Essential guide to understanding peer work in public health

What to expect from this essential guide

This guide explains in plain English the role of peer work in a public health response. We explain peer work in plain language first, and then provide information about how this fits into the W3 Framework.

Looking through a W3 lens

In each section like this, you will find information about how what we are talking about fits into the W3 Framework — the outcome of a process we call ‘looking through a W3 lens’.

You could skip these sections if you would prefer to read just the plain-language information. However, you can use these sections to help you understand how the W3 Framework works or how to use it to help describe peer work.

To get the most out of these sections, it helps to be familiar with the W3 Framework and the W3 Functions.

What is peer work?

Before we begin, it’s important to clarify what we mean by ‘peer work’ on this site. We also explain some of the other terms we use to help us talk about peer work.

Here is what we mean by the terms: peer work, peer response, peer, and peer worker.

Peer work and peer responses

These terms refer to the work that is done and the entities that do it.

When we talk about peer work, we mean work that is all of the following:

• Part of an organised community response within a broader overall public health response
• Organised by members of marginalised, vulnerable, or ‘at-risk’ communities (peers)
• Developed and led by peers (or at least involving strong and authentic participatory processes, and consultation with and leadership from peers)
• Carried out by peers (or a mix of peers and non-peers)
• Undertaken with the purpose of improving the wellbeing of the communities that the peers come from

We use peer responses as an umbrella term to refer to any of the following:

• Peer movements
• Peer-led organisations
• Peer programs
• Any other peer interventions or activities (such as peer support or peer education)

Peers and peer workers

These terms refer to the humans who do the work.

Although there is some debate about how to define ‘peer’, for our purposes, a peer is someone who both:

• Considers themselves a member of a community
• Is recognised by that community as one of its members

This two-way relationship is very important in peer work, as we will show later.

When we refer to peer workers, we mean any peers who are working as part of a peer response. This may include, for example:

• Paid staff or volunteers
• Those involved in direct service delivery
• Front-of-house staff
• Executive leadership and management teams
• Board members and other advisors

It is also important that workplaces and non-peer colleagues:

• Know and acknowledge that the peer workers are peers
• Value and act upon the contributions and advice of peer workers

Why is peer work important in public health?

Peer work is a crucial part of any effective public health response. This stems from the way peer responses can reach populations and tackle topics that challenge mainstream health services. It is also important because of how it helps empower people and decrease inequity.

Reaching vulnerable communities

Peer work typically promotes the health of communities whose members:

• Have diverse and complex unmet needs
• Face high levels of prejudice and stigma
• Experience criminalisation because of unjust laws
• Do not have many (if any) voices in positions of power

This work often centres on controversial, complex, and sensitive topics, such as:

• Highly stigmatised personal traits (such as diverse gender identity or expression, diverse sexuality, and disability)
• Highly stigmatised health issues (such as HIV, hepatitis C, mental illness, and alcohol or drug dependence)
• Behaviours that people tend to feel uncomfortable talking about and/or that are taboo or criminalised (such as sex, sex work, and drug use)

Mainstream health services often find working in these contexts difficult. Furthermore, people from these communities often feel nervous or uneasy about accessing mainstream health services. There are many reasons for this, but some important ones are:

• Community members might feel judged or unsafe in mainstream healthcare settings
• Mainstream health workers might not fully understand the issues faced by different communities
• Mainstream health services often aren’t set up to provide the specialised services community members need or want

Peer responses play a vital role in overcoming these barriers. Because peer workers are from the communities in question, they know who the communities are and how they work. They know about the issues faced by people from the communities — not because they’ve studied it (although they often have) but because they actually live it. It also means they know how to connect with people and support them to feel safe, unjudged, and understood.

Promoting health

The way peer responses work embodies the core features and values of health promotion. They do this through:

• Enabling people to take control of the things that determine their health
• Helping create political, economic, social, cultural, and physical environments that promote health
• Advocating for social justice and equity

Peer responses can contribute enormously to the wellbeing, safety, and rights of their communities. This has certainly been the case for peer responses led by people living with HIV (PLHIV), people who use drugs (PWUD), and consumers of mental health services (to name just a few).

Peer work can also contribute enormously to broader public health efforts. One example is the Australian response to HIV and hepatitis C. Peers from affected communities — including PLHIV; gay men, and other men who have sex with men; sex workers; and people who inject drugs (PWID) — have played a central role in the response from the very start of the epidemics. Many of the response’s internationally recognised successes come down to the powerful impact of this peer work.

How do peer responses work in a public health response?

In a public health response, peer responses work by being a bridge between two systems:

• Their communities
• The health sector and policy environment

It is important to understand that peer responses don’t just work in both systems. They are also a part of both systems.

Looking through a W3 lens: Overlapping systems

The W3 Framework shows this by placing peer work between two clouds that represent two systems: communities and the health sector and policy environment.

It is helpful to remember that even though these clouds don’t overlap in the diagram, peer work is a part of both systems. The clouds represent the parts of each system other than the peer response.

Think of it as a map of an overall public health response that focuses in on the role of peer work. The image below shows what we mean by this using overlapping boxes — yellow for communities and blue for the health sector and policy environment — across peer work in the middle.

Membership in the community

Peer responses emerge when members of vulnerable or marginalised communities come together to improve their health and wellbeing. The most effective peer responses are governed, staffed, and ultimately ‘owned’ by their communities. In other words, they are part of their communities.

Peer responses:

• Take part in, and interact with, their community
• Take part in community debate, tensions, and challenges
• Built and maintain long-term relationships with their community

They do this through both their work and the personal lives of their peer workers.

This means that peer responses have a strong and up-to-date understanding of their community’s diversity, needs, and experiences. Most importantly, they use this understanding to guide their work.

This article about Australian LGBTI-led organisation ACON illustrates this relationship.

Looking through a W3 lens: Membership in the community

To use the W3 Framework to describe the processes discussed above, follow the arrows:

1. That form the loop between communities and engagement. This represents the interactions and relationship between the community and the peer responses.
2. From engagement to practitioner learning, both directly and through peer-based activities. This represents the way peer workers learn and keep an up-to-date understanding of their community’s needs through their personal lives and their work.
3. To organisational knowledge, practices, and resources from engagement and practitioner learning. This represents the way peer responses learn and keep an up-to-date understanding through their work and through their peer workers.
4. From practitioner learning and organisational knowledge, practices, and resources through adaptation and back into peer-based activities. This represents peer responses using their understanding to guide their work.

Membership in the health sector and policy environment

Peer responses are professional services. Their peer workers have the requisite skills, training, and expertise to provide high-quality care and support.

As mentioned before, a deep understanding of community informs the services provided. Similarly, a deep understanding of the health sector and policy environment informs their work. This includes things like:

• Keeping up to date with current best practices, health technologies, research, and so on
• Providing services that are needed but that no-one else in the sector is providing (or providing well)
• Working with other services or individuals to provide them with peer expertise and/or to gain from their different expertise

Peer work includes all kinds of public health and social services, such as:

• Medical services, such as testing and treatment
• Social services, such as housing support
• Support navigating the healthcare system
• Training and health promotion workshops
• Relevant health information in plain, non-judgemental language

Additionally, to help create healthy and safe environments for their communities, peer responses:

• Provide professional development and training to enable mainstream organisations and their workers provide more culturally safe, inclusive, and appropriate services
• Advise organisations and government on relevant issues in order to promote more equitable polices and laws
• Take part in relevant public discussions and debates in order to give voice to their community’s needs and concerns

Looking through a W3 Lens: Membership in the health sector and policy environment

You can use the W3 Framework to describe this with the following pathways:

1. Health sector and policy environment to peer-based activities through alignment, organisational knowledge, practices, and resources, and adaptation. This pathway includes the way peer responses use their understanding and place in the health sector and policy environment to inform their work.
2. Engagement to communities through peer-based activities and influence. This includes how peer responses provide services and support to communities in order to create positive change within their communities.
3. Alignment to communities through peer-based activities, influence, and the health sector and policy environment. This includes how peer responses create changes within the health sector and policy environment that positively impact communities.

What makes peer responses so effective?

In a nutshell, peer work is so effective because peer workers are simultaneously:

• Community members, so they have a personal understanding of the needs and dynamics of their community
• Health professionals, so they can understand the health system and provide professional health services

Because of this combined expertise, peer workers are:

• Highly skilled and effective in supporting their peers to navigate both community and health systems
• Supported by their communities, other peer workers, peer organisations, and other partner organisations

Peer insight and skill

Because peer workers come from, and are constantly engaging with, their community, they have a uniquely nuanced understanding of their community and its members.

We call this uniquely nuanced understanding peer insight. With each peer-to-peer interaction, these insights become broader, deeper, and more up-to-date.

Peer workers draw their insights not just from their own personal lived experience but also from:

• Their professional lives as peer workers
• The insights of other peers and peer workers

This means that peer workers build an especially strong understanding of their community, which helps them develop the unique ability to:

• Engage deeply and authentically with their community
• Develop rapport with clients and consumers, even if their identity or experiences aren’t the same
• Pre-empt and adapt to their community’s changing needs
• Predict how changes to the environment the peer response is working in might impact their community
• Understand how (and why) their community might respond to these changes

We call this unique ability peer skill. Peer skill underpins peer work and sets it apart from mainstream service provision.

Looking through a W3 lens: Peer insight and skill

You can use the W3 Framework to describe this with the following loops:

1. Peer-based activities through practitioner learning and adaptation back to peer-based activities. This represents a constant process of peer workers learning from their work, improving the way they work because of their new knowledge, and then being able to learn and improve even further.
2. Engagement to practitioner learning (directly and through peer-based activities), then through adaptation, peer-based activities, influence, and communities back to engagement. This adds to the first pathway by including the way peer workers learn from their work and their personal life, improving the way they work, which also improves the quality of the work itself. This helps them build better rapport and connect more effectively with others in their community.
3. Both of the loops above plus the arrows from engagement and practitioner learning through organisational knowledge, practices, and resources to adaptation and influence. This addition represents the fact that it is not just the individual peer workers who benefit from their peer skill. The response also benefits from the collective peer skill of its peer workers.

The fact that these are loops means they are cycles of constant improvement: improved peer skill leading to improved peer responses leading to better community connection leading to improved peer skill, and so on and so forth.

Targeted service provision

Peer responses provide high-quality, targeted support and health services that are:

• Appropriate for, and accessible to, their community members
• Wanted, needed, and trusted by their community members

Because peer workers are health professionals, they have the expertise and experience to:

• Develop comprehensive health promotion interventions
• Understand and navigate the health sector
• In some circumstances, provide clinical services

Because they are also community members with a deep understanding of (and genuine concern for) their community’s experiences, needs, and priorities, they can make sure that the services and interventions they provide are nuanced, specialised, and targeted to the specific needs of their communities. This results in services that community members are more likely to use and benefit from.

Looking through a W3 lens: Targeted service provision

You can use the W3 Framework to describe this overall process in the following steps:

1. Communities through engagement to organisational knowledge, practices, and resources (directly and through peer-based activities and practitioner learning). This is how peer responses gain their expertise about their communities. They are continuously learning from their work and lived experiences in their communities.
2. Health sector and policy environment through alignment to organisational knowledge, practices, and resources (directly and through peer-based activities and practitioner learning). This is how peer responses gain their expertise about the health sector and policy environment. They are continuously learning from their work in this system.
3. Practitioner learning and organisational knowledge, practices, and resources through adaptation to peer-based activities. This is where the peer responses and their workers take what they’ve learned and use it to make sure their services are high quality, based on the most recent understanding of the issues being tackled and targeted to community needs.
4. Peer-based activities to communities through influence. This represents how the resulting (high-quality, targeted) peer work positively benefits the community.

Adaptability

Peer responses are acutely aware of changes in their environment and rapidly adapt their approach to stay relevant and effective. They can do this because of the way they are embedded in both their community and the health sector and policy system.

Peer workers pick up signals and experience the changes in their community firsthand through their work and lived experiences in their communities.

They are also made aware of changes as they happen in the health system, through their work and their networks of connections within this system.

An effective peer response can often accurately:

• Understand how changes may affect its community
• Pre-empt how its community might react or respond to changes

Peer responses use this knowledge to adapt their approach to protect and enhance their community’s safety and wellbeing.

This might mean taking advantage of positive changes to further improve their work. An example of this could be incorporating new or improved medical technologies or information into their work.

Or it might mean taking steps to mitigate negative changes. An example of this could be starting an advocacy campaign against new legislation that discriminates against their community members.

Looking through a W3 lens: Adaptability

You can use the W3 Framework to describe this overall process in the following steps:

1. Communities through engagement to organisational knowledge, practices, and resources (directly and through peer-based activities and practitioner learning). This is how peer responses know what is changing in their communities.
2. Health sector and policy environment through alignment to organisational knowledge, practices, and resources (directly and through peer-based activities and practitioner learning). This is how peer responses know what is changing in the health sector and policy environment.
3. Practitioner learning and organisational knowledge, practices, and resources through adaptation to peer-based activities. This is where the peer responses and their workers make sure they respond to the changes they’ve learned about in order to benefit or protect their communities.
4. Peer-based activities to communities through influence. This represents the times that the peer response’s activities directly benefit the community (for example, through direct service provision).
5. Peer-based activities to communities through influence, and the health sector and policy environment. This represents the times that the peer response’s activities indirectly benefit the community by improving the way the health sector and policy environment works for their communities.

Trustworthiness, credibility, and influence

Peer responses are trusted sources of credible information for both their communities and the health sector and policy environment. This comes down to three strengths that stem from membership and work in both systems.

Firstly, that peer responses are part of, working for, and owned by their communities promotes community trust in their work. This is especially important among communities who have experienced of discrimination and poor service at the hands of mainstream healthcare providers.

Secondly, they have unique expertise about the issues facing their community. This expertise comes not only from their community expertise but also from their expertise as health professionals. This gives credibility to any advice or information they develop related to their community.

Finally, they are professional health service providers, which promotes confidence in the quality of their services.

Peer responses are vital points of information for community members about any changes in the health sector and policy environment. (This was shown during the start of the COVID-19 pandemic, when communities turned to their peer responses for answers about how the new coronavirus might affect them.)

Similarly, they are often the health sector and policy environment’s only source of real-time information about what is happening in communities.

All of this together creates a unique platform from which peer responses can:

• Create positive, meaningful, lasting change within communities
• Support mainstream health services to improve their services for vulnerable communities
• Generate high-level system and policy changes

Looking through a W3 lens: Trustworthiness, credibility, and influence

You can use the W3 Framework to describe this in the following pathways:

1. The loop between communities and community. This represents how peer responses are embedded in communities.
2. Communities through engagement to organisational knowledge, practices, and resources (directly and through peer-based activities and practitioner learning). This shows how peer responses gain expertise about the issues facing their community through their lived and professional experience.
3. Health sector and policy environment through alignment to organisational knowledge, practices, and resources. This shows how peer responses gain further expertise about the issues facing their communities from the perspective of health professionals.
4. Practitioner learning and organisational knowledge, practices, and resources through adaptation to peer-based activities. This is where the peer responses and their workers use their expertise to develop credible advice, information, and services.
5. Peer-based activities and organisational knowledge, practices, and resources through influence to communities. This represents the way peer responses work to benefit their communities.
6. Peer-based activities and organisational knowledge, practices, and resources through influence and health sector and policy environment to communities. This represents where peer responses work to support the health system and policy environment to benefit (or at the very least, not harm) their communities.

The combination of 5 and 6 above are how peer responses can create positive, meaningful, and lasting change within communities.

Challenges faced by peer responses

Despite its effectiveness, peer work faces considerable challenges.

Community membership makes peer responses susceptible to the same environmental factors and changes that impact their communities. Discriminatory and stigmatising social attitudes, policies, and laws create challenges and barriers, which are often amplified by limited funding.

Peer responses are also susceptible to the same factors that affect any other health services, such as:

• Funding limitations
• Public opinion
• Changing policies
• Politics and elections

These challenges mean that often, peer responses must work harder than mainstream services to:

• Ensure safe working environments for their workers
• Secure funding and support for their work

Using the W3 Framework to overcome challenges

The W3 Framework provides a structured way of looking at and describing how peer responses work.

In addition to being useful for explaining what is happening, the W3 Framework can help peer responses look at what should be happening. This can help peer responses evaluate and identify where they can improve their work.

In time, this information should help peer responses better demonstrate their value to potential funders.

Keen to learn more about peer work in public health?

If you’re still eager for more information about how peer-led responses work, you may enjoy ‘Five surprising things we learned about peer-based programs‘.