Five surprising things we learned about peer-based programs

Co-author: Daniel Reeders, Research Officer (W3 Project Stage 1)

Five surprising things we’ve learned about peer-based programs

A young woman, Jess, stops in briefly at a needle and syringe exchange. 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 her partner’s friends. Its reach within networks of people who use drugs has increased. This creates new opportunities for practical education about safer drug use, and helps Jess and her friends manage risks and avoid harm.

Vignette based on a scenario we discussed with staff from a peer-based needle and syringe program

During a workshop, 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 spotted needs and opportunities we hadn’t thought of 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 about peer approaches. These things might come as a surprise if your only knowledge about peer approaches comes from published research.

1: ‘Peer’ is more about skill than just sameness

‘Same same–but better’

There’s a lot of debate about what is a ‘peer’ in peer-based health promotion. The literature and international guidance on peer programs often emphasise the need for peer workers to be ‘same same–but better’. (Maybe not quite in those words, though).

They often claim that peer workers/volunteers should match clients/participants in all relevant characteristics, such as age, gender, sexuality. At the same time, they should be people who participants can look up to. (Or, at least, they could be with the right training.) That is to say, they should be ‘role models’.

However, this limited view of a peer is not consistent with how the staff from the peer-based programs we worked with discuss the concept.

Cultural peers

Participants emphasised the idea of a ‘cultural peer’. This is as opposed to 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 to you in some aspects but quite different in many others. The key is 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: ‘Community is the relation that arises even among those with nothing in common …’

Peer skill

Participants also strongly emphasised the need for ‘peer skill’ – not everyone can work 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.

We know that good peer workers constantly learn and refine their knowledge. But we started to consider if peer skill might be something that can’t be taught. It certainly does not seem to be the same as the communication and facilitation skills taught to new peer workers.

One peer worker who had worked in a range of peer roles described peer skill with people who use drugs. They likened it to a sex worker’s ability to assess a client’s mood and 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 also help explain the particular value and resonance of the peer approach in marginalised communities.

2: Peer approaches are not about disseminating information

Our review of the literature for this program found numerous examples of non-peer organisations:

1. Recruiting respected members of a target community
2. Sitting them down in a classroom environment
3. Training them in an expert-developed curriculum
4. Tasking them to replicate this experience in small groups of their community members
5. Calling this an innovative ‘peer’ approach

By contrast, practitioners in our workshops understood peer approaches as involving a two-way exchange of knowledge. That is to say, the peer worker also learns from the peer client/contact.

Indeed, having knowledge they can exchange with peer workers was viewed as one reason clients may feel they don’t come to peer services empty-handed. They have insights to share and confidence their information will be respected and used appropriately. Participants in one workshop described this confidence as a sense of ‘ownership’.

Some participants contrasted this experience with the stigmatising ‘deficit model’ that they felt was imposed on clients accessing mainstream services. (Hospital-based needle and syringe programs are one example.)

3: Peer programs can be an asset to organisation strategy and policy advocacy

The previous insight describes a view held by some researchers and policymakers that peer programs are all about disseminating information. If widely held, it could limit the contribution of peer programs to community-level and organisational-level prevention strategies.

Our workshop participants talked about their own constantly evolving mental models of their work and the cultures/communities they engage with. They noticed patterns and changes in the needs and issues raised by client encounters. As members of the community they engage with, peers felt better able to understand not just what changed but why. This enabled them to try new things or advocate internally to meet new and shifting needs.

We would argue that peer-based programs are sites of constant practical innovation. However, the knowledge generated by this process is often not shared or recorded. It can stay within individual workers’ heads, or get discussed (but not documented) by their team.

Social research is too slow to reflect real-time trends accurately

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 a situation has already changed.

Within the broader health sector, peer-based programs may be 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 knowledge from peer-based programs and translate it 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 or discipline where a peer program is situated. This situation was sometimes described as a ‘silo’ effect.)

Our preliminary analysis suggested 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. That is, when they can answer questions like, ‘How widespread is this problem?’ and ‘Whose perspective does this story represent?’

4: Lower-quality non-peer services might be ‘being let off the hook’ by peer services

One workshop participant talked about the role his organisation plays within its state’s alcohol and other drug sector. He described it 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 other services that excluded or refused treatment for people who currently use drugs or people with mental health conditions who use drugs.

The peer organisation’s lack of exclusion criteria and flexible service model were points of pride for staff in that workshop. However, it had an important unintended consequence.

Having a ‘safety net’ service in the local sector seemed to let non-peer services ‘off the hook’ by reducing their need to:

• Address gaps
• Improve the quality and flexibility of their services
• Address their stigmatising or exclusive attitudes and practices

Of course, we are not saying it’s a bad thing to have a safety net. From the client’s perspective, it is absolutely vital. From a funder’s perspective, it helps reduce the number of people falling through the cracks. But it also means that ‘safety-net’ services may be trying to meet more complex needs with the same performance indicators.

For peer-based programs in this situation, it would be important to understand the extent to which they use their program resources responding to gaps in the broader service environment. Programs could then use this practice knowledge in policy advocacy to re-define what counts as success and create incentives to reorient health services.

5: Prevention might be an emergent effect of the networks and cultures that peer-based programs engage with

We held one of our workshops with health promotion workers from a range of organisations responding to the HIV epidemic in Australia among HIV-positive and HIV-negative gay men and other men who have sex with men.

In our workshops, we collaboratively drew a system map of the interconnected causal influences from program activities and other social determinants of HIV transmission. We then asked participants to nominate three items or relationships they thought:

• Would be most important to keep track of in order to monitor whether the system was working the way we’d mapped it
• We could take our eyes off if it looked like the system was working

One group said something that seemed a bit counter-intuitive. They suggested we could take our eyes off the national strategy goal of ‘HIV prevention’. This idea is worth exploring in more depth.

They were not 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 used systems thinking to articulate how practitioners in peer-based programs understand their work and the networks, communities, and culture they engage with.

This post was previously published on the original W3 Project website in July 2014. It was most recently edited and updated in April 2022.