Experiences of peer educators in a high school sexual and reproductive health peer education programme in Rwanda

Abstract

Background:

To contribute to a reduction in teenage pregnancy among in-school adolescents in Rwanda, a sexual and reproductive health peer education programme (SRHPEP) was developed and implemented. Reflecting on the unique characteristics of this newly implemented programme, and understanding peer educators’ (PEs) and facilitators’ perspectives, can provide insights into the programme’s effectiveness and feedback to improve the programme in the future. This study explored the experiences of being a PE in the SRHPEP from the perspectives of PEs and facilitators.

Design:

Qualitative exploratory design.

Setting:

Data collection took placed in three public high schools in Rwanda.

Method:

Three focus group discussions (FGDs) with 22 PEs and 5 in-depth interviews with facilitators were conducted.

Results:

Thematic analysis identified the benefits of being a PE, including increased competence, enhanced relationships and an improved society’s understanding of sexual and reproductive health (SRH). PEs faced challenges, however, including bullying, limited resources and time constraints. A support system (comprising PEs themselves, facilitators and school leadership) and refresher training made being a PE easier. Study participants suggested allocating enough time, training larger numbers of PEs and the provision of contextually relevant educational materials to improve the programme.

Conclusion:

Findings from this study can be used to guide the development of future ways of strengthening the SRHPEP in schools. They can also help to ensure that PEs are adequately supported in their roles and the needs of the students are met.

Background

Teenage pregnancy continues to be a global problem. Every year, approximately 21 million girls aged between 15 and 19 years in developing countries become pregnant (Darroch et al., 2016; Sully et al., 2019). The burden of this problem is especially prominent in low- and middle-income countries (LMICs) where an estimated 12 million girls aged 15–19 years old become unintendedly pregnant each year (Darroch et al., 2016; Sully et al., 2019). The overall prevalence of teenage pregnancy in sub-Saharan African (SSA) countries is nearly 25% (Asmamaw et al., 2023) and in the East African Community (EAC), where Rwanda is located, the prevalence is more than 50% (Worku et al., 2021).

In Rwanda, according to the recent Rwanda Demographic Health Survey, there was a pregnancy rate of 5% among adolescents aged between 15 and 19 years at the end of 2020 (National Institute of Statistics of Rwanda (NISR) et al., 2020). While the figure indicates some improvement from the 7% reported in 2014–2015, the situation is still alarming. The burden of teenage pregnancy is highest in the East and South provinces (6% each) and the lowest in the West and the City of Kigali (4% each) (National Institute of Statistics of Rwanda (NISR) et al., 2020). It is particularly concerning that the problem primarily affects girls who are attending secondary schools. Kirehe district also warrants attention in this regard, where an estimated 85% of adolescent pregnancies occur in girls attending school (National Youth Council, 2015). When teenagers become pregnant while attending school, it can lead to poor school attendance, contribute to their school dropout, and create long-term financial insecurity as young women do not get a chance to complete their studies and, therefore, end up with limited access to employment (Diabelková et al., 2023). Comprehensive sexuality education programmes can help address this issue by providing adolescents with accurate information about reproductive health, contraception and responsible sexual behaviour (Kim et al., 2023). Good quality programmes of this kind, alongside appropriate services, can empower adolescents to make informed decisions, ultimately reducing the incidence of adolescent pregnancies and their associated challenges.

To address this problem, several top-down health education strategies have been implemented in Rwanda, including the introduction of sexual and reproductive health (SRH) teaching as part of science classes and mass community sensitisation events in efforts to curb teenage pregnancy. However, despite this work, after almost a decade of implementation, evidence shows limited effectiveness (Michielsen et al., 2014). Most adolescents still prefer to seek SRH information from their peers, who often have little or incorrect knowledge about SRH (Collectif des Ligues et Associations de Défense des Droits de l’Homme au Rwanda, 2016). Thus, engaging peer educators (PEs) as key messengers to meet adolescents’ SRH needs could be an effective strategy.

To meet the needs of youth in Rwanda and contribute to the reduction in teenage pregnancy, we developed a sexual and reproductive health peer education programme (SRHPEP) which was implemented in three high schools in Kirehe district, Rwanda (Nkurunziza et al., 2020). The project set out to help both boys and girls acquire accurate and reliable knowledge and skills so that they can take action and make SR-informed decisions. The reasons for focusing on school-going young people were twofold. First, in recent years, Rwanda has managed to increase school enrollment, and therefore, the school is an ideal place to reach adolescents in a cost-effective intervention manner. Second, PEs can help overcome the barriers to educating adolescents about their bodies and sexuality that previous interventions have failed to address, because peers come from the same context and know how to relate to each other (Michielsen et al., 2014).

The development and implementation of the SRHPEP programme are described elsewhere (Nkurunziza et al., 2020, 2023). As part of the programme, students were selected to become PEs who were trained in communication skills; male and female reproduction; the menstrual cycle; sexually transmitted infections; and contraception. Interactive methodologies and evidence-based experiments were used in the training workshops. Efforts were also made to help PEs to discover new information independently. To ensure PEs were fully involved in the learning process and retained the information provided, we used active learning methods such as role-plays, simulations and educational games (Montalti et al., 2023). Afterwards, peers started to teach age-mates in their schools.

Considering the unique characteristics of this newly implemented programme, an exploration of PEs and their facilitators’ perspectives can contribute to improving the SRHPEP if it is to be adopted in other schools in Rwanda and the region. According to a recent review, most evaluations of similar programmes have focused on assessing the impact of interventions on adolescents’ knowledge improvement and attitude change. However, they have failed to explore PEs’ experiences as experts in implementation (Mason-jones et al., 2023). Assessing PE perspectives in evaluating SRHPEPs is crucial for understanding programme effectiveness and can offer unique insights into the real-world impact of interventions, shedding light on aspects such as accessibility, cultural relevance and participants’ overall experience (Adekola and Mavhandu-mudzusi, 2022).

By incorporating PEs’ perspectives, evaluations can become more holistic and ensure that SRHPEPs meet the needs and preferences of the target population. Therefore, this study aimed to explore the experiences of ‘being a PE’ on the SRHPEP from the perspectives of PEs and facilitators.

Research questions

Specific research questions explored were as follows:

• What are the benefits of being a PE in the SRHPEP in a high school in Rwanda?

• What are the challenges of being a PE in the SRHPEP in a high school in Rwanda?

• What are the enabling factors for PEs in the SRHPEP in a high school in Rwanda?

• What recommendations are there to improve the SRHPEP from PEs in high schools in Rwanda?

Methods

Design and setting

A qualitative approach was used to help understand how PEs construct their understandings of being a PE in the SRHPEP (Creswell, 2014). PEs and facilitators from three public secondary schools in Kirehe district were included in the study. One of the schools was a mixed-sex boarding school, while the other two were mixed-sex day schools.

Study population, sample size and sampling technique

This study had initially intended to recruit 30 students who had been trained as PEs at the project’s inception in 2019 to participate in three focus group discussions (FGDs) (Nkurunziza et al., 2020). However, one PE was absent at the time of data collection, two had already graduated from high school, two had relocated to other schools and three had been repatriated to their country of origin since they were refugees. Therefore, only 22 PEs participated in this study.

Three focus groups were considered sufficient to elicit recurrent themes (Guest et al., 2017; Morgan, 1997). When interviewing young people, scholars recommend keeping the number of participants per group to around seven (Bernard, 2006; Flores and Alonso, 1995; Morgan, 1997; Raby, 2010). The first, second and third groups comprised nine, seven and six study participants, respectively, with groups based on participants’ schools. We did not take gender into account when allocating PEs to groups because boys/young men and girls/young women had been trained and assumed their roles together (Nkurunziza et al., 2020).

Three school leaders (one from each school) and two teachers participated in in-depth interviews as key informants (KIs) because they actively supported PEs. Three experienced research assistants (as moderators and observers) from the University of Rwanda led the FGDs for PEs and the in-depth interviews for facilitators. The longest interview lasted for 1 hour 45 minutes while the shortest lasted 1 hour 36 minutes. For in-depth interviews, the longest interview lasted 41 minutes while the shortest lasted 32 minutes.

Data collection instrument and procedure

Teaching faculty members and senior researchers in SRH at the University of Rwanda developed the interview guides. Ethical clearance for the study was received from the University of Rwanda, College of Medicine and Health Sciences’ Institutional Review Board (Approval No 158/CMHS IRB/2019). Following approval, the principal investigator travelled to Kirehe district and shared details of the study with Kirehe district leaders as well as to the headteachers of the schools where the study would be carried out, to seek approval to conduct the study locally.

After receiving permission to do so, the headteachers invited PEs and facilitators to participate. The RAs introduced themselves to the study participants, explained the nature of the study and handed out printed information. PEs aged less than 18 years old completed assent forms, and their legal guardians completed informed consent forms. Participants who were over 18 years old and the school leaders who participated in in-depth interviews provided informed consent themselves.

To explore the experiences of PEs, this study employed FGDs. FGDs offer a conducive environment for participants to share their stories and voice their opinions while disregarding a predetermined sequence of questions (Stewart and Shamdasani, 2014). This methodology is particularly well suited to data collection from adolescents and young people, as it allows them to express themselves freely and authentically (Adler et al., 2019). We used individual in-depth interviews to elicit the perspectives of KIs and gain insight into their experience supporting PEs. Data were recorded in Kinyarwanda (the national language) or English (the medium of instruction in secondary schools in Rwanda) depending on the participant’s preference and were audio-recorded with their permission. Data were collected in March 2022.

Data analysis

Data collection and analysis were conducted concurrently. This iterative process allowed us to gain real-time insights from the data, enabling us to identify patterns and trends that might not be apparent otherwise. The audio-recorded data were transcribed verbatim and where necessary translated into English by the research team members (J.B., J.B.H.H. and O.T.) who were fluent in Kinyarwanda and English. Field notes were also reviewed. Dedoose software was used to organise the data. Thematic analysis was used to identify, analyse and report on themes (Braun and Clarke, 2006).

Five researchers from the overall project team (A.N., G.T., E.Rw., M.H. and E.Ru.) were involved in data analysis. Each researcher had a specific area of focus based on their expertise. Open and axial coding was used to identify themes within the data. The results of the analysis were then discussed by the whole project team, and consensus was reached about the themes present in the data (Braun and Clarke, 2006). Several strategies were utilised to ensure rigour, including the use of RAs who had expertise in midwifery education and qualitative research, regular debriefing meetings after each interview, maintaining a clear audit trail throughout data collection and analysis, and exercising reflexivity and triangulation (Lincoln and Guba, 1986).

Findings

A total of 22 PEs aged between 15 and 20 years participated in three FGDs. Of these, 12 were young men, and 12 were enrolled in advanced level grades (10–12) at school. Five KIs, including two teachers, a director of studies, a headteacher and a school patron, participated in this study. Almost all the KIs had over a decade of working experience in high schools. The thematic analysis revealed four main themes: the benefits of being a PE; the challenges of being a PE; facilitators of peer education; and recommendations to improve SRHPEP.

Benefits of being a peer educator

Increased competency

PEs reported that since joining the project and carrying out their responsibilities, they had increased knowledge and skills about SRH. ‘. . . I was unable to teach them [other students] how to use male and female condoms. I am now very well-equipped to teach the students and do demonstrations’ (FGD3, PA). PEs also reported that as a result of the training they had received, they could not respond to challenging questions with confidence. ‘Teaching my schoolmates created self-confidence; I eliminated [my] frustration. I can easily figure out how to deal with the people who challenge me’ (FGD1, PE).

Nine PEs reported improved public speaking and communication skills in line with their increased competencies. They said they could now deliver their message in front of an audience without fear, as it used to happen to some. ‘I learned to speak in public because, before the training, I was unable to stand in front of a large audience’ (FGD1, PH). PEs also demonstrated clear and confident communication skills when engaging with their peers. As one KI explained, ‘These PEs have demonstrated remarkable progress in their ability to present in public. Their presentations are clear and concise and leave a lasting impact on their audiences. Their ability to captivate and engage their audiences is truly commendable’ (KI3).

Due to the limited time available in which to deliver their message, PEs learned to get organised, and use their limited time effectively: ‘I learned how to select the appropriate content at the right time. It was not easy to find enough time, but we used the little time we had efficiently’ (FGD1, PH).

Building strong relationships with peers

Study participants described how the SRHPEP had improved their relationships with peers. ‘I have got many friends due to this project’ (FGD2, PF). Even though it had been challenging at the beginning, the PEs and their facilitators reported that now the PEs were well-respected and trusted individuals, taken as role models in the school and had gained many friends and supporters.

Improving society’s understanding of SRH

One of the benefits of programme involvement was knowledge transferability. SRH has been talked about with family members and out-of-school teenagers. ‘[Initially] . . . it was difficult to talk about SRH in my family. My parents could not discuss that with us. However, using the knowledge and skills I gained from PEP, I taught my siblings’ (FGD1, PH). PEs also played a role in reducing teenage pregnancies in their schools. KIs reported that before the programme, there were more teenage pregnancies every year, but after the introduction of the PEP, the teenage pregnancy rate had dropped. ‘We used to have many teen pregnancies; before the project, at least 5 girls were pregnant each year. Now, there are no teen pregnancies’ (KI5).

Challenges of being a peer educator

Being bullied

At the start of the programme, PEs had been verbally and socially bullied by their colleagues. Some of them were given weird names. ‘The first time, they laughed at me and called me “Mom Bishegu”, meaning a woman who promotes sexual behaviour and things like that’ (FD1, PA). PEs also reported being teased by their colleagues during teaching sessions. They had been tested many times with challenging questions. One participant said, ‘The students who are in the sciences options for example, Biology, used to ask me challenging questions to test my knowledge’ (FGD1, PI).

Working with limited resources

During the programme, both PEs and KIs reported a lack of materials and insufficient PEs to deal with challenges they faced. While the SRHPEP did provided materials to facilitate the teaching programme, according to both PEs and the facilitators, these materials were not enough, or not available due to the fact that they were kept by the directors of the schools, who sometimes are not available. ‘The teaching materials were kept in the Director’s office and when we needed them, he might not be around or was assuming other duties’ (FGD1, PG). According to the KIs, since they did not have enough PEP manuals and didactic materials, storing what they had in their own offices allowed them to maintain control over distribution and use.

Since the project had started, 30 PEs had been trained across the three schools. However, this number was not enough to accommodate the needs. As shared by one study participant, ‘We have a lot of students, around 800 [in our school], which is a big number compared to the 10 trained PEs at the same school’ (FGD1, PH).

Time constraints

One of PEs’ most significant challenges was balancing academic responsibilities with peer education commitments. PEs typically had a busy schedule, incorporating classes, homework, examinations and extracurricular activities alongside their responsibilities as PEs. As a result, challenges could arise, especially during critical periods such as mid-term examinations and final examinations. As one PE explained, ‘At the beginning, I had a problem planning how to teach students and do my courses as usual. I could not find enough time dedicated to peer education’ (FGD3, PB).

Facilitators of peer education

Sources of support

PEs described how they organised themselves to prepare content and support each other for better education. They shared resources, exchanged ideas and provided feedback to each other. ‘We used to get help between us [PEs]; one of us prepares a topic, and we sit together to see if the content is appropriate to the time allocated and potential questions to be asked’ (FGD1, PD). KIs had also noticed teamwork among PEs. They appreciated the collaboration, communication and problem-solving skills that PEs developed through their work together.

Teachers also provided guidance and support and were often the first point of contact for PEs. They acted as mentors and role models, inspiring PEs to reach their full potential and providing resources and support to ensure PEs’ success. As one peer education explained, ‘Our biology teachers support us in organising our content and answering some difficult questions’ (FGD1, PG).

The importance of school leaders’ role in supporting PEs was also reported in the study. This included scheduling special times for SRHPEP and providing resources such as computers and a telephone to enhance the PEP experience. Furthermore, school leaders ensured that PEs had the resources and support to maintain a positive learning environment. ‘Scheduling a [specific] teaching time by our school, such as Wednesday afternoon, was helpful. They also gave us a phone to contact our teachers or the health centre’ (FGD1, PH).

Refresher training

Study participants expressed appreciation for the refresher training they received midway through the programme. This additionally helped PEs maintain momentum and enhanced their skills and knowledge: ‘Something that helped me a lot was the training you gave us during the project implementation. It refreshed my mind. I got some solutions to the challenges I faced before the training’ (FGD2, PE).

Recommendations to improve the SRHPEP

Allocating sufficient time

To strengthen the programme, study participants proposed the creation of a special time to reach a large number of students at once. This would allow PEs to engage with their peers and discuss topics in depth. One per educator requested our team to ‘ask the school director (head teacher)/ authorities to schedule SRH teachings and determine a specific time for that’ (KI2).

Training additional peer educators

Participants in the study recommended training more PEs to replace the departed ones. Most of the trained PEs were in senior year 3 (grade 9), which meant that they were likely to move on to other schools, and others were soon to be graduating. ‘PEs finish their studies and go, others shift to other schools so to ensure the sustainability of this programme [so] we require more skilled PEs’ (KI4).

Using contextually relevant resources

To further strengthen the programme, study participants recommended the greater use of local language materials, pamphlets and other resources. For example, one facilitator observed, ‘The teaching materials are in English, which is challenging for some to translate the content into Kinyarwanda; this requires our constant support. We need materials in Kinyarwanda’ (KI2).

Discussion

This study sought to explore the experiences of PEs of the SRH in high schools in Rwanda. PEs’ increased competencies/knowledge provide an indicator that the PE training accomplished its goal of empowering youth with relevant and evidence-based information; and the trained young people reported to know where to access accurate SRH information if needed. Perhaps the most telling outcome of this study was PEs’ reported self-confidence and newly acquired communication skills. This enabled them to overcome the anxiety of speaking in public and enhanced their problem-solving abilities. Our findings align with those of studies conducted in other settings (Güldal et al., 2012; Conner, 2014; Layzer et al., 2014) by highlighting the positive impact of PE training on youth empowerment. Equipping young people with accurate information, communication skills and problem-solving abilities boosts their self-confidence and enables them to more easily make informed decisions about SRH.

Moreover, PEs reported that after some initial setbacks due to bullying, their relationship with peers had improved and they had formed friendships. These findings echo those documented in studies conducted in North Carolina and Tanzania, which revealed that PEP improved PEs’ social well-being with colleagues and promoted connectedness (Layzer et al., 2014; Ito et al., 2022). The connectedness reported among PEs in Rwanda helped them overcome challenges. For instance, at the inception of the programme, our findings revealed that some students disrupted the peer-led education sessions, some attendees uttered derogatory words towards the trainers and others attended the sessions with the intention of asking challenging questions so that peers could appear uninformed. To overcome these difficulties, PEs decided to prepare their sessions as a group and, when teaching, taught in teams complimenting each other when one felt short. As a result, the disruptive behaviour disappeared and constructive discussions ensued.

In this study, PEs reported that receiving support from other PEs, teachers and school leaders to facilitate their SRH teaching contributed greatly to the overall success of the SRHPEP. These findings are consistent with those from studies conducted in other settings (Chinyama et al., 2020; Frantz, 2015). Understanding the nuances of this support can provide valuable insights into best practices and strategies for improving the SRHPEP in secondary schools.

When asked about their connection to the larger school population, PEs reported that their relationship with others in the school gave them a sense of being respected and trusted. They felt they became role models for others, which helped them achieve their teaching goals. KIs affirm this as they reported that PEs changed their behaviour, were informed and communicated succinctly. As other research has shown, the ability to act as a role model influences how PEs deliver educational messages (Frantz, 2015).

When recruiting volunteers to become PEs, we did not seek young people who were perceived as role models in their schools. Through the work of this project, we learned an important lesson: namely, giving accurate information to a person who is willing to change their behaviour, and willing to help others improve can exert a leveraging effect. Our findings agree with the social learning theory which posits that in order to learn a new behaviour, people need a realistic role model (UNAIDS, 1999).

There was some evidence from this study of PEs reaching out-of-school-age mates and family members. In one example, a PE who, after providing an SRH teaching session to a group of young people in her community in support of a local non-profit organisation, was encouraged to start a club teaching SRH to other young people in her community. The present study demonstrates the benefits to youth of having access to good quality SRH information in the community. PEs can help educate their peers, even in cultures where talking about SRH topics might be considered taboo. A similar transfer of knowledge was also reported in a project conducted by the Gender Centre in Ghana which found that PEs transferred the knowledge they had gained not only in the school but also in the wider community (Nuvor, 2018).

While our study revealed the success of the peer education programme in the school, there were challenges. At the school level, teachers and PEs themselves signalled the need to have an increased number of trained peers in the school. This would make good the deficit created by the number of PEs who complete their studies and leave the school, or relocate to other schools. Similar observations were made in a study in Indonesia which described shortages of PEs due to finishing school, dropping out and/or getting married (Hull et al., 2004). These findings suggest that to ensure the sustainability of the PEP and its long-term effectiveness, it is crucial to establish a system for continuing recruitment and training of new PEs.

In our programme, refresher training had not initially been planned for in the project (Nkurunziza et al., 2020). However, during ongoing monitoring and evaluation, it became clear it was needed to deal with some of the challenges PEs were facing (Nkurunziza et al., 2023). Most study participants reported that the training provided was helpful in reinforcing their knowledge and skills, boosting their confidence and improving their performance on the project. These findings are in line with previous research in Ethiopia which concluded that refresher training can help PEs improve their performance (Fikree et al., 2018).

In this study, PEs mentioned that their school programme was filled with activities and the time available for teaching SRH was short. These findings align with those from the study by McNulty et al. (2020), which found that PEs’ SRH work often competed with other school priorities.

Taken together, these findings emphasise the importance of providing educational materials in the local language, Kinyarwanda; training more PEs; and utilising new technology and digital platforms to ensure that the content is culturally relevant and relatable to students (Fahme et al., 2022).

Limitations

Given this study’s exploratory nature, its findings should be interpreted accordingly. The findings from the study should not be interpreted as definitive, as the sample size was relatively small, and the researchers’ conclusions were based on subjective accounts and interpretations of the data. In addition, the study’s results may not be transferable to a larger population. Throughout the programme, PEs received support differently depending on the school. PEs at one school received considerably more support from school leaders, who provided computers, telephones and scheduled dedicated time for peer education, compared to PEs at other schools. This suggests that this study’s findings may not be representative of experiences across the programme. In addition, different levels of support at each school may have affected the results, as PEs in supportive schools may have had more resources and support than those in less well-supported settings.

Conclusion

This study explored the views of PEs and facilitators towards being a PE in the SRHPEP programmes. Its findings revealed the benefits, challenges and support for PEs alongside recommendations to improve the programme. Findings from the study provide valuable insight into the potential of, and a guide for optimising, the SRHPEP experience for all those involved. Moving to the future, the SRHPEP needs to incorporate the perspectives of all stakeholders, including teachers, school leaders and students, in order to guarantee its successful implementation and success.

In addition, anti-bullying training should be arranged for all students before any future project begins. Providing anti-bullying training helps ensure that the project can address the issue head-on and that students are better prepared to recognise and report any signs of bullying. Beyond this, future implementers must prioritise the provision of health education materials in students’ mother tongue to ensure key messages are well conveyed. To encourage the use of technology and respond to PEs’ needs in the current study, there is a need to produce digital SRH teaching materials and upload them to computer laboratory machines. This will help both students and PEs access these materials more easily and efficiently.

Finally, more research is needed to understand the perspectives of other stakeholders’ such as parents, guardians and community members. This will help ensure that SRHPEP is adequately supported and receives the resources necessary to guarantee its medium- to long-term success. Further research is also needed to explore the impact of SRHPEP on student outcomes. With the implementation of these strategies, the SRHPEP can build upon its initial success in delivering key message and skills to students.