found no support for the contention or increased
activity of such programs. If any effect is observed, it is almost without exception related to
the postponement of the initiation of sexual intercourse and/or effective use of contraception.
Failure to provide appropriate and timely information misses the opportunity of reducing the
unwanted outcome of unintended pregnancy and transmission of STIs and is therefore in the
disservice of youth.
According to the WHO, adolescents can be divided into two different target groups. The first
consists of those who have not begun sexual activities, and the second of those who already
are sexually active. Furthermore, because some young people begin having sex as early as the
age of 12, the report recommends that formal sex education through a peer education
program should begin before this age (WHO, 2005).
3.1 Sexual reproductive health rights framework
The rights to comprehensive information and access to education regarding the factors that
affect sexual and reproductive health, include the right to education about how different
hormonal changes can influence both girls’ and boys’ development. It also includes the right
to instruction concerning behaviours that relate to reproductive and sexual health. A study in
Latin America and the Caribbean documented that fewer than 25% of young men between
the ages of 15 and 24 could identify the female fertile period (Oster, E. 2007).
The right to equality and freedom from all forms of discrimination in one’s sexual and
reproductive life includes the right of adolescents to decide whether they will be sexually
27
active or not and with whom. Significantly, this freedom might encourage adolescents to
engage in homosexual relationships which are unfavourable in some contexts and societies.
The discrimination and marginalization suffered by homosexual young men and lesbian
young women can make it much more difficult for them to practice healthy sexual behaviour
since they feel compelled to hide their sexual preferences.
The right also includes the adolescents’ right to privacy and confidentiality when they seek
access to sexual reproductive health services because they are very sensitive when it comes to
sexuality. Greater effort is needed to enable young people to participate in designing,
implementing and evaluating SRH services so that they become truly youth-oriented and
youth-friendly (UNAIDS, 2008).
3.2 Peer educators and STDs- HIV\AIDS prevention
A peer educator is a person belongs to certain group containing an equal participating
member, similar in ages, backgrounds and interest who trained with special kind of
information. According to UNESCO, this information should be on STDs, HIV/AIDS, the
use of condoms and the Information-Education-Communication (IEC) materials. Peer
educators can educate different kind of peers who lack information about sexuality and
reproduction. Sex workers might be one of the groups who lack this knowledge, but it is
unnecessary for peer educators to be sex workers to know and understand their problems.
Peer educators can still successfully transfer this knowledge to them, educate and encourage
them to change their behaviours when they are practicing sex, use condoms, go in for regular
check-up for STIs, and support those people in the target group, who are suspected of having
HIV/AIDS (UNESCO, 2003). In the book about the contemporary philosophy of social
science, by Brian Fay argues that you don’t have to be one to know one. Fay here uses
“know” in the sense of having the same experience as the other. For instance, people who
have had similar experiences to the ones that I have had are likely to be more able to
understand me, but it does not mean that someone has to be me to know who I am. “Know” is
just to know the experiences of others, not necessarily having the experience itself. In other
words, we don’t have to be one of the sex workers or have the same experiences as them to
know and understand them, because there are differences between knowing, being, and
doing.
28
The theory of solipsism holds that one can be aware of nothing but one's own experience. In
other words, it is impossible to know exactly what the world looks like from another person's
perspective. This, however, does not mean that we can't or shouldn't try to understand and
emphasize with the experiences of others (Fay, 1996).
Peer educators convey information about sexuality and reproductive health to their peers in
order to stimulate change in behaviour by creating more supportive and understanding
attitudes toward people who are infected with HIV/AIDS through changing their knowledge,
attitude, belief. As those people are convey such support and understanding to others, peer
education becomes a continuous process (UNICEF, 2002).
Peer educators attempt to combat widespread ignorance and misconceptions about
reproductive health and sexual knowledge by providing information about such issues as
pregnancy prevention, the use of condoms and contraception’s and sexual hygiene (UNICEF,
2002).
Ideally, peer educators are nonprofessional, respectful and open-minded people, who are well
trained in talking to and working with peers also helping them to receive correct information
about reproductive and sexual health, particularly as it relates to STIs and HIV/AIDs
(UNAIDs, 1999).
According to the WHO, the ideal peer educator is respected, charismatic and literate. He or
she has good communication skills with other peers and is interested in educating others. Peer
educators are often chosen by the members of a target group because they are already viewed
as leaders and effective individuals from their first experience with peer education. In the first
stage of the peer education program the peer was receiving information. Later, he or she is
trained to convey this information to others and this is when the peer becomes a peer
educator. Now, he/she will be able to work with individuals and groups in a variety of
settings and different people. It is also important that peer educators are able to contact
different groups of peers in different settings. This is considered one of the helpful factors in
the evaluation process, in which peer educators are able to know whether his or her peers
received the correct information or not (WHO, 2002).
29
3.3 Advantages of peer education
According to AIDSCAP (AIDS Control and Prevention Program), peer education has many
advantages as it provides a means of delivering culturally sensitive messages from within, it
serves as a link to other community based strategies by supporting and supplementing other
programs, and it is usually accepted by the target audience as it provides a large service at a
small cost in an effective way. According to UNAIDS, peer education is considered one of
the most cost-effective intervention strategies compared to counselling and testing. It costs
less to implement in a given population and location and produces the same or even better
HIV-related outcomes (UNAIDS, 1999).
Peer education has become increasingly popular in many countries in Europe, Asia and
Africa. For example, in the UK it is carried out as a way of promoting health among young
people, but the evaluation of the program’s effectiveness remains largely unpublished.
Moreover, explanatory evaluations using qualitative methods in the UK and other countries
are seldom done (K. Backett & S. Wilson, 2009, P.85).
3.4 Evidence of the impact of peer education programs globally
Global peer education has become one of the most common and used approaches for
addressing sexual and reproductive health issues, and it is the most applicable method in
changing sexual behaviour today. As Senderowitz argues, peer education programs effect
change among the participants of the same peer groups and other groups. The documentation
and publication of program evaluations have increased and show the programs’ impact on the
targeted populations. The documentation yields evidence to peer educators themselves and
other peer as increased knowledge and adoption of safer sex behaviour is raised and using
condoms as well as improved attitudes (Senderowitz, J. 2000).
Several countries succeed in using peer education programs, For example, a program that
included peer distribution of condoms was compared to the provision of small business loans
to adolescents in Zambia. Both of the activities show an impact on using safer sexual
behaviours; however the peer education programme showed a greater impact than the
programme involving small business loans (Population Council, 2001).
Evaluations in Nigeria and Ghana revealed that peer education had a measurable impact on
reproductive health knowledge, perceived self-confidence, and behaviour especially for
30
young people in secondary schools. Furthermore, the study indicated that a program’s effect
can differ for males and females, and in different settings (Annabel S, 2004).
AIDSCAP project evaluations show that; 95% of peer educators had made changes in their
life and behaviour, 31% were using condoms and practicing safer sex, 20% had reduced their
number of sexual partners, and 19% had changed their own attitudes. During the
implementation of AIDSCAP projects run by Family Health International and USAID, it was
found that peer education programs were employed and adopted in several countries in
Africa, Asia, Latin America, and the Caribbean (AIDSCAP, 1996).
Some studies have been done to evaluate the effectiveness of peer education programs.
Gallant (2004), for example, found that the program he evaluated had a great impact on the
use of condoms and contraceptives, and that it increased safe sex practices. Also, the
evaluation shows a decrease in the number of sexual partners, while the number of people
turning to abstinence increased. There were, however, some negative effects in that some of
the adolescents reported that they did not believe that condoms protect against HIV. Overall,
though, the study suggested that the variations in the impact of peer education programs may
emerge from the management and supervision of each program, rather than from the
effectiveness of the program itself (Gallant, 2004).
The terms impact and effectiveness are used in order to permit a mutual substitution
concerning the evaluation of the programs, in which the terms “impact and effectiveness”
both refer to “Whether and to what extent a programme causes change in the desired
direction among a targeted population” (Rossi F, 1993).
UNFPA engaged the services of the Sustainable Research and Development (SRD) to
perform an evaluation of their peer education program, Y-peer. SRD evaluated Y-peer with
respect to organizational and administrative processes, implementation strategies, outcomes
and the impact of the project activities. The evaluation process was carried out by several
teams with key personnel representing the UNFP and Y-peer program who visited eight
countries, including Turkey, Bosnia & Herzegovina, Bulgaria, Egypt, Serbia, Russia,
Macedonia, and Tunis.
The evaluation of the program in the eight countries took place from December 2007 to
February 2008. All the indicators showed that the project has a great impact on the
31
establishment of youth networks, the capacity of countries to build sexual and reproductive
health services, and on the quality of peer education that is available in each country.
Furthermore, the evaluation illustrates that the peer education networks were successful,
comprehensive, cost effective and efficient method to address sexual behaviour. Therefore
the program was implemented in more countries.
This evaluation also showed that the demand for educational programs provided by peer
educators is increasing, as is the demand for awareness raising programs among adolescents,
including the awareness on sexual reproductive health “SRH". Furthermore, the need for
SRH information has been acknowledged, and behaviours have been changed among the
adolescents who participated. The programs resulted in the spread of safe sexual and
reproductive health messages and reduction in HIV/AIDS and sexual transmitted diseases
(Lisa M, etal, 2001).
32
Chapter Four
4. A comparison between Sudan’s and Egypt’s experience with peer education
In this chapter I will compare the experiences with peer education programs in Sudan and
Egypt. I will use a comparative method of differences and similarities. Each variable
affecting the progress of peer education program will be provided and the different
challenges facing them will be considered. Finally, I will discuss how peer education can be a
tool to escape a vicious circle in Sudan and Egypt.
I will begin with Sudan. Sudan is the largest country in Africa with a total population of 41.1
million and a 2.1 percent growth rate. 50 percent of Sudan’s population is below the age of
18, while 20.9 percent are between the ages of 15 and 24. These groups make up one third of
the Sudanese population. Only 36 percent of these groups are participating in the national
economy and most of the population still remains below the poverty line despite the increase
in the per capita average.
According to UNFPA, many youth researchers have found that the young people in Sudan
are lacking accurate information about sex, sexuality, reproductive health, and health services
provided by the government. Most of these young people are not actively involved in the
development of policies addressing their sexual health and reproductive rights, and are not
even a part of the policy development process (UNFPA, 2009).
Egypt is a country located in northern Africa, with Sudan bordering on the south. It is one of
the most populated and populous country in Africa and the eastern Mediterranean areas. In
2008, it had a population of 79 million people. 43 percent of Egyptians live in urban areas
with the majority spread around the densely populated areas including Cairo, the capital,
Alexandria and other big cities along the banks of the Nile. According to the UNFPA, Egypt
had a 1.68 percent of population growth in 2008 and 1.64 percent in 2009. Adolescents over
the age of 15 represent 32 percent of the population with a 71 percent literacy rate. 78 percent
of the adolescent males are literate and 63 percent of adolescent females are literate. Also,
Egypt is considered to be a middle-income country. Although Egypt has had a rapid
population growth over the last 40 years due to medical advances and a massive increase in
agricultural productivity, it still has low economic growth, leading to poverty and high
unemployment and illiteracy rates (WHO, 2005).
33
Sudan and Egypt are both different and similar. The similarities between them appear to
increase the spread of STDs, HIV/AIDs, and risky sexual behaviour. These similarities
include, the high percentage STDs transmission, hepatitis, lack of knowledge related to
HIV/AIDs and reproductive health, cultural taboos, illiteracy, unemployment, and
governmental policies. Conversely, some of the differences between Sudan and Egypt are
each country’s population and population growth rate, the ethnicity and ethnic group within
the country, IDPs, refugees, migrants and the war in Sudan. Also, widespread poverty is one
of the main reasons for problems related to sexual behaviour and the lack of relevant
information about such behaviour.
4.1 Challenges of Sudan and Egypt toward peer education/ viscous circle
The educational level and the literacy rates among adolescents in Sudan and Egypt are
different. In Sudan adolescents aged 15 and above represent 20.9 percent of the population,
and the literacy rate in this population is 50 percent. Of those who are literate, 51 percent are
males and 49 percent are females. The illiteracy rate is much higher in the rural areas
especially in the western and southern states of Sudan. Interestingly, peer education programs
have been found to be effective, especially in the rural areas where illiteracy is prevalent. For
instance, Neyala “Darfur” is one of the areas that gained benefits from peer education
programs by acquiring sexual and reproductive knowledge, communication and leadership
skills for their personal, societal, mental and professional development. Adolescents in Egypt
from the age of 15 and above represent 32 percent of the overall population, 78 percent are
males and 63 percent are female, with a 71 percent of literacy rate. These rates suggest
Egypt’s relative success when it comes to education and literacy. These rates also facilitate
the implementation and adoption of peer education programs (WHO, 2005).
The lack of education is one of the most important factors in the spread of diseases and risky
sexual behaviour. The educational systems in both Egypt and Sudan are lacking a lot of
health information. Biology, for example, is an important subject and should be taught to the
students in schools in their early years so they can learn as much about their bodies as
possible and also learn about diseases that they want to avoid.
34
The educational curriculums in the two countries do not contain much about biology,
sexuality or sexually transmitted diseases. Biology in Egypt is only taught in the third year of
secondary school to those students who are classified as biology majors. Furthermore,
information regarding sexually transmitted diseases, risky sexual behaviour, reproduction,
family planning and preventive methods are only provided at the university level and at
certain colleges that teach biology.
This is similar to the situation in Sudan where the curriculum does not provide adequate
information about sexually transmitted diseases or their prevention. Prevention and family
planning is only taught in university subjects. This is considered one of the factors that lead
to the spread of the sexually transmitted diseases and HIV/AIDs. Again, here peer education
programs have replaced the lack of formal education about these issues for adolescents
(UNICEF, 2004). Therefore, peer education can be considered a rare opportunity for young
people and adolescents to receive knowledge about sexuality and reproduction. In addition, it
can facilitate the development of leadership skills among peer educators, and this may also
protect them and their community from risky sexual behaviour (WHO, 2005).
In Sudan 49% of females and 35 % of males between the ages of 13 and 15 are illiterate.
These rates are even higher among those aged between 16 and 18. According to the WHO,
Sudan had a 50 % adult literacy rate in 2007. 51 % of those who are literate are adult males
and 49 %are adult females. Moreover, according to UNICEF from 2000-2007, the literacy
rate in Sudan was 20-27 percent (PPFA - UNICEF – SNAP, 2006). Egypt also experienced
high rates of illiteracy and unemployment and these people are increasingly becoming
infected with HIV. The education curriculums teach biology only in the third year of
secondary school, and the government is not willing to integrate reproductive health formally
in its education curriculum (Y peer Egypt, 2008).
Since the end of World War II, Sudan has found that the need for education and health
awareness has increased beyond the capacity of their educational resources. The educational
policies in Sudan lack financial resources, only 6.35 percent of the national income is going
to the educational system. Although the number of teachers is increasing, the number of
students is increasing at twice the rate of the teachers. This results in an increasing gap in the
educational system. The need for more educational programs, more teachers and trainers
increases day by day (The Federal Ministry of Education, 2004). However, adolescents in
35
Sudan are far from participating in the policies and are not actively involved in the
development of policies addressing their sexual health and reproductive rights, not even as a
part of the policy development process (The Federal Ministry of Education, 2004).
According to some researchers in Egypt, Egypt has a similar problem. They say that there is a
lack of youth involvement in the planning of policies and programmes targeted at youth by
the government. On the other hand, some UN agencies such as UNFPA, the Global Youth
Partners initiative, does give youth the opportunity to be involved by inviting them to plan
and implement an advocacy campaign (UNFPA, 2009).
Health issues, such as female genital mutilation (FGM), and the spread of diseases, such as
HIV/AIDS and hepatitis, are some of the challenges facing both countries. FGM is
considered one of the biggest problems facing both countries. Sudan has the high prevalence
rate of FGM. 90 percent of Sudanese women are subjected to this practice. In Egypt, FGM is
still widely practiced among young females with a highest prevalence rate of 97 percent. 14.5
% of females between the ages of 15 and 19 who live in urban areas are married, while in the
rural areas 47 % of all females are married. 54 percent have one or two children. The average
age of the first sexual encounter is 14, which is definitely below and far from the age of
marriage, and this can create a lot of complications for the woman and any potential children
(PPFA - UNICEF – SNAP, 2006).
Most Egyptian females marry at an early age and go through several complications during
pregnancy and delivery, Furthermore, 30% of females in remote rural areas of Egypt are
married and many of them become sexually active at an early age. Frequently, they have
limited knowledge about sexuality, STDs, and HIV/AIDS, and this might make them more
prone to sexually transmitted infections.
The spread of HIV/AIDs and STDs is a challenge for both countries. The need for
information about sexuality, prevention and family planning is large in both countries.
Although Sudan has the highest percent of HIV/AIDs cases, an estimated 1.4 percent in 2007.
Although the rate of HIV/AIDS is lower in Egypt, the country still lacks educational
programs about health, reproduction, sexuality, condom-use and family planning (WHO,
2009).
A survey conducted by the Sudanese National AIDS program (
SNAP), shows that 70
percent of registered cases of HIV/AIDS are among migrants and displaced people in Sudan.
36
In remote rural areas of Egypt, more than 30 percent of married women have sexually
transmitted infections and has little knowledge about HIV/AIDS. Also according to SNAP, in
2008, HIV/AIDS was becoming one of the most serious diseases in Sudan, with increasing
infection rates in young people as well as in adults (SNAP, 2008).
Egypt also has a high percentage of hepatitis c, which is similar to HIV/AIDs in its mode of
transmission. Moreover, young people face many challenges in terms of high rates of
unemployment and low socioeconomic levels. They are also dealing with a multitude of
SRH-related issues such as teenage marriages, teenage pregnancies, FGM, reproductive tract
infections, hepatitis B infections, and (illegal) abortions (Y peer Egypt, 2008).
Similarly, Sudan also has a high percentage of hepatitis and is classified as a country having a
high prevalence of hepatitis B. The number of people with this virus is much higher among
pregnant women, according to study done in Sudan/Omdurman, which found that 5.6 percent
of pregnant women were hepatitis B positive (Mudawi, 2008). In other words, although the
prevalence rates differ in each country, both Sudan and Egypt struggle with STDs/
HIV/AIDS and FGM,As I will show later, these programs do seem to result in increased
awareness about health and sexually transmitted diseases in both countries HIV/AIDS and
FGM.This suggests that these programs do result in increased awareness about health,
sexually transmitted diseases and FGM in both countries.
In addition, culture is one of the factors that contributes most in the implementation and
progress of peer education programs. Although the countries have very different cultures,
they both consider sexuality and sexually transmitted diseases to be culturally sensitive
issues; this is especially true among the adolescents and their parents or within the family.
Talking about sexuality and condom use is rarely done, and such matters cannot be discussed
in the community or addressed adequately in the educational system. Information regarding
the sexual transmission of diseases, risky sexual behaviour, reproduction, family planning
and preventive methods are only provided in universities. So, here the peer education
programs are very helpful in giving this kind of information to adolescents who do not reach
the university level (WHO, 2009).
According to SNAP and UNICEF, young adolescents in Sudan need to be liberated from
cultural taboos, old beliefs and thoughts when they are old enough to think about their bodies,
sexuality, and their rights. They should be free to control their lives and prevent themselves
37
from contracting STDs and HIV/AIDs, for instance by contacting different educational
groups, discussions and lectures related to their health and sexuality. Since 2004, the peer
education programs have been implemented in Sudan by the UNFPA and the PPFA. Over
time, several other organizations have begun to implement it, in order to raise awareness and
increase the educational level among adolescents (UNICEF – SNAP, 2006).
Because there is a lack of formal sexual reproductive health education in Egyptian schools,
Y-Peer in Egypt is an appropriate method for increasing knowledge and awareness and
changing attitudes. The cultural sensitivities of the majority of Egyptians do not promote the
idea of sexual education or contraception outreach. Sex work is considered illegal, women
and young people have limited access to reproductive health services, and there is a law
prohibiting abortion by any medical doctor except where the life of the mother is being
threatened (Y peer Egypt, 2008).
The unemployment rate is also a challenge facing both countries. In Sudan, the
unemployment rate is very high, 18.7 % according to an estimate done in 2008. In the same
year, the unemployment rate in Egypt was 11 %. Peer education programs in both countries
target adolescents and unemployed adolescents, but the programs were also found to be
accepted among unemployed adults (WHO, 2009).
4.1.1 Particular challenges facing both of Sudan and Egypt
Both countries are different in terms of mixed populations, numerous ethnicities and
languages, as well as the presence and effects of conflicts and civil war.
Egypt has a much larger population and population growth rate compared to Sudan. In fact,
the population of Egypt is double that of the population in Sudan. Egypt has a population of
79 million, with a 1.6 percent population growth rate, while Sudan has a population of 41
million, with a 2.1 percent population growth rate. Even though Egypt has a much denser
population, the results of peer education programs were better than in Sudan, because Egypt
has a better economy and more resources than Sudan. Egypt was able to provide educational
programs throughout the country using different teaching methods, tools and materials. This
had a good effect on communicating with recipients as well as the media. The imbalance in
the geographical distribution of the Egyptian population produces economic constraints,
38
influencing the stability and the progress of Egyptian societies and affecting their
population’s quality of life (WHO, 2009).
Both countries have a variety of different ethnicities. Sudan considers ethnicity to be one of
the factors that affects the implementation, adoption and the success of peer education
programs. Sudan has more than six hundred ethnic groups speaking more than four hundred
languages. Most of the citizens are migrants and refugees from other countries. Egypt is not
as ethnically diverse. Egyptians make up the largest ethnic group in the country, which is
estimated to be 94 percent of the total population. There are also however, a number of
refugees and asylum seekers (World Bank, 2003).
The different ethnic groups and the many languages in Sudan definitely have an effect on
teaching methods and the language of instruction. More resources and different teaching
materials are needed, but they are not easy to access, especially in the rural areas of Sudan.
Moreover the conflicts and the IDPs in the country, since the Second World War, the need for
education and health awareness in Sudan has increased more than the educational resources
available. Educational policies in Sudan suffer from a lack of financial resource and at the
same time the numbers of teachers and learners are increasing as well. Because the formal
education system is under so much pressure and is not able to accommodate everyone, the
peer education programs are an effective method to reach many who are unable to attend
schools and universities (The Federal Ministry of Education, 2004).
The conflicts in Sudan have had a large effect on adolescent education. The conflict which
erupted in 2003 resulted in a mass displacement of the population and a disruption of
services. Most of the internally displaced people have come to the capital Khartoum and
settled in refugee camps. 85 percent of the population is between the ages of 18 and 30. Many
camps were established near the bigger cities in the states. As a result of the high percentage
of internally displaced people, the low socio-economic status of the population, high
illiteracy, a lack of awareness concerning HIV, and the high HIV/AIDS prevalence in
neighbouring countries (what is referred to as an AIDS belt; Uganda, Ethiopia, Kenya, DR
Congo and Central Africa), there is an increased risk that transmission of HIV/AIDS can be
spread throughout the country (World Bank, 2003).
39
Working through peer educators in refugee camps is an appropriate method in preventing
STIs/HIV/AIDS among the displaced population and other communities and might be
effective in reaching a population in crisis. Therefore, these programs might be considered
beneficial in Sudan, particularly in southern and western Sudan, where the conflict takes
place (UNESCO, 2003).
4.1.2 Peer education as a tool to escape a vicious circle in Sudan and Egypt
According to several measurable forms evidence, peer education programs in Sudan and
Egypt are effective. The evidence includes increased awareness about health, reproduction
and sexuality, a high rate of condom distribution and the use of family planning methods.
Therefore, peer education has contributed to a successful diffusion of knowledge and
awareness through the dissemination of information about sexuality, reproduction and health.
This strategy of diffusing knowledge from peer to peer and from community to community
has become well- recognized in Sudan, where it has been used in urban areas, such as
Khartoum and in rural areas.
From 1992 to 2002, a report carried out by the Sudan Comprehensive National Strategy,
emphasized the importance of youth and adolescent’s rights concerning their involvement
and participation in youth policies. Through a network of approximately 30 centers in
different states of Sudan, the strategy offered development, training and rehabilitation
procedures. In addition, a few information, education and communication programs were
established by NGOs in the field of family planning and HIV/ AIDS (Youth Net, 2006).
At the end of 2003, the Network for Adolescent Youth of Africa (NAYA) was the first
network to start conducting Knowledge, Attitudes and Practices (KAP) studies in Sudan.
These studies concern youth and adolescents and sexually transmitted diseases through peer
education programs. KAP studied the students’ knowledge of reproductive health, family
planning methods and the use of contraceptives in five universities in Khartoum State. The
results indicated a large gap in all subjects they taught (UNICEF – SNAP, 2006).
A project done in Sudan targeted a total of 39,545 young displaced people of both sexes. The
main objectives were to raise awareness in the target population about STIs/HIV/AIDS and
40
promote condom use. Peer education was an appropriate approach for reaching a population
in crisis; therefore, the strategy was considered appropriate for the displaced population. The
project results encouraged the replication of similar activities to reach a greater number of
displaced people in order to educate them and promote condom use. In the end, peer
education programs have become accepted by organizations, associations and many
communities. They have been implemented in different parts of the country, including rural
areas and the capital (Annabel S, 2004).
In another project, 274 community-based workers and peer educators were trained by PPFA.
The project reached 68,122 people with its messages about sexuality and reproductive health.
The project conducted 1,125 information, education and communication sessions. All the
surveys showed important behaviour changes resulting from the project. Among the target
groups, HIV awareness increased: 87 percent of women changed their practices by using
condoms and having only one partner. Also, 89 percent of women said that they do not intend
to circumcise their daughters in the future. This is in comparison to 43 percent before the
launch of the program (WHO, 2005).
In 2006, PPFA cooperated with UNICEF and SNAP on a one-year program called youth peer
educators (YPEs), which focused on RH and HIV/AIDS. Several training sessions took place
in five states including Khartoum, Kassala, Wau, Malakal, and Juba. The number of trainees
in this program was 243. Several meetings were held for the monitoring and evaluation of the
program. The program itself reached 12,722 people. Furthermore, the monitoring and
evaluation showed the program’s progress in all five states (Cafa reports, 2008).
The program later expanded to include four northern states; Kadugli, Damazin, Gedarif and
Port Sudan. More than 44 awareness sessions were conducted for approximately 22,000
young people. The results reflected the feasibility of implementing RH programs that focus
on HIV/AIDS in the different states and showed improvement in the reproductive health
knowledge and well-being of youth and adolescents (Cafa reports, 2008).
According to UNESCO, a United Nation Program on HIV/AIDS found that peer education is
accepted and valued and widely used in Sudan as a preventive strategy for HIV/AIDS. They
found that peer educators are the most effective and credible source for changing behaviour
since peers feel comfortable to talk to each other about their personal concerns such as
sexuality. Also, according to UNESCO in 2003, most of the adolescents probably learned
41
more about sex and reproductive health from each other than they did from anywhere else
(UNESCO, 2003).
In order to prevent HIV/AIDS transmission, UNFPA distributed the work of peer education
to several organizations and associations in Sudan. CAFA is one such association that works
with peer education. Their activities take place in different conflict areas in the Capital and
rural areas where health education and sexual knowledge is not prevalent or openly
discussed. To address HIV/AIDS prevention activities and reduce the risk of transmission
significantly, CAFA used one of the comprehensive systematic intervention approaches in the
North: the introduction of a wide youth peer education approach as an effective method for
raising HIV/AIDS awareness in the community (UNFPA, 2005).
In 2007 CAFA conducted several training sessions for youth peers on reproductive health and
HIV/AIDS. The sessions took place in Nyala “the capital of the southern Darfur state” and
were funded by UNICEF. The association facilitated the trainings and four of the facilitators
were from CAFA. There were 31 participants and all of them were from the southern Darfur
state. The participants were provided with information about RH issues, YPE, Gender Based
Violence (GBV), STIs, growing up, RH & gender, FGM, HIV/AIDS, and FP. They were also
trained on communication, how to use teaching materials, how to write reports and how to
monitor and evaluate plans (Cafa reports, 2008).
After the training sessions CAFA experienced increased demand for condoms. The number
of condoms distributed increased from 9.999 condoms in October 2008 to 16.665 condoms in
January 2009. According to the pre and post-tests done, the analyses show that there was an
increase in their information and knowledge on RH issues, sexually transmitted diseases and
HIV/AIDS. The results also show the students’ acceptance of this kind of information as they
started to use it in their everyday life. All this is considered evidence of the success of peer
education programs (Cafa reports, 2008).
CAFA provided recommendations concerning youth. They emphasized the need to
strengthen YPE activities and create YPE networks for youth from South Darfur. They also
recommend giving students advance training (TOT) that will help them to fight HIV/AIDS
actively. Lastly, CAFA recommended starting a monthly planning meeting with trained
youth.
42
Egypt also faces challenges in relation to illiteracy rates, reproductive health problems,
family planning, child health and the care of adolescent and youth. They will need a
comprehensive program to address all these topics. Young people will need to be empowered
to make informed decisions and choices for promoting their own health and well being
through different approaches, including adolescent peer education (WHO, 2005).
The Y-Peer network in Egypt increased the knowledge about sexual reproductive health
among adolescents, improved the information regarding the availability of and rights to
services, and also achieved some progress in maternal and child health care and reproductive
health. Moreover, as a result of successful national family planning programs, fertility rates
have decreased among women in reproductive ages, and 60 percent of these women are using
contraceptives. Also, there are indicators, which reflect an increase in the awareness
regarding sexual reproductive health (SRH). The need for SRH information has been
acknowledged, the awareness of SRH rights has increased, and behaviours have changed
among those participants trained as peer educators (Y peer Egypt, 2008).
Also, to counteract the lack of sexual education and the provision of information about HIV
in schools, the NGO Caritas established Anti-AIDS Clubs in 25 schools in Alexandria. The
number of young people reached by these clubs is limited, but they still play an effective role
in the provision of information, education, and communication related to HIV/AIDS to the
youth they do reach, and the clubs have also produced interactive discussions among young
people (UNFPA, 2009).
An evaluation of Y-Peer Egypt which addressed the implementation of project activities and
the achievements of those activities was conducted. The methodologies employed by this
evaluation included; key informant interviews organized by UNFPA and Y-PEER Focal
Point personnel, a review of project documents, including service statistics and other program
records, a survey of key contacts and attendance of meetings, in addition to an extensive
review of related literature. Analysis of data collected showed that Y-PEER Egypt has
achieved a remarkable level of organizational capacity within a short period of time (Y peer
Egypt, 2008).
43
Y-peer Egypt found that peer education is an efficient methodology accepted by the UN as
well as governmental agencies. However, they recommend that advocacy efforts should be
strengthened to influence governmental and governorate machineries to adopt this method as
a formal and informal educational strategy that might help eradicate reproductive health
issues and prevent the spread of HIV/AIDS (Y peer Egypt, 2008).
4.2 Results
In sum, when we compare Sudan and Egypt, we can say that there are many similarities
between Sudan and Egypt: high rates of illiteracy and unemployment, low socio-economic
status, and a high prevalence of hepatitis. In addition, the cultures in the two countries do not
facilitate the exchange of sexually related information. Also the education systems do not
provide adequate information to students regarding sexual behaviour. All these factors may
reflect the need for peer education in the two countries and facilitate peer education program
implementation and adoption.
Peer education appears to have been implemented and adopted with more success in Egypt
than in Sudan. This could be a result of the differences between the two countries. According
to the method of differences the factor “X” may exist in one but not both countries. In this
case, “X” is represented by the existence of a vast number of different ethnicities and ethnic
groups, conflicts, and war in Sudan. The presences of these elements have had a big effect on
the application of peer education programs. We can also note the differences in the
population, the education of adolescents and teaching methods, as well as the ability to accept
new information, especially information regarding sexuality and sexually transmitted diseases
targeting adolescents in this conflict situation. All of these factors contribute to an
explanation of why peer education programs might be less applicable than in Egypt, where
there is no conflict or war. In addition, teaching materials and teaching methods are better in
Egypt than in Sudan, much because Sudan lacks financial resources for education. Of course
peer education programs have been implemented and accepted among adolescents in Sudan,
but as mentioned above, certain factors lead the strategies of peer education program to be
more effectively applied in Egypt than in Sudan. Mostly this is because a lot of the Sudanese
efforts are currently directed at conflicts and war, and the country’s main priority is to try to
make peace inside and in the areas around the country.
44
Chapter Five
In this chapter I will present a brief overview of the resistance against peer education
programs, and I will outline some of the critiques directed at such programs.
5. Resistance against peer education
Many African communities consider the use of condoms problematic (Ahlberg, 2001). This
means that the risk of spreading STDs such as HIV is ignored.
As I have mentioned before, talking about sex, sexuality and condom use is considered a
culturally sensitive issue in some countries. This is in part related to religious and traditional
beliefs. For example, in Islam discussing these issues is not allowed and might lead to social
stigmatization. Sex outside of marriage and the use of condoms is often believed to promote
sexual impurity and to cause people to have sex with multiple partners, and some even see
these practices as a way to encourage prostitution. Sudanese ideologies in terms of culture
and education are heavily influenced by official Islamic views (Breidlid, 2005), and this
might account for some of the reluctance to discuss such issues both in public and in private.
The Sexuality Information and Education Council of the US (SIECUS), an organisation that
along with the World Association for Sexual Health (WAS) participated in drafting the
Montreal declaration, “Sexual health for the millennium” analysed peer education and
reproductive health programs in developing countries. This analysis found few studies that
demonstrate that sex education results in behaviour change (Kelly & Lwis, 2001).
Resistance towards sex education, however, is not only found in developing countries.
Despite the global and national realities, a number of current US policies deny adolescents
the right to full and accurate information on sexuality and reproduction, and limit their access
to respectful, confidential and comprehensive health care that they require to reach adulthood
in good health (Igra & Irwin, 1996).
Finally, because there is limited funding allocated to the evaluation process of peer education
programs, the evaluation timelines are guided by practical constraints rather than theoretical
considerations. Thus, the evaluations are not as effective and helpful as they otherwise might
have been.
45
5.1 Criticism of peer education programs
Despite all of the advantages of peer education programs mentioned above, there are some
problems have been noted. Some reviewers have described a number of difficulties in the
assessment of the effectiveness of peer education programs. Some of these problems are poor
reporting of any difficulties adhering to the planned methods, the lack of a control group
and/or pre-test and post-test comparison, and problems controlling for the wide range of
possible influences on program outcome (DRUGINFO, 2006).
Another major criticism directed at the evaluation of peer education programs, is that it
appears that a number of the evaluations that have been adequately documented in fact focus
on the implementation of the programs themselves rather than on the impact of the programs.
It has also been noted that despite the often innovative nature of peer interventions, workers
in the field frequently have little experience in organising these types of programs and that
much of the work of peer volunteers remains unsupervised. Therefore, some of the peer
education programs mentioned that they are facing some difficulties in controlling young
people. Peer educators have also reported some problems. One such problem relates to
dealing with personal questions about their own experiences. Also, they brought up concerns
about the need to become an expert source of information as some peer educators reported a
lack of trust from other young people, who some felt were viewing them more as teachers
than as peers (DRUGINFO, 2006).
46
Chapter Six
6. Conclusion
At the moment the adolescents make up largest generation in the world. Far too many of
these adolescents are lacking adequate information and knowledge about their sexuality and
sexually transmitted diseases, which are prevalent in this age group. In my study I found that
adolescents face many troubling factors that prevent their access to correct information.
Adolescents might therefore base their actions on incorrect information from an array of
unreliable sources. Although parents and trusted adults have traditionally been the source of
information about sexuality and STDs there is no doubt that a large proportion of adolescents
gather information from their peers.
Peer education programs find a way to reach our future generations in an effective and
popular manner.. Peer programs occur in a variety of settings, they are easy to use, and they
provide a means of delivering culturally sensitive messages. They diffuse knowledge about
sexual and reproductive health among peers, they link to other community based strategies,
and they are accepted and adopted in many countries in Europe, Asia and Africa. Peer
education has become one of the most common approaches for addressing sexual and
reproductive health issues, and it is the most applicable method in changing sexual behaviour
today. Most of the results show that adolescents are eager to learn about sexuality and
reproductive health from their peers and that they accept their peers’ advice when it comes to
handling their personal problems.
Sudan and Egypt share several troubling factors, including the prevalence of poverty, high
illiteracy rates, the spread of HIV/AIDS and other sexually transmitted diseases and
educational curriculums that largely ignore sexual education. All these factors speak to the
reasons why both countries have facilitated and adopted peer educational programs.
47
References
1. Ahlberg, B., Jylkäs, E. & Krantz, I. 2001. Gendered construction of sexual risks:
implication for safer sex among young people in Kenya and Sweden. In:
Reproductive Health Matters. Volume 9. Sweden
2. Annabel S Erulkar. 2004. Behaviour Change Evaluation of a Culturally Consistent
Reproductive Health Program for Young Kenyans. Volume 30, Number 2,
International Family Planning Perspectives.
3. Baldwin, Julie. 1995. Using peer education approaches in HIV/AIDs programs for
youth: a review of literature. In the peer facilitator quartery vol. 12, No. 3, p.30-36.
Minneapolis, educational media crop.
4. Bandura, A. 1986. Social foundations of thought and action: a social cognitive theory.
Englewood Cliffs, NJ, Prentice Hall.
5. Breidlid, Anders (2005). Education in the Sudan: the privileging of an Islamic
discourse. Compare, vol. 35, no. 3, 247-263.
6. CAFA. (2008). Report on: For youth peer education on reproductive health focusing
HIV/AIDS. Omdurman.
7. Campbell, S. 2005. Using peer education projects to prevent HIV/AIDS in young
people. Nursing Standard. 20, 10, 50-55. November 16 :: volume 20 no 10: Harrow,
ROYAUME-UNI
8. Clasen, Jochen, (1999). Comparative social policy concepts, theories and methods.
Blackwell ltd libarary of congress cafalogin-in-publication data.
9. David, R. (2000). Young people health in developing countries, a neglected problem
and appropriate health policy and planning, 15(2): 137-144. Oxford University.
10. Dmchak S et al. (2000). Monitoring and evaluation of adolescent’s reproductive
health programs. Washington: William
11. DRUGINFO. (2006). Peer education, Prevention Research Quarterly: current
evidence evaluated ISSN 1832-6013.
12. Elizabeth, G. (2000). Sex education helps prepare young adults. Network adolescents
reproductive health, 20(3): 7-13
13. Fay, Brian. 1996. Contemporary Philosophy of Social Science: A Multicultural
Approach. Cambridge, Massachusetts: Blackwell Publishing.
48
14. Fishbein M. Ajzen. (1975). Belief, attitude, intention and behaviour: an introduction
to theory and research. Reading, MA, Addison-Wesley.
15. Falola, T. (2004). Teen Life in Africa. London: Greenwood press
16. Fougner, A., Utne, B. and Tønnesson, Henning (2008), What do students learn from
facilitating the learning process of younger students? Description of a peer tutoring
program at Bachelor of Child Care and Welfare, Faculty of Social Sciences, Oslo
University College. Nordic Studies in Education 28:. 287-302.
17. Gallant, M. and Maticka-Tyndale E. (2004). School-based HIV prevention programs
for African youth, Social Science & Medicine, 58(7): 1337– 1351. University of
Windsor, Canada
18. Helman, Cecil G. 2007. Culture, Health and Illness. Fifth edition. New York:
Hodder Arnold
19. Hussein, Rania (2002). The knowledge attitude and practice of university student on
reproductive health issue research submitted as a partial fulfilment of degree for
M.B.B.S, Omdurman, Ahfad.
20. Igra, v. & Irwin (1996). Theories of adolescents risk taking behaviour “p. 25-53 in
Hand book of adolescent Health Risk Behaviour. New York, Plenum press.
21. Kelly, K. (2000): communication for action. A contextual evaluation of youth
responses to HIV/AIDs. Sentinel site monitoring & evaluation project. Summary of
findings. Beyond Awareness campaign HIV/AIDS and STDs directorate. Department
of health, Cape Town.
22. Kelly, K, parker, w. &Lwis, G.(2001): “reconceptualising behaviour change
HIV/AIDs context” in stones, C. Socio-political and psychological perspective on
South Africa. London, Nova science.
23. Kennett Patricia (2004). A hand book of comparative social policy. Edward Elgar
Cheltenham, UK.northampton, mt, ust. libarary of congress cafalogin-in-publication
data.
24. Kjelstadi, Knut. (1988). Nytten av a sammenligne, tidsrift for samfundsforskning 29
25. K. Backell & s. Wilson. Health education research theory & practise vol.15 No. 2009
pages 85. Oxford University Press.
26. Landmann, Todd. (2003). Issues and methods in comparative politics, an
introduction. London: Rutledge
27. Oster, E. (2007). HIV/AIDs and sexual behaviour change: why not Africa?
University of Chicago and NBER.
49
28. Population Council. (2003). Peer education and HIV/AIDS: past experience, future
directions. Horizons. http://www.popcouncil.org/pdfs/peer_ed.pdf - 2003-05-06
29. PPFA, SNAP, UNICEF, (2006). Training of trainers manual for youth peer education
on reproductive health, Sudan, volume 1
30. Ragin, C. (1989). The comparative method, moving beyond qualitative and
quantitative strategies. University of California.
31. Rogers E. (1983). Diffusion of innovations. New York, Free Press.
32. Roger, E. M. (2003). Diffusion of innovation. Fifth edition. Free press, New York.
33. Rossi, P. Freeman, H. (1993). Evaluation: a systematic approach. Newbury Park,
Sage Publications.
34. SNAP, (Dec. 2008). A proposal for Content Analysis Study of the National Sudanese
Media. Sudan-Khartoum
35. Senderowitz, J. (2000). A Review of Program Approaches to Adolescent
Reproductive Health. Poptech Assignment. No. 2000.176. Arlington, Virginia:
Population Technical Assistance Project.
36. UNAIDS. (1999). Peer education and HIV/AIDS: concepts, uses and challenges:
report of a consultation. Geneva: UNAIDS. data.unaids.org/publications/IRCpub01/jc291-peereduc_en.pdfUNICEF Ghana. (2002). Evaluation of HIV/AIDS
Prevention Through Peer Education, Counselling, Health Care, Training, and Urban
Refuges in Ghana. Evaluation and Programme Planning
37. UNESCO. (2003). Peer Approach in Adolescent Reproductive Health Education.
unesdoc.unesco.org/images/0013/001305/130516e.pdf
38. UNFPA. (2005). Training of Trainers Manual. ISBN: 0-897-14759-6
39. Williamson, N. (2000). The Need to Evaluate Youth Programs Network: 2000, Vol.
20, No. 3. Family Health International (FHI)
40. WHO. (2002). Information, Education and Communication: Lessons learned in IEC
specific to reproductive health. http://www.who.int/reproductivehealth/
41. WHO. (2005). Adolescent peer education informal and non-formal settings. Cairo.
42. WHO. (2009). Country profiles, Sudan/ Egypt
43. Y-PEER. (2008). Strengthening and Expanding Capacity for Delivery of High Quality
Peer Education Systems in Arab States, Eastern Europe and Central Asia. The
Sustainable Research and Development Centre. Jordan
44. UNAIDs. (2008). Report on the global HIV/AIDs/08. 25 E/ JCI0E.
50
45. UNFPA. (2009). Young people report on progress made on the UNGASS declaration
of commitment on HIV/AIDs/09.
46. UNFPA. (2007). POPULATION ISSUES Supporting Adolescents & Youth.
December.
47. Youth Net. (2006). Youth peer education in reproductive health and HIV/AIDs
48. World Bank. (2003). Sudan: Stabilization and Reconstruction Country Economic
Memorandum. Vol. No. 1
49. The Federal Ministry of Education. (2004). General Directorate of Educational
Planning. Khartoum.
50. UNICEF. (2004). “Status Report: Teacher Training Policy Recommendation”,
(Working Draft).
51