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‘On the same level’: facilitators’ experiences running a drug user-led safer injecting education campaign Callon, Cody; Charles, Grant; Alexander, Rick; Small, Will; Kerr, Thomas Mar 6, 2013

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RESEARCH Open Access‘On the same level’: facilitators’ experiencesrunning a drug user-led safer injecting educationcampaignCody Callon1,2, Grant Charles2, Rick Alexander4, Will Small1 and Thomas Kerr1,3*AbstractBackground: Unsafe injection practices play a major role in elevated rates of morbidity and mortality amongpeople who inject drugs (IDU). There is growing interest in the direct involvement of IDU in interventions that seekto address unsafe injecting. This study describes a drug user-led safer injecting education campaign, and exploresfacilitators’ experiences delivering educational workshops.Methods: We conducted semi-structured qualitative interviews with 8 members of the Injection Support (IS) Teamwho developed and facilitated a series of safer injecting education workshops. Interviews explored facilitator’sperceptions of the workshops, experiences being a facilitator, and perspectives on the educational campaign.Interviews were transcribed verbatim and a thematic analysis was conducted.Results: IS Team facilitators described how the workshop’s structure and content enabled effective communicationof information about safer injecting practices, while targeting the unsafe practices of workshop participants.Facilitators’ identity as IDU enhanced their ability to relate to workshop participants and communicate educationalmessages in language accessible to workshop participants. Facilitators reported gaining knowledge and skills fromtheir involvement in the campaign, as well as positive feelings about themselves from the realization that theywere helping people to protect their health. Overall, facilitators felt that this campaign provided IDU with valuableinformation, although facilitators also critiqued the campaign and suggested improvements for future efforts.Conclusions: This study demonstrates the feasibility of involving IDU in educational initiatives targeting unsafeinjecting. Findings illustrate how IDU involvement in prevention activities improves relevance and culturalappropriateness of interventions while providing individual, social, and professional benefits to those IDU deliveringeducation.Keywords: Injection drug use, Safer injecting education, User-led interventionBackgroundInjection drug use is a growing public health concern,due to the morbidity and mortality observed amongpeople who inject drugs (IDU) [1-5]. IDU are vulnerableto an array of health related harms, including but notlimited to HIV, hepatitis C, bacterial and fungal infec-tions, and venous damage [3,6-9]. Many of these healthharms are the result of unsafe injection practices, whichare preventable given proper preparation and adminis-tration of drugs by injection.In response to increased concern for the health and wellbeing of IDU, a number of intervention and preventionstrategies have been implemented to address the harmsstemming from injection drug use. Most prominentamong these are distribution of sterile syringes and injec-tion paraphernalia [10-12], harm reduction outreach pro-grams [13,14], medically supervised injection facilities[15-17], and educational and behavioural interventions[18-20]. Educational materials such as posters and pam-phlets are a mainstay of educational programs, and manypublic health initiatives are founded on the assumption* Correspondence: uhri-tk@cfenet.ubc.ca1British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada3Department of Medicine, Faculty of Medicine, University of British Columbia,2194 Health Sciences Mall, Vancouver, BC V6T 1Z3, CanadaFull list of author information is available at the end of the article© 2013 Callon et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (, which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly cited.Callon et al. Harm Reduction Journal 2013, 10:4 IDU lack knowledge regarding correct injection pro-cedures [21,22]. However, there is a pronounced lack ofevidence-based evaluation of these materials. Despite im-plementation of all of the aforementioned interventionand prevention strategies in Vancouver Canada, researchshows that high rates of unsafe injecting persist [23-26].Given ongoing injection related problems, there is agrowing interest in the involvement of IDU in initiativesthat address unsafe injecting practices and the associatedadverse health consequences and costs. Researchers ina number of settings internationally have implementedpeer-driven network oriented HIV prevention interven-tions in which public health experts train peer leaders todisseminate prevention information and supplies throughmicro- and macro- networks of IDU [27-32]. Evaluationof these approaches highlights several advantages of peersover traditional outreach methods. Peers are often viewedas more credible and influential sources of information[27,28,33], and have the ability to use already establishednetworks to reach more hidden and diverse populations ofIDU [27,28,33,34]. Furthermore, peers are able to reachIDU with prevention information and supplies in placesand at times when high-risk behaviours are most likely tooccur [27,28,33], and peer-based education is often morecost effective than traditional outreach programs [27,28].Much less is known about the effectiveness of inter-ventions that have been developed by IDU, which haveemerged from drug-user led efforts to address the harmsassociated with unsafe injecting. Although descriptionsof user-led organizations of IDU in Europe and Australiaare available in the literature [35-38], there are few eval-uations of the educational initiatives developed by thesegroups. Evaluations of the Mitsampan Harm ReductionCentre operated by the Thai Drug Users Network inBangkok, Thailand, and programs organized by theVancouver Area Network of Drug Users in Vancouver,Canada, show that these user-led initiatives extend thereach and effectiveness of harm reduction servicesavailable in these areas [39-43].Given the remarkable lack of description and evaluationof user-led approaches to reducing the harms associatedwith injection drug use, and complete absence in theliterature of the perspectives of IDU that lead user-ledinterventions, we conducted a qualitative explorationof facilitators’ experiences leading a user-led saferinjecting education campaign.The VANDU Injection Support TeamThe Vancouver Area Network of Drug Users (VANDU)is active in direct action and advocacy, and has run avariety of drug user-led programs, including needledistribution and recovery, an outreach-based alley patrolprogram, as well as various action, education, and sup-port groups [40]. In response to the harms associatedwith assisted and unsafe injection practices, VANDUexpanded their alley patrol program in August 2005 todevelop an ‘Injection Support Team’ (IS Team), whichfacilitates education and engagement with large numbersof IDU. The IS Team is composed of nine current andformer IDU who are recognized as ‘hit doctors’, individ-uals who are regularly asked to provide assistance withinjections, within the local injecting scene. This group ofindividuals initiated the IS Team on a volunteer basis inresponse to the ongoing harms associated with unsafeand assisted injecting, as well as the prohibition onassisted injections at the supervised injection facility. Fol-lowing the establishment of the IS Team, a community-based research project was initiated in partnershipbetween VANDU, the IS Team, and the British ColumbiaCentre for Excellence in HIV/AIDS. The IS Team devel-oped the following mission statement emphasizing theirbasic purpose and activities:The VANDU IS Team is a user-led program thatprovides peer-to-peer education and assistance topromote safer injecting practices. Through advocacyand outreach the IS Team seeks to reduce the harmsresulting from unsafe injection and preserve the healthof injection drug users.Although the IS Team began as an outreach-basedprogram, there was ongoing interest among the IS Teammembers in developing a safer injecting education cur-riculum that could be delivered in a group setting. Whenthe IS Team decided to undertake this curriculum devel-opment process, all IS Team members were invited toparticipate, and only one member declined the oppor-tunity. Curriculum development and workshop facilita-tion responsibilities were then divided amongst the ISTeam members based on their individual interest andexpertise.The IS Team education campaignUtilizing a participatory education approach [44,45]drawing on research findings, outreach activities, andcommunity consultation, the IS Team developed a cur-riculum, training materials, and novel demonstrationprocesses for five 90 minute workshops promoting saferinjecting practices. The IS Team education campaignwas implemented between November 2009 and April2010 at five separate locations in Vancouver’s DowntownEastside (DTES) including, the VANDU storefront office,two NGO operated single room occupancy hotels, andtwo public drop-in centres.The first workshop in this campaign described variousunsafe injection practices (e.g., sharing syringes andother paraphernalia, jugular injections, and assisted in-jection), provided an overview of the history, training,Callon et al. Harm Reduction Journal 2013, 10:4 Page 2 of 10 outreach activities of the IS Team, and outlined theformat and content of upcoming workshops. The secondworkshop focused on the consequences of unsafeinjecting including, information on how bacteria getsintroduced during the injection process, adulterants andadditives commonly contained in illicit drugs, anddescription of the viral infections, venous damage, andbacterial infections resulting from unsafe injection prac-tices. This workshop concluded with a discussion of thelocations where participants can access relevant healthcareservices. The third workshop involved step-by-step handson demonstrations and practice of injecting skills andtechniques concurrent with a discussion of why each stepis important. Common barriers and challenges to safeinjecting (e.g., lack of supplies, not having a safe place toinject, and police surveillance and interference) werediscussed, as were strategies that can be used to injectsafely more often. The fourth workshop provided step-by-step demonstrations on how to correctly prepare variousdrugs common in the local context including heroin, co-caine, crack, methamphetamine, and a range of divertedpharmaceuticals1 for injection. The final workshop cov-ered transmission and prevention of HIV and hepatitis C,attempted to dispel common myths about these diseases,and provided information about where testing, treatment,and other services are available.Each workshop was facilitated by three IS Team mem-bers. The IS Team education campaign utilized a mixtureof visual learning materials, including PowerPoint slides,poster sized images, and handouts, to visually communi-cate step-by-step processes, various symptoms of illnesses,and modes of disease transmission. In workshops involv-ing demonstrations, facilitators divided participants intothree smaller groups where they discussed, demonstrated,and supervised proper technique and procedure for prep-aration and administration of injections. IS Team mem-bers’ facilitation style involved a participatory educationapproach in which facilitators and workshop participantsengaged as equals and co-learners in the educationprocess. Drawing on the collective knowledge and experi-ences of each group, facilitators provided contextually ap-propriate safer injecting education while using real lifestories and scenarios to stimulate broader discussion ofrelevant myths as well as the challenges and barriers tosafer injecting practices. Within workshops, facilitatorsaimed to promote mutual support based on shared experi-ence and equality, while emphasising a harm reductionapproach focused on caring and self-preservation. Facilita-tors were compensated $20 (CAD) for each workshop andworkshop participants received $3 (CAD) for their partici-pation. Compensation rates were openly negotiated be-tween the IS Team members and the VANDU Board ofDirectors, and were consistent with the compensationstructure used at VANDU.MethodsThis project utilized a community-based research approach[46,47] involving active collaboration with members of theIS Team throughout the planning, development, andimplementation of the project. A member of the researchteam (CC) attended all planning and development meet-ings related to the IS Team education campaign, observedall IS Team education campaign workshops, and activelysought team member’s opinions and feedback on researchprocess and emerging themes.In-depth interviews were conducted with IS Teammembers to discuss their perceptions of the workshopsthey facilitated, their experiences being a facilitator, andtheir perspective on the overall IS Team education cam-paign. All IS Team members who facilitated educationcampaign workshops were invited to participate in aninterview. All interviews lasted between 50 and 80minutes and were conducted between June and August2010.Interviews were facilitated using a semi-structuredtopic guide to encourage discussion of how IS Teammembers viewed the format and content of the educa-tion campaign, how this compared to their previousexperiences with safer injecting education, how they per-ceived their role within the campaign, and perspectiveson facilitating drug user-led safer injecting education.All interviews were audio-recorded and transcribedverbatim. A qualitative descriptive methodology wasemployed for the analysis of these interviews [48].Analysis began with a detailed open coding of transcriptsand theoretical memoing in Atlas.ti software, then vali-dated through systematic review using a constant com-parative analysis [49,50]. One member of the researchteam (CC) was responsible for conducting all interviewsand coding all transcripts. Emergent themes and relevantexcerpts from the interviews were shared and discussedwith all IS Team members to ensure accuracy ofinterpretations.Every IS Team member interviewed provided in-formed consent to participate, and the study was under-taken with appropriate ethical approval granted by theProvidence Healthcare/University of British ColumbiaResearch Ethics Board. IS Team members were compen-sated for their time in the research interview with a $20(CAD) honorarium. There were no refusals of the offerto participate in the interview, and no drop-outsoccurred during the interview process.ResultsIn total 340 unique individuals attended IS Team educa-tion workshops, including 157 (46%) women, 177 (52%)men, and 6 (2%) transgendered individuals. IS Teammembers who participated in qualitative interviews in-cluded 3 females and 5 males. The median age of ISCallon et al. Harm Reduction Journal 2013, 10:4 Page 3 of 10 members was 47.5 (range = 35–59 years). The ISTeam included a mix of Caucasian and Aboriginal mem-bers as to reflect the demographic of the local drugusing population. One of the nine IS Team memberswas not asked to participate because he withdrew fromthe team early in the development phase of this educa-tion campaign. Representative excerpts from the qualita-tive interviews are presented below in order to illustratethe central themes that emerged in the analysis. Consid-erable overlap was observed across thematic areas.Format and content of IS Team educational workshops -‘it taught the nitty gritty of what you’re doing’IS Team facilitators described a number of aspects ofthis education campaign that contributed to their abilityto communicate information about safer injecting prac-tices while identifying and addressing the unsafe prac-tices of workshop participants. Facilitators expressedthat an important aspect of the curriculum was that itwent beyond the mechanics of safe injection, to describewhy each step is important, and the consequences thatcan arise from incorrect implementation.That’s why our workshops were so successful, becauseit taught the nitty gritty of what you’re doing and whatyou’re doing wrong . . . tell ‘em why it’s not right youknow, and make it so the right thing fits into theirritual. Not to stop doing it, but make it fit into theirritual. (Female Facilitator #1)The participatory and interactive nature of these work-shops was seen as a critical factor in engaging partici-pants. This enabled discussion of the realities ofindividual’s injecting rituals, the context in which theyuse, and the strategies that can be implemented to im-prove injecting practices.You could tell some people got really jazzed when theywere talking about personal experiences and stuff.Which I thought was a really good thing . . . becausepeople’s own experiences, that’s what it’s all aboutright? . . . Cause we’re talking about it from a, this isthe way it should be, not necessarily the way it is, andthey’re talking about it from the way it is. So I think itwas really important. (Male Facilitator #2)An example of a common barrier to enacting risk re-duction practices frequently identified within workshopswas the inability to access sterile cookers necessary tocorrectly prepare drugs for injection. IS Team facilitatorsemphasized the importance of always mixing and filter-ing drugs prior to injection, and a common solution theyproposed was to carry a metal spoon or use theconcaved bottom of a beverage can for mixing, whilealways being sure to disinfect the preparation surfacewith an alcohol swab.Most facilitators reported that facilitating with twoother IS Team members was a strength of the educationformat. Working in groups of three created structureamong facilitators, while allowing them to educate basedon their topics of expertise, and enhancing opportunitiesto incorporate stories with their explanations.I was the more structured one and he was the more offthe cuff type of guy. Like when questions came up andstuff he had more information because of hisexperience. (Male Facilitator #2)The use of various forms of education materials and dif-ferent teaching styles were described as major strengths ofthe campaign because it engaged a wide range of partici-pants with different learning needs. It is notable that theimages utilized were described as particularly useful forcommunicating the severity of the consequences of unsafeinjecting, and assisted facilitators in maintaining theirfocus when interacting with workshop participants.The shock value of the pictures and then being able tonote how not to let that happen to yourself, it wasreally good . . . it also gave us something to focus on . . .if we got lost on something we could just turn to thepictures. (Female Facilitator #1)Shared identity of facilitators and participants - ‘in thesame sort of head space’All IS Team facilitators expressed that their knowledgeand experience as IDU fostered a sense of shared iden-tity and equality with workshop participants, which en-couraged trust and rapport. This also allowed them topresent safer injecting information with examples andlanguage that was appropriate and easy to understand.The people that were facilitating it and the peoplethat were the members, they’re more or less on thesame level. So you could understand, [you] don’t haveto ask questions or why they didn’t get that, you justknow right. Cause you’re both in the same sort of headspace, you’re street people right. (Male Facilitator #3)Many facilitators described their familiarity with work-shop participants as increasing their credibility and mak-ing participants more comfortable asking questions orsharing information.I sound like I’m just talking with buddies cause I’mjust sitting there talking to people that I know . . . Andthere’s the other part of it, I’m not at the front of theroom because I’m more important than you, I’m justCallon et al. Harm Reduction Journal 2013, 10:4 Page 4 of 10 one that’s doing most of the talking, but you guyskick in when you can cause you guys want answers asdo we, and I’m trying to draw them out and get themto participate. (Male Facilitator #6)Facilitators identified how having IDU as facilitatorsminimized power dynamics that frequently exist betweeneducators and learners. Facilitators expressed that theirapproach differed from their previous experiences re-ceiving safer injecting information.We’re them, it’s not like we’re gonna preach to them. . . Most of them [formal educators] kind of seem olderor else like they’re trying to talk at them, talk down tothem. It’s more of a classroom type way they talkinstead of talking like friends or drug users talk toeach other, the same way we’re talking . . . You canpick up more that way cause you don’t feel like you’rebeing lectured to. (Male Facilitator #4)Facilitator’s personal gains - ‘it was a really goodexperience for me’IS Team facilitators articulated various personal gainsfrom their involvement with the campaign, as mostexpressed that facilitating these workshops improvedtheir overall confidence and public speaking skills. Facili-tators also expressed that workshops enhanced interper-sonal social skills and network connections, as well aschanging their attitude towards dealing with other orga-nizations and professionals.I’d gotten into pretty much a mode where I’d just hangout by myself so I didn’t really talk to anybody. This. . . got me back on meeting people, and talking topeople, and realizing the common ground with otherpeople in the community. (Male Facilitator #7)I have developed a more professional attitude whendealing with professionals. I’m more polite, courteous,well-spoken, time to listen. I’ll do everything but wearthe tie and nametag. (Male Facilitator #6)Facilitators also described the positive feelings theygained from the realization that they were making a dif-ference by helping people to protect their health.The idea of imparting knowledge to people that ishopefully going to do something positive for them, Imean, what’s better than that . . . Especially when youknow there’s a need for it. . . . Like I said, when I firstgot into it, it was just for the financial thing, but onceI got into it, knowing that you’re actually making adifference, that you might actually help someone orsomething, that’s a good feeling. I’ve never done thattype of thing, so it was a really good experience for me.(Male Facilitator #2)A few facilitators reported the added benefit of makingchanges to their own injecting practices based on infor-mation they learned through the development and im-plementation of the campaign. For example, facilitatorsreported using alcohol swabs and ties more consistentlyand avoiding the re-use of their own syringes.Campaign impact - ‘it works . . . it’s better’IS Team facilitators overwhelmingly felt that this cam-paign provided participants with valuable safer injectinginformation, some of which including information onprevention of bacterial infections and how to correctlyprepare various drugs for injection, is not currentlyavailable anywhere else. Most facilitators articulated thateducational workshops not only change injection prac-tices, but also have the added benefit of connecting IDUwith VANDU and other health services.I hear it from people every day. Every day somebodycomes up to me and says something. Oh, I tried this,I tried that. It works, it works, it’s better. Can I go totreatment? Where do I go to treatment? You know justquestions that were all brought up from thoseworkshops. And it brought a lot of people to VANDU.(Female Facilitator #1)Although all IS Team facilitators spoke of the value ofproviding IDU with accurate information about prepar-ation and administration of injections, they also empha-sized numerous contextual barriers and challenges thatcan make injecting safely difficult. Most commonly,facilitators identified not having a safe place to injectand fear of the police as the predominant contextualfactors that can make it difficult to implement saferinjecting knowledge.If people don’t have a home, if they don’t have a sterileplace, if they’re forced to try to hide in a back alley, orin a bush, or some other place where they can’t befound cause they’re so scared of cops. How do youexpect any part of that to be clean or safe?(Female Facilitator #8)Given the limits of education in addressing contextualfactors that perpetuate unsafe injecting, facilitators artic-ulated a desire to expand and improve their activities topursue broader change beyond education. Their sugges-tions predominately focused around opening a user-led fa-cility and further expanding their outreach activities.Callon et al. Harm Reduction Journal 2013, 10:4 Page 5 of 10 a separate spot off the VANDU property thatpeople could come to get assisted injection and have acoffee, you know stuff like that . . . A safe [inhalation]site, a safe injection site, that’s not run by governmentfrigging employees. (Male Facilitator #7)Numerous facilitators suggested that it would be benefi-cial to expand their outreach activities beyond provisionof harm reduction supplies and safer injecting educationto assist with finding housing, provision of lifeskills, assist-ance finding employment, and support in accessinghealthcare and addictions services.Criticisms and suggestions - ‘I wanted to do more’Criticisms of the campaign varied from facilitator to facilita-tor based on their experiences and the specific workshopsthey facilitated. A number of the facilitators identified otherfacilitators arriving at workshops sick, or not showing up,as major issues that impacted the rest of the facilitator’sability to properly cover workshop curriculum.Sometimes she would be sick when she came in, andshe wasn’t very together, so that’s when I’d have toprolong the workshop I was doing.(Female Facilitator #1)A few people didn’t show up to do it . . . they’d go anddo something else. (Male Facilitator #7)A couple facilitators also indicated that sharing of mis-information was a problem that sometimes occurredduring workshops when facilitators deviated from factsto opinions.She was giving her own personal opinion on thingsthat weren’t actually proven to be true and we don’twanna give that kind of information out.(Female Facilitator #1)Although facilitators spent a significant amount of timedeveloping workshop curriculum, no time was spent priorto the implementation of the campaign developing the fa-cilitation skills of the IS Team members. A few facilitatorsnoted that managing a large group of IDU can be difficult,and that they would have benefited from more time spentdeveloping facilitation skills before starting the campaign.I’d of had better preparation for the facilitators . . .maybe it would be a practice class. I don’t know howto solve the problem. (Male Facilitator #6)Facilitators noted that information on overdoses wasmissing from the curriculum and could have been addedto strengthen the overall campaign.I wanted to do more things to let people know to givemouth-to-mouth if your buddy goes down [overdoses]in a hotel room. Cause through Christmas time we losta few people just because they didn’t breathe. Nobodygave them mouth-to-mouth. (Female Facilitator #5)Culture and gender specific issues were also identifiedas important types of information that were missingfrom the curriculum. While information regarding issuescommonly experienced by female injectors (e.g., assistedinjection) was included in the workshops, some felt thatit would be beneficial to incorporate increased emphasison particular elements to better address gender-specificeducational needs.There’s issues that women deal with that are differentfrom men. Like maybe they don’t know how to injectbecause they’ve always been hit [injected] by theirboyfriend . . . With the women you can haveinformation based on jugging [injecting into thejugular vein] and why this is more common . . . moreinformation on the different reasons people use, youknow women are more affected by emotional things,we could talk about that. (Female Facilitator #8)Similarly, this facilitator suggested that these work-shops might have had a greater impact on AboriginalIDU if specific information was included on the highrates of injecting related morbidity among this sub-population.I think you could stress what huge a problem this isfor the Aboriginal community . . . maybe they’re notaware of how serious and how terrible a thing this is. . . and maybe by educating them they would becomemore concerned and maybe it would change things.(Female Facilitator #8)One of the facilitators of the HIV and hepatitis Cworkshop felt that they were not fully prepared to re-spond in-depth to participants’ questions about thesediseases and treatments available.It should’ve been two workshops. One on hep C andone on HIV because I don’t know all that much aboutHIV . . . And maybe a nurse with it because there’s lotsof HIV facts and stuff that you need a nurse to tell youabout, your medications and stuff, that I just wasn’tprepared for. (Female Facilitator #1)Facilitators of this particular workshop felt that itcould have been improved by incorporating the technicalexpertise of a professional educator alongside IS Teammembers.Callon et al. Harm Reduction Journal 2013, 10:4 Page 6 of 10 this study, facilitators described how aspects of ISTeam workshop structure and content, including theparticipatory approach, facilitating in groups, and thevariety of educational materials used, helped facilitatorscommunicate information about safer injecting practiceswhile addressing the realities of participant’s injectingrituals. Facilitators felt that their knowledge and experi-ence as IDU increased their credibility and allowed themto communicate with workshop participants in clear andunderstandable ways. Most IS Team facilitators reportedgaining knowledge, skills, and positive feelings aboutthemselves from their involvement in this educationcampaign. Overall, facilitators felt that this campaignprovided IDU with valuable and necessary safer injectinginformation, however facilitators also provided criticismsand suggestions for future improvement.The findings that facilitators’ experiences as IDU in-creased their credibility as educators is consistent withother studies demonstrating that knowledge from per-sonal experience and trust are important aspects of peerinterventions, which contribute to greater credibility andinfluence over behaviour change [27,33,37,40]. Givenconsiderable local variation among cultures and historiesof IDU, researchers have argued that successful interven-tions targeting this population need to involve IDU withextensive knowledge and local experience [40,51]. Previ-ous research on interventions involving IDU as educatorsand outreach workers suggests that these individuals havethe most knowledge and best information about the expe-riences and current practices of IDU [27,28,37,40]. This issupported by study results indicating that IS Team facilita-tors utilized their existing knowledge of commonly occur-ring unsafe injecting practices to identify mistakes madeby local IDU during preparation and administration of in-jections. Based on their own experiences, facilitators wereable to adopt a pragmatic approach to discussing variousinjection practices by identifying why each step is import-ant, potential consequences of unsafe practice, anddiscussing the contextual factors that can make followingthese steps difficult, as well as the strategies that can beused to address them. Through their focus on commonbarriers to safer injecting and navigating common situa-tions experienced by local IDU, the IS Team campaignnot only expands the reach of safer injecting education,but also incorporates novel elements which are not cur-rently available elsewhere. Furthermore, examinations ofpeer-driven interventions from other settings have shownthat IDU involvement provides built-in accommodationto the cultural and ethnic diversity of the IDU populationby couching prevention and intervention messages in lo-cally appropriate terms [28,52,53]. The results of thisstudy further these findings by showing that IS team facili-tators were able to communicate and share information ina language accessible to workshop participants, and weresuccessful in drawing from their own experience to enablediscussions of the realities of participants’ injecting rituals.Facilitators emphasized that this mutual understandingminimized unequal power dynamics often existing be-tween educators and learners, which have been identifiedby other researchers as being counterproductive to educa-tional goals [37,52].Previous research has found that peer involvement inprevention and advocacy work leads to positive identityand pro-social role development, engendering a sense ofpurpose and self-respect among IDU, which contraststhe stigma often imposed on them by society [40,53,54].The present study supports these findings as most facili-tators reported developing social and professional skillsas a result of their involvement in IS Team workshops.Furthermore, many facilitators described the positivefeelings they gained from realizing that they were mak-ing a difference in their community by helping people toprotect their health. This is consistent with research onmotivation among peer workers showing that concernfor one’s own community and gaining satisfaction fromhelping others are major motivators for conducting peerprevention work [27,53]. Facilitators also reported im-proving their own injection practices following the ISTeam education campaign. This is consistent with exam-inations of peer leaders within larger social network in-terventions showing that peers involved in educationand outreach report the greatest reductions in injectionrisk behaviours after a follow-up period [27,28,30,53,54].The results of this study suggest that employing non-users in prevention and intervention work restricts IDUfrom receiving the aforementioned benefits of this typeof work, while evidence indicates that they may in factbe the most suitable candidates to deliver educationalmessages.Results of the present study indicate that the IS Teameducation campaign provided participants with culturallyappropriate safer injecting education that addressed is-sues relevant to local IDU. In this way, the IS Team con-tinues a tradition of education and support programs atVANDU that meet the immediate needs of IDU locally[40,41,43]. This is consistent with research on the harmreduction and prevention activities of user groups andIDU in other settings demonstrating that IDU are cap-able of active participation in their individual and col-lective health and often develop novel interventions thatextend the range of existing services [38-41,51,55]. Facil-itators’ experiences in this campaign also raised a fewpractical considerations for the development anddelivery of these types of programs in the future. First,facilitator’s participation was frequently impacted by in-stabilities such as illness and competing priorities, whichare common in the lives of IDU, and must be plannedCallon et al. Harm Reduction Journal 2013, 10:4 Page 7 of 10 and navigated within the development and imple-mentation of user-led projects. Other VANDU programshave addressed this issue by training multiple individualsfor each role within a program, then arranging for theseindividuals to fill in for one another if someone missestheir appointed duty. Second, although the facilitatorsspend a large amount of time on curriculum develop-ment, there was a greater need to develop their present-ing skills before starting the campaign, and workshopsinvolving detailed medical information would have bene-fited from the addition of a professional educator suchas a nurse. Overall, the findings of this study indicatethat greater efforts are needed to support existing user-led initiatives and to promote their growth and develop-ment as a means of providing education and services toIDU. Furthermore, health authorities and service pro-viders developing services for IDU should incorporatethe perspectives of IDU in service development andimplementation to improve the relevance and culturalappropriateness of these services.The present study has a number of limitations. First,the study focused exclusively on the perspective of indi-viduals who were directly involved in the developmentand facilitation of IS Team education workshops. Assuch, the views presented by IS Team members may notbe representative of the experiences of IDU involved inother interventions. Second, the perspective of one of theinitial IS Team members was not captured because hewithdrew from the team early in the development phaseof this education campaign. This member withdrew topursue another employment opportunity, although wehave no reason to believe that his perspective would havebeen inconsistent with that of the remaining team mem-bers. Third, although IS Team members were told thattheir identity would be kept confidential and were encour-aged to provide open and honest feedback on their partici-pation, some participants may have been inclined toprovide overly positive evaluations given their associationwith the campaign. However, an overly positive evaluationdoes not appear to be reflected in the findings, as facilita-tors provided numerous critiques of their own efforts andexpressed a desire to improve and expand their existingactivities to address additional issues facing local IDU.Finally, this study sought the feedback and impressions ofworkshop facilitators, yet it is also important to evaluatethe perspective of the recipients of this education. Whilethese data have been collected, we have elected to focushere on the experiences of facilitators and will present thefindings related to the perspectives of recipients in aseparate manuscript.In conclusion, this study demonstrates the feasibilityof involving IDU in educational initiatives targeting un-safe injecting. Our findings demonstrate that involvingIDU in prevention activities improves relevance andcultural appropriateness of interventions while providingindividual, social, and professional benefits to IDU dir-ectly involved in development and implementation ofsuch interventions.Endnotes1 Given that varied forms of pharmaceuticals requiredifferent preparation procedures, specific informationwas provided on how to prepare morphine eslon cap-sules, morphine kadian capsules, hydromorphone, talwinand ritalin, and methadone for injection.AbbreviationsIDU: People who inject drugs; VANDU: Vancouver area network of drugusers; IS Team: Injection support team; DTES: Downtown eastside.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsTK, WS, and CC conceived and designed the study. CC collaborated with theIS Team, attended all planning and development meetings related to theeducation campaign, observed all education campaign workshops,conducted all interviews, and actively sought team member’s opinions andfeedback on research process. CC coded and analysed transcripts with inputfrom IS Team members. RA assisted with analysis and interpretation of thedata. TK and CC prepared the first draft of the manuscript. GC and WSassisted with the main content and provided critical comments on the finaldraft. All authors have read and approved the final version submitted forpublication.AcknowledgementsWe would particularly like to thank the IS Team for their time, participation,and ongoing collaboration on this project. We would also like to thank theresearch and administrative staff at the B.C. Centre for Excellence in HIV/AIDSfor their research assistance. Special thanks are due to Nicole Latham, BrianO’Neill, Kate Shannon, Caitlin Johnston, Andrea Krusi, Danya Fast, and TerryHoward. This study was supported by community-based research [CBR-79873] and qualitative [MOP-81171] grants from the Canadian Institutes forHealth Research. Cody Callon is the recipient of a Canadian Institutes ofHealth Research HIV/AIDS Community-Based Research Award. Thomas Kerr issupported by the Canadian Institutes for Health Research and the MichaelSmith Foundation for Health Research.Author details1British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada. 2School of Social Work,University of British Columbia, 2080 West Mall, Vancouver, BC V6T 1Z2,Canada. 3Department of Medicine, Faculty of Medicine, University of BritishColumbia, 2194 Health Sciences Mall, Vancouver, BC V6T 1Z3, Canada.4Vancouver Area Network of Drug Users, 380 East Hastings Street, Vancouver,BC V6A 1P4, Canada.Received: 9 March 2012 Accepted: 25 February 2013Published: 6 March 2013References1. Webb L, Oyefeso A, Schifano F, Cheeta S, Pollard M, Ghodse AH: Cause andmanner of death in drug-related fatality: an analysis of drug-relateddeaths recorded by coroners in england and wales in 2000. Drug AlcoholDepend 2003, 72:67–74.2. Darke S, Hall W: Heroin overdose: research and evidence-basedintervention. 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Harm Reduction Journal 2013 10:4.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at et al. Harm Reduction Journal 2013, 10:4 Page 10 of 10


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