An Introduction to Adolescent Health Issues

INTRODUCTION TO HEALTH ISSUES IN PERU

Peru has been recognized for making strides to curb maternal and infant mortality, and increase life expectancy.  Peru’s economy has been growing at an impressive rate and generous funds have been allocated to improve health care delivery and organize interventions to address urgent issues at a local level.  Peru’s national Ministry of Health recognizes its critical role in increasing access to health care services and addressing the health issues plaguing children which prevent them from becoming productive adults.

The Ministry of Health has outlined a plan of action to address a range of health issues across several target populations, and has partnered with Peace Corps Peru to carry out critical interventions to ensure adequate development of children under three years of age and adolescents aged 12-17.  Adolescents are generally lacking in reproductive health education and access to resources for the prevention of unintented pregnancy, HIV and sexually transmitted infections.  The teen pregnancy rate nationally hovers around 13% (for girls aged 15-19) but is slowly creeping upwards.  Locally, in the Piura region, statistics from 2012 show the rate has risen above 16%, a dramatic increase from 9% in 2000.

 COMMUNITY DIAGNOSTIC

The district of El Tallán is comprised of four neighborhoods, with about 2,500 residents (not including the annexes).  The main neighborhood of Sinchao Grande hosts the municipal building, the health center and the only high school serving the district.  Among the 2,000 residents of the community of Sinchao Grande, just over 600 are adolescents.  Students attend high school for five years and graduate high school around age 16.

To determine the most pressing social issues impacting adolescents in the community of Sinchao Grande, I interviewed two community leaders who operate a church-affiliated youth group for teens, plus several parents and teachers.  In addition, I surveyed a group of high school students on their knowledge of pregnancy prevention and transmission of HIV and sexually transmitted infections (STIs).  Lastly, I conducted a SWOT analysis to record perceptions of the resources available to youth in the community.

According to statistics provided by the Ministry of Health RED Bajo Piura, 21 teenagers visited the El Tallan health center in 2012.  One-third of these patients (7) sought attention for an existing pregnancy, and six received services to treat a sexually transmitted infection. Only three teenagers sought family planning services last year at the health center.

The statistics show that among the 612 adolescents between the ages of 12 and 17 living in the district of El Tallán, the prevalence of sexually-transmitted infections (STIs, including HIV) and teen pregnancy rates are remarkably low.  STI rates are at 0.98 % and the pregnancy rate for teens is at 1.14%.  If the data correctly reflect the true incidence of adolescent pregnancies in the district, the rate for the district is 14 times lower than for the region as a whole, which is unlikely given the lack of adequate pregnancy prevention and STI-focused public health interventions in the district.

We should bear in mind that these statistics represent the number of cases reported to the local health facility.  There is a good possibility that more cases of teen pregnancy and sexually transmitted infections existed among adolescents in El Tallan in 2012 which were not reported to authorities.  An unfortunate aspect of the health facility is its visibility and the lack of privacy afforded to patients seeking services, which was reported to me by community members and noted through casual observation.  Even if a woman or girl sought reproductive health services under the guise of a different (less controversial) issue, there would be no assurance to her that the health workers would maintain her confidentiality, given the existence of a legal obligation to obtain consent from her parents.

Adolescents who participated in the Community Diagnostic survey indicated no current or past sexual activity, even though one of the participants admitted to being in a dating relationship.  Less than half of the participants indicated having received instruction on sexual and reproductive health.  Among those who had received instruction in school, several mentioned that they felt that the instruction was insufficient.  Only one had received instruction on a sexual health topic at the health facility.

Key points from the Community Diagnosis and SWOT Analysis:

• 30% of adolescents could not name one method to prevent unwanted pregnancy and sexually transmitted infections.

• Only one person was able to describe the steps to use a condom correctly.

• Less than half of the participants could name at least one method of preventing transmission of HIV.

• Adolescents mentioned a lack of opportunities to develop leadership skills and job skills.

• Adolescents expressed the desire to improve communication with parents.

With respect to adolescents, there is clearly a lack of understanding of the methods to protect against unwanted pregnancy and sexually transmitted infections. Given the reportedly low teen pregnancy rate, it will be important to reinforce healthy behaviors among this generation of young adults who are serving (willingly or not) as role models to influence the next generation of youth.

Furthermore, the lack of opportunities to acquire leadership skills and job training may leave youth unprepared for the demands of a career, or full contribution to the community. These opportunities can give legitimacy to the decisions that teens make with respect to the delay of initiation of sexual activity, as placing a value on activities that expand the possibilities for the future can reduce the desire to engage in risky activities that could derail future plans.

The ideal program will incorporate life planning as one component in a comprehensive reproductive and sexual health curriculum with a peer education component.  Please continue reading to find out how we addressed these issues by utilizing best practices in Peru and adapting them for the particular needs of the community.

Please continue reading about the Pasos Adelante project to improve the health of adolescents.

PASOS ADELANTE - A Project for Adolescent Reproductive and Sexual Health

Pasos Adelante (or Steps Forward in English) is a program that was developed by Peace Corps Peru in coordination with Peru’s national Ministry of Health to help youth develop essential life skills to avoid unwanted pregnancies and make healthy life decisions.

The program consists of fourteen lessons on a variety of topics:

1.       SELF-ESTEEM and SELF-CONFIDENCE

2.       POSITIVE VALUES

3.       MANAGING STRESS

4.       ALCOHOL AND DRUGS

5.       DECISION-MAKING

6.       DOMESTIC VIOLENCE

7.       PLANNING FOR MY FUTURE

8.       ADOLESCENCE AND SEXUALITY

9.       GENDER AND SEXUALITY

10.   STIs (Sexually Transmitted Infections)

11.   HIV & AIDS

12.   PREGNANCY

13.   ABSTINENCE & SEEKING AN IDEAL PARTNER

14.   CONDOMS AND MODERN BIRTH CONTROL METHODS

The program is intended to reduce the number of sexually transmitted infections, prevent early pregnancy, prepare adolescents to make responsible decisions about their sexuality, and give them the tools to become leaders in their communities.

The Pasos Adelante program can be adapted to provide opportunities for students to train other students in the aforementioned topics as peer educators.  Research shows that youth more readily trust and retain the information provided by other youth more than information provided by adults.  Multiple research studies have concluded that peer education program are more effective in improving knowledge among adolescents and is recommended as a strategy to reduce the prevalence of pregnancy and STIs among youth.

The Pasos Adelante program was designed with the concept that skills and learned behaviors between peers can be very effective in promoting healthy decision-making among young people.  Expected outcomes of the program are that:

• Fewer young people will become infected with an STI, HIV, or AIDS, and fewer young people will become pregnant during adolescence;

• Young people will take safe and responsible decisions about the best time to start having sex and how best to protect them when they have them; and 

• Young people will develop tools and characteristics to become leaders in their communities, including high self-esteem, assertive communication and healthy decision-making skills.

THE PLAN

My interactions with youth during the diagnostic phase and afterward led me to believe that the high level of timidness around and ignorance of sexual health issues demonstrated by teens in the community may serve as a challenge to finding an adequate number of youth interested in becoming peer educators.  Initially, I utilized the resources and expertise of the health center staff to teach the Pasos Adelante lessons to high school students as a way to provide opportunities for youth to reach a comfort level with the material and to coach the health center staff in using non-formal teaching techniques.

I coached the health center staff, who prepared to teach six of the Pasos Adelante lessons to students in the 3^rd and 4^th year classes.  In the following school year, we planned to select ten of the best 4^th and 5^th year students to develop their leadership and presentation skills, who in turn, would replicate the Pasos Adelante lessons to a new group of 3^rd and 4^th year students.  This process could be repeated each year, and it allowed for students to participate in the lessons two years in a row, which contributed to memory retention and increased comfort level with the material.

During the 2013 school year, the health center staff taught six of the Pasos Adelante lessons to 40 students in 3^rd year and 13 students in the 4^th year classes in the following topics: Decision-Making, Seeking My Ideal Partner, Sexuality and Adolescence, Condoms and Modern Methods of Family Planning, Sexually Transmitted Infections, Alcohol and Drugs, and Planning for My Future.

We observed the interest and leadership skills of the students during the lessons, which allowed us to select the best students to serve as peer educators during the following school year, as these students entered the 4^th and 5^th year of high school.  During the 2014 school year, students were invited to apply to become peer educators and teach lessons to other students.

Among the 14 students who applied, five 4^th year students and five 5^th year students were selected to participate in a training event to develop their leadership abilities.  Eight students attended the training to become peer educators (four 4^th year students and four 5^th year students).  The training consisted of lessons in developing personal values, self-esteem, leadership skills, and managing stress presented by health center staff and by a recommended Psychologist.  Following the training, I worked closely with the students in one-on-one or small group sessions to develop their presentation skills and ability to use non-formal teaching techniques.

The four 4^th year students were paired up and assigned a topic to teach alongside a health center staff member.  The responsibilities were divided such that the health center staff served as the experts on the topics and each presented factual information while the students directed the activities to practice the newly acquired knowledge and behaviors.  The 5^th year students declined to participate further after attending the peer educator training due to school workloads and responsibilities at home.

The students were paired up and trained to use non-formal education techniques to present practice activities for experiential learning.  The presentation topics were Domestic Violence, Condoms and Modern Birth Control Methods, HIV & AIDS, and Abstinence & Seeking an Ideal Partner, which were presented to 53 students in the 3rd and 4th years of high school.

Parents School

In order to improve communication between parents and their children and reinforce the information presented in Pasos Adelante, we developed a Parents School event. It was intended to provide parents with positive communication techniques that would allow them to engage with their children about sensitive issues, such as sexuality and reproductive health, and planning for the future.

Parents School was focused on building trust and respect between parents and children.  After completing the course, parents were able to demonstrate a better knowledge and behaviors for use in supporting the healthy development of adolescents.

HIV Awareness

Once a teen decides to initiate sexual activity, it is essential that s/he has the knowledge and access to the use of contraception and protection against sexually transmitted infections and HIV. A key component in the effort to protect teens from unwanted pregnancy and infection is correct and consistent condom use.

The statistics of the health facility reflect that a very small number of adolescents have sought the services of family planning, probably because of the embarrassment and the risk of gossip.  In order to increase the likelihood that adolescents obtain and use condoms, we launched an HIV awareness event that included a condom demonstration.

The event was designed to normalize the use of condoms and remove at least some shame in obtaining condoms and initiating conversations with partners.  The event included information on the difference between HIV and AIDS, how infection occurs and testing methods, presented by a nurse technician and through educational videos provided by the Ministry of Health.  The demonstrations covered myths about HIV transmission, and challenged teams of students to describe the steps to use a condom correctly in an effort to win prizes.

Given that the Pasos Adelante program initially reached only 53 of the total 612 adolescents in four main villages in the district of El Tallán, we hoped this event could reach a wider audience and bring these messages of health and safety to more adolescents.  It was held after school hours to allow for participation among teens that attend other schools outside the district, or attend the local high school but are not enrolled in the 3^rd and 4^th year classes.

Please continue reading to discover the reality and the challenges of the project.

PASOS ADELANTE - Reality and the Challenges

THE REALITY

During the 2013 school year we taught six of the Pasos Adelante lessons during the tutorial period (study hall) to 40 third-year and 13 fourth-year high school students once per week for 6 weeks. 

A special guest expert (personnel from the health center) was invited during each session to present on the topic of the week. 

DATE (2013)	TOPIC	AUDIENCE	PRESENTERS
October 29	Healthy Decision-making Seeking My Ideal Partner	3RD year students  4TH year students	Karen Crow, Peace Corps volunteer Elena Iman, Nurse Technician
November 5	Adolescent Sexuality	3RD year students 4TH year students	Dr. Mayulli Rubio Ancajima Karen Crow, Peace Corps volunteer Elena Iman, Nurse Technician
November 12	Family Planning Methods	3RD year students 4TH year students	Cristina Gutierrez, Nurse Technician Santos Albines, Nurse Technician Elena Iman, Nurse Technician
November 19	Sexually Transmitted Infections	3RD year students 4TH year students	Norma Fiestas, Nurse Technician Karen Crow, Peace Corps volunteer Elena Iman, Nurse Technician
November 26	Drugs and Alcohol	3RD year students 4TH year students	Dagoberto Martinez Navarro, Nurse Technician Karen Crow, Peace Corps volunteer
December 3	Planning for My Future	3RD year students 4TH year students	Elena Iman, Nurse Technician Stefani Cano Vasquez, Lead Nurse

CHALLENGES IN 2013

1.       The lessons were taught during the once-weekly tutorial period, which were originally 50 minutes in length.  As the weeks passed, the teachers insisted on utilizing more and more of the tutorial period time to review material for upcoming exams.  Eventually, our time was reduced to 30 minutes per lesson.  

            a.       The lessons are intended to be carried out over a longer time period (1.5 hours) than we were allotted as part of the tutorial period (35-45 minutes).

            b.      Because of the shortened time, we were forced to cut out most of the activities that would have allowed students to practice and apply the newly learned material.

2.       The quantity of students in each lesson was not easily manageable.  There were 13 students in 4^th grade and 41 students in 3^rd grade, giving us 54 students in the combined class.  It was challenging to maintain their attention, keep them on task and limit the distractions and rowdiness.

3.       The Director of the school was suddenly relieved of his position in September of 2013, just as the school was returning from winter break.  After two months passed, the newly appointed temporary Director gave us permission to teach lessons, but the delay due to the circumstances cut short our teaching schedule.  We had only 6 weeks before the end of the school year, allowing us to teach only 6 once-weekly lessons.

4.       We worked as best we could within the confines of the educational system, knowing that taking the lessons outside of the high school walls would have severely reduced participation.  Most teens  are overburderned with responsibilities in the home and spend their afternoon hours studying, working on school projects, working on the family farm, taking care of farm animals, doing household chores, attending church services and/or participating in family activities.  It is rare for a teenager in my community to have free time, especially time to attend additional lessons outside of school.

5.       The copy machine in the Municipality often broke down and was left unrepaired for long periods of time, requiring me to utilize more grant funds for making copies than was originally intended.  Also, the workplan changed several times throughout the lifespan of the project, and a new Pasos Adelante manual was issued (the second edition), requiring additional unanticipated copy and printing needs.

RESULTS OF ACTIVITIES IN 2013

Results of the final survey administered after the end of the last educational session in 2013:

1.       Number of youth trained in sexual reproductive health and modern birth control methods in a small group setting, who can:

a.       identify at least 2 ways to prevent unwanted pregnancy and the transmission of sexually transmitted infections, and

b.      demonstrate the steps to correctly use a condom.

Males aged 10-14	7
Males aged 15-17	14
Females aged 10-14	11
Females aged 15-17	18
TOTAL	50

2.       Number of youth aged 15-24 who reported engaging in sexual activity in the past 3 months and who used a condom at last sex:

Males aged 15-17	1
Females aged 15-17	1
TOTAL	2

SCHOOL YEAR 2014

In June of 2014 my main counterpart and I developed a launch plan and presented it the new, permanent Director of the high school who readily accepted.  We created application materials and invited students in the 4th and 5th year classes to apply to become a peer educator/youth health promoter for the Pasos Adelante program.

Fourteen students applied to become peer educators.  Ten were accepted and invited to attend a training session during the school break in July.  I coordinated with a local Psychologist, along with the Obstetrician and Doctor from the health center to provide the selected youth with leadership-focused educational sessions on self-esteem, self-confidence, choosing positive values, and managing stress.  Among the 10 youth selected to attend the leadership training, 8 completed the four training sessions; four girls from 4^th year, and four girls from 5th year of high school.

Following the leadership training, the eight students were placed in pairs and each pair selected one lesson topic from the list of Pasos Adelante lessons that they intended to present to their peers in during the weekly tutorial periods in September.  During each lesson, a health professional from the community was invited to present an informative speech on the topic, and the two youth peer educators directed activities to practice and reinforce the information provided.

2014 Schedule of Educational Session in El Tallán  High School:

DATE (2014)	TOPIC	AUDIENCE	PRESENTERS
September 17	Pregnancy Prevention	3rd year students	Lic. Digna Nunura Calderon Karen Crow
September 18	Alcohol and Drugs, Decision-making	4th year students	Santos Albines Karen Crow
September 25	Planning for My Future	4th year students	Cristina Gutierrez Karen Crow
October 7	My Ideal Partner Abstinence	1st year students	Elena Iman Quintana Karen Crow
October 9	HIV and AIDS	4th year students	Lic. Digna Nunura Calderon Karen Crow
October 15	Condoms and Methods of Birth Control	3rd year students	Lic. Digna Nunura Calderon Karen Crow
October 22	HIV and AIDS	3rd year students	Lic. Digna Nunura Calderon Karen Crow
October 30	Condoms and Methods of Birth Control	4th year students	Lic. Digna Nunura Calderon Karen Crow

CHALLENGES IN 2014

1.       After summer vacation ended and the 2014 school year began in March, our challenges mounted as the temporary Director was replaced by a permanent Director one month after the start of the new school year.  As the new Director juggled his new responsibilities amid the chaos of launching a new school year, weeks turned into months of waiting to launch the program, and motivation to move forward waned among the health center staff and the focus turned to more immediate, pressing needs.

2.       There was a lack of interest among male students who were too shy to serve as peer educators, had no interest in the lessons, or did want to serve in a leadership role.  Among applicants, two males were accepted but did not participate in training.

3.       The four 5th year students who had been trained to serve as peer educators were overwhelmed with schoolwork and preparing for the next steps after high school, and were therefore unable to participate.  Among the eight students who had received training to become peer educators, only four girls in the 4^th year of high school remained interested and willing to participate.

4.       It was difficult finding time outside of school for the pairs to prepare and practice the lessons, which restricted their ability to learn and digest the material in a manner sufficient to present with confidence on the topic.  Given the circumstances, I decided to continue the practice of inviting special guest experts from the health center to provide the factual information during each lesson, and allow the two peer educators to direct the activities that provided opportunities for students to practice and apply the information learned.  This structure allowed each party to utilize their strengths -- health professionals presenting factual information, and students engaging other students in activities – while sharing leadership responsibilities.

5.       After teaching a lesson on abstinence to 1^st year high school students, a parent complained that the lesson was intended to incentivize the children to engage in sexual activities.  As a result of this complaint, the Director decided that lessons can only be taught to 3^rd, 4^th and 5^th year students, which cut us off from reaching the 1^st and 2^nd year students.  This required that we reach these students outside of class.

6.       Due to the complaint mentioned above, the condom demonstration that was originally planned to take place in the high school was re-scheduled to occur during after school hours, running the risk of losing attendance.

7.       School was closed without prior notice for the elections, religious holidays and teacher in-service trainings, which required us to cancel sessions that we were not able to reschedule prior to the end of the project.

PARENTS SCHOOL

Mothers and fathers of the 53 students in the 3^rd and 4^th year classes of high school were invited to attend an educational session to develop tools and skills needed to improve communication between parents and their teenagers. The educational session was intended to help parents improve communication with their teenagers and reinforce the information presented in the Pasos Adelante lessons.  It offered an opportunity for mothers and fathers to gain important communication skills and learn to use techniques to discuss sensitive issues such as family planning, critical for building trust, respect and communication between parents and children. Each participant was asked to apply the newly acquired behaviors and report the effective use of communication skills and better communication with their teenagers.

The session was taught by a local Psychologist who had been recommended by a nurse working in the community health center.  I spoke with the Psychologist and informed her that her presentation should cover the following topics:

1.       Understanding communication styles

2.       Positive communication techniques

3.       Demonstrating active listening

4.       Speaking clearly, precisely and assertively

5.       Barriers to good interpersonal communication

Twelve parents attended the session and were very interested in improving their parenting skills and improving communication with their children.

CHALLENGES OF PARENTS SCHOOL

Unfortunately, the session did proceed in the manner in which we had planned.  The Psychologist did not prepare a presentation that followed the topics we had agreed upon. 

Instead, the main points of the session were:

1.       Don’t beat your children

2.       Be a good role model to your children

3.       Speak with respect to your children

While these are valuable points in general, the information covered in the session did not follow the list of topics (above) that I had provided to the presenter.  Clearly lacking were simple, easy-to-remember steps for working through difficult conversations that parents could have taken home and put into practice immediately.  This created a problem for tracking progress of the goal to improve communication between parents and children.  Given that the parents had not learned nor practiced new communication techniques during the educational session, it was impossible to document use of those techniques. 

It may not have been a total failure, however, as the attendees appeared to enjoy the session and generally seemed appreciative of the opportunity to participate.  My hope is that it sparked some desire to make an effort to change the way parents interact with their children, and possibly some will discover on their own ways to improve communication.

Ideally, this would be the first session in a series, with the second and third sessions including concrete steps and detailed action items for attendees.   I envisioned the second session involving parents learning and practicing steps to improving listening and speaking skills, and breaking down barriers to good communication.  After the second session, parents would be expected to utilize their newly acquired skills and report on the results during the third session.  The third session would involve both parents and teens, who will together learn and practice enhanced communication techniques.  This session would provide a safe space for the teens to discuss with their parents topics learned in the Pasos Adelante lessons, which could include sexuality and reproductive health issues, as well as planning for their future.

HIV AWARENESS EVENT

The Pasos Adelante program initially reached a small number (53) of the total 612 adolescents in four main villages in the district of El Tallán with information on avoiding HIV transmission and unintended pregnancy.  A broader outreach effort was needed to reach more youth with critical messages to promote healthy decision-making in a sexual health context.  

A community-wide event was designed to provide accurate information about HIV, dispel myths and normalize the use of condoms for reducing the risk of transmission.  The event was scheduled to occur after school hours to avoid complications from parents resisting sexuality-based education on school grounds.

We began by showing a series of videos provided to us by a representative of PEPFAR (President’s Emergency Plan for AIDS Relief), which included a variety of messages from humorous television commercial spots to documentation of discrimination against people living with HIV/AIDS in Peru, as well as an informative teaching tool detailing the facts about HIV transmission, testing and treatment.  After viewing the videos, a nurse from the local health center reviewed the differences between HIV and AIDS and an overview of routes of transmission.

Next, two peer educators directed an activity to allow students to practice the new information by forming groups that were given the task of categorizing a set of situations as either being a risk for HIV transmission or not a risk.  Following this activity, a different pair of peer educators demonstrated the steps to using on a condom.  Each group of participants was provided with cards listing the steps, and the groups worked in a competitive manner to list the steps in the correct order and demonstrate the steps by placing a condom on a plastic soda pop bottle.

CHALLENGES OF THE HIV AWARENESS EVENT

1.       Adolescents are often overburdened with schoolwork and chores in the home and cannot attend events after school.

2.       It was difficult to attract a variety of teens from the community beyond those who had already received or participated in the HIV lessons.

3.       The reluctance of parents to allow their children to participate may have had an effect on the number of participants.

Please continue reading to find out the impressive results of the project.

PASOS ADELANTE - The Results

2014 FINAL SURVEY RESULTS

85 unduplicated adolescents were trained on sexual and reproductive health and the use of modern contraceptive methods; includes students who participated in the Pasos Adelante lessons in the high school in 2013 and 2014, plus the students who attended the HIV workshop.

·         77% of adolescents can correctly identify at least one way of preventing the sexually transmitted         infections (including HIV)

·         96% of adolescents recognize two (2) myths about HIV transmission

                 --> Represents a dramatic increase from 35% reported in 2013

·         70% of adolescents can identify at least two or more behaviors to prevent pregnancy or STI                 transmission

·         75% of adolescents report having adopted at least one new behavior to prevent pregnancy and STI       transmission

                -->Represents an increase from 30% reported in final survey from 2013

                -->55% of adolescents report abstinence or delaying the initiation of sexual activity as a                            method having been adopted to prevent pregnancy

                     -->29% of adolescents report use of condoms as a method having been adopted

·         31% of adolescents report that a condom was not used during their last sexual activity

The results are quite promising, especially comparing results from 2013 to the results from 2014.  Some of those students received two sets of lessons, which may have contributed to the dramatic increases in reported recognition of myths about HIV transmission and adolescents reporting having adopted at least one new behavior to prevent pregnancy and STI transmission.

A notable result is that 26 students (31%) reported that a condom was not used during their last sexual activity.  It is disconcerting to discover that a third of participating youth are engaging in risky sexual activities.  It demonstrates the need for more education to help youth make healthy decisions about sexual activity and increased access to reproductive health services.

RECOMMENDATIONS

1.       Present Pasos Adelante lessons during tutorial period within regular school hours.  Students are often too busy with responsibilities in the home and school homework to attend lessons after class.

2.       Provide copies of the lesson plans to the Director prior to class so that he can be prepared if a parent or teacher has a question.

3.       Present formal documentation to the teachers of the Director’s approval for the lessons, and make sure they have advance notice regarding use of class time or tutorial time.

4.       Invite health center staff to be guest experts to make informative presentations during the Pasos Adelante lessons, and pair each guest with peer educators to direct the practice activities.  Sharing responsibility for presentation of material will contribute to sustainability.

5.       Schedule lessons to begin as early in the school year as possible, because classes will be cancelled without notice.

6.       Invite 3^rd and 4^th year students to serve as peer educators.  While the 5^th year students may be interested, they are often too overwhelmed with schoolwork to get involved.

7.       Encourage male students to become peer educators.

8.       The Parent School should involve a series of workshops that focus on learning new behaviors to practice in the home, and then building upon the lessons learned in each workshop.  Each session should include simple, easy-to-remember steps for working through difficult conversations that parents could take home and put into practice immediately. 

9.       Offer at least one event outside of school for youth to attend and learn about HIV, sexually transmitted infections, preventing pregnancy and other reproductive and sexual health topics, in order to capture the students who had not participated in lessons at school (because 1^st and 2^nd year students did not receive lesson, or because the student attends high school outside the district).

LESSONS LEARNED

Youth are very interested in learning about HIV and sexual health topics, especially how to protect themselves from sexually transmitted infections and prevent unintended pregnancies.  There is a good amount of motivation among the Pasos Adelante project committee members who are very interested in teaching youth but need guidance on how to address sensitive topics and engage youth in the learning process.  After utilizing the lesson plans, several of the committee members appeared eager to continue the project and they have indicated that they are looking forward to presenting future lessons and working with the peer educators.