OUTREACH - United Nations Office On Drugs And Crime

2. Outreach – General ConsiderationsOutreach is a systematic approach to deliverIDUs tend to remain hidden and are notharm reduction services to people who injectready to reveal themselves.drugs and to their sex partners/spouses in their own environments.Preconceived notions regarding IDUs, thatexist amongst some service providers, alsoact as barriers to IDUs accessing services2.1 Why is Outreach Essential?Traditionally, the approach to providing services isfrom fixed sites. The daily life of an IDU centres on findingto set up centres and cater to the clients who visitmoney, buying drugs and injecting everythese centres. However, people who have high riskday. As a result, he/she is not able to focusbehaviour and are termed as ‘High-Risk Groups’on other needs or seek help.(HRGs) are reluctant to access such centres. ThisAs a result of the above, it becomes necessary foris because:service providers to reach out to IDUs at places Drug use is not a socially approvedbehaviour. The general community looksdown upon people who use drugs. This isespecially true for those who inject drugs. where they are most likely to be found. This methodof service provision is referred to as ‘outreach’.Reaching out to IDUs and their sex partners throughthe PEs and ORWs, with the prime objective ofpreventing transmission of Blood-Borne VirusesDrug use is illegal. This affects the ability of(BBV) by reducing needle, syringe and equipmentIDUs to come forward and seek services.sharing, is an essential strategy of harm reduction.Outreach Enables Scaling-up provision of services and reaching out to IDUs who are hidden, stigmatized anddiscriminated against. Identifying new IDUs. Linking them to appropriate services, such as DOTS, STI, ICTC, ART, which will help themto access other health related services. Accessing services like primary healthcare. Reaching IDUs who do not want to access services from the DIC. Observing and understanding injecting behaviour, drug sharing culture, IDU networks andrisk taking behaviours. Gathering information from the field which can be used for effective planning, effectiveoutreach, and meeting possible challenges.4STANDARD OPERATING PROCEDURE

OUTREACH2.2 Principles of Outreach Empowerment: providers of outreachservices should empower the IDU clientsOutreach for IDUs is based on several principlesto take decisions for their own health andwhich are interlinked and dependent on each other.welfare. A ‘client-generated’ demand helpsIf one principle is not followed, the overall outreachin greater acceptability of services providedobjective can be compromised. Effective outreach,by the TI.that helps in bringing services to the doorstep ofIDUs, has to be based on these principles: Do no harm: the service provider shouldensure that clients/beneficiaries are not Respect: service providers should respectharmed in his/her attempt to provideand trust IDUs as individuals. services.Team work: delivering outreach is teamwork. Efficient team work helps in ensuringgreater delivery of services. 2.3 Services through OutreachAn effective outreach strategy should ensure that atNon-judgmental: service providers shouldleast 80%2 of the estimated IDUs under the coveragenot have preconceived negative notionsarea receive the following components as a packageabout the beneficiaries. Such judgementaland not as stand-alone services.attitudes act as impediments for successfulservice delivery including outreach.Services Provided through Outreach Education, advice and information either in individual or in group settings on: Risks of Human Immunodeficiency Virus (HIV), Hepatitis B Virus (HBV), Hepatitis C Virus(HCV), STIs and means of reducing these risks. Safer injecting and safer sex practices, including prevention and management ofoverdose. Services for abscess management, STI diagnosis and treatment, HIV testing, ART andTB treatment which may be available at the DIC and/or other facilities. 2Regular distribution of the following, as per need of the IDUs and their regular sex partners: New needles and syringes. Abscess prevention materials – alcohol swabs, cotton swabs, distilled water, etc. Condoms – free as well as socially marketed. IEC materials, as and when required. Collection of used/old needles and syringes. Referral services to appropriate healthcare and other agencies.WHO, UNODC, UNAIDS technical guide for countries to set targets for universal access to HIV prevention, treatment and care for injectingdrug users.5

2.4 Staff for ConductingOutreach – Roles andResponsibilitiesOutreach is conducted as a team with planneda good rapport with the IDU community and shouldunderstand the issues and challenges faced by IDUs.Key roles and responsibilities of the ORW in anoutreach setting are to: Develop outreach plan in consultation withPEs and IDUs from the hotspots. Facilitate weekly work plan for his/her teamof PEs. Develop a list of target areas with socialmapping of each target area. Co-ordinate outreach activities and visithotspots with PEs on a regular basis. Supervise outreach and monitor PEactivities. Ensure regular and uninterrupted supply ofharm reduction materials for each outreachvisit. Provide referral and networking serviceswith other agencies. Provide information on HIV/AIDS, hepatitis,STIs, safer injecting, safer sex practices,overdose management, early treatmentand services available to IDUs. Establish systems of regular contact withsecondary outlets. Identify stakeholders for advocacy forcreating an 'enabling environment’. Collect data and consolidate the same fromthe field/PE.services at predetermined sites/routes. Outreachteam consists of: Outreach Workers Peer EducatorsApart from this, the counsellor/ANM conductsoutreach on a need basis. Finally, the projectmanager also conducts field visits in outreach area tomonitor outreach work being delivered. Additionally,he/she is responsible for the overall managementand supervision of outreach, including procurementand stock management.Outreach WorkersOutreach workers should be current or ex-drug users.Apart from conducting outreach, ORWs support andsupervise PEs in planning and conducting outreach,monitor the quality of services provided, ensureeffective working systems, and consolidate collecteddata and information from the PEs. At some places,the ORW can also be a non-IDU, but he/she shouldhave an excellent understanding of the geographicalterrain, including the local language and customsfollowed locally. Additionally, the ORW should haveCriteria for a Good Outreach Worker Non-judgmental attitude and willingness to work for IDU community. Previous experience of working in IDU TI (desirable). Belief in one’s ability to lead a team of peer educators and be led by senior TI staff. Strong facilitation skills. Communication skills. Knowledge of local language. Ability to document. Ability to lead small group discussions.6STANDARD OPERATING PROCEDURE

OUTREACHPeer EducatorsA peer educator in an IDU-TI should be a current orex-injector who works towards influencing attitudesto bring about behaviour change among IDUs. PEsare responsible for providing information on HIV/STI, hepatitis, harm reduction including overdoseprevention, condom promotion and engaging IDUsin group discussions, meetings and events. Each PEwill target/cover between 25-40 IDUs. Selection andretention of PEs is an important issue in an IDU TI.Key roles and responsibilities of the PE in anoutreach setting are to: Conduct outreach and maintain contactwith IDUs – at least once in 15 days. Identify new IDUs and contact them. Provide dialogue-basedcommunication.inter-personal Encourage service uptake (Needle andSyringe, condoms). Motivate IDUs to attend DIC regularly. Demonstrate safer injection and condomuse. Invite and organize group discussions. Advocate with local level stakeholders. Providereferralinformation. Take notes in field diary/note book. File reports. Attend trainings. Attend weekly planning and reviewmeetings. Train new PEs (within the project andoutside).andnetworkingThe Ideal PE for Various AudiencesTarget audienceWho will be the ideal PEFemale injecting drug users.Female current/ex-injecting drug user.Female injecting drug users who are also sex workers.FIDU sex worker – can be current or ex-user.Male IDU.Male current/ex-injector.Spouse of male IDU.Spouse of current/ex-injectors.IDU who are also MSM.MSM IDU.Selection Criteria for PEsQualities to look for in a PE are: Ability to give time for the project. Acceptability to the target community (IDUs) as a peer – trust, known, language, age,behaviour and gender. Knowledge of the local context. Tolerance and respect for others. Good listening, communication and inter-personal skills. Self-confidence and potential to be a leader. Good role model. Open to learning new things from the field. Commitment – gives time and support to the IDUs in crisis. Sensitive to the values of the community and maintains confidentiality.7

Auxiliary Nurse Midwife (ANM)/CounsellorKey roles and responsibilities of the PM in anIn addition to DIC related activities, the ANM/outreach setting are to:counsellor also has to visit the field to conduct some Ensure that outreach team conductsof outreach based activities. The counsellor alsooutreachassists the project manager to monitor outreachoutreach.planningbeforeconductingservices being provided in the project area. Ensure that outreach team meets eachKey roles and responsibilities of the ANM/other on a weekly basis to update on thecounsellor in an outreach setting are to:activities conducted in the previous week Conduct counselling (individual and group),for IDUs who are not able to visit the DIC. Ensure that sufficient commodities areavailable at the DIC/Non GovernmentalDIC.Organization (NGO) office for conductingMotivate IDUs for HIV testing as well asoutreach activities. Make home-visits to access the partners ofIDUs. Motivate IDUs who are not willing to visitother referral services. and plan for the coming week.Set-up a routine monitoring mechanism forsupervision of outreach work. Ensure that there is a backup plan forConduct Focus Group Discussions (FGDs)outreach staff taking leave/being absentamong the IDUs to understand thefrom providing outreach services.adequacy of services being provided byoutreach team. Ensure that staff drop-outs are replacedurgently to avoid any lapse in outreach Interact with the general community, obtainservices.feedback and gain insight into their thoughtsand opinions. Monitor outreach activities, through routinefield visits, interactions with staff members,Project Managergeneral community and beneficiaries (IDUThe Project Manager (PM) is the most senior of theTI staff and gives overall direction to outreach as wellas other services being provided in the IDU TI. He/clients) and provide regular feedback. burnout among the staff is minimized.she is responsible for ensuring that outreach activitiesare being conducted in accordance with the project Build the capacity of outreach team throughframework. The PM must understand the challengestrainings/exposure visits on a regularfaced by outreach team in the field, address thembasis.and also keep the morale of outreach staff high.8Build the morale of the staff to ensure thatSTANDARD OPERATING PROCEDURE

OUTREACH2.5 Steps in OutreachAll the three steps are interrelated, with each oneinfluencing the other. Though it would seem thatOutreach can be divided into three steps:Planningconducting outreach is the main step, it shouldbe remembered that planning and monitoring areimportant steps that need to be carried out regularlyto take stock of the changing scenarios in thefield. Effective outreach depends on planning andMonitoringConductingmonitoring.9

3. Outreach PlanningOutreach planning is a process to facilitate Local high risk group mapping data (can beobtained from the SACS, if available) List of hotspots (these can be identifiedthrough field visits by the PEs and ORWs) Local Behavioural Surveillance Survey(BSS), HIV Sentinel Surveillance (HSS),Integrated Biological and BehaviouralSurveillance Survey (IBBS) data (can beobtained from SACS, if under BSS/HSS/IBBS sentinel surveillance site) Information from baseline assessments (ifconducted)individual level planning and follow-up ofservice intake, based on high risk and vulnerability.Effective outreach planning will ensure: Maximum IDUs are covered in a givenperiod of time. Optimal services are provided to every IDUclient. The existing human resources of the TIproject are optimally utilized.The team for outreach planning consists of the PEs,The team should gather as many of these resourcesas possible in order to make the planning easier andmore effective.the ORWs and the PM. The PEs bring in the data/information from the field and the ORWs processthis information by using various tools. PM shouldsupervise and provide inputs when necessary toOutreach Planning Toolsmake the plan robust and practicable.Outreach planning is made easier by the use of aOutreach planning teamProject Coordinator/ Project ManagerORW IPE 1PE 2PE 3ORW 2PE 4PE 1PE 2IDUPE 3PE 4PE 1PE 2IDUPE 3PE 4IDUEven before the team sits down for the actualnumber of aids, called planning tools. The tools usedplanning, the following should be gathered and keptin the context of IDU TIs are:ready: Social mapping.The geographical maps of the area to Spot analysis.be covered under the TI (these can be Contact mapping.collected from the local administration – Work plans. Outreach activities.panchayat, municipal corporation, etc.)10ORW 3STANDARD OPERATING PROCEDURE

OUTREACHSOCIAL MAP - areamarking IDU gatheringplaces, stakeholdersSPOT ANALYSIS - selectedspots from social map areanalyzed tounderstand the number ofclients, types of drugs used,frequency of injection, etc.OUTREACH - field workstartsWORKPLAN - made aftergaining all possibleinformation and planmaximum contacts amongstthe PE with time, NS etc.3.1 Social MappingCONTACT MAPPING - planmade with PE to delegate thenumber of IDU to each PEask them to draw the map showing all the placeswhich are important for them. Give them 20 minutesA social map is a rough diagram of the interventionto draw.area showing an overview of the sites where IDUsgather/come together. It is a visual illustration of thesites/areas where IDUs gather (hotspots) as wellas service points such as hospitals, NGO, clinics,referral centres, etc.An ORW would normally have one social map butif the area is too large, it may be subdivided andsocial maps can then be drawn separately for eachsub-area. Mapping can be conducted either in thefield or at the DIC by PEs and ORWs. The IDUThe social map should be updated as per the localclients should be involved in the mapping; overallsituation. For example, if there is frequent movementthe process should be facilitated by a senior staffof hotspots, the social map may be updated oncemember, preferably the PM.every two to three months. At places, where thehotspots do not change frequently, the social mapsmay be updated once every six months.What is important in a social map?The key principle of drawing a social map is toprovide a visual overview of the area. This enablesWho should draw the map?IDUs, PEs led by ORWHow is the map to be drawn?creation of an effective outreach plan for PEs.Direction coordinates, i.e., North South, West andEast (NSEW), IDU gathering place, peddling areas,temples, cemeteries, NGOs, hospitals, churches,Arrange chart paper, pencils, colour pens, scale, etc.and other relevant services that IDUs can access orDivide the participants, PE and IDUs into groups andavail should be marked. An index or legend should11

be provided In each social map. This index is the3.2 Spot Analysismain indicator of the signs/drawing, that help inreading and understanding the map.A hotspot is extracted from a social map byidentifying common places where IDUs gatherWhy is it important to analyze spots?In each social map, there are spots where IDUscongregate at certain times of the day. This spotbecomes important to analyze. This is done through'Spot Analysis' for effective outreach planning.Sample maps are given below:at certain times of the day. The objective is to findthe right time to meet maximum IDUs, and provideservices and referrals to them. The informationcollected during needs assessment, related to eachhigh risk spot/site in their respective project areas, isthen compiled.Each spot is different from the other and a projectsite will usually have more than one site or hotspot.Spot analysis should give the break-up of IDUs in aparticular spot according to their: Time of availability–IDUs may frequent theparticular hotspot to buy drugs, inject, orrest after injecting. The time at which theyare available should be recorded, and maybe divided into morning, afternoon, eveningand night.Sample 1After drawing the social map, one hotspot (for e.g.,North AOC (Imphal) in the above sample) is selectedfrom the social map. A detailed analysis of thehotspot is then conducted. In the next map (sample2) the yellow circled site/spot will be analysed forbest outreach services. Age of the IDU. Type of drugs injected. Volume of injecting – This is a roughcalculation of the number and frequency ofinjecting episodes. Classically, it is dividedinto high volume (more than three episodesper day), Medium volume (one to threeepisodes per day) and low volume (lessthan one injecting episode per day).Another simple way of calculating theinjecting episodes is to divide the IDUsinto two categories – daily injectors (atleast one injecting episode per day) andnon-daily injectors (less than one injectingepisode per day). This manner of division iseasier and helps the program to prioritizeindividuals who have to be provided NSEPservices on a daily basis.Sample 212STANDARD OPERATING PROCEDURE

OUTREACHThe spot analysis format is provided as Annexure 1.Who: ORWs and PEs along with IDU clients,facilitated by senior staff.After spot analysis the potential client (PWID) namesand code numbers are written down in anotherformat “contact mapping”. In the above diagramnumbers circled are estimated total IDU populationHow: through a group discussion with IDUs engagedin needs assessment, facilitated by senior staff.Explain the link between the social map and spotanalysis. Follow the steps or questions: What is learned during the situation andand numbers in different colors represent each PEand ORW. For example out of 50 estimated IDU,only 6 5 7 5 4 27 IDU are known and rest 33are not known. The outreach team will plan how toincrease contact to all 50 IDU in one small spot.needs assessment process? What information is required about IDUsoperating in a spot? (E.g. volume of clients,typology of drugs, age groups, frequency ofinjection per day/week.) contacts with IDUs in each spot and helps in analysingtheir needs. After the spot analysis is completed, thenames of the potential IDU clients are written downthe time of operation and frequency ofin the contact mapping f

2.3 Services through Outreach 5 2.4 Staff for Conducting Outreach - Roles and Responsibilities 6 2.5 Steps in Outreach 9 3. Outreach Planning 10 3.1 Social Mapping 11 3.2 Spot Analysis 12 3.3 Contact Mapping 13 3.4 Work Plan 14 4. Conducting Outreach 15 4.1 Services Provided through Outreach 16 5. Documentation 21 5.1 Individual PE Tracking 21