The prevalence of hepatitis C varies geographically. In most developed countries including Australia, Canada, USA and countries in Europe the prevalence of hepatitis C varies between <1% and 2%. Regions where countries have a high prevalence include Africa, Latin America and Central and South-Eastern Asia. In these regions, prevalence figures between 5% and 10% are frequently reported for many countries. For example, the high hepatitis C prevalence in the Nile delta of Egypt increases with age from 19% in those 10–19 years of age to about 60% in people aged 30 years, and is thought to be the major cause of the high prevalence of liver cirrhosis in the country.
Country of birth is not routinely collected on hepatitis C notifications in Australia. Therefore limited data exists on the impact of hepatitis C among people from CALD communities. However, it is estimated that 29,000 people with hepatitis C antibodies have migrated to Australia from high hepatitis C prevalence countries.
People born in countries of high hepatitis C prevalence now living in Australia may have been infected in their country of birth through unsterile medical, dental or vaccination programs and other health care and traditional practices involving blood to blood contact. Unsafe injecting practices among injecting drug users from CALD communities account for some cases of hepatitis C transmission, with several studies finding very high levels of hepatitis C among CALD injecting drug users, particularly people from South East Asian backgrounds.
Furthermore, people born in high prevalence countries often acquire hepatitis C at a young age and may not be aware of their hepatitis C status until later in life, which may result in late presentation to health services and possibly higher risk of developing serious liver disease such as cirrhosis and/or hepatocellular carcinoma.
Educators involved in providing hepatitis C training and support to people from CALD communities and/or workers involved with CALD communities need to be aware of the challenges and unique experiences of their audience. Developing and maintaining partnerships with CALD organisations will assist educators to gain an understanding of the needs of communities and provide access to culturally appropriate services, referral points and resources.
CALD communities are diverse and education and training strategies need to account for and respect the differences between communities and their hepatitis C learning needs.
An initial consideration for educators working with CALD communities is that for many English is not the audience’s first language. Therefore, educators must consider their presentation style and adapt to the needs of the audience without sacrificing the detail of the information provided. Plain English is recommended, so is the provision of explanations of technical terms (e.g. antibody positive) and acronyms (e.g. HCV or PCR) before they are used in a presentation. Try to avoid using unnecessary jargon during education sessions and use audiovisual materials that are in plain English or in the audience’s first language, if available.
In addition, educators should consider delivering education and training activities in collaboration or with the assistance of qualified interpreters or bi-lingual workers who have received hepatitis C training.
Another important consideration for educators is what they need to know about the community before providing education. Are there cultural sensitivities around injecting drug use for the community? Or communication styles, gender-related issues or reluctance to use western medicine that may be relevant to a hepatitis C presentation? Performing basic research about the community and possible cultural considerations will help ensure the hepatitis C education will be positively received. One of the easiest ways to do this is to contact a community organisation or a multicultural health worker and ask for their advice about providing education to the particular community or invite them to co-present the session.
People from CALD communities may experience a range of barriers and/or difficulties in accessing health care in Australia. Fear related to accessing the health system and distrust of the health system may relate to issues of grief, trauma and loss associated with experiences in either Australia or their country of origin. In addition, difficulties in accessing hepatitis C services and programs due to cultural and language barriers and the fear of breaches of confidentiality and stigmatisation from within and outside their communities inevitably affect their willingness and ability to access such services.
Before advising people from CALD communities to access hepatitis C care from their local hospital it would be worthwhile discussing their access to general health services, their experiences in the health system and where their community access health care. The information gathered may be useful in making an appropriate referral that acknowledges previous experiences and/or potential difficulties or barriers and will ultimately benefit the individual.
While it may be difficult in many areas to access face-to-face interpreting services it is important that educators promote the use of interpreters, especially when people are receiving detailed health information or new diagnoses. A national telephone interpreting service can be used where health care interpreters are not available. Individuals can use the Translating and Interpreting Service by calling 131 450 from anywhere in Australia for the cost of a local call. Private medical practitioners can access telephone interpreting with their patients at no cost by calling 1300 131 450.
There may be a lack of culturally appropriate and language specific information about hepatitis C, which is a concern not only for prevention initiatives, but also health maintenance and treatment activities. People from CALD communities require prevention, treatment and health maintenance services that are culturally appropriate and in a language they understand. Therefore, resources need to be produced in community languages and plain English and need to be focus tested with members of the relevant community to assess the cultural appropriateness of the resource. Even if individuals speak English, they may feel more literate and comfortable reading or hearing information in their first language.
Educators need to identify resources that are produced in community languages and have been developed “in-language” in contrast to resources that are directly translated from an English format that was aimed at the Anglo-Celtic, predominantly IDU population, to a community language. These resources do not address the information needs specific to CALD communities such as skin penetration practices that have resulted in hepatitis C transmission including eyebrow and eyelid tattooing for cosmetic reasons or traditional practices such as scarification, circumcision and acupuncture. Educators should be aware of resources that have been developed in-language and promote them (refer to Section 1 – Resources for educators working with CALD communities). Educators should be encouraged to share positive feedback about the resource with their colleagues to promote the use of the resource to CALD communities.
Hepatitis C educators have an important role in building the capacity of CALD communities with regard to viral hepatitis. Particularly considering that health and welfare workers may be ill equipped to address the hepatitis C needs of CALD communities and people from CALD communities may have limited hepatitis C knowledge, including a poor understanding of hepatitis C transmission. Dev et al. (2004) identified that the majority of a cohort of South East Asia patients were unaware of how they had acquired hepatitis C and how hepatitis C is transmitted. Their low knowledge was most likely a result of inadequate risk factor assessment, poor understanding of cultural concepts of disease and inability of health professionals to provide culturally appropriate information.
It is essential that hepatitis C educators build networks and partnerships and work collaboratively with CALD organisations, to ensure hepatitis C information and education is appropriate and sensitive to the cultural and linguistic needs of communities and results in increased access to appropriate support and treatment services for CALD communities.
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