The perspective of peer educators : What are their experiences , feelings , and thoughts ?

Introduction: Although peer education is accepted as one of the most effective methods for sexual and reproductive health education, the feelings, thoughts and self-affection of peer educators are not very well known. Our aim is to investigate what it is like to be a peer educator. Methods: This phenomenological study was conducted in Izmir as a part of “Modern Stork Legends” project supported by the European Union. Two focus group interviews were made with 18 peer educators of the project. Data were analyzed with NVivo 8 BS software. Results: All of the students stated that they participate in the project “to enhance their knowledge” and “to inform their social circle”. They are concerned about the tasks and expectations, and anxious about the subject of counseling. They think that anything related with sexuality is taboo in Turkey and it was also the same for them. They observed that, gender defined roles are reflected on students’ behaviors and attitudes. Their tolerance in understanding of inhibitions and hesitations of their peers formed the basis of their success. They stated that working in this project helped them to overcome their prejudices and contributed their development in many ways. Conclusion: Peer educators internalize substantial amount of knowledge and gain self-confidence and important skills such as communication, problem solving and access to information.


INTRODUCTION
Peer education is a popular concept that implies an approach, a communication channel, a methodology, a philosophy, and a strategy.The term "peer" means fel-low, equal, like, co-equal or match according to the dictionary of synonyms (Oxford Thesaurus).Until recent times the term is used in reference to education and training and is now viewed as an effective strategy for behavioral change [1].In education "peer education" is being described as the improvement of knowledge and skills by means of efficient help and support among the ones who are at the same status [2].Educators can interact with their peers in any environment.Power of this method comes from the reliability and credibility of the educator for the target group.Peer education is accepted as a most effective method for changing the risky behaviors of the target group.Its structure and mechanism are compatible with basic health behavior models [3].Usefulness of peer education is widely accepted and used for individuals from the different ages and backgrounds, and it is shown to be effective in many areas of public health, including nutrition education, family planning, substance use and violence prevention [4][5][6][7].Reproductive health is one of the popular areas in which peer education is used and provides good outcomes.
Family planning, unwanted pregnancies and sexually transmitted diseases, are problems all over the world in a certain degree especially among young people.According to WHO, the number of pregnancies between ages 15 and 19 for every 1000 pregnancies are 117 in African countries, 41 in US, 14 in Canada, and 24 for European countries.Turkey is the tailender of this ranking with 54 pregnancies [8].Although, on average, younger women are more fertile than older women, the basic reason of adolescence pregnancies is underuse of birth control methods [9,10].A study in USA demonstrated that 38.9% of sexually active students had not used a condom during their last sexual intercourse [11] similarly as the study in one of the Turkey's metropolis cities showed that condom usage ratio during first sexual intercourse was 47.4% [12].Although there are some improvements, reproductive health is still an important problem for Turkey as it is in the world [13][14][15].In our country these problems mostly arise from inequalities in socioeconomic status, education and accessibility of health services.Although, in Turkey, socioeconomic status is gradually improving and there are mother and child health and family planning clinics all over the country without any charge, reproductive health indicators among young people still have not reached to the desired level.
As in most of the countries, in Turkey for young people it is often difficult to obtain clear and correct information about issues that concern them such as sex, sexuality, substance use, reproductive health, HIV/AIDS and STIs.Many studies conducted in Turkey showed that, among the adolescents and young people, the knowledge on reproductive health is not sufficient and full of misbeliefs [16][17][18].
In Turkey, sexual education classes are being recently implemented in primary and secondary school curriculums.This education is conducted mostly as a special biology and morality classes, not much about intimacy, feelings, and real life.The results of these classes are not studied yet but effectiveness of formal sexual health education is doubtful even though it is widely implemented [19,20].Sexual health education is not easy particularly in certain cultures.Turkey is one of the countries that have this cultural obstacle.Talking about and discussing sexuality is still a taboo in Turkey.Although the attitudes of Turkish people vary according to their social classes, in this sense, they are generally very traditional.In Turkey, the cult of virginity and the ban on premarital sexual relations make it very difficult for young adults to have open loving relationships with each other.The sexual education of children and adolescents within the family is very poor, and sometimes it is forbidden to talk about sexuality in traditional Turkish families.Talking about sexuality can be possible with one's intimate friends (of the same sex) but only in a great secrecy.Conversations about sexuality take place mostly among same-sex groups and between peers.Taking this fact into consideration, peer training would be one of the most effective methods ever used to train adolescences in sexual and reproductive health [7,[21][22][23].
Our project aimed to improve knowledge and change risky behaviors of adolescents regarding reproductive and sexual health by means of peer education.Results of the project were published in two articles [24,25].
Although results and effectiveness of peer education were widely studied, the effect of this method on peer educators was not investigated.It is important to know the experiences, observations, thoughts, emotions, and motivators of these young consultants during peer education especially about a hard-to-talk subject, such as reproductive health.In our study, we investigated the experiences of university students who received education on reproductive health to educate their peers.

METHOD
A phenomenological study was conducted in Izmir as a part of "Modern Stork Legends" project within the scope of Turkey Reproductive Health Program supported by the European Union.Two focus group interviews were made with 18 participants purposively selected out of 263 peer educators of the project.During the project, peer educators mostly worked together in groups and shared experiences together.They also get together monthly and discussed how things were going.So they were used to talk each other on the topic of project.We decided to run focus groups for data collection even though it is not very common for phenomenological studies.At the last monthly group meeting, PE's are invited to participate in a focus group discussion.26 PE's applied.We aimed to make three focus groups interviews with the participants taking into consideration the variety of their faculties, sex and the number of consulting.If during the interviews the different experiences still are going on sharing, the number of focus group interview will be increased.
After two interviews with PEs, data saturation appeared to have been reached, as no new views came forward from the second interview onward.Hence, third potential focus group interview was not done.
All focus group discussions were recorded audiovisually and then transcribed into text.These texts were coded, categorized and analyzed thematically by two different researchers and then they compared their results and compromised after discussion.For analysis qualitative analysis software (NVivo 8 BS) was used.
Ethical approval was given by the ethics committee of the Dokuz Eylul University Faculty of Medicine.The written informed consents were obtained at the beginning of the interviews.

PROJECT
Training of peer educators took place as an activity of the project.The target group of the project, which aimed to contribute to create a conscious society and a healthy generation via improving the knowledge regarding sexual and reproductive health as well as changing the attitudes and behaviors of adolescents, were young people aged between 16 and 25 years and living in Buca-İzmir region.To achieve this goal, a wide array of activities has been organized.The main activity was peer education.
been faced, how they dealt with these situations and what was left for them at the end.

Being a Peer Educator
Main reasons to participate this project were "to enhance their knowledge" and "to inform their social circle".
"Like many of my friends, my knowledge about it is mostly hearsay from my circle of friends.First, I want to learn and then try to raise awareness by informing my friends." Most of the peer educators are students of social sciences, such as faculty of business administration and faculty of education.They think they can provide leadership about the subject during their future professional carriers.There are also other factors which motivated them to be a peer educators including curiosity about the project, to gain experience in projects, to enrich their CV's, to improve their social relations, to recreate their off-school times, recommendations of their peer educator friends, being interested in subjects related with health, and to get rid of the monotonous life.
Their training for being an educator seems to be an important learning and adaptive process for peer educators.Some of them, who thought that they have sufficient knowledge prior to the project realized that they have lacks of knowledge, so that "they also may need a consultant."Positive approach and support of educators, interactive education methods, group works, and roleplaying sessions which are used during education facilitated their learning and motivated them to a great extent.Some students stated that, after the education, they wanted to travel all around the country "village by village, from Izmir to Igdir" and consult their peers.

Fears and Difficulties
From the beginning of the project, peer educators are concerned about the tasks they need to achieve and expectations from them.
"... especially, in the beginning, we experience a lot of hesitation while consulting, educating our peers.This happened to me too.I was wondering what people think about me, will they ask questions or take me seriously?One of my friends asked me if I was a pervert (laughs…) I hardly explained the situation.So it was not easy for any of us.Especially giving education to the people we did not know." "We have many fears during education.We will be peer educators and try to inform our peers.Will they listen to us?Will they pay attention to us?But now I know that peer education is the correct approach… I mean, for reproductive health." According to peer educators, although young people talk about sexuality with their close circle of friends, these conversations generally are fragmented and remain very superficial.This leads to the spreading of inaccurate information and wrong beliefs.Peer educators stated that the situation also was the same for themselves.
"First of all, I think, sex is taboo in our society, and we can't easily talk about it." "I tried to overcome my own taboos first and then my environments' as much as I can." "We could not ask about these issues to our elders.We would be ashamed.Although we have counseling units in our school or health center, we generally hesitated to take our elders' advice about these issues." Peer educators stated that, more or less, same reactions could be expressed anywhere regarding sexual issues.
"If this questionnaire was implemented in Belgium, they may have been confronting similar problems.May be not as much as we did.But I believe that they have similar problems." Peer educators stated that participation and answers of their peers to questionnaires investigating sexual attitude and knowledge are greatly determined by the fear that someone may recognize them and read their answers.This mistrust restricted peer educators in many aspects.Young people did not trust peer educators in the beginning.Although peer educators overcame this mistrust with their efforts, this time, students hesitated to apply to health centers they were directed.Peer educators observed that when students seek help, they preferred to express their problems as if it belongs to someone else.First year students, especially the ones from rural areas, showed more hesitation and mistrust.
"They were anxious about being recognized when we recommend them to apply to the student health center.When we said that they won't have to give their names or ID's, they relieved.After you gain trust, you can solve many problems.But it takes time." "… and then students began to consult with me.In the beginning, they said that one of their friends have that or this problem… and then, they were courageous enough to say that: 'I have this problem'." Peer educators observed that gender-defined roles are reflected on students' behaviors and attitudes.For example, some female students were thinking that they do not have to hurry to learn anything because they will not have any sexual intercourse before marriage, and when the time comes, they will only start to learn when they are getting married.
"They said that: 'In any case before the wedding, my mother, my sister, or someone else will come and tell me what I should do.You know… this traditional 'wedding night' thing.They think that they won't need it until that time." For male students, major obstacle was the thought of they do not need to learn anything because they know everything.
Sexual discrimination directly affected the work of peer educators.Training period became an opportunity to evaluate their own attitudes on this issue, and later on in their practice, they have a chance to observe this discrimination more closely.Even those who believe that sexual issues should be discussed openly realized that they may express discriminative attitudes.
"First of all, we observed that a young woman student did not want to take advice from a male student.This was a real taboo." "It is very strange for many of our friends to see a female student who took out a condom from her purse… You couldn't explain it.They were weird out." "One of our lecturers proposed that female students will consult the female lecturer, and male students will ask their questions to the male lecturer.I think this was sex discrimination.This was kind of strange." Sometimes, peer educators come across with very sharp reactions.They could manage these reactions more easily in one-to-one sessions.But in groups, these reactions were difficult to manage.In large groups, there were various reactions.
"When we were implementing the questionnaire, there were more than 70 students, some, may be five, of them left out by throwing the questionnaire saying that 'What is this thing?Who prepare these shameful questions?'" "We were trying to implement the questionnaire in the faculty of education.I think it was the department of culture of religion and moral values.The whole class refused to answer the questionnaire." "Especially in faculty of education, there were many weird reactions.Some people said that, a 2-month-old baby was raped a month ago because of the people like us." Peer educators managed to talk easily and openly about sexual issues as they gain experience.In the beginning, university students found this manner odd and perceived it as an invasion of their private lives.Some of them showed their reactions by taunting.Sometimes, the reactions showed themselves as insensitivity and ignorance.These activities were sometimes perceived as an excuse for sneaking out of classes.

Overcoming Obstacles
Peer educators emphasized that the university is one of the stakeholders of the project so that they can overcome the feeling of shame and hesitation of giving education on sexual issues.At first, they talk about the more general and easy-to-talk subjects, such as the project in general and certain diseases, and then, they proceed to the more hard-to-talk subjects about reproductive health.
Training of educators mostly focused on how to con-sult those who need counseling.Yet, in practice, one of the most important difficulties for peer educators was to "find out" those who need counseling."We've made role-playings during trainings.A person came to us, and we tried to help him/her.We thought that it would be like that.People will come to us, and we will help them.But it was not the case.We forced our peers to come to us and take counseling.This caused a great difficulty." Peer educators have tried many ways to reach out to students.Most groups started with a small circle of friends, and then, these circles enlarged.
"We just let a small drop, which is expanding and widening in the form of waves.People who consult us will tell their friends, and they will tell their friends also.This will enlarge the circle… wave effect." "This is just like a new shop offering a different, novel service.People are passing by and hesitate to go inside.Once you step inside, it is easier to go inside again." "We tried to say that these are natural things.It could have happened to everyone.I think, in that way, we could raise a confidence." "Some of the students did not want to answer the questionnaire.I said "You know."I know that if I forced them to answer, the reaction will be much stronger.But I felt that these students at least read and examine the questionnaire although they did not answer it.This may be a bad thing for our research, but I think, in terms of my goals, this is something.A question mark, an awareness, was raised.They thought that such issues also can be investigated.If you can raise a conflict within oneself, this can raise an awareness." For drawing attention of these groups, they woke up perturbation with the possible results of sexually transmitted diseases, created a competitive environment by betting on frequently misunderstood issues, created mettle, and aggravated the discussions by catching up the false information of the students.
Sometimes, they draw the attention of small groups by talking about reproductive health casually, and then introduced themselves and started a debate on reproductive health issues.They also made use of social activities to bring up the subject; they did not push the limits of the students.Sometimes, they only gave brochures regarding actual and more acceptable subjects, such as HIV or Hepatitis B, and they observed that these students come by themselves later.Students owned their problems with time, which they once brought as belonging to someone else.Especially in groups, as many subjects were passed over lightly by jokes and laughs, peer educators stated that many students called them later and asked questions and advices.
Peer educators gained enough experience in time so that they can use different approaches to different people automatically.Peer educators, students, and even parents use humor to normalize the taboo subject, such as sexuality.
"Usually in ages of 17 -19, people are more prone to make fun out of it.We asked how many times they have had intercourse.Someone wrote 55 (laughs).For example, they asked the same question to me." "No, I think people overcome their shameful feelings with humor." One of the important obstacles of peer educators was the anxiety of their parents' reactions.
"When I came to the first training, it was Saturday; my parents asked me where do I go?I said 'I am going to stork project.'They asked "What is this project?"I could not say that this is about reproductive health." "We are from Izmir… we have very good communica-tion… but my mother was reactive at first, my father asked 'What kind of things you talked about in the project.'I explained the project.I said that we will become peer educators.Then, with time, my mother got used to the idea.Sometimes she even came to me and asked about some things she discussed with our neighbors (laughs…)" "We were searching the peer educator candidates.I telephoned one of our friends' house and said 'I am calling from reproductive health project' she said 'No… I did not apply.'Then, five minutes later, she called and said 'I am sorry I could not tell my family.But I want to participate so much when and where is the training?'"

Gains
Peer educators stated that working in this project contributed their own development and changed them in many ways.Various experiences contribute their development by breaking down their own prejudices.
"He said that he is gay, even bisexual.I froze… In our training, we talked about it.There was this character called Cemil (laughs…) Is there someone like this in real life?We always thought that these people, like their own sex, should behave differently.But he was not like this.When he began to ask questions, I thought that, first of all, I have to talk very carefully.This is a very important moment.(laughs…) He said that it is not easy for himself.He talked about his mood.This was an amazing and surprising experience for me.Then, we became friends.A sexual preference of people is not so important.I am so happy to firstly realize this myself and then share with my friends." Another contribution of peer education is the experience they gained in social relations and communication.This enabled them to expand their environment and helped them to establish new friendships.Working on a health-related project made positive changes in health behaviors of peer educators.Their fear of doctors diminished, and they felt more responsible for their own health.
"Like I said, I fear hospitals.I was an asthma patient and treated for ten years in Dokuz Eylul University.I was trying to answer my health-related questions via internet.I got rid of this fear." "After the project, I was treated for cysts.I postponed looking into my health problems many times.The project raised my awareness.After the project, I went to the doctor." They did not limit their counseling responsibilities with the project.After the project, they continued their counseling with everyone they can reach.They stated that the education given to young people and children would be given to the families of the future.They stressed the change that would create in the community.
"In fact, first of all, education should be given to the families.In the first place, a child is educated by his/her family.This training has been given to the parents of the future.The impact of this education will reflect to their children." They started to have an idea about the power of nongovernment activities and tasted the satisfaction of working as a volunteer; this opened new horizons for themselves.They experienced the role of an individual and NGOs in changing the society and began to feel responsibility on this issue.
"People generally don't think that an individual could do or change something.Before the project, we thought that way.As a citizen, you go and vote for the elections.But we clearly realized that, as civilians, we have power and some other ways to change the society." "It is very important to gain awareness of volunteerism.This is not just for this project.It feels very good to work without expecting anything."

DISCUSSION
Although the purpose of this study is to explore experiences and feelings of peer educators, it was not easy to investigate these detached from the topic of education.But since peer education is mostly used and found to be useful for the subjects that cannot be easily taught by teachers, maybe it is better to find out PEs thoughts in the context of their teaching subject.
In many studies, superiority of peer education to classical education has been shown [4,26,27], but there are very limited research available on the experiences of peer educators and their preferability [28][29][30].

Training of Peer Educators
PE's worked in our project stated that they learned a lot and benefited from the training of trainers.Short-and long-term results of this training were shown with another study [25].Although the training especially deepened their knowledge on reproductive health, changed their misconceptions and provided them new information, it did not help them to stop worrying about how to get use to the idea of training their "peers".Moreover, they were not sure of themselves in educating their peers about "what they need" and to give this education "when it is needed" in a learner-centered manner.They thought that their peers would not listen to them, would not take them seriously, and would not believe them.Furthermore, they felt hesitations about difficulties of giving education to the people they do not know.There were very few PE's that left the project after the training the trainers course or after a few attempts of counseling.This study did not cover those PE's which may be one of the weaknesses of the study.Although they justified their leave as lack of time to executives of the project, still their thoughts and feelings may add more to the knowledge on that issue.

The Subject of Peer Education
The subject of counseling, in terms of reproductive health, increased their anxiety especially at the beginning of the project.Communities, in which sexuality is a taboo, develop coherent behavior patterns.Extramarital sexual relations or multiple sexual partners are strongly forbidden for women.In contrast for men, many sexual acts are not prohibited and sometimes encouraged by society.At a certain age, a man should have sexual experience.However, when it comes to a woman, regardless of her age, she should not experience any sexual act before marriage.Both sexes experience trouble in their sexual lives under this paradoxical pressure, which may lead to early marriages, forced sexual intercourses, unwanted adolescent pregnancies, and abortions or curettages.Peer educators think that sexuality is one of the taboos in Turkey, and this came across them as a major obstacle.They expressed their embarrassments and fear from the negative thoughts about them.That made difficult for peer educators giving education especially to opposite sex.But later they felt better and maybe become keen on this.This may be due to recognizing their help to others, positive reactions of their friends and not perceived as immoral person by talking on sexuality.The sharpest reactions have occurred in crowded environments where students do not feel safe and possibly be criticized by others.

Reactions
Although norms and taboos are not embraced by young people, they lead them to live their sexual lives under great secrecy.Young people are very hesitant in talking about sexual issues, and they can express their problems only when they feel complete trust.In our study PE's have been able to establish this trustful relationship with their peers.Positive reactions are seemed to be provided especially by repetitive interviews which occurred in the place and time required by the counselee.
Their work is relieved by the support of official authorities, teachers, opinion leaders but negative approaches impair their motivation and confidence.In fact at the beginning of the project PE's provided confidence and legality as the university was the proprietor of these activities.They stated that teachers who help them made their tasks easier.Most importantly defining themselves as a group encouraged them.In a short period of time they were perceived as a group and began to be called with the name "Storks" by their peers.As the project progress, students like who were calling them as "stork" by inspiring from the name of the project, asking questions or adressing their friends with problems to them motivated PEs and also showed establishment of community involvement and ownership which is important for the continuity and sustainability of a peer education program [1].

Gains of Peer Educators
Peer educators have many gains besides the increase in their knowledge.As educators, PEs use their creativity and force themselves to find their own ways to distinguish who needs education, to start a communication and to draw attention of the people they do not know.Their tolerance with their understanding of inhibitions and hesitations of their peers form the basis of their success.Peer educators' good understanding of the norms and culture of the society to which they belong enables them to understand their target population very well.
Differently from other learning/teaching experiences, being a peer educator not only results in gaining experience as an educator but also offer an insight into one's own limits, taboos as well as ways of coping with these limits and taboos.This process also leads to behavioral and attitudinal change in PE's.These aspects distinguish peer education form other educational experiences.During this project PE's became more open-minded regarding homosexuality and searching medical help for sexual problems.They learned to adopt an unprejudiced and non-judgmental approach in many sexual issues.Providing education to their peers in sexual and reproductive health is a behavioral change itself.Although the peer educator is the best person to disseminate new information and knowledge to the group members s/he can also become a role model to others by "practicing what s/he preaches".A peer educator not only tells the peers about a desired risk reduction practice but also models it.S/he demonstrates behavior that can influence the community norms.The change in the knowledge, behavior and attitude of peer educators have been shown in ripples study [28].In our study although we don't know how reproductive health behavior of peer educators will be effected, just being a peer educator on a hot topic as reproductive and sexual health should be considered as shaking community norms.
PE's also found a chance to develop their skills in a broad spectrum such as communication, working in a project, human relationships, apart from the educational process and its subject.

CONCLUSIONS
Our results reveal some important aspects regarding the perspective of peer educators.Firstly, our study shows that PEs experiences and observes the usefulness and effectiveness of peer education.According to experiences of PEs, young people are prone to learn from their peers and this helps them to change their behavior on reproductive health and health care seeking behavior.Other results are mostly about peer educators themselves.There are many benefits for PE's themselves."Learning by teaching" is the best learning method with which educators internalize substantial amount of knowledge on the topic that they teach.Especially, being a peer educator on a subject like sexual health leads to changes of their own ideas, attitudes and behaviors.On the other hand, it also helps them to gain self-confidence and important skills, such as communication, problem solving, and access to information.Working in this project creates awareness about presence of different ways to intervene society.
Our study also shows that peer education is self-devoted way of teaching and very much dependent on the educator's motivation and creativity.Being a source of information and education may go beyond the limits of a project for the PEs.
It is important for PEs to feel safe so that they may need a support system which covers both peer educators and peers.
This study does not include the feelings, thoughts, fears of the PEs who leave the study and the long term effects of being a peer education if there is any.So, considering the role of educators on the success of certain education methods, further studies would be useful on the experiences of PEs.