The outline of incentive amounts is a guide. Some sites have changed these amounts to suit the local conditions. For example, some sites have provided $20 for screening, results and 3rd hepatitis B vaccination ($10 more than other sites), and $10 for each person a client recruits to the Deadly Liver Mob program ($10 less than other sites). This is because sexual health is not directly co-located and a greater incentive may be required for participants to screen and return for results, especially where significant travel is required.

The distance that clients need to travel to access DLM sites is important particularly for non-metropolitan sites. Some clinics provide transport within the local area. However, return to the clinic for results may require round trips of hundreds of kilometres. Flexibility in providing results such as over the phone (and holding vouchers for when the client next returns) or the use of outreach or mobile services may be required. Of course, all activities must be in line with the policies of the health service.

In other areas, parking at the Deadly Liver Mob site was identified as a barrier to the program as potential clients were not able to stay in the site for the time required for education and testing. Trouble shooting is required in the local area to find alternatives to support participation in the program.

Fixed sites for Deadly Liver Mob need to be carefully considered as some Aboriginal clients will not attend specific areas if, for example, a program site is situated where there are family or community rivalries or conflicts, or because of ‘shame’ or embarrassment. The use of ‘liver’ in Deadly Liver Mob was a specific choice to ensure that the program did not attract negative reaction.

Some sites were required to interrupt or delay the Deadly Liver Mob program because of priorities in the community, such as Sorry Business. These community priorities must be respected. These disruptions to Deadly Liver Mob programming can be noted and examined when evaluating the impact of the program.

Several Deadly Liver Mob sites conducted outreach to a range of services. These sites noted the limitations of encouraging people to come to a fixed site. Outreach Deadly Liver Mob sites allowed the program to contact potential clients in sites where they already access services. In doing outreach, Deadly Liver Mob programs need to organise the ways in which the aspects of the program (including testing and medical records for sexual health services) will be managed.  The provision of incentives may be sensitive at the host service, so consultation around this issue needs to occur early.

Further, if travel is required (particularly in non-metropolitan areas) for outreach work, this may mean that Deadly Liver Mob workers have less time to complete administration and other tasks associated with the program and other aspects of their work.

Some sites have provided Deadly Liver Mob at one-off events (festivals and community gatherings).

Newer testing technologies may assist when it is difficult to organise clinical services. For example, dried blood spot testing for HIV and hepatitis C is available in NSW. However, this test does not include STI, hepatitis B or liver function tests. Similarly, point of care machines are available in some sites, but only hepatitis C RNA will be assessed. At present these tests are not available for general use. Advances in this field should be monitored to ensure that clients of Deadly Liver Mob are able to access the most convenient services.

Some sites had difficulty covering the increased costs associated with pathology tests. For example, Needle and Syringe Programs may not be provided with budgets for clinical services, or sexual health services do not include full hepatitis C testing (including RNA tests) as part of their core work. This remains a challenge in some settings. Early discussion of these issues in setting up Deadly Liver Mob programs is required. Further, jurisdictional health services can support the program by ensuring that sexual health strategies are inclusive of hepatitis C testing and treatment as core business.

The vouchers typically used in the Deadly Liver Mob program are for major supermarket chains and have restrictions for the purchase of alcohol and tobacco in line with health authority policy. It is up to new sites to decide if restrictions for the purchase of alcohol and tobacco are required.

In some sites, there are no major supermarkets. Vouchers for local vendors can be purchased. Negotiations with vendors will be required if restrictions are required to exclude the purchase of alcohol and tobacco.

There may be varying levels of support for providing incentives for the Deadly Liver Mob program. Indeed, interviews with staff involved in the program showed some strong and negative attitudes towards incentives, at least initially. We have summarised the evidence regarding the benefit of incentives particularly for marginalised communities. It may be worth taking time to explain this to all staff involved in the program.

The Deadly Liver Mob program needs to re-contact participants to provide results of tests if participants do not return. Program workers used a variety of ways to keep connected including: phone number (of the client and others close to them), email, Facebook messaging and contact via other services. All of these contact mechanisms need to be in line with privacy regulations and with the client’s consent.

Most Deadly Liver Mob sites showed an initial spike in the number of Aboriginal clients attending the program. This is an exciting and motivating response to the program. However, such increased rates of participation cannot be maintained over time. It is important to manage expectations of program sponsors so that any subsequent drop in numbers of clients is not seen as a program failure. As shown in the section on program evaluation, participation of Aboriginal clients is not stable across time but is significantly higher than baseline (that is, prior to the Deadly Liver Mob program starting).

In most cases, the Deadly Liver Mob program required the participation of Needle and Syringe Program (NSP) and sexual health services. In some health districts, these services were managed by the same area and were even co-located, hence coordination of support was managed within that group. In areas where NSP and sexual health services are managed by different groups, early consultation is required to bring each group into the program with an understanding of how it operates, the expectations of each service and the benefit that the Deadly Liver Mob program can provide to the community and to the operations of each service.

The Deadly Liver Mob sites have developed a range of ways to support clients to engage with hepatitis C treatment. Some Needle and Syringe Program sites offer hepatitis C treatment on-site. Some sexual health physicians are prescribers of hepatitis C treatments.  Referral to off-site services (especially general practitioners) was described as least effective, as co-located services were most effective in connecting clients to care. Developing the treatment pathway should be a key aspect of developing a Deadly Liver Mob program. As changes in hepatitis C treatment continue, the Deadly Liver Mob program will need to change and evolve to keep step.

Staffing composition is important for the success of a scaled-up program. The Deadly Liver Mob team should be a mix of Aboriginal and non-Aboriginal people, though the primary front-line worker must be Aboriginal.

Staff may witness first-hand clients’ disadvantage and trauma, putting workers at risk of burn-out. The mental and physical health of workers requires monitoring and supporting through debriefing programs and ongoing primary care. Most mainstream health workplaces require mandatory training in Aboriginal cultural awareness. In addition to this, it is helpful if non-Aboriginal staff can attend programs to familiarise workers with the social disadvantage faced by Aboriginal communities and the impact that disadvantage has on clients’ health.