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4. Overview of Projects Funded

A total of 110 projects were funded during fiscal year 2000-2001 and were thus eligible to be included in this report ³. These encompassed:

• projects funded in year one (1999-2000) and completed in year two (2000-2001);
• year one (1999-2000) projects that received additional funding in year two (2000-2001) - e.g., to undertake follow-up or new activities;
• projects funded in year two (2000-2001) and either completed or still in progress at year-end (March 31, 2001).

During 2000-2001, the Program disbursed a total of $3,113,000 for projects in all regions of the country. The initiatives funded were varied, and focussed on community and organizational aspects of responding to hepatitis C, preventing the spread of the disease through educational and other means, and addressing the needs of specific populations.

Ninety projects received funding for the first time in 2000-2001, and another 20 projects were carried forward from 1999-2000. In terms of size and time frame, these projects ranged from a five-month $7,000 initiative to a $153,000 endeavour spanning 36 months.

By the end of the fiscal year, 25 of the 90 new projects had been completed, 65 were still under way, and five had not yet commenced. Of the grand total of 110 projects funded in 2000-2001, 32 had been completed by March 31, 2001, and 78 were still under way.

The breakdown of projects by region is shown in Table 1 below.

Table 1: Distribution of funded projects, by region (2000-2001)
Region	2000/01	(from 1999/00)	Total (Projects)
Atlantic	9	(0)	9
Quebec	11	(4)	15
Ontario/Nunavut	27	(8)	35
Manitoba/Saskatchewan	8	(2)	10
Alberta/NWT	15	(3)	18
BC/Yukon	20	(3)	23
Total	90	(20)	110

4.1 Project Issues and Themes

The second funding year saw a continuation of the literature reviews, needs assessments and other preliminary activities that had characterized year one, coupled with a focus on strengthening community/organizational skills and knowledge, and determining how to respond to identified needs. It was not uncommon for projects to undertake a mix of these activities.

There were four main clusters of activity:

1. information collection (to meet the need for more/improved information as a prerequisite to the development and targeting of meaningful initiatives);

2. capacity-building (to meet the need for adequate skills and knowledge, appropriate systems, structures and strategies, and strong partnerships and linkages - the "ba sics" of effective interventions);

3. outreach/support to persons infected/affected/at risk (to reach and meet people "where they are at", and to address their immediate, day-to-day needs);

4. awareness/education (to meet people's need for information about hepatitis C, its risk factors, modes of transmission, symptoms, progression, treatment options and management - and about sources of assistance and support).

Information collection and capacity-building activities affect organizations and their personnel and outreach/support and awareness raising/education activities affect client populations (persons infected, affected, at risk).

a) Information Collection

The collection of baseline information remained a core activity in year two. Efforts to clarify and document local-level hepatitis C-related issues focussed on:

• identifying populations at risk or in need;
• determining the coping skills, support concerns and information requirements of such populations and their subgroups (each facing particular barriers);
• pinpointing gaps in the knowledge, skills, structures, programming and resources of a wide array of community service-providing organizations, their staff and volunteers.

Populations and their needs

Many projects attempted to document the needs of specific client populations, as well as the community groups/agencies and workers serving them. Such initiatives were aimed variously at:

1. Infected and affected groups, including those for whom a hepatitis C diagnosis can be especially complex and challenging (e.g., persons with hemophilia or HIV/AIDS);

2. Populations at risk, reflecting a recognition that support measures - while important and necessary - need to be backed up with preventive measures (e.g., an examination of the risk behaviours and education needs of Calgary's rave community);

3. Community organizations/groups (e.g., an environmental scan and assessment of the research needs of HIV/AIDS-related groups concerning their ability to address co-infection, prevention, service and support issues);

4. Service providers (e.g., an assessment of the needs of medical practitioners serving hepatitis C-infected homeless persons).

A number of projects also sought to identify hepatitis C-infected/affected/at risk populations in defined areas (e.g., health regions and/or districts; areas served by local chapters of national non governmental organizations [NGOs]; urban and rural areas).

Approaches

Several projects began by conducting literature reviews, aimed either at documenting the facts about hepatitis C (risks, transmission, treatment and care) or probing topics related to intervention planning (e.g., adult learning styles, learning in a correctional facility).

Projects also gathered information directly from their client populations and the groups/personnel serving them through community forums and consultations, focus groups, face-to-face interviews, telephone surveys, and written questionnaires.

Uses of information

Projects identified a wide range of uses for the information collected:

• to establish provincial priorities on education, prevention and support services and programming for hepatitis C-infected persons and their families;
• to inform the development of infra structural, educational and support programs for hepatitis C-positive persons with hemophilia and their families across the life stages;
• to improve the coordination of partnerships with community groups;
• to design an educational conference to meet local service providers' identified needs;
• to enhance staff skills within community-based organizations, through training and resource development.

b) Capacity-Building

Information gathering supplies the evidence that is needed in order to do effective capacity-building. With reliable information, groups/agencies are better placed to identify strengths and weaknesses in community service systems and structures, and to clarify what action is needed to fill the gaps.

As the year two projects show, capacity-building can occur at different levels. For example, after assessing community needs groups/agencies may conclude that they need to upgrade their knowledge and/or skills, or they may decide to develop new models or redesign existing structures, or perhaps to concentrate on strengthening community linkages. Each type of activity is discussed below.

Worker education and training

Across all regions, projects placed considerable importance on improving staff/frontline skills and knowledge and developed activities for various groups:

• public health and hospital workers (including emergency department nurses);
• non-professional workers serving persons with addictions;
• volunteers working with street populations and youth;
• correctional/prison officers;
• non governmental organization staff and volunteers;
• pharmacists;
• community workers in potential contact with hepatitis C-infected persons, including police, firefighters and paramedics;
• general practitioners.

A number of projects targeted all or most of their resources to worker training, whereas others addressed both worker and client needs.

These worker training sessions took many forms, based on the type of information to be conveyed and the needs and learning styles of the groups involved. They included the following:

• conferences, panel discussions and round-table meetings;
• workshops, including "train-the-trainer" and peer-led sessions;
• continuing education and other seminars (e.g., for medical professionals);
• community forums, educational "speaks" (e.g., for workers in group homes);
• presentations and information sessions (for staff in men's shelters, drop-ins, Aboriginal-serving groups, addictions agencies, detention facilities and public health departments).

A wide range of material about hepatitis C and related subjects was presented to service providers:

• basic information on symptoms, disease progression, co-infection, and treatment options;
• methods and techniques - e.g., hepatitis C prevention/intervention, peer counselling, and support group facilitation;
• information on "bigger picture" issues, such as the determinants of health.

Model development and redesign

At least two projects sought to create new models for dealing with hepatitis C challenges. One of these was a proposed joint community/federal/territorial initiative by the Native Women's Association of the Northwest Territories (NWT). Its goal was to develop a new funding model for HIV and hepatitis C prevention/awareness projects in NWT communities. The other project, an outreach initiative, was already under way when the need became apparent for an in-house protocol on hepatitis C testing, counselling and follow-up. The project responded to this need by developing the necessary protocol.

A number of groups/agencies found that they lacked the tools and/or infrastructure needed to tackle hepatitis C effectively. They used their funding to make the needed changes - for example, to:

• integrate hepatitis C issues into the mandate, expertise and programs of a local community council charged with planning/programming in blood-borne pathogens and harm reduction outreach;
• incorporate Aboriginal/spiritual values and concepts into the delivery of education, prevention/harm reduction and support to inmates;
• adapt an information manual to the needs of smaller communities and volunteer-run programs.

Collaboration

Reflecting a growing recognition of the benefits of sharing - not only of resources, expertise and experience but also of visions and goals - many initiatives focused on "building bridges" within, between and beyond communities.

Collaboration was commonplace in the projects (a funding requirement). However, some groups explicitly aimed their activities at increasing the linkages among concerned community agencies/sectors. Many groups chose to formalize their connections with partners and other stakeholders from the start, by establishing work teams. Other groups reached out into the community for specific types of assistance - for example, to the media for publicity, to community centres and churches for meeting space, to local clubs for resource dissemination, to schools for classroom time, and to businesses for sponsorship and the underwriting of products/events. Many projects built and strengthened networks by sponsoring conferences, linking up with groups and institutions outside the region, sharing resources with sister agencies/groups, and/or sitting on each other's committees.

The reports reveal that many beneficial connections were formed or reinforced as a result of all these activities. Reflecting on the advantages of collaboration, groups said that working with others had helped them to extend their reach, raise the profile of hepatitis C issues locally, increase their own visibility and credibility, and lay the foundation for future collaboration - all strong indicators of growing community capacity. Other encouraging signs of capacity development reported by groups and communities included the following:

• their increased ability to influence decision-making;
• increased membership/greater visibility of the group/agency;
• an expanded volunteer base;
• improved coordination, planning and referral systems;
• new partnerships with remote/rural communities;
• improved fund raising ability;
• a greater sense of confidence and effectiveness among volunteer/peer workers.

c) Outreach and Support

In year two, outreach and support remained central features of project activities. Many initiatives, especially in communities receiving funding for the first time, sought to increase the availability and accessibility of support - immediate practical assistance to those infected with/affected by hepatitis C. The assistance took many forms, and included facilitating access to medical treatment and specialist care, self-help, advocacy and other community programs and services ("walk-in" support, one-on-one counselling/follow-up, telephone help lines/referrals, etc.).

Many projects launched active outreach initiatives to client populations that, for social, cultural, language or other reasons, are often difficult to reach. Such groups included inner-city dwellers - many of them poor, young, inadequately housed/homeless, or addicted - as well as individuals in trouble with the law and ethno cultural populations. One rural project even appointed an "Outreach Ambassador" to develop connections with the local drug-using community.

Project reports noted various challenges. In some communities, for example, there were difficulties associated with confidentiality. One report commented on the reluctance of clients living in outlying areas to visit the local clinics. These individuals apparently felt more secure travelling to a larger nearby town for services, and clients from that town preferred to obtain services in the province's capital in order to protect their confidentiality.

Many groups sought to make local services and resources more accessible and available. Project activities in this category included the following:

• developing a credit-card sized "Hep C Help Card" with contact information and toll-free numbers;
• linking client populations to practical community resources (including housing, medical treatment, addictions treatment, transportation, and emotional support) to inner-city residents with hepatitis C;
• presenting information on hepatitis C to workers in remote camps, and leaving posters in the washrooms;
• developing a booklet series on risk, diagnosis, treatment special needs and concerns for injection drug users, including access points for specialist care.

A critical aspect of outreach and support was ensuring that the activities were appropriate to the population in question - be they women in conflict with the law, Aboriginal persons, sex trade workers, inmates/parolees or injection drug users. In addition, projects recognized that clients can face many different challenges. To address communication barriers, one project developed a brochure on "How to talk to your doctor about hepatitis C" and - to help clients lead a relatively "normal" life - a another brochure entitled "You are not your disease, or are you?".

d) Awareness and Education

Information was developed and disseminated in various forms to infected/affected/at risk populations. Groups also sought to combat persistent myths and misconceptions about hepatitis C - for example, a notion reportedly held by street youth in one city that hepatitis C was no more dangerous than getting the flu.

Confidentiality emerged as a major concern for some awareness-raising projects. Their reports alluded to the existence of "hidden" populations in need of accurate information - for example, rural and other small-community dwellers too embarrassed to come to public events or to talk to local health professionals. One project report noted that in the context of "small town" culture, injecting drugs is a very secretive behaviour. It surmised that in the absence of any observable population of injection drug users, local people were less likely to be aware of the dangers.

Across the country, education and awareness-raising efforts sought to overcome these and other barriers, by making appropriate, understandable, practical information available and accessible to people in the forms and forums least likely to intimidate them. While a number of initiatives were aimed at "the public" - for example, through pamphlets, public service announcements and newspaper articles - most were carefully targeted to specific audiences. Written/printed materials of all types were created, tested and distributed to sites frequented by particular groups:

• pharmacies, for individuals who used needles to inject prescription and non-prescription drugs;
• clubs, for the rave community;
• friendship centres, for Aboriginal people;
• drop-ins, shelters, and similar venues for street youth and adults;
• web sites, for some communities (e.g., persons with thalassemia).

Many of the resources were designed to address the support needs of people already infected/affected. In addition, risk and prevention were prominent themes. Examples included posters (e.g., "Are you at Risk?"), orientation packages for inmates upon entry and release from prison, a 90-page workbook with information on hepatitis C risk factors incorporating Aboriginal teachings, and "Prevent and Protect", a pamphlet directed to injection drug users.

Language was recognized as a barrier for some populations. A British Columbia project translated its resources into French, Spanish and a number of East Asian, South Asian and South East Asian languages. Projects in Ontario and Atlantic Canada targeted Francophone populations, and several bilingual resources were created, including newsletters and web sites. One Quebec initiative reached out to English-speaking, Italian, Vietnamese and other language groups. Other projects used graphic approaches, educational games and playing cards with a hepatitis C theme to overcome literacy barriers among street populations and prison inmates.

Among the diverse approaches used to educate clients and raise their awareness were:

• school health fairs and class presentations;
• workshops and impromptu sessions for street populations;
• a "family weekend" for hepatitis C-infected persons with hemophilia and their families;
• presentations to female prison inmates;
• information booths and shopping centre displays;
• a tattoo art contest and drama skits on high-risk behaviours for youth.

4.2 Project Approaches

Projects varied widely in both scope and complexity. In some instances their activities were designed to unfold sequentially - in effect, building one on the other. An example of this type of project is the (still ongoing) "Model Development and Implementation of Hepatitis C Services for the Homeless in Calgary". Sponsored by the Calgary Urban Project Society (CUPS) Community Health Centre, this project comprises three distinct phases:

• to identify barriers to hepatitis C testing, treatment and support for homeless people;
• to adapt existing methods of service to address these barriers;
• (using a model development approach) to identify key elements of a comprehensive strategy to effectively meet the needs of the client population.

Also common were projects comprising several independent activity sets that could either run concurrently or overlap in time. For example, the York Region Chapter of the Hepatitis C Society of Canada undertook to:

• raise the profile of its work with the local media;
• support public forums on hepatitis C;
• conduct monthly support group meetings; and
• create a directory of community services.

Still other projects were single-focused - for example, a training initiative entitled "Hépatite C sans frontières". In a series of one-day workshops, this Quebec project trained non-professional community health and social service providers such as community addiction workers, street workers and youth centre workers, to engage in preventive and other interventions with their respective clienteles.

4.3 Groups and Organizations

As in year one, nationally-focused NGO's played a part in most projects. Approximately one-third of all the year two initiatives were sponsored by these NGOs (or their chapters); they were directly concerned with:

• hepatitis C specifically (e.g., Hepatitis C Society of Canada) or liver disease in general (e.g., Canadian Liver Foundation);
• related health issues (e.g., Canadian Hemophilia Society, Thalassemia Foundation of Canada, Canadian Mental Health Association);
• related social issues (e.g., the Elizabeth Fry and John Howard Societies).

Year two saw an encouraging upswing in the number of projects undertaken by groups that were themselves partnerships - for example, coalitions, committees or networks encompassing several community agencies/groups. This suggests that the benefits of working together are already apparent in many communities. The "partnership groups" included many that were HIV/AIDS-related. Non-HIV/AIDS examples included a harm reduction committee (Chatham-Kent), a street-health coalition, and an interprovincial initiative involving groups from New Brunswick and Prince Edward Island (Atlantic Region).

Besides national NGOs and coalitions, funding recipients included an array of local, regional and community-based groups/agencies:

• public health units and health districts/boards⁴;
• community health and Aboriginal health/friendship centres;
• street-health groups;
• resource centres and support groups;
• youth organizations;
• addictions agencies.

4.4 Partners

In their reports, project groups were inconsistent in their interpretation of the word "partner" ⁵. Some groups identified their major partners only, whereas others listed virtually every organization they had worked with during the course of their project - more than 20 in some cases. (An example of this was "A Living Support Project Using a Holistic Healing Approach", organized by the John Howard Society of Manitoba, which involved between 25 and 30 different groups). At the other extreme were project reports that referred to their partners generically (as "stakeholders", "community organizations"or "hospitals") , rather than naming them directly.

Somewhat surprisingly, approximately 20 percent of the projects made no mention of partners at all. Of these, a small number were groups receiving small one-time community grants for "support group development and capacity-building" activities, which may have been undertaken singlehandedly (few reports received). Other such projects were undertaken by chapters of national NGOs, and frequently involved in-house capacity building activities. As a group, NGO-run projects appeared to involve fewer partners than those undertaken by other types of groups/agencies. However, there were some exceptions to this.

Most projects drew in at least three partners. Reflecting the breadth of community interest and concern and the Program's Guiding Principle on working closely with community partners, other (i.e., non-health) sectors and society's institutions these partners came from:

• community health and social service agencies - e.g., public health units, community health centres, needle exchanges, substance abuse agencies;
• client groups - e.g., Safer Crack Coalition, Illicit Drug Users Union of Toronto; inmates committees;
• educational organizations - e.g., universities/colleges, school boards and districts;
• law enforcement and corrections-related bodies -e.g., police, RCMP, justice departments, correctional facilities;
• community/advocacy groups and agencies - e.g., United Way, food banks, citizens' and women's action groups;
• health/medical professionals and their associations - e.g., pharmacists;
• businesses - e.g., pharmaceutical companies, tattoo shops;
• ethno cultural organizations;
• media outlets, both community and national.

Upon receiving their funding, approximately one-sixth of the projects formed committees, working groups, panels or similar bodies. In some cases, these groups steered the project, in others their role was advisory, and in still others they assisted with evaluations. Their membership was drawn variously from partner groups/agencies, peer groups and other community sources.

As discussed under Capacity-building, some projects directly named the strengthening of a network/partnership as one of their objectives. Other projects seemed to take for granted that working collaboratively would have this effect. An analysis of project results suggests that, in general, these expectations were borne out.

4.5 Populations

Client groups

Over one-third of the projects from across all regions identified their "priority populations" generically as:

• hepatitis C-infected groups;
• groups affected by hepatitis C (spouses, families, caregivers, social support networks);
• groups at risk of contracting hepatitis C.

While approximately 15 projects aimed their activities at the "general public", it was more common for clients to be defined according to their demographic characteristics or social circumstances, such as:

• geographic location - e.g., residents of Quebec's Mauricie Region, Alberta's Grande Prairie area;
• setting - e.g., rural (or "non-urban"), urban (or "inner-city") dwellers;
• social circumstances - e.g. street-involved, homeless, marginalized persons;
• legal circumstances/status - e.g., individuals entering, serving in or leaving correctional institutions (variously described as federal or provincial inmates, parolees, and women in conflict with the law);
• risk circumstances/behaviours - e.g ., injection drug-users (prescription and/or non-prescription), sex trade workers;
• health status - e.g., co-infection (persons infected with both HIV and hepatitis C virus; persons with hemophilia infected with hepatitis C virus and/or HIV; and persons infected with hepatitis B and C and/or HIV);
• age - e.g., youth;
• gender;
• ethno cultural origin and/or language - e.g., Aboriginal populations, Vietnamese and Italian-speaking residents of Montreal.

Reflecting the complexity of the issues, many projects directed their activities to a clientele that combined several of these characteristics - for example, the youth population (including individuals who were street-involved, addicted/injection drug users and/or incarcerated).

Health and community workers

Approximately half of the projects funded in 2000-2001 targeted frontline and other staff, professional and non-professional health/social service providers and/or volunteers and peer helpers.

4.6 Determinants of Health

Among the major factors known to influence the health of populations are gender, culture, income/social status, education, employment and working conditions, the physical and social environments, personal health practices/coping skills, the availability of social support networks, and health services. Known as the determinants of health, these factors may act individually or in combination. To encourage project organizers to take a broader perspective when developing and delivering their interventions, the funding application requires that they specify the health determinants they plan to address.

Disappointingly, many projects made no reference at all to the determinants of health in their reports. This lends credence to the remark of one regional program consultant that "the determinants of health are never talked about after the application form is filled in."⁶ Even so, it does appear from the reports that an appreciable number of groups - especially those operating at the front lines (streets, prisons, etc) - have an instinctive grasp of the connections between health risk and various forms of disadvantage. Judging from their project approaches, attention to social barriers, sensitivity to client realities, and their descriptions of desired outcomes, these groups have a solid understanding of what, ultimately, determines health.

Most projects addressed more than one determinant of health. As Table 2 shows, the health determinant most frequently addressed by the year two initiatives was personal health practices and coping skills (72 projects), followed by social support networks (69 projects). To some degree this reflects the priority accorded to support initiatives - those concerned with providing immediate practical measures that will make a difference in people's lives. A large number of projects (45) also addressed culture - i.e., barriers and/or issues facing populations with distinctive languages, beliefs, values and understandings (such as Aboriginal peoples, ethno cultural groups, and the youth, drug, street and prison subcultures).

Table 2: Determinants of health addressed or identified by projects (2000-2001)
Health Determinant	Projects1 (addressing/identifying)
Gender	2
Culture2	45
Income/social status	6
Education3	18
Employment/working conditions	1
Physical/social environments	26
Personal health practices/coping skills4	72
Availability of social support networks	69
Health services	24
Most projects addressed multiple determinants. Broadly interpreted to include barriers/issues facing not only Aboriginal peoples and ethno cultural populations, but also the youth, drug, street and prison cultures, each with its own language, beliefs, values, etc. See discussion below. Some projects addressed both, while some addressed only one.

Some misunderstanding appeared to surround the meaning of education as a determinant of health. Although 18 projects identified education as one of their determinants, with several possible exceptions (such as the use of low-literacy materials and graphic/non-written approaches), their educational interventions were of a "downstream" rather than an "upstream" nature. In other words, they were seeking behaviour changes, not tackling root educational deficits - something that initiatives of this type would be virtually powerless to do.

Although addressing certain aspects of the determinants of health was beyond the scope of their projects, groups adopted a realistic approach to the challenge before them. Following are some of the ways in which projects addressed specific determinants:

• personal health practices and coping skills, largely through educational interventions;
• social support networks, through the formation of support groups (with opportunities for members to discuss issues among themselves), and through outreach to families and friends;
• social environments, through sensitivity training to service providers (to reduce social stigma) and community development work (to increase support for those infected);
• culture, through consultation with Elders and by incorporating the Medicine Wheel into Aboriginal education materials, using street-sensitive approaches with homeless populations and gender-sensitive interventions with women;
• income barriers, by helping clients to access child welfare, rent subsidies and social services, as well as government compensation and funding for medical expenses and health services.

An example of stakeholders understanding the determinants of health was provided by the Manitoba project, "Lights On". Its report noted: "The workshops ... made staff (who are predominantly Aboriginal) aware of statistical evidence showing the much higher prevalence of all types of hepatitis disease in their community. It was sobering to see the children and youth who come to [the facility] reflected in all the main risk factors associated with contracting all the hepatitis type diseases". The report noted that "the strongest determinant of health appears to be income level - poverty", and pointed to the importance of linking not just hepatitis C but also other health issues - AIDS, drugs and alcohol, sexual behaviours - with the determinants of health. It concluded: "Through analysis of the determinants of health there is a greater recognition among funders and other service providers of the impact we [the sponsoring organization] have on at risk youth's health."

Hepatitis C virus tends to thrive in conditions of social inequality. Living on the margins of society - be it on the street, crowded into a shelter, in prison, or unemployed on a remote reserve - increases the risk of transmission. Recognizing this, at least two projects set time and resources aside to inform key project participants about the determinants of health and their links to hepatitis C. In one instance, a regional health authority organized a workshop for stakeholders on the social determinants of health. In another, an AIDS-related group discussed the determinants of health with its peer educators as part of their training.

Ultimately, changes related to the determinants of health - sometimes requiring decisions beyond the health sector - are what will really make a difference. Understanding this, community-serving groups working at the front lines (including larger, national-level NGOs) often complement their community initiatives with advocacy efforts, which they see as an important part of their role.

4.7 Involvement of Client Populations

Capacity-building is not just about organizations. It is about community people, whose support and involvement at every stage are vital to the success, continued growth and sustainability of local initiatives. Many projects recognized the potential benefits of involving hepatitis C-infected or affected persons in their activities - not just as an add-on, for political correctness, but because it was effective.

The majority of groups involved clients actively in at least one phase of their project. In some instances, clients participated with other stakeholders on formal advisory committees and work teams. As well, clients frequently contributed to needs assessments through focus groups, community meetings, questionnaires and informal encounters.

Several projects involved client group members in virtually all of their activities. One such project, "Hepatitis C Education in a Correctional Setting", detailed the ways in which hepatitis C-infected/affected inmates, including injection drug users, had participated in project activities. As members of the advisory committee and project working group, clients had provided direction on needs and possible educational approaches, and played a key role in the development of educational tools. Plans called for their continued involvement, by giving advice and feedback, and in the pilot testing of resources. Another project envisaged client participation at every major stage, from needs identification through program planning, delivery (as trained peer educators), and evaluation.

Between 10 and 15 percent of the project groups said that they had called on client expertise in the planning, development and/or delivery of their interventions. Among other things, clients reportedly helped to:

• plan conferences and panel discussions;
• design and create tools and resources - e.g., a newsletter carrying client "personal accounts and stories", and a prevention kit for prison populations;
• develop and perform in educational drama skits/plays (for schools, young audiences).
  

Perhaps the widest use of client groups was in the review (focus testing) of resources. More than one in 10 projects reported seeking out clients for feedback and pilot testing. In a single region alone, HIV/HCV co-infected prisoners, young offenders, marginalized inner-city populations and Aboriginal persons were involved in activities of this kind.

Projects found various other ways to capitalize on their clients' special knowledge and expertise. For example, clients were recruited to:

• help access priority populations (e.g., fellow inmates when detention centre staff members refused to cooperate);
• offer specialized guidance (e.g., on safe injecting practices);
• facilitate or co-facilitate support groups;
• help gather and deliver information (in one correctional institution's prevention/education program, inmates and Elders played a "crucial" role as information channels).

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