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Work experiences and conditions among people who use drugs engaged in peer work : a critical examination… Greer, Alissa Merielle 2019

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  WORK EXPERIENCES AND CONDITIONS AMONG PEOPLE WHO USE DRUGS ENGAGED IN PEER WORK: A CRITICAL EXAMINATION OF PEER WORK IN  BRITISH COLUMBIA, CANADA  by  ALISSA MERIELLE GREER   B.A., University of Victoria, 2010 M.P.H., University of Toronto, 2013      A DISSERTATION SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF   DOCTOR OF PHILOSOPHY   in   THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES  (Interdisciplinary Studies)       THE UNIVERSITY OF BRITISH COLUMBIA  (Vancouver)  October 2019   © Alissa Merielle Greer, 2019     ii  The following individuals certify that they have read, and recommend to the Faculty of Graduate and Postdoctoral Studies for acceptance, the dissertation entitled:  WORK EXPERIENCES AND CONDITIONS AMONG PEOPLE WHO USE DRUGS ENGAGED IN PEER WORK: A CRITICAL EXAMINATION OF PEER WORK IN BRITISH COLUMBIA, CANADA      submitted by  Alissa Greer  in partial fulfilment of the requirements for     the degree of  Doctor of Philosophy             in    Interdisciplinary Studies         Examining Committee:    Jane Buxton, School of Population and Public Health, University of British Columbia   Co-supervisor     Victoria Bungay, School of Nursing, University of British Columbia   Co-supervisor      Bernadette Pauly, School of Nursing, University of Victoria   Supervisory Committee Member     Elizabeth Hirsh, Department of Sociology, University of British Columbia   University Examiner     Jennifer Baumbusch, School of Nursing, University of British Columbia   University Examiner      iii Abstract  Engaging with ‘peers’, or people with lived experience of illicit substance use (past or present) who use their experiential knowledge to inform their professional work in decision-making and service provision, has been increasingly recognized as best practice within mainstream health and ham reduction institutions across British Columbia, Canada, and elsewhere. Yet, the operationalization and structure of work in peer engagement contexts have not been studied in great depth. In this research, I generate a critical and in-depth understanding of peer work conditions, the organization of peer work, and the structural factors that shape equity, inequities, and constraints in the context of the everyday work experiences of peer workers. Grounded in critical theoretical perspectives and a qualitative research design informed by interpretive descriptive methods, I conducted fifteen interviews with people engaged in peer work in British Columbia. Data coding and analysis occurred concurrent to data collection and themes were generated inductively and recursively using constant comparison techniques.  Study findings indicate that peer work was demanding, oppressive, and inequitable. The emotional demands of peer workers’ day-to-day working lives were illustrated by reports of trauma and structural harms. Expressions of oppression, including powerlessness, marginalization, and exploitation, were linked to a range of interlocking, interrelated systems that structurally shaped peer work conditions and perpetuated inequity. These findings illustrated how, despite peer workers’ efforts to engage in their work, systems of oppression and inequity that were structured into the organization of peer work may enable or constrain peer workers’ agency in these settings. Inequitable access to supports appeared to make it challenging for peer workers’ roles to be effectively utilized or recognized within institutions. Collectively, study findings suggest how equity, inequity, and oppression can be shaped through the organization   iv and operationalization of peer work. While there may be good intentions to promote the inclusion of people who use drugs in health promotion and harm reduction organizations, I provide evidence that there are potential consequences to work that is misunderstood, poorly organized, and unsupported.    v Lay Summary  The purpose of this research was to understand how work conditions influence the day-to-day work experiences of people who use or have used drugs or alcohol in the context of peer engagement work in British Columbia, Canada. The findings offer significant contributions to the literature by providing new and complementary knowledge about how peer work is experienced, organized, and supported. The definition of peer roles, organization of peer work, and labor market were linked to demanding and challenging work conditions. A complex constellation of interlocking and interrelated social, economic, and political factors appeared to perpetuate these inequities. Findings indicate that peer work conditions may not result from one factor, but influenced by a range of systems that limit and disadvantage people who use drugs working in peer engagement settings. Acknowledging and addressing these systems and factors may be essential for future meaningful participation.    vi Preface  This dissertation is original, unpublished, and independent work by the author, A. Greer.  Ethical approval for this study was submitted to and approved by the UBC Behavioural Research Ethics Board prior to its commencement (#H17-02039).    vii Table of Contents  Abstract ........................................................................................................................................ iii Lay Summary ................................................................................................................................. v Preface ........................................................................................................................................... vi Table of Contents ........................................................................................................................ vii List of Tables .................................................................................................................................. x List of Acronyms ........................................................................................................................... xi Glossary ....................................................................................................................................... xii Acknowledgements ...................................................................................................................... xv Dedication .................................................................................................................................... xvi 1 Chapter One: Introduction to the Dissertation .................................................................. 1 1.1 SITUATING THE PROBLEM ............................................................................................................ 2 1.2 PROBLEM STATEMENT ................................................................................................................. 6 1.3 RESEARCH PURPOSE AND QUESTIONS ......................................................................................... 7 1.4 ORGANIZATION OF THE DISSERTATION ....................................................................................... 8 2 Chapter Two: A Review of Existing Literature ................................................................ 10 2.1 INTRODUCTION ........................................................................................................................... 10 2.2 LOCATING PEOPLE WHO USE DRUGS WITHIN THE EMPLOYMENT CONTEXT ............................... 12 2.3 PEER WORK AND ITS BENEFITS ................................................................................................... 18 2.4 ORGANIZING PEER WORK ........................................................................................................... 21 2.4.1 Frameworks for peer engagement work ................................................................................ 21 2.4.2 Understanding peer work ...................................................................................................... 22 2.4.3 Workplace stigma and discrimination ................................................................................... 24 2.4.4 Work arrangements ............................................................................................................... 25 2.4.5 Funding peer work ................................................................................................................. 26 2.5 PEER WORK CHALLENGES AND BARRIERS .................................................................................. 28 2.5.1 Peer worker roles .................................................................................................................. 28 2.5.2 Workplace hierarchies ........................................................................................................... 29 2.5.3 Role demands ......................................................................................................................... 31 2.5.4 Community connection .......................................................................................................... 32 2.5.5 Substance use and peer work ................................................................................................. 33 2.5.6 Socioeconomic disadvantage ................................................................................................. 35 2.6 SUMMARY .................................................................................................................................. 36 3 Chapter Three: Research Design and Implementation ................................................... 38 3.1 INTRODUCTION ........................................................................................................................... 38 3.2 THEORETICAL PERSPECTIVES ..................................................................................................... 38 3.2.1 Structural oppression and inequity ........................................................................................ 41 3.2.2 Perspectives and concepts of work ........................................................................................ 43 Labor markets ............................................................................................................................. 44 Organizational arrangements ...................................................................................................... 45 Features of precarious work ........................................................................................................ 46   viii 3.3 DESIGN AND METHODOLOGY ..................................................................................................... 47 3.3.1 Interpretive description .......................................................................................................... 48 3.4 STUDY PROCEDURES .................................................................................................................. 49 3.4.1 Study context .......................................................................................................................... 49 3.4.2 Sampling and recruitment ...................................................................................................... 51 3.4.3 Interviews ............................................................................................................................... 53 3.4.4 Data analysis ......................................................................................................................... 56 3.5 METHODOLOGICAL RIGOR ......................................................................................................... 58 3.6 ETHICAL CONSIDERATIONS ........................................................................................................ 62 3.7 SUMMARY .................................................................................................................................. 65 4 Chapter Four: The Organization of Peer Work ............................................................... 66 4.1 INTRODUCTION ........................................................................................................................... 66 4.2 OVERVIEW OF PARTICIPANTS AND THE CONTEXT OF PEER WORK ............................................. 66 4.3 OPERATIONALIZING PEER WORKER ROLES ................................................................................ 71 4.3.1 Role titles ............................................................................................................................... 71 4.3.2 Role expectations ................................................................................................................... 74 4.3.3 Role compatibility .................................................................................................................. 76 4.3.4 Role preparation .................................................................................................................... 78 4.4 PEER WORK ARRANGEMENTS ..................................................................................................... 79 4.4.1 Distancing peer work ............................................................................................................. 80 Physical distance ......................................................................................................................... 81 Social distance ............................................................................................................................ 82 Administrative distance .............................................................................................................. 84 4.4.2 Gatekeepers ........................................................................................................................... 85 Gatekeeping control .................................................................................................................... 86 Disrupting gatekeepers ............................................................................................................... 87 Allied gatekeepers ...................................................................................................................... 88 4.4.3 Organizational commitment .................................................................................................. 90 Future work uncertainty .............................................................................................................. 90 Job insecurity .............................................................................................................................. 92 4.5 SUMMARY .................................................................................................................................. 94 5 Chapter Five: Peer Work Demands, Supports, and Substance Use ............................... 96 5.1 INTRODUCTION ........................................................................................................................... 96 5.2 PEER WORK DEMANDS ................................................................................................................ 96 5.2.1 Frontline work demands ........................................................................................................ 97 Traumatizing work ...................................................................................................................... 97 Relentless demands ..................................................................................................................... 99 Emotional impacts .................................................................................................................... 100 5.2.2 System navigation work demands ........................................................................................ 101 Facing oppression ..................................................................................................................... 103 Bridging worlds ........................................................................................................................ 104 5.2.3 Professional and personal overlap ...................................................................................... 106 Leveraging the connection ........................................................................................................ 107 A pressure to succeed ............................................................................................................... 108 Meaningful and purposeful work .............................................................................................. 109 5.2.4 Workplace demands ............................................................................................................. 111 Learning the rules ..................................................................................................................... 111 Rule constraints ........................................................................................................................ 112 Personal and professional boundaries ....................................................................................... 113 5.3 SOCIAL SUPPORT IN PEER WORK .............................................................................................. 115   ix 5.3.1 A need to debrief .................................................................................................................. 115 5.3.2 Formal social support .......................................................................................................... 116 5.3.3 Informal social support ........................................................................................................ 118 5.4 PEER WORK AND SUBSTANCE USE ............................................................................................ 120 5.4.1 Using substances to cope ..................................................................................................... 121 5.4.2 Re-initiating use ................................................................................................................... 122 5.4.3 Substance use as a condition of the job ............................................................................... 123 5.4.4 Substance use supports ........................................................................................................ 124 5.4.5 Peer worker roles as therapeutic ......................................................................................... 125 5.5 SUMMARY ................................................................................................................................ 127 6 Chapter Six: Peer Labor Market and Economic Insecurity ......................................... 128 6.1 INTRODUCTION ......................................................................................................................... 128 6.2 CONSTRUCTION OF THE PEER LABOR MARKET ........................................................................ 128 6.2.1 Labor market segmentation and segregation ...................................................................... 129 Labor market discrimination ..................................................................................................... 130 Job marketability ...................................................................................................................... 132 6.2.2 Labor market strategies ....................................................................................................... 134 6.3 INSECURITY AND CONSTRAINTS ON CHOICE ............................................................................ 136 6.3.1 Labor market inequity .......................................................................................................... 136 6.3.2 Economic insecurity and low pay ........................................................................................ 138 6.4 PEER WORK AND INCOME ASSISTANCE .................................................................................... 140 6.4.1 Fear of reporting income ..................................................................................................... 141 6.4.2 Cash-based work ................................................................................................................. 142 6.4.3 Dependence on income assistance ....................................................................................... 144 6.5 SUMMARY ................................................................................................................................ 146 7 Chapter Seven: Discussion ................................................................................................ 147 7.1 INTRODUCTION ......................................................................................................................... 147 7.2 SUMMARY OF MAIN FINDINGS .................................................................................................. 147 7.3 CONTRIBUTION AND IMPLICATIONS ......................................................................................... 149 7.3.1 Emotionally demanding and unsupported roles .................................................................. 150 7.3.2 Operationalizing peer roles ................................................................................................. 153 7.3.3 Precarious peer work .......................................................................................................... 156 7.3.4 The structural organization of peer work ............................................................................ 160 7.4 RECOMMENDATIONS ................................................................................................................ 163 7.4.1 Organizational strategies .................................................................................................... 164 7.4.2 Work practices ..................................................................................................................... 165 7.5 RESEARCH DIRECTIONS ............................................................................................................ 166 7.6 RESEARCH LIMITATIONS .......................................................................................................... 169 7.7 CONCLUSION ............................................................................................................................ 172 References .................................................................................................................................. 174 Appendices ................................................................................................................................. 198 APPENDIX 1: RECRUITMENT LETTER ..................................................................................................... 199 APPENDIX 2: INTERVIEW GUIDE ............................................................................................................ 200 APPENDIX 3: INTERVIEW CONSENT FORM ............................................................................................. 203    x List of Tables  Table 1  Characteristics of participants………………………………………………..…. 67   xi List of Acronyms  BC   British Columbia  BCCDC  British Columbia Centre for Disease Control  BCHRSS  British Columbia Harm Reduction Strategies and Services  CAD  Canadian dollars  PEEP  Peer Engagement and Evaluation Project  PWUD  People who use or have used alcohol or other drugs illicitly  VANDU  Vancouver Area Network of Drug Users     xii Glossary  Agency The freedom to make decisions and enact choices.  Community A group of people who share a common social, political, economic, or geographic characteristic.  Compensation A range of goods, incentives, wages, and other rewards that hold value, which are given in exchange work.  Employer A person or body (i.e. organization, group of people) that utilizes worker efforts or knowledge.  Employee Someone who is engaged under a formal contract of employment.   Employment For the purposes of this dissertation, employment refers to formal or standard work defined by a formal hiring process, a paid job, and labor standards.  Inequity Unfair disparities or gaps in opportunities or resources, including power and employment, between groups which inhibit people from meeting their full potential. They are often accompanied by discrimination, social exclusion, and poverty. Therefore, they are preventable and avoidable due to their systemic nature.   Labor market A concept referring to the arena where interaction between workers and employers take place; often an arena defined by a supply of workers and demands of available employment or jobs.  Oppression The constraining or limiting of one social group by a more powerful social group.   Organizations Institutions in which work is conceived of and designed, including the recruitment, pay, coordination, and control of efforts and roles.  Pay Monetary value for the trade of effort or information from one party (employer) to another (peer worker).  Peer A term used to describe a person with current or past illicit drug use experience whose participation in research, program, service, or policy   xiii settings draws on this lived experience to inform their formal or informal work in peer engagement and/or harm reduction settings.  Peer engagement A term used to describe an approach to decision-making, planning, advocacy, and practice where peer workers or people who use drugs are involved in policy development, research, and programming.  Peer work For this dissertation, peer work is an activity that requires mental or physical energy that is informed by that person’s substance use experience as a means of achieving a purpose or result. Examples of purpose include tasks in needle distribution services, overdose prevention education, community support and outreach, progressive policy development, and community-based research projects.  People who use drugs or PWUD In the context of this study, people who use drugs are defined as people with past or present experience of illicit drug or alcohol use.   Power  Control over and access to economic, social, and political resources, systems, practices, and policies.  Power inequities An imbalance of power between people and groups due to who is in a position of power and has control over resources.   Precarious work Unpredictable, insecure, informal, and random work arrangements, often offering little social benefits, low job security, and low wages.  Privilege Invisible, unearned advantages over other groups which are based on social identity.   Stigma A negative attitude or belief about a person or group of people due to their social position or identity.   Stipend A one-time, often same-day payment for work.  Structures/ systems From a critical perspective, are the relations and arrangements between and within institutions, such as culture, institutional practices, and policies, whose parts are repeated and work together to maintain power and social order or hierarchy.    xiv Substance use In the context of this study, substance use entails illicit drug use and alcohol use.    Work conditions A range of topics and issues that cover the parameters of work that impact worker’s circumstances, such as hours, schedules, and pay, as well as the physical environment, job demands, and work pressures.  Volunteering/ volunteer work Activities and efforts that are altruistic in nature, benefit others, and promote goodness. Volunteering is assumed to receive no financial gain, or enter into an employment relationship.  Work Activities and efforts put out by a person to achieve a purpose or result. Work can be formal employment or non-standard/informal efforts. In this thesis, the terms labor relationship and regular employment mean the same. The elements of standard work include ongoing employment, adequate social benefits, a single employer, steady work day frequency and duration. Non-standard work includes part-time, contractual, and temporary work, as well as working arrangements outside of an employment relationship.  Work arrangements Work arrangements include the location, duration and frequency of work, and source of administrative control over work parameters. They include standard or formal work arrangements, including full-time employment, as well as arrangements that are nonstandard or informal, including casual or temporary work arrangements.  Worker rights  Relations between a worker and their employer relating to fairness and responsibility of pay, benefits, and work conditions; usually accessed and obtained under local labor laws.       xv Acknowledgements     First, I am forever indebted to all the participants and community members I have worked with over the past decade – you have taught me the most. I especially want to express my gratitude to the PEEPs who continue to inspire me daily. Thank you for your patience, guidance, and knowledge that you have selflessly shared with me time and time again. I hope this piece of work will ever so slightly, or maybe substantially, make a positive impact.  I also feel truly inspired and privileged for the opportunity to work with three of the most strong, hardworking, and inspirational women I know in my Ph.D.: Jane Buxton, Victoria Bungay, and Bernie Pauly. It’s been an amazing journey. I learned and grew so much from each of you in unique ways. Thank you for challenging and pushing me; expanding my mind, perspectives, and possibilities. And especially, Jane: your patience (and more patience) and support through challenging times personally and professionally kept me going. You knew exactly when to push, pull, support, and let go.   I am thankful for the resources granted to me in supporting this goal, including the Vanier Canadian Graduate Scholarship, Public Scholars Initiative, Michael Smith Foreign Study Supplement, CIHR Bridge Fellowship, Interdisciplinary Graduate Studies Program, and the School of Population and Public Health.  I am deeply grateful for the people in my life who have supported this long (and at times seemingly endless) road. Mom: you have been there every step of the way, and buoyed me up with your support and belief in me. I could not have done this without you. My heartfelt thanks, as well, to my family and friends for your patience and encouragement: Ryan, Mike, Madeline, Alister, and my soul sisters Rebekah, Julia, Taryn, Emma, and Alia – you each inspire me. And thanks to Scott, Tim, and my CISUR family who provided me with a strong foundation and ongoing support. And, Dad: I hate to admit it, but you were the centre of all of this.    Last, but certainty not least, to my patient and caring partner, Graeme. I am incredibly humbled by your belief in me. Thank you for being there throughout the long days (and nights and weekends), and encouraging me to unplug and take an adventure or two. You have truly made this all worth it.    xvi Dedication     For Graeme. My heart is yours.                 1 1 Chapter One: Introduction to the Dissertation  To begin this dissertation, I situate peer work within the context of peer engagement in the province of British Columbia (BC), Canada by looking at how peer engagement has evolved and expanded locally, and its potential impact on the people who work in these contexts. Peer work is a unique labor context in public health where people who use or have used drugs or alcohol (PWUD) are engaged for their lived experience and ability to connect with their community. Although a long history of grass-roots community organizing and involvement of PWUD in harm reduction exists, peer engagement has recently taken on a different form. Several factors have catalyzed the trend towards greater involvement of PWUD within large health and harm reduction organizations locally, including several projects promoting peer engagement, the HIV epidemic, and the ongoing opioid overdose crisis across the province. Given the reshaping yet increasing trend of peer engagement within large organizations, researchers have started to investigate and problematize how peer workers are engaged – particularly for those who are working in roles related to the opioid overdose crisis. Evidence suggests a great potential for inequity through the operationalization and organization of peer work (Greer et al., 2019; Greer et al., 2018; Salmon et al., 2010; Bardwell et al., 2018; Guta, Flicker & Roche, 2013). Yet, researchers have rarely looked at the work conditions of PWUD in peer engagement contexts from a critical or labor perspective. Many gaps in the research remain as to what peers’ working conditions are, how they are shaped, and what the impacts are. This dissertation will help to address these gaps by examining peers’ working conditions and how they influence the experiences of PWUD who work in peer engagement contexts.     2 1.1 Situating the Problem   Work is a major institution within capitalist societies which shapes the social, economic, and political realities of its citizens (DeVault, 2008). Work is also a known facilitator of social inclusion, mental health, and quality of life (Evans & Repper, 2000; Wistow & Schneider, 2003). Certain people or groups may choose not to participate or they can be systematically excluded or disadvantaged from participating in work due to factors outside of their control (Das, 2013). PWUD are among those less present in employment contexts. Labor market discrimination and exclusion of PWUD have been tied to the stigma of substance use and its lack of fit within employment or employee ideals (Richardson, Sherman, & Kerr, 2012). Peer engagement in harm reduction is a unique labor context where PWUD engage in work for their lived experience of substance use and unique ability to connect with the community. Peer engagement is a participatory approach to advocacy, decision-making, and service provision primarily in health and harm reduction research, policy, and practice contexts. Peer workers utilize their lived experience (past or present) of substance use as a form of expertise in their professional work in these contexts (Closson, McNeil, McDougall, Fernando, Collins, Baltzer Turje, et al., 2016; Faulkner-Gurstein, 2017; Greer, Amlani, Burgess, et al., 2018; Greer et al., 2016; Guta, Flicker, & Roche, 2013; Ti, Tzemis, & Buxton, 2012). Institutions have largely used and reproduced the word ‘peer’ in harm reduction settings to describe people with lived experience who use their experience to inform their professional work (Closson et al., 2016; Greer et al., 2016; Greer et al., 2018; Gillespie et al., 2018; Wilson et al., 2018). Conversely, the term ‘peer’ labels workers by whether or not they have a substance use history; thus, institutionally differentiating PWUD from other workers who do not require or have such a label. PWUD themselves have problematized this term:   3 The use of the word ‘peer’ is also increasingly being used to mean ‘person with lived experience’ in the context of including PWUD in research, service delivery, and policy settings. While some of us welcome the use of the word ‘peer’ and have embraced it as a word that recognizes and acknowledges our lived experience, there are situations where identifying people as ‘peers’ can be problematic. (Canadian Association of People Who Use Drugs, 2014, p. 1)  Although the term has come to promote jobs for people with lived experience in harm reduction settings, in some contexts this term may also produce unintended consequences, such as discrimination, as it specifically labels and differentiates workers who are engaged for their lived experience of substance use. Furthermore, this term may be appropriated by institutions rather than being defined, used, and reproduced by PWUD themselves. Peer engagement has a long history in the field of harm reduction, although the practice and shape of it appear to have shifted over the past several decades. Peer engagement emerged from grassroots organizing among PWUD for harm reduction and human rights during HIV crises of the 1970-1990s. Scholars have documented self-organizing groups of PWUD internationally from the 1970s to more recently (Canadian Association of People Who Use Drugs, 2014; Friedman et al., 2007; Rockwell, Joseph, & Friedman, 2006). For instance in 1997 in BC, the Vancouver Area Network of Drug Users (VANDU) formed in response to an HIV crisis among local people who inject drugs, focusing on “bring[ing] the ‘voice of users’ into mainstream political discourse” (Kerr et al., 2006, p. 63). For over two decades, VANDU (among other self-organizing groups of PWUD) has provided peer support, education, advocacy, and harm reduction programming (Canadian HIV/AIDS Legal Network, 2006; Kerr et al., 2006) and have been involved in a range of research (Jozaghi, Greer, Lampkin, & Buxton, 2018). Today, self-organizing groups of PWUD continue to be at the forefront of public health efforts to ensure they are included in decisions and initiatives that affect their community (Canadian Association of People Who Use Drugs, 2014).   4 Despite this history of engagement with self-organizing groups of PWUD within harm reduction, peer engagement has taken on new forms and practices most recently. In contrast to grassroots, user-led advocacy for the rights of PWUD, peer engagement today can be seen taking shape as a top-down, institutionally-led and motivated initiative (Greer, Amlani, Burgess, et al., 2018). Researchers and scholars have noted how the involvement of PWUD appears to have evolved from primarily self-organizing PWUD harm reduction efforts, to now engaging peer workers more operationally with mainstream public health institutions (Faulkner-Gurstein, 2015; Gowan, Whetstone, & Andic, 2012; Marlatt, 1996; Roe, 2005; Smith, 2012, 2016) – a distinction that Albert (2012) has called the difference “between what we can crudely call ‘bottom up’ or drug user-led, and ‘top-down’ or professional approaches to harm reduction” (p. 7). Several ‘top-down’ initiatives can be seen as coinciding and mainstreaming peer engagement into government agencies and public health organizations. First, institutions have mandated a commitment to peer engagement. For instance, the Government of Canada endorsed the United Nations’ Declaration of Commitment on HIV/AIDS in 2001, which has called for the greater inclusion of people living with HIV including PWUD, and the Canadian Institutes of Health Research’s Strategy for Patient-Oriented Research (Canadian HIV/AIDS Legal Network, 2006; “Strategy for Patient-Oriented Research,” 2019). The BC Government’s Patients as Partners Initiative has advocated for greater community involvement in public health decision-making (“Patients as Partners,” n.d.). Other projects have formed in BC to promote peer engagement within Health Authorities. For instance, the Peer Engagement and Evaluation Project (PEEP) aimed to make peer engagement the norm in BC, expand peer networks, and create peer engagement best practices for provincial Health Authorities (BC Center for Disease Control, 2017).    5 In addition to these initiatives to expand peer engagement in mainstream health and harm reduction organizations, the proliferation of opioid overdose deaths in BC has influenced the involvement of PWUD provincially. The opioid crisis has claimed more than 9,000 opioid-related overdose deaths between January 2016 and June 2018 in Canada (Government of Canada, 2018). In 2016, BC’s Minister of Health declared a public health emergency in the province due to skyrocketing overdose death rates (“Provincial health officer declares public health emergency,” 2016). Since the opioid overdose crisis was declared in 2016, a scale-up of harm reduction and public health responses has unfolded across BC and elsewhere in North America (Strike & Watson, 2019). Recent reports indicate that BC has the highest overdose-related death rate in Canada (Government of Canada, 2018), with approximately 1,500 deaths reported in both 2017 and 2018 (Office of the Chief Coroner, 2018). A crucial feature of these initiatives is that they are promoted, designed, and run by peer workers (Lupick, 2016; Strike & Watson, 2019; Thomson, Lampkin, Maynard, Karamouzian, & Jozaghi, 2017). Despite these initiatives, drug overdose rates have not declined. Peer engagement has been recognized as a main effort in the response to the overdose emergency by the BC Government (BC Ministry of Mental Health and Addictions, 2019) and a priority item for several provincial task groups (BC Center for Disease Control, 2018; City of Vancouver, 2018). Research is limited as to what peer work looks like within large institutions, particularly from a labor perspective. Although employment of PWUD in peer engagement contexts has been said to provide a sense of meaning, purpose, and legitimacy among peer workers and non-peer coworkers (Closson, McNeil, McDougall, Fernando, Collins, Turje, et al., 2016; Dickson-Gómez, Knowlton, & Latkin, 2004; Greer et al., 2019; Henman, Paone, Jarlais, Kochems, & Friedman, 1998; Salmon, Browne, & Pederson, 2010), this is not a given. Albers (2012) notes:    6 There still remains, even within the harm reduction industry, a strong reluctance to employ people who actively use drugs in positions of responsibility or authority, at the very most they are used as voluntary peers, usually directed by a worker who has either never been a person who uses drugs, or is a former user. (p. 7).  For instance, recent studies have documented peer workers as unpaid volunteers, casual stipend-based workers, contractors, or are paid through incentives such as public transportation coupons, gift cards, or clothing alongside other staff who are paid in salaries, grants, and social capital (Bardwell, Anderson, et al., 2018; Dickson-Gómez, Knowlton, & Latkin, 2003; Gillespie, Lasu, & Sawatzky, 2018; Greer, Amlani, Pauly, Burmeister, & Buxton, 2018). Alongside this evidence of inequity, studies have begun to document the impact of the opioid overdose crisis on peer workers. Studies suggest peer workers face a disproportionate amount of pressure, burden, and trauma in overdose response roles (Bardwell, Kerr, Boyd, & McNeil, 2018; Gillespie et al., 2018; Kennedy et al., 2019; Wagner et al., 2014). Researchers have also suggested peer work is generally unsupported (Bardwell, Kerr, et al., 2018; Gillespie et al., 2018; Kennedy et al., 2019; Wagner et al., 2014). Considering the emerging findings that peer engagement in the context of the opioid crisis may be producing negative consequences for peer workers, scholars have raised questions about the ad-hoc manner in which the involvement, organization, and integration of peer workers into harm reduction initiatives, and its impact on the inclusion and empowerment of PWUD (Bardwell, Fleming, Collins, Boyd, & McNeil, 2018; Bardwell, Kerr, et al., 2018; Boyd et al., 2018; Gillespie et al., 2018; Greer et al., 2019, 2016; Kennedy et al., 2019; Thomson et al., 2017).  1.2 Problem Statement  While the upward trend of peer engagement may indicate institutional support for social justice and social inclusion for PWUD in harm reduction, there may be several challenges and limitations in this approach from a labor and equity perspective. Few studies have documented or   7 examined details about the peer work context, or how peer engagement has been operationalized into working roles and the potential consequences of the evolution of peer engagement over the past several years. Gaps in the literature beg the question of whether or not promoting peer engagement as an inclusive, empowering, and socially just approach within large organizations has produced and reproduced inequity for peer workers. The organization and operationalization of peer workers’ roles, work conditions, the factors that shape these conditions and how equity and inequity may become produced within them have not been explored in great depth. A better understanding is needed of the structures that shape peer work conditions and PWUDs’ experiences in them to promote equity in peer engagement. 1.3 Research Purpose and Questions  The overarching purpose of this research was to gain an understanding of the structural organization and conditions of peer work, and the factors that influence how PWUD experience these conditions the context of peer engagement. My inquiry was driven by the following research questions:  1. How is peer work organized, and how does this structure enable or constrain effective roles and the utilization of peer workers’ roles?  2. What challenges and systemic disadvantages do peer workers’ face in the context of their everyday work lives?  3. What and how do social, economic, and political systems shape conditions of equity and inequity among PWUD working in peer engagement contexts?  This research provides a critical look into mechanisms of equity and inequity by examining the organization and structuring of peer work and workers’ roles, and how different systems of oppression influence peer workers’ experiences. Exploring how these work experiences are influenced may promote an understanding of the challenges and enablers to meaningful peer   8 engagement, and the factors that contribute to systems of inequity and oppressive work conditions.  1.4 Organization of the Dissertation  In this first chapter, I have situated and framed peer work within the context of peer engagement in BC. I have also posed the research problem, objectives, questions, and its importance. In Chapter Two, I report on the findings from a review of the literature. This review provides a synthesis and narrative around what is known about employment, work, and peer engagement experiences among PWUD. In this review, I briefly examine the nature, depth, and range of the literature and identify gaps or discrepancies which justify the current study. Following this, Chapter Three details the theoretical perspectives, research methodology, and methods used. I situate my study within critical theoretical perspectives, focused on structural oppression and concepts of equity and inequity. These theories oriented me towards a qualitative research approach, as well as methods from interpretive description methodology. I explain how the application of these theories and methods enabled me to examine peer workers’ descriptions of their work experiences to illuminate conditions that produce inequity, and the systems and structures that produce these conditions.  The next three chapters present findings that are analytically distinct in terms of their focus. Chapter Five begins by presenting a brief description of the sample. Following this, I present an in-depth examination of the organization of peer work; including peers work arrangements and the role of peers within organizations. The focus of this chapter is on the operationalization of peer roles, the positioning of peer workers within organizations, and the ways peer work arrangements impact their work conditions, including the ways in which their roles are enacted, utilized, and supported. In Chapter Six, I take a closer look at the work peers’   9 do and the demands they face, with emphasis on two roles: roles in overdose response situations, and system navigation roles. I explore peer role demands and the influence of the structure, organization, and support of peer work. I also consider some of the challenges peer workers’ experience navigating and negotiating their substance use in the context of peer work. The final findings chapter, Chapter Seven, takes a relatively wider lens to the labor market and its influence on peer workers’ experiences, and the challenges they face given their positionality within labor market structures combined with their socioeconomic insecurity. I show the perpetuation of inequities through various economic mechanisms, including their interplay with peer workers’ enrollment in government income assistance programs and cash-based work systems. Finally, I conclude the dissertation with Chapter Eight where I provide a summary of the key findings, a discussion of the contributions of the study within the literature, study limitations, and recommendations for future organizational strategies, work practices, and research directions. I end the dissertation with some concluding remarks.    10 2 Chapter Two: A Review of Existing Literature  2.1 Introduction  To position this study in the literature and evaluate existing knowledge, I conducted a review of relevant peer-reviewed publications and grey literature related to peer work and employment practices in peer engagement contexts (i.e. PWUD working in services, programs, policymaking, advocacy, and research). I was interested in gathering information related to the extent, nature, and limitations of this literature, as well as synthesizing what is known about peer work relative to my research questions. Relevant literature was identified through a range of searches, including electronic database searches (e.g. University of British Columbia library, PubMed, Google Scholar), individual journals (e.g. Harm Reduction Journal, International Journal of Drug Policy), Google searches, website searches, reference lists, and grey literature. I did not limit my search to one field (e.g. public health, sociology, labor studies), or region. There was no date range to the search but articles were restricted to those written in the English language.  I organized my review into two literature searches. First, I searched for what was known about employment among PWUD (in non-peer work contexts) and related mechanisms that shape their employment conditions. Since I was concerned with the structure of peer work and experiences of peer workers, this examination provided an understanding of how employment among PWUD was framed in the literature and what the issues are. This review was relatively less in-depth to that of peer work, as the specific context of peer engagement was of primary interest. However, this review of work experiences among PWUD provided key insights into the study of employment among this population and the main issues implicated in their employment. From the review of employment among PWUD, three main themes related to employment   11 among PWUD emerged: 1) labor market participation; 2) labor market discrimination; 3) alternative income sources. In the second part of the review, I focused specifically on the scope, breadth, and nature of empirical knowledge related to peer work. I explored the general findings, recurrent topics, methodological approaches, and gaps in the research specifically related to the work peers’ do as PWUD engaged in health promotion and harm reduction contexts. Although there is an abundance of research on peer engagement that has been conducted among people experiencing disabilities, mental health, and HIV/AIDS, I decided to include studies which only focused on PWUD. As I have outlined in Chapter 1, there is a long history of community organizing and peer engagement that has been documented. However, it was more difficult to find studies which focused on labor experiences or framed PWUD as workers alongside other staff given the evolving shape of peer work institutionally. I noted that peer work was framed loosely in the literature by a range of concepts, such as volunteer work and participation in research. At times, it was not considered as a form of work at all. Yet, I found that a small body of literature and studies superficially discuss issues related to labor among peer workers who were PWUD. As such, I expanded my search to include literature which illustrated peer engagement, in general, to determine if articles provided additional insights into the labor context. Considering this evaluation of the literature, I included that which mentioned peer work conditions or experiences despite this subject matter not being the main focus of previous research. At the same time, I had a specific interest in findings and systems related to peers’ work conditions, the organization of their work, and what roles they played in the workplace.  In the sections that follow, I present an assessment of the nature, depth, and range of evidence, as well as some of the themes I discovered from the literature review. My synthesis is   12 both narrative and evaluative – a summary of the evidence and evaluation of what is known about peer work, as well as some of the identified challenges and issues in peer work evident amongst the literature.   2.2 Locating people who use drugs within the employment context    Employment among PWUD is problematic and has been of longstanding interest to researchers. Historically, PWUDs labor market participation has been markedly infrequent relative to other groups (Henkel, 2011; Platt, 1995; Redonnet, Chollet, Fombonne, Bowes, & Melchior, 2012). For instance, a review of 130 relevant articles published between 1999-2010 found unemployment was consistently more prevalent among PWUD (Henkel, 2011). Similarly, a population survey in Australia found that people who were unemployed were 1.5 times more likely to have used an illicit drug in the previous twelve months than the general population (Australian Institute of Health and Welfare, 2016). In Canada, from 2014 to 2015, approximately 38% of adults seeking public drug treatment services were unemployed (McQuaid, Di Gioacchino, & National Treatment Indicators Working Group, 2017). In BC, specifically, one cohort study demonstrated an employment rate of between 9-12% among 1,190 PWUD over almost four years (Richardson, Wood, Li, & Kerr, 2010).       Given the evidence of low participation or inclusion of PWUD in the labor market, researchers have shown interest in this relationship and consistently noted its complexity. There is a large body of qualitative and quantitative studies which have explored substance use impacts on work-seeking behavior and work entry, as well as the influence of substance use on employment, and if substance use predicates negative employment outcomes (Henkel, 2011). Studies often attempted to identify attributes that are predictive of unemployment. Factors significantly associated with unemployment among PWUD have included older age, female   13 gender, aboriginal ethnicity, HIV and HCV positive serostatus, daily heroin injection, daily crack use, sex work involvement, recent incarceration, and unstable housing (Richardson et al., 2010). Conversely, other studies have shown an inverse relationship between employment and injection initiation (Richardson, DeBeck, Feng, Kerr, & Wood, 2014), daily drug use (Sherman, German, Cheng, Marks, & Bailey-Kloche, 2006) and life stability (Richardson et al., 2010).   Other researchers have framed associated characteristics of unemployment as barriers to work among PWUD. Several systematic literature reviews have suggested a lack of skills, education, and supports, as well as health and social disadvantages, as common barriers for obtaining employment among PWUD (Platt, 1995; Sutton, Cebulla, Heaver, & Smith, 2004). Studies suggest a linkage with barriers and factors that mediate employment for PWUD, including structural and social mechanisms that limit access to employment, including education, criminal records, and health and housing status (Boyd et al., 2018; Cebulla, Smith, & Sutton, 2004; McCoy, Comerford, & Metsch, 2007; Morgenstern et al., 2015). These findings suggest that the relationship between substance use and employment is not a heterogeneous pathway. Instead, it may be influenced by a myriad of structural factors related to PWUDs life circumstances.   Over the past five years, Richardson and colleagues have explored the complexity of the relationship between drug use and employment both qualitatively and quantitatively among a longitudinal cohort study of PWUD in the downtown east side of Vancouver, Canada. In a qualitative study with 22 PWUD, Richardson et al. (2016) demonstrated several pathways linking unemployment to PWUD, including suboptimal employment outcomes, labor market exclusion, and catastrophic life events. Evidence of these pathways challenged the primacy of drug use in determining employment outcomes, and suggests multidimensional pathways to   14 employment or unemployment among this population (Richardson, Small, & Kerr, 2016). This group of researchers has also explored the social, structural, and physical features associated with employment and unemployment among PWUD. In 2013, in an effort to identify contextual features that influence PWUD’s labor market outcomes, Richardson et al. analyzed data from over 1,500 people who inject drugs collected between 1996 and 2005. Over 70% of the sample remained unemployed during this study period, which corresponded to participants’ demographic disadvantages (e.g. housing, health, education). Researchers demonstrated exposure to specific physical, social, and structural conditions, including public injecting scenes, unstable housing, economic deprivation, sex work involvement, and recent incarceration, significantly constrained PWUD’s transitions into employment (Richardson, Wood, & Kerr, 2013). These findings suggest PWUD face many contextual or structural barriers to gaining employment. Richardson et al. (2019) most recently explored the relationship from a different direction – they were interested in looking at what factors were related to suboptimal employment outcomes or employment cessation. Findings showed that among 1,222 PWUD who were employed at some point during 2005-2015, 618 participants (50.6%) transitioned out of employment at least once. Among this group, 1,154 employment cessations were reported over this ten year period. Researchers found employment cessation was significantly associated with unstable housing, high-risk drug behaviors, ending enrolment in methadone maintenance treatment, and initiation into informal or illegal income generation (e.g. involvement in sex work) (Richardson, Mammel, Milloy, & Hayashi, 2019). Employment exits were significantly related to increased drug use and encountering a barrier to entering drug treatment (Richardson et al., 2019). Collectively, findings suggest that transitions into employment (Richardson et al.,   15 2013) and out of employment (Richardson et al., 2019) coincides with a level of socioeconomic marginalization and drug use.   Other Vancouver-based researchers have similarly found a structural connection to unemployment among PWUD. For instance, Boyd et al. (2018) interviewed street-involved PWUD about their experiences with alternative income generation activities and analyzed data from a critical perspective. They found multiple overlapping factors in PWUDs risk environment influenced their transition from unemployment to employment, including physical barriers (e.g. injury, disability, substance use) as well as structural barriers (e.g. negotiating drug use within a labor context and labor market discrimination). Scholars suggest that PWUD’s labor market outcomes “represent[s] a means to negotiate survival given multiple barriers to employment and inadequate economic supports” (Boyd et al., 2018, p. 42). These researchers urged future studies to reconsider the framing of the employment status of PWUD. Few studies have taken a critical lens to the issue of employment among PWUD. Several studies have noted more attention needs to be taken to the structural drivers of supports for employment which may make visible and therefore begin to address some of the barriers PWUD face (Boyd et al., 2018; Richardson et al., 2015, 2012).   Labor market discrimination may be a central sociostructural feature influencing employment access and trajectories for PWUD. Labeling and negative stereotyping have consistently been shown to be the basis of the discrimination of PWUD and their labor market exclusion (Cebulla et al., 2004; Richardson & Epp, 2015; Sutton et al., 2004). PWUD appear to be deeply impacted by stigmatized or “spoiled” identities (Goffman, 2009), and labeled as “chaotic” (Bourgois & Schonberg, 2009), “junkies” (Conner & Rosen, 2008; Draus, Roddy, & Greenwald, 2010), and “scroungers” (Wincup & Monaghan, 2016) within employment contexts.   16 Studies have raised concerns that such labels can invoke notions of risk, fear, and a threat to social order which, as they have pointed out, fall outside normalized notions of the ideal worker (Dickson-Gómez et al., 2004; Draus et al., 2010; Fraser & Moore, 2008; Grover & Paylor, 2010; Richardson & Epp, 2015; Souleymanov & Allman, 2016; Wincup & Monaghan, 2016). In this way, the stigma of substance use may be a “potent function” of organizations “with an interest of keeping [PWUD] away from power resources” (Souleymanov & Allman, 2016, p. 1437).   Several studies suggest that negative stereotypes of PWUD as workers may be reproduced and reinforced within various economic, social, and political systems which embed the stigma and discrimination into the mechanisms that structure employment experiences (Link & Phelan, 2014). Among the structures that may perpetuate stigma were criminal record checks and drug testing which may embed abstinence-based work standards into the workplace through these systems. Research has shown drug treatment approaches to workforce entry for PWUD have required drug screening or regular drug testing (Platt, 1995), which makes employment access and wages contingent on abstinence (Richardson et al., 2012; Silverman et al., 2007; Tunnell, 2004). These policies may perpetuate the notion that people who work in society should be abstinent, thus systematically marginalizing PWUD in the labor market.    Unemployment among PWUD has also been attributed to the criminality of the behaviors among this social group (Platt, 1995). Criminal record checks may systematically exclude PWUD by virtue of “marking” PWUD with the label of ‘criminal’ in ways that mediate their employment outcomes (Pager, 2003). As Pager (2003) has discovered, drug convictions have negatively credentialed people in the employment process by socially stratifying them into a group which disqualifies them from work.   17 In light of the barriers to work that PWUDs have faced, including labor market discrimination, researchers have been interested in the impacts of labor market exclusion and structural disadvantage. Among PWUD who have secured work opportunities, work conditions have typically been informal, infrequent, and poorly paid – which, as some have pointed out, has made it challenging to access opportunities for education, formal employment, and social inclusion (Cebulla et al., 2004; DeBeck et al., 2007; McCoy et al., 2007). Several studies have quantitatively demonstrated that unemployment and poor work conditions are most common among economically and socially marginalized PWUD (Cebulla et al., 2004; DeBeck et al., 2007; Koo, Chitwood, & Sánchez, 2007; McCoy et al., 2007).  Researchers have suggested a lack of job options limits labor market participation, thus constraining PWUD to alternative income generation activities. Numerous studies have shown that PWUDs trajectories out of the labor market coincide with their participation in illegal activities to generate income, including sex work and drug dealing, and well as other activities such as street vending and recycling (Bourgois & Schonberg, 2009; Boyd et al., 2018; DeBeck et al., 2007; Draus et al., 2010; Jaffe et al., 2018; Kerr et al., 2008). PWUD’s engagement in informal markets and economic insecurity has also been shown to produce vulnerability to different forms of violence (Boyd et al., 2018; Richardson et al., 2015) and encounters with law enforcement (Jaffe et al., 2018). The limitations to these alternative forms of income generation have a compounding impact on their ability to find and hold employment by further stigmatizing them (DeBeck et al., 2007; Jaffe et al., 2018). In this way, scholars have described how PWUD are within “the most marginal positions in both the underground and legitimate economies” (p. 1272) in a cyclical and reinforcing way (Dickson-Gómez, Knowlton, & Latkin, 2004). Scholars   18 from this body of research regularly suggest a need for low barrier employment options for PWUD.  Across studies that have taken broad and close examinations of employment outcomes and experiences of PWUD, the literature suggests that unemployment may not simply be explained by the primacy of drug use. Although the association between drug use and unemployment has been documented, the complex interrelationships between these factors and other socioeconomic disadvantages have also been tied to PWUD’s employment outcomes. Some studies have shown that PWUD may face multiple complex barriers and structural disadvantages, which partly explain their employment outcomes, including frequent job loss and labor market exclusion. Low barrier employment options for this population were suggested in light of these findings. In-depth research has not yet been conducted on the perpetuation of inequities through economic and labor systems which may entrench PWUDs structural disadvantage.  2.3 Peer work and its benefits    Peer engagement presents a unique labor context where PWUD’s employment is based on their past or present experience of substance use. For several decades, PWUDs lived experience of substance use has been utilized as a skill and form of expertise to enhance the relevance, acceptability, and accessibility of programs, advocacy efforts, community organizing, policymaking, and research via peer engagement initiatives (Australian Injecting and Illicit Drug Users League, 2012; Bardwell, Fleming, et al., 2018; Gillespie et al., 2018; Goodhew, Stein-Parbury, & Dawson, 2018; Greer et al., 2016; Kennedy et al., 2019; Z. Marshall, Dechman, Minichiello, Alcock, & Harris, 2015; Wagner et al., 2014). Peer work appears to fall under a variety of contexts which engage and involve PWUD internationally, although most evidence   19 has been from health promotion and harm reduction contexts in Western Europe, North America, and Australia. In Australia, consumer involvement or participation initiatives have engaged PWUD mainly in substance use treatment and drug policymaking settings (Australian Injecting and Illicit Drug Users League, 2012; Bryant, Saxton, Madden, Bath, & Robinson, 2008; Treloar, Rance, Madden, & Liebelt, 2011). In the United Kingdom, service user involvement has engaged PWUD in the design of public health services and substance use treatment (Beresford, 2013; Bradshaw, 2008; Patterson, Weaver, & Crawford, 2010). And, in Canada and the United States, peer engagement (used herein) is commonly an approach to involving PWUD in designing and implementing service, advocacy, research, and policy efforts in various health and harm reduction settings (Closson, McNeil, McDougall, Fernando, Collins, Turje, et al., 2016; Greer et al., 2016; Jozaghi, Lampkin, & Andresen, 2016).   Researchers, policymakers, and community groups have shown a range of benefits to peer engagement and the work of peers. Practical benefits have included improvements to the reach, effectiveness, and relevance of initiatives due to the connection peer workers have with the community (Damon et al., 2017; Greer et al., 2016; Pallaveshi, Balachandra, Subramanian, & Rudnick, 2014; Ti et al., 2012). In harm reduction service work, including that which focuses on providing care, connecting people to resources and counselling, pragmatic advantages to peer involvement have been demonstrated. For instance, Bardwell et al. (2018) interviewed PWUD from shelters in Vancouver’s downtown east side neighborhood who reported a sense of support, safety, and overall preference for peer workers compared to non-peer staff. Other researchers have recently observed and interviewed PWUD in overdose prevention sites also in Vancouver (Kennedy et al., 2019; Wallace, Barber, & Pauly, 2018). They too have found peer workers fostered a safe and comfortable environment for other PWUD, and that peer workers “were   20 critical to the work of implementing and operating these sites as part of the province-wide public health response to the overdose epidemic” (Kennedy et al., 2019, p. 64). This preference to workers with lived experience of substance use may be attributed to peer workers’ demonstrated ability to uniquely connect and communicate with the community that is rooted in their shared life circumstances (Bardwell, Kerr, et al., 2018; Greer et al., 2019; Kennedy et al., 2019; True, Alexander, & Fisher, 2017).    Benefits of community engagement have also been demonstrated among peer workers themselves. In a rapid review of the literature, Marshall, Piat, and Perreault (2018) explored some of these psychological benefits among peer workers in overdose response settings. Among eight studies reported, PWUD demonstrated positive feelings related to their role in overdose response work, including empowerment, dignity, pride, and confidence (C. Marshall, Piat, & Perreault, 2018a). Qualitative and quantitative studies outside overdose response contexts reflect these findings, indicating the personal growth of peer outreach and research through a sense of ownership, purpose, and altruism (Bardwell, Anderson, et al., 2018; Goodhew et al., 2018; Greer, Amlani, Pauly, et al., 2018; C. Marshall, Piat, & Perreault, 2018b; Rance & Treloar, 2015). Peer work has also been shown to have positive impacts on workers’ relationships with others, including family and friends (Dickson-Gómez et al., 2004).    Finally, several studies have focused on the social justice benefits to peer engagement and the work of PWUD in these contexts. Qualitative studies suggest participation foster a sense of social inclusion by decreasing the social distance between them and other groups (non-peer staff) and finding common ground by working together (Belle-Isle, 2016; Greer, Amlani, Pauly, Burmeister, & Buxton, 2018). Researchers have framed similar findings as “a buffer against social isolation and disempowerment” (Marshall et al., 2018, p. 286) that can “build   21 collaborations between communities and research organizations, and lead to interventions and policies informed by community expertise” (True et al., 2017, p. 68), and “’shift the balance of power’ towards community empowerment” (Brown, 2013, p. 4). In this way, studies have framed peers’ involvement as a vehicle to socially, economically, and politically empower PWUD.  2.4 Organizing peer work  2.4.1 Frameworks for peer engagement work  One of the challenges with enabling the enactment and utility of peer work within organizations may be in the operationalization of peer engagement in the workplace – that is, moving from peer engagement as a set of principles to the reality of understanding, organizing, executing, and supporting the work and workers. Several community organizations and researchers have written about or developed frameworks to guide hiring, training, paying, and supporting peer work (Balian & White, 2010; BC Centre for Disease Control, 2018; Pacific Aids Network, 2014; Vancouver Coastal Health, 2016; Burrows, 2012; Closson, McNeil, McDougall, Fernando, Collins, Turje, et al., 2016; Greer & Buxton, 2018). These frameworks appear to be aimed at both PWUD and employers to promote equitable peer engagement, including hiring and paying workers. For instance, Balian and White’s (2010) manual ‘Harm Reduction at Work’ discusses the value of staff who use drugs, strategies to support PWUD at work, and managing challenges. Most guides provide practical suggestions and practices which relate to participation, including areas of concern, challenges, staff issues, and recommendations (Australian Injecting and Illicit Drug Users League, 2012; BC Centre for Disease Control, 2018; Balian & White, 2010; Greer, Amlani, Burgess, et al., 2018). However, the implementation of these frameworks has not been explored in depth.    22   Although different models for supporting peer work within organizations have existed for over a decade, peer work may not be routinely standardized. In an evaluation of peer engagement in BC from 2010-2014, scholars have noted that initiatives were regularly organized on an ad-hoc basis and that resources to guide how to do peer engagement were needed (Greer et al., 2016). Only one study (to my knowledge) has quantitatively explored how peer involvement has been organizationally supported: this survey of 50 organizations across the United Kingdom found between 19% and 33% had a payment policy to pay peer workers (Patterson et al., 2009). In their scoping review, Gillespie et al. (2017) also observed that there may be no consistent method of recruiting, training, and supporting peer work. Part of this variance may be explained by the nature of organizing and implementing peer engagement initiatives. For instance, peer engagement is noted as an iterative and flexible process (Greer, Amlani, Pauly, et al., 2018; Greer et al., 2016). As such, understanding the contextual factors that influence the operationalization of peer work, and potential systems of inequity and oppression that may be produced through this unfolding is needed.  2.4.2 Understanding peer work  Among studies which have described peer engagement processes or projects, issues related to the organization of peer work have been noted – several of which may impact the way peer work is utilized by employers. First, there is evidence of an overarching lack of understanding among stakeholders towards peer engagement and peers’ roles. For instance, a mixed-methods study conducted by Patterson et al. (2009) in the United Kingdom demonstrated that non-peer service providers and PWUD lacked an understanding of peer workers’ roles and their contribution to programs. These views were associated with opposition towards engaging or employing peer workers’ within organizations among service providers. Among PWUD, most   23 participants’ lacked knowledge about peer workers’ roles or its value, and about 50% were interested in engaging in it. Similar to results in this study, a peer-based organization conducted an audit of 64 organizations in Australia that engaged peer workers. (Australian Injecting and Illicit Drug Users League, 2008). They found the number one reason for organizations not undertaking participatory activities was unawareness among non-peer staff (Australian Injecting and Illicit Drug Users League, 2008). These studies suggest that without an appreciation for what peers’ roles are meant to be, roles for PWUD within organizations may continue to be limited.  An organizational understanding of peer work may directly translate to peer workers’ role support. For instance, communicating role expectations may be particularly crucial as they can produce performance, task, and process expectations for peer workers and produce an understanding of the fit of peer work within the organization. However, there is evidence that these expectations may not be adequately communicated to peer workers (Greer, Amlani, Pauly, et al., 2018; Greer et al., 2016; Z. Marshall et al., 2015; Souleymanov et al., 2016). According to one qualitative study of peer roles in policymaking across BC, Belle-Isle (2016) demonstrated that a lack of role expectations for peer workers created ineffective roles within policymaking contexts. This gap in role support was rooted in a lack of employer understanding of what peer workers can do, making it difficult for employer and supervisors to provide support. Similarly, other researchers interviewed employers of peer workers who lacked knowledge about the day-to-day working lives of peer workers, which resulted in some degree of unsupported roles (True et al., 2017). The process of providing such support has been loosely captured within studies which reflect on their community-engaged research process or observed social inequities in the workplace. The ways in which this informational or organizational gap is produced within the peer work context has not been examined in depth.   24 2.4.3 Workplace stigma and discrimination    Evidence suggests that peer workers have faced stigma and discrimination in peer engagement contexts that are associated with their experience of substance use. Across studies, peer workers and other service providers have described that PWUD were not always accepted as staff in the workplace due to this social identity (Belle-Isle, 2016; Coupland & Maher, 2005; Goodhew et al., 2018; King, 2011; Patterson et al., 2009); although, by contrast, peer workers’ substance use history has given them credibility among the community (Dickson-Gómez et al., 2003). Numerous qualitative studies have reported that non-peer staff have negative attitudes towards peer workers which are based in negative stereotypes and stigma towards PWUD (Bryant et al., 2008; Goodhew et al., 2018; King, 2011; Patterson et al., 2009). Attitudes identified by studies have included claims from staff that peer workers were “unstable,” “manipulative,” “untrustworthy,” “vulnerable,” and “lacking capacity to participate” (Bryant, et al., 2008; Goodhew et al., 2018; King, 2011; Patterson et al., 2009). Some researchers have suggested that these negative labels of PWUD can become attached to peer workers thereby promoting increased surveillance, and loss of autonomy and agency (Broadhead, Heckathorn, Grund, Stern, & Anthony, 1995). For instance, one study reported that peer workers were constrained to working in certain rooms within the workplace due to a lack of trust towards PWUD (Rance & Treloar, 2015).   Negative stereotypes about PWUD have also been expressed by scholars. For instance, one article reporting findings from a peer outreach project suggested that, “obviously, in actively recruiting people with solid street credentials, outreach projects set themselves up to hiring some applicants who are already prepared to pull a con job on the projects themselves” (Broadhead et al., 1995, p. 534). Another study described that non-peer workers have viewed peer work   25 suspiciously or peer workers were seen as doing peer outreach as “just another ‘hustle’ to support their drug habit” (p. 1277), even though peer workers in this study were not compensated (Dickson-Gómez et al., 2004). Such sentiments suggest that regardless of the participatory goals of engaging with PWUD in various contexts, these settings may not be a vacuum that evades the influence of negative stereotypes towards PWUD. 2.4.4 Work arrangements  Work arrangements are typically defined as standard or nonstandard; nonstandard arrangements are typically classified as work falling outside of formal or standard employment (Vosko, 2006). Two main characteristics of peers’ work arrangements were noted amongst the literature: peer work was typically nonstandard and framed as ‘volunteering’, and wages were varied yet, stipends were normalized. Volunteer peer work has been problematized in the literature. In one study that looked at experiences of peer workers in substance use treatment services, Hinton (2011) noted that volunteering is labor intensive but that  rewarding these efforts with monetary compensation is not always the norm. Similarly, in an Editorial, Shearer (2018) most recently highlighted that:  In contrast to those available to employed individuals, there is a stark lack of resources and supports, including remuneration and workplace supports, for marginalized community members who shoulder the responsibility of early overdose intervention, largely as peer workers receiving modest stipends or unpaid volunteers. (p. 2)  Researchers have suggested that formal, paid employment arrangements (rather than volunteer arrangements) have the potential to validate peer workers and formally recognize their experiences as a valued expertise (Bardwell et al., 2018; Bell & Salmon, 2015; Greer et al., 2018; Guta et al., n.d.). Formal employment arrangements for peer workers also boost morale, decrease isolation and exclusion, and build transferable skills (Bardwell et al., 2018; Greer et al., 2018; Guta et al., 2014; Souleymanov et al., 2016a; Wagner et al., 2014; Salmon et al., 2010).   26 Furthermore, paid peer work opportunities promote formal sector employment, which helps build experience, credibility, and legitimacy of work that can be applied to other employment (Bardwell, Kerr, et al., 2018; Canadian HIV/AIDS Legal Network, 2006; Greer & Buxton, 2018; Greer et al., 2018; Wallace & Quilgars, 2005; Salmon et al., 2010).  Volunteering may be known as a way to persuade peer workers’ into accepting low paid work. Scholars have suggested that PWUD should not be paid differently from those in similar or equal jobs without a history of drug use, yet there is ongoing evidence suggesting that they are (Souleymanov et al., 2016a). Relative to peer workers, other staff were regularly compensated through higher salaries, benefits, and rewards more from grants, awards, and publications (Jozaghi et al., 2018; Salmon et al., 2010; Souleymanov et al. 2016), contributing to feelings of being taken advantage of by employers (Collins et al., 2018). For instance, Bardwell et al. (2018) recently demonstrated qualitatively that non-peer workers were paid higher wages than peer staff in the same roles among PWUD and other workers in housing settings. Other literature has shown instances where peer workers were paid below provincial hourly minimum standards (Salmon et al., 2010; Vancouver Coastal Health, 2016). However, payment has been partly driven by community norms (Greer, Pauly, Scott, et al., 2018; Salmon et al., 2010). For example, one quantitative survey of fifty different peer engagement settings in the United Kingdom found that payments ranged from $9 to $49 USD per activity (Patterson et al., 2009). These findings suggest that pay and work standards may vary by context. 2.4.5 Funding peer work  Support for the organization of peer work may partly shape work conditions that produce inequity. For example, poor funding and strained budgets were noted as main reasons and justification for inconsistent and low wages (Griffiths & Hancock-Johnson, 2017; Roose,   27 Cockerham-Colas, Soloway, Batchelder, & Litwin, 2014; Salmon et al., 2010). Organizations have reported challenges regarding budgets and reporting of funds which are not accommodating to peer workers’ pay barriers (Greer & Buxton, 2018; Salmon et al., 2010). The pay process can also be fraught with miscommunications and misunderstandings from funders themselves (Brown, 2013). Yet, as researchers have underscored, these microeconomic politics should not prevail over concerns for equity (Salmon et al., 2010).  Providing role support may be rooted in the degree of capacity and resources within organizations. In their literature review, Needle et al. (2007) underscored the ongoing need for training, payment for work, adequate supervision, and access to support to prevent burnout in peer work. Funding appears to be a main barrier in peer engagement (Brown 2013); in one survey of community-based research, 85% of participants reported insufficient resources as a barrier to pay in Toronto. Scholars have urged peer engagement initiatives to “assess their mission, policies, practices, attitudes, and beliefs… to ascertain their readiness to integrate peer workers” (Gagne, Finch, Myrick, & Davis, 2018, p. S264) – sentiments also expressed by peer engagement work done in BC (Greer et al., 2018). Within the context of low budgets and poor funding, pay inequity in peer work may be produced and driven by the framing of peer works as a “low-cost” solution to staffing within non-profits. Within a sector that has historically been riddled with funding challenges (Baines, Cunningham, & Shields, 2017; Fanelli, Rudman, & Aldrich, 2017), advocacy organizations have competed with others over pay and having to rely on volunteers (Salmon et al., 2010). Peer work has been described as a low-cost solution to staffing in the literature (Treloar et al., 2015; Roose et al., 2018; Palleyshi et al., 2013). For instance, Pallayeshi et al. (2013) note that “peer-led groups can allow…savings in professional time…assuming that the common reality of peer   28 support providers being paid less than professionals may not fully change any time soon” (p. 394). Some scholars have suggested that peer engagement does not need large budgets to be successful, but instead can encourage peer educators to volunteer their time (Roose et al., 2018).  2.5 Peer work challenges and barriers  2.5.1 Peer worker roles  Peer workers’ roles and responsibilities within peer engagement contexts have not typically been the focus of studies but were described alongside other characteristics of the projects involving them. Within these studies, peer engagement makes up an umbrella under which a range of peer roles and responsibilities fall. To examine peer roles in harm reduction and the nature of this work, a systematic literature review conducted by Marshall et al. (2015) who examined 164 research articles on peer engagement to examine the work peers’ do. They found a combination of 36 different peer role descriptions and characterized these into five categories of work (from the greatest to least represented roles):  1) harm reduction education (e.g., creation of educational materials);  2) direct harm reduction and health services (e.g., distributing injection supplies);  3) support, counselling, and referrals (e.g., facilitating groups);  4) research assistance (e.g., data collection);  5) advisory committee participation (e.g., input in policymaking).  These researchers noted the influence of role categories on peers’ work purpose or function (Z. Marshall et al., 2015). From their review, the most commonly described roles were service-based (e.g., street outreach), followed by self-mobilization and advocacy in the community. Work with more decision-making control (e.g., cooperatively setting research agendas) were represented in   29 less than five of 164 sources. Marshall et al.’s review resembles quantitative findings from an audit of organizations which engage peer workers in Australia (Australian Injecting and Illicit Drug Users League, 2012). Here too, peer workers’ roles were only utilized in the functional sense. PWUD have also underscored how peer workers appear to be distributed among roles with a low degree of involvement in decision-making (Australian Injecting and Illicit Drug Users League, 2012). Unlike Marshall et al.’s review, other researchers have discussed peer workers’ roles by their level of participation or involvement, rather than the work they do (Belle-Isle, 2016; Greer et al., 2016; Z. Marshall et al., 2015; Ti et al., 2012). Much of this literature has conceptualized peer workers’ roles on a hierarchy, often depicted as ‘ladders,’ where the lower rungs depict a low degree of involvement (i.e. information sharing or consultation), and higher rungs reflect greater participation or involvement (i.e. shared decision-making between peer workers and other professionals) (Arnstein, 1969; Belle-Isle, 2016; Greer et al., 2016; Z. Marshall et al., 2015; Ti et al., 2012). In this way, the roles peer workers’ perform may reflect a gradient of power and control across social groups and may explain the formation of hierarchies in the workplace.  2.5.2 Workplace hierarchies  Hierarchies based on social stratification are demonstrated among studies which have demonstrated peer engagement contexts where peer workers have occupied positions with low worker agency, while non-peer workers have the privilege of occupying positions with more power and control (Bardwell, Anderson, et al., 2018; Belle-Isle, 2016; Damon et al., 2017; Shannon et al., 2007; True et al., 2017). Of note, community-based research projects have demonstrated how power hierarchies created through the division of labor have fostered feelings   30 of marginalization and exploitation among peer research assistants (Damon et al., 2017; True et al., 2017). These studies have interviewed peer researchers who perceived an unequal distribution of work benefits and burdens between peer workers and other staff, where they perceived peer workers being ‘used’ to drive the interests and careers of academics, while peer workers were poorly paid and underrepresented in decision-making (Damon et al., 2017; True et al., 2017). In addition to these studies, researchers have questioned if the representation of peer workers in functional roles have reflected the participatory goals of peer engagement, such as inclusion and empowerment, or if peer workers’ involvement might only meet the operational purposes and interests of agencies (Belle-Isle, 2016; Damon et al., 2017; Salmon et al., 2010; True et al., 2017). Studies have not, however, explored these hierarchies beyond descriptive observations – therefore, a more nuanced examination of how social stratification may be systematically produced in peer work contexts is needed.   Examining such hierarchies and the potential power inequities produced in them is particularly concerning given the social justice basis of peer engagement and the work peers’ do. Scholars have emphasized the potential for social inclusion and empowerment through peer engagement (Canadian HIV/AIDS Legal Network, 2006; Greer, Amlani, Burgess, et al., 2018). However, indications that inequities may be produced in these work contexts stand in direct conflict with the participatory ideals of peer engagement. As Salmon et al. (2010) have noted, participatory approaches with PWUD regularly do not consider the enactment of its practices and work; thus, participation can easily fall under “romantic emancipatory possibilities” (Varcoe, 2006) which may render invisible work inequities and conditions that are potentially oppressive. This “romantic” lens of peer engagement may be the reason for negating some of the potentially damaging outcomes of this approach. Many studies have not reported on or acknowledging   31 power inequities in their work, although it is evident through the description of certain projects. As such, a critical perspective on the work peers’ do, and the outcomes of peer engagement are warranted.  2.5.3 Role demands    Peer workers may need support for their roles linked to the unique challenges they face. One main issue consistently highlighted among studies, especially recently, is the degree of work stress peer workers face (C. Marshall et al., 2018a). Researchers have emphasized the need to support workers in maintaining personal wellness and community boundaries, as well as support to process grief (Ahmed, Hunter, Mabe, Tucker, & Buckley, 2015; C. Marshall, 2017; Norman et al., 2008; Tookey et al., 2018).    These issues were raised mainly in jurisdictions including BC where the presence of peer workers and the rate of overdose deaths may be increasing concurrently. Although the number of peer workers currently engaged in peer work is unknown, publications have suggested they are at the forefront of the response of the opioid crisis (Bardwell, Kerr, et al., 2018; Kennedy et al., 2019; Lupick, 2016; C. Marshall, Perreault, Archambault, & Milton, 2017; Shearer, Fleming, Fowler, Boyd, & McNeil, 2018; The Canadian Press, 2017; Wallace et al., 2018). Several qualitative studies in Vancouver and elsewhere have examined the experiences of people in peer-based overdose response work which has regularly exposed workers to a high degree of emotional, mental, and physical stress (Bardwell, Kerr, et al., 2018; Kennedy et al., 2019; Norman et al., 2008; Teti, Bowleg, & Spencer, 2009; Wagner et al., 2014; Wallace et al., 2018). These studies have also indicated regular experiences of trauma and expressions of burnout among peer workers engaged in overdose work.    32   In the context of the overdose epidemic in BC, scholars highlight that the “provision of supports for peers assuming first-responder positions is critical to the sustainability of community-based overdose response interventions” (Shearer et al., 2018, pp. 1-2). Researchers are quick to note that peer workers provide support for community members experiencing grief and trauma, yet peer workers themselves were unsupported (Bardwell, Fleming, et al., 2018; Bardwell, Kerr, et al., 2018; Kennedy et al., 2019; Shearer et al., 2018; Wallace et al., 2018). Several literature reviews have concluded that supporting peer roles, both in and out of overdose work contexts, are essential to their effectiveness (Gillespie et al., 2018; Greer, Amlani, Burgess, et al., 2018; C. Marshall et al., 2018a). These findings may reflect how poorly peer work is understood, thus systematically not enabling effective role support, or might be a result of inequities and workplace discrimination toward peer workers.  2.5.4 Community connection    The literature has suggested that peer workers’ may face unique role challenges from the nature of peer work. Peer workers’ close connections with the community were a core issue suggested amongst scholars. For instance, focus groups with peer workers conducted reported added stress and burdens from living and working in the same community, such as running into friends while at work or clients while off work and seeking healthcare (True et al., 2017). In a similar vein, participants in this study spoke about the challenges of ‘wearing multiple hats’ at work which contributed to psychological distress and burnout.     Other researchers have suggested that peer roles might be particularly stressful and traumatic due to the close relationships they have with community members for whom they provide support (Shearer et al., 2018; Teti et al., 2009). These claims are supported by a study which presented qualitative findings from thirty peer workers from an overdose prevention   33 program in Los Angeles, California (Wagner et al., 2014). They found that although responders gained a sense of control, confidence, and pride, they were fearful they could not help their community, emphasizing the pressure they felt to make a positive impact (Wagner et al., 2014). In this study, respondents attempted to cope with the stress associated with witnessing and responding to overdose by cutting social ties to their community (Wagner et al., 2014).     The literature also has suggested that peer workers may face a unique challenge of having to navigate multiple overlapping and transitional identities as peer workers, community members, and service users (Ahmed et al., 2015; C. Marshall, 2017; Teti, Bowleg, & Spencer, 2009; Tookey et al., 2018; True et al., 2017; Wilson, Vannice, Hacksel, & Leonard, 2018). Among them, one case study of two peer workers described a literal or symbolic journal in the shifting identity from client to peer (Tookey et al., 2018), while others have suggested peer workers are “stuck” in the identity of PWUD which may introduce issues between coworkers (Wilson et al., 2017).  2.5.5 Substance use and peer work    Research has shown mixed findings on substance use among peer workers. For instance, in a case study of two peer workers in overdose prevention settings conducted by Wilson et al. (2018), interviews with workers showed some were triggered from exposure to drugs and ‘drug talk’ in the workplace. Other research demonstrates contradictory findings where peer outreach work has prevented re-initiation into substance use (Dickson-Gómez, Knowlton, & Latkin, 2004) In some settings such as peer-based organizations, peer workers have consistently worked around and under the influence of drugs in these settings (Bardwell, Anderson, et al., 2018). Several studies suggested that peer work may actually decrease drug use among peer workers; findings that were associated with the social connection and time structure around their jobs   34 (Bardwell, Kerr, et al., 2018; Dickson-Gómez et al., 2004). Differences between these studies indicate that there may be structural differences across contexts which mitigate or support the wellbeing of workers and may influence peer workers’ substance use.     Some studies have suggested the perpetuation of abstinence-based work cultures may reinforce the stigma towards PWUD as peer workers. Researchers in Canada have suggested that harm reduction settings which prohibit substance use among peer workers, particularly those who are opioid dependent, may perpetuate negative views towards peer workers (Wallace et al., 2018). Other research has noted that this culture is systematically produced through various policies and practices that promote abstinence. For instance, Hinton (2010) discusses “two year rule [of abstinence before] engaging in volunteer work or paid employment” (p. 45) in substance use treatment settings. They note that although the rule was implemented over a decade prior to their study, it resulted in lasting effects on the culture around substance use in peer work. To promote abstinence, others have shown that employers suggest refusing to pay if peer workers are intoxicated (Roose et al., 2014). Work agreements proposed by Roose et al. (2014) have indicated that if peer workers come to work under the influence of substances, they would forfeit their stipend. As abstinence-based work cultures are valued in the broader labor market, these studies have indicated that peer-based initiatives do not operate in a vacuum, but can systematically reproduce stigma in peer engagement initiatives. Researchers have consistently suggested shifting workplace cultures to be more inclusive of PWUD as an essential element to promoting meaningful peer engagement (Goodhew et al., 2018; Patterson et al., 2009, 2010; Wallace et al., 2018).   The way substance use is treated in peer engagement settings may constrain peers’ opportunity to work or be effective. Substance use among peer workers has been noted a “risk   35 factor” (Coupland & Maher, 2005) and one of the most cited issues raised for outreach workers and peer workers in substance use treatment settings among several literature reviews (Goodhew et al., 2018; World Health Organization, 2004). Among qualitative research, service providers have actively voiced their concerns about peer workers’ exposure to other PWUD and their concerns of increased substance use (King, 2011). 2.5.6 Socioeconomic disadvantage  Finally, dispersed throughout the literature was evidence of other unique challenges and barriers peer workers face due to their life circumstances. Of note, numerous studies have stated a need for studies to attend to the significant structural barriers to engagement and employment that PWUD face as a marginalized group in society. Some have suggested that attending to workers unique life circumstances that were preventing peer workers from working, such as their experiences of homelessness and criminalization, were main barriers to work (Weeks et al., 2006). In their study of 130 peer workers doing health advocacy in Connecticut, 80% were unemployed, 49% were experiencing current homelessness, and 29% had been in jail or prison within the previous six months (Weeks et al., 2006). These findings echo Dickson-Gomez et al. (2004) study which found 70% of 250 peer workers in Baltimore were unemployed at the time of the study, and among those who reported any current employment experience, 80% were involved in low-wage service work for a short duration (e.g. janitors, restaurant workers). Among this sample, 70% reported earning $300USD or less in the past 30 days.  In their experience of engaging women who use drugs in a participatory project, Shannon et al. (2007) noted several barriers peer workers may face in employment contexts. For one, they discussed how peer workers’ life circumstances, including their interactions with the criminal justice system, drug treatment, housing, and childcare, were constant challenges in carrying out   36 the project, as well as providing training and support to peer workers. In interviews with peer outreach workers, Dixon-Gomez et al. (2004) found among peer workers criminal records were a barrier to employment, which in turn led to increased drug use. Findings from Vancouver, Canada similarly suggest that grief from deaths of people in the community, serious illnesses, evictions, and violence were major challenges that women who used drugs faced which constrained their capacity to participate  in employment in research settings (Salmon et al., 2010). As Salmon et al. (2010) suggest, it was these life circumstances that were often misunderstood or missed by employers within participatory initiatives.  2.6 Summary  The literature review has demonstrated how peer work has been studied and operationalized in the literature. Peer engagement is intended to be an inclusive and empowering practice within health promotion and harm reduction. Studies to date have promoted these benefits. Although peer work may have emerged from the pragmatic and social justice ideals of peer engagement, my critical review of current knowledge and evidence presents several challenges and issues which may undermine those ideals. Research suggests that structural features of the work and systems have the power to shape equity for PWUD. Many PWUDs are discriminated against and structurally disadvantaged by their social grouping. Peer work presents a unique context where social and economic systems of inequities have the potential to be reproduced through the operationalization of peer roles in work contexts.  In examining the peer engagement literature, some insights were provided on issues regarding peer work effectiveness, utility, conditions, and the nature of the work itself. The operation of peer work may be predicated on the organization of peers’ roles, including how they   37 are structured and systematized within organizations. Descriptions of some of the challenges in organizing, supporting, and utilizing peer work illustrate conditions reveal that they are potentially oppressive.  A handful of studies have noted structural issues in peer work; but, I found no published study that had specifically examined what exactly these structures are, how they are shaped, and how they influence the work experiences of peer workers from a labor perspective. Work conditions, including work arrangements, pay arrangements and role support, have rarely been examined or are merely described. Studies have also rarely considered the context in which peer work is organized, its operationalization, and the construction of peer work systems and their influence on the creation, reproduction, or reinforcement of social and economic inequities. Research is needed that specifically examines what structures and systems shape peers’ work experiences, and work conditions, and how these conditions are experienced among the affected community. The chapters of this dissertation that follow will address some of the knowledge gaps identified here. Before the findings chapters, the next chapter describes the research design and methods that were suitable to reach my research objectives.    38 3 Chapter Three: Research Design and Implementation  3.1 Introduction    In this chapter, I detail my chosen research design and methods employed. First, I present my theoretical ‘scaffolding’ – the theoretical ideas that played a significant role in its design and implementation. This theoretical foreground will locate the study within theoretical allegiances, disciplines, and ideas (Thorne, 2006). Then, I present the qualitative methodology of interpretive description that guided the design and methods used, along with the procedures used to collect my data including details about sampling, recruitment, honorariums, data collection, coding and analysis, memoing, and reflexivity. Lastly, I discuss the steps taken to enhance methodological rigor, as well as the ethical procedures in this study.   3.2 Theoretical perspectives  This study was informed by critical perspectives. Critical perspectives come from a diverse linage of critical theories, which are understood as being concerned with “issues of power, and justice and the ways that the economy, matters of race, class and gender, ideologies, discourses, education, religion and other social institutions, and cultural dynamics interact to construct a social system” (Kincheloe & McLaren, 2000, p. 281). There are numerous critical theories and, while there are subtle differences between these theories, the distinct features of critical theoretical perspectives shaped the current study. The tenets of critical perspectives include: 1) critiques taken-for-granted processes that are shaped by institutional and societal structures; 2) considers oppression from a structural perspective by analyzing and challenging the role of systemic mechanisms which sustain this oppression; 3) analyses of oppressive power structures and divisions between social groups; 4) understanding that reality is subjectively produced; and 5) commits to confronting injustice through a critique of the structures that create,   39 sustain, and reinforce oppression (Denzin & Lincoln, 2011; Browne, 2016; Freeman & Vasconcelos, 2010). Iris Marion Young’s (1990; 2001) theoretical developments about various forms of oppression and robust structural analysis was particularly useful for building on and unpacking oppression that exists institutionally. Young, whose views draw on critical traditions and align with political and feminist philosophers, is critical of the everyday experience of individuals within their wider social context and offers an approach to looking at social justice in terms of oppression and domination (Young, 1990; Reimer Kirkham & Browne, 2006). Young’s (1990) insights were particularly useful for me to bring out issues of decision making, social hierarchies, and the division of labor and pay that were different between social groups and embedded through institutionalized patterns and arrangements. Collectively, the integration of critical perspectives and tenets provided a foundational lens and set of assumptions with which to approach and view my research problem, data, and findings.  Each of the key features of critical perspectives shaped the study. First, critical perspectives consider a wide influence of societal factors that cause social and contextual circumstances that are oppressive or inequitable. They offered me ways to look at the relationships peer workers have with social structures and institutional practices that they work within and encounter in their everyday work lives (Young, 1990). In this way, I focused on the range of antecedent factors that influence peoples’ day-to-day realities. Thinking about the problem and analyzing the data from this perspective therefore supported an unpacking of a “plausible structural story” (Young, 2001, p. 16) of ways oppression came to be embedded in interlocking, interconnected, and reinforcing systems of inequity and the ways this structure manifested in peers’ everyday work context (Young, 1990).   40             A second central feature of critical perspectives is that they focus on oppression that is based in divisions between powerful and powerless individuals of social groups (Crowne, 2016). Looking at oppression from this perspective enabled me to ask how peer workers’ social relations were built into peer work institutionally, as well as examine the ways this work was structured differently peer workers and how this structure influenced peer workers’ agency. This was not to say that individuals did not have agency, or were passive in their choices or decisions (Sherwin, 1998). From a this perspective, nexus of support and constraints that are structurally-based influenced the agency of peer workers by negating, enabling, or influencing their actions, choices, and strengths (Sherwin, 1998).             Third, critical perspectives view knowledge being produced subjectively, which aligned well with my study and its methodological approach (Morrow & Brown, 1994; Scotland, 2012). Methodological foundations of studies from a critical paradigm locate individuals within structures that produce power and control for these groups by analyzing experiences that have an interpretive dimension (i.e. Browne, 2016). From this perspective, I assumed that the meaning of peer workers’ lived realities was constructed in ways that both revealed and concealed their subjective experiences within structures. Examining the qualitative accounts of peer workers’ descriptions of their work conditions and experiences were, therefore, the best approach for exploring the structural basis for oppression and inequities in peer work.             Finally, research from a critical perspective commits to understanding societal problems in ways that make its structural determinants visible and, therefore, potentially remedial (Denzin & Lincoln, 2011). This stance aligned with my intention of confronting injustices in peer work and the structures that create, sustain, and reinforce inequity and oppression. In line with this   41 thought, I generated recommendations for practical organizational strategies, work practices, and research directions which may promote equity in peer work. 3.2.1 Structural oppression and inequity   In addition to these central tenets which aligned with and added to the theoretical positioning of my study, critical perspectives framed social activities, power, and difference as being entrenched within the structuring of things such as habits, relations, arrangements, practices, organizations, and policies which are taken-for-granted in our world. Iris Marion Young’s (1990) scholarship on structural oppression was particularly useful for examining peer work, including the conditions that determined the distribution of nonmaterial resources, such as power, in the context of this work. Young (1990) was especially interested in and critical of the way oppression is reproduced and embedded in norms, rules, and major institutions and how they are reflected in people’s everyday experiences. For her, oppression was not necessarily the result of any one individuals’ intent or a few people’s choices, but the conditions that shape choices and experiences, and the ways these experiences are socially constructed, historically located, and institutionally produced (Young, 1990). This understanding became an analytic device that illuminated different ways that work conditions were oppressive, with expressions of oppression reflected through the everyday experiences of peer workers.   Young posits five ‘faces’ or expressions of structural oppression: marginalization, exploitation, powerlessness, cultural imperialism, and violence. Three of these ‘faces’ of oppression – marginalization, exploitation, and powerlessness – were used by Young (1990) to examine the distribution of non-material economic and social resources based on people’s positions within labor contexts, including labor markets. I found them particularly useful to examine social and economic divisions in peer work. The ways work conditions, including those   42 that were marginalizing, exploitative, and disempowering, are constructed differently for PWUD compared to others was central to this study.  For instance, the process of marginalization suggested that peer engagement socially excluded and denied groups participation, agency, and self-determination in various aspects of human life, such as work. By marginalization, I mean the process of exclusion of people from participating in parts of society, such as work or aspects of work, in ways that are segregating, involuntary, and depriving (Young, 1990). Exploitation refers to the degree that people can exercise their capacity “under the control, according to the purposes, and for the benefit of other people” (Young, 1990, p. 14). It can be seen in capitalist societies by looking at who works for whom and under what conditions. Exploitation can occur through labor structures and systems which serve or of benefit to certain groups over others, such as non-peer versus peer workers, and are reinforced for the interest of maintaining this imbalance (Young, 1990). This process perpetuates class differences by keeping those with privilege and status (or the rich) as benefiting from this system and those without privilege and agency (or the poor) as deprived of these benefits. Finally, powerlessness speaks to power differentials between groups that are rooted in status and class differences. Young (1990) specifically uses powerlessness to describe workers who must take orders and rarely have the right to give them; have little opportunity to develop or exercise skills; have little to no work autonomy, creativity or judgment; and lack respectability in the workplace. For me, powerlessness speaks to those who have less social and economic power over others, such as limited or restricted access to and autonomy in opportunities, decisions, and status, due to their class or social positioning. Collectively, these three ‘faces’ of oppression served as a set of theories which heightened my awareness to the particular ways peers work   43 experiences may be oppressive and led me to question the drivers or structural basis of these expressions.  Scholars have regularly used Young’s theories of structural oppression to illuminate the systemic disparities that disadvantage certain groups as a consequence of social conditions (i.e. Pauly et al., 2013; Young, 2001) – differences that are known as inequities (Weinstein, Geller, Negussie, & Alina Baciu, 2017). The notion of inequities complements structural oppression as these differences that disadvantage certain groups are inherently structural (Kagan, Smith, & Chinn, 2014; Young, 2001). I borrow from Weinstein et al.’s (2017) concept of inequity as a way of conceptualizing how systems and structures produce disadvantages for certain groups over others. This way of critically thinking about how and why peers’ experienced work as different from others complemented theories of oppression in my analysis by giving meaning to how disparities could arise from the organization of resources, capacities, and opportunities between groups in work. 3.2.2 Perspectives and concepts of work  Participants’ descriptions of their work experiences were the focus of my inquiry from which I examined the perpetuation of inequities via the social, economic, cultural, and political systems of work. As scholars point out, work systems and its organization “reveal much about the social order, how it is changing, and the kinds of problems and issues” (p. 2) in society (Kalleberg, 2009). Therefore, various concepts of work enhanced my critical theoretical lens to provide me with ways to think about and look at how work is structured and the ways systems of inequity and oppression may be perpetuated through this structuring.      44 Labor markets  Broadly, the structure of labor markets was of interest to me due to the way PWUD have historically been excluded or marginalized from participating in them (see Chapter 1) (Henkel, 2011). Labor markets can systemically create, promote, and reinforce certain work conditions and social order (Kalleberg & Sorensen, 1979). For instance, markets can determine the means by which social groups are distributed among jobs and the rules that govern employment, job growth, expertise or job skills, and value (Kalleberg & Sorensen, 1979). They also produce and reproduce different norms between types of jobs and workers to fill those jobs (Kalleberg & Sorensen, 1979).  Labor markets can contribute to the social stratification of groups. Notions of dual labor markets can be seen as a theory of segmentation where the labor market is dichotomized into two sectors – primary and secondary – that are defined along social lines (Conner & Rosen, 2008). Dual market theories posit that labor market segments can be differentiated as primary and secondary sectors which are characteristically different in terms of the type of work done, work conditions, and workers within them (Loveridge & Mok, 2012; Wachter, Gordon, Piore, & Hall, 1974). These theories suggest that jobs in the primary sector offer jobs with good working conditions, including relatively high wages, advancement opportunities, role support, and stability. In contrast, secondary sector work tends to be precarious, lacking security, job growth, and fair wages, and differs by workers’ wages, employment, job type, job mobility, and agency. The key mechanism that drives the dichotomy between these markets is the little chance of advancement or crossover of certain social groups into the primary sector; thus, segregating these individuals to the secondary or subordinate market. Workers here are often socially marginalized and denied entry to the primary sector work because of their disadvantage in earnings, choice,   45 and job mobility. Some scholars have noted how marginalized workers’ lack of access to other parts of the labor market and segregation to precarious, subordinate work thereby create a process where “workers in the secondary sector are essentially trapped there” (Wachter et al., 1974, p. 638).  The construction or influence of the labor market brings into question how peer workers’ agency and power become constrained and conditioned by its structure and systems. Through a critical lens, an analysis of how peers’ work experiences pointed to labor market systems which produced particular socioeconomic conditions that disadvantage or constrain groups. For instance, the interactions between peer workers and employers were linked to the construction of the labor market and ways in which it positioned and limited people (or not) in particular ways (Kalleberg & Sorensen, 2009; Burgess & Campbell, 1998). Organizational arrangements  Examining how work is structured and systematized within organizations can speak to the ways conditions might produce inequities through a myriad of organizational interests and power structures. In their book, Watson and Korczynski (2011) describe how the structure of work within organizations are expressions of political, cultural, economic, and social systems. For instance, the social and economic arrangements that people are stratified, ordered, and grouped within organizations can produce relationships and boundaries within and across roles and social positions in ways that can be discriminatory, inequitable, and oppressive (Watson & Korczynski, 2011). However, people are not merely ‘slotted’ into these institutions but rather, are implicated in those processes and relationships. Analyzing the organization of peer work illuminated organizational systems of inequity and oppression which were produced and   46 reproduced in  work practices and arrangements that create differences between groups and constrain people to particular circumstances. Features of precarious work  Concepts of precarious work provided different ways of looking and thinking about dimensions, conditions, and experiences of work. Precarious work is typically characterized by various dimensions of work conditions – nearly always nonstandard work arrangements, low wages, job insecurity, and a lack of workers’ rights and benefits (Kalleberg, 2009). Nonstandard work arrangements include temporary, short-term, contingent, contract, and casual work, and introduce other precarious dimensions, such as low wages, job insecurity, and a lack of benefits or protections (Kalleberg & Vallas, 2017). Work arrangements can structurally determine the location, duration, and frequency of work, source of administrative control, and support (Ashford et al., 2007). Precarious work conditions are notably and predominantly occupied by marginalized and structurally vulnerable groups globally (Kalleberg & Vallas, 2017; Standing, 2014a). As a conceptual framework, thinking about how precarious work conditions were experienced and structured underscored the structural origins of inequitable work arrangements and relations, in addition to the oppressive construction of labor markets.  Theoretical notions of precarious work were additionally relevant to my study as a way to describe a relational or subjective condition that speaks to uncertainty and unpredictability based on aspects of work combined with the social positioning and circumstances of workers (Campbell and Price, 2010). Considering precarious work from this perspective reflects writings from Butler (2004), who presents precariousness as a social or relational condition that depicts how people are dependent on and vulnerable to others. For Butler, precarious experiences speak to the ways socioeconomic and political institutions structurally distribute life conditions,   47 including work conditions, unequally. Clement et al. (2009) extends these notions to labor and ask: “precarious [work] for whom and under what conditions? Are all lives becoming more precarious or does precariousness hit certain people more than others?” (p.6). These views complement and echo notions of equity and inequity as precarious experiences can reveal the way some groups are disadvantaged by these experiences, thus illuminating how these experiences are socially and relationally based. A critical perspective of labor opens up questions of how different labor conditions are constructed and interact with the lives of peer workers in particular contexts – enriching an examination of what peer work looks like to what its conditions potentially do (Millar, 2017). Views of work from these perspectives illustrated expressions of inequity that are rooted in the structures which render and are rendered by the lived experiences as different for some and not others and critically points to why those differences may be.  3.3 Design and methodology   The aim of conducting this study was to critically engage with and develop an in-depth understanding of peers’ work conditions, the organization of the work, and the structural factors that shape inequities and constraints in the context of peers’ everyday working lives. I did not see inequities or oppression as something to be objectively captured, but sought a research design which kept intact the complexities of systemic inequities and oppression (Thorne, 2016). In line with a critical theoretical lens of peer work, I sought to understand peer work through the construction of multiple subjective truths, realities, and the meaning of these at the time and context of the study (Lincoln & Guba, 1985). I viewed this knowledge as being depicted qualitatively through the lived experiences of peer workers that were highly subjective, constructed, and specific to the time and context of inquiry (Lincoln & Guba, 1985; Thorne,   48 2016). Elucidating qualitative insights into peers’ everyday work experiences illuminated patterns, conditions, and systems that were shaped by various mechanisms such as organizations, labor markets, policies, work arrangements, and power differences between groups. Qualitative research provided methods and practices that enabled me to explore the construction of peer workers’ roles by examining the lived experiences of this work context and all of its complexities (Denzin & Lincoln, 2011; Thorne, 2016). 3.3.1 Interpretive description   In designing this study, I employed a qualitative research methodology that allowed me to uncover different systems and structures that shaped peer workers experiences. Interpretive descriptive methodology appealed to me as a methodology that utilizes techniques to discover potential associations, relationships, and patterns described by looking at underlying meanings to illuminate what is happening, while considering the real world context (Thorne, 2016). Interpretive description techniques allowed me to both identify and infer different unseen or unspoken factors that explained how or why participants were describing and perceiving peer work in particular ways (or not) (Thorne, 2016).   This methodology also enabled me to be iterative in my approach. Interpretive description does not prescribe to a particular ‘cookbook’ of methods, but instead draws on methods, often borrowed from traditional qualitative methods, that complement and facilitate a more intentional and purposeful inquiry (Thorne, 2016). Therefore, I stayed flexible and focused on methods that fit the context and purpose of my study.   Finally, interpretive description was explicitly positioned within an applied disciplinary domain, which complemented my critical orientation to my research problem. Thorne (2016) has stated that interpretive description “addresses a distinct need for inquiry approaches where   49 certain kinds of clinical problems or populations warrant inquiry that describes and interprets patterns of experience, action, or expression” (p. 68). This methodology therefore aligned with my intent of generating knowledge that could have a practical application. This approach stood in contrast to traditional qualitative methodologies, such as grounded theory, which seeks to generate a new theory but not necessarily the application of it (Patton, 2003; Thorne, 2016). The applied approach of interpretive description urged me to re-contextualize my data within complex processes and systems that peers’ work within while generating real-world recommendations to promote equitable work conditions by transforming my findings into potential practices (Thorne, 2016).   3.4 Study procedures  3.4.1 Study context    This dissertation is situated within a particular peer engagement context. There are five regional BC Health Authorities (Interior, Island, Northern, Vancouver Coastal, and Fraser Health Authorities), as well as two Health Authorities that span the province – the Provincial Health Services Authority and First Nations Health Authority. The BC Centre for Disease Control (BCCDC) provides harm reduction supplies, such as safer drug use and safer sex supplies, to harm reduction programs operated by these Health Authorities (BC Center for Disease Control, 2014). The BCCDC and Health Authorities also work together as part of the BC Harm Reduction Strategies and Services (BCHRSS) committee which develops and guides provincial harm reduction policies and programs by convening with peer workers from across the province at a bi-annual meeting held in Vancouver. The BCHRSS committee has promoted, studied, and adopted peer engagement as a best practice approach in harm reduction since 2010 (Greer et al., 2016).     50   The Peer Engagement and Evaluation Project (PEEP) is one project that is related to the current study. From 2015-2018, I was the research coordinator for PEEP alongside the Principal Investigator (Dr. Jane Buxton, dissertation co-supervisor) and co-investigator Dr. Bernadette Pauly (committee member). Initiated by the BCHRSS committee, this community-engaged research project is one example of an initiative to promote peer engagement in harm reduction that has resulted in peer work across many policy settings, programs, and research projects in the province. The aim of PEEP was to make peer engagement the norm in BC, expand peer networks, and create peer engagement best practices for provincial health authorities (BC Center for Disease Control, 2017). Over three years, this community-engaged, cross-jurisdictional research project worked with five contracted peer research assistants who informed and participated in the research process from its inception to knowledge translation. Several publications from PEEP relate to the current study, these include: Greer, Amlani, Burgess, et al., 2018; Greer et al., 2019, 2016; Greer, Amlani, Pauly, Burmeister, & Buxton, 2018; Greer & Buxton, 2018; Greer, Pauly, et al., 2018; Jozaghi, Greer, Lampkin, & Buxton, 2018. These studies do not have overlapping data with my dissertation.    The context of my past experiences of engaging with peer workers’ is, however, also central to this dissertation. In my experiences while coordinating PEEP and working in harm reduction, I became sensitize to several issues and challenges in peers’ work conditions. Issues included concerns raised by peer workers regarding their labor conditions, as well as organization issues raised by other people in the harm reduction community. These experiences and insights were unquestionably a catalyst to the current study, and I was driven to examine more deeply the systems and structures that shaped the challenges and circumstances people were facing in peer work.      51 3.4.2 Sampling and recruitment   In line with interpretive description, the aim of my sampling was to maximize understanding and depth rather than representativeness (Sandelowski, 1995; Thorne, 2016). I used purposeful sampling to identify and recruit people who provided perspectives and experiences of peer work and its conditions (Patton, 2003). Purposeful sampling is widely used in qualitative research and is known for “the logic and power of… selecting information-rich cases for study in depth” (Patton, 2002, p. 230). This approach enabled me to strategically recruit a sample with subjective experiential knowledge of peer work from different positions, circumstances, and perspectives (Patton, 1999; Patton, 2003; Thorne, 2016). In this, I was interested in similarities and differences in perspectives and experiences by context (i.e. geographic location, type of organization), role (i.e. outreach worker, research assistant), and work arrangements (i.e. volunteer, standard employee, length of employment). For instance, my initial sample was mainly peer workers engaged in intermittent volunteer work, so I purposefully sought people in standard employment (i.e. full-time salaried peer workers) next. I also took into consideration participant characteristics, including participant age, gender, ethnicity, geographic location, substance use (i.e. type, current or past lived experience), and socioeconomic status. While the main aim of my analysis was not to examine experiences based upon these characteristics, each of these groupings highlighted different social positions, work conditions, and experiences that evoked oppression in diverse ways. Purposeful sampling enabled me to identify and expand the variation of my sample based on these characteristics.  Several recruitment strategies were used. I started with peer workers who were known to me and who were readily available at the time of recruitment. These initial recruits allowed me to pilot my interview guide and begin data analysis, which informed the next stage of sampling   52 and adapt the guide in light of the emergent findings. Next, I asked participants, if they were willing, to give a recruitment flier to peer workers with characteristics or experiences of interest to me at that point in the purposeful sampling strategy. This strategy allowed me to maximize my ability to purposefully sample for specific and diverse cases while expanding the network of peer workers I had access to. Lastly, fliers (see Appendix 1) were distributed to harm reduction organizations. This strategy similarly enabled me to recruit peer workers outside my professional network and capture variances in peer work, which I may not have been aware of.    The main inclusion criteria for participating in this study were: 1) aged 16 or older; 2) spoke English; 3) self-identified as a peer worker, namely: a person who has lived experience (current or former) of substance use who has used that experience in their professional work in public health services, organizations, or research projects within the past twelve months (i.e. as an outreach worker, community consultant, research assistant, advisor, etc.). The criteria were aimed to include both youth and adults who use drugs; youth (particularly marginalized youth aged 16-19 years) may experience employment and pay practices in ways that differ from adults (Karabanow, 2004). The sample was limited to people who engaged in peer work in the previous twelve months to promote relevance within the current context and recall accuracy but also spanned enough time to account for recent circumstances (i.e. illness) that may have inhibited people from recent work. I limited this research to English speakers as translators were not accessible.  The final sample comprised of fifteen participants. After thirteen interviews, I was confident in the richness of the data collected in that it illustrated the complexities of peer workers’ experiences and felt complete, but conducted another two interviews to reinforce my conclusion that further gathering of data would not create a significantly deeper understanding.   53 The fifteen interviews provided me with sufficient richness and depth in the data, as was evident in the patterns and themes that emerged during my concurrent sampling and analysis.  Interested individuals were given a one-page recruitment flier and/or verbal description of the project’s aims and what was involved (i.e. time commitment, honorarium, location, confidentiality, contact information) (Appendix 1). Participants had a minimum of 24 hours to consider their participation. They were asked to contact me via telephone, text, or email after 24 hours if they were interested in participating. At that point, an interview was scheduled at a time and location most suitable for them.  Participants were provided with a $20 CAD cash honorarium before the interview began. Participants were provided reimbursement for any costs incurred such as transportation to the interview, as well as refreshments. Resources regarding peer work were offered and made available including Peerology, Nothing About Us Without Us, Paying Peer Research Assistants guide, and the Community Based Research Ethics documents (i.e. Canadian Association of People Who Use Drugs, 2014, Canadian HIV/AIDS Legal Network, 2006; Greer & Buxton, 2016).  3.4.3 Interviews   The primary data source of this inquiry was one-on-one interviews to provide a deep and subjective account of peer work experiences. Interviews were a “conversation with a purpose” (Dexter, 1970, p. 136, cited in Morrow, 2005) where participants’ provided rich insights into experiences, attitudes, feelings, and perspectives through their own words and based on their life experiences (Denzin & Lincoln, 2011). These conversations were guided by a semi-structured interview guide (Appendix 2). I developed the guide in a way to allow for flexibility and included several questions to elicit peers’ experiences in work. The questions were informed by   54 previous knowledge, my theoretical perspectives, the literature review, and conversations with peer workers. I knew I wanted to garner descriptions of the “normal processes in everyday life” (Young, 1990, p. 41) of peer work that illuminated the systems and structures which shaped them. For me, descriptions of these experiences were where expressions of structural oppression and difference could be seen. Questions focused on generating descriptions about the process of finding and keeping peer work, current and previous work conditions and experiences, and how these might differ from others (peer and non-peer workers), within the context of that work. I also probed into some of these experiences to gather any perspectives participants had on any particular work systems or experiences that shaped them.  Interviews started with a brief description of the project, my objectives, and an overview of the research questions. Questions started with general questions (i.e. “can you tell me about some of the work that you do as a peer”) and moved to those more specific (i.e. “can you tell me how much you were paid as a [participants’ identified role]?”). I engaged with participants from the stance of a “curious learner,” honoring their knowledge, and allowing them to choose the stories and experiences that they wanted to tell (Thorne, 2016). This approach freed me from asking questions in a specific way or the need to ask all questions in the interview guide and gave me more freedom to “pursue hunches and improvise with the questions” (Marlow, 2005, p. 167), as well as explore angles of inquiry emerging from concurrent data analysis (described below). I probed for varied experiences and insights from different angles which illuminated different aspects or parts of work structures and systems. As the project evolved, the sampling strategy and interview guide were shaped following each interview throughout the study to seek these perspectives until I found a rich understanding of the complexities and nuances of participants’ experiences in peer work and how these were shaped.   55   The interview guide was piloted in the first three interviews. After these interviews, I asked for feedback from these participants regarding the way I asked questions and the language I used. This feedback, as well as my reflections on the information generated, led to slight modifications in the wording of the questions. Several ‘probing’ questions contributed to the conversation and elucidated more in-depth information (i.e. “can you tell me a little bit more about what made you feel that way?” or “what are some of the reasons you think that happened?”). To wrap up the interview, I asked each participant if they had anything else to share. I concluded by asking five sociodemographic questions about the participant’s age, ethnicity, gender, region, and peer work tenure – questions that were less deep or sensitive in nature. Other demographics came out throughout the interviews unprompted, including substances used, current or former use, housing status, previous employment, and if they were social benefit recipients.   Field notes were recorded electronically after each interview to capture any nonverbal communication, the setting, and the interaction between us and the environment. Notes were also written about any initial or evolving ideas about themes, insights, and potential future interview questions. I continually referred back to these notes during the analysis, which informed my sampling strategy.  Given that I was based in Vancouver, interviews of participants who were unable to meet in Vancouver or Victoria were conducted by phone. One-third (5 of 15) of the sample was interviewed by phone. In-person interviews were conducted in locations where participants were recruited or locations selected by the participants (i.e. coffee shop, park) to promote a comfortable setting. If in a public space, the interview was distanced away from other individuals to ensure privacy. The interviews were between approximately 45-120 minutes, depending on   56 how much participants wanted to share – some people were keen to talk longer than our initial time of one hour. All interviews, including those on the telephone, were digitally audio recorded. 3.4.4 Data analysis    Audio recordings of the interviews were sent to a professional transcriptionist within 24 hours of the interview and transcribed within one week. Upon receiving the transcript, I checked the reliability of the transcripts by listening to the audiotapes against the written text, making note of any significant pauses, annunciations, or expressions that added to the meaning or interpretation of the passage. Memos were written about any interesting observations from this exercise. I then cleaned the data, deidentifying any personal information of participants (i.e. names, places, organizations). At this time, participants were given a random pseudonym. As such, the names herein have all been changed and do not resemble participants’ names but do reflect gender normative names (i.e. Carla for female, Peter for male).  The analysis occurred by moving between data, field notes, theory, memoing, and the literature in a non-linear and iterative way throughout data collection and thereafter. Coding evolved and happened concurrently through this process. The data was coded initially by hand (pen and highlighter) to develop open codes and comprehend the data. This step facilitated wide, fluid, and iterative coding to not over-use or commit themes or codes too early on. For Thorne (2014), interpretive description coding is less about line-by-line “fine-tuned level of words and expression” and more about the “realm of themes and ideas” (Thorne, 2016, p 145). In coding, I noted similarities and differences, or things that were unusually emphasized (or not) by participants. This initial coding phase focused on how people responded to questions, the stories and experiences they told, and ideas that answered the broad question of: “what’s happening here?” (Thorne, 2016, p. 145). These codes included terms that captured experiences related to   57 these conditions such as ‘wages’, ‘volunteering,’ ‘substance use’, and ‘coworkers.’ As data collection and analysis progressed, the data was imported to NVivo (QSR International, version 12), a qualitative data organization program, where the coding progressed.  Memoing was useful throughout the analysis to identify links between constructs within analytic categories. I explored ideas and relationships through visual representations of the concepts, making connections between them, but found they were often overlapping, complex, and non-linear. This exercise was useful for illustrating connections between analytic categories and moving my analysis forward. The constant memoing during data collection and analysis added to the comparative, concurrent data analysis process, which elucidated both emerging themes and limitations to the data being generated. Through the process of memoing and mapping, I continued to record my reflections and positionality relative to the data, participants, and the research problem. Writing served as a reflexive tool, as well as a means to appraise and refine the interview guide and to probe subsequent participants in new, interesting, and meaningful ways.   As the coding and memoing progressed, themes began to emerge and coding was refined. Linkages to theory began to develop a richer view of the nature of peer work as well as how peer work was constructed. The goal was not to make the data fit theory; instead, I used theory to tune-in to the ways in which systems were connected to experiences of equity or inequity and oppression. It provided me with a way of understanding and attributing to some of the emerging relationships and patterns I was seeing (Freeman and Vasconcelos, 2010). In this way, I used theory inductively and deductively to conceptualize what was occurring and why.   From my theoretical positioning, I focused on participant’s accounts of opportunity or constraint and tried to elucidate how these experiences were rooted in different systems,   58 practices, arrangements, cultures, policies, or settings. I paid attention to how their work was divided, conditioned, and influenced by various factors and how these constructed different expressions of oppression or disadvantage. For instance, illustrative examples emerged of work conditions that produced inequity through different social and economic systems. I continued with interviews, moving between my coded data, the literature, theoretical perspectives, and my notes until the analysis eventually linked and wove together into a complex constellation of various arrangements, hierarchies, practices, policies, systems, and organizations that structured peer work. Together, the analysis led me to different associations, relationships, and patterns within and between different lived realities of peer work constructed a complex myriad of social, economic, and political factors that produced and embedded inequity and oppression within their work conditions and relations (Freeman and Vasconcelos, 2010).     3.5 Methodological rigor  Interpretive description, like other qualitative analytic approaches, necessitates interpretation through coding, constant comparison, and active reflection, which is highly subjective, inductive, and reflexive. It was this interpretive feature that led me to its methodology. The ‘trustworthiness’ of interpretive research is in making the complexities of study procedures visible with an openness (Thorne, 2016). I embraced this openness and employed several strategies to enhance the validity and reliability of my research as it unfolded.   The first strategy I used is an essential part of research from a critical and interpretive paradigm: reflection and reflexivity. Reflexivity is a mechanism by which to make my interpretive claims explicit (Thorne & Varcoe, 1998). I acknowledged my power and privilege and their potential impact on my research. Locating this subjectivity, I was careful about how it   59 impacted my interpretation. Reflexivity occurred in a cyclical manner, as I situated myself in the approach, analysis, and interpretation of findings. I found journaling a particularly useful tool for exploring ideas in an informal and non-judgmental way while reflecting on my personal biases.   Thorne (2016) suggests implementing a readily accessible reflective journal to record thoughts, questions, and ideas as studies progress. These thoughts were documented through an unstructured and informal research journal (on paper and electronically) where I recorded ideas throughout the study in moving through data collection, coding and analysis, and reading theory and literature. This process freed me from committing to findings or themes too early and allowed me to explore ideas in different ways.  I acknowledged that as a researcher, I was situated within certain social, economic, and political positions that shape the construction of my research and its findings. I was aware of my privileged position as a white, middle-classed, housed, able-bodied woman, and a doctoral student and professional in BC. This positionality is coupled with my involvement in harm reduction and peer engagement work for over the past decade or so. Although I do not identify as a ‘peer’ per se, I do have illicit substance use experience. As well, I have close connections with PWUD. My father (among other family and friends) has struggled with illicit drug use, mental health, and poverty, as well as a history of precarious work, selling drugs within illicit markets, and contact with the criminal justice system throughout my life. I have also been personally impacted by poverty, class, precarious work, and mental health challenges. These experiences are coupled with my involvement in harm reduction and peer engagement. It is these experiences and connections that have formed my critical lens and position from where I aim to advocate for social, political, and economic fairness for marginalized groups, including those impacted by substance use and the structures that constrain them.    60  In reflecting on my positionality, how I came to this research, and how my perceptions are shaped by these experiences, the reflexive process was critical to understanding how my interpretations were shaped. Throughout the analysis and writing of the dissertation, I consistently asked questions like: “Which of my ideas are supported or challenged by this data?”; “Is this a previous assumption?”; “How does my presence have influenced this participant’s description?”; “Why am I privileging this description and not something else?”; “What story am I not telling?”; “What stereotypes or stigmas am I be perpetuating through this work?” These questions helped me discern and process if and how my interpretations of the data were a projection of my positionality, previous experiences, or biases, and if the findings reflected the stories and experiences that participants wanted to showcase. I became aware that the information shared with me by participants likely reflected their assessments about what I would like to hear or what they thought I already knew and potentially did not need to know – particularly among participants with whom I developed a previous working relationship. For this reason, it is key to highlight that the findings are one part of multiple subjective realities.   I was aware that peer workers’ unique knowledge comes from years of lived experience, and is often not framed as an ‘expertise’ relative to academic experience. I saw this privileging of academic experience as oppressive to peer workers who work in harm reduction. Yet, as a Ph.D. student conducting research on peer work, I was attempting to interpret peer workers’ experiences and perceptions of their work. Reflecting on my decisions and positionality, I have hopefully prevented findings from being overly deterministic or authoritative, and are hopefully rooted in participants’ realities at that time. To resist this potential for oppression via my research, reflexivity, and humility promoted participants’ voice and the narrative they wanted to tell (Muhammad et al., 2015).    61  To ensure peers worker’ voices did not get lost in my interpretations, the second main credibility strategy I employed was to talk about the emerging findings with PWUD and other people working in harm reduction. Bringing the data, themes, and/or findings back to the community or participants from which they came is a common approach in qualitative research to validate findings relative to their experiences (Sandelowski, 1993; Thomas, 2017). These conversations added credibility to the findings by having purposeful, regular, non-recorded discussions with peer and non-peer workers (i.e. employers or supervisors) about what was emerging from my data. Conversations were with supervisors or employers (n=3), as well as peer workers (n=7). Some were former study participants (n=4). These conversations were informal yet purposeful, focused around what was emerging (or not) from my data. These conversations were paramount to my analysis as they verified or challenged interpretations, while also validating the perspectives and experiences of the community. Some people provided feedback that they enjoyed or valued these conversations more than the interview themselves.  Lastly, the trustworthiness of the study was enhanced by working with other researchers. The methodology and progression of data analysis were overseen and discussed regularly with my supervisors (JB and VB) throughout the study. For instance, during concurrent data collection and analysis, preliminary and emerging themes were shared, followed by a long discussion between us about the data, interpretation, codes, and gaps in the data. Incongruities between our views added value as they encouraged discussion and insight that helped refine my codes and themes (Barbour, 2001). These discussions prompted me to read literature and theory related to ideas that percolated. As themes evolved throughout the project, we met as a team to discuss the interpretation of findings and their relation to the theoretical framework and my   62 research questions. The entire committee also provided regular feedback on the dissertation as to what and how findings were presented.  3.6 Ethical considerations  The proposal and other documentation was submitted to and approved by the UBC Behavioural Research Ethics Board prior to commencing my research (#H17-02039). Operational approval was also obtained from Vancouver Coastal Health as recruitment occurred at harm reduction agencies within their jurisdiction. Ethics approval from other health authorities was not required. The research protocols, recruitment procedure, strategies to promote confidentially, informed consent process, data management, honorarium, and process for responding to distressing circumstances for participants was also informed by the Tri-Council Policy Statement (Canadian Institutes of Health Research, Natural Sciences and Engineering Research Council of Canada, and Social Sciences and Humanities Research Council of Canada, 2010).   Upon recruitment, each participant was given a copy of the consent form and information about the study. Potential participants were asked if they had questions, and interview arrangements were discussed. To promote respect for potential participants’ ability and right to give informed consent, each participant had >24 hours and up to one week to decide and confirm their interest in participating once contact was made. Before each interview, I obtained verbal consent to participate; verbal consent was obtained, so no names were recorded. I ensured participants had a copy of the form before the interview and to take away. The informed consent form (Appendix 3) included the study purpose and procedures, possible benefits and foreseeable risks, data storage, confidentiality protection, honoraria details, right to withdraw, data utilization, ethics approval, contact information, and consent to participate. The consent form   63 was reviewed orally in detail, and the participant was asked multiple times throughout if they had any questions or concerns. I highlighted that participation would not affect their employment and no information would be shared with employers (or others). For participants’ whom I had a previous working relationship with, I emphasized that the interview would not impact our relationship and that confidentiality would be maintained. I also encouraged them to speak honestly and openly.   To minimize inducement, I highlighted before the interview that they would receive the $20 CAD cash honorarium regardless of their participation. This dollar amount was chosen for several reasons. Ethically, I aimed for the dollar amount to not coerce participation. Locally it was best practice to pay in cash and an amount similar to other research projects in the region (Greer and Buxton, 2016; Salmon et al., 2010). This amount in BC was between $15 to $25 CAD. The honorarium for the interview also considered loss of income generation through other formal or informal work, which respected the time they committed to participating in the study (Greer and Buxton, 2016; Salmon et al., 2010).   To promote a respectful relationship between participant’s and myself, I aimed to develop rapport and trust with participants. I listened and answered any questions they had honestly. This included being transparent and open with participants’ about my critical perspectives on the research question, including the potential for inequities in peer work. Tending to reflexivity throughout the study promoted this process, as well as ongoing engagement with the community.  Given the potentially sensitive nature of talking about structural harms and oppression, it was possible that the interview would bring up distressing experiences. I was mindful of this potential throughout the interviews. I gauged participants’ comfort level and modified the   64 questions I asked, how I asked them, and the way interviews proceeded in light of my assessments. Each participant was asked at the end of their interview if there was anything else they wanted to talk about to make room for debriefing about any distressing topics. I also made resources available to each participant, including information on workers’ rights and peer engagement. I did not identify any undue foreseeable risks or harms for participants prior to the study. In any study, confidentiality cannot be completely guaranteed. No names or personal identifying information were recorded in the field notes or research journal. The field notes were recorded by their interview number (i.e. 1, 2, 3…) and no names or other identifying information were recorded in these files. I replaced participant names with pseudonyms in the data and writing of the dissertation. If names were provided in quotes, pseudonyms were used. Due to the small size of the sample and the community of peer workers, identifying information such as organizations or employers’ names were removed. Given that peer workers in this study were part of a close and small network of PWUD involved in harm reduction work in British Columbia, only pseudonyms and no other identifying information, such as age, ethnicity, region, length of employment, or type of work, were not noted for each participant to promote confidentiality. As mentioned, all interviews were recorded using a digital audio recorder (including telephone interviews). Audio recordings were transferred to a professional transcription company using a password protected and encrypted website. Transcriptionists signed a confidentiality agreement. Transcribed data, audio recordings, and NVivo files were stored in a password protected file on a secure server at the University of British Columbia. These files were accessible only to my research committee members. Data will be destroyed in January 2023, five years after the data was collected, as per ethical standards of the University of British Columbia.   65 3.7 Summary  This chapter has detailed the research design and methods employed in my study. Informed by critical perspectives and utilizing interpretive descriptive methods in complementary and robust ways, my study has employed a methodology that can tend to the perspectives of peer workers to explore and examine their experiences of work to elucidate the systems and structures that shape these experiences. The next three chapters provide the findings that came from these procedures, followed by a discussion chapter that discusses the findings overall and situates them in the broader empirical realm of peer work.   66 4 Chapter Four: The Organization of Peer Work  4.1 Introduction  This first analytic chapter presents the findings of the analysis into the operationalization and organization of peer work by looking at experiences of the everyday lives of peer workers. This examination situates peer work and peer workers’ roles organizationally. I explore how and to what extent peer workers are utilized and enabled to be effective through the operationalization of their roles within peer engagement contexts. The themes in this chapter are intentionally presented first because they provide a backdrop of the organization of peer work. This backdrop will lend itself to the next two findings chapters which speak to some of the oppressive consequences of the operationalization and organization of peer workers’ roles and work.  Below, I first briefly present an overview of participants and the context of peer work in BC described by the sample (section 4.2). Then, I present the findings and themes under two analytic categories: operationalizing peer worker roles and peer work arrangements. This chapter will conclude with a brief summary of these findings.  4.2 Overview of participants and the context of peer work    The participants in this study were peer workers defined as people who have lived experience (past or present) of substance use who have used that experience to inform their professional work. At the end of each interview, participants were asked a series of demographic questions. The sample reported a median age of 45 years (range: 27-60 years) and over half of participants were female (n=8). Over half of the participants identified as currently using illicit substances (n=8) whereas seven participants’ spoke about their past use. Participants identified their ethnicity primarily as Caucasian (n=10; 67%). Four (27%) identified as Indigenous and one (6%) as Black. Participants lived in each of the five regional Health Authorities; they were   67 mainly from the Vancouver area (n=4) and Vancouver Island (n=5). The time from first being engaged as a peer worker ranged from three months to 30 years (median: 7 years). An overview of these demographic characteristics is provided in Table 1. Table 1: Characteristics of participants (N=15)  n % Age group, in years         25-34 2 13.3       35-44 5 33.3       45-54 6 40.0       55+        Median       Range  2  44 27–60 13.3 Gender Female Male   8 7  53.4 46.6  Ethnicity Caucasian Indigenous Black   10 4 1  66.7 26.7 6.6 Residence by Health Authority Vancouver  Island  Fraser  Interior  Northern    4 5 3 1 2  26.7 33.3 20.0 6.6 13.3 Time doing peer work, in years       <2 years 5  33.3      2-5 years 1 6.7      6-9 years 5 33.3      10+ years 4 26.7  Median  Range 7 0.25–30     Substance use history Current Past   8 7  53.4 46.6    68  Although identifying information of each participant, such as age, ethnicity, region, length of employment, or type of work, are not identified for each quote in this dissertation, collectively there are notable and diverse aspects to participants’ life circumstances and identities that provide context to the varied and similar disadvantage and disparities within and between participants’ experiences that occurred in multiple and complex ways. Although thirteen participants mentioned somewhat stable housing, one participant was homeless at the time of the interview and another in extremely precarious housing. All participants described living in low socioeconomic conditions and poverty, detailing their current or past financial strain and struggles to meet their basic personal needs (such as food, shelter, health); although, one participant described themselves as “middle class.” At least ten participants’ were receiving income or disability assistance at the time of the interview and mentioned this income source when speaking about peer work. Compensation in peer work was diverse – hourly wages ranged from $5 CAD to $30 CAD, although these wages varied widely and changed constantly both within and between participants and jobs; as well, two participants did not discuss their income. At least six participants had earned a higher income (i.e. $25 - $30 CAD per hour) in the past twelve months. These participants were notably engaged in peer work for a longer period of time or had more consistent work opportunities compared to other participants. However, those engaged in formal work (n=4) earned between $15 - $20 CAD per hour. Infrequent and intermitted work opportunities, such as office cleaning or a one-time meeting, were often associated with lower wages, and participants engaged in these roles appeared to elicit greater social precarity. There did not appear to be major differences in earnings by ethnicity or gender. It should be underscored, however, that virtually all participants had engaged in more than one   69 form of peer work (i.e. full time work and attend meetings) in the past year, and that the earnings fluctuated between jobs. Participants’ regularly mentioned mental (i.e. anxiety disorder) and physical ailments (i.e. back injury)  as challenges to participating in work. Participants engaged in more consistent or formal employment notably did not report such challenges, although these were not probed for in every interview.  Several participants mentioned  educational barriers to employment – although, two participants noted their past post-secondary education, which did not appear to be associated with their current employment context. Nearly all participants reported a history of alternative income-generating activities within illicit markets (some of which were recent), including at least five participants who had past drug trade or sex work involvement. However, participants’ rarely went into depth about these experiences. Two participants discussed their incarceration history in the context of their work opportunities. Drug preference was not explicitly asked about in the interview, although two participants discussed their crack cocaine use, whereas most others described prior or current opioid use. Among those who were Indigenous, participants’ descriptions were interlaced with evidence of colonization of Indigenous peoples, although experiences specific to these intersecting identities were not probed in detail. Both men and women in the sample talked about their (young or adult) children or other close family members in the interviews (n=11), and the added pressure to obtain and sustain income in the context of these narratives. As will be shown in subsequent chapters, the range of participants’ diverse life circumstances described here often exacerbated peer workers’ precarity in a magnitude of ways.    Work characteristics were identified from the interviews and therefore may not be as comprehensive as the demographic questions, but do further describe the socioeconomic characteristics of the sample. Four participants were formally employed, while three participants   70 exclusively ‘volunteered’ (engaged in informal peer work infrequently), and the remainder engaged in nonstandard or informal work arrangements that were not classified by participants as ‘volunteering’. Four participants currently worked for peer-based organizations (three different organizations were represented), whereas five worked for a peer-based organization previously but did not identify these settings as their current or primary workplace. One participant reported previously engaging in peer-based work while incarcerated.    The main type of work reported was direct service, including distributing needles, street outreach, or overdose response work. Peer workers’ also described roles in their community where they helped marginalized people navigate and confront different systems, policies, and procedures, such as income assistance programs. The majority of participants recently attended government organized meetings as peer representatives. For three participants, peer work was their first job in the formal labor market. Roles in the workplace varied. They were often described and later categorized rather than being named explicitly by the participant themselves. The most prevalent roles were consultation at meetings and service work, whereas the least prominent role was on advisory boards. Three participants coordinated the roles of other peer workers, often via positions of leadership at peer-based organizations. About half of participant’s also worked in research capacities, these experiences were mentioned less often in the interviews. Among the sample, work experiences with several types of organizations were represented: peer-based organizations or networks, government agencies , Health Authorities, and organizations that provided services (i.e. overdose prevention sites, needle and syringe programs). The vast majority of participants, including those in full-time employment, regularly worked across multiple organizations. As such, their experiences were not exclusive to one   71 particular organization but peer work conditions more generally. Participants’ often noted that their experiences within a type of organization varied across agencies – for instance, many reported stark differences between the organization of peer work in some peer-based organizations compared to others. They also rarely attributed an experience to the organization it was housed in or stated differences between organizations such as peer work in peer-based organizations versus among Health Authorities. Nonetheless, I distinguish organizational differences when particular features were highlighted or flagged as relevant by participants (i.e. the social connectedness within peer-based organizations compared to others).  4.3 Operationalizing peer worker roles  Operationalizing peer worker roles is an analytic category which speaks to the understanding, support, and definition of roles within organizations. The peer role assumes, in theory, that individuals draw on this lived experience to add value to a decision or action, or is valued because of their ability to connect with people. Yet, how peer workers utilize and receive recognition for this unique experiential knowledge may depend on how peer workers’ roles come to be defined and enacted. Below, I examine participants’ descriptions of their and other peer workers’ roles, as well as the definitions of peers’ roles and accompanying responsibilities. This first analytic category is organized into four themes related to peer workers’ roles: (1) role titles; (2) role expectations; (3) role compatibility; (4) role preparation. 4.3.1 Role titles  Participants’ role title partly alluded to peers’ responsibilities. Titles indicated their position relative to others, such as a peer coordinator who inherently held different responsibilities than a peer outreach worker. In the interviews, participants regularly indicated   72 that their jobs lacked titles or they lacked an understanding of their titles. Beyond being known as a ‘peer’, their roles were generally vague. They seemed to be regularly positioned simply under the ‘peer’ title without an indication of what this title entailed. When asked about their role title, participants relayed its vagueness, stating they were “just a peer” (Debra). The language of ‘peer’ seemed to not reflect any underlying duties of their job. Those who held more description to their title, such as ‘peer coordinator’ or ‘peer outreach worker’ seemed to have more of an understanding of their role expectations compared to those who simply attended meetings or informed on policies under a blanketed ‘peer’ title.  Job titles appeared to be an informative feature of roles for some participants to develop a defined job identity. Peer workers’ described that their jobs were “not recognized universally” (Shauna) by employers or peer workers themselves, thus creating issues with how peer work was commonly defined and understood. As one participant explained: “[other staff] might be more trained in a society way and people can respect a scientist and a nurse – and so we live in a funny, like, in between” (Craig). For this participant, creating a well-defined occupational identity for peer workers had the potential to increase the legitimacy and respectability of the peer role. In contrast to occupations like a nurse, teacher, or accountant, it was evident that peer work as a concept lacked a universal knowledge about what activities occur within the peer role. Generating a better understanding of the peer worker title appeared to be one way that their roles were legitimized institutionally, and more deeply incorporated into organizations. When talking about using the title of ‘peer,’ one participant said: “it’s [the word peer] is important because it’s current in discussions, with the health authority that word comes up” (Josh). The peer title for him was viewed as a way to promote the recognition of peer work as a legitimate and formal role within the organization. Conversely, others talked about the   73 institutional “understanding [of] peer work itself” (Kelly) being meaningful as it promoted organizational support for their work, such as employers’ knowing what training or information to provide and how. While role titles may foster role clarity and legitimacy, others alluded to the differences – and disadvantages – created by using the ‘peer’ title. Some stated that in being known as a peer introduced stigma. As they pointed out, the stigma of being labeled as a ‘peer’ was a barrier to finding work opportunities, advancing in their work, or being fairly compensated. When asked how this specific title impacted them, some participants underscored the inequity introduced. One participant stated that defining roles under the ‘peer’ title altered “the way it gets paid… there’s us [without the peer title] and then there’s people who are working for stipends and stuff like that” (Debra). Being identified as a peer, as this participant explained, also limited them to temporary and informal work arrangements. Others explained: I don’t know if you’re interested, it’s not semantics, but it’s saying persons with lived experience rather than peers because there’s becoming a thing in the neighborhood where peers is starting to feel like a put down in a weird way. (Carla)  In this conversation, she also questioned if and why the word ‘peer’ was necessary for describing the roles of peer workers. She suggested they wanted to obtain work using their experiential knowledge without the peer title. In summary, these conversations indicated that the peer title may produce differences between social groups that may reinforce the oppression of peer workers institutionally, rather than providing clarity of the role itself. The way in which the ‘peer’ role title constrained workers beyond the organization, or in the external labor market, is examined in Chapter Six.     74 4.3.2 Role expectations  Clarity about peer workers’ role responsibilities and expectations seemed to be a major challenge. In addition to vague role titles contributing to confusion about roles and responsibilities, participants’ regularly did not know details about their jobs, including information about programs, policies, or issues at hand; how they could contibute or when; and if or how their contributions were used. In the interviews, I asked participants about how their role expectations were communicated to them by employers. Some described the process as a casual conversation about their roles general terms, whereas others had no information about their responsibilities, expectations, or role utility within the organization. The vagueness of peers’ job and role expectations were particularly evident among those in informal work arrangements, although peer workers in formal employment also described role uncertainty and unclear expectations. Therefore, peer workers’ role ambiguity and lack of role expectations appeared to partly originate within the organization of peer work itself, and lack of role support or communication offered by employers or supervisors. The communication of role expectations through formal job descriptions may provide details to peer workers about peer workers’ duties and responsibilities in the employment context. Within peer work settings, however, it was apparent that job descriptions were rare. The influence of job descriptions for peer workers was evident among two participants in formal employment who made an effort in their interview to retrieve the hard copy of their job descriptions and read them aloud in the interview1. This gesture within the interview seemed important for peer workers to legitimize their role and to provide important information about  1 These interviews were conducted on the telephone, thus participants could find their job descriptions on-hand.    75 their roles. However, among these participants, the job descriptions subsequently did not reflect their descriptions of the actual day-to-day work. The inadequate information peer workers received regarding what their roles involved, as well as the disconnect between role expectations and descriptions, created endless possibilities of what peer workers’ role duties entailed. Without clear expectations, peer roles seemed to potentially encompass any and all activities. For instance, a participant stated that his role was “eclectic. There’s a lot of different things I end up doing. And it could go off in all kinds of different directions” (Peter). Similarly, a woman explained: “always something I can make up in [peer work]… answer the phones, clean up, whatever it is I can do, I’ll do it” (Melissa). These examples show that peer workers often defined their roles and responsibilities on their own, which created a diverse range of duties and tasks they undertook.  The constraints imposed on peer workers’ from the lack of role expectations was emphasized by one participant in particular who identified as a ‘peer’ but lacked any clarity about what her role was. She stated repeatedly: “I don’t really know what I have to offer” (Jackie), demonstrating confusion over why she was engaged at various harm reduction meetings related to the opioid crisis over the past year. She explained: “I didn’t know what I was doing or going to… I didn’t know what I was going for. I really didn’t. I knew it involved harm reduction and… like I said, I didn’t know” (Jackie). This participant used the word ‘peer’ to describe her job title and knew that she was invited because of her substance use history, but she was unclear as to how or even why she could use that experience. Her description of her experience underscores how peer workers may feel or be seen as ineffective considering their lack of role clarity or expectations.    76 Much of this unknowingness was rooted in a lack of communication from employers, which was nonexistent among most participants. For instance, one participant in a formal employment arrangement explained that they had no defined responsibilities, but was asked to define the role themselves: “But they’ve also, with this position… they’re allowing me to create it as I go along. So they don’t have a whole lot of ‘this is what we expect’”2 . While this participants role was given a high degree of independence, she was unaware of how to meet any unstated role expectations, making her vulnerable to being perceived as underperforming and potential job loss. This experience echoed others participants’ descriptions in formal and informal work arrangements who reported vague productivity and performance expectations due to a lack of communication from employers, and the related insecurity of these positions.   4.3.3 Role compatibility     A lack of organizational understanding of peers’ roles was evident through many instances of role incompatibility where peer workers’ expertise or skills did not align with their role. The way that diversity was represented among peer worker roles was a clear example of this role incompatibility. As one participant explained: Sometimes I think people just don’t know enough and they’re trying to do the right thing…we’re going to hire the first person that identifies as Aboriginal. You know, like, go find me some Indians... Hey, have you done sex work? Can you come and I got a job for you! That’s not okay…a peer can be defined in many different ways. It can. And there is a spectrum, a continuum, right, you have a peer who’s, you know, completely still street involved, using drugs… someone who’s specific, like, say, sex work, you have someone specific to HIV, it is really, really diverse and multidimensional. (Shauna)  This quote indicates that organizations or employers may not have a clear understanding of peers’ roles within the organization, treating PWUD as a homogenous group and not ensuring their lived experience or expertise was compatible with the issue at hand. Instead, participants  2 Pseudonym not provided to promote confidentiality.   77 indicated a lack of representation of PWUDs diverse experiences within organizations. The treatment of PWUD as a homogeneous group was illustrated among people engaged under a broad stroke of PWUD, where their experiential knowledge did not relate to their job. For instance, several participants reported a stimulant use history but worked in jobs that needed to be informed by an opioid use history. And, by not having role compatibility with their expertise, they expressed feeling ineffective in their roles. For example, a participant explained:  I haven’t really shared much yet… Because I don’t use opiates and I don’t use, I’ve never been in the position of helping overdoses or saving someone or any of that stuff… So I don’t feel like I’m on the same, I haven’t gone to healthcare because I was overdosing and been treated like crap by the doctors. I’m a crackhead... I don’t feel like it’s the same [as opioid use].3   As this quote explains, by not having role compatibility with her particular experience, it was difficult for some to feel effective and utilized in their roles. Instead, these findings suggest that peer workers’ presence was more symbolic or tokenistic by engaging any PWUD, regardless of their lived experience, rather than being rooted in a meaningful effort to identify what representation the organization was seeking from the diversity of PWUD.   Finally, role incompatibility was demonstrated among those who engaged in roles which did not draw on any lived experience. Several participants explained they were ‘peers’ per se, but limited to office cleaning, cooking, or answering phones. Roles seemed to not be defined by their unique expertise of substance use, and they were not asked to draw on it. This evidence of role incompatibility similarly suggests a lack of organizational understanding of peer workers’ roles and contributions that peer workers can make through their unique skills and expertise.     3 Pseudonym not provided to promote confidentiality.   78 4.3.4 Role preparation  Preparing peer workers’ for their roles, including organizing them with the tools and training was essential for providing them the means they needed to be effective. Role preparation, including training, education, and resources, seemed to be consistently lacking in organizations. A lack of job training in particular constrained peer workers’ opportunity to perform effectively. One experience reported in particular, by Debra, underscored the disadvantage produced from the lack of role preparation: I wish that I would have more time to have gone over the stuff that they were going to ask me and stuff like that, so that I could have been more on the ball with the questions and that. Because then somebody kind of came in behind me and took over. Because… I didn’t have enough knowledge … I needed to know what kind of information they were going to tell me. I needed to know what they were going to, kind of things that they were going to be asking so that I could have been more prepared. (Debra)  This quote conveys that Debra was unsure how to use her lived experience in her role as she received no training or information about what the work entailed. She explained later that her work was informally arranged and “a last minute kind of thing” and was not provided with role preparation; thus, she was supported to effectively contribute in her role. It was apparent that role preparation, including providing information and training, was vital to prepare peer workers to do their jobs effectively. Other participants gave examples of roles not set up to be effective within the organization, drawing attention to a lack of understanding among employers for supporting peer work. One participant described the support she received from her employer and talked about the disparity in understanding of peer work among employers. She explained what she meant: There’s not a whole lot of education around what it takes to support a peer… there’s a lot more to it than just going “here’s a job”… people should really if we want to, you know, show value and build capacity, I know lots of co-workers that don’t come from lived experience that get tons of training and they have money provided for it... I call it capacity   79 building, but they call it something else... everybody should be treated the same kind of thing, right, but some people will have unique needs as far as education. (Shauna)  This quote underscores the inequity within organizations for supporting peer roles – what this participant referred to as “extreme tokenism” produced by a lack of organizational understanding and its impact on peer workers’ ability to be effective. Participants felt strongly about the importance of supporting peer workers through role preparation, including training and capacity building. Participants noted particular supervisors or employers who provided more role preparation than others, although these individuals’ efforts were not always linked to organizational support.  4.4 Peer work arrangements  In addition to the operationalization of peer workers roles’ in peer engagement contexts, peers’ work arrangements, including the location, duration, and frequency of work, and source of administrative control over work, was a central and related analytic category among the findings. Nonstandard work arrangements, such as those that were temporary, informal, and casual, were the norm for most participants (n=11). Some participants (n=4) engaged in formal (part-time (n=2) or full-time (n=2)) employment, yet all noted that they worked in nonstandard arrangements in the past. Nonstandard work arrangements were particularly evident in roles related to meetings or policymaking and also service and outreach roles in all types of organizations. Some organizations (government, health authority, service agency, and peer-based organization) provided formal employment for peer workers, although standard work arrangements were not the norm. Interviews with participants revealed various ways that nonstandard work arrangements systematically produced and reinforced differences and disadvantaged peer workers. In the   80 themes and subthemes below, I organize the analytic findings related to work arrangements (primarily related to nonstandard work arrangements) into three main interrelated themes to illustrate how peer work is organized and how inequity is introduced through these arrangements: 1) distancing peer work; 2) gatekeepers, and; 3) organizational commitment. Several subthemes within these themes are also examined. 4.4.1 Distancing peer work  First, a main structural feature of peers’ work arrangements was its distance - socially, geographically, and administratively, from the organization and other workers. Nonstandard arrangements in particular enabled this distancing by shaping peer workers’ positions as temporary, contingent, and independent – not materially tied to the organization. At the same time, peer workers’ roles seemed to be required by policy or program mandate, sometimes operating in indispensable roles of the organization. Yet, peer workers’ did not feel completely recognized or integrated into the organization.  In this way, peer workers’ nonstandard work arrangements situated workers in a sort of grey area – positioned neither fully integrated nor fully excluded organizationally. As I show in this and other chapters, the situating of peer work within this grey area, between organizational and workplace integration and exclusion, systematically produced and reinforced social and power inequities by segregating peer workers to a positionality marked by marginalization and powerlessness. In the subthemes below, I demonstrate the ways this grey area was structurally produced by situating peer work at a physical, social, and administrative distance from the organization.      81 Physical distance  Physical distancing included geographic, workplace, and symbolic features which systematically separated peer workers’ physically from the organization. First, it was common for participants to live a long distance from the organization’s main work site. Some participants worked in Northern BC4, which required peer workers to travel several days by car, plane, and bus to reach meetings in Vancouver, where most peer engagement work was situated. Some participants5 from rural areas explained that the distance to peer engagement opportunities was a disadvantage, largely attributed to unpaid travel days. For instance, one person was paid “$15 for two hours of your time to spend three days to travel to [city].” Another participant from Northern BC explained:  So depending on where people were coming from across Canada, depending on flights and people from rural areas, obviously had to leave a day earlier and leave a day later. And there was no compensation for that time. You were just kind of in limbo doing travel. Which people could have been doing other work.  Here, the physical distance from the organization produced inequity in their compensation compared to others situated closer to their workplace. However, participants in these regions also noted the lack of opportunities available to them in rural areas, thus requiring them to travel. Peer workers’ descriptions of their work also illustrated a physical distancing of peer work from the organization by not having a space to call their workplace. Having a physical workspace to make contact and interact with coworkers, store belongings, and do the work, was identified as a need among several participants. For instance, in different regions peer workers’ explained that “it would be nice to be, having a, working out of an office or a small place”  4 Northern BC is a large geographic area but has the lowest population in the province. The main city, Prince George, is approximately 800 kilometers from Vancouver, the largest city in BC. 5 The pseudonym of participants from Northern BC were removed to promote confidentiality as, in conjunction with the specificity of context and experiences described quotes by this individual, may be identifying.   82 (Randall) and another person said “we’re talking about establishing some sort of footprint, getting some space in the neighbourhood. ‘Cause I mean, people need it” (Carla), and that “right now we don’t have an office so we end up meeting in just people’s places and stuff like that” (Peter). A physical space to do the work appeared to be a way to legitimize peer work, and also give peer workers’ a sense of inclusion and recognition for their roles. It was clear that without a physical presence or affiliation with the organization, they felt marginalized by not being entirely recognized nor integrated. Participants additionally talked about wanting a symbolic connection to an organization, underscoring a longing for role legitimacy and integration. For instance, some wanted a formal uniform: “something that says who we’re from and what we’re doing… So people could see that we’re not just picking up trash, that we’re doing a service and what the service is” (Randall). This quote highlights the potential sense of legitimacy and inclusion fostered from physical symbols such as a uniform. This symbolic connection seemed to be important for peer workers’ sense of inclusion and cohesion among coworkers without a substance use history. Social distance  Situating peer workers’ roles in the grey area, between organizational integration and exclusion, also socially distanced peer workers’ in several ways. Speaking more to the relational characteristics of the positioning of peer workers’, social distancing is a concept that speaks to the social division and isolation of certain workers, which is often based on work arrangements that constrain the opportunity to build relationships or a sense of closeness with co-workers and employers (Clarke, Lewchuk, de Wolff, & King, 2007). Social distancing was evident in peer workers’ descriptions of feeling isolated and the lack of contact or opportunity to socialize. For some, a social distance was created from a social vacuum created from peer workers’ physical   83 distance. Being located in a different region or province altogether, some explained the limitations to developing relationships with others via email or telephone. Peer workers’ situated within nonstandard work arrangements across regions also explained that they found it challenging to build relationships over time because of the inconsistency of staff throughout intermittent work arrangements as there was often a lack of continuity with co-workers.  However, although the social distance between workers was particularly evident among people in nonstandard work arrangements which administratively and physically disconnected peer workers, those in standard employment arrangements also echoed a low level of intimacy or relationship building with co-workers and employers. As one peer in standard employment stated: “It’s [peer work is] not about building relationships whatsoever” (Shauna). Statements like this depicted social distancing from other staff within the workplace that was associated with a lack of communication or mutuality between workers. Similarly, another participant said: “[my employer] doesn’t communicate with me about clients and there wasn’t really a receptive ear to hearing what my input was… They [non-peer workers] don’t talk to you. There’s no collegiality” (Michael). Comments indicated that a lack of role support in peer work heightened a sense of social distancing between peer workers and employers.  The social distancing between peer and non-peer workers was also produced culturally and economically. For instance, some participants spoke about co-workers who met after work hours to connect in ways that differed from or excluded peer workers. For example: “I isolate quite often because they go out for drinks and food. And they make good money. Well, I can’t go drop $15 on a half a glass of wine like you guys [non-peers] can. So I go to my room quite often and, you know, eat cheap food and do whatever” (Kelly). Socially connecting at a restaurant was a cultural norm that some peer workers did not feel welcomed to, or that they could financially   84 participate in. Social and cultural norms within the workplace appeared to divide workers, creating a separation between social groups (i.e. peers and non-peers). This social distancing also appeared to be linked to disadvantages in terms of receiving opportunities for social and role support. The lack of social support in peer work is a theme explored more fully in Chapter Five. Administrative distance  Participants’ nonstandard work arrangements additionally appeared to distance them administratively. Nonstandard work arrangements appeared to cut off peer workers from organizational operations. Many had no direct contact to management such as finance departments, directors or principal investigators, or human resources. Some participants’ talked about being “not really sure who was actually in charge of [finance decisions]” (Kelly) so were unaware about the pay process and whom to contact with an issue. In contrast, peer workers with formal employment talked more about their interactions with these administrative entities.  Administrative distancing structurally disadvantaged peer workers in many ways. Without a direct administrative connection, peer workers often lacked awareness of policies, processes, and procedures, revealing ways that nonstandard work arrangements structurally created an informational disadvantage. This informational disadvantage was especially evident among those who were unclear about key procedures or policies, as well as schedules, compensation, or hiring practices. Many times, it seemed that participants were also unclear about where or how to get this information.  Administrative distance from the organization also created a perceived lack of consistency within organizational systems, such as decision-making and policy changes, which produced confusion about procedures. Participants described:   85 Rules would change in a really ad-hoc manner…there’s no consistency. People would be dropped from the schedule and never told why. And they wouldn’t know if it was a mistake or someone was mad and for what, they didn’t know. (Carla)  Because of the administrative distancing, policies and procedural changes often were not communicated to peer workers, therefore creating confusion about policies or workplace practices. The unknowingness regarding workplace procedures and operations appeared to add to the sense of role ambiguity. Administrative distancing was also reflected in the lack of peer workers’ participation within the governance of their work. Role decision-making and evaluation was separate from them, as indicated in the indirect ways that peer workers learned about administrative changes, typically via word-of-mouth. Some participants reported: “there was no questions. That’s what we’re doing now… got wind of it and rumour of it, but not ‘til it [schedule changes] actually did go down” (Josh). This quote underscores Josh’s compromised sense of agency that was associated with his distanced positionality and being cut off from decisions related to his role. Many did not have access to information about decision-making  or if their contributions influenced decisions. Thus, participants’ nonstandard work arrangements structurally perpetuated power inequities which rendered peer workers powerless to decisions that others (typically non-peer workers) made. 4.4.2 Gatekeepers  The positioning of peer workers’ at a distance from the organization made it difficult for them to access information and resources by being administratively and physically distanced from the institution. The distancing of peer workers appeared to structurally limit their connection to organizations through a single individual or access point. These individuals were typically a project or program supervisor or coordinator (almost exclusively non-peer workers),   86 or the person who initially contacted or engaged them into the work. Some participants’ referred to these individuals as “gatekeepers” – people who served as a gateway into or out of the main operations of the organization. Gatekeepers were brokers of information and opportunities, where peer workers were constrained from such resources without them. Structurally, this relationship produced power inequities where gatekeepers held disproportionate control over access to resources among peer workers. These resources included knowledge about work arrangements, future work, compensation information, wages, and training opportunities. Structuring peer work around gatekeepers funneled and constrained resources and knowledge in ways that benefited gatekeepers and disadvantaged peer workers. The ways in which such arrangements produced inequities from peer work arrangements is examined in the subthemes related to gatekeepers below. Gatekeeping control  Gatekeepers appeared to be systematically granted control over information and resources due to the distanced and disconnected positionality of peer workers. Nonstandard work arrangements constrained peer workers to marginalized positions which limited their contact with others, thus rendering peer workers dependent on gatekeepers. A participant captured these oppressive dynamics: I don’t want to go through you. I don’t want to have to be gatekept to go talk to the Minister of Health. You bring me and, like, eight doctors and a cop into the room. Fuck that. I don’t want that. I want to develop my own networks. Like, I want to develop my own facing relationship with the government, with politicians, with all of that. I don’t want to have to serve your agenda in order to get into these rooms and access to it. (Peter)  Rather than enabling them to create their own networks, some peer workers appeared to be restricted to certain “rooms” or decisions under gatekeepers’ discretion. And, in constraining   87 peers’ access and opportunity to build their own networks, gatekeepers’ control over future work, wages, and opportunities seemed to be reinforced. Participants’ descriptions also spoke to gatekeepers’ interest in reproducing nonstandard work arrangements and their dependence on peers’ positions. These exploitative conditions were evident among those who explained how their work arrangements may be leveraged to reinforce inequities that benefited gatekeepers.  The fact is that it’s a pretty serious job. It’s an important job. And it’s probably more important than the people that actually hired me to do this job. They [gatekeepers] don’t want to do this job ‘cause it’s just too hairy and too scary and whatever it is. They don’t want to be part of that. They more like to employ people to do that, subcontracting people to do that maybe. The answer is subcontract it out and say, okay, this is what I’m going to give you for this. I don’t know how it works exactly, but something along those lines. (Josh)  This participant explained that the process of gatekeeping systematically enabled employers to funnel less desirable work to peer workers by restricting their access to other opportunities and information. Without access to other work arrangements, compensation, or work, peer workers appeared to be limited to choose what gatekeepers offered. Peer workers’ lack of choice in the labor market seemed to exacerbate their sense of dependency to gatekeepers, which was associated with these work arrangements – a theme explored more fully in Chapter Six. Disrupting gatekeepers  Evidence of resistance to oppressive working arrangements was rare; but, some participants talked about directly searching for information about their rights or attempting to access resources and people within the organization. In attempting to go around gatekeepers, however, some participants seemed to be reprimanded for attempting to disrupt power relations. A participant reflected on his experiences of disrupting power inequities. In gaining access to decision-making situations outside of a gatekeeping relationship, this participant stated: “It [my   88 access] scares them because that’s their power kind of going down and our power going up a little bit relatively” (Peter). By not relying on gatekeepers and directly accessing decision-making tables and jobs himself, he realized the voice, actions, and outcomes of peer engagement may no longer be controlled by one or a few gatekeepers. Evidence of resistance was greater among peer workers who were relatively more integrated into organizations – integration that happened over time and through standard employment arrangements. Two of the four participants in standard employment arrangements reflected on their experiences, both noting that their integration was a “threat” to the structural production of inequities that benefited gatekeepers. There appeared to be a sense of freedom by integrating into organizations over several years, thus not as administratively, physically, or symbolically distanced, or having to rely on gatekeepers. They stated “people look at me as a threat,” and explained “I’m also, you know, continuing education, I’m articulate. I pay attention. I speak my mind. I’m not fearful. I mean, there was times that I was, but I’m not anymore…if I was using I’d be very, very paternalized but because I’m not, people see me as a threat” (Shauna). By moving beyond the “paternalized” relationships with gatekeepers and equalizing power differentials through integrating and gaining access to information, education, and resources, Shauna’s new positionality disrupted power inequities – inequities which previously rendered her silent. Greater organizational integration appeared to enable peer workers’ agency in sharing their expertise, developing relationships, and having access to sources and opportunities. Allied gatekeepers  Although some participants’ voiced their frustrations with the unequal power relations between peer workers and gatekeepers, others viewed these relations as an opportunity to access   89 arenas they were otherwise excluded from. In these situations, gatekeepers were framed as “allies.” Participants assumed that allied gatekeepers had their best interests in mind. For instance, in talking about one gatekeeper, Emma stated that she was “fortunate enough” to be connected to this person as they granted her and other PWUD access to health systems and resources in times of need. She explained that one allied gatekeeper “actually got to, you know, call the higher powers, if you will, and got some really important people to [help]” (Emma). This account emphasizes where gatekeepers mediated access to a healthcare network, thus enabling, rather than constraining, the expansion of peer workers’ professional connections, integration, and role effectiveness.  The contrast between allied gatekeepers and gatekeeping driven by power inequities also suggested a fragility to these relationships. This fragility was captured by a participant who used the word ‘ally’ to explain:  The way that people [‘allies’]who purport to represent them [PWUD], deprive them of agency and voice is ridiculous. And it happens to me all the time by people who claim to be allies. And it’s like we’re not-- we’re clearly not on the same team here because you’re treating people who are actually down like props. You’re using people as props for your arguments and for your whatever…There’s always these shifting allegiances to some extent…people will insist that they are your ally, but it’s like actually these are different battles. I think it’s a contested term. I think that, I think it’s very, I hate the word “problematic” a lot, but it is problematic. I think that there’s lines of congruence that sometimes are temporary. (Carla)  Gatekeepers were in positions of power and control that structurally produced and reinforced the organization and reproduction of nonstandard work arrangements. These arrangements, therefore, structurally situated these individuals in positions of power that privileged them to enact control at any point.     90 4.4.3 Organizational commitment  In addition to distancing peer workers and the positioning of gatekeepers, nonstandard work arrangements reflected a lack of organizational commitment for peer work. Formal employment arrangements were the minority among the sample but also represented amongst their descriptions of the peer work sector overall. Several participants reported years of being constrained to nonstandard work conditions – indicating a lack of organizational commitment and formal recognition for peers’ roles in the workplace. As one participant explained: “it’s been about eight years and now I just, you know, got hired [formally]” (Shauna). Others too reported similar patterns of long term informal work across all types of organizations. This lack of commitment towards formal work arrangements appeared to make peer work precarious. Herein, subthemes demonstrate the lack of organizational commitment for standard work arrangements and the structural production of precarious work conditions for peer workers. Future work uncertainty  Nonstandard work arrangements enabled employers to retain control over future work, job parameters, resources, and decision-making. They also removed employers’ need to commit to future work, thereby stripping peer workers’ of control over their economic future. Many described their unpredictable and intermittent periods of informal work marked by lengthy periods of unemployment which often required them to engage in multiple, back-to-back, and temporary positions. These work patterns were accompanied by the uncertainty of future work, hours, wages, or location. There was dissatisfaction with the inconsistent nature of precarious work. Participants stated: “[it’d be] nice to have some kind of surety of work” (Craig) and “I hope there’s more to come and not so sporadic and random” (Jackie). Their dissatisfaction was   91 mainly linked to the challenges some participants faced in planning their lives or trying to create or maintain stability.  The uncertainty of peers’ precarious work conditions clearly impacted some. Participants’ shared examples of housing and economic insecurity, as well as interpersonal problems associated with their uncertain work futures. Others talked about the debts they accrued from periods of no work or from their low wages. Yet, it appeared that peer workers’ nonstandard work arrangements negated employers’ responsibility or requirement to commit to future work or work standards, thus structurally disadvantaging and disempowering peer workers under these arrangements. An example from one participant underscores the repercussions of peer workers’ uncertain and unpredictable work futures due to the lack of organizational commitment for a formal employment relationship with peer workers. Kelly described that she was called randomly throughout the year engage in informal roles with various organizations which required her to travel to different locations. For her, it was challenging to make future plans and create financial stability: “Now got credit card debt up the ying-yang and now I gotta to try and pay that off with, and I don’t even, we don’t even know what’s going on with [employer] at this point” (Kelly). Given her nonstandard work arrangements, she was uncertain if and when she would work again. Her pay was equally uncertain. For months she was not paid; she faced eviction and serious interpersonal problems: [Partner] was at the point where he’s, like, okay, you gotta leave because you are lying to me. Because I was borrowing money off him for … stuff on the credit card. And I was, like, no, I’m going to get paid. And he goes, like, “you work for the frickin’ [organization]. Are you telling me you haven’t been paid in [a while]? Like, that doesn’t even make sense to me. Like, you’ve got, at this point, now you’ve got to be lying to me.” So it got really bad and really ugly. And then finally I started getting paid. And then part of the problem with that as well was when they [employer] didn’t have, because of   92 their scheduling, they didn’t have any places to go, any work for me to do. They didn’t want to pay me. (Kelly)  Like Kelly, peer workers’ informal work seemed to jeopardize their financial security and personal relationships, safety, and housing. These consequences and the constraining nature of peers’ work arrangements in light of no other opportunities in the labor market is explored more in Chapter Six. Job insecurity  The lack of standard work arrangements for peer workers seemed to produce ongoing job insecurity within their roles. The apparent authority of organizations to terminate or refuse work at any time structurally produced inequity for peer workers by creating a long-term informal probationary period where peer workers needed to prove themselves to employers time and time again to secure future work. This long-term probationary period was illustrated in several contexts, including a prominent harm reduction organization that stood as an example to other peer-based work. Peter explained: It’s partly a control thing and partly to, like, if people have been working, you know, doing stuff that they don’t like they have an ability to go, okay, well, if you want to keep working here, stop doing this, this, and this. And all that kind of stuff. (Peter)  Given that peer workers were vulnerable to job loss or being cut off from future work at any time, nonstandard work arrangements enabled employers to retain control over the security of peer workers’ jobs. Participants’ explained: “the fear for our jobs is used quite often” (Shauna), underscoring the power inequities created through the ability for employers to terminate peers’ work at any time. The lack of performance or productivity expectations (a theme explored in the previous section) reinforced this insecurity and heightened awareness of their job precariousness. The powerlessness among peer workers’ that this structure created was emphasized by a participant who said: “I mean, you have to be so damned careful when you’re in the presence of   93 management that the people in the room and, they are asking you questions about the work you do” (Michael). The fear represented in this quote speaks to the oppressive conditions created from their job insecurity. Employers’ power over peer work was more apparent among some participants than others. For instance: You know, they’ll [employers will] sort of turn on you for some, like, really stupid reason. And that stuff happens a lot and you just kind of have to be, like, okay, and go with it… It’s trying to make people feel like that, that’s what’s going on. But it’s absolute crap. That happens all the time. It’s happened to me… it’s all part of this, like, we can make you what you are or we can take it away… But we also haven’t given you anything, any real or meaningful power. (Peter)  What was particularly evident and problematic about the vulnerability exemplified in this quote was that some peer workers felt insecure if they resisted their work conditions out of fear of job loss. Yet, limiting peer workers to informal arrangements compromised their workers’ protections and rights, as well as reinforced precarious work conditions. As one participant explained: There’s a complete lack of accountability in any sense. And they can all be arbitrarily fired at the drop of the hat and then rehired, just so they know that they have no rights… Just arbitrarily and it was, like, part of it was just like the supervisors and the staff person were just, like, I mean, you know how that works. It’s just like letting people know that everything, that they, letting people know who’s in charge for one thing. Letting people know that they shouldn’t rely on anything. (Carla)   This quote highlights the lack of employer accountability present in nonstandard work arrangements. It appeared to be known among participants that their nonstandard work arrangements negated and work protections that may apply under a formal or standard employment relationship. Peer workers were, therefore, at the mercy of the employers’ decisions over how, if, and when they would work again.     94 4.5 Summary  In this chapter, I located peer workers’ roles organizationally by critically analyzing descriptions of the positioning, arrangement, and operationalization of peer work. In the first analytic category, I demonstrated the diverse ways that peer workers’ roles have been operationalized through their role definition, work arrangements, and positionality. I also illustrated peer workers’ role ambiguity, positions of powerlessness, and precarious work conditions. In examining the operationalization of peer workers’ roles, it was clear that peer workers may be disadvantaged from unclear or undefined role expectations, the utilization of their roles, as well as a lack of role support. In this way, the operationalization of peer workers’ roles constrained participants’ opportunity to enact agency or for their roles to be effectively utilized within organizations. These findings put into question the degree of organizational and employer support for peer work, as well as the understanding for peer workers’ roles within the organization. In the second analytic category, I focused on work arrangements as a key structural feature of peer work which organizationally disadvantaged and constrained peer workers. Nonstandard work arrangement positioned peer workers in roles that situated them at a distance from the organization physically, socially, and administratively. Power inequities appeared to be produced through the structural production of gatekeeping roles which held control over resources and information that peer workers had access to. Nonstandard work arrangements also enabled organizations to be noncommittal towards peer work, thus reinforcing their power and control over these arrangements.  Together, the themes presented in this chapter suggest that role support and work arrangements can structurally undermine peer workers’ roles, impacting their ability to enact   95 agency and be effectively utilized within organizations. In the chapters that follow, I build upon the demonstrated structural disadvantage peer workers’ can face from the structural organization of their roles by exploring other interrelated systems of inequity that leveraged the disadvantage of peer workers and perpetuated oppression. In the next chapter, Chapter Five, I examine some of the consequences of peer workers’ highly undefined, unsupported, and precarious roles. Following this, Chapter Six provides an examination of the labor market and economic systems that created and reinforced inequities in peer work, and the ways peer work conditions that constrained workers through various overlapping economic, political, and social systems.    96 5 Chapter Five: Peer Work Demands, Supports, and Substance Use   5.1 Introduction  In the previous chapter, I explored the organization of peer work by analyzing the operationalization of peer workers’ roles and their work arrangements, focusing on the ways that inequities become embedded through the structure of peer work. In this chapter, I examine the realities of peer workers’ day-to-day jobs by exploring peer workers’ role demands, how they cope with these demands, and some consequences related to them. Three dynamic and interrelated analytic categories related to the everyday working lives of peers are presented below. 1) peer work demands; 2) social support in peer work; 3) peer work and substance use. The themes and subthemes presented in these categories are interrelated and certainly not exhaustive.   5.2 Peer work demands  Work demands were evident through peer workers’ descriptions of what they do in their everyday working lives and the different challenges they face. Work demands related to specific roles as well as the challenges they faced in terms of navigating their jobs and roles in the workplace. Four themes are presented related to the category of peer work demands: 1) frontline work demands; 2) system navigation work; 3) professional and personal overlap; 4) workplace demands. As such, the first two themes and their subthemes relate specifically to the practice of peer work in two roles, whereas the latter two themes relate to the unique challenges peer workers’ face in these roles.     97 5.2.1 Frontline work demands  Frontline work included service jobs6 and street outreach7 that regularly involved interacting with other PWUD, such as handing out syringes (at fixed and mobile sites), offering health information and education, and responding to overdose emergencies by administering naloxone and giving rescue breathing. Participants’ repeatedly described roles which required work in overdose response. Although I did not purposefully sample peer workers or questioned their experiences in the opioid crisis, frontline overdose response work (i.e,. responding to overdoses with naloxone) was pronounced and clearly on the forefront of participants’ minds. In frontline roles, stress from their work demands appeared to be mounting; illustrated by participants’ descriptions of intense and traumatic experiences. Participants described the high pressures they felt to perform and explained the consequences of continually working in stressful and demanding roles. Three subthemes related to frontline work demands are detailed below: 1) traumatizing work, 2) relentless demands, and 3) burnout, are explored below. Traumatizing work  The numerous and in-depth narratives of witnessing or responding to overdoses in peer work depicted deeply distressing and disturbing experiences. Participants’ explained their perceptions of these experiences as emotionally traumatizing. “there’s a lot of trauma” (Kelly) or that “we’re doing all this work. We’re doing as deeply, you know, important but traumatizing work” (Peter). The work was traumatizing in that peer workers regularly experienced intense emotional responses to witnessing death and emergency situations, especially in situations with their family and friends. The traumatizing nature of frontline work was particularly evident in the  6 Service includes tasks and efforts that meet the needs of individuals or communities. It often involves working one-on-one with other PWUD (i.e. handing out drug consumption equipment such as syringes). 7 Outreach includes connecting with people who otherwise would not access services in the community; bringing services and information to people where they are at (a principle of harm reduction).   98 way participants’ recalled these events. Many cried while they spoke, and used vivid language to recall emotionally intense situations. For instance, a story was told where two people simultaneously overdosed and the peer worker “scream[ed] for help while breathing for two people” (Emma). Another participant talked about “walk[ing] in on a horrific death scene, you know, someone’s been in a [place] for eight, nine hours” (Michael). Some participants seemed to process the distressing and disturbing events they witnessed by talking about them at length in the interview. One participant, Josh, stood out as someone who wanted to tell his experience in frontline work. He recalled responding to an overdose: We thought she should be dead, but then we looked at each other, we had that look, like oh, fuck, I knew it. Oh, this is not good. She’s not coming back, right... I don’t stop talking. I’m pinching, I’m slapping, I’m talking. And then the Narcan’s out and that kind of stuff and just, I get into a rhythm… There’s so many people watching what we’re doing right now. Like, oh my god, I just filled up, right. I just, I went, holy shit. You are coming back. You’re not done. You’re not done. You come on back now. She woke up. She was, like, she was terrified. She started crying and then she just wanted to hug me. (Josh)  This story is filled with descriptive language indicating its traumatic nature. The number of mental and emotional demands in this situation (e.g. helping the woman, performing in front of a crowd, and providing emotional support for others including her spouse and his co-worker), was not out of the ordinary as evidenced by similar stories. He later reflected, “I guess to some degree without me even realizing it, it’s pretty hardcore. I mean, it’s pretty dramatic what goes on at those moments” (Josh). This statement is revealing in that Josh, among others, appeared to have not previously reflected on events from work or understood their impact. Many participants were aware of the traumatic nature of their work, but it seemed to be uncommon to verbally articulate or reflect on such experiences.     99 Relentless demands  The demanding and distressing experiences evident in peer work did not seem to be standalone or rare events, but rather a regular occurrence in their everyday working lives. Participants’ repeatedly articulated witnessing and responding to multiple overdoses, sometimes daily, at work. A man shared: “people all over town, finding dead bodies now” (Randall). The perceived enormity of the crisis was echoed by another man who explained: I’ve done over a hundred overdose reversals. Yeah, I quit counting when it got to triple digits… I’ve lost lots of people. You think about the [one area] and there’s 10,000 drug addicts, that’s a conservative estimate, and a thousand people a year dying from the fentanyl crisis, a lot of them are from here. You can imagine how many people you would know that died. People in my building, across the hall… it’s constant. If I stay home for a few days the list is going to be long… I step out of the street, oh yeah, did you hear, did you hear, did you hear. It’s horrible lately.8   Peer workers’ seemed to view the opioid crisis as vast and relentless, and that the intensity of their roles was escalating at an accelerated rate within this context. The unrelenting opioid crisis appeared to leave peer workers’ with little time to process or debrief what happened in between or before the next traumatic or high-intensity work events. The lack of time to stop and grieve was captured by quote among a man who said, “I mean, if you’re boiling someone an egg at 8:00 and by 9:00 the next morning you find out they’re dead, you know, it’s very jarring. But you can’t stop what you’re doing” (Michael) and other quotes reinforced, “you don’t have time to grieve” (Emma). Statements like these reinforced the idea that there was a lack of time to process the trauma they faced considering the rapid occurrence of overdoses. These quotes also depicted the incessancy of the emotional demands peer workers faced in frontline work. Since overdoses happened so regularly, frequently, and in their immediate community, experiencing trauma and witnessing death appeared to be inescapable for some: “there’s no time for twiddling  8 Pseudonym not used to promote confidentiality.    100 your thumbs and feeling sorry for yourself. There’s shit to do... I just can’t stand by and do nothing. Or sit in my room and cry; that’s not going to get it done” (Donald). This quote underscores the pressure some peer workers expressed that related to meeting the relentless demands of the crisis, in combination with a persistent determination to work despite regularly experiencing emotionally straining events. Yet, the relentless nature of the crisis made some question the impact of their efforts. For instance: Our group has gotten really big and at the same time the overdose epidemic has gotten so much worse. So it’s, like, this weird time where you’re, like, wow, we’re doing really successful things but no, we’re not, we’re not doing shit. Look how many people are dying. And it’s like a weird frustrating contradiction. (Peter)  For some, it was unclear if peer work impacted the unwavering overdose rates, which was associated with feelings of hopelessness. Others expressed concern about the crisis “slipping people’s minds” (Donald) – indicating fear about the resources available for peer engagement and their jobs if the crisis relented. Therefore, there appeared to be an added pressure to meet their job demands and make a difference while work was available. Emotional impacts    The incessant demands of peer workers’ jobs seemed to have an emotional impact on participants. They talked about being tired, exhausted, and overwhelmed. The incessancy of the opioid crisis combined with unprocessed grief evoked expressions of hopelessness and exhaustion among participants. The connection between the crisis and feelings of being inundated or submerged in the demands of the crisis was clearly captured by one man who said: They’ll come in two’s sometimes or three’s or, it’s so random. But we take these hits a lot, and so you can’t stop your work. And so it doesn’t come at you, that kind of trauma, face-on. It’s like a big wave coming down on top of you. (Michael)    101 The regular traumatic experiences that peer workers witnessed cumulatively weighed on Michael “like a big wave”, which supported the notion of overwhelm among peer workers in frontline work. Similar sentiments reverberated from those who spoke about the overpowering emotional demands peer workers’ face from regularly witnessing traumatic events: “I think that just piles on people” (Emma). Here too, the cumulative weight of the grief and trauma peer workers experienced seemed to be impacting workers in a deep way.  Emotional exhaustion was particularly evident among frontline workers who regularly experienced trauma without having time or space to process it. Participants’ narratives linked the lack of time available to process and deal with the traumas they were enduring and how this contributed to feelings of burnout. In an attempt to make time and space, some participants attempted to remove themselves from observing, reacting or processing additional work demands. For instance: But once my work week is over I do retreat. It’s almost like I go into seclusion. I can’t handle anymore. I can’t absorb anymore. I don’t want to think about it. And so I escape that way, right. And it’s not that I’m disassociating from the trauma. It’s just that I have to do something proactive personally for my own self-care in order to carry on… But you know it’s killing my body. I’m tired. I come home, I go to bed. Or I stay up all night and try to distract myself through a movie on Netflix, whatever. And I’m pretty good at doing that. (Michael)  In this quote, the sheer exhaustion from doing frontline work was exemplified. The participant was attempting to cope the best way he knew how – isolating and dissociating. Peers’ emotional exhaustion was also directly related to the lack of social supports available to peer workers – a theme explored later in this chapter.  5.2.2 System navigation work demands   In addition to one-on-one overdose response and street outreach work, peer workers’ engaged in different capacities beyond the frontlines of the opioid crisis. One role was frequently   102 discussed is what I term system navigation work – a role where peer workers’ helped others traverse, understand, and overcome systemic inequities and structural vulnerabilities that they were facing. Several participants described this role within the community: I coach people how to navigate that [bureaucratic systems]. And there’s a couple of groups down here that do, specifically that’s their gig is they just navigate people through welfare and getting I.D. and dealing with the feds… most people down here, there’s a lot of people, like, you know, they’re illiterate. They’ve been unplugged from society forever and they just don’t know. They haven’t got a clue. So for them, it’s just like a big wall and it’s too hard to even navigate. So they accept what they’re given, if they’re given anything, and keep their heads down… I try to help people in that. (Donald)  This participant used his lived experience or learned structural literacy to inform other marginalized individuals who were less knowledgeable about systems, policies, and processes. Some participants referred to this navigation work as “office outreach” where they worked one-on-one with structurally vulnerable individuals, including PWUD and people experiencing homelessness, in traversing high barrier systems.    System navigation work included duties such as assisting others in health, social, and political systems, enabling access to things such as healthcare, social income assistance, and housing. Some duties participants described facing political red tape” (Randall), the “bureaucratic system” (Shauna), and “helping people understand, you know, who holds power, how to access it, strategizing, stuff like that” (Peter). Some provided navigation support for others by talking to doctors, government workers, or other professionals. They described taking people to and from appointments, doing paperwork, or facing the “administrative nightmare” (Michael) when applying for income assistance or other programs. Many emphasized drawing on their knowledge of the language “the bureaucracy” used: There’s a certain amount of bureaucratic language that most people just don’t understand. And there’s a lot of, like, I’m not sure the proper term for it, but I think it’s almost like a defense mechanism for bureaucratic people to start bringing out the big words when they’re not sure how to respond. Which creates kind of a language barrier, I guess, and   103 it’s condescending, and people can sense that. But they don’t have the vocabulary to respond to it. So it’s stressful for some people. (Vivian)  This quote is an example of how peer workers provided support translating language and information in a way both their community and the bureaucracy understood.    Organizationally, it appeared that most system navigator roles were not recognized, paid, and or formally arranged. No one was trained in these roles, and understanding them was learned through peer workers’ prior lived experience. Participants’ emphasized using this lived experience in their roles, as highlighted by one participant:  So I was an injection drug user. I was a sex worker. I was, you know, I had gone through, in my conflict with the law. So I brought all of that and, you know, system navigation skills to my work. And then a whole lot of empathy and compassion and passion.9   This quote and others spoke to the expertise gained through peer workers’ lived experiences and the ways it added value to their work, especially given their compassion for others facing high barrier systems. Yet, this work was unpaid and not formally recognized or acknowledged by organizations. Several subthemes related to the demands peer workers faced in system navigation work surfaced in participants’ descriptions. Subthemes included: 1) facing oppression and 2) bridging worlds. Facing oppression   In working with people who experienced structural harms, participants’ regularly faced their own histories and current structural oppression. They frequently stated how challenging it was to face people such as a co-worker who once (or currently) participated in oppressive systems. Peer work, for them, was about “entering the system that’s caused a lot of harm to me  9 Pseudonym removed to promote confidentiality.   104 and to other people that I know” (Shauna). Many talked about facing people in positions of power and privilege, especially in the context of attending meetings. Participant’s explained the difficulty in interacting with these individuals in the context of peer work: “I don’t feel comfortable in the room with those people” (Kelly). Working face-to-face with people who embodied the sources of their oppression introduced a sense of anxiety among several participants. One participant in particular explained the mental anguish she endured in spaces that she was previously excluded from: I still have a hard time adjusting my head to the power dynamics when I go into places. Like we went to a training the other day at [agency], and it was in [a room], you know, for employees only… I know I’m not even allowed to be [there] as a homeless person. But as a worker, I just get completely different treatment and it really, likes, messes with your head that they can treat me completely different because I’m a [peer volunteer]. But I was the exact same girl four years ago asking for help. And they still just treated me like shit, and it’s only over a little label. So, I don’t know… It’s an ongoing thing. I think I’m still learning how to process it. (Emma)  This experience exemplifies the emotional distress of moving into privileged spaces or being actors within systems of inequity. In some ways, facing oppression seemed to heighten their awareness of their previous and former experiences of powerlessness and marginalization, and also put into question their role in these very systems. The reflections on their roles highlighted the shift in identity some participants were struggling to process – a subtheme explored next. Bridging worlds  The organization of peer navigation work and other roles, such as consulting at meetings, occurred within the systems that currently or previously oppressed peer workers. In describing their experiences in these roles, participants regularly grappled with identity struggles or tensions. Some participants’ described their identities as being in an “in-between” place where peer workers’ demonstrated a tension between an oppressed subjectivity (current and historic) and the possibility of liberation from oppression. Many felt not entirely included or excluded by   105 organizations, speaking to their roles within a grey area (as described in Chapter Four). Others talked about having to “bridge the gap” or “bridge both worlds,” reflecting on a borderline social position between “the straight world” and “criminal world.” As one man explained: I like working in the streets, but then I don’t like going to meetings with people who own homes and have really nice tans and, you know, nice vacations and talking to them, who are the deliverers of money. And then having to go back and listen to people who my heart’s invested in their life about how, nobody fuck all to help them. And I feel like I’m one of those people because all I did was go talk to two assholes in a suit who make $150 and $200 G’s a year respectively. (Craig)  For Craig, peer work was mentally and emotionally demanding as he was troubled by possibly being “one of those people” from integrating into a system that once structurally oppressed him. Other participants’ similarly demonstrated their desire to integrate yet resisted identifying as an actor within oppressive systems. You try to be part of, at the risk of sounding cliché, you try to be part of a solution for the client, okay. And not a problem for them, right. Because they’re already oppressed enough and I, you know, don’t want to be just one more person who is oppressing them, right. That’s a challenge. (Michael)  The challenge referred to here was the mental demand of reflecting on and struggling with whether they were part of the solution, or participating in and reinforcing inequity.  At the same time, the systems that organized peer work were not entirely accepting of them either. Peer workers’ marginalization within systems contributed to their sense of being an outsider: “I don’t know if I just feel like I’m a right in-between person… I get such crazy anxiety, maybe like I don’t belong in there. Or I’m not supposed to be in there” (Emma). This in-between position highlights the complexity of the peer role and the stress many peer workers’ faced with being positioned both as an insider to the system while simultaneously resisting or being excluded from it.    106 5.2.3 Professional and personal overlap     Peer work was partly defined by the experiential knowledge of the local context of drug use and access to networks of PWUD. Peer workers’ deep connection to the community of PWUD was inherent in these roles. For those who were currently using drugs or engaged in service work, the deep personal connection to their community was accentuated. However, the connection presented an inseparable overlap between peer workers’ professional and personal lives which complicated their roles and the demands they faced. This overlap between work and personal was one of the most profound but pervasive ways that inflicted demands in peer work. Comments from Craig were the most obvious to problematize this overlap: Like, hey, aren’t you the person that I saw this morning? So, you do end up volunteering your time back to the community because once you’ve been doing a lowly paid stipend job like that for a while, all the people know you. And they expect you to be there. They don’t know the difference between a volunteer and an employee if you’re living on the street. They just know you come by every day at 7:30. (Craig)  This participant described the process of peer workers returning to their community after work and interacting with people or “clients” they helped earlier. It appeared to be challenging for many to disengage from their job demands, as the community was their workplace: “It’s just kind of who I am. So it happens every day” (Donald). Consequently, there was an expectation from themselves and other community members to be available at any time or place. As the conversation with Craig illustrated, some came to rely on peer workers essentially volunteering their time day and night.    In contrast to peer workers with an inherent connection to the community, participants’ noted that non-peer workers were able to leave their responsibilities at work. One participant said: “You realize - hey, this is real stuff, you know, the bureaucrats go home at the end of the day. But I stayed” (Michael). Unlike “the bureaucrats,” peer workers did not as easily disengage   107 from the demands of work each day given that their workplace was the in their immediate community. Since peer workers’ workplace was always accessible within the community, participants’ found it particularly difficult to find time to decompress – a central structural feature of peer work that contributed the inability for peer workers to take time to process their work demands and decompress. Leveraging the connection     Peer workers often engaged in work within their communities that was unrecognized and unpaid by employers. However, some participants’ experiences suggested that employers leveraged peer workers’ personal connection with the community to meet organizational and programming needs, while also not paying or formally recognizing these efforts. Some peer workers felt obligated to meet community needs and found it difficult to decline requests to fill gaps in services. Participants’ shared experiences of being contacted for their personal networks and informal positionality in the community to connect with PWUD and others whom service providers otherwise could not reach. For instance, one participant described: I have, like, an underground network of people that contact me… because I can go get her. I’m not a professional. My job isn’t on the line. It doesn’t matter, I’m not breaching any propriety agreement or code of conduct, you know…This is stuff that people do because they genuinely care about the people that they’re taking care of… [but] there’s logistics involved. I have to stop whatever I’m doing to go respond to a crisis call, and I don’t get paid for any of this. So I can only do so much. (Vivian)  Vivian was often called on by service providers who leveraged her close personal connections with members of her community and the sense of responsibility some felt to meet the service demands of their community. Yet, peer workers’ efforts were almost ubiquitously unsupported in terms of the time, effort, or emotional impact of this work.   Participants’ shared that they felt pressured into doing unpaid work and sacrificing themselves if employers leveraged peer workers’ personal connections to their community.   108 Similarly, a conversation with one participant indicated: “I’ve never felt like I’m really doing something important to people who I care about and what matters… and then they’re turned around and treated like that” (Carla). The sense of purpose and connection to her community (combined with a lack of a formal employment relationship) was captured here. Nevertheless, her sense of purpose influenced or pressured her into doing unpaid work, which she negatively judged.    However, some participants indicated that they preferred to work separate from the organization due to constraining organizational policies (particularly workplace norms around ‘boundaries’ – a theme explored in Chapter Six). In this way, peer workers’ also leveraged their connections with the organization and community to help meet the service needs of their networks. This subtheme regarding the appeal to work outside organizational rules is explored next. A pressure to succeed  Participants depicted a sense of duty to help people experiencing structural vulnerability given the critical nature of the issues they were helping with and their knowledge of the potential repercussions. Navigating and gaining access to high barrier systems put pressure on peer workers to help others, and guilt if they failed. As one participant said: “I have endless stories of people’s lives being affected by one rejection from a healthcare provider and it’s very, I mean, it’s a lot of pressure” (Vivian). While they were aware of the barriers they faced, many participants revealed anxiety and tension from the weight of this responsibility.  A clear example of this pressure to succeed came from one participant who recounted helping a person seeking healthcare for wounds related to their homelessness. The participant spoke about providing counselling and contacting healthcare services on their behalf. However,   109 despite efforts over several weeks, the person underwent amputation related to their wounds: “But [they] was so traumatized from going to doctors in E.R.’s that [they] just wouldn’t go in there. So we tried to do what we could for as long as we could, but [they] ended up [having an amputation].” The participant cried in the interview while recalling this story saying “I know it’s not my fault, and I know I did everything I could, but, like, [I] see it all the time, like all the people who just keep falling through the cracks” . For those who could not overcome structural barriers or systematic inequities, stories such as this one revealed a deep sense of guilt by witnessing the structural violence and harms among their community.  While participants knew they were not immediately responsible for the outcomes, witnessing suffering and harms was difficult and seemed to weigh on peer workers’ conscience. For instance: It was about a month, every person I sent to the hospital died. It was really weird, yeah. Strange effect. That was, you know, I convinced them to go because you could just see, you know, like, their wounds were so bad you could smell them, that sort of thing. I counted that a few times. They just have to go and, yeah, it was just a space of, a short period of time and there was people dying every time I sent them to the hospital. So, yeah, that was a bit much. (Donald)  The emotional demands intensified the pressure for peer workers’ to succeed as well as the helplessness and hopelessness many felt in their roles; peer workers’ personal connections with people they helped within the community exacerbated this pressure. Meaningful and purposeful work  Part of the pressure to succeed also came from the deep sense of purpose and passion peer workers’ expressed about their work. Participants’ were quick to describe the meaning they found in peer work. Many participants’ described positives such as helping the community: “There’s a lot of gratitude [from the community” (Charlie) and “people are always very grateful and happy” (Debra). Others gave examples of a time where they helped someone, demonstrated   110 leadership, or impacted the community. Participants’ shared that other people including family and friends were also proud of their roles:  My kids have just totally, they’re so proud of me now. They’re always saying, “My mum works at [organization].” And they come here all the time and they see the big change in me. Now they’re calling me; I’m calling them. They’re coming to my house. They come here. So it’s changed me in every way for the best, everything. I would be devastated if there, if [organization] ended. (Melissa)  This sense of purpose and meaning in the community motivated many. For instance, “seeing people that I cared about every day was great. And going, getting up and me being all jazzed up every morning to go and fight the good fight” (Carla) and others said “I love working with other people who use drugs. I love when we sort of make progress on something or I know that, like, I helped people out, helped them get paid” (Peter). So, the purpose peer workers’ derived from their work was not just about the work itself, but seeing the impact their efforts made on the community and getting positive feedback from them. Among those doing unpaid work in their own time, there was a sense of altruism and peer workers’ seemed to emphasize this selflessness over the monetary gain in the interviews.  I don’t know very many people that would do what I do for basically peanuts. But again, like I said, if I won the lottery I’d be right down here doing it anyway so it doesn’t matter to me. And I really do feel uncomfortable asking for more money and that sort of stuff. I’m not in it for the pay. I’m here to serve is what I’m doing. Giving back as much as I can… and the money thing, like I said, just makes me feel uncomfortable, asking for more money. (Donald)  Peer workers’ passion for their jobs appeared to be linked to extra hours and duties they engaged in within their personal time. For instance: Like being a peer worker, even if you do get paid not that much it’s still a pride thing. ‘Cause for some people that’s an identity that they didn’t have before. And that’s something else that I think we have to understand is that for some people this is better than nothing. And that’s exploitation to me right there. (Peter)    111 In this way, the deep sense of purpose peers’ expressed influenced their determination but, at times, also intensified the pressure to perform and the demands of their roles, which could be leveraged or unrecognized by employers.  5.2.4 Workplace demands   The articulation of workplace rules sometimes seemed to occur formally in peer work, such as through policies, or informally through social and cultural norms. Young (1990) suggests that, in workplaces, what is deemed acceptable or a ‘rule’ is largely determined by those in a place of privilege and power. In this way, norms and rules were tools that reinforced the dominant (non-peer) culture by relaying what was acceptable and unacceptable at work. The ways participants’ navigated these norms (informal rules enforced socially or culturally) and formal rules are explored here. Learning the rules    Learning to work within the constraints of workplace rules proved to be challenging. Although participants’ tried to acculturate quickly, assimilating into the dominant workplace culture was complex. Participants talked about differences in the rules of the “straight world” or dominant culture and “underworld”: Because in the world that we live in, like the underworld or the criminal world, like, if you want to do something you just do it. And you don’t have to check with your boss. And if you don’t like what the person ahead of you did, then you move him off, right. So there’s none of this, like, learning to work in the straight world is different than learning how to work in the other world. (Craig)  This quote implied that dominant workplace norms and rules were not only different but reinforced the notion that many workplace rules were constraining. Some participants attempted to draw parameters around appropriate work behavior. For instance: We were in a rural community and we almost all already knew each other, when we were doing the surveys with peers, we had to be very ethical and professional when we were   112 doing that. Because we weren’t coming at it from a buddy system like on the street when we were, if people were sharing dope or buying dope with each other and they had past, even negative experiences with each other. That people needed to set that stuff aside and needed to be very ethical and professional. And be mindful that you are at work here right now. (Kelly)  Although they knew people, peer workers felt compelled to behave or interact differently than “on the street.” Since the articulation of workplace rules were not always clear, many explained the need to figure out the rules on their own. The lack of communication about rules was especially challenging for peer workers without previous experience in formal workplaces. One participant, whose job was his first, spoke about the vulnerability he experienced in the workplace by not knowing or understanding workplace norms and rules: It was challenging at times. Like, often the co-workers were, ‘cause for a lot of people, including myself, not a lot of experience at jobs and stuff. And sometimes it would be their first job. So there was, you know, basic training about how to serve people and be respectful. And, you know, barriers around inappropriate talk and that sort of thing. (Donald)  Donald’s experience alludes to appropriate workplace behaviors language – “basic skills” many peer workers may not be attuned to. Peer workers’ often taught or shared what was appropriate or not with others, but not abiding by these rules left peer workers structurally vulnerable. Rule constraints  Participants shared their perceptions and experiences in traversing workplace norms and rules, including their structurally constrained ability to work effectively. They talked about working under the scrutiny of professional ideals and rules, which made their work with community challenging. When asked about integrating more into the organization by taking a formal job, Michael explained:  I kind of have to respect their things which is fine. But I kind of like the idea of saying, okay, well, maybe what we’re doing is not the right thing…‘cause I like the idea of going by instinct and by feel rather than okay, the rules say I can’t do that. Or the rules say I can’t do this. I can’t do that. I can’t do this… now I got to work, you know, within a   113 small parameter to help someone. And that little parameter might not cover what I need to help them with so that might be the barrier [to doing peer work]. (Michael)  This example illustrates the constraints imposed by the regulations and rules in the formal workplace. Peer workers’ felt held back from doing “the right thing” or performing effectively in their work, which some said was a barrier taking on formal employment in peer engagement contexts. Similarly, some participants talked about how they quit their job when formal restrictions were placed on their roles. For instance, one participant left their work as rules restricted them from providing hands-on harm reduction work, such as assisting others with injections. For them, such institutional restrictions constrained their ability to be effective in their roles; thus, compelling them to leave their roles as peer workers altogether. Other participants appeared to work within informal, unpaid arrangements given the restrictive workplace rules they reported. One participant explained: “it feels a lot better than actually getting paid… It’s like, I got her off the street. I got, like, I did this, I did that. It’s more like bigger picture I guess” (Emma). Given that formal employment restricted some peer workers’ ability to make an impact, unpaid peer work enabled more role effectiveness by being able to enact agency and focus on tasks which truly met the needs of the community. Personal and professional boundaries  The topic of boundaries relayed the problematic nature of workplace rules about personal and professional relationships. Boundaries are a concept regularly used to establish norms and are articulated in rules about workplace behavior, personal limits, and personal and workplace relationships (Malin, 2000; Ward et al., 2010). On the topic of boundaries, Shauna said: “I’m getting in trouble with boundaries all the time. They’re always talking about boundaries and I’m, like, well, have they been really clear about what do they mean by boundaries?” Participants’ made it clear that expectations about managing personal and professional relationships in the   114 workplace was a topic not regularly broached by employers. These often unstated and arbitrary workplace norms and rules around boundaries produced a vulnerability for peer workers’ as they faced ramifications, including exclusion and job loss, if they did not abide by them.    A clear example of how rules constrained peer workers’ from doing their work effectively through the ideals of the “straight world” and professional boundaries was around hugging – a topic that participants repeatedly addressed. Hugging other people at work was a behavior that was not considered appropriate workplace boundaries: “We’ve had things like you can’t hug people. Like we’ve had riots happen over that. Don’t fucking us tell us that we can’t hug people” (Shauna). Later, this participant said: There were concerns about being too close to the people that were accessing services. But that’s kind of by definition what happens in peer work. That it’s, like, they have this special ability to build relationships, if not, already have some of them maintained, you know, to support people … if that’s why you’re hiring them, then you should have an understanding of that. (Shauna)  Restricting physical contact (e.g. hugs) with others was a workplace norm imposed by non-peer workers, which concurrently prevented peer workers from building trust and connection with the community. For peer workers, this physical comfort was an essential part of serving their community. Participants gave numerous examples of the ways in which hugging built connection. In her work, Kelly explained: “…bring[s] you together and support you and we support each other. And they instant, people will come up and hug me.” When describing her work at a peer-based organization another participant said: “we’re like family. Lots of us, like, we hug and we hug, when we come in, we hug, when we go out, and it’s made me feel like I belong, and it’s made a lot of the girls, women feel like they belong” (Melissa). As well, participants often talked about hugging while comforting others in their stories of responding to overdoses. These experiences highlights that although workplace norms dictated hugging as inappropriate,   115 hugging was instrumental to peer workers feeling effective in their roles. For them, hugging was a necessary tool for providing care and building trust with others; although, utilizing it was reprimandable if not traversed carefully in the workplace.  5.3 Social support in peer work  In the previous analytic category, section 5.2, I explored some of the emotional and mental demands in peer work. One way to mitigate perceived work stress is through social supports (Viswesvaran, Sanchez, & Fisher, 1999). Social or interpersonal support, such as with coworkers, supervisors, and peer workers’ extended social networks, was seen as a potential outlet to talk about and process events, emotions, and job demands. Yet, nearly all participants stated an unmet need for social support to help them process their highly demanding and deeply traumatic work. The lack of social support for peer workers was clearly linked to evidence of burnout, including expressions of overwhelm, hopelessness, and exhaustion. In this section, I examine the need for social supports, as well as the types of social supports available (informal and formal), including the inaccessible, inappropriate, and unavailable nature of them. These subthemes are: 1) a need to debrief; 2) formal social support; 3) informal social support.  5.3.1 A need to debrief   The lack of social supports in peer work was primarily evident through participants who voiced an explicit need to debrief after events. As a form of social support, debriefing is the formal or informal coming together of individuals to discuss stressful or traumatic incidents (Brough, 2005; Brough & Fram, 2004). Participants described it as: “somebody you can turn and talk to and debrief with….You need it in this work. It’s hard work” (Shauna). Numerous participants voiced that they wanted access to allocated time, space, and someone to talk through their experiences at work. “I do have a wish that I had someone that I could talk to or vent about   116 at the end of the day or at the end of a hard week. Because I feel like there really is no support” (Emma). The need to debrief in peer work appeared to be a long-standing gap for participants. One man stated: No, they don’t agree with that [debriefing]. I’m talking over 20 years I’ve wanted it… Debrief time, you guys. What’s wrong with you? You’re licensed counselors. How come you don’t understand how we need time to regroup after something like that? Why don’t you get that?... I want the time to just sit and get better. (Josh)  The emphasized an ongoing need to debrief was linked with voiced frustrations over this gap as they regularly witnessed the consequences of unprocessed trauma, including burnout. “If we don’t debrief it and talk about it with each other then we, it exhibits itself laterally with each other. We’re really nitpicking and very hard on our co-workers which is not a healthy thing” (Michael). Debriefing though was not a standardized process in peer work. Instead, participants emphasized a lack of time or a formal process to speak about experiences in their work with others. Peers’ informal work arrangements appeared to be one factor that contributed to the lack of standardized time and process to debrief but was also a consequence of the incessancy of role demands and lack of time. 5.3.2 Formal social support    The access, availability, and appropriateness of formal social supports, such as counselling, were topics raised in the interviews. In addition to the lack of debriefing processes in peer work access to other support was also absent. One provincial initiative several participants talked about was referred to as the “Mobile Response Team”. They explained this group provided support, education, and training related to the opioid crisis in BC. Participants explained that when the initiative was first introduced, they were excited about the possibility of accessing the Mobile Response Team as a potential solution to the social support gap in peer work. However, this service was inaccessible to peer workers. As one woman explained:   117 We were hoping the Mobile Response Team was going to be the answer… it’s navigated for, like straight people who are dealing with second-hand trauma from dealing with the job. So that threw a wrench in what we were hoping for. And we haven’t come up with anything since then. (Emma)  Peer workers’ expressed their disappointment that the initiative was accessible to “just professionals” (Michael) and not for most peer workers. Since most peer work was informal, accessing this resource did not appear to be an option: “There’s the Mobile Response [Team] which is new which is a good thing if they’re readily available. But it would have to be something pretty devastating for them to actually be brought in” (Michael). Such perceptions towards accessing the Mobile Response Team underscored the uneven distribution in social supports available. This inequity further spoke to the inadequate recognition for peer work among organizations and employers who did not offer other options. As one participant suggested: Service providers almost always have the options for counselling and different things to support them when they’re working with people where, like, they themselves can be traumatized by the things that they’re exposed to. And quite often peers don’t have that same option. And we quite often need that more than service providers do. (Kelly)  This quote underscores that peer workers were susceptible to stress and experiencing trauma, and yet they reported minimal access to support. Participant’s shared they wanted “the same kind of supports that everybody else has,” (Randall) which emphasized this inequity regarding different opportunities for wellness between workers associated with their structurally constraining work conditions.    The inequity in access to social support was partly attributed to inadequate capacity or understanding of peer engagement organizationally. As one participant pointed out: “there’s not a whole lot of education around what it takes to support a peer” (Shauna), suggesting that organizations are naïve to practicing peer engagement effectively though job support.   118 Participants also emphasized the need for any social supports to be peer-based. One participant in full-time employment talked about counselling through an employee assistance program. He reported:  I have accessed them once. I mean, that’s there but nobody does access it …It’s not necessarily helpful sometimes to deal with those people. Maybe they don’t understand what I’m talking about, because they don’t have the lived experience, right. And so, I mean, it’s a good sounding board sometimes. But, you know, there’s that. (Michael)  Here, Michel explained that formal counselling may not be appropriate for peer workers if they are not provided by people with lived experience of peer work. Others also expressed the need for peer-based social supports: “It’d just be nice to debrief with someone who’s in that situation” (Emma). Having support designed and delivered by people with lived experience was important for them. Nonetheless, as highlighted, standardized or peer-delivered social supports in the workplace appeared to be non-existent. Peer workers’ suggested that one way to mitigate this gap was to make sure peer work was designed in collaboration with people with lived experience.  5.3.3 Informal social support  Reports of informal social support, or those not standardized institutionally (such as casual or informal conversations with coworkers or friends), varied among the sample. Informal social support was almost ubiquitously offered by other people with lived experience, although informal social support among friends or family was also described. Participants’ provided different perspectives and reasons for having or not having access to informal social support.  By contrast, he explained that he regularly sought informal social support outside the organization: “I can get, like, 10 hugs in a six-block area. So I have that constantly so that’s a good thing, a source to get over it.” For him and others, the larger community was a key source of social support.    119 Some peers’ workplaces did not provide a culture or offer informal social support by cutting them off socially. Often, peer workers’ expressed that non-peer co-workers could not provide adequate social supports due to their lack of lived experience and other social barriers between them. However, by contrast, others indicated that peer workers were sometimes reluctant to lean on each other given the pervasive burnout and overwhelm the community was experiencing. Participants’ perceived little capacity among people with lived experience, especially other peer workers, to provide them with the social support they needed. For instance, one participant suggested that seeking support from other peer workers was “something I try really hard to not do” (Kelly) and that “finding non-using peers who are stable enough to actually talk to is a challenge” (Emma). Participants’ experiences depicted their hesitation in informally burdening others with their work grief.  The importance of lived experience as a form of informal social support was a topic raised by others. Participants’ described regularly being the sole peer worker within the workplace. For instance: “I get invited to a lot of stuff where I’m the only drug user. And it’s really lonely” (Peter). Others reinforced this notion, explaining that others with lived experience provided a central source of informal social support: “it’s important that there’s two peers at least so that we can at least lean on each other if we’re feeling vulnerable in any way or anything like that” (Kelly). Other participants’ similarly identified people with lived experience as a key source of informal social support. Some explained not wanting to confide in their social network external to the work. Some raised the idea of their family and friends as support but noted that “[they] don’t understand” (Josh), speaking to the need for social support from people with lived experience of peer work. At other times, informal supports were simply not available   120 – in or out of the workplace. This lack of available informal social supports was captured in a quote by one participant who shared: It’s lonely, because you come home at night and you’ve had a goddamned tough day and there’s no one to share it with. Nobody. And so you say, well, I’ve helped people all day. Now what about me? Who’s here for me? What am I going to do? It’s lonely. (Michael)  Sometimes, participants’ described examples of reaching out to co-workers or supervisors for informal social support only to be rejected. For instance: I was actually kind of disappointed. [Employer] said, you know, if you need anything, and when I asked, just no answer, you know what I mean. I needed to be heard, and [they] wouldn’t hear me. (Donald)  Donald later explained though that informal social supports were “a personal thing,” but not ubiquitously accessible given the social divide between coworkers – thus, underscoring the need for, yet lack of access to, informal social supports available for many peer workers.  5.4 Peer work and substance use  Substance use was frequently mentioned by participants throughout our conversations rather than a main topic of my investigation. Substance use among peer workers was sometimes a consequence of work, source of stress, or coping mechanism – other times, it was all three. My focus on substance use as a theme then is an opportunity to illustrate how several topics presented throughout this chapter interweave with each other. Below, I explore several themes related to peer work and substance use, including: 1) using substances to cope; 2) re-initiating use; 3) substance use as a condition of the job; 4) formal substance use supports; 5) peer work as therapeutic.     121 5.4.1 Using substances to cope  Substances use patterns and descriptions were diverse across the sample. Some identified current regular substance use, while others indicated they had been abstinent from substances for a long time period. However, many participants perceived current drug use as common in peer work. No participants discussed having to avoid withdrawal and its impact on their work. Several participants talked about how substances helped them cope with pain, and restricted substance use undoubtedly debilitated them from going to work. Participant’s talked about substance use in both a negative and positive light. Amongst those who framed their use with respect to their job performance, some saw it as a way to function. As one man stated: More drugs. That’s usually my stock answer and most people laugh, but I can tell, and I’m not the only one that does that. I’m just the only one that voices it, ‘cause I can. I’m a functioning drug addict. (Donald)  Like Donald, others wanted it known that substance use was not always detrimental to their ability to work, but helped them function and perform. Some explained drugs (both stimulants and opioids) made them “better equipped” (Donald) or helped them “get up and get active” (Randall). For these participants, drug use was perceived to positively improve their job performance and productivity. More predominantly, drug and alcohol use appeared to be used as a coping mechanism – physically, mentally, and emotionally. While the specific drugs used in different ways and times were not discussed, it was a way to deal with stress. Participants said: “I use drugs” (Kelly) or “I’ll go home and get shitfaced” (Michael), and “As soon as I started to work I started to use more. Yeah. Again, because I’ve, I can’t do this job straight” (Donald). Substance use was framed as an accessible and available means to dissociate and detach from the trauma and strain from work.   122 5.4.2 Re-initiating use  Working within this context made it challenging for some to manage their use or abstinence. Many explained that their substance use changed since they started peer work – and not always in a positive and functional way. Increasing drug use frequency or amount, or using more harmful drugs, was commonly reported. Participants’ often grappled with their exposure to substance use and its frequency because of the nature and orientation of peer work.  The expressed challenge of managing substance use and re-initiating use given the apparent demands of peer work was what one participant referred to as “relapse due to work” (Kelly). She explained how “the only con on my list [of doing peer work] was that I may use more than I want to. Or may use when I don’t want to” (Kelly). The dilemma here was that for some people, managing their substance use required them to quit peer work. Others reported: “people can’t handle it, working around drugs all the time… they ended up slipping up after the first week so, it’s not for everybody” (Emma). Some participants suggested certain environmental factors that prompted or urged peer workers to use substances. Various work contexts, including where the work occurred, who was present, and nature of the job, seemed to trigger a desire to use substances. These work contexts were characterized as “safe” or “danger zone[s]” (Kelly) where they felt more equipped to manage their use in some places compared to others because of contextual cues. Examples as to where substance use was triggering included in “smoke pits” or hotel rooms. Working around other PWUD, including in places where peer workers congregated, appeared to be triggering or produced urges to use. As Kelly explained:  Well, you’re with people who are actively using substances, right. So for me, when I go out of town, I don’t often like to use when I’m working. And sometimes it’s hard to avoid that when you’re in a smoke pit and everybody’s talking in a conversation. And they’re all figuring out how to get their dope together, and you’re just like fuck it, can somebody score me something too? (Kelly)    123 This quote suggested that people who engage in peer work away from their home community may be particularly vulnerable to triggers given that they are outside and away from their personal support system.  5.4.3 Substance use as a condition of the job    Substance use knowledge from past and present experience defined peer work. However, this same definition appeared to impact peer workers current substance use. Participants indicated an implied expectation or assumption about having current substance use experience as a condition of the work. One woman recalled a peer co-worker who “was struggling with some things going: ‘I feel like I wouldn’t have this job if I stopped using drugs’” (Shauna). This example indicates that substance use was perceived as a condition of peer workers’ employment. For others, they explained peer work justified their substance use. As one participant said: Am I going to be okay if I am clean? Like, am I still going to have it [a job]?... I don’t know if [my substance use] is good or bad… only because I’ve let it. And that’s the only reason, like, I don’t know, because I think I use it as an excuse to use, right. That I’m allowed, so I’m allowed to do this kind of thing. (Debra)  In this conversation, Debra reflected on the way in which peer work justified or “allowed” her to use – which, as she later pointed out, became problematic. This awareness was posed as a dilemma: “it’s good and sometimes it’s not good” or “a catch 22.” Yet, she indicated a fear of losing work if she no longer identified as a PWUD. This particular interview mirrored some of the consequences related to employers’ lack of communication and understanding of peer work which translated into poor role expectations – including about lived or living experience.    The connection made between peer coworkers and others in the community through substance use also influenced their decision to use. As one participant explained: They’ll go, what? You use drugs? And I’m, like, yeah. That’s the whole point of me being here is my lived experience is why I work this project and work with you guys…   124 people will come up and hug me. That’s because I’ve just identified once again that I use drugs. It’s like, you’re one of us. (Kelly)  As this quote exemplifies, substance use elicited a sense of legitimacy, credibility, and social integration not only with the community but other peer workers. This acceptance among peer workers based on substance use added to the ways peer work was triggering. 5.4.4 Substance use supports    In addition to the need for better organizational and social supports in peer work, support for substance use was also lacking – particularly in the formal sense (i.e. substance use treatment and detox). No participants indicated accessing formal substance use support, although they may have been accessible among those with employment benefits. In contrast, participants’ in nonstandard work arrangements highlighted the inequity in accessing treatment for those working in a grey area.   One particular example highlighted the need for substance use treatment, as well as the systemic inequity that exists for peer workers seeking substance use support. Kelly, who recently re-initiated using, explained the impact of nonstandard work arrangements. She did not receive substance use support through her employer. As such, she personally navigated and paid for treatment: “I now have credit card debt up the ying-yang… pay that off and we don’t even know what’s going on with [future job] at this point” (Kelly). Evidence of paying treatment after ‘relapse due to work’ was particularly concerning with regard to the time peer workers needed to take off to attend treatment. Furthermore, peer workers’ uncertain future work and taking time off to attend treatment was financially burdensome.    Given that peer workers reported relapsing specifically because of work conditions, these inequities were problematic. Kelly later reflected on these circumstances, criticizing the lack of access to substance use supports:   125 It would be important when dealing with peers, that peers have a benefit where if they need to go to treatment, if they’re abstinent when they start but maybe they relapse due to, you know, life situation or even the work is very triggering… if somebody is either presently or abstinent that if the work is triggering and people are using more often or they’re abstinent and the work triggers and they start using again, that there needs to be some type of support for them…, if you’re working for, take a six-month contract or something like that. Although that would make sense as well because it doesn’t take long for people to relapse and their lives to become unmanageable… And what is their obligation has been my question as well to somebody that’s hired. I mean, maybe they need to have a clause in advance of those things... there might be some type of support for that or something. (Kelly)  Whether employers were obligated to offer substance use supports to peer workers was questioned. As she pointed out, peer workers voiced a vulnerability to negative consequences on substance use, such as increased exposure, trauma and susceptibility to re-initiating use. Without substance use supports, however, peer workers needed to manage, seek, and pay for help on their own. 5.4.5 Peer worker roles as therapeutic  While such formal substance use supports were not readily available, participants’ narratives reinforced how their social network was a main source for support for them. Social support for substance use was particularly evident among participants who worked in peer-based organizations. If I tell them I need something they might go out and buy it for me. But then they, the drug user, might make me sit with them and have coffee with them for a couple hours, just to show me that I don’t need it. And then, you know, they feel good ‘cause I don’t do the drugs, and I just bought them a free hit for the night, you know. So I find, like, peers are really helpful for me too. (Emma)  Working with other PWUD, Emma this social network consisting of PWUD at work for support. Simply being around others was the support they needed: “loneliness is a big part of why I use. So when I’m here I don’t” (Melissa). This quote alludes to the access to a social network as well   126 as the purpose found in peer work. It also highlighted the potential impact of working in isolation – which, as was described in the previous chapter – was often evident in peer work. Several others described the sense of purpose they found in their work and how their community helped them not use. Participants described peer work supportive in that it was “therapeutic,” (Emma) particularly in peer-based organizations where the social distancing of peer workers was less apparent. A man who worked in a peer-based organization explained: I find the work to be, like, a lot of times I don’t use the word “recovery” but I find it to be, like, almost like a therapy program. Like, it’s satisfying… it’s what drives me… I’m making things better… it’s almost like a recovery program for me or something like that. But it’s also, like, to me seeing recovery not just as an individual recovery, it’s like, community-wide recovery. Like, we’re trying to recover our communities in a sense, right. And making, improving them and making them safer and better and healthier and stuff like that for, you know, people. (Peter)  Seeing the work benefits on the community gave this participant a deep sense of purpose and meaning, which positively impacted his substance use and wellbeing. Others also reported the positive impact of peer work on their lives and substance use. One woman described: I noticed a huge change in my mental health and how I was feeling. Because giving back and then socializing again and getting normalized with a sober headspace and being able to do so in such a low-barrier area was just really therapeutic for me. And I think that’s what’s kept me clean this whole time. (Emma)  As this quote indicated, peer work enabled stability and social integration in their lives that was linked to a reduction in substance use. Similarly, Melissa talked at length about how peer work “changed [her] life […] Because I just feel like, how can I put it? I just feel like I’m not just a drug addict, and that I’m just not, like, just a nobody. I feel important. I really do. And I feel loved. I really do. It’s genuine” (Melissa). The life changes described were both personal and social. These sentiments were reinforced by the participants who described their introduction into peer work during a transitional period in their life, such as recent release from prison, and how peer work supported their self-esteem, social integration, and stability.    127 5.5 Summary  The analysis in this chapter builds on the previous, Chapter 4, to show how the organization of peer workers’ roles and work conditions are actually experienced. I illustrated some of the demands peer workers face and how they cope with these demands in light of their unsupported roles. Many negative consequences of their work conditions and structural inequities, such as burnout and re-initiating substance use, were attributable to the unsupported and demanding nature of their jobs. In this examination, I illuminated some positive aspects related to peer work, such as the potential social benefits of peer work, as well as, the industriousness and initiative peer workers’ took to meet the needs of their community. However, the strengths and benefits of peer work appeared to be tenuous given its organization and support. These findings underscore the consequences of peer work that is conditioned by systems of inequity. Next, in Chapter Six, I build from these examinations to study some larger, overarching structures that create, maintain, and reinforce these systems.       128 6 Chapter Six: Peer Labor Market and Economic Insecurity  6.1 Introduction  In this final analytic chapter, I build from the previous two by focusing on how peer work is produced and operated via labor market and economic mechanisms. Specifically, I will explore the structural disadvantages and oppression constructed and reproduced in labor markets, as well as the exacerbation of peer workers’ economic insecurity. Peer workers’ interactions with government assistance programs are also explored here in relation to their economic insecurity, precarious work conditions, and labor market conditions.  The chapter is organized into three analytic categories: 1) construction of the peer labor market, 2) insecurity and constraints on choice; 3) peer work and income assistance. Collectively, these findings demonstrate the structural production and systemic reinforcement of oppression, including the considerable challenges posed to peer workers regarding choice and agency in the labor market, and the ways that these conditions produce and reinforce their economic insecurity.  6.2 Construction of the peer labor market  As detailed in Chapter Three, labor markets are arenas “in which workers exchange their labor power in return for wages, status and other job rewards” (Kalleberg & Sorensen, 1979, p. 351). Dual market theories posit that labor market segments can be differentiated as primary and secondary sectors which are characteristically different in terms of the type of work done, work conditions, and workers within them, with primary sector jobs offering good working conditions whereas secondary sector work offering that which is precarious, insecure, and poorly paid (Kalleberg & Sorensen, 1979). Such theories of segmented labor markets were suggestive of the   129 labor market in which peer workers navigated and worked, illuminating several key features of inequities and oppressive conditions produced through the construction of the labor market. The themes detailed in this section which related to the labor market include: 1) labor market segmentation; 2) labor market discrimination; 3) job marketability; 4) labor market strategies. 6.2.1 Labor market segmentation and segregation  Participants’ narratives revealed a labor market that was constructed through a process of stratifying workers into hierarchical segments or sectors. Participants’ narratives illustrated a tiered labor market in their descriptions of labor market “spheres,” “worlds,” or “levels.” They talked about differences in the type of work and job conditions between them, as well as the people and opportunities. For instance, participants’ descriptions suggested peer work was a subordinate or marginal sector: “low level” (Shauna); “it’s the layman level, you know” (Josh). These descriptions depicted a hierarchical difference between peer workers, “a low-tier worker”(Craig) and “educated business-like professionals up there” (Jackie). In combination with the differences between groups of workers, participants’ commented on the different types of work available to them. They attributed stable employment, fair wages, and job growth to the primary sector from which they experienced exclusion; whereas precarious work conditions, with nonstandard work arrangements, low wages, lack of job growth, and job insecurity, were available and accessible to peer workers in the secondary sector.  Segmenting peer work and segregating peer workers into a separate sector occurred as a result of social stratification based on group difference that structurally produced inequities in the labor market. Participants’ narratives depicted a dual labor market differentiated by conditions, workers, and jobs which operated in a way that allowed some people into the primary sector while keeping others out. Participants explained that PWUD “don’t have an entry way into   130 the real, into the legit employment sphere” (Carla). Evidently, peer workers’ exclusion from primary sector work segregated them to relatively more precarious and marginal jobs in the secondary sector, or they risked not working at all. As I will explain in the next two subthemes, the way labor market segmentation separated and positioned peer workers into a subordinate sector of the labor market, segregating them here, appeared to be the result of two related and reinforcing mechanisms related to market immobility – labor market discrimination and job marketability. Labor market discrimination  Labor market discrimination occurs when workers are denied jobs within occupations or across markets on the basis of their social grouping rather than capability (Das, 2013). Substance use history appeared to be a main factor that provoked such discrimination in peer work. Being known as a ‘peer’ or PWUD, workers’ expertise related to substance use was identified, and subsequently subjected to and judged by negative stereotypes or stigma over their actual skills and expertise. These judgements often took precedence over their job skills, which appeared to segregate them to menial work. For instance, one man explained being constrained to doing menial work: “Because I was a heroin addict. Because I don’t have no fucking teeth… He’s a piece of shit junkie, looks like shit, has no teeth. So he can do this” (Craig). Being labeled with negative stereotypes or stigmatized identities, peer workers described experiencing status loss in the labor market which led to unequal outcomes. The little opportunity peer workers’ had to move between sectors or access jobs and other forms of discrimination were related to being labeled a PWUD. They explained the differences in pay between peer workers and other staff, noting: “almost always the people using [drugs and/or alcohol] are the ones who are getting paid these stipends. And the staff are non-users” (Peter). In this way, workers and the   131 opportunities offered them in peer engagement contexts appeared to be divided along social lines which discriminated against peer workers due to their substance use history. Participants’ also talked about the stereotypes about PWUD in the labor market and being grouped into a homogenous whole, rather than recognizing the entire spectrum of skills and abilities that they offered. They talked about being put into a “box” which limited peer workers to whatever jobs fit this social identity. The peer workers’ constrained job choice was captured by a participant who explained its relation to the stigmatization of the word ‘peer’: [I’m] stuck in a box where I can’t access legitimate work at this point because I’m publicly known as someone who causes trouble and uses drugs. It’s because there’s this perception that if you have the word ‘peer’ on your resume, you’re never going to get a job… except as a peer, right. (Carla)  This quote describes how people were labeled as a PWUD or ‘peer’ in the labor market and segregated to “peer jobs” regardless of what capabilities workers offered. The peer title seemed to be synonymous with a drug use history in the labor market, thereby excluding these individuals from the primary sector and segregating them to the secondary sector.  People who currently used substances found it especially challenging to find work in the labor market relative to abstinent peer workers, reinforcing the notion that labor market discrimination was based on substance use. As one participant reflected: “I think we’re more than capable. I just don’t think that people really have invested or looked at it through that lens…if you’re still using somehow you’re not an expert? But if you quit you are?” (Shauna). As this quote demonstrates, current substance use degraded individuals’ expertise based on moralized judgements of abstinence in the labor market which systemically reinforced the marginalization of PWUD and stigmatization of substance use.  As such, some participants spoke about the dilemma of whether to disclose their substance use history and become constrained to the secondary sector or risk complete labor   132 market exclusion. Participants talked about the decision to disclose their substance use history within the labor market and the consequences of this decision. They also made observations that others (people who do not publicly disclose a substance use history) moved more freely in the labor market, underscoring the differentiation of peer workers that was associated with their substance use history. I could not get a good job. So there is, it’s the equivalent to a witch hunt. People that, there’s people that do a lot of drugs, but they won’t admit it and they pretend they don’t. And they’ll look and they’ll get in with the other people and look down on these junkies. (Vivian)  As described in this quote, peer workers’ known substance use experience had marginalizing effects in the labor market. Yet, identifying as a person with substance use experience seemed to give people access to the labor market (albeit it being a secondary sector) in which they historically experienced exclusion. Their labor market inclusion simultaneously appeared to constrain them to a secondary or subordinate sector. These processes suggested that labor market discrimination was a mechanism of inclusion and exclusion by identifying as a PWUD. Job marketability  The production and reinforcement of labor market segmentation and segregation was also associated with participants’ job marketability across sectors. The mechanisms that constrained peer workers’ mobility were mainly a consequence of the differences in the distribution of achieved characteristics (i.e. education, skills, knowledge) demanded by or marketed to employers in the different sectors, and differences in the distribution of marketable characteristics between groups. Many described the challenges in crossing over into the primary sector from their disadvantages in acquired capabilities, including formal education. Participants’ descriptions illuminated how these inequities were structurally produced and reinforced,   133 particularly relating to the constrained development, transferability, and marketing their capabilities that was tied to their socioeconomic status and organization of peer work. First, participants’ narratives highlighted the educational inequality that systematically stratified the labor market, limiting them to the secondary sector. Without a formal education, many felt limited in their job mobility or prospects in the labor market. Quotes attributed their limited job mobility to a lack of education. For instance, one participant said: “in the professional sector, they’ve gone to school for years” (Randall) and another explained: “they didn’t hire people that didn’t have a formal education” (Shauna). In this way, formal education appeared to be a mechanism of structural oppression; a way to marginalize peer workers and screen them out of the primary sector. There were exceptions, however. Some participants reported a formal educational background yet were limited in their labor market mobility. For them, it appeared that their known substance use history limited their job choices– underscoring the relation and influence of stigma and discrimination in the labor market.  Another part of the challenge peer workers’ faced was developing marketable job skills that were applicable across sectors. Their disadvantage appeared to be associated with the structural organization of peer work. Precarious work dimensions, which were distinctly characteristic of peer work conditions, made it challenging for workers to build a unified and transferable skillset. For instance, the infrequent and inconsistent nature of the work often did not support job growth and a cohesive skillset developed over time. Peer workers’ in standard work arrangements also described poor job growth opportunities, such as training, as well as limited alternative job options. So, while peer workers’ attempted to improve their skills and knowledge, the opportunity to build a marketable skillset seemed limited without mechanisms that supported   134 job growth and training. This limitation underscored the lack of organizational or role support that was suggested in Chapter Four. Finally, participants’ described challenges they faced in communicating job skills to employers within the labor market. Some struggled to describe and convey their skills and knowledge in normative and translatable ways, like through a CV or resume. Others expressed concern about how or if employers understood their roles or their value in the labor market. A quote from one woman demonstrated these concerns: It’s [peer work is] very hard to define, and it’s very hard to, certainly impossible to quantify. And I’m also not very good at self-promotion... I’m very bad at keeping track of what I do. I do some writing. I do this and that. I mean, I forget all these different things. They don’t fit together well. I’m not on a career track. (Carla)  Participants’ were unsure of if or how their skills could be utilized across sectors. As such, navigating the labor market and marketing themselves within it seemed challenging as they struggled with conveying or identifying the application of their skills across sectors. 6.2.2 Labor market strategies  The construction of the labor market appeared to provoke particular labor market strategies among peer workers. Given the challenges peer workers’ faced in the labor market and precarious nature of their jobs, participants described spending a significant amount of time thinking about and looking for future work. Volunteering was a main labor market strategy that participants’ described. Volunteer peer work encompassed that which was paid and unpaid; paid volunteer work was regularly linked to cash-based stipends. Volunteering for little or no pay for weeks, months, or years appeared to grant peer workers internal access to jobs based on their proximity and visibility to opportunities and employers. In doing so, unpaid or low paying work seemed to be normalized as a way to gain access to future, stable, or higher paying jobs.   135 However, this strategy appeared to reinforce oppressive and exploitative work conditions, as employers seemed to routinely rely on volunteer peer workers as a primary source of labor.  A second labor market strategy described by participants was accessing work by word-of-mouth. This strategy was especially evident as there were no instances of participants finding work through job advertisements; instead, participants became aware or opportunities from people they knew. This word-of-mouth strategy seemed to limit peer workers’ opportunities and reinforce labor market segregation and power inequities. Relying on word-of-mouth, limited peer workers’ to whatever jobs were available or known through their social or professional networks, rather than seeking the work they wanted. Also, the lack of widely advertised job opportunities appeared to give unfair advantages and opportunities to peer workers in close proximity to employers, or those who knew others connected to that work; thus, systematically excluding less connected PWUD from engaging in peer work. Labor market strategies based on proximity and connections to employers underscored that job opportunities were less about the acknowledgement of peer workers’ exceptional capabilities and more about established relationships. The avenues by which peer workers’ accessed jobs seemed to reinforce the subjective and discretionary power of employers – particularly those in gatekeeping situations (Chapter Four). While finding work through word-of-mouth is not an uncommon strategy in the labor market more broadly, the reliance on these relationships among peer workers in the secondary sector appeared to systematically reproduce inequities. This strategy emphasized the need to maintain positive relationships with employers or risk being shut out of the labor market altogether. Participants’ were acutely aware of the need to maintain these positive relationships. By systematizing job access through word-of-mouth emphasized the need for peer workers to ensure their behaviors and social demeanor made them   136 likeable to employers, which depreciated their actual job suitability and skills in the labor market.  6.3 Insecurity and constraints on choice  In this section, I build upon the backdrop of the labor market in which peer workers are segregated to a secondary labor sector marked by precarious work conditions. Labor market conditions were challenging given many participants’ positionality within it, combined with their financial insecurity. These factors collectively produced conditions for inequity and seemed to constrain peer workers’ capacity to exercise choice and agency within a prescriptive labor market. Below, I examine the structural production of peer workers’ labor market and economic insecurity, and the ways in which these collectively disadvantaged and constrained their choices. Two related subthemes are explored here, including 1) labor market inequity and 2) economic insecurity and low pay.  6.3.1 Labor market inequity  Peer workers’ insecurity in the labor market seemed to partly be due to the supply and demand of workers in the labor market. The balance of workers and vacant jobs in a sector of segmented labor markets can greatly determine who has power and control over its conditions (Loveridge & Mok, 2012). Participants portrayed a crowded work sector produced by an excess of unemployed PWUD competing for scarce job opportunities within it. Several participants described this volume of PWUD as a “pool” of people seeking work: “the pool of them [available peer workers] is a mile wide and an inch deep” (Donald), portraying a reserve of workers waiting on the periphery of the market. One reason for this density of workers seemed to   137 be from the segregation of an unemployed population who were systemically constrained to a relatively small, segmented sector. The supply and demand conditions of the peer labor sector appeared to create an imbalance of bargaining power between workers and employers. As captured by one participant, “peers [were] treated like a disposable labor force or something” (Carla), speaking to the precariousness of peer work existing within an ethos of worker expendability. These attitudes reflected the apparent labor market power dynamics which favored employers who controlled work and pay conditions. Such dynamics seemed to influence peer workers’ compliance considering their replaceability if they asked questions or became resistant. Participants’ narratives spoke to these dynamics: “[employer] can make the argument: fuck you guys, we’ll go down the block. We’ll get a hundred more. And that’s probably a legitimate argument from their point of view. Because it’s true” (Craig). In other words, the ability to replace or fill their informal positions with people from the “pool” of available peer workers disproportionately skewed the power to favor employers. As such, they seemed to control the few jobs and resources available to peer workers in the labor market. In light of the segmented labor market, the crowded peer sector limited worker capacity to choose their jobs freely and shape their work conditions. Some participants critiqued their work and pay conditions, but also appeared to accept and remain in them given their constrained ability to enact agency. Many expressed feeling powerless in these structural circumstances by recounting difficult decisions of whether to accept low paying, precarious, and exploitative work or go without. For instance, one man reported ridicule and physical intimidation by an employer. Yet, he was reluctant to quit due to his lack of other job options. He explained: “I quit after, I think, I lasted 18 months. I don’t know how I lasted that long. I’m a resilient character. And I   138 just didn’t have any other opportunities” (Donald). This experience reflected the reluctance in leaving poor work conditions that many participants’ described which was linked to their lack of other work opportunities. Peer workers’ lack of choice systematically constrained them having to often accept precarious, low paying, or marginal work conditions. 6.3.2 Economic insecurity and low pay  Peer workers’ experiences of poverty intersected with their labor market insecurity in ways that challenged their capacity to exercise agency or control. Participants’ regularly described experiences of poverty and financial insecurity. They shared experiences of struggling to meet their basic needs, including housing and food. Income from peer work provided some financial support. Participants with children, partners, or pets especially relied on this income. Others accentuated their need to find paid work to meet personal substance use needs. The financial insecurity of peers, therefore, seemed to augment the need to find and keep paid work. The impact of any income was magnified by peer workers’ experiences of poverty and struggle to meet their basic needs. Consequently, their need to earn income seemed to make some participants vulnerable to tolerating or accepting poor work conditions. For instance, some explained: “when people are really down they don’t ask for much. Twenty bucks is a lot… when you’re hard up you’ll take what you’re given” (Donald). Peer workers capacity to choose freely in the labor market under these conditions was compromised given their severe economic need. Wages below provincial minimum standards were attractive to some who reported challenges in meeting their basic needs.  Peer workers’ need for paid employment therefore suggested a vulnerability to tolerating poor work conditions, thus perpetuating oppressive work and pay standards. Exploitative work appeared to be an interplay between peer workers’ economic insecurity, asymmetrical power   139 structures, and labor market conditions, where peer workers were compelled to accepting low paying and marginal work. These conditions were advantageous to employers by facilitating power inequities that worked in favor of employers’ interests. Participants described peer workers as a source of “cheap labor” (Donald) in the labor market given their wages and knowledge that peer workers’ would accept low wages and poor work conditions because of their economic need and labor market inequity.  Indeed, participants often reported pay under minimum wage and sometimes as low as $3.00 per hour, although many were unpaid altogether. Peer workers’ low wages were deflating for some and contributed to a sense of stigmatization and devaluing due to their social position. Participants’ explained: “sure, the [non-peer] program workers make, like, 23 bucks an hour, you’re doing the exact same work and you’re making 10 or 15 if you’re lucky” (Donald). Another discussed the distinction between “’I did all this shit and now I’m making a whole bunch of money because of it.’ I mean, that’s a lot less stigmatizing than being, like, ‘I did all this shit and I got a $5.00 stipend for it’” (Peter). In this way, low wages were associated with the negative and oppressive impacts of being identified as a PWUD within institutions. Other participants’ linked their low wages to the notion that organizations maximized the reach of their budgets by hiring peer workers as a low-cost labor source who accepted such low wages. Many quotes expressed these exploitative conditions, including from a man who talked about employers’ interests in taking advantage of peer workers’ economic insecurity to retain control over the labor market: When [employer] fucking finds out from another agency that their employees are getting paid twice as much in [one region] than they make in [another region], in a more expensive environment, I imagine the [employer] won’t like me very much…. in [one region] they poverty pimp…[they have] such a high amount of people who are so desperate that you could just go out to [one street] and you could find five times the amount of people who would work for $7 to $10 an hour. ‘Cause they’re unemployable.   140 They’re not employable at other places. So why would you pay them value in the job they do? (Craig)  This quote links how crowded labor sector conditions contributed to peer workers’ economic insecurity, as well as how they could be leveraged by employers to retain power and perpetuate low pay norms. Others echoed the idea of “poverty pimping” that Craig spoke of, speaking to the marginalized and powerless positionality of peer workers, as well as the unequal distribution of resources in the labor market: I mean, cycling very, very, you know, poor and marginalized and oppressed groups of people, like, meat through a grinder… not only are they poverty pimping their clients. But they’re doing it to their low, quote/unquote, low level, but the ones that are with the most work on the frontline. (Shauna)  This participant emphasized the leveraging of peer workers’ economic and market insecurity to meet the interests of public health at the expense of “poor and marginalized and oppressed” peer workers. In the context of the opioid crisis, with strained resources and funding, peer workers’ appeared to be positioned to fill temporary, overworked, underpaid, and noncommittal jobs as a way to meet provisional public health needs.   6.4 Peer work and income assistance  The construction of the labor market, as well as the structurally-based inequities created from labor market conditions, seemed to heighten peers’ economic insecurity. Peer workers’ labor market and economic insecurity, as well as the lack of options for consistent work, similarly was linked to a reliance on other sources of income. A predominant source of income for peer workers’ was income assistance10. Most participants (n=11) were currently enrolled in these programs. The annual dollar amount individuals earned from paid work under their specific  10 Income assistance is defined as financial support from the provincial government to help individuals and their families. Income assistance has also been referred to as ‘welfare’ and ‘State benefits.’   141 program was determined by Income Exemption Limit policies (Government of British Columbia, n.d.). However, earning income above these limits required recipients to pay back income and could jeopardize their eligibility if their income was seen as sufficient by the government (Government of British Columbia, n.d.). Enrolment in income assistance programs and these limits appeared to be key factors that exacerbated many participants’ vulnerability to inequity. The relationships between peer work and income assistance programs – the final analytic theme of this chapter and dissertation – contributed not only to how peer workers’ experienced this vulnerability but also to the way in which peer work was organized and operationalized. The subthemes I explore below relate to 1) fear of reporting income; 2) cash-based work; 3) income assistance dependence.  6.4.1 Fear of reporting income  While BC’s Income Exemption Limit policies claim to promote the reintegration of recipients into the workforce (Government of British Columbia, n.d.), the interviews with peer workers revealed that they were a major driver of peer workers’ experiences of marginalization and economic insecurity. The imposed income ceiling created a deep fear of meeting or exceeding their limits considering the potential repercussions, including losing this source of income altogether. As one woman explained:  It’s [peer work has] helped a little bit with some income, right. Which I’m afraid to tell anybody about... Because, you know, they could change it one month and next month they’re going to find out that I’m making a little bit extra money and then they’re going to take it all… they [peers] should be allowed to make a little bit extra money. Who can live on $600 bucks? (Debra)  In light of the poverty many faced, income assistance was a major source of income that subsidized their daily living, yet was extremely precarious. Receiving wages from peer work instilled a fear their income assistance income may be jeopardized. This fear was exacerbated by   142 their economic insecurity and lack of other opportunities. Some spoke about this relationship, noting that it was “not worth it” to report their income: Well, fuck. It’s not just the welfare. It’s the benefits. It’s the medical stuff. It’s the prescription costs. All that stuff adds up. And it’s losing it could mean, you know, losing all that for a short-term job that might not be permanent is not worth it. (Peter)  Earning near or above exemption limits was therefore seen as risky as it impacted any financial gain from these programs. However, as I will show, such fear also appeared to influence how much and what type of work to accept.   The interviews also suggested that the fear of reporting peer work earnings was rooted in a history of structural violence. Participants’ shared stories of entrapment and bureaucratic errors in the income assistance program that had catastrophic impacts on their lives from losing eligibility. Participants’ numerous accounts of hostile interactions with government employees gave the sense that workers and policies were uncompassionate, obstructive, and penalizing. Some described that peer workers were “so helpless or alone…’cause they’re so oppressed, and, you know, they’re oppressed by the system. […] it’s fucking cold the way those people [government workers] operate, and close the door on you and leave you vulnerable” (Michael). Examples of impacts from losing income assistance highlighted their economic insecurity, including evictions, interpersonal violence, or having to engage in other types of income generation activities such as sex work. Several participants also reported not knowing how to report their earnings, and not knowing where to get this information. This unknowingness magnified their fear of facing or interacting with the government. 6.4.2 Cash-based work   Given participants’ fears of losing their benefits and interacting with the government, many regularly avoided making contact with income assistance systems altogether. As such,   143 there was an inclination towards work arrangements that concealed their income or enabled their avoidance from interacting with government systems. Cash-based work was an opportunity to do both. Participants emphasized cash as “way more accommodating” (Jackie) or that it made “a huge difference being able to get cash” (Emma) because of the barriers peer workers faced in other forms of compensation (i.e. cheque), including needing to report this income to the government. Instead, participants’ experiences suggested that cash was obscured through organizational financial systems – framed as a loophole that did not require formal identification of the earner (peer worker) and seemed to grant discretion to the earner of whether or not to report it. In this way, cash-based work arrangements were a main work system that subsidized peer workers’ income assistance without immediately impacting it or having to interact with the government.  The suggested appeal of these arrangements for peer workers’ reinforced cash-based pay systems institutionally – pay systems that were a key mechanism that exacerbated inequities and oppression related to peers’ work arrangements. For instance, some participants felt indebted towards their employers for facilitating “a cover up…an inside job” (Debra) that concealed their income. The secrecy of these pay systems furthered the powerlessness of peer workers as employers controlled arrangements and negated the bargaining power of peer workers. The hidden and secret dynamics of cash-based pay appeared to require peer workers’ compliance; alternatively, they risked reporting their income or losing their jobs. A quote by one participant captured this structural vulnerability: That’s one of the reasons I think they get away [with pay inequity], if they pay you daily out in cash, they tend to say that we can only pay you this much a day, otherwise we have to, you know, or we can pay you every two weeks or whatever… the excuse that you’re getting paid cash daily so we can pay you less - that has to go. (Peter)    144 As this quote suggests, cash-based work socialized peer workers’ into accepting the low paying, marginal, and powerless positions tied to cash-based systems. Peer workers’ chose between weathering the labor market and accepting non-cash work (thus risking income assistance loss), or accepting work and pay inequity. Both choices appeared to leave peer workers’ economically marginalized and structurally oppressed. 6.4.3 Dependence on income assistance  In light of peer workers’ economic and labor market insecurity, combined with a fear of benefit loss and contact with the government, participants’ experiences often reflected a “precarity trap” (Standing, 2000, p. 172) which appeared to be structural and “self-reinforcing… which cause[d] poverty to persist” (Azariadis & Stachurski, p. 326). This cycle of self-reinforcing systems that constrained peer workers to low pay and poor work conditions was evident in the multiple reinforcing mechanisms and consequences that interacted and reinforced each other to perpetuate such conditions. For instance, some peer workers lowered their hours because of the earnings ceiling, thereby reinforcing their reliance on precarious work. They were aware that at a particular threshold (usually the participants’ income exemption limit), increasing wages or hours produced declining financial returns to labor; therefore, it was disincentivizing to work more. Some participants’ reported reducing their time or wages to stay under these limits, and others described a reliance on informal work out of fear of their income ceiling. For instance: “We make such shitty money that, like, if we had an eight-hour day wage of 23 an hour, that would infringe on my disability. But 4 hours a day, it kind of works out, right” (Craig), and “because if you have someone who’s on disability, can only earn so much money, maybe they could do it on a part-time basis instead” (Kelly). Participants’ income thresholds created a reliance on nonstandard work while simultaneously creating a dependence on state benefits to   145 support any economic stability. This reinforcing relationship between precarious work and state benefits structurally imposed a ‘trap’ considering the high barriers to gaining stable and fair work in the labor market to establish independence from the state.  The reinforcing nature of income assistance programs and peer workers job conditions highlights that facing poverty for many was a structural condition and not a choice. Instead, they were constrained to jobs with precarious work conditions and relying on state benefits, or faced further marginalization and financial insecurity. Being oppressed through these systems was disempowering and marginalizing for participants, as exemplified in one quote:  It’s not helping anyone to say, well, you’re on disability, so that’s, or you have social housing, so that should be fine. It’s, like, no, actually everyone should have a decent place to live and make, and be able to earn a decent amount, a sufficient income. (Carla)  As this quote indicates, some people expressed their desire for social inclusion and independence from the state. Peer workers’ indicated their desire for opportunities to engage in formal and consistent employment to escape state benefits and precarious work. For some, this desire to not rely on income assistance related to social inclusion and self-esteem. One woman talked about her desire to access more stable work, explaining: …so that you wouldn’t have to rely everything on welfare. You’d feel so much better. It’d be so good. It just helps people, don’t want to be on welfare. It’s horrible. It’s embarrassing, and it just makes you feel like shit. (Melissa)  While people talked about the desire to be untethered from the government, they also expressed concern that they could ever be financially secure and stable.  The desire to work in full-time standard employment was not shared by everyone. Part of their reluctance related to individuals’ physical disabilities that restricted their work – some of which related to on-the-job injuries. Others expressed mental health barriers to full-time or standard employment so relied on low-barrier, casual work. For instance, a participant shared:   146 “I’m just introducing myself back into the world right now. And I have too many panic attacks to be in [store], but I’m working towards being able to be around people so that I can get myself into a workplace again” (Emma). Cash-based work facilitated peer workers’ reintegration to the workforce if they were not ready full-time jobs. Others similarly expressed that their work conditions accommodated the precariousness in their lives. In other words, while their work conditions did not alleviate their reliance on state benefits, they were adaptable to people’s life circumstances.  6.5 Summary  In this chapter, I presented a critical analysis of the themes related to the structure of the labor market, its conditions, and how these structures influence peer workers given their economic insecurity. I illustrated the construction of the labor market and how peer workers experience this structure in challenging and inequitable ways. Economic systems reproduced in the labor market maintained and reproduced discrimination, powerlessness, and exploitation that appeared to compromise peer workers’ economic security, agency, and social or labor market inclusion. The segregation of peer workers to a secondary sector constrained them to participate in systems of inequity or risk not working at all. The oppressive consequences of being segregated to a crowded labor sector exacerbated their economic insecurity, yet perpetuated precarious low paying work which peer workers’ came to rely on. This chapter as a whole has demonstrated the complexities and interrelatedness between an inequitable labor market, oppressive economic systems, and the economic fragility of peer workers that appeared to both produce and reinforce the marginalization, powerlessness, and exploitation of peer workers.     147 7 Chapter Seven: Discussion  7.1 Introduction  In this final chapter, I discuss the study findings collectively and place the findings into the context of the current literature. I start with an integrated summary of the study to orient the reader to the major themes and findings. I then discuss four main contributions to the literature by considering how the findings add to, refute, and support the current knowledge base, as well as the implications of these findings. From this discussion, policy, practice, and research recommendations follow. I end with some considerations of study strengths and limitations, followed by a brief conclusion.   7.2 Summary of main findings  My study explored peer workers’ descriptions of their experiences of work to gain an understanding of the structural organization and conditions of peer work, and how these factors influence how workers are enabled or constrained in the context of peer engagement. Findings illustrated the structural organization of peer work and how the positioning of workers within these structures was oppressive (research question #1). Nonstandard work arrangements were a key dimension of peer work that structurally positioned peer workers at a distance from organizations; thereby economically, politically, and socially marginalizing peer workers. This positioning produced power inequities, particularly relative to gatekeepers, that undermined peer workers’ ability to enact agency in their roles and choose their work conditions. Labor market conditions further perpetuated inequities. For instance, in a crowded and segregated labor sector, peer workers faced exploitative conditions given their socioeconomic insecurity and lack of choice.    148 Organizations, including those that were peer-based, along with Health Authorities, government groups, and harm reduction agencies, played a central role in the organization of peer work, as well as the operationalization and support of peer roles. Organizations appeared to determin the operation of peer work, including the parameters and arrangements of the work. Peer workers’ efforts were regularly unrecognized as a legitimate role and were often unpaid and/or poorly paid. It was often unclear as to how organizations utilized peer workers’ roles. At times, their roles did not draw on their lived experience, or employers did not utilize their unique skills or expertise altogether. Peer workers’ roles were also not supported in ways that enabled role agency or effectiveness, such as a lack of role expectations and the training necessary to carry out duties or tasks. I also explored a magnitude of demands and disadvantages peer workers’ reported facing in the context of their everyday working lives (research question #2). Peer workers’ expressed intense pressures to perform and emotional stress from the work. They regularly experienced trauma and structural harms. Precarious work conditions, as well as their close personal connection with the community they worked with, exacerbated peer workers’ stress. Although peer workers provided unwavering support to their community, supports available to peer workers, including role, social, and substance use supports, were generally lacking. Peer workers’ expressed signs of burnout, including a deep sense of grief, exhaustion, and overwhelm which linked to their work conditions. Peer workers’ also reported sometimes using substances or isolating themselves from other people and the work to help cope with their work demands. These consequences appeared to be a clear articulation of how peer work structurally negated and negatively influenced peer workers’ mental health, wellbeing, and ability to continue to perform in their roles.    149 Finally, in examining the challenges and inequities peer workers’ face in the context of their everyday working lives; findings illustrate a complex constellation of interlocking and interrelated social, economic, and political systems which perpetuated these inequities (research question #3). Findings revealed a complex “structural story” (Young, 2001, p. 16) of interlocking and interrelated factors that structurally constrained and disadvantaged peer workers. Precarious work arrangements negated peer workers’ efforts and limited their opportunities. For instance, informal work arrangements systematically constrained peer workers’ access to role and social supports. As well, their low, insecure, and informal pay systems reinforced their economic insecurity, while also appearing to render peer workers’ reliant on cash-based pay systems and social assistance benefits. Their work conditions also seemed to make it difficult to access job advancement opportunities and to build a marketable skillset, thus disadvantaging peer workers in their marketability and job mobility outside of a segmented and segregated labor sector. Findings also suggest that systems of inequity impacting peer work may reinforce each other. For example, cash-based work was accessible only through nonstandard work arrangements and negated worker protections, pay standards, or employer accountability, while also reinforcing their reliance on such systems. Together, I have shown that peer workers’ difficult working conditions were not the result of any single individual or system, but influenced by a range of systems that structurally peer workers’ in oppressive and inequitable ways.  7.3 Contribution and implications  The findings of this study make several significant contributions to the literature. Four main contributions and their implications are discussed: 1) emotionally demanding and unsupported roles; 2) the operationalization of peer work; 3) precarious peer work; 4) the   150 structural organization of peer work. Following the discussion, I will provide recommendations, study limitations, and conclusions.  7.3.1 Emotionally demanding and unsupported roles  One of the main findings of this study was how highly demanding yet unsupported peer work is. Peer workers’ role demands included the distressing nature of the work, pressures to perform, and incessancy of the work. Several factors related to the positionality of peer workers contributed to the magnitude of the demands they faced. For instance, peer workers’ close personal connections to the community accentuated their work stress. Similar to other studies, role tensions articulated by participants related to their co-occurring roles as community members, clients, and peer workers (Moran et al. , 2013; Tookey et al., 2018; Wagner et al., 2014; Wilson et al., 2018). Peer workers’ faced other related challenges associated with the overlap between their personal and work lives, including the difficulty they faced in escaping their work demands. These findings support others who demonstrate the added stress and burden on peer workers’ roles from living and working in the same community, including running into friends (True et al., 2017). However, peer workers’ in my study explained that employers might unfairly leverage their overlapping positionality between work and community to meet their interests at the expense of the worker. Furthermore, this work was not formally recognized or paid by employers. My study findings additionally suggest that peer workers’ role tensions and demands are linked primarily to work inequities related to poorly communicated expectations from employers – thus, reframes the source of stress outside of individual workers and draws the attention to peer work conditions. Previous research with peer workers suggests peer workers’ may cut ties from their community given the stress these connections produce (Wagner et al., 2014). Peer workers’ in   151 my study similarly appeared to isolate from others and dissociate from the work given the high degree of work stress. Given that for many peer workers’, their community was their sole source of social support, evidence of disconnecting from the community is concerning. For individuals’ who must disconnect from their community to cope, access to appropriate social supports may especially be needed. In the context of an opioid overdose crisis, peer workers’ roles on the frontlines were particularly stressful. Other research positioned in this context, especially recently, recognizes the propensity towards burnout among frontline peer workers, underscoring the emotional stress and trauma experienced among those regularly witnessing and responding to overdoses (Bardwell, Fleming, et al., 2018; Bardwell, Kerr, et al., 2018; Kennedy et al., 2019; Wallace et al., 2018). These studies similarly underscore the need for better social and emotional support to be available for workers in light of the burdens and stress peer workers faced under their work conditions (Bardwell, Fleming, et al., 2018; Bardwell, Kerr, et al., 2018; Kennedy et al., 2019; Wallace et al., 2018). My study makes significant contributions to this body of work by demonstrating inequities in the supports available to peer workers. Peer workers’ reported that supports were available to non-peer first responders, but were lacking in peer work. As Shearer et al. (2018) note in their commentary: “in contrast to those available to employed individuals, there is a stark lack of resources and supports, including remuneration and workplace supports, for marginalized community members who shoulder the responsibility of early overdose intervention, as peer workers receiving modest stipends or unpaid volunteers” (p. 2). Among the supports that exist in harm reduction work, peer workers found them either inaccessible or inappropriate. Findings also suggest that this inequity was tied to the positioning and framing of peer workers’ roles. In combination with suggestions from others who underscore the lack of   152 genuinely recognizing peer workers’ as first responders (Wallace et al., 2018; Woo, 2019), my findings reinforce the importance of offering them more formally recognized employment opportunities and legitimizing peer workers’ roles as first responders institutionally. Some scholars call for the immediate provision of social supports in overdose response roles which may ameliorate burnout among this workforce (Kennedy et al., 2019; Bardwell et al., 2018; Wallace et al., 2018; Walker et al., 2014). My study emphasized a gap in dedicated or formalized space and time to debrief and is also the first to suggest that the type of social supports available may matter. For instance, formal social supports, such as counselors without lived experience of peer work, were inappropriate and inaccessible. Peer workers’ also strongly suggested that lived experience was a crucial component of a supportive work environment, as demonstrated among those in peer-based organizations who reported the community to be therapeutic. These findings may help guide the approach to designing social and other supports for future peer engagement projects. Considering the lack of supports available to peer workers, it was not surprising to learn some participants used substances as a strategy to cope with work demands. These findings support others who have found that PWUDs increase their substance use and that this increase is related to coping with work stress (Draus et al., 2010), and also research which suggests peer workers’ substance use might not change or decrease (Bardwell et al., 2018). However, my study provides a more nuanced look into a range of reasons why peer workers may use, not use, or change their frequency of use within the context of peer engagement work settings. For instance, it was unexpected to learn that some peer workers perceived current substance use experience to be a condition of peer work and that these assumptions influenced their substance use behavior. To my knowledge, this finding was not reported in the literature. Nonetheless, this finding was   153 one of the many diverse patterns or expressions of substance use among the sample. Some used substances as a way to function or cope with work demands, whereas others described the workplace as therapeutic and supportive of their decision not to use substances. These findings suggest that substance use may not invariably be a consequence of peer workers’ roles or the work itself. Rather, it may be associated with the stressful and unsupported conditions in it.  For instance, communication about substance use and other expectations were absent, making it unclear as to whether employers’ expected or allowed peer workers to use substances in the context of peer work. Similar to findings in my study, researchers suggest that the work culture make it difficult for peer workers’ to disclose their substance use, clarify use expectations, and reach out for support (Wilson et al., 2018). Such communication around substance use and available supports may also be crucial in light of other findings which show peer workers may be worried about losing their jobs due to their substance use (Wilson et al., 2018). Peer workers in my study suggested that work conditions may instigate ‘relapse due to work,’ yet given their informal work arrangements did not offer support for substance use treatment or therapies. These findings indicate that in an occupation predicated on current or past substance use experience, access to substance use supports was inequitable. 7.3.2 Operationalizing peer roles  In some ways, the operationalization of peer workers’ roles demonstrates how the organization of peer work lays the foundation for the way in which participation proceeds within large institutions. Whiteford and Hocking (2011) suggest that if people are “denied the means through which they can participate… social inclusion as ends becomes purely aspirational. This is because, without the means, the structural vehicles as shaped by policy dictates, inclusion through participation cannot realistically be achieved” (p. 201). These suggestions are reinforced   154 by findings in my study and others, given that peer workers’ ability to enact agency and use their strengths in their roles appeared to be constrained by the utilization and understanding of peer workers’ roles organizationally. Similar to my study, Belle-Isle (2016) found that constrained agency among peer workers’ in drug policymaking settings was related to inconsistent role support in pay, hiring, and the work among BC Health Authorities. Findings from my study may urge others to emphasize employment equity, therefore promoting a meaningful foundation for how participation efforts proceed. Previous research suggests that the sheer presence of peer workers’ in the workplace indicates that peer engagement is empowering and inclusive (Bardwell, Kerr, et al., 2018; Kennedy et al., 2019). However, although involving peer workers can provide recognition of the unique expertise of PWUD and enable these individuals to enhance their skillsets and employability (Kennedy et al., 2019; Bardwell et al., 2018), the apparent lack of resources and attention to the implementation of peer engagement in practice underscores the taken-for-granted nature of inequity may be overlooked (Taylor, 1990). My study suggests, in contrast to previous work, that while the intention of participation may indicate these principles, a lack of understanding for meaningful participation and equity may undermine the intention to be inclusive and empowering. For example, by exploring the operationalization, utilization, and support of peer work within organizations, peer workers’ were often denied the means through which they could effectively participate, or their efforts could be effectively utilized, became evident. Peer workers’ regularly expressed difficulty participating given the lack of communication about their roles and responsibilities, as well as a lack of training opportunities. Peer workers’ positioned in roles which did not recognize their efforts or utilize their unique skills or expertise suggested that   155 employers may not fully understand the value of peer workers’ roles or how to utilize them within the organization. These findings add to a small body of research showing employers and non-peer co-workers often do not understand what peer workers do or the value they add (Belle-Isle, 2016; Coupland & Maher, 2005; Goodhew et al., 2018; King, 2011; Patterson et al., 2009). However, my study suggests that the lack of understanding of peer workers’ roles undermines their role effectiveness, and may produce the perception that individuals are ineffective, rather than the organization of the work itself.  The undermining of peer workers’ roles was concerning given the potential for peer engagement initiatives to challenge or reinforce negative discourses regarding PWUD in the workplace. Previous research demonstrates that a lack of understanding of peer workers’ roles among employers, peer workers, and non-peer coworkers has resulted in the perpetuation of negative stereotypes and unacceptance of peer workers (Belle-Isle, 2016; Coupland & Maher, 2005; Goodhew et al., 2018; King, 2011; Patterson et al., 2009). As mentioned, previous studies suggest that non-peer co-workers may view peer workers as “unstable,” “manipulative,” “untrustworthy,” “vulnerable,” and “lacking capacity to participate” (Bryant, et al., 2008; Goodhew et al., 2018; King, 2011; Patterson et al., 2009). The lack of employer or organizational understanding of peer workers’ role utility may perpetuate views of them as ineffective or unvalued, particularly if they continue to be unsupported. Previous scholars demonstrate similar consequences from inconsistent and informal work arrangements. For instance, Standing (2011) suggests that informal workers are often compelled to account for their time and efforts to challenge ‘lazy’ discourses about their social identities, which can be difficult in work arrangements that do not enable agency, effectiveness, or opportunity. However, in my study, organizations which did not acknowledge or enable peer workers’ efforts, aspirations, and   156 activities, seemed to undercut the value of peer work because of a lack of recognition of their efforts or skills. The finding that peer workers’ roles were inconsistently operationalized and may be poorly understood was somewhat unexpected given recent efforts to promote equity in peer engagement (Greer et al., 2018) and various models and frameworks for supporting peer work (Balian & White, 2010; Closson et al., 2016; Greer & Buxton, 2018; “Peer framework for health-focused peer positions in the Downtown East Side,” 2016). My findings suggest that peer work may not be standardized routinely within organizations. Participants’ descriptions indicated that peer engagement was organized on an ad-hoc basis – findings reflected in a previous evaluation of peer engagement in BC from 2010-2014 (Greer et al., 2016). In this study, I found that efforts to standardize and promote equity in peer engagement contexts may not be improving and that this gap may be associated with a lack of accountability or resources for practice standards. 7.3.3 Precarious peer work  The finding that peer work was precarious contributes to a large body of research in labor studies which demonstrates precarious work conditions and determinants amongst a range of marginalized groups globally (Benach et al., 2014; Bujold & Fournier, 2008; Kalleberg & Vallas, 2017; Vosko, 2006). Precarious work conditions among migrants and minority ethnic workers, people with disabilities, and youth are particularly evident (Benach et al., 2014). Like these groups, peer workers’ positioned in precarious work conditions reinforced their socioeconomic marginalization. To my knowledge, only one study has situated PWUD (in this study youth who use drugs) in precarious labor conditions (not in the context of peer work or engagement settings) (Morissette, Maranda, & Lessard, 2006). Similar to my study, Morissette et al. (2006) found precarious work conditions push PWUD towards marginalization, yet were   157 constrained here because of their economic insecurity. They also suggest that formative elements within the trajectories of youths’ lives may mitigate the harms of precarious work and that some of these factors become embedded through the structural organization of the work (Morissette et al., 2006). This study emphasized the role of management styles, selective recruitment procedures, and flexibility practices that “trap” or confine youth who use drugs to precarious work conditions. Findings from my study reinforce this notion, indicating that peer workers may find it extremely challenging to accept anything but precarious work arrangements given their labor market and economic insecurity, in combination with the oppressive features of precarious work conditions. Authors note that the subjective experiences of those experiencing precarity from work is rarely captured in studies of precarious work conditions (Campbell & Price, 2016). Among peer workers, precariousness was evident in the layering and compounding feelings of insecurity, uncertainty, and instability – precarity that extended into other domains of participants’ lives. For instance, among participants’ who reported economic, food, and housing insecurity, it was evident that their precarious work conditions negatively impacted their emotional, social, and economic wellbeing, particularly by establishing economic and social stability despite their concerted efforts.  In this study, my findings diverge, in some ways, from studies which claim all work of the precarious type are inherently constraining (Standing, 2012, 2014b). Researchers almost ubiquitously frame full-time employment as the ‘pinnacle’ of work relations (Benach & Muntaner, 2007), and make broad calls to eradicate work of the precarious kind (Standing, 2014b). In examining how precarious work impacted peer workers, it was evident that peer workers’ experiences in nonstandard and standard work conditions were diverse and not   158 ubiquitously negative or positive, respectively. For some, precarious work conditions introduced an added level of uncertainty and instability; for others, they fit well within their current circumstances. For instance, some participants wanted the security of full-time employment, whereas others preferred the flexibility of intermittent work, which they could adapt to their life circumstances. The evident diversity in how peer workers’ experienced these conditions stand in contrast to the framing of precarious work conditions in the literature. These findings support others who argue that most people require or desire formal employment arrangements. For instance, Campbell and Price (2016) note that “the literature continues to struggle with the implications of precarious work… the temptation to leap freely from precarious work to precarious lives (or precarious lives) should be resisted” (p. 336).  These conceptualizations of precarity are significant as they underscore the interaction of contextual factors in peer work. For instance, Campbell and Price (2016) suggest that training, access to an alternative source of income, access to alternative career paths, and stage of life mediate people’s experiences of work. Similar to my study, researchers found that life circumstances, including lack of social integration, and access to alternative income and career paths, exacerbated their work precarity. These findings are similar to other research conducted by Campbell and Price (2010), who qualitatively demonstrated how the relatively secure life circumstances of high school students resulted in hypo-precarity compared to the hyper-precarity of migrant workers whose lives were profoundly insecure. Similar to what my findings suggest, researchers showed that social integration and access to alternative economic pathways may mitigate people’s experience of precariousness (Campbell and Price, 2010). Other researchers suggest powerlessness and domination can magnify experiences of precarity (Morissette et al., 2006). Therefore, rather than necessarily addressing the dimensions of work, emphasis may be   159 placed on how these conditions constrain workers or magnify their experiences of precarity within the everyday context of their work. In addition to contributions to literature in labor studies, the notion that peer work was precarious adds to the harm reduction literature. Previous studies in harm reduction have not explicitly examined or characterized peer work conditions from a labor perspective. Similar to recommendations by Morisette et al. (2009), my study indicated that PWUD are a diverse workforce who may be structurally vulnerable to precarious work conditions and may require a contextualized approach that is sensitive to equity. They suggest that employers need insight into workers’ structural constraints of the job market, the diverse situations of workers, support, and de-stigmatization efforts. Results from my study highlighted some of these factors that may promote equity standards in peer work across a range of work preferences which may apply to harm reduction and peer engagement settings.  Scholars in the harm reduction literature repeatedly suggest that better efforts should be made to offering ‘low barrier’ work to PWUD and peer workers, including arrangements that are informal, periodic, and immediately compensated (often with cash) (Bardwell et al., 2018; Boyd et al., 2018; Richardson et al., 2012). These work conditions are, as findings showed, defined by precarious dimensions. Although calls for low-barrier work may be attempting to address inequities, without understanding the structural basis for inequities – findings discussed more in the next section – they may only heighten peer workers’ socioeconomic insecurity and marginalization. Instead, the diversity of experiences and preferences of peer workers may sensitize employers to the importance of offering a range of standardized employment options (including those that are cash-based) that focus on equity, rather than broad calls for the distribution of particular arrangements (e.g., cash-based work for all).   160 7.3.4 The structural organization of peer work  A critical aspect of this study was understanding how the organization of peer work positioned and constrained peer workers within systems of inequity and oppression. No single factor or person that was the cause of the perpetuation of inequitable work and pay in the context of peer work. Instead, I illustrated a constellation of structures and systems which were similar to what Young (2001) refers to Marilyn Frye’s (1983) concept of oppression as “wires in [a] cage; seen alone they reveal nothing about people’s freedom or well-being. Seen together as spaced and reinforcing, however, they explain a great deal” (p. 16). Similarly, a myriad of interrelated, interlocking, and complex systems shaped peer work, and these systems reinforced each other in ways that constrained the agency and choice of peer workers. By examining how these systems are shaped and perpetuated through the organization and operation of peer work, it was evident how structurally oppressive and inequitable peer work can be.  Due to the lack of research on peer work conditions from a critical labor perspective, studies have routinely called for a more in-depth and critical analysis of the systems and structures that shape experiences of work among PWUD (Boyd et al., 2018; Richardson et al., 2013). Most studies had not yet unraveled and analyzed the structural organization of peer work and systems implicated in pay and work inequity in peer engagement. As such, my findings significantly expand and add to research which has pointed to a structural basis for pay and work inequities among PWUD (Boyd et al., 2018; Bardwell et al., 2018). My study offers a contribution both in the richness of the data collected and analyzed, as well as illuminating the structural basis for pay and work inequities in peer engagement contexts. The structural nature of oppression in peer work challenges individualistic notions of worker agency and outcomes. Scholars note that without understanding the structural basis for   161 inequities “can contribute to rectifying the misdiagnosis, blame, and maltreatment that accompany the experience of poverty and cultural subordination” (Quesada et al., 2011, p. 340). Participants in my study demonstrated their agency in the ways they navigated systems and structures, met the needs of the community, questioned their work conditions, strategized to find stable employment, and made ends meet despite persistent barriers to employment. They also consistently demonstrated concerted efforts to participate in the labor market, aspired to perform well, and sought recognition and value for their efforts. However, their social position severely constrained peer workers’ through systems of inequity, thus negating their strengths in the labor market. In this study, I found that labor market outcomes may be based on employment arrangements, including precarious work, that may remove some barriers to engage yet severely limit their choice, opportunity, and trajectories to being autonomous and empowered agents. Similar to findings in my study, research shows that discrimination, stigma, and the criminalization of drugs can be embedded in work cultures, norms, and policies (Boyd et al., 2018; Richardson et al., 2013; Salmon et al., 2010). For instance, Boyd et al. (2018) similarly suggest that productivity standards and individual capacities to engage or move within the labor market are limited (Boyd et al., 2018). These analyses, like mine, took a critical perspective to understand individuals’ agency in the context of work or participation with PWUD (Boyd et al., 2018; Quesada et al., 2011; Salmon et al., 2010), therefore urging others to shift the focus from individual workers’ outcomes to understanding how work conditions and systems of oppression may shape these outcomes. Young (2001) suggests that oppression becomes embedded through a complex constellation of factors which produce a “structural story” of systems and mechanisms that shape conditions and experiences. This “structural story” in my study was about the structural   162 organization of peer work, such as peer workers’ distanced positioning, a segregated labor sector, and income assistance policies. These structural features not only constrained peer workers’ ability to enact agency, but also systemically disadvantaged them in ways that further reinforced their positionality and the social, economic, and political systems that produced inequities. Although my study analyzed several complex and interlocking systems of oppression and equity, they were likely non-exhaustive. Future studies have an opportunity to gather more breadth of these systems and subsequently map how they are connected.  My findings additionally suggest that peer engagement contexts are not impervious to systems of inequities and oppression simply because they fall under the banner of ‘peer engagement.’ Peer work did not operate within a vacuum, impermeable to stigma, discrimination, and other forms of oppression that historically plague many PWUD in work contexts. Rather, discrimination based on substance use history persisted in peer engagement and harm reduction. One mechanism in particular which contributed to labor market discrimination and inequities in peer work was the ongoing institutionalization of the term ‘peer’. Findings revealed several ways in which this label was used to differentiate and disadvantage workers in both the workplace and the labor market. This finding supports concerns raised by PWUD nearly five years prior to my study (Canadian Association of People Who Use Drugs, 2014), and raises questions about the appropriation and ongoing institutionalization of the word ‘peer’ within harm reduction organizations. Findings such as these may be of vital importance for future initiatives in the organization of peer work systems which may be susceptible to perpetuating similar systems of inequity and oppression – systems which may undermine the goals of peer engagement altogether.   163 The demonstrated structural challenges of enacting agency in peer workers’ roles, organizations, and the labor market were examples of the oppressive forces that shape inequity and peer work environments. Moreover, while this structural orientation to understanding peer work illuminated some of the ways that arrangements organized peer work and its intersections with oppression, equity, poverty, and harm, it is the structural basis of these harms that render them invisible within in everyday life (Young, 1990; Taylor, 2013). What is challenging in addressing structural oppression is the systemic changes that need to occur (Taylor, 2013). Young (1990) purports that structural oppression cannot change by replacing staff or individuals, by allocating a certain number of paid employment opportunities within organizations, or by merely a commitment to being better. Instead, scholars suggest the importance of making inequities and the sources of them visible, therefore making them actionable (Pauly, MacKinnon, & Varcoe, 2009; Taylor, 2013). In this respect, the findings from my study illuminate several sources of inequity in peer work and, by doing so, it may be possible suggest several achievable initiatives to promote equitable actions and accountability in future peer engagement.  7.4 Recommendations  The preceding section, I presented a discussion of findings relative to the current literature. From this examination, I make several recommendations. Below, I offer several practical and actionable recommendations that may promote equity for future initiatives by shaping conditions influencing patterns, systems, and arrangements of work in peer engagement. Recommendations include those related to: 1) organizational strategies, 2) work practices, and 3) research initiatives.     164 7.4.1 Organizational strategies  The apparent underutilization of peer roles and lack of formal recognition for their efforts was identified in my research, suggesting a lack of organizational commitment and understanding. As such, an opportunity exists for enhancing commitment, support, and capacity for peer work within organizations. Recommendations are as follows: Forward-facing organizational commitment to peer work. Peer workers’ descriptions of their work within organizations demonstrated a need for organizations to commit to the greater inclusion of peer workers institutionally. Establishing a forward facing organizational commitment for peer work may systemically enhance the value and legitimacy of peer work, and produce more significant opportunities for inclusion. Education within organizations about peer workers’ roles. Organizational mandates for peer engagement and work may reflect a commitment to inclusion; nevertheless, understanding the practice of peer work itself may be essential for supporting participatory initiatives. Education is needed which speaks to peer workers’ roles, including the added benefit of their skills and knowledge and its fit organizationally can enhance organizational understanding for peer roles and thus, promote role support, legitimacy, and recognition.  Making inequity visible. In addition to education about peer workers’ roles, there is an opportunity to educate people within organizations’ about the structural determinants of work equity and their link to poverty, social inclusion, and wellness. Illuminating the root causes of inequities make them visible institutionally, and may promote the opportunity to redress systems that may inadvertently reproduce inequities through the structural organization of peer work. Awareness of these systems of inequity could diminish the distanced nature of peer work, create   165 more diverse pay and work arrangements, promote formal work arrangements, dismantle gatekeeper roles, and broaden PWUDs’ professional networks and opportunities.  7.4.2 Work practices    One of the main findings of this study was how the lack of role supports undermined the effective utilization and recognition of peer workers’ roles. For one, peer workers lacked role clarity, expectations, and training. The expressed need for greater access and availability of formalized social supports for peer work was also undeniable. Based on these findings, several operational strategies for supporting this work are needed. Work participation. One way to promote work equity in the operationalization of peer work is through participation in the oversight and design of the work itself. Participants’ emphasized the importance of peer-based supports, mentors, and voice in their work conditions. Starting from the planning stages of engagement, people with lived experience of substance use and/or peer work could be hired to design, implement, and support other workers’ roles to ensure their needs are addressed. Work participation among PWUD may additionally shed light on potential context-specific barriers and challenges, including the use of the terms ‘peer’ and ‘peer engagement,’ which could potentially alleviate or disrupt systems of inequity.  Communicating expectations. There is an apparent need for better and regular in-person communication about performance and role expectations, as well as expectations about hours and schedules, pay, individual duties and how these differ from others, substance use and its supports, social supports, boundaries, training, benefits, vacation time, travel time and other expenses, and access administration support. Such role support may foster more work agency, autonomy, and role effectiveness.   166  Role and employment development. Supporting employment progression could include creating job ladders with multiple options, rungs, and pathways for advancement built within and outside of organizations. A defined career progression may additionally build a career identity for peer work, which was lacking in the context of my study. Specific options could include giving workers the option and right to convert their positions into permanent jobs after a certain time period or creating mechanisms that convert contracts into fixed employment under certain conditions. Training within positions is also essential yet severely lacking in peer work. Greater access to training may promote peer workers’ role capacity and promote job mobility within and across sectors, thus mitigating labor market segregation.   Emotional and social supports. Gaps in social supports included time, space, and a process to debrief for people in formal and informal work arrangements. Participants’ also indicated that social support (such as EAPs) was inappropriate given the lack of lived experience among counselors and therefore were viewed as inaccessible. Instead, peer workers’ found comfort in each other, and the peer community was their primary source of emotional support. However, indications of community exhaustion and burnout due to the high degree of work demands and the opioid overdose crisis put into question the sustainability of the community as an ongoing source of support for peer workers. As such, to promote the sustainability and wellbeing of the peer workforce and community, greater attention to social supports available and accessible to peer workers is essential.  7.5 Research directions  There are a number of limitations to this research. First, the perspectives of supervisors or employers who currently organize and manage peer engagement are unknown. As such, there is   167 an opportunity to gather these perspectives, triangulate findings, and gain an understanding of policies and processes which peer workers may not have exposure to given their positionality. Qualitative data has not yet been collected from this perspective, yet is needed to assess organizations’ understanding of peer engagement and the translation of peer engagement principles into work processes. Quantitative surveys with employers and other staff in peer work contexts were collected from other jurisdictions (Patterson et al., 2009), but are unknown in Canada. Qualitative and quantitative data could reveal different aspects and nuances into the structural organization of peer work, including some of the economic and political systems that may constrain its operation. These studies may also provide critical information about organizational gaps and resources needed to support peer work equity adequately. Second, my study suggests that the economic marginalization and perpetuation of precarious work arrangements was apparent among economically insecure individuals who were receiving state benefits. These programs appear to perpetuate precarious work systems for peer workers. Further research is needed on BC’s income assistance policies and their influence on employment systems and trajectories for PWUD.  Third, participants’ descriptions of peer work suggested that the organization played a primary role in shaping and supporting peer work in my study. I am mindful that there may be profound differences in systems of inequities between organizations. I did not aim to compare organizational differences across agencies, such as peer-based organizations, Health Authorities, governments, or other non-profit organizations. My study demonstrated differences in the understanding, utilization, organization, and support for peer work. Considering that peer-based organizations have peer work participation built into their structure (i.e. peer-based leadership), these organizations may mitigate several systems of inequity inherently. Future research is   168 needed that examines the structural benefits and barriers within peer-based organizations and how these systems differ from other agencies. An examination of how these organizations operate under structural constraints imposed by broader economic and social systems that impact hiring and employment practices is needed. In doing so, context-specific strategies for specific organizational structures may develop. Finally, several authors who adopt a critical perspective to exploring equity issues affecting marginalized groups underscore the importance of adopting an intersectional lens to their methodology (Hankivsky et al., 2010; Herk, Smith, & Andrew, 2011; Pauly, Shahram, Dang, Marcellus, & MacDonald, 2017; Smye, Browne, Varcoe, & Josewski, 2011). By applying an intersectional perspective, future research can explore peer workers’ multiple social locations and their influence on their work experiences. Peer workers’ occupied multiple groups, including their social positioning according to age, ethnicity, disability, and class. While I acknowledge that each of these intersecting systems of oppression existed in the context of peer workers’ experiences, my study did not specifically examine how these systems mutually influenced their positionality and oppression through an intersectionality lens (Crenshaw, 1991). Instead, my findings indicate the powerful influence of peer workers’ social grouping as a PWUD. In doing so, findings indicated that peer workers’ positionality was primarily shaped by their social grouping as a PWUD yet was closely related to other socially constructed systems of inequity – particularly systems of social class (e.g. differences socially constructed between rich and poor). These findings indicate that intersecting social and economic positioning of PWUD are central in how they experience systems of inequity and oppression. Future research could similarly take a critical lens to qualitative data to illustrate intersecting systems of class, gender, race, and age   169 were relevant in the context of peer work to expose how different systems of oppression socially organize groups and contribute to inequities. 7.6 Research limitations  My study and its findings have some limitations. During data collection, I noted that several participants were well known in the harm reduction community and referred to the study for their leadership in activism within their community. I was mindful of this trend, so aimed to capture more diverse perspectives by recruiting people who were recently introduced to peer work or were volunteers. This approach better captured and enabled me to contrast the everyday work perspective of peer workers who were not as vocal as others. I also noted that many participants knew each other despite concerted efforts to diversify the sample across settings and jurisdictions. Observing this closeness was a finding in itself: peer networks appeared to be small, tight, and connected, pivoting around access points, gatekeepers, and organizations. Because of the tight-knit community of peer workers, I was aware that many participants attended the same meetings, or worked in the same settings. While these perspectives were reinforcing and triangulated insights into the same context, it was also a sampling limitation. Participants’ language may reflect a common discourse rather than the diversity across communities. Perspectives of PWUD who could not access peer work or denied access from unknown barriers were likely excluded due to the inclusion criteria of people with peer work experience. Others suggest that the failure to include population subgroups in research is a matter of social justice by perpetuating power imbalances and recommending actions that exclude members of society (Bungay, Oliffe, & Atchison, 2016). Bungay et al. (2016) underscore the use of a social justice lens to explicitly strategize in addressing the underrepresentation of subgroups in using purposive sampling. Future research may benefit from targeting hidden community   170 members, such as those terminated from peer work or more alienated geographically or socially, who are represented in the current sample.   In the interviews and analysis, I aimed to provide a balanced approach to eliciting positive, negative, and neutral experiences. I could not overlook the consistent and explicit expressions of oppression demonstrated by participants in each interview. I was also mindful of the stories participants’ wanted to tell. Thus, this dissertation focuses mainly on the disempowering and constraining work conditions to ensure I captured and shared the significance of these narratives. Descriptions of the oppression of peer workers were not always balanced with examples of resistance and agency. I recognize that in focusing on findings that explore systems of inequity and oppression may depict peer workers as passive victims within a dysfunctional system. On the contrary, I attempted to  adequately portray peer workers as active members that can resist, strategize, respond, and adapt to these conditions, and recognize the ways systems impede their resistance. Nonetheless, it is undeniable that systems of inequity and oppression shape the lived experiences of peer workers in powerful ways. More research is needed that better captures and examines peer workers’ experiences of resistance within work contexts.  Due to the interpretive nature of this study, other analyses of the data may result in different findings, although the volume and richness of the data illustrating patterns and themes combined with transparency efforts speak to the trustworthiness of the current findings. The interpretive nature of the study was one reason why I did not conduct formal member checking with the community, although I found informal conversations with the community throughout the study immensely beneficial in terms of enhancing the validity and reliability. My approach to community validation balanced my interpretive approach with community views by meeting   171 with peer workers and other staff throughout the study to discuss my research design and findings as the study unfolded. This strategy allowed me to gather feedback on the study, findings, and patterns. I found this approach to produce a deep understanding of what was happening in the data, as well as pointed me to new areas of inquiry in subsequent interviews. This study was not participatory; I did not engage participants or other peer workers in the analysis. The interpretations of the data are my own, but are not the only way that the data could be analyzed, interpreted, and presented.   It is worth noting limitations in contextualizing the current findings. The study procedures took place in a context and the time period that likely shaped participants’ experiences and my interpretations of them. Since I collected data, the opioid crisis has not abated – an additional eighteen months of witnessing death and trauma of their community in an unsupported work environment. These eighteen months have undoubtedly taken a toll on peer workers and the entire community. In reflecting on the findings of this study and talking to peer workers since collecting data, I anticipate that the findings may be different in some ways if the data were collected today. The impacts of trauma and other work demands may be much more profound. Participants’ may also have different opinions or perceptions of their work environments, coworkers, employers, and themselves. I would expect several participants not to be working any longer because of the impact of the crisis. Coping strategies, as well as instances of resistance to oppression, may be more varied and pronounced. Collectively, I am mindful that the current results may mute the cumulative impact peer workers’ work conditions over the past eighteen months. It may be beneficial for future research to capture peer workers opinions and experiences in frontline work today to demonstrate if the context is shifting over time and how the crisis impacts workers.   172 In this study, I aimed to gather a diverse set of views from peer workers across health authorities, some of whom resided in rural communities. These participants’ indicated, in Chapter Five, that they often engaged in work in Vancouver but also worked in their local communities informally. I did not purposefully sample based on their peer work experiences in rural and urban areas, nor did I aim to analyze such differences between peers in these regions. However, findings indicate that there may be significant differences in peer work experiences between regions, such as the organization and operationalization of peer work, as well as the extent of stigma and discrimination experienced and its impact on peer workers in rural areas. This level of granularity to regional differences in peer work experiences was not applied in my research. Future studies are necessary to assess the needs and experiences of rural peer workers as well as differences between those in urban and rural areas. Finally, throughout this study, I was bound by the time and resources of my research. One of the central impacts of these limited resources was on knowledge translation during the study. I hoped to work more closely with PWUD throughout the study and to produce reports and manuscripts. Also, in studying the appalling work conditions and the toll they took on the community, I felt an enormous responsibility to share participants’ stories in a timely, applied, and effective manner. Moving forward, it is a priority to translate the findings to the community and organizations.   7.7 Conclusion   This study aimed to capture the lived experiences and perceptions of peer work among PWUD and to examine the systems and structures that shape these experiences. The qualitative accounts of peer workers’ experiences and descriptions of their work conditions illuminated   173 some of the structures and systems that impact the everyday experiences of peer workers. The findings show peer work was challenging, demanding, and constraining. Considering these findings within the participatory goals of peer engagement, it is concerning that peer work conditions may systematically produce and reinforce inequity and oppression. Mechanisms by which peer work was shaped may continue to undermine these goals if its conditions are marginalizing, disempowering, and exploitative. 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Journal of Political Philosophy, 9(1), 1–18.        198 Appendices   Appendix 1: Recruitment flier  Appendix 2: Interview guide  Appendix 3: Interview consent form   199 Appendix 1: Recruitment letter  Project Title: Experiences of pay in the context of peer work among people who use drugs in British Columbia  What is the purpose of this study? • We are interested in gain an understanding of the nature and scope of peer work • We want to hear about how the type of work peers do and if or how they been paid in that work • We hope to create payment recommendations and standards for peer work   What will I do to participate in the study? • Your participation will take approximately 90 minutes (1 ½ hours) of your time. • We will meet at a location that you are comfortable with, including the BC Centre for Disease Control, the Robert and Lily Lee Centre, or a quiet public place (like a park). • You will be asked questions (conversation style) about your experiences in doing peer work. We will talk for about an hour. • By ‘peer work’ we mean paid or unpaid work that is informed by your lived experience of substance use. For example, being an outreach worker, doing naloxone training, or informing on harm reduction programming or policy. • Your participation will not affect your employment, and our conversation will not be shared with your employer. • The interview will be audio-recorded for accuracy. • Your participation is completely voluntary and you can withdraw from the study at any time. • You will remain anonymous and your information will be kept confidential. • You will receive a $20 cash honorarium, public transit reimbursement, food, and access to information about peer work, even if you decide not to participate.   Who is eligible for the study? • Aged 16 years or older. • Speak English. • Categorize yourself as a ‘peer’. By ‘peer’ we mean someone with previous illegal substance use experience who uses that experience to inform your work (paid or unpaid work).  Interested? Please contact Alissa Greer. E-mail: name@email. Phone: XXX-XXX-XXXX.    200 Appendix 2: Interview guide  PEER INTERVIEW GUIDE Project Title: Experiences of pay in the context of peer work among people who use drugs in British Columbia  INTRODUCTION: Thank you for taking the time to talk with me today. First, let me tell you a bit more about this study and what were here to talk about. This study is looking at what it is like to work as a peer and get paid for that work. By ‘peer’ we mean people who have lived experience of substance use who use that experience to inform their professional work. When I say ‘work,’ I mean paid or unpaid (so employment or volunteer) efforts that you would consider ‘work’. Peer work can happen in different settings, such as in health or harm reduction service delivery or program development, community-based research, or policy or decision making tables. Examples of peer work would be people with lived experience who do street outreach, work in a harm reduction kiosk, do naloxone trainings, inform on substance use policy decisions, advise on research, or help design policies. We are especially interested in hearing if you’ve been paid for the work you have been doing, what the process of being paid has been like, and if paid work has impacted your life in any way. Also, when I say ‘pay’, it might mean different forms of compensation including money (by cash or cheque), gift cards, food, and other things, which maybe we’ll talk more about today. Do you have any questions about the aims of the study?  Great. So, I’ll ask you a series of questions so we can explore some of these things together. Sometimes I might ask you for more information. There are no right or wrong answers. Our conversation should last about an hour, but it could be a little bit more or a little bit less depending on how our conversation goes. If you need a break at any time just let me know. Or if you don’t feel like answering any questions, that’s ok too. Does that sound alright? Any questions about the interview before we begin?  SECTION 1: PEER WORK This first set of questions are about the work, paid or unpaid, that you do as a peer. For time sake, I’m going to ask you about up to three volunteer or work experiences that you have had over the past year. These experiences might have been mainly positive, mainly negative, or maybe you felt average about them. Again, there’s no right or wrong here. So, thinking about the work you have done as a peer, let’s first talk about the one that you think has impacted you the most or, the one that really sticks out. Have one in mind? [when ready, proceed to question #1 and 2]:  1. Can you tell me a little bit about your work you do as a peer? (Probes: What was title of your role? What were some of the main tasks or duties you did in that role? What were you responsible for in your role? What does a typical day look like to you? a. What sorts of things do you like doing in your role? What are some things you don’t like doing? Is there anything you wish you did instead? b. Do you feel like you were equipped with the skills you needed going into that role? If yes, what sort of skills do you think you used? If no, what skills do you think you needed?   201 c. Do you think that this work you did benefited from your lived experience of substance use at all? If so, how? Or, if not, why do you think this is? How do you use your lived experience? Can you give me an example? d. Are there any other experiences from the past, like different work experiences or skills you got from other jobs, that helped you in this role at all? If so, how?  2. Context of peer work:  a. Can you tell me a bit about how you got introduced into this role?  b. What is the setting or environment like where you work (prompt: Office? Outside? Type of organization)?  c. What are some of the other people you work with? (What is it like working with other people with lived experience/peers? What is it like working with other people who do not identify as peers? What is it like working with these people?)  d. Did you enjoy working there? What did you like/not like about it? What was it that made you like/not like working there? What would you change or stay the same?  3. Impact: What do you think it is about this one experience that stands out for you? How has the experience been for you overall? 4. Has the experience you’ve had working as a _____ at ________impact your life in any way? If yes, how (prompt: positive way at all? Negative way at all?)? If no, why?  a. Has your role impacted your health at all? How about your substance use? b. How about other people in your life? Did your work impact them at all?  5. Of the roles you have told me about, are there any main differences between these roles that stand out for you? (anything you like more/less about them)?   SECTION 2: PAYING PEERS This next set of questions I’m going to ask you is about being paid or compensated for the work you just told me about.  1. So, thinking about this role you just told me about, were you compensated for your time and effort? a. If yes: I was wondering if you could take me through the whole process of compensation. Can you tell me a bit about: how much you were compensated? How you were compensated? Who compensated you? When you were compensated? b. Was the way in which you are paid, so like how much you are paid, how, and when you were paid, communicated to you beforehand? If so, how? What was that experience like for you? c. Are you currently on government assistance like disability? Has your work you do as a peer impacted your assistance at all? If so, how? d. Did you face any barriers to compensation? If so, what were they? e. What about facilitators? Anything that positively contributed to this experience?  2. If no: what do you think are some of the reasons why you were not paid for your efforts?  a. Was this communicated to you beforehand? If so, how?    202 3. In your opinion, is the way in which peers are paid, so like cheque, cash, or gift card, impact people important? If so, how is it important? If not, why does this not make a difference?  3. Did the way in which you were paid impact the relationship between you and ______ (employer/organization) at all? Why do you think this is?  4. Is there anything in particular that stands out for you in this experience of getting paid (or not getting paid)? (prompt: the way in which it happened or the way in which you were treated or the way in which it impacted you or your life)  -------Repeat section 1&2 until up to three experiences discussed ------   PART 3: FUTURE RECOMMENDATIONS Now I’m going to ask you a few questions about what you think peer work and what the compensation for that work should look like moving forward.  1. Peer work: a. Is there anything in particular about the setting or circumstances of peer work that you would like to see improved? If yes, what would you like to see change? What would you like to see stay the same? b. What types of work would you be interested in doing in the future? What type of work would you like to see peers in general doing in the future?  2. Peer pay:  a. Say you could redesign the way peers are paid. Would you change anything? If yes, what would you change? What would you keep the same?  b. How do you think paying peers should look in the future? What is the number one thing that you think would make the biggest difference?  PART 4: DEMOGRAPHICS Before we wrap up, I’m going to ask you some very short, basic questions about yourself. Can you tell me: 1. How old you are? 2. What gender you identify with? 3. What ethnicity you identify with? 4. How long you have done peer work? 5. Where in BC do you usually work as a peer?  COMMENTS  1. Is there anything else you’d like to talk about or say today that we haven’t discussed?   Thank you so much!   203 Appendix 3: Interview consent form        Peer Interview Consent Form Project Title: Experiences of pay in the context of peer work among people who use drugs in British Columbia   Principle Investigator Dr. Jane Buxton  School of Population and Public Health, University British Columbia  Phone: XXX-XXX-XXXX   Co-Investigators Alissa Greer, PhD Candidate  Interdisciplinary Studies Graduate Program, University of British Columbia Phone: XXX-XXX-XXXX   Dr. Victoria Bungay  School of Nursing, University of British Columbia   Dr. Bernadette Pauly  School of Nursing, University of Victoria    Invitation to participate in research: You are being invited to participate in a research study. Participation is free and voluntary. Before you agree to participate in the study please take a moment to understand what the research involves. If there is information in this form that you do not understand or if you have questions about participating, please feel free to ask one of the researchers at any time. You may choose to not participate in this study or to not answer particular questions. You may leave at any time and still receive the honorarium.    What is this study all about? We want to know about experiences in peer work and getting paid, or not, for that work. We will ask you questions about these experiences, such as the type of work you have done, how you were paid or not, and how your work and pay has impacted your life.   What will happen if I agree to take part in the interview? If you agree to take part in this study, you will join an approximately 1-hour (60 minute) long interview with a researcher. The interview may be longer or shorter, depending on what you   204 discuss and how long you talk. The researcher will ask some questions about your experiences in peer work. We will ask you questions such as “can you tell me a time you were asked to be involved in project where you were asked to draw on your lived experience of substance use as a form of expertise?” or “can you tell me how much you have been paid for peer work in the past? Do you think what you were paid was fair?” You need only answer when you feel comfortable to share, and only need to share information that you’re comfortable sharing. All interviews will be tape-recorded. The tape recording is so we can re-listen to the audiotape to ‘analyze’ or compare and contrast what you said alongside the other audio tapes of interviews we have.   Are there any benefits to me for participating in the study? The results from this study may benefit you and other people who use drugs by providing recommendations on how to engage people who use drugs in peer work, and what the best way to pay them is. Hopefully, the results from this project will support fair compensation and standards for peers in work settings across the province.   We value your participation in the study and will give you $20 cash for your time. We will also provide some snacks, resources, and information about labor standards in the province, and can reimburse you for any public transportation you take to/from the interview. If you leave before the end of the interview you will still get these incentives.   Could this study be harmful to me in any way? We do not believe that this study will be harmful to you in any way. This study will not affect your employment in any way, and what we talk about in the interview will not be shared with your employers. The questions will be based on your general experience in peer work settings. You can choose not to answer any questions. We will make every effort to maintain confidentiality but, as in any study, we may not be able to guarantee absolute confidentiality. Your confidentiality will be kept within the limits of the law. By consenting, you have not waived any rights to legal recourse in the event of research-related harm.  Who will have access to what I talk about and what will happen to it? The academic investigators on the project (listed above) are Drs. Jane Buxton, Bernadette Pauly, Victoria Bungay, and Graduate Student Alissa Greer. The research team will use our conversation to write recommendations and payment standards for paying peers, and will be available on the BCCDC website. Results will also be written up in Alissa Greer’s doctoral dissertation and in publications. It will also be used to inform payment processes and standards at the BCCDC.   If you would like results of the study you can request a copy from the contacts listed on this form.   What happens to my information? We will not share any information about you outside the research team. Any names or identifying information (like locations or names of organizations) will be removed from the transcripts. If we need to use names, we will create pseudonyms. Your real name will never be used. The electronic tape recordings and files of our interview will be on a secure password protected computer at the BC Centre for Disease Control. Data will be kept for a minimum of 5   205 years after completion of the study and then destroyed. Any hard copies of the audio-files will be stored in a secure locked file cabinet at the BCCDC.   This study is voluntary:  It is ok if you don’t want to answer some of the questions. You have the right to choose if you want to participate in the study and you are free to stop at any point during the discussion. Withdrawal from this study will not affect your access to services.   Contact Information  If you have any questions or require further information about this study, please contact Dr. Jane Buxton at XXX-XXX-XXXX or Alissa Greer at XXX-XXX-XXXX.   If you have any concerns or complaints about your rights as a research participant and/or your experiences while participating in this study, contact the Research Participant Complaint Line in the UBC Office of Research Services at XXX-XXX-XXXX or if long distance e-mail or call toll free XXX-XXX-XXXX (Toll Free: XXX-XXX-XXXX”).  Thank you for your assistance. Please keep this information in case you have questions later and want to contact us.  


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