Section 6. Using Outreach to Increase Access

Learn how to implement an outreach service to expand access to health services, practices, or products.

 

• What is outreach?

• When is outreach needed?

• What are some common methods of outreach?

• How do you implement outreach?

If you build it, they will come -- right?

It worked for Kevin Costner in the movie "Field of Dreams," but in the real world of creating healthier communities, the definitive answer is "Maybe." In one Midwestern town, for example, a nonprofit health care clinic that provides free service to the uninsured discovered it was reaching only 10 percent of the people who qualify for its services.

This reflects a similar problem on the national scale. Despite eligibility for health coverage through Children's Health Insurance Program (CHIP), as many as 7 million children remained uninsured in 2000.

Both facts highlight the difference, and sometimes the great divide, between a person's eligibility for a service or program and her actual use of it.

When a gap like this exists, outreach is often the next step. In order to carry out your program to improve the health or well-being of people in your community, you might need to carry it to them in some way.

Or, put another way, in order to serve the "hard-to-reach," it will help to change your thinking. Your goal is to reach the "yet-to-be-reached."

What is outreach?

It can be:

• Providing new needles and bleach in an area frequented by intravenous drug users
• Bringing a mammography van into a rural area without a hospital
• Demonstrating correct child car seat installation at a busy discount store on the weekend
• Handing out coupons for condoms at a coffee shop that is popular with teens
• Training individuals to provide health education in their own communities

They all involve reaching out -- but the type and degree of outreach depends on an effort's purpose, goals and target population.

People use the word "outreach" to describe a wide range of activities, from actual delivery of services to dissemination of information. As a tool to help expand access to healthy services, practices or products, outreach is most often designed to accomplish one of the following (or some combination):

• Directly deliver healthy services or products
• Educate or inform the target population, increasing their knowledge and/or skills
• Educate or inform people who interact with the target population (often called community health advisors)
• Establish beneficial connections between people and/or organizations

When is outreach needed?

In some fields and with some populations -- such as the elderly, or minorities, or intravenous drug users -- outreach is the primary method of service. Decisions in this case focus more on which type of outreach is most effective. In a study of reproductive health outreach programs for young adults, for example, Judith Senderowitz compares efforts that are designed to reach young people by attracting them to centers with those that reach out to them where they already gather for social, vocational, and recreational activities (see Internet Resources below).

In other situations, outreach can be one component of a program or a support structure to the main endeavor. If you aren't sure whether or not outreach will help achieve your objectives, it is probably time to analyze your target population again (or for a first time if you haven't). Before reaching out, take a step back and consider:

• Have you determined who your users are (or should be)?
• Do you know what the best ways are to reach and serve your users?
• Have you identified any gaps in use of your program or service?

Many health programs in the U.S. are designed for a seemingly homogeneous population -- usually financially comfortable whites. But what if the people who need your services represent a different group, in terms of culture, language, race, values, education, economics, or some other trait?

You need to know who you are trying to reach in order to know how to reach them. You can gather information about your constituents and their environments in numerous ways, including conducting surveys, focus groups, and interviews.

This information in turn will help you determine if the essentials for program success are in place. In order for any program to accomplish its purpose, users or participants must:

• Know that the program, service or product exists
• Be willing to use it (cultural norms, for example, sometimes impose stigma)
• Be capable of using it (have access)

If you determine that one or more of those pieces is missing or flawed, outreach in some form can help you bridge the gap by focusing on one of these goals, which are elaborated on below:

• Outreach to increase access for users (enhance a person's ability to use, acquire or employ your healthy service, product, or practice)
• Outreach to expand peoples' willingness to use your service or product
• Outreach to increase awareness of your service among potential users or those who will refer them

Outreach to increase access for users (enhance a person's ability to use, acquire or employ your healthy service, product, or practice)

Some access problems can be fixed through programming changes. In the case of the health care clinic mentioned above, limited clinic hours did contribute to low use, so the clinic created more evening and weekend hours for clients.

Other access problems can be addressed with outreach. If lack of transportation is keeping some of your users away, find volunteers to drive them to your site, or work with a local taxi company to provide reduced fare rides. Similarly, if lack of childcare is keeping users at home, provide on-site childcare during visits.

Making sure you have a translator on-site -- and that your brochures are printed in the language of your users -- might be another way of improving access. And in all of these cases, of course, you'll need to let your users know the services are available.

Outreach to expand peoples' willingness to use your service or product

Is a personal or cultural stigma attached to using your service or product? Do potential users fully understand the benefits?

If low use of your program is related to user attitudes or values, you might need to focus on a social marketing campaign to explain the benefits of your service or initiative.

Marketing is a form of outreach in that it requires you -- once again -- to find out who your users are, where to reach them, and how to communicate with them. After reaching out to understand your users with surveys, interviews, or focus groups, you can reach out again with a marketing campaign that helps change attitudes and correct misperceptions. (Of course, you might also revise parts of your program based on the information you gather.)

Some marketing-type outreach takes the form of incentives. If you distribute coupons for condoms at the local teen hangout, you are not only reducing the cost, but you 're also increasing awareness of a product or service while providing an incentive to behave differently.

Outreach to increase awareness of your service or product among potential users or those who will refer them.

Let's consider the case of the underused free clinic again. Access, in the form of limited clinic hours, was one problem. But the clinic's board of directors also realized that lack of awareness contributed to low use.

The board members understood that the people who typically use this type of service also have the least access to communication, including newspapers and television. Therefore the clinic has relied on word-of-mouth publicity and referrals from other health professionals in the community. They also inform eligible patients with outreach programs through soup kitchens and the Salvation Army.

But the clinic still needs to reach further to inform and attract those who would benefit from their service. How? Once again, social marketing and outreach are likely partners for improving the situation. If the clinic's services themselves will not be delivered in a different way -- such as literally taking the services to the users -- the word about services must be spread more effectively, both to potential users and to those who can guide them to the clinic.

There are many vehicles for informational outreach (beyond paid advertising) that can help you spread your word more widely, or to target certain populations. See the Tools section for suggestions.

What are some common methods of outreach?

You've decided that outreach will help your effort. Now you need to decide just how to reach out. These common methods are discussed here:

• Outreach to deliver healthy services or products
• Outreach to educate or inform the target population, or those who interact with the target population (often using community health advisors)
• Outreach to establish beneficial connections between people and organizations
• A combination of outreach efforts to deliver services, enhance skills and knowledge, and raise awareness

The nature of your initiative should determine what type (or types) of outreach you use. Although we discuss these methods by category, the divisions are not rigid. Be creative in adapting and combining to serve those "yet-to-be-reached" people.

Outreach to deliver healthy services or products.

Outreach often means bringing health and human services to someone's home turf -- as with the mammography van that visits rural areas. It often involves one-on-one interaction or support, as in a program where job counselors work with the unemployed to complete applications and conduct their job searches.

"Delivery" outreach commonly serves people who are hampered by barriers such as lack of transportation, low income, lack of health insurance, and cultural differences. It is frequently used in working with people who live in rural areas, underserved urban areas, and on Native American reservations. (Telemedicine has become an important component in reaching people in rural and low population areas.)

Visiting nurse programs are one well-known form of delivery outreach in urban areas as well as rural. Direct delivery of services or products can be an effective strategy for serving population groups that lack power or resources, such as youth, intravenous drug users, the disabled, or the elderly.

Outreach to educate or inform the target population, or those who interact with the target population (often using community health advisors or workers).

The acts of "educating" and "informing" are part of the same continuum. Educating typically involves more sustained interaction with your target population.

If your goal is to disseminate information and raise awareness about a service, product, or practice, outreach can take several forms. A public health department that seeks to reduce teen pregnancy, for example, might send representatives into area schools to make presentations on the risks of unprotected sexual activity. The purpose of these sessions might also be to inform teens of the services available to them at the health department.

For this health department, an alternate -- and complementary -- form of informational outreach could be to post flyers in coffee shops and record stores that are popular with teens, including those coupons for condoms or other birth control. Like the lecture, the flyer raises awareness (in a non-confrontational way) of the health center's support for teens, while the coupon reinforces safe sex messages.

A third form of outreach that would make it even easier for the teens to use health center services involves actually bringing them to the center. Some health centers have developed programs with their local school districts that incorporate a school-sponsored visit to the center. Once a teen has been to the center, a repeat visit is more likely.

Another way to translate information into action is through instructional outreach that is delivered one-on-one or in small group settings. Many public health programs use community health advisors or outreach educators to take training into neighborhoods and communities, either directly to the target population or to others who are influential in their lives.

Community health advisors or workers (CHAs or CHWs) play an essential role in helping minorities in underserved communities to obtain health care. According to a study in the U.S. funded by the Annie E. Casey Foundation and the Healthy Start Program of the government's Maternal and Child Health Branch, CHAs help low-income and minority people gain access to the nation's health care system in affordable, more familiar ways. (See Internet Resources for this study.)

This study also found that CHA's are particularly critical in rural areas due to the lack of culturally competent mental and physical health services. But whether your environment is rural or urban, a culturally attuned, personal approach works best in communities where people experience barriers to accessing health care.

Outreach educators or CHAs can empower their target audience to care for themselves (or their children or neighbors) by increasing their knowledge and skills. Whether they are paid professionals or trained volunteers, the Casey Foundation study found that the most productive CHAs share these traits: they possess communication skills, interpersonal skills, service coordination skills, capacity building skills, teaching skills, organizational skills, and a knowledge base.

A positive ripple effect is at work in these outreach initiatives that use some type of community health advisor.

All are listed in Internet Resources.

• In Spanish speaking communities in the U.S., "promotora" or lay health educator programs have helped expand health service access. As described by Lisa Duran in "Health Care, Equity and Access: Promotora Programs in Latina Populations", these programs use existing social networks to recruit informal leaders, often women, who are trained to do health education outreach in their own communities. Promotora programs not only help increase positive health outcomes, but also foster community empowerment.
• In Atlanta, Georgia, the ZAP Asthma program trains residents as community health workers (CHWs) to help reduce asthma deaths among children and young people, especially African Americans. The CHWs educate other members of their community to assist them in becoming more responsible for their health. Home visits are the most important part of the educational process for ZAP Asthma families. CHWs conduct audits of the home environment and teach parents about the environmental conditions in the home that trigger asthma and how to control them.
• Internationally, Global Health Action has used educational outreach to stimulate the creation of sustainable, community-based health programs. GHA has trained more than 5,000 health and community leaders from 85 countries worldwide over a 30-year period, and estimates that these graduates and those they teach now serve the health care needs of more than 70 million people.

Outreach to establish beneficial connections between people and organizations.

Some outreach efforts take shape as programs intended to create opportunities and prevent problems. If you see an immediate or long-term need, outreach can be used to cultivate healthy habits, skills, and interests in your target population.

This type of outreach usually involves working through existing channels -- schools, clubs, churches, and other organizations -- to reach your desired audience.

A state university sponsors "Project Outreach," a program that pairs minority junior high students in the city with college students who serve as their tutors and mentors. The purpose is to help first generation college students (those will be the first in their family) prepare for higher education at a critical intervention stage.

The strategies of the program are multiple. It helps students with academics, but also exposes them to the college experience (including football games). The mentors provide after-school tutoring at the junior high, and also invite the younger students to campus once a month to learn about its resources and opportunities. Parents are involved through parties and other events.

The director of the program describes the outreach effort as a collaboration with "ally" organizations. The Office of Multicultural Affairs at the university sponsors the program, drawing volunteers and some funding from the student senate. Community organizations are essential to helping carry out activities, though. The director works with representatives in the local school district, the Boys and Girls Club, and several churches to identify junior high participants and to continue developing beneficial outreach.

A combination of outreach efforts to deliver services, enhance skills and knowledge, and raise awareness.

If outreach is the primary strategy of an initiative, some combination of outreach methods is usually employed. In Massachusetts, a comprehensive, multi-faceted outreach program was used to close the gap between eligibility for health insurance and actual enrollment that was mentioned in the opening of this section.

This highly successful outreach program involved numerous stages, and paid community-based outreach workers were the backbone of the effort.

The first step was to locate people who were eligible for health insurance coverage but not enrolled -- that involved some aggressive and creative outreach in the areas of raising awareness and connecting with people. The next steps were to actually enroll eligible people in health care programs and then help them learn how to use their coverage.

In the beginning phases, the outreach workers gave group presentations, distributed localized information, and held one-on-one meetings. As families were enrolled, the outreach workers followed through personally with their clients, making sure individuals understood and knew how to use the available services.

This involved regular one-on-one meetings with family members and well-organized follow-up. Sometimes that meant the outreach worker made phone calls to a doctor's office to check the status of a claim or helped a parent fill out paperwork. In one case, incorrect information had not been removed from a child's records; the outreach worker helped locate that error as the source of a problem (denial of coverage) and to correct the records. The worker also helped her clients find other health coverage options for the parents because although their children qualified for insurance, the adults didn't.

This outreach worker not only delivered service, but taught her clients a range of skills that built their self-confidence. The parents gained understanding of the health insurance system (including the paper trail from doctor's office to insurer) and, perhaps more important, developed problem-solving skills (how to gather information, follow through, and persist to resolution of a problem).

How do you implement effective outreach?

The following guidelines and strategies for outreach are adapted from Outreach Works. While that program focused on health insurance coverage, many of the elements can be applied to other health promotion and community development efforts.

Guidelines for effective outreach.

• Meet people where they are
• Be respectful
• Listen to your community
• Build trust and relationships
• Get the word out in a non-stigmatizing manner
• Offer service and information in a variety of locations (including home visits) and at non-traditional times, especially after work hours
• Make written information friendly and easy to understand
• Provide information in the primary language of those who will use the service
• Follow-up, follow-up, follow-up!

Planning and implementing effective outreach.

Depending on the nature of your initiative and the type of outreach you think is needed, consider the following steps as you begin or expand your outreach.

Determine the purpose and methods of outreach for your initiative (based on discussion above).

Determine staffing needs. If you use trained outreach workers, it helps if they come from the community they work in and are familiar with its characteristics. Outreach workers can play a vital role in developing community trust and a good reputation "on the street." Workers who live in the community they serve will understand the needs, concerns, and questions of the people they serve, and understand the barriers they face. They are better equipped to develop strategies designed to address the specific needs of your population, especially in minority communities.

Whether your staff is paid or volunteer, they must be well-trained and knowledgeable. Provide training through modeling by other workers experienced in outreach, time on the job, a formal training program, supervised case review for education purposes, identifying resources for keeping current and distance learning, Internet access, or other innovative methods for workers in rural or isolated areas.

Choose physical space carefully (if you need it). The location and feel of an outreach office sets a tone. Look for a space that:

• Is on a major transportation line
• Is accessible to the disabled
• Has a private area for meeting with clients
• Provides a cheerful environment
• Accommodates children

Plan your services or activities. Develop strategies and action plans using principles for effective program design.
If a local, national or international organization can provide resources or programming (such as for breast cancer awareness week), take advantage of their materials and marketing. For an outreach plan, organizational preparation should include:

• Developing systems and making information available in manuals or other formats
• Establishing protocols
• Integrating services with other organization or agencies to increase effectiveness.

Consider potential partners. Partnering, of course, can influence your services or activities, so this step might come earlier in the sequence for your effort. Again, depending on your purpose, find people and organizations to work with as your allies. Identify their motivations (how they will "profit") and work to develop win-win partnerships. Depending on your initiative and target population, you can look for partners in:

• Community leaders
• Churches, synagogues, mosques, temples and other places of worship
• Hospitals (including emergency rooms)
• Health centers (including office staff such as medical secretaries)
• Doctors' office (including office staff and billing managers)
• Pharmacies
• Billing agencies that serve medical providers
• Health-related clinics (such as immunization, blood pressure, smoking cessation)
• Visiting Nurse Associations
• Schools (nurses, counselors, health coordinators). This might require the initial support of the superintendent, principal, or PTA
• Childcare centers and home daycare (including "unofficial care providers")
• Housing authorities
• Courts, police and public safety departments
• Local businesses and employers
• Local agencies or local offices of state or national associations that provide services to your population
• Programs for those in need (shelters, job training, literacy programs)
• Local media (print, radio, TV, billboard)
• "Satisfied customers" of your services. Word of mouth is the best source of referrals

Expand your outreach gradually. There are many possible avenues for outreach, so new outreach programs are wise to develop a prioritized strategy for raising awareness. The authors of Outreach Works suggest a gradual expansion of outreach by moving through "zones."

Start with activities that are easier and most comfortable and move toward less familiar and more challenging ones. Here are some sample activities for gaining and building on success in outreach:

Examples for Zone one: Most comfortable/easiest

• Conduct outreach activity for a community group well known to you.
• Provide in-service or referral information for other programs in your organization.

 Examples for Zone Two: Moderately familiar/more challenging

• Offer a training or information session to a local school, medical provider, neighborhood group, or human service agency.
• Participate in joint outreach activities with another organization.

Examples for Zone Three: Least familiar/most challenging

• Establish relations with informal community leaders not known to you, and ask them to sponsor an outreach activity at which you will speak.
• Conduct a presentation for a human service agency that already has outreach workers, but is unfamiliar with your program, to determine how you can help them.

Make the most of your outreach. Even if you have great sums of money for outreach (which most of us don't), it is possible for outreach to fail if you don't understand the issues of access and barriers to access for your population.

Inefficient outreach doesn't reach the desired individuals or group. It may be presenting its message in the wrong language, or in a form that does not communicate well with its intended audience.

And remember that people need to hear about something three to seven times before they act, so outreach needs to be varied and constant. In addition to "Follow-up, follow-up, follow-up," the keywords for an effective outreach program are, "Repeat, repeat, repeat!"

In Summary

Outreach can be the foundation of an effort to improve the health and well-being of a population, or one component of it. In whatever measure you employ outreach, it will be most effective if you know your users and community, and are creative, trustworthy and very determined.

No single outreach practice works for all initiatives. Likewise, in one initiative, what works in one community might not work in another. A broad repertoire of options increases the chances of success in an outreach effort.

Practitioners of outreach identify certain factors that seem to impact success:

timing; credibility and sensitivity of outreach staff; organization and publicity of the outreach effort; and the local culture and attitudes. People need to hear about your program and efforts from several different sources before they will use your service or contact you.

While your initiative might not have the magical allure of the cornfield ballpark in "Field of Dreams," you can definitely build it outwards to reach those you want to serve. The better you know your potential users, the more effective your outreach will be.