Methods: Community assessment was used in the planning stages and included pre-project focus groups with students and teachers. Outreach methods included peer tutor selection, train-the-trainer sessions, school and community outreach, and pre- and posttests of MedlinePlus training sessions. Evaluation methods included Web statistics; end-of-project interviews; focus groups with students, faculty, and librarians; and end-of-project surveys of students and faculty.

Results: Four peer tutors reached more than 2,000 people during the project year. Students and faculty found MedlinePlus to be a useful resource. Faculty and librarians developed new or revised teaching methods incorporating MedlinePlus. The project enhanced the role of school librarians as agents of change at Med High. The project continues on a self-sustaining basis.

Conclusions: Using peer tutors is an effective way to educate high school students about health information resources and, through the students, to reach families and community members.

Even when an innovation promises a change for the better, introducing that innovation is not always easy. Many factors about the community and its social structure affect acceptance of the change. A successful outreach project must be based on strategies that integrate well into a given community.

This paper describes a project that used high school peer tutors as one method of introducing MedlinePlus to the Hispanic community in the Rio Grande Valley of south Texas.

The Med High Peer Tutor MedlinePlus Pilot Project was a component of a two-year multifaceted outreach project focused on the Hispanic majority community in the Lower Rio Grande Valley (LRGV), which is the southernmost region of Texas and borders Mexico. The University of Texas Health Science Center at San Antonio (UTHSCSA) Library received funding from the National Library of Medicine (NLM) in September 2001 to conduct this project, named the Texas Lower Rio Grande Valley Health Information Hispanic Outreach, at its branch library at the Regional Academic Health Center (RAHC) in Harlingen, Texas. The project included a baseline community needs assessment, from which several pilot projects involving community organizations were developed and conducted. The Med High Peer Tutor MedlinePlus Pilot Project was the most comprehensive of the four pilot projects.

The overall project investigated the role that MedlinePlus, the NLM Website for consumer health information, and the RAHC Library could play in strengthening Hispanic awareness and use of health information. The RAHC is strategically located in one of the most medically underserved regions of the United States [1]. NLM funded this project as part of its efforts to strengthen health literacy in Hispanic populations. NLM believes increasing health literacy is one strategy that will contribute to the reduction and ultimate elimination of health disparities among minority and medically underserved populations [2]. In this sense, the overall project was, in part, an extension of earlier outreach pilot projects that NLM had funded in connection with the initial stages of the development of MedlinePlus [3, 4].

The Med High Peer Tutor MedlinePlus Pilot Project was located at the South Texas High School for Health Professions (referred to as Med High). The first regional magnet school in the valley, Med High is one of the schools of the South Texas Independent School District (STISD) and serves three counties and twenty-eight school districts in the LRGV [5]. Table 1 provides a school profile.

Table 1 Med High School profile

As a magnet school, Med High offers intensive health-related courses and practicum rotations in clinical settings, in addition to the standard high school curriculum. Many students participate in one of the local chapters of the Health Occupations Students of America (HOSA) and in HOSA-sponsored competitions, including community awareness projects. The high school library, known as Biblioteca Las Américas (BLA), serves the students of both Med High and Science Academy and is located at the center of the STISD campus in Mercedes.

Med High was selected as the site for the first pilot project because of the interest and enthusiasm of the Med High librarians. The project director for the Med High Peer Tutor MedlinePlus Pilot Project was the RAHC library director/assistant library director for valley services at the UTHSCSA Library (referred to in this paper as the “RAHC librarian”). The BLA librarian (referred to as the “Med High lead librarian”) and her library staff were also key participants.

An important facet of the project was a thorough evaluation plan based on the NLM publication Measuring the Difference [6]. This evaluation manual was prepared in part to address the generally limited evaluation efforts of previous NLM-sponsored outreach projects [7]. The project also employed the services of a UTHSCSA evaluation specialist (referred to as the “project evaluator”) throughout all phases of development and implementation.

The community assessment indicated that students at Med High:

• a. perceived themselves to be atypically high users of Internet technology compared to family, community members, and students from other high schools,
• b. often helped family members find Internet resources,
• c. usually had Internet access at home but felt their access was unusual for LRGV residents, and
• d. thought their teachers needed more training in Internet resources.

Teachers indicated that they:

• a. learned about the Internet mostly from their students,
• b. were often frustrated by not finding what they needed, and
• c. limited student use of Internet resources in papers and projects, because they found that the quality of Internet resources was questionable and were concerned about plagiarism because of the ease with which students could cut and paste information directly into their work.

Two other key findings emerged from the community assessment. First, the school community had a great deal of trust, respect, and loyalty for the Med High lead librarian and wanted to include her in the training process. Second, the Med High librarians often used peer tutors to teach new multimedia software packages to teachers and other students. Because the concept was already part of the school culture, the project evaluator suggested use of the peer tutor format for this pilot project.

The project began in January 2002 and continued intensively through the fall 2002 semester. Evaluation and other follow-up activities continued through spring 2003. The project has now become part of the school's regular activities. The RAHC librarian still participates in activities as time allows.

Figure 1 Role-playing used in Med High training

In preparation for the diverse situations students might encounter, peer tutors were also trained to recognize some of the more difficult personal situations that librarians face when providing consumer health information, such as an upset person newly diagnosed with cancer. They were cautioned to involve a librarian early if such transactions arose.

Peer tutors conducted training for Med High teachers, ninth-grade orientation activities, health occupations courses, and parent open houses. Table 2 lists the types of activities and number of participants reached through the training. Most activities involved the peer tutors as presenters and/or trainers. Peer tutors also took the initiative to make presentations at a regional HOSA conference in the LRGV, reaching 350 students from the 4 LRGV counties.

Table 2 Summary of Med High training activities

The Med High lead librarian and staff developed their own ideas for providing behind-the-scenes support to the students. They designed a Website highlighting the resources and suggesting their potential use in classes. They also placed a link to MedlinePlus on the library's own home page to make access easier for their students. A link to the UTHSCSA RAHC Library highlighted the partnership between Med High and the RAHC. They were also always available to consult with and encourage the peer tutors as the project progressed.

Process evaluation The process was evaluated frequently and systematically throughout the project. The RAHC librarian held feedback sessions with the peer tutors to help them assess themselves and improve their teaching skills. To track increasing resource usage, the Med High technology coordinator purchased and installed Web usage–tracking software (Web Trends) that documented page hits, bytes downloaded, visits, and most popular sites. The coordinator monitored the software and prepared “traffic” reports throughout the year. To monitor participant reaction to the peer tutor sessions, trainees completed session evaluation forms asking participants to rate the usefulness of the training and their plans for using the health information resources in the future.

Outcome evaluation A mixture of quantitative and qualitative methods was used to assess the outcomes of the project. Toward the end of the project, outcomes were assessed through post-project focus group interviews with teachers, students, peer tutors, and librarians and individual interviews with the lead librarian and school principal.

A survey was designed to explore the degree to which outcomes identified in interviews were experienced schoolwide. In January 2003, the survey was administered by health sciences technology (HST) teachers to determine the degree to which students were using MedlinePlus and for what purposes.

One question asked students to list up to 3 people (contacts) with whom they had shared the MedlinePlus Website or materials. After responses were typed verbatim into a database, a rater coded students' responses for their relationship to the listed contact (mother, father, friend, teacher, etc.) and the purpose for sharing the Website (personal, school, professional). To check the reliability of the ratings, a second rater recoded 20% of the contacts (randomly selected) and showed 100% agreement across relationship of contact and 91% agreement across purpose. A similar survey was administered to the 10 Med High teachers who received training.

Teachers commented that they thought their students enjoyed the interactive nature of the peer tutor sessions. Each session typically used examples suggested by the students and included hands-on activities appropriate to the grade level.

Figure 2 Med High MedlinePlus usage data, megabytes downloaded (March 2002–March 2003)

The classroom survey with students in January 2003 produced 500 usable responses (23% ninth grader, 23% tenth graders, 21% eleventh graders, 13% twelfth graders, and 20% unknown). Sixty-six percent of the students reported using MedlinePlus outside of a formal training session. Of these students, more than 80% used MedlinePlus for school research projects (Table 3).

Table 3 Med High end-of-project student survey, selected results

Survey results indicated that the students educated others in the broader community beyond the school. Of those students reporting use outside of training, approximately 50% cited using MedlinePlus as a referral source for others who needed health information. More than 33% said that they had used MedlinePlus for personal or family health issues. Only 16% accessed Spanish language materials, which was not surprising, because students at Med High used English as their primary language. Most of those who accessed Spanish language materials found MedlinePlus very useful.

When asked to list up to 3 other people with whom they had shared MedlinePlus or MedlinePlus materials, 46% of respondents specified 1 or more contacts, with a total of 429 contacts reported. Each student entry was counted as a contact: a reply of “my mother” or “family members” was counted as one contact, so students reached more than 429 people. Most often, students assisted contacts with personal health concerns of friends or family members (55%). Students also helped others use the resource for school-related projects (43%) and for work-related problems (2%).

Because the pilot project primarily targeted students, outcomes assessment with teachers was less comprehensive and consisted of a focus group and survey of ten HST teachers. Results showed patterns similar to the student survey. All teachers rated MedlinePlus very or somewhat useful. Eight of ten reported using MedlinePlus for information relevant to their own or a family member's health. They had referred others to MedlinePlus for the same reasons. In the final teacher focus group, one teacher with a second job in a hospital had trained staff there to use MedlinePlus, because it was superior to the database purchased by the hospital.

Of those who used MedlinePlus beyond a training session, 99% were very confident in the quality of the information they found and rated MedlinePlus as useful overall. In interviews, some students reported that they were more focused on schoolwork when using MedlinePlus than when using search engines such as Yahoo and Google, which included more distracting features.

According to the principal, HST teachers began implementing research exercises in their ninth-grade courses, making MedlinePlus part of their lesson plans. Prior to the peer tutor project, teachers introduced research projects in the eleventh grade. School librarians reported that some teachers had incorporated more hands-on exercises and case studies into their classes, similar to the techniques they observed in the peer tutor training sessions.

In a focus group interview, HST teachers reported they were now more willing to accept Internet resources in student research papers (a finding corroborated in the student focus groups). They said they trusted the quality of resources found through MedlinePlus.

The school librarians also have become more involved with other librarians in the region. They have become active members of a higher education consortium in the LRGV called Valley MedShare. Further, the Med High lead librarian now participates in a statewide task force and has presented to the Texas Association of School Library Administrators about the role of the Med High Library in the school community.

The Texas Library Association (TLA) awarded its Library Project of the Year Award to the Med High Peer Tutor MedlinePlus Pilot Project in April 2003. At the presentation, the project was introduced with this description, “The students and the community became more closely connected to the library. Moreover, the residents of this Lower Rio Grande Valley Community are aware of a valuable medical database that will help them become more literate about their health.”

The outcomes of the Med High peer tutor project show that students can effectively introduce MedlinePlus to their peers and to their community. The project is noteworthy in that it (a) went far beyond the walls of the school to reach friends, family members, and community members connected to Med High students and staff; (b) has become self-sustaining, using school staff and curriculum time; and (c) has produced unanticipated positive outcomes for a number of the program's stakeholders.

Researching the culture of the group or organization and including that research was critical in the planning and evaluation of the project Burroughs and Wood, Scherrer, and Wood et al. have emphasized the importance of the community assessment to the success of outreach projects. [6, 8, 9]. For the Med High peer tutor project, the single most important success factor was the peer tutor concept and the enthusiastic partnership of the students and librarians. A second important factor was including a project evaluator on the planning team from the outset. The evaluator was instrumental in applying community assessment data to the project planning process and provided insight about the school culture that was critical in the development of a successful project.

For instance, we learned that participants, particularly teachers, did not want a “white knight on a horse” approach to this project, so the project emphasized partnership with the school librarians and student peers. In each of the training sessions, the RAHC librarian was careful to allow peer tutors and librarians to take the lead. The RAHC librarian spoke during a class training session only to answer questions from a peer tutor or to briefly emphasize the partnership between Med High and the RAHC.

The community assessment also indicated that teachers' doubts about Internet resources for school projects had to be addressed before MedlinePlus would be adopted for use in school projects. To deal with these doubts, peer tutors always addressed the question of the quality of the information from Websites in their presentations. Teachers appreciated learning about the authoritativeness of the MedlinePlus site and later felt comfortable asking questions about how students could cite Web resources in their projects. Toward the end of the project, teachers willingly accepted resources obtained through MedlinePlus.

Application of a behavior change theory to development of training activities was instrumental in designing outreach methods The advice given in Measuring the Difference to use a theory-based model for outreach proved to be invaluable. Our use of diffusions of innovations (DI) theory as a guide was critical to our success [6, 10, 11]. For instance, instead of targeting the entire school, we identified and targeted school community members described in DI theory as innovators and early adopters (usually 16% of a given community or population). In our “training the trainers” approach, we realized that we could attract the interest of the school librarians and some high-achieving high school students with MedlinePlus. As predicted, they willingly experimented with the resources and quickly saw their usefulness for themselves and others. They then voluntarily became the mentors and role models for others in the school community and beyond. The RAHC librarian worked behind the scenes to develop the training skills of these few individuals who, in turn, spread the word to hundreds of people. Table 4 describes the factors leading to the diffusion of innovation, the related community assessment findings for Med High, and the resultant project design for each factor.

Table 4 Application of diffusion of innovations theory to Med High pilot project

Flexibility and empowerment were essential to success Although the project leaders did not always find it easy, we believe that permitting participants to design and carry out their own project is critical to developing a sustainable outreach program. This means that project directors must be open to methods that do not fit their original plans and be prepared for unexpected outcomes.

For instance, we had not planned at the beginning of the project to train students to teach peers to navigate MedlinePlus. Yet, all our initial focus group interviews confirmed that students teaching students would be the critical element. Our responsiveness to the community ultimately led to a very successful program. Med High students responded eagerly to learning from their peers, because the tutors talked to the students in their own language. Students reported that they could see that the Website could be easily navigated by students, not just by adults. They also added that peers added humor that students could relate to and made learning less boring. They also felt that the peer tutors taught them to get more from the resources than they would get on their own.

Much to our surprise, being a peer tutor has become “cool” at Med High, demonstrated by the number of students interested in becoming peer tutors for the second year of the project. As the Med High lead librarian wrote in the TLA award application, the project raised awareness and many students realized that just a few individuals could bring about substantial behavioral changes in others. The peer tutors believe that they have made a difference in the quality of learning in their school. The status gained by both the peer tutors and the librarians has made them role models for their school.

The project has had some unexpected impacts on the Med High library staff. They report that the library is now seen as having a greater commitment to helping students succeed and providing a leadership role in developing students' skills. The library has become more connected to the curriculum, and the staff has been energized by this change. The librarians are also now perceived as agents of change in their school.

The most obvious extension would be to similar health sciences magnet high schools in Texas and other states. At least nine communities have health magnet high schools in Texas. The Med High model project might also be of interest to some general science and technology magnet schools.

Another outreach opportunity would be to adapt the Med High model by working with HOSA and local HOSA chapters around the country. The Med High project was well received by the regional HOSA chapters and helpful to Med High students working on HOSA projects and competitions.

The Centers for Disease Control and Prevention's “Healthy Youth” initiative [12] has established goals of health education, a healthy school environment, and family and community involvement for youth. Persons establishing programs to meet these goals may be interested in the Med High peer tutor model.

The Med High project successfully introduced an innovation (MedlinePlus) by using high school students as leaders of the innovation. The highly motivated students at Med High will continue to introduce these high-quality consumer health resources to the school community. Students, in turn, presented the resource to their families, friends, and others throughout the LRGV.

The pilot project has proved to be sustainable by the students, librarians, and teachers at this magnet health professions high school. This project provides a model that can be replicated at other health magnet schools in Texas and around the United States and can be applied in a wide variety of youth outreach projects and contexts.

The Med High peer tutor pilot project worked well and met or exceeded its goals, for several reasons.

• The project incorporated theory with a strong community assessment. Leadership for the project came from the community. The participants set their own goals and strategies.
• The medical librarian was a resource and built and maintained relationships and opportunities for communication. However, control over the MedlinePlus training resided with the community members.
• Targeting students provided entry into the local community, beyond the walls of the school. The diffusion of information gained from the project happened quickly and moved beyond the students to their family, friends, and community.

Future applications of this model will add valuable information about its ability to extend to other student cohorts, locations, and types of communities.

This project would not have been possible without the exemplary contributions of the four outstanding Med High peer tutors: Serena Arancibia, Cecelia Castañeda, Joey Nichols, and William McCormick. The coauthors also acknowledge the vital contributions of the Med High librarians and participating Med High faculty and staff, and, in particular, Javier Jiménez, technology coordinator, and Catherine Burroughs, assistant director, Outreach Evaluation Resource Center, University of Washington Health Sciences Library, National Network of Libraries of Medicine, who provided valuable project planning and evaluation assistance. The support of the Med High administrators—Lucy Fernandez, principal, and Marla Guerra, superintendent— was also important to project success. The coauthors also gratefully acknowledge the management support from Elliot R. Siegel, associate director for health information programs development, National Library of Medicine, and Evelyn Olivier, former deputy library director, University of Texas Health Science Center at San Antonio.