Streetworks, Edmonton 2001

INTRODUCTION
Injection drug use is an ongoing and growing concern in Canada. The rising rates of HIV and Hepatitis C in this group are staggering. As well, overdoses and other opportunistic infections historically plague people who use injection drugs. The difficulty has always been in how to work with this group. They are often viewed as chaotic and non-compliant. Natural Helpers, a community development initiative based on harm reduction philosophies, is a concept that creates avenues to allow the injection drug use community to work with service providers. Not only do service providers gain information, injection drug users have the opportunity to express their needs, and contribute in the creation of a safer and healthier community.

HISTORY
Boyle Street Community Services Co-operative is an agency that attempts to fill many of the gaps experienced by people living in poverty in the inner city of Edmonton. Services include but are not limited to adult outreach, adult literacy, a drop-in, and Streetworks (Edmonton’s needle exchange program). Through thirty years of experience, the staff recognized that there were people in the community who had a natural inclination to help their friends and family. Some of these people were leaders in the community, but there was a large segment that received little or no recognition for the work that they did. To acknowledge the important role these people played in the community, the term Natural Helpers was coined.

Streetworks has been in operation for over ten years. Its services are based on a harm reduction model, with a focus on relationship-based programming. Streetworks focuses on community development and building on the strengths of individuals, therefore, the concept of Natural Helpers was a perfect fit. The staff began to identify people in the injection drug using community who felt a need to help their friends and family.

Streetworks’ definition of the Natural Helpers project is to provide and/or enhance the skills, knowledge, resources and support that they need to be able to do their “job” better. It was soon recognized that more needed to be done. Streetworks began to explore funding sources that would enable the staff to acknowledge and expand the roles of Natural Helpers in the community.

Funding was obtained through Health Canada. A nurse was hired to bring together a group of Natural Helpers to explore what they would see as being most helpful to them in their role. After the initial challenges of bringing a slightly chaotic group together and trying to capture all the ideas, a wealth of information, ideas, and dreams arose. It was decided within the group to compile the knowledge and experiences that they shared to develop a booklet on safer injecting. As a result the Vein Care Handbook was born.

The novelty of having a group of injection drug users in one room who were stable enough and willing to talk, quickly gained attention. There were many requests from various sectors to meet with the group to gain some firsthand knowledge from people who had “been there”, not just those who worked with them. These requests were brought to the group and they had the final say as to whether they would meet with the interested parties. The Streetworks staff encouraged those who wanted to speak with the group to consider a consultation fee as part of the process.

Streetworks was able to confer with this small segment of the community about changes to the program and resource development. The group gave input and approval to resources that were developed in the program before distribution to the wider community.

The initial project was extremely successful and opened the doors for additional funding. The new funding (granted by the Edmonton Community Lottery Board) allowed the group to continue, adding new members as needed. The next project took over a year, and resulted in the Street First Aid: ‘Cause You Just Never Know booklet. This was an expansion beyond issues directly related to injection drug use and showed the growth of the group. The Natural Helpers group quickly took up a new project, and has just completed work on a germ book, focusing on infectious diseases.

There has been widespread interest not only in the resources developed, but also in the group development. This has created various opportunities for presentations by the group facilitators, as well as the group members.

FORMING THE GROUP
Streetworks hired a nurse and appointed another staff member to be facilitators of the Natural Helpers project. The facilitators observed the community members closely and identified those who took care of others in their community. They asked questions like “how many people do you exchange for”, “why do you exchange for others”, “how do you take care of others”, and “what would you need to help you do what you are doing better”. One community member who had developed a strong relationship with Streetworks was included in the group. Once people were identified, a meeting place and time was set and they were asked to attend. Group size was limited to 10 members initially, although it grew to about 14. The group was representative of the drug using community that accesses Streetworks with respect to gender, race, type of drug use, and age. Natural Helpers were treated as consultants and were provided $10 per hour.


A. GROUP STRUCTURE
Meetings were held once to twice per month. An environment where community members felt safe and comfortable

GUIDING PRINCIPLES
The Natural Helpers project, a community development initiative based on harm reduction concepts, has many benefits. It is a strength-building project where information and expertise is shared mutually between the facilitators and the community members. Community members involved in injection drug use participate in harm reduction strategies and also learn to advocate for themselves. Natural Helpers access a hidden portion of the injection drug use population. There is potential to improve the health of the entire community.

Building on Strengths
Developing a Natural Helpers Group builds on the strengths of people who are typically viewed as weak, and sometimes scorned by the mainstream. Living with a 20 year addiction affords one a wealth of knowledge from experience - imagine the skill it takes to survive a 20-year addiction and remain relatively healthy. The facilitators must genuinely acknowledge and respect the strengths of injection drug users (IDU’S).

Mutual Respect
The facilitators should respect the group members as people on equal ground with themselves. Both the group members and facilitators possess knowledge that can be shared. The facilitators should expect to learn as much as they teach.

Advocacy
Natural Helpers Group members advocate for their community both directly and indirectly. The NH group can speak on behalf of IDU’s to professional groups who want to access the drug using population. The facilitators will gain insight into the lives of IDU’s. This insight is invaluable and allows the facilitators to advocate more effectively on behalf of IDU’s.
Community Involvement in Harm Reduction
NH members will be honing their prior skills and adopting new harm reduction strategies. They carry them into the broader IDU community. The NH members may not identify their new knowledge base as harm reduction.

Reach a Hidden Population
Programs aimed at the injection drug use population should anticipate that they do not see every person that they target. NH members access a portion of the hidden drug use population. The NH project is an opportunity to spread harm reduction strategies to this group.

Improves the Health of the Entire Community
There is potential to improve the health of the entire community. Harm reduction meets people where they are at and provides skills, knowledge, resources, and support necessary to live safer and healthier lives. Improved health of the community is anticipated if more of the population is practicing harm reduction strategies.

ORGANIZING A GROUP
The first step in creating a group is to find community members who are “natural helpers”. Ask the staff to observe the service users closely and to identify those who seem to be caring for others in their community. Ask the service users questions such as “How many people do you exchange for?”; “Why do you exchange for others?”; “How do you take care of others?”; and “What would you need to help you do what you’re doing better?”. Identify and include 1 or 2 regular service users who have developed strong relationships with your agency. Limit the group size to about 8 to 10 members. Ensure the group is representative of the population you are trying to reach with respect to gender, race, type of drug use and age. NH members should be treated as consultants, provide some kind of reimbursement for their participation. Ask those who have been identified if they would like to be involved in this project. Ask people when is a good time of day to have meetings (maybe afternoons). Set up a time and place for the first meeting.
GROUP DYNAMICS
Be aware of how much time you have and what resources are available. Explore funding options. Set start and finish dates for the project. Let the group know how long the project will last. Limit group meetings to about 2 hours with 2 fifteen-minute breaks. Understand that NH group members may have limited experience with group work. Avoid trying to make individuals fit in. Go with the flow. Have a couple staff take notes. Let the process take shape naturally. The group process will eventually evolve into its own unique format. Find a comfortable, safe place big enough for everyone to fit. Be sensitive to individuals’ lifestyles. If people smoke, allow for breaks. Provide both nutritious food and sweets. People who use injection drugs may struggle when discussing drug use. It can be a trigger for some to feel the need to use. Let the group members know that they can leave anytime or stop the discussion if necessary. Understand that people may not be straight when they attend meetings. Decide with the group at what point people will be asked to leave (this group made a rule that if someone comes high, they must be productive and not nodding out).

STAFF ROLE
Try to have at least one or two staff as facilitators. Initially, the facilitators may need to take the reigns. They should ease off as the group naturally progresses. Keeping a diary of the meetings helps the facilitators reflect and watch the group grow. It also acts as a reminder to back off so the group can own itself. A diary or log is essential for evaluation. The facilitators must be non-judgmental and approachable. Let the group know that everyone has expertise to share. The facilitators should not be afraid to ask questions. They should be honest and genuine. Respect each other. The group members should be treated as consultants with expertise.

GROUP PROCESS
At the first meeting, let everyone know what the group is all about. Start a discussion about trends and issues on the street. Brainstorm ideas and write EVERYTHING down. It might be necessary for the facilitators to narrow the focus. With group involvement, review the overall themes and decide on a realistic goal. If there is more than one goal, prioritize. Foster group involvement as much as possible.

EVALUATION
Evaluation should be ongoing. The facilitators should be constantly evaluating the process. Ask questions like “Are we maintaining the focus?”, “Are we on schedule?”, “Is the group progressing?”, “Do we need more group members?”, “Are group members taking ownership?”, “Do group members feel listened to?”, etc. Evaluate the outcomes of the process. “Did the group complete the project?”, “What unexpected outcomes occurred?”, “Did the group accomplish what you expected it to?”, “What the group expected it to?”, “What could have been done different?”, etc.

IMPORTANT POINTS
The goal of the NH project is not therapeutic support. Although it may naturally occur, it should not be the focus of the group meetings. Nor is it peer education. These people are already involved in actions, which contribute to a healthier community.
The facilitators should back off as the group takes ownership. If the facilitators think they can empower someone, they assume that they have all the power. Empowerment is a process of individuals/groups who discover their own power and act upon it.
Try not to underestimate group members. Listen to what people have to say.

STREETWORKS’ NATURAL HELPERS
Streetworks’ Natural Helpers group has been operating off and on since 1997. Accomplishments include a Vein Care Handbook, Street First Aid: Cause you just never know, The Germ Book, Clean Points; Tips on Hepatitis C video and a STD handbook. There has been interest in the first aid and germ books from across Canada and the United States. They have consulted on a number of other resources. The group has acted as speakers, advocates, and consultants to a variety of professionals. This Natural Helpers group also hosted a poster presentation at the 1st Annual Alberta Harm Reduction Conference.

UNEXPECTED OUTCOMES
Some community members involved with Streetworks’ Natural Helpers made some positive changes in their lives. Four members are dealing with their addictions and taking steps to quit. One member bought a first aid kit and cruises around Edmonton’s inner city to help out where he can. He also frequents inner city hotels and collects used needles to exchange. Some community members know they can visit this fellow for supplies if they can’t access the needle exchange sites. Three members have taken steps to attend education programs. One member has recently started a new job as a parking attendant. The group members over time bonded and act as a support for each other outside of meetings. Group members will often start the meeting by asking everyone around the table how things are going. As people discover that they have skills and expertise, their ability to take control over their lives and health will increase, and positive personal changes can occur.

FUTURE POSSIBILITIES
The Natural Helpers’ focus to this point has been mainly on resource development. This was due to many factors; especially the groups’ need to have something very tangible to focus upon, and various funders’ requirements. As the group grew together, other possibilities began to emerge. These potential areas included mutual support, consultation to the community at large, and creating a political voice for a seldom heard segment of the population. Any of these areas could be expanded on with potentially powerful results.

The benefits that the group members and the organization experienced could easily be transferred to other marginalized groups in society. Some potential groups might include: injection drug using youth, sex trade, street-involved transsexuals, women whose partners are injection drug users, and so on. The potential for positive health impacts on marginalized populations are enormous.