Outreach Work in High Risk Settings

Thoughts on Outreach Work in High Risk Settings

The advice (or thoughts) we share today, or at any time, is only theoretical and based on our own experiences in high risk settings, so please do not apply any of it to your services without thorough consultation first with experts in the field (Police, Military, Health, Education, Social Care and Solicitors/Legal professionals) local to you (eg USA or UK or EU), and local to the project (eg EU, South Pacific, Africa, Central America) and further to your own local risk assessments reviewed regularly over time.  

We usually spend 1-3 years to complete a bio-psycho-social needs, resources and risk assessment in local areas by liaising with local authorities, services, professionals and communities, and further to this process, and identifying a risk management plan, we propose a service model to the DOH.  If they agree on common goals and processes, and further to extensive continued liaison with local professionals and professionals in the host country, all parties then decide if we go ahead, so that risk would likely be reduced for local communities, rather than increased and so that benefits are sustained (eg focus on education throughout services).  We then start informing, along with preparing and training, volunteers (from the UK, USA, Canada etc), and start with practical arrangements.  Only in this context can we give specific advice to professionals or services, relevant to the local community at this specific time.  We then often have to review this risk assessment every week, due to the dynamic nature of risk.

Please know that we are medical doctors and therefore write from this perspective.

Please get official advice from professionals in every field, locally and from the host country, before making any decisions for your own service.

General Thoughts (we add to this section, as new questions posed):

• We always recommend starting any project with liaising with all local leaders in every context to determine whether they believe a service to protect children, in terms of nutrition or immunisations etc, would be helpful. Without the ‘approval’ and ‘welcome’ of local leaders in every context, risk is often increased rather than reduced. Negotiations in terms of goals are important here and this will affect collaborative relationships and sustainability, along with the success rate of your project.

• Goals must be shared by all parties and leaders, as above – for example, a specific percentage reduction, within an agreed time period, in admissions to a specific hospital(s) of children with conditions as a consequence of malnutrition (e.g. Kwashiorkor).

• It is essential to use useful language that reduces risk rather than increase risk. Your presence as a service, or even discussing a service, can easily increase risk, rather than reduce risk, so start, continue and end in a very respectful way, asking questions, learning about needs and listening, with the end goal to meet needs in a sustainable fashion and reduce general risk.

• Work collaboratively WITH local authorities and BEFORE starting the needs, resources and risk assessment; this includes Health, Social care, Police, Military if need be, Education and Law.

• Integrated and collaborative Police or Military involvement, accompanying you every day to assist with planning routes or advising on security or safety decisions for staff and community. An important role of the staff during the service towards community should be addressing stigma and building positive relationships with all systems present, so this often means being dressed in plain clothes and playing ball games with kids or serving coffee to elders.

• We would always recommend significant (at least 10 years) experience working with high risk cases and in high risk contexts or settings, including developing countries, and appropriate training for the lead person or persons.

• We would recommend choosing volunteers carefully, suited to various settings, based on their own cultural backgrounds, temperament, training and experience. Working collaboratively in high risk settings is not suited to every temperament, but common goals usually bridge the gaps.

• Legal advice, local and host country, with all decisions, is usually very important, including with volunteer selection.

• We recommend a medical doctor completing physicals and immunisation consultations for every volunteer and staff member, to reduce biological risk.

• Risk assessment collaboratively with local hospitals and social workers, along with Police and Military is always recommended.

• We recommend to always work with local hospitals (district clinics and tertiary hospitals) to have emergency management plans in place from a medical, psychological and social point of view. Relationships have to be established long before the project starts.

• We recommend always having a medical doctor (at least two), social worker and police officer taking the role as above, present every day, along with psychologists, therapists and other volunteers.

• Plan to develop sustainable services (so you can hand over in 3 years, for example) and then remain available for several years so that your departure does not mean the end of services to communities.

Our thoughts on specific questions posed throughout the years (especially if repeated):

• We recommend marketing services to ‘communities’ or to ‘children’ – we have never found problems with this approach, and we deliver this service. “Victims do not have an age or gender or colour, anyone can suffer greatly and then get very mad if they are not considered because they are not in the box” – psychologist, Africa.

• It can increase risk to market services to a specific part of the community for various reasons eg “no one talks about the extreme violence boys and men experience from women or other men, so it makes me angry that we are forgotten, as if we don’t matter” – 45 year old nurse in Africa, “I don’t want people to tell me what to do if they don’t live in my neighbourhood or understand my world, my culture is my culture and I get very angry if I am told I am wrong” – 56 year old leader of community, Africa.

• We also recommend the goals to be welcoming and ‘safe’ and encourage people to attend, such as immunisations and nutrition or baby care. In this manner men, women, children with HIV, TB, significant medical, mental health and social problems attend, speak openly and stigma, along with risk, is often reduced in this manner.

• Access to mental health care is often a significant problem in many countries, however, stigma and ‘threats if you attend’ are also very difficult problems to address; we suggest starting with education and normative activities, which is also often the place mental health services will start, such as establishing a football club that Police host for kids every afternoon in areas (with no agenda, except to ‘be part of something fun’ so “belonging and being busy” as the 93 unaccompanied minors of Liverpool said changed their lives.

• Always link in with local health clinics from day one, so that medical services and pathway for referral for emergencies, urgent and routine matters are established and predictable.

• Working against traditional healers often increases risk. The goal is to understand and to learn and to educate each other. ‘We learn from each other’ is the goal and message.

• Always remember that your input or ‘help’ can increase risk, rather than decrease risk, so start what you propose in the right way, with questions, listening carefully to the community, leaders, elders and authorities, ongoing liaison, positive relationships established, risk assessments by professionals in various fields, and reviewing your proposed model with experts in the host country and locally. Working collaboratively with leaders in every context, with common goals, is essential. Stick to your goals and working agreement – transparency.

• First priorities should always relate to water, nutrition, immunisations, safety and health.

• Systemic thinking during every process or decision is essential.

• Safety matters are usually managed successfully if you are ‘welcomed’ locally by the community and leaders (if you started off by asking if you can offer something that they might want or need).

• Risk assessments and management plans must be reviewed daily and weekly.

• Have a clear plan for emergencies eg suicidal intent, medical emergencies, mental health emergencies, social emergencies, and establish pathways and professional responses (roles and responsibilities) at the beginning of the project.

• Agree on details and sign paperwork to support the proposed model.

• Prepare volunteers well and ensure they are informed of all risks.

• Buses are usually parked (when not in use) in locked garages/areas such as Police parking lots.

• Buses are usually parked (when in use) in clear, accessible, open spaces with shade available.

• Decommissioned busses can usually be purchased cheaply and restored cheaply, and consider the function, ie ‘conversations’ or ‘immunisations’ when planning layout. Large tents alongside buses also create informal and friendly atmospheres. Play or serving coffee is usually a good way to address stigma, engage the community and encourage conversation. Step one is Trust.

Anticipate difficult roads or problems with transport. We have been informed in various areas in the Pacific or EU that we need to be able to travel via motorbike, boat and/or horse to reach areas of need, and we have made provision for this or attended training. Many people live on islands or areas without roads and these hard to reach areas or hard to reach children (or communities) require access to services.

• Outreach services include local clinics, taking walks with people to chat, and even chatting to children refusing to get out of the trees.

• Having a regular, predictable schedule can be important, e.g. having three areas you return to Monday, Wednesday, Friday, can be useful (so you return to the same location every Monday). Keep clear notes, as if any other working day.

• Coffee, tea, water, bread, music – essential. In previous years volunteers have learnt traditional dances to engage with communities such as Cuban salsa (project not in Cuba, but in Latin America), and this encouraged wonderful conversation and positive relationships of respect and appreciation. Everyone also enjoyed this tremendously. We observed grandmothers dancing with grandchildren standing on chairs (2 yrs old) and the community coming together sharing this traditional experience. Communities teaches you something every day!

• We usually recommend 2-4 consultants, GPs, Paediatricians, social workers, psychologists, therapists, teachers, police officers. This depends on context.

• Always be prepared, before you start the project, even after years of work, to ‘pull the plug’ if you believe your presence will increase risk rather than reduce risk, or you cannot offer an acceptable degree of safety and security to staff, volunteers and communities. There are always alternative ways to achieve goals, and going back to the drawing board if it will save lives is the only option sometimes.

• It is essential to have the most important therapeutic options available for children such as behavioural therapies, CBT, CAT, psychodynamic therapy, family therapy and play therapy (different children and clinical presentations require different therapy, a ‘CBT for all’ approach is seldom helpful), alongside social intervention for all children (eg involvement in normative activities such as joining a Football team, or horse riding lessons with positive and responsible adults and peers where positive experiences, learning and enjoyment can be experienced at least weekly) and medication if indicated (not kept on the bus). Bio-psycho-social approaches for children are essential if progress is to be made relating to mental health and development.

It is essential to take a bio-psycho-social approach in all services – always consider clean water, food, safety, health, mental health, and have an action plan for referrals (so that there are no surprises for any party).

• Communities and leaders often feel ‘safer’ if they know you will not share details of the work with the wider world. People often want their doctors, psychologists, professionals, staff members, volunteers to be ‘ordinary people’, rather than ‘important’ or ‘famous’ in their fields. We usually refuse that details of our names or organisation be published for this reason.

• Some health ministries or leaders prefer that we sign non-disclosure documents relating to services we offer. We are usually happy with this, but we always ask our organisation’s solicitors or solicitors offering pro bono input to review all agreements or documentation.

• It is important that all parties are comfortable with goals, processes, actions to be taken if problems etc, so that transparent, no surprises and focus can remain on the task.

• Review progress and outcomes, as planned, at least weekly, and monthly with external parties, such as colleagues in the UK. Sharing information confidentially (no names or identifiable details mentioned) will encourage learning and assist with risk assessments and management plans.

• We always recommend working alongside solicitors, the local health ministry, local leaders, Health, Social Care and security experts such as Police or Military.

• Work with local services, even if fragmented, this process will reduce fragmentation and focus on education (learn from them and teach as you go through work), so that all parties learn and develop.

Primary Obstacles to Plan for / and Good Surprises:

• Medical colleagues are often significant obstacles, because they are concerned that the identified need and demand will increase significantly if outreach services are introduced.

• We have found that local health ministries are often the most helpful and can clear obstacles and introduce us to networks that can increase sustainability. We recommend starting there and asking if they believe a service would be helpful.

• Legal colleagues in the UK have been more helpful to us than we would have ever hoped for, and they often offer their input pro bono.

• Anticipate bus breakdowns and plan for mechanics and drivers and for alternative transport to be on standby.

• We usually aim to provide accommodation for volunteers.

• Route planning and various routes for locations very important.

• No medication or valuables on the bus or mobile clinic.

• Expectations or goals must be clear and shared amongst professionals, volunteers, communities and leaders for good outcomes.

• Professional registration is often the most difficult obstacle, as some countries believe if you are registered you can take the ‘lead’ in projects. For medical professionals we recommend full registration as doctors in the country.

“It is often more difficult to work or offer services in your own country or home country, because you are invested in the system working and things working, so this emotional investment can increase the risk, so be aware of it, and in different countries, where you are less emotionally invested, the risk is often less, because if things don’t work as it should you don’t experience such strong emotions”, social worker.

Please feel free to send us more questions to admin@mentalhealthbus.co.uk or to arrange a consultation session to discuss more details.

We also hope to learn from other professionals so please send us thoughts on your own experiences relating to outreach work in high risk settings if you want.

Our sincere thanks to professionals and volunteers who contribute to providing services in hard to reach areas or for hard to reach communities or children such as homeless children, young offenders or unaccompanied minors.

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