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Hepatitis C: Intervention Programming for Youth at Risk - Final Consolidated Report

2. Information Review

A review of current programs and materials regarding hepatitis C directed specifically to youth was conducted, covering the following elements:

• programs delivered via intermediaries, including peer intermediaries;
• promising materials to raise awareness of the issue among youth at risk; and,
• websites of interest to intermediaries and youth.

2.1 Research Methodology

To conduct this review, the following activities were undertaken.

• A review was completed of programs and materials of Health Canada-funded hepatitis C projects across Canada, with information as provided by Ottawa staff.
• A literature search of published research on effective programs was conducted. The programs and studies used in this information paper were found through targeted Internet searches with different search engines (Google™, Yahoo®, Altavista™), periodical searches at the Health Canada library using SydneyPlus and through the Medline/Publine online database of health-related periodicals, supplied by the US National Library of Medicine and the National Institutes of Health.
• An Internet search was done for programs listed on reputable websites, as found using the search engines cited above.
• Information provided through health promotion list serves was reviewed.

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.

2.2 Initiatives for Youth at Risk

Programs

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.

• Needle exchange programs, often staffed by peer intermediaries/peer educators, which may also offer health screening services.
• Drop-in centres with peer counsellors and other intermediaries on staff. Telephone hotlines are also available through some centres, as are support groups for youth infected with hepatitis C.
• Theatre productions used to convey information on sex, sexuality, risk factors and self-esteem, which encourage audience interaction (asking questions, etc.).

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.

Materials

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.

Program and material messaging

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:

• the risk factors for contracting the hepatitis C virus (through injection drug use, non-sterile application of body art and piercing, unprotected sex with multiple partners, or other risk factors);
• the means of preventing hepatitis C, including use of clean needles, use of hygienic tattoo/piercing practices, safe sexual practices, etc.;
• the symptoms of suspected hepatitis C infection (fatigue, changes in urine/feces colour, jaundice); and,
• where further information and help is available to youth.

2.3 Intermediary Programs

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

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

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.

Intermediary programs

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:

• "Train the Trainer" type initiatives provided by organization intermediaries to volunteers, youth workers and other health care workers (e.g. YouthCo and HIV Edmonton);
• Educational workshops for both youth and front-line youth workers, to expand general hepatitis C knowledge (risk factors, transmission, symptoms, etc.) (e.g. YOUTHLINK, ACCESS The AIDS Committee of Sudbury, Rossbrook House, Get Together to Get Better in Cape Breton);
• Traditional support groups (e.g. HIV Edmonton, ACCESS, Wabano Centre for Aboriginal Health; and,
• Telephone "Helplines" staffed by intermediaries offering support to individuals affected by hepatitis C (e.g. Hepatitis C Support Project of San Francisco).

Intermediaries

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.

2.4 Materials

For youth

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

• YouthCo HEPCats - pocket guide produced by YouthCo on hepatitis C information
• Straight up on Hep C - pocket guide produced by Youthlink Innercity on hepatitis C information
• Sex, Drugs & Prevention: Hepatitis C - pamphlet produced by Sexuality Education and Resource Centre (SERC) - one of a series which includes HIV/AIDS, Hepatitis B, Herpes, Chlamydia & Gonorrhea, Genital Warts
• What is Hepatitis C? - postcard produced by AIDS Calgary - one of a series which includes What is an STD?, What is HIV/AIDS?, What is Harm Reduction? Safer Partying Tips, Youth Empowerment - You can make a difference
• Fun Ways to F*!k Around Safer C - pocket guide produced by Youthlink Innercity with information and instructions on safe sexual practices (also mention of body piercing and HIV/AIDS)
• Condoms…Your best bet for safer sex - pocket guide with information and instructions on condom use, originally produced by the AIDS Committee of Toronto, reproduced by the Village Clinic (Manitoba)
• Dam It: Facts about safer oral sex - pocket guide with information on oral sex instructions on dental dam use, produced the Village Clinic (Manitoba)
• Germs: How to Stay Healthy on the Street - booklet produced by StreetWorks with information on hepatitis C, AIDS, other STDs and communicable diseases
• Harsh Reality - booklet produced by Kali Shiva AIDS Services and SERC with information on hepatitis C, AIDS, and other STDs
• Be Street Smart - booklet produced by Love Lives Here with information on hepatitis C, AIDS, and other STDs
• Condom key ring from Think Again

Tattooing and Piercing

• Safe Tattooing and Piercing: Finding a studio that's right for you - pamphlet produced by The Wellington-Dufferin-Guelph Health Unit
• Safe Body Art: Are you thinking about getting a Tattoo or Body Piercing - pamphlet produced by HIV Edmonton
• Tattooing and Piercing: Make it safe - pamphlet produced by the Region of Peel
• Body Art, Body Smart - pocket guide produced by YouthCo
• Why get a body piercing or a tattoo? - postcard produced by AIDS Calgary - one of a series (see above)

Drugs and Needle Use

• Injection Drug Use - pocket guide produced by Youthlink Innercity, information and instructions on safer injection practices and associated risk factors
• Harsh Reality - booklet produced by Kali Shiva AIDS Services and SERC with information on drug use including safer injection practices
• Be Street Smart - booklet produced by Love Lives Here with information on drug use including safer injection practices
• What You Need To Know About Using Steroids - pamphlet produced by The AIDS Committee of Guelph & Wellington County -information on safe injecting practices and risks for contracting HCV
• Hi Dad - Public service announcement (30 seconds) produced by the Alberta Community Council on HIV

Others

• Hepatitis C: Manitoba's Hepatitis C Support Guide - booklet produced by the government of Manitoba - information for people living with hepatitis C

For Intermediaries

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.

• Hepatitis C Peer Education Mode l- guide produced by Kali Shiva AIDS Services as an introduction to peer education principles
• A Peer Training and Resource Manual for HIV + Injection Drugs Users - guide produced by Kali Shiva AIDS Services as resources for peer educators
• Harm Reduction: Considered and Applied - guide produced for Health Canada dealing with the application of harm reduction principles in dealing with HIV and hepatitis C in Aboriginal communities.
• HIV/AIDS: Can you provide me with information that does not distort the facts? - pamphlet produced by YouthCo with information on the HIV/AIDS programs they offer to schools, community groups etc.

Youth-oriented websites

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.

• The Queensland (Australia) Sexual Health and Hepatitis C website for young people
• The Teen Health Centre Website, based in Windsor, Ontario
• YouthResource - A sexual health website aimed at gay, lesbian, bisexual, transgender, and questioning (GLBTQ) young people, based in Washington, DC
• AADAC's youth website (focus is on drugs, alcohol and gambling)

References cited in this section

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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