What should we be looking for in OUTREACH WORKERS
Richard Pates and Virginia Blakey
Are good outreach workers 'born', or can they be made? Pates and Blakey offer their guidelines for the selection and management of outreach workers
Outreach work with drug users and prostitutes is a relatively recent phenomenon. This is particularly the case in the UK, where outreach workers have mainly been employed as part of the response to HIV, in recognition of the need to take prevention messages to drug users and prostitutes who are not currently in contact with services. Drawing on the experience of an agency employing three outreach workers, and on a review of some of the relevant literature, this paper aims to highlight some of the issues which need to be addressed in selecting and managing outreach workers.
The agency referred to is the South Glamorgan Community Drug Team, based in Cardiff, South Wales. This health authority agency is a multi-disciplinary team which includes doctors, nurses, social workers and a psychologist. The city of Cardiff has a population of approximately 300 000, with a drug problem no larger than most British cities and smaller than many others. The main injected drugs are amphetamine sulphate (widely available and cheap), some heroin and other opiates, and illicitly obtained benzodiazepines. Other drugs, including barbiturates and cocaine, may also be, injected on an infrequent basis. The use of Ecstacy is increasing rapidly. So far as is known, the city has a very low incidence of HIV infection among the drug-using population.
By the mid 1980s, the Community Drug Team recognised that new forms of service needed to be developed in order to reach drug users who were not currently in touch with any drug projects. The very low incidence of HIV infection at this time was seen as an incentive for implementing harm-reduction measures. A needle and syringe exchange has been established and three outreach workers are currently employed: two of these work with drug users, and one with women prostitutes. The three workers organise their work collaboratively, rather than within strictly defined task boundaries. To date, they have been very successful in terms of making contact with drug users and prostitutes, working with them on the streets of Cardiff, and encouraging referrals to the Community Drug Team and other relevant agencies. We believe that this success has been due at least in part to the selection procedures used.
CRITERIA FOR EMPLOYMENT
Any attempt to define the qualities required by an outreach worker raises a number of questions. Reviews projects within the UK and elsewhere (Friedman et a1., 1990; Hartnoll et al., 1990, 1991) show that selection criteria tend to vary. Selection needs to be based on a job description setting out clearly what the worker will be expected to do, and a complementary personnel specification for the post. The following attributes may be seen as relevant and important:
l. Professional background.
2. Whether the worker is 'indigenous' or not
5. Personal qualities and skills.
Each of these factors raises issues which need to be resolved before selection.
There is as yet no professional qualification for outreach ] work, and therefore no formal body of knowledge with which an outreach worker should be familiar. Hartnoll et al. ( 1990) report that the majority of outreach workers in the UK are from professional backgrounds such as | nursing, social work or youth work. The skills offered by these professionals are relevant for working within a | drugs agency, and may often be useful in an outreach context. However, professional qualifications as such are not sufficient for outreach work. The practices and requirements of professions such as nursing or social work may in fact make it difficult to work in a different and sometimes contradictory way. Outreach workers are required to work informally; through their work, they become aware of illegal situations, and may be entrusted with knowledge which might compromise some professional codes of conduct.
A further disadvantage for an outreach worker from a professional background is that outreach offers no career structure. Stepping out of their chosen career can mean standing still professionally.
The outreach workers employed by South Glamorgan Community Drug Team do not have professional qualifications, but they do have the back-up of a multidisciplinary professional team.
Indigenous outreach workers
'Indigenous' refers to an organism occurring naturally in a culture. In the context of outreach work, the phrase is used to describe people who are or have been drug users or prostitutes (depending on the nature of the project). The employment of indigenous outreach workers is far more common in the USA than in the UK.
There are obvious advantages to using indigenous workers in terms of knowledge of the culture and environment, and of access to groups who are often difficult to contact. Many US projects have used indigenous workers and have found this an appropriate way of working.
However, there may also be disadvantages. Some US projects are becoming more aware of the potential difficulties of employing ex-users as outreach workers because of the risk of relapse (Friedman et al., 1990; Abdul Quader et al., 1992). This may be a cause for concern among funders or management committees of drugs projects. Given that other projects employ drug users who are still using, the issue here may more appropriately be one of support for the outreach worker rather than a moral concern about relapse.
Experience has shown that some ex-users will assume at interview that the past history makes them ideally suited for outreach work. However, without other appropriate personal attributes, an individual's history of drug use may be irrelevant. In Cardiff, two conflicting reactions have been noted among drug users towards the employment of an ex-user. One reaction was favourable to the worker, who was seen as providing a role model for the future. The other saw the worker as having sold out to the establishment. Both outreach workers and management need to be aware of these possible reactions before starting work, as they can have a marked impact on working practices.
It was initially thought within the Cardiff Project that male outreach workers would be more suited to working with male clients, and female workers more suited to working with female clients, particularly those involved in prostitution. This has proved to be a naïve assumption. Rent boys will happily approach a female outreach worker, and the male outreach worker is able to work with female prostitutes when their female outreach worker is not available, without any detrimental effect on the take-up of services. A second female outreach worker is now in post who is working very effectively with both male and female drug users. In addition, both drug users and prostitutes interact with the broad spectrum of team members, male and female, in ways which indicate that gender is less important than the personal characteristics of the worker.
Friedman et al.(1990) have noted similar finding In at least two of the settings studied, they found th male outreach workers were more effective in communicating with female users, and female outreach worke were more effective with male users.
However, it is important to recognise that most drug services in the UK do not cater adequately for the needs of women users. In addition, women who are involved in prostitution and who are also drug users face a double stigma which may make them very reluctant to approach services. It is important that all possible steps are taken to meet the needs of this group. Clearly for many intimate issues a woman may prefer to confide in another woman, and may also find information from this source more credible (for example, in relation to contraception or discussion of sexually transmitted diseases or STDs). This needs to be considered by agencies in appointing outreach workers.
Many of the situations raised in this discussion of gender have parallels in relation to the ethnicity of the outreach worker and members of the client group.
Recruitment of drug workers from ethnic minority groups is an important and complex issue which goes beyond the scope of this paper. We would simply note that the points made in the preceding paragraph about the need to make services more relevant and attractive to women would apply equally to people from Afro-Caribbean, Asian and other ethnic minority groups.
The issue of previous experience in terms of drug use and sex work has already been touched on in the discussion on 'indigenous' workers. However, there are other aspects of experience which need to be addressed. The appointment of someone from outside the local area (for example, from a different city) may raise problems if the individual concerned is not familiar with the geography of the patch. This may make for a delay in working effectively. More important still may be the issue of local knowledge, local networks and individual contacts. It is difficult to move into an area and start from scratch. Experience in Cardiff has shown that workers who bring local experience with them are able, to work more effectively, as they often have a ready made informal network of contacts.
Other experience which may be relevant includes previous work in the drugs field or some similar field involving work with marginalised groups, awareness of the difficulties which this involves, and insights into ways of overcoming these problems. Unfortunately drugs and prostitution are sometimes seen by those with little experience as glamorous or as offering scope for evangelical activities. As a result, advertisements for outreach workers often attract those who 'want to save fallen women' but have no experience of the realities involved. Fortunately, these applicants are usually easily recognised at the short-listing stage.
All the previously mentioned qualities can be important in selection, but are not sufficient in themselves. The issue of personal qualities, however, is central to selection, as these can make or break an outreach worker.
In selecting workers in Cardiff, three key factors were considered: disposition, skills and style. Disposition refers to factors such as the following: being able to use initiative, and also to take direction; being able to work alone, as well as in a team context; being tough-minded, but also non-judgemental.
Stability, maturity and creativity are also Important. One crucial factor, also highlighted by Sittitrai (1990) in his work in Thailand, is that of respect for the client group.
The skills needed include: communication skills; organisational skills; some record-keeping skills; the ability to network; and, ideally, some familiarity with health and social services.
Style refers to the ability to work both within a treatment setting as well as on the streets, and in formal as well as informal ways. This has been found to be very important in terms of explaining and 'selling' the concept of outreach work both within the health authority and to other statutory agencies such as the police.
This brief presents a wide-ranging and sometimes seemingly contradictory set of qualities. It seems to demand an exceptional person. Such a brief may seem unrealistic and inappropriate, given the low pay of out reach workers and their present lack of career structure However, it is important to recognise that without at least minimal levels of these qualities, the outreach worker will find the job impossible and will probably not cope. The selection process needs to identify those areas where deficits can be met by training, and those where the deficit relates to aspects of personality and basic approach which make the individual unsuitable for the job.
When the last outreach worker was appointed in Cardiff in 1991, out of 50 applicants only 6 were deemed suitable for interview. Following interview, only 2 were thought appropriate for the post. This may seem hard; but the success of the project and the job satisfaction of the worker will depend upon rigorous selection.
The actual selection process can affect the successful : appointment of the outreach worker. Assuming that the worker will be based within a team (and it is difficult to imagine outreach work succeeding without that support), then the team's participation in the selection is likely to be helpful in securing the right person who will blend in with the team.
Within the Cardiff team, it has become practice to invite those short-listed for the post to a two-stage interview. This begins with an informal session in the morning, where information exchange takes place and where the prospective worker can explore aspects of the job before the formal interview. All staff from the Community Drug Team are involved in this informal session. They therefore have the chance to assess potential colleagues, and to give feedback which is passed on to the formal interviewing panel.
The informal morning session also allows a chance to assess communication skills, attitudes and assertiveness, all of which will be relevant for outreach work. It provides an opportunity to look at candidates in a more relaxed situation than the stressful atmosphere of a formal interview. Formal interviews take place in the afternoon, and representatives of the team are included on the panel.
This two-stage process ensures that a new worker is not appointed to the team by a management board who may not be fully in touch with all the needs of the post and the team. The team also feel a collective responsibility for the appointment, as their views have been taken into account in making the final choice.
Management of outreach workers requires a similar approach to the management of any project, but particular attention needs to be paid to some areas because of the special nature of the work. Outreach workers have to work in informal ways, often in hostile environments, and with people who are not and who probably will not become clients of the agency.
In recruiting outreach workers, the skills and personal attributes already mentioned are sought. It is clear that similar qualities are required in managers of such projects. As Yates and Gilman (1990) have noted:
'If they are to have any measure of success, those "doing" outreach work must be adaptable, open-minded, willing to take risks, and able to judge when risks are unacceptable. Those "managing" outreach work require exactly the same attributes.'
In discussing management of outreach work, four aspects are of key importance: judgement, flexibility, support and advocacy.
Judgement is needed to provide a workable framework for outreach initiatives, which can take into account both the need for flexible working conditions and the need to provide adequate feedback on outreach activities for monitoring purposes. It is also important in assessing what the potential risks are for workers, and the point at which those risks become unacceptable.
Outreach workers are asked to be flexible in their approaches to work, and to be adaptable in different situations. Management must share this flexibility. They need to give workers scope to experiment; Friedman et al. ( 1990) have observed that projects in which workers have little autonomy are more likely to experience low morale. However, managers also need to be able to recognise when an approach is not working, and to provide guidance on when it is necessary to abandon or change direction.
Provision of adequate support for outreach workers is clearly a key part of the manager's role. This support needs to cover not only regular supervision, but also aspects of training, safety at work, and provision of adequate back-up where necessary. Training is important both at induction and on an on-going basis. In addition to relevant formal courses and seminars, establishment of links with other outreach projects in the area and creating a network for exchange of experience may be an important way of enhancing workers' skills. Managers need to recognise the value of this and actively encourage outreach workers to set up a local forum.
The safety issue is paramount. Outreach workers in Cardiff have as part of their work guidelines a rule that their safety must always take priority over other issues. In any situation where they feel uneasy or suspect that there are risks, the guideline is that they should withdraw, with the knowledge that management will fully support them on this. Obviously not all risky situations can be identified in advance, and safety can never be absolutely guaranteed. Nevertheless, clarification of guidelines about working in potentially dangerous situations, particularly on issues such as contact points, reporting in, and means of communication, provide some safeguards and give workers some sense of security.
Finally, management have an important advocacy role. Outreach workers will often be working in situations which are very different from those of most health and social service agency workers: for example, spending their afternoons in a cafe, pub or laundrette. Managers need to understand and be able to justify this use of time to funding bodies or higher levels of management. It is also important that managers are prepared to take on an advocacy role on behalf of outreach work with other bodies such as local authorities or the police. In conclusion, management of outreach projects needs to be carried out in a way that is sympathetic to the work being undertaken, that provides an appropriate degree of autonomy for workers, but which also retains clear lines of responsibility. Good outreach should be as professional and as professionally managed as any other part of drug services.
- Richard Pates, South Glamorgan Community Drug Team
- Virginia Blakey, Health Promotion Authority for Wales
Abdul-Quader, A.S., Des Jarlais, D.C., Tross, S., McCoy, E., Morales, G. and Vele2, 1. (1992) Outreach to injecting drug users and female sexual partners of drug users on the Lower East Side of New York City. British Journal of Addiction 87, 681-6(88
Friedman, S.R., Sterk, C., Sufian, M., Des Jarlais, D.C and Stephenson, B. (1990) Reaching out to injecting drug users. In: J. Strang and G.V. Stimson (eds), AIDS and Drug Misuse, pp. 114-185. London/New York: Routledge.
Hartnoll, R,. Rhodes, T., Jones, S., Holland, J. and Johnson, A. ( 1990) A survey of HIV outreach intervention in the United Kindgdom. Drug Indicators S Project, Birkbeck College, University of London
Hartnoll, R., Rhodes, T. and Holland, J. (1991) Ol~t ()f the Agency and on to the Streets: a Review of HIV Outreach Health Education m Europe and the United l States. Drug Indicators Project, Birkbeck College, University of London
Sittitrai, W. ( 1990) Outreach to bar workers in Bangkok. Hygiene 9, 25-28.
Yates, R. and Gilman, M. (1990) Seeing more drug users: outreach work and beyond. Lifeline Project, Manchester.