Innovative approaches for engaging adolescents in Primary HIV prevention: lessons from the peer-Led health education program in Nimule, South Sudan

Abstract

Background

The involvement and engagement of adolescents in community-based HIV prevention programmes are crucial for enhancing the effectiveness and sustainability of these programmes yet few programmes have documented their engagement strategies. This study aimed to describe and innovative approaches used to actively engage adolescents in HIV prevention health education programmes designed to increase awareness of HIV prevention methods, reduce risky behaviours, and increase uptake of HIV testing.

Methods

We employed participatory approaches involving pre-programme consultations with adolescents’ peer educators and conducting post-programme reflection sessions. The pre-programme consultations were aimed at identifying objective opinions from peer educators on the best approaches for actively engaging peers in health education sessions. The post-programme reflection sessions involving peers were aimed at collecting feedback across eight approaches adopted to identify which of those motivated and actively engaged them in their groups. Thematic context analysis was used to identify and validate the most preferred approaches.

Results

Of the 50 participants, 27 (54%) were female and 23 (46%) were male adolescents. The participants were within the age range of 14–17 years. More than 90% of the adolescents identified that being in groups facilitated by a peer of the same gender, having a peer educator representing greater diversity, being in a group with flexible meeting dates, times, and venues, and staying connected were the major motivators for their active engagement in their groups. Conversely, having peer educators with good facilitation skills, finding mental health and psychosocial support, and having a sense of ownership of the group were the least rated motivators.

Conclusions and recommendations

Employing approaches that enhance active participation can substantially improve adolescents engagement in HIV primary prevention interventions. This implies that employing a multifaceted and innovative approaches is a game-changer in actively engaging adolescents in community-based HIV programmes and hence the need to advocate for adolescents' engagement in HIV prevention as well as future research into approaches crucial in strengthening and scaling effective programmes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12978-025-02234-4.

Introduction

In South Sudan, decades of armed conflict has created one of the world’s worst humanitarian crisis where high levels of poverty, illiteracy, and weak health systems have limited access to HIV information [1, 2]. In comparison to Uganda, access to HIV information, testing and treatment remains limited, with only 35% of people accessing HIV testing services and less than 50% of people living with HIV receiving lifesaving antiretroviral therapy [3, 4]. Furthermore, bio-behavioural studies conducted in Juba and Nimule found severe knowledge gaps and increased HIV prevalence by 39% and 24.0% among young sexually exploited female sex workers, respectively [5]. The combination of armed violence, poverty, and high illiteracy continues to create formidable barriers to HIV health information and other preventative programs for young adolescents. However, the delivery of health education and addressing behavioural, biological, and structural variables are known to reduce gaps in HIV prevention among adolescents [6, 7]. Given this, addressing knowledge gaps becomes a critical intervention, particularly in post-conflict situations like South Sudan [8, 9]. Effective engagement of adolescents in community-based HIV prevention programs can be transformative in accelerating progress in primary HIV prevention outcomes, especially in resource-limited settings [10, 11]. Other emerging approaches widely used in engaging adolescents in HIV prevention programmes include artificial intelligence and machine learning and other online platforms [2, 12–14]. This exposure to social media has also been linked to increased knowledge of Sexual and reproductive health among adolescents in India [15, 16]. While this is true, cultural diversity may present an uphill challenge to such programs [17]. The World Health Organization has recommended the use of a participatory approach in actively engaging adolescents while implementing such programs [18]. Moreover, the United Nations Population Fund and the United States Government’s Presidential Emergency Plan for AIDS Relief, through its funding for the Orphans and Vulnerable Children Program, have also reinforced this approach by recommending the use of comprehensive services to address the needs of adolescents and young people [19, 20]. Despite these recommendations, studies conducted in Sub-Saharan Africa have revealed inadequate participation and engagement of adolescents in community-based prevention programs [21]. In contrast, the use of a participatory approach involving adolescents, parents and community leaders in a contraceptive promotion program among refugee adolescents in Chad revealed increased interest and uptake of contraceptives [22, 23]. Similarly, a recent study involving the use of a peer-led health education model in Lesotho and Nimule town of South Sudan correlated this engagement with active participation and ownership of the program, resulting in an increased level of knowledge of HIV prevention methods and uptake of HIV testing services [24, 25]. The lack of clear engagement of adolescents in the implementation of sexual and reproductive health rights programs has been identified as a key barrier to the success of these programs [26]. The goal of this study was to document and disseminate innovative approaches used to actively engage adolescents in HIV prevention health education programs delivered in humanitarian settings.

Methods and approaches

Study design

We analysed qualitative data collected from a group of adolescents to assess the approaches employed to motivate and actively engage adolescents for a period of three months in health education group sessions in a two-year study. Before the start of the study, adolescent peer mentors were consulted to identify some of the approaches they identified as highly motivational and actively engaging. These, among others, included the use of games and sports as breakaway sessions, having smaller group sizes of about 10 members per group, having separate sessions for both boys and girls and giving groups greater autonomy to have flexible meeting dates, times and venues. This feedback was used to operationalise the groups. After two years of programme implementation, we conducted five reflection sessions comprising ten members each to validate each of the various approaches used and identify the most preferred approaches as agreed by the majority of the adolescents who participated in the reflection sessions.

Data handling

A reflection session guide consisting of eight themes (greater flexibility, diversity of the facilitators, skills and approaches used by motivations used by facilitators, social connections of members, greater sense of ownership of groups, greater autonomy, mental and psychosocial support and being in a group of my same sex) was used to gather participants views through a show of hands approach during the discussions. We then employed Thematic Context Analysis to summarise responses across each of the eight themes to assess the strength of each approach used. Summary findings were presented using Table 1.

Table 1.

Summary of post program reflection session (n=50)

Themes	Yes	No	Total
Greater flexibility motivated my active engagement in my group	45 (90%)	5 (10%)	50 (100%)
The peer educators represent greater diversity of group members and this acted as a motivator of my participation in my group?	48 (96%)	2 (4%)	50 (100%)
Peer Educators possessed greater skills and use various motivational approaches which motivated my participation in the group	32 (64%)	18 (36%)	50 (100%)
Staying connected to my peers was a strong motivator for me participation in my group	42 (84%)	8 (16%)	50(100%)
Feeling a sense of ownership in my group made me have a strong attachment to my group	20 (40%)	30 (60%)	50(100%)
Finding a greater degree of autonomy motivated me to stay in my group	47 (94%)	3 (6%)	50 (100%)
Finding a source of emotional support within my group was a strong motivation to actively participate in my group	26 (52%)	24 (48%)	50 (100%)
Belonging to peers of same gender enhanced my active participation in my group	49 (98%)	1(2%)	50(100%

Participants

The study participants recruited were adolescents aged 10–17 years from HIV-affected households within Nimule peri-urban town.

Settings

The study was conducted in Nimule, a peri-urban town of South Sudan, which is located at the border between Uganda and South Sudan. The proximity of Nimule, a peri-urban town to the Ugandan border, makes it a safe place for hundreds of thousands of internally displaced persons (IDPs), leading to high population density and increased cross-border movement.

Intervention

The main intervention in this study was health education aimed at reducing risk behaviours and enhancing uptake of HIV and sexually transmitted infections screening and management.

Inclusion and exclusion criteria

All the 10 adolescent peer educators were included in the consultative meeting. During the reflection sessions, only those who randomly picked a piece of paper marked “Yes” were included.

Participants Selection

During the consultation event, ten peer educators were asked to identify the most motivational and engaging approaches they would want to use to engage their peers in their groups. During the reflection sessions, five representative peers were selected using a simple random approach from each of the ten peers groups formed during the study. Random selection was performed using papers put in a small envelope with five papers marked “Yes” and five marked “No”. All those who picked “Yes” were considered to participate in the reflection session.

Study procedures

Adolescents were recruited into health education groups managed by trained peer educators. While the health education sessions were delivered for three months, adolescents were followed up for two years in the larger study. Before the start of the health education sessions, peer educators were asked to identify the most suitable approaches to motivate and engage their peers in the groups. Findings were later incorporated into the design of the group sessions, ensuring that they reflected the approaches identified by the peers. After delivery of the sessions, a sample of peers from each group was sampled and asked to provide their objective opinion on which of the eight approaches adopted by the program motivated and actively engaged them in their groups. Below were some of the program enablers adopted: -.

Building consensus through consultative meetings

Before the start of the study, we held four consultative meetings with a small group of adolescents (6-8 per session) to identify peer leaders as well as collect their views on how they would want to engage in the study, particularly their roles and responsibilities. These consultations were done separately for both boys and girls recognising that gendered experiences might share distict priorities and insights. During the consultative meetings, adolescents were asked to rank their peer leaders in terms of being influential, having a network size of 5–10 peers, being able to speak at least one local language and English, being knowledgeable about the neighbourhoods, and being willing to accommodate and support others. At these meetings, peer leaders were selected based on meeting at least four of these attributes. In terms of program implementation, adolescents were asked to provide insightful views on the group sizes of the health clubs, gender compositions of the group members, meeting schedules (dates and times), duration of sessions, meeting venues deemed safe, and what their roles and responsibilities would be. This information was used to make key decisions including limiting group sizes to 6–8 members per group, male and female adolescents having separate group sessions, having meetings mainly on weekends to accommodate those in schools, having sessions run for 40–60 min in churches, schools and health facilities as opposed to community venues, and taking part in mobilising group members and co-facilitating sessions. While community venues were accessible, they were viewed as not convenient due to intrusion by security operatives and other members of the community. These key issues were identified during the initial consultation. The well-informed decisions ensured that adolescents had greater involvement in decision-making and that their concerns were taken care of. This consultative approach was also used in other similar interventions where adolescents were empowered to take greater roles rather than being recipients of the program [27, 28].

Training and deployment of peer educators

The selected peer educators completed a ten-day facilitator training before they were deployed to their neighbourhood. Before their deployment, we conducted a mapping of Nimule town into seventeen neighbourhoods: Motoyo East, Motoyo West, Kololo East, Kololo West, Rock City, Melijo, Hai Kanisa, Matara, Abila, Malakia West, Malakia East, Bio I, Bio II, Jeli, Nimule Central, Olikwi and Rei. This mapping was designed to ensure that each of the neighbourhoods where the adolescents were recruited had a designated peer educator and a designated meeting venue.

Feedback mechanisms

We also implemented systems that allow adolescents to provide feedback on the peer-led sessions. This could enhance program efficacy, as input from participants helped refine content and delivery methods to better meet the needs of adolescents. Incorporating Q&A sessions, experience-sharing forums, and anonymous feedback channels to continuously adapt the content based on adolescents’ evolving needs.

Adopting the one-stop-shop approach

Anchoring on the principles of layering of services for adolescents recruited in our health education groups. These services included comprehensive sexuality education, referrals for multiple sexual and reproductive health services such as screening for HIV and Sexually transmitted infections, gender-based violence prevention and psychosocial support and economic strengthening activities. This service package ensures that adolescents have a variety of services meeting their diverse and unique needs. The layering of the services was anchored under the Determined, Resilient, Empowered, Mentored, Safe and AIDS-free (DREAMS) approach of delivering layered services for adolescents [29]. Other studies have also identified the use of peer educators as a catalyst for positive behaviour change in Nigeria to increase awareness in HIV and STIs prevention, stigma reduction, and condom use [30]. Similarly, for adolescents living with HIV and AIDS in DR Congo [31, 32] and Kenya [33], working with influential peer educators was also observed to enhance treatment literacy, status disclosure, and psychosocial support [34]. In our study, we engaged the adolescents in the inception meetings, explained to them the benefits of the program, as well as underscored the risks and vulnerability to HIV infections among adolescents. In Lesotho, for example, peer-led support for adolescents living with HIV and AIDS significantly improved viral load suppression in the intervention groups than in the control, suggesting how effective this program is in enhancing adherence to ARVs [35].

Skills development

To shift the peer supporters’ role beyond HIV health education, we also provided opportunities to enhance their skills in areas related to trauma-informed care, safe menstrual hygiene practices, facilitation skills, leadership, and conflict resolution, which empowered them to confidently manage their groups, lead discussions and handle sensitive questions regarding sexual and reproductive health rights.

Getting caregivers involved

The role of the caregiver has been identified to influence adolescent HIV prevention programs [36, 37]. Considering the incredible role caregivers play in enhancing household income, offering a non-violent environment and safety net supportive of improved HIV prevention and mental health outcomes, we trained caregivers in positive parenting skills, trained them in financial literacy. Similar approaches were also used in South Africa [38, 39] and South Sudan [40, 41].

Results

Of the 50 participants in the five post-program reflection sessions conducted, 27 (54%) were female and 23 (46%) were male adolescents. The participants age ranged from 14–17 years. When asked what strongly motivated and actively engaged them in their groups for the period of the health education, (49/50,98%) strongly agreed that they were motivated to participate in groups facilitated by peers of the same gender. Other key motivators were having a peer facilitator representing greater diversity (48/50, 96%), having grater group autonomy (47/50,94%), having flexible meeting schedules and venues (45/50,90%) and feeling of staying connected (42/50,84%) were the strong motivators. Conversely smaller proportions, though still notable identified additional motivators such as having a peer with good facilitation skills (32/50,64%), finding good mental health and psychosocial support within the group (26/50,52%) and having a sense of ownership of the group (20/50,40%). A summary of the post-program reflections is presented in Table 1.

Discussions

The study identified five major innovative approaches that motivated adolescents to actively engage in their peer groups. (1) having groups facilitated by a peer educator of the same gender (either male or female) as their peers’ members, (2) having a peer facilitator representing greater diversity of their peer members in the group, (3) exercising greater autonomy of the group, (4) having greater flexible meeting schedules, meeting times and venues, and finally (5) feeling of staying connected with peers.

Gender diversity

The association of the gender of the facilitator with active participation among their peers could have been perceived as creating an environment free of fear of expression and participation of members in their respective groups. On the other hand, recruiting peer educators representing a greater diversity of age, socio-economic status, HIV status, education and area of residence could have been perceived as a strong reflection of how group members felt accommodated in their groups. For instance, we recruited adolescents living with HIV as peer supporters of those living with HIV. Based on their lived experiences, these adolescents were relevant to supporting peers on treatment, and this helped reduce levels of stigma and discrimination, which is a major barrier in South Sudan.

Greater autonomy

We consistently observed greater interest in groups who preferred to work at their own pace rather than following rigid meeting schedules defined by the program. For example, where sessions were clashing with priority activities for the majority of the members, they would willingly agree to reschedule to more convenient time. Groups also demonstrated strong willingness to accommodate one another's challenges. For example, where the majority of members had family and school-related commitments, they would reschedule their sessions. These attributes provided group members to balance their broader responsibilities while remaining in the group sessions.

Fostering ownership

Adopting the “Nothing for us without us” approach a cultivated strong buy-in of the adolescents themselves [42, 43]. This approach took into consideration the power of adolescents in driving peer-led programs. We did this by first consulting with community leaders, partners and peers who are influential and personate about community work. This initial consultation enabled us to identify those adolescents known to support their groups. This first group of adolescents, referred to as starters, was instrumental in providing insightful thoughts and suggestions on how the program can achieve strong buy-in from their peers. For instance, the length of delivery of sessions, venues, and dates, blending the sessions with plays, games and sports activities, integrating other activities such as storytelling into the program, as well as quickly identifying and paying attention to concerns raised. For instance, adolescents in school preferred meeting on weekends (Saturday and Sunday) mainly at churches and health facilities. In some instances, adolescents wanted more time for storytelling, question and answer sessions, and time to play and sing songs as an engager.

Connectedness

The greater sense of feeling connected was probably linked to creating a strong social cohesion among group members who preferred to remain together rather than being alone when out of the group-thereby creating a positive pressure of remaining in the group and belonging together. As part of knowing group members, peer educators mapped all households of their group members and physically visited them. The smaller size of 6–8 members ensured that peers were able to physically connect to each other easily both in their groups and also within the same neighbourhoods. This physical contact in the household also ensured that caregivers were aware of the peer educators and built trust. This social connection also extended up to the schools, where peer educators maintained contact with group members and reminded them about the next group meeting. This connectedness, both at home and in school, was seen as a strong driver of the teamwork and group cohesion between the peers and their peer educator.

Conclusions, recommendations and forward thinking

Conclusions

Gender diversity of peer educators, greater group flexibility and autonomy to decide freely on their meeting schedules and venue, and building string social cohesion were the major motivators of active engagement of adolescents in primary HIV prevention health education program.

Recommendations

While the adoption of group-based innovative approaches is crucial in actively engaging adolescents in primary HIV prevention programmes, our findings also have policy implications in advocating for the inclusion of adolescents in HIV prevention interventions, while also advocating for more research to explore the effectiveness of these approaches.

Forward thinking

In light of emerging artificial intelligence and social network platforms such as TikTok, the future of actively engaging adolescents in group activities needs to be extensively explored. Attention may need to be paid to whether or not physical group meetings would be replaced by virtual meetings, whether or not program managers need to adopt different approaches to engage urban and rural adolescents, and adolescents in conflict zones.

Authors’ contributions

SB led the conceptualising and developing concept paper and full research proposal, supervised data collection, drafted the manuscript, developed study instruments, guidelines, and standard operating procedures, trained data collectors, and obtained ethical approvals. GK, PM and AA technically reviewed, edited, and formatted all associated documents.

Funding

This research has been co-funded by UKRI (CVR00600), UNDP Accelerator Lab (00117753 ACC LAB), and DAAD (91750377).

Data availability

Data Availability Statement [The dataset named “Appendix 3- DATA_SSD_2022” supporting this study is available on the ICPSR at [Workspace(openicpsr.org)](https:/www.openicpsr.org/openicpsr/workspacegoToPath=/openicpsr/194381&goToLevel=project), reference number (openicpsr-19438)]. All supporting materials, including consent forms, ethical approvals, data collection tool, and HIV risk screening tool, have been attached.

Declarations

Ethics approval and consent to participate

Ethical considerations: The study received ethical approval from the South Sudan Ministry of Health Research and Ethics Review Board (MOH/RERB/24/2020) and the Strathmore University Institutional Ethics and Research Committee. All participants gave informed consent, and participation was entirely voluntary, with assurances of anonymity and privacy throughout the study. Consent for minors [11, 17–20] was obtained from their caregivers, while emancipated minors [21–23] provided their own verbal consent. Caregivers and emancipated adolescents aged 15–17 received thorough information on the study’s goal, procedures, benefits, risks to participate right of withdrawal of consent at any time, and privacy and confidentiality. All individuals provided informed consent before data collection during the baseline assessment. A workshop was conducted to go over the study procedures and information contained in the consent/assent forms. The process included: (1) oral and written information to consider participation; and (2) a version for illiterate participants, who could provide consent through the signature of a literate witness (not a member of the research team). Each participant was given complete information about the study before giving their consent (written or oral, as indicated above). To illiterate participants, the information was read aloud in front of an impartial witness who was not associated with the study to ensure that potential participants fully understood what it meant to participate and that they could withdraw their consent at any time without explanation. It was also made clear that refusing to continue in the study would not affect the type of support they received. The research assistants provided ample time to address all of the participants’ questions and concerns. The informed consent method for the participation of young adolescents (10–14 years of age) was a two-step process: First, carer approval was gained for their child’s participation in the study as part of the informed consent process, which involved the same caregivers and procedures as described above. Second, if caretaker approval was acquired, children’s verbal assent to participate in the study would be obtained before tool delivery. This study followed the ethical guidelines outlined in the Helsinki Declaration of 1964, as revised in 2024. In this regard, the study ensured that the health and well-being of the adolescents and their caregivers involved in the study were safe from any harm. Before the study, the Research Assistants signed a confidentiality agreement and a child safeguarding policy statement. Any breach of confidentiality and abuse of children was monitored during the study by the principal investigator.

Consent for publication

Not applicable.

Competing interests

The authors report no competing interests.