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

5. Conclusions and recommendations

5.1 Broad Parameters of Success

The three elements of this research project (information review, interviews with intermediaries and focus groups) point to very similar conclusions regarding programming to prevent the transmission of HCV among youth at risk. There are broad parameters for successful programs that are supported in the literature, by intermediaries and by youth themselves.

• Led by youth
  Whether in programming or the development of materials, youth must have a strong voice in shaping the initiative. Involvement should commence at the very beginning of the project to give youth a hand in determining what the project should be and how it should be run. Skilled adults can be important as guides and assistants, as their knowledge of hepatitis C and of processes required to move project forward will be instrumental, but youth should be in charge of the project.

• Show respect
  A successful program will be built upon respect for the target audience: youth at risk. Whether it is led by youth or adults, an open, non-judgmental attitude and respectful tone is paramount to opening the lines of communication required to move any initiative forward. Understanding youths' circumstances in life is key: proceeding with that insight through all steps of the project will be important, beginning with goal setting and extending to issues like the size of the project team, the creative approach used, hours of operation, deadlines and all other elements. A harm reduction approach is, of course, implicit in this process.

• Provide appropriate support
  Screening, training and on-going support are important to youth-centred programs. As mentioned previously in this report, initiatives run by youth at risk can be difficult to organize and maintain. Screening tools or approaches that may assist in identifying youth who have the personal skills to be effective as youth intermediaries would be useful. Training on knowledge of HCV would be a minimum requirement. Depending on the nature of the project, development of facilitation and listening skills, and training in conflict resolution, suicide prevention and mental health issues would be tremendous assets.

• Use appropriate materials
  Discussions with intermediaries and youth at risk supported the literature review in emphasizing that materials must be focused on the issue at hand, and appropriate to the audience. Clear language, eye-catching graphics and small size are important to have youth take materials away and read them. A fair number of good materials exist; however, there continue to be gaps. Intermediaries noted that very little exists for youth aged 12 to16. These younger youth are unlikely to be engaged in IDU, but may be drinking alcohol, a common pre-cursor to drug use or other risky behaviours such as non-sterile tattooing or piercing. Some materials exist that address tattooing and piercing separately from injection drug use, which is important as there continues to be a stigma around injection drug users. Materials that relate drinking to these risky behaviours were not found in the fairly extensive search conducted as part of this project. In addition, few materials focus specifically on snorting and non-IV drug paraphernalia. This void is of particular concern, as the possibility of transmission through straws and other snorting equipment was not understood, and in fact, was rejected by a majority of the youth who participated in the focus groups.

• Are targeted at specific audiences
  Just as materials need to be targeted to specific behaviours, programs must address specific age groups and types of behaviour. Intermediaries felt that first-time or infrequent injection drug users may be at greatest risk of infection, as they are considerably less aware of the risks. They tend to view HCV as a disease of the hardcore, of which they are not a part. Rural youth at risk are also in a precarious situation, as they have few resources available to them, and little chance of anonymity in a small community. Anonymous telephone help lines may be considered for these youth.

5.2 Most Promising Programs

This review revealed a wide variety of programs that can be effective in raising awareness of HCV, from street outreach, to workshop, to theatre. The parameters of success identified above are the threads that run through them all. Specific programs that show the most promise are as follows.

• Youth intermediary programs
  Training youth to be ambassadors of the prevention message is seen to be most effective, both in spreading the message and in having a long-lasting effect on their own behaviour. Providing marginalized youth with employment in this way would tap into and expand their skills and abilities while they assist their peers, and was seen as an extremely constructive approach for all involved. Benefits include increased self-esteem, job experience and improved stability in their lives.
   
  Once established, this training could be disseminated as a "train-the-trainer" course, with experienced youth participating in training of other youth across Canada. YouthCo (Vancouver) is currently using this approach very effectively. Trained youth could then determine how they want to apply their knowledge and skills. Youth suggested a wide range of options, from speakers' bureaus and workshops, to street outreach, to the development of theatre or video productions, to attendance at youth events, like raves and concerts. Examples of all of these types of programs exist currently and could be modeled. As stated above, the keys are in developing an effective training program and providing youth with the power to direct and implement the project.
   
  In addition, it is important to recognize that the actual product resulting from this type of project is less important than the process, including the ongoing connection with a group of people. Less emphasis should be placed on tangible products, and more on skills and process.
  Note: For further details on involving youth at risk in community projects, refer to Health Canada's report on Meeting the Needs of Youth-at-Risk in Canada: Learnings from a National Community Development Project

• Adult intermediary programs
  A wide variety of adults could be drawn in as messengers of the hepatitis C prevention message. Unfortunately, many lack the skills and knowledge necessary. Training programs for service providers in the health and social services sectors, involving and at least partially led by youth would help raise awareness and knowledge of street culture and hepatitis C. Such a program could be spread to tattoo artists, servers at coffee houses, hairdressers and others who interact with youth to bring the message to the wider street community.

5.3 Key Messages and Messengers

Messengers
Both youth and adults were identified as good messengers of the hepatitis C prevention message. Knowledge of the subject, an open and non-judgmental attitude, and confidentiality were cited as key characteristics of good messengers.

Given these attributes, youth clearly are more open to messages from other young people, particularly if these messengers are personally affected by hepatitis C. The credibility and transparency they bring to the issue are clearly assets.

Adults from a wide range of professions can be effective communicators. Youth counsellors and health professionals are obvious ones. Some relatively untapped sources of the prevention message are tattoo artists, extreme athletes and artists, who themselves have an alternative lifestyle. Adults who themselves come from a street culture also have credibility.

Teams involving youth and adults also appear to have a lot of merit, combining the approachability of another youth with the knowledge and experience of an open adult. Generally, youth said they would relate better to someone who approached the hepatitis issue C based on their personal experience rather than education alone. A combination of both was felt to be ideal.

Mass media
When asked about the best approaches to reach youth, they raised mass media outlets as being effective. Along with mainstream avenues such as posters, television and radio advertising, they suggested transit ads, in buses, bus shelters and on bench advertising as sites that would catch their attention.

Key messages
Beyond general information about hepatitis C and the risks of transmission, there was general consensus among the intermediaries and youth that the most important messages to relate to younger youth at risk (ages 12 to 16) are:

• the methods of transmission of hepatitis C, including drug injection and sharing of drug equipment, but particularly snorting and tattooing/piercing, as these methods appeared far less known;
• steps individuals can take to prevent its spread;
• the importance of testing; and,
• the effect that hepatitis C will have on a person's life.

The potential risk for hepatitis C to be transmitted through snorting equipment is almost completely unknown among youth, and should be a larger focus of attention. Most youth do not view snorting drugs as risky to their health in the way that injection drug use is.

Tattooing and piercing are frequent behaviours among youth at risk. Clear direction on what to look for and ask about at tattoo parlours was one element of the Filter video (YouthCo) that was very much appreciated by youth. Few print materials go into the explicit detail, including pictures, required for youth to safeguard themselves.

5.4 Support Resources Required

To recap the ideas presented above, the following resources are required to develop effective hepatitis C prevention programs for youth.

Materials
Although many good materials exist today, some areas remain unaddressed, including:

• the specific needs of younger youth; and,
• drinking, as a precursor to other risk behaviours.

In addition, the messages currently being circulated need to be reviewed for accuracy and consistency. For example, one new set of materials uses the slogan "Be aware if you share!" Messages must be clear on the fact that drug paraphernalia, razors, toothbrushes, etc., should never be shared. Being "aware" is not a strong enough message.

Training materials
A key approach being suggested in this report is a train-the-trainer method of preparing both youth and adult intermediaries to spread the hepatitis C prevention message. An effective screening tool to seek out appropriate candidates for training as youth intermediaries would be helpful to this effort. In addition, materials need to be sought out or developed that address:

• information on hepatitis C;
• facilitation methods and approaches;
• conflict resolution;
• suicide prevention; and,
• mental health issues.

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