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Chopped Liver is a 50 minute black comedy written by Kamarra Bell-Wykes and produced by Ilbijerri Aboriginal and Torres Strait Islander Theatre Cooperative in Victoria. The play discusses key issues related to hepatitis C and its impacts on those affected, as told through the stories of two Aboriginal people. The play contains relevant, factual information about hepatitis C. NSW Health funded the play to tour NSW Aboriginal communities for five weeks in June – July 2008.

A partnership between NSW Health (AIDS & Infectious Diseases Branch), the Aboriginal Health & Medical Research Council of NSW (AH&MRC), the Hepatitis C Council of NSW (HCC), the State-wide Aboriginal Sexual Health Worker Network (ASHWN) and the Ilbijerri Aboriginal and Torres Strait Islander Theatre Cooperative (Ilbijerri) was formed to promote and support the tour, as well as provide workforce development opportunities for Aboriginal Sexual Health Workers on hepatitis C.

The play drew an audience of more than 1300 people from 28 Aboriginal communities. The tour was organised and promoted locally by the collaborative efforts of state wide services, locally based Aboriginal Sexual Health Workers, Aboriginal Community Controlled Health Services, Area Health Service staff (particularly those in the sexual health and blood borne viruses) and locally based non government organisations.

The framework for hepatitis C interventions targeting NSW Aboriginal communities is detailed in the NSW Hepatitis C Strategy 2007-2009 and the NSW HIV/AIDS, Sexually Transmissible Infections and Hepatitis C Strategies: Implementation Plan for Aboriginal People 2006-2009.

In particular, the strategies identify the following priority focus areas:

• Increasing Aboriginal community engagement with hepatitis C and related programs.
• Decreasing stigma associated with injecting drug use and related issues including harm reduction.
• Increasing access to hepatitis C and related services by Aboriginal people.
• Strengthening the hepatitis C work undertaken by Aboriginal sexual health workers.

The key objectives of the NSW 'Chopped Liver' tour were to:

• Raise awareness of hepatitis C and related issues in Aboriginal communities in NSW.
• Improve awareness about hepatitis C prevention, transmission, testing, treatment and care in Aboriginal communities in NSW.
• Deliver messages and create opportunities for discussion in culturally appropriate ways in community settings.
• Strengthen the response to hepatitis C and related issues within communities through the development of relationships between Aboriginal health organisations, community members, other health organisations and hepatitis C organisations.
• Strengthen the hepatitis C and related work undertaken by Aboriginal sexual health workers.

The project's performance indicators were:

• Project reference group supported and meets at a minimum three times during the life of the project.
• A minimum of fifteen NSW Aboriginal communities visited by the tour.
• A minimum of fifteen people attend each performance.
• State and local stakeholders involved in the implementation of the project.
• Evaluation demonstrates significant improvement among target group of hepatitis C and related knowledge measures, including in relation to prevention, testing and service availability.
• Evaluation demonstrates significant capacity enhancement of the Aboriginal sexual health workers in relation to hepatitis C and related work undertaken by them.

The project was evaluated by independent consultants.

Hepatitis C is a blood borne virus, transmitted through blood to blood contact. The main risk factors for hepatitis C transmission in Australia is through the sharing of injecting drug equipment, and unsafe tattooing and body piercing practices particularly in prison. In fact, being in prison is an independent risk factor for hepatitis C.

There is currently limited data on the prevalence of hepatitis C in Aboriginal communities in NSW. In states and territories where data is available (South Australia, Northern Territory and Western Australia), hepatitis C rates are twice that of non Aboriginal population (Dept Health & Ageing 2005). The data from these jurisdictions also shows that hepatitis C notifications for non-Aboriginal people are decreasing, while there appears to be an increasing trend for Aboriginal notifications.

Nationally, it is estimated that there are 264,000 people who have been exposed to the hepatitis C virus (Estimates and Projections Working Group 2006), with approximate 40% of the burden of disease occurring in NSW (NCHECR 2008). The Hepatitis C Estimates and Projections working group estimated that there were 22,000 Aboriginal and Torres Strait Islander people exposed to the hepatitis C virus, and 16,000 Aboriginal and Torres Strait Islander people living with chronic hepatitis C (Dept of Health & Ageing 2005). This is approximately 8% of all people living with hepatitis C in Australia, and is a significant over-representation, as Aboriginal people comprise just 2.4% of the total Australian population (ABS 2001).

It is likely that Aboriginal people are over represented in the estimates of hepatitis C cases because of particular population characteristics and transmission risk factors. These include:

• a higher proportion of young people compared with the broader population,
• significantly higher levels of incarceration, compared with the non Aboriginal population,
• the mobility of the Aboriginal population, and less access to health services in general,
• the level of knowledge of hepatitis C within the Aboriginal community, and
• the increase in injecting drug use and its associated risks and harms.

Data from the National Needle and Syringe Program Survey shows that Aboriginal participation in NSW ranged from 12 -16% during the period 2003-2007 (NCHECR 2008). The survey also found that there is a more sharing of injecting equipment amongst the Aboriginal participants, compared to the non Aboriginal participants. Nationally, hepatitis C antibody prevalence in the survey is slightly higher amongst Aboriginal participants. For example in 2007, 74% for Aboriginal participants had hepatitis C antibodies compared to 69% for non Aboriginal participants (NCHECR 2008).

Small surveys have highlighted some of the injecting drug issues for Aboriginal communities. For example, a small study in Western Australia showed that injecting had increased by 50% or more in Aboriginal communities over a 7 year period (Curtin University 2002). Another study in Victorian found almost every family in a Melbourne Aboriginal community was affected by IDU (Lehmann & Frances 1998).

Being in prison is an independent risk factor for acquiring hepatitis C. The NSW Inmate Health Survey (Butler & Milner 2001) found that rates of hepatitis C are 40% amongst adult men, and 65% amongst adult women. This compares to about 1% hepatitis C rates in the general Australian community. Hepatitis C antibody prevalence was also higher among participants reporting imprisonment in preceding year in the annual NSP survey (NCHECR 2008).

Aboriginal people are incarcerated at much higher rates compared to non Aboriginal people.  In NSW in 2007, 21% of all adult inmates identified as Aboriginal (Dept Corrective Services 2008). Aboriginal people in prison are also younger, more likely to have prior adult imprisonment, are more likely to be imprisoned for shorter periods and more often, therefore increasing potential exposure to hepatitis C. Many Aboriginal people in prison may be exposed to injecting drug use for the first time, and can potentially return to their communities with the virus.

While it has taken some time for a clear picture to emerge, it is evident that hepatitis C is an issue worthy of considerable concern for Aboriginal and Torres Strait Islander communities across Australia. Chopped Liver was originally developed in 2005 by Ilbijerri, the Victorian Department of Human Services, the Victorian Aboriginal Community Controlled Health Organisation, and the Hepatitis C Council of Victoria, to address some of the issues outlined by the epidemiology. The play has since gone on to tour communities and prisons in Victoria, South Australia, Western Australia, Tasmania and NSW.

Ilbijerri is an Aboriginal community controlled organisation with a long history of providing Aboriginal theatre to Aboriginal people. Chopped Liver was written, directed and acted by Aboriginal people. Told through the stories of Lynne and Jim, the play discusses issues related to hepatitis C transmission, treatment and care. One of the characters contracts hepatitis C through a prison tattoo, the other through injecting drug use. In addition to the health impact, the play also raises the social and emotional impact of living with hepatitis C.

The AH&MRC learnt of the success of the play through networks with the Victorian Aboriginal Community Controlled Health Organisation in early 2007, and invited Ilbijerri and the Hepatitis C Council of Victoria to talk to a NSW audience at a workshop hosted by the Consortium for Social Policy Research on HIV, Hepatitis C and Related Diseases.

NSW Health, in consultation with the AH&MRC, the state-wide Aboriginal Sexual Health Worker Network Coordinators, and the Hepatitis C Council of NSW, then invited Ilbijerri to perform Chopped Liver at the Aboriginal Sexual Health Workers Network meeting at Coffs Harbour in October 2007. The audience consisted of approximately 25 Aboriginal Sexual Health Workers (ASHWs), as well as well as staff from the key agencies, the NSW Department of Health, and the Chair of the Aboriginal Sexual Health Advisory Committee. The CEO of Bulgarr Ngaru Aboriginal Medical Service also attended the performance.

After the play, the audience participated in a workshop to discuss the appropriateness of the play for NSW Aboriginal communities. The participants agreed that the play would be an effective tool for the implementation of hepatitis C strategies for NSW Aboriginal communities, and their feedback on what additional strategies could be used to ensure the success of a Chopped Liver were incorporated into the project planning. One of the strategies identified was providing opportunities for a post performance discussion between workers in the area of hepatitis C, and community members.

Once it had been agreed that the play was relevant for Aboriginal communities in NSW, a Reference Group was formed to oversee both the project.  The Reference Group was made up of members from the AH&MRC, Aboriginal Sexual Health Worker (ASHW) representatives, the two state-wide ASHW Network Coordinators, the Hepatitis C Council of NSW, the Chair of the NSW Aboriginal Sexual Health Advisory Committee (ASHAC), a HIV and Related Programs Manager (HARPM) from an Area Health Service, the NSW Department of Health (AIDS and Infectious Diseases Branch), and Ilbijerri.

Prior to funding the tour, NSW Health approached the AH&MRC Board of Directors for their endorsement and participation on the Reference Group.

The Project Reference Group met 3 times over the duration of the Chopped Liver program development, and had input into the site selection, promotion of the tour, and liaising with their relevant networks, workforce opportunities for the AHSWN and the participated in the final evaluation.

The selection criteria for the locations invited to host the play included:

• High Aboriginal population,
• At least one performance in each of the AH&MRC regional areas,
• Locally available Aboriginal Community Controlled Health Service or other health infrastructure where hepatitis C health care is available,
• Feasibility of travel to venues given time and distance limitations.

Key stakeholders in Area Health Services and the Aboriginal Community Controlled Health Sector were kept informed of the process via NSW Health, the AH&MRC and the Hepatitis C Council.

To address the key objective to 'Strengthen the hepatitis C and related work undertaken by Aboriginal Sexual Health Workers', the AH&MRC, the state-wide ASHW Network Coordinators and the Hepatitis C Council, provided training and support for Aboriginal Sexual Health Workers to better respond to the needs of people in their communities in relation to hepatitis C transmission, prevention, testing and treatment.

The Chopped Liver tour ran from 17th June to 17th July 2009. Table 1 lists the venues and dates of the performances.

Table 1: Performance Schedule

For the majority of the performances, Aboriginal Sexual Health Workers were identified as the local contact person. In places where ASHWs are not located, local contacts were identified within the Aboriginal Community Controlled Health Service or Area Health Services. The local contact was responsible for booking the venue, organising Welcome To Country speakers, provide morning or afternoon tea, and promoting the play amongst local Aboriginal organisations and communities. Costs were funded by NSW Health HIV and Related Programs.

The show has been devised specifically to be performed in non-theatre spaces. Local contacts were encouraged to select venues that were culturally appropriate and easily accessible for the community. Shows were presented in a wide range of settings, including ACCHSs meeting spaces, churches, performing arts centres, youth centres and RSLs.

Post – performance morning or afternoon tea was organised as part of the tour to provide an opportunity for actors, ASHWs, Hepatitis C Council workers and Aboriginal community members to discuss issues highlighted by the play. Workers were introduced at the beginning of the performance and audience members were invited to talk to workers at the end of the play. Aboriginal specific and mainstream resources about hepatitis C were available for audience members to take away.

The play was promoted through NSW Health and the Area Health Services, through the AH&MRC and the ACCHSs, and through the Hepatitis C Council networks. Local workers were provided posters of the play to distribute amongst key organisations. Some local workers advertised the play on radio stations and in local newspapers, but the most effective method was via word of mouth and where local workers had arranged transport for community members to attend the performance.

Training and support of the ASHWN was provided prior to the 'Chopped Liver' tour.

A two day professional development training program on blood borne viruses was organised by the ASHWN coordinators, AH&MRC and the Hepatitis C Council of NSW. The workshop was funded by the Australasian Society for HIV Medicine (ASHM), and 25 Aboriginal Sexual Health Workers attended. The topics covered included an update from Ilbijerri, Hepatitis C pre and post -test discussion, Testing for hepatitis C, Living with Hepatitis C: C-een & Heard Speaker, Hepatitis C: drug & alcohol, mental health, prison, Basic treatment for hepatitis C, Supporting and Managing patients on treatment, and Preparing for 'Chopped Liver'. The program included panel discussions, case studies, interactive activities and lectures from specialists.

In addition to the two day training, the AH&MRC held 11 full-day workshops on the resource "Dr BBV" – an interactive game about blood borne viruses for young Aboriginal people. Game workshops were hosted by the ACCHSs and generally co-facilitated with a local ASHW. A shorter training session was also held for Justice Health adolescent workers. The aims of the "Dr BBV" workshops were to:

• Enhance workers understanding of blood borne virus transmission, prevention and treatment.
• Enhance workers understanding of blood borne virus epidemiology in Aboriginal communities.
• Teach workers to play the game & have confidence to facilitate with a group.
• Promote the upcoming Chopped Liver tour.

During the lead up to the tour, the Hepatitis C Council also provided rural education sessions. The Council ensured that resources about hepatitis C were distributed to all communities where the play was touring, prior to the commencement of the tour. The Council also developed and distributed a resource that had local referral information, including specialist hepatitis C services and Aboriginal Community Controlled Health Service information.

AH&MRC workers, Hepatitis C Council workers and the state-wide ASHWN coordinators supported local workers by touring with the play, and being available for discussing any issues that audience members had post-performance.

The local contacts, primarily the Aboriginal Sexual Health Workers, used a variety of strategies to implement the tour locally. Some ASHWs organised transport for community members to attend the performance, invited schools to attend, organised Aboriginal people from Drug and Alcohol services to attend, promoted the play on local radio and local newspapers, liaised with other Aboriginal organisations and workers, promoted the play at interagencies, PCYC, youth centres, organised men's and women's groups and Aboriginal elders to attend, organised Welcome to Country speakers and invited friends and family.

NSW Health, in consultation with the reference group, evaluated the 'Chopped Liver' tour to determine:

• Whether the tour model is a successful mechanism for creating dialogue about hepatitis C among Aboriginal people.
• The extent to which the tour influences hepatitis C service engagement in tour locations.
• The impact of the tour and associated activities on Aboriginal Sexual Health Workers' awareness and understanding of hepatitis C prevention, transmission, testing and treatment, and their confidence to talk to people in their communities about hepatitis C.
• The extent to which the tour involves a range of relevant Aboriginal health organisations.
• Whether the tour is a culturally appropriate way of providing information about hepatitis C.
• Whether the project meets its performance indicators in relation to the number of communities visited and the number of people that attended each performance.

The Cultural and Indigenous Research Centre Australia (CIRCA) were engaged to conduct the evaluation.

Table 2 details the methodology used to evaluate the NSW 'Chopped Liver' tour and supporting initiatives.

Table 2: Methodology for evaluation

While it would have been ideal to also consult with community members that attended the play, this was not possible due to time restrictions and ethics committee requirements. A further limitation of the evaluation was that it did not capture the experiences of services without an ASHW and other stakeholders such as HIV and Related Programs (HARP) and ACCHS management that were involved in varying ways with the tour.

The evaluation examined each of the Performance indicators and made recommendations for if a second tour was to be considered in NSW. A summary of the findings are provided below.

Table 3: Summary of findings from evaluation of 'Chopped Liver' NSW Tour

The evaluation found that audience members and workers judged the play to be an effective and culturally appropriate way to discuss health issues. Feedback from the comments book which travelled with the play demonstrated that the audience could relate to the use of story telling, and the use of Aboriginal actors and script. Almost 400 people made comments in the book, which is about one-third of the audience, and in itself this is a positive indicator that people were engaged by the performance. The use of humor was highly regarded and seen as effective for engaging target groups including young people, and for addressing stigma.

The overwhelmingly positive feedback suggests that the play was an effective, non confrontational and culturally appropriate way to communicate health messages. ASHW observations of audience reactions also reinforced that the play was well received and that audiences were engaged. Workers commented that people "laughed the whole way through" and that people were so focused on the play that you could "hear a pin drop".

"Watching the responses of the audience, it did have an impact…The elders of the Aboriginal community were appreciative of the play and took information for their community and said this knowledge will be shared and discussed in their community." (Local stakeholder, health worker)

The main reasons the play was felt to be culturally appropriate were: the use of story telling as a culturally appropriate medium; the use of humour as an effective way to reach Aboriginal audiences and youth; and the use of Aboriginal actors and script.

The use of theatre was seen as a strong cultural fit with Aboriginal learning because it provided 'experiential' learning, was not text based and was fun and enjoyable. Feedback highlights that the use of story telling and theatre was an effective way of delivering a message.

"Great skit, this is the way to get the message across to our people as it was how it was done for thousands of years and we understand it better than in a book or pamphlet. We rode the highs and the lows, saw the visions and the dreams. The actors were fabulous they took us on the journey and we could see the scene in our minds. The manuscript was perfect, relating to our people like no other medium." (Comments book) 

The comparison between written media and theatre was reinforced by another audience member.

"Powerful stuff! Worth more than a million pamphlets." (Comments book)

Humour was seen as a particularly effective tool for engaging young people, who workers felt were often the hardest group to engage. "They actually stayed and listened." Humour was also seen as an effective way for addressing stigma and 'shame'.

"It tackled something that makes a lot of people say, 'I'm shame - I'm not clean.'" (ASHW)
"It pulled down the shame and the mystery…and it did it very powerfully." (ASHW)

Audience members appreciated that the play was acted by Aboriginal actors and that it was clearly written by Aboriginal people.

"[It's] great to see Koori actors" (Comments book).

Comments by workers that the play was "down to earth" and something Aboriginal people "could relate to" demonstrate the appropriateness. Some people felt that the political references in the play added to its cultural appropriateness and felt it showed the play was written by Aboriginal people.

"I could certainly relate to the lingo. You do blackfellas proud." (Comments book).

Many people commented that they felt the use of theatre was so effective that it should be used to educate about other health issues such as diabetes, HIV etc.

"Deadly. We need more of these performances about other diseases. This is a great educational tool." (Comments book)

Department of Health & Ageing, National Aboriginal and Torres Strait Islander Sexual Health and Blood Borne Virus Strategy 2005 – 2008. Commonwealth of Australia, Canberra 2005

Ministerial Advisory Committee on AIDS, Sexual Health and Hepatitis C Working Group, Hepatitis C Projections Working Group: Estimates and Projections of the Hepatitis C Virus epidemic in Australia 2006, The University of NSW, Sydney

National Centre for HIV Epidemiology and Clinical Research. HIV/AIDS, viral hepatitis and sexually transmissible infections in Australia, Annual Surveillance Report. National Centre for HIV Epidemiology and Clinical Research, The University of NSW, Sydney

Australian Bureau of Statistics, 2001 Census, ABS, Canberra.

Butler T, Milner C. The 2001 NSW Inmate Health Survey 2001. Corrections Health Service. Sydney

Department of Corrective Services, 2007/2008 NSW Department of Corrective Services Annual Report. Department of Corrective Services, Sydney.

Aboriginal Health & Medical Research Council
Phone: 02 9212 4777