A review of current programs and materials regarding hepatitis C directed specifically to youth was conducted, covering the following elements:
To conduct this review, the following activities were undertaken.
Overall, there was little information available on evaluated programs targeting youth at risk and hepatitis C prevention; however, some Australian studies were found to have examined the role of peer intermediaries in reaching youth at risk and providing them with prevention information. These study results will be discussed in a subsequent section of this document. Many of the programs found were closely linked with AIDS programming, based on a common method of transmission for these two infections (i.e., injection drug use/IDU).
Secondary searches were also conducted to determine what programming options currently exist for youth at risk in relation to other health behaviours such as substance abuse and tobacco usage. Some different programming options were found as means to encourage the cessation of tobacco use among teens and youth at risk.
These programming options included some of the more traditionally focused youth at risk options such as outdoor education programming ("Outward Bound" types of initiatives, weekend retreats, etc.) and community-supported programming where smoke-free, alternative environments (e.g. community centres, dances, playgrounds) were set up and which youth were encouraged to use.
Attempts were also made (unsuccessfully) to contact via phone and e-mail the program managers and researchers related to the programs and studies found.
This report outlines effective approaches and materials aimed at preventing the spread of infections among youth at risk. These issues were further explored via interviews with intermediaries and focus groups with youth.
Note: A series of reports has been developed by Health Canada relating to youth and substance abuse. Their findings are not repeated here. They can be accessed via Health Canada or on its website.
Programming targeted to youth at risk was often found to include the use of peer intermediaries/peer educators to reach the intended audience. In some instances, the intermediaries (peer and otherwise) involved in the programming activities were former injection drug users who may also have been diagnosed with hepatitis C. These types of intermediaries, who have experienced the same circumstances and faced the same risks as the target youth audience, may share a common perspective with the youth.
Current hepatitis C programming activities in use that target youth at risk include the following.
Much of the traditional programming around issues such as drug use and sexually transmitted diseases (STDs) has been done in school settings. Often, however, these programs miss youth who may have dropped out of school, or they use approaches that do not engage this particular population.
New programming options, such as the activities listed above, in non-traditional venues (i.e., at needle exchange programs rather than school assemblies) and in non-traditional formats (i.e., theatre productions rather than lecture formats) are being used to attempt to reach youth at risk in settings they may be more familiar with. These options employ formats that are more appealing to this group, and are not dependent upon youths' literacy skills.
In conjunction with programming initiatives, hard copy materials are also being produced and distributed to youth at risk to further "bring home" the programming messages. Materials used in targeting this population make use of plain language approaches, including the use of common street or slang terms for drug use and sexual contact. These materials make good use of graphics and images to combat issues of literacy and the lack of familiarity with medical terminology.
Much of the material produced is in the form of pamphlets, stickers, post cards, key chains and other materials that can be easily distributed to youth on the street. This facilitates the distribution of these materials in settings other than schools.
In addition, several youth-oriented websites exist, but may need to be combined with other programming approaches (such as designated terminals in drop-in centres) as access to the Internet may not be readily available for this population, especially homeless youth.
Overall, these programs and the accompanying materials aim to get across specific messages of hepatitis C prevention to youth. The target messages being conveyed include:
Two recent initiatives in Australia examined the efficacy of peer-based education/counselling programs for youth at risk. A pilot project and a study were conducted using grants from Australia's Federal Health and Aged Care department.
Dr. S. Sawyer, as cited in the Report on the Strategic Research Development Committee's Program of Social and Behavioural Research into Hepatitis C (See references, at the end of Section 1) indicated that much of the information available to young injection drug users about blood awareness, such as how blood-borne viruses may be transmitted, was not appropriate, i.e. language used, tone, etc.
For the study, 65 youth were recruited from needle exchange programs and given basic education on HCV. After receiving the education, the recruits were asked if they would in turn be interested in recruiting other youths to the program and educating their peers.
The significant findings of this study were twofold. First, participants in the program reported that they had learned new information that resulted in a change to some aspect of their behaviour, with regard to HCV prevention (again, details were not given as to what specific behaviours changed). Second, the youths found that becoming a peer educator had a "significantly greater effect on knowledge" of HCV risks, preventative measures, etc., than when they had only received peer education. However, both groups (peer educators and the recipients of the peer education) did indicate that they had learned from being part of the study.
This study seems to suggest that peer education or peer intermediary programs hold benefits for the youth who receive peer education, but that more significant gains may also be obtained through increased recruitment and training of the peer intermediaries themselves. This study also suggested that the use of peer intermediaries was a more appropriate means of transferring information to youth at risk than some of the current materials available. It did not specify, however, what materials had been used.
The second study, conducted by Dr. Nick Crofts (cited in the same Report on the Strategic Research Development Committee's Program of Social and Behavioural Research into Hepatitis C) had similar results to the Sawyer study, based on pilot-testing of a peer-based hepatitis C counselling and testing service at a needle and syringe program. This study placed trained peer counsellors at needle/syringe exchange programs to provide HCV testing and counselling services to injection drug users. It concluded that the counselling provided helped to decrease risk-taking behaviour or recipient injection drug users, and that "the delivery of these services by a trained and experienced peer ... is an appropriate and effective model."
Canadian programmers are also employing a peer intermediary model in their hepatitis C programs targeted to youth at risk. The following are examples of two Canadian peer intermediary programs.
YouthCo is a Vancouver-based non-profit organization that works with youth on HIV/AIDS programming. Included in their repertoire is the HEPCats program (Hepatitis C Advocacy and Treatment), that uses peer-counselling initiatives to provide support and information to youth infected with AIDS and HCV or youth at risk of contracting HIV and/or HCV.
The Teen Health Centre in Windsor-Essex County, Ontario, has a hepatitis C division with several programs targeted to youth dealing with HCV either personally or in their families. In particular, the Speakers' Bureau program is aimed at youth at risk, including recovering injection drug users. The program aims to help these youth increase their decisions-making capacity surrounding healthy lifestyle choices. The program concludes with participants making presentations about the program to other youth and peers in the community.
The intermediary programs available to youth, including programs targeted to youth at risk by organizations with programs focused on hepatitis C issues, run the gamut from informal drop-in centres staffed by intermediaries to formal education and counselling sessions, workshops, medical screening and referral services. The intermediary programs may be offered on the organization's premises, but many also operate through mobile outreach units that work at youth-oriented venues (concerts, raves, demonstrations) and at needle exchange programs in order to make themselves visible to youth who may be in need of their services.
A less traditional approach being used by intermediaries to address issues of risk-taking behaviours including substance abuse and sex, is interactive theatre group performances. These performances encourage audience participation through questions related to the issues being presented onstage.
This type of initiative also makes use of peer intermediaries, as youth in the community are recruited to help create and stage the theatre performances. YouthCo of Vancouver, HIV Edmonton, and Rossbrook House in Manitoba, are all currently employing this type of programming in their organizations.
A second programming approach being employed by these organizations is the establishment of "Dinner Clubs". Having found a low response rate and buy-in for traditional support group settings in the at-risk population, and particularly among injection drug users, YOUTHLINK Inner City in Toronto instead established informal dinners where youth at risk could gather and speak to one another and available counsellors, without the setting confines of a group support session. YOUTHLINK reported that this program had to be re-examined and reworked on a couple of occasions in order to find the format that would best accommodate the non-traditional lifestyles of their clientele. They found that holding the suppers at the end of a traditional "workday" when many of the youth were already at the centre for other programs, meant that the youth would stay for the dinner club program. Scheduling the suppers later in the day, which would require the participants to potentially leave for a few hours and then return, proved ineffective, as the participants' lifestyle, including drug use, would often prevent them from returning later.
YouthCo of Vancouver also provides dinner club type programming, as well as monthly events programming and a yearly retreat for program participants.
The Alberta Alcohol and Drug Abuse Commission (AADAC) (has established a youth advisory council, in order to help inform intermediaries making programming decisions. AADAC intermediaries work with the Youth Council members to garner opinions on AADAC's print materials, television campaigns and website content, as well as providing suggestions on programming needs.
Other intermediary programming options being offered by various organizations include:
Some of the organizations currently supplying hepatitis C programming have also tried to find other intermediaries in the community who may have contact with individuals at risk of contracting HCV. As such, these organizations have instituted educational programs in order to reach other possible community-based intermediaries. One example is the development of community workshops specifically for pharmacists, prepared and delivered by Hep C - CB (Cape Breton). In response to the pharmacists' organization identifying an increase in prescriptions for injection pharmaceuticals, Hep C - CB was planning a daylong session for pharmacists surrounding injection drug use in general and HCV in particular.
In addition, a study out of Australia, entitled "An intervention to improve compliance with skin penetration guidelines in tattooists, beauty therapists and hairdressers" (See Strategic Research Development Committee Report) suggests that, despite introduction of health guidelines, tattoo artists, and body piercers (as well as hairdressers and beauty therapists) are still lacking knowledge of how to prevent blood-borne diseases such as hepatitis C, and that education of this population could be done through intermediaries such as public health officials who are already doing premise inspections.
This could be a future direction for some Canadian intermediaries - to provide additional prevention counselling to a group that is working first-hand with youth at risk in an area where prevention is a key issue. Educated tattoo artists and body piercers would then, in a sense also become secondary intermediaries, working with youth to prevent blood-borne transmission of HCV through the promotion of clean tattooing and piercing practices. Social and outreach workers, youth corrections officers and others who work with youth would also fall into this category of intermediaries.
The materials being produced by various organizations targeting youth at risk tend to be comprised of pocket-sized pamphlets, brochures, stickers, key chains, etc., that are easily distributable from a variety of locations such as street corners, needle exchange programs, concerts, malls, etc.
A good example of a materials based initiative, is the distribution of "party packs" at local area raves by the Youth ESsential (YES) project, administered by AIDS Calgary Awareness Association. The party packs contain stickers, temporary tattoos, lubricant, condoms and lollipops, much of which is branded with the YES program logo. This has raised awareness and increased the visibility of the YES program.
The following is a list of some of the materials in production (at the time of writing) for youth listed by subject matter.
Hepatitis C, AIDS and safe sexual practices
Tattooing and Piercing
Drugs and Needle Use
Others
For intermediaries working with youth at risk in the area of hepatitis C prevention, there are several resources that have been produced that may be of use in establishing peer training programs and in finding available services.
As stated previously, several organizations have also created websites directed to youth with specific information on hepatitis C. For this type of material to be effective, however, accessibility barriers must be overcome. As such, some organizations may find it useful to provide access to these types of websites at drop-in centres, though mobile terminals, etc., in order to remove access barriers.
The following is a list of some youth targeted health and information sites.
Health Canada. 1997. Meeting the Needs of Youth at Risk in Canada: Learning from a National Community Development Project. Ottawa, ON: Health Canada, p.2.
Strategic Research Development Committee. No date. Report
on the Strategic Research Development Committee's Program of
Social and Behavioural Research into Hepatitis C.
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