What is the Program?
The Remote Outreach Project is the abbreviated name for the Blood Ties Four Directions Centre’s Bringing the HIV Transmission Guidelines to Northern Remote Communities Project. This project delivers HIV- and hepatitis-C-related education and support (based on the Canadian AIDS Society’s HIV Transmission: Guidelines for Assessing Risk) to nine remote First Nations communities in the Yukon. It does so through structured workshops on transmission, education about the basics of HIV and hepatitis C, and informal conversations.
Originally, the program was designed as a way to support communities to address issues related to HIV and hepatitis C by offering education programs tailored to each community’s specific needs. The goal was that eventually members of each community would take on the role of HIV and hepatitis C educator to their fellow community members, based on the work that Blood Ties would do to build local capacity.
Through their initial outreach efforts, Blood Ties staff discovered that remote communities are often overburdened and under-resourced with multiple social and health-related challenges (low literacy, lack of housing and clean water, domestic violence, drug use, etc.), and thus often had little choice but to de-prioritize HIV and hepatitis C education. Furthermore, sexuality and sexually transmitted infections (including HIV and hepatitis C) were found to be highly sensitive topics for members of these communities and were not easily initiated directly by community leaders.
In this context, it became clear that a regionally and culturally specific interpretation of “community development” was required for remote communities with small populations and numerous social and health-related issues. By adjusting the program to allow for the Project Coordinator to return to each of the nine communities twice a year or more to deliver workshops and support, the Blood Ties staff was able to build the communities’ capacity to cope with HIV and hepatitis C more effectively than if the communities were asked to deliver programming themselves.
Why Was the Program Developed?
Aboriginal people in Canada are disproportionately affected by HIV and hepatitis C. According to the Public Health Agency of Canada, 29% of people who tested positive for HIV (in tests in which ethnicity was recorded in 2008) were Aboriginal.
The hepatitis C prevalence rate in the Yukon, where 23% of the population is of Aboriginal ancestry, is estimated at the highest in Canada, though lack of representative data in this region makes even measuring the impact of HIV and hepatitis C a major challenge. While over two-thirds of Yukon’s population lives in the capital of Whitehorse, the proportion of Aboriginal people in remote areas is higher. Populations in these hard-to-reach communities number in the hundreds, not thousands. Sexually transmitted illness in these communities, when acknowledged, carries a heavy stigma.
In 2004, Blood Ties participated in a steering committee for a project that attempted to use workshops and other activities to engage First Nations women to act as leaders in the education of their communities on HIV. It was called Reducing Vulnerability to HIV and was led by the Yukon Aboriginal Women’s Council. An evaluation of the project identified the following ongoing issues in the region:
- While there was a general awareness of HIV in remote communities, knowledge of HIV and hepatitis C transmission and risk assessment was lacking.
- Community acceptance of people living with HIV was low.
- There was often a reluctance to admit that HIV can affect one’s community.
- Local health and social service providers had little or no training in HIV/AIDS and were unprepared to address issues related to HIV in their communities.
- Remote Yukon communities required an ongoing outreach program.
- Workshops on HIV and hepatitis C were needed for all community members and at-risk populations, not only women.
Blood Ties Four Directions Centre—having served a dual mandate of providing HIV and hepatitis C prevention education in remote communities across the territory since 2001—was identified as the most suitable organization to address these issues with an educational and capacity-building program.
In partnership with the Council of Yukon First Nations, Blood Ties, technically a non-Aboriginal organization, established a project steering committee, which included Health and Social Service Directors and other stakeholders from First Nations communities, to ensure that the project activities were relevant. Critical to the project’s effectiveness was the use of communication methods and learning environments that were in harmony with First Nations values and identities.
How Does the Program Work?
The project is delivered in remote First Nations communities in the Yukon, and the project coordinator is based at the Blood Ties office in Whitehorse. While there are 14 remote communities in the territory, due to funding limitations only nine participate in the Remote Outreach Project. The best time for program delivery to the communities served is during the winter; however, this is the time of year when having a person “out on the road” can be the most dangerous.
With input from the steering committee and based on Blood Ties’ experience working in the region, communities most in need of support were chosen first according to conditions of community readiness. Having an agency that already has a record of delivering HIV and hepatitis C programs in each community is very helpful. One community, Old Crow, was included in the project though it was visited only once per fiscal year due to its geographic location with no road access.
Recruitment and Engagement
Outreach to remote communities can be challenging for outsiders. The Blood Ties Coordinator involved in delivering remote outreach is not a member of any of the communities the organization aims to serve. Community Health Representatives (CHRs), meanwhile, who work primarily in First Nation and Métis communities across Canada to deliver health and social services in health promotion, health protection and community advocacy, are often considered insiders. Therefore, forging and maintaining solid relationships with these CHRs, who are often longtime residents of the communities in which they deliver health and social services, or someone in a similar position, is crucial to engaging other community members as participants.
To encourage local residents to participate in workshops, the Project Coordinator and the CHR work together to plan the date and location of each event. The Coordinator relies heavily on the CHR to do the bulk of community engagement and workshop recruitment work by:
- advertising the workshop through flyers posted at community centers, coffee shops and other places where locals tend to congregate
- promoting the project and its coordinator though informal conversations with clients and locals in general
When the Coordinator arrives in the community, she engages the community on an ongoing basis by approaching people in respectful, casual ways to introduce who she is and why she is visiting. Workshops are scheduled at least twice a year to build trust through continuity.
“You really need a Coordinator who is relaxed, easy to approach and not shy about approaching people. You also have to have buy-in from the CHR. If the Coordinator is even a bit abrasive or ignorant, we would not get anywhere. People don’t come out to your workshop unless you’re really good at talking to people during the daytime and convincing them to come out” –Patricia Bacon, Executive Director, Blood Ties
In each community, workshops occur at least twice a year, allowing the Coordinator to build trust and rapport. Each visit lasts two to three days and is scheduled in consultation with the CHR around other community activities.
The project was originally designed to bring the Coordinator to each remote community for a one- or two-week visit, with the idea that an extended presence would further help to build trust. After operating the project in this manner for a year and a half, it was recommended that Blood Ties visit communities for shorter periods of time but more frequently to show locals they are being more consistently served over the long run and to reduce Coordinator burnout, which is common when spending extended periods of time in secluded communities.
Workshop content is based on the Canadian AIDS Society’s HIV Transmission: Guidelines for Assessing Risk and adapted in consultation with the CHR to be accessible to participants at their current level of awareness of HIV and hepatitis C. To translate material to be easily absorbed by locals, the coordinator must have a solid understanding of the learning style of the community. In early sessions, it was discovered that the program did not require a great deal of adaptation from one community to another, as all of the remote communities of the Yukon shared the same basic needs for HIV and hepatitis C information. This realization allowed Blood Ties to focus efforts on more effective standardized programming.
It was also discovered that “capacity building” in the context of these remote communities was best fostered by continuing to deliver the project through the Blood Ties Coordinator rather than through CHRs or other local leaders. Not only did Blood Ties have the necessary expertise, but the communities indicated that they actually preferred to leave the expertise in the hands of Blood Ties and the Project Coordinator rather than taking on HIV and hepatitis C education on their own.
“The CHRs like it when we connect with them because they are very busy and often do not receive training in HIV and hepatitis C information. CHRs address so many health issues that are happening in these communities. Sometimes having someone come into their community and do the HIV work relieves at least part of the burden.” –Patricia Bacon, Blood Ties
As the communities visited by the Coordinator are quite small, interactions with locals can be spontaneous and impromptu. The following six activities serve as a general guideline for program structure, though the inclusion and scheduling of any activity will depend on the immediate practicalities of the community during the Coordinator’s visit. Various materials are used during education workshops, including those found in the CATIE Ordering Centre and a small number developed by Blood Ties. Resources were used to illustrate teachings on HIV and hepatitis C prevention and transmission. (Please see Other Useful Resources for examples of these resources.) Food and refreshments are provided to all workshop participants at all sessions, which helps to encourage attendance and “break the ice.”
Activity One: Community suppers and workshops with general population and specific populations
This event, which is most often hosted on the Coordinator’s first night in the community and can be held in a variety of locations such as a community centre or home, includes providing a meal to community members and engaging them in conversation about HIV and hepatitis C. It is open to all and usually attended by a cross-section of the community. This event encourages the general population to come out to meet the Coordinator and to start thinking about HIV and hepatitis C.
This workshop can be designed to attract youth, adults and elders. Often, an Aboriginal person living with HIV and/or hepatitis C will be invited to attend the workshop to tell her or his story. This person’s active presence is very effective in helping the audience connect with the topic.
Activity Two: Workshop with health and social service providers
This activity was done early in the project. Blood Ties brought 15 health and social service providers to Whitehorse for three and a half days of training. The goal of this activity was primarily to assist health and social service providers in increasing their overall comfort with working with community members who have HIV or hepatitis C or who are at risk. Initially, despite their knowledge of HIV and hepatitis C, CHRs lacked comfort with the idea of supporting an HIV-positive person directly, and this workshop increased their comfort level. A secondary goal was to provide CHRs with up-to-date information about hepatitis C.
Activity Three: Casual conversations
When the Coordinator is out and about in the community, she can engage people in one-on-one discussions about HIV, hepatitis C, sexual health and harm reduction to answer questions and provide referrals. She does this by being very proactive in approaching people respectfully. Once she has developed a strong rapport with community members, locals begin to approach her for information and informal conversation.
Activity Four: Movie night
Engaging community members to come together to watch a movie gives the Coordinator another opportunity to build rapport and have discussions. Movies, often focusing on remote rural and First Nations experiences, are chosen to help facilitate discussion on HIV and hepatitis C stigma in the local context. Some of the most popular films that have been presented are: The Long Walk Home, California Syringe Access, Under the Skin and Kecia. Additionally, Blood Ties worked with a filmmaker to have a rural Yukon film produced. HIV YT is frequently presented and well received in rural Yukon communities.
Activity Five: Ongoing support
Besides conducting workshops during each visit, the Coordinator provides referrals and support to health and social service providers, who often do not have training in serving clients living with HIV and/or hepatitis C.
- 1 Project Coordinator
- 1 Community Health Representative (CHR) per community
- an HIV-positive Aboriginal person to attend a workshop and tell her/his story (if available)
The character of the Project Coordinator is critical to the success of this project. The staff person does not have to be a First Nations person but must demonstrate:
- comfort in remote northern First Nations communities
- respect for First Nations culture and ways of life
- ability to design and facilitate workshops that are culturally appropriate to First Nations communities
- ease working independently in remote areas, where feelings of isolation are common
- HIV Transmission: Guidelines for Assessing Risk: A Resource for Educators, Counsellors and Health Care Providers (Canadian AIDS Society)
- Movies to encourage discussion about HIV and hepatitis-C-related stigma
- Basic movie projection equipment (Television, VCR or DVD player)
- Food and refreshments
- The annual cost of the Remote Outreach Project, which is funded by the Public Health Agency of Canada, not including staff compensation, is approximately $65 000, most of which covers the cost of extensive travel to remote communities.
- $100 to $200 per community visit to cover the cost of food
- There is a strong resistance to acknowledging the risk and/or existence of HIV and hepatitis C within remote communities.
- Remote communities can be challenging to get to, both logistically and financially.
- It can take a long time for a non-Aboriginal outsider to build trust with locals.
- High turnover rates (as well as conflicting personal and professional responsibilities) among Community Health Representatives can make it difficult to maintain a consistent long-term relationship with the communities they serve.
- Short-term project funding can make it challenging to build the capacity of a community to lead HIV and hepatitis C education and support initiatives in their own community, requiring the adaptation of a broader interpretation of “capacity building.”
Blood Ties evaluated the Remote Outreach Project twice with the support of external community evaluators in March 2008 and March 2009. They were interested in learning: (1) if the Canadian guidelines combined with culturally appropriate workshop presentations met northern Aboriginal needs; (2) if CHRs increased their ability to respond to HIV and hepatitis C issues, and (3) if community members increased their understanding of the spectrum of risk, harm reduction practices, and where to access support and advocacy services.
The evaluators answered these questions through a review of reports submitted by the Project Coordinator after each community visit and through structured interviews with the CHRs, the Blood Ties staff and remote community members who attended the workshops as well as those who chose not to.
Key recommendations from the first evaluation were implemented:
- Visit each community for shorter periods of time but more frequently. This will allow for time to perform duties and will help to build an ongoing presence.
- Make clearer distinctions for participants between high- and low-risk behaviour as they apply to remote rural communities (e.g., clearly explain how sharing a bottle of beer has no risk of HIV transmission).
- Build alliances with the Yukon First Nations community beyond health and social departments to expand community participation; include Elders, Council Members, Chiefs and youth group workers.
The most significant recommendation was somewhat contrary to common community development practices: Service delivery agencies and funders need to understand, accept and support the reality that some rural health professionals and community members prefer to access HIV and hepatitis C education and support services from a visiting health agency with expertise in that area. Staff capacity, staff transition and confidentiality issues underlie this preference. This recommendation might have implications for other rural service providers delivering HIV and hepatitis C education and support services.
The second evaluation determined that the Canadian HIV Transmission Guidelines are a useful tool in the dissemination of HIV and hepatitis C information, particularly when the Project Coordinator illustrated the information with examples that reflect northern living and when each participant was given a copy of the guidelines to take home with clear instructions on how to use the book.
The second evaluation also determined that the majority of CHRs and program participants reported having an increased understanding of HIV and hepatitis C in general, the spectrum of risk and harm reduction. The majority of participants also stated that they had an increased understanding of where to seek other advocacy and support services.
The project was found to be successful in establishing a presence in the communities that needed support and in generating open discussion about HIV and hepatitis C within these communities. As Blood Ties executive director Patricia Bacon says, “This project put HIV on the map in these communities.”
The 2009 evaluation also indicated that the project offered Blood Ties an opportunity to gain knowledge about what is happening in remote rural First Nation communities in the Yukon in order to better address the needs of those communities.
Funding for the project was made possible by the Public Health Agency of Canada’s Non-Reserve First Nations, Inuit and Métis Communities HIV/AIDS Project Fund in partnership with the Council of Yukon First Nations.
- Building strong ongoing relationships with trusted community leaders can take time but is critical in reaching remote Aboriginal communities.
- It is possible for non-Aboriginal organizations that are respectful of Aboriginal culture and ways of life to build strong relationships and work effectively with Aboriginal communities.
- Community meals, gatherings and even informal encounters can serve as invaluable settings for trust building and education.
- Using examples that reflect local experiences helps to illustrate and engage participants in HIV and HCV transmission information.
- Movie nights can attract community members and create the basis for dynamic discussions.
- Once established, relationships with remote communities are best maintained through semi-annual (or more frequent) visits.
- In small remote communities, “capacity building” is sometimes best accomplished through continuous, long-term engagement (e.g. ongoing community visits) rather than one-off activities.
- HIV transmission guidelines for assessing risk : a resource for educators, counsellors and health care professionals