The basis of harm reducing peer support is based on the idea that peer workers can act responsibly and as important information distributors and support mentors, even if they themselves use drugs or work in the sex work industry. Peer workers belong to the target group for whom the support organisation offers services. The strength of peer activity lies in the similar lifestyles of the peer workers and the people they are helping. Peer workers can ultimately change attitudes, habits and beliefs in their own social networks. Peer workers have the unique opportunity of getting involved in those concrete, daily situations in which the target group lives. Peer workers can also reach those people who do not for some reason or another join the service organisation.

Peer work on different levels

Peer work can be performed at various levels. The first level of peer work is peer support, which entails the mutual sharing of drug-related information and experiences between drug users.

The second level of peer work includes, for example, Snowball peer education, where representatives of the target group are trained to become mentors who pass on health information within their network of friends and family. Peer workers will also work in the field and collect information on the level of basic knowledge and attitudes among the target group. Information is distributed through a structured interview during which the peer workers both pass on health information to the interviewees and collect information from them. Snowball activity is based on ensuring anonymity among the target group, as well as the active participation and responsibilities of peer workers. Along with the longer lasting Snowball education, various customised education and informative sessions on different topics can be offered to the target group as necessary.

The third level of peer activity includes the actual peer work, where the peer workers who have completed the Snowball education, receive personal and customised duties. Duties are carried out, for example, at the service provider organisation’s service centres or within own their social networks, i.e., in the field.

Peer workers as a part of developing activities

Peer activities must meet the ever-changing needs of the clients and adapt to each challenge, phenomenon and problem typical for that time. The work must be persistent, continuous, and constantly developing. Peer workers must be a part of the development.

Peer workers need professional, social and mediological support. The need for support is formed by individual needs, but also group support is important. The support that is formed in the groups also brings a new level to the development of peer activity when people doing the same work can assess their work together.

Motivation among peer workers requires a clear definition of their roles, treating them as fellow associates and ensuring they have a stake in their own development. Also, respecting peer workers and taking them seriously, will lift their self-esteem and motivate them to continue their work.

I PEER TRAINING IN A MULTICULTURAL ENVIRONMENT:

GROUP TRAINING

1. The basis and background of the multicultural Snowball Educational Programme

Russian speaking clients form the largest immigrant and foreign client base in drug and substance use services in Finland (Puro 2005). A particular cause of worry in the capital region’s substance use service system is the situation of infectious diseases connected with drug abuse in neighbouring regions (e.g., Russia and Estonia). These infectious diseases include HIV, hepatitis and tuberculosis. The HIV epidemic is spreading faster in the Baltic Sea area than anywhere else in the world.

According to estimates, infections are limited quite clearly to the socially excluded and can be reflected in increasing crime figures as well as a higher demand for social and public health services. The matter, however, also has importance in terms of the general attitudes when the differing viewpoints between the socially excluded and the rest of the population widen. The importance of preventative work is also emphasised when preventing the majority population from becoming infected.

The primary need, however, is to increase knowledge of methods known to prevent the viruses from spreading within the drug using populations. Good results have been received from work methods and peer work experiments that operate through a so-called low threshold principle. For example, the services of Munkkisaari’s Service Centre, Kurvi’s Drug Outpatient Department and the Vinkki Health Advice Centre have reached not only the socially excluded but also drug users at risk of infection. Peer work experiments have also proven to be important channels of influence, especially in situations where contact with the service system would not otherwise take place.

The primary aim in developing the Russian-speaking substance use services is the integration of the Russian-speaking substance use services into Finnish-speaking services, by increasing language skills and cultural know-how and highlighting the low threshold principle. The needs for development are highlighted amongst preventative work methods, peer work and family-based work (Puro 2003). In Autumn 2002, the A clinic’s Vinkki Health Advice Centre executed a Snowball operation for those Russian-speaking drug uses who had moved to the capital region. Vinkki has executed Snowball operations aimed at Finnish-speaking drug users since 2001 (Puro 2004). At the end of 2006, Vinkki had carried out ten Snowball operations in total. Training sessions have been successful and feedback from clients has been positive and constructive throughout:

‘I am so pleased with this project, I rarely get such enlightenment. Thank you!’

The particular aim of the Snowball project (2002) aimed at Russian-speaking individuals was to reach those Russian-speaking drug users wishing to receive services from within the system, including health advice centres, who did not seek / receive service not due to different immigration status and/or cultural reasons, for example, language barriers or fear of authorities. The aim was also to gain information on the target group’s views on developing the service system, on procedures that would lower the threshold of seeking services and what they thought of the Snowball method’s suitability in the Finnish context as a work method of ethnic substance use work (Puro 2004).

The Aura Project executed, with a help from Correlation project, an multicultural Lumipallo educational programme in eastern Vinkki in spring/summer 2005. The operation focused on the questions of deportation and the situation and rights of immigrants in Finland.Both Finnish- and Russian-speaking drug users took part in the training. The training was organised in collaboration between employees of the Aura Project, Vinkki and Correlation. After the operation in spring 2005 Russian-speaking participants were recruited to a more profound training. The multicultural Snowball Educational Programme is explained in more detail in the following chapters.

2. What is Snowball ?

The Snowball Educational Programme is aimed at preventing threats such as HIV and hepatitis, and is based on the active participation of drug users. Originally it have developed in Belgium in 1987. It differs from other preventative drug services, because the workers are either former or still active drug users. Most of the people who have undergone Vinkki’s Snowball Educational Programme are active drug users. The goal of the trainees is to create contacts with other drug users. Their task is to find out the ways in which individuals take and use drugs, and inform them about how to prevent the risks associated with spreading infectious diseases (e.g., risks assocated with injection and sexual contacts). The trainees’ duties also include informing other drug users how to prevent poisoning and overdoses connected with drug use, as well as informing them about first aid.

As a method for the decreasing the harm associated with drug use, the main goal of Snowball is to inform drug users about the risks involved in their actions and how to reduce them. The second goal is to inform drug users about available services, such as health advice centres. The third goal is to collect information on drug users’ experiences, behaviour patterns and attitudes, and communicate this silent knowledge to decision makers.

The trainees’ duty is to participate in the entire training course. The overall view of the education is formed by topical meetings and a fieldwork period. During the outreach period, trainees must meet 10 different drug users and interview them. During this period, trainees are also taught how to act as peer workers and share information about harm reduction. Trainees will also commit to sharing their own experiences, thoughts and opinions amongst other trainees and teachers. Listening and respecting others means respecting yourself. This is also important because the trainees must remain non-judgemental towards their fellow drug users whilst working in the field.

Trainees are encouraged to contact the organisers every time they come across questions to which they do not know the answers. The outreach period of the educational programme is demanding and may create problems and situations that seem impossible at the time. Together, with the instructor and possibly with another trainee, solutions will be found to all problems. Mutual support and solidarity are both concepts learned in Snowball.

‘Great interaction between the users and the health care staff’.

‘Mutual benefits for both the instructors and the participants’.

3. Services of the Vinkki Health Advice Centre and levels of peer support

A Clinic Foundation’s Vinkki Health Advice Centre in Helsinki, which provides services for drug users, bases its operation on reducing drug-related harm. At Vinkki, users can exchange their dirty syringes and needles for new, clean ones, as well receive health advice, guidance and help for taking care of their own health. It is also possible to receive vaccinations for hepatitis A and B, testing for HIV, hepatitis and STIs, pregnancy testing and medical care for small fees, as well as to receive guidance and support for seeking a refuge and/or managing daily tasks. Peer work amongst clients is an important part of Vinkki’s services (Malin 2005).

The aim of peer work is to ensure that the health advice reaches user networks via the same route that the disease-causing viruses do – that is, through the drug users who are trained as peer workers. Vinkki Health Advice Centre already has several peer workers (mentors and assistants) who work in the field distributing health advice to drug user networks about the importance of clean injection instruments and infectious diseases. Peer workers are not required to stay sober. The whole basis of the idea is that the peer workers can feel accepted even if they use drugs. The originality and strength of Vinkki’s peer work lies in the similar and equal lifestyles of the peer worker and the drug user. Both are in the same boat, so to speak (Malin 2005). The levels of Vinkki’s peer work are as follows:

1^st level

PEER SUPPORT = Vinkki’s clients exchange information, knowledge and experiences on drug use. Peer support, i.e., ‘from me to you’ support, is equally given and received at Vinkki and within drug user networks.

2^nd level

MENTORS = Mentors have completed the health advice education (Snowball Educational Programme, customised trainings, etc.) and pass on the health advice knowledge to drug user networks.

3^rd level

ASSISTANTS = Assistants have completed both the basic and the advanced training of the Snowball Educational Programme. They receive customised duties which they carry out at the health advice centres or within drug user networks.

‘More information so that you can’t miss it’

4. Planning and realisation of the multicultural Snowball Educational Programme

4.1 Planning

The Aura Project carried out a Snowball peer education programme in Spring/summer 2005,with the help of Correlation project at the Vinkki Health Advice Centre in Helsinki. Snowball educational programmes have been organised for drug users at Vinkki since 2001. It was important for the success of the multicultural Snowball Educational Programme that Vinkki’s Correlation employees took part in the planning of the training. The training was, therefore, organised in close collaboration between the employees of Vinkki and the employees of the Aura Project. The planning of the training benefited from Vinkki’s employees’ know-how and experience in organising training seminars. The topics of the training were formed based on previous Snowball educational programme themes. Because the target group for the training was Russian-speaking drug users, one important training topic was the status of foreigners in Finland as well as deportation issues.

Participants for the training seminar were recruited from Vinkki’s client base. Recruitment was carried out by employees of both Vinkki and the Aura Project by asking clients to take part in the training. Clients were motivated to participate by telling them about the content, responsibilities and rewards involved in the training. They were also told that participating in the training requires a committment to attend every topic meeting and fieldwork session.

4.2 Realisation

The training was named the multicultural Snowball Educational Programme because people from different nationalities (Russian, Finnish and Roma) took part in it. Ten clients in total completed the Multicultural Snowball Educational Programme, five of them were Finnish and five of whom were from foreign countries. The purpose of the training was to inform drug users about infectious diseases related to drug and sexual contact, as well as overdose, first aid, the Finnish substance use services and legislation.

Training was held at the premises of the Vinkki Health Advice Centre. Coffee and food was served at each training session. The first training session concentrated on getting to know each other, using various games and role plays. Each participant received a folder, which contained written material on the topics discussed. There was also an interpreter on hand to translate from Finnish to Russian and vice versa. When planning the training, it was considered a necessity that the Russian speaking trainees could get information in their own language.

The timetable for the Snowball Educational Programme was as follows:

Tuesday 19.4.2005 – The Snowball Method and Grouping

Thursday 21.4.2005 – Overdose and First Aid / Ambulance medical officer James Boyd

Tuesday 26.4.2005 – Finland’s Social Affairs and Health Services / Kirsi Marttinen and Marina Stendahl

Thursday 28.4.2005 – Hepatitis / Researcher Markku Kuusi

Monday 2.5.2005 – HIV, AIDS and Safe Sex / Henna Korte

Tuesday 3.5.2005 – The Status of a Foreigner in Finland and Deportation Issues / Solicitor Markku Fredman

Preparing for fieldwork sessions

Fieldwork session 4—31.5.2005

Tuesday 31.5.2005 – Conclusion of Snowball and Assessment

After training for two weeks, trainees moved on to the outreach sessions. During outreach sessions, trainees distributed the health advice and information they had learned during training among their own user networks. Along with information, trainees also interviewed drug users and filled in a questionnaire. The purpose of the interview, as well as the questionnaire, was to collect information on how much drug users really know about infectious diseases, for example. Each trainee interviewed ten different drug users during the outreach period.

At the end of the Snowball Educational Programme, trainees met for a feedback meeting to return all completed questionnaires and to assess the success of the training. At the end of the meeting, all participants received a certificate and €100 as a token of appreciation for taking part. An assessment day was also organised for all employees who took part in the training programme.

‘A great project that works well. The interview was easier to conduct with a person you already knew. Every user should have a place with humane conditions to spend a night in, clean up and cook’.

5. Assessing the training

5.1 Assessing the trainees

At the final meeting, trainees assessed the success of the training programme. The assessment was conducted as a group assessment using SWOT analysis. Participants formed two groups: a Finnish-speaking group and a Russian-speaking group. The aim of the division into groups was to bring out the different opinions and ideas that any cultural differences formed. The Russian-speaking group included employees from Vinkki and the Aura Project, as well as an interpreter and guests from PRO Support centre and St. Petersburg. The Finnish group included employees from Vinkki and a project researcher from the A Clinic Foundation. The SWOT analysis is described below.

STRENGTHS / RUSSIAN-SPEAKING

Training

- Good and warm atmosphere

- Easy to be part of the group due to the relaxed atmosphere

- Maximum length of the training session was 3 hours

- Received enough information on treatment clinics

Fieldwork Sessions

- Interviews were conducted for both Russian- and Finnish-speaking people

- Approximately 90% of people accepted leaflets, which were also actively distributed

- Most of the interviewees knew about hepatitis A, B and C; hepatitis D and E were unfamiliar to them

- Re-infection was familiar to 50% of the interviewees

- Older interviewees knew about infectious diseases

- Young interviewees did not know about infectious diseases or risks related to them

- No problems occurred when interviewing Russian-speaking people

STRENGTHS / FINNISH-SPEAKING

Training

- Received information on fieldwork

- Received information on infectious diseases

- Received information on infectious disease situation in nieghbouring regions

- The theoretical meetings of the training were important for establishing correct information

- Good staff and catering at training

- The functionality of theoretical meetings is a positive thing

- Trainers were good

- Distributing condoms is a positive thing

Outreach Sessions

- Information reached drug users through interviews

- Interviewees were not afraid to ask questions on subjects they did not know about

- Reminder notes on the questionnaires were good and helpful

WEAKNESSES / RUSSIAN-SPEAKING

Training

- Questionnaire had questions about tuberculosis although it was not discussed in the training

- Although there was a lot of information about treatment clinics, there was not enough information about seeking and receiving treatment

- One of the lecturers (a solicitor) portrayed an overly positive and hopeful picture on things (also a threat)

- Some of the trainers discussed matters too theoretically

Outreach Sessions

- Trouble finding interviewees, because the drug user circle is so small and most had already participated in Snowball, which then created overlapping interviews

- The questions related to sexual behaviour were difficult, particularly those regarding paid sex

- Russian-speaking trainees found it difficult to find people to interview

- Too many questions on hepatitis

- Hepatitis was difficult to explain, especially to underage interviewees

- Getting information on the risks and dangers of drug use is altogether insufficient in Finland

- Material did not include information regarding places where users can exchange syringes and needles

WEAKNESSES / FINNISH-SPEAKING

Training

- Questionnaire had questions about tuberculosis although it was not discussed in training

- One of the lecturers was not sympathetic to the trainees; bad attitude

- New drugs were not discussed

- Some of the trainees did not commit to attending every training session

- Training sessions should include more activities; now, it includes too much theory

- Insufficient discussion regarding injection and its associated risks

- It is a bad thing that there is no advanced training for the Snowball Educational Programme

- More information should be provided on hepatitis C

Outreach Sessions

- Conducting interviews is hard work

- Interviewees did not believe what mentors were saying (also a threat)

- No premises for peaceful interviewing (also a threat)

POSSIBILITIES / RUSSIAN-SPEAKING

Training

- Additional meetings for participants should be organised (social evenings)

- Vinkki’s client base needs a sense of community

- Vinkki’s activities could be expanded to other life areas as well, for example, organising trips and other fun group activities, so that clients can for a moment forget that they are users

- Consider how to reach unreachable drug users to come to Vinkki and get involved in activities and training

Outreach Sessions

- The peer work that takes place in the field needs a more official certificate; the current document does not convince police of the work carried out. (One arrest occurred during Snowball’s fieldwork sessions, even though a certificate was shown.)

Comments from employees:

- Training meetings could also include topics other than those directly connected with drug use. Meetings could also be held somewhere other than on Vinkki’s premises

- Snowball’s course certificates could be more official looking, and have, for example, the A Clinic’s stamp and lamination; this would enhance the feeling of having completed a valuable training which is also respected by the organisers

- The fieldwork session could include a shorter questionnaire as an alternative to the current longer one

- Peer worker’s social status, perceived as equals and role amongst professionals is important

- A list of physicians who help drug users should be included for use during in the fieldwork sessions

POSSIBILITIES / FINNISH-SPEAKING

Training

- In future, it’s important to organise recreational activities for all Snowball graduates

- Health advice services and the Snowball educational programmes should also be organised in other parts of Finland

- ‘Meet and greet’ visits should be available to Vinkki for new clients

- The Snowball Educational Programme could be organised for non-users as well, so that they too can distribute information

- People who do not use drugs should be informed about the services available through health advice centres

- Trainings save money as infectious diseases do not spread

Outreach Sessions

- Interviews can motivate new people to participate in training

THREATS / RUSSIAN-SPEAKING

Training and outreach sessions

- New people will not be reached if the content of the Snowball Educational Programme is not updated; new topics and methods of realising them are needed

- Civilian police officers are a threat to the work of mentors

- Russian-speaking drug users are familiar with Finnish legislation in theory, but do not even attempt to sort out their issues because they think it will not make a difference when dealing with solicitors

- There are no CCTV cameras around Vinkki’s premises

THREATS / FINNISH-SPEAKING

Training and outreach sessions

- People are participating in the training solely because of the money

- If the drug users’ circumstances are unstable, they cannot finish their training

- New interviewees are no longer reached

5.2 Assessing the employees

An assessment day was organised for all participants of the multicultural Snowball Educational Programme. The purpose of the assessment day was to assess the training as a whole. Whilst assessing the planning of the training, special attention was paid to the planning process, the team, timetable, division of labour, distributed materials and their production, as well as the content of the training, and the most essential development needs.

The aim of the training’s realisation assessment was to concentrate on the realisation process, recruitment of trainees, the content and topics of the training, and work on training sessions’ amongst the responsible persons, as well as the lecturers, practical organization of the training sessions, field period, realisation of the trainees’ assessment and the most essential development needs.

The assessment day was attended by employees of the Aura Project from the A Clinic Foundation and PRO Support Centre, the employees of Vinkki who participated in the training, as well as a project researcher from the A Clinic. The content of the assessment day is detailed below:

5.2.1 Assessing the planning and the most essential development needs

Symbols explained:

Assessment ( - )

Development needs (è)

Planning process as a whole

- The planning process differed from previous Snowball Educational Programmes because the initiative originated with the Aura,Correlation Projects rather than from the client base, which has been the ‘ideological’ basis of previous Lumipallo educational programmes

- The planning process, therefore, started in a new manner for the employees of Vinkki as well; there was pressure to organise a Russian-speaking training based on the goals of the project

The following also affected the commitment of the employees:

- The planning process had to be started on a tight schedule (e.g., less than two months was spent on planning)

- One of the Aura Project’s employees had only been working at Vinkki for less than a month, so the schedule was too rushed in this respect as well (e.g., the time to get to know clients was too short)

-> Must consider the basis of the operational organisation

-> Must schedule enough time for planning

-> Must pay attention to the staff’s abilities to commit to the operation

-> Must consider how clients could participate in the operational planning

Teamwork and the division of labour

- The lack of a work pair increased confusion regarding the division of labour

- The plan on how different employees participate in the training was not agreed upon until the last minute

- The employees’ holiday schedule did not blend in with the realisation of the training

- The preparatory tasks for the operation were completed in tandom with other duties

- The time needed for preparatory tasks was unknown/not planned for, although the time needed, for example, for printing and purchasing was considerable

-> Training needs a work pair that carries the overall responsibility

-> The work pair structure clarifies the division of labour

-> Holiday and operational plans and timetables should be combined

-> The time needed for preparation must be defined during the planning stage and taken into consideration for each employee’s work plan

Timetable

- An overly hectic timetable made the whole planning more difficult: content, recruitment, production of materials and translation

- Preparation tasks, such as printing, were done amongst other duties

- The news about Vinkki’s move added to the rush and disrupted resources. The move was not known at the planning stage of the operation

-> Must schedule enough time for planning and preparatory tasks

-> Must schedule enough resources for planning and preparatory tasks

-> Must consider how to save time and financial resources during material production; ordering services (e.g., printing) from a third party

Training content

- The training material was finished too late from the point of view of translation; there was also uncertainty about what materials needed translating

- The training rules about trainees’ absences, tardiness, or leaving during training as well as compensation for the above-mentioned were not considered beforehand, which meant that there was no mutual procedure which further added to the uncertainty with regards to employee actions

- The questionnaire was too long and there was some uncertainty about correct answers

- There were not enough questions designed specifically for the Russian-speaking clients

- The questionnaire included questions on matters that were not discussed at the training

-> Must schedule enough time for the translation of materials

-> Must plan the training material carefully

-> The contents of the training and the questionnaire must correspond with one another

-> The questionnaire must include a list of correct answers

-> Must consider which questions from the questionnaire are relevant to each operation, and what other questions could be added according to the viewpoint of ongoing fieldwork

-> The questionnaire should also be updated according to the viewpoint of Vinkki’s client feedback and other important matters about Vinkki’s activities

-> Rules (for example, absences and compensation) must be agreed upon in advance

-> In future, the content of the training could be planned and executed so that it is more individually tailored to different target groups

-> In future, there should be a separate plan for how to utilise the materials produced (such as the Russian-language materials) after training has finished

5.2.2 Assessing realisation and the most essential development needs

Symbols explained:

Assessment ( - )

Development needs (è)

Realisation process as a whole and content of the training

- Training is too theoretical, particularly the lecture on hepatitis

- The actual work, i.e., the use of functional methods, was not sufficient

- At times, the training sessions had a restless atmosphere

- The solicitor’s contribution to the Russian-speaking group was not sufficient (only 1 hour). There could have been more focus on questions relevant to the Russian-speaking group (e.g., deportation issues, etc.)

- Some of the guests asked too many questions which left insufficient time for the actual trainees

-> Training needs more practical information

-> Training needs more functional methods

-> Training sessions need careful preparation and possible interference factors (such as, the seating order, which may increase restlessness) must be anticipated

-> Guests must be well informed regarding their roles in advance

-> Any special needs of the training group must be considered

Recruitment

- The recruitment of the trainees was different from previous Snowball operations, i.e., it was executed based on workers

- The recruitment principle was changed during the process, i.e., expanded from Russian-speaking to Finnish-speaking

- The group of trainees represented various drug cultures

6. Results from interviews completed during the outreach sessions

6.1 Sociodemographic information of the interview participants

6.1.1 Place of interview, age, sex, official domicile, nationality and mother tongue

A total of 104 interviews with individuals were conducted during the outreach session of the Snowball Educational Programme, 62 (60%) of whom were Finnish and 42 (40%) of whom were from other countries. Most of the interviews from both groups were conducted in eastern regions of Helsinki, such as Kontula, Itäkeskus and Mellunmäki. Some of the interviews took place in Vantaa, Espoo, Porvoo, Seinäjoki and Tallinn. The average age of Finnish interviewees was 28, while the average among foreigners was 25. The Finnish group included 37 (60%) men and 25 (40%) women, while the foreign sample included 34 (81%) men and only 8 (19%) women.

In the foreign-born sample, 47 (88%) individuals said they were officially studying in Finland, three (17%) in Estonia and two (5%) in Russia. Among foreigners, 17 individuals (40%) said their nationality was Estonian and 13 (31%) were Russian. Other stated nationalities included Georgian, Latvian, Lithuanian and Ukrainian. Six people (14%) said they were without a nationality. Among the foreign-born sample, most people, i.e., 32 (76%) said their mother tongue was Russian, five (13%) said Russian and Finnish, three (7%) said Estonian, one (2%) said Vietnamese, and one (2%) said Georgian.

Percentage-wise, our sampling was good result, since 40% of those who took part and were interviewed were foreign-born.

‘This is a great project, because you learn a lot and are not embarrassed to ask questions since you know the person conducting the interview’.

6.1.2 Domicile, employment situation and education

Among the Finnish sample, 46 (74%) had a permanent domicile and 16 (26%) did not. Among the foreign sample who live in Finland officially, 31 (84%) had a permanent domicile and 6 (16%) did not. Considering that the average age of the foreign interviewees was 25, and most had a permanent domicile, it was assumed that most of them still lived with their parents.

Among the Finnish group, 51 (82%) did not have paid employment and 11 (18%) did. Among the foreign interviewees officially living in Finland, 20 (54%) did not have paid employment and 17 (46%) did. Among the Finnish respondents who answered the question their place of study, 33 (92%) were not currently studying and only 3 (8%) did.

The number of foreign respondents in paid employment was considerably high compared to the Finnish sample – 46% vs. 18%.

‘I wish I’d get help in finding accommodation’.

6.1.3 Substitution therapy

Among the Finnish respondents who answered the question on substitution therapy, 13 (21%) said they had occasionally received official substitution treatment in Finland. At the time of the interview, 5 (9%) said they had occasionally been within the substitution treatment range in Finland – 3 people (60%) said they had received subutex, and 2 (40%) said they had received suboxone substitution therapy at the time of the interview.

Among the foreign-born respondents who answered the question about substitution treatment, 6 (16%) said they had occasionally received official substitution therapy in Finland. At the time of the interview, 5 people (15%) said they had received official substitution treatment in Finland. All of the people, who had received substitution treatment had been given methadone as the substitution treatment medicine.

‘More substitution treatment clinics are needed; the queues are too long’.

6.2 Injection drug use

Among the Finnish group, 56 (90%) said they had occasionally used drugs by injection. The average age for initiating injecting drug use was 18. Of those who answered the question about negative information, 21 (38%) said they had not received any negative information about injecting drug use before initiating it. Thirty (30) respondents (55%) said they had heard that injecting is addictive; 31 (56%) had heard that injecting drug use exposes one to HIV and hepatitis; 29 (52%) had heard that injecting carries the risk of overdose; and 9 (16%) had also received other negative information about injecting drug use, such as the chills and inflammations.

Among the foreign sample, 35 (83%) said they had occasionally used drugs by injection. The average age for initiating injecting drug use was 18. Among those who answered the question about negative information, 7 (21%) said they had not received any negative information about injecting drug use before initiating it; 23 (68%) said they had heard that injecting is addictive; 21 (62%) had heard that injecting drug use exposes one to HIV and hepatitis; an 22 (65%) had heard that injecting carries the risk of overdose.

Among the Finnish respondents who answered the question about positive information, only 4 (8%) said they had not received any positive information about injecting drug use before initiating it; 38 (72%) said they had heard injecting makes you feel good; 40 (76%) had heard that drugs work better when injected; and 15 (28%) said they had received some positive information about injecting, e.g., less drug is needed and injecting is cheaper.

Among the foreign sample who answered the question about positive information, only 2 (7%) said they had not received any positive information about injecting drug use before initiating it; 21 (68%) said they had heard injectng makes you feel good; 24 (77%) had heard that drugs work better when injected; and 5 (16%) said they had received some positive information about injecting, e.g., less drug is needed and injecting is cheaper.

Among the Finnish interviewees who answered the question about injecting drug use, 22 (40%) said the first time they injected was at a friend’s house,18 (33%) said their first injection occurred at home, 8 (14%) on the street, 5 (9%) at a partner’s home, one (2%) in prison, and one (2%) in a restaurant lavatory. Forty (40) Finns (73%) said someone else had injected them the first time. Tips for injecting were mostly received from user friends (67%), but also from one’s partner (18%). Approximately every fifth Finn said noone had encouraged them to inject. The biggest reason for injecting use was curiosity (64%). Almost half (45%) said the injection just happened, 28% said they injected because they knew it would affect them immediately, 26% because someone else had suggested it, 17% due to financial reasons, and 13% had been planning on injecting for quite a while.

Among the foreign respondents who answered the question about injecting drug use, 14 (41%) said the first time they injected was at a friend’s house, 11 (32%) said their first injection happened on the street, 5 (15%) at home, two (6%) in prison, one (3%) at a partner’s home, and one (3%) somewhere else. Twenty-six foreigners (79%) said someone else had injected them the first time. Tips for injecting were mostly received from friends (71%). Approximately every fifth (18%) foreigner said noone had encouraged them to inject, and approximately every tenth (12%) had received advice from a partner. Over half of the interviewees (53%) said the biggest reason for injecting use was curiosity, 32% said they injected because they knew it would affect them immediately, 27% because someone else had suggested it, 27% due to financial reasons, 18% had been planning on injecting for quite a while, and 15% said the injection just happened.

The most commonly used drugs in the past month among both Finnish and foreign respondents were amphetamines, subutex, cannabis and benzodiazepines. Many people said they also used suboxone and heroin. Heroin use was more commonly among the foreign respondents than among the Finnish sample. The most common administration method in both groups was injecting.

The average age for injecting drug users was 18 among both samples, and injecting was started most often with a friend. The information received from friends about the positive affects of injecting seemed to be the biggest factor in initiating injecting drug use. The peer and harm reduction work amongst youngsters must be greatly expanded so that the information reaches them before they initiate harmful injecting drug use.

‘I need clean needles, but haven’t dared to go and ask for any from health advice centres due to my shyness.’

6.3 Risk behaviour linked with drug use and sexual contact

Among the Finnish respondents who answered the question about injecting instruments, almost half (46%) said they had borrowed someone else’s syringe in the past six months. Some (6%) also said that, in the past six months, they had used a syringe they had found. More than half (59%) had lent their own syringe to someone else in the past six months. Half (50%) had used someone else’s other administration equipment (injecting portion dish, ‘clique cup’, filter, etc.) in the past six months. Almost half (46%) had lent their other administration equipment (‘clique cup’, filter, etc.) to someone else.

Among the foreign respondents who answered the question about injecting instruments, every fourth (26%) said they had borrowed someone else’s syringe in the past six months. Some (7%) also said that in the past six months they had used a syringe they had found. Less than half (41%) had lent their own syringe to someone else in the past six months. Approximately every third (30%) individual had used someone else’s other administration equipment (‘clique cup’, filter, etc.) in the past six months. Over half (52%) had lent their other administration equipment to someone else.

Among the Finns who answered the question about sexual partners, over half (55%) said they had had one sexual partner in the past six months. A third (33%) had had two or more sexual partners and every tenth (12%) had had none. Most of the people (71%) who answered the question about unprotected sex said they had had unprotected sex in the past six months. Of those who answered the question about paid sex, every tenth (10%) said they had received drugs or money in exchange for sex.

Among the foreign respondents who answered the question about sexual partners, 40% said they had had one sexual partner in the past six months. Thirty-eight percent (38%) had had two or more sexual partners and 22% had had none. Over half of the people (54%) who answered the question about unprotected sex said they had had unprotected sex in the past six months. Out those who answered the question about paid sex, every tenth (10%) said they had received drugs or money in exchange for sex.

The answers from both the Finnish and foreign groups show a real need for intensifying health advice and peer work. Approximately half of the interviewees from both groups had in the past six months been in high risk situations connected with injecting drug use and sexual relations.

‘It’s good to get information on matters you are too embarrassed to ask about elsewhere’.

6.4 HIV

Among the Finnish respondents who answered the question about HIV testing, most (88%) said they had occasionally been tested for HIV. Over half (54%) had been tested at a health advice centre, 43% in prison, 41% in a hospital, 37% in a health centre, and 20% in a drug treatment clinic. Among those who answered the question about HIV positive status, two (4%) had tested positive for HIV. The result of the latest test had been received on average about 13 months prior to the interview.

Among the foreign respondents who answered the question about HIV testing, most (85%) said they had occasionally been tested for HIV. Just under half (43%) had been tested at a drug treatment clinic, 37% in a health centre, 26% at a health advice centre, 23% in a hospital, and 23% in prison. Of those who answered the question about HIV positive status, noone had tested positive for HIV. The result of the latest test had been received on average about 5 months prior to the interview.

Most (95% and 93%, respectively) of the Finnish and foreign interviewees knew that HIV is transmitted through anal and vaginal intercourse without a condom. Every tenth (10%) individual thought that HIV could also be caught through consuming the same food or drink; 79% of the Finnish sample thought that HIV could be transmitted from mother-to-child during pregnancy, whereas just 67% of the foreign sample thought the same; 8% of the Finnish and 14% of the foreign sample thought that HIV could be transmitted via shared cigarettes or marijuana joints. Most (95% and 93% respectively) of the Finnish and the foreign samples knew that HIV was transmitted through shared syringes and needles. Every fifth (19%) Finnish respondent believed that HIV could be transmitted by kissing, whereas 40% of the foreign sample thought the same. Only 8% of the Finnish sample thought that HIV could be transmitted through a handshake, whereas 19% of the foreign sample thought the same; 77% of the Finnish and 69% of the foreign samples believed that HIV could be transmitted via oral sex. Ninety percent (90%) of the Finnish and 88% of the foreign sample believed HIV is transmitted via tattoo and piercing instruments; 77% of the Finnish and 71% of the foreign sample believed HIV could be spread through shaving instruments. Additionally, 71% of the Finnish and 55% of the foreign sample thought HIV could be spread via toothbrushes. The questionnaire also had questions about re-infection. Only 37% of the Finnish and 40% of the foreign sample knew what HIV re-infection is (see Table 1).

Table 1. Interviewee conceptions on HIV transmission routes (in percentages)

Transmission route	Finnish N= 62	Foreign N= 42
Anal / vaginal intercourse without a condom	95 %	93 %
Consuming the same food or drink	10 %	10 %
From mother-to-child during pregnancy	79 %	67 %
Via cigarettes or marijuana joints	8 %	14 %
Through shared syringes and needles	95 %	93 %
Through kissing	19 %	40 %
Through a handshake	8 %	19 %
Via oral sex	77 %	69 %
Via tattoo and piercing instruments	90 %	88 %
Via shaving instruments	77 %	71 %
Via toothbrushes	71 %	55 %

The general knowledge on HIV transmission routes was good among both groups, but knowledge on re-infection was completely inadequate.

‘Better than good. There are a lot of druggies who don’t know about the risks. It’s good that your own crowd distributes information on HIV; maybe the users will become more responsible’.

6.5 Hepatitis

Among the Finnish respondents who answered the question about hepatitis A testing, 23 (40%) said they had occasionally been tested for hepatitis A. Among those who answered the question about hepatitis B testing, 47 (84%) said they had occasionally been tested for hepatitis B. Forty-seven (87%) who answered the question about hepatitis C testing said they had occasionally been tested for hepatitis C. Every seventh (14%) respondent who answered the hepatitis A question said they had suffered from hepatitis A. Every sixth (16%) individual who answered the hepatitis B question said they had suffered from hepatitis B, and 95% of those who answered the hepatitis C question said they had been diagnosed with hepatitis C. Seventy percent (70%) of the Finnish respondents who answered the question about hepatitis A vaccination said they had been vaccinated for hepatitis A, while 77% had been vaccinated for hepatitis B.

Among the foreign respondents who answered the question about hepatitis A testing, 30 (79%) said they had occasionally been tested for hepatitis A. Of those who answered the question about hepatitis B testing, 33 (83%) said they had occasionally been tested for hepatitis B. And, 85% of those who answered the question about hepatitis C testing said they had occasionally been tested for hepatitis C. Every fifth (19%) individual who answered the hepatitis A question said they had suffered from hepatitis A. Also, every fifth (19%) individual who answered the hepatitis B question said they had suffered from hepatitis B, and 81% of the people who answered the hepatitis C question said they had been diagnosed with hepatitis C. Sixty percent (60%) of the foreign respondents who answered the question about hepatitis A vaccination said they had been vaccinated for hepatitis A, while 67% had been vaccinated for hepatitis B.

Seventy-four percent (74%) of the Finnish and 88% of the foreign sample thought that hepatitis C was transmitted through anal and vaginal intercourse without a condom. Approximately every tenth (11%) Finn and every fifth (19%) foreigner believed that hepatitis C was transmitted by consuming the same food or drink; 71% of Finns and 74% of the foreigners thought that hepatitis C was transmitted from mother-to-child during pregnancy. Half (50%) of the Finnish and every fifth (19%) foreign respondent believed hepatitis C could be transmitted via sharing cigarettes or marijuana joints. Most (92% and 98%, respectively) of the Finnish and foreign respondents said hepatitis C was transmitted through shared syringes and needles. Eighty-four percent (84%) of Finns and 95% of foreigners believed hepatitis C was transmitted through shared filters, spoons or clique cups. Every sixth (16%) Finn and every fourth (26%) foreigner believed hepatitis C could be transmitted by kissing; 23% of Finns and 29% of the foreigners thought hepatitis C could be transmitted via snuff pipes, and 73% of the Finnish and 74% of the foreign respondents said hepatitis C was transmitted via oral sex. Only 77% of the Finnish sample said hepatitis C could be transmitted via tattoo and piercing instruments, whereas 93% of the foreign sample thought the same. And, 74% of the Finnish and 76% of the foreign sample said hepatitis C could be transmitted via shaving instruments, and 61% of the Finnish and 64% of the foreigners believed hepatitis C could be transmitted via toothbrushes (see Table 2).

Table 2. Interviewee conceptions on Hepatitis C transmission routes (in percentages)

Transmission route	Finnish N= 62 (%)	Foreign N= 42 (%)
Anal / vaginal intercourse without a condom	74 %	88 %
Consuming the same food or drink	11 %	19 %
From mother-to-child during pregnancy	71 %	74 %
Via cigarettes or marijuana joints	50 %	19 %
Through shared syringes and needles	92 %	98 %
Through shared filters, spoons or clique cups	84 %	95 %
Through kissing	16 %	26 %
Through snuff pipe	23 %	29 %
Via oral sex	73 %	74 %
Via tattoo and piercing instruments	77 %	93 %
Via shaving instruments	74 %	76 %
Via toothbrushes	61 %	64 %

The prevalence of hepatitis C in both groups is alarmingly high. The number of clients who had received vaccinations for hepatitis A and B was at a good level, due to the Finnish vaccination programme for injecting drug users.

‘I’d like some help monitoring my hepatitis/liver values’.

6.6 Overdose

Among the Finnish respondents who answered the question about overdoses, 31 (52%) said they had occasionally overdosed on drugs. Of those who answered the question about hospital care, 18 (58%) said they had occasionally received hospital care due to an overdose. Likewise, 39 (71%) Finns who answered the question about other overdose situations said they had occasionally been present at someone else’s overdose; 29 (69%) of those who answered the question about first aid had administered first aid in an overdose situation. The first aid administered usually involved resuscitation, face slapping, calling the emergency number, and taking the individual for a cold shower.

Among the foreigners who answered the question about overdoses, 10 (25%) said they had occasionally overdosed on drugs. Of those who answered the question about hospital care, seven (70%) said they had occasionally received hospital care due to an overdose. Likewise, 27 (82%) foreigners who answered the question about other overdose situations said they had occasionally been present at someone else’s overdose situation; 20 (71%) of those who answered the question about first aid had administered first aid in an overdose situation. The first aid administered usually involved resuscitation, face slapping, calling the emergency number, and taking the individual for a cold shower.

Folk remedies (such as taking a patient for a cold shower) were still used in overdose situations. Accurate and relevant advice on how to act in overdose situations is still important to our clients.

‘It is brilliant in a way that certain myths are abolished and one can get realistic information’.

6.7 Using services

Among those who answered the question about exchanging syringes and needles, 96% of the Finns and 85% of the foreigners said they had received clean syringes and needles from the health advice centre. An interesting observation was the fact that most (91%) of the foreigners said they had purchased clean syringes and needles from the pharmacy. The corresponding figure amongst Finns was 85%; 39% of the Finnish and 21% of the foreign sample said they had also used the services of a mobile health advice unit (see Table 3). Clean injecting equipment was also obtained from friends.

Table 3. Places where interviewees exchanged their syringes and needles

Place	Finnish N=52 (#)	Finnish %	Foreign N=34 (#)	Foreign %
Health advice centre	50	96	29	85
Pharmacy	44	85	31	91
Mobile unit	20	39	7	21

The questionnaire surveyed the interviewees’ service needs for the following six months. The most common places from which services were received included health advice centres, A clinics, test and vaccination centres, substitution treatment clinics, rehabilitation centres, health centres, physicians, pharmacies, social welfare offices and prisons.

The questionnaire shows that the use of health advice centre services is good among the interviewees. There is, however, a demand for more information on minimising harmful factors. Peer workers’ help in distributing this information is essential. The wide demand for social welfare and health services among our clients puts health advice centres in a position where networking and the distribution of information on a wide scale about the available services is important.

‘I think it’s a brilliant project. Important information about infectious diseases and prevention methods can be distributed to people who don’t yet know everything. The voice and viewpoints of users is heard and both new and old information is distributed. I’m sure everyone receives some new information, for example, about treatment and the risks associated with drugs. It also may motivate users to quit. I myself am interested in getting information, for example, about resuscitation’.

6.8 Summary of the interview material

Based on the interview data from both the Finnish and the foreign groups, it can be established that more women were reached in the Finnish sample than in the foreign sample. The average age among the foreign interviewees was younger than among the Finns. Most of the foreign interviewees seemed to be living in Finland officially. Most of them were Estonian, however, most said their mother tongue was Russian.

Particularly noteworthy was the fact that almost half of the foreign interviewees said they were in paid employment. The corresponding figure amongst the Finnish sample was considerably lower. The average age for initiating injecting drug use was 18 in both groups. The first ever injection happened at a friend’s place for most people in both samples. The most common drugs used were amphetamines, subutex, cannabis and benzodiazepines, although heroin use was more common among foreigners than among Finns.

In the past six months, risk behaviour connected with injecting drug use seemed to be less common among foreigners than among Finns. This was also the case with sexual contact. However, in both groups, surprisingly many (every tenth) respondents said they had occasionally received money or drugs in exchange for sex.

In the foreign sample, nobody had been diagnosed with HIV, whereas two Finns reported being HIV positive. The foreign interviewees had had their latest HIV test a lot more recently than the Finns. An alarming finding was that less than half of all interviewees knew what HIV re-infection is.

The appearance of hepatitis C seemed to be less common within the foreign sample than within the Finnish sample. Also, overdoses occurred less frequently amongst the foreign sample than among Finns. The foreign interviewees seemed to exchange fewer syringes and needles at health advice centres than the Finnish respondents. The service needs were diversified in both groups. Therefore, it can be established that those interviewed had multiple problems and needed several services, particularly those provided by the public health service.

7. Conclusions

The planning and realisation of the multicultural Snowball Educational Programme succeeded fairly well overall. Organising the training was, however, a difficult process and required a lot of time and resources from its employees. When organising future Snowball educational programmes, more attention should be paid to scheduling enough time for the entire training process. Training that is organised in a rush and too quickly puts a strain on employees. Also, the responsibilities of each worker must be agreed upon and limited in advance, so that individual workers are not put under too much strain.

Recruitment for the training was successful. Overall, 11 people were recruited for the training of whom one had to leave for personal reasons after two training sessions. Ten trainees in total completed the training. Recruitment also needs to be considered when planning advanced trainings, so that enough trainees can be secured and motivated to take part. It is important for the success of the training that trainees are allowed to be part of the planning process. Peer work must be up-to-date and address ongoing phenomenon, challenges and problems. Also, the changing needs of the client base must be taken into consideration during training and in peer work in general (Malin 2005, 2006).

The Snowball educational programmes aimed at drug users are worthwhile because they spread health advice connected with drug use (e.g., hepatitis, HIV, injecting, etc.) within drug user networks. By training peer workers, the availability of clean injecting equipment can be more effectively secured within drug user networks. Through peer workers, drug users can also be educated and guided towards the available services. Peer work also allows drug users who are outside the service system to be reached. This work also brings new clients to the services of heath advice centres. An important viewpoint is that peer work enables contact with a minority group, such as Russian-speaking and Roma populations. The work in general reaches a diversified group of drug users, i.e., young persons, the elderly, casual users and users with with family. Peer work provides an opportunity to influence reigning attitudes, beliefs and actions amongst drug user networks. Peer workers also act as information distributors between the drug users and the authorities (Malin 2005, 2006).

One significant viewpoint is that the peer workers’ self respect grows through peer work and training. Seeing oneself as important and useful can be a significant factor in viewing and re-organising one’s own life. The drug users’ experience particularly the notion that they are valued just as they are, can be a first step in battling drug addiction. Training and peer work strengthen, and help one to see their own life from a different angle and can possibly also provide the push necessary to change one’s lifestyle (Malin 2005).

II PEER TRAINING IN A MULTICULTURAL ENVIRONMENT:

INDIVIDUAL TRAINING

1. The basis and background behind customised peer training

In the development of substance abuse services for people who have moved from the former Soviet Union, service modes carried out using the so-called low threshold principle are essential. Such service modes include, for example, independent services and improving the availability of support by expanding the languages in which services are available and cultural know-how. Based on the research here and resettlement issues, as well as language and cultural components, it is necessary to pay attention to the development of substance abuse services for Russian-speaking populations, especially with the help of peer work models. Through peer work, it has been possible to support the familiarity and empowerment of people who have moved to Finland from the former Soviet Union.

The aim of the Aura Project was to meet and support these Russian-speaking individuals whose circumstances put them at increased risk of societal exclusion through drug use. The basis of the training was to prevent the exclusion of drug users, direct them towards substance abuse-related services and support their empowerment by developing and executing the modes of individual and peer work activities. The starting point was also to lower the trainees’ threshold in seeking support from the social support and public health service systems.

The Aura Project carried out with a help from Correlation project an customised peer training programme during 2006. There was a demand for customised peer training from the client’s point of view. Some of the Russian-speaking clients were interested in the theoretical part of the Snowball Educational Programme, but not in the outreach sessions of the training. Some clients had previously undergone Vinkki’s Snowball Education Programme, and did not want to take part again. Clients also wanted to receive new information on drug-related matters. Also, the fact that Vinkki was mainly visited by the same familiar clients made it clear that there was no point in organising a new Snowball Educational Programme. Instead, the realisation of a new kind of training mode had to be contemplated.

The starting points of customised peer training differed from the starting points of the Snowball Educational Programme. Customised peer training wanted to try new methods in training often problematic and hard to reach drug users. The aim was to provide training using a low threshold principle according to the trainees’ own needs. Training was provided as individual education. Individual education made it possible to discuss the trainees’ personal matters openly during the meetings. The privateness of the training grabbed the trainees’ interest and got them to participate in it. In practice, this meant that trainees received training when it was most suitable for them and when they felt able to take in the information. The length of the training meetings depended on the concentration skills, resources and health of the trainees. Meetings were organised in a flexible manner and the trainee had the opportunity to rearrange meeting times by calling an employee of the Aura Project. The meeting places varied according to the agreements and the circumstances of the trainees, i.e., trainees who were receiving substitution treatment were not met at the premises of the Vinkki Health Advice Centre. The content of the training was designed so that some of the topics were compulsory for all trainees and some were formed according to trainees’ own individual interests. The theoretical and fieldwork sessions of training were realised simultaneously. At the beginning of the training, theoretical meetings were organised about once a week, but as the training progressed the theoretical meetings lessened. In between theoretical meetings, trainees worked in the field amongst their own social networks.

2. The objects of customised peer training

The aim of the customised peer training was to survey the situation amongst drug users in the field, and to find out how many of the Russian-speaking users did not use the services of the Vinkki Health Advice Centre, and why.

The aim of the customised peer training was to recruit clients to use the services of Vinkki Health Advice Centre as well as to guide them towards other treatment services. The aim was also to find out what kind of incorrect knowledge drug users held, for example, about infectious diseases and different types of treatment and services.

Distributing accurate information to young persons and drug users living outside the service systems was the aim set for peer training. Information was distributed, for example, by distributing printed materials.

One important aim was the prevention and reduction of drug-related harm amongst those drug users who do not inject drugs. Such clients were, for example, those receiving medical substitution treatment. Through training, it was also possible to support the drug user’s own desire and motivation to change at all stages of drug abuse. With many drug users, discontinuing injecting was more likely than quitting drugs altogether. Customised peer training also made it possible to develop different treatment relationships and provide trainees with help, support and interpreting services flexibly in different situations.

3. The content and topics for customised peer training

The customised peer training was designed so that part of the content and training topics were compulsory for all trainees. Part of the training content was agreed upon together with the trainees. The topics agreed upon with trainees varied according to the trainee’s own interests and goals. The compulsory part of the training is detailed below:

1. Goals and content of the peer work and peer training (Snowball Educational Programme)

2. Activity (history, services, statistics and rules) of the Vinkki Health Advice Centre

3. Introduction to the Aura Project

3. Introduction to the Correlation Project

4. Health risks and harms associated with injecting drug use and preventing them

5. Problems associated with different injection sites (groin, neck, subclavia and feet)

6. Bacterial inflammations and infections

7. Substances that depress and boost the central nervous system

8. Overdose, poisoning, prevention and first aid

9. Hepatitis and vaccinations

10. HIV and AIDS (HIV, pregnancy and children)

11. Safe sex and STIs (untreated and recurring infection and its consequences)

The contents and topics agreed upon with the trainees are discussed in the following chapters. The customised peer training was executed between January—June and August—September of 2006. The length of the meetings varied from an hour to three hours.

4. Client descriptions

4.1 Client 1

The first person to participate in the training was a woman. She took part in the training once she got out of a rehabilitation treatment centre. An employee of the Aura Project had introduced the client to Vinkki’s peer work and customised training prior to her entering the rehabilitation treatment centre. There were seven theoretical meetings in total. Training also included homework.

Along with the compulsory topics, the content of the training was planned together with the client. The training content reflected the client’s own interests and goals. The training package planned together with the client is detailed below:

1. Various drug treatments (substitution therapy)

2. Alcohol, drugs, pregnancy and child development (observation and treatment during pregnancy)

3. Child Protection Act and taking children into care

4. Infertility and artificial insemination

5. Recreational drug use and signs of addiction

6. Long-term drug use and assessing one’s own addiction

7. Tips and control methods involved with substance use

8. Motives associated with quitting substance use

9. Necessary changes in recovery and maintaining sobriety

10. Planning for change and maintaining it

11. Relapse, preventing relapse and factors leading to relapse

At first, the client was very interested in the training and actively attended theoretical meetings. After the rehabilitation treatment, she stayed sober for a while. She also applied to study again and tried to get a job. After Summer 2006, there have been no further private meetings with the client. An employee of the Aura Project did, however, meet the client with her mother. In Autumn 2006, contact with the client ceased.

4.2 Client 2

The second participant was a man who was receiving methadone treatment. He had previously completed a Snowball educational programme. He had learned about the customised training from a woman who had begun the training before him. He was very interested in the training and wanted to participate in it. The client was extremely motivated to receive information on all possible subjects. There were over 10 theoretical meetings in total. Training also included homework.

Along with the compulsory topics, the content of the training was planned together with the client. The training content was designed according to the client’s own interests and goals. The training package planned together with the client is detailed below:

1. Alcohol, drugs and medications: their affects on health

2. Insomnia and depression

3. Substitution treatment and maintenance treatment (methadone and accompanying use, buprenorphine and poly-drug use)

4. Motives associated with quitting substance use

5. Tips and control methods involved with substance use

6. Relapse, preventing relapse and factors leading to relapse

7. First aid (bleeding, electric shock, drowning and suffocating)

8. Liver functioning and cirrhosis of the liver

9. Kidney functioning and diseases

10. Interferon treatment

There have been regular meetings with the client throughout the training. Meetings usually took place in a library or a cafeteria because the client no longer visited Vinkki. Substitution treatment has been successful; and the client has retained his driving license and tried hard to enter a place to study. The client has carried out peer work among clients of a substitution treatment centre. An employee of the Aura Project is still in contact with the client and meetings continue.

4.3 Client 3

The third participant was a woman who was receiving methadone treatment. She had learned about the customised training from Vinkki’s Russian-speaking clients, as well as a Correlation worker from Vinkki. She became interested and wanted to take part. There were six theoretical meetings in total.

1. Long-term drug abuse and assessing one’s own addiction

2. Motives associated with quitting substance use

3. Necessary changes in recovery and maintaining sobriety

The client was met throughout Spring 2006. Meetings were held on Vinkki’s premises. The client’s substitution treatment was successful overall. She did, however, relapse and started using drugs at one point. She developed a serious complication from an injection which landed her in institutional care. After the treatment, the client’s circumstances improved considerably. She quit the substitution treatment in Summer 2006 and got clean. She has been in paid employment and is now living with a partner.

4.4 Client 4

The fourth participant in the training was a man who was actively using drugs. He had learned about customised training from a Correlation worker. Correlation worker gave the client information on the course and directed him to an employee of the Aura Project course. The client had previously completed Vinkki’s Snowball Educational Programme. There were eight theoretical meetings in total.

1. Alcohol, drugs and medication: their affects on health

2. Long-term drug use and assessing one’s own addiction

3. Insomnia and depression

4. Various types of drug treatment (substitution treatment)

5. Liver functioning and cirrhosis of the liver

10. Interferon treatment

Training began in Spring 2006. Meetings were held occasionally, but not regularly. The client mixes amphetamines, medications and alcohol, which lead to the fact that meetings did not always happen as planned. Meetings were always held at Vinkki’s premises. An employee of the Aura Project is still in contact with the client. The plan was that the client would first participate in a peer field course organised by Vinkki, but it was not completed due to the client’s poor health. The client has said he wants to continue being part of the peer work, but due to his poor health it is not possible at the moment. The client has himself stated that he cannot get clean from drugs and would, therefore, need amphetamine substitution treatment.

5. Information obtained from customised peer training

Customised peer training has produced a lot of diverse information about the circumstances of the Russian-speaking drug users. The average age of the four individuals who took part in the training was 28. Clients who took part in the peer training have managed to guide new Russian and Estonian drug users towards the services of Vinkki. All new clients have been injecting drug users for quite a while. Poly-drug use is common, and in particular, buprenorphine (subutex) is mixed with medications. Most of Vinkki’s new clients have tried to quit drugs with the help of institutional or outpatient treatment. The clients’ benzodiazepine addiction is extremely alarming. Some of the clients are interested in substitution treatment and some want to enter a rehabilitation clinic in St. Petersburg, Russia.

During the customised peer training, it has also emerged that Russian-speaking drug users do not have enough knowledge on the following subjects:

1. Institutional and outpatient treatment clinics in Finland

2. Criteria ofr substitution treatment

3. Benzodiazepine addiction

4. Interferon treatment

5. Diverse services (vaccinations, testing, service guidance, care for cuts, fieldwork) available through Vinkki Health Advice Centre

6. Complications caused by not using filters

7. STIs and complications associated with them

8. Monitoring during pregnancy and the affects of substance use on the foetus’s / child’s development

9. Child Protection Act and taking children into care

10. Condom use

Clients who have moved from the former Soviet Union still have problems with study permits. Problems are usually caused by previous criminal offences. Most of the Russian-speaking drug users can speak Finnish fairly well. The Russian-Estonian clients try continuously to find a job or a place of study.

The number of Russian-speaking clients and their visits to Vinkki has lately decreased because some of the clients buy their injecting equipment from a pharmacy or drug dealers, or exchange their instruments at a mobile unit. Vinkki’s opening hours do not suit all clients because they work or study. It is good, therefore, that they use the other services available for the exchange of injecting equipment. Most of the Russian-speaking drug users use subutex. Injecting equipment exchange also occurs between friends, as the amount of exchanges of injecting equipment (80/100/200) has risen considerably. Because the amount of exchanges of injection instruments has risen, client visits to Vinkki have decreased. The visits have also decreased because most of the Russian-speaking clients have already been tested for hepatitis and HIV, and received the required vaccinations. Also, the fact that clients use clean injecting instruments may be a reason why they do not feel the need to get tested at Vinkki. It can, therefore, be assumed that the risk behavior associated with drug use has decreased among Russian-speaking drug users. Some Russian-speaking drug users have also been admitted to medical substitution treatment and, thus, away from their circle of friends. Accompanying use amongst people in substitution treatment is rare; thus, they do not need Vinkki’s services as often as they previously did. The number of clients has also decreased because some of the Russian-speaking drug users have been deported from Finland.

Clients who have undergone customised peer training do not have new Russian-speaking acquaintances among the drug user network. They are, however, aware of the fact that new young persons who use drugs occasionally have appeared in drug user networks. These occasional drug users do not, at least yet, inject drugs.

Some of the Russian-speaking drug users attend medical substitution treatment in Tallinn, Estonia. The substitution treatment situation in Finland with its long queues and demanding assessment processes cause clients to move to within range of Estonia’s medical treatment. People who are receiving substitution treatment in Tallinn have fortunately received knowledge of Tallinn’s heath advice centre. We have ongoing contact with Estonian partners and our educated peers have visited, with the help of Correlation, twice in Tallin to see their premises, so they can direct their peers to needle exchange and other services what they could need in Tallin. We have also made brochure, to our clients, how to find services and help from Tallin.

Distributing this information to the client base has been one of those aims of peer work that has succeeded well.

6. Conclusions

Based on the new information and benefits brought by the Russian-speaking, multicultural and customised peer training, the following can be established:

Peer work reaches new clients from different services. The number of Russian-speaking clients reached is not vast, but it is important to anticipate and be aware of their special needs and cultural differences so that we can offer knowledge-based help in crisis situations, or if a new substance wave among the Russian-speaking young persons occurs again, like it did in mid-1990s.

The Russian-speaking client base is younger than the majority of clients. This fact raises some special issues that in part can be answered by ‘observational research among injecting drug users’ carried out between 2000—2003 (Partanen, A., Malin , K .Perälä, R. 2006).

It is extremely important to distribute appropriate information about the importance of clean injecting instruments to young persons who have only recently initiated injecting drug use, because the prevention of infectious diseases that spread via blood is most effective among them since prevalence is still low. How can we reach young, and other, clients who do not yet visit health advice centres? One good way to reach this group is to train peer workers, and distribute the appropriate information on health advice and harm reducation through them. According to the interviews conducted among the peer workers (Malin, 2006), user habits and methods, especially amongst young users, are often linked with negligence and thoughtlessness, which can encourage risk behavior associated with drug use. A certain lack of consideration, irresponsibility, fear of authorities and boasting may also be linked with short-term injecting drug use. Through peer work, the health advice and harm reduction messages can reach young persons in their own environment and circle of friends, which can further add to the possibility of better accepting the health advice information. Information distributed through peer work can achieve changes in attitudes and administration methods connected with drug abuse.

7. Recommendations

The voice of the clients

The experiences and wishes of the clients are the basis of all work. Their participation in all of the activities planned for them is vital for the success of the work so that resources are not lost or inappropriately allocated.

Detached work / peer work

Detached / peer work reaches unknown clients and produces the required services / information for those client networks that we do not have access to or contact with. Peer workers who distribute accurate information about hepatitis C, for example, are needed amongst new clients who have just started using drugs.

Cultural interpreters

The recruitment of cultural interpreters / key figures is one of the pivotal issues when working with any marginal group. The cultural interpreter must be part of the group for whom the services are produced. Without them, entry into these groups is incomplete or fails altogether. This issue must be carefully considered because, for example, among the Roma , the issue might be about disagreements between families, or with the Russian-speaking minority, it may be about problems between different nationalities. Language issues related to one’s own mother tongue or young persons’ street language may also arise.

When it comes to the employees, the issue is the same with clients. There must be employees with knowledge regarding cultural matters and language, so that out clients are seen, heard and understood.

Materials production

The materials produced for clients should be created together with clients. If this is not possible, it should at least be assessed by the clients so that materials will not produced which do not meet the client base’s needs or the information is not understood by clients.

Networks

The modes and customs of collaboration must be established with the associations or other activists who work with marginal groups, because they usually have up-to-date knowledge on the phenomenon and understand the demands of the client base. At its best, collaboration between different activists produces functional and innovative work modes that correspond to client needs (Aura)(Correlation). Pro-tukipiste : ( Correlation partner “the support centre for sex workers”) accomplished modified Snowball operation called “Rubberball” for Russian speaking sex workers in Helsinki. Two workers of Pro-tukipiste made an questionnaire of the prevalence and service needs of Russian-speaking prostitution girls/women.

Collaboration across borders / within neighbouring regions

The widespread prevalence of drug-related problems in neighbouring regions, such as Estonia, must be observed when addressing the situation in Finland. Collaboration with local activists on issues related to knowledge, know-how and information distribution brings a wider perspective and richer experience on the needs that apply to our clients as well. (Correlation, Aura) Collaboration should be fostered between different activists in Finland, Estonia and Russia.

Training

The information learned from our marginal groups should be distributed to the national network in every possible way, so that our clients can receive the support they need, for example, in prisons, judicial systems, basic public health services, schools, police and so on.

Give friendly, helpful advice where you can – its our lives !

References

Malin Katja 2005: Vertaistoiminnalla vähennetään huumehaittoja. Yhteiskuntapolitiikka 2/2006: 197-203.

Malin Katja 2006: Piikkihuumeiden käyttäjien riskikäyttäytymiseen vaikuttaminen. Esitys 28.9.2006.

Puro Päivi 2003: Pääkaupunkiseudun päihdetyön toimijoiden kokemuksia venäjänkielisten maahanmuuttajien huumeongelmista ja niiden ratkaisumalleista 2001-2002. Yhteenvetoa tutkimustuloksista. Venpro 2001-2003.

Puro Päivi 2004: Venäjänkielinen Lumipallo-operaatio Helsingissä 2002. Julkaisematon osaraporttiluonnos 30.8.2004.

Puro Päivi 2005: Maahanmuuttajien päihdepalvelujen kehittämistarpeita 31.5.2005.

Airi Partanen, Katja Malin, Riikka Perälä, Outi Harju- Koskelin, Antti Holopainen, Pekka Holmström, Henrikki Brummer-Korvenkontio : Riski-tutkimus 2000-2003 Pistämällä huumeita käyttävien seurantatutkimus

Alexis Gooded, Fabienne Hariga, Dominigue Theys : Euro Boule de Neige, Methodological Snowball Handbook. Modus Vivendi 1999

Franz Trautman, Cas Barendregt : European peer support manual. Trimbos Institute 1994

Adviesbureau Theo van Dam

Advies vanuit cliënt perspectief

Peer training

THE BASIS AND IDEOLOGY BEHIND PEER SUPPORT 2

THE BASIS AND IDEOLOGY BEHIND PEER SUPPORT

‘I am so pleased with this project, I rarely get such enlightenment. Thank you!’

‘Great interaction between the users and the health care staff’.

‘Mutual benefits for both the instructors and the participants’.

‘More information so that you can’t miss it’

STRENGTHS / RUSSIAN-SPEAKING

WEAKNESSES / FINNISH-SPEAKING

POSSIBILITIES / RUSSIAN-SPEAKING

Training

- Additional meetings for participants should be organised (social evenings)

POSSIBILITIES / FINNISH-SPEAKING

THREATS / RUSSIAN-SPEAKING

Planning process as a whole

Teamwork and the division of labour

Timetable

Training content

Realisation process as a whole and content of the training

Recruitment

‘I wish I’d get help in finding accommodation’.

‘More substitution treatment clinics are needed; the queues are too long’.

‘It’s good to get information on matters you are too embarrassed to ask about elsewhere’.

‘I’d like some help monitoring my hepatitis/liver values’.

6. Conclusions

Detached work / peer work

Cultural interpreters

Materials production

Networks

Training

Give friendly, helpful advice where you can – its our lives !