fond_ppt cov_ppt Slides and teaching notes: Training guide for HIV prevention outreach among injecting drug users PROGRAMME MANAGEMENT WORKSHOP Managing outreach programmes among injecting drug users WORLD HEALTH ORGANIZATION DEPARTMENT OF HIV/AIDS See Training guide book for: •Preparation and materials needed for this workshop, overview of sessions, training and learning objectives and key learning points See CD-ROM for: •Exercises •PowerPoint Slides for other modules •Handouts •Photographs •Videos •Training guidelines book (electronic version) •References •Additional training resources fond_ppt Role of outreach wOutreach is an effective strategy to reach, engage, and enable IDUs to reduce HIV risks C 1.10 Source: Needle R, et al. Effectiveness of community-based peer outreach for IDUs: a preliminary report. Paper presented at 13th International Conference on the Reduction of Drug-Related Harm, Ljubljana 3-7 March 2002. Slide C 1.10: It must be emphasized that, where effective action has been taken to prevent or control HIV epidemics among IDUs, no single element has been found to be effective on its own. Successful prevention has been achieved through comprehensive prevention programmes, based on community development principles, operating in supportive environments that include access to social welfare and primary health care. But the available evidence clearly shows that outreach is an effective strategy to reach, engage, and enable IDUs to reduce their risks of acquiring and or transmitting HIV. Most studies of outreach to IDUs for HIV prevention were carried out in developed countries. However, there is a growing literature being reported in languages other than English and from developing countries. The evidence is compelling; the findings are consistent despite variation in characteristics of types of outreach workers, places where outreach is conducted, time and components of the programmes. Outreach is most effective when it is linked with other services, especially needle and syringe provision, and when IDUs are provided with explicit information and education, developed with the involvement of IDUs themselves. fond_ppt Cyklický diagram Who is the hidden population? w Meditative stage Premeditative stage Maintenence stage Stage of action Stage of decision making 1.Awareness stages 2.Other comorbid problem 3.Stigma 4. Slide C 1.10: It must be emphasized that, where effective action has been taken to prevent or control HIV epidemics among IDUs, no single element has been found to be effective on its own. Successful prevention has been achieved through comprehensive prevention programmes, based on community development principles, operating in supportive environments that include access to social welfare and primary health care. But the available evidence clearly shows that outreach is an effective strategy to reach, engage, and enable IDUs to reduce their risks of acquiring and or transmitting HIV. Most studies of outreach to IDUs for HIV prevention were carried out in developed countries. However, there is a growing literature being reported in languages other than English and from developing countries. The evidence is compelling; the findings are consistent despite variation in characteristics of types of outreach workers, places where outreach is conducted, time and components of the programmes. Outreach is most effective when it is linked with other services, especially needle and syringe provision, and when IDUs are provided with explicit information and education, developed with the involvement of IDUs themselves. fond_ppt Planning outreach programmes: wAims and objectives wTarget group and area wAssessment of the injecting drug use wHuman and financial resources wAddressing important organizations C1.11 Session C.1.2. Planning outreach programmes I Slide C1.11: Inform participants that there are some aspects of managing an outreach programme that need to be planned prior to starting one. These aspects are covered in module B of these Training guidelines. The key activities that should have been completed prior to this training course are: •setting of aims and objectives for the outreach programme; •selecting of target groups and target areas for initial outreach work by the programme; •completion of a Rapid Situation Assessment of the HIV/AIDS and injecting drug use situation in the locality where the outreach programme will operate (using WHO Rapid Assessment and Response methods) or some other assessment of the situation in the locality; •identification and planning of the type of outreach programme and organizational structure; •identification of human and financial resources for the outreach programme, and funding secured for starting the programme; and •contact of important organizations, identification of allies who have subsequently been informed of the outreach programme and identification of potential obstacles. •Ensure that all participants are aware of these steps. Inform participants that, after the break, they will be asked to develop and present basic outreach plans to the plenary group. Break Normally a break would be held at about this point for coffee or tea, and to allow participants to move around and meet one another. It is common practice for such a break to be around 15-20 minutes long. Session C.1.3. Planning outreach programmes II See Exercises on CD-ROM fond_ppt Peer education w"A set of specific education strategies devised and implemented by members of a subculture, community or group of people for their peers, where the desired outcome is that peer support and the culture of the target group is utilized to effect and sustain change in behaviour" C 1.9 Source: Kinder P. HIV and AIDS: Looking at peer education. On the Level , 1995, 3 (2): 41-46. Slide C1.9: Peer education has been defined as: "A set of specific education strategies devised and implemented by members of a subculture, community or group of people for their peers, where the desired outcome is that peer support and the culture of the target group is utilized to effect and sustain change in behaviour" (Kinder, 1995). The key elements of peer education are that: • the education strategies and messages are specifically for one group or subpopulation (for example, IDUs in a specific locality or female IDUs); •the strategies and messages are developed and used by members of the subpopulation; and •peer education is based on the widely-recognized principle that members of a group or subpopulation are more likely to understand each other and be able to develop useful messages and strategies for people like themselves. fond_ppt Community-based peer outreach is most widely used and is also very effective ...why? wLeast costly wContributes greatly to preventing HIV infections in IDUs and their sexual partners wA major component of a comprehensive strategy C 1.8 Source: Needle R, et al. Effectiveness of community-based peer outreach for IDUs: a preliminary report. Paper presented at 13th International Conference on the Reduction of Drug-Related Harm, Ljubljana 3-7 March 2002. Slide C1.8: The Evidence for Action paper on outreach refers specifically to community-based and peer outreach. It is referred to as community-based because it is organized to access and reach hidden populations of IDUs in a process of risk reduction in the communities where they congregate (rather than intervening with drug users who attend clinics to access services). The outreach worker is often referred to as a “peer”, or in some programmes as an “opinion leader.” In this context, peer refers to someone familiar with the IDU “community”: an active or ex-IDU, or a non-injecting drug user or non-user with close links to IDUs, who can be trusted by IDUs, who is preferably from the same gender group as his or her peers, is trained to provide services, and preserve confidentiality. The paper found that outreach is the most widely used intervention to prevent HIV among IDUs globally, with evidence of outreach programmes to address these issues on almost all continents. It is the least costly intervention and is often the easiest one to begin (compared to large targeted education, NSP or substitution drug treatment programmes). Several studies have shown that outreach can be effective by itself and that it is usually plays a major role in a comprehensive HIV prevention programme among IDUs. In summary, outreach contributes greatly to the prevention of HIV among IDUs and their sexual partners. If peer education is an unfamiliar term for participants, you may want to use the next slide: fond_ppt Making contact: Decide wWhere to hang around wWhen to visit a place wWhen to start a conversation wWho to contact first wWhether to be direct or indirect wWhat can be offered wWhen to stop C2.11 Source: Trautmann F and Barendregt C. Utrecht, European Peer Support Manual Trimbos Institute/European Commission, 1994. Session C.2.5. Making contact with drug users Start a discussion among participants about ways to contact drug users. First, ask what information is needed in order to identify how to make contact? After each discussion, show the related slide. Slide C2.11: For getting into contact one has to decide: •where to hang around: at which site, at a distance or near by people, etc; •when to visit a place: sometimes several visits at different times are needed to discover the best times for regular visits; •what is the right moment to make a move: do people have time to talk, are they in the mood for a talk, etc. •who to contact first: there is often a leader in any group and it is usually good practice to contact the leader first; •what is the right way to approach: direct or less direct (see below); •what can be offered: can a card or pamphlet or condom or needle and syringe be offered? •when to stop—for a while—when to give it a break and leave: this may be caused by IDUs starting to use drugs or buy or sell drugs, by tension among IDUs, etc. Next, ask what should outreach workers do when they go to an outreach area? fond_ppt Their space, their rules wDress appropriately wSpeak appropriately wDon’t threaten wObey rules C2.12 Slide C2.12: The main task of outreach work is to go to where IDUs are, to enter “their space” where drug users feel comfortable. This means that the outreach worker needs to abide by the norms or rules that govern this space. The outreach worker should: •Dress appropriately: in some cultures, this means dressing in a similar way to IDUs; in others, it may mean similar dress but slightly different to show that the outreach worker is in the “space” for some reason other than buying, selling or using drugs. •Speak appropriately: outreach workers need to know the “language of the streets”, the words and phrases IDUs use, so that education occurs in a language with which IDUs feel familiar and comfortable. •Not be threatening: IDUs are usually fearful of new people as they may be police (undercover), so outreach workers need to use gestures and non-verbal communication that reassure the drug users that the outreach worker is not a threat to them, or be accompanied by a member of the group of drug users. •Obey the rules: for example, if outreach workers receive a message (verbally or non-verbally) to leave an area because of possible violence or other problems, they should do so directly. It may also mean, women talking to only women and vice versa. fond_ppt Ways of making contact wIntroduce yourself wBe introduced by others wIndirect: casual chat wDirect: Introduce yourself and your programme C2.13 Source: Trautmann F and Barendregt C. Utrecht, European Peer Support Manual Trimbos Institute/European Commission, 1994. Slide C2.13: Two ways of making contact include: •doing it on your own: this can be difficult and may require long periods of outreach workers being present in an area until they feel confident they can make contact with an IDU without problems; and •getting introduced by someone: this is usually easier. Two ways of introduction: •indirectly, by starting some casual chat about the day, weather, mutual friends; •or by directly introducing yourself as an HIV-prevention worker, explaining what your task is, and what organization you work for. One approach is to say: “We are here because we are concerned about the problem of HIV/AIDS in the community and we want to help reduce further spread of infection.” This focuses further discussion on establishing the fact that HIV does represent a clear and present danger in their community. By talking about the problem of HIV/AIDS in the community, the topic of personal threat to IDUs from HIV can be avoided before a relationship of trust and credibility has been established. When AIDS is introduced as a general rather than personal threat, most people are comfortable about listening, discussing, debating or arguing. The objective is to increase HIV/AIDS awareness to the point that IDUs begin to become concerned about what that means to them personally and this transition is a good way to help IDUs begin considering reducing their own risks for HIV. Next, ask what the tasks involved in making contact are. Once contact is established, what should you say next? Record answers on the white board or flip chart. fond_ppt Gain trust by... wShowing that you are „non judgmental and understanding wAlways being honest wBecoming familiar C2.14 Source: Trautmann F and Barendregt C. Utrecht, European Peer Support Manual Trimbos Institute/European Commission, 1994. Slide C2.14: The main task after making contact is to gain the trust of the IDUs, establishing credibility, for example by: •showing that you are one of them (for example, by referring to your own drug use experience, or sometimes being the same sex as they, especially among female IDUs); •always being honest (about what you are, what you are able to do, etc.); •becoming familiar: by returning to the same space several times, talking to the same people on many occasions, trust is built over time. Next, ask what methods or materials can help you to make contact? fond_ppt Methods and materials wGiving out condoms/syringes wCollecting information: Completing a questionnaire wProviding information: Giving out leaflets, newsletters wOrganizing activities C2.15 Source: Trautmann F and Barendregt C. Utrecht, European Peer Support Manual Trimbos Institute/European Commission, 1994. Slide C2.15: Methods and materials to assist outreach work: •giving out condoms/syringes: this is an excellent way to build trust and should be coupled with educational messages we will discuss this afternoon; •collecting information: you can build trust by asking IDUs to assist you in your work by providing information on drug using practices, etc; •completing a questionnaire: while a questionnaire normally has a research purpose, it can also be used to ensure that IDUs spend some time speaking with the outreach worker; •giving out leaflets, newsletters, magazines on topics relevant to IDUs: these are very useful when time is a major problem (they can be slipped into IDUs’ hands or pockets quickly if police or other problems prevent longer talks) and can also be used as the basis for education (“Did you see the page on needle cleaning? What do you think about that?”); and •organizing activities: these may range from simple social events to peer education training sessions or starting drug user organizations. Emphasize that the main task of outreach is to engage IDUs in conversation, to gain trust and develop rapport. The above methods and materials can assist that work, but should not detract from the main task. Next, state that, after rapport has been built between outreach workers and IDUs, the topic of HIV prevention in the IDU’s life needs to be raised. Ask what some ways are of raising this topic. fond_ppt Aims of outreach counselling wHIV/AIDS and other deseases spread prevention wProvide accurate information about HIV/AIDS wHIV/AIDS testing wPersonal risk assessment wRisk reduction counselling wMotivation to reduce risks wRefering to other relevant serices like treatment programs C2.19 Source: Ball A and Crofts N. HIV risk reduction in injecting drug users. In: Lamptey PR and Gayle H, eds. HIV/AIDS Prevention and Care in Resource-Constrained Settings. Arlington, Family Health International, 2002. Slide C2.19: Aims of outreach counselling: •to provide accurate information about HIV/AIDS transmission and prevention; •to help IDUs carry out a personal risk assessment: to help IDUs to examine their drug using and sexual behaviour to see where they may be at risk of acquiring or transmitting HIV; •to help IDUs understand what they can do to reduce their risk, including problem solving and stress management; and •to motivate IDUs to reduce their risk: both through ongoing counselling and education, and provision of materials such as needles, syringes, condoms, etc. (where possible). Next, state that there are some established rules for effective outreach counselling. Provide Handout C1. Ask participants to read the handout in preparation for the next exercise. Session C2.6. Communicating with drug users II See module C Exercises on CD-ROM LUNCH At around this point, break for lunch. Lunch break usually lasts for about one hour, though this may depend on the local culture. Trainers should meet during lunch discuss the results of the morning’s work and to decide what changes, if any, may be needed in the remainder of the day. fond_ppt One-to-one education can be... wa part of outreach counselling wprovided in prisons, wtreatment centres, hospitals walso pre- and post-test counselling C2.28 Source: Burrows D. Starting and managing needle and syringe programs: a guide for Central and Eastern Europe/ Newly Independent States. New York, International Harm Reduction Development/ Open Society Institutes, 2000. Slide C2.28: One-to-one education of IDUs by outreach workers can normally only be done after establishing trust and rapport. Education of this type is normally provided as part of the outreach counselling process described in C2.5. One-to-one education also occurs within institutional settings such as drug treatment centres, prisons, hospitals, etc., usually as part of a wider range of educational and/or counselling activities. People working in these settings may need to balance the need for education, which will assist a drug user to remain as healthy as possible with the need to abide by the operating philosophy of the institution. Institutions (such as prisons or detoxification units) may have to be educated and persuaded to recognize that the life-saving nature of harm reduction messages may mean that they have to change their attitude towards discussion about drugs and drug use and sexual behaviour. One-to-one education also occurs as part of pre- and post-test counselling for HIV or hepatitis antibody tests. Education at these points has been found to be extremely effective in personalizing the issue of HIV or hepatitis and in impressing on drug users the need for safe behaviours. This will be dealt with in greater detail on Day 3 of this course. fond_ppt Group education is useful in... wOutreach to groups wTraining in peer education, support, leadership wEvents-based/targeted activities C2.29 Source: Burrows D. Starting and managing needle and syringe programs: a guide for Central and Eastern Europe/ Newly Independent States. New York, International Harm Reduction Development/ Open Society Institutes, 2000. Slide C2.29: Group education can be provided in a range of settings. Much of it relies on the social networks that drug users form since these can have a positive effect on those members trying to change, or maintain safer behaviours. Gender of the groups might be important. Also, groups of men might be found in different places than groups of women.‘Classical group education’ takes place with facilitation or information provision by an authoritative figure such as a doctor, epidemiologist, drug treatment worker or NGO worker who has control over the information and education the drug users receive. Unless this person has a clear idea of the educational needs of the group, this type of group education may be ineffective. Targeting social networks of injecting drug users through peer education, peer support or peer leadership has become increasingly popular in recent years. Some authors have suggested that peer education should not be seen as ‘teaching’ by a ‘good drug user’ to change the behaviour of another drug user, but as drug users sharing information with each other on how to inject as safely as possible, given their current circumstances. With this approach, drug users work together to reduce the risk of injecting. This leads to a supportive peer environment in friendship networks, and allows the development of materials for friendly and supportive education rather than lecturing. Another type of targeted education campaign is based on specific events that injectors are known to attend, such as rock concerts, rave parties and festivals that are aimed at specific subcultures. Activities at these events range from simple provision of leaflets about HIV and drug use to booths where festival participants can come to learn more about these topics and discuss any problems or issues with workers, either through the booth or meeting outreach workers who are moving through the crowds. fond_ppt Slogans and sayings are useful for... C2.30 Source: Burrows D. Starting and managing needle and syringe programs: a guide for Central and Eastern Europe/ Newly Independent States. New York, International Harm Reduction Development/ Open Society Institutes, 2000. wConstant repetition of the same message e.g. XNew fit for every hit XDifferent spots=no tracks XFriends do not share wSpecific focus: spoons week wConvert slogans into longer talks Slide C2.30: Constant repetition of the same message has the same effect as an advertising slogan: the words—and the idea or product—stay in our minds. In Australia, drug users are advised to ‘use a new fit (needle and syringe) for every hit’. This slogan appears on the packaging of some syringes, on business cards for needle and syringe programmes and on stickers, leaflets, cards, brochures, posters and booklets. At Chicago Recovery Alliance (United States of America), staff are encouraged to develop ‘one-liners — quick reminders that staff can say to clients. Here are some examples on the subjects of safer injection, vein care and safer sex: •‘Different spots = no tracks’ (i.e. visible puncture marks are reduced if you rotate sites). •‘One shot, one sterile syringe.’ •‘Use your own — needles, cookers, filter, water.’ •‘The cleaner everything is, the better.’ •‘New paraphernalia + clean hands = safer shots.’ •‘Shoot with the flow’ (of blood). •‘Release the tie (tourniquet) — before you get high.’ •‘Knowing your condom is safer than knowing your partner.’ •‘You can’t tell if someone is infected by looking at them.’ Other methods are to have a specific focus for a specific period in which a single message is provided to all outreach contacts over a given period — such as having a ‘spoons week’ during which risks related to sharing spoons are highlighted. Such interventions put health and safer injecting ‘on the agenda’ and make it clear that outreach staff are happy to answer questions or discuss any of this information, if the drug user has time. Staff need to be able to convert these short exchanges into longer educational discussions. However, slogans and sayings represent a first step in building a relationship with IDUs in which they begin to see the outreach staff as a reliable source of information about reducing the risks of their injecting. fond_ppt Leaflets and booklets: wExplain/advertise outreach programme wConcise information on specific subject wHelps in making contact and starting conversations wEasy to read with illustrations wBut does not replace human contact C2.31 Source: Burrows D, et al. Training Manual on HIV/AIDS prevention among injecting drug users in the Russian Federation. Moscow, Medecins Sans Frontieres - Holland, 1999. Slide C2.31: Leaflets and booklets: •are useful in outreach work to inform drug users on various issues such as to: –explain what you are doing and why –provide concise information on a specific subject such as needle cleaning or overdose prevention –recruit drug users to the service or invite them to specific events such as meetings •are useful in assisting outreach workers to make contact with drug users •should be easy to read and use pictures or illustrations to provide information in visual as well as text form •do not replace human contact: pamphlets can never replace a face-to-face conversation but can act as a reminder and support for positive behaviour change. fond_ppt Newsletters and magazines: wCircular: contact IDUs to contribute, produce, distribute w“Voice” for drug users wRegular updates wExpensive in time, money, man power wMay be controversial if “voice” C2.32 Source: Burrows D, et al. Training Manual on HIV/AIDS prevention among injecting drug users in the Russian Federation. Moscow, Medecins Sans Frontieres - Holland, 1999. Slide C2.32: Magazines and newsletters can assist outreach work in a circular way by making/keeping contact with IDUs through contributions (from IDUs), production (with or by IDUs) and distribution (with or by IDUs). They can be used: •to provide a voice for drug users to communicate with other drug users: for this reason they are a common tool in drug user organizing; •to provide a voice for drug users to inform drug assistance services and policy- makers about their views and their needs: this is another key area of drug user organizing; and •to inform drug users about health-related issues, including regular updates on changing topics such as HIV treatments. Magazines/newsletters: • take a great deal of time to produce: it is better to have smaller newsletters published regularly than large, high-quality magazines produced irregularly; •may be controversial if they are used as a “voice” for drug users, because control of the content must be totally or mainly in the hands of the drug users themselves. Conclude by saying that all these publications and messages should be developed using the process outlined in C9. This development process can be used by outreach workers as a way of raising issues related to HIV risk, by showing publications being developed, by asking IDUs for slogans, etc. Remember that requesting the view of drug users helps to increase their commitment to safer behaviour and that discussing a leaflet is also passing the message among the target group. Effective HIV prevention requires the provision of the same messages in different levels of detail and in different media to reach the same group of IDUs many times over a sustained period of time. Session C2.12. Slogan exercise See Exercises on CD-ROM Session C2.X: Evaluation and close See Exercises on CD-ROM fond_ppt Hire ex-drug users? zIf ‘Yes’…why? wStability, continuity, role models wDraw from experiences, contacts z zIf ‘No’…why? wKnowledge may be out of date wJudgmental attitude, Relapse C3.6 Source: Trautmann F and Barendregt C. Utrecht, European Peer Support Manual Trimbos Institute/European Commission, 1994. Slide C3.6: Should ex-drug users be recruited as outreach workers? Yes - arguments · Can contribute to the continuity of a project · Can serve as role models for what drug users can aim for: having a job, being acknowledged as an expert · Can draw from their experiences to help IDUs modify unsafe behaviours · Often have established relationships with the treatment system, so they may be able to provide advice and referral on treatment as well as build support in treatment agencies for peer support programmes No - arguments · Ex-users have stopped using drugs so they may have less access to drug users and drug using locations than active drug users · Knowledge of drug use practices may be out-of-date · May have a harsh judgemental attitude to drug use (caused largely by their fears of relapse), which can cause mistrust and credibility problems · Often relapse into drug use unless precautions are taken fond_ppt Hire mixed teams? zIf ‘Yes’…why? wAdvantages e.g. sharing ideas, increasing mutual respect wDivision of tasks z zIf ‘No’…why? wConflict? C3.7 Source: Trautmann F and Barendregt C. Utrecht, European Peer Support Manual Trimbos Institute/European Commission, 1994. Slide C3.7: Should a mixed group of drug users and ex-users (and non-users such as university students) be recruited as outreach workers? Yes - arguments •Can result in all of the advantages of using drug users and ex-users •Can lead to sharing of ideas and increasing mutual respect between drug users and ex-users •Can lead to division of tasks so that drug users do the tasks they are most suited to (e.g. street outreach, writing messages from drug user to drug user ), and ex-users carry out other tasks such as discussing peer support activities with police, health department, drug assistance services No - argument Mixed group can be a source of conflict where drug users and ex-users may have different interests and priorities: this sometimes leads to a power struggle: e.g. active users may have feelings of distrust, envy or inferiority towards ex-users and ex-users may despise or feel superior towards active users Next, state that, after deciding on the composition of the team, there are several further steps needed in recruitment: fond_ppt Recruiting outreach workers wDiscuss and decide selection criteria wFind potential candidates wDevise a selection process wDraw contract/work agreement wSet up a training plan C3.8 Source: Power R, ed. Guidelines on community-based peer intervention aimed at drug prevention and harm minimisation. London, North Thames Peer Intervention Forum, 1996. Slide C3.8: Recruiting outreach workers: •Selection criteria are needed so that appropriate people are recruited as outreach workers. •Potential candidates need to be found and informed about the outreach worker jobs. •A selection process is needed to ensure that candidates are suitable for the job. •A con •tract or work agreement is needed to ensure the outreach worker knows what he or she is hired to do, and knows what remuneration and other conditions will be provided. •Usually, new outreach workers need to be trained to carry out their tasks effectively. Next, remind participants of the attributes exercise and state that selection criteria should be composed from those attributes. Decisions are needed about what are very important (essential) and what would be useful but are not essential (desirable). Repeat that the most important attribute is credibility among the specific networks of IDUs where the programme will operate. It is also important to note that outreach teams should usually consist of both male and female workers, of a range of ages to ensure that all IDUs can feel comfortable with at least some members of the team. Participants need to gauge the extent to which the potential outreach worker’s knowledge and access to particular networks of drug users match the aims and objectives of the outreach programme. It is also important to gain some appreciation or their role and status in drug user networks, as this may influence their ability to penetrate any given drug scene. Next, use the flip chart for a brainstorm. Ask where potential candidates may be found for outreach workers. Write the places up as they are called out. If they are not mentioned, add: •places where drug users congregate; •drug treatment centres; •high schools, universities; and •advertising in selected community and media outlets. Also, if no one mentions it, state that snowballing can be an effective recruitment method. Once a good candidate is found, he or she can seek out other candidates among friends and acquaintances. Other points of recruitment may include clubs and pubs. Next, state that a selection process is needed to decide which candidates should become outreach workers. In some cases the recruitment and assessment processes are combined in introductory training sessions, where the programme is described and the role of the outreach worker is outlined. In this model, the assessment process takes place throughout training and continues during the outreach worker’s initial involvement with the programme. Supervision sessions can be used to address issues and problems around suitability as and when they arise. fond_ppt Training should provide... wUnderstanding of programme aims wKnowledge and skills needed for outreach work wUnderstanding of legal, cultural and ethical issues wClarification of expectations and boundaries C3.10 Source: Power R, ed. Guidelines on community-based peer intervention aimed at drug prevention and harm minimisation. London, North Thames Peer Intervention Forum, 1996. Slide C3.10: In general, any peer training programme should aim to equip outreach workers in the following ways. After training, outreach workers should have a: •clear understanding of the aims and objectives of the outreach programme, including the philosophy of the programme (and, where relevant, its host agency); •precise knowledge and understanding of the style and nature of the work involved and the type of messages and/or materials to be produced and delivered; •basic overview of relevant HIV/AIDS and injecting drug use issues, alongside any matters specifically relevant to the programme and the target group; •basic knowledge of relevant legal and ethical matters related to the programme; •clear idea of the parameters of their role as outreach workers and the expectations of the programme; and •clear understanding of the boundaries between their work and the work of other professionals such as doctors or psychologists. Basic practice guidelines to reinforce the training should also be provided. These will also be discussed in the afternoon. fond_ppt WHO Outreach training is to... wGain knowledge: yHIV/AIDS, drug injecting risks, outreach techniques z wAcquire skills: y Making contact, y Starting conversations, y Counselling, education C3.11 fond_ppt Facilitating management: wDefine areas/working hours wList specific tasks/steps wSet times for supervision, team meetings, intervision, training wDecide on work agreements/contracts wClarify policies/procedures/ rules C3.13 Session C3.6. Managing outreach staff Management of outreach workers can be difficult. Outreach may occur in places far from the office or clinic where an outreach team is based. Outreach workers may need to work at odd hours (nights, weekends) and in different patterns (a few hours of work followed by a few hours of rest and more work) to contact and communicate with IDUs at times convenient to the clients. Outreach work itself is not like ordinary work: workers need to be flexible so there are often a lack of clarity about targets or outputs of the work. This can cause problems for managers trying to supervise outreach workers, and evaluate and adapt outreach methods used in their programme. Slide C3.13: To facilitate management, most outreach programmes have developed some set methods of working and some documents to assist outreach workers and managers. First, areas are defined for outreach work and working hours are established: these can be rigid (such as “visit the main plaza and try to contact IDUs each week night from 17:00 to 19:00) or more flexible (such as “provide 20 hours of outreach per week among IDUs in the southern suburbs of the city”). Specific tasks are provided for outreach workers. These can be a list of options (contact IDUs, build trust, communicate with IDUs about health topics including HIV/AIDS, distribute condoms”) or a set series of steps. Examples of step-by-step methods are provided in the case studies on Outreach methods in Annex 2. Set times are arranged for supervision (by the outreach manager), team meetings and for other processes such as intervision (where outreach workers assist each other in solving outreach problems) and ongoing training. These arrangements and others, as required, are usually formalized in a work agreement or contract between the programme and each outreach worker. Other useful documents are policies and procedures, and rules of working (including safety issues). fond_ppt Procedures and rules wBasic practice wUnacceptable behaviour wSecurity and safety wDiscipline and dismissal wOther: overdose, forms, meetings wBalance needed C3.15 Slide C3.15: Procedures and rules may all be needed to assist outreach workers in carrying out their tasks effectively and safely. These should start with basic practice procedures and rules that inform outreach workers how to do their work, what behaviour is advisable and what is unacceptable. Due to the many risks that can occur during outreach, safety guidelines should be drawn up prior to the programme beginning operations and these should be adapted and added to as new safety issues arise. Another procedure that should be in place very early is a discipline and dismissal procedure so that there is a transparent process that both managers and staff know and understand to deal with persistent problems. Other procedures that are often useful are guidelines for dealing with overdosed clients; filling in monitoring forms and diaries; procedures for meetings and so on. It is important to balance the need for clear guidelines with the need to do effective outreach work on the streets: procedures should not be so many and so constraining as to interfere with effective work. fond_ppt Unacceptable behaviour wSelling/dealing drugs wSelling project materials e.g. needle, syringe, condom wUsing drugs (in case of active drug user peer educators) during outreach wTheft wViolence, sexual manipulation wPretending to work wNot completing forms, attending supervision, etc. C3.16 Slide C3.16: Basic practice guidelines should include the main tasks of outreach work. They should also include rules relating to unacceptable behaviour: these should be developed together with reasons why the behaviour is unacceptable (for example, drug selling by staff may lead to loss of funding and closure of the programme). With IDUs, ex-drug users and people regularly exposed to drug use, many situations can occur which can lead to problems or even closure of the programme if they are not addressed. For example, most programmes have a strict rule that no outreach worker can sell to or buy drugs from clients. Another common rule is that theft by an outreach worker is grounds for discipline and (in some cases) dismissal. Another may be that violence or sexual manipulation by an outreach worker towards another worker, manager or client will lead to suspension or dismissal. fond_ppt Safety procedures and rules wStay safe: work in pairs? wDo not handle used needles and syringes without gloves wKnow methods of dealing with aggressive and violent clients wCarry identity cards wKnow what to do if arrested C3.17 Slide C3.17: Safety guidelines should encompass the full range of risks faced by outreach workers. The most important safety advice is that if outreach workers feel unsafe due to verbal or non-verbal signs (chaos, abuse, aggression), they should leave an area immediately. A common safety guideline is that outreach work must always be done in pairs so that if one outreach worker gets into trouble, the other can either help or seek assistance. (Many programmes have this as a basic rule of outreach work.) Safety guidelines should also address handling needles and syringes, and needle stick injuries. They should cover practical issues such as procedures if apprehended by the police and how to deal with aggressive or violent clients. Distribute Handout C6 with examples of procedures for handling needles and syringes and for dealing with needle stick injury. Among other tasks, work guidelines should provide a clear idea of the way that supervision, team meetings and intervision (if used) will take place (these will be discussed in Session C3.8). fond_ppt Final statement zMUDr Prof Michael Gossop “The urgent need to respond to the threat of HIV and AIDS has radically altered the drugs agenda. The rhetoric of United States and some other countries may continue to promote the discredited ideals of the “war against drugs” and “zero tolerance”, but living with drugs has now become an imperative.” C3.17 Slide C3.17: Safety guidelines should encompass the full range of risks faced by outreach workers. The most important safety advice is that if outreach workers feel unsafe due to verbal or non-verbal signs (chaos, abuse, aggression), they should leave an area immediately. A common safety guideline is that outreach work must always be done in pairs so that if one outreach worker gets into trouble, the other can either help or seek assistance. (Many programmes have this as a basic rule of outreach work.) Safety guidelines should also address handling needles and syringes, and needle stick injuries. They should cover practical issues such as procedures if apprehended by the police and how to deal with aggressive or violent clients. Distribute Handout C6 with examples of procedures for handling needles and syringes and for dealing with needle stick injury. Among other tasks, work guidelines should provide a clear idea of the way that supervision, team meetings and intervision (if used) will take place (these will be discussed in Session C3.8).