eer pressure often moves people to take risks, put their life on the line - skydiving, mountain climbing, car racing, drug and alcohol use. Why then, thought Robert Broadhead, can't it work in reverse? Why can't peer pressure help move people away from risk-taking to safer behaviors?

The answer, he believes, is that it can. And his message was convincing enough for the National Institute on Drug Abuse, last December, to award him and his colleagues a $2.6 million grant to prove it.

Broadhead, a sociology professor, and graduate students Yael van Hulst and Michael Carbone, who will work with him on the four-year project, are developing just such a peer-driven intervention. It will open its doors July 1 at two locations in New Haven.

The goal of the project, an outgrowth of Broadhead's research for more than a decade, is to rely on HIV-positive drug users to "pressure" their peers into a routine. That routine involves keeping up with medical care, including appointments with doctors and counselors, taking prescribed medications on time, working to decrease at-risk behaviors, and keeping appointments with one another in the project's storefronts.

Advocates for Each Other
The active involvement of research subjects with their peers is part of what makes Broadhead's study innovative. Subjects provide counseling and support to their peers, and administer questionnaires and gather data regarding their treatment and medication schedule. Each subject serves as a health advocate for another subject. Thus, one day a week, a particular subject is wearing the hat of a health advocate, helping someone else; on another day, the same subject is helped by a different participant acting as health advocate.

Participants also meet weekly with a full-time professional health educator, assigned to each storefront, for a "debriefing," during which the health advocate will discuss how well his or her peer is doing, and in what ways the advocate could be more successful in helping the peer.

As an extra incentive, the advocate receives rewards for the peer's success in participating and keeping up with medical care: $10 if the peer attends their weekly meeting, another $3 for each scheduled medical appointment the peer keeps, and another $2 each time the peer fills a prescription on time. Since peers also work as advocates, they understand the frustrations of losing rewards owing to a peer's intransigence.

The theory is simple, says Broadhead: "It's a 'we' thing, not a 'me' thing. The advocate gets nothing unless his or her peer comes in and can show that they're following their prescribed course of treatment. It's an example of what we call 'group mediated social control.' You're working with someone like you, who is in the same boat as you, who understands exactly what you're going through and is encouraging you to do exactly what he or she also needs to be doing."

Broadhead, who has conducted extensive research into needle exchange programs and other peer-support interventions, ran a pilot program of his current effort in 1996 that demonstrated the feasibility of the proposed project. Working with the Yale University School of Medicine - which is also a partner in the current project - the six-month study included 14 adult active drug users, who were receiving medical care for HIV in New Haven. As in the current study, peers were paired with one another on the basis of gender, ethnicity and drug use. At the conclusion of the study, the peers had succeeded in keeping 95 percent of their meetings with health advocates. And the peers' weekly medication adherence scores averaged 80 percent or higher.

Broadhead and his colleagues are hopeful the new, enlarged study of 300 HIV-positive drug users - divided evenly between a "usual care" group and an experimental "peer-driven" group - will yield similar results, even though the program will only accept the toughest possible clients.

"We are not hoping to enroll people who are already good patients. We're looking for people who need help in keeping up with their medical appointments, who don't take their medications, and who are active drug users," says Broadhead. And those who have tested positive for HIV.

People who are found to be ineligible for the project will still be helped: staff professionals will work with them to see if they qualify for state or federal assistance or help them gain entrance to other programs.

Broadhead is concentrating on drug users with HIV, because they have been documented to have the greatest problems in gaining access to, and staying in, medical care programs.

"Active drug users suffer from both low utilization of, and adherence to, primary care for HIV disease," he says. "Combining drug treatment and primary care on-site reduces these problems significantly because it creates a support structure in which program staff can monitor patients' adherence and provide ongoing encouragement.

"Many of these people are homeless. Most are active drug users. They typically lack health insurance and depend on emergency rooms when they become seriously ill," Broadhead says. "But if they're approached by someone they have things in common with, someone they know, they can be reached."

An Effective Model
Broadhead first noticed that peer-based efforts work during research he conducted in San Francisco from 1988-1992, during an early study of ways to control the spread of AIDS. That research also was funded by the National Institute on Drug Abuse, as was his research in the mid-1990s that created the Eastern Connecticut Health Outreach project, which provided HIV prevention services for drug users in four different towns.

Broadhead says peer-driven programs are now being tested at several locations across the nation, primarily involving the prevention of HIV among drug users. He believes the peer-based model of counseling and support could be used for reducing any number of other at-risk behaviors, and for new programs working to help people keep up with difficult treatments, such as those for diabetes and hypertension.

The benefits of having people who suffer from the same problems help one another are well demonstrated. Peer-based models are also known to be much less expensive than programs that rely on professionals.

During the first year of the new project, Broadhead - whose research has so far brought more than $6 million in grants to Storrs - will receive about $40,000 in in-kind support from the University, through the Office of the Vice Provost for Research and Graduate Education and the College of Liberal Arts and Sciences.

"We're trying to create an affordable support structure that will work to bring HIV-positive, active drug users into primary care, including drug treatment, and help them keep up with both," says Broadhead. "That's a very rare combination."

Richard Veilleux