A Drop in the Ocean - Hepatitis C amongst Chronic Disease in the Prison Population; Is Self Management Possible?

A drop in the ocean

• Hepatitis C amongst chronic disease in the prison

population, is self management possible?

Copyright © Hepatitis Victoria

Hepatitis Victoria

• Hepatitis Victoria is the peak not-for-profit community

organisation working across the state for people affected

by or at risk of viral hepatitis. We work to

• prevent the transmission of viral hepatitis,

• increase access and referral to quality viral hepatitis

information, care, treatment and support,

• Provide leadership and coordination for the

community response to viral hepatitis.


Hepatitis Victoria

• Hepatitis Infoline 1800 703 003

• Community participation

• State-wide Indigenous, Prisons and Young People Programs

• Training and education

• Campaign and Advocacy

• Good Liver Magazine

• www.hepvic.org.au - (03) 9380 464

– hepvic

• facebook.co loveyour.livervictoria

http://www.hepvic.org.au/

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Acknowledgments

• Louisa Walsh,

Hep C Take Control Program Coordinator

Hepatitis Victoria.

• Sexual Health & Viral Hepatitis Team ,

Prevention and Population Health Branch

Department of Health Victoria


Viral Hepatitis in Prisons

• Hepatitis C

• 35% of BBV prison entrants

• 43% Indigenous

• 33% non-Indigenous

• Hepatitis B core antibody positive (past exposure)

• 21% of BBV prison entrants

• 42% Indigenous

• 17% non-Indigenous


History of the Prisons Program

• 2001 – originally funded as the ‘Prisons Project’ through

Commonwealth HCEPI

• Original work focused on new prison entrants and staff

• Developed a focus on training with prison peers

• Four major prisoner led projects- for prisoners, by

prisoners

• Ongoing involvement in pre-release education programs

• Ongoing involvement in staff training.


Chronic disease in prison inmates

• 25% of prison entrants self-report that they have a current

chronic medical condition (Australian Institute of Health and Welfare, The Health of

Australia’s Prisoners 2009

• Cardio Vascular disease within the 35 to 44 age bracket

for prisoners is at twice the rate of the general population

at 4% compared to 2%.

• Diabetes

• 2% of prisoners in the 25- 34 age bracket compared with

the general population 0.5%.

• 5% of prisoners in the 35- 45 year age group living with

diabetes compared to 2% of the rest of the population.


Health behaviours amongst prisoners

• Smoking

– female (78%) , male (74%) entrants were daily smokers

• Alcohol & Other Drugs Overall, 55%

– 3 in 5 (58%) prison entrants reported consuming alcohol at

hazardous levels during the 12 months prior to prison entry

– two-thirds (66%) reported illicit drug use in the previous 12

months

• 740 prison entrants of the NPEBBV&RBS had ever injected

drugs

– one in five (20%) had re-used someone else’s used needle

or syringe, and 15% had shared injecting equipment with

one or more persons.


Heart disease and Hepatitis C

• Proposed link between poor health behaviours and

physiological causes of people living with hepatitis C and

liver damage or the increased risk of developing cardio-

vascular disease. Hepatitis C Virus Infection and the Risk of Coronary Disease

• Physiological causes via the role of cytokines, which are

markers of inflammation.

• Cytokines are regulators of host responses to infection,

immune responses, inflammation, and trauma.

• Pro-inflammatory cytokines can affect other areas of the

body, increasing a person’s likelihood of developing

rheumatoid arthritis, fibromyalgia and cardio vascular

diseases.


Diabetes and Hepatitis C

• Diabetes 2% of prisoners in the 25- 34 age bracket have

diabetes, compared with the general population of the

same age group having just 0.5%.

• Older prisoners- 5% of prisoners in the 35- 45 year age

group living with diabetes compared to 2% of the rest of

the population.

• a family history of type 2 diabetes increases susceptibility

of developing diabetes, or onset at earlier age.

• 1. An insulin-resistant liver, commonly due to fatty

deposits in the liver produces unwanted glucose.

• 2. Insulin-resistant muscle does not absorb insulin from the

bloodstream, leading to high levels of sugar in the blood.


Hep C: Take Control Project

• Hepatitis C-specific chronic disease self management program:

– 6 week group program

– Incorporating hepatitis C-specific health education and goal

setting/behaviour change intervention.

– Pilot project in 2009/10

– Now core business of Hepatitis Victoria

– Currently working with community-based integrated hepatitis

C nurses to target harder-to-reach, more marginalised,

clients.


Hep C: Take Control Results

• More than 60 people have been through the course.

• Show improvements in all health areas required for self

management as measured by the hei-Q, but especially,

problem solving, negotiating the health system and social

integration and support.

• Areas of self-identified health priorities – stress and worry,

managing to work, diet, exercise, quitting smoking, fatigue.


What is chronic disease self management?

• Self management involves the individual with the chronic

condition working in partnership with their carers and

health professionals so that they can:

1. Know their condition and various treatment options;

2. Negotiate a plan of care and review/monitor the plan;

3. Engage in activities that protect and promote health;

4. Monitor and manage the symptoms and signs of the

condition; and

5. Manage the impact of the condition on physical functioning,

emotions and interpersonal relationships.

Flinders University 2006


CDSM does not…

• Mean self treatment.

• Discourage visits to the doctor or other health

professionals.

• Increase the risk of becoming unwell.

• Threaten health professionals’ role or expertise.

• Reduce the cost of care through reduction in services.


CDSM benefits

• Better clinical outcomes.

• Improved health and QOL.

• Reduced ‘crisis’ medical intervention (unplanned GP visits,

emergency presentations, hospital admissions).

• Increased self efficacy.

• Increased client satisfaction with service.

• Increased job satisfaction for workers.


Hep C: Take Control Course Outline

• 6 week course, 2 hours per week

– Week 1: Introduction

– Week 2: Diet and Exercise

– Week 3: Sleep, Fatigue, Alcohol and other Drugs

– Week 4: Thoughts and Emotions

– Week 5: Disclosure, Stigma and Support

– Week 6: Treatment and The Future


Week 1: Introduction & the Virus & it’s Effects

• Myth busting

• Gives an opportunity for participants to express their

knowledge

• Opportunity for facilitators to clear up misinformation or

confusion of messages, explain how to find information

• What is self management?

• Gives participants a clear understanding of course content.

• Facilitator can gauge responses


Week 2: Diet and Exercise

• SMART Goals- adapt to group discussion (resistance?)

• Diet options differ and have limitations for prison to prison.

• Participants to discuss limitations, challenges (what will

make success difficult?)

» Inappropriate equipment/exercise for gender,

age.

• Opportunity for participants to explore what changes they

could make, be it very small. (what will help you succeed?)

» Regular meals, canteen choices

» access to gym and sporting equipment


Week 3: Sleep, Fatigue, Alcohol and Other Drugs

• Sleep & fatigue

• May be affected by medications & high stress rates

amongst prisoners (medications, pharmacotherapy's,

depression, anxiety)

• Participants to explore how to manage this.

• Alcohol and other drugs

• Smoking, reduction, cessation

– (83% being current smokers, and almost three-

quarters (74%) daily smokers

• Returning to alcohol & other drugs on release.

– goal setting, looking at past successes, failures


Week 4: Thoughts and Emotions

• Cycle of depression and anxiety (In 2010, 31% of prison entrants

reported having ever been told that they had a mental health illness)

– Chronic illness, Stigma relating to hepatitis C,

Managing depression

• Change your thinking style! Helpful & unhelpful thinking

– basic cognitive therapy exercise (may encounter

some resistance)

• Rewards! (??) How do you give yourself a reward in a place of

punishment?!

• Lapse & relapse

– re-evaluating strategies, recognising what works


Week 5: Disclosure, Stigma and Support

• Disclosure- What and when to disclose, who and how?

– Prisoners often are used to disclosing information to

those in authority, often not realising their rights

– Often believe they should know others status.

• Have you ever experienced stigma or discrimination

because of HCV? What action can you take?

• Circles of support

– Who?

– When?

– How?


Week 6: Treatment and The Future

• Self esteem activity (positive attributes, everyone has

them!)

• Treatment options

• Where to from here? Options for ongoing support after

course

– Prison peer educators, medical, friends, each other!

• On release

• Hepatitis Victoria (Info line, Support Group) counselling,

family, friends, partners

• Review current goals

– Encourage setting a goal for the next 2 months.


Foreseeable challenges

• Choices limited when it comes to diet and preferred

exercise regimes

• Women in particular find themselves less active and prone

to weight gain while inside- more gender and age

appropriate activities needed

• Limited access to prevention and harm reduction if

engaging in injecting drug use while incarcerated.


Foreseeable benefits

• Access to health services, exercise facilities and regular

meals in prison

• A break from behaviours on the outside that are harmful to

health

• May complement other, current prison programs around

behaviour change and life skills

• Goals and direction of course are participant led, so gives

a certain amount of control


Conclusion

• Could be adapted for other health conditions

• Has ‘in principle’ approval from Justice Health Victoria

• Would require comprehensive evaluation

• Past courses have been externally evaluated, therefore

comparable to other environments and target groups.

• Should and could cover chronic hepatitis B

Health & Medicine

A Drop in the Ocean - Hepatitis C amongst Chronic Disease in the Prison Population; Is Self Management Possible?