4.1 NSP access in general
4.2 Indigenous access
4.3 Types of NSP service
4.4 Other issues
4.5 Range of possible responses
4.6 Key recommendations

4.1 NSP access in general

In many ways the access barriers and enablers affecting Indigenous use of NSP services are naturally similar to those affecting all IDUs. Some of these broad generic issues are summarised below:
  • Barriers:
    • Limited hours of NSP operation
    • Limited geographical coverage/need for clients to travel
    • Negative staff attitudes (especially in some secondary outlets and pharmacies)
    • Visibility when using NSP services
    • Charges for equipment in some cases

  • Enablers:
    • Increased hours of operation, especially at night and at weekends
    • Increased trialling/use of vending or dispensing machines
    • Ongoing improvement in number/location of NSP outlets
    • Ongoing improvement in training and support for people providing NSP services
    • Location and layout of premises that offer privacy
    • Minimising charges
Longer hours of NSP operation, increased availability of vending machines in suitable locations, improvements in the geographical coverage of NSP outlets, improvements in layout and design that protect clients' privacy, minimisation of charges for injecting equipment, and ongoing training and support for people who deliver NSP services – all of these can be expected to improve access to NSP services for both Indigenous and non-Indigenous IDUs.
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4.2 Indigenous access

Beyond this there are specific issues which arise more often or more significantly for Indigenous IDUs. These reflect a range of background factors, such as the following:
  • Indigenous Australians tend to live in relatively small and close-knit communities – both in country and in city areas. This tends to make issues of privacy and anonymity especially significant for Indigenous IDUs.

  • This and earlier studies suggest that in Indigenous communities there is often a lack of awareness/acknowledgement of the reality of drug injecting.

  • Relatively large numbers of Indigenous Australians live in regional and rural areas where health and community services may be limited and where there may be few options for IDUs to obtain injecting equipment. Quality of service from pharmacies and secondary outlets in non-metropolitan areas is therefore one important element in effective access for indigenous IDUs.

  • Indigenous IDUs may perceive mainstream services – even specialist NSP outlets – as intimidating, racist, unwelcoming or simply unfamiliar.

  • Indigenous disadvantage, marginalisation, lack of resources and pessimism about the future may on the one hand be factors underlying the misuse of drugs, and on the other can be reflected in risky behaviour and disinclination to use NSP services.

  • The Indigenous population includes relatively high numbers of young and of mobile, transient or homeless people, among whom there is again the possibility of more risk-taking and less likelihood of accessing services.
While barriers of ignorance, fear and embarrassment may stand in the way of many IDUs accessing NSP outlets or other sources of clean injecting equipment, such barriers are likely to be especially significant for Indigenous IDUs because of their doubly marginalised status, their doubts about how mainstream services will receive them, and concerns about their drug use becoming public knowledge. In this situation many people may prefer to rely on obtaining equipment through friends or acquaintances.

One possible response to some of these issues is to locate more NSP services within appropriate Indigenous agencies or organisations – in particular in community controlled health services. However, there have in the past been difficulties with this approach both at the 'supply' and at the 'demand' end. As for supply, relatively few Aboriginal or Islander health services have to date been willing to offer NSP services. Various possible reasons for this have been discussed in earlier sections of the report (eg section 3.2.3), and can be summarised as follows:Top of page
  • injecting issues and hepatitis C tend to rank low on the crowded Indigenous health agenda and must compete for resources with many other concerns
  • the NSP harm reduction approach runs counter to the abstinence philosophies which are fairly common among Indigenous community leaders, including for example some ACCHS Board members
  • there has to date been little funding to support ACCHS provision of NSP services, and staff are not sufficiently trained in issues relating to drug injecting and hepatitis C
  • services for IDUs may be seen as difficult to offer in the 'family atmosphere' of an ACCHS
  • it may be thought that offering NSP services could have adverse impacts on medical services in terms of their relationships with neighbours, other community organisations etc
  • some medical services are concerned about what they see as possible legal implications of offering an NSP service.
By the same token, this (and earlier) research suggests there is reluctance among some Indigenous IDUs to access Indigenous-specific NSP services (eg at an ACCHS) because:
  • given the 'shame' or stigma associated with injecting drug use, they fear being recognised as injectors by staff or other clients who know them or their family (there may well be a cousin or auntie in the waiting room or behind the counter)
  • they are not confident that medical service staff will be knowledgeable about injecting issues, and fear that they may well be judgemental.
One result has been that the clients of NSPs based in Indigenous health services have typically included many – perhaps mostly – non-Indigenous clients.

Clearly there needs to be ongoing support for Indigenous-specific health services which are willing to provide an NSP service. However, attempting to persuade reluctant ACCHSs to participate directly in the NSP may not represent the best use of resources at this point. While there is broad agreement among stakeholders that workers in the Indigenous health sector should receive more information and education about hepatitis C issues and risks, such information and education should possibly focus on enabling them to play a positive role in providing accurate information and guidance for IDUs and making appropriate referrals to mainstream NSP services.

Given the complexities involved, promoting effective approaches within the Indigenous health sector to preventing and treating hepatitis C – including NSP services – is perhaps best seen as a medium-term goal. Also needed in the short term is a concerted effort to make sure that all mainstream services operate in an inclusive manner and are supported in facilitating access by diverse groups of Indigenous IDUs. This could mean a range of approaches involving, for example, closer liaison between the NSP and Indigenous health sectors at national, State and local level, training for mainstream NSP workers in cultural competence and safety, recruitment of Aboriginal staff in appropriate situations, seeking input on quality and appropriateness of services from Indigenous IDUs and other community members, display of 'Indigenous-friendly' posters, signs and the like, and further development of Indigenous-specific resources.
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4.3 Types of NSP service

This research indicates that Indigenous IDUs currently make use, to varying extents in different places, of the full range of NSP services and outlets available. However, it was frequently reported that they tend to be somewhat reluctant users of Emergency Departments and community pharmacies – essentially because they fear being treated poorly, made to feel embarrassed, or looked down upon. As noted above, there are also particular issues surrounding people's willingness to use NSPs located within Indigenous-specific services.

Broadly speaking the most acceptable kind of service is one which offers as much privacy as possible, where Indigenous clients can be confident of being treated in a courteous and helpful way, and where equipment is available free. Across the country there are numbers of primary and secondary services which meet these criteria to a reasonable degree. Ease of physical access is also important; mobile and outreach services of various kinds are valued both as facilitating access and as possibly offering greater privacy. Evening and weekend access are also regarded as highly desirable – but there are only limited numbers of high quality services which operate on this basis. Since they can offer both anonymity and extended hours of availability, vending or dispensing machines are another desirable element in a comprehensive range of services. Ensuring that IDUs have some choices or options open to them is a significant enabler.

4.4 Other issues

  • A key conclusion from this research is that high priority needs to be given to delivering more effective access to services for young Indigenous IDUs, who are widely regarded as an especially vulnerable and hard-to-reach group. Those consulted during the study frequently made the point that young people are generally unlikely to seek out services early in their injecting life, that their behaviour is often ill-informed and unsafe, and that by the time they are sufficiently well informed and confident to approach an NSP they may well be HCV positive already. There do not appear to be any simple ways of turning this situation around, but it is important that there be concerted efforts to inform and educate young people on issues relating to BBVs, the health risks associated with injecting and how to reduce these.

  • A range of youth strategies needs to be considered - for example development and dissemination of targeted resources (Streetwize comics could be one good precedent); information programs for high school students; work through both mainstream and Indigenous-specific youth services and organisations; and targeted youth projects such as the Hoops 4 Health project in Darwin. It appears that a peer-based service such as The Connection in Canberra can play an important role in engaging young IDUs and supporting safer behaviour and appropriate use of services. Given that young people may be initiated into drug injecting by older friends or relatives, and may rely on other people to obtain injecting equipment for them, there is also a need to consider how such peers or intermediaries can be encouraged more consistently to support safer behaviour among young and less experienced drug users.

  • Although community pharmacies are an important element in NSP coverage across Australia, this research suggests that some Indigenous IDUs are reluctant to use them. Pharmacies which already have links with Indigenous communities (eg as the usual prescriber for the local AMS) and which have significant numbers of indigenous customers should be encouraged to sell injecting equipment if they do not already do so.

  • People consulted during this study made the point that an agency or service provider which does not enjoy the confidence of Aboriginal people generally is not likely to represent a particularly useful service for Aboriginal IDUs. It was suggested that this is one reason why some Indigenous IDUs may be reluctant to seek injecting equipment from hospital Emergency Departments. In establishing new secondary NSP outlets, particular attention should be given to agencies/organisations which are already familiar to and well-regarded in the Indigenous community.

  • Past initiatives to facilitate Indigenous access have sometimes been limited by the short-term nature of their funding. These are long-term problems and finding solutions is likely to require adequate funding over a reasonable period of time.

  • There is a need for collection of more adequate and reliable information about Indigenous Australians' drug use and drug injecting – including, for example, surveillance of risk that may arise in remote locations.

  • This study points to a pressing need to address unsafe injecting in prisons and for implementation of relevant pre-release and post-release programs for Indigenous prisoners.
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4.5 Range of possible responses

The suggestions for improving access which emerged from this study were of several different kinds. Some focussed on fostering effective links or partnerships between NSP planners and providers and the community controlled health sector, so as to ensure that NSP services are more consistently informed by Indigenous perspectives and insights. Some related to NSP improvements or developments of a general kind, while others aimed to address barriers perceived as affecting Indigenous IDUs in particular. Some related to initiatives within Indigenous communities or Indigenous health services. Suggestions and proposals are summarised below.

Partnerships, strategy and advocacy

  • Further development of linkages between the Indigenous health sector (including NACCHO and its affiliates) and those responsible for planning and managing NSP services – in particular, State and Territory health departments.

  • More active advocacy for Indigenous community/IDU needs relating to blood borne viruses, and funding support for positions which will have this focus.

  • Stronger links between the Indigenous health sector and non-government organisations such as AIDS and Hepatitis Councils and with drug user support organisations, together with support of drug user organisations' work in responding to the needs of Indigenous IDUs.

  • NSP service providers building relationships with and seeking input and advice from local Indigenous groups and organisations, and also seeking ongoing feedback from Indigenous IDUs.

  • Research and education projects undertaken by bodies such as NACCHO involving Indigenous IDUs and the broader Indigenous community – for example, research on the needs of particular groups of Indigenous IDUs (eg women) or on improving services in regional and rural areas.

Role of Indigenous health services

  • Training and awareness raising for people in the Indigenous health workforce on BBVs in general and hepatitis C in particular.

  • Funding and support for community controlled health services which choose to offer NSP services.

Community information and education

  • Ongoing information/education for Indigenous communities on issues such as drug injecting, HIV, hepatitis C, harm reduction and NSP services, taking account of varying community attitudes and expectations.

  • Use of Indigenous radio programs to disseminate health messages on BBV issues and risk factors.

  • Use of this report in consultations on BBV and NSP issues with Indigenous communities.

Data and research

  • Continuing and improved surveillance of hepatitis C infection, including monitoring of the situation in remote communities.

  • Ongoing funding for research and data collection on the extent and nature of drug injecting among various Indigenous populations.
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NSP service improvements

  • Ongoing review of the location/distribution of NSP services, with the aim of increasing client options and with needs of Indigenous IDUs specifically taken into account.

  • Improved after-hours access to clean injecting equipment – including wider use or at least trialling of vending machines.

  • Increased use of appropriately staffed mobile or outreach services, with particular attention to the needs of Indigenous IDUs.

  • Ensuring flexibility in policy on the amount and type of equipment that NSPs can supply.

  • Training for mainstream NSP staff in cultural competence and safety, with Indigenous services or organisations being proactive in promoting or supporting such training.

  • Recruiting Indigenous workers and volunteers wherever appropriate, and exploring the possibility of making Indigenous-specific appointments designed to extend the reach of NSP services.

  • Increased emphasis on peer-based education for Indigenous IDUs, including support of existing NSP clients in playing a more consistent role in helping prevent HCV infection.

  • Supporting the development of more 'holistic' NSP services which may offer drop in facilities, primary health care or referrals etc.

  • Funding provision for enhanced NSP services in areas which are judged to have significant unmet need among Indigenous IDUs in particular.

  • Display of appropriate Indigenous symbols and materials (purpose-designed posters and notices, the Aboriginal and Torres Strait Islander flags, etc).

  • Facilitating access to NSP services by female clients – eg by ensuring that both male and female workers are employed.

  • Information and resources designed, in a consultative fashion, to communicate effectively with diverse groups of Indigenous IDUs, and to communicate messages that may be especially relevant for them.

Young people

  • Education on drug injecting, BBVs and harm reduction for secondary school students.

  • Enabling/resourcing youth services, and especially indigenous-specific youth services, to offer information and support around drug injecting, hepatitis C and harm reduction.

  • Information materials specifically designed to communicate with Indigenous youth, made available in a variety of ways including through print and other media targeting Indigenous young people.

  • Outreach projects, activities and events targeting Indigenous young people in particular.

The prison system

  • Co-ordinated efforts to develop and implement education, treatment and harm reduction programs within adult and juvenile detention facilities.

The prison system

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  • Co-ordinated efforts to develop and implement education, treatment and harm reduction programs within adult and juvenile detention facilities.

4.6 Key recommendations

  1. Both previous research and the present study (see eg section 2.2.1, section 2.2.2 and section 3.2.4) indicate that there are significant numbers of young Indigenous IDUs, that this group may be particularly hesitant to access NSP and related services, and that they represent a group at high risk of BBV infection. Therefore:

    In consultation with communities, the Australian, State and Territory Governments should give high priority to identifying effective ways of reducing rates of HCV infection among young Indigenous Australians, and implement policies, projects and practices designed to achieve this.

  2. There has in the past been only limited liaison and co-operation between the NSP sector and key agencies and organisations in Indigenous health. This has been reflected in limited Indigenous input in the development of NSP policies and services, and insufficient articulation of and advocacy for the needs of Indigenous IDUs (see eg section 2.2.8). In recent years, however, NACCHO and its State and Territory affiliates have been more actively involved in identifying and addressing HCV and drug injecting issues and challenges in Indigenous communities. Therefore:

    The Australian, State and Territory Health Departments should promote and support active co-operation between the Indigenous health sector and those responsible for planning and delivering NSP services, and in particular ongoing involvement by NACCHO and its affiliates in relevant research and policy development

  3. Given that relatively few Indigenous-specific health services have to date been ready to offer NSP services, plus the fact that many Indigenous IDUs may have reservations about using such services to obtain clean injecting equipment (see eg section 2.2.8 and section 3.2.3), mainstream services will for the foreseeable future remain the main source of supply for Indigenous IDUs. Therefore:

    At this stage improving access to mainstream NSP services represents the most effective way of facilitating access for Indigenous IDUs. This needs to be pursued both through general service improvements (eg continuing improvement in the number and location of NSP outlets, longer hours of operation including evenings and weekends, wider use of vending machines, offering IDUs some choice of services wherever possible, flexibility in amount and types of equipment offered), and also through initiatives designed to address the needs of Indigenous IDUs in particular. Policies and practices specifically addressing Indigenous access should include:

    • training in cultural competence and safety for mainstream NSP workers

    • consultation by NSP planners and service providers with relevant Indigenous organisations, Indigenous communities and Indigenous IDUs themselves

    • employment of Indigenous staff where this is considered appropriate

    • in planning and designing of NSP services, identification and consideration of factors relevant to Indigenous access in particular – for instance significant concentrations of Indigenous population

    • specific attention to minimising access barriers for Indigenous women

    • consideration of options for 'enhanced' NSP services in areas potentially serving significant numbers of Indigenous clients

    • expansion and improvement of NSP services in regional and rural areas in particular, including ongoing training for people providing services through secondary outlets and pharmacies

    • increased use of mobile and outreach services

    • increased use of peer-based approaches

    • continuing development and distribution of information and resources targeting various groups of Indigenous IDUs

    • use of posters, signs and the like which indicate that service providers are Indigenous-aware and Indigenous-friendly

    • making use of secondary NSP outlet sites and pharmacies which are already familiar to or well regarded in the indigenous community

    • use of Indigenous media, eg radio and print, to disseminate information about BBVs and NSP servicesTop of page

    • more secure funding for innovations, projects and pilot programs designed to address Indigenous needs.

  4. There are some community controlled health services which have played and continue to play a valuable role in delivering NSP services, and such work needs to be encouraged and supported. Indigenous-specific health services which may not wish to be directly involved in the providing NSP services can still contribute actively to addressing BBV issues among IDUs by providing relevant information, building closer relationships with mainstream NSP service providers, making referrals and the like. Therefore:

    Where Indigenous organisations are willing to deliver NSP services there should be continuing support and encouragement for them to do so; the possibility of offering some funding assistance for this purpose should be considered. Indigenous health services which do not wish to offer NSP services directly should be encouraged (for example through assistance with staff training) to play an ancillary role through liaison with NSP outlets in their area, providing information to clients and referring people to NSP services where appropriate.

  5. Indigenous IDUs, both male and female, are much more likely than non-Indigenous IDUs to be, or to have been, in prison; further, it is widely believed that unsafe injecting in prison is a significant factor in the spread of HCV (see eg section 2.1.2 and section 2.2.9). Therefore:

    DoHA and the State and Territory Health Departments should give high priority to research and policy initiatives designed to address the issue of unsafe drug injecting in adult and juvenile prisons .

  6. Effective long-term strategies for combating HCV infection among Indigenous Australians require engagement with and support from Indigenous communities themselves. Therefore:

    DoHA and the State and Territory Health Departments should make use of this report in undertaking consultation and information-sharing with Indigenous communities around the issues of blood-borne viruses, injecting drug use, and ways of reducing hepatitis C infection among Indigenous Australians.