STI prevention and the male sex industry in London: evaluating a pilot peer education programme

Objective: To evaluate the effectiveness of a pilot peer education STI prev ention programme with male sex workers. Design: A process and outcome evaluation of the pilot programme undertaken in three London male escort agencies, using a quasi-experimental design. Subjects: Workers in three London escort agencies, including 88 who complet ed a questionnaire, five peer educators, and a further 16 men (including ma nagement) working in two of these agencies. Methods: A peer education STI prevention programme run by the Working Men P roject (WMP), a specialist sexual health service for male sex workers, was piloted in two London escort agencies. Five male sex workers participated i n a 2 day peer education training programme. They then returned to their re spective agencies to disseminate information and condoms, in an attempt to influence norms of behaviour. An outcome evaluation aimed to assess changes in STI related knowledge, hig h risk sexual behaviour, and attendance at a sexual health service. A pre-i ntervention questionnaire assessing variables such as STI related knowledge , sexual behaviour, and demographic information was administered in both ag ency A and agency B and a third agency, C, which acted as a control. Ten we eks after the peer educators returned to their agencies, the same questionn aire was administered in the same agencies. Peer educator referrals to the WMP were also recorded over this time period. The process evaluation involv ed interviews and focus groups with peer educators, and the completion of d iaries about their experiences in the role. A further 16 men working in the agencies (including managers and an owner) were interviewed about their ex perience of the programme. Participant observation was also undertaken thro ugh regular outreach work to the agencies. Results: 57 men completed the questionnaire at time 1 and 44: at time 2. Un fortunately, only 13 of these were matched, precluding any meaningful analy sis of change in STI related knowledge and sexual behaviour. The questionna ire provided a profile of the men working in the agencies. Of the 88 men wh o completed the questionnaire at least oner, the majority were homosexual, and in their late teens/early 20s. Most were of a "white" ethnic group, tho ugh there was some range within these categories. Most preferred to speak E nglish and education levels were high. Relative STI knowledge revealed a hi gh understanding of HIV and hepatitis B, moderate understanding of gonorrho ea, syphilis, genital warts and herpes, and little knowledge of non-specifi c urethritis (NSU) or chlamydia. Sexual behaviour suggested a highly sexual ly active population with both male and female paying and non-paying partne rs. Condom use was highest for paying partners, particularly for anal sex. Condom use for oral sex with all partners was less consistent, and condom u se for all types of sex with regular partners was lower than with other par tners. The small number of men engaging in vaginal sex with paying and regu lar partners were less likely to use condoms. 26 new patients registered at the WMP as a result of peer educator referrals, representing 65% of all ne w contacts over thr study period. The process evaluation revealed that whil e the training programme was considered adequate and while peer educators f elt the programme and their roles to be a success, their experience of the role was difficult. The role of management support was crucial in supportin g the programme. The assumption that "peers" are particularly effective edu cators was not borne out by the results. While peers were considered suitab le to discuss some aspects of the industry, many preferred to consult "prof essionals" about health related matters. The concept of "peers" was problem atic with most of the men drawing "peers" from subgroups within the agencie s. Other constraints on behaviour such as a lack of power, particularly wit h regard to a lack of management support, or poverty, had a substantial imp act on behaviour which were not influenced by the peer educators. Conclusions: The study illustrated the difficulties of utilising quasi-expe rimental evaluation methodology with this client group. It also demonstrate d the limitations of peer education based on information provision health e ducation models which focus on individual behaviour change. Suggestions are given for future interventions.