Chapter 5: Outreach programs: planning, implementation and evaluation

In this chapter

Key points

Outreach programs can be an effective way to reach groups at risk of sexually transmitted infections (STIs) and blood-borne viruses (BBVs) who have limited access to existing services.
Outreach programs can consume a lot of time and resources so should be well targeted and properly evaluated to ensure the aims of the program have been met.
Health service data should be used to identify whether the target group is already accessing the health service, whether STI and BBV management is appropriately integrated into routine visits and supported by health services systems, or whether services can be reorganised to become more accessible and acceptable for the target group.
Effective outreach programs rely on good planning and effective partnerships between organisations.
Evaluation of the process and outcomes is integral to the ongoing success of outreach programs.

What is an outreach program?

Outreach programs involve targeting health care to priority populations at risk of STIs and BBVs, particularly those who may be marginalised or who have limited access to existing services. Outreach programs can be delivered outside of established health services or they may use existing services in a way that is more suitable and acceptable to the target group.

STI and BBV outreach programs have many direct and indirect benefits including that they can:

enable engagement with priority populations who may be marginalised or who have limited access to services
provide access for a lot of people to information, testing and treatment in a short time
be tailored to meet the needs of the priority population
provide a level of anonymity for people to access testing and treatment
enable the development and strengthening of partnerships across a range of services.

While outreach programs can be very effective, they can also consume a lot of time and resources and involve careful planning and implementation. When a program comes to an end, evaluation is important to ensure that priority populations were appropriately engaged and that the goals of the program were met in a cost-effective manner.

Planners should bear in mind that outreach programs:

are time and resource intensive and so should be targeted only to priority populations who have limited access to services
should align with the broad aims of national and WA sexual health and BBV strategies
should involve careful planning and engagement with key stakeholders, including priority populations, community, health and other organisations, to maximise success
should be evaluated to ensure that the aims of the program were met or to enable parts of the program to be reviewed and fine-tuned to ensure the success of ongoing programs
may be difficult to sustain in the longer term so should also aim to facilitate ongoing access for marginalised groups to existing services
should not be delivered at the expense of ensuring that STI and BBV testing and management has been appropriately integrated into existing primary healthcare services already accessed by those at risk.

Models of delivery of outreach programs

Outreach programs can be delivered in many different ways but should be tailored to meet the needs of the priority population and delivered in the most cost-effective way. STI and BBV outreach programs should focus on those at highest risk, such as 15 to 30 year olds or specific risk groups such as men who have sex with men (MSM), sex workers or injecting drug users. Be mindful that some priority populations within a community may not be easily identifiable or easily defined by young age alone. Consultations and partnerships with appropriate community members and organisations can assist to better identify priority populations and how best to improve access for them. While it may not always be possible to identify individuals at risk, it may be easier to identify and work with their broader social groups and networks to reach individuals within those groups who may be at risk of STIs or BBVs.

Priority population groups

Australia's response to STIs and BBVs is targeted towards specific priority populations who are identified based on epidemiological data. Past STI, hepatitis B, hepatitis C and human immunodeficiency virus (HIV) national strategies have specified the following priority populations:

Gay men and other men who have sex with men
People who inject drugs
Young people
Aboriginal and Torres Strait Islander People
Sex workers
People living with HIV and/or other BBVs
People living within custodial settings
Culturally and linguistically diverse populations
Migrants and new refugees
People from high HIV prevalence countries
Travellers and mobile workers.

Outreach programs can have different goals and be delivered in a number of ways through:

providing information, awareness raising, health promotion
testing and treatment
standalone STI and/or BBV programs
integrated into, or delivered alongside, other outreach programs such as adult health checks or immunisation
non-clinical settings in the community
existing services reorganised to make them more accessible and acceptable, such as dedicated clinics, changing opening hours or providing transport.

It is always ideal to offer programs that are holistic and aim to deliver a number of outcomes, but this must be balanced by what is realistic and achievable, particularly in view of time and resource constraints. If integrating into or delivering alongside other outreach programs, ensure that the target group for the existing program aligns with the priority population for STI and BBV programs.

Where and how outreach programs are delivered will vary depending on many factors including what other services are available and accessible. Programs can be enhanced by developing and strengthening partnerships with other organisations that deliver services to the priority population. The services that people may already access within communities might include:

youth or community centres
sport and recreation centres
educational facilities such as high schools and TAFE colleges
employment programs
drug and alcohol services
mental health services
corrective services.

There are many different examples and models that have been used across the country to deliver successful outreach programs to priority populations. Many have involved partnerships between health services and other organisations in a variety of settings to capitalise on the mix and skills of staff and maximise access to priority populations in an appropriate and acceptable way. Examples of outreach programs and models of STI and BBV testing include:

annual community-wide STI screening conducted by health services such as the Nganampa Health Council, Ngaanyatjarra Health Service and Spinifex Health Service
partnerships between Aboriginal Community Controlled Health Services (ACCHS) and other services such as schools, drug and alcohol services, and corrective services
mobile buses
programs coordinated by sexual health services and public health units (PHUs) that use hospital emergency departments to conduct STI testing among 15 to 30 year olds
chlamydia and BBV testing using websites for young people to access pathology test request forms so they can drop off specimens via the mail or directly to a laboratory

Planning and implementing outreach programs

Successful outreach programs rely on good planning, effective engagement with the target community and collaboration with other services. The Sexual Health and Blood-borne Virus Applied Research and Evaluation Network (SiREN) has developed a toolkit to help plan and evaluate programs. The toolkit can be used and SiREN program staff can be contacted to help set up programs. The toolkit contains templates and checklists, and other resources include the Aboriginal Health and Medical Research Council of NSW (AH&MRC) STI and BBV Manual. These and other comprehensive resources can be adapted and simplified to meet the needs of many outreach programs.

https://siren.org.au

http://www.ahmrc.org.au

When planning outreach programs, here are some things to consider:

Identify the priority population for the program and think about the following:
- Are members of the target group already accessing existing clinical services and, if so, are they offered appropriate information, testing and management for STIs and BBVs?
- Is an outreach program warranted or do existing services, systems and staff need to be reorganised to make them more appropriate, acceptable and accessible?
- What other services do they access?
- Is there a target group such as a peer or social group that truly does not access services and that should be prioritised?
- Are other outreach programs already delivered to them and, if so, can they be integrated?
Identify the goals of the outreach program:
- Is it to provide education, health promotion or to test and treat?
- What other organisations should be involved to ensure an appropriate mix of skills is used to maximise the success of the program?
Outline how the program will be delivered:
- Do partnerships already exist between relevant services or do they need to be developed or strengthened?
- Will it be delivered over one or several days?
- What sites or organisations will be needed to implement the program and do they enable a safe environment for staff and participants?
- Will follow-up be needed and where and when will that take place?
- Have you clarified the roles and responsibilities of organisations and staff involved?
- Have you mapped what resources will be needed with regards to time, equipment, workforce and mix of skills?
- Have you estimated the number of participants and amount of equipment, medications and other supplies that may be needed?
- Can the program be run within existing resources or will additional funds be needed for certain parts of the program?
- Does transport need to be organised for participants?
- Do you need to use any activities, competitions or incentives to engage participants?
- How will consent be gained from participants?
- Does an information sheet or consent form need to be developed to assist with the consent process?
Community ownership and engagement:
- Does permission need to be gained from community representatives and leaders to run the program?
- Have you liaised with the appropriate community representatives with regard to where and when to run the program and how to advertise it effectively?
- Have you sought permission from community Elders prior to any program delivery? (Contact the local ACCHS for guidance on who to talk to within the community. In the absence of a local ACCHS, seek advice from other Aboriginal organisations such as the local land council.)
Clarify the roles and responsibilities of staff and community members engaged to run the program with regard to:
- engaging the target group
- planning the fine detail
- implementing the program
- following up
- entering data
- evaluating the outcome
- ensuring provision is made to keep staff and participants safe, such as the safe disposal of sharp implements and medical waste.
Data management:
- What information will be recorded? (e.g. the number of participants by age and gender, test results, treatment given)
- How will information be recorded? (e.g. entered into an existing HIS or into a database or spreadsheet specifically for the program, or both)
- Do you need to record unique identifiers to follow up abnormal test results?
- How will confidentiality be maintained?
- Regardless of the system used, data should be entered in a way that is easily extracted to enable evaluation.
- Who will be responsible for data entry, extraction and analysis?
- How will information about the program be fed back to staff and participants or community representatives?

Testing and treatment

If the aim of the outreach program is to provide testing for STIs or BBVs, planning needs to include both follow-up and management of abnormal test results. Outreach programs may aim to provide both testing and treatment at the same time, or may provide information only and links to clinical services that can provide testing and treatment.

For example, while information on STIs and BBVs is often provided to adolescents at schools, it may not always be appropriate or acceptable to staff and parents for adolescents to access testing and treatment at school. However, it may be acceptable to provide information regarding the clinical services that can be accessed for testing and treatment. If outreach programs aim to strengthen access for youth to existing services, it is important to ensure that part of that program is to work with health services and staff to ensure that the services are accessible and acceptable for adolescents and that they are offered appropriate testing and treatment for STI and BBVs when they do access the service. This may involve reorganising clinic hours, having specific clinics or staff on designated days or providing transport to improve access and ensure appropriate management.

When planning to test for STIs and BBVs through outreach programs:

Clarify what STIs and BBVs will be tested for and what specimens will be required such as:
- first void urine or self-obtained lower vaginal swab (SOLVS) for polymerase chain reaction (PCR), +/- blood for BBVs
- follow-up blood tests for BBVs for those with an STI detected (if not done initially).
Determine how consent to testing will be obtained – on the day of testing or beforehand? Verbally or by signing a simple information and consent form?
Ensure confidentiality and access to toilets and rooms for privacy.
Clarify how participants will be informed of abnormal results, clarify the method for giving these results and ensure contact details are up-to-date.
Determine how many staff members will be needed for the different stages of the program to ensure effective use of time and flow of participants (e.g. providing information, gaining consent, checking contact details and conducting testing).
Determine whether the laboratory needs to be notified and prepared for additional specimens to process.
Know where and when follow-up and treatment will be given (e.g. will staff return to the site of testing to treat the following week or will participants be advised to access a particular health service for treatment?).
If treatment is to be given on the day of testing:
- will testing be conducted on the basis of an STI detected (if point of care testing is to be conducted)?
- will presumptive treatment (before the receipt of test results) be given to all participants on the basis of high positivity rates and to avoid loss to follow-up?
Will other tests be taken at follow-up?
How will contact tracing be conducted?

Regardless of whether testing occurs within an established clinic or off-site, the same principles apply such as consent to testing, follow-up and management of abnormal results, contact tracing, appropriate handling, storage and transport of specimens to the laboratory, and occupational health and safety.

Evaluation

Evaluating outreach programs is important to ensure that the aims were met and that the outcomes were worth the time and resources used. A continuous quality improvement (CQI) approach can also be used to review the measurable outcomes of outreach programs. CQI and program evaluation is discussed in more detail in Chapter 6 and resources such as the SiREN planning toolkit can be used as a guide.