National Hepatitis C Resource Manual 2nd Edition
Discrimination in the health care setting
In the health care setting, discrimination against people with hepatitis C can be subtle or overt. Best practice guidelines should determine the work practices and professional interactions of health care workers, and each individual worker should think about the circumstances in which discrimination might occur. As examples, hanging signs indicating infection status, or talking in public areas about a person’s infection or disease status is unacceptable.
Common examples of discrimination by health care and allied workers:
- refusal to provide pain relief to people with a history of drug use;
- overt or open accusations of ‘malingering’ or hypochondria to explain symptoms of fatigue;
- negative reactions to disclosure of current or past drug use – including an assumption of ongoing illegal behaviour;
- refusing to provide service on the basis of a person’s hepatitis C status or drug use;
- marking or ‘branding’ of people with hepatitis C in health settings (e.g. with coloured armbands or other tags);
- advice to terminate a pregnancy, or to discontinue breastfeeding even if no blood is present; and
- funeral workers refusing relatives permission to view the body of a deceased person who had hepatitis C.
Good clinical and health care practice means having a sound knowledge of hepatitis C and applying this to any discussion about a person’s current health status and their behaviours. It is important that service providers accept and monitor their own biases and personal attitudes, so that their behaviour does not have a negative impact on the person with whom they are working. This also allows the health care worker to concentrate on the person’s clinical needs, assess and respond to them effectively, and provide appropriate education.
Health care workers living with hepatitis C may also experience discrimination. Hepatitis councils and counsellors can offer assistance in deciding who to tell and how to handle questions and reactions. Health care workers with hepatitis C can continue to carry out roles and functions they can perform safely in their job. However, health care workers who perform exposure-prone procedures (EPPs) have a professional and ethical obligation to know their hepatitis C RNA status and, if positive, must not perform EPPs. The issue of relevance in employing health care workers is whether they can safely fulfil the requirements of the position without putting a patient at risk of infection with the hepatitis C virus during medical or dental procedures.
Health care workers, who have cleared the hepatitis C infection with or without treatment, should continue to monitor their HCV status. Refer to the National Hepatitis C Testing Policy and Infection Control Guidelines.
Discussing risk behavioursDiscussing both current and past behaviour requires a great deal of sensitivity. A greater understanding of hepatitis C-related issues enables health care
workers to answer questions and provide education on:
- transmission risks;
- social, physical and psychological effects of licit and illicit drug use;
- access to and the effectiveness of NSPs;
- access to and the effectiveness of treatments; and
- the broad range of issues that affect people with hepatitis C and those around them.
Both the health care worker and the individual may be uncomfortable with questions about alcohol and other drug use, and about behaviours associated with the risk of hepatitis C transmission. People from marginalised groups, including people who inject drugs, may fear that revealing current drug use will invite discrimination. Trust is an essential part of establishing an open and dynamic information exchange between the health care worker and the individual. Using exact, non-judgemental language (see below), combined with a sincere concern for the person’s welfare, helps to build trust in the health care relationship.
TerminologyAvoid using the following terms: addict, addiction, drug addict, drug abuse, drug abuser, junkie and intravenous drug user. Such terms may be offensive or misleading and could be considered as discriminatory. Instead, use the terms:
- injecting rather than intravenous (not all drugs are injected into a vein, e.g. steroids);
- drug use, not abuse;
- injecting equipment, not needles;
- presence of withdrawal symptoms and/or dependence, not about addiction;
- person who injects drugs, rather than injecting drug user; and
- clarify meaning of any colloquial and/or sub-cultural terms associated with drug use, such as fits, smack, sharing etc.
Questions useful in evaluating health care practice:
- does this action disclose the person’s hepatitis C status without their consent?
- do I need to know this to provide good care?
- is this part of standard infection control procedures?
- do I undertake this infection control procedure for everyone?
- do my questions or comments imply negative opinions about the person’s behaviour?
Strategies to reduce discrimination in the health setting
- Use standard infection control precautions with all people receiving care.
- Take care not to identify a person’s hepatitis C status by speaking about it publicly, or ‘branding’ them, their case notes or their bed with a coloured band, tag, label or any other identification.
- Be aware of and implement your service’s confidentiality policy.
- Acknowledge that pain relief for a current drug user of some substances may be complex as they may have a higher tolerance than others to pain medication e.g. opiates. Involve the care team and the person in nonjudgemental communication about current use and the level of dose required to achieve pain relief without overdosing.
- Be aware of the language used. Language carries all sorts of implicit messages.
- Work toward reducing harms and be careful to be non-judgemental when providing education to a person with hepatitis C.
- If you see discriminatory practice in your workplace, discuss the need for further staff education with your manager or the infection control consultant.
- Assume nothing about how a person may have acquired hepatitis C. Some people may not know themselves or they may have more than one risk factor which has contributed to their infection; others may not be able to identify any specific risks. Making assumptions can further stigmatise people.
- Consider whether knowing how a person contracted hepatitis C is at all relevant or important.