Daniel Reeders and Graham Brown
A young woman, Jess, stops in briefly at a needle and syringe exchange, where she chats to the peer worker putting her ‘fit pack’ together. He commiserates about the lousy strength of the product available and asks a couple of questions, nothing heavy. From her answers, the worker learns that she normally uses with her partner, who scores from his mates. He wonders if her partner might use a bit with them on the side. ‘Maybe next time we could outreach to you,’ he says, ‘drop off some kits, save you making a trip after work?’ Pretty soon, the service is in regular contact with Jess, her partner and his friends. Its reach within networks of people who use drugs has increased. This creates new opportunities for practical education about safer use of drugs, and helps Jess and her friends to manage the risks and avoid harm.
This vignette is based on a scenario we discussed with staff from a peer-based needle and syringe program (NSP) participating in our project. We invited participants to think about what Jess might experience at their own service compared with a non-peer approach in a community or hospital based service. One of the more striking findings was how participants were able to spot needs and opportunities that we didn’t even know about in a narrative we wrote. For them, encounters with clients like Jess are not just about meeting their immediate needs in a safe and welcoming way – they’re also a strategic opportunity to build the organisation’s knowledge and reach.
This post details five things we’ve learned so far about peer approaches – things that might come as a surprise if your only knowledge about them came from published research.
- ‘Peer’ is more about skill than just sameness
- Peer approaches are not about disseminating information
- Peer programs can be an asset to organisation strategy and policy advocacy
- Peer services might let lower quality non-peer services ‘off the hook’
- Prevention might be an emergent effect within the systems (networks, communities and cultures) that peer programs engage with
1: ‘Peer’ is more about skill than just sameness
There’s a lot of debate about what constitutes a ‘peer’ in peer based health promotion. The research literature and international guidance on peer programs often emphasise the need to find peer workers and volunteers who are ‘same same–but better’ (not quite in those words).
They often claim that peer workers/volunteers should match clients/participants in all relevant characteristics, such as age, gender, sexuality, but at the same time, they should be (or, with the right training, could be) people who participants can look up to – that is to say, ‘role models’.
So far, this limited view of a peer is not consistent with how our workshop participants have discussed the concept. We’ve done two one-day workshops with staff from community-based organisations and peer-based programs across Australia, and two workshops over two half-days with staff from community organisations working with people who use drugs (PWUD) and in gay men’s health.
Participants have emphasised the idea of a ‘cultural peer’, rather than matching at a pair or group level with clients/participants on individual characteristics. In other words, you can have a peer relationship with someone who is similar in some aspects but quite different in many others. The key was to be a credible peer in the culture, attributes and experiences that matter.
This makes sense: gay men’s sexual cultures, and networks and cultures among people who use drugs exist despite enormous diversity among their participants.
As University of Sydney researcher Kane Race observes, the -munos in ‘community’ is about the connection you create with people who are different from you.
But participants also strongly emphasised the need for ‘peer skill’ – not everyone is capable of working effectively in a peer role. Peer skill is what enables a peer worker to draw on their personal attributes and experiences in a way that makes them relevant and helps them connect with clients/contacts despite their difference.
Although good peer workers constantly learn and refine their knowledge, as researchers we started to consider if peer skill might be something that can’t be taught. It certainly does not seem to be the same thing as the communication and facilitation skills taught to new volunteers in peer programs.
After one workshop, a participant who had worked in a range of peer roles described peer skill with people who use drugs as similar to the ability of a sex worker to assess a client’s mood and engage with them to rapidly establish trust and calm.
This is a powerful insight we are keen to explore in future workshops: it suggests peer work may draw on capacities for resilience and survival that peer workers have developed in the face of marginalising or potentially traumatising life experiences.
Peer work may, for some people, be an opportunity to re-purpose those skills and experiences in order to connect with and support others facing similar circumstances. This might help explain the particular value and resonance of the peer approach in marginalised communities.
2: Peer approaches are not about disseminating information
One of the assumptions made by (some) funders and policy-makers is that peer programs are all about one-way dissemination of accurate information from trusted sources to members of target communities. This also drives the way many of these programs are evaluated.
Our review of the literature for this program found numerous examples of a non-peer organisation recruiting respected members of a target community, sitting them down in a classroom environment and training them in an expert-developed curriculum, tasking the community members to replicate this experience in small groups of their community members, and then calling this an innovative ‘peer’ approach.
By contrast, practitioners in our workshops understood peer approaches as involving two-way exchange of knowledge between a peer worker and a peer client/contact.
Having knowledge they can exchange with peer workers was viewed as one reason why clients may feel they don’t come to peer services empty-handed. They have insights to share and have confidence the information will be respected and used appropriately – a confidence described in one workshop as a sense of ownership that was closely related to the organisation’s willingness to receive feedback.
Some participants contrasted this experience with the stigmatising ‘deficit model’ that they felt was imposed on clients accessing traditional health services and education, for example at hospital-based needle and syringe programs.
3: Peer programs can be a strategic asset to organisations
The previous insight describes a mental model held by some researchers and policy-makers in which peer programs are all about disseminating information. If widely held, it could limit the contribution that peer based programs are able to make to prevention strategy at the organisational and community levels.
For example, our workshop participants talked about their own constantly evolving mental models of their work and the cultures/communities they engaged with. They noticed patterns in the needs and issues raised by client encounters, and noticing patterns enabled them to notice new needs and shifting patterns of need. This enabled them to try new things or advocate internally to meet new needs.
As ‘cultural peers’ – members of the community they engage with – they felt they had a better chance of understanding the bigger picture: not just what changed but why it was changing.
We would argue that peer based programs are sites of constant practical innovation. However, the knowledge generated by this process can stay within individual workers’ heads, or get discussed but not documented by their team.
At one peer based service, workers had a firm commitment to a flexible model that let them meet a wide range of needs for anyone who walked through the door. They were focused on getting on with the job, but constantly shared stories about their work, and in turn their manager was constantly asking “Well did you write it down?”
Participants expressed some frustration about social research not reflecting real-time trends in the communities they work with. As researchers we had to acknowledge that even the most rapid academic research may not generate findings until long after the situation has undergone further change, making those results outdated.
Within the broader prevention sector, organisations hosting peer based programs may have the only source of real-time knowledge about the communities and cultures they engage with. This is a comparative advantage that can inform and lend weight to their activities in policy advocacy and strategic planning.
Our question in the W3 project is whether we can support community organisations to capture, analyse and translate knowledge from peer based programs into shareable formats that will have credibility with a wide range of external stakeholders.
(As we noted in one workshop, some of those stakeholders may be ‘internal’ to the organisation but ‘external’ to the department and discipline where a peer program is situated – a situation sometimes described as a ‘silo’ effect.)
Our preliminary analysis suggests that practice knowledge from peer based programs can be most persuasive when stories are packaged up with a bit of service use or ‘epi’ data and a sense of perspective – answering the listener’s questions ‘how widespread is this problem’ and ‘whose perspective does this story represent’.
4: Peer models might let low quality non-peer services ‘off the hook’
A participant in one of our workshops talked about the role his organisation plays, within the alcohol and other drug sector in its state, as a ‘safety net’ or ‘service of last resort’ for clients with the most complex needs and chaotic life circumstances.
He detailed admission criteria at some agencies which exclude a person who is still using drugs from treatment programs funded for people who use drugs, or refuse to treat a person who uses drugs who also had a mental health condition.
Their agency’s lack of exclusion criteria and flexible service model were points of pride for participants in that workshop – but with an important unintended consequence: having a ‘safety net’ service in the local sector might reduce the demand on other services to address gaps.
In effect, this might let the non-peer services ‘off the hook’ for improving the quality and flexibility of their service and addressing stigmatising or exclusive attitudes and practices.
We are not saying it’s a bad thing, though, to have a safety net – from the client’s perspective it is absolutely vital, and from a funder’s perspective it helps reduce the number of people falling through the cracks. But it does mean safety net services may be trying to meet more complex needs with the same performance indicators.
It might be important for peer based programs in this situation to recognise how much of their program resources may be used in responding to gaps in the broader service environment and to use practice knowledge in policy advocacy to re-define what counts as success and thereby create incentives to reorient health services (WHO, 1986).
5: Prevention might be an emergent effect of the networks and cultures that peer based programs engage with
One of our workshops was held with health promotion workers from a range of different organisations, all of them engaged in responding to the HIV epidemic among HIV positive and HIV negative gay men and other men who have sex with men in Australia.
In our workshops, we collaboratively draw a system map of the interconnected causal influences from program activities and other social determinants of HIV or HCV transmission, and then invite participants to nominate which three items or relationships they think it would be most important to keep track of in order to monitor whether the system was working the way we’d mapped it.
We also ask participants what three items/links we could take our eyes off, if it looked like the system was working. One group said something a bit counter-intuitive: we could take our eyes off the national strategy goal of ‘HIV prevention’. This idea is worth exploring in more depth.
They weren’t saying this goal didn’t matter – their energetic engagement with the material in a challenging full-day workshop made their commitment to prevention very clear.
They were saying that prevention could not be measured and predicted in terms of the individual activities and determinants listed on the map – instead, prevention may be the aggregate outcome of all those things working together.
In a nutshell, that’s exactly why we’re interested in using systems thinking to articulate how practitioners in peer based programs understand their work and the networks, communities and culture it engages with. Our next post in this series will cover the five key lessons we’ve learned so far about applying systems thinking with community organisations.
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