Youth-to-Youth–Peer Workers in HIV/AIDS Youth Programs: A Peer Development Guide

This guide is drawn from the experiences of several organizations funded to demonstrate and refine service delivery and care models designed specifically for young people. Although the focus of these projects has been on the delivery of HIV care (as well as the integration of such care in the larger context of more general adolescent health issues), their experience with peer-based programming is applicable to many kinds of youth services providers. The models of care were themselves based in a variety of human service landscapes, from residential substance abuse rehabilitation to hospital-based programs. The common element among the projects was a desire to meet the needs of an inherently hard-to-serve target population.

This guide reflects a myriad of lessons learned and contains practical tips from a wide variety of program staff, including youth outreach workers and program coordinators, licensed physicians, social workers, case managers, and other public health professionals. To draw from the experiences of only adult professionals (or only from youth staff for that matter) in discussions about youth programming would limit the validity and practical application of those perspectives. The perspectives presented in this guide reflect the actual voices of the staff who shared them.

The guide addresses many aspects of youth involvement in adolescent health programming from youth development philosophy to outreach tactics and lessons learned in program development. While language varies greatly from one perspective to the next, the context from which the guide was written is consistent throughout. Concept essays (originally published in youth provider publications), practical tips in hiring youth staff and developing their skills, strategies to promote healthy youth development and leadership skills, and other practical strategies for engaging young people are applicable to both adult and youth staff in a variety of youth-focused programs.

The practices historically connected with empowering young people – raising self-esteem and sense of self-worth, encouraging self reliance, building skills, and developing identity – are becoming increasingly popular among adolescent health focused programs, particularly those with an emphasis on HIV care and prevention. The following articles, written by Steven Tierney, Ed.D. and Ron Henderson, M.A., both staff at Health Initiatives for Youth, illustrate some of the key tenets of youth empowerment from their perspectives as experienced adult professionals.

Peer staff are increasingly recognized as important members of service delivery teams working with at-risk youth. Studies that examine the utilization of peer staff serving at-risk youth show that peers are an extremely effective means of reaching young people and decreasing risk-taking behavior. With this trend of employing youth workers comes much discussion and literature on the advantages of the use of peer staff and the modes by which agencies can maximize utilization of peer staff.

The word "peer" has been used loosely and applied broadly. In spite of the current discussion on peer staff, there is still not a uniformly accepted definition of a "peer." Individuals who fall under the title of "peer provider" are as diverse as the young people with whom they are working. Within this guide, the word "peer" is used to identify any young person who works with other young people. A peer provider may share many characteristics with the population with whom he or she works or may not be at all representative of the target population. There is no single profile of a peer provider. Young people seek out work in youth services for various reasons, ranging from the specific (personal experience with an issue such as substance abuse) to the broad (general interest in and commitment to the future of young people).

In some agencies that serve youth, there are individuals who have transitioned within the agency from client to provider and are, therefore, highly representative of the target population. These peer providers often share many of the same past experiences as their clients, such as gang involvement and substance abuse. There are also peer providers who have not transitioned from client to provider, but may nonetheless share critical life experiences with their clients (history of addiction or abuse). Some peer providers have little in common with their clients in terms of past experience, yet have similar or identical cultural, gender or sexual identifications as the youth with whom they are working. Finally, there are also peer providers who have no clear similarities to the youth with whom they are working, with the exception of age, yet have a strong commitment to youth services.

While this guide deals with youth-specific services and, therefore, uses "peer" in an age dependent context, peer providers can also be individuals who share some strong commonality with the population being served other than age. There are many recovering adults working with youth in substance abuse treatment. The fundamental common experiences that these two individuals share permits them to be labeled peers. Similarly, young people who have previously been homeless who work with adults who are presently homeless can also be considered peer providers. It is important to recognize that peer providers need not always be young nor of equal age to their clients.

Peer workers are instrumental when working in youth-specific services because they are successful at reaching young clients, establishing strong communication links and, ultimately, engendering positive behavioral change. For the peer worker who has transitioned from client to provider, the link to the target population already has been established. This peer provider can more readily establish a connection with clients based on shared experiences and common backgrounds. Such a relationship may take the shape of a young addict in recovery counseling a young addict trying to get clean.

Young people often feel isolated in their struggles, especially young people living with HIV or challenged by an addiction. Interacting with someone who has experienced their pain and can offer practical advice may comfort them. A young person who has made the transition from client to provider can offer practical advice and hope based on his or her own successes in overcoming adversities similar to a client’s.

How important is it that a peer worker is culturally representative of the target population with whom they work? This is a difficult question because ‘culture’ can be multi-faceted. For example, there is a young person’s culture of origin, gender or sexual identification, there is a young person’s street or social culture, and there is ‘youth culture’ at large. Like shared past experiences, shared cultural identities can be a good foundation from which a peer provider and young client can establish a relationship. A young person may identify better with a provider who shares his or her ethnic or racial heritage, religion or sexual orientation. This can provide a base of trust, especially if the young person is accustomed to engaging exclusively with other youth from his or her own cultural background.

Many young people identify with their culture of origin, but young people also can strongly identify with social or street-based sub-cultures (for example, punk or hippie.) Many youth, particularly veteran ‘street youth,’ are likely to identify with these street-based sub-cultures more readily than they do with ethnic or familial cultures. These young people, especially those coming directly off the streets, may be more comfortable interacting with peer providers who identify with one of these same sub-cultures.

In addition to providing the framework for a more comfortable and familiar interaction, shared cultural identification between client and peer provider also can be useful on a treatment level. Cultural affiliation can be directly correlated with behavioral tendencies and modes of communication. A peer provider with a strong awareness of the client’s particular cultural identification may be better able to understand the client’s behaviors and, therefore, offer more effective intervention strategies.

While shared experience and cultural similarity are two characteristics that make a peer provider effective in his or her relations with clients, the message, not the messenger, must be the emphasized. Many target populations are so diverse that it is nearly impossible for one individual peer provider to be wholly, or even somewhat, representative of the client pool. Having a peer provider who is different in many ways from their clients can be beneficial. It can be healthy to encourage young clients to relate to and engage with diverse individuals. For example, if a young woman were to counsel a young man, the initial dynamic may not be as comfortable as if the counselor were male. However, this type of diverse pairing encourages open and honest communication between the sexes and may ultimately better prepare the young man for future relationships. Young people will have to interact with various types of people in the larger social world and it can be useful for them to gain exposure to and achieve a level of comfort with diverse populations.

Some peer providers chose to pursue work in human services based on their academic background. They may have little else in common with their clients other than age; however, such peer providers can be extremely effective when applying academic skills on a practical level. Knowledge of psychology, social work or public health can be invaluable when devising intervention strategies and treatment plans for young people. Moreover, many high-risk youth suffer from mental illness, so general knowledge of mental health issues, on the part of the peer provider, can be useful in understanding the client’s behaviors, both past and present.

Some peer providers may not have any relevant academic background, but may seek out work in human services simply out of a desire to advocate for youth. These providers may be of similar age to their clients, but may have had vastly different and often more positive life experiences. They can serve as role models or mentors and can encourage pro-social behavior in young clients. These peer providers can expose clients to more diverse lifestyles and communities as well as encourage them to break away from a single and often limiting social identity. In most cases, this means exposure to more positive and healthy approaches to living.

Sometimes it is clearly more effective to match a provider with a client or client population based on demographic representation. For example, if the target population were ninety percent Hispanic, a peer provider who is culturally representative of this population would probably be most appropriate, especially if there were monolingual members in the target community. Similarly, a population of young women with histories of abuse by males will most likely be more comfortable working with a female provider.

On the other hand, in some cases diverse matching is the more effective strategy. For example, a population of young people who have histories of gang involvement may profit more from a young provider who was not gang involved and can share different life experiences. It is important that the persons responsible for hiring peer providers explore the advantages of hiring a provider who is representative of the target population or a provider who may have little in common with the target population, yet may make significant contributions in other ways.

For agencies employing peer providers, it is necessary to examine each potential hiring situation and systematically weigh the benefits of hiring different types of peer providers. Ideally, an agency should hire more than one type of peer provider, thereby increasing peer worker diversity and possibilities for culture-specific matches with clients when appropriate. It is also useful to look at similar populations being served in other agencies and find out which providers have been successful in reaching youth and for what reasons.

When this guide refers to peer counselors/educators or youth workers, it is encompassing a diverse and rich community of young people who strive to guide and support other young people in need. The only real prerequisite to being a peer provider is a desire to make positive changes in the youth community. While there are a multitude of different ‘types’ of peers working in youth services, they all share this common desire; they use their various tools and strengths to help their peers work towards a more hopeful future.

Adult’s Role in Youth Empowerment

"Young people must know that they are loved and we must share with them the wisdom of our experience." — Marian Wright Edelman

The youth empowerment movement presents a number of critical challenges for youth service providers and advocates:

• How involved should adults be in a youth empowerment program?
• How do adult service providers and advocates protect youth from physical and emotional harm if adults are not in charge?
• How do adult service providers and advocates measure success if they don’t design the program?
• What is the reward for adult service providers and advocates of standing on the sidelines and providing only a safety net?

Well-intentioned adult providers trying to "give youth space to grow" sometimes hand over a program or activity to youth and move on to other matters. Young people are left to plan, manage, fund, and operationalize the programs. Oftentimes, this approach leads to negative outcomes.

Conversely, we see adults plan and establish youth empowerment programs with well-articulated goals and outcomes. Then they recruit and engage youth for the program. The problem with this approach is that empowered youth, by definition, should be able to establish their own agenda and outcomes.

Finding the balance between these two extremes is a complicated matter. A balanced approach requires the acknowledgement of what each youth and adult planner contributes to these efforts. Concerned and committed adults bring their life experience, their training and education, and their willingness to create safe, nurturing and rewarding spaces and programs. Youth bring immediacy and vision unique to the social and cultural context of their lives.

Adults who work as youth advocates or service providers often were themselves youth community leaders. They were accustomed to being creative and implementing their ideas. They were leaders precisely because they set the agenda and achieved results. Now they must be prepared (as well as trained and supervised) to coach, mentor, and support a new generation of youth leadership. Since their role has changed, it may be difficult for them to take a hands-off approach to leadership. This challenge can be particularly difficult when the difference in age between youth and professional is narrow.

Young people know best the world they live in. They discover their own music, create an ever-changing lifestyle, and express challenging ideas and original perspectives. They are often acutely aware of and vulnerable to the dangers of the world. Young people involved in promoting healthy choices can assert an important and positive influence on their peers. They can engage their peers in dialogue and activities that affect their choices and behaviors and that encourage the development of values.

Adults also have an important part to play in youth-for-youth programs. They can fulfill key roles as mentors, guides, consultants, and supervisors. Finding the balance between being helpful and supportive as opposed to being directive and controlling is the key challenge adults face in working with youth peer educators and counselors. The following key elements may be helpful when developing a youth project involving peers.

Adults must demonstrate a genuine respect for youth. This involves hearing their ideas, criticisms, dreams, and questions with an open mind and an interested and supportive attitude. It means seeing a whole person, not just a young person. Adults should be conscious of interactions that may cause youth to feel discounted, unheard, overruled or patronized. When mutual respect is practiced in the work environment, a dynamic fusion occurs between the creativity, enthusiasm, and fresh ideas of the young employees and the academic, professional, and life experiences of the older staff members.

Young people need a solid foundation for their success. Adults, therefore, need to give careful thought and planning when integrating young people into a work environment, and take time to orient and describe the systems within which youth will be working. Being clear about expectations, policies, and job descriptions can help young people feel grounded and safe. Regularly scheduled meetings during which the peer can check in with progress or problems are necessary, and supervision should focus on the young person’s personal and professional growth. When starting a new program, adult leaders should balance focus, opportunities, and guidance with freedom for young people to fly with their own ideas, creativity, and passion.

Youth need tools to assist them in building successful programs. All projects should begin with adequate training on a variety of topics, including adolescent health and development, teamwork, cultural diversity, public speaking, training techniques, and computer skills. Interactive or experiential training allows young people to be engaged fully and helps them incorporate the information presented into their work and lives. Facilitators of these workshops have the opportunity to model presentation and facilitation skills.

Congratulating young peer educators for small and big achievements is an important way in which adult staff can acknowledge youth efforts. This validation can be verbal, in one-to-one conversations, or in larger group settings when appropriate. Handwritten notes of praise or encouragement are often very special to young people (as they are to all people). The important thing is to be creative; leave a fun note on a desk or computer screen or celebrate a group effort with a special pizza party or field trip. Support the strengths you see in a young person and let them know that you believe in their ability to grow, advance, and succeed.

A partnership between young people and adults, which incorporates the principles of respect, structure, training and validation, will create a youth-friendly work environment where a peer-operated project can enjoy dynamic success.

In a time when young people are the fastest growing population contracting HIV, meeting the health needs, especially regarding risk behaviors, of young people is a vital task. However, the fact that these young people can prove especially difficult to reach, and are often unreceptive, if not resistant, to the efforts of service providers, makes this task extremely challenging.

More and more, service agencies and organizations working with hard-to-reach young populations are employing youth workers to act as a bridge between formal service delivery systems and the target population’s informal social system. Social learning theory suggests that group culture and social norms greatly affect behaviors among young people¹. Young people often refer to popular social standards as a framework for their own behavior. Peers are important in establishing standards for acceptable behavior. The use of peer workers to generate normative behavioral standards within the youth community has proven effective. Embedded in the social influence theory, a school-based prevention program utilizing peer workers helped reduce substance abuse and sexual risk-taking behavior among adolescents². In their review of other prevention programs, these researchers noted a study in which adolescents who perceived their peers as supporting condom use were more than four times as likely to be consistent condom users compared to those who thought their peers did not support condom use³. Thus, peer workers can significantly affect the behaviors of their young counterparts, encouraging them to make healthier and more responsible decisions.

It is often more difficult for adult professionals, whose past and current life experiences are vastly different from the youth with whom they are working, to develop a social basis through which they can relate to and communicate with young clients. It can be helpful for these professionals to identify young people in the community who can more readily establish a link with young clients both linguistically and culturally. Young clients are often more receptive to the efforts of youth workers, as peers are less threatening and seemingly less authoritative than adults. However, it is also essential that these young service providers work in close partnership with adult or non-peer staff. Combining this "adult" perspective with the "youth" perspective provides a greater diversity of input regarding service delivery, ensuring each client the maximum in terms of choices. Providing a structure that will lead to more client-centered treatment planning is crucial to delivering services that are as appropriate as possible.

The varied roles of adult staff working with peer staff are critical in maximizing the effective utilization of peer staff. Adult staff may act as supervisors to the peer workers, acculturating them to the agency and providing job details and direction. Adult staff members are a source of emotional support for the young person who may feel overwhelmed with the responsibility of guiding and providing services to their peers. The adult worker is also a role model, serving as an example of appropriate and effective behavior for the young person. Functioning as a mentor is another valuable role, involving one-on-one interaction that can guide the peer worker through professional and non-professional challenges. An intrinsic part of the adult-youth partnership is a system of checks and balances in which adults provide constructive criticism and feedback regarding the young person’s job performance. There is also a need for a safe space for the young person to ask questions, to voice concerns, and to make mistakes.

One of the most significant roles of the adult worker is that of advocate for the youth worker. The adult colleague serves as a liaison between the young person and the larger adult community within the agency, ensuring that the young person (and their role) is recognized and respected. A frequent challenge for a peer worker is establishing himself or herself within an agency that is comprised mostly of more experienced adult workers. The adult worker should facilitate this transition by advocating for the youth and encouraging the community to embrace the young person as a valuable resource for young clients. It should constantly be stressed within the agency or organization that adult-youth cooperation is crucial when serving young people.

The primary role of youth workers, regardless of their agency’s specific service context, is to provide accessible, non-judgmental care and support. As a member of the direct service staff, the youth worker carries many other responsibilities. The presence of youth workers enables young people to interact with and seek support from other youth. By acting as a positive role model, youth workers can empower their peers by offering them a tangible picture of success within their own subculture. Moreover, similar to the adult role of advocate, youth workers can advocate for their peers and serve as a voice for the young community.

The practical roles of peer workers are varied and dependent upon the specific services offered by each agency. When working with high-risk youth, education is an essential catalyst for behavioral change. Young people learn about the repercussions of their negative behaviors, and more positive choices are presented within a framework that facilitates change.

Beyond education, there are many other arenas in which peer workers can be of great use. They can organize social and recreational activities for young clients and, thereby, offer a setting in which they can interact freely with the youth and clients can interact with people of all ages. The close association of high-risk youth with young role models, especially in a social setting, can contribute to positive behavioral changes. It enables the youth workers to demonstrate attractive alternatives to negative behavior patterns in young people.

Both adult and peer staff working with high-risk youth require extensive training in relevant subjects, such as substance abuse and HIV/AIDS. In addition, they should both receive education about cultural and ethnic differences and how these differences may manifest themselves in a young person’s behavior. For adult workers, it is important to provide training about youth and youth culture. This will be utilized both in making the adult-youth partnership function more effectively and in making the adult’s direct services to youth more productive. In terms of making the partnership work, peer staff may benefit from training about the organizational context of the program. Explaining policies and procedures and clearly defining expectations are examples of two areas where formalized organizational training is beneficial.

In terms of the direct delivery of services to the target population, training for peer staff that emphasizes issues concerning boundaries, transference, and ethics (particularly, confidentiality) are imperative. The proximity in age between youth workers and their clients may make it difficult at times to maintain clear boundaries. It is not unheard of for ambiguous job roles to combine with unclear boundaries and result in peer workers adopting (and possibly, falling back into) negative behaviors. This is especially an issue if they have histories of high-risk behaviors, such as substance abuse and criminal involvement. It is essential that youth workers be taught to establish clear boundaries from the start. An invaluable addition to training is a relationship with an adult supervisor where boundary issues are discussed as part of an ongoing dialogue. Issues such as how much personal information to disclose to clients may be covered in formal training, but often these issues are not relevant for new peer staff until they actually begin interacting with clients. Many other areas call for a comparable blending of formal with experiential training. Openness in observing, communicating, and decision-making is needed for the partnership to work.

Footnotes

1. Eng, E., Parker, E., Harlan, C. Lay Health Advisors Helping Continuum. Health Education and Behavior. 1997 Aug. 24 (4): 413-417.

2. O’Hara, P., Messick, J., Fichtner, Ronald R., et al. A Peer-Led AIDS Program for Students in an Alternative School. 1996 May. 66 (5): 176-182.

3. Ibid.

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Section 2: Youth Leadership Development: The Indiana Youth Group (IYG) Experience

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