Although Aboriginal and Torres Strait Islander people make up 2.4% of the Australian population it is estimated Aboriginal and Torres Strait Islander people constitute eight percent of the Australian population with hepatitis C. There are approximately 22,000 Aboriginal Australians living with hepatitis C antibodies and of those 16,000 are chronically infected. While the rates of hepatitis C infection in the non-Indigenous population have improved, rates of hepatitis C in the Aboriginal population continues to rise.
It is difficult to determine the exact prevalence of hepatitis C among Aboriginal people as Indigenous status is not reported in a high proportion of notifications. Of the 11,855 notifications of hepatitis C for people living in Western Australia, South Australia, and the Northern Territory in 1999-2003, 793 (7%) were identified as Indigenous. However in 34% of notifications, Indigenous status was not stated. Therefore, because of the large proportion of notifications in which Indigenous status was not stated, the prevalence rates are likely to under estimate the true occurrence of hepatitis C among Aboriginal people.
Aboriginal people are particularly vulnerable to hepatitis C due to lack of access to needle and syringe programs (NSPs) and over representation in the correctional system. Many Aboriginal people have limited access to NSPs because there are fewer NSPs in rural areas where many Aboriginal people live and the costs associated with travelling and buying equipment from pharmacies and other locations is prohibitive. Lack of access to NSPs has a significant impact on hepatitis C prevention efforts in Aboriginal communities. Imprisonment has been identified as an independent risk factor for hepatitis C transmission. Aboriginal and Torres Strait Islander people are 14 times more likely to be incarcerated than non-Indigenous Australians and constitute 27% of the total prison population.
In order to be successful, hepatitis C education programs need to be offered in partnership with Aboriginal health services and communities to create working environments that encourage Aboriginal and Torres Strait Islander people to contribute to educational programs and policy and facilitate control over the programming and implementation of the projects. Aboriginal communities are not heterogenous. Therefore, partnerships with Indigenous organisations will assist in providing hepatitis C educators with guidance and support to address the cultural, community-specific and educational considerations for working with Aboriginal and Torres Strait Islander people.
Aboriginal and Torres Strait Islander people are younger, more mobile and much more marginalised than the non-Indigenous population. Consequently, research indicates that illicit drug use is higher among Indigenous Australians than for non-Indigenous Australians., Illicit drug use is both the cause and a symptom of underlying issues including physical and mental ill health, poverty, unemployment, loss of cultural identity, discrimination, family violence and imprisonment. Aboriginal and Torres Strait Islander people who inject drugs may experience disapproval and social marginalisation within their own communities, which may lead to reluctance to access preventative services such as NSPs. Access to NSPs is limited in Aboriginal communities. Improving access to NSPs is a priority of the National Aboriginal and Torres Strait Islander Sexual Health and Blood Borne Virus Strategy 2005-2008 because access to harm reduction measures will greatly impact on hepatitis C transmission.
The National Hepatitis C Strategy 2005-2008 has identified Aboriginal and Torres Strait Islander people who engage in risk behaviour as one of three priority populations at increased risk of hepatitis C transmission. However, Aboriginal and Torres Strait Islander people are over represented in two of the other priority populations identified in the strategy, namely people who inject drugs and people in custodial settings. Aboriginal people accounted for 10% of all participants within the National Needle Syringe Survey 2001 – 2005 and were more likely to be imprisoned. High levels of shame associated with illicit drug use exist in many Indigenous communities. Therefore, hepatitis C educators must be respectful and sensitive to the community’s approach to illicit drug use and hepatitis C.
Exploring preventative messages surrounding individual use and the prevention of sharing of drug using equipment and personal hygiene items within a cultural context, which embraces sharing and reciprocity as a positive cultural value can be a complex health message. Studies have found that some Indigenous people do not view sharing injecting equipment as a problem because they belong to the same family and have the same blood, often associating strong blood with the protection from disease. Sharing, reciprocity and family bonds can still be maintained within the socio-cultural setting while promoting health initiatives, which minimise hepatitis C transmission.
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There are several considerations that educators needs to be aware of when providing culturally appropriate education for Aboriginal and Torres Strait Islanders. Firstly, research indicates that Aboriginal and Torres Strait Islander people respond to education about health issues if the information is culturally appropriate, incorporates elements of story telling and respects the preference for gender specific groups for education, especially when talking about sexual or personal issues.
Educators need to allocate enough time to consult with Aboriginal people and organisations about their hepatitis C training needs and build partnerships with these organisations before they begin to work with the community. There is little benefit from developing and delivering education and training programs on topics that are neither relevant or of interest to Aboriginal people. Therefore, educators need to work with the Elders and the experts in the community and identify whether hepatitis C is an issue of interest. Concurrently, developing partnerships with Aboriginal organisations at the beginning will overcome the potential for the development of irrelevant programs. Training and health promotion programs need to be holistic and involve the whole community. Involving sport or the arts in the delivery of health promotion messages or programs can assist in tailoring the program to the local community. The assumption cannot be made that training or health promotion activities will be appropriate or effective across different Aboriginal communities, which highlights the importance of the partnership approach in working with Aboriginal communities.
The provision of education services needs to be flexible and may include working outside the traditional education setting for example, providing outreach services, one-to-one education or home visits, while being aware and respectful of the line of authority within the local community. Flexibility in education delivery, the timing and scheduling of training sessions are important elements of providing culturally appropriate training.
Sensitive health and welfare issues may not be widely discussed amongst Aboriginal and Torres Strait Islander people, let alone with people outside their community. Therefore, hepatitis C educators need to be respectful and sensitive in how they address issues such as drug use and sharing of injecting equipment with Aboriginal people. Respecting the need for same gender groups and ensuring there are both male and female educators available to provide training for Aboriginal people is culturally respectful.
Communication style is another important consideration when educating Aboriginal and Torres Strait Islander people. Educators need to have an awareness of their own communication style and the impact their style could have on individuals and groups. In addition, educators need to be respectful of the needs and styles of others. For example, some Aboriginal people feel very uncomfortable if group communication involves continual eye contact. However, in the Anglo-Celtic culture eye contact is synonymous with interest and attentive listening. Therefore, cultural consideration is required.
There is a strong emphasis on oral communication in Aboriginal culture, with story telling providing an important medium for education and information exchange.
In addition, some Aboriginal people often identify with Aboriginal art and colour more comfortably than with written words. Art has strong links with cultural, spiritual and identity issues for Aboriginal people and has been used to communicate complex social and cultural issues that oral and written communication can not. Therefore, if written information is used in the context of education it needs to be succinct. The use of art and story telling, in preference to written words, reflects the family cultural learning experience and should be considered when planning education for Aboriginal communities.
If educators wish to use Aboriginal art work as a component of a training program, it is important to seek the permission of the relevant artist who has the rights over the art work. Seeking the advice and permission of the community to use or engage with local artists is another important aspect of the partnership approach between Aboriginal and mainstream organisations.
Aboriginal and Torres Strait Islander people experience numerous chronic conditions simultaneously and therefore, health conditions are prioritised according to urgency. Anecdotal information suggests that hepatitis C may not be a health priority for some Aboriginal and Torres Strait Islander people because hepatitis C infection may not cause symptoms or cause someone to feel unwell for over a decade. Due to simultaneous chronic conditions that may cause immediate health concerns and social marginalisation including homelessness, unemployment or family violence, hepatitis C infection may be a low priority and subsequently “forgotten”. Educators should consider evidenced based approaches and work closely with Aboriginal organisations to ensure relevance of hepatitis C education activities and encourage participation, while recognising that hepatitis C be a low priority need.
Combo, T. Aboriginal and Torres Strait Islander project. Hepatocrat 2007; May edition.
National Centre in HIV Epidemiology and Clinical Research. HIV/AIDS, viral hepatitis and sexually transmissable infections in Australia: annual surveillance report 2003. Sydney: National Centre in HIV Epidemiology and Clinical Research.
National Centre in HIV Epidemiology and Clinical Research. 2004 annual surveillance report: HIV/AIDS, viral hepatitis and sexually transmissible infections in Australia. 2004; Sydney: National Centre in HIV Epidemiology and Clinical Research
Australian Institute of Health and Welfare. Statistics on drug use in Australia 2002. (Cat. No. PHE 43 (Drug Statistics Series no. 12)) 2003; Canberra: Australian Institute of Health and Welfare.
Australian Bureau of Statistics, Australian Institute of Health and Welfare. The health and welfare of Australia's Aboriginal and Torres Strait Islander people 2003. Canberra: Australian Institute of Health and Welfare and the Australian Bureau of Statistics.
National Aboriginal and Torres Strait Islander Sexual Health and Blood Borne Virus Strategy 2005-2008. 2005; Canberra.
National Centre in HIV Epidemiology and Clinical Research (2006) Australian NSP Survey National Data Report 2001-2005. Sydney: National Centre in HIV Epidemiology and Clinical Research.
Shoobridge J, Vincent N, Allsop S, Biven A (1998) Using rapid assessment methodology to examine injecting drug use in an Aboriginal community. A collaborative project conducted by the Aboriginal Drug and Alcohol Council, the Lower Murray Nungas Club, and the National Centre for Education and Training on Addiction. National Centre for Education and Training on Addiction and the Aboriginal Drug and Alcohol Council
The Box Project. ‘The Box Project Report: Results from the General Community Hepatitis C Needs Assessment and an Audit and Education and Training Needs Assessment’ unpublished 2002: Hepatitis C Council of Queensland, Brisbane.
Ibid.