Field-Test of a Peer Educator Workbook
for the Prevention of Fetal Alcohol Syndrome
and Fetal Alcohol Effects

Rey A. Carr
Peer Resources

Alcohol continues to have devastating effects in Canadian society. In addition to the contribution of alcohol to crime, violence, traffic fatalities, organ failure and other adult health problems, the consumption of alcohol during pregnancy has been consistently associated with a variety of fetal health problems including birth defects, psychiatric and cognitive disorders, and eating and sleeping disorders. Prenatal alcohol intake has been identified as the primary cause of mental retardation (Steinhausen, 1993), and although some symptoms decline over time, severe damage at birth leads to significant lifetime disabilities (Abel, 1990).

Although the adverse effects of alcohol on the fetus were recognized as far back as the Old Testament (Niccols, 1994) and scientific evidence of the effects of drinking during pregnancy were identified in the latter 19th century, it was not until 1973 that the term, "Fetal Alcohol Syndrome" (FAS) was created to describe the pattern of birth defects identified in children born to mothers who consumed alcohol during pregnancy. A few years later the term, "Fetal Alcohol Effects" (FAE) was established to include infants who demonstrated less severe effects of maternal alcohol consumption.

Incidence of FAS/FAE
According to Abel and Sokol (1991), FAS occurs among the general population of the Western world at the rate of one per 3000 live births. Estimates have placed FAE at about three per 3000 live births. While no data exist for the incidence of FAS/FAE in Canada, it is possible to estimate that based on a Canadian population of 30 million and a birth rate of 14 per 1000 that of the 420,000 children born in 1994, approximately 150-420 children were born with FAS/FAE. Studies conducted in particular communities in British Columbia have revealed FAS/FAE incidence rates as high as 190/1000 live births (AADAC, 1993). This translates into an incidence of 500 times higher than the general population.

AADAC (1993), Atkinson (1993) and Cordero, et. al. (1994) have identified a number of problems associated with calculating reliable and valid estimates of FAS/FAE. Difficulties associated with gathering data, lack of standardized diagnostic criteria, and inconsistent inclusion procedures were three problems that led AADAC to view Canadian estimates as problematic. However, AADAC concluded that incidence rates reported in Canada are likely to be conservative and under report actual incidence.

Prevention of FAS/FAE
While determining the number of children born in Canada with FAS/FAE may be somewhat problematic, it is clear that prenatal alcohol consumption poses a severe health risk to the newborn, and a significant cost to society. In addition to the trauma, frustration, and challenges of providing a nurturing life for children with FAS/FAE, family and public financial burdens for on-going health care and treatment are extensive. Treatment costs in the United States alone have been estimated at $300 million per year (Abel and Sokol, 1987).

However, regardless of problems associated with incidence, and despite almost 90 years of study and more than 1500 reports in the professional literature, interventions to reduce the impact of FAS/FAE have shown little success (Schorling, 1993). This is particularly frustrating since FAS/FAE is both irreversible and preventable.

Typically interventions have been information-based relying on pamphlets, posters, television media campaigns (Casiro, et. al., 1994), prenatal education and counselling (Schorling, 1993), package (bottle) warnings, surgeon general abstinence recommendations, and professional health practitioner persuasion techniques. More recent attempts at lowering risks associated with pregnancy have included interactive multimedia computer programs (Kinzie, et. al., 1993) and formalized social support (Villar, et. al. 1992).

When Hodnett (1993) reviewed the results of controlled experiments using social support to reduce high-risk pregnancy, she concluded by way of meta-analysis, that "social support interventions for pregnant women are not associated with a lower rate of preterm birth." (p. 218). However, Hodnett cautions that social support may have meaning for pregnant women that has not been adequately investigated. In addition social support research has not developed fully enough to assess factors such as timing, amount, scope, and length of support.

The Potential of Peer Education
One form of social support which has potential for reducing high risk pregnancy is peer education (Carr, 1987; Lapierre, et. al., 1995). Rather than just involving clients as the receivers of health information, peer education is based on the idea of involving peers in the delivery of health education services. Peer educators are typically persons who are within the natural, social networks of women at-risk of an FAS/FAE outcome pregnancy, who have experience with being at-risk themselves, and who tend to be the kind of person that friends seek out when they need help.

Peer education works primarily because people experiencing frustrations, concerns, and challenges are more likely to seek out friends, not professionals, for support, assistance, and advice (Carr, 1984; Gottlieb, 1978; Stone and Keefauver, 1990). Peers can provide information and support that can increase knowledge, change behaviour, and change attitudes, in ways that may not be accessible to professionals. In addition peer educators can supplement and act as a bridge to professional services (Gottlieb, 1985; Carr, 1984).

While peer education has been shown to be effective in school-based substance abuse prevention campaigns (Carr, 1989; Klepp, Halper, and Perry, 1986; Benard, 1988; Tobler, 1986), and peer education has been used to increase contraceptive practices during adolescence (Carr, 1991), no studies have been conducted on the effectiveness of peer education to reduce substance use and abuse during pregnancy. The reasons for this lack of attention are easy to understand. First, the majority of peer education programs have been located in educational settings and only recently has attention been paid to adult, community-based peer-based initiatives. In addition community initiatives are primarily service-centered rather than research-based.

Second, gaining access to the potential target group (women at-risk during pregnancy) and their peer groups is not easily accomplished since, unlike school-based peer programs, there is no typical location or area where participants can be contacted. Recent attention to parenting programs for prenatal parents, community-based services for women, and the cooperation of health specialists has, however, contributed to resolving this problem.

Third, while there are considerable resource and training materials available for other types of peer education programs (Carr and Saunders, 1981) and support materials are available for peer educators (Roberts, 1987), no specific materials exist for peer education in the area of FAS/FAE. How applicable these generic peer training materials might be for an FAS/FAE specific peer program has yet to be determined.

Project Organization
The purpose of this project was to field-test a workbook created for use by FAS/FAE peer educators as part of their training to deliver peer education services. The workbook was developed by the Alcohol and Drug Education Service of British Columbia under contract with the British Columbia Ministry of Health, Drug and Alcohol Programs (See Note I).

Volunteer peer educator participants were solicited in the Nanaimo (British Columbia) region through the assistance of the Tillicum Haus Pregnancy Options Program and a brochure distributed in the Nanaimo region (See Note 2).

Nineteen persons were selected to participate in the training program. Participants met for twelve consecutive weeks, one full-day per week, beginning in March, 1994. Participants received on-site child care and nutritional snacks and lunch meals as part of their training day. Training took place at the Tillicum Haus Health Clinic.

The training sessions were co-led by two experienced peer trainers. Both trainers were parents and had worked with a variety of individuals from different cultural groups in their work as peer trainers. Following each daily session with participants, the co-trainers discussed the dayÕs activities with the site coordinator.

Training design followed the experiential learning model as developed by Peer Resources (Carr, 1987). Various interpersonal skills were introduced by soliciting from participants their experiences as helpers and as persons being helped. Skill-based exercises and activities were then provided by the trainers with debriefing discussion led by the trainers. Training sessions concluded with an emphasis on participants making commitments and plans as to how to use the skills and knowledge learned to help peers.

Project Assessment Method
At the end of each training session (day), the trainers requested written feedback from the participants regarding their impressions or ideas regarding their daily experience. This information was used primarily to assist the trainers to prepare, alter or modify training planned for the next training session. In addition the feedback was used to assess the effectiveness of the training as a whole.

Trainers also kept a log or diary of their experiences, particularly focussing on spontaneous comments from the participants regarding the workbooks. The trainers also from time to time prompted the participants to comment on the workbooks, but no specific, written feedback was gathered from the participants. The trainers relied on verbal comments and made summaries of such comments in their log books.

From time to time, participant questions, concerns, or ideas led the trainers to vary the skill training focus and find additional resources to meet trainee needs, including bringing in guest speakers, videos or other resources.

Results of Workbook Assessment
1. Participant impressions or reactions to the workbook were influenced by their experiences during the training sequence.

While all participants received a copy of the workbook prior to the start of the first training session, by week three, only five of the participants had either opened the workbook or skimmed its pages. The training content did not require the use of the workbook, nor did the trainers request that the participants examine any specific part of the workbook as a result of or as preparation for any training activity.

In contrast participants initially expressed delight and relief that what they were learning was contained within the interpersonally-based training sessions, and that there was minimal written work or reading required. However, during the initial training sessions several participants expressed concern about learning the facts and details regarding Fetal Alcohol Syndrome and Fetal Alcohol Effects.

After a few training sessions, this concern for factual information changed dramatically. While there was still an interest in gaining the knowledge regarding FAS/FAE, the participants developed a consensus that the helping skills and the process involved in helping another person make healthy decisions was less related to providing facts and more related to providing interpersonal support and relationship.

At the same time participants valued having a section within the workbook that summarized the latest information regarding FAS/FAE and presented it in a factual way. Some participants recommended that it might have been even more interesting if the information had been presented using graphics of characters that depicted a peer educator and a "client" having a dialogue that showed examples of providing support and facts at the same time.

2. Participants believed that providing FAS/FAE information depended on timing and circumstances within the life situations of their potential clients.

Peer educators strongly believed that the majority of people with whom they were involved and who themselves might be involved with poor prenatal health practices did not value getting "facts" regarding FAS/FAE as a high priority in their lives. Instead the peer educators believed that the persons they would likely be working with would be more concerned about personal survival issues, resolving traumatic life experiences, or dealing more effectively with stress caused by others in their lives.

Peer educators would describe various life situations that they or their peers had faced or were facing. Several of these situations were role played during the training. Trainees could assess the value of providing FAS/FAE information or providing interpersonal support during a variety of life event discussions. In most cases peer educators increased their belief that what people perceived as most helpful in such situations was someone to listen, understand, and assist in problem-solving, rather than someone to provide facts or pamphlets only.

One interchange between participants serves as a summary of this point for all the participants. Participants were discussing the "reality" of certain FAS/FAE "facts." For example, while there is considerable agreement that drinking alcohol during pregnancy can have an impact on the fetus, it is not known how much alcohol must be consumed over what period of time for alcohol to have the FAS/FAE impact. However, it might happen that a peer educator might wind-up getting into an argument with a friend who insists that 3 drinks a week "wonÕt hurt." The peer educators in the training session recognized that "arguing over the facts" was much less important than "discussing needs." In other words the training participants took on the view that while they wanted to be knowledgeable about the facts, "enforcing" the facts wasnÕt their role; instead, their role was to help their friends and peers express their needs and find healthy solutions to those needs.

3. Participants expressed strong support for the self-reflective components of the workbook.

Participants developed the idea that to help another person meant to be clearer about one's own personal issues that might interfere with helping another person. While there was no conclusion that one must heal oneself in order to help others, there was consensus that one must have a greater understanding of oneÕs own path, as well as what was left to be resolved in oneÕs own life. Understanding one's self, recognizing one's own attitudes, values and beliefs took on greater meaning for the participants. Participants concluded that it was essential to recognize oneÕs own triggers when working with another person.

4. When participant self-esteem was enhanced, their use of the workbook increased.

Although not explicitly stated at first, participants were somewhat skeptical that anything could be done to help people who were experiencing the types of problems they had experienced or the friends they knew who were experiencing such problems. However, soon after a sense of group trust was developed, and it was clear to the participants that their feelings and ideas were valued within the structure of the group training, they began to express their own worries, concerns, and experiences.

Typical of these feelings and experiences were statements regarding hopelessness and severe depression. Participants expressed the view that they often felt hopeless and not in control of circumstances surrounding their lives. Participants stated that they and people they knew were often surrounded by "black depression." However, when participants expressed their feelings and viewpoints, and these feelings and perspectives were accepted and understood by the trainers, as well as acknowledged and supported by other participants, their sense of personal competence increased. In addition as participants observed the impact of peer helping skills on each other, they recognized how useful skills such as listening without interrupting, demonstrating understanding and empathy, and five-step problem-solving could be in generating personal efficacy.

Learning that interpersonal skills were in fact concrete ways to help others, participants felt more capable and able to offer something of value to others. This increase in self-esteem contributed to an increased willingness to explore various exercises and activities in the workbook. For example, participants paid more attention to the self-reflection exercises within the workbook, and talked to the trainers as well as other participants regarding the purpose and value of the workbook activities.

5. Some sections of the workbook had greater appeal to the participants than others.

Sections in the workbook that provided more details about particular skills being learned within the training session were valued by the participants. In addition the section on referrals was valued by all participants.

Some participants, who described themselves as having learning disabilities, believed that the workbook was harder for them to read and understand. They found themselves avoiding reading of any kind as a way of getting information, and relied considerably on oral communication and television to gain information. When the training sessions were supplemented by additional written information (updated articles on FAS, for example), the distribution of this material was typically accepted with a query as to "how is this information going to be helpful to us in doing our job as peer educators?"

Helping participants recognize the relevance (to them) of any of the material such as handouts, training activities, or workbook content was, according to the participants, an essential aspect of any written material, and was often not included within the workbook itself. Some participants felt that the tone in the workbook did not match the intensity of what they were experiencing in the training sessions.

Other participants disliked the balloon format used in the workbook, viewing it as childish and unnecessary. Others felt that the workbook language talked down to them. Some participants believed the material in the workbook was repetitive and insulting, and they lost interest in further exploration of the workbook. The "mirror" on the front cover was not considered useful, but generally participants felt the workbook was very reader or user oriented.

6. Participants believed the workbook had uses beyond the actual training sessions.

After the fifth week of training, participants began to state that they valued having the workbook as a record of some of the things they covered in the training. Very few participants took notes, but they were encouraged to make whatever comments or notes they wanted to in the workbooks themselves. Using the workbooks to make personal comments increased as the training sessions continued, and participants believed the workbooks would serve as a useful reminder or prompter of the different skills they learned.

In addition participants believed the workbook would assist them once they left the formal training sessions as a reminder and booster when they were out on their own. Several participants mentioned showing the workbook to spouses or family members as a way of describing or explaining what they were learning.

While not specifically related to the workbook, most participants evaluated the training as providing them additional motivation to participate in other educational or training experiences. In addition most participants described how they were using what they learned in other volunteer, family, or interpersonal situations. Many of the participants who had taken other types of workshops prior to the peer education workshop, such as Nobody's Perfect, believed that the peer training and workbook validated their internal wisdom and what they had previously learned about helping others.

Project Recommendations
Workbook revisions. The workbook was useful in providing supplemental support for the peer education training. According to participants, the language used in the workbook can be slightly upgraded and should more accurately reflect the types of interactions (content and intensity) peer educators are likely to encounter. Self-reflective and self-directing experiential exercises should be maintained and increased. Sections on referrals and resources should be strengthened.

A facts and fictions section regarding FAS/FAE should be maintained, but should be placed within the context of discussing personal needs rather than arguing about the veracity of facts.

Attention should be directed to persons with learning disabilities, and difficulties participants may have in reading the material should be acknowledged within the text with possible solutions for such a situation identified.

The cover should be improved graphically and the simulated mirror should be removed.

The workbook should continue to reflect the process encountered in the training experience and should be a supplement to the training. It should not be perceived as a stand-alone, self-help document, but should allow each participant to personalize his or her own copy, and use for support in post-training self-review.

Additional trainings should be provided following revisions to the workbook to field-test a final draft version.

Training program changes. One problem associated with this project was that the workbook for participants was created prior to the creation of the training manual and materials for the trainers. Paradoxically this left the trainers with a need to study the workbook in order to prepare a variety of matching training materials.

This preparation was somewhat difficult as the completion of the final copy of the workbook and arrangements for the start of the training did not exactly coincide with each other due to a number of project completion and scheduling conflicts.

A guide for trainers should be created to help maximize the use of the workbook within the context of the training course.

Follow-up of the initial training. While the focus of this project was on assessing features of the workbook, no formal attention was paid to the degree to which the training was effective in reducing at-risk pregnancy. Therefore, little information is available regarding how successful the training was in establishing an FAS/FAE Peer Education Program.

Any further revisions to the workbook should be accompanied by a follow-up survey of initial workshop participants. In addition, a trial field peer education program should be initiated that would include the components associated with successful peer education program delivery.

Note 1
The workbook developed by Alcohol and Drug Education Services (ADES) was the result of a collaborative effort of ADES, Peer Resources, and the Ministry of Health Drug Programs Branch. Peer Resources provided consultation for the content, organization, and structure of the workbook, to ADES, who, in turn, was responsible to the Ministry of Health for the final product.

In producing the workbook, several concerns were identified. First, insuring an appropriate reading level for workbook users was considered paramount. Differences of viewpoint existed regarding this point. On the one hand, some persons believed that typical target persons (FAS/FAE peers) possessed lower reading levels (grade 4-6) than the normal population, and therefore, required clear, jargon-free, simple language in the workbook.

Another view stated that target person experience with typical written materials was that the materials often had little to do with their life experience. It was proposed that material directly related to their life experience would increase their motivation to read and would contribute to an ability to read at a higher level; therefore, while material should remain clear, and jargon-free, it could also include new vocabulary and be written at the high school level. This view believed that material written at too low a level would be perceived as condescending, childish, or inappropriate by adult users. Whereas, material that was perceived by the user as being at a higher level than normal would be accepted and mastered because of peer support and greater motivation to understand the personalized materials.

It was also considered essential that regardless of the content of the workbook, there should be a strong emphasis on a visual, graphic, as well as a text-based method of including facts, activities, and information.

Differences of viewpoint centered around the role of the workbook within the training program. Some persons believed the workbook should be a stand-alone or "self-help" document, basically allowing a person to learn how to be an FAS/FAE peer educator independent of the training course. Therefore, the content of the workbook should emphasize information, FAS/FAE facts, and extensive information regarding the "helping" process. In contrast, another view stressed that the workbook was a supplement to the interpersonally-based, FAS/FAE peer educator training experience. Components of the workbook would stress self-reflection and would extend or deepen learning that was taking place in the training experience. Therefore, the workbook would contain support material for what the trainees were learning in training experience.

Another concern centered around the fact that a participant workbook was being created prior to the training manual being created. This meant that whatever workbook content was developed had to be tied in some way to an existing training guide so that the two resources could, in fact, be used together. The Peer Counselling Starter Kit (Carr and Saunders, 1981), was used as the training manual guide, and while the training portion of the Kit was particularly appropriate for training peer educators in helping skills, some of the other information in the Kit was more specifically directed towards developing institution-based peer programs. Therefore, the Kit did not assist the trainers to develop FAS/FAE activities, specifically to help trainees develop greater skill, confidence, and ability in this area. Consequently, the workbook with its greater emphasis on FAS/FAE, wound-up being supplemented by activities designed by the trainers during the actual training sessions, which are not reflected in the content of the workbook.

The resulting workbook project, supervised by Greg Millar of ADES, was an attempt to coordinate these viewpoints.(Return to Text)

Note 2
Financial support for this project was shared by the British Columbia Ministry of Health (Alcohol and Drug Programs Branch, Michael Egilson, contact person), and Canada Health and Welfare (Health Promotion & Social Development Office, Carole Legge, contact person).

Administration and repository of funds was provided by Tillicum Haus. Program liaison for Tillicum Haus was Tillicum Health Clinic coordinator, Alice Padgham. Further details regarding budget, costs and reporting of administrative procedures can be obtained from Tillicum Haus (RR #1, Site A, C-13, Nanaimo, British Columbia, V9R 5K1).

Design and distribution of the brochure as well as interviews and selection of peer educators, and training and trainee support was provided by Peer Resources (1052 Davie Street, Victoria, British Columbia, V8S 4E3, contact Rey Carr).(Return to Text)

Correspondence to:
R.A. Carr, M.A., C.Ph.
Peer Resources
1052 Davie Street
Victoria, British Columbia
V8S 4E3, Canada