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

Health outreach programs for youth aim to connect specific target populations to care. Two different types of outreach have emerged in recent decades – street outreach and agency outreach. Street outreach involves direct communication with targeted youth where they hangout or reside, which may be on the streets, on basketball courts, in clubs or public housing units. Agency outreach, referred to as "in-reach" by some health professionals, identifies high-risk youth who are already linked to existing systems of care, including school-based health centers, youth correctional facilities, and residential programs.

Specific goals and objectives among outreach programs vary greatly. However, most programs targeting high-risk and HIV-positive youth employ peer outreach workers who share common experiences with the target groups. These outreach workers strive to link youth with age appropriate and sensitive health care services, and to encourage youth to make informed decisions about risky behaviors that may impact their health and well being.

While both Children's Hospital of Boston's Boston HAPPENS project and the Greater Bridgeport Adolescent Pregnancy Program's TOPS project utilize peers to provide outreach, Boston HAPPENS provides outreach to youth in the HIV/AIDS care system and GBAPP/TOPS provides street-based outreach. This section describes, in further detail, key elements of street and agency outreach, and shares unique perspectives and approaches of these two different program models of outreach.

Using a multifaceted approach to enrolling clients, including allowing adolescents to give input into enrollment strategies and a non-judgmental approach, builds trust and creates a safe environment in which to meet the needs of youth. The basic enrollment process includes a psychosocial intake, family history, needs assessment, and other information as necessary. Youth meet staff members during the first visit to begin building familiarity.

Below are some of the outreach strategies that have been employed by Boston HAPPENS.

Agency Outreach. Agency outreach can assist in identifying community-based and youth serving agencies that can be allies/gateways for enrollment. Interviews, focus groups, and knowledge of the community program can assist in identifying agencies/programs that have a good track record serving youth. Once identified, outreach/case management staff members market the program to these agencies and learn more about what services they provide. By identifying contact people at these agencies, referrals can be made to specific persons, thus increasing the likelihood of follow-through for youth. Also, during site visits it is important to observe the atmosphere of the potential referral.

School-Based Health Centers. With the emergence of school-based health centers and health curriculums, outreach to schools may identify at-risk youth. This can be done by letter, phone call, site visit, or presentation to school nurses. Outreach or health education staff may also connect with school-based health centers by teaching health education classes or organizing forums or assemblies.

Youth Correctional Facilities. Youth detention, correctional, and residential treatment facilities contain at-risk, court-involved youth, some of whom may have STDs or HIV/AIDS. Presentations at staff meetings or to youth groups there will assist in identifying young people who need services. Boston HAPPENS was able to pilot an HIV antibody pre-test screening group curriculum at six Department of Youth Services facilities. The Massachusetts Department of Public Health developed the curriculum to present basic HIV/AIDS information, along with specific adolescent counseling and testing services, to groups of youth at Department of Youth Services facilities. Through this process, Boston HAPPENS was able to link at-risk youth to needed services soon after discharge.

Residential/Treatment Facilities. Boston HAPPENS did extensive outreach, training, and service provision to and for youth and staff at various youth residential facilities. Project staff have assisted youth at some of these facilities to maintain consistent access to health services, outpatient counseling, and HIV counseling and testing. These facilities include hospital adolescent psychiatric wards and treatment facilities for substance abusing, runaway or troubled teens.

Youth Events. Youth events offer opportunities for programs to market their services. These include, but are not limited to, educational, cultural, and entertainment events. Youth conferences or workshops can be initiated to educate young people.

Even if programs provide a wide array of comprehensive health services, they will often need to refer outside the program for other youth-related services. Good referral management will include identifying a designated person (possibly by outreach/case management/peer education staff) to create a list of referral sites. All staff should be able to assist in making referrals, which can be done by having the designated person make a referral resource list with contact names. There should be a mechanism in place to follow-up and track the types of referrals made. The likelihood of referral appointments being kept increases if the name of a person is given to the client.

One of Boston HAPPENS’ collaborative agencies has a van that provides basic medical care "in the hood," and another has outreach teams on the street and a drop-in center. This enables HAPPENS staff to connect youth to services on their "turf" as well. Having a HAPPENS staff member on the Bridge Over Troubled Waters medical van or on the Boston Street Youth Outreach Program Team, assists in fostering trust through consistency.

Client/youth input and involvement may include focus groups, individual interviews, and youth and consumer advisory boards. Having a peer education/leadership component is also a way to have ongoing youth involvement and continual feedback. Boston HAPPENS received feedback through a series of focus groups convened prior to formally setting up the HAPPENS clinic and its related services. Youth were asked to profile a clinic where they would feel comfortable receiving services and the type of services and providers they would like to see.

Some programs may utilize an ongoing youth advisory board that clients also participate in as the primary vehicle for input. Client/youth involvement in planning and program implementation can foster a design that is more conducive to adolescent lifestyles and needs. Also, creating opportunities for clients to be involved in social events or field trips shows clients that they are seen as unique individuals and not only as clients who receive medical or social services.

Ultimately, programs should strive to achieve a partnership between the peer leaders, clients, youth representatives on the advisory board, and the adult staff of a program.

Retaining clients who are at-risk, homeless, runaway, street youth, or HIV-positive adolescents can be challenging. The time and resource commitment, however, is well worth it. Being flexible, having comprehensive services, transportation, home visits, and available outreach staff may help facilitate retention of clients. Linking clients to individual or group counseling can improve client retention. Exhibiting a partnership with clients and checking in with them about the delivery of services can keep them actively engaged.

Retaining youth in employment, as speakers or peer educators, involves a lot of the same action steps used to retain young clients. The main difference is the fact that youth staff is held to similar standards as the adult staff. As long as standards or guidelines are developed by youth, discussed up front, and clearly understood by youth, retention rates are high.

There are many forms of outreach that can be utilized to reach potential clients and identify needed services. The key is to have a multifaceted approach to reaching out that involves input from youth, whether they are clients or staff, and is adequately supported by your program. Employing a multidisciplinary team of community-involved and aware providers increases the likelihood of connecting youth to care. At HAPPENS we have found that having providers who are trained in adolescent wellness, and are up to the challenge of working with adolescents on all aspects of their lives, makes the program effective at fostering change in the lives of youth in the community.

Having good communication and connections at health/community-based organizations can increase the rate of referral appointments kept and the overall retention rate for youth in the program. Moreover, having a monthly or quarterly call or site visit can keep the lines of communication open and gives the opportunity to update contact names as staff changes occur at these sites. Youth served are treated better at other agencies if our staff makes the connections.

Youth involvement is critical to the success and longevity of youth programs. Word of mouth and name recognition spread through youth staff, peer educators, and members of the youth advisory board, can draw more youth in for access to services. Being a program that serves HIV-positive and at-risk youth, we find this one of the best ways to reach out to youth who are not in school. Also, our HIV-positive youth become community resources, links, and support to other HIV-positive young people.

The following is a description of the "who, why, where, when, and how" of street outreach with peer support. Very important to note is that this section was written from the peer educators’ perspective and includes their direct input. GBAPP’s peer educators are young Bridgeport, Connecticut residents aged 15-24 years, who themselves come from disadvantaged environments. Their life experience and age give them the unique ability to become extremely effective educators and prevention specialists.

Since HIV/AIDS prevention is the primary goal of the GBAPP/TOPS project, peer educators start by simply talking with teens on the street, in community centers, on basketball courts, and in housing projects. In building a relationship, mutual respect and trust must first be established before broaching subjects such as sexuality, pregnancy prevention, sexually transmitted diseases, and HIV/AIDS testing and counseling.

Clients are the reason we do what we do. Client enrollment is important in order to be able to spread information about HIV and messages about safe sex in the community. In order to recruit clients into the program, TOPS gives potential clients something interesting to come to, something that will catch their eye. TOPS has found that structured activities are a good way to provide an opportunity to engage potential clients. Basketball games and tournaments, card games, and pool are all ways of reaching clients. These activities provide an informal way to begin talking to clients so that a relationship can be established. Once such a relationship is established, staff begin to speak about HIV and program activities, such as GBAPP/TOPS' weekly rap sessions. These rap sessions allow an open and honest discussion of topics, such as gang and gun violence, HIV, and teen pregnancy. Potential clients are invited to these group sessions.

Client recruitment can be done in several ways. The following section discusses a variety of ways to conduct outreach to youth, as well as ways in which to do it safely and achieve the most impact.

• Notify the community of the type of outreach your agency will be conducting. Express the concern that HIV disease and substance abuse is a community problem.

• Bonding with peers in the community is essential to the recruitment process.

• Gatekeepers (individuals who can help you gain access to the community) are the key players in getting to know who’s who and what’s going on.

• Engage in peer-to-peer casual conversation, such as "Hey man what’s up?" or "What up, Yo!"

• Introduce the HIV prevention kits (condoms, literature, survival kits) to potential clients and outreach agencies.

• Informally invite youth to a rap session conducted for teens, by teens.

• Distribute colorful, eye-catching street flyers that are appealing to young people.

• Hold an event that attracts youth, such as field trips, picnics, basketball tournaments, pool, concerts, etc.

• Conduct outside agency referrals.

• Conduct inter-agency sign-ups.

At the time that activities or rap sessions are going on, each individual is asked to come into the office to sign them up as a formal member of the program. Clients can come and be a part of the group whenever they want. Clients need to be in an office where they feel comfortable.

If the outreach is at a place such as a video entertainment center, permission from the owner to do outreach is required before staff begin to speak to the young people present. TOPS staff begin by talking about the different types of games and entertainment they have available, what school they attend, or if they like sports. Then, very quietly, staff advise them of their purpose for being there and offer them an HIV prevention kit, and encourage them to read the literature. If they reject the offer, staff thank them for their time and move on. As time goes on, staff become a more familiar sight on the premises and build rapport with the young people and invite them to take the prevention kits, read the literature, and attend rap sessions.

Many clients will not be part of a structured activity, so going to the streets is an effective way to find them. There are specific areas that are known hangouts, such as street corners, project areas, crack houses, shooting galleries, and video entertainment centers. These locations exist everywhere and each agency needs to hire people who are accepted in and comfortable and familiar with these surroundings.

The time factor varies and is determined by specific activities at specific times. An example of this would be outreach at a shooting gallery or crack house, which would most likely have more people there during the evening hours, after dark, and early morning hours. Between 4PM and 7PM is generally the ideal time to reach high numbers of people at a video entertainment center. Each agency has to fine-tune these timing strategies to fit their particular situations.

When at places like a crack house, shooting gallery or street corner, TOPS’ approach needs to be tactful because of a great potential for danger. To avoid conflicts, it is important to speak to someone living there, or representing him or herself as being in charge of the premises, to inform them who we are and how we would like to serve the occupants of the house or area. TOPS staff maintain a sincere, compassionate, understanding, cooperative, and knowledgeable attitude about the drugs being used, their effects, and the resources necessary to get clients the help they need.

Gatekeepers are people in the community who are the key players in getting to know what’s going on and who’s who in the area. Developing relationships with gatekeepers is key to being accepted in the neighborhood. Gatekeepers come in many shapes, sizes, and professions. For example, some may be mothers, drug dealers, or community residents.

There are times when staff should not be in a certain place, and if told it is not a good time, we respect that message and leave the area. Certain locations are known for violence and constant police surveillance, so try to be in tune with what is happening. This is a trial and error process as we try to improve our individual level of service and efficiency to troubled populations.

• Peer educators should know that when doing outreach to youth, what the appropriate age group is for their project. When you approach people on the street it is vital to ask them their age before distributing a condom.

• When a peer approaches a person who refuses a condom packet, suggest that they pass it on to a friend.

• Peers should never confront a person who is in the midst of arguing with another person. That can mean danger. When the person cools down, then hand them a condom packet. When doing outreach, stay with the other educators and senior staff members at all times. There is no reason to leave the group. Do not let anyone talk you into a "quick ride" or invite you into his or her home.

• Always have a positive attitude about doing outreach. When someone is having a bad day, you could brighten it by being nice and polite to that person.

• When going into an inner-city environment, or any environment where drug transactions or life-threatening situations are taking place, peer teams should NOT wait around to provide any type of education. Instead they should leave the area and come back another day. For some communities, these types of activities go on 24 hours a day. The GBAPP/TOPS Project peer teams go into areas where there is less traffic and where they are well known. Because they live in these areas, they are viewed in a different light.

• Make sure your attire is presentable since some people look at what you’re wearing. Tight jeans, belly shirts, no shirts or anything sexually suggestive are not appropriate for an outreach environment. If someone you encounter wants your number, politely work around to saying "No."

The do’s and don’ts always depend on where you are performing outreach and the people you are trying to target.

• Do carry identification at all times.

• Do be in contact with the gatekeepers of the community.

• Do maintain a positive relationship with the local police (Bridgeport GBAPP/TOPS suggests doing an in-house training for incoming police recruits).

• Do always listen to your senior outreach leader because communication is key to success and safety.

• Do always be aware of your surroundings because anything can happen when you are working.

• Do notify your senior outreach leader if you become scared of going into a certain area because you feel it is unsafe for the group. Confidence is important in getting out the right message.

• Do always approach the youth with a calm and steady attitude. You don’t want to make that person uncomfortable or edgy.

• Do always go on outreach with sufficient information and outreach material.

• Do suggest that youth speak to the senior outreach staff if you don’t know the answer to a question they ask. Getting out the right information is what it is all about.

• Do dress appropriately.

• Do be creative in how you approach different youth in different areas. Not everyone goes about doing things the same way.

• For peers in recovery, maintain a support system for recovery.

• Do hit the ground immediately when gunfire erupts or find somewhere to hide to protect yourself.

The Don’ts

• Don’t leave sight of senior outreach staff.

• Don’t buy, receive, or do drugs or alcohol while conducting outreach.

• Don’t buy or receive property from anyone on the streets while conducting outreach.

• Don’t loan or give money to anyone while conducting outreach.

• Don’t receive, carry or confiscate weapons during outreach activities.

• Don’t lose your cool and become nervous or violent if a person rejects your information. It is their body and health; you are just trying to help.

• Don’t approach youth with disorderly conduct, it could lead to a misunderstanding.

• Don’t act as an individual when conducting outreach – you are part of a team.

• Don’t wear seductive clothing while performing outreach.

• Don’t use work time to speak to the opposite sex for personal reasons. Confine your interests to the job you’re required to do.

Peers need to have basic HIV/AIDS 101 training courses to be effective on the streets while conducting outreach. After completing the course, peers can correctly answer basic questions about HIV/AIDS raised by the youth they encounter. Knowing and understanding the routes of transmission, the stages and symptoms of the virus, and ways to avoid contracting the virus are building blocks to sending the right message and information to young people on the street.

Peers also need training on barriers and how to overcome them. Developing skills to overcome barriers is key to success in outreach. Examples of barriers are not knowing the language of your target population, not being culturally sensitive, lacking knowledge and respect of territorial boundaries, and making moral judgments about clients’ lifestyles. Clients often use street language and slang routinely, so it is important to know the meanings of the sayings. A particular greeting might be, "Yo, what up?" or "How you be?" Expressing these greetings may create bonding, warmth, acceptance, and access to continued dialogue. In the African-American culture, some people are not always inclined to speak openly about deeply rooted personal issues that are causing problems for them, whether it is their parents, relationships, history of incarceration, or family issues. In the Hispanic culture, sometimes condoms are viewed as a sign of rejection, that something is wrong with the individual so they must use protection. Although it is important to understand such aspects of clients’ lives and try not to move beyond what they are willing to discuss before they are ready or able, it is equally important not to make generalizations or snapshot judgments about people that you encounter on the street based on their race alone or where they live.

Safety issues are important to stress through training. It would be helpful for an agency to think about creating a training video that points out the Do's and Don'ts of street outreach. The peers should be trained to follow their supervisor’s directions at all times when they are out in the community. Specific strategies should be employed to minimize harm and conflict and to maximize acceptance, efficiency, and safety. Clothing, drugs, language skills, stolen property, and firearms are some of the issues to cover during training.

Peers also require training on how to interact and communicate with someone who is dealing with HIV/AIDS and substance abuse. Sensitivity and caring are important topics in this category. Outreach workers should not alienate someone because of a careless, insensitive remark or action. The objective is to promote caring, congenial compassion and a sense that we are there to provide services to meet their needs.

Self-discipline and self-reliance to increase confidence are important lessons to teach peers. Self confidence is greatly important to help peers deal with their own problems and to gain the correct perspective in order to project the appropriate poise and appearance on the street.

In closing, it is important to have some type of therapeutic outlet for peers to help them deal with the troublesome issues in their own lives. Because of their youth and background, issues surrounding school, lack of parental guidance, encounters with the law, relationships, employment, drugs and alcohol, and violence can wreak havoc on their lives and limit their coping skills and effectiveness in helping others. Regularly scheduled groups, meetings, or private one-on-one sessions to discuss these issues are of monumental value in stabilizing peers.

Unquestionably, peer educator outreach is healthy, informative and revitalizing for all parties concerned. Periodically, we have outreach training along with HIV and substance abuse education to keep everyone abreast of all the latest information and techniques. The peer educator concept has been wonderfully enlightening to me as a peer education supervisor and I’m excited about continuing this collaborative effort.

On a typical day of street outreach, prior to going out we count the number of HIV prevention packets we have for distribution, check out attitudes to make certain that everyone is in a good frame of mind, determine which location we are going to, and then depart. Once we reach our destination, we remind each other that if there is any sign of danger or alarm we should look to the supervisor for direction and leave the area as soon as possible by the shortest route available. Also, we tell each other to always be courteous and respectful.

Often, the places we frequent are rundown, destroyed, unclean, drug-infested, and are known for having lots of crime and violence. We see pain and despair etched in the faces of the inhabitants caused by the circumstances that surround them. Some people are carrying firearms, some are selling drugs openly, and in many cases the ingestion of alcohol and drugs are done in plain view. As outreach workers, we need to be aware of what’s going on and adjust our behavior accordingly. We must approach and speak to people in a casual, non-threatening and informal manner. We identify ourselves as GBAPP/TOPS outreach workers, show our HIV prevention packets in open view, and hand them to the people. At that point we might depart from our principal mission and begin talking about anything in general, such as sports, music, or relationships.

The idea is to establish the bonding process before beginning to talk about issues such as STDs, HIV testing, and substance abuse. An outreach worker must be caring and sensitive to the prospective client, otherwise they will be totally ineffective. If someone recognizes that they are insincere, they may damage their chances of connecting with that person.

As we continue talking about things in common, the relationship between the outreach worker and the individual begins to develop, creating a climate to move forward with other issues. This is a gradual and incremental process that ultimately can pave the way for education and services. It is absolutely amazing how a breakthrough can occur when both parties are speaking the same language. We are proud to say that the peer educators and adult staff persons have the "street language" skills to communicate with our clients and produce positive change in the targeted youth population.

Footnotes

6. This section was written and developed by the following Peer Educators at GBAPP/TOPS: Darrin Wilson, Tyinell Serrano, Michael Perez, and Tiffany Johnson. Senior adult staff who contributed were: Garry Geter, Robert Miller, and Sandra Vining-Bethea.

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Section 5: Youth Empowerment Programs: The Health Initiatives for Youth (HIFY) Experience

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