Working with the “hierarchy in the Underworld”: Insights for Communication Skills Training with Peer Educators

Peer education programs emphasize training in communication skills but provide little direction on training content. This research examines the specific strategies used by people who inject drugs (PWID) when engaging peers in education to promote safer injecting and to prevent the transmission of blood-borne viruses. People who inject drugs (PWID) participated in a series of three focus groups to develop peer education messages and strategies which they then trialed in their networks. Participants' strategies for peer education were profoundly shaped by concerns about not offending or challenging others' perceived social status. Some participants preferred only to influence others' injecting practice using nonverbal strategies, such as modeling safer practice. Although peer education may be based on the notion of a shared social status among PWID, these results demonstrate the heterogeneity of social relations existing within networks of PWID. PWID trained as peer educators require a repertoire of communication skills to be deployed in appropriate circumstances.