In 2013, 9 million of 30.5 million Peruvians lived in Lima, Peru’s capital city. One-third of Lima’s inhabitants are within-country immigrants, making Lima a culturally diverse environment with major socioeconomic disparities (10). This project was conducted in 3 geographic areas of Lima, Ate (east), Independencia (north), and Villa El Salvador (south), all of them in peripheral areas of the capital that historically have served as receiving areas for immigrants. In Lima, 1 in 3 people are aged 19 or younger, and 9.3% are aged 15 to 19 (10); the enrollment rate in secondary school and high school is 94% (11).

Low- and middle-income countries are undergoing a shift from infectious and communicable diseases to chronic diseases and experiencing the economic impact of NCDs (12). Peru is a middle-income country where NCDs are responsible for 66% of total deaths (13). During the last decade, the mortality pattern has rapidly changed from one dominated by infectious diseases to one dominated by NCDs and injuries (14). NCD risk factors are strongly associated with lower socioeconomic status in Peru (15).

Most data available for NCDs and their main risk factors among Peruvian children and adolescents are related to overnutrition. Rates of overweight and obesity among Peruvian children and adolescents are high (16) and have not declined in the past 15 years (17). For instance, in 2010, rates of excess body weight, including overweight and obesity, were 24.4% among children aged 5 to 9 years and 14.2% among those aged 10 to 19 (16). These estimates of excess body weight are similar to regional Latin American rates: 18.9% to 34.5% among children aged 5 to 11 years and 16.6% to 35% among those aged 12 to 19 (18).

Because the school enrollment rate is so high in Lima, schools are an ideal place to explore and develop prevention strategies. Schools, however, can also serve as environments that promote unhealthful lifestyles — for example, by offering processed foods and beverages — and, conversely, that discourage healthful lifestyles — for example, by limiting opportunities for active movement and reducing time allocated to exercise (19). A study of nearly 1,800 school children in 80 primary schools in Lima found that half of the children had low physical activity levels (20). In alignment with other Latin American countries (21,22), obesity and NCD prevention is a priority for the Peruvian government; for example, a recent law restricts the marketing of processed foods to children and adolescents in school environments (23).

Our project aimed to train a group of Peruvian adolescents (aged 15 to 17), named multiplicadores jóvenes (MJs), to design and disseminate messages promoting healthful lifestyles among their school peers. Our global objective was to engage adolescents in the community in playing an active role in health promotion by multiplying their messages to raise awareness about NCDs and unhealthful lifestyles among other young Peruvians.

Our project was conducted from January through December 2011. Nine public schools were chosen from the 3 geographic areas: 3 from the south, 3 from the north, and 3 from the east of Lima. In Peru, public schools are government funded and are the main providers of education services.

The following criteria were used for selecting schools: public, coeducational, at least 200 students per school, students studying in morning shift, and schools close to each other (maximum 10 minutes by public transportation). The decision to choose schools according to distance was to enable after-school group activities among students from different schools.

Selection of students was conducted with the support from tutors of each school. Tutors are members of the school’s staff who, in addition to their teaching responsibilities, are also assigned to look after a whole grade. Because of their roles, tutors spend more time with students during school hours and usually are more acquainted with them. Tutors were asked to select students based on leadership, motivation toward the project, and availability. We did not establish a quota according to sex. For each school, we requested tutors to select 5 students in the 4th or 5th secondary grades (in a 5-year secondary school plan). The rationale for selecting final-year students was based on the students’ potential to understand technical knowledge, their ability to use the project’s communications tools, and their potential influence as role models for younger peers. Our team held a 30-minute meeting with the students being recruited, where we described the project in detail and clarified expectations of both the students and the research team, so that a true commitment to the project was generated. We initially recruited 45 students: 33 girls and 12 boys.

The 16 training sessions (Box) were led by 2 young professionals in social communications. Almost every week, from April through September, MJs attended training sessions divided into 3 groups, 1 group for each geographic area (north, south, and east). These sessions were explanatory, participatory, and dynamic, and emphasized straightforward language and group work. Social networking (ie, Facebook) was an important tool for communication and integration within student groups.

Training sessions were classified into 4 categories: workshops, experiential sessions, informative sessions, and feedback sessions. The workshops and experiential sessions were conducted separately for each of the 3 geographic areas to ensure working in small teams. In contrast, informative and feedback sessions, which required more specialized professionals, were conducted as a single activity with all participants from all schools together.

We started with a workshop to provide a solid background on communication skills. Feedback sessions took place during the last 2 months of the project, after MJs had their communication training. Workshops and experiential and informative sessions took place throughout the project.

Workshops. Based on their professional and teaching experience, the social communications professionals developed and led 10 workshops in which MJs were introduced to methods of communication through interactive and participatory exercises. Simple tools (eg, communication theory, human language, verbal and nonverbal language) and technologies (eg, blogs, social networks) were introduced to the MJs to help them develop effective messages and communication products for young audiences (Figure 1).

Experiential sessions. In 2 sessions, MJs worked with local practitioners, 1 physician trained in internal medicine and 1 physician trained in public health, who introduced them to public health issues and basic principles of clinical and public health research. MJs took part in public health fieldwork research by participating in community field visits and taking blood pressure and body and weight measurements among themselves.

Informative sessions. Researchers from our team led these 2 sessions. The first session aimed to build understanding of NCDs in lay terms and focused on diabetes and cardiovascular diseases and its main risk factors (eg, physical inactivity, junk food consumption, high salt intake). The aim of the second session was to describe the basic principles, the process, and the relevance of public health research.

Feedback sessions. In these 2 sessions, MJs groups presented a detailed description of their campaigns and received feedback from a panel of experts including professionals from communications, clinical medicine, and health research.

To guarantee participation in all of these activities, transportation was provided or its cost was reimbursed to MJs if needed. To concur with the spirit of the initiative, healthful food snacks were provided during the sessions. Also, to encourage engagement among all MJs, 2 local trips were organized to public spaces in Lima, and the project team covered transportation costs and entrance fees.

During the last 4 workshops, each MJ team developed a health promotion communications campaign. MJs were free to choose the topic, target audience, and campaign strategy. Students were asked to use the approaches they believed would be the best for their target audiences. MJs contacted the project’s clinical practitioner to verify health-related content when necessary.

For production, each team was allocated a small amount of funds to secure materials and services (eg, rental of equipment or recording rooms). In addition, each school team was mentored by a communications professional to support final production and execution. No compensation was offered to MJs. A single prize, an MP3 player, was given to the MJ group with the best campaign.

Two young social communicators were hired part-time to coordinate the process of communicating with schools, selecting students, and developing the training sessions. These communicators were supervised by a researcher from our group with a background in psychology and public health. After the training sessions, in preparation for the final presentation of their campaigns, MJs received onsite support from additional communications professionals. The role of these professionals, hired part-time for 2 weeks, was to refine and fine-tune each campaign.

We evaluated our project in 3 areas. First, we monitored attendance of MJs at training sessions. Second, communications campaigns were considered successful if they were developed and delivered by MJs to their school peers. In addition, an independent evaluator conducted focus groups with 23 MJs from 7 schools after the completion of the campaigns to obtain information on the perceptions among MJs about the project.

This study was approved by the institutional review board at Universidad Peruana Cayetano Heredia, Lima, Peru; each MJ assented to participate, and parents consented to their participation.

Thirty of 45 students completed the training; of those who dropped out, 9 students were from 2 schools. During the focus groups, several MJs described their participation as a great life experience. According to them, the most valuable aspect of the training was learning about healthful lifestyles and NCDs, which motivated them to improve their own eating habits and to persuade their peers to avoid unhealthful behaviors such as consumption of junk food: “I learned a lot about NCDs. . . . Now, I take more care of myself. . . . I do not buy much junk food from the school kiosk . . . but I do not drink enough water . . . that is something I still need to change.” In addition, MJs related their learning to their situation at home: “[O]ne of my grandparents suffers from diabetes and the other has hypertension. Now I know better how to take care of them.”

Most MJs positively rated the playful atmosphere and straightforward language of the sessions, the quality of educational videos, the visits to our Center’s research facilities, and the opportunity to meet students from other schools and learn about teamwork. Another aspect valued by MJs was the attention paid to details: “[T]he lunchboxes that we received during prolonged training sessions had fresh juice, and fruits — no sodas or potato chips!”

The communications campaigns ran in 7 of 9 schools, reaching about 1,200 students. Target audiences were reached through innovative strategies: video reports, video clips, radio spots, graphic design advertisements, and flash mobs (a short entertaining activity performed in a public place). All campaigns featured the promotion of healthful food and rejection of junk food and sodas (Figure 2) because MJs considered these topics to be most relevant to their peers and themselves: “[W]e focused on junk food, and our goal was for young people to get our message about which foods are good and bad, because we wanted to spread the information we learned in the training session to others.”

All MJs greatly appreciated the experience of running their own campaigns, an activity that they considered the most important of the project. The organization and execution of the campaigns, not always supported by schools authorities, demanded great effort and time from the MJ teams, especially because of their small size, and was also an opportunity to overcome personal fears and discover communication and leadership skills: “I learned how to speak in public, I used to be afraid of it but I lost that fear. . . . I never thought I would record a radio spot, design a campaign, be part of a working group.”

Dynamic hands-on methods and staff commitment to the project encouraged MJs to increase their own involvement: “[O]n the central campaign day, the project promoter arrived at school at 7 am, right when we arrived: their sacrifice was similar to ours.”

Most MJs believed their peers were receptive to the campaign messages and showed commitment to the campaign activities. After the project, some MJs felt that they had more recognition not only from their peers but also from school’s teachers and were motivated to be part of similar initiatives in the future.

Fifteen students, 9 of whom were from the 2 schools that did not implement a campaign, discontinued the project. The main reason for discontinuing was a heavy workload in addition to school duties. Several participants had education-related activities after school hours, and others had to take care of relatives or work to support their household. In most schools, tutors and authorities were not interested in collaboration, and there was little flexibility with timetables to allow MJs to participate.

At the beginning of the project, some parents had concerns about project activities that took place outside school hours. These concerns not only cast doubts on the relevance of the project but also signaled conflicting demands related to employment and money issues.

Sometimes, the workload required to design and implement the project simultaneously in 9 schools overcame the capacity of our part-time coordinators. Similarly, the number of MJs selected per school, up to 5, was small, considering the amount of time involved in developing and implementing a campaign.