HIV Australia | Vol. 11 No. 3 | October 2013
By James Ward, Joanne Bryant, Heather Worth, John Kaldor, Dea Delaney-Thiele, Marian Pitts, Dy Kelaart, Elizabeth Moore, Sallie Cairnduff, Sidney Williams, Peter Waples-Crowe, Kat Byron, Andrew Bamblett, Sarah Betts and Tony Coburn on behalf of the GOANNA study team.
Aboriginal and Torres Strait Islander young people are a priority population in all national and jurisdictional sexually transmissible infection (STI) and blood borne virus (BBV) strategies, but until recently we have had little information on which to build and evaluate responses. This situation has changed radically in the past two years, with the implementation of the GOANNA study.
GOANNA is the first national survey of Aboriginal and Torres Strait Islander people aged 16–29 in relation to sexually transmitted infections and blood borne viruses, with an emphasis on young people’s levels of knowledge, risk behaviours and health service utilisation.
The survey was initiated because Aboriginal and Torres Strait Islander people are particularly disadvantaged with regard to STIs and BBVs – these being major causes of ill health, as well as substantial contributors to personal distress and relationship breakdown.
Across Australia, cases of these infections are far more frequently diagnosed among Aboriginal and Torres Strait Islander young people than among their non- Indigenous counterparts,1 and despite a long history of providing programs and policies aimed at preventing STIs and BBVs in Aboriginal and Torres Strait Islander populations, there has so far been limited change in their prevalence or incidence, apart from in a few areas.2
To address this we undertook a national cross-sectional survey asking young Aboriginal and Torres Strait Islander people (aged 16–29) questions about knowledge, risk behaviour and health service utilisation.
This article discusses the survey findings related to STI and HIV risk behaviour, knowledge and health service access.
Survey method
The survey used methods originally developed through a collaborative project between the Aboriginal and Health and Medical Research Council of NSW and the former National Centre in HIV Social Research (now known as Centre for Social Research in Health) based at the University of New South Wales.3 , 4
The methodology was then extended to all jurisdictions, with the support of an ARC Linkage Grant involving partners from both government and the community-controlled sector.
Recognising that conventional sample approaches such as household or schools-based sampling were unlikely to yield representative samples of this population, Aboriginal and Torres Strait Islander cultural and sporting events were considered ideal occasions that provided an opportunity to sample a random cross section of young people.
Sampling from community events has been used with other hard-to-reach populations in Australia, such as men who have sex with men (MSM) in the Gay Community Periodic Surveys, with a demonstrated capacity to monitor risk practices over time.5
Events where surveys were administered included Australia Day/ Survival Day events, Aboriginal State and Territory sports carnivals, spirit and cultural events, and NAIDOC week (the National Aborigines and Islanders Day Observance Committee) events.
In order to ensure self-determination in this research, Aboriginal organisations and staff were engaged at every level of the project.
Administering the survey
Surveys were collected using portable handheld Personal Digital Assistants (PDAs) or hand held computers.
The PDAs were loaded with a specialised program to administer the prepared questionnaire and collect information in a de-identified, secure format.
Participants were expected to read the questions and provide their responses by touching the screen with a small stylus. Audio recordings of the questionnaire were also available to the participants from the device.
The audio recordings were in English, with a choice of either a male or female voice to ensure gender acceptability. Audio recordings translated in local Aboriginal languages were also trialled on the device at selected locations.
The project was administered by State and Territory National Aboriginal Community Controlled Health Organisation (NACCHO) Affiliate organisations.
Each affiliate was asked to nominate a key person to drive the project. It was this person’s responsibility to nominate events in their jurisdiction where the survey could be administered.
These individuals were also responsible for recruiting and training survey collection staff, liaising with events managers and administering, collecting and storing data from the PDAs.
Capacity building was a key component of the project; at all stages it was our desire to engage young Aboriginal people in the research collection process.
Over two years, the survey was implemented at 40 events across all eight jurisdictions. A total of 2,877 young people participated: the median age was 21 and 60% were female.
Around half the participants were residents in major cities, 36% were from regional centres, and 9% were from remote areas. 57% of respondents were single at time of participation, and of those in a relationship, 53% reported their partner to be Aboriginal and/or Torres Strait Islander.
A series of questions pertaining to HIV and other STI transmission and risk were asked to gauge participants’ understanding and levels of knowledge about these topics.
Survey findings
Participant scores on each of the knowledge questions were aggregated to form a composite knowledge scale, with scale scores ranging from 0–12. A score of 12 corresponded to all questions answered correctly. The overall mean composite score for knowledge was 9.1.
Mean scores were lower in the younger age groups; 8.5 for 16–19 year olds compared with 9.9 in the oldest age group 25–29. Men had a lower mean score overall than women; 8.8 compared with 9.3.
Despite having good knowledge overall, participants reported poorer knowledge about chlamydia (particularly in relation to its effect on pregnancy) and hepatitis B transmission.
Overall, the average age of sexual debut was 15 years of age. 67% of participants aged 16–19 reported previous vaginal sex, compared with 87% and 93% of people aged 20–24 and 25–29 respectively. 46% of respondents reported only one sexual partner in the previous 12 months.
The majority of respondents reported having sex with similar aged partners; for example, 74% of 16–19 year olds reported having had sex with people aged 16–19.
Men aged 16–29 reported having sex with someone they had just met at double the rate reported by women (20% vs 9%).
Condom use was reported by many people aged 16–19, with 50% stating they always used a condom in the last year compared with 26% of people aged 25–29.
Condom use at last sex did not vary between urban and remote communities.
A third of all men reported being drunk or high at last sexual encounter compared to 22% of women aged 16-29.
Overall, 41% of respondents reported that they had been tested for STIs in the last year (men 39%, women 44%). People aged 16–19 reported lower STI testing rates in the last year than for people aged 20–24 and 25–29.
Of those that had been tested, Aboriginal medical services were the most common place where STI testing occurred (55%), followed by private general practice (34%).
Overall, 30% of respondents reported they had been tested for HIV. In total, 55% of respondents reported having an adult health check in the last year.
Aboriginal Medical Services were reported by participants as the best way to seek help for STI/ BBV advice (58%) and for alcohol and other drug issues (51%).
Conclusions
This data provides baseline information from young Aboriginal and Torres Strait Islander people about levels of knowledge, risk behaviours and health service access.
Levels of knowledge were lowest for the youngest age groups, in particular men and for residents in more remote areas.
Greater efforts are required to ensure safe sex and sexual health information is appropriate and accessible for young people, particularly young men.
Importantly, this includes providing information translated into local Aboriginal languages in communities where English is not the primary spoken language.
This data also provides compelling information about where targeted interventions are needed, particularly where efforts should be made to improve information and reduce risk practice among young men. Health service access for young Aboriginal and Torres Strait Islander people appears reasonable.
Testing for both STIs and HIV are lowest for the 16–19 year old age group.
Men attend testing less frequently and report lower testing rates, compared with women. Strategies to address men’s health are required, as are strategies to ensure testing occurs more frequently when people aged 16–29 attend health services.
Through this study we have collected data that will enable us to identify behavioural, demographic and access correlates of STI and BBV risk and other key outcomes.
It has set the foundation for repeatable and ongoing rounds of surveys to assess changes and trends over time in these areas, much as the Gay Periodic Surveys have done for MSM over many years.
The GOANNA project provides evidence to shape policy and programs in this area and contribute to the broader body of knowledge in the area of Aboriginal and Torres Strait Islander sexual and blood borne virus health.
It also places young Aboriginal and Torres Strait Islander people in a good position to answer questions related to the types of policy and programs that should be rolled out in communities, as well as opportunities to counter stereotyping of young people as often reported in mainstream media in Australia.
Further information about the GOANNA study can be obtained from James Ward, Deputy Director, Baker IDI, Central Australia, Alice Springs.
References
1 The Kirby Institute. (2011). Bloodborne viral and sexually transmissible infections in Aboriginal and Torres Strait Islander people: surveillance and evaluation report 2011. The Kirby Institute, University of NSW, Sydney.
2 Guy, R., Ward, J., Su, J-Y., Skov, S., Rumbold, A., Silver, B., et al. (2012). The impact of STI programs in remote Australian Indigenous communities. Sex Health, 9(3), 205–212.
3 Ward, J., Bryant, J., Worth, H., Hull, P., Solar, S., Bailey, S. (2012). Use of health services for sexually transmitted and blood-borne viral infections by young Aboriginal people in New South Wales. Aust. J Prim Health 19, 81–86. doi 10.1071/PY11032 2012.
4 Bryant, J., Ward, J., Worth, H., Hull, P., Solar, S., Bailey, S. (2011). Safer sex and condom use among Aboriginal young people in New South Wales. Sex Health, 8(3), 378–383.
5 Zablotska, I., Kippax, S., Grulich, A., Holt, M., Prestage, G. (2011). Behavioural surveillance among gay men in Australia: methods, findings and policy implications for the prevention of HIV and other sexually transmissible infections. Sex Health, 8(3), 272–9. doi: 10.1071/SH10125.