Best Practices - Early Intervention, Outreach and Community Linkages for Women with Substance Use Problems

2.6 Outreach

For related results from Key Informant Interviews, see section 3.4
For related results from Focus Groups, see section 4.6

Outreach services are a critical part of the continuum of care. Outreach involves meeting clients in their own environments to engage them in treatment or assist them in accessing other needed services (van der Walde et al., 2002). Outreach activities are beneficial for establishing links with women who are known to have, or be at risk for substance use problems. These efforts may address problem substance use issues that are recent or longstanding (Department of National Health and Welfare, 1992). Many of the early intervention strategies outlined in the previous section can be applied in outreach programs. For example, motivational interviewing and brief interventions are important techniques that can be employed during outreach interventions.

Clients who require outreach services to facilitate access to treatment tend to be further disengaged from formal, informal and family support systems (Tommasello, Myers, Gillis, Treherne, & Plumhoff, 1999). Marsh et al. (2000) noted that women who require outreach were among the heaviest substance users and exhibit a range of other co-morbid health conditions and psychosocial challenges. Community-based outreach services may be particularly effective in engaging clients with challenges or conditions such as homelessness, injection drug use, HIV and other blood-borne infections, concurrent mental health disorders, unemployment, history of abuse and conflict with the law (Melchior, Huba, Brown, & Slaughter, 1999; Rowe, Fisk, Frey, & Davidson, 2002; Tinsman, Bullman, Chen, Burgdorf, & Herrell, 2001; Tommasello et al.; Yahne et al., 2002).

Outreach programs can be designed within larger treatment programs that offer an array of services or within independent programs associated with other community service providers. They can also be linked to a wide range of community-based health settings that screen for problem substance use and provide referrals to appropriate treatment (NIDA, 2000).

2.6.1 Location of Outreach Services

Outreach services are often most effective when they are accessible in a variety of locations. Given that women with problem substance use are found throughout the community, outreach programs need to take into account the natural living environments of those who could benefit from treatment. Traditional office-based settings, where clients must arrange transportation and attend scheduled appointments, can be difficult for some. Clients who lose faith in the existing system of care may require individualized outreach services to engage them (Tinsman et al., 2001; Tommasello et al., 1999). Community-based or more natural settings can provide increased accessibility and convenience for connecting with clients.

The NIDA (2000) Community-based Outreach Model underscores the importance of face-to-face outreach contacts with clients in a variety of potential settings, including:

• store fronts;
  
  
• soup kitchens and food banks;
  
  
• homeless shelters;
  
  
• temporary locations in hotels or motel rooms;
  
  
• hospital emergency departments; and
  
  
• accessible offices in buildings with community-based health services.

Other locations can include sites where substances are purchased and used on a regular basis. Appropriate outreach locations can be determined by consulting with community service providers (e.g. police and health agencies) and local agencies that are aware of where and when people at risk spend time (NIDA, 2000; Rowe et al., 2002; Witbeck, Hornfeld, & Dalack, 2000).

2.6.2 Structuring Outreach Interventions

Outreach programs and intervention efforts should respond to the unique needs and circumstances of those requiring treatment services. Workers must be committed to engaging clients in personally assessing their own risk behaviours and having them take part in realistic discussions of resources available to support changes (NIDA, 2000; Yahne et al., 2002).

There is some variety in how outreach services can be structured to address both operational concerns and the needs of clients. They may be delivered through street-based contacts, or be operated through drop-in centres that provide easy access to clients for meeting with workers and other health professionals. Mobile units that combine delivery of health-based programs can also assist in reaching people who would not seek out more structured services (Rowe et al., 2002; Tinsman et al., 2001).

The hours of operation should reflect when clients are easily contacted. On-call protocols for supervisor support should be organized to provide assistance to outreach workers while they are in the field. It can be beneficial for outreach personnel to work in teams of two. As changes in staff take place, teams can provide continuity and ensure stability in relationships with clients (NIDA, 2000).

Outreach programs should obtain information that will facilitate making subsequent contact with clients. For new clients, attempts should be made to obtain personal information, including the participant's name, street name, home address, mailing address, telephone number, alternate contact information (friends or family) and locations in the community where the client regularly spends time (NIDA, 2000; Yahne et al., 2002).

2.6.3 Outreach Personnel

Outreach workers play a key role in client engagement and retention. They support clients by encouraging contemplation about behaviour, consulting on treatment planning and acting as a liaison with other service providers (Rowe et al., 2002).

Providing services by outreach workers who live in the area may be beneficial. They are acquainted with the local community and may be aware of existing drug use subcultures (NIDA, 2000). They may have increased opportunity to be credible role models, educators and advocates. They may also be in a better position to monitor community activities related to local drug use settings and sensitize other program staff to emerging issues that impact clients or the delivery of outreach services. They may be in a unique position to:

• recognize situational barriers that may limit progress toward risk reduction measures;
  
  
• understand the values and norms of specific client groups;
  
  
• build trust with identified client groups;
  
  
• identify and gain access to high-risk sites; and
  
  
• enhance community acceptance of outreach programs and organized intervention efforts (NIDA, 2000).

It is beneficial for outreach workers to reflect the "ethnic, gender or cultural" profiles of the identified client groups to help reduce language barriers and ensure that outreach services are responsive to the unique needs of individual clients and groups (Health Canada, 1996a).

A range of skills and attitudes are associated with effective outreach, including:

• communicate unconditional caring and respect for clients;
  
  
• apply knowledge of local resources to the needs of problem substance users;
  
  
• network within groups of individuals at risk;
  
  
• organize and maintain accurate records;
  
  
• work in both structured and unstructured service settings; and
  
  
• obtain and provide referrals to a comprehensive range of services and facilities (NIDA, 2000).

NIDA (2000) indicates that some outreach programs have found it advantageous to employ outreach workers who have personal substance use experience. They can credibly share their experiences about the key actions required to initiate and sustain change. These outreach workers are often able to communicate in terms familiar to the client target group. The examples they provide of their own experiences can be a model for clients. If staff members have been former drug users, it is recommended that they demonstrate at least two years of abstinence. The use of support groups assists staff who consider themselves to be in recovery from problem substance use (NIDA, 2000).

Staff should receive specialized on-the-job training and mentoring to support the independence that is needed to be an outreach worker. Many programs use a two-phase training approach, including office- or classroom-based instructional sessions followed by supervised training in the field. The content for in-service training programs should include instruction on how to:

• recognize and make contact with target group members;
  
  
• explain the intent of the outreach program and establish trust;
  
  
• identify locations for follow-up contact and meetings with clients;
  
  
• work and collaborate with other community service providers;
  
  
• address personal safety and security concerns; and
  
  
• structure brief interventions and help clients access services (NIDA, 2000; Rowe et al., 2002).

2.6.4 Key Outreach Activities

Interactions between outreach workers and at-risk women may be brief or involve longer periods of time. The content involved in these meetings can include:

• exploring risk behaviours;
  
  
• identifying realistic strategies for reducing harm;
  
  
• providing educational information to support risk reduction efforts; and
  
  
• facilitating referrals to needed services (NIDA, 2000).

During informal sessions, outreach workers can use a range of strategies or approaches to engage clients, including:

• using active listening skills to encourage clients' exploration of areas of concern;
  
  
• exploring pros and cons of continued substance use;
  
  
• formulating plans to address potential barriers to accessing needed services;
  
  
• identifying potential social support networks; and
  
  
• affirming the clients' ability and commitment to undertake change.

Outreach usually involves building trust and engaging clients gradually over brief encounters. Many of the preceding strategies reflect the use of brief intervention modalities, including motivational interviewing and applied negotiation processes (NIDA, 2000; Rowe et al., 2002).

In addition to providing support for reducing substance use, outreach workers are in a unique position to help clients access services for immediate needs, such as lodging, food, income support, referral for medical attention, and linking with supportive formal or informal social networks. Outreach personnel have been referred to as the "glue" that links the service system together for people with problem substance use (Rowe et al., 2002; Tinsman et al., 2001).

2.6.5 Research Related to Outreach to Women

Melchior et al.(1999), studied 665 women participating in an enhanced outreach and treatment readiness preparation program to determine patterns of treatment entry. They found that, after 4 years, 82.9% of the women had received referrals to substance abuse treatment programs, and of these 51.4% enrolled. As well, the frequency of outreach was inversely related to the likelihood that women with substance use problems would be referred for services. Women who received and accepted referrals were less likely to remain on the streets to receive contact by outreach workers.

Continued contact is essential for engaging women who are not yet ready to accept treatment. The authors stress the importance of enhancing client motivation to change through the application of brief intervention and motivational interviewing techniques. Tinsman et al. (2001) noted that women who received a pre-treatment intervention through outreach were more likely to enter treatment at women-focussed centres.

Women living in circumstances involving domestic violence or in high-risk behaviours are less likely to carry through on outreach referrals for treatment (Melchior et al., 1999). For these women, problem substance use may not be the most immediate concern or challenge they are facing. They may be more concerned with their own personal safety or that of their children. Women with multiple vulnerabilities have a greater range of concerns and challenges, which can reinforce the belief that meaningful change is not possible. Outreach services must work in the context of the immediate situation and provide additional support for the problem substance use and the other areas of concern. Comprehensive support approaches can be critical for enhancing women's willingness and commitment to address their problems.

A study of an outreach program for female street sex workers employed a brief intervention approach using motivational interviewing (Yahne et al., 2002). Twenty-seven women were interviewed about their substance use, health risks and plans for change. This interview technique focussed on conveying genuine concern, asking direct questions and eliciting self-motivational statements. Outreach workers asked clients about their readiness to reduce their substance use and prompted them to consider the supports required for them to make positive changes. Four months after the initial contact, participants were re-interviewed. At the close of the study, the women reported an increase in the drug abstinent days, from 15% to 51%. They also reported reductions in sex trade work during the same time period. The authors of the study also reviewed the priorities set by women at the outset of the investigation. It is significant that without reliable housing, few of these women would have had the resources necessary to escape the cycle of prostitution and drug use (Yahne et al.).

Marsh et al. (2000) compared an enhanced substance use treatment program with a regular rehabilitation program in a quasi-experimental study that focussed on women with children. Of the total sample of 468 selected clients, 148 agreed to participate in the study: 73 clients were randomly assigned to the enhanced program that provided the "access services" of outreach, transportation, on-site child care and at-home child care and 75 clients were randomly assigned to the regular rehabilitation program. The results, measured 14 months after entering treatment, showed that involvement in the enhanced program was significantly negatively correlated with problem substance use and the provision of access services led significantly to greater use of community-based social services, which was in turn also related to decreased substance use. This study supports the notion that providing access services for health- and social-related services can be effective for women with children.