Evaluation on the street-level interventions of Blue Cross and the ‘Step by Step’ programme
This is the final report from a formative evaluation of two Blue Cross programmes for people with addiction problems: the street-level programmes and the Step by Step rehabilitation programme. The formative evaluation has been underway since 2018. Two reports from the evaluation work have been published during this period.
The first report, with the title ‘Better life skills and social inclusion’, described the structure of the interventions and the methods that were used to address the service users’ needs. In addition, a needs analysis for both services was presented in light of the prevailing challenges in the field of addiction (Hansen, Bråthen, Aagesen and Lien 2019). A mid-term report was submitted in February 2021 (Bråthen and Brunovskis 2021). Both reports included assessments of how the initiatives function and recommendations for their further development. The formative evaluation is empirically oriented, with a focus on how the initiatives unfold through practical action and are perceived by the actors and users involved.
The formative evaluation has two general research questions:
- How do the Blue Cross initiatives help promote social inclusion and better life skills among persons with addiction problems?
- How are the Blue Cross initiatives supplementing public service provision to persons with addiction problems?
The Contact Centre in Oslo and the Varmestua initiative in Fredrikstad have been the cases for our evaluation of the so-called street-level services. The evaluation of the Step by Step programme was based on case studies of the services in Oslo, Bergen and Kristiansand.
The final analysis includes a separate assessment of the collaboration and the potential for collaboration between the Step by Step rehabilitation programme and the treatment division of Blue Cross. The Loland and Slemdal treatment centres and the outpatient clinic in Oslo, and their collaboration with Step by Step in Kristiansand and Oslo are included as cases.
The street-level programmes mainly consist of running a café that provides food and care, but a social counselling service and a specific motivational methodology have also been developed as part of this activity to help convince the users that they can improve their life situation and quality of life.
Step by Step is an individually adapted programme that offers support to each participant in their process towards establishing the life that they want for themselves. Keywords in the programme include life skills, support for social inclusion and management of daily life.
The street-level services and Step by Step address different target groups. The street-level services are primarily intended for people with active addiction, while Step by Step is intended for those who would like support in a process to establish a drug-free life.
‘Time givers’, which is the designation used for Blue Cross volunteers, represent a resource in both programmes, but their activities vary between the programmes. In the street-level services, time givers are involved in running the café, and their engagement with the users is a part of the services. In Step by Step, individual support by time givers is a key part of the concept and a service to the users as a support for various forms of social participation, activities, or practical matters in their process to establish a normal life.
The final report is based on analyses and results presented in the two previous reports, but also includes analyses of comprehensive data material collected in the final part of the evaluation period. The data material consists of qualitative interviews with staff members, time givers and participants in Step by Step and three Blue Cross treatment programmes, as well as a survey among participants in all of the six local Step by Step programmes around Norway. Desk studies have also been undertaken. In the street-level programmes, interviews have been conducted with staff at the Contact Centre in Oslo and the ‘Varmestua’ in Fredrikstad, as well as desk studies that include a review of user surveys conducted in these two programmes.
The COVID-19 pandemic has affected the activity in the two programmes, as well as data collection These issues are described in the report.
Results and assessments
The evaluation shows that in both the street-level programmes and Step by Step, the activities, services and methods are geared towards enhancing the quality of life, life skills and social inclusion of the users and participants. The services have been further developed during the evaluation period with a view to reinforcing these dimensions.
Care and food are basic elements in street-level programmes and the primary reason why users seek them out. This makes it possible to engage in various measures to improve the service users’ quality of life and motivate them for change. The motivation efforts, which apply a methodology developed at the Contact Centre in Oslo, are integrated to varying degrees in all Blue Cross street-level café programmes.
Social counselling and education have become an established part of the services at Varmestua in Fredrikstad. The report shows the importance of embedding services in local contexts and adapting the original method to ensure that the services function well in the Fredrikstad setting. Other services are being developed as an extension of the efforts established locally, including an ambulant social counselling service. Blue Cross collaborates with the local authorities in their work with persons with addiction problems, and examples of coordination and collaboration on services for the target group can be found. As part of an increased emphasis on motivation work, an agreement has been signed with Østfold University College on recruitment of time givers from the study programme for health and social workers to supplement the established recruitment of time givers. This helps raise the level of competence in the provision of services to users.
At the Contact Centre in Oslo, the provision of food and care services has reached new groups during the COVID-19 pandemic. This includes people who are outside or at the margin of the defined target group. This is partly due to an increased need for these types of services during the pandemic, but also to the fact that the requirement for membership in order to be a guest at the centre was suspended during this period. The motivation work and social counselling are significant elements of the services provided by the Contact Centre, although its operational activity has been somewhat curtailed during the pandemic. A separate residential centre has been established and continues to operate. The collaboration with the real estate department of Blue Cross provides the participants with an offer of housing. This is considered to have produced good results for the handful of participants who have used this option, which has helped improve stability with regard to housing for persons who have previously struggled with this. Collaboration has also been initiated with Slemdal treatment centre on services for persons who are heading for therapy, and there seems to be a potential for making use of the services of the residential centre as part of this collaboration.
Step by Step has developed its concept and expanded its activities since the start of the evaluation period in 2018. There are now six such programmes around Norway, and two more are at the start-up stage. In the three programmes that have served as cases during the evaluation (Oslo, Bergen, and Kristiansand), the number of participants and time givers has increased.
The material shows that the operation of the three programmes is largely aimed at helping the participants get on with their lives and establish a life without drug use, and at supporting each individual in their process to achieve the goals they have set for themselves. In this chapter, we show that the service provision has become more professionalised in several respects. The role of counselling has been developed and become more central than it did initially. The Recovery model has been established as a knowledge framework for the methods used. The dimension involving the time givers has been more specifically defined as a contribution towards achieving clearly stated goals.
The three programmes in Oslo, Bergen and Kristiansand all have their local character, but their concept is nevertheless very similar. In addition to individual follow-up, all the programmes have a number of shared services and activities, although Kristiansand stands out in having a centre that finds small jobs for participants. We can also see that the Step by Step house in Bergen provides a venue for more informal interaction between participants and staff than is available in Oslo. Individual support by time givers is a key element of the services in Oslo and Bergen, but not in Kristiansand.
The more established nature of the programme is illustrated by the fact that in our survey, a large proportion of the respondents report having learned about the programme through staff in treatment institutions, prisons, or the local authority.
In the survey, the majority of the respondents report wanting help with social participation, activities and networking, but also with drawing up a plan and defining goals for the life that they want for themselves.
The participants appear to feel that in Step by Step, they are being listened to, met with acceptance and recognition, and provided with the help they want. In the survey, many report to achieve the goals they set for themselves and cope better with addiction and life in general as a result of the programme. Relatively fewer report to have obtained a wider social network and to have become more active. Promoting social participation and networking is a key element of Step by Step, and in the report, we point out the need to focus more on this aspect going forward. However, the results from the survey must be interpreted in light of the fact that for the last 18 months we have been living with the social restrictions imposed as a result of the COVID-19 pandemic.
Step by Step is often associated with support to lead a normal life; support provided by ordinary people. This implies that the more the role of counselling in the programme becomes professionalised and prominent, the more important it will be to maintain the boundary with addiction advisors and other services provided by the local authority. The role of the counsellor is in a grey zone that borders on social work and the role of social educator. There is a need for continuous critical reflection on the role of counselling.
Clear quality assurance procedures have been established for the work of time giver in the Step by Step programme, and individual time giver support is managed within a framework referred to as ‘assignment-based voluntariness’.
The objectives for involving a time giver are clearly specified, and there are procedures for following up the collaboration between the participant and the time giver. Many participants benefit greatly from their contact with the time giver, and this can serve as an important resource for becoming more socially active and building networks. The analyses show, however, that it is important to take into account the vulnerability this may entail. For many participants, the involvement of a time giver can be a big step, and safe frameworks are essential to ensure that this is perceived as a resource.
In Step by Step, a distinction is maintained between support by a time giver and regular friendship, and care is taken to ensure that the relationship does not assume a private nature. The analyses nevertheless show that in social assignments, in particular, the support by a time giver depends on a friendly relationship, and that good procedures are required to safeguard both the time giver and the participant from the vulnerability that such a relationship may entail.
Step by Step is primarily designed to support participants in their activities in various arenas in society, and not establish separate activities and options. The programme has expanded its provision of shared services. This could be helpful in providing safe arenas for coping as a first step on the road ahead, but there is a need for critical reflection on the balance between providing shared services on the one hand and promoting participation in ordinary arenas on the other.
In the concluding chapter, the report discusses whether professionalisation of the services may cause them to lose their distinctive character.
The professionalisation of the services in the Step by Step programme has helped raise their quality, but certain elements of this professionalisation pose a risk that the programme loses its distinctive character. Its distinctive feature is that quite ordinary people can provide support for social inclusion of people with addiction problems. To put it in simple terms, this is a matter of involvement of civil society and mobilisation of ordinary people versus professionalised follow-up and assistance.
Similarly, with regard to the street-level programmes, there needs to be a continuous reflection on the balance between professional social work and motivation methods on the one hand and the encounters with the service users and provision of care on the other. This dimension of care is the reason why the service users seek out the programmes, which gives a position for motivating for change and better quality of life for those who use the venues.
The analyses in this final report point to considerable potential for increased collaboration within Blue Cross and a possible synergy from a clearer definition of the interfaces between different programmes. Blue Cross provides services to persons who engage in active addiction as well as treatment options and support to those who wish to become drug-free. Across its different programmes, Blue Cross can help achieve coherence and continuity in services to persons who have drug and addiction problems but wish to establish a normal life, as they themselves define it.
