The role of community outreach workers in improving the sexual health of hard to reach populations
Updated: Jun 18, 2020
Inspired by her work at the Terrence Higgins Trust and Spectra, Laura J Brown writes about the importance of community sexual health outreach workers.
In 2015, approximately 435,000 sexually transmitted infections (STIs) were diagnosed in England . Approximately 103,000 people are living with HIV in the UK, 17% of whom are undiagnosed . Actively targeting groups underrepresented at clinic-based services, particularly black and ethnic minorities (BME), as well as other at-risk populations such as men who have sex with men (MSM) and young people [1,3,4] is important for addressing the country’s sexual health burden. This briefing describes recent trends in the distribution of HIV and STIs in these groups and discusses the role of community outreach workers in improving their sexual health.
Distribution of HIV and STIs Prevention of STIs and HIV should include a focus on the country’s highest-risk groups. This includes black and ethnic minorities (BME), men who have sex with men (MSM), and young people (15-24 year olds). These groups may be particularly vulnerable and at risk from poor sexual health .
BME Black and ethnic minority populations are disproportionately affected by sexually transmitted infections (STIs), being three times more likely to have gonorrhoea and chlamydia than the general population .
MSM STIs are also increasing in men who have sex with men. For example, gonorrhoea has increased by 21% since 2014 in this population .
Young people 15-24 year olds have the highest rates of STIs in the country and contribute to 61% of chlamydia diagnoses and 52% of gonorrhoea diagnoses .
Benefits of community outreach These groups are less likely to access clinical settings for a variety of reasons. These include a belief among BME that clinical settings are unlikely to understand their cultural needs or to speak their language, as well as fearing disclosure of immigration status and HIV-related stigma and discrimination . Across BME, MSM and young people, there is also a lack of knowledge and concern over individual risk of contracting HIV and other STIs. Clinic-based settings often have restricted opening times and may be difficult for people to travel to. Services provided in community settings are more able to capture these often hard to reach populations by providing a more accessible, acceptable and convenient sexual health service.
Outreach services can help to identify cases of HIV and STIs that might otherwise go undetected  and therefore are important in protecting public health. Engaging the public through community outreach activity is essential to ensuring community based services are promoted and used by those who would benefit from them most.
Community-based services are often run by volunteer or charity organisations with experience in engaging with marginalised groups , for example the Terrence Higgins Trust  and Spectra  which both work predominantly with MSM and BME communities. The community clinics and outreach workers provided by these organisations also often work in collaboration with other local projects to facilitate both access to - and successful engagement with - at-risk individuals (e.g. with homeless shelters or in schools).
Community outreach has the added bonus of helping to engage community leaders and obtaining community knowledge and insights by building community networks . This further aids the spread of sexual health and wellbeing messages, as well as service uptake.
Services provided Rapid HIV testing and chlamydia and gonorrhoea screening are the main sexual health services provided in community-based settings. HIV results are available within 15 minutes  and chlamydia and gonorrhoea results within 7-10 days. Providing rapid testing in outreach settings may increase testing uptake relative to traditional testing methods  where clients may have to wait up to 2 weeks for their results. Testing also provides an opportunity to discuss safer sex practices and clients are also often given free condoms and contraceptive advice as part of their visit.
These services are designed to supplement (rather than replace) those provided in clinical settings in order to cover more of the population.
The role of outreach workers Outreach workers engage with members of the public, promoting the sexual health services on offer and good sexual health and wellbeing.
Outreach workers advertise a service that may not otherwise be known about. Their presence outside or nearby the pop-up community clinics signals the services on offer. By approaching and talking to people on streets, in community centres (such as leisure centres, libraries and churches), in educational settings and in bars and clubs, outreach workers are able to advertise opportunistic testing to people who might otherwise not have known about the community-based service.
By discussing sexual health and wellbeing topics openly and non-judgmentally, another important role of community-based services, and outreach workers specifically, is to help to tackle the stigma associated with STIs and HIV . These are skills taught in outreach worker training.
Through their training, outreach workers are also informed of the most at risk populations and how to engage with them in culturally appropriate ways. Services are offered to everyone, but at-risk groups (BME, MSM and young people) are targeted specifically. Efforts are also made to recruit outreach workers from the at-risk populations of interest themselves - which further facilitates public engagement and use of services.
Funding for outreach workers Local authorities have been responsible for commissioning sexual health services since 20135. The severe funding cuts in 2015 have however reduced the funding available for outreach services . Late notice of funding cuts has also made it difficult for local authorities to plan services effectively .
Spending on sexual health services and interventions is cost effective, for example, early testing and diagnosis of HIV reduces treatment costs by almost 50% per annum per patient . The cuts have also meant that outreach worker remuneration has been reduced. Although hiring volunteers can help to reduce costs, paying outreach workers can aid employee retention and reduce the extra costs associated with high volunteer turnaround (such as ongoing recruitment and training costs).
Overview There is still a large unmet need for sexual health services in England, particularly among the high risk groups of BME, MSM and young people. Community-based sexual health services offer an alternative to clinical settings that may be more suitable for these groups. Outreach workers play a key role in engaging the public and encouraging hard to reach groups to access services such as HIV and STI testing that they may not otherwise use. Funding for community services and outreach workers is currently unstable and could have adverse consequences on sexual health outcomes in the future.
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