Participant characteristics
Table 1 describes how participants (i.e. community outreach workers, parents, healthcare employees, and inter-sectoral partners) were involved in the different data collection strategies.
Table 1
Number of stakeholders participating in interviews and focus groups
Data source
|
Stakeholder participants
|
Total Number
|
Community outreach workers
|
Parents
|
Healthcare employees
|
Intersectoral partners
|
Community Organizations
|
School
|
Municipal
|
Individual interviews
|
5
|
9
|
5
|
3
|
2
|
-
|
24
|
Focus groups
|
3
|
7
|
3
|
4
|
1
|
2
|
20
|
Characteristics of the population served
Regarding the characteristics of the individuals served, three sub-themes were described: 1) family characteristics, needs and dynamics, 3) children’s characteristics and needs, and 3) relationships with services.
Themes and subthemes
Three main themes were identified from the content analysis which included: 1) characteristics of the population served, 2) actions of the community outreach workers, and 3) perceived impacts of the community outreach work on families and children). All these main themes were discussed in the three data sources (Table 2).
Table 2.
Themes and subthemes
Themes
|
Sub-themes
|
Document analysis
|
Interviews
|
Focus groups
|
1) Characteristics of the population served
|
1.1) Family characteristics, needs and dynamics
|
X
|
X
|
X
|
1.2) Children’s characteristics and needs
|
X
|
X
|
X
|
1.3) Relationships with services
|
-
|
X
|
X
|
2) Actions of the community outreach worker
|
2.1) Overall approach
|
X
|
X
|
X
|
2.2) Tasks and strategies to reach families
|
X
|
X
|
X
|
2.3) Specificities of the practice
|
-
|
X
|
X
|
3) Perceived impacts of community outreach on parents and children
|
3.1) Increasing social capital
|
X
|
X
|
-
|
3.2) Increasing family empowerment
|
X
|
X
|
-
|
3.3) Increasing access to services
|
X
|
X
|
-
|
Characteristics of the population served
Regarding the characteristics of the individuals served, three sub-themes were described: 1) family characteristics, needs and dynamics, 3) children’s characteristics and needs, and 3) relationships with services.
Family characteristics, needs and dynamics
Families served by community outreach work were described as those living in vulnerable contexts with many socio-economic needs. Families who spoke English at home, who were from multi-ethnic backgrounds, single parent homes, families living in rural areas, and those with low incomes were perceived to living in vulnerable contexts and who community outreach workers hoped to reach. Low family incomes were perceived to be associated with families living with generational poverty, parents who were students themselves and/or who received low salaries, or those living with situational poverty caused by a trigger (e.g. accident, lost employment). Family dynamics were reported to be complex, with parents perceived to be physically present but sometimes struggling to be emotionally present, meaning they might not be aware or overlook their child/children’s needs. Parents felt that community outreach worker help was important for getting organized to attend multiple appointments. Parents reported needing help to understand their kids, and to feel reassured and protected. Examples of needs discussed by parents included planning school entry or accessing kindergarten, being more organized on a day-to-day basis understanding their child’s physical and/or psychological diagnosis(es) and responding properly to their needs. Beyond concrete help, families reported that having the involvement of outreach workers helped to reduce their isolation, improve relationships, give them time to breathe and release emotional stress. Families described themselves as being resilient in the face of adversity, being resourceful and creative, proud of their families, and down to earth.
Another key characteristic of the families was that they faced persistent, interrelated challenges at different levels. Many parents faced physical and psychological health problems, lack of social and parental abilities, difficulties reading, writing and communicating. Some families had violent couple relationships and experienced conflict in relationships with others in their neighbourhood. Many also suffered social isolation. Regarding occupation, some parents worked, while others didn’t, but most had limited employment opportunities. Some were reported to be involved in criminal activities and prostitution. At the financial and material levels, some of them were on the welfare program. Issues with managing money and setting priorities were discussed, and families were reported to frequently search for an apartment or furniture, but often have their electricity services stopped due to limited resources. These families often did not have enough resources to cope with stressors, including poor family member support, living at long distances from organizations making it difficult to reach them. Also, they were not aware of the resources around them and/or mistrusted those resources.
There’s a lot of isolation, that is voluntary or not, but it’s very present. […] There’s not a lot of resources you know, so we stay isolated, in the known. In this way, nobody [community partners] will come to say that we do our parental job wrongly. (Parent)
Children’s characteristics and needs
Many children were reported to have physical and psychological health problems (e.g. autism, attention difficulties, anxiety, language problems). Community outreach workers and inter-sectoral partners perceived that their basic needs were neglected with children lacking food, clothing or proper hygiene. They also perceived that these needs could bring more sickness, with the need for more medication. Many children were isolated, and were reported to have poor interactions with their parents. Frequently, the home environment lacked rules and structure, which created challenges when entering preschool/school. Children often had to assume adult roles, such as taking care of their parents or supporting them. Children spent more time playing free games than organized games, with poor sleep habits, and some falling asleep in front of the television late at night. There were additional developmental challenges such as lack of emotional care and stimulation, the presence of academic difficulties and challenges at preschool. Taken together, these difficulties appeared to suggest that children from these families would begin life with more disadvantages than other children. Despite these, children had many strengths and were described as being autonomous, and having good motor skill development, perhaps related to the fact that they often play outside and protected their siblings.
We [the health care partner and the community outreach worker] work with children with a lot of developmental problems, it’s constantly seen. It’s children that are under stimulated, with a gap. Often, they have language problems. (Healthcare partner)
Relationships with services
A lack of awareness about resources and services was reported among families. Even when families knew about these resources or lived with close access to healthcare settings, they might not seek assistance because of a fear of losing their children to the youth protection authorities.
The community outreach worker is less menacing than us [healthcare partners], because she doesn’t have the youth protection hat as we do. For her, people see that she works in a ________ [basic office right in the community], and don’t know how much she is paid for this job. For us, we are menacing, because we don’t have choice to report families to youth protection in certain cases. When there are more reports to youth protection, less families come to our services, because it’s a little world, everybody knows each other. Sometimes, it’s not even us who reported, but some stay mistrustful after that. In this context, it’s very less menacing when the community outreach worker does the approaches with them. (Healthcare partner)
As a result of this fear, parents may not enrol children in kindergarten, thereby increasing further their family and child’s isolation. Some families struggle with rigid processes to access resources or services, may not understand those processes, and may have difficulties completing paperwork due to poor reading and writing abilities and the French language, all of which can provoke misunderstanding and family. Families are aware of long wait lists to access services. When their children live with difficulties without knowing the diagnosis, they report losing faith in the healthcare system knowing that they may wait months or years to see a specialist. The rigidity of the healthcare system can be a challenge for them. When they miss appointments, they may be discharged. They are required to set needs and goals but may not be able to identify them, often after a limited number of appointments, provoking frustration and a feeling of wasted time for both families and professionals.
Actions Of The Community Outreach Workers
Three subthemes were described for the actions of the community outreach workers including: 1) overall approach, 2) tasks and strategies to reach families, and 3) specificities of practice.
Overall approach
The overall approach to community outreach followed the philosophy underpinning the proximity approach. This included principles such as being grounded in families’ reality and context, being flexible, strengths-based, and informal, creating a strong trust relationship, and fostering engagement and participation of families. Compared with other approaches, providing education or information to a family was perceived to be secondary to being present in the moment and respecting the rhythm of the family and their capabilities. This approach was reported to allow children and parents to celebrate successes, experience pleasure and emotion, and is designed to reduce family fragility. This approach is designed to help families to identify their own needs and then to support them and even accompany them as they access needed services. Other characteristics of the proximity approach reported include helping families to have a better understanding of their situation, helping them to trust healthcare and other services and to stay involved and engaged when they are waiting for healthcare services.
By using the proximity approach, we try by every manner to be available and have a familiar presence. It’s not only about giving information. People don’t care about information. They want to have a familiar presence, a welcoming face. They don’t know about our functions, they don’t care. By deploying community outreach workers and using the proximity approach in the community, we create trust links, and we are anchored in the community. (Community Organization Partner)
Community outreach workers’ tasks were perceived to address several important aspects. They were reported to provide direct support to families, by accompanying families to the organizations and helping translate professional language into lay language, being presence in difficult moments, and advocating for parents.
They need to be accompanied because they are in a disorganisation period. They can’t do it alone and it’s complex to analyse the situation. In vulnerable environment, people don’t have a lot of education. Also, the system, like welfare, hospital, etc., works with forms. It’s a barrier that contribute to reduce their understanding of the situation. Sometimes, they go to an appointment alone, and they say that it went well, but they don’t even know why. (Community outreach worker)
They also helped to reduce barriers, link families with other parents and the community and introduce new families, and provide knowledge and practice information about fostering child development. Community outreach workers connect with other partners, work collaboratively, create confidence in, and promote their role with other organizations. Also, outreach workers improve their own practice and their profession by finding new strategies to connect families, and by documenting and developing a culture of regular evaluation, sharing their knowledge of barriers to access services, and the lack of services with all partner organizations to help them adapt the services they offer.
Tasks and strategies to reach families
Different strategies were used by the community outreach workers to connect with families. Those strategies could be: 1) active or passive (going to the street to meet people or letting people come to them), 2) traditional or imaginative/roundabout (introduce themselves directly to offer a ride and talk during this time), and could 3) involve the outreach worker only, or other people (pivotal person, other families). Primary strategies included public strategies, such as appearing on community television or placing posters in targeted areas where families typically frequent, including grocery stores and health partners’ offices. Workers provided families with transportation, as a pretext to talk with them and create a relationship. They were active on social networks, including those of their own profession, those of other partners, local Facebook pages and Facebook Messenger application. The most used and recognized strategy was visiting places where families were. Community outreach workers try to connect with families in this way to show that they are an integral part of the settings where families gather, and to increase confidence in their work and reduce fear towards them.
All the pretexts are good. The idea is to create a first contact. […] The more you are seen, the more you are part of the picture. The person will come talk to you like you know each other, even if you don’t really. (Community outreach worker).
Specificities of practice
Specificity in community outreach work was related to the posture, or stance, taken by the outreach worker. They are closer to families than conventional workers, providing opportunities to intervene or discuss with family issues that might be sensitive or difficult for them. Also, they act as mediators between families and the healthcare system or other services, filling in the gap left by differences in language and/or culture. They can act as a guide to help service partners recognize the barriers related to service access, the lack of services, and how those partners might improve their services. Outreach workers can be available to a family almost instantly, and are able to build relationships slowly with families over months and years. They are also able to help obtain services for a family, and be with the family while they are waiting to keep them involved and engaged. They contact families in a number of ways, including use of texts and social networks, which is not possible for some organizations. Also, it was noted that perceived areas of weakness of the healthcare structure for these families were actually the strengths of outreach practice, including humanity and availability, and that families didn’t need to have a specific issue to consult workers.
I see her like a help, a support, somebody who listen to me. It’s all that a friend could do, but with more resources, more directions to give. (Parent)
Perceived impacts of community outreach work on families and children
Perceived impacts of the community outreach work on families and children included: 1) increasing social capital, 2) increasing family empowerment, and 3) increasing access to services.
Increasing social capital
With the help of the community outreach worker, parents reported being less isolated and socialized more with their children and community. The same observation was made for the children, who tended to socialize more. Community outreach workers proposed different types of social activities to families and were present with parents during difficult times. Outreach workers helped parents to help their children, and developed stable, significant relationships with them.
It goes a lot with activities. […] In every activity, like collective cooking, coffee meeting, it’s really interesting to go search the families, to get people to know you. For example, for moms who stay at home with their kids, and being anti-kindergarten, if they are going in collective cooking, and that children play together, it’s a good debut. It can work the child socialization, decrease the isolation and see other way to do things It’s a bit the same for the parents. (Healthcare partner)
Increasing family empowerment
Increasing families’ empowerment was related to increasing parents’ feelings of self-efficiency, overall self-esteem, and their parenting abilities, but specifically to helping parents develop positive parenting practices. Parents became more responsible about their children’s needs, skills, and development. They adopted more healthy behaviors, were more available for their children, and tend to be more socially active. All of the above contributed to fostering child development and well-being, by increasing their autonomy, ability to express emotions, and communication skills.
There is a big change. She is saying that I learned to her how to clean her house to protect her kids. How she is now capable to organize her time. It responds at her kids needs by her actions. (Parent, with the help of translator)
Increasing access to services
Community outreach workers helped to increase families’ confidence towards accessing community social and healthcare services which encouraged them to seek support services. They were able to create trust between themselves and the families, something that can be more difficult to establish with the traditional healthcare system and the school system. Many participants mentioned how important it was to put names to faces, to humanize services, and to understand the function and the pathways of the health care services. These actions helped prepare families to access community health and social services. Many participants believed that this helped to improve the continuum of care and ensure children received the services they needed.
[families think this way, according to this Comm. Outreach Worker] I want to go, but I don’t know how. I don’t want to go alone. There’s mistrust. The health care system is frightful. It’s hospital, not home. The health care system doesn’t make any sense for them, it’s too big. But, if I present you [name of a psychosocial counsellor], if he goes with you, it might make sense to go there. (Community outreach worker).