In total 340 unique individuals attended IS Team education workshops, including 157 (46%) women, 177 (52%) men, and 6 (2%) transgendered individuals. IS Team members who participated in qualitative interviews included 3 females and 5 males. The median age of IS Team members was 47.5 (range = 35–59 years). The IS Team included a mix of Caucasian and Aboriginal members as to reflect the demographic of the local drug using population. One of the nine IS Team members was not asked to participate because he withdrew from the team early in the development phase of this education campaign. Representative excerpts from the qualitative interviews are presented below in order to illustrate the central themes that emerged in the analysis. Considerable overlap was observed across thematic areas.
Format and content of IS Team educational workshops - ‘it taught the nitty gritty of what you’re doing’
IS Team facilitators described a number of aspects of this education campaign that contributed to their ability to communicate information about safer injecting practices while identifying and addressing the unsafe practices of workshop participants. Facilitators expressed that an important aspect of the curriculum was that it went beyond the mechanics of safe injection, to describe why each step is important, and the consequences that can arise from incorrect implementation.
That’s why our workshops were so successful, because it taught the nitty gritty of what you’re doing and what you’re doing wrong … tell ‘em why it’s not right you know, and make it so the right thing fits into their ritual. Not to stop doing it, but make it fit into their ritual. (Female Facilitator #1)
The participatory and interactive nature of these workshops was seen as a critical factor in engaging participants. This enabled discussion of the realities of individual’s injecting rituals, the context in which they use, and the strategies that can be implemented to improve injecting practices.
You could tell some people got really jazzed when they were talking about personal experiences and stuff. Which I thought was a really good thing … because people’s own experiences, that’s what it’s all about right? … Cause we’re talking about it from a, this is the way it should be, not necessarily the way it is, and they’re talking about it from the way it is. So I think it was really important. (Male Facilitator #2)
An example of a common barrier to enacting risk reduction practices frequently identified within workshops was the inability to access sterile cookers necessary to correctly prepare drugs for injection. IS Team facilitators emphasized the importance of always mixing and filtering drugs prior to injection, and a common solution they proposed was to carry a metal spoon or use the concaved bottom of a beverage can for mixing, while always being sure to disinfect the preparation surface with an alcohol swab.
Most facilitators reported that facilitating with two other IS Team members was a strength of the education format. Working in groups of three created structure among facilitators, while allowing them to educate based on their topics of expertise, and enhancing opportunities to incorporate stories with their explanations.
I was the more structured one and he was the more off the cuff type of guy. Like when questions came up and stuff he had more information because of his experience. (Male Facilitator #2)
The use of various forms of education materials and different teaching styles were described as major strengths of the campaign because it engaged a wide range of participants with different learning needs. It is notable that the images utilized were described as particularly useful for communicating the severity of the consequences of unsafe injecting, and assisted facilitators in maintaining their focus when interacting with workshop participants.
The shock value of the pictures and then being able to note how not to let that happen to yourself, it was really good … it also gave us something to focus on … if we got lost on something we could just turn to the pictures. (Female Facilitator #1)
Shared identity of facilitators and participants - ‘in the same sort of head space’
All IS Team facilitators expressed that their knowledge and experience as IDU fostered a sense of shared identity and equality with workshop participants, which encouraged trust and rapport. This also allowed them to present safer injecting information with examples and language that was appropriate and easy to understand.
The people that were facilitating it and the people that were the members, they’re more or less on the same level. So you could understand, [you] don’t have to ask questions or why they didn’t get that, you just know right. Cause you’re both in the same sort of head space, you’re street people right. (Male Facilitator #3)
Many facilitators described their familiarity with workshop participants as increasing their credibility and making participants more comfortable asking questions or sharing information.
I sound like I’m just talking with buddies cause I’m just sitting there talking to people that I know … And there’s the other part of it, I’m not at the front of the room because I’m more important than you, I’m just the one that’s doing most of the talking, but you guys kick in when you can cause you guys want answers as do we, and I’m trying to draw them out and get them to participate. (Male Facilitator #6)
Facilitators identified how having IDU as facilitators minimized power dynamics that frequently exist between educators and learners. Facilitators expressed that their approach differed from their previous experiences receiving safer injecting information.
We’re them, it’s not like we’re gonna preach to them … Most of them [formal educators] kind of seem older or else like they’re trying to talk at them, talk down to them. It’s more of a classroom type way they talk instead of talking like friends or drug users talk to each other, the same way we’re talking … You can pick up more that way cause you don’t feel like you’re being lectured to. (Male Facilitator #4)
Facilitator’s personal gains - ‘it was a really good experience for me’
IS Team facilitators articulated various personal gains from their involvement with the campaign, as most expressed that facilitating these workshops improved their overall confidence and public speaking skills. Facilitators also expressed that workshops enhanced interpersonal social skills and network connections, as well as changing their attitude towards dealing with other organizations and professionals.
I’d gotten into pretty much a mode where I’d just hang out by myself so I didn’t really talk to anybody. This … got me back on meeting people, and talking to people, and realizing the common ground with other people in the community. (Male Facilitator #7)
I have developed a more professional attitude when dealing with professionals. I’m more polite, courteous, well-spoken, time to listen. I’ll do everything but wear the tie and nametag. (Male Facilitator #6)
Facilitators also described the positive feelings they gained from the realization that they were making a difference by helping people to protect their health.
The idea of imparting knowledge to people that is hopefully going to do something positive for them, I mean, what’s better than that … Especially when you know there’s a need for it. … Like I said, when I first got into it, it was just for the financial thing, but once I got into it, knowing that you’re actually making a difference, that you might actually help someone or something, that’s a good feeling. I’ve never done that type of thing, so it was a really good experience for me. (Male Facilitator #2)
A few facilitators reported the added benefit of making changes to their own injecting practices based on information they learned through the development and implementation of the campaign. For example, facilitators reported using alcohol swabs and ties more consistently and avoiding the re-use of their own syringes.
Campaign impact - ‘it works … it’s better’
IS Team facilitators overwhelmingly felt that this campaign provided participants with valuable safer injecting information, some of which including information on prevention of bacterial infections and how to correctly prepare various drugs for injection, is not currently available anywhere else. Most facilitators articulated that educational workshops not only change injection practices, but also have the added benefit of connecting IDU with VANDU and other health services.
I hear it from people every day. Every day somebody comes up to me and says something. Oh, I tried this, I tried that. It works, it works, it’s better. Can I go to treatment? Where do I go to treatment? You know just questions that were all brought up from those workshops. And it brought a lot of people to VANDU. (Female Facilitator #1)
Although all IS Team facilitators spoke of the value of providing IDU with accurate information about preparation and administration of injections, they also emphasized numerous contextual barriers and challenges that can make injecting safely difficult. Most commonly, facilitators identified not having a safe place to inject and fear of the police as the predominant contextual factors that can make it difficult to implement safer injecting knowledge.
If people don’t have a home, if they don’t have a sterile place, if they’re forced to try to hide in a back alley, or in a bush, or some other place where they can’t be found cause they’re so scared of cops. How do you expect any part of that to be clean or safe? (Female Facilitator #8)
Given the limits of education in addressing contextual factors that perpetuate unsafe injecting, facilitators articulated a desire to expand and improve their activities to pursue broader change beyond education. Their suggestions predominately focused around opening a user-led facility and further expanding their outreach activities.
Just a separate spot off the VANDU property that people could come to get assisted injection and have a coffee, you know stuff like that … A safe [inhalation] site, a safe injection site, that’s not run by government frigging employees. (Male Facilitator #7)
Numerous facilitators suggested that it would be beneficial to expand their outreach activities beyond provision of harm reduction supplies and safer injecting education to assist with finding housing, provision of lifeskills, assistance finding employment, and support in accessing healthcare and addictions services.
Criticisms and suggestions - ‘I wanted to do more’
Criticisms of the campaign varied from facilitator to facilitator based on their experiences and the specific workshops they facilitated. A number of the facilitators identified other facilitators arriving at workshops sick, or not showing up, as major issues that impacted the rest of the facilitator’s ability to properly cover workshop curriculum.
Sometimes she would be sick when she came in, and she wasn’t very together, so that’s when I’d have to prolong the workshop I was doing. (Female Facilitator #1)
A few people didn’t show up to do it … they’d go and do something else. (Male Facilitator #7)
A couple facilitators also indicated that sharing of misinformation was a problem that sometimes occurred during workshops when facilitators deviated from facts to opinions.
She was giving her own personal opinion on things that weren’t actually proven to be true and we don’t wanna give that kind of information out. (Female Facilitator #1)
Although facilitators spent a significant amount of time developing workshop curriculum, no time was spent prior to the implementation of the campaign developing the facilitation skills of the IS Team members. A few facilitators noted that managing a large group of IDU can be difficult, and that they would have benefited from more time spent developing facilitation skills before starting the campaign.
I’d of had better preparation for the facilitators … maybe it would be a practice class. I don’t know how to solve the problem. (Male Facilitator #6)
Facilitators noted that information on overdoses was missing from the curriculum and could have been added to strengthen the overall campaign.
I wanted to do more things to let people know to give mouth-to-mouth if your buddy goes down [overdoses] in a hotel room. Cause through Christmas time we lost a few people just because they didn’t breathe. Nobody gave them mouth-to-mouth. (Female Facilitator #5)
Culture and gender specific issues were also identified as important types of information that were missing from the curriculum. While information regarding issues commonly experienced by female injectors (e.g., assisted injection) was included in the workshops, some felt that it would be beneficial to incorporate increased emphasis on particular elements to better address gender-specific educational needs.
There’s issues that women deal with that are different from men. Like maybe they don’t know how to inject because they’ve always been hit [injected] by their boyfriend … With the women you can have information based on jugging [injecting into the jugular vein] and why this is more common … more information on the different reasons people use, you know women are more affected by emotional things, we could talk about that. (Female Facilitator #8)
Similarly, this facilitator suggested that these workshops might have had a greater impact on Aboriginal IDU if specific information was included on the high rates of injecting related morbidity among this sub-population.
I think you could stress what huge a problem this is for the Aboriginal community … maybe they’re not aware of how serious and how terrible a thing this is … and maybe by educating them they would become more concerned and maybe it would change things. ( Female Facilitator #8)
One of the facilitators of the HIV and hepatitis C workshop felt that they were not fully prepared to respond in-depth to participants’ questions about these diseases and treatments available.
It should’ve been two workshops. One on hep C and one on HIV because I don’t know all that much about HIV … And maybe a nurse with it because there’s lots of HIV facts and stuff that you need a nurse to tell you about, your medications and stuff, that I just wasn’t prepared for. (Female Facilitator #1)
Facilitators of this particular workshop felt that it could have been improved by incorporating the technical expertise of a professional educator alongside IS Team members.