International Journal of Drug Policy 26 (2015) 380–387

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International Journal of Drug Policy journal homepage: www.elsevier.com/locate/drugpo

Research paper

Community health workers: A bridge to healthcare for people who inject drugs Kirsty Morgan ∗ , Jessica Lee, Bernadette Sebar Population and Social Health Research Program, School of Medicine, Griffith University, Gold Coast, Australia

a r t i c l e

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Article history: Received 4 June 2014 Received in revised form 17 September 2014 Accepted 4 November 2014 Keywords: Injecting drug use Community health workers Ethnomethodology Healthcare access Peer workers

a b s t r a c t Background: Although people who inject drugs (PWIDs) have increased healthcare needs, their poor access and utilisation of mainstream primary healthcare services is well documented. To address this situation, community health workers (CHWs) who have personal experience of drug injecting in addition to healthcare training or qualifications are sometimes utilised. However, the role peer workers play as members of clinical primary healthcare teams in Australia and how they manage the healthcare needs of PWID, has been poorly documented. Methods: A qualitative ethnomethodological approach was used to study the methods used by CHWs. Data was collected using participant observation of CHWs in a PWID-targeted primary healthcare centre. CHW healthcare consultations with PWID were audio-recorded and transcribed verbatim. Transcripts along with field notes were analysed using membership categorisation and conversation analysis techniques to reveal how CHWs’ personal and professional experience shapes their healthcare interactions with PWID clients. Results: CHWs’ personal experience of injecting drug use is an asset they utilise along with their knowledge of clinical practice and service systems. It provides them with specialised knowledge and language – resources that they draw upon to build trust with clients and accomplish transparent, non-judgmental interactions that enable PWID clients to be active participants in the management of their healthcare. Existing literature often discusses these principles at a theoretical level. This study demonstrates how CHWs achieve them at a micro-level through the use of indexical language and displays of the membership categories ‘PWID’ and ‘healthcare worker’. Conclusion: This research explicates how CHWs serve as an interface between PWID clients and conventional healthcare providers. CHWs deployment of IDU-specific language, membership knowledge, values and behaviours, enable them to interact in ways that foster transparent communication and client participation in healthcare consultations. The incorporation of community health workers into clinical healthcare teams working with IDU populations is a possible means for overcoming barriers to healthcare, such as mistrust and fear of stigma and discrimination, because CHWs are able to serve as an interface between PWID and other healthcare providers. © 2014 Elsevier B.V. All rights reserved.

Background People who inject drugs (PWID) have significantly higher rates of morbidity and mortality than non-injecting drug users in Australia. Despite PWID’s increased healthcare needs, their poor utilisation of mainstream primary healthcare services is well documented (Day, Islam, White, Reid, Hayes, & Haber, 2011; McCoy,

∗ Corresponding author at: PO Box 223, Southport, QLD 4215, Australia. Tel.: +61 423162850; fax: +61 7 5678 0303. E-mail address: kirsty.morgan@griffithuni.edu.au (K. Morgan). http://dx.doi.org/10.1016/j.drugpo.2014.11.001 0955-3959/© 2014 Elsevier B.V. All rights reserved.

Metsch, Chitwood, & Miles, 2001; McDonald, 2002). Contributing factors to this problem include a lack of material resources, complex service systems that are difficult for many PWID to navigate, and poor relationships between PWID and conventional healthcare providers (Ahern, Stuber, & Galea, 2007; Holt, Treloar, McMillan, Schultz, & Bath, 2007; Merill, Rhodes, Deyo, Marlett, & Bradley, 2002; Neale, Tompkins, & Shear, 2008). In response to these concerns, a number of primary healthcare services for PWID were established in a few Australian cities with prevalent street-based drug use. Some of these services employ community health workers (CHWs) who have personal experience of drug injecting as well as occupational training and/or tertiary qualifications. This study

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examined how community health workers performed their role and how their personal experience of injecting shaped the delivery of primary healthcare services to PWID. There is consensus in the literature that primary healthcare is made more accessible and acceptable to PWID if it is delivered within a harm reduction framework, employs peer workers, is non-judgemental, free of cost, confidential and provided by a multidisciplinary team on a non-appointment basis (Day et al., 2011; Holt et al., 2007; Islam, Topp, Day, Dawson, & Conigrave, 2012; van Beek, 2007). It is also suggested that primary healthcare centres augmented to needle and syringe programs (NSPs) are the most effective model (Day et al., 2011; Islam et al., 2012; McDonald, 2002). Furthermore, the literature shows that peer workers extend the reach and effectiveness of conventional public health interventions. Peers have been used to educate and influence injecting behaviours in order to reduce blood-borne virus (BBV) transmission in Australia for more than two decades. A systematic review of drug-related harm reduction literature (Ritter & Cameron, 2005) concluded that there is good evidence to support the effectiveness of peer outreach services (such as provision of injecting equipment and HIV prevention information) in reducing HIV risk behaviours. According to Broadhead et al. (1998) and Power, Jones, Kearns, Ward, and Perera (1995) the use of PWID peer workers improves the reach of health interventions with PWIDs, whose behaviour is illegal and highly stigmatised. Peer workers are described as being able to use the language and terminology of the IDU subcultures and are aware of the social rules, thereby enabling credibility and trust to be established more readily (Australian Drug Foundation, 2006; Trautmann, 1995; Treloar & Abelson, 2005; UNAIDS, 1999). Research findings from Latkin (1998), Treloar and Abelson (2005) and Shen et al. (2011) also suggest that injecting-related information from peers is likely to have greater influence on injecting behaviours than information from other sources. The weight of this evidence is reflected in Australia in the Commonwealth’s HIV Strategy and Hepatitis C Strategies 2014–2017, which identify peer-based approaches as integral to blood-borne prevention efforts. Although the use of peer workers in BBV prevention interventions, such as needle and syringe programs and health education, and the use of peer support workers in drug rehabilitation interventions, is well documented, there is scant reference to the use of IDU peer workers in clinical roles in Australia. The role of a peer educator, peer outreach worker, support worker or NSP worker is distinctly different to that of a peer CHW involved in the delivery of clinical services and the healthcare management of patients. One of the few examples of evidence that could be found on the topic of IDU peer workers in clinical care teams in Australia, was an article reporting the demonstrated feasibility and acceptability of a peer worker role within a liver clinic providing hepatitis C treatment to PWID in Melbourne. The qualitative evaluation found that the inclusion of a peer worker in the clinical care team improved client/doctor communication and increased the clinic’s ability to provide broader healthcare that was responsive to psychosocial as well as biomedical needs, thereby improving clients’ experience of treatment (Norman et al., 2008). Another relevant study reported on the evaluation of a pilot project using peer-delivered hepatitis C testing and counselling. The evaluation found that hepatitis C screening by a peer worker negated fear of disclosure of illegal heroin use and stigma, thereby enabling PWID to discuss their lives at a level of depth and detail which was unlikely to occur under more traditional clinical conditions; thus the potential for addressing people’s health problems was enhanced (Aitken, Kerger, & Crofts, 2002). The findings of these studies are supported by Ti and Kerr (2013), who argue that task shifting of healthcare duties to trained lay workers may serve as means of addressing barriers to HIV testing and treatment among IDUs.

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There is also an expanding body of literature discussing the use of CHWs internationally. Literature reviews (e.g. Bhutta, Lassi, Pariyo, & Huicho, 2010) illustrate their effectiveness in addressing the most common causes of morbidity and mortality in South Asian and African countries, such as childhood illness, prevention and treatment of malaria, TB and HIV. In the United States, CHWs are being increasingly used to address the disproportionate burden of disease that exists among vulnerable populations. Their growing recognition is evidenced by the US Department of Labor decision in 2010 to assign a specific designation for CHWs and they have their own professional association supporting a workforce comprising of an estimated 121,200 CHWs (United States Department of Health and Human Services, 2007). Large variations in roles undertaken by CHWs were found in the literature, with some working with specific ethnic communities and others working to address specific diseases such as diabetes, CVD and HIV/AIDS. To encompass the breadth of the role The American Public Health Association (2012) has developed a broad definition, describing CHWs as front line public health workers who are trusted members of and/or have an unusually close understanding of the community being served. A desktop review by the World Health Organization (Lehmann & Sanders, 2007) to assess the effectiveness of CHW programmes found that there is robust evidence that CHWs’ actions lead to improved health outcomes and that CHWs make healthcare more accessible and appropriate to marginalised communities. The review, however, found many CHW programs to be inadequately documented. There is a lack of literature that describes how CHWs perform their role and the explicit methods used by CHWs in their healthcare interactions. Previous studies, such as the Community Health Worker National Workforce Study (U.S. Department of Health and Human Services, 2007), the World Health Organization review (Lehmann & Sanders, 2007) and the Centers for Disease Control and Prevention (2011) recommend that research be conducted to further clarify the methods used by CHWs and identify and share common ‘best processes’ of CHW programs. Despite CHWs’ international recognition as valued members of the healthcare workforce, their use in Australian clinical settings with IDU-populations is not well documented or understood. By increasing our knowledge of the CHW role, their unique skill-set may be better utilised to enhance the healthcare for this population. It is also necessary to establish the practical content of CHWs’ work practices in order to define best practice for CHW programs and train future CHWs. This study attempts to address the gap in the literature regarding the role of community health workers working with PWID in Australia and increase knowledge of how they manage the healthcare needs of people who inject drugs. It examines in detail their work practices and seeks to explain how they serve as a bridge between the healthcare system and marginalised PWID. The research aims are facilitated by: (1) examining how CHWs structure healthcare consultations, make decisions and deliver healthcare. (2) exploring how CHWs use their personal experience of injecting drug use to communicate with PWID and how it influences clients’ healthcare encounters. The CHWs under study are employed as part of a PWID-targeted primary healthcare service. Community health workers delivering healthcare services to PWID as members of clinical teams constitute a small workforce in Australia. In accordance with HREC conditions and to protect the confidentiality of the CHW study participants, the city in which these CHWs are based cannot be named (ethical approval was granted by the Griffith University Ethics Committee GU Ref: PBH/42/11/HREC). The primary healthcare clinic in which the CHWs work is attached to a needle and syringe program (NSP)

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that at the time of study saw around fifty PWID per day. Aside from the NSP, the physical structure of the primary healthcare service is not dissimilar to many general practice clinics in Australia. Service users enter a reception area, which is attached to several small clinic rooms where they are seen by a member of the primary healthcare team. The team comprises a General Practitioner (GP), Community Health Nurses (CHN) and Community Health Workers. The CHW role provides a wide range of services including: triage and assessment prior to GP consultations, HIV, hepatitis C and B testing (pre/post-test counselling and venipuncture), assistance with hepatitis C pre-treatment workups, sexual history taking and STI screening, pregnancy testing, basic wound care, dental and allied healthcare referrals, overdose monitoring and response, mental health firstaid, vein care and safer injecting advice, opiate substitution treatment assessments and referrals, and support in response to legal issues, homelessness, material aid and domestic violence. The CHWs function as integrated members of the primary healthcare team; no clients are singularly managed by CHWs, CHNs or the GP. Some CHWs hold qualifications in community development, social science, psychology or social work. However, formal tertiary qualifications were not a prerequisite to employment in the role. Due to the relatively recent emergence of the CHW role in Australia, no formal credentialing for CHWs yet exists and there is no formal pathway into the role, hence they are paid under the social and community services award. The CHWs under study were employed on the basis of their knowledge derived from both personal experience of injecting and their demonstrated experience in working with the target group, knowledge of harm reduction and the social and health concerns affecting the local injecting population. All had previous experience working within needle and syringe programs and community development programs. All of the CHWs had been provided with additional training by the health service, including but not limited to: venipuncture and pathology collection, BBV and STI testing, pregnancy testing, wound care and advanced first aid and resuscitation, and mental health first aid. They also received continuous mentoring and supervision from experienced Community Health Nurses and the General Practitioner. To understand the role of the community health workers under study, knowledge of the primary healthcare needs of the population they serve is requisite. Although the location of the service population cannot be named, the area in which it is located can be described as an inner urban environment where street-based drug activity was prevalent. Results from the Illicit Drug Reporting System (2012) undertaken in the area, indicated that this IDU population predominantly inject heroin, and benzodiazepine, alcohol and cannabis use was common (Kirwan, Dietze, & Lloyd, 2012). Studies of PWID in inner urban areas of Australia indicate they score poorly on almost every social determinant of health; unemployment, incomplete secondary education, a history of homelessness and incarceration are common characteristics (Horyniak et al., 2013; Kirwan et al., 2012). Data are consistent in reporting that PWID delay access to treatment for injecting-related problems such as ulcers, abscesses, cellulitis, and thrombosis, resulting in acute conditions and in some instances, emergency department presentations that may have been prevented with better access to primary healthcare (Fairbairn et al., 2012; Kirwan et al., 2012) They also suffer from high levels of chronic disease such as hepatitis C and mental health disorders that require ongoing monitoring and management (Fairbairn et al., 2012; Kirwan et al., 2012; Riddell, Shanahan, Roxburgh, & Degenhardt, 2007). The limited data on health conditions not directly attributable to injecting indicate that the general state of health and wellbeing of many PWID is poor. Fairbairn et al. (2012) and Horyniak, Dietze, and McElwee (2009) identified that PWID suffer from a range of other health concerns, most commonly poor dental health and respiratory infections and disorders.

Methods A qualitative ethnomethodological approach was used to achieve the research aim. Ethnomethodology is a sociological approach founded by Garfinkel (1967) in the 1960s to address the shortcomings of the social sciences, which in Garfinkel’s opinion had paid very little attention to routine everyday practices (Atkinson, 1988). He argues that in order to answer questions regarding how ordinary actions are accomplished, we must find the answers ‘in situ’, by analysing the language and behaviours people use in a particular setting to accomplish practical actions (e.g. court room procedures and medical consultations). Ethnomethodology (EM) has contributed significantly to our understandings of how police, doctors and lawyers work, because it focuses on and explains the practical content of occupational tasks. Psathas (1995) explains that ethnomethodology’s ‘studies of work program’ reveals ‘the actual, ongoing, situated practices, the mastery and use of natural language, the competencies involved in doing the work” (Psathas, 1995, p. 148, emphasis in original). This study aims to reveal the essence of what CHWs do, the distinct skill-set that CHWs possess, and how it distinguishes them from other healthcare occupations. This has been done by analysing the structure of their interactions and the verbal and nonverbal communication styles they employ. This study, in accordance with EM practice, is not seeking to test a hypothesis, but rather discover and describe the methods used by CHWs to deliver healthcare to PWID. EM does not have prescribed data collection and analysis methods; however, it heavily emphasises the need for fieldwork and participant observation. It is fully consistent with this practice to take a localised approach to sampling with a small number of people. In keeping with this methodology, the data in this study was collected using participant observation of CHWs in a PWID-targeted primary healthcare centre. The lead author spent four weeks in the primary healthcare service observing the CHWS and recording observational field notes that focused on the physical and social environment in the primary healthcare centre, body language, how people were arranged in clinic rooms, physical demonstrations of explanations, visual greetings, tasks undertaken, their sequential order and nonverbal communication regarding the commencement and completion of activities. Descriptive and interpretative field notes were separately recorded, as suggested by Spradley (1979) and then analysed to identify common patterns of task construction and the common processes occurring in interactions between the CHWS and the clients. A convenience sample of 13 healthcare consultations between two CHWs and 13 different PWID were audio-recorded and transcribed verbatim. Each observed consultation lasted between twenty to ninety minutes. The CHWs were purposively sampled. They were selected because the role they were performing best fitted descriptions of CHWs in the literature. To increase the validity of this study we used data triangulation. As well as collecting observational field notes and audio-recording consultations, two CHWs were interviewed. This enabled us to check if the initial patterns identified from the field notes and transcripts from consultations, matched with the CHWs descriptions of their role and approach to tasks undertaken in healthcare consultations. We were interested in exploring how they identified themselves in membership category terms (i.e. ‘IDU peer’ or ‘healthcare service provider’) and we examined the value assumptions conveyed in the CHWs language. In contrast to other sociological theories of collective membership, ethnomethodology is concerned with the way membership identities are interactionally occasioned through language and peoples’ displays of common-sense knowledge in their everyday activities (Coulon, 1995; Flynn, 1991). A member of a particular category, such as a doctor or lawyer, is socially competent in the activities, language and methods used by that group, and this allows

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that person to be recognised and accepted by other group members (Coulon, 1995). In researching CHWs, we were interested in exploring if and how CHWs display the membership categories ‘person who injects drugs’ or ‘healthcare service provider’ and what purpose it served to display a particular member category when communicating with the PWID clients or external health and welfare agencies. Descriptive field notes and the verbatim transcripts of consultation and interviews were deconstructed and paragraphs and phrases coded manually, initially using open coding. Our approach to coding and data analysis was informed by Coffey and Atkinson (1996). Coding centred on activities and tasks being done, how tasks are initiated and implemented, decision-making processes, ways of talking, displays of membership and the use of memberspecific knowledge and styles of nonverbal communication. After establishing the patterned structure of CHW consultations and the core practices being undertaken by the CHWs, we then examined in close detail particular sections of the transcripts during which these core processes were taking place, and analysed the talk that occurred in order to accomplish these core CHW processes. In presenting the findings, a montage of the CHW participants has been used so that individual participants’ identities are protected. We have also avoided the use of individuals’ names or services. Findings The findings are presented by the key communication methods that were routinely used by community health workers in the observed healthcare consultations. These included: transparent and non-judgmental practice, displays of PWID-membership through the use of language specific to injecting drug using subculture, and shifting membership category displays from ‘peers of PWID’ to ‘healthcare service providers’ depending on the objective of the interaction. Verbatim quotes are used to illustrate key points. Transparent and non-judgmental practice Our analysis of community health worker interactions with PWID found that they routinely used communication practices that enabled information sharing and transparency in the delivery of healthcare. For example, community health workers seated clients next to them in front of a large computer screen displaying the client’s electronic medical record. When interviewing the community health workers, we asked them what the purpose of this seating arrangement was. The CHW responded: To include someone in the process, like I suppose to be very clear, you know what I know. . .this is what we are doing, like I have nothing to hide from you, like I’m not actually sitting at my computer screen writing ‘fucking junkie’ or ‘drug seeking’ or anything like that without telling you. This is something we are doing together. I believe people have a right to consent to what is happening to them and um, it’s like you know, those little and large things. It’s those little tests that they didn’t talk to you about or they’ve done this or they’ve interpreted you in a certain way – that you never even got a chance to look in on. Transparency is also achieved through the community health workers’ communication of the reasoning process guiding their actions. CHWs routinely explain the motivations for their questions or for discussing a particular topic when the topic is not client initiated. By accounting for the topics raised in the consultation, the client is kept informed and actively involved in the interaction. Mishler (1984) suggests that when patients do not understand

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the motivations behind health physicians’ questions, the patient is likely to lose interactional control and the interaction becomes dominated by the practitioner. Non-judgmental communication was found to be central to CHWs’ practice, resulting in PWID clients being able to openly discuss their healthcare needs in the context of their drug use and be actively involved in consultations and decision-making about their health. The consultations observed contained regular statements by CHWs which communicated to clients that they accepted clients’ drug using practices as a normal part of their lives, and that they did not hold any negative moral judgments towards this. It is clear that the CHWs make such statements to give clients permission to talk openly about their drug use, without fear of it being viewed as a character deficiency. This enables CHWs to then deliver relevant harm reduction advice. The following excerpt is a typical example of non-judgmental communication. The CHW is doing a risk assessment as part of the pre-test discussion for HIV, hepatitis C and B testing.

CHW: alright so these questions are about injecting. Um, what’s your frequency of injecting drug use? Currently? Ordinarily? Client: it’d be twice a week CHW: and where? Is it at home, in a car or at a dealer’s house or on the street or wherever? Client: it’d be, um, public toilets CHW: OK Client: and, um, sometimes. You know, I try not to CHW: yeah that’s what people do, it’s fine. And um have you ever shared any equipment? Do you use by yourself? Client: yeah CHW: so everything’s solo? Client: yeah, everything but that one time yeah CHW: so how long ago was that?

We can observe the hesitation and ‘um’ by the client before the client states he injects in public toilets and again when he adds it is only “sometimes” and “I try not to”, intimating that he feels some shame about the behaviour. The CHW responds by reassuring the client that she does not judge the behaviour and she proceeds to normalise it by stating, “that’s what people do, it’s fine”. Following the excerpt shown here, the CHW proceeds with a discussion about safer injecting practices that minimise the risk of transmitting blood borne viruses. Information that is relevant to the client’s injecting practices is imparted in response to what the client has disclosed about their injecting. The following excerpt provides another example of how CHWs accomplish non-judgmental practice in their delivery of wound care advice. The client has presented with a significant wound on his hand, the GP has reviewed the wound and the CHW is dressing it.

1. CHW: and are you still having to, I don’t care, it’s not about, but are you still using, having a bit of a taste, cause ah, if you could just avoid using that arm I reckon it’s a good idea, while you’re trying to, you know, just give this arm the best chance to heal properly. It’s not that it’s a bad thing to do, I’m just saying if you can. Which hand do you inject with? 2. Client: oh I inject that way 3. CHW: you’ve got great veins anyway, Jesus Christ! So, but yeah, I’d just try to, if you could 4. Client: use that hand 5. CHW: yeah just to give your arm a bit of a break 6. Client: yeah cause I got on um last week, on the weekend cause sort of just to eh, escape, if you know what I mean

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In statement (1) of this interaction the CHW tells the client “I don’t care” to communicate that she will not judge him for using heroin and thus gives him permission to talk openly about his drug use. She also hesitates a number of times before asking “are you still using?” and then rephrases it in member-specific language and asks if he’s been “having a bit of a taste?” She then follows the question about whether he has been using with an explanation – that his injecting drug use is not of concern, only where he is injecting because this may slow down his wound healing. The client then proceeds to tell the CHW about his recent drug use. Statement (3), in which the CHW remarks on the quality of the client’s veins, is another example of the CHW displaying her PWID membership identity – it is unlikely that a health practitioner without injecting drug use experience would so enthusiastically compliment a client on the size of their veins! The talk presented here in these excerpts illustrates the ways in which non-judgmental practice gets done by community health workers: by making statements that communicate that they view drug use as an acceptable behavior, by explaining the reasoning for their questions and by using language specific to injecting drug using sub-cultures. This leads to clients openly discussing their injecting practices and the CHWs then providing them with relevant harm reduction interventions.

Displaying membership knowledge through the use of language specific to injecting drug using sub-culture The community health workers under study are uniquely different from other health practitioners in that their personal experience of injecting drug use is considered to be an attribute, which along with their occupational and/or academic training better equips them to perform their role. We explored instances of CHWs displaying membership knowledge and attitudes that infer that they belong to the member group category ‘a person who has/does inject drugs’ and discuss what purpose this serves in the healthcare interaction. In the following example, a client is being triaged by the CHW before seeing the GP to review his cellulitis – his foot is swollen from where he missed the vein when injecting.

1. 2. 3. 4. 5.

6. 7. 8. 9. 10. 11.

12. 13.

CHW: do you inject your methadone? Client: I’ve tried to CHW: but that will fuck up your veins absolutely Client: it doesn’t do anything anyway CHW: yeah well that’s cause if you were what’s called opioid naïve you’d be wasted, you’d be having a great time, but your body is completely used to opiates Client: yeah I know, that’s why I don’t even know why I even inject a lot still CHW: well there’s probably lots of reasons for that (chuckle). What dose are you on currently? Client: eighty CHW: on eighty you are going to need a lot of heroin to get a taste over and above your dose Client: well I inject, I inject grams or half grams, I don’t even do hundreds or anything CHW: Ok. Are you using, has your using increased lately because you’re not getting anything in a vein, your body’s not absorbing as much as when you were getting clean hits, so you may find you’re using a bit more in chasing that level of intoxication Client: yeah CHW: so you keep having crappy misses and not getting it. . .with the quality of the gear at the moment, you might find you just have to bite the bullet for a while – have your ‘done

dose, try to get on top of that and just get your using a bit more into a payday reward or whatever you want to do. Sacks (1972) argues that people’s statement in conversation are recipient-designed – the speaker can endeavour to infer certain things, and if the hearer should seek to use them, they can discern a person’s social identity and make assumptions regarding the morals that person is likely to have because they are tied to that social identity (Silverman, 1993). By applying Sacks’s concepts of membership categorisation (as presented by Silverman, 1993) and Garfinkel’s argument that people use member-specific language and knowledge to accomplish an interaction, we will illuminate how the community health worker is using her PWID membership category to accomplish the delivery of clinical advice to the client. In statement (1) the CHW asks in a direct fashion whether the client injects his methadone. The client’s response: “I’ve tried to”, allows for some ambiguity – he alludes that he has, but avoids a direct admission that he has injected his methadone. The CHW’s response “but that will fuck up your veins absolutely”, can be heard as non-judgmental. The CHW avoids making a judgment that it is morally wrong and dangerous to inject, or that he should not be doing it because it is a medication that has been prescribed for oral consumption. In the CHW choosing to use the phrase “fuck up your veins”, she is applying member-specific language. It also displays to the client that she understands what is valued by the client. Maintaining viable, intact veins is highly valued by PWID – veins are after all, a PWID’s pathway to pleasure. Without a viable vein to inject into, the pleasure they can attain from injecting drugs is no longer possible. She therefore approaches the issue of avoiding injecting his oral methadone from the client’s value position – that keeping intact veins for injecting drug use is important. In statement (5), the CHW exhibits a clinical knowledge of neuro-adaptation and drug tolerance, but incorporates PWID member language, such as ‘wasted’, when explaining to the client why injecting methadone is having no effect. The phrase she uses also acknowledges a PWIDs’ perspective that taking drugs is a pleasurable pass time: “you’d be wasted, you’d be having a great time”. It is noteworthy that the client’s following communications, in statements (6) and (10), are very open and honest about his frequency and level of illicit drug use. His statements exhibit no hesitancy or reservation in asserting that he injects a lot, and with large amounts. It is also worth noting that he talks to the CHW using terminology that he expects her to understand: “I don’t even do hundreds”. In statement (9), the CHW again uses a PWID member expression with the word “taste”, when explaining to the client their level of opiate tolerance: “you are going to need a lot of heroin to get a taste over and above your dose” – again exhibiting an understanding and lack of judgment towards the client’s desire to seek intoxication. It is also observable that the CHW draws on her PWID member knowledge in statement (11) by positing to the client that it would be understandable to be using an increased amount of heroin to gain a pleasurable effect and that he may be doing this because he has been injecting into tissue rather than a vein. Once again, a member specific expression is used with “clean hits”. In statement (13), the CHW then provides the client with clinical advice suggesting that he reduce his frequency of injecting. PWID member terms are again used, such as “crappy misses” when referring to injecting into soft tissue and “done” in reference to methadone. In communicating the advice, the CHW contextualises the information using her member-specific knowledge: that the purity of the heroin is currently low, and that PWID when trying not to use everyday, often choose payday as the day that they will use. Analysis of the transcripts demonstrate that CHWs utilise their personal experience of injecting drugs in their talk with PWID clients. This is made visible through the use of language specific to

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IDU groups and displays of insider knowledge of drug using practices. This piece of data, and others examined, suggest that CHWs do this to encourage clients to talk openly about their injecting practices so they can communicate relevant healthcare education and deliver the education in a culturally appropriate way. CHWs shifting displays of membership category An objective of this study is to explain how CHWs serve as a bridge between PWID and the healthcare system. According to Sacks (1972) and Maynard (1991), the setting and talk situationally accomplish who is the ‘professional with expert knowledge’ and who is the ‘lay person who lacks expertise’. The way talk is constructed within a healthcare interaction actuates and makes accountable who is the expert and who is the one seeking help. The community health workers in this study fall into neither category neatly. In their interactions with clients, community health workers are the health service providers, but at the same time they are lay people – they sit between the two membership categories. We were interested in exploring how community health workers see themselves – as belonging to what member category – ‘expert’ or ‘lay person’. When interviewing the CHWs, we asked them to describe the role of CHWs. The following CHW description elucidates how she categorises the role as being in between ‘professional with expert knowledge’ and a ‘lay person who lacks expertise’. In her view, this characteristic of being in between the two membership categories enables her to better communicate healthcare information and advice to this population. When I tell people that don’t work here I kind of say quasi nurse in a way because, I mean I can’t handle medications and stuff like that but there’s an element that’s still quite medical, but it’s also very psychosocial . . . it’s like a cross section of lots of different roles I suppose – so a bit social worker, a bit AOD worker, sometimes counsellor, sometimes nurse, because we do some wound care and testing. And working with the doctor, you learn lots of medical knowledge, so that’s useful to impart. And it’s kind of a bridge as well in way, ‘cause I think for a lot of people that come here we are between ‘no knowledge’ and ‘a doctor’ so we help merge that information for people, so it’s like a bridging role as well . . . But there’s other things – like being an advocate for people, so you’re advocator or you’re a support person . . . role modelling, like that’s a big thing about our job, you know, role modelling for other users; showing them appropriate ways to communicate. So if you can introduce something over the phone, and that went well, they might think, ‘oh I’ll try that next time’. Community health workers regularly displayed shifts in membership categories. The following excerpt shows how CHWs display their healthcare provider role category when talking with an external service, but then shift their relational positioning when talking to a client. CHW (on phone): hi my name is [name], I’m a community health worker in [suburb name] and I’m wondering if I can make an appointment for a young gentleman who has come in for some support to recommence pharmacotherapy . . . [name and contact details] . . . I’ll supply the two photos for [name] to take with him for the doctor . . . 2 o’clock? Alright, excellent, thank you so much for that. Alright. Bye (hangs up phone). CHW (to client): cool mate, we’re in for 2 o’clock. In the above excerpt, the CHW through her use of language changes how she categorises herself. In the phone call to the

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medical practice she speaks displaying herself as belonging to the category ‘professional service provider’. She does not only do this by stating her job title, she employs, what Sacks calls, a relational device to categorise herself. By stating that a young gentleman has come to her for support, she exhibits her role identity as ‘professional service provider’. Of note is how she talks to the client after she has finished the phone call. Presumably she could have stated something like: “I have got you a 2 o’clock appointment with the doctor”, but instead she uses the pronoun ‘we’ as if it is an appointment that they are going to have together. It is also noteworthy that when talking to the service provider, the CHW refers to the client as ‘a young gentleman’, rather than ‘mate’ – the informal pronoun commonly used by CHWs with the clients. Community health workers’ use of different styles of communication when talking with clients and when talking with external service providers, was a patterned occurrence throughout the observed consultations. The CHWs’ shift in membership category identities is another communication method CHWs use to accomplish ‘being a bridge to healthcare for PWID’. Depending on what they are endevouring to achieve in their talk, they elect to display themselves as a member of the group ‘health service provider’, or they group themselves with the client if wanting to appear in partnership with them. CHWs’ identities as ‘peers of PWID’ and as ‘service providers’ are not fixed; they produce these identities in interactions to create an affiliation with the listener and enable good communication. It is their familiarity with both member categories that enables them to ‘naturally’ and easily, affiliate themselves with both social groups and serve as a bridge – an intermediary, between marginalised PWID and the healthcare system.

Discussion and conclusion The simplistic answer to the question, “how do CHWs serve as a bridge between the healthcare system and marginalised PWID?” would be that they serve as a bridge by providing referrals and healthcare services. This however, would be an incomplete answer and would fail to capture the haecceity of CHWs work – to borrow Garfinkel’s term, the ‘just what’ CHWs do that makes their role distinct from other service providers. Instead, we have addressed the central research question through close examination of CHWs’ talk and nonverbal communication to reveal ethnomethodologically, how CHWs accomplish their role of being a bridge. CHWs deployment of IDU-specific language, membership knowledge, values and behaviours, enable them to interact in ways that foster transparent communication and client participation in healthcare consultations. Calls for non-judgemental, client-centred and culturally appropriate healthcare are usually theoretical and pay little attention to the ways in which these principles might actually be achieved at a microlevel. Our research helps explicate how CHWs apply these principles in their day-to-day interactions with clients. Although it is beyond the scope of the study to measure the impact of community health workers on this population’s health outcomes, it is widely acknowledged that these attributes improve healthcare practice. A major theme identified in the literature on PWIDs’ access to healthcare was that communication barriers, such as mistrust, exist between the healthcare system and PWID populations (Ahern et al., 2007; Day, Ross, & Dolan, 2003; Merill et al., 2002; Neale et al., 2008). These communication barriers may preclude appropriate diagnosis, treatment and follow-up for this vulnerable population with high level healthcare needs. The incorporation of community health workers into primary healthcare service delivery is a possible means for tackling this problem, because CHWs possess specialised knowledge and communication skills that enable them

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to serve as an interface between PWID and other healthcare providers. Growing health inequity is cited as being one the most significant challenges presently facing public health (Baum, Begin, Houweling, & Taylor, 2009; Marmot, 2007). The World Health Organization (Bhutta et al., 2010) and U.S. Centers for Disease Control and Prevention (2011) consider the expansion of the CHW workforce to be an essential strategy for resolving health inequity and improving the health outcomes of marginalised populations. The problem of health inequity is complicated by the growing shortage of doctors and nurses (Bhutta et al., 2010) and those likely to be most affected by these shortages are marginalised populations. Furthermore, there is evidence in the literature that already only a small number of health practitioners are willing to work with PWID clients (Abouyanni et al., 2000). This may exacerbate the problem of meeting the healthcare needs of this population. Should Australian health policy makers follow the direction being taken in the US and developing countries, to establish a CHW workforce to help meet the needs of its marginalised populations, studies such as this one provide valuable knowledge for understanding the role and practices employed by CHWs in the delivery of healthcare to PWID in Australian settings. In order to develop a CHW workforce here in Australia, the authors suggest the development of a specific professional designation for community health workers, similar to what has been established in the United States or the designation that is in place for Aboriginal health workers in Australia. This would enable pathways to be established for PWID to become CHWs. For this to occur, decisions would first need to be made regarding the core competencies and skill-set required for members of this emerging workforce. It was evident from this study that knowledge and language derived from personal drug using experience, and an ability to display the ‘person who injects drugs’ member category in interactions with PWID clients, equips these workers with skills required to perform the role. However, it was also evident that these workers required skills attained through occupational training and that their role capabilities are maximised when working as members of a multidisciplinary team. To extend the application of CHWs in the provision of primary healthcare service, opportunities need to be established for PWID to participate in occupational training programs that would enable PWID to attain the necessary skills to perform CHW tasks. Given the evidence indicating the benefits of peer workers in BBV prevention, expanding the use of peers in clinical teams to manage the healthcare needs of PWID, may serve to overcome the social barriers that exist for PWID in accessing healthcare services. To conclude, we also suggest the need for research that investigates the role of CHWs in increasing the capacity of GPs and nurses to provide healthcare to PWID. This study did not include the perspective of the nurses and GPs in the multidisciplinary team in which the CHWs work. It would be valuable to assess whether the utilisation of CHWs supports them to service a greater number of PWID clients – thereby increasing the efficiency of the healthcare system to meet the high level healthcare needs of this population – and whether the inclusion of CHWs also enables them to provide better quality healthcare for this population. Conflict of interest We wish to confirm that there are no known conflicts of interest associated with this publication. References Abouyanni, G., Stevens, L. J., Harris, M. F., Wickes, W. A., Ramakrishna, S. S., Ta, E., et al. (2000). GP attitudes to managing drug and alcohol dependent patients: A reluctant role. Drug and Alcohol Review, 19, 165–170.

Ahern, J., Stuber, J., & Galea, S. (2007). Stigma, discrimination and the health of illicit drug users. Drug and Alcohol Dependence, 88. Aitken, C., Kerger, M., & Crofts, N. (2002). Peer-delivered hepatitis C testing and counselling: A means of improving the health of injecting drug users. Drug and Alcohol Review, 21. The American Public Health Association. (2012). Community health workers. Retrieved from: http://www.apha.org/membergroups/sections/aphasections/ chw Atkinson, P. (1988). Ethnomethodology: A critical review. Annual Review of Sociology, 14, 441–465. Australian Drug Foundation. (2006). Current evidence evaluated: Peer education. Prevention Research Evaluation Report 17. DrugInfo Clearinghouse. Retrieved from: http://www.druginfo.adf.org.au/attachments/352 PRQ 06MAr Peer education. pdf Baum, F., Begin, M., Houweling, T. A., & Taylor, S. (2009). Changes not for the fainthearted: Reorienting health care systems toward health equity through action on the social determinants of health. American Journal of Public Health, 99(11), 1967–1974. Bhutta, Z. A., Lassi, Z. S., Pariyo, G., & Huicho, L. (2010). Global evidence of community health workers for delivery of health related millennium development goals: A systematic review, country case studies, and recommendations for integration into national health systems. Geneva: World Health Organization. Retrieved from: http://www.who.int/workforcealliance/knowledge/publications/alliance/ Global CHW web.pdf Broadhead, S., Heckathorn, D. D., Weakliem, D. L., Anthony, D. L., Madray, H., Mills, R. J., et al. (1998). Harnessing peer networks as an instrument for AIDS prevention: Results from a peer-driven intervention. Public Health Reports, 113(1), 42–57. Centers for Disease Control and Prevention. (2011). Community health workers/promotores de salud: Critical connections in communities. Atlanta: CDC. Retrieved from: http://www.cdc.gov/diabetes/projects/pdfs/comm.htm Coffey, A., & Atkinson, P. (1996). Making sense of qualitative data: Complimentary research strategies. Thousand Oaks, CA: Sage. Coulon, A. (1995). Ethnomethodology: Qualitative research methods series 36. Thousand Oaks, CA: Sage. Day, C., Ross, J., & Dolan, K. (2003). Hepatitis C-related discrimination among heroin users in Sydney: Drug user or hepatitis C discrimination? Drug and Alcohol Review, 22, 317–321. Day, C., Islam, M., White, A., Reid, S. E., Hayes, S., & Haber, P. S. (2011). Development of a nurse-led primary healthcare service for injecting drug users in inner-city Sydney. Australian Journal of Primary Health, 17, 10–15. Fairbairn, N., Milloy, M. J., Zhang, R., Lai, C., Grafstein, E., Kerr, T., et al. (2012). Emergency department utilization among a cohort of HIV-positive injecting drug users in a Canadian setting. The Journal of Emergency Medicine, 43(2), 236–243. Flynn, P. J. (1991). The ethnomethodological movement: Sociosemiotic interpretations. Berlin: Walter de Gruyter. Garfinkel, H. (1967). Studies on ethnomethodology. Oxford: Blackwell Publishers. Holt, M., Treloar, C., McMillan, K., Schultz, L., & Bath, N. (2007). Barriers and incentives to treatment for illicit drug users with mental health comorbidities and complex vulnerabilities. Canberra: Commonwealth of Australia. Retrieved from: http://www.nationaldrugstrategy.gov.au/internet/drugstrategy/publishing.nsf/ Content/87388A80B499F44BCA25739B000A2DF2/$File/mono61.pdf Horyniak, D., Dietze, P., & McElwee, P. (2009). Findings from the illicit drug reporting system (Australian drug trend series no. 40). Retrieved from: http:// www.med.unsw.edu.au/NDARCWeb.nsf/resources/IDRS 2009/$file/VIC IDRS 2009.pdf Horyniak, D., Higgs, P., Jenkinson, R., Degenhardt, L., Stoove, M., Kerr, T., et al. (2013). Establishing the Melbourne injector cohort study (MIX): Rationale, methods and baseline and 12-month follow-up results. Harm Reduction Journal, 10(11) http://dx.doi.org/10.1186/1477-7517-10-11 Islam, M., Topp, L., Day, C. A., Dawson, A., & Conigrave, K. M. (2012). The accessibility, acceptability, health impact and cost implications of primary healthcare outlets that target injecting drug users: A narrative synthesis of literature. International Journal of Drug Policy, 23. Kirwan, A., Dietze, P., & Lloyd, B. (2012). Findings from the illicit drug reporting system (IDRS), Australian drug trends series no. 76. Retrieved from: http://ndarc.med.unsw.edu.au/sites/ndarc.cms.med.unsw.edu.au/files/ndarc/ resources/VIC IDRS 2011.pdf Latkin, C. A. (1998). Outreach in natural settings, the use of peer leaders for HIV prevention among injecting drug users’ networks. Public Health Reports, 113(1), 151–159. Lehmann, U., & Sanders, D. (2007). Community health workers: What do we know about them? The state of the evidence on programmes, activities, costs and impact on health outcomes of using community health workers. Geneva: World Health Organisation. Retrieved from: http://www.who.int/healthsystems/ round11 7.pdf Marmot, M. (2007). Achieving health equity: From root causes to fair outcomes. The Lancet, 370, 1153–1163. Maynard, D. W. (1991). The perspective-display series and the delivery and receipt of diagnostic news. In D. Boden, & D. H. Zimmerman (Eds.), Talk and social structure: Studies in ethnomethodology and conversation analysis (pp. 164–192). Cambridge: Polity Press. McCoy, C. B., Metsch, L., Chitwood, D. D., & Miles, C. (2001). Drug use and barriers to use of health care services. Substance Use Misuse, 36, 789–806. McDonald, P. (2002). From streets to sidewalks: Developments in primary care services for injecting drug users. Australian Journal of Primary Health, 8(1), 65–69.

K. Morgan et al. / International Journal of Drug Policy 26 (2015) 380–387 Merill, J. O., Rhodes, L. A., Deyo, R. A., Marlatt, G. A., & Bradley, K. A. (2002). Mutual mistrust in the medical care of drug users: The keys to the narc cabinet. Journal of General Internal Medicine, 17, 327–333. Mishler, E. G. (1984). The discourse of medicine: Dialectics of medical interviews. Norwood, NJ: Ablex. Neale, J., Tompkins, C., & Shear, L. (2008). Barriers to accessing generic health and social care services: A qualitative study of injecting drug users. Health and Social Care in the Community, 16(2), 147–154. Norman, J., Walsh, N., Mugavin, J., Stoove, M. A., Kelsall, J., Austin, K., et al. (2008). The acceptability and feasibility of peer worker support role in community based HCV treatment for injecting drug users. Harm Reduction Journal, 5(8) http://dx.doi.org/10.1186/1477-7517-5-8 Power, R., Jones, S., Kearns, G., Ward, J., & Perera, J. (1995). Drug user networks, coping strategies and HIV prevention in the Community. Journal of Drug Issues, 25(3), 565–581. Psathas, G. (1995). Talk and social structure and studies of work. Human Studies, 18(2/3), 139–155. Riddell, S., Shanahan, M., Roxburgh, A., & Degenhardt, L. (2007). The cost of drugrelated hospital stays in Australia, 1999–2005. NDARC Technical Report Number 285. Sydney: National Drug and Alcohol Research Centre, University of New South Wales. Ritter, A., & Cameron, J. (2005). Monograph no. 06: A systematic review of harm reduction. DPMP Monograph Series. Fitzroy: Turning Point Alcohol and Drug Centre. Sacks, H. (1972). An initial investigation of the usability of conversational data for doing sociology. In D. Sudnow (Ed.), Studies in social interaction (pp. 31–74). New York: Free Press.

387

Shen, S. Y., Zhang, Z. B., Tucker, J. D., Chang, H., Zhan, G. R., & Lin, A. H. (2011). Peerbased behavioural health program for drug users in China: A pilot study. BMC Public Health, 11(693) http://dx.doi.org/10.1186/1471-2458-11-693 Silverman, D. (1993). Interpreting qualitative data: Methods for analysing talk, text and interaction. London: Sage. Spradley, J. P. (1979). The ethnographic interview. New York: Holt, Rinehart and Winston. Ti, L., & Kerr, T. (2013). Task shifting redefined: Removing social and structural barriers to improve the delivery of HIV services for people who inject drugs. Harm Reduction Journal, 10(20) http://dx.doi.org/10.1186/1477-7517-10-20 Trautmann, F. (1995). Peer support as a method of risk reduction in injecting drug user communities: Experiences in Dutch projects and the European Peer Support Project. Journal of Drug Issues, 25(3), 617–628. Treloar, C., & Abelson, J. (2005). Information exchange amongst injecting drug users: A role for an expanded peer education workforce. International Journal of Drug Policy, 16. UNAIDS. (1999). Peer education and HIV/AIDS: Concepts, uses and challenges. Geneva: UNAIDS. Retrieved from: http://www.whqlib.doc.who.int/unaids/ 1999/UNAIDS 99.46E.pdf U.S. Department of Health and Human Services. (2007). Community Health Worker National Workforce Study, USA. Retrieved from: http://bhpr.hrsa. gov/healthworkforce/reports/chwstudy2007.pdf van Beek, I. (2007). Case study: Accessible primary health care – A foundation to improve health outcomes for people who inject drugs. International Journal of Drug Policy, 18(4), 329–332.